Untitled

Vulnerable Populations in Clinical Care

• Social Determinants of Health (SDoH) include conditions of birth, growth, living, working, and aging that are shaped by resource distribution at global, national, and local levels.
• Economic stability (employment, income, housing stability), education (literacy, early childhood education), healthcare access (insurance coverage, provider availability), and neighborhood/environment (air quality, crime rates) are all SDoH.
• Health-related social needs are individual-level, immediate social and economic barriers affecting health and needing intervention.
• Food insecurity, unstable housing/homelessness, and transportation issues limiting healthcare access are health-related social needs.
• Health disparities are differences in health outcomes between groups, often influenced by social, economic, or environmental disadvantages.
• An example of a health disparity is higher infant mortality rates among Black Americans.
• Increased prevalence of diabetes in low-income communities is also a health disparity.
• Healthcare disparities are differences in access to and quality of healthcare services among different populations.
• Lack of health insurance among racial/ethnic minorities is a health disparity.
• Lower rates of preventative screenings in rural areas is also a healthcare disparity.

Impact of Health-Related Social Needs

• Food insecurity can lead to poor nutrition and chronic diseases.
• Individuals with limited access to healthy food are more likely to develop obesity, diabetes, and heart disease.
• 13% of US citizens experienced food insecurity in 2016.
• 20% of children experienced food insecurity in 2016.
• Food insecurity doubles the risk of diabetes.
• Food deserts are census tracts with low-income residents who have low access to a grocery store or affordable food.
• Housing instability increases the risk of illness and mental health issues.
• Unstable housing is linked to higher rates of asthma, stress, and infectious diseases.
• Lack of transportation can result in delayed medical care.
• Patients without reliable transportation may miss medical appointments, worsening chronic conditions like hypertension or diabetes.

Socioeconomic Status (SES)

• Socioeconomic status (SES) measures someone's social and economic position in society.
• SES impacts access to healthcare and overall well-being.
• Income affects access to healthcare, housing, and nutritious food.
• