Ending "domestic helicopter research".

"Helicopter research" refers to a practice where researchers from wealthier countries conduct studies in lower-income countries with little involvement of local researchers or community members. This practice also occurs domestically. In this Commentary, we outline strategies to curb domestic helicopter research and to foster equity-centered collaborations.

Promoting Anti-Racism in Clinical Practice: Lessons Learned in the Process of Removing the Race Coefficient from the Estimated Glomerular Filtration Rate Algorithm.

Background: Promoting anti-racism in medicine entails naming racism as a contributor to health inequities and being intentional about changing race-based practices in health care. Unscientific assumptions about race have led to the proliferation of race-based coefficients in clinical algorithms. Identifying and eliminating this practice is a critical step to promoting anti-racism in health care. The New York City Department of Health and Mental Hygiene (NYC-DOHMH) formed the Coalition to End Racism in Clinical Algorithms (CERCA), a health system consortium charged with eliminating clinical practices and policies that perpetuate racism. Objective: This article describes the process by which an academic medical center guided by the NYC-DOHMH tackled race-based clinical algorithms. Methods: Multiple key interested parties representing department chairs, hospital leaders, researchers, legal experts, and clinical pathologists were convened. A series of steps ensued, including selecting a specific clinical algorithm to address, conducting key informant interviews, reviewing relevant literature, reviewing clinical data, and identifying alternative and valid algorithms. Key Outcomes: Given the disproportionately higher rates of chronic kidney disease risk factors, estimated glomerular filtration rate (eGFR) was prioritized for change. Key informant interviews revealed concerns about the clinical impact that removing race from the equation would have on patients, potential legal implications, challenges of integrating revised algorithms in practice, and aligning this change in clinical practice with medical education. This collaborative process enabled us to tackle these concerns and successfully eliminate race as a coefficient in the eGFR algorithm. Conclusions: CERCA serves as a model for developing academic and public health department partnerships that advance health equity and promote anti-racism in practice. Lessons learned can be adapted to identify, review, and remove the use of race as a coefficient from other clinical guidelines.

Community Perceptions of Health Equity: A Qualitative Study.

INTRODUCTION: Notable inequities in patient experiences exist in the healthcare system. Communities with a large concentration of blacks and immigrants are often marginalized rather than centralized in the healthcare system. These inequities may fuel distrust and exacerbate adverse outcomes, thereby widening the health gap. Addressing differences in patients' experiences of care is paramount for reducing health inequities. METHODS: In this qualitative study, we used a purposive sampling method to recruit 62 participants to conduct 10 FGs (44 participants total) and 18 key informant interviews with stakeholders across Central Brooklyn. RESULTS: The data revealed three primary themes: Trust, Discrimination, and Social Determinants of Health (SDOHs). Each theme comprised subthemes as follows: For Trust, the subthemes included (1) confidence in the healthcare professional, (2) provider empathy, and (3) active participation in healthcare decisions. Regarding Discrimination, the subthemes involved (1) racism and identity, as well as (2) stigma related to diagnosis, disease state, and pain management. Lastly, for Social Determinants of Health, the key subtheme was the acknowledgment by providers that patients encounter competing priorities acting as barriers to care, such as housing instability and food insecurity. For the first theme, participants' interactions with the healthcare system were prompted by a necessity for medical attention, and not by trust. The participants reported that experiences of discrimination resulting from identity and stigma associated with diagnosis, disease state, and pain management amplified the disconnect between the community, the patients, and the healthcare system. This also exacerbated the poor healthcare experiences suffered by many people of color. For SDOHs, the participants identified housing, food security, and other various social factors that may undermine the effectiveness of the healthcare that patients receive. CONCLUSIONS: Improvements in the health system, based on feedback from patients of color regarding their unique care experiences, are important initiatives in combating inequities in healthcare.

Reconsidering Community-Engaged Research Through a Syndemic Theoretical Framework: Lessons from COVID-19.

