Racial Disparities in Substance use and Services
Dr. Ty Borders, Principal Investigator

The overall objective of this study is to examine racial (especially African American vs. white) differences in need for treatment for substance use (both illicit drug and alcohol use) and access to formal substance abuse services. A secondary objective is to describe rural/urban differences in need for treatment services, including whether African American vs. white disparities are exacerbated in rural areas. To address these issues, we plan to conduct in-depth statistical analyses of the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative in-person interview conducted by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The NESARC, which is publicly available for use by researchers, is a very unique data source as it contains information on both alcohol use and illicit drug use among approximately 40,000 persons. A better understanding of racial and rural/urban differences in access to substance abuse services would enable health policy makers, treatment program managers, and providers to make more informed decisions about the targeting and tailoring of programs aimed at improving entry into the substance abuse treatment system.

The WORD (Wholeness, Oneness, Righteousness, Deliverance): Feasibility test of a healthy weight program for rural, Southern churches
Dr. Karen H. Kim Yeary, Principal Investigator

Despite multidisciplinary efforts to control the nation’s obesity epidemic, obesity has persisted as one of the U.S.’s top public health problems, particularly among African Americans and rural residents. To combat current disparities in health, innovative approaches to address obesity that are sensitive to the unique issues of rural African Americans are needed. Current approaches have emphasized the importance of culturally appropriate materials and the potential impact of a faith-based intervention in underserved rural communities. The purpose of this pilot is to conduct a feasibility test of a faith-based weight loss intervention culturally adapted for rural African American adults. The materials will incorporate weight loss methods and materials from evidence-based behavioral weight loss interventions and will adapt these materials to integrate deep structure cultural components, and spiritual and faith related themes. The pilot will test a culturally adapted, faith-based behavioral weight loss intervention implemented among African American churches. The pilot will build upon preexisting relationships with the Faith Task Force, which consists of over 30 churches and community organizations in rural, low income Arkansas counties, and with which the Pilot PI has been involved for over 3 years.

Practice-based Methods to Improve Quality of Care and Reduce Health Disparities in Diabetes and Cardiovascular Disease
Dr. Creshelle R. Nash, Principal Investigator

Approximately 6% of Americans (19 million people) have diabetes, with substantially higher rates among ethnic and racial minority populations. This translates into a significant economic and personal burden. Arkansas ranks in the top 5 states in the country for diagnosed diabetes. Timely access to preventive care and routine disease management services and enhanced adherence to current standards of treatment could prevent many diabetes-related complications. Unfortunately, many people do not receive these services, and there are wide disparities across racial and gender groups. Ethnic and racial minority groups also have substantially higher rates of CVD morbidity and mortality and have significantly lower rates of being offered and receiving appropriate care. Physician practice-based methods to enhance adherence to practice guidelines and improve overall quality of care have been examined in a variety of prevention and treatment arenas, however there is little research in using these methods to reduce health disparities by improving overall quality of care. Therefore, formative research is critical to understand how best to approach practices to engage them in promoting appropriate care for diabetes and CVD among minority patients and how best to facilitate enhanced adherence to established practice guidelines so that health disparities are reduced. The specific aims of the proposed pilot are to conduct qualitative research to explore these important themes at a practice level, to inform the design of an intervention approach tailored to the needs of the practices and to evaluate the feasibility of conducting this intervention in practice-settings on a larger scale.

Understanding the Underutilization of Tobacco Cessation Programs in the Mississippi Delta
Dr. Christine Sheffer, Principal Investigator

Tobacco use is the leading cause of preventable death, contributing greatly to the incidence and progression of coronary heart disease (CHD). Cessation provides immediate and major health benefits, lowering the CHD death risk almost immediately. Lower socio−economic (SES) groups have more difficulty with cessation and suffer disproportionately from CHD and other tobacco−related disease. This disparity is linked with access to evidence−based treatments for tobacco dependence. Several Arkansascounties lie in the heart of the Mississippidelta region, a historically underserved area with some of the highest CHD death rates in the country as well as the lowest rates of participation in the state-sponsored, tobacco dependence treatment programs. New methods for engaging this population are needed; however, there is a lack of understanding as to why there are disparate levels of participation. Community-based participatory research (CBPR) methods will be utilized to build on existing collaborations in the communities; analyze the social, economic, cultural, environmental, and historical context; and conduct guided focus groups. Results from the focus groups will be used to develop a survey instrument that will be administered to selected residents in the larger community. Outcomes cannot be defined prior to completing the formative research, but are likely to include common issues such as trust, awareness, social influences, motivation, self-efficacy, outcome expectancies, and access to services. This formative research is expected to result in suggested methods to significantly increase participation in the tobacco treatment programs in targeted counties. If generalizable, the results of this pilot project will provide important information about engaging marginalized groups in treatment for tobacco dependence. The suggested methods will be tested in subsequent research.

