Retention in care among vulnerable HIV-positive populations: the impact of socio-contextual factors

Thesis (Dr.P.H.)--Boston UniversityBackground: HIV is now manageable as a chronic disease for those who are adherent to medication and remain in care for life. However, remaining in care and achieving optimal health outcomes is challenging for many HIV-infected individuals. Examining the impact of socio-contextual factors may provide an opportunity to design interventions to improve retention in HIV care among vulnerable populations. Objectives: This study examines the relationship between retention in HIV care, social support, and stigma among two vulnerable populations of people living with HIV: racial ethnic/minorities and older Black women. Methods: I analyzed data collected from a multi-site study of six urban HIV clinics to quantitatively examine the relationship between social support, stigma, and age with retention in HIV care. I also conducted semi-structured qualitative interviews with 20 older Black women (age 50+) who were currently in care at Boston-area HIV clinics. The qualitative thematic analysis examined how the two primary domains, the role of stigma and the role of social support, were related to engagement and retention in care among the older Black women interviewed. Results: The multivariable results from the quantitative analysis showed that social support, stigma, and age were not significantly associated with retention in care. Among the older Black women I interviewed, those who did not receive social support or experienced ongoing stigma portrayed their social world as a source of potential distress that affected their ability to engage in care. However, women were able to engage in care if they could successfully limit their distress by disclosing their HIV status to someone and receiving social support. Conclusions: Despite the null results from the multivariable analysis, the qualitative findings highlight nuanced and important roles of stigma and social support among a particular vulnerable population. The negative consequences related to both stigma and low levels of social support, as revealed by the qualitative interviews, highlight their remaining importance among older HIV-infected Black women. Future research and interventions can focus on empowering patients to self-manage their HIV care as they age and reducing the effects of stigma and low social support to improve patient engagement in HIV care

The Economic Impact of Potential Closures of Rural Hospitals in Mississippi

Rural hospitals across the nation are facing a crisis due to ever-changing economic, policy, and population factors. To better understand how the present economic climate and policies are impacting rural hospitals in Mississippi, this report provides a comprehensive assessment of the: health and economic characteristics of hospitals and the communities they serve, factors that impact hospital viability, economic impacts of the “most at-risk” hospitals in Mississippi, and potential innovations and policy considerations to address the challenges facing rural Mississippi hospitals

Local IGFBP-3 mRNA expression, apoptosis and risk of colorectal adenomas

Abstract Background IGF binding protein-3 (IGFBP-3) regulates the bioavailability of insulin-like growth factors I and II, and has both anti-proliferative and pro-apoptotic properties. Elevated plasma IGFBP-3 has been associated with reduced risk of colorectal cancer (CRC), but the role of tissue IGFBP-3 is not well defined. We evaluated the association between tissue or plasma IGFBP-3 and risk of colorectal adenomas or low apoptosis. Methods Subjects were consenting patients who underwent a clinically indicated colonoscopy at UNC Hospitals and provided information on diet and lifestyle. IGFBP-3 mRNA in normal colon was assessed by real time RT-PCR. Plasma IGFBP-3 was measured by ELISA and apoptosis was determined by morphology on H & E slides. Logistic regression was used to compute odds ratio (OR) and 95% confidence intervals. Results We observed a modest correlation between plasma IGFBP-3 and tissue IGFBP-3 expression (p = 0.007). There was no significant association between plasma IGFBP-3 and adenomas or apoptosis. Tissue IGFBP-3 mRNA expression was significantly lower in cases than controls. Subjects in the lowest three quartiles of tissue IGFBP-3 gene expression were more likely to have adenomas. Consistent with previous reports, low apoptosis was significantly associated with increased risk of adenomas (p = 0.003). Surprisingly, local IGFBP-3 mRNA expression was inversely associated with apoptosis. Conclusion Low expression of IGFBP-3 mRNA in normal colonic mucosa predicts increased risk of adenomas. Our findings suggest that local IGFBP-3 in the colon may directly increase adenoma risk but IGFBP-3 may act through a pathway other than apoptosis to influence adenoma risk

Panel 5: Health

The Mississippi Delta is widely known for suffering from persistent problems related to poor health outcomes, such as obesity, cardiovascular disease, and infant mortality. However, these challenges have given rise to innovative approaches to improve health care and population health using community-based models. These include the once famous black-led Taborian Hospital, the Delta Health Center - the nation\u27s first rural federal community health center, and wrap around services, such as those provided through Aaron E. Henry\u27s Community Health Services Center. Additionally, unique partnerships have been developed, such as the Tallahatchie General Hospital Wellness Center which evolved through a community-based participatory research initiative. The panelists for this session have been deeply involved in building, evaluating, and advancing these alternative models, and they will reflect on their organizations, lessons learned, and their thoughts on what the future holds

Rural Hospitals: Economic and Health Implications in Mississippi

The healthcare delivery and financing systems in the United States are evolving rapidly, and the impact on small rural hospitals is made evident by increasingly common news of closures or employee layoffs. Since 2010, 58 rural hospitals have closed nationally, mostly in the South, including two in Mississippi. Another 283 hospitals nationwide have been identified as “vulnerable,” with 22 of those in Mississippi. As a percentage of all rural hospitals in the state, Mississippi has the highest proportion of its rural hospitals classified as “vulnerable.” The Center for Mississippi Health Policy commissioned a study by researchers from the Social Science Research Center (SSRC) at Mississippi State University to examine the economic impact of rural hospitals on Mississippi communities. The detailed SSRC Report and an Issue Brief summarizing the Report and outlining policy options are available for downloading from the links on the side bar to the left. SSRC identified nine “most at risk” hospitals around the state. The economic impact analysis determined that the closure of all nine “most at risk” hospitals would lead to a loss of an estimated 2,600 jobs, approximately $8.6 million in state and local tax revenue, and a total economic impact of$289.2 million. A variety of factors has made it increasingly more difficult for small rural hospitals to survive and thrive. Federal payment policies have been foundational to the financial status of these hospitals. Congress has taken several policy actions in the past that were designed to support small rural hospitals, but many of these provisions are scheduled to expire or have been targeted for change. Many hospitals have sought technical assistance in making operational improvements to assist in adapting to the changing environment, and some have demonstrated success in these efforts. Often the strategies employed are focused on increasing revenue to improve the hospital’s financial condition, which may or may not be consistent with meeting the key health care needs of the community. Better alignment of economic and health incentives would help hospitals adapt more effectively

