Public Health Projects from 2022

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  Behind Closed Doors: Substance Use Disorder and Human Trafficking in Vermont

  Arif S. Ahsan, Adaugo Chikezie, Jordan S. Franco, Heather A. Kettlewell, Caitlin E. Marassi, Dan J. Mitchell, and Kae L. Ravichandran

  Background: Human trafficking is a humanitarian crisis. Current literature identifies risk factors predisposing individuals to becoming trafficked, including housing insecurity, substance use disorders, and disrupted childhood households. This study investigates the relationship between human trafficking and substance use disorder in Vermont.

  Methods: Nine qualitative interviews were conducted with professions directly interacting with victims of human trafficking in Vermont, representing Law Enforcement, Healthcare, and Community Services professionals. A standardized interview guide included questions that aimed to uncover risk factors, health and support needs, and challenges victims face. Two coders individually reviewed each set of interview notes prior to meeting to finalize themes and subcategories, to construct a thematic network.

  Results: Substance use was cited as strongly associated with human trafficking by each category of professionals, and several additional themes emerged. Accessibility to resources was cited twice as frequently as the next most common theme, the nature of human trafficking, with subcategories of limited ability to help victims and victim’s lack of transportation most frequently mentioned. The nature of human trafficking theme included sex work/trafficking and Vermont-specific issues as the most frequent subcategories, while complex medical issues and socioemotional concerns shared the third most cited theme.

  Conclusion: Human trafficking and substance use disorder are closely entwined in Vermont. To address this public health crisis, national guidelines should be augmented with regional risk factors and accessibility concerns. Additional research must be conducted to expand this Vermont specific data set. Risk factors and accessibility concerns in Vermont should be compared to other regions in the United States.

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  Using Telehealth to Meet the Unique Needs of Rural Communities

  Lindsay Aldrich, Jack J. Braidt, John S. Burke, Ryan P. Kelly, Kelly J. Knight, Elizabeth M. O'Neill, Virginia S. Ramirez, and Gabriela F. Sarriera-Valentin

  Introduction: Many Vermonters report difficulties in accessing healthcare, and telehealth became a widespread solution during the COVID-19 pandemic. The continued use of telehealth may improve health disparities for Vermonters. The objective of this study was to investigate perspectives on telehealth among patients and healthcare providers.

  Methods: A cross-sectional survey-based study design was used. Provider surveys were distributed via e-mail and patient surveys were distributed via Front Porch Forum throughout Vermont. A major limitation of the study is that this was a convenience sample and may not equally represent all Vermont practitioners and patients.

  Results: Scheduling appointments was 2.04 times easier for those with private insurance vs public insurance (P< 0.05), and was 2.57 times easier for those < 60 years old compared to those ≥60 years old (P< 0.01). There were no statistically significant differences between Chittenden County and the remainder of Vermont. 73% of providers agreed that telehealth has led to improvements in patient outcomes, and pediatricians were twice as likely to be satisfied with their patient interactions via telehealth.

  Conclusion: Overall, most patients in our study were satisfied with their telehealth interactions (72%) and agreed that telehealth expanded their access to healthcare (60%). The lack of significant differences in our study between Chittenden County and the remainder of Vermont may be due to variations in public/private insurance, internet access, and specialists under-utilizing telehealth. The biggest concerns among respondents were the lack of physical exams via telehealth, which could be addressed through patient and provider education and the use of at-home technologies.

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  The Impact of Resource Modality on Reported Outcomes in Cancer Patients

  Clemens An, Ellie Bradley, Katelynn Briere, Hannah Donovan, Tin Nguyen, Edward Simon, Jennifer Toner, and Bryan Shin

  Background: The state of Vermont is one of the most rural states in the nation as more than 80% of people live in either rural areas or small cities. This provides a unique challenge for cancer survivors in Vermont to find and access appropriate forms of support. With the shift towards virtual medicine due to COVID, cancer survivors had to significantly adapt to new restrictions which hindered their ability to find resources for emotional support and information. Due to these circumstances, we wanted to identify the trend in usage and efficacy of various modalities for support by cancer survivors.

  Methods: Cancer survivors completed an online opt-in self-reported survey regarding which resources they accessed and their experiences during their cancer treatment. The goals of this study were to identify prominent informational and supportive sources accessed by cancer patients, compare the frequency with which cancer patients used online versus in-person resources, evaluate the impact each resource had on patient outcomes, and elucidate optimal strategies of disseminating crucial information to cancer survivors.

