Providing Culturally Competent Care in the Face of Health Disparities: Assessment and Training Recommendations

Background: Community health centers are a critical source of care for populations who disproportionally experience health disparities, including the uninsured and underinsured, racial and ethnic minorities, and patients with a preferred language other than English. Optimus Health Care (Optimus) is the second largest health center in Connecticut, with clinics located in Bridgeport and Stamford. Cultural competency, or a set of behaviors, attitudes, and policies that enable professionals to work effectively in cross-cultural situations holds immense potential for improving patient-physician communication and for providing effective service delivery. Objectives: This study sought to (1) better understand the barriers to care faced among patients at Optimus (2) assess staff knowledge, attitudes, and skills regarding cultural competency to make recommendations regarding future cultural competency staff trainings. Methods: Electronic medical records (EMR) of patients seen at Optimus between January 2012 and March 2013 who had a diagnosis of hyperlipidemia, hypertension, and/or diabetes were analyzed to describe characteristics related to insurance status, race/ethnicity, primary language, age, gender, and clinic location. A web-based survey was developed based on the Cultural Competence Self-Assessment Questionnaire (CCSAQ) and distributed electronically to Optimus staff. Survey results were analyzed to compare responses according to staff position type and themes were examined among respondent assessments of the current cultural competency trainings provided by Optimus. Results: The majority of patients included in the EMR analysis receive Medicare or Medicaid (75.8%) and the majority of chronic conditions among the sample were among racial and ethnic minorities. Interestingly, the majority of Optimus patients with a diagnosis of diabetes, hypertension and/or hyperlipidemia were between the ages of 30-54. Cultural Competency survey respondents noted difficulties in providing care due to language barriers, limited knowledge of intra-cultural group differences, and limited knowledge of how the causes of mental health are viewed by different cultural groups (Survey response rate: 22.4%). When asked to critique Optimus’ current cultural competency training, staff members reported efficiency as a strength and lack of applicability to a practical setting as a weakness, emphasizing the need for an interactive training. Conclusions and Recommendations: In concordance with the national trend, the results of our study indicate that Optimus patients of racial and ethnic minorities are disproportionally affected by chronic illness. Several areas were identified that can be targeted for improving the cultural competency knowledge, practice and delivery, and training needs of Optimus staff. Future studies should assess patient perceptions of cultural competency to allow for further insight into this emerging area of research.https://elischolar.library.yale.edu/ysph_pbchrr/1041/thumbnail.jp

The Engaged University: Providing a Platform for Research That Transforms Society

Despite a growing recognition that the solutions to current environmental problems will be developed through collaborations between scientists and stakeholders, substantial challenges stifle such cooperation and slow the transfer of knowledge. Challenges occur at several levels, including individual, disciplinary, and institutional. All of these have implications for scholars working at academic and research institutions. Fortunately, creative ideas and tested models exist that provide opportunities for conversation and serious consideration about how such institutions can facilitate the dialogue between scientists and societ

A novel isolator-based system promotes viability of human embryos during laboratory processing

In vitro fertilisation (IVF) and related technologies are arguably the most challenging of all cell culture applications. The starting material is a single cell from which one aims to produce an embryo capable of establishing a pregnancy eventually leading to a live birth. Laboratory processing during IVF treatment requires open manipulations of gametes and embryos, which typically involves exposure to ambient conditions. To reduce the risk of cellular stress, we have developed a totally enclosed system of interlinked isolator-based workstations designed to maintain oocytes and embryos in a physiological environment throughout the IVF process. Comparison of clinical and laboratory data before and after the introduction of the new system revealed that significantly more embryos developed to the blastocyst stage in the enclosed isolator-based system compared with conventional open-fronted laminar flow hoods. Moreover, blastocysts produced in the isolator-based system contained significantly more cells and their development was accelerated. Consistent with this, the introduction of the enclosed system was accompanied by a significant increase in the clinical pregnancy rate and in the proportion of embryos implanting following transfer to the uterus. The data indicate that protection from ambient conditions promotes improved development of human embryos. Importantly, we found that it was entirely feasible to conduct all IVF-related procedures in the isolator-based workstations

Challenges and opportunities for implementing integrated mental health care: a district level situation analysis from five low- and middle-income countries.