Understanding sexual and reproductive health and the impact of migration in an emerging Latino community in Arkansas
Drs. Katharine Stewart & Eduardo Ochoa, co-Principal Investigators

The relationship between migrant status and sexual/reproductive health (SRH) outcomes in the Mexican migrant and immigrant population is poorly understood, yet appears to be quite complex. On one hand, migration appears to have a positive impact on infant health, both for the children of women who migrated to the US and for women who remain in Mexico but whose partners are temporary migrants to the US. However, migrant workers and their spouses or sexual partners who remain in Mexico also appear to be at higher risk for negative outcomes as well, including STD/HIV risk, decreased access to SRH care, decreased access to prenatal and well-baby care, disruption of social support networks and coping structures, and depression/anxiety. The objectives of the proposed project are (1) to identify immigrants’ perceptions of the facilitators and barriers of SRH-promoting behaviors, including condom use, STD/HIV testing and screenings for cancers of the reproductive system, use of informal health care systems, prenatal care, and well-baby care, and (2) to describe immigrants’ expectations and utilization of informal, public health, and individual health systems in Mexico and Arkansas. We will conduct four focus groups, two groups with men and two groups with women, enrolling a maximum of thirty-two participants, all of whom will be adults aged 18 to 45 years of age who have migrated to Arkansas from Mexico at least three months but no more than three years prior to the date of their enrollment in the study. All participants must have had contact with a health care provider in the past twelve months for sexual or reproductive health care, including testing or treatment for sexually transmitted infections, prenatal or well-baby care, or another sexual or reproductive health concern. Participants will be reimbursed for their time and travel. Confidentiality concerns and the risk of potential discomfort with personal questions will be managed with well-defined and established procedures. Results of the study will be used to identify the principal concerns regarding sexual and reproductive health care among recent immigrants from Mexico, approaches used in this community to reduce sexual and reproductive health-related risks, and perceived barriers to and facilitators of accessing sexual and reproductive health care.

Engaging at-risk youth in physical activity and health improvement: Feasibility analysis of the iPod Sports Kit and digital feedback
Dr. Alan VanBiervliet, Principal Investigator

Statewide in-school BMI measurements have documented very high rates of overweight children in Arkansas, particularly among children in rural areas and in African-American and Hispanic children. Overweight children are at increased risk of having lipid, cardiac and vascular abnormalities. Research clearly shows that increasing physical activity is one of the cornerstones of pediatric obesity treatment along with dietary and behavioral change. Many programs for decreasing childhood obesity have been implemented in schools and clinics, but few have succeeded in long term weight management. The long term goal of the proposed research is to develop and evaluate a strategy that can engage at risk youth in healthy physical activity that can be maintained throughout their lives. This strategy could be incorporated into a wide range of intervention programs involving physical activity, nutrition, and behavioral change. This pilot study will conduct a systematic feasibility analysis of an iPod Sports Kit physical activity program designed for at risk youth from minority and lower socioeconomic households in rural and urban communities. The project will be accomplished through a partnership with public schools in the Little Rock area. Using community-based participatory methodologies groups of representative youth and professionals will participate in a structured process to identify design guidelines, create prototype graphical user interfaces, design music playlists, create graphical components, design a performance tracking and feedback system, and participate in the evaluation of the system. An iterative user-centered development process following the Usability.gov guidelines will result in design specifications for the complete development of the system in the second phase of the research project. The prototype system will undergo systematic formative analysis and initial testing during this pilot phase.

