Awardees of autumn 2022 Tier 1 pilot research grants report final project outcomes

Leveraging a Community-based Participatory Research approach for a Qualitative Study Exploring the Methamphetamine Use Continuum among Cisgender Men and Transgender People who Have Sex with Men

Investigators
Arjee J. Restar, Department of Epidemiology
Christopher Archiopoli, Peer Seattle
Mike Barry, Department of Epidemiology
Peter Cleary, Project NEON, Seattle’s LGBTQ Center (formerly Gay City Health Project)
Kristin Beima-Sofie, Department of Global Health
Jane J. Lee, School of Social Work

Project summary
This project’s proposed aims were to (1) explore facilitators, contextual experiences, and patterns of methamphetamine (MA) use among cisgender men and transgender people who have sex with men (MTSM) through qualitative interviews (N=40) and (2) generate an MA use continuum framework for later use in the development of a quantitative, population-level study instrument.

In the corresponding evaluation plan, we identified two markers of success in our work: (1) the inclusion of >20 transgender individuals in our study and (2) the effective, active inclusion of our community partner agencies throughout the research work.

At the conclusion of data collection (August 2023), we had interviewed 49 individual MTSM with a history of MA use, including 20 transgender, nonbinary and gender nonconforming (gender diverse) individuals. The findings of this work can be successfully translated to the development of a quantitative instrument that measures MA trajectories and associated risk factors in a large sample.

Spatiotemporal high-resolution prediction of wildfire smoke exposure: Leveraging satellite remote sensing and low-cost sensor data

Investigators
Jianzhao Bi, Department of Environmental & Occupational Health Sciences
Joel Kaufman, Departments of Medicine and Epidemiology
Adam Szpiro, Department of Biostatistics
Nicole Errett, Department of Environmental & Occupational Health Sciences
Elizabeth Gribble Walker, Clean Air Methow

Project summary
The project aimed to address the lack of accurate exposure estimates for wildfire smoke PM2.5 and develop a proof-of-concept framework for high-resolution wildfire PM2.5 estimation in Washington, with an ultimate goal of expanding it to cover the entire US in future projects.

In this pilot project, we developed a prototype machine learning framework based on the Random Forest algorithm. The framework has demonstrated its ability to effectively incorporate multiple data sources into wildfire PM2.5 prediction, including satellite, low-cost sensors, high-resolution meteorology and a comprehensive set of geographic covariates. The framework form the solid foundation for our subsequent wildfire PM2.5 modeling analysis. We organized and rigorously tested high-performance computing resources, ensuring that our modeling analysis can be efficiently executed. These developments highlight the project’s alignment with the original research and evaluation strategy, which ultimately aims to enhance the accuracy of epidemiological analyses and advancing early warning systems for severe smoke episodes.

Notably, the preliminary outcomes from this pilot grant have already facilitated the applications of two larger grants. One is the ECHO AWARE initiative funded by NIH, and another is an NIEHS K99/R00 grant with a fundable score. These achievements underscore the invaluable role of the pilot grant in laying the statistical groundwork, validating exposure assessment methodologies and providing crucial insights that have contributed to the success and expansion of our research endeavors.

Evaluating a community-based doula program to inform upcoming expansion of doula care under Medicaid in Washington: a mixed-methods, community informed approach

Investigators
Taylor Riley, Department of Epidemiology
Dila Perera, Open Arms Perinatal Services
Anjum Hajat, Department of Epidemiology
Mienah Z. Sharif, Department of Epidemiology

Project summary
Community-based doulas, who provide informational, physical, and emotional perinatal support and are from the same communities of the families they serve, are increasingly recognized as a strategy to improve perinatal health and health inequities. However, little is known about successful implementation and sustainability of community-based doula programs. Therefore, the goals of this project were to conduct a mixed-methods study to examine the implementation and health outcomes of a community-based doula program serving low-income families and the barriers and facilitators that influenced these outcomes. This project was conceptualized and implemented by a collaborative academic-research team including Open Arms Perinatal Services and social epidemiologists at the University of Washington.

We conducted an explanatory sequential mixed methods design (quan->QUAL) with programmatic data and focus groups with community-based direct service providers. First, we analyzed programmatic data, including time spent with families and health outcomes, among all families enrolled in the program from January 2016-December 2022. Then, building on these quantitative findings, we conducted four in-depth focus groups with the program’s direct service providers. Qualitative data were analyzed using thematic analysis. Additionally, we had a member checking event where we shared and discussed the preliminary mixed-methods findings with participants in order to validate these findings.

