Qualitative Evaluation of RADx-UP Projects Addressing COVID-19 Testing Disparities Among Underserved Populations.

In this article, we present findings from a May 2022 to March 2023 qualitative evaluation of Rapid Acceleration of Diagnostics-Underserved Populations (RADx-UP) projects addressing COVID-19 testing disparities among underserved populations. Interviews with academic and community partners from 13 RADx-UP projects revealed that despite the pandemic, projects were able to build trust and relationships with underserved populations. By prioritizing community voices during a public health emergency, RADx-UP projects improved health equity and pandemic preparedness in these communities, successfully conducted community-engaged research, and built long-lasting community partnerships. (Am J Public Health. Published online ahead of print March 28, 2024:e1-e6. https://doi.org/10.2105/AJPH.2024.307632).

Benefits, Challenges, and Opportunities in Addressing Medicaid Beneficiaries' Non-Medical Risks to Health: A Qualitative Analysis.

CONTEXT: North Carolina's Healthy Opportunities Pilots (HOP) is a Medicaid 1115 Waiver program that seeks to address nonmedical risks to health for Medicaid beneficiaries through multisector collaboration. Among other stakeholders, HOP involves collaboration between human services organizations that deliver interventions, network leads, which establish and oversee the human services organizations within a region of the state. OBJECTIVE: To understand how employees at human services organizations and network leads prepared to deliver HOP services. DESIGN: Qualitative analysis of semistructured interviews. Interviews were conducted between April and June 2022. Interviews were recorded, transcribed verbatim, coded thematically, and analyzed using a conceptual model derived from the consolidated framework for implementation research. SETTING: Organizations within North Carolina counties participating in HOP. PARTICIPANTS: Employees of human services and network lead organizations across all 3 HOP regions of North Carolina. RESULTS: The researchers interviewed 37 participants. Overall, organizations experienced benefits from HOP participation, including capacity-building resources, flexibility in allocating resources, and creating community-wide enthusiasm for addressing nonmedical risks to health. There were also key challenges. These included the time needed to build capacity, adjustments to the work processes and regulations inherent to multisector collaboration, geographic variation in availability of services to offer, and the difficulty of addressing different needs. Finally, participants recognized substantial opportunities that HOP presented, including membership in a more extensive network, exposure to a learning community, and a more sustainable funding source. CONCLUSIONS: The perspectives of individuals preparing to deliver HOP services offer important lessons for those developing and implementing large-scale programs that can address nonmedical threats to health.

Racial disparities in stroke incidence in the Women's Health Initiative: Exploring biological, behavioral, psychosocial, and social risk factors.

Background: - Disparities in incident stroke risk among women by race and ethnicity persist. Few studies report the distribution and association of stroke risk factors by age group among a diverse sample of women. Methods: - Data from the Women's Health Initiative (WHI) Observational Study collected between 1993 and 2010 were used to calculate cumulative stroke incidence and incidence rates among non-Hispanic African American (NHAA), non-Hispanic white (NHW), and Hispanic white or African American (HWAA) women by age group in participants aged ≥50 years at baseline (N = 77,247). Hazard ratios (HRs) and 95% CIs for biological, behavioral, psychosocial, and socioeconomic factors overall and by race or ethnicity were estimated using sequential Cox proportional hazard regression models. Results: - Average follow-up time was 11.52 (SD, 3.48) years. The incident stroke rate was higher among NHAA (306 per 100,000 person-years) compared to NHW (279/100,000py) and HWAA women (147/100,000py) overall and in each age group. The disparity was largest at ages >75 years. The association between stroke risk factors (e.g., smoking, BMI, physical activity) and incident stroke varied across race and ethnicity groups. Higher social support was significantly associated with decreased stroke risk overall (HR:0.84, 95% CI, 0.76, 0.93); the degree of protection varied across race and ethnicity groups. Socioeconomic factors did not contribute additional stroke risk beyond risk conferred by traditional and psychosocial factors. Conclusions: - The distribution and association of stroke risk factors differed between NHAA and NHW women. There is a clear need for stroke prevention strategies that address factors driving racial disparities in stroke risk.

Health Care Access and Cognitive Function in Older Adults: A Cross-Lagged Panel Longitudinal Analysis.

