Student-centered Pipeline to Advance Research in Cancer Careers (SPARCC): Diversifying the Clinical Cancer Research Workforce.

A lack of diversity in the clinical cancer workforce causes undue burden limiting research and patient care advancements. Recruitment and retention of individuals underrepresented in medicine/research can enhance patient-provider concordance. The Student-centered Pipeline to Advance Research in Cancer Careers (SPARCC) uniquely prepares underrepresented minority students to quickly transition into the clinical research workforce and seek advanced graduate degrees. Experiential learning theory and culturally responsive pedagogy ground SPARCC's rigorous competency-based curriculum incorporating cancer care, clinical trial development, social supports, and mentored research experiences. Concurrent mixed-methods analysis includes evaluations of workshops, clinical-practicums, and pre-, post-, and 6-month-post-knowledge, attitudes, and practices. Analysis of data included stepwise multivariate regression analysis, Spearman's rho correlations, and assessments of inter-item reliability via Cronbach's alpha (IBM® SPSS® 24.0). Inductive content analysis coded phrases and analytic patterns were distilled enhancing descriptions of experiences. From January 2019 to March 2019, 62% of applications came from underrepresented minorities. Ten students were accepted, 90% identified as underrepresented minority. All ten students completed the pre-, post-, and 6-month-post-evaluations. Overall scores increased significantly from pre-evaluation to 6-month-post-evaluation. Evaluation data came from 431 responses of 60 workshops, with a mean score of 9.1 (10-point scale). Students completed three clinical practicums, which received an overall mean score of 8.2 (10-point scale). A robust curriculum, structured recruitment, diverse faculty, and comprehensive evaluations made SPARCC a compelling strategy for supporting underrepresented minority students to seek immediate employment as clinical research professionals or application to advanced graduate degree programs.

The association of HIV status with rural-urban differences in wealth in Malawi: 2004-2015/16.

This retrospective cross-sectional study examined the association of HIV status with wealth in Malawi using the 2004, 2010, and 2015/16 Malawi Demographic and Health Survey (MDHS) data. A harmonized wealth index was generated using factor analysis of the pooled data. Bivariate and multivariate linear regression models were estimated to examine the association of HIV status with wealth stratified by urban and rural communities in Malawi. The sample consisted of 33,484 individuals(3,419 were HIV positive and 30,065 HIV-negative). While only 52% of the participants were female, women constituted 61% of those who were HIV positive. Findings showed a positive association between HIV status and wealth in rural but not in urban locations. In rural locations, HIV status was significantly associated with increased wealth (ß=0.11; 0.07, 0.15), whereas having more children in the household (ß=-0.02; -0.03, -0.02) and being employed (ß=-0.07; -0.09, -0.04) were associated with decreased wealth. Given our findings of increased HIV prevalence among those with a higher wealth index in rural Malawi, broadening HIV-prevention efforts to include programs that target the wealthy in Malawi might help mitigate new HIV infections. To effectively address HIV in Malawi, HIV programming policies must target women and men at all socioeconomic status levels.

Factors associated with bed-sharing for African American and White mothers in Wisconsin.

Mother-infant bed-sharing has been associated with a higher risk of sleep-related infant deaths, which affects African Americans at a disproportionately higher rate. Although "separate but proximate sleep surfaces" for infants has been recommended since 2005, bed-sharing remains a common practice, especially among African Americans. This study examined factors associated with bed-sharing among African American and White mothers. Separate logistic regression models were constructed for African American and White respondents to the 2007-2010 Wisconsin Pregnancy Risk Assessment and Monitoring System. The sample consisted of 806 African Americans and 1,680 Whites (N = 2,486). A significantly larger proportion of African Americans (70.6 %) reported bed-sharing than Whites (53.4 %). For both races, partner-related stress was significantly associated with bed-sharing; no significant differences were found between the two racial groups. For African Americans, partner stress (OR 1.8: 1.2-2.6) and maternal education of 13-15 years (OR 2.0: 1.2-3.4) or ≥16 years (OR 2.7: 1.1-6.3) was associated with increased odds of bed-sharing. For Whites, partner stress (OR 1.3: 1-1.8), breastfeeding (OR 2.5: 1.9-3.1), income of $35,000-$49,999 (OR 1.6: 1.2-2.3), being unmarried (OR 1.5: 1.1-2.2), needing money for food (OR 1.6: 1.1-2.3), and non-supine sleep (OR 1.8: 1.2-2.6) were associated with increased odds of bed-sharing. Differences were found in bed-sharing factors between racial groups which suggests a need for culturally-relevant, tailored safe infant sleep interventions. Providers should ask families about their infant's sleeping environment and address safety issues within that environment. More research is needed on the context and reasons for bed-sharing.

