Winter 2023 Tier 2 pilot grant awardees share their final project findings

Family medicine contributions to maternal health in maternity care deserts: To what extent does family medicine fill the gap in addressing our dire public health crisis?

Investigators
Emily Godfrey, Departments of Family Medicine and Obstetrics & Gynecology
Maegan Dirac, Departments of Health Metrics Sciences and Family Medicine
Anna Fiastro, Department of Family Medicine
Yalda Jabbarpour, The Robert Graham Center
Molly Ruben, Department of Family Medicine
Paula Trepman, Department of Family Medicine
Grace Walter, The Robert Graham Center

Project summary
Our multidisciplinary team of family physicians, health services researchers, health metric experts and trainees collaborated with partners at the Robert Graham Center in Washington, DC, to assess the impact of family medicine maternity care clinicians in March-of-Dimes-defined maternity care deserts. We began with two aims, and we were able to add an additional analysis as the project evolved.

• Aim 1: Compare 2011-2019 maternal mortality ratios (MMR) between maternity care deserts where family physicians provide obstetrical care with “true” maternity care deserts (MCDs).
• Aim 2: Compare 2011-2019 low birth weight (LBW) incidence between maternity care deserts where family physicians provide hospital obstetrical care with “true” maternity care deserts.
• Additional analysis: Compare 2011-2019 fetal mortality ratio between maternity care deserts where family physicians provide hospital obstetrical care with “true” maternity care deserts.

Our unit of analysis was counties. We identified counties as “maternity care deserts” (MCDs) using the March of Dimes 2022 report, and defined “true” MCDs as those where no family physicians reported providing obstetrical care when they responded to the American Board of Family Medicine Maintenance of Certification practice survey during the years 2011-2019. Data for outcome variables and race and ethnicity variables for people giving birth were obtained from mortality and natality data from the National Vital Statistics System (NVSS) National Center for Health Statistics of the U.S. Centers for Disease Control and Prevention. The maternal vulnerability index (MVI) of Surgo Ventures was obtained and employed to control for factors such as reproductive healthcare, general healthcare, physical health, socioeconomic status, mental health and physical environment.

Due to our exposure of interest (presence of family physicians providing obstetric care) only being measured once per respondent on a rolling basis over the years 2011-2019, all outcome variables and confounders of interest were aggregated to the same period. All outcomes were treated as counts, log-transformed, and modeled using a generalized linear model with negative binomial likelihood function, an offset for number of livebirths, fixed effects for the exposure of interest and each confounder of interest, and random effects for states.

In fully adjusted models, the presence of family physicians providing obstetric care was not significantly associated with any of the outcomes of interest. This was maintained in sensitivity analyses that treated family physician obstetrical providers as an ordinal (rather than binary) variable. This suggests no county-level impact of having family physicians provide obstetrical care when comparing amongst counties defined as “maternity care deserts.” This may be due to misclassification of exposure, given true exposure is likely time-varying and our measurement was aggregated over 10 years, residual confounding due this lack of temporal granularity, or true lack of difference mediated by a variety of mechanisms (e.g., insufficient training, insufficient volume to maintain skills, insufficient infrastructure in which to provide care).

An mHealth intervention to promote adaptive coping and medication adherence among HIV-positive Men Who Have Sex with Men (MSM) in China: A Feasibility Pilot Studys

A portion 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
Jane M. Simoni, Department of Psychology
Weichao Yuwen, School of Nursing & Healthcare Leadership (UW Tacoma)
Vibh Forsythe Cox, Department of Psychology
Huang Zheng, Shanghai CSW&MSM Center, SCMC
Zhen Ning, Shanghai Municipal Center for Disease Control & Prevention (SCDC)
Liying Wang, Department of Psychology

Project summary
Men who have sex with men (MSM) bear a disproportionate burden of HIV and mental health problems in China, hindering HIV-related care engagement and medication adherence. mHealth interventions have shown promising effects in improving mental health outcomes. Following the intervention development project funded by a Population Health Initiative Tier 1-funded award, this project aimed to 1) assess intervention acceptability, feasibility and app usability; 2) examine the preliminary effects of the intervention on mental health outcomes, ART adherence and coping outcomes.

