What is the cutting edge in Social Medicine in 2011, at least in the Bronx?

The 18 social medicine projects completed by the 2011 graduates of Residency Program in  Social Medicine offer one perspective.  These projects cover a wide variety of topics; three were conducted internationally (Quito Ecuador;  Andhra Pradesh, India; and Rwanda). Among the questions addressed were:

1) Are medical schools and residency programs accountable to the broader society?

2) Does the promotion of Zumba dance in the clinic  improve the health of diabetics?

3)  What are the barriers to reproductive health care among homeless adolescents living in shelters?

4) What is a social medicine doctor?

The abstracts published below represent work by residents in Social Pediatrics, Family Medicine, and Social Internal Medicine/Primary Care. The actual presentations were made during Social Medicine Rounds on May 24, May 31 and June 7, 2011.

 The objectives of this study are to obtain information about where teenagers receive their information about sexual health topics, to obtain information about the use of the internet/social networking, and to evaluate adolescent knowledge concerning reproductive health. Male and female adolescents between the ages of 14 and 21 were recruited from two urban clinics in the Bronx. They were asked to complete an anonymous survey which included basic demographic information, internet availability, a knowledge assessment, and questions assessing sources of information and their usefulness. Participants were also asked specifics about websites/social networking resources utilized. Responses to survey questions were tabulated in Excel and descriptive statistics were calculated.

One-hundred and eighty-nine adolescents were surveyed during their clinic visits. The median percent correct on knowledge questions was 64.7%. The most common sources were medical professionals (93%), mothers (85%), friends (86%) and the internet (83%). Information provided by medical professionals was seen as the most useful (92%) followed by mom (81%), boy/girlfriend (79%) and the internet (73%). The most common websites used were Google (74%), Yahoo (26%), and Wikipedia (26%). The top four search terms were sex, condoms, birth control, and HIV.

To assess the potential of group visits in comparison to individual visits, a Centering Parenting Model of group well-child care was implemented at a Federally Qualified Health Center in an urban primary care setting designated as Patient-Centered Medical Home.

Study participants are parent-baby dyads and are established patients at the Family Health Center. Centering Parenting groups consisting of 5-10 pairs meet at predefined routine well-child visits to receive routine well baby care in a group setting.

The purpose of this project is to provide group well child care as an alternative to individual provider care with the hope of improving quality outcomes and parent satisfaction.

 Background: Cervical cancer is a completely preventable disease. Yet 470,000 new cases of cervical cancer are diagnosed each year and 300,000 women die annually worldwide. The overwhelming majority of these cervical cancer cases occur in the developing world. Pap smears are the main screening test for cervical cancer but many developing countries lack the infrastructure to perform pap smears. To address this need for cervical cancer screening in the developing world, the medical organization Prevention International: No Cervical Cancer (PINCC) developed a mobile service which screens for precancerous cervical cells using direct visual inspection of the cervix with acetic acid (VIA) and immediately removes suspected lesions in a single visit using either cryotherapy or LEEP. This study aims to evaluate the effectiveness of PINCC’s mobile cervical cancer screening program in Andhra Pradesh, India.

Methods: For 12 days in August and in December 2009, PINCC went to a different village each day in Andhra Pradesh, India. Mobile cervical screening using VIA was performed on non-pregnant, non-menstruating women between the ages of 23 and 75 who did not have signs of vaginitis. Pap smears were often performed for VIA-negative lesions, or if the squamocolumnar junction (SCJ) was not fully visualized because it extended into the cervical os. Biopsies were taken of VIA-positive lesions. Cryotherapy was performed if VIA-positive lesions covered less than 75% of the cervix and there was adequate visualization of the SCJ. Women with VIA-positive lesions covering >75% of the cervix received LEEP. PINCC referred all women suspected of having cervical cancer to the local hospital, based on the screening VIA results and biopsy. These women did not undergo cryotherapy or LEEP treatment.

