Autumn 2023 Tier 1 pilot awardees report midpoint project progress

Housing affordability and chronic stress in the US: Does affordability modify the effect of neighborhoods on health?

Investigators
Amy J. Youngbloom, Department of Epidemiology
Stephen J. Mooney, Department of Epidemiology
Anjum Hajat, Department of Epidemiology
Isaac Rhew, Department of Psychiatry & Behavioral Sciences
Rebecca Walter, Runstad Department of Real Estate

Project update
This project seeks to explore the association between housing affordability and chronic stress, and the role that national housing assistance programs may play in reducing chronic stress. The project team has completed and received approval for its application for National Health and Nutrition Examination Survey and Department of Housing and Urban Development. The datasets include the use of latitude and longitude data for linking to environmental factors.

We will be paired with an analyst who will use the public data we provide to link neighborhood and environmental factors to individuals based on buffered areas around their home and that linked data will be de-identified and shared with us for our analysis. Currently we are working on obtaining Special Sworn Status, which is required to access this data in the Research Data Center (RDC), where all analysis will take place.

Once Special Sworn Status is obtained, we will be working with the Northwest Federal Statistics Research Data Center to finalize the project and get access to the RDC at UW. We are hoping to have access to the data by this summer, at which point we can complete analyses at the RDC and move forward with the project.

Increasing Monolingual Spanish Speakers’ Participation in HIV/AIDS Clinical Trials: The Language Access and Justice Initiative

Investigators
Alison Cardinal, School of Interdisciplinary Arts and Sciences (UW Tacoma)
Michele Andrasik, Fred Hutch Cancer Center
Pedro Goincochea, Fred Hutch Cancer Center
Rafael Gonzalez, Fred Hutch Cancer Center

Project update
This project seeks to understand why participation of Hispanic/Latino/a individuals in HIV/AIDS clinical research in the United States (US) is low (<12%) and identify ways on how to increase it, especially those Spanish speakers who have limited English proficiency (LEP). The Hispanic/Latino/a population in the US is the second most impacted group by the HIV epidemic, comprising nearly 30% of new HIV cases (CDC 2023). Research is essential to identify innovative ways to prevent the acquisition of HIV and identify new HIV therapeutics and a cure for HIV infection. Therefore, clinical research requires that participation in clinical trials be diverse and that enrollment in HIV research studies reflect the composition of the population most affected by the epidemic. Increasing participation of Hispanic/Latino/a individuals in HIV research is key for the generalization and application of research results and to contribute to Ending the HIV Epidemic in America by 2030. The HIV/AIDS clinical trials networks of the National Institute of Allergy and Infectious Diseases (NIAID) are designed to address those scientific research priorities.

The team is working to establish proof of concept by conducting interviews and focus groups of community educators and recruiters, clinical research staff, and principal investigators across the country at clinical research sites implementing HIV prevention clinical trials to understand the challenges and strategies utilized to recruit diverse participants, especially LEP individuals. In our original project, we proposed to conduct a survey, interviews and a focus group discussion. Our timeline suggested that at this point, we will have collected our data and are in the process of analysis, and we have met our targets. We have finished our research data collection with the HIV Vaccine Trials Network (HVTN) and are in the process of analyzing the data. We have developed a coding scheme, coded transcribed interviews, and are finalizing in-depth analysis of our coded interviews.

Differentiated service delivery for HIV: tailoring community ART delivery for people living with HIV in refugee settlements in Uganda

Investigators
Robin E. Klabbers, Departments of Global Health and Emergency Medicine
Kelli N. O’Laughlin, Departments of Emergency Medicine and Global Health
Jacob Oluma, Medical Teams International
Timothy Muwonge, Makerere University

Project update
Our study, also known as “ART2FIT,” leverages the infrastructure of a cluster-randomized trial (Head StART) taking place at 12 health centers in five refugee settlements in Uganda to identify key barriers to participation in community antiretroviral therapy (ART) delivery experienced by people living with HIV (PLHIV) in refugee settlements and key barriers to implementing this differentiated service delivery model faced by health workers and expert clients. Perspectives on optimal community ART delivery for this context were gathered in in-depth interviews (PLHIV) and focus group discussions (health workers and expert clients) and will be used to inform the design of a discrete choice experiment to quantify community ART delivery preferences for PLHIV in refugee settlements in Uganda.