  Results: We hypothesized that online resources would have the highest rates of usage, while in-person support networks would result in greater efficacy. Based on the results (n=20), more people utilized in-person resources, and in-person resources were associated with more favorable patient outcomes.

  Conclusion: This study revealed that cancer patients utilized in-person resources, such as relationships with healthcare professionals and support networks, more often than online resources. The use of these in-person resources was correlated with higher average patient emotional well-being and level of informedness.

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  How Vermont State Legislative Health Leaders Prioritize Community Health Needs: A Qualitative Analysis

  Anayis M. Antanesian, Sarah Caffry, Nicolas Hutt, Andrew Leckerling, Jiayi Luo, Kadi Nguyen, Anthony Quach, and George Zhang

  Background: The Affordable Care Act requires hospitals to develop Community Health Needs Assessments (CHNAs) every 3 years, identifying community-specific health goals and implementation strategies. However, it is unclear how CNHAs are translated into healthcare policy. College of Medicine students analyzed how Vermont state legislative health leaders prioritized community health needs and their alignment with hospital CHNAs.

  Methods: The Senate Committee on Health and Welfare participated in a virtual focus group; all five committee members were asked six questions by a student moderator. The session was transcribed and corroborated with video review. Utilizing qualitative analysis, responses were independently reviewed and coded into common themes to identify trends in health priorities as identified by the policymakers, and Senators’ methods used to identify those health needs.

  Results: Community health priorities identified by Senate health policymakers aligned with many reported in CHNAs, although CHNAs were not used in their decision-making process. All Senators cited mental health services, affordable housing, and substance use; categories also listed in the top five needs by most Vermont hospital CHNAs.

  Conclusion: This study found that top health priorities of Senate health policy leaders align with CHNAs. While policymakers did not prioritize use of CHNAs as a resource to inform decision-making, CHNAs may provide a beneficial resource for them moving forward. For example, childcare and obesity often appear in CHNAs, but were not highlighted in the focus group. Future broader studies may give a more comprehensive understanding of potential CHNA utility in real-world health care policy development and implementation.

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  Best Practices for Reducing High Emergency Room Utilization Among SASH Participants

  Anupama Balasubramanian, Max Breidenstein, Jacob P. Cappiello, Bradford R. Clark, Chellam E. Nayar, McLaine S. Rich, and Taylor R. Walker

  Background: SASH is a Vermont-based health promotion program that aims to provide affordable housing and care for older Medicare recipients. SASH organizes programs including monthly events, learning presentations, group physical activities, and blood pressure clinics. Through these programs and with the support of their care nurses, SASH has significantly reduced overall Medicare expenditure for their participants, but high-ED utilizers remain a population in which further intervention can decrease costs and resources.

  Methods: This project used statistical analysis of SASH patient data for variables of interest to examine the leading reasons for high ED utilization among SASH participants, then explored ways to address these issues with a literature review. These programs were then compared to existing SASH programs, and based on this comparison, recommendations were made on ways that SASH can address frequent ED usage among its participants.

  Results: SASH patients had a median of seven visits throughout the duration of data collection. Issues related to hypertension, type 2 diabetes, and falls were leading causes of high-ED utilizer visits.

  Conclusion: This study determined that there are several feasible programs that SASH can implement to decrease ED utilization among its participants, including: utilizing a screening questionnaire to connect patients with PCPs and flag high-risk patients, training nurses to assist with blood glucose monitoring and fall prevention education, expanding monthly health events (eg. technology literacy workshops), creating educational videos on falls prevention and healthy diet planning, and expanding food and exercise support to include activities like field trips to the grocery store.

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  A Survey of College Youth Habits Surrounding Electronic Nicotine Delivery Devices in Vermont

  Emily C. Battle, Caitlin Early, Audree Evans, Stefanie Geiger-Kelsey, Callan Gravel-Pucillo MMS, Anirudh A. Hirve, Caleb P. Maness, and Dhiraj Patel

  Background: Teen e-cigarette use increased between 2017 and 2019; however, youth perceived that non-cigarette tobacco products were less addictive than traditional cigarettes, when in fact many vaping devices contain more nicotine than cigarettes. Although vaping in middle and high school students has been extensively studied, data surrounding undergraduates is lacking.

  Methods: The present study surveyed undergraduate students from three Vermont colleges. Of the 326 respondents, 147 reported vaping at some point in their life. The survey was created using RedCap and analysis was conducted using SPSS.