We have successfully completed the aims we proposed for this project. We conducted a feasibility trial, where 30 participants were randomly assigned to an intervention or a control for a four-week study period. Participants in the intervention group received the hybrid mHealth intervention we designed, including coping skills learning on an app, online skills group and on-demand skills coaching. Participants generally found the intervention to be acceptable, feasible and app interface easy to navigate. The preliminary results suggested that the intervention improved depression, emotion dysregulation and HIV mastery, as well as coping self-efficacy around emotions and reaching out for support. Despite the limitations of being a feasibility pilot, this work has important implications for cross-cultural adaptation of Dialectical Behavioral Therapy (DBT) and its extension into digital mental health interventions.

Community-engaged home environmental assessments to support a multi-modal "healthy home" intervention in Yakima Valley, WA

Investigators
Catherine Karr, Departments of Pediatrics and Environmental & Occupational Health Sciences
Linda Ko, Department of Health Systems and Population Health
Elizabeth Torres, Northwest Communities Education Center (NCEC)/Radio KDNA
Allison Sherris, Department of Environmental & Occupational Health Sciences
Christine Loftus, Department of Environmental & Occupational Health Sciences
Elena Austin, Department of Environmental & Occupational Health Sciences
Adriana Perez, Yakima Valley Farm Worker Clinic
Corbin Schuster, Heritage University
Kait Wolterstorff, Yakima Health Department
Maria Carriedo, community member and early child care provider in Toppenish, WA

Project summary
This project was designed with a larger vision to develop an intervention that can address multiple community identified environmental health threats during pregnancy and infancy to prevent child illness in the Yakima Valley (WA) community. In support of that larger vision this project sought to learn about community priorities for environmental health threats and pilot a multi-environmental health concern home assessment protocol. We set out to complete:

• Pilot an early life healthy home assessment protocol in eight households in the lower Yakima Valley. The protocol included environmental and biological sampling for analyses of indoor air pollutants, lead, pesticides and drinking water contaminants. We also surveyed participant knowledge, concerns and behavior related to pollutant sources and exposure pathways.
• A focus group to reunite participants to discuss the acceptability of home assessments and potential interventions.
• Provide report back of findings related to air pollution, drinking water, lead and pesticides.
• Co-design a new early life healthy home intervention to address community priorities identified in Aim 1, incorporating Core Advisor and interdisciplinary team input.
• Evaluate the acceptability and feasibility of the home assessment protocol (piloted in Aim 1) and proposed intervention (developed in Aim 2) in focus groups with Aim 1 participants.

With the expertise of our team and our collaborating Core Advisors from the Yakima Valley, we developed a pilot home assessment protocol in English and Spanish. We successfully recruited eight participants to participate in a home assessment using the protocol. The homes were located throughout the lower Yakima Valley (Mabton, Sunnyside, Wapato, Granger). Five of the assessments were conducted in Spanish and three in English, based on participant preference. The assessment comprised a questionnaire regarding perspectives on environmental health priorities and exposures, home surface and product testing with a portable XRF device, PM2.5 indoor air monitoring over two weeks, water sampling and pesticide testing in household dust and participant urine. All participants received written information regarding their own results. All received information on how to reduce exposure to the common hazards that were addressed in this project. Materials were available in Spanish or English, as preferred. Community-wide updates on the project were delivered at community events in March and September 2024.