Results: PINCC screened 623 women for cervical cancer during the 24 days that they were in Andhra Pradesh, India. Cervical samples from only 543 women were used in this study since there were missing data for 80 screened patients. Of the 543 women screened, 431 were VIA-negative and 112 were VIA positive. The VIA-negative group included 391 completely normal cervical screening after adequate visualization of the SCJ and 40 women who had to undergo pap smears for inadequate visualization of the SCJ. Precancerous cervical cells were found in 3 of 40 pap smears. Of the 112 participants with positive VIA lesions, 21% had cryotherapy, 27% had LEEP, and 45% were biopsied only without treatment due to either a non-functional cryotherapy or LEEP. Squamous cell carcinoma was found in 1.3% of the screened women. Of all the 112 VIA-positive lesions seen, biopsies found cancer or precancerous cells in 53 women, for a positive predictive value of 47%.

Conclusions: In 24 days, PINCC effectively screened 543 women with the low-cost method of VIA and immediately treated them with cryotherapy or LEEP. The PPV of VIA to detect precancerous cells was similar to other studies involving VIA. Further measures need to be taken to reduce the number of samples with missing data and to ensure operational equipment. A mobile “see and treat” model is a feasible method to address the high cervical cancer rates in the developing world.

The Montefiore Transitions Clinic (TC) was established to provide access to primary care, mental health services and social services for recently incarcerated adults. In July, 2009, we established a TC for recently incarcerated adults through partnership with Bronx Parole Board and The Osborne Association, a local prisoner advocacy community based organization (CBO). Initially, referrals to TC were primarily from parole officers and the overall burden of chronic illness was low. Here we report on the impact of a community health worker (CHW) on patient recruitment and disease severity.

To evaluate the impact of the referral source on the disease prevalence seen at TC, we performed a retrospective chart review comparing patients seen before and after the CHW was hired. Data was available for the first 39 TC patients, of whom 38 were referred by the Parole Committee, and the 30 most recent TC patients, 29 of whom were referred by the CBO through the CHW. Our primary measure of interest is prevalence of chronic disease in TC patients, including HIV, hepatitis C, mental illness, opioid dependence and diabetes. Secondary measures include time from correctional facility release to first clinic visit and insurance status.

With the assistance of a CHW, the TC has reached a population of former inmates with a higher burden of chronic illness. Referrals from a CBO, coordinated by a community health worker, identified a population with a high prevalence of chronic diseases including HIV, hepatitis C, mental illness and opioid dependence. system of facilitated referrals, along with access to health centers where barriers to care are minimized, can help bridge gaps in care for the formerly incarcerated population.

Needs and Objectives: Although weight loss can lead to a reduction in diabetes and hypertension and improve health outcomes, only 42% of obese U.S. adults report that their physicians have counseled them about weight loss. Even when weight loss is advised, most physicians do not discuss specific weight loss strategies, indicating that the quality of counseling may be poor. To address this gap, we adapted, implemented, and conducted a pilot evaluation of a previously developed theory-based obesity counseling curriculum for residents using a 5A’s behavioral change model. In this model, residents are trained to assess obesity risk, agree on mutual goals, advise a weight-control program, assist in establishing appropriate intervention, and arrange for follow-up. The objective of our evaluation was to determine the feasibility and impact of a novel obesity counseling curriculum, which incorporates training and practice in obesity counseling skills, on residents’ self-assessed competency in obesity counseling.

Setting and Participants: Our target audience was 28 interns and residents in the Primary Care/Social Internal Medicine Residency Program at Montefiore Medical Center, Bronx, New York.

Description: The curriculum was delivered 4 times over a 6 month period to groups of 5 to 10 residents during ambulatory medicine blocks. One week prior to curriculum participation, residents completed a previously validated survey with 9 items measuring self-assessed obesity counseling competence, based on the 5A’s model. Each question used a 4-point likert scale. The 3-hour 5A’s Obesity Curriculum included a 2-hour didactic and discussion session on the epidemiology of obesity, 5A’s obesity counseling framework and practical tools for its implementation. Case-based discussions of treatment modalities included behavior change, medication, and surgical options for weight loss. The final hour involved reviewing motivational interviewing (MI) and practicing with a standardized patient. Two months after participation, residents completed a post-intervention survey, and gave general feedback. Preliminary analyses compared median scores before and after curriculum participation using the Wilcoxin test.