BACKGROUND: Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care. METHODS: A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts. RESULTS: The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care. CONCLUSIONS: The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care

The investigation of health-related topics on TikTok: A descriptive study protocol

The social media application TikTok allows users to view and upload short-form videos. Recent evidence suggests it has significant potential for both industry and health promoters to influence public health behaviours. This protocol describes a standardised, replicable process for investigations that can be tailored to various areas of research interest, allowing comparison of content and features across public health topics. The first 50 appearing videos in each of five relevant hashtags are sampled for analysis. Utilising a codebook with detailed definitions, engagement metadata and content variables applicable to any content area is captured, including an assessment of the video’s overall sentiment (positive, negative, neutral). Additional specific coding variables can be developed to provide targeted information about videos posted within selected hashtags. A descriptive, cross-sectional content analysis is applied to the generic and specific data collected for a research topic area. This flexible protocol can be replicated for any health-related topic and may have a wider application on other platforms or to assess changes in content and sentiment over time. This protocol was developed by a collaborative team of child health and development researchers for application to a series of topics. Findings will be used to inform health promotion messaging and counter-advertising

Molecular Analysis of Precursor Lesions in Familial Pancreatic Cancer

PMCID: PMC3553106This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Evaluating the Quality of Research into a Single Prognostic Biomarker: A Systematic Review and Meta-analysis of 83 Studies of C-Reactive Protein in Stable Coronary Artery Disease

Background Systematic evaluations of the quality of research on a single prognostic biomarker are rare. We sought to evaluate the quality of prognostic research evidence for the association of C-reactive protein (CRP) with fatal and nonfatal events among patients with stable coronary disease. Methods and Findings We searched MEDLINE (1966 to 2009) and EMBASE (1980 to 2009) and selected prospective studies of patients with stable coronary disease, reporting a relative risk for the association of CRP with death and nonfatal cardiovascular events. We included 83 studies, reporting 61,684 patients and 6,485 outcome events. No study reported a prespecified statistical analysis protocol; only two studies reported the time elapsed (in months or years) between initial presentation of symptomatic coronary disease and inclusion in the study. Studies reported a median of seven items (of 17) from the REMARK reporting guidelines, with no evidence of change over time. The pooled relative risk for the top versus bottom third of CRP distribution was 1.97 (95% confidence interval [CI] 1.78–2.17), with substantial heterogeneity (I2 = 79.5). Only 13 studies adjusted for conventional risk factors (age, sex, smoking, obesity, diabetes, and low-density lipoprotein [LDL] cholesterol) and these had a relative risk of 1.65 (95% CI 1.39–1.96), I2 = 33.7. Studies reported ten different ways of comparing CRP values, with weaker relative risks for those based on continuous measures. Adjusting for publication bias (for which there was strong evidence, Egger's p<0.001) using a validated method reduced the relative risk to 1.19 (95% CI 1.13–1.25). Only two studies reported a measure of discrimination (c-statistic). In 20 studies the detection rate for subsequent events could be calculated and was 31% for a 10% false positive rate, and the calculated pooled c-statistic was 0.61 (0.57–0.66). Conclusion Multiple types of reporting bias, and publication bias, make the magnitude of any independent association between CRP and prognosis among patients with stable coronary disease sufficiently uncertain that no clinical practice recommendations can be made. Publication of prespecified statistical analytic protocols and prospective registration of studies, among other measures, might help improve the quality of prognostic biomarker research

Comparison of dot chromosome sequences from D. melanogaster and D. virilis reveals an enrichment of DNA transposon sequences in heterochromatic domains