Results indicated community-based doulas provide extensive support to the families they serve during pregnancy, labor, and delivery, and postpartum. Among the over 2,000 families served, there were 14,672 total home visits that totaled 17,774 hours. Over $87,000 in direct funds and 7,000 tangible items (e.g. diapers) were dispersed to families. Preterm birth ranged from 4-9% across programs and the vast majority (>94%) were lactating at birth. Direct service providers identified holistic, culturally-matched services and “doula-ing the doula” (organizational infrastructure to support doula’s work) as facilitators. Barriers included the intersecting systems of oppression that underlie the primary challenges faced by direct service providers, including lack of community resources and power asymmetries within birth settings, that can lead to provider burnout. These findings document the positive impact of community-based doulas and bolsters the calls for their increased compensation and structural supports.

Optimizing cervical cancer screening guideline adherence and adoption

Investigators
Michelle Shin, Department of Child, Family, and Population Health Nursing
Allison Cole, Department of Family Medicine

Project summary
The goal of this study was to identify socioeconomic factors associated with cervical cancer under-screening by screening modalities in a national sample of commercially insured population in the United States (US). We used a nationally representative anonymized longitudinal administrative claims dataset called Optum Clinformatics® Data Mart, which contains all claims (e.g., verified, adjudicated, adjusted, and denied) for approximately 13 million annual covered lives.1 During the award period, we successfully worked with the University of Southern California (USC) Schaeffer Center for Health Policy and Economics to establish the Optum Data License Agreement and access to the de-identified, limited data set through the shared secure network terminal at USC.

We used Optum Clinformatics® Data Mart from 2012-2021 to identify individuals aged 30-64 to examine over and under-screening to understand national patterns of guideline adherence. Average-risk females with continuous enrollment for six years for years starting in 2013-2017 and at least one claim were included. Those with a history of hysterectomy and/or cervical cancer were excluded. According to the 2012 US Preventive Services Task Force guideline, adherence was defined as a screening interval of 4.5-5.5 years for co-testing/HPV testing as the index screening modality and 2.5-3.5 years for cytology-only, and over-screening as <4.5 years and 5.5 years and >3.5 years including lack of subsequent screening, respectively. We compared the distribution of screening adherence by screening modality, race, education level and household net worth using chi-squared test.

A total of 1,422,258 individuals ages 30-64 were included in the analysis. Among the eligible sample, 1,016,067 individuals received at least one cervical cancer screening from 2013-2017. Only 7.4% received guideline-adherent cervical cancer screening in this nationally representative sample of commercially insured females. Over- and under-screening varied significantly by screening modalities, race, education level and household net worth, indicating the need for tailored strategies while ensuring equity. Our study demonstrated that more research is needed to ensure that guideline changes, introduction of screening modalities, and de-implementation of cytology do not exacerbate existing disparities. The findings can inform policies for incentives that address over-screening and under-screening to eliminate cervical cancer disparities in the US.

Conducting a needs and capacity assessment with midwives in rural Bangladesh to develop a tailored mental health promotion curriculum for Bangladeshi women during the perinatal period

Investigators
Annika Sahota, Mental Health Matters of Washington
Jody Early, UW Bothell School of Nursing & Health Studies
Iftikher Mahmood, Hope Foundation for Women and Children of Bangladesh

Project summary
Bangladesh presents a unique atmosphere because they have made significant strides as a nation to achieve maternal and child health objectives; yet, perinatal mental health care remains to be essentially non-existent. This is ultimately due to a lack of infrastructure and investment in psychological wellbeing. The aim of this project, in collaboration with the HOPE Foundation for Women and Children of Bangladesh, was to begin building the foundation for improving perinatal mental health promotion across all socio-ecological levels.

While conducting our preliminary assessments, three areas of work emerged: 1) clinical procedures and protocols 2) midwifery training and 3) social impact. Conversations were held with HOPE employees with various roles as well as with partner NGOs (specifically within refugee camps), and patient families to become more knowledgeable about current clinical processes for detecting, preventing and treating psychological challenges during pregnancy within HOPE patient populations. Through these conversations we learned that a single clinical psychologist serves all HOPE facilities and an external psychiatrist visits the field hospital once a month to provide care. Furthermore, we learned that mental health evaluations are not standardized practices. We also learned that collection of patient history and communication between providers typically does not occur unless specifically requested by the psychologist or psychiatrist.

It must be noted that the HOPE Foundation has created a guideline for post-delivery mental health visits, but the barrier to perinatal mental health care is ensuring these guidelines are implemented. These guidelines indicate that mental health visits should occur 5 days, 14 days, 28 days, and 3 months after delivery. The clinical psychologist informed us that patients are advised to attend these mental health check-in appointments at the discretion of their provider (e.g., physician, midwife, etc.). This ultimately leads to many perinatal mental health conditions going undetected as the vast majority of healthcare providers at the HOPE Foundation do not have foundation training in mental health care.