Evaluation: To date, 16 residents have completed the curriculum and surveys, with another 10 scheduled to participate. Residents reported their counseling competence in: 1) assessing patients’ stage of change, 2) diet and 3) current level of physical activity; 4) agreeing on mutual goals for weight loss; 5) assisting patients in goal setting for weight loss; 6) responding to patients’ questions about behavior change; 7) offering medication and 8 ) surgical weight loss options; and 9) using MI techniques to change behavior. After the curriculum, there was a significant increase in the median scores from 2 to 3 (2=somewhat able to perform, 3=able to perform adequately) in residents’ report of assessing stage of change, assisting in goal setting, discussing treatment options and using MI techniques. There were no differences in the remaining domains. On qualitative questions, residents reported a high degree of satisfaction with the curriculum and requested additional skills practice sessions in MI.

Discussion: We developed and implemented a novel curriculum for residents to address strategies for weight loss using the 5A’s behavior change model, which incorporated obesity counseling skills practice. Preliminary pre and post curricular analyses showed improvements in several areas of residents’ obesity counseling competence. Implementing this three hour curriculum in a residency program was feasible. Post curricular questionnaires indicated that residents were satisfied with the curriculum, and were eager for additional sessions for continued practice and refinement of obesity counseling using MI skills. Further evaluation, with additional learners, and direct observation of counseling skills is needed to fully elucidate the impact of the curriculum in promoting effective obesity counseling skills.

Chronic malnutrition is associated with childhood mortality and affects up to a quarter of children in Ecuador. In southern Quito, lack of knowledge and poor diet diversification are contributing factors. Existing research has shown health education is a critical component in influencing behavioral changes and local collaborators, such as the Ecuadorian Ministry of Health and community physicians, have identified health education as an area that merits further investigation in their patient population. Hence, the objective of our study was to assess the effectiveness of a health education intervention given at a government-run clinic in Quito, Ecuador.

A 20-minute workshop and pictogram handouts were developed to provide education on the effects of protein malnutrition and highlight locally available protein sources. The workshop was offered daily over a 4-week period and the handout was distributed to a subset of patients after the workshop. Oral questionnaires were developed to assess protein nutrition knowledge, confidence in participant’s own knowledge, and protein intake pre- and post-workshop and at home visits three weeks later. A total of 98 participants completed pre- and post-workshop questionnaires and 57 completed home visit questionnaires. We found that knowledge and confidence increased after protein education workshops with retention at home visits. The utilization of pictogram handouts in educational sessions improved protein intake. These findings support continuing to work with Ecuadorian collaborators to further develop one-time, concise educational interventions to improve dietary behavior.

[This presentation won the Daniel Leicht Social Medicine Award and the Chairman's Research Award.]

Purpose: Seen as a public good, graduate medical education (GME) was financed by Medicare 1965, expecting that this responsibility would continue “until the community bears the cost in some other way”. Over 40 years later, Medicare is still bearing the brunt of GME financing, spending $9.5 billion last year. Many have suggested that academic health centers have become dependent on such financing. We sought to better understand the perceived responsibility of GME institutions in addressing the needs of the nation, and the utility of and most likely methods to measure and compare the social impact of GME institutions.

Method: Eighteen informants were interviewed via semi-structured interviews done by phone and in-person. Key informants were chosen from salient national agencies/associations after developing a sampling matrix to ensure appropriate breadth of perspectives. Snowballing technique was employed, and informant interviews were continued until saturation of themes was achieved and confirmed via search for disconfirming data.

Results: Seventeen of eighteen informants noted that GME institutions have a responsibility to be socially accountable. Informants’ definitions of social accountability included: training of future physicians, addressing workforce shortages and providing service to the institution’s community. Multiple informants noted barriers to measuring social accountability, though many informants suggested possible tools for measurement of social accountability.

Conclusions: GME is largely seen as a public good, and multiple informants noted that recipients of GME funding should be responsible to their communities. However, time constraints, financial limitations, and curriculum overload limit GME institutions’ ability to be socially accountable. Financial incentives, accreditation requirements and maintenance of mission values can address GME institutions’ responsibility to medical education, workforce shortages and community service.