Objective: The current longitudinal study examined how (1) cognitive measures, including episodic memory, executive function, and global cognition, predict later healthcare access and how (2) healthcare access predicts later cognition. Methods: Drawing a sample (n = 9920) from the Health and Retirement Study dataset, we created a cross-lagged panel model to examine the longitudinal association between cognitive measures and healthcare access from 2012 to 2018. Results: Results revealed that cognitive measures significantly predict later healthcare access, with effects increasing across waves. However, within sub-domains, memory was more predictive of later healthcare access over time compared to executive function. Discussions: Our study suggested an increased link between cognition and healthcare access during aging. Even outside of the context of AD, there are likely both policy-based and practical implications to ensure those experiencing cognitive decline continue to maintain access to care.

Translation in action: Influence, collaboration, and evolution of COVID-19 research with Clinical and Translational Science Awards consortium support.

The National Institutes of Health (NIH)'s Clinical and Translational Science Awards (CTSA) consortium aims to accelerate translational processes that move discoveries from bench to bedside. The coronavirus disease 2019 (COVID-19) pandemic presented unmatched challenges and applications for CTSA hubs nationwide. Our study used bibliometrics to assess features of COVID-19 publications supported by the national CTSA program to characterize the consortium's response to the pandemic. Our goal was to understand relative scientific influence, collaboration across hubs, and trends in research emphasis over time. We identified publications from NIH's curated iSearch COVID-19 Publication Portfolio from February 2020 to February 2023; 3234 peer-reviewed articles relevant to COVID-19 cited a CTSA grant. All 66 CTSA hubs were represented, with large-size and longstanding hubs contributing more publications. Most publications cited UL1 grants, 457 cited KL2/TL1 training grants, and 164 cited multiple hub grants. Compared to a random sample of non-CTSA-supported COVID-19 publications, the CTSA portfolio exhibited greater clinical relevance, more human research, and higher altmetric and citation influence. Results were similar for multi-hub publications involving networked initiatives like multi-site clinical trials or the National COVID-19 Cohort Collaborative. Shifts from molecular/cellular-oriented research toward human-oriented research over time were evident, demonstrating translation in action. Results illuminate how the CTSA consortium confronted the pandemic through high-quality projects oriented toward human research, working across hubs on high-value collaborations, advancing along the translational spectrum over time. Findings validate CTSA hubs as critical support structures during health emergencies.

Exploring barriers and facilitators of implementing an at-home SARS-CoV-2 antigen self-testing intervention: The Rapid Acceleration of Diagnostics-Underserved Populations (RADx-UP) initiatives.

BACKGROUND: Evaluating community-based programs provides value to researchers, funding entities, and community stakeholders involved in program implementation, and can increase program impact and sustainability. To understand factors related to program implementation, we aimed to capture the perspective of community partners engaged in organizing and executing community-engaged programs to distribute COVID-19 at-home tests in underserved communities. METHODS: We conducted semi-structured interviews and focus groups with community-based stakeholders informed by the Outcomes for Implementation Research framework. RESULTS: Findings describe how community-engaged communication and dissemination strategies drove program adoption among grassroots stakeholders. Establishing and sustaining trusted relationships was vital to engaging partners with aligned values and capacity. Respondents characterized the programs as generally feasible and appropriate, and community partners felt capable of delivering the program successfully. However, they also described an increased burden on their workforce and desired more significant support. Respondents recognized the programs' community engagement practices as a critical facilitator of acceptability and impact. DISCUSSION: Implementation evaluation aims to inform current and future community outreach and engagement efforts with best practices. As we continue to inform and advance community-engaged disaster response practice, a parallel reimagining of public health funding mechanisms and timelines could provide a foundation for trust, collaboration, and community resiliency that endures beyond a given crisis.

Evaluating Leadership Development Competencies of Clinicians to Build Health Equity in America.

INTRODUCTION: To achieve more equitable health, health care must be grounded in an understanding of social determinants of health. Clinicians need hands-on, equity-centered training in interdisciplinary settings where they can further develop leadership skills and apply learnings in real-time. The Clinical Scholars program trained five cohorts of health care professionals in 25 leadership development competencies to contribute toward advancing health equity within the organizations and communities where they work. This study describes the self-reported ratings of three dimensions of competencies within four domains. METHODS: Data from 169 Fellows were collected at three time-points during the three-year training program using Qualtrics and Research Electronic Data Captrue software. Analysis was conducted in R and included descriptive statistics, fitting a linear mixed-effects model using random intercepts, and paired-sample t tests to assess significance between baseline and endpoint ratings. RESULTS: We found improved ratings over time for each of the three competency dimensions (knowledge, self-efficacy, use) and significant differences in ratings from baseline to endpoint, by domain (personal, interpersonal, organizational, community, and systems). DISCUSSION: These findings support the effectiveness of an equity-centered leadership development curriculum in training health care professionals to address health challenges in their communities and organizations, thereby furthering the broader goal of achieving more equitable health for all.

