Faculty Bibliography

Annually, 100 million people experience homelessness worldwide. Most adults that are struggling with homelessness are living to age 50 years or older and need age-appropriate screening for cancer. Cancer-related death in homeless adults is twice as high as the average in the adult population in the USA. However, few studies have examined the rates of and barriers to cancer screening in homeless people. This Review explores cancer-related health disparities between homeless people and the general population by providing a review of data and definitions relating to homelessness, an analysis of barriers to screening in this population, and a discussion of the current and potential interventions and strategies to improve cancer screening in homeless individuals. Recommendations include implementing appropriate data collection methods for this population, supporting cancer screening in places where homeless people usually access care, assessing the effectiveness of approaches to increasing cancer screening in homeless people, and addressing adequate housing as a fundamental social factor.

Cervical cancer disproportionately affects low-resource settings. Papanicolaou, human papillomavirus (HPV), and visual inspection of cervix with acetic acid (VIA) testing, each with different characteristics, will reduce cervical cancer burden. We conducted a critical literature review using PubMed, Cochrane, WHO, and grey literature from 1994 to 2020. We examined efficacy, harms, and comparative effectiveness of screening methods by age, human immunodeficiency virus, provider characteristics, and assessed implementation challenges in low-resource settings. Comprehensive data on utility and efficacy of screening tests indicates that each screening has strengths and shortcomings but all confer acceptable performance. HPV and VIA appear more promising. Primary HPV test-and-treat, self-testing, and co-testing have been studied but data on triage plans, cost, support system, implementation and sustainability is unclear in low-resource settings. HPV testing could help target subgroups of older or higher risk women. VIA offers local capacity-building and scalability. Quality VIA technique after HPV testing is still required to guide post-screening treatments. VIA competencies decline gradually with current standard trainings. Stationary cervicography improves VIA quality but isn't scalable. Affordable smartphones eliminate this barrier, enhance training through mentorship, and advance continuing education and peer-to-peer training. Smartphone-based VIA facilitates cervical image storage for patient education, health promotion, record-keeping, follow-up care, remote expert support, and quality control to improve VIA reliability and reproducibility and reduce mis-diagnoses and burden to health systems. Rather than ranking screening methods using test characteristics alone in study or higher-resource settings, we advocate for scalable strategies that maximize reliability and access and reduce cost and human resources.

BACKGROUND/UNASSIGNED:There is a dearth of data regarding diabetes control among patients experiencing homelessness. METHODS/UNASSIGNED: = 418; homeless: 356 and domiciled: 58) seen in shelter-clinics in New York City in 2019. The outcomes were the rates of inadequately managed diabetes and associated factors. FINDINGS/UNASSIGNED: = 0·010) were associated with lower HbA1c, suggesting better support in respective shelters. There was no statistically significant association between inadequately managed diabetes with several traditional risk factors including substance or alcohol use disorder, health insurance, or other chronic diseases. INTERPRETATION/UNASSIGNED:Interventions at shelters or shelter-clinics should target subgroups in addition to addressing traditional risk factors to improve diabetes control. mHealth strategies could be considered to improve engagement, care delivery, and medication taking. Ultimately, homelessness itself needs to be addressed. FUNDING/UNASSIGNED:There are no funding sources to declare.

INTRODUCTION:Uncontrolled hypertension (HTN) is prevalent in persons experiencing homelessness (PEH) and contributes to significant suffering and financial cost. Mobile health approaches such as short messaging service (SMS) texting have led to better control of HTN in the general population. Despite the high utilisation of mobile phones by PEH, SMS texting to support HTN control has not been evaluated among this population. We hypothesise that an SMS testing programme will enhance health communication, information management, outreach and care coordination, and provide behavioural support to address some barriers to HTN management in PEH. METHODS AND ANALYSIS:This study will use a mixed-methods study design to address two objectives: First, it will evaluate, in a randomised controlled trial, the efficacy of a 6-month SMS texting strategy vs an attention control on blood pressure reduction and adherence to medications and clinical appointments in 120 adults PEH with uncontrolled HTN. Outcomes will be measured at 0, 2, 4 and 6 months. Second, it will assess patients' and providers' acceptability and experience of SMS texting using semistructured interviews with PEH (n=30) and providers (n=10). The study will be conducted in shelter clinics in New York City in collaboration with community organisations. The primary statistical analysis will be on an intention-to-treat basis. The trial results will be reported as comparative summary statistics (difference in response rate or means) with 95% CIs and in accordance with the Consolidated Standards of Reporting Trials (CONSORT). Interviews will be transcribed, coded and analysed using an inductive grounded theory analysis. ETHICS AND DISSEMINATION:This study has been approved by the Institutional Review Board (IRB) at George Washington University. Written consent will be obtained from participants. The findings will be disseminated in peer-reviewed journals. TRIAL REGISTRATION NUMBER:NCT05187013.

