Short messaging service (SMS) texting for uncontrolled diabetes among persons experiencing homelessness: Study protocol for a randomized trial.

BACKGROUND: Diabetes mellitus (DM) is common among persons experiencing homelessness (PEH), often inadequately managed, and carries significant costs. mHealth strategies including short messaging service (SMS) texting have been feasible and acceptable, and improved control of chronic diseases including DM. SMS strategies for DM have not been tested among PEH despite the accessibility of mobile phones. We propose an SMS strategy could offer better communication, education, and information management; improve outreach; facilitate care coordination; explore barriers to care; and support behavior changes. METHODS AND ANALYSIS: This mixed-methods (RCT and qualitative) study will be implemented in shelter-clinics in New York City in collaboration with community organizations, allowing for sustainability and scalability. Aim 1 will evaluate the efficacy of a 6-month SMS program for DM management versus an attention control on changes in HbA1c and adherence to DM self-care activities, medications, and appointments at 9 months in adult PEH with uncontrolled DM (n = 100). Outcomes will be measured at 0, 3, 6, &9 months. AIM 2 will assess patients' and providers' attitudes, acceptability, and experience of the program through semi-structured interviews with PEH (n = 20) and providers (n = 10). DISCUSSION: DM is not well-addressed among PEH. SMS strategies for DM have never been tested in PEH despite evidence of their effectiveness and access to mobile phones among PEH. Results from this study will provide important empirical data to inform evidence-based strategies to avert personal suffering and significant costs. It will have broader policy implications in control of DM and other chronic diseases.

A Medical Student-Run Telehealth Primary Care Clinic During the COVID-19 Pandemic: Maintaining Care for the Underserved.

BACKGROUND: In this report, we outline our approach to implementing a hybrid in-person and virtual clinic model at a student-run free clinic (SRFC) during the COVID-19 pandemic. Individuals of low socioeconomic status (SES) are at an increased risk for COVID-19 infection and severe clinical outcomes. It is unclear if telehealth is a viable continuity of care enabler for the underserved. METHODS: The Weill Cornell Community Clinic (WCCC) implemented a novel telehealth clinic model to serve uninsured patients in May 2020. A phone survey of was conducted to assess WCCC patients access to technology needed for telehealth visits (eg, personal computers, smartphones). Patient no-show rates were retrospectively assessed for both in-person (pre-pandemic) and hybrid continuity of care models. RESULTS: The phone survey found that 90% of WCCC patients had access to technology needed for telehealth visits. In the 8 months following implementation of the hybrid model, telehealth and in-person no-show rates were 11% (14/128) and 15% (10/67) respectively; the combined hybrid no-show rate was 12% (24/195). For comparison, the in-person 2019 no-show rate was 23% (84/367). This study aligns with previous reports that telehealth improves patient attendance. CONCLUSION: Literature on the transition of SRFCs from in-person to telehealth care delivery models is limited. At the WCCC, the reduction in no-show rates supports the feasibility and benefits of adopting telehealth for the delivery of care to underserved patient populations. We believe the hybrid telehealth model described here is a viable model for other student run free clinics to increase access to care in low SES communities.

Diabetes care and its predictors among persons experiencing homelessness compared with domiciled adults with diabetes in New York City; An observational study.

