Population Health

February 7, 2023

Awardees of spring quarter 2022 Tier 1 pilot research grants report their progress

Research project team engaged in discussionThe Population Health Initiative awarded 11 Tier 1 pilot grants in May 2022 to teams representing researchers from seven different UW schools and colleges, as well as UW Tacoma and numerous community-based partners, in May 2022.

These awards from the initiative’s Tier 1 pilot grant program were intended to support researchers in laying an interdisciplinary foundation for a future project to generate proof-of-concept.

The projects have reached its respective mid-point and investigators are reporting a range of progress in their work, with specifics regarding that work described in the following sections.

Patient acceptability of clinical suggestion of social needs automatically identified from clinical notes in the electronic health record

Andrea Hartzler, Department of Biomedical Informatics & Medical Education
Angad Singh, Department of Family Medicine
Patrick Wedgeworth, Department of Biomedical Informatics & Medical Education
Kevin Lybarger, Department of Biomedical Informatics & Medical Education
Serena Xie, Department of Biomedical Informatics & Medical Education
Herbie Duber, Department of Emergency Medicine
Brian Wood, Department of Medicine

Project update
Identifying patients’ social needs is a first critical step for health systems to address Social Determinants of Health (SDoH). Yet, SDoH screening at UW Medicine is arduous and underused since it requires clinical care teams to complete numerous discrete data fields in the electronic health record. Although it is technically feasible to reduce this burden by automatically extracting SDoH and suggesting social needs from patients’ historical clinical notes, patient acceptability of this “SDoH auto suggest” strategy is unknown. The purpose of this project is to illuminate the patient voice regarding potential use of SDoH auto-suggest in health care. We are meeting this objective through two aims to (1) Co–produce inclusive study materials with clinical and community champions, and (2) Interview patients about their acceptability of SDoH auto-suggest.

To date the team has co–produced inclusive study materials with clinical and community champions. It has conducted key informant interviews with eight interdisciplinary domain experts (“clinical champions”) to vet and refine the interview recruitment plan, participant sampling, and interview procedures and materials. The team has also recruited five “community champions” as diverse advocates for communities that include patients with social needs and convened two 90-minute community champion workshops. In the first workshop, community champions provided input to vet and refine the interview materials. In the second workshop, the community champions responded to initial results from patient interviews and discussed strategies for disseminating study results to priority communities and the public.

The team has interviewed patients about their acceptability of SDoH auto-suggest and has pilot-tested interview materials that were co-produced with clinical and community champions. They are actively recruiting in one primary care clinic with outreach to expand to two more clinics. The team has shared initial results with clinical and community champions for review and feedback, and has begun developing plans for dissemination to academic, UW Medicine and community audiences.

They expect to complete data collection and analysis for patient interviews by the end of the year. They also plan to engage clinical and community champions in the review of results and reports (i.e., manuscripts, executive summaries, community materials) that will be disseminated in the new year.

Understanding the Impacts of Washington Paid Family Leave Policy on American Indian and Alaska Native Birthing Parents and Newborns

Teresa Abrahamson-Richards, School of Social Work
Jennifer Romich, School of Social Work
Rose James, Urban Indian Health Institute

Project update
This project is undertaking a community-engaged study design process, conduct preliminary analyses, and enable the researchers to acquire the necessary quantitative data to conduct a future study examining birth outcomes among first time American Indian/Alaska Native (AIAN) birthing parents.

Over the first four months of the grant period, the team collaboratively engaged the Urban Indian Health Institute and partners working in AIAN maternal and child health in identifying priorities and crafting questions about how research on Washington’s Paid Family and Medical Leave (PFML) policy can be used to support equitable paid leave access for AIAN families (Aim 1 of the pilot grant project). These partners expressed their strong interest in learning more about trends in AIAN access to paid parental leave and positive outcomes families have experienced as a result of the PFML benefit.