BACKGROUND: Community-engaged research is a well-established approach to tackling health disparities in communities of color. However, the devastation caused by coronavirus disease 2019 (COVID-19) calls for a reexamination of the practice of community-engaged research. Syndemic framework characterizes the clustering and synergistic interactions between two or more diseases amid an underlay of social and environmental threats. This framework has been used to explain the disproportionately higher rates of COVID-19 in communities of color and may have utility in guiding future community-engaged research. OBJECTIVES: This article describes the process by which a syndemic framework was used to generate discussions on lessons learned from COVID-19 and describes the ensuing collaborative writing process that emerged from this discourse. METHODS: This article was developed by the Community Engagement Working Group (CEWG) of the Jackson Heart Study, a community-based epidemiologic study focused on cardiovascular disease among African Americans in the Jackson, Mississippi Metropolitan Area. By drawing upon a syndemic framework and lessons from COVID-19, the CEWG identified gaps and opportunities to enhance community-engaged research. CONCLUSIONS: Using syndemic framework as a starting point, the CEWG identified the following as aspects of community-engaged research that may warrant further consideration: 1) the need to examine multiple dimensions and assets of a community, 2) the need to view communities through an intersectionality lens, 3) the need to acknowledge the impact of historical and current trauma on the community, and 4) the need to provide support to community-engaged researchers who may be members of minoritized groups themselves and therefore, experience similar trauma.

R.E.A.C.T: A framework for role modeling anti-racism in the clinical learning environment.

PURPOSE: In 2020, medical schools across the U.S. were called to task by students who demanded a response to structural racism in medicine. Many medical schools made anti-racism declarations and pledged to promote more inclusive learning environments. Much of the focus was on changing the pre-clinical curriculum and less on the everyday interactions that occur in clinical settings. As medical educators, we have an obligation to reinforce statements of solidarity by role modeling behaviors that demonstrate anti-racism in clinical practice. METHODS: This article proposes a framework that provides practical steps for role modeling anti-racism in the clinical learning environment. These steps are drawn from a review of the literature on role modeling, constructs from Social Cognitive Learning Theory, and anti-racism praxis. RESULTS: The resulting framework uses the acronym R.E.A.C.T to describe practical steps that include Reflecting on implicit biases, Educating ourselves on historical and current forms of structural racism, Assessing the use of race in clinical practice and asking how racism is impacting a clinical interaction, Calling out behaviors that perpetuate racism, and Treating everyone with dignity and respect. CONCLUSIONS: The R.E.A.C.T framework is of value to medical educators because it provides practical steps on role modeling anti-racism in the clinical learning environment. The framework calls medical educators not to merely passively 'react,' but to be introspective, proactive, and intentional in their response to racism. Examples are provided on how each step can be actualized and adapted for different learning environments.

Factors influencing decision making for kidney transplantation among Black and Latino patients on dialysis: A qualitative study applying the social ecological model.

OBJECTIVES: This qualitative study explored factors that may influence decisions regarding kidney transplantation among African-American and Latino adults on dialysis. METHODS: Qualitative interviews were audio-recorded and transcribed. Open-coding techniques were used to identify concepts, categories, and themes. The Social Ecological Model (SEM) was used to organize themes and identify potential solutions across multiple levels (individual, interpersonal, community, and policy/health system). RESULTS: Thirty-six patients were interviewed. Their mean age was 53 SD 12 years; 50% were female; and their duration on dialysis was 4.9 SD 6 years. Five themes emerged and were organized according to the levels of the SEM: 1) Fear about the outcomes of transplantation and 2) faith in God (individual level); 3) Family dynamics and reluctance to involve family in the decision making process (interpersonal level); 4) The experiences of friends and social networks (community level); and 5) Concerns about the social and economic impact of transplantation (policy and health system). DISCUSSION: The application of a Social Ecological model in this study helped to illuminate the complex and multilevel factors that may influence the decisions for kidney transplantation. Future studies are needed to further explore how family members, social networks, faith communities, and policies/health systems influence the decision making process.

The Implication of Dropping Race from the MDRD Equation to Estimate GFR in an African American-Only Cohort.