Evaluation of a social marketing campaign to increase awareness of immunizations for urban low-income children.

OBJECTIVE: To assess community awareness of childhood immunizations and intent to immunize children after a social marketing immunization campaign. METHODS: We used 2 interviewer-assisted street-intercept surveys to evaluate awareness of childhood immunizations and intent to immunize low-income children. The "Take Control! Immunize" social marketing campaign was developed using a community-based participatory research approach and used billboards, flyers, and various "walking billboard" (eg, backpacks, pens) to deliver immunization messages in the community settings. RESULTS: Over 85% of community members recalled the "Take Control! Immunize" message. Almost half of those who saw the immunization message indicated that the message motivated them to act, including getting their children immunized or calling their physician to inquire about their children's immunizations status. All respondents indicated that immunizations were important for children and that they were likely or very likely to immunize their children. Respondents who reported that "Take Control!" messages motivated them to act in the first intercept survey were significantly more likely than those in the second intercept to report being likely or very likely to immunize their children. CONCLUSION: Culturally appropriate social marketing immunization messages in targeted urban settings can increase parental awareness and behavioral intention to immunize children.

Medical Home Care and Educational Services for Children and Youth on the Autism Spectrum: A Scoping Review.

This scoping review examined current evidence on medical home care and its association with educational services for children and youth on the autism spectrum. We searched five databases and grey literature resulting in 328 publications. Publications meeting inclusion criteria were mapped to medical home care component(s) addressed, type(s) of educational services and their strength and type of association. The Andersen Behavioral Model of Health Services Use was used to summarize predisposing, enabling, and need factors considered. Eighteen publications were reviewed, including eight practice/policy reports and ten original research publications. Medical home care components most addressed included family-centered care (n = 10), referrals (n = 16), and effective care coordination (n = 13). Seven publications also addressed multiple educational service types. Two of the five publications that established a significant association between medical home care components and educational services had mixed results, with one publication reporting a negative association and the other publication reporting a positive association. Challenges to medical home care and educational services were most categorized as enabling factors. Results suggest three areas for further investigation: (1) limited evidence on the strength and type of association between medical home care components and educational services; (2) limited use of population data sources; and (3) the need to consider a broader range of factors when examining their association.

"You learn to go last": perceptions of prenatal care experiences among African-American women with limited incomes.

African American infants die at higher rates and are at greater risk of adverse birth outcomes than White infants in Milwaukee. Though self-reported experiences of racism have been linked to adverse health outcomes, limited research exists on the impact of racism on women's prenatal care experiences. The purpose of this study was to examine the experiences of racial discrimination during prenatal care from the perspectives of African American women in a low income Milwaukee neighborhood. Transcripts from six focus groups with twenty-nine women and two individual interviews were analyzed to identify important emergent themes. Validity was maintained using an audit trail, peer debriefing, and two individual member validation sessions. Participants identified three areas of perceived discrimination based on: (1) insurance or income status, (2) race, and (3) lifetime experiences of racial discrimination. Women described being treated differently by support staff and providers based on type of insurance (public versus private), including perceiving a lower quality of care at clinics that accepted public insurance. While some described personally-mediated racism, the majority of women described experiences that fit within a definition of institutionalized racism-in which the system was designed in a way that worked against their attempts to get quality prenatal care. Women also described lifetime experiences of racial discrimination. Our findings suggest that African American women with limited incomes perceive many provider practices and personal interactions during prenatal care as discriminatory. Future studies could explore the relationship between perceptions of discrimination and utilization of prenatal care.

