The Social Medicine Portal

Social Medicine Projects, 2008 RPSM Class

Residents in the Montefiore Residency Program in Social Medicine are required to produce a social medicine project in the course of their 3 year residency. These projects can involve community service, advocacy or research (and often a combination of all three). These projects are presented to the Department in the last Social Medicine Rounds before graduation in June. Here are the abstracts from the presentations by the 2008 graduating class:

Rashiah Elam, MD & Robert Roose, MD, MPH

Increasing Uptake of Buprenorphine Among HIV Physicians and Non-Physicians

Office-based buprenorphine places health care providers in a unique position to combine HIV and drug treatment in the primary care setting. Despite this, few physicians prescribe buprenorphine. Our first study examined barriers to obtaining waivers to prescribe buprenorphine and found that physicians with waivers were less likely to be male (51.1 vs 63.7%, p<.05), more likely to be in New York (51.1 vs 29.5%, p<.01), less likely to be infectious disease specialists (25.5 vs 41.6%, p<.05), and more likely to be general internists (43.6 vs 33.5%, p<.05). Adjusting for physician characteristics, confidence addressing drug problems (adjusted odds ratio [AOR]=2.05, 95% confidence interval [95% CI]=1.08 - 3.88) and concern about lack of access to addiction experts (AOR=0.56, 95% CI=0.32 - 0.97) were significantly associated with having a buprenorphine waiver. Understanding and remediating barriers HIV physicians face may lead to new opportunities to improve outcomes for opioid-dependent HIV-infected patients.

Furthermore, federal legislation restricting nurse practitioners (NPs) and physician assistants (PAs) from prescribing buprenorphine may limit its potential for uptake and inhibit the role of these nonphysician providers in delivering drug addiction treatment to patients with HIV. Our second study aimed to examine the level of interest in prescribing buprenorphine among nonphysician providers and found that, overall, 48.6% (n = 92) of nonphysician providers were interested in prescribing buprenorphine. Compared to infectious disease specialists, nonphysician providers (adjusted odds ratio [AOR] = 2.89, 95% confidence interval [CI] = 1.22 - 6.83) and generalist physicians (AOR = 2.04, 95% CI = 1.09 - 3.84) were significantly more likely to be interested in prescribing buprenorphine. To improve uptake of buprenorphine in HIV settings, the implications of permitting nonphysician providers to prescribe buprenorphine should be further explored.

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Kim Nguyen, MD

Screening for depression in elderly Vietnameses at Family Health Clinic Bronx, NY.

A recent depression screen for elderly Asians in New York City in 2003 concluded that more than 40 % are considered to be depressed. Our hypothesis is that the percentage is much higher for elderly Vietnameses at the Family Health Clinic as this unique group seems to be more socially and cultural isolated than others. A validated GDS screen tool for Vietnameses was used. Approximately 40 % of elderly Vietnameses over 65 who came to clinic between January 2008 and April 2008 were found to have GDS score > 5, which is suggestive of depression. In conclusion, using the same GDS screen, this study has the same result as in the previous study.

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Teryn Edwards, MD

Creating and Evaluating a Peer-Developed Exercise Program for Overweight Inner-City Girls

Obesity is an ever-increasing national epidemic that we see mirrored in urban settings and in urban adolescents. While exercise is a proven method of weight reduction, overweight teen girls from ethnic minorities are less likely to exercise. While numerous programs have been devised for this population, they have been designed by the investigators, based upon their perceptions of the target population’s needs. The goal of this project is to design an exercise program for overweight inner city girls using their input. Using a focus group model, we aimed to determine what overweight inner-city teen girls perceive as the most important and desirable components of an exercise program for their peers. Additional goals were to determine the effects of a peer-developed exercise program on the girls’ utilization and satisfaction with the class.

