Pilot evaluation of a Psychological First Aid online training for COVID-19 frontline workers in American Indian/Alaska Native communities.

Introduction: The COVID-19 pandemic exacerbated mental health concerns and stress among American Indians and Alaska Natives (AI/ANs) in the United States, as well as among frontline workers responding to the pandemic. Psychological First Aid (PFA) is a promising intervention to support mental wellbeing and coping skills during and after traumatic events, such as the COVID-19 pandemic. Since PFA is often implemented rapidly in the wake of a disaster or traumatic event, evidence evaluating its impact is lacking. This paper reports pilot evaluation results from a culturally adapted PFA training designed to support COVID-19 frontline workers and the AI/AN communities they serve during the pandemic. Methods: This study was designed and implemented in partnership with a collaborative work group of public health experts and frontline workers in AI/AN communities. We conducted a pre-post, online pilot evaluation of a culturally adapted online PFA training with COVID-19 frontline workers serving AI/AN communities. Participants completed a baseline survey and two follow-up surveys 1 week and 3 months after completing the PFA training. Surveys included demographic questions and measures of anxiety, burnout, stress, positive mental health, communal mastery, coping skills, PFA knowledge, confidence in PFA skills, and satisfaction with the PFA training. Results: Participants included N = 56 COVID-19 frontline workers in AI/AN communities, 75% were AI/AN, 87% were female, and most (82%) were between the ages of 30-59. Participants reported high satisfaction with the training and knowledge of PFA skills. Pilot results showed significant increases in positive mental health and social wellbeing and reductions in burnout from baseline to 3 months after completing the PFA training among frontline workers. There were no changes in communal mastery, coping skills, stress, or anxiety symptoms during the study period. Discussion: To our knowledge, this is the first pilot evaluation of a PFA training designed and culturally adapted with and for AI/AN communities. Given that many AI/AN communities were disproportionately impacted by COVID-19 and prior mental health inequities, addressing acute and chronic stress is of crucial importance. Addressing traumatic stress through culturally adapted interventions, including Indigenous PFA, is crucial to advancing holistic wellbeing for AI/AN communities.

Equitable Care for Hypertension: Blood Pressure and Patient-Reported Outcomes of the RICH LIFE Cluster Randomized Trial.

BACKGROUND: Disparities in hypertension control are well documented but underaddressed. METHODS: RICH LIFE (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) was a 2-arm, cluster randomized trial comparing the effect on blood pressure (BP) control (systolic BP ≤140 mm Hg, diastolic BP ≤90 mm Hg), patient activation, and disparities in BP control of 2 multilevel interventions, standard of care plus (SCP) and collaborative care/stepped care (CC/SC). SCP included BP measurement standardization, audit and feedback, and equity-leadership training. CC/SC added roles to address social or medical needs. Primary outcomes were BP control and patient activation at 12 months. Generalized estimating equations and mixed-effects regression models with fixed effects of time, intervention, and their interaction compared change in outcomes at 12 months from baseline. RESULTS: A total of 1820 adults with uncontrolled BP and ≥1 other risk factors enrolled in the study. Their mean age was 60.3 years, and baseline BP was 152.3/85.5 mm Hg; 59.4% were women; 57.4% were Black, 33.2% were White, and 9.4% were Hispanic; 74% had hyperlipidemia; and 45.1% had type 2 diabetes. CC/SC did not improve BP control rates more than SCP. Both groups achieved statistically and clinically significant BP control rates at 12 months (CC/SC: 57.3% [95% CI, 52.7%-62.0%]; SCP: 56.7% [95% CI, 51.9%-61.5%]). Pairwise comparisons between racial and ethnic groups showed overall no significant differences in BP control at 12 months. Patients with coronary heart disease showed greater achievement of BP control in CC/SC than in SCP (64.0% [95% CI, 54.1%-73.9%] versus 50.8% [95% CI, 42.6%-59.0%]; P=0.04), as did patients in rural areas (67.3% [95% CI, 49.8%-84.8%] versus 47.8% [95% CI, 32.4%-63.2%]; P=0.01). Individuals in both arms experienced statistically and clinically significant reductions in mean systolic BP (CC/SC: -13.8 mm Hg [95% CI, -15.2 to -12.5]; SCP: -14.6 mm Hg [95% CI, -15.9 to -13.2]) and diastolic BP (CC/SC: -6.9 mm Hg [95% CI, -7.8 to -6.1]; SCP: -5.5 mm Hg [95% CI, -6.4 to -4.6]) over time. The difference in diastolic BP reduction between CC/SC and SCP over time was statistically significant (-1.4 mm Hg [95% CI, -2.6 to -0.2). Patient activation did not differ between arms. CC/SC showed greater improvements in patient ratings of chronic illness care (Patient Assessment of Chronic Illness Care score) over 12 months (0.12 [95% CI, 0.02-0.22]). CONCLUSIONS: Adding a collaborative care team to enhanced standard of care did not improve BP control but did improve patient ratings of chronic illness care.