The widely used Modification of Diet in Renal Disease (MDRD) formula adapts a 1.212 multiplier for individuals who are identified as African Americans (AAs) or Blacks, which leads to a higher GFR estimation. As it stands, AAs have a lower prevalence of chronic kidney disease (CKD) but higher incidence of end-stage renal disease (ESRD) compared with Whites. Many hypotheses have been postulated to explain this paradox, but the imprecision of the GFR estimation with race-adaptation could be contributory. We performed a single-center, longitudinal, retrospective study on a cohort of outpatient AA patients using the MDRD and MDRDrace removed and CKD-EPI and CKD-EPIrace removed and their progression to CKD G5 (eGFR <15 ml/min/1.73 m2). 327 patients were analyzed. Median follow-up was 88.1 months (interquartile range, 34.4-129.1). When race was removed from MDRD, 39.9% of patients in CKD G1/2 were reclassified to CKD G3a, 72.6% of patients in CKD G3a would be reclassified to CKD G3b, and 54.1% and 36.4% of patients would be reclassified from CKD 3b to CKD G4 and CKD G4 to CKD G5, respectively (p < 0.0001). Comparing the CKD-EPI formula against the MDRD in our cohort, we found that 8.2%, 18.8%, and 11.4% of patients were reclassified from CKD G1/2 to CKD G3a, CKD G3a to G3b, and CKD G3b to CKD G4 respectively. Overall median time to progression to CKD G5 was 137.4 (131.9-142.8) months in patients who were not reclassified and 133.6 (127.6-139.6) months for patients who were reclassified by MDRDrace removed(p < 0.288). Concerns of inequitable access to healthcare have elicited calls to review race-corrected eGFR equations. A substantial number of individuals would have their CKD stage reclassified should have the MDRDrace removed equation be adopted en masse on an AA-only population. The discrepancy is highest at the 45-59 and >60 ml/min/1.72 min2 ranges. This will have tremendous impact on our center's approach to pharmacological dosing, referral system, best practices, and outcome surveillance. Comprehensive review of the current "race-corrected" eGFR will require a multifaceted approach and adjunctive use of noncreatinine-based approach.

Increased Metabolic Burden Among Blacks: A Putative Mechanism for Disparate COVID-19 Outcomes.

Mounting evidence shows a disproportionate COVID-19 burden among Blacks. Early findings indicate pre-existing metabolic burden (eg, obesity, hypertension and diabetes) as key drivers of COVID-19 severity. Since Blacks exhibit higher prevalence of metabolic burden, we examined the influence of metabolic syndrome on disparate COVID-19 burden. We analyzed data from a NIH-funded study to characterize metabolic burden among Blacks in New York (Metabolic Syndrome Outcome Study). Patients (n=1035) were recruited from outpatient clinics, where clinical and self-report data were obtained. The vast majority of the sample was overweight/obese (90%); diagnosed with hypertension (93%); dyslipidemia (72%); diabetes (61%); and nearly half of them were at risk for sleep apnea (48%). Older Blacks (age≥65 years) were characterized by higher levels of metabolic burden and co-morbidities (eg, heart disease, cancer). In multivariate-adjusted regression analyses, age was a significant (p≤.001) independent predictor of hypertension (OR=1.06; 95% CI: 1.04-1.09), diabetes (OR=1.03; 95% CI: 1.02-1.04), and dyslipidemia (OR=0.98; 95% CI: 0.97-0.99), but not obesity. Our study demonstrates an overwhelmingly high prevalence of the metabolic risk factors related to COVID-19 among Blacks in New York, highlighting disparate metabolic burden among Blacks as a possible mechanism conferring the greater burden of COVID-19 infection and mortality represented in published data.

"Always on the go": A qualitative study of the perceptions of cardiovascular disease risk among Latino cab drivers.

