Spring 2024 pilot awardees are reporting progress in their projects

Integrating end-user needs and perspectives in the measurement of young adult climate change distress

Investigators
Jessica Acolin, Department of Psychiatry & Behavioral Sciences
Sonya Jampel, Public Health – Seattle & King County
Jennifer Atkinson, Interdisciplinary Arts & Sciences (UW Bothell)
McKenna Parnes, Department of Psychiatry & Behavioral Sciences
Jason Kilmer, Department of Psychiatry & Behavioral Sciences
Brittney Hultgren, Department of Psychiatry & Behavioral Sciences

Project update
The objective of this project is to develop and pre-test the Climate Distress Questionnaire (CDQ), a brief measure of climate distress suitable for epidemiologic surveys. This project had two Aims. Aim 1 was to conduct focus groups with end-users of the CDQ. Aim 2 was to conduct qualitative pre-testing of the CDQ among young adults. At the mid-point of the project, we have reached significant achievements with regards to Aim 1.

To date, we have conducted five focus groups with a total of 28 end-user participants. We conducted one focus group in August with environmental epidemiologists (N=6) working in the areas of climate change and other environmental hazards and interested, but not yet involved in, climate change distress research. Participants were based across the United States. This was an important group to include, given their expertise specifically in population-level epidemiologic surveys and their eventual role in using the future CDQ to quantify prevalence, investigate etiologic mechanisms, and explore disparities.

We conducted two focus groups in September with mental health clinicians who have treated climate distress in their practice (N=4 and 3). Participants included mental health clinicians, including psychologists, mental health counselors, and social workers, in private and group practice based in the United States and Canada. All clinicians specialized in providing services for climate-related mental health concerns. This was an important group to include, given their on-the-ground experience with the phenomenon and clinical training and insights into diagnostic considerations, differentiating climate distress from other forms of distress or disorder, as well as their eventual role in translating research findings related to the future CDQ into treatment and prevention.

We conducted one focus group in September with experts based in community organizations (N=8). Participants included communications specialists, educators, artists, and non-profit leaders, all of whom had supported young adults experiencing climate distress through their work focused on climate change. This group was important to include for their cross-disciplinary insights into climate distress, particularly how the construct may be perceived and experienced in the general public, as well as their eventual role in translating future research findings into communications and education materials.

We conducted one focus group in September with professionals at state and local health jurisdictions from across the United States (N=6). Participants included epidemiologists, program coordinators, and program managers focused directly on climate change or on related fields, such as injury prevention or teen mental health. This group was important to include for their applied public health insights into specific use cases for the future CDQ.

We are also in the process of recruiting of survey administrators with expertise in large, population-based surveys. Due to concerns that individuals in this group would be hesitant to share specific information about their surveys to “competing” surveys, we have elected to collect data individually via interviews and written questionnaires. To date, we have one completed response as well as interest from additional administrators. All focus groups have been transcribed for analysis, and analysis is underway.

Identity safety in medicine: a qualitative study to elicit patient perspectives and develop a framework to apply in clinical settings and research

Investigators
Brian Wood, Department of Medicine
Justin Bullock, Department of Medicine
Crystal Brown, Department of Medicine
Reggie Casanova-Perez, Department of Biomedical Informatics and Medical Education

Project update
The principal aim of our project is to gain a better understanding of patient perspectives on identity safety in healthcare, which we hope will contribute to development of strategies to help individuals feel safe during medical encounters, feel that they can be their true authentic selves with medical staff and medical providers and feel that they can discuss difficult issues or share sensitive information, which will improve the quality of their healthcare.

We are accomplishing this through a qualitative study in which we are enrolling people with HIV at three clinical sites with varied geopolitical environments (sites from a major metropolitan area in Washington, a more mid-size city in Montana, and a lower population area of Idaho). We are enrolling individuals with HIV because of a relatively high rate of stigma around HIV plus a relatively high occurrence of intersectionality with other stigmatized conditions, such as mental health issues, substance use, incarceration, and others. A secondary aim of the study is to create a framework for understanding and studying identity safety in healthcare in future research.