BACKGROUND:Diabetes mellitus (DM) is common among persons experiencing homelessness (PEH), often inadequately managed, and carries significant costs. mHealth strategies including short messaging service (SMS) texting have been feasible and acceptable, and improved control of chronic diseases including DM. SMS strategies for DM have not been tested among PEH despite the accessibility of mobile phones. We propose an SMS strategy could offer better communication, education, and information management; improve outreach; facilitate care coordination; explore barriers to care; and support behavior changes. METHODS AND ANALYSIS/METHODS:This mixed-methods (RCT and qualitative) study will be implemented in shelter-clinics in New York City in collaboration with community organizations, allowing for sustainability and scalability. Aim 1 will evaluate the efficacy of a 6-month SMS program for DM management versus an attention control on changes in HbA1c and adherence to DM self-care activities, medications, and appointments at 9 months in adult PEH with uncontrolled DM (n = 100). Outcomes will be measured at 0, 3, 6, &9 months. AIM 2 will assess patients' and providers' attitudes, acceptability, and experience of the program through semi-structured interviews with PEH (n = 20) and providers (n = 10). DISCUSSION/CONCLUSIONS:DM is not well-addressed among PEH. SMS strategies for DM have never been tested in PEH despite evidence of their effectiveness and access to mobile phones among PEH. Results from this study will provide important empirical data to inform evidence-based strategies to avert personal suffering and significant costs. It will have broader policy implications in control of DM and other chronic diseases.

Large number of people with non-communicable diseases (NCDs) face barriers to adequate healthcare in humanitarian settings. We conducted a systematic literature review in MEDLINE/PubMed, Web of Science, EMBASE/DARE, Cochrane, and grey literature from 1990 to 2021 to evaluate effective strategies in addressing NCDs (diabetes, cardiovascular diseases, COPD, cancer) in humanitarian settings. From 2793 articles, 2652 were eliminated through title/abstract screening; 141 articles were reviewed in full; 93 were eliminated for not meeting full criteria. Remaining 48 articles were reviewed qualitatively to assess populations, settings, interventions, outcome, and efficacy and effectiveness; 38 studies addressed treatments, 9 prevention, and 7 epidemiology. Prevention studies broadly addressed capacity-building. Treatment and epidemiology studies largely addressed hypertension and diabetes. Interventions included web-based/mobile health strategies, pharmacy-level interventions, portable imaging, and capacity building including physical clinics, staff training, forging collaborations, guideline development, point-of-care labs, health promotion activities, EMR, and monitoring interventions. Collaboration between academia and implementing agencies was limited. Models of care were largely not well-described and varied between studies due to contextual constraints. Barriers to interventions included financial, logistical, organizational, sociocultural, and security. Cancer care is significantly understudied. Simplified care models adapted to contexts and program evaluations of implemented strategies could address gaps in applied research. Inherent challenges in humanitarian settings pose unavoidable perils to evidence generation which requires a shift in research mindset to match aspirations with practicality, research collaborations at the inception of projects, reworking of desired conventional level of research evidence considering resource-intense constraints (HR, time, cost), and adapted research tools, methods, and procedures.

The burden of Clostridioides difficile infection (CDI) has greatly increased. We evaluated the risks for CDI transmission to community members after hospitalized patients are discharged. We conducted a systematic literature review in MEDLINE/PubMed, EMBASE, CINAHL plus EBSCO, Web of Science, Cochrane Library, and gray literature during January 2000‒February 2019 and identified 4,798 citations were identified. We eliminated 4,554 citations through title and abstract screening; 217 additional citations did not meet full criteria. We reviewed texts for the 27 remaining articles qualitatively for internal/external validity. A few identified studies describing risks to community members lacked accurate risk measurement or preventative strategies. Primary data are needed to assess efficacy of and inform current expertise-driven CDI prevention practices. Raising awareness among providers and researchers, conducting clinical and health services research, linking up integrated monitoring and evaluation processes at hospitals and outpatient settings, and developing and integrating CDI surveillance systems are warranted.

Psychosocial stressors are prevalent and linked to worse health outcomes, but are less frequently addressed than physically apparent medical conditions at primary care visits. Through a community-academic partnership between an art museum and a federally qualified health center, we developed an innovative museum-based intervention and evaluated its feasibility and acceptability among diverse, underserved patients and its perceived effects on psychosocial stressors. Guided by experiential learning and constructivist approaches, the intervention consisted of a single, three-hour session that incorporated group discussions and interactive components, including art-viewing, sketching, and object-handling. We used post-intervention focus groups to elicit feedback qualitatively. From July 2017 to January 2018, 25 patients participated. Focus groups revealed that the intervention exhibited therapeutic qualities, fostered self-reflection, catalyzed social connectivity, and functioned as a gateway to community resources. These findings can guide future research and development of community-based interventions to target the growing burden of psychosocial stressors among the underserved.