Prison release rates in New York City correlate directly with poverty rates, and a disproportionate number of prisoners are returning to the Bronx. Recently released individuals attempting to reintegrate into the community are among the most marginalized of populations and have grave health outcomes. RPSM residents provide care for many of these patients who are directly or indirectly impacted by incarceration. The goal of this project was to develop a longitudinal training program in correctional health for family and internal medicine residents. Methods included reviewing existing correctional health training programs, interviews with medical and academic directors, rotations and site visits to correctional facilities and transitions clinics in San Francisco and New York City.

The proposal for a longitudinal correctional health curriculum is comprised of required clinical and didactic components: Transitions Clinic sessions at FHC and CHCC during elective blocks throughout residency as the foundation; health education workshops, targeted outreach and discharge planning at Rikers Island and VCBC; buprenorphine training and case-based discussions with a substance abuse specialist; and cross-track conferences to discuss syllabus readings. Residents interviewed unanimously support a longitudinal model of learning and this proposed curriculum provides an example of a rigorous training program to meet their educational needs.

Description: During the academic year 2010 – 2011 we initiated an iterative educational process to engage residents in a dialogue about SBP. An anonymous web-based survey was sent to all 19 PGY2 and 3 residents asking them how they would handle four common clinical scenarios that occur when the resident is not in clinic or between patients’ clinic visits: (1) following up of critical lab values; (2) scheduling non-routine follow-up appointments; (3) handling urgent care situations when patients call from home; and (4) titrating medications. Each scenario was derived from our clinical experience and piloted with colleagues prior to survey distribution. Results were analyzed and a set of best practices was created. At a program-wide retreat attended by approximately 25 residents and faculty we moderated a two-hour discussion on the survey results, best practices and other SBP topics identified. A second anonymous survey was sent to the same 19 residents assessing the value of monthly SBP meetings.

Evaluation: Seventy-four percent (14/19) of residents responded to the initial survey, with up to 5 solutions given for each scenario. Responses varied by the skill level of the clinic staff member asked to assist with the task, the number of phone calls, emails, and hand-offs required, and the time needed for task completion. Given the heterogeneity of responses a set of best practices, emphasizing non-physician resources, was created and disseminated. Our second survey used a 5-point Likert scale (5=Quite Valuable, 1=No Value) to quantify the value of monthly SBP discussions. One hundred percent (14/14) of responders reported that sessions would be valuables or quite valuable. We then initiated monthly discussions (60-75 minutes) during ambulatory blocks (4-8 residents/month). To date we have held two sessions. Prior to each session we solicit SBP topics and distribute a resident derived agenda. Afterwards, we email key takeaway points and post updates on our program’s searchable website.

Background: Chlamydia and gonorrhea (GC) screening in specific populations, including substance users, is recommended. Entry into methadone maintenance treatment presents an opportunity to screen a high risk population, yet the prevalence of Chlamydia and GC infection in this population has not been well-defined. To address this gap, we began to routinely offer screening to women admitted to our Bronx methadone maintenance treatment program (MMTP).

Methods: A chart review of consecutively admitted adult female patients from June 1, 2010 is underway. Using a structured chart review instrument, we abstracted sociodemographics (age, race, income), substance type, injection use, trauma and incarceration history; HIV antibody status, syphilis titer, and urine GC and Chlamydia results.

Results: Forty-nine women were entered treatment between June and December 21, 2010. Eleven (22%) self-identified as Black, 32(65%) as Hispanic. Their mean age was 40 All had heroin dependence. Thirty-one (63%) reported cocaine use. Twenty-two (45%) had injected. Eleven (22%) had experienced domestic violence and 30(61%) had been incarcerated. Nine (18%) were HIV positive, and five (10%) had serologic evidence of syphilis infection. None of the 46 (94%) women tested for GC and Chlamydia were positive.

Conclusions: Although women entering MMTP are typically considered at high risk for sexually transmitted diseases, routine testing GC and Chlamydia testing did not identify any infections. The HIV and syphilis infection rates we found warrant routine screening, but the absence of GC and Chlamydia in this population does not thus far support routine screening with drug use as a sole risk factor.