Community outreach and engagement strategies from the Wisconsin Study Center of the National Children's Study.

The purpose of this methods article was to describe and evaluate outreach and engagement strategies designed to initially build county-wide awareness and support for the National Children's Study (NCS or the study) and subsequently to target the segment communities where recruitment for the study occurred. Selected principles from community outreach, social marketing, and health care system and personal referral formed the foundation for the strategies. The strategies included a celebration event, community advisory board, community needs assessment, building relationships with health care providers and systems, eliciting a network of study supporters, newsletters, appearances at local young family-oriented events (health fairs, parades), presentations to local community leaders, community forums, "branding" with assistance from a women-owned local marketing firm, and mailings including an oversized, second-touch postcard. Six months after study launch, approximately 4,600 study-eligible women were asked in a door-to-door survey if and how they became aware of the study. On average, 40% of eligible women reported being aware of the study. The most frequently cited strategy to cultivate their awareness was study-specific mailings. Awareness of the NCS increased by 7.5% among those receiving a second-touch postcard relative to controls (95% CIs [4.9, 10.7] z = 5.347, p < 0.0000, d = 0.16). Community outreach and engagement strategies, in particular the oversized postcard as a second-touch effort, may be used effectively by researchers for participant recruitment and by public health nurses for delivery of important population-focused messages.

Racial/ethnic disparities in maternal morbidities: a statewide study of labor and delivery hospitalizations in Wisconsin.

We examined racial/ethnic disparities in maternal morbidities (MM) and the number of MM during labor and delivery among hospital discharges in Wisconsin. We conducted a retrospective cohort study of hospital discharge data for 206,428 pregnant women aged 13-53 years using 2005-2007 Healthcare Cost and Utilization Project State Inpatient Dataset (HCUP-SID) for Wisconsin. After adjustments for covariates, MM (preterm labor, antepartum and postpartum hemorrhage, hypertension in pregnancy, gestational diabetes, membrane-related disorders, infections and 3rd and 4th perineal lacerations) were examined using logistic regression models, and number of MM (0, 1, 2, >2 MM) were examined using multivariable ordered logistic regressions with partial proportional odds models. African-Americans had significantly higher likelihood of infections (OR = 1.74; 95% CI 1.60-1.89), preterm labor (OR = 1.42; 1.33-1.50), antepartum hemorrhage (OR = 1.63; 1.44-1.83), and hypertension complicating pregnancy (OR = 1.39; 1.31-1.48) compared to Whites. Hispanics, Asian/Pacific Islanders, and Native Americans had significantly higher likelihood of infections, postpartum hemorrhage, and gestational diabetes than Whites. Major perineal lacerations were significantly higher among Asian/Pacific Islanders (OR = 1.53; 1.34-1.75). All minority racial/ethnic groups, except Asians, had significantly higher likelihood of having 0 versus 1, 2 or >2 MM, 0 or 1 versus 2 or >2 MM, and 0, 1 or 2 versus >2 MM than white women. Findings show significant racial/ethnic disparities in MM, and suggest the need for better screening, management, and timely referral of these conditions, particularly among racial/ethnic women. Disparities in MM may be contributing to the high infant mortality and adverse birth outcomes among different racial/ethnic groups in Wisconsin.

Predictors of wealth index in Malawi - Analysis of Malawi demographic Health Survey 2004-2015/16.

Objectives: To examine the wealth index over a decade utilizing Malawi's Demographic and Health (DHS) survey data from 2004, 2010, and 2015/16, and to explore factors that predict higher wealth. Study design: This was a retrospective descriptive study. Methods: The study utilized DHS data from 2004, 2010, and 2015/2016. The total number of participants was 77,194. Linear regression models were used to assess the effects of the predictors. All analyses were conducted in Stata version 13. Results: Findings showed no significant increase in wealth between the survey years. However, significant increases in wealth were associated with smaller family size (-0.09[-0.10, -0.08]), age (0.02[0.02,0.02]), having formal education (0.21[0.18, 0.24]), and living in urban areas (-1.84[-1.98, -1.70]). Differences in wealth also existed among the different ethnic and religious groups with the Chewa reporting less wealth than other groups, and people with any form of religion reporting more wealth than people with no religion. Conclusions: Minimal changes in wealth have occurred in Malawi between 2004 and 2015/16, and sociodemographic, socioeconomic, and cultural factors are associated with wealth in this population.