BACKGROUND:Cervical cancer is among the most common preventable cancers with the highest morbidity and mortality. The World Health Organization (WHO) recommends visual inspection of the cervix with acetic acid (VIA) as cervical cancer screening strategy in resource-poor settings. However, there are barriers to the sustainability of VIA programs including declining providers' VIA competence without mentorship and quality assurances and challenges of integration into primary healthcare. This study seeks to evaluate the impact of smartphone-based strategies in improving reliability, reproducibility, and quality of VIA in humanitarian settings. METHODS AND FINDINGS:We implemented smartphone-based VIA that included standard VIA training, adapted refresher, and 6-month mHealth mentorship, sequentially, in the rural Shiselweni region of Eswatini. A remote expert reviewer provided diagnostic and management feedback on patients' cervical images, which were reviewed weekly by nurses. Program's outcomes, VIA image agreement rates, and Kappa statistic were compared before, during, and after training. From September 1, 2016 to December 31, 2018, 4,247 patients underwent screening; 247 were reviewed weekly by a VIA diagnostic expert. Of the 247, 128 (49%) were HIV-positive; mean age was 30.80 years (standard deviation [SD]: 7.74 years). Initial VIA positivity of 16% (436/2,637) after standard training gradually increased to 25.1% (293/1,168), dropped to an average of 9.7% (143/1,469) with a lowest of 7% (20/284) after refresher in 2017 (p = 0.001), increased again to an average of 9.6% (240/2,488) with a highest of 17% (17/100) before the start of mentorship, and dropped to an average of 8.3% (134/1,610) in 2018 with an average of 6.3% (37/591) after the start of mentorship (p = 0.019). Overall, 88% were eligible for and 68% received cryotherapy the same day: 10 cases were clinically suspicious for cancer; however, only 5 of those cases were confirmed using punch biopsy. Agreement rates with the expert reviewer for positive and negative cases were 100% (95% confidence interval [CI]: 79.4% to 100%) and 95.7% (95% CI: 92.2% to 97.9%), respectively, with negative predictive value (NPV) (100%), positive predictive value (PPV) (63.5%), and area under the curve of receiver operating characteristics (AUC ROC) (0.978). Kappa statistic was 0.74 (95% CI; 0.58 to 0.89); 0.64 and 0.79 at 3 and 6 months, respectively. In logistic regression, HIV and age were associated with VIA positivity (adjusted Odds Ratio [aOR]: 3.53, 95% CI: 1.10 to 11.29; p = 0.033 and aOR: 1.06, 95% CI: 1.0004 to 1.13; p = 0.048, respectively). We were unable to incorporate a control arm due to logistical constraints in routine humanitarian settings. CONCLUSIONS:Our findings suggest that smartphone mentorship provided experiential learning to improve nurses' competencies and VIA reliability and reproducibility, reduced false positive, and introduced peer-to-peer education and quality control services. Local collaboration; extending services to remote populations; decreasing unnecessary burden to screened women, providers, and tertiary centers; and capacity building through low-tech high-yield screening are promising strategies for scale-up of VIA programs.

INTRODUCTION/BACKGROUND:Data regarding underpinning and implications of ethical challenges faced by humanitarian workers and their organisations in humanitarian operations are limited. METHODS:We conducted comprehensive, semistructured interviews with 44 experienced humanitarian aid workers, from the field to headquarters, to evaluate and describe ethical conditions in humanitarian situations. RESULTS:61% were female; average age was 41.8 years; 500 collective years of humanitarian experience (11.8 average) working with diverse major international non-governmental organisations. Important themes included; allocation schemes and integrity of the humanitarian industry, including resource allocation and fair access to and use of services; staff or organisational competencies and aid quality; humanitarian process and unintended consequences; corruption, diversion, complicity and competing interests, and intentions versus outcomes; professionalism and interpersonal and institutional responses; and exposure to extreme inequities and emotional and moral distress. Related concepts included broader industry context and allocations; decision-making, values, roles and sustainability; resource misuse at programme, government and international agency levels; aid effectiveness and utility versus futility, and negative consequences. Multiple contributing, confounding and contradictory factors were identified, including context complexity and multiple decision-making levels; limited input from beneficiaries of aid; different or competing social constructs, values or sociocultural differences; and shortcomings, impracticality, or competing philosophical theories or ethical frameworks. CONCLUSIONS:Ethical situations are overarching and often present themselves outside the exclusive scope of moral reasoning, philosophical views, professional codes, ethical or legal frameworks, humanitarian principles or social constructivism. This study helped identify a common instinct to uphold fairness and justice as an underlying drive to maintain humanity through proximity, solidarity, transparency and accountability.