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Adam Richards MD, MPH

Public Health & Human Rights Praxis in Burma: Training Internally Displaced People to Control Malaria & Document Associations between Human Rights Violations & Health

Civil war has ravaged Eastern Burma for over 40 years and displaced hundreds of thousands of villagers. Adam discusses over eight years of experience training internally displaced people (IDPs) to document and take action to ameliorate the deplorable health status of their own communities. The discussion will focus on data presented in four primary- or co-authored research papers published in or submitted to peer-reviewed journals, including exclusive estimates of 1) mortality rates and 2) malaria prevalence from eastern Burma; 3) the successful reduction of malaria transmission among over 40,000 IDPs; and 4) novel methods to document associations between exposure to human rights violations and health outcomes. We will conclude with a discussion of the uses of data to inform policy and advocacy at the US and international levels.

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Minesh Shah, MD

Interfaces With The Law: Criminal Justice Involvement Among Patients Presenting For Primary Care

Background: In 2005, almost 72,000 arrests were made in Bronx County, NY, a 45% increase from 1990. From the time of arrest, individuals are navigated through a complex process, which includes arrest, detention, arraignment, plea bargain or trial, and if convicted, sentencing and incarceration in jail or prison. Each of these stages poses various potential health risks, particularly the disruption of continuity care. There are also several health risks related to incarceration, including exposure to high rates of HIV, Hepatitis C, and TB infection, and inadequate mental health care. Upon release, individuals return to their families and communities, often ill-equipped to manage the re-entry process. Although it is suspected that many patients from underserved populations have a high burden of criminal justice involvement, this has not been well quantified. In a pilot study, our goal was to describe the extent and nature of criminal justice involvement of patients and their family members presenting to a community-based, primary care clinic in the South Bronx.

Methods: The sample consisted of consenting patients who presented to a single resident-physician for primary care at a community clinic in the South Bronx during a 4 week period. Patients were asked to participate in a standardized survey to explore current and past legal involvement of themselves and their family members. Legal involvement was divided into trials, arrests, and incarceration in jail or prison. In addition to criminal involvement, patients were also asked about civic legal proceedings involving housing, child support, employment and immigration. The data were analyzed using Microsoft Excel spreadsheet software. Results: Of 44 patients completing the survey, 30 (68%) were women and 22 (50%) were foreign-born. At the time of the interview, 17 (39%) were currently participating in active legal proceedings, of which 10 were criminal charges. In addition, 8 respondents (18%) had been incarcerated in jail or prison in the past 2 years, and 11 (25%) had a spouse or significant other who had been incarcerated during that time. More than half of all respondents (24, 55%) had themselves or had a family member (including 12 children) who had been arrested in the past 2 years. Furthermore, 7 respondents (16%) currently had a family member in jail or prison. Finally, 30 respondents (68%) felt that they would utilize legal services if they were available at the clinic. Conclusions: Questions about criminal justice involvement are not typically asked at intake or as part of routine medical visits. Our study found that, when asked, patients will agree to share this information. In our South Bronx population, we found a high burden of criminal justice involvement among primary health care patients. Although not specifically elicited, some respondents also described how this involvement affected their health care. Better integration of health and legal services could be of significant benefit to providing health care to similar patient populations. Further research is needed to better delineate the type of involvement and its impact on the health of individuals, families, and communities.

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Anagha Loharikar, MD

Mental Health Care Needs of Latino Families in the South Bronx: Perspectives of Parents and Pediatricians

Background: Latino communities in the United States suffer disparities in access to adequate mental health (MH) care, which has been attributed to systemic barriers and coordination between health care providers and community based organizations. While some studies have reported on perspectives of the Latino community on MH, no studies have reported perspectives of pediatricians working in such communities. We present data collected as part of an AAP CATCH grant to develop a MH home for Latino families in the South Bronx, where 63% of the population is Latino.