Since the award of the Initiative Pilot Research Grant, ethical approval to conduct this work has been obtained from the University of Washington Human Subjects Division and the Makerere University Infectious Diseases Institute Research Ethics Committee in Uganda, and an application to the Uganda National Council for Science and Technology is pending. Data collection instruments have been finalized including study consent forms, interview guides and focus group discussion guides. A research assistant has been recruited to lead data collection and preparations are underway to conduct a training in early May during which Head StART research assistants will be familiarized with the study protocol and trained in qualitative data collection and analysis methods.

Developing and Disseminating Cold Injury Prevention Education

Investigators
Barclay T. Stewart, Department of Surgery
Colleen Chalmers, King County Regional Homelessness Authority
Tony Machacha, King County Regional Homelessness Authority
Caitlin Orton, Department of Surgery

Project update
The aims of this project were to develop and disseminate two cold injury prevention education materials in collaboration with people experiencing homelessness (PEH). Additionally, we aimed to build a sustainable and effective partnership between UW Medicine Regional Burn Center, Harborview Medical Center (UWMRBC/HMC) and King County Regional Homelessness Authority (KCRHA) to address cold injuries among people who are unhoused.

During the focus groups with community stakeholders, it was made clear that the aims of developing and disseminating cold injury prevention needed to be adjusted. Our community asked for increased clarity and transparency during the development phase to ensure that the lived experiences of those who are living unhoused are integrated and respected. Thus, we expanded the development phase to include a more in-depth consumer testing period and will increase the number of education materials that will be developed.

We also heard an explicit need from our community to develop fire and burn injury prevention education materials that in addition to the planned cold injury prevention given related hazards (e.g., keeping warm with open flames). Our research team decided they would be able to meet this need and will now expand the education materials in the newly named Equity in Injury Prevention (EQUIP) Toolkit to include fire and burn injury prevention education. Our research team has already collected qualitative data on fire and burn injury prevention in collaboration with PEH. Through this work, we identified the circumstances and environments in which burn and cold injury hazards and risks overlap in the context of living unhoused. This reinforces the need to develop one toolkit that aims to provide burn and cold injury prevention and mitigation strategies.

Our updated aims are:

• Aim 1: Develop and consumer test the EQUIP Toolkit in collaboration with people who are unhoused and KCRHA-identified community partners that includes prevention education material, dissemination strategies, and practical implementation tips. The EQUIP Toolkit will include four fire and burn injury prevention materials and two cold injury prevention educational materials.
• Aim 2: Build a sustainable and effective partnership between UWMRBC/HMC and KCRHA to support this and future collaborative projects.

Developing a digital mental health intervention for Arab refugee adolescents and young adults in Jordan

Investigators
Anna Larsen, Department of Psychiatry & Behavioral Sciences
Dror Ben-Zeev, Department of Psychiatry & Behavioral Sciences
Ahmad Y. Bawaneh, International Medical Corps – Jordan

Project update
The goal of our Population Health Initiative Tier 1 Project is to co-develop a community-informed evidence-based mHealth intervention for Arab refugees through partnership between University of Washington (UW) and International Medical Corps (IMC) researchers. We will achieve this goal through four project aims: (1) Expand partnerships with local Arab refugees and key stakeholders (e.g., community leaders, service providers) in-country through collaboration with IMC and the establishment of a project-specific community advisory board in Jordan (2) Conduct a user-centered mixed-methods needs assessment using a community-participatory approach to identify gaps and priorities for mHealth intervention to address mental health concerns of the Arab refugees living in Jordan (3) Integrate our empirical findings with evidence-based theory to generate a model to guide our next steps to generate a proof-of-concept (4) Evaluate our prospective model with community members and key stakeholders to assess its acceptability and feasibility using the IDEAS (Integrate, Design, Assess, and Share) framework, laying the groundwork for large internal and external grant application submissions to develop and test our proof-of-concept.

This project will set the stage for the first digital mental health intervention tailored for use with Arab refugees in the Middle East with the overall goal of improving health and social equity. Since activation in January 2024, our team has made substantial progress toward project aims. We have compiled a cross-cultural, multi-disciplinary study team including a PI (Larsen; Epidemiologist, UW), Co-I (Bawaneh; Country Director, International Medical Corps – Jordan), Co-I (Ben-Zeev; Director of the Behavioral Research in Technology and Engineering Center, UW), a Research Manager (UW), a Qualitative Researchers from IMC Monitoring & Evaluation team, and two Arabic-speaking linguistic and cultural adaptation consultants. We have completed several operational and research milestones toward achieving all of our aims and are on track to complete the project within our proposed timeline.