  Results: The reported mean age of vaping initiation was 16.5 ± 2.1 years. Of all participants who had ever vaped (n=147), 61% reported trying to quit at some point, 25% reported never trying to quit, and 14% failed to answer the question. Of the respondents who vaped within the last 30 days (n=74), 77.1% obtained vaping products from a physical store, 20.0% from friends, 1.4% online, 1.4% from another provider not listed, and 0.0% from family. A significant association was found between a history of vaping and agreement with the statement: “it’s cool to vape on campus” (X2: (2, N= 320) = 20.968, p< 0.001).

  Conclusions: Although participants commonly cited friends as a reason for initiating vaping, many denied feeling direct peer pressure to vape. Students reported being more likely to vape at school than at home. Additionally, the most common method reported of purchasing devices was through physical stores. Future research should identify effective strategies to assist youth struggling to quit and reduce underage purchasing in physical stores.

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  Improving Blood Donation Rates through Analysis of Motivational Factors for Repeat and New Black Donors

  Jasmine A. Bazinet-Phillips, Ashfi Chowdhury, Olivia Darko, Michelle Falcone, Benjamin M. Glickman, Alec M. Schrager, and Tyler VanDyk

  Background: During the COVID-19 pandemic, vaccination clinics held in community centers provided a solution for increasing vaccination rates in the Black community Blood donations, like vaccination turnouts, could correlate with accessibility of donation center location. Our project asked new and recurrent Black blood donors, about their donation preferences to identify recruitment solutions.

  Methods: An eighteen-question, online-anonymous survey, was distributed to American Red Cross (ARC) blood donors who self-identify as African American and have donated > 1 time since 1/1/2019. Responses from 512 blood donors were received regarding their knowledge of sickle cell disease, frequency of donation, familiarity with the donation venue, their preferred informational medium, and motivations for donating. Responses collected 4/20/222 - 4/27/22 were stratified into “repeat donors” (>3 times since 2019, n=329) and “new donors” (< 3 times since 2019, n=183).

  Results: New donors who preferred to donate blood at a community center (28.0%) were more likely to co-select “giving back to [their] community” as a primary motivation (80.8%, p = 0.048). New donors also indicated “walk-in” scheduling preference compared to recurrent donors (54.8% vs 42.8%, p= 0.032), whereas recurrent donors demonstrated significant preference for scheduling “>1 month in advance” (22.6% vs 42.2%, p < 0.0001). Additionally, new donors were unsure of where to donate blood as compared to recurrent donors (11.3% vs 3.8%, p=0.009).

  Conclusions: The study results indicate that consideration should be given to disbursement of information regarding the location of the venue and scheduling options for blood drive participants.

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  Understanding the Communication Experiences of Patients with Intellectual and Developmental Disabilities in Healthcare Settings

  Ty E. Bever, Olivia Dominque, Charlotte Evans, Aathmika Krishnan, Michael H. Le, Ashwini Sarathy, Rachel Thompson, and Richard Q. Vuong

  Background: Recent studies demonstrate that individuals with intellectual and developmental disabilities (IDD) face communication challenges in healthcare settings. To evaluate the efficacy of communication between healthcare providers (HCPs) and individuals with IDD in Vermont, we surveyed and interviewed HCPs, direct support professionals (DSPs) and individuals with IDD.

  Methods: We used a mixed methods approach to evaluate communication challenges patients with IDD face. Surveys were distributed to HCPs, DSPs and individuals with IDD. The surveys indicated the communication strategies preferred by each group and measured the experience level of HCPs and Ds working with individuals with IDD. Individuals with IDD and Ds were interviewed. Quantitative data were compared using non-parametric tests, with linear regression identifying factors related to patient comfort. Qualitative data were categorized by common themes.

  Results: 91 surveys were completed by 18 DSPs, 2 individuals with IDD, and 71 HCPs. The proportion of HCPs with >5 years of experience working with IDD patients was significantly higher than DSPs (90.1% vs 66.7%, p=0.003). However, 55.6% of DSPs reported witnessing communication challenges between individuals with IDD and HCPs. The proportion of HCPs that routinely ask patients with IDD how they best communicate was significantly lower than the proportion of DSPs willing to share this information (50.7% vs 91.7%, p=0.010).

  Conclusion: Despite high levels of provider experience, communication in the healthcare setting remains challenging for individuals with IDD. Areas for improvement include targeted interventions such as personalized communication tools and patientcentered approaches. HCPs must address these factors to improve quality of care for individuals with IDD.

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  Primary Care Provider and Medical Student Knowledge and Attitudes Regarding Cannabis in Vermont

  Seth Brownmiller, Ana Homick, William Hsu, Clara Maxim, Leland Nguyen, Annie Penfield-Cyr, Serra Sozen, and Eric Stoutenburg

  Background: There is growing debate about the use of cannabis containing products and community implications. Current research emphasizes determining the impact cannabis has on the short and long-term health of an individual. Our research was focused on the perception of cannabis use between medical students and primary care providers (PCPs).