A Pandemic of Misinformation: Understanding Influences on Beliefs in Health and Conspiracy Myths.

BACKGROUND: Personal characteristics may be associated with believing misinformation and not believing in best practices to protect oneself from COVID-19. OBJECTIVE: To examine the associations of a person's age, race/ethnicity, education, residence, health literacy, medical mistrust level, and sources of health-related information with their COVID-19 health and conspiracy myth beliefs. DESIGN: We surveyed adults with hypertension in Maryland and Pennsylvania between August 2020 and March 2021. Incorrect responses were summed for eight health (mean = 0.68; range 0-5) and two conspiracy (mean = 0.92; range 0-2) COVID-19 questions. Higher scores indicated more incorrect responses. Statistical analyses included two-sample t-tests, Spearman's correlation, and log binomial regression. PARTICIPANTS: In total, 561 primary care patients (mean age = 62.3 years, 60.2% female, 46.0% Black, 10.2% Hispanic, 28.2% with a Bachelor's degree or higher, 42.8% with annual household income less than $60,000) with a diagnosis of hypertension and at least one of five commonly associated conditions. MAIN MEASURES: Sociodemographic characteristics, health literacy, medical mistrust level, source of health-related information, and COVID-19 conspiracy and health myth beliefs. KEY RESULTS: In multivariable analyses, participants who did not get information from medical professional sources (prevalence ratio (PR) = 1.28; 95% CI = 1.06-1.55), had less than a bachelor's degree (PR = 1.49; 95% CI = 1.12-1.99), were less confident filling out medical forms (PR = 1.24; 95% CI = 1.02-1.50), and had higher medical mistrust (PR = 1.34; 95% CI = 1.05-1.69) were more likely to believe any health myths. Participants who had less than a bachelor's degree (PR = 1.22; 95% CI = 1.02-1.45), were less confident filling out medical forms (PR = 1.21; 95% CI = 1.09-1.34), and had higher medical mistrust (PR = 1.72; 95% CI = 1.43-2.06) were more likely to believe any conspiracy myths. CONCLUSIONS: Lower educational attainment and health literacy, greater medical mistrust, and certain sources of health information are associated with misinformed COVID-19 beliefs. Programs addressing misinformation should focus on groups affected by these social determinants of health by encouraging reliance on scientific sources.

Evaluating Effects of Multilevel Interventions on Disparity in Health and Healthcare Decisions.

In this paper, we introduce an analytic approach for assessing effects of multilevel interventions on disparity in health outcomes and health-related decision outcomes (i.e., a treatment decision made by a healthcare provider). We outline common challenges that are encountered in interventional health disparity research, including issues of effect scale and interpretation, choice of covariates for adjustment and its impact on effect magnitude, and the methodological challenges involved with studying decision-based outcomes. To address these challenges, we introduce total effects of interventions on disparity for the entire sample and the treated sample, and corresponding direct effects that are relevant for decision-based outcomes. We provide weighting and g-computation estimators in the presence of study attrition and sketch a simulation-based procedure for sample size determinations based on precision (e.g., confidence interval width). We validate our proposed methods through a brief simulation study and apply our approach to evaluate the RICH LIFE intervention, a multilevel healthcare intervention designed to reduce racial and ethnic disparities in hypertension control.

Effect of Race and Insurance Status on Treatment and Outcomes in Diabetic Retinopathy: Analysis of 43 274 Eyes Using the IRIS Registry.