Characterization of urinary glyphosate levels in the US population by environmental and social factors

Investigators
Lianne Sheppard, Departments of Environmental & Occupational Health Sciences and Biostatistics
Anjum Hajat, Department of Epidemiology
Magali Blanco, Department of Environmental & Occupational Health Sciences
Amanda Gassett, Department of Environmental & Occupational Health Sciences
Cynthia Curl, Boise State University
Carly Hyland, University of California Berkeley
Edward Kasner, Department of Environmental & Occupational Health Sciences
Anne Reiderer, Department of Environmental & Occupational Health Sciences

Project update
Glyphosate is the most widely used herbicide worldwide, and increasing evidence links it to adverse health outcomes. Still, studies characterizing exposures in large populations are lacking. The goal of this project is to characterize environmental and social factors associated with glyphosate levels in the US population. We are combining individual-level urinary glyphosate and sociodemographic measures from the National Health and Nutrition Examination Surveys (NHANES) with numerous environmental data sources to evaluate whether agricultural land proximity, urbanicity, the consumption of foods with high glyphosate residue levels, race and ethnicity, or socioeconomic status (SES) are associated with elevated glyphosate levels.

We have made substantial progress on this project. To date, we have submitted a restricted NHANES data request, which includes linking NHANES participant geolocations to numerous environmental measures, a detailed methodology, and our planned output. We have also prepared external environmental datasets, are developing analytic code, and are in communications with the Northwest Federal Statistical Research Data Center (NWFSRDC), the secure research facility where we will run our analyses at the UW. We anticipate having our restricted data request approved in the next few weeks, which will enable us to link the required datasets and run our drafted analyses in the NWFSRDC. We will report our findings in the form of at least one manuscript and several presentations.

Estimating True Demand of Acute Pediatric Mental Health Services in Washington State

Investigators
Shan Liu, Department of Industrial & Systems Engineering
Lawrence S. Wissow, Seattle Children’s Hospital
Alysha Thompson, Seattle Children’s Hospital

Project update
The primary goal of this project was to estimate the current usage and future true demand of pediatric mental health services in WA with statistical needs estimation using diverse data sources. We started by analyzing the Washington State Comprehensive Hospital Abstract Reporting System’s in-patient discharge (CHARS) data from 2016, WA census data from the 2021 American Community Survey (ACS), and survey data from the National Survey of Children’s Health (NSCH). We have done a literature search on relevant factors affecting youth mental health from previous studies using the NSCH. We are currently estimating the true prevalence of each mental health condition (e.g., our first focus is depression) in the WA children/youth population aged 3-17. We built multivariate regression models using the NSCH dataset. Independent variables in the regression models include age, sex, race, family structure, language, income, health insurance, education, etc. Results from these regression models are applied to each WA census tract by creating synthetic population proportions based on the Census to estimate the true disease prevalence in each location. This step involves calibrating a synthetic population to match with the ACS’s marginal distributions on corresponding input variables from the regression models (e.g., age, sex, race, etc.) in each census tract.

We are currently testing this method with a single WA census tract and placeholder values from the WA Healthy Youth Survey. We analyzed hospital admissions for pediatric mental health and its relations with patients’ geographical location in CHARS 2016. We calculated the hospital admission volume for patients with any mental health diagnosis code and overlaid them with the total population of children and the percentage of children in each zip code. In addition, we examined inpatient admission and its relations with pediatric patients’ social vulnerability geographically to understand disparities in mental health treatment access.

In our preliminary analysis with CHARS 2016, we used the Social Vulnerability Index (SVI) for patients’ home residences and Social Deprivation Index (SDI) for hospitals’ surrounding locations. Results showed that patients living in areas with higher SVI tend to go to hospitals in the area with higher SDI in WA. We plan to repeat this analysis using more recent years of CHARS data to identify geographic gaps in access. We began the process of requesting the WA Healthy Youth Survey and the recent years of CHARS data from 2017-2022.