Due to the combination of these factors, only 30% of high risk patients attend the first appointment, 5 days postpartum. Approximately 35% of the patient population will skip at least one appointment but attend at least one of the later appointments. Lastly, of those who do no attend any appointment, approximately 50% of this population express suicidal ideation some point postpartum. Factors influencing a patient’s attendance are believed to be directly correlated with the severity of mental state. For instance, an individual’s mental wellbeing has deteriorated to such a point that they no longer care about the social stigma. Additionally, patients who attended follow-up mental health appointments from the start typically expressed having greater familial support and recognition of psychological wellbeing. Through our evaluation a few recommendations we have suggested are: administration of institutional questionnaire to all patients– regardless of appointment type, integration of mental health check-ins with newborn check-ups, improving connection and communication among providers, and investing in the clinical psychologist by providing supplemental training opportunities.

While evaluating the midwifery training program offered by the HOPE Foundation through evaluation of the curriculum and scoping conversations with students we learned there is a significant gap in the midwifery education. Currently midwifery students have little to no formal knowledge or training in mental health issues. This is a systemic problem as the midwifery curriculum is determined at the governmental level, meaning all institutes must provide the same courses and training without modification. One potential ‘loophole’ to this rule to begin implementing change internally prior to obtaining governmental approval is to classify perinatal mental health specific training as an extracurricular activity.

Finally, while examining behaviors and perceptions towards mental health from the community level to an individual level we learned there is a lack of awareness among patients about maternal health, specifically mental health care. Other social factors impacting access to effective care include early and child marriages, Islamic beliefs, use of traditional birthing practices, and biological sex preference of fetus / neonate. Moreover, mother-in-law and husband-related stressors were identified as leading causes of mental health issues among women.

Self-employment, well-being, and the social determinants of health: an exploratory study of microenterprise home kitchen operations in California and Washington

Investigators
Will von Geldern, Evans School of Public Policy & Governance
Anjum Hajat, Department of Epidemiology
Heather Hill, Evans School of Public Policy & Governance

Project summary
This project team sought to understand how entrepreneurs perceive the effects of self-employment on their mental health and social determinants of health such as financial security, social capital and health care access. We also hoped to elucidate the decision-making processes of self-employed individuals from marginalized communities to better inform future policymaking in this area.

We completed 37 interviews with active home-based food business owners recruited through community partners in San Diego and Seattle. After completing approximately half of our anticipated interviews, we began coding interview data through an iterative and collaborative process. Collaborative coding of several transcripts enabled the development of a codebook, and codes were subsequently applied to all 36 valid interview transcripts. We then met to discuss potential themes for manuscript development.

Initially, we had planned to focus our analysis on several potential topics including the perceived effects of self-employment on mental health and social determinants of health and the importance of formal home kitchen permits to health outcomes and social determinants. Our discussions, the content of interviews, and additional reading led us to focus instead on precarious employment as a framework for understanding the self-employment experiences of study participants. Precarious employment is a multidimensional concept which scholars have used to assess employer-worker relationships, and which has been consistently connected with adverse health outcomes.

Many low-income workers in the United States face significant health-related consequences as a result of precarious employment relationships. Our analysis identified some ways in which self-employment aligned with experiences of precarious employment and other ways in which self-employment seemed to be very different. Existing research has not thoroughly described how self-employment in marginalized communities differs from other employment opportunities, and how this relates to mental and physical health outcomes. We believe our data could help identify mechanisms underlying the precarity (and benefits) of self-employment and contribute to further research in this area.

We will present early findings of our analysis using a precarious employment framework at the Association for Public Policy Analysis and Management (APPAM) conference in November 2023. These findings suggest that self-employment helped mitigate or eliminate some adverse experiences associated with precarious employment such as unpredictable work schedules, social isolation and physically damaging working conditions. The ability to work from home was also a widely-noted benefit of self-employment within our unique sample. On the other hand, participants referenced common experiences of precarious employment such as low and unstable incomes, long hours and multiple jobs.