Under Aim 2 of the project to create preliminary findings on pre-PFML AIAN employment trends and estimated PFML eligibility, the team is using state administrative data sources to generate baseline findings to inform the larger follow-up study. This work is progressing as planned, and findings will be used during the remaining grant period to shape the follow-up study aims and design. The team has experienced some obstacles in preparing a request for additional state administrative data, and they are working with its state partners to identify appropriate next steps to move forward with our third aim to obtain recent-years’ birth and employment data for a future study.

Examining share pantry/refrigerator safety and potential as a hyper-local alternate means of food assistance in the Puget Sound

Emily Hovis, Department of Environmental & Occupational Health Sciences
Joe Graham, Washington State Department of Health
Tania Busch Isaksen, Department of Environmental & Occupational Health Sciences

Project update
Access to safe and wholesome food, regardless of whether donated or purchased, is an expectation for all Washingtonians. Anecdotal evidence suggests that some share pantries and community refrigerators may provide unsafe food (such as home-prepared foods, unpackaged foods, and food held at improper temperatures). For this reason, our primary project focus was to evaluate the safety of share pantries/refrigerators within the context of existing food rules. Our secondary focus was to analyze existing locations and gather user data to better understand where they are, what communities they serve, who is using them and why.

To date, the project team has mapped 284 pantries and 11 community refrigerators within the project area of Puget Sound, conducted 104 safety assessments, and received 78 survey responses. Our preliminary findings show there are some safety concerns associated with this type of food sharing. However, few survey respondents indicated they have concerns with the safety of the food available (6% reported always having safety concerns and 16% reported often having safety concerns).

Looking forward, the team will conduct a survey to better understand who is operating these share pantries/refrigerators and learn best practices for providing this type of food sharing. Additionally, we hope to finalize publications and prepare to apply for funding to expand this research with an interdisciplinary focus on supply chain logistics, food safety and food rescue/waste reduction.

Development and Evaluation of a Culturally-informed Food Insecurity Screening Protocol with American Indian Adults: Evidence from Northern Navajo Medical Center

Amanda M. Fretts, Department of Epidemiology
Terra Yabeny, Navajo Department of Health
Preyanka Makadia, Northern Navajo Medical Center
Cassandra Nguyen, Washington State University Partnerships for Native Health

Project update
The goal of this pilot project is to work in partnership with clinicians at the Indian Health Services (IHS) Northern Navajo Medical Center to develop and test a new food insecurity screening protocol that is strengths-based and culturally relevant for American Indian patients.

During the first five months of the project, the team was able to accomplish several major study activities—primarily related to the design of the data collection instruments and the completion of all Phase 1 activities. They have obtained Institutional Review Board (IRB) approvals from both the University of Washington IRB and the Navajo Nation IRB. All staff members who are not current employees at the IHS Northern Navajo Medical Center have also completed background checks and other necessary security processes to conduct research at the medical center.

During July and August 2022, all data collection instruments and consent forms were developed/finalized. The creation of the data collection instruments was an iterative process since the team included both the food security questions currently being utilized at the clinic, and also new strengths-based questions. The final versions of the data collection instruments for Phase 1 were imported into REDCap.

Phase 1 data collection occurred on August 30th and September 28th, 2022 at the Northern Navajo Medical Center. In total, 25 IHS patients participated in Phase 1. Phase 1 comprised 20-minute interviews during which participants were asked about their impressions of the food insecurity screener currently being used at the clinic, as well as an alternate set of strengths-based food insecurity questions. During October 2022, all interviews from Phase 1 were transcribed and analyses completed. Information derived from the interviews was used to refine the strengths-based food security screener.

The final version of the strengths-based food security screener has been entered into REDCap, and pilot testing to ensure the validity of the logic built into the REDCap programming of the screener is complete. Phase 2 data collection is scheduled to begin on December 8th, 2022. Given that residents and interns at the Northern Navajo Medical Center are serving as the primary recruiters for the project, they have worked around their availability within the clinic when selecting data collection dates.