Participant survey responses support highest concern regarding outdoor air quality, wildfire smoke and drinking water, followed by lead, mold or dampness, pesticides or other indoor air quality. Regarding outdoor air quality, all participants had noticed poor air quality in the past year and were familiar with the term “AQI”. 7/8 noticed wildfire smoke in the last 3 years and 5/8 felt they had enough information about air pollution. Perceived issues with water quality included low pressure or not enough water (3/8), bad taste or smell (3/8) and mineral build up (5/8). The majority (5/8) perceived their water a unsafe/very unsafe. Half of participants endorsed using insecticides in their homes, using herbicides in the lawn, having a household member involved in agriculture, and experiencing pesticide drift.

Lead-contaminated items were identified in four households using the portable XRF (ceramic pot, ceramic sink, ceramic cup, vinyl blinds). Pyrethroid insecticides were detected in dust samples from all participants. Organochlorine pesticides were detected in one dust sample and organophosphate pesticides were not detected in the dust samples. In urine samples, neonicotinoid insecticides and glyphosate herbicide were detected in all participants. Nitrate was near the regulatory standard for water in one household. One participant had arsenic concentration above the regulatory standard (MCL) and one participant had detectable lead. No e. coli or total coliform bacteria was found. The median PM2.5 concentrations for indoor air quality ranged from 1-12 ug/m3, the mean PM2.5 concentrations were d5-63 ug/m3.

This project underscored the ongoing concerns for pesticide exposure, drinking water quality and wildfire smoke in the Yakima Valley community.

Using School Community Collaboratives to Address Student Disciplinary Outcomes Linked to School Policing: A Pilot Study

Investigators
Monica Vavilala, Harborview Injury Prevention and Research Center, Department of Anesthesiology and Pain Medicine
Marcus Stubblefield, King County Executive Office, Office of Performance, Strategy, and Budget
Keith Hullenaar, Harborview Injury Prevention and Research Center, Department of Epidemiology
Eric Bruns, School Mental Health Assessment, Research, & Training Center (SMART), Department of Psychiatry & Behavioral Sciences
Chelsea Hicks, Harborview Injury Prevention and Research Center, Department of Pediatrics

Project summary
The original project proposal defined three goals: 1) Implement Schools Community Collaboratives (SCC) pilot programs in three school districts with School Resource Officers (SROs); 2) Examine variation in feasibility, acceptability, and appropriateness of using SCC programs across school districts with SROs; and 3) Examine whether the SCC program is associated with school safety policy changes and improved school-police relations in school districts with SROs.

The proposed SCC remained an essential element of our intervention but in response to community partner feedback, we also considered issues such as power, implementation science frameworks, sample size and scope of SCC model, addressing school priorities and model flexibility. We evaluated existing holistic safety models and selected the adapted CDC framework (Whole Child, Whole School, Whole Community; WSWC). We also developed and implemented a comprehensive project planning tool to guide our work. We conducted two workshops with seven school districts (Olympia, Seattle Public Schools, Renton, Federal Way, Tukwila, Highline and Auburn) which included District leadership, including Superintendents, school safety liaisons, disciplinary liaisons, Chief Information Officers (CIOs) as well as building personnel. While we intended to include students and family representatives, schools preferred to do this work internally with school personnel first before inviting families to join, which we respected.

Pre-workshop planning meetings were held with each district to collaboratively engage them in the design and implementation process. The full-day workshop agendas included brief presentations on the CDC model, OSPI Report Card and Healthy Youth Survey data, as well as intensive district roundtable discussions exploring school safety best practices, refining district safety plans, and prioritizing action steps. Schools requested support with identifying a prioritization model, which we provided. Roundtable discussions were supported by King County Criminal Justice expert facilitators paired with UW team members. Participants left the workshop with a partially completed assessment of local safety practices and a tool to use to complete development of a holistic school safety plan. We supported participating districts to engage in this work by asking questions that helped them align their priorities with best practices we discussed at workshops and that were and will be incorporated in their 2024-2025 school safety plan. Highline School District withdrew from this project after participating in the workshop but the rest remain committed to ongoing work with King County, Puget Sound Educational School District and the UW. Feedback from participants was favorable to continuing the work using the CLASS project format.