A Systematic Review of Electronic Community Resource Referral Systems.

INTRODUCTION: Community Resource Referral Systems delivered electronically through healthcare information technology systems (e.g., electronic medical records) have become more common in efforts to address patients' unmet health-related social needs. Community Resource Referral System connects patients with social supports such as food assistance, utility support, transportation, and housing. This systematic review identifies barriers and facilitators that influence the Community Resource Referral System's implementation in the U.S. by identifying and synthesizing peer-reviewed literature over a 15-year period. METHODS: This systematic review was conducted following PRISMA guidelines. A search was conducted on five scientific databases to capture the literature published between January 2005 and December 2020. Data analysis was conducted from August 2021 to July 2022. RESULTS: This review includes 41 articles of the 2,473 initial search results. Included literature revealed that Community Resource Referral Systems functioned to address a variety of health-related social needs and were delivered in different ways. Integrating the Community Resource Referral Systems into clinic workflows, maintenance of community-based organization inventories, and strong partnerships between clinics and community-based organizations facilitated implementation. The sensitivity of health-related social needs, technical challenges, and associated costs presented as barriers. Overall, electronic medical records-integration and automation of the referral process was reported as advantageous for the stakeholders. DISCUSSION: This review provides information and guidance for healthcare administrators, clinicians, and researchers designing or implementing electronic Community Resource Referral Systems in the U.S. Future studies would benefit from stronger implementation science methodological approaches. Sustainable funding mechanisms for community-based organizations, clear stipulations regarding how healthcare funds can be spent on health-related social needs, and innovative governance structures that facilitate collaboration between clinics and community-based organizations are needed to promote the growth and sustainability of Community Resource Referral Systems in the U.S.

Potential gaps in income support policies for those in poor health: The case of the earned income tax credit-A cross sectional analysis.

Background: The federal Earned Income Tax Credit (EITC) is the primary income support program for low-income workers in the U.S., but its design may hinder its effectiveness when poor health limits, but does not preclude, work. Methods: Cross-sectional analysis of nationally-representative U.S. Census Current Population Survey (CPS) data covering 2019. Working-age adults eligible to receive federal EITC were included in this study. Poor health, as indicated by self-report of at least one problem with hearing, vision, cognitive function, mobility, dressing and bathing, or independence, was the exposure. The main outcome was federal EITC benefit category, categorized as no benefit, phase-in (income too low for the maximum benefit), plateau (maximum benefit), phase-out (income above threshold for maximum benefit), or earnings too high to receive any benefit. We estimated EITC benefit category probabilities by health status using multinomial logistic regression. We further examined whether other government benefits provided additional income support to those in poor health. Results: 41,659 participants (representing 87.1 million individuals) were included. 2,724 participants (representing 5.6 million individuals) reported poor health. In analyses standardized over age, gender, race, and ethnicity, those in poor health, compared with those not in poor health, were more likely to be in the no benefit (2.40% vs. 0.30%, risk difference 2.10 percentage points [95%CI 1.75 to 2.46 percentage points]), and phase-in (9.28% vs. 2.74%, risk difference 6.54 percentage points [95%CI 5.82 to 7.26 percentage points]) categories. Differences in resources by health status persisted even after accounting for other government benefits. Conclusions: EITC program design creates an important gap in income support for those for whom poor health limits work, which is not closed by other programs. Filling this gap is an important public health goal.

Adapting the Evidence Academy model for virtual stakeholder engagement in a national setting during the COVID-19 pandemic.