  Methods: We used an anonymous, 5-point scale survey to assess the knowledge and attitudes about cannabis use, including thoughts on Vermont’s upcoming adult use marketplace. Key emphasis was placed on the attitudes of public health, driving safety, effectiveness for medical conditions, and patient education.

  Results: Roughly 64% of respondents believe cannabis may negatively affect public health, yet 90% of students and 58% of PCPs support the creation of an adult use marketplace. This is especially interesting to consider when an overwhelming majority of both students and PCPs agreed that alcohol use had a negative impact on public health. Confidence in patient education was also evaluated, which demonstrated an opportunity for both medical students and PCPs to receive additional training on the positive and negative impacts of cannabis to share with patients.

  Conclusion: It is our goal that this work be used to further the conversation both inside and outside our healthcare system to better understand the public perception on cannabis, and the impact its use may have on the people in our communities. We hope this project will inspire future collaboration with the VT Cannabis Control board to serve as a source of valuable information about healthy policy surrounding cannabis use.

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  Weight Bias in Medical Students and Healthcare Professionals

  Vyha T. Do, Jharna Jahnavi, Ryan Kamkar, Dana L. Kramer, Casey Krueger, Karena P. Nguyen, Vennela Pandaraboyinau, and Neeki Parsa

  Background: Weight bias in healthcare leads to poorer communication, misdiagnoses, and less time spent with higher BMI patients. A gap in the literature exists for characterizing weight bias in healthcare. Our study aims to understand weight bias in local practitioners and medical students. We explore awareness of bias, confidence in navigating bias, and potential interventions to reduce the impact of weight bias

  Methods: The 8-item Beliefs About Obese Persons questionnaire and adapted Attitude Towards Obese Patients and Perceived Weight Bias in Health Care questionnaires were distributed to medical students and physicians via email lists.

  Results: 136 responses from preclinical students (n=73), clinical students (n=26), and physicians (n=22), were analyzed with paired t-tests. Physicians had the least amount of bias, followed by preclinical and then clinical students. Physicians were more likely to believe weight bias is an issue and be confident in their ability to navigate bias than preclinical students.

  72.1% of all survey respondents indicated that weight bias is a problem. Open-ended field questions were coded and indicated that more training is needed, that weight bias exists in healthcare, and that bias is difficult to discuss. Respondents chose workshops as an effective intervention.

  Conclusion: In our study, physicians showed the least bias, followed by preclinical students. Our results suggest longitudinal clinical exposure may help mitigate weight bias. Many participants regard weight bias to be present and concerning and view existing methods as ineffective. This study will inform future weight bias interventions to ensure improved outcomes for patients.

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  Preventing Child Sexual Abuse: Educators' Perspectives on School-Based Curricula in Vermont

  Kate A. French, Luke Giangregorio, Annie Glessner-Fischer, Zachary Kramer, Casey Little, Matthew R. Rzemien, Paige Song, and Jessica Wyn

  Background: Child sexual abuse (CSA) is associated with longitudinal repercussions in academic performance and physical and psychological health outcomes (1). Vermont passed Act 1 in 2009 aiming to mitigate the incidence of CSA via school-based curricula. Act 1 requires each district to have organized training on CSA for its employees and lessons for students at every grade level (2). This project surveyed six schools in Vermont to evaluate how districts have aimed to meet the mandate, obstacles they have encountered, and subjective efficacy of their current program.

  Methods: Individuals involved with CSA prevention programs from six VT schools (preK-8th grade) were interviewed. Interviews addressed 1) efficacy of CSA prevention program in use, 2) parental involvement, and 3) general thoughts. Interview transcripts were coded to identify key concepts and beliefs. Lastly, codes were grouped into minor themes, which were assessed and compared to establish overarching themes.

  Results: Many of the CSA programs addressed inappropriate behavior, standing up for yourself, sexuality, and the fear of speaking out. Shared obstacles for the schools included: time restriction in student and educator schedules, financial barriers including the cost of purchasing an effective program and hiring staff to teach it, and lack of parental involvement.

  Conclusions: This study explored how six Vermont school districts have incorporated CSA education in response to Act 1. Overall, the educators expressed a dire need for a state-sponsored and standardized curriculum that is relatable for students and regularly updated, strict specifications for who should teach the curriculum, and clarity on the parental and/or community involvement.