BACKGROUND: The taxicab industry is a burgeoning occupation that predominantly employs immigrant males from low socioeconomic backgrounds. Factors such as sedentary nature, environmental factors, high stress coupled with socioeconomic factors may increase cardiovascular disease risk among taxicab drivers. Latinos, a growing immigrant population make up approximately 20% of this industry. However, few studies focus on their experiences as cab drivers or on the factors that may increase their cardiovascular risks. METHODS: This was an ethnographic qualitative study. Data was collected via individual interviews combined with Go-Alongs. The Go-Along is an observational qualitative method whereby researchers accompany participants during routine activities and make observations. Interviews and observations were transcribed and coded to identify emerging themes. RESULTS: Thirty-two Latino male cab drivers participated; their mean age was 45 + 12 years; 47% did not finish high school; and 63% earned $30 000 or less. Time and stress emerged as dominant themes. Time constraints posed a barrier to healthy eating and physical activity. Drivers reported stress from constantly worrying about their finances and personal safety. Drivers also described stress from the physical toll of driving on the body. Go-Alongs supported these themes and identified social interactions and environmental factors that could be leveraged for health promotion. CONCLUSIONS: This study provided an opportunity for cab drivers to describe their perspectives on reasons why their occupation was associated with a high risk for cardiovascular disease. The Go-Alongs contributed to the understanding of the social and environmental context that characterized cardiovascular risks in this occupation.

Factors Associated With Use of a High-Volume Cancer Center by Black Women With Ovarian Cancer.

OBJECTIVE: Disparities exist between population subgroups in the use of gynecologic oncologists and high-volume hospitals. The objectives of this study were to explore the experiences of black women obtaining ovarian cancer (OC) care at a high-volume center (HVC) and to identify patient-, provider-, and systems-related factors affecting their access to and use of this level of care. MATERIALS AND METHODS: Twenty-one semistructured interviews were conducted as part of an institutional review board-approved protocol with women who self-identified as black or African American, treated for OC at a single HVC from January 2013 to May 2017. Recurring themes were identified in transcribed interviews through the process of independent and collaborative thematic content analysis. RESULTS: Five themes were identified: (1) internal attributes contributing to black women's ability/desire to be treated at an HVC, (2) pathways to high- and low-volume centers, (3) obstacles to obtaining care, (4) potential barriers for black women interested in treatment at an HVC, and (5) suggestions for improving HVC use by black women. Study participants who successfully accessed care were comfortable navigating the health care system, understood the importance of self-advocacy, and valued the expertise of an HVC. Barriers to obtaining care at an HVC included lack of knowledge about the HVC, lack of referral, transportation difficulties, and lack of insurance coverage. CONCLUSION: In this qualitative study, black women treated at an HVC shared attributes and experiences that helped them access care. There is a need to collaborate with black communities and establish interventions to reduce barriers, facilitate access, and disseminate information about the value of receiving care for OC at an HVC.

Life Without a Breast: Exploring the Experiences of Young Nigerian Women After Mastectomy for Breast Cancer.

PURPOSE: The majority of women managed for breast cancer in Nigeria are relatively young, many in their forties. Mastectomy, the most common surgical treatment, raises psychosocial concerns. Understanding these concerns may help address the fears of women who refuse treatment and aid in the care of those who have had mastectomy. METHODS: Using qualitative methods, we purposively sampled women 45 years of age and younger who underwent mastectomy for breast cancer at a Nigerian teaching hospital. One-on-one in-depth interviews were conducted using an unstructured interview guide. Data were transcribed verbatim and analyzed to identify themes and subthemes. RESULTS: The study identified six major themes on the impact of mastectomy on psychosocial lives of women, namely decision for mastectomy, postmastectomy transition, body image changes, relationship with husband and sexual life, coping with life postmastectomy, and social support. CONCLUSION: Our findings highlight the importance of addressing individual patient's psychosocial needs and preferences when discussing breast cancer treatment with young women. The experiences of women described in this study reveal several useful themes for planning treatment protocols and postmastectomy care.

Barriers to mammography screening in Nigeria: A survey of two communities with different access to screening facilities.

Delayed presentation of breast cancer is a common theme in most low- and middle-income countries. This study evaluates barriers to mammography screening in two Nigerian communities with different geographic access to screening facilities. A 35 item questionnaire was administered to women, 40 years and older, 1,169 (52.6%) in Ife Central Local Government where mammography services are offered and 1,053 (47.4%) in Iwo Local Government where there are no mammography units. Information on breast cancer screening practices and barriers to mammography screening were compared between the two communities. Most women had heard of breast cancer (Ife 94%, Iwo 97%), but few were aware of mammography (Ife 11.8%, Iwo 11.4%). Mammography uptake in Ife Central was 2.8% and 1.8% in Iwo, despite the former offering mammography services. Knowledge and practice of mammography were not statistically different between the two communities (p = 0.74, 0.1). Lack of awareness was the commonest reason cited for not having mammography in both communities. Others include lack of perceived need and cost. Awareness creation to ensure optimal utilisation of existing facilities, as well as innovative measures to address the barrier of cost, is required to improve breast cancer screening uptake in Nigeria.

