Initiative-funded 2018 pilot research grant awardees report final outcomes

Addressing Health Disparities Faced by Rural Underserved Agricultural Communities

Investigators
Vanessa E. Galavíz, Environmental and Occupational Health Sciences
June Spector, Medicine (General Internal Medicine)
Gino Aisenberg, Social Work

Project abstract
Through a community‐academic partnership, researchers from the University of Washington partnered with Community to Community Development (C2C) to conduct a community‐wide survey and housing assessments for farmworkers in Skagit and Whatcom Counties. The purpose of this study was to characterize and understand the underlying social-ecological interactions that affect rural migrant and seasonal farmworkers. By taking a bottom‐up, community‐driven approach, C2C and the UW engaged farmworkers in a process to improve their own health. Data collection for this project was conducted by Promotores, who are local, trusted community members.

In the summer of 2018, UW researchers and trained C2C Promotores administered 348 farmworker surveys and completed 24 housing assessments. The survey covered topics such as current jobs and tasks being performed at work, work history in agriculture, access to water and sanitation facilities, previous work-related injuries, housing conditions, safety training preferences and access to community resources.

A subset of farmworkers also participated in a housing assessment. This assessment included a detailed home environment checklist, temperature and humidity measurements inside the home for approximately one to two weeks using Kestrel D2 Drops, and an assessment of sleep duration and efficiency using Actigraph accelerometers.

In addition, key informant interviews and a focus group was conducted to help inform the development of an environmental and occupational health-training curriculum (Rural AgX Certification). The goal for this training is to support the capacity of promotores who work with farmworkers and agricultural worker communities.

Farmworkers continue to be disproportionately impacted by cumulative social, environmental and economic impacts that result in greater health inequality than the general population. This is a result of often inadequate workplace conditions, lack of access to health care services and limited availability of community resources. To address the social, economic and structural barriers faced by farmworkers requires a multi-level collaboration and equitable inclusion of farmworkers in the research and decision-making process.

Health for Homeless Youth and Companion Animals in Seattle: Pilot Research into Healthcare, Social Services, and Rights for the Human-Animal Unit

Investigators
Peter Rabinowitz, Environmental and Occupational Health Sciences, Family Medicine, Global Health
Josephine Ensign, Psychosocial & Community Health
Lisa Kelly, School of Law
Charlotte Sanders, Social Work

Project abstract
In the initiative-funded proposal, the project team put forth a community-based participatory research pilot study focusing on the human-animal bond between homeless youth and their companion animals, and the creation of an innovative “One Health” clinic that treated the human-animal unit. The team’s activities to date include – and surpass – its expectations of what they could complete in a year, and set a good foundation for future work.

The team conducted 44 semi-structured interviews (including both quantitative and qualitative data) and successfully retained 19 of the 25 participants recruited for PhotoVoice over the course of the study. Seventy-six percent of respondents (n=31) reported barriers to resources due to having an animal, and 64% (n=27) reported being harassed for having an animal. These are high numbers considering that 55% (n=24) indicated that their animals are designated service animals or emotional support animals, both of which are protected (at various levels) under the City of Seattle jurisdiction. Questions regarding the locations of available resources and the mapping of safe/unsafe zones were included in the interviews and the resources have been added to the Doorway Project’s Interactive Map.

Nineteen young adults and adults participated in a PhotoVoice project that involved having the subjects use a camera provided to them to take pictures and create text to accompany the pictures. Participants spent an average of 32 days with their cameras and collectively created nearly 800 images documenting their lives with their animals. The images and narratives were used to stage a number of pop-up art galleries around Seattle to generate empathy and understanding of about why someone living in houselessness or housing insecurity would own an animal.

The team piloted a “One Health Clinic” in partnership with NeighborCare Health, the largest provider of primary medical care for people experiencing homelessness in Seattle. At these clinics, a NeighborCare Health nurse practitioner provides human health care in conjunction with UW University District Street Medicine volunteers (consisting of students from the UW Health Sciences programs including medical and nursing students, social work and public health students). At the same time, a Washington State University team consisting of a veterinarian preceptor and veterinary students provides animal health care in a space directly adjoining the human health clinic space.

Using an iterative process, the team is working on a clinic protocol that will help other clinics around the country reproduce what it is doing in Seattle. They are also working to analyze charts of patients seen to date and summarize these results.

