Residential Structural Racism and Prevalence of Chronic Health Conditions.

Importance: Studies elucidating determinants of residential neighborhood-level health inequities are needed. Objective: To quantify associations of structural racism indicators with neighborhood prevalence of chronic kidney disease (CKD), diabetes, and hypertension. Design, Setting, and Participants: This cross-sectional study used public data (2012-2018) and deidentified electronic health records (2017-2018) to describe the burden of structural racism and the prevalence of CKD, diabetes, and hypertension in 150 residential neighborhoods in Durham County, North Carolina, from US census block groups and quantified their associations using bayesian models accounting for spatial correlations and residents' age. Data were analyzed from January 2021 to May 2023. Exposures: Global (neighborhood percentage of White residents, economic-racial segregation, and area deprivation) and discrete (neighborhood child care centers, bus stops, tree cover, reported violent crime, impervious areas, evictions, election participation, income, poverty, education, unemployment, health insurance coverage, and police shootings) indicators of structural racism. Main Outcomes and Measures: Outcomes of interest were neighborhood prevalence of CKD, diabetes, and hypertension. Results: A total of 150 neighborhoods with a median (IQR) of 1708 (1109-2489) residents; median (IQR) of 2% (0%-6%) Asian residents, 30% (16%-56%) Black residents, 10% (4%-20%) Hispanic or Latino residents, 0% (0%-1%) Indigenous residents, and 44% (18%-70%) White residents; and median (IQR) residential income of $54 531 ($37 729.25-$78 895.25) were included in analyses. In models evaluating global indicators, greater burden of structural racism was associated with greater prevalence of CKD, diabetes, and hypertension (eg, per 1-SD decrease in neighborhood White population percentage: CKD prevalence ratio [PR], 1.27; 95% highest density interval [HDI], 1.18-1.35; diabetes PR, 1.43; 95% HDI, 1.37-1.52; hypertension PR, 1.19; 95% HDI, 1.14-1.25). Similarly in models evaluating discrete indicators, greater burden of structural racism was associated with greater neighborhood prevalence of CKD, diabetes, and hypertension (eg, per 1-SD increase in reported violent crime: CKD PR, 1.15; 95% HDI, 1.07-1.23; diabetes PR, 1.20; 95% HDI, 1.13-1.28; hypertension PR, 1.08; 95% HDI, 1.02-1.14). Conclusions and Relevance: This cross-sectional study found several global and discrete structural racism indicators associated with increased prevalence of health conditions in residential neighborhoods. Although inferences from this cross-sectional and ecological study warrant caution, they may help guide the development of future community health interventions.

COVID Collaborations: A Physician Assistant Program and Health Department Partnership.

ABSTRACT: The onset of the COVID-19 pandemic resulted in the displacement of clinical-phase medical learners across the country. Physician assistant (PA) and other health professions programs were challenged to innovate and offer alternate learning experiences that would meet students' needs as future health care professionals. At the same time, local and state health departments were faced with quickly increasing their capacity for contact tracing and case investigation in response to the growing number of COVID-19 infections. Through a collaborative partnership based on the needs of the local health department and clinical-phase PA students, the Duke PA program developed an elective in which students served as contact tracers and case investigators. PA students provided over 1500 hours of contact tracing and case investigation support to the local health department. Qualitative review showed students gained a greater appreciation of the impact of social determinants of health, saw first-hand how the pandemic disproportionately affected communities of color, and increased their knowledge about the role of public health. The partnership between the PA program and the health department was mutually beneficial and established a foundation for future collaborative experiences that support both the community and the needs of health professions' learners.

Perceived Benefits of Training Clinicians in Community Engagement for a Leadership Development Program.

