Contribution of Health Care Practitioner and Maternity Services Factors to Racial Disparities in Alabama: A Qualitative Study.

OBJECTIVE: Black patients are three times more likely to die of pregnancy-related causes than White patients in the United States, and Alabama has the third worst maternal mortality rate in the nation. We sought to identify health care practitioner and maternity service factors contributing to disparities in Alabama, as well as potential strategies to address these contributors. METHODS: We conducted key informant interviews with obstetricians, nurses, doulas, lactation counselors, health system administrators, and representatives of professional organizations who deliver maternity care to racially and ethnically diverse patients in Alabama. The interview guide was developed using Howell's conceptual framework on racial and ethnic disparities in severe maternal morbidity and mortality. Adopting a thematic analysis approach, we coded and analyzed transcripts using NVivo 12 software. Open coding and selective coding were conducted to identify themes related to health care practitioner- and maternity services-level determinants. RESULTS: Overall, 20 health care practitioners or administrators were interviewed. Primary themes related to health care practitioners included implicit bias and explicit racism, lack of communication and lack of positive patient-health care practitioner relationships, lack of cultural sensitivity, and variation in clinical knowledge and experience. Primary themes related to maternity services included lack of accessibility, inadequate quality and content of care, lack of continuity of care, discriminatory facility policies, and workforce shortages and lack of diversity. Strategies suggested by participants to address these factors included bias trainings for health care practitioners, improvements in racial and interdisciplinary diversity in the maternity workforce, and evidence-based interventions such as group prenatal care, disparities dashboards, simulation trainings, early warning signs criteria, and coordinated care. CONCLUSION: We gained diverse perspectives from health care practitioners and administrators on how maternity health care practitioner and maternity health services factors contribute to inequities in maternal health in Alabama. Strategies to address these contributing factors were multifaceted.

Community and Systems Contributors and Strategies to Reduce Racial Inequities in Maternal Health in the Deep South: Provider Perspectives.

Purpose: Black pregnant individuals in Alabama are disproportionately affected by severe maternal morbidity and mortality (SMM). To understand why racial disparities in maternal health outcomes persist and identify potential strategies to reduce these inequities, we sought perspectives from obstetric health care providers, health administrators, and members of local organizations who provide pregnancy, delivery, and postpartum care services in Alabama. Methods: We conducted qualitative in-depth interviews with stakeholders (n=20), purposively recruited from community-based organizations, clinical settings, government organizations, and academic institutions. Interview guides were based on Howell's conceptual model of pathways to racial disparities in maternal mortality. Data were coded using a modified framework theory approach and analyzed thematically. Results: Racism, unjust laws and policies, and poverty/lack of infrastructure in communities emerged as major themes contributing to racial disparities in maternal health at the community and systems levels. Inadequate health insurance coverage was described as a strong driver of the disparities. Service providers suggested strategies for Alabama should be community focused, evidence based, and culturally sensitive. These should include Medicaid expansion, expanded parental leave, and removal of laws restricting choice. Community- and systems-level interventions should include community infrastructure improvements, choice in maternity services, and provision of digital communication options. Conclusions: Providers shared perspectives on community and structural areas of intervention to reduce racial inequities in SMM. These results can inform discussions with health system and community partners about Alabama and other Deep South initiatives to improve maternal health outcomes in black communities.

Training and Dissemination of Lung Cancer Education Curriculum Among Community Health Advisors in the Deep South: a Program Evaluation.

Lung cancer is the leading cause of cancer mortality in the USA. In the rural Black Belt region of Alabama, high rates of lung cancer incidence and mortality coupled with disproportionate lack of access to health services stresses the need for navigating high risk and disproportionately affected groups towards successfully obtaining lung cancer screenings. We utilized our well-accepted Community Health Advisor (CHA) model for education and awareness. This study seeks to evaluate the results of the Alabama Lung Cancer Awareness, Screening, and Education (ALCASE) training on CHAs, program evaluation, and lessons learned. A total of 202 participants were eligible and enrolled for CHA training. One hundred thirty CHAs were included for the final analyses. Descriptive statistics were computed; differences in pre-test and post-test scores were compared across demographic characteristics of the participants using paired t-test/one-way ANOVA. Of the 130 CHAs, 46% were 65 years or older; 98% were African Americans, and 87% were female; 17% of participants were cancer survivors. The mean post-test scores were 2.2 points greater than mean pre-test scores, and the difference was significant (mean (SD): pre-test = 20.8 (2.8) versus post-test = 23 (2.2); p = 0.001). No notable difference in pre-test and post-test scores were observed by CHA's demographic characteristics except by their county of residence or work (p = 0.0019). We demonstrate the capability and value of successfully recruiting and training motivated community members to be able to serve educators to better reach medically underserved and historically excluded communities.