Objective: To understand and compare the perceptions of Latino parents and practicing pediatricians regarding 1) the causes of MH problems, 2) barriers to MH services, and 3) MH needs. Design/Methods: We conducted a qualitative study. Parents of children with a history of MH services referral, use or need were recruited at a federally-qualified community health center to participate in a focus group. We conducted two 90-minute groups with parents. Next, we conducted one 90-minute focus group with pediatricians at the same health center. Focus groups were audio-taped and transcribed. Two investigators independently coded each transcript for thematic content. Differences in coding were resolved via consensus.

Results: Causes: Parents and pediatricians both identified familial disruption as well as poverty/violence as etiologies of MH problems in Latino children. Parents also emphasized a causal relationship between the actions of God and the devil on MH. Barriers: Both parents and pediatricians acknowledged stigma associated with MH disorders. Parents described distrust of authority and public institutions and incompetence among MH providers, including lack of caring. Pediatricians attributed lack of access to systemic barriers, such as lack of insurance. Needs: Both groups described a need for preventive services in the community. Parents described consequences of MH problems on self, family, and community. Parents emphasized a need to be heard and for community awareness about MH. Themes distinctive to the pediatricians included the high prevalence and range of MH problems of their patients and discomfort with personal experiences in managing MH. Conclusions: Parents and pediatricians gave differing perceptions of the MH needs of the Latino population in this inner-city setting. Further exploration can inform the intervention-design of the CATCH initiative to improve access to MH care.

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Giliane Joseph, MD

Prevalence of isolate Hepatitis B core antibody positivity in the MMG population

A descriptive study looking at the various serology results in our patient population; and looking for a pattern in the patients who lose or never develop protective immunity.

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Sara Doorley, MD

The underutilization of Comprehensive Health Care Center (CHCC) services by the foreign-born population in the South Bronx

Objectives: Increase utilization of health care services by the uninsured immigrant population in the South Bronx. Create a collaborative team of Community Health Workers (CHW), resident physicians, and Community Based Organizations (CBO) to facilitate access to care among new immigrants.

The Montefiore CHCC is federally qualified health center in the Highbridge-Morrisania (HM) section of the South Bronx where 30% of the population is foreign born and 45% do not have a personal doctor. The CHCC established the OPEN-IT Clinic (Opportunities Pro-Immigrant Elderly Newcomers-International Travel) to provide culturally appropriate clinical services to immigrants, and educate resident physicians in immigration/travel medicine. The multiple barriers for HM residents to access available health care services include language, cultural differences, fear of retribution (for undocumented residents), and lack of knowledge regarding available services. To address these barriers, the CHW-OPEN-IT clinic collaboration recruited and trained Community Health Workers (CHWs). The training began with bilingual health classes led by Montefiore medical residents and progressed to a biweekly “health promoter certification” for interested participants. In collaboration with CBOs, the CHWs conducted outreach to places of worship, businesses, immigrant organizations, and schools. The CHWs accompanied interested new immigrant patients to the OPEN-IT clinic to facilitate the registration, visit, and follow-up processes. The CHWs also arranged for home visits to clients by physicians when necessary and conducted follow-up phone calls to the patients. The CHWs were available to assist residents in providing cross-cultural care and facilitate communication between patient and physician.

Findings to Date: 1) Increased utilization of health care services by the foreign-born population. Via our collaboration, 57 new immigrant patients have received health care at the Montefiore CHCC OPEN-IT clinic. 2) Discovery of barriers to receiving health care services at the CHCC. We learned that uninsured patients erroneously received bills from the clinic and were hesitant to return for follow up. Although prescriptions are available to uninsured patients on a sliding-fee basis, we learned that some OPEN-IT clinic patients were charges full prices for medications. 3) Novel feelings of provider trust and service satisfaction by the new patients

Key Lessons Learned: Community Health Workers can link the health care sector with the community, improve utilization of existing services, provide valuable feedback regarding patient care, and dissolve existing barriers to access.