A Framework for Prioritizing Urban Green Space Protection and Restoration to Improve Health

Kristin Hayman, School of Marine & Environmental Affairs
Jeremy Hess, Department of Environmental & Occupational Health Sciences
Phillip Levin, School of Marine & Environmental Affairs
Josh Lawler, School of Environmental & Forest Sciences
Jamie Robertson, The Nature Conservancy, Washington
Julie Fox, Washington State Department of Health
Buffi LaDue, Washington State Department of Health
Allison Ertl, Washington State Department of Health
Christopher Ahmed, Washington State Department of Health
Marnie Boardman, Washington State Department of Health

Project update
The purpose of this project is to work with public health and conservation practitioners to develop and implement a framework for identifying locations across the Puget Sound region where protection and restoration of urban green space have the greatest potential to promote health and well-being, abate environmental health disparities and further environmental resilience.

To-date, the team has conducted an extensive literature review of over 100 peer-reviewed journal articles. Via this literature review, they investigated the dose-responses of a suite of health outcomes to green space, with a major take-away that very few dose-responses between green space and health outcomes have been identified by the literature to date.

Via the literature review, the team also selected three focal health metrics that are affected by green space and conveyed via direct contact with green space: all-cause mortality, depression and self-reported health status. They have pulled data from the Environmental Health Disparities Index and the Center for Disease Control and Prevention (CDC) as proxies for the sensitivity of populations in each census tract to the focal health metrics.

The team has pulled data from the Stormwater Heat Map to estimate green space density in each census tract. Further, they have used green space density per census tract as a proxy for the average exposure of populations in each census tract to green space. They have also pulled data from the US Census Bureau to estimate population in each census tract, and have begun to prioritize census tracts and to create heat maps of the Puget Sound region that depict the relative priority of each census tract.

Establishing a rural Food Equity Collaborative to increase healthy food retail options for Latinos in WA

Barbara Baquero, Department of Health Systems and Population Health
Elizabeth Torres, Northwest Communities Education Center/Radio KDNA
Ria Francisco, Department of Health Systems and Population Health

Project update
Through this community-based participatory research project, the University of Washington Health Promotion Research Center (HPRC) and Northwest Communities Education Center (NCEC)/ Radio KDNA, proposed formative research to: 1) establish an academic-community Collaborative to advance Latino food equity in rural Washington; and 2) examine the contextual factors (geographical, epidemiological, socio-cultural, socio-economic, ethical, legal, political) that would influence healthy food retail promotions for Latinos in rural Washington.

The team has made substantial progress towards both of these objectives. This includes hiring of one UW HPRC graduate research assistant and determining NCEC/Radio KDNA team members to dedicate to the project. The team submitted an IRB application and received approval and research-exempt status, identified 35 individuals from 26 organizations as potential academic and community partners, and traveled for in-person meeting with UW HPRC and NCEC/Radio KDNA in Granger to strengthen partnership, reduce communication barriers, and host retail food store audit training. They also solidified and approved its food equity definition.

The team has completed 10 informational interviews with potential partners to date, with 14 more interviews scheduled and multiple individuals interested in forming a Latino Food Equity Collaborative. It also scheduled the first Collaborative meeting to introduce partners and establish the Latino Food Equity Collaborative, modifying the schedule of Collaborative meetings to align with partner priorities and interview scheduling.

In addition, the team randomly selected a sample of nine tiendas across Yakima, Benton and Franklin to visit in order to conduct food retail audits and completed training for these audits. It also completed a literature review on academic and gray literature and publicly available sources to draft a summary report on contextual factors (geographical, epidemiological, cultural, economic, legal, ethical, political) that would influence healthy food retail promotions for Latinos in Yakima, Benton, and Franklin counties.