Growth and persistence of place-based mortality in the United States: The rural mortality penalty

Objectives. To examine 47 years of US urban and rural mortality trends at the county level, controlling for effects of education, income, poverty, and race. Methods. We obtained (1) Centers for Disease Control and Prevention WONDER (Wide-ranging ONline Data for Epidemiologic Research) data (1970–2016) on 104 million deaths; (2) US Census data on education, poverty, and race; and (3) Bureau of Economic Analysis data on income. We calculated ordinary least square regression models, including interaction models, for each year. We graphed standardized parameter estimates for 47 years. Results. Rural–urban mortality disparities increased from the mid-1980s through 2016. We found education, race, and rurality to be strong predictors; we found strong interactions between percentage poverty and percentage rural, indicating that the largest penalty was in high-poverty, rural counties. Conclusions. The rural–urban mortality disparity was persistent, growing, and large when compared to other place-based disparities. The penalty had evolved into a high-poverty, rural penalty that rivaled the effects of education and exceeded the effects of race by 2016. Public Health Implications. Targeting public health programs that focus on high-poverty, rural locales is a promising strategy for addressing disparities in mortality

Local IGFBP-3 mRNA expression, apoptosis and risk of colorectal adenomas

<p>Abstract</p> <p>Background</p> <p>IGF binding protein-3 (IGFBP-3) regulates the bioavailability of insulin-like growth factors I and II, and has both anti-proliferative and pro-apoptotic properties. Elevated plasma IGFBP-3 has been associated with reduced risk of colorectal cancer (CRC), but the role of tissue IGFBP-3 is not well defined. We evaluated the association between tissue or plasma IGFBP-3 and risk of colorectal adenomas or low apoptosis.</p> <p>Methods</p> <p>Subjects were consenting patients who underwent a clinically indicated colonoscopy at UNC Hospitals and provided information on diet and lifestyle. IGFBP-3 mRNA in normal colon was assessed by real time RT-PCR. Plasma IGFBP-3 was measured by ELISA and apoptosis was determined by morphology on H & E slides. Logistic regression was used to compute odds ratio (OR) and 95% confidence intervals.</p> <p>Results</p> <p>We observed a modest correlation between plasma IGFBP-3 and tissue IGFBP-3 expression (p = 0.007). There was no significant association between plasma IGFBP-3 and adenomas or apoptosis. Tissue IGFBP-3 mRNA expression was significantly lower in cases than controls. Subjects in the lowest three quartiles of tissue IGFBP-3 gene expression were more likely to have adenomas. Consistent with previous reports, low apoptosis was significantly associated with increased risk of adenomas (p = 0.003). Surprisingly, local IGFBP-3 mRNA expression was inversely associated with apoptosis.</p> <p>Conclusion</p> <p>Low expression of IGFBP-3 mRNA in normal colonic mucosa predicts increased risk of adenomas. Our findings suggest that local IGFBP-3 in the colon may directly increase adenoma risk but IGFBP-3 may act through a pathway other than apoptosis to influence adenoma risk.</p

Genetic variants in IGF-I, IGF-II, IGFBP-3, and adiponectin genes and colon cancer risk in African Americans and Whites.

PURPOSE: Evaluating genetic susceptibility may clarify effects of known environmental factors and also identify individuals at high risk. We evaluated the association of four insulin-related pathway gene polymorphisms in insulin-like growth factor-1 (IGF-I) (CA)( n ) repeat, insulin-like growth factor-2 (IGF-II) (rs680), insulin-like growth factor-binding protein-3 (IGFBP-3) (rs2854744), and adiponectin (APM1 rs1501299) with colon cancer risk, as well as relationships with circulating IGF-I, IGF-II, IGFBP-3, and C-peptide in a population-based study. METHODS: Participants were African Americans (231 cases and 306 controls) and Whites (297 cases, 530 controls). Consenting subjects provided blood specimens and lifestyle/diet information. Genotyping for all genes except IGF-I was performed by the 5'-exonuclease (Taqman) assay. The IGF-I (CA)(n) repeat was assayed by PCR and fragment analysis. Circulating proteins were measured by enzyme immunoassays. Odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated by logistic regression. RESULTS: The IGF-I (CA)( 19 ) repeat was higher in White controls (50 %) than African American controls (31 %). Whites homozygous for the IGF-I (CA)(19) repeat had a nearly twofold increase in risk of colon cancer (OR = 1.77; 95 % CI = 1.15-2.73), but not African Americans (OR = 0.73, 95 % CI 0.50-1.51). We observed an inverse association between the IGF-II Apa1 A-variant and colon cancer risk (OR = 0.49, 95 % CI 0.28-0.88) in Whites only. Carrying the IGFBP-3 variant alleles was associated with lower IGFBP-3 protein levels, a difference most pronounced in Whites (p-trend <0.05). CONCLUSIONS: These results support an association between insulin pathway-related genes and elevated colon cancer risk in Whites but not in African Americans