Attenuation of Polycyclic Aromatic Hydrocarbon (PAH)-Mediated Pulmonary DNA Adducts and Cytochrome P450 (CYP)1B1 by Dietary Antioxidants, Omega-3 Fatty Acids, in Mice.

Numerous human and animal studies have reported positive correlation between carcinogen-DNA adduct levels and cancer occurrence. Therefore, attenuation of DNA adduct levels would be expected to suppress tumorigenesis. In this investigation, we report that the antioxidants omega 3-fatty acids, which are constituents of fish oil (FO), significantly decreased DNA adduct formation by polycyclic aromatic hydrocarbons (PAHs). B6C3F1 male mice were fed an FO or corn oil (CO) diet, or A/J male mice were pre-fed with omega-3 fatty acids eicosapentaenoic acid (EPA) and/or docosahexaenoic acid (DHA). While the B6C3F1 mice were administered two doses of a mixture of seven carcinogenic PAHs including benzo(a)pyrene (BP), the A/J mice were treated i.p. with pure benzo[a]pyrene (BP). Animals were euthanized after 1, 3, or 7 d after PAH treatment. DNA adduct levels were measured by the 32P-postlabeling assay. Our results showed that DNA adduct levels in the lungs of mice 7 d after treatment were significantly decreased in the FO or EPA/DHA groups compared with the CO group. Interestingly, both qPCR and Western blot analyses revealed that FO, DHA and EPA/DHA significantly decreased the expression of cytochrome P450 (CYP) 1B1. CYP1B1 plays a critical role in the metabolic activation of BP to DNA-reactive metabolites. qPCR also showed that the expression of some metabolic and DNA repair genes was induced by BP and inhibited by FO or omega-3 fatty acids in liver, but not lung. Our results suggest that a combination of mechanism entailing CYP1B1 inhibition and the modulation of DNA repair genes contribute to the attenuation of PAH-mediated carcinogenesis by omega 3 fatty acids.

A community-engaged approach to understanding environmental health concerns and solutions in urban and rural communities.

BACKGROUND: Focus groups and workshops can be used to gain insights into the persistence of and potential solutions for environmental health priorities in underserved areas. The objective of this study was to characterize focus group and workshop outcomes of a community-academic partnership focused on addressing environmental health priorities in an urban and a rural location in Alabama between 2012 and 2019. METHODS: Six focus groups were conducted in 2016 with 60 participants from the City of Birmingham (urban) and 51 participants from Wilcox County (rural), Alabama to discuss solutions for identified environmental health priorities based on previous focus group results in 2012. Recorded focus groups were transcribed and analyzed using the grounded theory approach. Four follow-up workshops that included written survey instruments were conducted to further explore identified priorities and determine whether the priorities change over time in the same urban (68 participants) and rural (72 participants) locations in 2018 and 2019. RESULTS: Consistent with focus groups in 2012, all six focus groups in 2016 in Birmingham identified abandoned houses as the primary environmental priority. Four groups listed attending city council meetings, contacting government agencies and reporting issues as individual-level solutions. Identified city-level solutions included city-led confiscation, tearing down and transferring of abandoned property ownership. In Wilcox County, all six groups agreed the top priority was drinking water quality, consistent with results in 2012. While the priority was different in Birmingham versus Wilcox County, the top identified reason for problem persistence was similar, namely unresponsive authorities. Additionally, individual-level solutions identified by Wilcox County focus groups were similar to Birmingham, including contacting and pressuring agencies and developing petitions and protesting to raise awareness, while local policy-level solutions identified in Wilcox County included government-led provision of grants to improve septic systems, and transparency in allocation of funds. Workshops in 2018 and 2019 further emphasized water quality as the top priority in Wilcox County, while participants in Birmingham transitioned from abandoned houses as a top priority in 2018 to drinking water quality as a new priority in 2019. CONCLUSIONS: Applying a community-engaged approach in both urban and rural locations provided better understanding of the unique opportunities and challenges for identifying potential interventions for environmental health priorities in both locations. Results can help inform future efforts to address locally defined environmental health issues and solutions.

Characterization of heat index experienced by individuals residing in urban and rural settings.