The Contribution of Obesity to Poor Quality of Care Among Elderly Nursing Home Residents
Holly Felix, Ph.D., MPA, Principal Investigator

Racial and ethnic health disparities in chronic disease, disability and death are well documented, with African Americans having higher mortality rates and higher prevalence rates of many health conditions compared to whites, including higher rates of obesity. Disparities also exist with the quality of medical care, with African Americans receiving less than standard care for many conditions including colorectal cancer, coronary artery disease, and stroke. These unfortunate disparities in care persist into other health settings, including nursing homes. African Americans are more likely than whites to be residents of nursing homes having the highest number of deficiencies in quality, including deficiencies actually causing harm. Research has also shown that obesity is associated with receipt of poorer quality of care in medical care settings and nursing homes. Given the association between obesity and functional decline as well as nursing home admission, and higher rates of obesity among African American elders, it is possible that obesity is contributing to the poorer quality of care received by African American elders in nursing homes. LTC is an area of significant public policy importance given the current volume of usage, the likely increased demand with the aging of the Baby Boomers, and the substantial public resources invested into it. Efforts to improve the LTC quality exist; however, these efforts are not addressing disparities in quality by race or weight status. Furthermore, reducing racial and ethnic disparities is a national health priority. However, no known research has investigated the relationship of race and obesity on nursing home quality of care. Therefore, the purpose of this proposed pilot project is to explore the interaction of obesity and race on nursing home quality of care in Arkansas using one year of data from the Minimum Data Set. The results of this exploratory research will inform the development of a research proposal to further investigate and explore the interactive effects of obesity and race on nursing home quality of care across with US and ultimately improve access to quality LTC for all persons regardless of race or weight.

School-Based Telemedicine Education for Rural Children with Asthma
Tamara Perry, M.D., Principal Investigator

Asthma is the most common chronic illness of childhood and a major cause of childhood disability. Children from ethnic minority and low-income groups suffer disproportionately and have increased risk for asthma diagnosis, morbidity, and death. Nationwide data on asthma prevalence and morbidity reveal that these risks exist for minority and low-income children, whether living in urban or rural children are lacking. Implementation of national asthma guidelines has been shown to successfully improve asthma outcomes; however, there is a significant and persistent gap between well-established recommendations for appropriate asthma care and actual care received particularly among minority and low-income children. Children in these groups are significantly less likely to receive adequate asthma education and more likely to receive inadequate medical therapy for their level of disease severity. These disparities in asthma care are even more pronounced in severely medically underserved regions such as the Mississippi Delta Region of Arkansas. Our central hypothesis is that an innovative school-based asthma telehealth intervention utilizing national asthma guidelines will improve asthma health outcomes in a predominately minority, low-income pediatric population in the Delta Region of Arkansas. Our translational approach will utilize national evidence-based asthma guidelines to: 1) provide comprehensive asthma education to children with asthma and their caregivers and 2) provide physician prompts to the primary care provider based on the child�s longitudinal asthma symptoms profile. The Delta Region of Arkansas is one of the most medically underserved and impoverished regions of the United States and high rates of asthma prevalence, asthma morbidity, and asthma mortality have been identified by our research team. The proposed study will test the effectiveness of a school-based telehealth intervention on asthma outcomes, as well as child and caregiver quality of life, asthma knowledge, and self-efficacy among a high-risk pediatric population. Data from the proposed project will directly inform public health policies and outreach strategies to improve rural health outcomes, not only in asthma but also in other chronic health conditions, in high risk and underserved pediatric populations. Data will be used as critical preliminary and feasibility data in a future RO1 application.

Physician Characteristics, Patient Race, and Disparities in Health Care
Qayyim Said, Ph.D., Principal Investigator

There is increasing evidence that racial and ethnic minorities receive lower quality care and have lower access to health care. Understanding the sources and types of racial disparities in health care is critical for designing effective interventions to reduce these disparities. Association of patient level characteristics with provision of quality care has been well researched and documented. However, a question is whether variations in quality of care could be explained by physician characteristics. A further question of interest is to explore disparities across races and ethnicities by employing physician level data along with physician perspective. Specifically, an inquiry into physician characteristics including physicians’ racial and ethnic background and its interaction with patients’ racial and ethnic characteristics warrants attention.

The current study proposes to determine if and to what extent a physician’s patient racial composition is related to the structural quality of care provided by the physician and to determine if patient racial composition is related to access to secondary and specialty care. This study will shed light on the extent to which minority patients are accessing physician providers that have lower structural quality, such as fewer informational technologies that can improve the quality of care. The study will also explore the extent to which minority patients are accessing physician providers who have characteristics associated with poor access to secondary and specialty care. The specific aims of the study are: (1) To investigate the relationship between patient racial composition and physician characteristics including physician race, with physician practice structural quality of care measures, (2) To investigate the relationship between patient racial composition and physician characteristics including physician race, with access to secondary and specialty care.