Purpose: To examine disparities in visual acuity (VA) outcomes 1 year and 2 years after initiation of diabetic retinopathy (DR) or diabetic macular edema (DME) treatment in patients based on race/ethnicity and insurance status, accounting for disease severity. Methods: This retrospective analysis used the IRIS Registry and included DR patients older than 18 years with documented antivascular endothelial growth factor (anti-VEGF) treatment and VA data for at least 2 years. International Classification of Diseases, Tenth Revision, Clinical Modification codes were used to determine the severity of DR and DME presence. VA outcomes were assessed using multivariable linear regressions and anti-VEGF drug use by multivariable logistic regressions, with race and insurance status as independent variables. Main outcome measures comprised the mean VA change at 1 year and 2 years and percentage of patients treated with bevacizumab. Results: The study included 43 274 eyes. White patients presented with a higher mean VA and lower mean DR severity than Black patients and Hispanic patients. Multivariable logistic regression showed Hispanic patients were significantly more likely to be treated with bevacizumab than White patients across all insurance types, controlling for disease severity and VA. After 1 year, the letter improvement was 1.73, 1.33, and 1.13 in White patients, Black patients, and Hispanic patients, respectively. Multivariable linear regression suggested that across races, Medicaid-insured patients had significantly smaller gains in VA than privately insured patients. Conclusions: Race-based and insurance-based differences in 1-year and 2-year outcomes after anti-VEGF treatment for DR and anti-VEGF treatment patterns suggest a need to ensure earlier and more effective treatment of minority and underserved patients in the United States.

Discrimination faced by radiology residents: an analysis of experiences and mitigation strategies.

RATIONALE AND OBJECTIVES: Literature shows that discrimination has been pervasive in the field of medicine. The aim of this study was to collect experiences related to discrimination among US radiology residents, including type and source, as well as the residents' perception on lectures about discrimination and harassment. We also explored the barriers to reporting, and suggested strategies to overcome them. MATERIAL AND METHODS: Following Institutional Review Board (IRB) approval, an online survey was sent to program directors and coordinators across the US, who were asked to forward the link to their radiology residents. A reminder email was sent over a period of 4 months. The participants were reassured the survey was confidential and anonymous. RESULTS: Among the respondents, the most reported types of discrimination were based in gender, race and nationality, the majority of which not being reported. The most common perpetrators were attending radiologists, co-residents, technologists, and patients. The main barriers for reporting were fear of retaliation, confidentiality concerns, and skepticism about a positive outcome. CONCLUSION: Our study examines some experiences of discrimination shared by residents during their training, with gender and race being the most common causes. This sheds light into a hidden and unspoken issue and highlights the need for more active discussions in radiology on microaggressions and implicit bias. Our data can guide future studies as well as residency programs to build effective strategies to address discrimination, aiming for sustainable changes.

Design and rationale of the cardiometabolic health program linked with community health workers and mobile health telemonitoring to reduce health disparities (LINKED-HEARTS) program.

BACKGROUND: Hypertension and diabetes are major risk factors for cardiovascular diseases, stroke, and chronic kidney disease (CKD). Disparities in hypertension control persist among Black and Hispanic adults and persons living in poverty in the United States. The "LINKED-HEARTS Program" (a Cardiometabolic Health Program LINKED with Community Health WorkErs and Mobile HeAlth TelemonitoRing To reduce Health DisparitieS"), is a multi-level intervention that includes home blood pressure (BP) monitoring (HBPM), blood glucose telemonitoring, and team-based care. This study aims to examine the effect of the LINKED-HEARTS Program intervention in improving BP control compared to enhanced usual care (EUC) and to evaluate the reach, adoption, sustainability, and cost-effectiveness of the program. METHODS: Using a hybrid type I effectiveness-implementation design, 428 adults with uncontrolled hypertension (systolic BP ≥ 140 mm Hg) and diabetes or CKD will be recruited from 18 primary care practices, including community health centers, in Maryland. Using a cluster-randomized trial design, practices are randomly assigned to the LINKED-HEARTS intervention arm or EUC arm. Participants in the LINKED-HEARTS intervention arm receive training on HBPM, BP and glucose telemonitoring, and community health worker and pharmacist telehealth visits on lifestyle modification and medication management over 12 months. The primary outcome is the proportion of participants with controlled BP (<140/90 mm Hg) at 12 months. CONCLUSIONS: The study tests a multi-level intervention to control multiple chronic diseases. Findings from the study may be leveraged to reduce disparities in the management and control of chronic diseases and make primary care more responsive to the needs of underserved populations. TRIAL REGISTRATION: ClinicalTrials.gov. Identifier: NCT05321368.