Lethal Means Assessment in Psychiatric Emergency Services for Suicide Prevention

Investigators
Ali Rowhani-Rahbar, Epidemiology
Paul Borghesani, Psychiatry and Behavioral Sciences
Jennifer Stuber, Social Work
Anna Ratzliff, Psychiatry and Behavioral Sciences
Frederick Rivara, Pediatrics

Project abstract
Lethal means counseling is an emerging approach to suicide prevention in which providers assess patients’ access to potentially harmful means such as medications and firearms. In 2017, Washington passed the first law in the country to require suicide prevention training for all healthcare providers. Since little is known about the uptake of lethal means assessment in clinical settings, the project team conducted a large-scale record review of patients who presented to Psychiatric Emergency Services (PES) at Harborview Medical Center (HMC) prior to the enactment of this law. In alignment with the Population Health Initiative’s Grand Challenge to nurture brain, behavior, and capability development, the team investigated several key factors in this vulnerable, high-risk population.

Specifically, they examined the overall frequency of documented lethal means assessment and characterized patient visits with and without documented lethal means assessment by health equity measures and suicide risk factors. The project led to new empirical findings on the quality of documentation at PES. These results will add important context to an emerging national discussion on this topic and immediately inform clinical practice at one of the busiest emergency departments in the Pacific Northwest.

The team submitted their findings to the 2019 International Summit on Suicide Research organized by the American Foundation for Suicide Prevention and the International Academy of Suicide Research. Additionally, the team’s Graduate Research Assistant used this study for her master’s thesis project and is actively preparing manuscripts for journal submission.

Data from this project proved imperative for a larger project that has received funding from the Centers for Disease Control and Prevention. The multidisciplinary nature of this team was not only critical in guiding their study, but also generated new partnerships in statewide suicide prevention outreach efforts to move the science and practice of suicide prevention forward.

Mama Ammaan (Safe Mother) Project: African Mother-to-Mother Antenatal Assistance Network (AMMAAN)

Investigators
James Pfeiffer, Global Health
Rachel Chapman, Anthropology
Bonnie Duran, Social Work
Myra Parker, Psychiatry and Behavioral Sciences
Melissa Mugambi, Global Health
Michelle Terry, Pediatrics

Project abstract
The specific goal of this pilot study is to test the feasibility of a culturally congruent, group perinatal-care, service delivery model. The pilot project worked with local doulas, nurses and midwives to assist East African immigrant and refugee communities in Southeast Seattle to access, navigate, and bridge community and provider identified perinatal health service gaps.

Since IRB approval in June 2018, the team completed community-based-participatory research documenting perceptions, preferences, practices of perinatal health-seeking, forms of resilience and resources among women in five populations carrying heaviest burdens of negative reproductive outcomes in Seattle’s most diverse and underserved neighborhoods; and identified barriers and facilitators to perinatal and birth care-seeking and service-utilization. The team also trained doulas, midwives and nurses in culturally congruent peri-natal care, birth education and umuula care (post-partum home care).

Based on research findings, the team developed a perinatal model that includes the following components:

• Conduct monthly community-building, isolation-breaking, peer-to-peer group perinatal birth education classes;
• Provide participating women with free certified doula and/or post-partum doula (in Somali, Umuula care) home visiting services up to one year post-partum;
• Connect pre- and post-partum mothers to other Somali women and resources through social media including WhatsApp, live Facebook feeds and SnapChat; and,
• Assist women in the Mama AMMAAN groups to directly access relevant resources including, but not limited to WIC, mental health screening and referral, Fresh-Bucks.

The team has established four ongoing pop-up community meeting sites (i.e., New Holly Library, EduCare White Center, Living Well Kent, Health Point Kent) and is awaiting response for partnering with three additional clinical sites (i.e., NeighborCare Columbia City and Rainier Valley and Health Point Kent).

The research partners on this grant are also committed to writing a new R21 or R01 to scale up an outcomes testing project of Mama Amaan core components. The team will also seek to collaborate with six other community health boards in Seattle to write a perinatal care proposal to direct more Medicaid dollars to cover doula and other perinatal care services for low-income and health vulnerable communities.