To date, since the launch of the grant our progress is as follows:

• Completed the IRB review and approval process
• Completed a successful community advisory board meeting, during which we gained insights and input from 10 community members, who gave feedback on our study goals and methods (including recruitment strategy and interview plans).
• Our study team reviewed, revised and finalized the interview guide, and focused on integrating advice and feedback from the community advisory board meeting.
• We began recruiting at all three clinical sites via study flyers and thus far have had significant interest from all three sites; interested parties complete a survey via REDCap that asks basic demographic factors and general questions about past feelings of safety or non-safety in the healthcare setting. We are prioritizing offering interviews to individuals of diverse backgrounds with various durations of time since their HIV diagnosis (the importance of this strategy was emphasized by the community advisory board) and to date we have completed 10 out of the 20 planned interviews.
• Of the completed interviews to date, two participants are from Montana, two from Idaho and six are from Western Washington. We have been successful at engaging volunteers from diverse demographic backgrounds and we feel that interviews have been rich and are providing valuable insight into experiences and perspectives on what it means to feel safe during a healthcare encounter and what clinicians and clinics can do to promote feelings of safety, promote comfort having difficult conversations, and encourage people to feel that they can be their true authentic selves during medical encounters.
• Volunteers who have completed interviews have been given Tango gift cards as a thank you for their time and participation.
• For the completed interviews, we have uploaded audio recordings to Rev and have begun reviewing transcripts and developing a code book for analysis.

Exploring the Impact of Communication Styles in Health Chatbot using Large Language Models to Support Family Caregivers from Multicultural backgrounds

Investigators
Elina Hwang, Foster School of Business
Stephanie Lee, Foster School of Business
Serena Jinchen Xie, Department of Biomedical Informatics and Medical Education
Rebekah Baik, Foster School of Business
Weichao Yuwen, School of Nursing & Healthcare Leadership (UW Tacoma)

Project update
Advances in generative large language models (LLMs) have created significant opportunities for AI-based chatbots in healthcare. However, concerns about their cultural sensitivity persist. It remains unclear whether these chatbots can understand the nuanced cultural differences essential for effective communication in healthcare, where building rapport is crucial for patient compliance, satisfaction and outcomes.

This proposal seeks to lay the groundwork for developing health chatbots that adapt to different cultural communication styles. First, we propose to conduct a literature review on cultural preferences in communication styles, with a focus on healthcare. This will help identify factors that can assist in adapting AI-based chatbots to be culturally sensitive (Aim 1).

Next, we propose to develop prototypes of AI-based therapy bots that incorporate multiple communication styles and gather feedback from participants of diverse racial and ethnic backgrounds (Aim 2). The findings are expected to enhance the cultural sensitivity and effectiveness of therapy chatbots for diverse patients. To achieve our goals, we have assembled an interdisciplinary team of faculty and doctoral students from the Foster School of Business, the School of Medicine, the Department of Communication and UW Tacoma’s School of Nursing & Healthcare Leadership. We meet weekly and have made significant progress toward achieving our goals. We have completed our literature review, and based on the insights gathered, we have developed prototypes of therapy bots with various
communication styles. Currently, we are creating surveys to evaluate their effectiveness.

Clinical and structural approaches to addressing substance use disorder in HIV care in Zimbabwe: Formative work

Investigators
Helen Jack, Department of Medicine
Malinda Kaiyo-Utete, University of Zimbabwe
Theresa Matson, Kaiser Permanente Washington Health Research Institute
Kudakwashe Takarinda, OPHID
Emily Williams, Department of Health Systems and Population health

Project update
The aim of this study is to validate a single-item substance use disorder (SUD) screening tool against a clinical interview for substance use (CIDI diagnostic interview) in a sample of 1064 patients in HIV care in Zimbabwe. This study will also provide the first prevalence estimate of substance use in HIV care and one of the first estimates of the prevalence of substance use in the country and will lay the foundation for future work to develop and implement interventions to address substance use.