Understanding mechanisms of social determinants of health and symptoms in adults with subarachnoid hemorrhage

Eeeseung Byun, Department of Biobehavioral Nursing and Health Informatics
Michael Levitt, Department of Neurological Surgery
Maria Bleil, Department of Child, Family & Population Health Nursing

Project update
This project seeks to better understand the role of social determinants of health as significant risk factors for poor subarachnoid hemorrhage (SAH) outcomes. The first aim of the project sought to explore relationships between individual-level social determinants of health, inflammation at early (i.e., days 2, 3, and 7) and late (i.e., months 2, 3, and 6) time points after SAH, and symptoms over six months in SAH survivors. The team is drawing from an existing dataset and exploring relationships between social determinants of health (demographics such as gender, race/ethnicity and socio-economic status), inflammation (i.e., TLR4 mRNA expression and pro-inflammatory cytokine [TNFα, IL1β, and IL6] concentrations), and symptoms (sleep disturbance, fatigue, and impaired cognition) over 6 months in SAH survivors.

The study’s second aim is to prepare for the submission of a large grant application by 1) examining demographics and socio-economic status in patients with SAH admitted to Harborview Medical Center, the planned recruitment site, in 2021 via medical chart review and 2) developing relationships with other potential recruitment sites that serve SAH survivors from diverse backgrounds and with investigators outside University of Washington. The UW Institutional Review Board (IRB) approved our study, and during the rest of the grant period the team will review medical records of and collect demographics and socio-economic status from admitted SAH patients to Harborview Medical Center. The team is also currently exploring if it could obtain data to accomplish Aim 2 from using existing data collected by the study with a longer period than our planned data collection period. The team will also initiate networking with potential recruitment sites and investigators outside the UW.

PrEParing for the future: preferences for HIV pre-exposure prophylaxis products and delivery models among cisgender men, transgender, and non-binary persons in Seattle, Washington

David Katz, Department of Global Health
Lauren Violette, Department of Epidemiology
Jodi Greathouse, Department of Global Health

Project update
This project aims to design, pilot, and implement a discrete choice experiment (DCE), a method to examine trade-offs in decision-making between options, to identify sub-population differences in pre-exposure prophylaxis (PrEP) product and delivery preferences among ~400 cisgender men who have sex with men, transgender persons and non-binary persons seeking HIV testing at a clinic in Seattle. It represents an opportunity to better target implementation of prevention services locally, drive pipeline development of newer PrEP formulations and modalities, and establish methodology for assessing local PrEP preferences to inform population-specific delivery in other settings.

The team has successfully designed, programmed and implemented the DCE and a brief supplemental survey addressing PrEP experiences and barriers in both English and Spanish. The first participants were enrolled on August 17, 2022. They have enrolled 47 participants (12% of our proposed sample size) as of October 27th and achieved a diverse sample in terms of race/ethnicity, gender, and prior PrEP use (Table 1). Most people (87%) who have been offered participation have chosen to complete the survey.

Residential Segregation and Pediatric Injury and Violence in Seattle, Spokane, and Tacoma

Chelsea Hicks, Department of Pediatrics
Frederick Rivara, Department of Pediatrics
Abril Harris, School of Social Work
Rebecca Walter, Department of Real Estate
Monica Vavilala, Department of Anesthesiology & Pain Medicine
Qian Qiu, Department of Pediatrics
Tony Escobar, Mary Bridge Children’s Hospital
Timothy Bax, Sacred Heart Medical Center

Project update
The goals of this project are to: 1) Create a model of the relationship between residential segregation, the built environment, and pediatric injury through a scoping review; 2) Quantify current association between residential segregation and pediatric injury and violence outcomes in three Washington state cities (Seattle, Tacoma, Spokane); and 3) Identify potential interventions through moderating and mediating mechanisms in the relationship between residential segregation and pediatric injury and violence.

A range of activities have been completed to date, including the hosting of multiple cross-institution full team meetings and weekly UW project team meetings. Data from the UW was received and the team conducted descriptive statistics on Seattle pediatric injury data. One of the two data sharing agreements has been executed with our collaborating centers, and the other is being reviewed by the appropriate administrative entities. Finally, the team’s literature review is in progress and residential segregation metrics have been identified.