Building Back Better: Innovative Methods to Measure Resilience

Investigators
Nicole Errett, Environmental and Occupational Health Sciences
Scott Miles, Human Centered Design and Engineering
Youngjun Choe, Industrial and Systems Engineering

Project abstract
The team’s research sought to understand if and how publicly available activity data, including personal health monitoring data from “activity trackers,” can be used to understand community resilience and inform recovery activities in the disaster recovery period. Using qualitative and quantitative methods, substantial student engagement, University and departmental resources and partnerships, and partnerships with public and community organizations, they:

• Identified publicly available data that is typically used to track recovery – including building permit and unemployment data – and completed preliminary descriptive analyses to identify post-wildfire trends in Santa Rosa.
• In partnership with the information technology team in the Department of Environmental and Occupational Health Sciences, developed and internally piloted a web server application to programmatically access data through the OAuth 2.0 protocol from FitBit, Google Fit and Strava users with their permission.
• Through a thematic analysis of 16 key informant interviews with fitness, parks or active transportation organization in Houston, TX and Santa Rosa, CA, identified individual, social and organizational, built environment and natural environment factors that were perceived to influence physical activity following Hurricane Harvey (Houston, TX) and the Tubbs wildfires (Santa Rosa, CA), as well as ideas, preferences and privacy considerations surrounding the use of personal health monitoring data to inform and assess recovery.
• Using bike and pedestrian path data from four Houston bike-ped trails, examined the immediate impact of Hurricane Harvey on physical activity and explored the potential for such data to examine recovery.
• Through a sublicense agreement with the Texas Department of Transportation, used Strava Metro data to describe physical activity trends in Houston before and after Hurricane Harvey and explored the potential for such data to examine recovery.
• Using insights and outputs from the Population Health Initiative grant, wrote and submitted a Planning Grant proposal to the National Science Foundation’s Smart and Connected Communities program, seeking a grant of $150,000 to develop a proposal for a larger SCC grant.

The UW MetaCenter for Global Disease Preparedness: Proof of Concept Research in Peru

Half of the funding for this award came via a partnership with the UW Office of Global Affairs, which seeks to enhance the UW’s global engagement and reach.

Investigators
Peter Rabinowitz, Global Health, DEOHS, Epidemiology, Family Medicine
David Pigott, Global Health
Cory Morin, Global Health
Beth Bell, Global Health
Ursula Valdez, UW Bothell
Adam Warren, History
Michael Gale, Immunology, Global Health, Microbiology
Paul Yager, Bioengineering, Oral Health Sciences, Global Health, Chemistry
Stefan Wiktor, Global Health
Lance Stewart, Biochemistry
Wesley Van Voorhis, Global Health, Microbiology
Janet Baseman, Epidemiology, Health Services
Jeffrey Heer, Computer Science and Engineering
Patricia Garcia, Global Health

Project abstract
The goal of this project funded by the UW Population Health initiative was to test the concept of a University-wide “MetaCenter” for Prevention of Pandemic Diseases effort that leverages myriad University resources in a concerted fashion to improve local resilience to disease outbreaks.

The specific proof of concept project involved the development of information visualizations to characterize the outbreak potential of different areas of Peru related to infections caused by viruses transmitted by the Aedes aegypti mosquito (e.g., dengue and Zika virus). Providing these tools to local decision makers could improve Peru’s capacity to respond to these threats by helping focus and prioritize resources in the areas with greatest vulnerability for outbreaks.

Project aims that were completed included: 1) characterizing the vulnerability in Peru to Dengue (DENV) at a regional level by incorporating local datasets of environmental, demographic, climate, health services and disease surveillance information, and 2) establishing peer-to-peer academic and professional exchanges between Universidad Peruana Cayetano Heredia (UPCH) and UW to enhance population health preparedness for disease outbreaks.

Using Digital Learning Tools to Enhance Emotional Regulation for Youth Hospitalized for Aggressive Crises

Investigators
Carol Rockhill, Psychiatry and Behavioral Sciences
Annie Chen, Biomedical Informatics and Medical Education

Project abstract
This project utilizes digital tools called emWave and Ripple Effects to teach disruptive youth skills to manage aggression at Seattle Children’s Inpatient Psychiatry Unit. The team successfully recruited 13 youth and parents for the individual therapy phase of the project (Aim 1), 13 youth and parents for the “groups as usual” and 15 youth and parents for the “groups with new materials” phase of the project (Aim 2).

For each participant, the team gathered data about baseline symptoms, function and strengths, as well as satisfaction measures from youth participants, parents, the therapist and group leaders who facilitated youth participants’ participation in the intervention. Procedures have gone well; both in terms of verbal feedback and in the satisfaction surveys, parents, youth and implementers have had positive feedback about the use of the new materials.

Baseline parent measures indicate a high level of symptom severity. On the positive side, the average youth participant is reported by parents to have moderate amounts of self-efficacy, assertiveness and as having social support. Parents report difficulty with self-control, empathy and problem solving. Parents see their participating children as having extreme difficulty with emotion regulation. Parent-reported levels of the child’s level of depression are extremely high, as are parent-reported levels of child disruptive behavior and functional impairment.