Unique risks of growing hazards: The influence of culture and marginalization on extreme heat health risks in Washington State

Investigators
Cassandra Jean, Department of Environmental & Occupational Health Sciences
Nicole Errett, Department of Environmental & Occupational Health Sciences
Ann Bostrom, Evans School of Public Policy & Governance
Dan Abramson, Department of Urban Design and Planning
Jamie Donatuto, Swinomish Indian Tribal Community

Project summary
Climate-sensitive hazards can jeopardize the health of all populations. However, certain population groups are more vulnerable to health and well-being effects from these hazards (e.g., from extreme heat). While youth, particularly those from historically marginalized groups and communities, are one of the populations at the highest risk, their abilities may be underutilized in local climate adaptation efforts. This exploratory research:

1. Investigated youth risk perceptions and impacts of various climate-sensitive hazards (e.g., wildfire smoke, flooding, rising sea levels, and extreme heat)
2. Explored spaces where youth and community leaders can support youth-led climate-related initiatives
3. Examined current barriers, resource needs and opportunities for young folks to engage in climate and environmental solution work

Through focus group discussions with youth and in-depth interviews with community youth leaders, this study identified opportunities to leverage youth experiences, perceptions and assets to promote a healthy and resilient community in the face of various compounding climate-related threats. While youth recognize the shifting climate and have become motivated to address such justice issues, barriers like limited financial capacity and political support impact their long-term participation. Findings suggest multiple benefits of supporting youth integration into climate adaptation efforts as they can:

1. Illuminate nuances of climate and health dynamics impacting community members
2. Create avenues for increasing outreach and education
3. Build community capacity through climate actions and advocacy work

Laying a foundation for a human centered design (HCD) hub within the Government of Tanzania to innovate nutrition solutions

Investigators
Tricia Aung, Department of Human Centered Design & Engineering
Sean Munson, Department of Human Centered Design & Engineering
Germana Henry Leyna, Tanzania Food and Nutrition Centre
Debora Niyeha, USAID Advancing Nutrition Tanzania
Rebecca Heidkamp, Johns Hopkins School of Public Health

Project summary
The goal of this project was to lay a foundation for a human centered design-trained hub within the government’s Tanzania Food and Nutrition Centre (TFNC) to lead initiatives that leverage HCD methods to create context-appropriate, community-informed solutions to priority nutrition issues.

The UW team completed a literature review of applications of design to improve health outcomes in LMICs. We conducted this literature review during the Winter 2023 quarter with a team of UW students across the Department of Human Centered Design & Engineering and School of Public Health. We pursued this literature review to inform content and strategy of the TFNC workshop curriculum. Our landscaping includes 127 articles from human computer interaction (HCI) and health publications, and identifies trends in geographic representation, health topics, artifacts designed, users, design methods, and scale up/sustainability plans across all articles and disaggregated by publication type. Beyond helping us identify guest speakers and relevant examples for the workshop, this activity fills a global knowledge gap on how HCD has been used for health projects in LMICs. We intend to submit two papers for peer-review; one paper will be drafted for a global health audience and one paper focused on technology-related innovations will be drafted for a HCI audience.

We integrated findings from the literature review, consultations with global health professionals that have conducted HCD workshops, existing HCD curriculum, and TFNC’s priorities to develop curriculum for a HCD workshop in Dar es Salaam, Tanzania. The workshop aims: (1) Learn basics of applying the design process to encourage innovative solutions using Tanzania nutrition issues as case studies; (2) Collaborate with team members to develop project ideas into concept notes; and (3) Expand collaboration between TFNC and HCDE. The workshop aimed to generate concept notes for projects that integrate HCD methods on three priority TFNC topics (exclusive breastfeeding, transition from exclusive breastfeeding to complementary feeding, and care-seeking for children with severe acute malnutrition). TFNC selected workshop participants by advertising the training opportunity to staff and reviewing application essays outlining what applicants hoped to get out of the training. At the end of the workshop, each of the three groups presented concept note outlines, which described the nutrition problem, identified research and design questions, and proposed methods for data collection and analysis.

Improving Birth and Delivery Outcomes among Afghan Refugees in Seattle/King County through a Community-Guided Approach

Investigators
Mienah Z. Sharif, Department of Epidemiology
Arjee J. Restar, Department of Epidemiology
Ariana Anjaz, Afghan Health Initiative

Project summary
The primary goals of this project was to identify the facilitators and barriers to improve practices of Afghan refugees during pregnancy including seeking prenatal care services and opting for hospital births. This project worked with the only Afghan-led community-based organization in Washington state to conduct focus groups with Afghan refugees (men and women) and to discuss findings and next steps with community members at a community townhall. The focus groups identified lack of transportation, lack of social support, husband’s work schedules, insurance coverage and long waiting periods for appointments as primary barriers to seeking prenatal care services and opting-in for hospital births. Participants described social support (e.g. home visits by healthcare staff), husband’s involvement and healthcare professionals with clear and welcoming communication are all facilitators to their healthcare seeking behavior during pregnancy.

The PI and the leadership of AHI have met to discuss interests in presenting the findings in peer-reviewed manuscripts and at public health professional meetings. We also plan to share the findings with other refugee-serving organizations in King County with the goal of co-developing proposals for better serving refugees based on common needs and challenges community members share across organizations. We also plan to convene early 2025 to apply for additional funding to expand the scope of the project.