Purpose: It is clear that social conditions contribute to ill health. This was described as early as the 19th century by Rudolf Virchow, generally considered the founder of social medicine. Yet, medical training continues to center on the molecular basis of disease. In efforts to create a different model of physician training, the Residency Program in Social Medicine (RPSM) of Montefiore Hospital was founded in 1970 to train a cadre of socially-minded physicians dedicated to providing care for the underserved. The RPSM is a holistic curriculum that encompasses an understanding of social problems affecting the health of individuals and communities and strategies for addressing these issues, while training in community health centers. This study investigates what encompasses a social medicine physician today, and how their practice differs from other primary care doctors.

Methods: All current residents, faculty and alumni of the Residency Program were eligible to participate in the survey, which was emailed in March 2009. A survey monkey questionnaire was used, and emailed to current department members and an alumni list-serve. The complete survey had seven items that included status (resident, faculty, or alumni); specialty (Family Medicine, Internal Medicine, Pediatrics); questions about the role of social medicine in regards to their practice, how it differs from other primary care doctors, and questions regarding the RPSM curriculum. Demographic data describing the participants was tabulated, and comments were grouped into themes and investigated via textual and qualitative analysis.

Results: The survey was completed by 173 participants. Forty-seven percent were in the field of Family Medicine, 30% in Internal Medicine, and 24% in Pediatrics. Fifty-six percent were alumni, 26% were faculty, and 21% were current residents. There were three main themes that were common to most responses, which were that social medicine doctors 1) have a broad knowledge of the social determinants of health, 2) have the ability to translate this broad knowledge of health into a specific treatment plan, and 3) promote social justice. Within each theme were various sub-themes which provided a richer description of social medicine concepts and its practice contrasted with the practice other primary care physicians.

Conclusions: Social conditions are not separate from medical conditions, an integral concept of social medicine and RPSM. Although this study was limited in that not all potential subjects responded and responses varied greatly in length and description, the concepts of social medicine are clearly central to their practice of medicine. Social medicine is thought to be valuable and essential in the treatment of individuals and communities, and an opportunity for social change. This model of medicine was viewed as fundamentally different from the practice of other primary care physicians. Further research in the practice of social medicine on patient outcomes, and perspectives of patients treated by social medicine doctors could be helpful in substantiating our findings and expanding the number of social medicine residency programs nation-wide.

The Patient Centered Medical Home (PCMH) has received attention as a cost-effective way to address the myriad problems facing the US primary care system. As more practices become PCMH’s, staff must carry out this change, however their perceptions of the PCMH and the change process may not be congruent. We will compare staff opinions of the PCMH transformation at two primary care clinics in the Bronx, NY, using focus groups consisting of providers and support staff, and analyze recorded transcripts for themes. We anticipate the analysis will yield insight into perceptions of the PCMH and the capacities of the clinics to carry out their transformations that will be useful to other practices as they begin their own transformation processes.

 Numerous studies demonstrate the deleterious health outcomes associated with substance abuse and dependence. To intervene early in the course of substance use, Screening, Brief Intervention, and Referral to Treatment (SBIRT) has been advocated by many.Few studies have examined the feasibility of or outcomes associated with conducting SBIRT in hospitalized patients. Although data regarding SBIRT for drug use has been sparse, with the rise in opioid use, abuse, and dependence, many advocate for SBIRT specifically for drug use. We sought to test the feasibility of conducting SBIRT for problematic opioid use targeting patients hospitalized on the medical wards of a large urban academic medical center.

We identified adult patients who were admitted floors of the medical wards and administered audio computer-assisted self-interviews assessing theirof problematic opioid use using the WHO ASSISTscreening tool.Patients were categorized as having no opioid use, or low, moderate, or high risk of problematic opioid use. Those who had moderate or high risk problematic opioid use received a brief computer-based intervention. We found that 42 (56.0%) reported no opioid use, 4 (5.3%) low risk, 26 (34.7%) moderate risk, and 3 (4.0%) high risk of problematic opioid use. Of the 29 patients with moderate or high risk, 19 (65.5%) were interested in referral to treatment and 27 (93.1%) reported that the brief computerized intervention was useful. We question whether our model of conducting SBIRT-with a dedicated person outside of the team delivering health care-is feasible. However, this urban inpatient population seems at significant risk thus more research is warranted on how to best use SBIRT to intervene on problematic opioid users in the inpatient setting.