This is a collaborative project between the Organization for Public Health and Development (OPHID), a Zimbabwean non-profit organization, and University of Washington. Data collection for this study is taking place in Bulawayo and Gwanda districts in southern Zimbabwe. This aim is nested within an ongoing study, funded by the UW Behavioral Research Center for HIV (BIRCH), to validate a three-item alcohol use disorder screening tool in HIV care in Zimbabwe. Progress to date includes:

1. Translation and cultural validation: Prior to beginning data collection, we engaged in an extensive process to translate to Ndebele (a local language) and culturally tailor the substance use screening tool, CIDI diagnostic interview, and the rest of the survey tool. This involved consultation with a linguistic anthropologist, having two translators translate the tools to Ndebele, reconciling the two translations, reviewing the translation line-by-line with the data collection team and getting their feedback, and piloting the full tool with three patients prior to beginning data collection. We also consulted with psychiatrists in Zimbabwe to develop a list of commonly used substances to use as part of the CIDI.
2. Building online survey tools: We created a set of digital data collection tools on UW RedCAP to facilitate data collection, tested these tools, and loaded them onto 6 tablets in Zimbabwe for data collection. Data collection will be verbal, and the data collectors will enter the data into RedCAP as they administer the tools.
3. Data collector training: Drs. Jack, Kaiyo-Utete and Takarinda conducted a three-day training for the data collection teams at OPHID’s offices in Bulawayo from October 9-11. There are three data collection teams, each of which is made up of a data collector (clinical psychology trainee or other person trained in healthcare) and nurse. The data collectors administer the screening tools and collect sociodemographic data, and the nurses administer the clinical interviews. During the training, we discussed the purpose of doing this study, reviewed the tools and translations in depth, role played data collection (Image 1), discussed research ethics, and went to one clinic to pilot the data collection processes.
4. Data collection: Data collection began on October 22, and we have collected data on 146 patients (of a total sample size of 1064) to date. In our power calculations, we anticipated the prevalence of substance use to be 6% and the prevalence of alcohol use to be 12%, but these were approximations, as there is no Zimbabwean data available. Analysis of the first 66 patients shows prevalence of alcohol use disorder of 28.8% and substance use disorder of 4.5% (primarily cannabis use disorder).
5. Next steps and additional funding: We have begun to lay the foundation for future work, as described below. In addition to the Population Health Initiative pilot award, our project team was also awarded a University of Washington Addictions, Drug, and Alcohol Institute (ADAI) Small Grant to support this work.

A community co-led epidemiologic study of methamphetamine use patterns and associated factors among cisgender men and transgender people who have sex with men

Investigators
Matthew R. Golden, Department of Medicine
Christopher Archiopoli, Strength Over Speed
Mike Barry, Department of Epidemiology
Jack Harlan, Peer Seattle
Barbra A. Richardson, Department of Biostatistics

Project update
In our proposal, we specified the following goals: (1) recruit >2,500 individual cisgender men and transgender people who have sex with men (MTSM) for the study between July and November 2024 and (2) hold two “meet the researcher” salons (i.e. community partner-hosted research meetings), one in July 2024 and the other February 2025.

To date, there have been 2,529 attempts to take the survey, 1,728 of which have resulted in at least partial survey completion. After de-duplicating individuals who appeared to have taken the survey >1 time, we have an analytic sample of 1,721. We are encouraged by the reach of the survey, although the analytic dataset is smaller than anticipated. However, in the next section, we will describe how the sample composition makes up for this smaller N.

In partnership with co-PI Mr. Archiopoli and co-I Mr. Harlan, we held a community salon in July as planned. Peer Seattle, our community partner, promoted the event at their brick-and-mortar location and publicized it in social media (flyer in appendix). >45 community members, most of whom are members at Peer Seattle, attended the event. Mr. Barry presented the preliminary qualitative study’s findings and elicited feedback on strategies to make the study instrument used in this work as affirming as possible to participants with a history of meth use. We look forward to sharing a formal evaluation of the two salons in our final report to PHI.

Additionally, Mr. Barry presented preliminary findings of this project at the UW CFAR Research Symposium on October 11. Community co-PI Mr. Archiopoli was present at the symposium. The section received positive feedback.