Heatwave warning systems rely on forecasts made for fixed-point weather stations (WS), which do not reflect variation in temperature and humidity experienced by individuals moving through indoor and outdoor locations. We examined whether neighborhood measurement improved the prediction of individually experienced heat index in addition to nearest WS in an urban and rural location. Participants (residents of Birmingham, Alabama [N = 89] and Wilcox County, Alabama [N = 88]) wore thermometers clipped to their shoe for 7 days. Shielded thermometers/hygrometers were placed outdoors within participant's neighborhoods (N = 43). Nearest WS and neighborhood thermometers were matched to participant's home address. Heat index (HI) was estimated from participant thermometer temperature and WS humidity per person-hour (HI[individual]), or WS temperature and humidity, or neighborhood temperature and humidity. We found that neighborhood HI improved the prediction of individually experienced HI in addition to WS HI in the rural location, and neighborhood heat index alone served as a better predictor in the urban location, after accounting for individual-level factors. Overall, a 1 °C increase in HI[neighborhood] was associated with 0.20 °C [95% CI (0.19, 0.21)] increase in HI[individual]. After adjusting for ambient condition differences, we found higher HI[individual] in the rural location, and increased HI[individual] during non-rest time (5 a.m. to midnight) and on weekdays.

Effect of an Additional 30 Minutes Spent Outdoors during Summer on Daily Steps and Individually Experienced Heat Index.

Spending time outdoors is associated with increased physical activity; however, high ambient temperature/humidity, together with built environment features in urban versus rural environments, may influence physical activity. We conducted an intervention trial with 89 urban and 88 rural participants performing normal activities on Days 1-2 (baseline) and spending an additional 30 min outdoors on Days 3-7 (intervention) in the summer. Participants wore a pedometer with real-time visual feedback to track daily steps taken and a thermometer clipped to their shoe to track temperatures experienced individually. Hygrometer-thermometers were deployed in participants' neighborhoods to collect finer resolution ambient heat indexes in addition to regional weather station measurements. Using linear mixed effects models and adjusting for ambient conditions and individual-level factors, participants on average walked 637 (95%CI (83, 1192)) more steps and had a 0.59 °C (95%CI (0.30, 0.88)) lower daily mean individually experienced heat index during intervention days compared to baseline days. The intervention benefit of increased physical activity was greater in rural residents who were less active at baseline, compared to urban residents. Our results suggest adding a small amount of additional time outdoors may improve physical activity without increasing participants' heat exposure, even during summer in a humid subtropical climate.

Methods for Estimating Wet Bulb Globe Temperature From Remote and Low-Cost Data: A Comparative Study in Central Alabama.

Heat stress is a significant health concern that can lead to illness, injury, and mortality. The wet bulb globe temperature (WBGT) index is one method for monitoring environmental heat risk. Generally, WBGT is estimated using a heat stress monitor that includes sensors capable of measuring ambient, wet bulb, and black globe temperature, and these measurements are combined to calculate WBGT. However, this method can be expensive, time consuming, and requires careful attention to ensure accurate and repeatable data. Therefore, researchers have attempted to use standard meteorological measurements, using single data sources as an input (e.g., weather stations) to calculate WBGT. Building on these efforts, we apply data from a variety of sources to calculate WBGT, understand the accuracy of our estimated equation, and compare the performance of different sources of input data. To do this, WBGT measurements were collected from Kestrel 5400 Heat Stress Trackers installed in three locations in Alabama. Data were also drawn from local weather stations, North American Land Data Assimilation System (NLDAS), and low cost iButton hygrometers. We applied previously published equations for estimating natural wet bulb temperature, globe temperature, and WBGT to these diverse data sources. Correlation results showed that WBGT estimates derived from all proxy data sources-weather station, weather station/iButton, NLDAS, NLDAS/iButton-were statistically indistinguishable from each other, or from the Kestrel measurements, at two of the three sites. However, at the same two sites, the addition of iButtons significantly reduced root mean square error and bias compared to other methods.

The effect of time spent outdoors during summer on daily blood glucose and steps in women with type 2 diabetes.

This study investigated changes in glycemic control following a small increase in time spent outdoors. Women participants with type 2 diabetes (N = 46) wore an iBUTTON temperature monitor and a pedometer for 1 week and recorded their morning fasting blood glucose (FBG) daily. They went about their normal activities for 2 days (baseline) and were asked to add 30 min of time outdoors during Days 3-7 (intervention). Linear mixed effects models were used to test whether morning FBG values were different on days following intervention versus baseline days, and whether steps and/or heat exposure changed. Results were stratified by indicators of good versus poor glycemic control prior to initiation of the study. On average, blood glucose was reduced by 6.1 mg/dL (95% CI - 11.5, - 0.6) on mornings after intervention days after adjusting for age, BMI, and ambient weather conditions. Participants in the poor glycemic control group (n = 16) experienced a 15.8 mg/dL decrease (95% CI - 27.1, - 4.5) in morning FBG on days following the intervention compared to a 1.6 mg/dL decrease (95%CI - 7.7, 4.5) for participants in the good glycemic control group (n = 30). Including daily steps or heat exposure did not attenuate the association between intervention and morning FBG. The present study suggests spending an additional 30 min outdoors may improve glycemic control; however, further examination with a larger sample over a longer duration and determination of mediators of this relationship is warranted.

