Impact of Community Health Workers on Access to Care for Rural Populations in the United States: A Systematic Review.

Community Health Worker (CHW) interventions have shown potential to reduce inequities for underserved populations. However, there is a lack of support for CHW integration in the delivery of health care. This may be of particular importance in rural areas in the Unites States where access to care remains problematic. This review aims to describe CHW interventions and their outcomes in rural populations in the US. Peer reviewed literature was searched in PubMed and PsycINFO for articles published in English from 2015 to February 2021. Title and abstract screening was performed followed by full text screening. Quality of the included studies was assessed using the Downs and Black score. A total of 26 studies met inclusion criteria. The largest proportion were pre-post program evaluation or cohort studies (46.2%). Many described CHW training (69%). Almost a third (30%) indicated the CHW was integrated within the health care team. Interventions aimed to provide health education (46%), links to community resources (27%), or both (27%). Chronic conditions were the concern for most interventions (38.5%) followed by women's health (34.6%). Nearly all studies reported positive improvement in measured outcomes. In addition, studies examining cost reported positive return on investment. This review offers a broad overview of CHW interventions in rural settings in the United States. It provides evidence that CHW can improve access to care in rural settings and may represent a cost-effective investment for the healthcare system.

Facilitators and barriers to utilization of medications for opioid use disorder in primary care in South Carolina.

OBJECTIVE: Utilization of medications for opioid use disorder (MOUD) has not been widely adopted by primary care providers. This study sought to identify interprofessional barriers and facilitators for use of MOUD (specifically naltrexone and buprenorphine) among current and future primary care providers in a southeastern academic center in South Carolina. METHOD: Faculty, residents, and students within family medicine, internal medicine, and a physician assistant program participated in focus group interviews, and completed a brief survey. Survey data were analyzed quantitatively, and focus group transcripts were analyzed using a deductive qualitative content analysis, based upon the theory of planned behavior. RESULTS: Seven groups (N = 46) completed focus group interviews and surveys. Survey results indicated that general attitudes towards MOUD were positive and did not differ significantly among groups. Subjective norms around prescribing and controllability (i.e., beliefs about whether prescribing was up to them) differed between specialties and between level of training groups. Focus group themes highlighted attitudes about MOUD (e.g., "opens the flood gates" to patients with addiction) and perceived facilitators and barriers of using MOUD in primary care settings. Participants felt that although MOUD in primary care would improve access and reduce stigma for patients, prescribing requires improved provider education and an integrated system of care. CONCLUSIONS: The results of this study provide an argument for tailoring education to specifically address the barriers primary care prescribers perceive. Results promote the utilization of active, hands-on learning approaches, to ultimately promote uptake of MOUD prescribing in the primary care setting in South Carolina.

A Telehealth Initiative to Overcome Health Care Barriers for People Experiencing Homelessness.

People experiencing homelessness (PEH) encounter barriers to health care, increasing their vulnerability to illness, hospitalization, and death. Telehealth can improve access to health care, but its use in PEH has been insufficiently evaluated. Needs assessment surveys completed by clients at an urban drop-in center for PEH (n = 63) showed mental (58.7%) and physical (52.4%) health challenges were common, as was emergency department (ED) use (75.9%, n = 54). Surveys collected after in-person and telehealth clinical visits showed patient satisfaction was >90% for both visit types (n = 125, 44.0% telehealth and 56.0% in person). Without access to telehealth visits, 29.1% of patients would have gone to the ED and 38.2% would not have gotten care. Providers (n = 93, 69.6% telehealth and 30.4% in person) were more likely to agree/strongly agree they made a positive impact on patients' health through telehealth (92.2%) than in person (71.4%) (p = 0.019). Telehealth is a feasible and potentially cost-effective method to increase access to health care and reduce health outcome disparities in PEH.

A cross-sectional study of United States family medicine residency programme director burnout: implications for mitigation efforts and future research.