Piloting a Strategy to Improve Pediatric Inpatient Guideline Adherence in Migori, Kenya

Megan Coe, Department of Child, Family, and Population Health Nursing
Sarah Gimbel, Departments of Global Health and Child, Family, and Population Health Nursing
Arianna Rubin Means, Department of Global Health
Beth Kolko, Department of Human Centered Design & Engineering
Benson Singa, Kenya Medical Research Institute
Ann Van Haney, Department of Global Health

Project update
This pilot study uses participatory approaches to identify and tailor an implementation strategy aimed at improving pediatric hospital care in Migori, Kenya. In Aim 1, a nominal group technique approach is used to match potential interventions to identified barriers and select a strategy to pilot. This strategy will be tailored to the needs of the health care workers using an iterative design process (Aim 2). After piloting, the team will evaluate the usability and feasibility of the piloted strategy for ongoing use (Aim 3).

The team has completed Aim 1 of the project to select a targeted implementation strategy using participatory techniques. Ethics approvals were obtained and in August 2022 we conducted a meeting with staff from Migori County Referral Hospital. First, preliminary results of an earlier qualitative study conducted at the site were presented to the participants. This study had identified barriers and facilitators to use of pediatric treatment guidelines. Four challenges that came out strongly in the qualitative results and were modifiable at the facility-level were identified and participants ranked them on their likelihood of change and potential for impact. There was consensus among participant that the focus of the pilot should be the challenge: Health care workers rely on nutritionists to handle many tasks related to nutrition. If the nutritionist is not available this can delay guideline adherent care (especially at night/weekends).

The group was then presented with examples of strategies that were mapped to the specific barriers that had been identified in the qualitative study. They then brainstormed to identify specific strategies that would be relevant to their setting. Six ideas were generated by the group. Participants ranked these options on three criteria (acceptability, feasibility, and impact), had a discussion about these options, and then reached consensus on an idea to pilot: Develop a summary of key information from the Integrated Management of Acute Malnutrition and other guidelines, merge them, and agree how they will be delivered by staff.

Based on the outcome of this activity, the study team has refined plans for the pilot study. This idea will form the basis of a Team Approach to Malnutrition Services (TeAMS Toolkit). They are currently in the process of obtaining ethics approvals to initiate Aims 2 and 3 of the pilot study.

Exploring Multicultural and Multilingual Methods in Developing Dialog-Based Health Technologies

Weichao Yuwen, School of Nursing & Healthcare Leadership, UW Tacoma
Trevor Cohen, Department of Biomedical Informatics and Medical Education
Magaly Ramirez, Department of Health Systems and Population Health
Serena Jinchen Xie, Department of Biomedical Informatics and Medical Education

Project update
More than 20 million family caregivers in the United States self-identified as having a racial or ethnic minority background spend on average more than 20 hours per week providing unpaid care to a care receiver. In addition, at least one-third of caregivers speak a language other than English at home. Existing barriers that prevent these marginalized caregivers from accessing services include a lack of culturally sensitive and linguistically appropriate programs of care. On-demand digital health technologies delivering interventions through text-based dialogs could be cost-effective solutions to support family caregivers.

Recent innovations in machine learning and artificial intelligence (AI) have the potential to automate labor-intensive work such as language translation. However, these technologies, if used without careful intention, can increase biases and existing imbalances for marginalized groups. To the team’s knowledge, there has not been the development of efficient multilingual AI language models in the health domain. They propose to conduct a literature review of multicultural and multilingual model development methods in developing health dialogs (aim 1) and perform pilot training using an existing caregiver-domain-specific dataset in English to translate to and train in Spanish (aim 2).

The team has established an interdisciplinary research team consisting of faculty members, undergraduate students, pre-doctoral and post-doctoral trainees from nursing, biomedical informatics, and public health. The team meets bi-weekly and have started working on both aims. One member of the team will be presenting a paper on cultural differences in family caregiving needs at the American Medical Informatics Association Annual Symposium (AMIA 2022). The team was recently awarded an Emergent Innovation Grant from the Rita & Alex Hillman Foundation for a pilot project building on this current project.

More information about the Population Health Initiative pilot grant program, tiering and upcoming deadlines can be found by visiting our funding page.