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Sara Lorenz, MD

A Descriptive Epidemiology Of Locus Of Control (Loc) Among Participants In The South Bronx Obesity Reduction Initiative (Sobori)

Despite the serious consequences associated with obesity, prevention and treatment continue to be difficult to achieve in part because there is little known about the factors affecting engagement in weight loss programs. The objective of this study was to assess beliefs and weight-related attitudes among a group who agreed to participate in a weight reduction program. We used internal-external locus of control as a personality construct to describe engagement in a weight reduction program among obese urban population. In our population we found that administering a full Multidimensional Health Locus of Control survey was not practical. However, particular items related to weight loss locus of control were feasible to administer and provided valuable data. These items revealed that patients have an external locus of control with regard to family understanding and availability of exercise infrastructure but an internal locus of control with regard to understanding of personal behavior as causes of obesity and perceived ability to change their health status. These scores predicted responses to weight-related measures and may be used in planning a new weight reduction program to specifically address the population’s needs.

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Bernice M. Vicil, MD

CAM use among children hospitalized with asthma

Children in New York State have substantially higher rates of asthma hospitalizations as compared to children in the U.S. This becomes even more notable in the borough of the Bronx, where pediatric asthma hospitalization rates have consistently towered above the rest. Since hospitalizations are a major marker of morbidity for asthmatic patients, it seems important to quantify, and analyze, CAM use among patients in this specific setting. A better understanding of the prevalence, and types, of CAM usage among children hospitalized with asthma can further enhance patient care by allowing the medical team to communicate more effectively with families regarding their child’s asthma, and its management. This study investigates the prevalence of CAM use among hospitalized children with asthma.

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Sharon Welch, MD

Spirituality, Religion and Medicine: A needs assessment survey

Research has shown that most patients would like for their physicians to inquire about spiritual issues especially in times of serious illness. However, many physicians have not done so for a variety of reasons including their comfort level, time and inadequate training. I wanted to assess residents reasons for not inquiring about spiritual issues and whether they think that this can be improved by formal training.

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Yadiera Brown, MD & Eric Churchill, MD, MPH

Spirituality, trust in the medical system and preferences for end of life care in two Bronx clinic populations

There are significant differences among ethnic groups in the utilization of hospice and palliative care services. This discrepancy persists even when sex, access to health care, income, marital status and existence of a living will are controlled for (Greiner 2003). There are many possible reasons for this discrepancy including a lack of trust in the medical system and a greater prevalence of strong religious beliefs or a general preference for more aggressive care. While many studies have shown that these traits exist in ethnic minority populations there has been little research attempting to correlate these beliefs specifically with preferences for end of life care (Brandon 2005). We have conducted a study of two MMG2 clinic populations, assessing religiosity, trust in the medical system and preferences for care at the end of life.

Refrences: Greiner KA. Perera S. Ahluwalia JS. Hospice usage by minorities in the last year of life: results from the National Mortality Followback Survey. Journal of the American Geriatrics Society. 51(7):970-8, 2003 Jul.

Brandon DT, Isaac LA, MS, LaVeist TA. The Legacy of Tuskegee and Trust in Medical Care: Is Tuskegee Responsible for Race Differences in Mistrust of Medical Care? J Natl Med Assoc. 2005; Vol 97 No 6 p951-56.

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Gabriella Gellrich, MD

Falling through the Cracks- stories of struggles and small victories within the current U.S. healthcare system

Inspired by her work at a community health center in the Bronx, Dr. Gellrich has created a short film that takes us on a journey in a culture where healthcare seems to be a privilege and not a right. Dr. Gellrich brings a special perspective to the film- she grew up in Canada- a country that affords its citizens universal health care at the expense of their tax dollars. She hopes this will serve as another inspiration for us to continue to rally for change, while also serving as a resource for both patients and providers. It reminds us of some of the strings that help make up the safety net for a health care system in need of major repair.

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Lisa Rubin Hartman, MD

Assessing the Needs of Adolescents in the South Bronx

A focus group study exploring the community needs of and access of services by teenagers living in the South Bronx.