BACKGROUND AND OBJECTIVES: Community engagement (CE), including community-engaged research, is a critical tool for improving the health of patients and communities, but is not taught in most medical curricula, and is even rarer in leadership training for practicing clinicians. With the growth of value-based care and increasing concern for health equity, we need to turn our attention to the benefits of working with communities to improve health and health care. The objective of this brief report is to increase understanding of the perceived benefits of CE training for primary care clinicians, specifically those already working. METHODS: We assessed perceived benefits of CE training for primary care clinicians participating in health care transformation leadership training through analysis of learner reflection papers. RESULTS: Clinicians (n=12) reported transformational learning and critical shifts of perspective. Not only did they come to value and understand CE, but the training changed their perception of their roles as clinicians and leaders. CONCLUSIONS: Educating primary care clinicians in CE as a foundational principle can orient them to the criticality of stakeholder engagement for daily practice, practice transformation, and population health improvement, and provides them with a new understanding of their roles as clinicians and leaders.

What Is Population Health?

This article defines population health as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. Population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two. Attention to social and environmental, as well as medical, determinants of health is essential. The population health lens can be used at the individual, practice, institutional, and community levels. The need for primary care to engage in population health stems from the importance of social and environmental factors, the nature of primary care, and contextual changes.

Methods and initial findings from the Durham Diabetes Coalition: Integrating geospatial health technology and community interventions to reduce death and disability.

OBJECTIVE: The Durham Diabetes Coalition (DDC) was established in response to escalating rates of disability and death related to type 2 diabetes mellitus, particularly among racial/ethnic minorities and persons of low socioeconomic status in Durham County, North Carolina. We describe a community-based demonstration project, informed by a geographic health information system (GHIS), that aims to improve health and healthcare delivery for Durham County residents with diabetes. MATERIALS AND METHODS: A prospective, population-based study is assessing a community intervention that leverages a GHIS to inform community-based diabetes care programs. The GHIS integrates clinical, social, and environmental data to identify, stratify by risk, and assist selection of interventions at the individual, neighborhood, and population levels. RESULTS: The DDC is using a multifaceted approach facilitated by GHIS to identify the specific risk profiles of patients and neighborhoods across Durham County. A total of 22,982 patients with diabetes in Durham County were identified using a computable phenotype. These patients tended to be older, female, African American, and not covered by private health insurance, compared with the 166,041 persons without diabetes. Predictive models inform decision-making to facilitate care and track outcomes. Interventions include: 1) neighborhood interventions to improve the context of care; 2) intensive team-based care for persons in the top decile of risk for death or hospitalization within the coming year; 3) low-intensity telephone coaching to improve adherence to evidence-based treatments; 4) county-wide communication strategies; and 5) systematic quality improvement in clinical care. CONCLUSIONS: To improve health outcomes and reduce costs associated with type 2 diabetes, the DDC is matching resources with the specific needs of individuals and communities based on their risk characteristics.

Results from a pilot promotora program to reduce depression and stress among immigrant Latinas.

The stressful experiences that Latino immigrants face throughout the migration process to the United States put them at increased risk for poor mental health. Latinas are at heightened risk due to stigma, limited access to mental health resources, domestic violence, and gender role expectations. In addition, for those who live in new immigrant settlement areas, such as the Southeast, these disparities are magnified by even fewer culturally appropriate services and limited social support. This study evaluates the impact of ALMA (Amigas Latinas Motivando el Alma/Latina Friends Motivating the Soul), a pilot promotora intervention offered in three North Carolina counties to improve mental health among Latinas by offering coping skills training. The intervention trained community-based promotoras to conduct outreach to Latina women in their social network (compañeras). Using a pre-post test design, we assessed the mental health outcomes of compañeras. Compañeras improved on the following outcomes: depressive symptoms, attitudes of depression treatment, perceived and acculturative stress, perceived social support, and positive coping responses. Our findings suggest that promotora interventions, such as ALMA, that focus on building self-care strategies can be valuable to reducing preclinical symptoms and addressing health care disparities that are exacerbated by unavailable or underused mental health services.

Just for Us: in-home care for frail elderly and disabled individuals with low incomes.

In response to increasing concerns about health care access, cost, and quality, Duke University Medical Center began a community-engaged, iterative, data-driven process in 1998 to develop innovative models to provide care earlier, more effectively, and at a lower cost. This commentary reviews Just for Us, an in-home care program launched in 2002 for low-income, frail elderly and disabled individuals.