Background: There is a dearth of data regarding diabetes control among patients experiencing homelessness. Methods: We retrospectively collected type 2 diabetes-related measurements, sociodemographic, and clinical indicators from medical records of all incoming adults with diabetes (n = 418; homeless: 356 and domiciled: 58) seen in shelter-clinics in New York City in 2019. The outcomes were the rates of inadequately managed diabetes and associated factors. Findings: Bivariate analysis showed that patients experiencing homelessness (63% Black; 32% Hispanic) 134/304 (43⋅9%) were more likely than domiciled patients 13/57 (22·8%) to have inadequately managed diabetes (OR 2⋅67, CI 1·38-5·16, p = 0⋅003). The average HbA1c among homeless (8·4%, SD± 2·6) was higher than that of domiciled persons (7·3%, SD± 1·8, p = 0·002). In logistic regression, domiciled status (OR 0⋅ 42, CI 0·21 - 0·84, p = 0·013), older age (OR 0·97, CI 0·95 - 0·99, p = 0·004), and non-Hispanic/Latino ethnicity were associated with well-managed diabetes. Among persons experiencing homelessness, non-Hispanic/Latino (OR 0·61, CI 0·37-0·99, p = 0·047) and older age (0·96, CI 0·94-0·99, p = 0·003) were associated with well-managed diabetes. In linear regression, mental illness (-0·11, p = 0·048) and older age (-0·15, p = 0·010) were associated with lower HbA1c, suggesting better support in respective shelters. There was no statistically significant association between inadequately managed diabetes with several traditional risk factors including substance or alcohol use disorder, health insurance, or other chronic diseases. Interpretation: Interventions at shelters or shelter-clinics should target subgroups in addition to addressing traditional risk factors to improve diabetes control. mHealth strategies could be considered to improve engagement, care delivery, and medication taking. Ultimately, homelessness itself needs to be addressed. Funding: There are no funding sources to declare.

Comparative assessment of test characteristics of cervical cancer screening methods for implementation in low-resource settings.

Cervical cancer disproportionately affects low-resource settings. Papanicolaou, human papillomavirus (HPV), and visual inspection of cervix with acetic acid (VIA) testing, each with different characteristics, will reduce cervical cancer burden. We conducted a critical literature review using PubMed, Cochrane, WHO, and grey literature from 1994 to 2020. We examined efficacy, harms, and comparative effectiveness of screening methods by age, human immunodeficiency virus, provider characteristics, and assessed implementation challenges in low-resource settings. Comprehensive data on utility and efficacy of screening tests indicates that each screening has strengths and shortcomings but all confer acceptable performance. HPV and VIA appear more promising. Primary HPV test-and-treat, self-testing, and co-testing have been studied but data on triage plans, cost, support system, implementation and sustainability is unclear in low-resource settings. HPV testing could help target subgroups of older or higher risk women. VIA offers local capacity-building and scalability. Quality VIA technique after HPV testing is still required to guide post-screening treatments. VIA competencies decline gradually with current standard trainings. Stationary cervicography improves VIA quality but isn't scalable. Affordable smartphones eliminate this barrier, enhance training through mentorship, and advance continuing education and peer-to-peer training. Smartphone-based VIA facilitates cervical image storage for patient education, health promotion, record-keeping, follow-up care, remote expert support, and quality control to improve VIA reliability and reproducibility and reduce mis-diagnoses and burden to health systems. Rather than ranking screening methods using test characteristics alone in study or higher-resource settings, we advocate for scalable strategies that maximize reliability and access and reduce cost and human resources.

Evaluating smartphone strategies for reliability, reproducibility, and quality of VIA for cervical cancer screening in the Shiselweni region of Eswatini: A cohort study.