BACKGROUND: Chromosome four of Drosophila melanogaster, known as the dot chromosome, is largely heterochromatic, as shown by immunofluorescent staining with antibodies to heterochromatin protein 1 (HP1) and histone H3K9me. In contrast, the absence of HP1 and H3K9me from the dot chromosome in D. virilis suggests that this region is euchromatic. D. virilis diverged from D. melanogaster 40 to 60 million years ago. RESULTS: Here we describe finished sequencing and analysis of 11 fosmids hybridizing to the dot chromosome of D. virilis (372,650 base-pairs) and seven fosmids from major euchromatic chromosome arms (273,110 base-pairs). Most genes from the dot chromosome of D. melanogaster remain on the dot chromosome in D. virilis, but many inversions have occurred. The dot chromosomes of both species are similar to the major chromosome arms in gene density and coding density, but the dot chromosome genes of both species have larger introns. The D. virilis dot chromosome fosmids have a high repeat density (22.8%), similar to homologous regions of D. melanogaster (26.5%). There are, however, major differences in the representation of repetitive elements. Remnants of DNA transposons make up only 6.3% of the D. virilis dot chromosome fosmids, but 18.4% of the homologous regions from D. melanogaster; DINE-1 and 1360 elements are particularly enriched in D. melanogaster. Euchromatic domains on the major chromosomes in both species have very few DNA transposons (less than 0.4 %). CONCLUSION: Combining these results with recent findings about RNAi, we suggest that specific repetitive elements, as well as density, play a role in determining higher-order chromatin packaging

The significance of the Van Nuys prognostic index in the management of ductal carcinoma in situ

<p>Abstract</p> <p>Background</p> <p>Debate regarding the benefit of radiotherapy after local excision of ductal carcinoma <it>in situ </it>(DCIS) continues. The Van Nuys Prognostic Index (VNPI) is thought to be a useful aid in deciding which patients are at increased risk of local recurrence and who may benefit from adjuvant radiotherapy (RT). Recently published interim data from the Sloane project has showed that the VNPI score did significantly affect the chances of getting planned radiotherapy in the UK, suggesting that British clinicians may already be using this scoring system to assist in decision making. This paper independently assesses the prognostic validity of the VNPI in a British population.</p> <p>Patients and methods</p> <p>A retrospective review was conducted of all patients (n = 215) who underwent breast conserving surgery for DCIS at a single institution between 1997 – 2006. No patients included in the study received additional radiotherapy or hormonal treatment. Kaplan Meier survival curves were calculated, to determine disease free survival, for the total sample and a series of univariate analyses were performed to examine the value of various prognostic factors including the VNPI. The log-rank test was used to determine statistical significance of differential survival rates. Multivariate Cox regression analysis was performed to analyze the significance of the individual components of the VNPI. All analyses were conducted using SPSS software, version 14.5.</p> <p>Results</p> <p>The mean follow-up period was 53 months (range 12–97, SD19.9). Ninety five tumours were high grade (44%) and 84 tumours exhibited comedo necrosis (39%). The closest mean initial excision margin was 2.4 mm (range 0–22 mm, standard deviation 2.8) and a total of 72 tumours (33%) underwent further re-excision. The observed and the actuarial 8 year disease-free survival rates in this study were 91% and 83% respectively. The VNPI score and the presence of comedo necrosis were the only statistically significant prognostic indicators (P < 0.05).</p> <p>Conclusion</p> <p>This follow-up study of 215 patients with DCIS treated with local excision and observation alone is one of the largest series in which rates of recurrence are unaffected by radiation therapy, hormone manipulation or chemotherapy. It has afforded us the opportunity to assess the prognostic impact of patient and tumour characteristics free of any potentially confounding treatment related influences. The results suggest that the VNPI can be used to identify a subset of patients who are at risk of local recurrence and who may potentially benefit from RT.</p