Community-Centered Service Design: Communal Approaches Toward Maternal Health Equity for Black Birthing People

Investigators
Leslie Coney, Department of Human Centered Design & Engineering
Julie Kientz, Department of Human Centered Design & Engineering
Monica McLemore, Department of Child, Family, and Population Health Nursing
Jazmin Williams, BLKBRY

Project update
The goal of this project is to (1) Establish a relationship with BLKBRY, a Black owned, community-based organization providing perinatal services and doula care for Black and Indigenous folks in Washington State and (2) Understand how Black birthing people use technology to access community maternal health resources during pregnancy and postpartum.

The founder of BLKBRY, Jazmin Williams, meet weekly to develop study materials such as interview scripts, screener surveys, recruitment materials, and more. We have received IRB approval for our research study and have started recruitment. We have also secured additional funding to plan and host a community baby shower to support 20 Black birthing people and families who are expecting or recently postpartum (up to three months).

A Qualitative Examination of Evictions Caused by Default Judgments in Washington State

Investigators
Will von Geldern, Evans School of Public Policy & Governance
Karin Martin, Evans School of Public Policy & Governance
Rachel Fyall, Evans School of Public Policy & Governance
Will Beck, Tacomaprobono Housing Justice Project

Project update
The goal of this project is to better understand tenants’ perceptions of the circumstances leading up to court absences that result in default judgments in eviction cases. Working with team members at Tacoma Probono (TPB), we have recruited four recently evicted participants to complete interviews as a part of our study. Progress has been hindered by staff capacity limitations at TPB. Although we had initially planned to complete interviews and begin transcribing and coding in May, we will likely pursue a more iterative process to accommodate the longer timeline for recruitment and interview completion.

To date, 11 former TPB clients have been identified and contacted, nine responded to our outreach, six scheduled interviews and four completed interviews. TPB is also in the process of compiling another list of approximately 10 potential participants.

Improving Prediction of Psychiatric Outcomes in Youth Using High-Dimensional Genetic and Phenotypic Data

Investigators
Katherine T. Foster, Departments of Psychology and Global Health
Jennifer Forsyth, Department of Psychology
Matthew P. Conomos, Department of Biostatistics
Daniel J. O. Roche, University of Maryland

Project update
The primary aim of this pilot is to incorporate a data collection pipeline for baseline genotyping into ongoing high-dimensional clinical assessments of children/families (n=400) – the PEARL(Y) study (PI: Foster). PEARL(Y) applies accelerated longitudinal cohort design (i.e., initial ages 10-25) featuring >90- day, biannual bursts of smartphone self-report of daily experiences (i.e., ecological momentary assessment, EMA) and digital phenotyping (e.g., passive sensing of physiology, location, etc.). Critically, youth/families are recruited from the community using a stratified sampling approach to ensure representation across the full spectrum of transdiagnostic clinical severity. That is, youth/families are sampled to ensure equal distribution across reports of current psychopathology, mild/subthreshold symptoms, and few or no current symptoms of psychopathology. Resultant multimodal data will be analyzed using machine learning techniques (e.g., elastic net regression and other approaches, Foster & Beltz, 2018, 2021) that select which putative risks (e.g., baseline genetic biomarkers vs. daily variation in individual psychosocial phenotypes) with the strongest predictive utility for forecasting clinical outcomes.

Our long-term scientific aims are to optimize clinical assessment prediction by identifying which biopsychosocial risk markers account for the most longitudinal variation in a wide variety of psychopathology outcomes. The success of precision psychiatric risk assessment will hinge on identification of risk markers alone or in combination that are accessible, low-cost, and maximally predictive of future psychopathology. While large-scale genetic studies have identified common variants robustly associated with psychiatric outcomes, signaling their utility when integrated with other phenotypic risk markers (e.g., psychological and social behavior), the funded work integrates multimodal data to select risk markers differentiating which symptoms will appear when for who, along what trajectory of illness, and following which early warning signs.

To date, funds from our Tier 1 research award have permitted initial development of a genetic testing pipeline (i.e., DNA collection, extraction, and genotyping) to support baseline assessment for participants the PEARLY study. Specifically, the necessary salivary DNA sampling kits have been purchased to support completion of genetic testing for the entire sample at baseline (n=400) and we have outlined the initial protocol for the extraction pipeline. Baseline testing will begin in June 2024 and collected DNA samples will be processed iteratively in batches (e.g., 75 samples per batch) for the remainder of the PHI award period, covering testing for approximately n=150 of the proposed sample. The collection process will be fine-tuned to maximize participant compliance and data quality across the longer recruitment period (e.g., 2 years of enrollment to reach the target n=400).