The COVID-19 pandemic raised the importance of adaptive capacity and preparedness when engaging historically marginalized populations in research and practice. The Rapid Acceleration of Diagnostics in Underserved Populations' COVID-19 Equity Evidence Academy Series (RADx-UP EA) is a virtual, national, interactive conference model designed to support and engage community-academic partnerships in a collaborative effort to improve practices that overcome disparities in SARS-CoV-2 testing and testing technologies. The RADx-UP EA promotes information sharing, critical reflection and discussion, and creation of translatable strategies for health equity. Staff and faculty from the RADx-UP Coordination and Data Collection Center developed three EA events with diverse geographic, racial, and ethnic representation of attendees from RADx-UP community-academic project teams: February 2021 (n = 319); November 2021 (n = 242); and September 2022 (n = 254). Each EA event included a data profile; 2-day, virtual event; event summary report; community dissemination product; and an evaluation strategy. Operational and translational delivery processes were iteratively adapted for each EA across one or more of five adaptive capacity domains: assets, knowledge and learning, social organization, flexibility, and innovation. The RADx-UP EA model can be generalized beyond RADx-UP and tailored by community and academic input to respond to local or national health emergencies.

Accelerating diversity, equity, and inclusion goals: a qualitative assessment from the lens of scientists at the 2020 Clinical Translational Science Awards Annual Meeting.

Participants in the leadership breakout session at the Clinical Translational Science Awards (CTSA) virtual 2020 conference discussed and ranked six recommendations in terms of feasibility, impact, and priority for advancing Diversity, Equity, and Inclusion (DEI) efforts to elevate underrepresented populations to leadership positions in CTSAs and their broader institutions. A thematic analysis of chat and polling data identified challenges and opportunities to achieve DEI goals, with the three most promising recommendations as: cross-institutional Principal Investigator (P.I.) action-learning workgroups, transparent policies for recruiting and promoting underrepresented minorities (URM) leadership, and a clear succession plan to nurture and elevate URM leaders. Suggestions are made to improve DEI in CTSA leadership and allow for greater representation in the translational science field.

Evaluating the impact of a CTSA program from 2008 to 2021 through bibliometrics, social network analysis, and altmetrics.

Introduction: We evaluate a CTSA program hub by applying bibliometrics, social network analysis (SNA), and altmetrics and examine the changes in research productivity, citation impact, research collaboration, and CTSA-supported research topics since our pilot study in 2017. Methods: The sampled data included North Carolina Translational and Clinical Science Institute (NC TraCS)-supported publications produced between September 2008 and March 2021. We applied measures and metrics from bibliometrics, SNA, and altmetrics to the dataset. In addition, we analyzed research topics and correlations between different metrics. Results: 1154 NC TraCS-supported publications generated over 53,560 citation counts by April 2021. The average cites per year and the relative citation ratio (RCR) mean of these publications improved from 33 and 2.26 in 2017 to 48 and 2.58 in 2021. The number of involved UNC units in the most published authors' collaboration network increased from 7 (2017) to 10 (2021). NC TraCS-supported co-authorship involved 61 NC organizations. PlumX metrics identified articles with the highest altmetrics scores. About 96% NC TraCS-supported publications have above the average SciVal Topic Prominence Percentile; the average approximate potential to translate of the included publication was 54.2%; and 177 publications addressed health disparity issues. Bibliometric measures (e.g., citation counts, RCR) and PlumX metrics (i.e., Citations, Captures, and Social-Media) are positively correlated (p < .05). Conclusion: Bibliometrics, SNA, and altmetrics offer distinctive but related perspectives to examine CTSA research performance and longitudinal growth, especially at the individual program hub level. These perspectives can help CTSAs build program foci.

Protocol for a study on Sitting with Interruption and Whole-Body Cardiovascular Health (SWITCH) in middle-aged adults.

BACKGROUND: Sedentary behavior (SB) is a biologically distinct yet understudied cardiovascular disease risk (CVD) factor. However, specific public health policy regarding the optimal strategy for SB interruption is unavailable. This paper outlines the protocol for part I of the Sitting with Interruption and Whole-Body Cardiovascular Health (SWITCH) study, including the rationale, objectives, methodology, and next steps. We additionally detail practical considerations that went into the development of the NIH R01 grant supporting this research. METHODS: Healthy men and women (n = 56, aged 36-55) who are inactive (<90 min/wk. of moderate-to-vigorous intensity physical activities for past 3 months) and sedentary (sitting for >8 h/day), will be recruited for this randomized crossover trial. Specifically, participants will complete the following 4-h conditions: (i) SB with once/h 5 min walk break; (ii) SB with once/h 15 min stand break; (iii) SB with twice/h breaks (alternating 5 min walk and 15 min stand); and (iv) SB with no breaks (i.e., control). Focus group discussions will refine our socioecological SB reduction model. RESULTS: The primary outcome will be change in aortic arterial stiffness (i.e., pulse wave velocity; PWV, m/s) for each substitution strategy relative to the control (SB with no breaks) condition. CONCLUSIONS: The outcomes from this study will facilitate the design of a subsequent randomized controlled trial to test a mechanism-informed, feasible SB-reduction intervention and support the development of SB policy.