Understanding of cardiovascular disease risk factors among Bangladeshi immigrants in New York City.

OBJECTIVES: Among all South Asians, Bangladeshis have the highest prevalence of cardiovascular disease (CVD). The purpose of our study was to compare the understanding of CVD risk factors among Bangladeshi immigrants to the general Caucasian population in the U.S. DESIGN: We surveyed Bangladeshi immigrants in Queens, New York using a CVD risk factor knowledge instrument used in the Coronary Artery Risk Development in Young Adults (CARDIA) study to assess awareness of risk factors. Using multivariate regression modeling, we compared scores on the knowledge instrument between Bangladeshis we surveyed and Caucasians from the CARDIA study, controlling for potential confounders. We subsequently examined the frequency of mentioning each risk factor to understand what was driving the difference in the overall score. RESULTS: The proportion of Bangladeshis scoring low on the knowledge assessment was 0.53, where as the proportion of whites scoring low in the CARDIA study was 0.32 (p value < .001). Whites were 34% more likely to score high than Bangladeshis (adjusted odds ratio [aOR] 1.34, 95% confidence interval [CI] 1.19-1.52). Bangladeshis were more likely to mention diet and cholesterol as risk factors and less likely to mention lack of exercise, being overweight, and smoking as risk factors. CONCLUSION: Understanding of cardiovascular disease risk factors was lower among Bangladeshis than whites. This was driven by Bangladeshis having less awareness regarding how exercise and being overweight contribute to CVD. Community based interventions and community health partnerships should target these behavioral risk factors in the Bangladeshi population.

Safety and feasibility of early postmastectomy discharge and home drain care in a low resource setting.

BACKGROUND: Early postmastectomy discharge with a drain in place is standard practice in most developed countries. Its feasibility has not been evaluated in low resource settings like Nigeria. METHODS: Consenting patients undergoing mastectomy were discharged on the third postoperative day and assessed as outpatients for wound complications as well as their experience at home. Wound outcomes were compared with patients who had traditional long stay. RESULTS: Forty-five of the 58 patients who had a mastectomy during the study period participated in the early discharge program (77.6%). Of these, four patients (8.9%) had drain malfunction, seroma occurred in eight patients (17.8%), eight patients (17.8%) had wound infection, and six patients (13.3%) had flap necrosis. There was no readmission. Compared with long stay patients, postoperative stay was significantly shorter (3 vs 11 days; P < 0.01) with significant cost savings, while complication rates were not statistically different. All the patients in the early discharge group were confident operating their drains and preferred early discharge. Being around relatives, reduced cost, and fear of the hospital environment were common reasons cited for their preference. CONCLUSION: Our results support the implementation of an early postmastectomy discharge program in a low resource setting.

Impact of Depression and Demoralization on Blood Pressure Control in African Americans with Hypertension: Findings from the TRIUMPH Trial.

BACKGROUND: African Americans develop hypertension earlier and have worse cardiovascular outcomes than Caucasians. Accumulating evidence suggests that psychological distress may play a role in the observed racial differences in hypertension. Several studies have investigated the relationship between depression and hypertension while little is still known about the role of demoralization. METHODS: Using data from the Trial Using Motivational Interviewing, Positive Affect, and Self-affirmation in African Americans with Hypertension (TRIUMPH), logistic regression models were used to estimate differences in blood pressure control at 12 months among participants with demoralization, depression, and both conditions. RESULTS: Our logistic models showed that reported psychosocial symptoms significantly differed in predicting success in blood pressure control at 12 months. Contrast analyses showed that, after adjusting for sociodemographic, clinical, and psychosocial variables, demoralized patients were less likely to achieve blood pressure control than participants without affective conditions (p = 0.020). Similar results emerged for patients with depression (p = 0.042) and both conditions (p = 0.022). CONCLUSIONS: Depression can be extremely debilitating and has serious health consequence. Our findings confirm this result and show that, even though depression and demoralization share common features, they are two distinct clinical phenomena with similar negative impact on blood pressure control in African Americans.