Exploring whether racial differences exist within physician or across physician providers is important to appropriately design strategies to reduce racial disparities. If the primary driver of disparities is across providers, or in other words, minorities accessing lower quality providers, strategies to mitigate these disparities may be best achieved by designing interventions to improve the overall quality of care provided to physicians caring for minority patients, expanding access to a broader range of providers in minority areas, or providing tools to help minority patients identify high quality providers.

Patient/Provider Perspectives on the Health Care Process: Formative Research
M. Kate Stewart, M.D., MPH, Principal Investigator

Women with chronic diseases such as cancers of the reproductive system, sexually transmitted diseases, hypertension, and diabetes frequently receive care from Obstetrics and Gynecology (Ob/Gyn) providers, and racial disparities in care for these conditions have been documented (Smedley et al., 2003; AHRQ, 2008; Mayberry, 2000). The Institute of Medicine study, Unequal Treatment, defines healthcare disparities as “racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention” (Smedley et al., 2003), and identifies determinants operating at the systems level as well as through individual discrimination such as provider bias and stereotyping. Research has shown physicians are more likely to have negative perceptions of African American than white patients, even after controlling for patient gender, age, income, and education (Van Ryn and Burke, 2002), and that they communicate less effectively with non-white than white patients (Saha et al., 2003; Siminoff et al, 2006; Johnson et al., 2004). A fundamental issue in addressing such racial healthcare disparities then, is the need to reduce such, often unconscious, provider bias (Burgess et al., 2007). Provider empathy has been highlighted as an important ingredient not only in overcoming bias but also in effective patient communication (Burgess et al., 2007; Hojat, 2007; Neumann et al. 2009). However, more research is needed to identify effective interventions for achieving less biased and more empathetic care. The overall purpose of the study proposed, then, is to conduct formative research with University of Arkansas for Medical Sciences (UAMS) Ob/Gyn faculty, residents, students, and patients to develop an intervention designed to reduce provider racial bias and improve empathetic communication. Subsequent funding will be sought to pilot the intervention and conduct a full-scale trial if feasibility is determined. The specific aims of this pilot are to: 1) Identify patient and provider perceptions and levels of empathy and provider bias to inform an empathetic communication intervention for providers and students, where the primary outcome is empathy, and the secondary outcomes are patient outcomes; 2) Use the qualitative and quantitative data collected to adapt preexisting cultural competency and provider empathy interventions to reduce racial bias and improve empathetic communication among providers and students; and 3) Prepare and submit a larger grant application to test the intervention’s feasibility and, subsequently, its efficacy in reducing racial bias and enhancing provider empathetic communication.

Enhancing Healthy Food Environments: Exploring Influences on Food Store Selection
Delia Smith West, Ph.D. and Rebecca Krukowski, Ph.D., Principal Investigators

Dietary intake and weight status play a significant role in many of the most common chronic diseases that contribute to health disparities. Healthy foods have been shown to be less available in predominately African-American communities and in low income neighborhoods; thus, reduced availability of healthy foods in these neighborhoods may present a barrier to health disparity risk reduction by dietary change or obesity prevention. A better understanding of how individuals select their primary food store (e.g., proximity to home or work, store appearance, healthy food availability, prices, presence of other merchandise) and the role that healthy food availability may play in this decision process would inform policies and programs to promote environmental changes which encourage dietary change and obesity prevention. Therefore, this project aims to: 1) explore factors relevant to choosing a food store (supermarket, smaller grocery stores, convenience stores, etc) and the perceptions of at risk individuals (i.e., African-American, low-income and rural populations) about their food store’s role in what they eat, using focus group methodology; 2) using these qualitative data, develop and refine a questionnaire that can be utilized in future research examining intervention strategies for making healthier food choices or altering food environments; and 3) using focus group methodology, explore interest in and begin to develop community-based interventions to create healthier shopping patterns. Ethnically-diverse focus groups from both urban and rural areas will be conducted to assure that the questionnaire is culturally appropriate for the food outlets commonly available in communities most vulnerable to obesity and diet-associated health disparities. The questionnaire will be piloted in a second ethnically-diverse sample to establish psychometric properties of the questionnaire. Consistent with the research goals of the Arkansas Center for Health Disparities, at the end of the project, a refined, psychometrically-sound questionnaire appropriate for diverse communities (including African-American, low-income and rural at-risk populations) will be available for research focused on the role of the food environment in contributing to health disparities and for interventions to reduce these disparities.