Paid Family Leave and Parent Mental Health: Evidence from Administrative Data

Investigators
Tom Lindman, Evans School of Public Policy & Governance
Anirban Basu, School of Pharmacy
Anjum Hajat, Department of Epidemiology
Heather D. Hill, Evans School of Public Policy & Governance
Jessica Jones-Smith, Department of Health Systems and Population Health

Project update
Our study evaluates the impact of paid family leave on the likelihood of parents receiving care for depression and anxiety. Data for the project come from Washington All Payer Claims Database insurance claims (APCD) linked with administrative records from the WA Paid Family and Medical Leave (WA PFML) Program. Our study leverages quasi-random features of WA PFML benefit rules to assess the impact of paid leave on parent mental health following the birth of a child. Our study will be the first in the U.S. to use administrative data to evaluate whether paid leave affects parent mental health outcomes. To date, the team has obtained IRB approval for all analyses in the study, begun cleaning and analyzing WA PFML records and is in the final stages of obtaining WA APCD
records.

Ensuring Equality: Language Access in Civil Protection Orders

Investigators
N. Jeanie Santaularia, Department of Epidemiology,
Alice M. Ellyson, Department of Pediatrics
Avanti Adhia, Department of Child, Family, and Population Health Nursing
Leticia Figueroa, King County Prosecuting Attorney’s Office

Project update
The overall goal of our pilot project is to describe language access challenges in civil protection order (CPO) processes across counties in Washington state. We have two aims:

• Aim 1. Characterize language access of written materials (e.g., websites, instructions, e-submission portals) required to file and receive a CPO for interpersonal violence.
• Aim 2. Assess language access in verbal settings (e.g., interpretation services in hearings) using court observations in a set of counties in Washington state.

To date, we have been in close communication with our community partners to receive input and feedback on all aspects of the project. We hired a graduate research assistant to assist on the project (MPH student in the Department of Epidemiology). For Aim 1, we created a data abstraction tool, piloted the tool with a small number of counties, double coded a subset of counties with the tool (i.e., had two independent coders code the same websites using the tool and comparing coding), and finished collecting the data from websites. For Aim 2, we submitted an IRB application and approval is pending. We have created the draft of the data abstraction tool, and we developed a plan to access CPO hearings in two counties (King and Pierce) virtually and in-person.

Exploring stakeholder perspectives on the use of controversial datasets in population health research

Investigators
Stephanie M. Fullerton, Department of Bioethics & Humanities
Sarah C. Nelson, Department of Biostatistics
Jacklyn Dahlquist, Department of Bioethics & Humanities
Stephanie M. Gogarten, Department of Biostatistics

Project update
The aims of this pilot project were to (1) perform a scoping literature review to identify relevant scientific and scholarly discussions of use of a controversial dataset (the Human Genome Diversity Project, or HGDP) in population health research, and (2) conduct a series of qualitative interviews with key
informants knowledgeable about the historic or current relevance of HGDP data for population health research and which communities may be impacted by its ongoing use.  

For Aim 1, we have completed the literature review and are now starting to prepare a manuscript for publication. We based our review in reverse citation searches of six key HGDP resource papers, identifying 1,848 manuscripts published since 2010 (as publications prior to 2010 were analyzed in a
previous publication). We manually screened abstracts, then full text, to exclude 631 publications that were either not primary research (e.g., commentaries and reviews) or did not directly use the HGDP data. The final collection of 1,217 articles were then each assigned to one of four categories of HGDP
research use: health‐related study, non‐health related phenotype, no phenotype (e.g., population genetics study), or methods development. Relevant meta data, including dates of publication, geographic locations of study authors and funding source have also been extracted and are being analyzed for the planned manuscript. 
 
For Aim 2, we have created a prioritized list of potential interviewees, based on reverse citation searches of the same six HGDP resource papers used in Aim 1, as well as early (published in 2005) accounts of the HGDP project written by social scientists. Our list includes geneticists and informaticians who have used
HGDP data, social scientists and historians who have written about the HGDP and its broader social significance, and indigenous data sovereignty scholars. We will begin contacting potential interviewees in mid‐November with the aim to completing all interviews by winter 2025

Building and evaluating AI-augmented treatment support for individuals with tuberculosis

Investigators
Martine De Cock, School of Engineering and Technology (UW Tacoma)
Sarah Iribarren, Department of Biobehavioral Nursing and Health Informatics
Fernando Rubinstein, Institute for Clinical Effectiveness and Health Policy
Daniil Filienko, School of Engineering & Technology (UW Tacoma)
Weichao Yuwen, School of Nursing & Healthcare Leadership (UW Tacoma)