Developing Novel and Fair Machine Learning Strategies for Glioblastoma Segmentation in Sub-Saharan Africa Patient Population

Investigators
Mehmet Kurt, Department of Mechanical Engineering
Jacob Ruzevick, Department of of Neurological Surgery

Project update
The project aims to develop deep learning models for segmentation (or boundary detection) of glioma brain tumors from MRI images taken in low resolution settings, with an emphasis on images taken in Sub-Saharan Africa. Furthermore, the broader scope of this project is to develop methods capable of generalized tumor segmentation of tumors beyond glioma and with the ability to adapt to variations in imaging protocols. These two aims address critical needs for the deployment of automated segmentation tools in clinical settings. The developed models are evaluated according to commonly used metrics such as Dice score and Hausdorff-Distance 95, which give a measure of accuracy in tumor segmentation. Presently, we have experimented with various deep learning frameworks including traditional fine-tuning, fine-tuning with frozen layers, and domain-adversarial training of neural networks. We are currently working on a novel unsupervised approach following insights gained from our previous experiments. We are also happy to announce that this work has been accepted for a poster presentation at the Medical Imaging with Deep Learning (MIDL) conference in Paris, France.

Additionally, as proposed in the submitted proposal, we have extended our collaboration framework across multiple global institutions. We primarily collaborate with Dr. Udunna Anazodo from McGill University, who has provided us with additional tumor datasets from Sub-saharan African patients. Furthermore, we are happy to announce that in collaboration with University of Lagos, Nigeria, McGill University, MRI Uganda, and Nepal Applied Mathematics and Informatics Institute for research, we have started The COnnecting Minds to Progress AI in Medicine Seminar Series (COMPASS), which is a student-led monthly online event that brings together students and professionals from various disciplines related to artificial intelligence (AI) and medical imaging for career advancement opportunities. The series serves as a platform for sharing insights, experiences, and the latest developments in this rapidly evolving field, with emphasis on connecting student researchers in Global South to their peers, colleagues, and experts around the world.

Community Codesign to Integrate Low-Barrier, Culturally and Linguistically Responsive Mental Health Care into Community-Based Social Services

Investigators
Lesley Steinman, Department of Health Systems and Population Health
Najma Mohammed, Neighborhood House

Project update
Our project proposes to use anti-racist, community-engaged, human-centered design and implementation science methods to co-design mental health programming that can be integrated into social service delivery. We will convene Somali staff and community members to lead formative work to understand barriers to accessing mental health care, identify adaptations to evidence-based mental health care to improve cultural and linguistic relevance, and to map the tasks and workflows of social service settings within which to embed mental health care. Our ultimate goal is to improve Somali mental health equity by reducing barriers to access while addressing social drivers of mental health and challenges. We have completed the following activities to date:

• We established our co-design council with Somali community members and staff from Neighborhood House, Somali Family Safety Task Force, Somali Health Board, Seattle Housing Authority, and Public Health Seattle King County​.
• We convened our co-design council in February and April 2024, setting agendas based on recommendations from the Collaborative Intervention Planning Framework to set the stage and conduct problem analysis and strengths and needs assessment for community-define evidence.
• We identified a mental health intervention (the WHO’s Problem Management Plus (PM+) that was developed to train lay health providers to support people facing adversity with problem-solving and behavioral approaches (social support, behavioral activation, stress management).
• We engaged with UW MPH student and Somali community member Samira Farah to conduct her practicum, reviewing Islamic healing principles, trauma-informed care, and stigma reduction to adapt PM+ based on identified strengths and needs of the Somali community.
• We collaborated with a community partner to translate data collection tools from English into Somali and met with the co-design council to review and edit as needed for different dialects.
• We submitted and were approved for an IRB application for our discovery and design activities.
• We worked with the Population Health Initiative to engage a summer Social Entrepreneurship Fellow, who brings co-design skills to support project sustainability post Initiative-funding.
• We obtained a pilot research grant from UW Alacrity Center (UWAC) to expand the PHI project.
• We submitted a service grant to the Public Health Preservation and Development Authority (PHPDA) to integrate a behavioral health response team into Neighborhood House’s services.