Mental disorders, health inequalities and ethics: A global perspective.

The global burden of neuropsychiatry diseases and related mental health conditions is enormous, underappreciated and under resourced, particularly in the developing nations. The absence of adequate and quality mental health infrastructure and workforce is increasingly recognized. The ethical implications of inequalities in mental health for people and nations are profound and must be addressed in efforts to fulfil key bioethics principles of medicine and public health: respect for individuals, justice, beneficence, and non-malfeasance. Stigma and discrimination against people living with mental disorders affects their education, employment, access to care and hampers their capacity to contribute to society. Mental health well-being is closely associated to several Millennium Development Goals and economic development sectors including education, labour force participation, and productivity. Limited access to mental health care increases patient and family suffering. Unmet mental health needs have a negative effect on poverty reduction initiatives and economic development. Untreated mental conditions contribute to economic loss because they increase school and work absenteeism and dropout rates, healthcare expenditure, and unemployment. Addressing unmet mental health needs will require development of better mental health infrastructure and workforce and overall integration of mental and physical health services with primary care, especially in the developing nations.

Unmet needs for specialty, dental, mental, and allied health care among children with special health care needs: are there racial/ethnic disparities?

We examined racial/ethnic disparities in unmet specialty, dental, mental, and allied health care needs among children with special health care needs (CSHCN) using data on 38,866 children in the National Survey of CSHCN. Compared with White CSHCN, Black CSHCN had significantly greater unmet specialty (9.6% vs. 6.7%), dental (16% vs. 8.7%), and mental (27% vs. 17%) health care needs. Hispanic CSHCN had greater unmet dental care needs (15.8% vs. 8.7%). Black females had greater unmet mental health care needs than other groups (41% vs. 13-20%). Most disparities disappeared after multivariate adjustment. Significant risk factors for unmet health care needs included uninsurance, having no personal doctor/nurse, poverty, and condition stability and severity. Eliminating unmet specialty, dental, and mental health care needs for all CSHCN, and especially minority CSHCN, may require greater efforts to reduce poverty and increase insurance coverage among CSHCN, better mental health care assessment of Black female CSHCN, and ensuring all CSHCN have a medical home.

Anatomy of Good Prenatal Care: Perspectives of Low Income African-American Women on Barriers and Facilitators to Prenatal Care.

BACKGROUND: Although early, consistent prenatal care (PNC) can be helpful in improving poor birth outcomes, rates of PNC use tend to be lower among African-American women compared to Whites. This study examines low-income African-American women's perspectives on barriers and facilitators to receiving PNC in an urban setting. METHODS: We conducted six focus groups with 29 women and individual structured interviews with two women. Transcripts were coded to identify barriers and facilitators to obtaining PNC; codes were reviewed to identify emergent themes. RESULTS: Barriers to obtaining PNC included structural barriers such as transportation and insurance, negative attitudes towards PNC, perceived poor quality of care, unintended pregnancy, and psychosocial stressors such as overall life stress and chaos. Facilitators of PNC included positive experiences such as trusting relationships with providers, respectful staff and providers, and social support. CONCLUSIONS: Findings suggest important components in an ideal PNC model to engage low-income African-American women.

Trends and Progress in Reducing Teen Birth Rates and the Persisting Challenge of Eliminating Racial/Ethnic Disparities.