Project update
Tuberculosis (TB) remains one of the world’s deadliest diseases, killing three people per minute. Each year an estimated 10.6 million people develop TB and 1.5 million die from this curable disease. A critical challenge to meeting the World Health Organization’s targets to end TB is ensuring patients’ adherence to the six-month treatment regimen. Innovative, patient-centered approaches are needed to empower individuals with TB and frontline healthcare workers to meet the end TB goals. The TB Treatment Support Tools intervention, iteratively developed by a UW team with patients and clinical partners, combines a Spanish-language mobile application for patient-centered support, monitoring and communication, with a drug metabolite test.

This project aims to utilize data from a pragmatic clinical trial of the TB-TST intervention to leverage and fine-tune large language models (LLMs) for automating services and conduct a preliminary evaluation comparing LLM-supported chatbot-generated responses with those of clinical experts. We have developed
several models powered by GPT4 that can answer questions such as “Do I take all of the pills together or some in the morning and some in the evening?” or “Is it normal to continue having night sweats?” To this end, we used various fine-tuning techniques such as prompt engineering, few-shot learning and retrieval-augmented generation. We are in the process of selecting the top three performing models that will then go forward for an evaluation by 10 clinical experts. These experts will include clinical community partners who served as treatment supporters during the trial, TB experts and bilingual Spanish graduate students. Each evaluator will engage with all the bots, simulating patient scenarios such as experiencing side effects or seeking information about the disease and its treatment. The evaluators will rate the quality of the responses of the support bots based on accuracy, linguistic appropriateness, clinical relevance and empathy.

Assessing readiness for newborn pulse oximetry screening in Northern Ghana

Investigators
Nelangi Pinto, Department of Pediatrics
Kristin Beima-Sofie, Department of Global Health
Alhassan Abdul-Mumin, Tamale Teaching Hospital
Donna Denno, Departments of Pediatrics and Global Health
Abdulai Abubakari, University for Development Studies
Rafiuk Cosmos Yakubu, University for Development Studies

Project update
The goal of this project is to conduct the first phase to co-design of newborn pulse oximetry screening (which has been implemented in many high-income countries to increase early detection of congenital heart disease and other significant newborn illness) implementation with communities in the Northern Region of Ghana (a region that experiences significant health disparities). Our specific aims were: 1) To Assess the current healthcare organizational capacity in the Northern Region for newborn POS and cascade care for positive screens and 2) to explore POS acceptability, appropriateness, and feasibility across facility levels and co-develop/adapt interview guides and site assessments for future use across the Northern Region.

In terms of progress to date, instruments for administrative data abstraction, health facility surveys (hospitals and primary clinics), provider focus groups and key informant interviews were drafted, reviewed and revised with the study team and providers in Ghana. Finalized instruments were submitted with the IRB application to UW (SCH relying) and The Navarango Health Research Centre Institutional Review Board (NHRCIRB) in Ghana. IRB exemption was granted by UW on August 1, 2024, as no identifiers will be provided to UW researcher. The NHRCIRB gave its ethics approval on August 30, 2024.

All instruments for data abstraction and site reviews have been programmed into the REDCap database and are currently being tested to facilitate data input by the Ghana research team. Facilities will be contacted for year end summary data in early November. Ghanian research coordinators have been hired and trained and are pilot testing the facility survey prior to its administration next month.

Sembrando Salud: Designing Healthy Eating Futures for Latinx Adolescents

Investigators
Carla Castillo, Department of Human Centered Design & Engineering
Sean Munson, Department of Human Centered Design & Engineering
Julie Kientz, Professor, Department of Human Centered Design & Engineering
Pia Chaparro, Department of Health Systems and Population Health

Project update
This project aims to explore how Latinx adolescents in rural Washington understand and experience food choices as they gain autonomy, focusing on their eating behaviors, family communication practices and dynamics. Additionally, we are working with adolescents and caregivers to identify challenges, opportunities and co-design concepts that could inform the design of an intervention.