Estimating Occupational Heat Exposure From Personal Sampling of Public Works Employees in Birmingham, Alabama.

OBJECTIVE: This study investigated whether using thermometers clipped on workers' shoes would result in different heat exposure estimation and work-rest schedules compared with using area-level meteorological data alone. METHODS: Alabama workers (n = 51) were individually monitored using thermometers on shoes. Wet bulb globe temperature (WBGT) was estimated using thermometer temperatures (WBGT [personal]) or nearby weather station temperatures (WBGT [WS]). Work-rest schedules were determined from WBGT, clothing, and hourly metabolic rates estimated from self-reported tasks and bodyweight. RESULTS: The percent of hours exceeding the threshold limit value (TLV, ACGIH, Cincinnati, OH) were estimated at 47.8% using WBGT (personal) versus 42.1% using WBGT (WS). For work-rest recommendations, more hours fell into the most protective schedule (0 to 15 min work/45 to 60 min rest) using WBGT (personal) versus WBGT (WS) (17.4% vs 14.4%). CONCLUSIONS: Temperatures from wearable thermometers, together with meteorological data, can serve as an additional method to identify occupational heat stress exposure and recommend work-rest schedules.

Effects of Indoor Thermal Environment on Human Food Intake, Productivity, and Comfort: Pilot, Randomized, Crossover Trial.

OBJECTIVE: It was hypothesized that exposure to mild temperatures above the human thermoneutral zone would decrease caloric intake in a sedentary office environment. METHODS: Women (n = 25) were randomized in a crossover design to perform seated office work for 7 hours in a thermoneutral condition (control, 19°C-20°C) and a condition above the thermoneutral zone (warm, 26°C-27°C). Food intake was estimated by weight and bomb calorimetry, peripheral temperature by thermal imaging, and thermal comfort and productivity by questionnaires. Mixed effects models were used to examine the effects of thermal condition on caloric intake. RESULTS: Participants ate, on average, 357 kcal less in the warm condition, adjusting for BMI and peripheral temperature (P = 0.0219). According to the survey results at midday (after 3.5 hours of exposure), 96% of the participants in the warm condition reported being comfortable (n = 24) compared with 32% in the control condition (n = 8). More participants reported being as productive or more productive than usual in the warm condition (n = 22, 88%) than in the control condition (n = 12, 48%). CONCLUSIONS: This line of research is worthy of further exploration. Untightening climate control toward warmer conditions during summer to increase comfort and productivity while decreasing caloric intake may prove both effective and comfortable.

Opportunities and Challenges for Personal Heat Exposure Research.

BACKGROUND: Environmental heat exposure is a public health concern. The impacts of environmental heat on mortality and morbidity at the population scale are well documented, but little is known about specific exposures that individuals experience. OBJECTIVES: The first objective of this work was to catalyze discussion of the role of personal heat exposure information in research and risk assessment. The second objective was to provide guidance regarding the operationalization of personal heat exposure research methods. DISCUSSION: We define personal heat exposure as realized contact between a person and an indoor or outdoor environment that poses a risk of increases in body core temperature and/or perceived discomfort. Personal heat exposure can be measured directly with wearable monitors or estimated indirectly through the combination of time-activity and meteorological data sets. Complementary information to understand individual-scale drivers of behavior, susceptibility, and health and comfort outcomes can be collected from additional monitors, surveys, interviews, ethnographic approaches, and additional social and health data sets. Personal exposure research can help reveal the extent of exposure misclassification that occurs when individual exposure to heat is estimated using ambient temperature measured at fixed sites and can provide insights for epidemiological risk assessment concerning extreme heat. CONCLUSIONS: Personal heat exposure research provides more valid and precise insights into how often people encounter heat conditions and when, where, to whom, and why these encounters occur. Published literature on personal heat exposure is limited to date, but existing studies point to opportunities to inform public health practice regarding extreme heat, particularly where fine-scale precision is needed to reduce health consequences of heat exposure. https://doi.org/10.1289/EHP556.

Mechanistic relationships between hepatic genotoxicity and carcinogenicity in male B6C3F1 mice treated with polycyclic aromatic hydrocarbon mixtures.