PURPOSE: We examined progress made by the Milwaukee community toward achieving the Milwaukee Teen Pregnancy Prevention Initiative's aggressive 2008 goal of reducing the teen birth rate to 30 live births/1000 females aged 15-17 years by 2015. We further examined differential teen birth rates in disparate racial and ethnic groups. METHOD: We analyzed teen birth count data from the Wisconsin Interactive Statistics on Health system and demographic data from the US Census Bureau. We computed annual 2003-2014 teen birth rates for the city and four racial/ethnic groups within the city (white non-Hispanic, black non-Hispanic, Hispanic/Latina, Asian non-Hispanic). To compare birth rates from before (2003-2008) and after (2009-2014) goal setting, we used a single-system design to employ two time series analysis approaches, celeration line, and three standard deviation (3SD) bands. RESULTS: Milwaukee's teen birth rate dropped 54 % from 54.3 in 2003 to 23.7 births/1000 females in 2014, surpassing the goal of 30 births/1000 females 3 years ahead of schedule. Rate reduction following goal setting was statistically significant, as five of the six post-goal data points were located below the celeration line and points for six consecutive years (2010-2014) fell below the 3SD band. All racial/ethnic groups demonstrated significant reductions through at least one of the two time series approaches. The gap between white and both black and Hispanic/Latina teens widened. CONCLUSION: Significant reduction has occurred in the overall teen birth rate of Milwaukee. Achieving an aggressive reduction in teen births highlights the importance of collaborative community partnerships in setting and tracking public health goals.

Relationship of Paternity Status, Welfare Reform Period, and Racial/Ethnic Disparities in Infant Mortality.

The objective of this study was to examine the relationship of paternity status, welfare reform period, and racial/ethnic disparities in infant mortality. The study used retrospective analysis of birth outcomes data from singleton birth/infant death data in Milwaukee, Wisconsin, from 1993 to 2009. Multivariate logistic regression was used to examine the relationship between paternity status, welfare reform period, and infant mortality, adjusting for maternal and infant characteristics. Data consisted of almost 185,000 singleton live births and 1,739 infant deaths. Although unmarried women with no father on record made up about 32% of the live births, they accounted for over two thirds of the infant deaths compared with married women with established paternity who made up 39% of live births but had about a quarter of infant deaths. After adjustments, any form of paternity establishment was protective against infant mortality across all racial/ethnic groups. Unmarried women with no father on record had twice to triple the odds of infant mortality among all racial/ethnic groups. The likelihood of infant mortality was only significantly greater for African American women in the postwelfare (1999-2004; odds ratio = 1.27; 95% confidence interval = 1.10-1.46) period compared with the 1993 to 1998 period. Study findings suggest that any form of paternity establishment may have protective effect against infant mortality. Welfare reform changes may have reduced some of the protection against infant mortality among unmarried African American women that was present before the welfare legislation. Policies and programs that promote or support increased paternal involvement and establishment of paternity may improve birth outcomes and help reduce infant mortality.

Satisfaction with care and ease of using health care services among parents of children with special health care needs: the roles of race/ethnicity, insurance, language, and adequacy of family-centered care.

OBJECTIVES: To examine whether racial/ethnic disparities exist in parental reports of satisfaction with care and ease of using health care services among children with special health care needs (CSHCN) and to identify factors associated independently with satisfaction with care and ease of use of health care services among CSHCN. METHODS: We analyzed data for 38,886 CSHCN <18 years of age in the National Survey of CSHCN, conducted from 2000 to 2002. Outcome variables included perceived satisfaction with care and ease of service use. Covariates included sociodemographic factors, insurance, interview language, condition severity and stability, adequacy of family-centered care measures, and having a personal doctor/nurse. RESULTS: The prevalences of reported dissatisfaction with care and problems with ease of using services among parents of CSHCN were 8% and 25%, respectively. Black and Hispanic parents were significantly more likely than white parents to be dissatisfied with care (13% and 16% vs 7%) and to report problems with ease of service use (35% and 34% vs 23%). Hispanic/white disparities in satisfaction with care and ease of use of services disappeared only after multivariate adjustment for parental interview language. Black/white disparities in satisfaction with care disappeared after adjustments for adequacy of family-centered care measures, but black/white disparities in ease of using services persisted. The severity of the child's condition, lack of insurance, parental interview in Spanish, and inadequate family-centered care were associated significantly with dissatisfaction with care and problems with ease of using health care services. CONCLUSIONS: Policies and strategies that reduce language barriers, promote insurance coverage and family-centered care, and improve ease of use of services among minority CSHCN have the potential to reduce racial/ethnic disparities in satisfaction with care and to promote ease of use of services among families with CSHCN.