We have developed recruitment materials, a food diary, interview protocols and co-design activities, refining these through piloting and feedback from collaborators. A directed research group, consisting of two undergraduate and two graduate students, meets weekly for two hours to support the study’s progress.

Over the past two months, we have worked with the IRB, making modifications based on their feedback to streamline the consent and assent process and address other clarifications. Study materials in English and Spanish have been provided to the IRB and approved. We plan to begin recruitment shortly.

Building Reparative Connections and Community Health Strategies across Sites Impacted by Nuclear Weapons Development

Investigators
Sasha Su-Ling Welland, Department of Gender, Women & Sexuality Studies
Holly M. Barker, Department of Anthropology

Project update
This project advances collaborative research about the environmental and health impacts of nuclearism on frontline communities created through weapons development and testing, mining and manufacturing, and waste management. We are working to bring together representatives of community health organizations
from Hanford (Washington), St. Louis (Missouri) and the Republic of Marshall Islands (RMI) to surface connections among these Manhattan Project sites siloed from one another along a chain of nuclear production shrouded in government secrecy; and to share strategies for meeting ongoing health care and
environmental needs.

This fall we communicated with community members about these plans and determined the most effective way to develop relations and assess future needs is to hold a three-day workshop on the University of Washington campus. We will focus especially on the caring labor of women leaders and will include one student (undergraduate or graduate) from each site to build intergenerational networks and develop and support future leadership. Our aims for the workshop are to:

• Cultivate relationships and understanding about the consequences of nuclear weapons development across entities
• Discuss the gendered dimensions of local leadership in the health arena
• Build a new community of support
• Conduct an in-depth needs assessment conversation to determine the types of research activities that would best support community-led advocacy
• Identify possibilities and challenges in community health strategies
• Provide training to a potential future leader from each location

Individual and community-level effects from climate change driven heat and wildfire smoke co-exposures among a Washington state agricultural community

Investigators
John Flunker, Department of Environmental & Occupational Health Sciences
Coralynn Sack, Departments of Environmental & Occupational Health Sciences and Pulmonology
June Spector, Department of Environmental & Occupational Health Sciences
Pablo Palmández, Department of Environmental & Occupational Health Sciences;

Project update
Our project seeks to examine the impact of extreme heat and wildfire smoke (WFS) co-exposures on the respiratory health of an at-risk agricultural population in Yakima County, Washington. Yakima County is the state’s top apple producing county, also supporting the state’s largest population of tree fruit workers. Residents of Yakima County and many Eastern Washington agricultural regions experience extreme heat and WFS co-exposure events that are increasing in frequency and duration. Tree fruit workers often must endure such exposure events with limited access to cool clean air while engaging in demanding physical labor. Little is known about the impacts of such exposures on the respiratory health of tree fruit workers and the communities in which they reside. We posit that tree fruit workers are on the front lines of heat and WFS exposures and may be the first members of the regional population to experience associated adverse respiratory health effects. We hypothesize that worker respiratory health will decline following acute heat (≥90°F) and/or WFS exposure events (PM2.5 ≥100 µg/m3), with the most pronounced reductions in respiratory health resulting from dual heat and WFS exposure events (in comparison to no/low exposure conditions).

During the award period to date we have established a tree fruit worker cohort and obtained sequential measures of respiratory health following heat and WFS exposure events. Specifically, we recruited 35 Yakima County workers from three apple farms, obtaining measures of respiratory health at baseline and during/following heat and WFS exposure events over a two-month period (August and September 2024). Within two days of the onset of an exposure event, a bilingual multi-disciplinary team of UW researchers travelled to farms and obtained self-reported heat-related illness and respiratory symptoms, spirometry and exhaled Nitric Oxide (i.e., airway inflammation) measures from workers. No high heat and WFS co-exposure events occurred during our study period (2024 was a year with relatively few heat and WFS exposure events); however, we were able to measure respiratory health following high heat and lower intensity WFS singular exposure events. We are currently analyzing associations between exposures and metrics of worker respiratory health. Results from this project will help to identify individual- and workplace- level risk factors for heat and WFS exposure and elucidate associations between exposure and reductions in lung health (and, potentially, chronic respiratory disease development). We will report our findings via a manuscript and several presentations.