BACKGROUND: Academic physician burnout is concerning. Too little is known about factors associated with residency programme director burnout. Continued uncertainty risks adverse outcomes including graduate medical education leadership turnover and negative impact on recruiting and retaining under-represented minority residency programme directors. OBJECTIVE: This study assessed symptoms of burnout (emotional exhaustion, depersonalization) and depression along with evidence-based individual and environmental risk factors in a U.S. sample of family medicine residency programme directors. METHODS: The omnibus 2018 Council of Academic Family Medicine Education Research Alliance survey was used to contact programme directors at all Accreditation Council for Graduate Medical Education accredited U.S. family medicine residency programmes via email. Descriptive data included programme director and programme characteristics, Areas of Worklife (workload, values and control), loneliness (lack companionship, feel left out and feel isolated), burnout (emotional exhaustion, depersonalization) and depressive symptoms. Chi-square tests contrasted descriptive variables with burnout and depressive symptoms. Logistic regression (LR) modelled associations between significant descriptive variables and burnout and depressive symptoms. RESULTS: The survey response rate was 45.2% (268/590). Programme directors reported: emotional exhaustion (25.0%), depersonalization (10.3%) and depressive symptoms (25.3%). LR models found significant associations with emotional exhaustion (Workload: lacking time and other work-related resources); lack of companionship, depersonalization (North West Central residency region; Workload and lack of companionship) and depressive symptoms (Black/African American ethnicity). CONCLUSIONS: One-quarter of U.S. programme directors report burnout or depressive symptoms. Future research should consider associated variables as possible intervention targets to reduce programme director distress and turnover.

Oxytocin Reduces Cocaine Cued Fos Activation in a Regionally Specific Manner.

Background: Oxytocin may be a possible treatment for multiple neuropsychiatric disorders, including cocaine addiction. Little is known about the site-specific effects of oxytocin on various drug addiction-related brain regions. Furthermore, sexually dimorphic effects of oxytocin on neural function in the addiction circuit have not been established. Here, we studied Fos expression following cocaine-cued reinstatement in both male and female rats. Methods: Male and female rats underwent self-administration, extinction, and reinstatement tests. On test days, rats were given oxytocin or vehicle, and lever pressing was measured in response to conditioned cocaine cues. Rats were perfused and Fos staining measured in the central amygdala, medial prefrontal cortex, nucleus accumbens core, and subthalamic nucleus. Fos/oxytocin double labeling occurred in the paraventricular nucleus of the hypothalamus. Results: Rats reinstated to cocaine cues relative to extinction responding and oxytocin reduced cocaine seeking. Oxytocin combined with contingent cue presentations increased Fos+ oxytocin cell bodies within the paraventricular nucleus of the hypothalamus relative to vehicle. Fos expression robustly increased in the central amygdala following oxytocin administration. Oxytocin reversed cue-induced Fos expression in the medial prefrontal cortex, nucleus accumbens core, and subthalamic nucleus. Central oxytocin infusion also attenuated reinstated cocaine seeking. Conclusions: Oxytocin decreased reinstated cocaine seeking, increased Fos activation in the paraventricular nucleus of the hypothalamus and central amygdala, but normalized cue-induced Fos activation in the medial prefrontal cortex, nucleus accumbens core, and subthalamic nucleus, thereby demonstrating regionally specific activation patterns. No sex differences were seen for the effects of oxytocin on cocaine seeking and Fos activation, indicating that oxytocin acts on similar central neural circuits critical to reinstated cocaine seeking in both males and females.

A Novel Case-Based Learning Activity With a Focus on Food Insecurity.