The genotoxicity of a complex mixture [neutral fraction (NF)] from a wood preserving waste and reconstituted mixture (RM) mimicking the NF with seven major polycyclic aromatic hydrocarbons (PAHs) and benzo(a)pyrene (BaP) was investigated by determining DNA adducts and tumor incidence in male B6C3F1 mice exposed to three different doses of the chemical mixtures. The peak values of DNA adducts were observed after 24 h, and the highest levels of PAH-DNA adducts were exhibited in mice administered NF + BaP, and the highest tumor incidence and mortality were also observed in this group. DNA adduct levels after 1, 7, or 21 days were significantly correlated with animal mortality and incidence of total tumors including liver, lung, and forestomach. However, only hepatic DNA adducts after 7 days significantly correlated with liver tumor incidence. Most proteins involved in DNA repair including ATM, pATR, Chk1, pChk1, DNA PKcs, XRCC1, FANCD2, Ku80, Mre11, and Brca2 were significantly lower in liver tumor tissue compared to non-tumor tissue. Expressions of proteins involved in apoptosis and cell cycle regulation were also significantly different in tumor versus non-tumor tissues, and it is possible that PAH-induced changes in these gene products are important for tumor development and growth.

Role of retinoic acid in the modulation of benzo(a)pyrene-DNA adducts in human hepatoma cells: implications for cancer prevention.

Carcinogen-DNA adducts could lead to mutations in critical genes, eventually resulting in cancer. Many studies have shown that retinoic acid (RA) plays an important role in inducing cell apoptosis. Here we have tested the hypothesis that levels of carcinogen-DNA adducts can be diminished by DNA repair and/or by eliminating damaged cells through apoptosis. Our results showed that the levels of total DNA adducts in HepG2 cells treated with benzo(a)pyrene (BP, 2 µM)+RA (1 µM) were significantly reduced compared to those treated with BP only (P=0.038). In order to understand the mechanism of attenuation of DNA adducts, further experiments were performed. Cells were treated with BP (4 µM) for 24h to initiate DNA adduct formation, following which the medium containing BP was removed, and fresh medium containing 1 µM RA was added. The cells were harvested 24h after RA treatment. Interestingly, the levels of total DNA adducts were lower in the BP/RA group (390 ± 34) than those in the BP/DMSO group (544 ± 33), P=0.032. Analysis of cell apoptosis showed an increase in BP+RA group, compared to BP or RA only groups. Our results also indicated that attenuation of BP-DNA adducts by RA was not primarily due to its effects on CYP1A1 expression. In conclusion, our results suggest a mechanistic link between cellular apoptosis and DNA adduct formation, phenomena that play important roles in BP-mediated carcinogenesis. Furthermore, these results help understand the mechanisms of carcinogenesis, especially in relation to the chemopreventive properties of nutritional apoptosis inducers.

Prevention of zearalenone-induced hyperestrogenism in prepubertal mice.

Previous methods for the control of zearalenone (ZEN)-induced hyperestrogenism in animals have proven largely ineffective. The main objective in this study was to identify an enterosorbent that decreases the dietary bioavailability, and subsequent estrogenic effects, of ZEN. Initial in vitro screenings in aqueous solution (4 microg ZEN/ml) indicated that an activated carbon (AC) was the most efficient sorbent (99%), followed by a combination of 2 parts AC plus 3 parts HEC (hectorite) (69%), cetylpyridinium-exchanged low-pH montmorillonite (CP-LPHM) clay (58%), hexadecyltrimethylammonium-exchanged low-pH montmorillonite (HDTMA-LPHM) clay (54%), and HEC alone (28%). Results from the adult hydra bioassay suggested that the addition of either AC or HEC effectively decreased the effects of ZEN on Hydra attenuata without toxicity, as was observed with the use of either CP-LPHM or HDTMA-LPHM. Based on these results, AC, HEC, and 2AC:3HEC were evaluated in prepubertal mice. At a dietary inclusion level of 0.8% (w/w), AC alone significantly protected mice against the estrogenic effects induced by 35 mg ZEN/kg feed. Inclusion of 1.2% HEC with the 0.8% AC showed no additional protection; whereas 1.2% HEC alone failed to decrease the estrogenic effects. Ground flaxseed (25% w/w) in the diet also elicited protection, but to a lesser extent. Preliminary studies suggested that three similar carbons failed to decrease ZEN bioavailability. These findings suggest that the AC used in this study may be efficacious as an enterosorbent in animals consuming ZEN-contaminated diets. However, further studies are needed to evaluate the binding specificity, as well as the safety of chronic exposure.