Zumba Bronx is a reproducible and sustainable form of dance exercise that is built on one of the strengths of an underserved community, the passion to dance. Dance aerobic exercise has been shown to improve participants’ s BMI. The 2010 ADA noted that a 5-10% decrease in weight translates into a decrease in HbA1c. The literature review indicated that successful programs for weight loss have consolidated exercise, diet, and behavior modification plans. In addition, studies have illustrated the utilization of pedometers as a useful tool to motivate diabetic patients to increase physical activity and maintain these efforts. The goal of this social medicine project is to promote physical activity for patients with diabetes at the Williamsbridge Family Practice. The study will utilize this culturally appropriate, and cost-effective form of dance exercise, Zumba, coupled with pedometers, and develop patient centered support that can be incorporated into the FHC and CHCC health centers in the future. The objective of this project is to provide diabetic patients with the tools to develop and maintain a healthy lifestyle.

The purpose of this study was to evaluate whether a dedicated immigrant health session within a larger primary care practice can achieve retention in and quality of health care for immigrants. This was a retrospective cohort study with medical record review of all new patients seen at the OPEN-IT clinic at CHCC from October 1, 2007 to September 30, 2009. The primary outcome was retention in care, defined as at least one follow-up visit within one year after the initial visit. Secondary outcomes included rates of age-appropriate cancer screenings and results of specific screening tests as recommended by the CDC for refugee populations, including Hepatitis B surface antigen, tuberculin skin test, complete blood count, and ova and parasites in stool. Results showed that 79% of patients were retained in care, with no detected difference in retention based on age, gender, length of time in US, or presence of chronic illness. Rates of mammography and cervical cancer screening were 82% and 79% respectively, but the rate of age-appropriate colorectal cancer screening was only 24%. We also found that over a quarter of patients screened had evidence of latent tuberculosis, anemia, and intestinal parasites, although our numbers were small. Our results support the need for clear recommendations regarding immigrant-specific screening. Further work needs to be done to improve rates of colorectal cancer screening within our model and to better understand which diseases need to be screened for in the immigrant population.

Medicines have meaning and these meanings affect both their efficacy and their perception of it. Perceptions about efficacy affect adherence to and retention in treatment. Observations by substance abuse clinicians suggest that patients in methadone maintenance treatment(MMT)hold perceptions about methadone and methadone doses that may not reflect current medical understanding about methadone, including about interactions and adverse effects. Literature about the experience of patients in MMT is sparse, and this study aims to understand the experience with and perceptions about methadone among patients in an urban methadone clinic. Individuals in substance abuse treatment are a marginalized population. It is anticipated that a better understanding of their experience in a particularly stigmatized realm of medical treatment will allow clinicians to better understand their needs, their response to treatments with potential for interaction to methadone, and thereby improve the adherence to and retention in methadone treatment.

 Homeless adolescents experience multiple barriers to contraceptive use and they have high rates of unintended pregnancy and poor birth outcomes. The goal is to conduct semi-structured interviews with homeless female adolescents ages 14-18 at family shelters in the Bronx and to have teen educational seminars at a homeless family shelter. Interviews include questions on demographic data and open-ended questions regarding beliefs about contraception, experiences with accessing reproductive healthcare, future plans, and specific barriers to accessing reproductive healthcare as an adolescent living in a family shelter. Teen seminars focus on pregnancy, sex, and STDs. The purpose of our study is to 1) describe the experience of unintended pregnancy, abortion, and contraceptive use; 2) identify barriers to reproductive healthcare access including contraception; and 3) describe preferences for reproductive healthcare access in homeless teens. This data will generate data for targeted changes in services.

 A survey of pregnant Rwandan women’s use of complementary medicine.

For more information, we invite you to view the short video about this year’s course, available at:

If you have any questions or are interested in applying, please email us at social.medicine@yahoo.com. Applications are due July 30, 2010.

Sincerely,
Michael Westerhaus, MD, MA
Julian Jane Atim, MD, MPH
Amy Finnegan, MALD, MA
(course instructors)

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.