Integrating special and underserved populations in translational research: Environmental scan of adaptive capacity and preparedness of Clinical and Translational Science Award (CTSA) program hubs.

The COVID-19 pandemic has exacerbated health disparities and rendered them acutely more visible. Special and underrepresented populations need to be fully integrated into the translational research process from the very beginning and all the way through. This article presents findings and rapid analysis mini-case studies from the Environmental Scan (E-Scan) of adaptive capacity and preparedness of Clinical and Translational Science Award hubs, specific to the goal of integrating special and vulnerable populations in different institutional research settings. In our discussion of the findings and case studies, we flexibly apply local adaptive capacity framework concepts and characteristics, and, whenever possible, we present ideas on how to enhance capacity in those areas, based on the challenges and practices identified through the E-Scan. Although the past year has recorded incredible achievements in vaccine development, clinical trials, diagnostics, and overall biomedical research, these successes continue to be hampered by our inability to turn them into achievements equally available and accessible to all populations.

Physicians' Perceptions of Race and Engagement in Race-Based Clinical Practice: a Mixed-Methods Systematic Review and Narrative Synthesis.

BACKGROUND: Using race-a socially assigned identity that does not adequately capture human genetic variation-to guide clinical care can result in poor outcomes for racially minoritized patients. This study assessed (1) how physicians conceptualize and use race in their clinical care (race-based care) and (2) physician characteristics associated with race-based care. METHODS: PubMed, CINAHL, EMBASE, and Scopus databases were searched. Qualitative, quantitative, and mixed-methods studies written in peer-reviewed, English-language journal articles evaluating US physicians' perceptions of race and physician factors associated with race-based care were included. Risk of bias was assessed using the Mixed Methods Appraisal Tool. Qualitative studies were evaluated using thematic analysis, and quantitative findings were summarized and combined with qualitative findings in a narrative synthesis. RESULTS: A total of 1149 articles were identified; 9 (4 qualitative, 5 quantitative) studies met inclusion criteria. Five themes emerged: (1) the belief in race as biological; (2) the use of race to contextualize patients' health; (3) the use of race to counsel patients and determine care; (4) justifications for race-based practice (evidence-based, personal experience, addresses disparities, provides personalized care, increases compliance); and (5) concerns with race-based practice (poorly characterizes patients, normalizes disparities, patient distrust, clinician discomfort, legitimized biological race). In quantitative studies, older age was positively associated with race-based care. DISCUSSION: Physicians had varied perceptions of race, but many believed race was biological. Concern and support for race-based practice were related to beliefs regarding the evidence for using race in care and the appropriateness of race as a variable in medical research. Older physicians were more likely to use race, which could be due to increased exposure to race-based medical literature, in addition to generational differences in conceptualizations of race. Additional research on the evolution of physicians' perceptions of race, and the role of medical literature in shaping these perceptions, is needed.

Using a most significant change approach to evaluate learner-centric outcomes of clinical scholars leadership training program.

BACKGROUND: Most significant change (MSC) analysis is an evaluative method used to supplement outcome and impact program evaluations. MSC stories provide mini-narratives contextualizing the effect a program had on an individual. The Clinical Scholars program evaluation team used MSC to explore learner-centric leadership outcomes of the Clinical Scholars leadership training program. PURPOSE OF THE RESEARCH: To identify thematic outcomes of trainees during the three years of their leadership training in the Clinical Scholars program. RESULTS: We identified three central thematic areas of most significant change: (1) leadership in practice, (2) self-awareness, and (3) equity, diversity, and inclusion. Other present themes included stakeholder engagement, effective leadership, collaboration, impact, expanded influence, innovation, networking, community engagement, evidence-based, implementation science, organizational development, hope, and advocating within organizations, teams, and the community. A total of 25 mid- and advanced-career level participants represented a diverse array of disciplines within the healthcare sector. CONCLUSIONS: MSC stories represented leaders' individual and team growth due to participating in the Clinical Scholars program. Results confirmed fidelity of program implementation to the original program goals, as outlined in the grant proposal. They highlighted three critical areas of development for this cohort of Fellows.