BACKGROUND: Cervical cancer is among the most common preventable cancers with the highest morbidity and mortality. The World Health Organization (WHO) recommends visual inspection of the cervix with acetic acid (VIA) as cervical cancer screening strategy in resource-poor settings. However, there are barriers to the sustainability of VIA programs including declining providers' VIA competence without mentorship and quality assurances and challenges of integration into primary healthcare. This study seeks to evaluate the impact of smartphone-based strategies in improving reliability, reproducibility, and quality of VIA in humanitarian settings. METHODS AND FINDINGS: We implemented smartphone-based VIA that included standard VIA training, adapted refresher, and 6-month mHealth mentorship, sequentially, in the rural Shiselweni region of Eswatini. A remote expert reviewer provided diagnostic and management feedback on patients' cervical images, which were reviewed weekly by nurses. Program's outcomes, VIA image agreement rates, and Kappa statistic were compared before, during, and after training. From September 1, 2016 to December 31, 2018, 4,247 patients underwent screening; 247 were reviewed weekly by a VIA diagnostic expert. Of the 247, 128 (49%) were HIV-positive; mean age was 30.80 years (standard deviation [SD]: 7.74 years). Initial VIA positivity of 16% (436/2,637) after standard training gradually increased to 25.1% (293/1,168), dropped to an average of 9.7% (143/1,469) with a lowest of 7% (20/284) after refresher in 2017 (p = 0.001), increased again to an average of 9.6% (240/2,488) with a highest of 17% (17/100) before the start of mentorship, and dropped to an average of 8.3% (134/1,610) in 2018 with an average of 6.3% (37/591) after the start of mentorship (p = 0.019). Overall, 88% were eligible for and 68% received cryotherapy the same day: 10 cases were clinically suspicious for cancer; however, only 5 of those cases were confirmed using punch biopsy. Agreement rates with the expert reviewer for positive and negative cases were 100% (95% confidence interval [CI]: 79.4% to 100%) and 95.7% (95% CI: 92.2% to 97.9%), respectively, with negative predictive value (NPV) (100%), positive predictive value (PPV) (63.5%), and area under the curve of receiver operating characteristics (AUC ROC) (0.978). Kappa statistic was 0.74 (95% CI; 0.58 to 0.89); 0.64 and 0.79 at 3 and 6 months, respectively. In logistic regression, HIV and age were associated with VIA positivity (adjusted Odds Ratio [aOR]: 3.53, 95% CI: 1.10 to 11.29; p = 0.033 and aOR: 1.06, 95% CI: 1.0004 to 1.13; p = 0.048, respectively). We were unable to incorporate a control arm due to logistical constraints in routine humanitarian settings. CONCLUSIONS: Our findings suggest that smartphone mentorship provided experiential learning to improve nurses' competencies and VIA reliability and reproducibility, reduced false positive, and introduced peer-to-peer education and quality control services. Local collaboration; extending services to remote populations; decreasing unnecessary burden to screened women, providers, and tertiary centers; and capacity building through low-tech high-yield screening are promising strategies for scale-up of VIA programs.

Reimbursement Incentives to Improve Adherence to Follow-Up of Cervical Cancer Cytology Screening Results in Peru.

OBJECTIVE: The purpose of this study was to determine Peruvian women's attitudes toward novel reimbursement incentives used to improve adherence to obtaining cervical cytology test results. MATERIALS AND METHODS: Women presenting for cervical cancer screening in Peru completed a 34-item Investigational Review Board-approved questionnaire. The questionnaire determined their attitudes toward various reimbursement incentives to improve adherence to obtaining cervical cytology results. Descriptive statistics, generalized linear models, and Kruskal-Wallis tests were used in the analyses. RESULTS: Completed questionnaires were available for 997 women. Most women (51%) would be more likely to return for their Pap result if an incentive was provided, 79% (759/956) agreed that they would pay for the Pap test, and 51% (402/859) would be willing to pay 10 Soles or less. Quechua-speaking women considered follow-up more difficult (p < .0001) but were less likely to return for their Pap results (p < .0001), pay for the Pap test (p < .0001), and afford paying more than 5 Soles (p < .0001) than women who spoke Spanish or both languages. More women who earn 1000 Soles/year or less would likely return if incentivized (p < .0001), felt the incentive would help them remember to return (p = .0047), and would be willing to pay whether there was a rebate (p = .010) as compared with women earning more money. CONCLUSIONS: A reimbursement incentive program designed to improve follow-up of cervical cytology test results was acceptable to most Peruvian women. Such a behavioral-modifying program may improve patient follow-up after cervical cytology testing. Implementation may reduce the morbidity and mortality of cervical cancer in remote regions of the country.