Similar to parents, youth report high levels of self-efficacy, and difficulty with emotion regulation, self-control and problem-solving. The youth report relatively high levels of social support, and report that they have more empathy than parent-report suggests. Youth self-report on emotion regulation difficulties indicate that the youth see themselves as having difficulty with emotion-regulation, but relatively less than what their parents report. Youth report on depression, disruptive behavior and functional impairment are at extremely high levels, but not as high as parent report.

Youth satisfaction was uniformly high among the small sample youth subjects who participated in individual therapy as usual, and high but not quite as high for youth who participated in individual therapy with the new materials. Satisfaction with group therapy was somewhat higher among the youth who participated in the group therapy with the new materials than those who participated in the groups as usual.

Implementing this project has changed the culture on the unit to being one of more openness to examine technology as part of the suite of tools that can be used to help youth. The implementers have been very enthusiastic about having new tools to work with youth.

Next steps include recruiting more patients for the individual therapy arms of the study, and sending the computer programs home with youth participants and encourage use at home. In addition, six-month follow-up measures are now starting to be collected. Ultimately, the team will compare baseline to six-month measures by group, to see whether youth who completed the study have more improvement in symptoms than those who received treatment as usual.

Addressing Health Disparities in Washington State: The Role of Social and Economic Inequities in Intersectional Marginalized Populations

Investigators
Karen I. Fredriksen Goldsen, Social Work
Barbara Cochrane, Family and Child Nursing
Corinne S. Heinen, Family Medicine
Marieka Klawitter, Evans School of Public Policy & Governance
Charles A. Emlet, UW Tacoma
Hyun-Jun Kim, Social Work

Project abstract
The overall goal of this study was identifying disparities in health and social and economic well-being among sexual/gender and racial/ethnic minorities in Washington State.

To this end, first, the team analyzed the 2011-2016 Washington State Behavioral Risk Factor Surveillance System (WA-BRFSS) data (N = 81,710) to estimate prevalence of physical and mental health, chronic conditions, access to health care, and health behaviors by sexual orientation and gender among those aged 18 and older residing in Washington State. They identified key health disparities among sexual minorities as compared to heterosexuals, including heightened risks of disability, poor mental health, financial barriers to health care and smoking among sexual minority women and men. Comparing with previous 2003-2010 BRFSS findings, they also identified changes in disparities among sexual minority older adults aged 50 and older. Health disparities newly observed in the 2011-2016 BRFSS data include higher prevalence of poor physical health, arthritis, asthma, high cholesterol and lack of physical activity among sexual minority older women and higher prevalence of financial barriers to health care among sexual minority older men. They further found racial/ethnic health disparities by sexual orientation and gender. For example, heightened risks of diabetes were observed among racial/ethnic minority women and men aged 18 and older; and the risk of hypertension was higher for lesbian and bisexual racial/ethnic minority women.

Second, the team collected self-administered survey data from sexual and gender minorities aged 18 and older in Washington State to extend its understanding of their economic and social inequities taking into consideration the racial/ethnic heterogeneity in Washington State. The development of the survey was based on extensive literature review and psychometric analyses of measures from the National Health, Aging, and Sexuality/Gender Study, which includes a demographically diverse sample (N=2,540) across all census divisions of the U.S. Nearly one-third reported recent suicidal ideation. Nearly half reported financial difficulties including income volatility, lack of access to securing food, as well as financial barriers to health care. More than a half reported difficulties in paying their rent or mortgage, with many experience housing insecurity.

The most common types of bias related experiences included micro-aggressions; for example, nearly 70% experienced people using derogatory terms to refer to sexual and gender minority individuals in their presence. Other common types included bullying, discrimination in health care service and victimization such as verbal insult and physical threat. Nevertheless, many sexual and gender minorities in Washington State reported social resources that are protective and buffer the negative effects of such marginalization. Nearly one-third have multiple members in their support networks; and the majority are connected to LGBTQ communities and engage in advocacy activities.

The configurations of health, economic and social /inequities found in this study varied by sexual orientation, gender identity and race/ethnicity highlighting the importance of understanding heterogeneity within LGBTQ communities. This project provides the information necessary to build upon this pilot research to inform the development of a R01 that will provide the information necessary to develop interventions, policies, programs, and to reduce health, economic and social disparities in these demographically diverse populations