OBJECTIVE: Food insecurity is a social determinant of health (SDOH) affecting 1 in 10 households per year in the United States and has major impacts on the course of chronic health conditions. It is beneficial to introduce screening and appropriate treatment plans to medical students. This study utilized a novel case-based learning exercise (CBLE) to assess confidence, attitudes and improvements in knowledge on recognizing and addressing food insecurity. METHODS: A CBLE focused on food insecurity was developed to be implemented in a 2-h session as part of the curriculum for all first-year medical students at the Medical University of South Carolina. The CBLE included a case for discussion, followed by an interview with a standardized patient. Students received invitations to complete pre- and post-CBLE assessment surveys. RESULTS: Completion of both pre- and post-surveys was achieved by 29% of students (48 out of 166). Knowledge around the formal definition of "food insecurity," how to recognize food insecurity versus hunger, and how to screen for food insecurity all increased significantly (P < .05). Responses relating to the association between certain chronic diseases and food insecurity did not change pre and post-CBLE. CONCLUSION: This novel CBLE was successfully implemented within a 2-h teaching session and improved knowledge on recognizing food insecurity in practice. However, additional learning exercises are likely needed to improve knowledge of the relationship between food insecurity and chronic disease states. Nonetheless, the CBLE structure provided students with multiple formats of learning and integration of skills, which shows promise and may be applicable to improve knowledge of other SDOHs.

Quality of YouTube Videos on Prostate Cancer Screening for Black Men.

BACKGROUND: Black men are disproportionately impacted by prostate cancer. Guidelines agree that Black men should make informed decisions about whether to engage in prostate cancer screening. YouTube is widely used among Black men and impacts understanding of health conditions. OBJECTIVES: Given that misleading online health information might be especially harmful to Black men, the objective of this study was to evaluate the quality of information regarding prostate cancer screening for Black men available on YouTube. METHODS: Four viewers watched the top 50 videos using the search term "Prostate Cancer Screening in Black Men." Videos were scored using the previously validated DISCERN quality criteria for consumer health information and the Patient Education Materials Assessment Tool (PEMAT). Results were compared based on video characteristics like presenter perceived demographics and viewer engagement metrics. RESULTS: Inter-rater reliability testing showed consistency for the PEMAT (interclass correlation coefficient [ICC] = 0.69) and DISCERN (ICC= 0.85). Few videos (16%) met the DISCERN quality threshold (54.4/80), and 28% of videos met the PEMAT threshold (10.5/15). Less than half of videos addressed racial disparities in prostate cancer. There was no difference in quality based on perceived race of the presenter (DISCERN P = .06, PEMAT P = .43). CONCLUSIONS: The overall quality of videos about prostate cancer screening in Black men is poor, including those with Black presenters. Clinicians should be aware of potential misinformation that Black patients receive from YouTube and the opportunity to improve the quality of available information about prostate cancer screening in Black men.

Extended cocaine-seeking produces a shift from goal-directed to habitual responding in rats.

Cocaine addiction is often characterized by a rigid pattern of behavior in which cocaine users continue seeking and taking drug despite negative consequences associated with its use. As such, full acquisition and relapse of drug-seeking behavior may be attributed to a shift away from goal-directed responding and a shift towards the maladaptive formation of rigid and habit-like responses. This rigid nature of habitual responding can be developed with extended training and is typically characterized by insensitivity to changes in outcome value. The present study determined whether cocaine (primary reinforcer) and cocaine associated cues (secondary reinforcer) could be devalued in rats with different histories of cocaine self-administration. Specifically, rats were trained on two schedules of cocaine self-administration (long-access vs. short-access). Following training the cocaine reinforcer was devalued through three separate pairings of lithium chloride with cocaine infusions. Cocaine history did not have an impact on devaluation of cocaine-associated cues. However, the reinforcing properties of cocaine were devalued only in rats on a short-access cocaine schedule but not those trained on a long-access schedule. Taken together this pattern of findings suggests that, in short access rats, devaluation is specific to the primary reinforcer and not associative stimuli such as cues. Importantly, rats that received extended training during self-administration displayed insensitivity to outcome devaluation of the primary reinforcer as well as all associative stimuli, thus displaying rigid behavioral responding similar to behavioral patterns found in addiction. Alternatively, long access cocaine exposure may have altered the devaluation threshold.