Developing a Breast Cancer Screening Program in Nigeria: Evaluating Current Practices, Perceptions, and Possible Barriers.

PURPOSE: In low- and middle-income countries like Nigeria, women present with advanced breast cancer at an earlier age. Given the limited resources, development of screening programs that parallel resource capabilities of low- and middle-income countries is imperative. The objective of this study was to evaluate the perceptions, practices, and barriers regarding clinical breast examination (CBE) screening in a low-income community in Nigeria. MATERIALS AND METHODS: A cross-sectional survey of women age 40 years or older in Ife, Nigeria, using multistaged sampling was performed. Information on sociodemographics, knowledge of breast cancer, screening practices, and willingness to participate in CBE screening was obtained using an interviewer-administered questionnaire. RESULTS: A total of 1,169 women whose ages ranged from 40 to 86 years (mean age, 47.7 years; standard deviation, 8.79 years) were interviewed. The majority of women (94%) knew about breast cancer, whereas 27.5% knew someone who had had breast cancer, the majority of whom (64.5%) had died of the disease. Of the 36% of women who had breast screening recommended to them, only 19.7% had an actual CBE. Of these, only 6% had it in the last year. The majority of women (65.4%) were willing to have regular CBEs and did not care about the sex of the examiner in most instances. Lack of perceived need was the reason cited by women unwilling to participate. CONCLUSION: The majority of women were aware of breast cancer and knew it as a fatal disease. With the relatively encouraging number of those willing to be examined, a carefully designed CBE program coupled with advocacy to correct uneducated beliefs seems promising.

Community-Based, Preclinical Patient Navigation for Colorectal Cancer Screening Among Older Black Men Recruited From Barbershops: The MISTER B Trial.

OBJECTIVES: To test the effectiveness of a preclinical, telephone-based patient navigation intervention to encourage colorectal cancer (CRC) screening among older Black men. METHODS: We conducted a 3-parallel-arm, randomized trial among 731 self-identified Black men recruited at barbershops between 2010 and 2013 in New York City. Participants had to be aged 50 years or older, not be up-to-date on CRC screening, have uncontrolled high blood pressure, and have a working telephone. We randomized participants to 1 of 3 groups: (1) patient navigation by a community health worker for CRC screening (PN), (2) motivational interviewing for blood pressure control by a trained counselor (MINT), or (3) both interventions (PLUS). We assessed CRC screening completion at 6-month follow-up. RESULTS: Intent-to-treat analysis revealed that participants in the navigation interventions were significantly more likely than those in the MINT-only group to be screened for CRC during the 6-month study period (17.5% of participants in PN, 17.8% in PLUS, 8.4% in MINT; P < .01). CONCLUSIONS: Telephone-based preclinical patient navigation has the potential to be effective for older Black men. Our results indicate the importance of community-based health interventions for improving health among minority men.

Trouble in transit: Organizational barriers to workers' health.

BACKGROUND: Valuable insights on the health and behavior of transit workers can be obtained from qualitative research that considers the social environment, which affects job performance and determines levels of perceived stress. METHODS: Using a grounded theory approach, semi-structured interviews were conducted with American transit workers (n = 32). Recorded interviews were transcribed and analyzed using a constant comparative method. RESULTS: Participants described categories related to entrenched organizational practices, particularly managements' leadership style, which created an atmosphere of distrust. High demanding work schedules, as a result of technological advances, were discussed in relation to diminished breaks, fatigue, and unhealthy diets. Transit workers also attributed increased work demands and irregular working hours to compromised time with family and friends. CONCLUSIONS: The described barriers to positive health behaviors and social support underscore the need for interventions that ensure adequate breaks and recovery between shifts and increase safety for transit passengers. Am. J. Ind. Med. 60:350-367, 2017. © 2017 Wiley Periodicals, Inc.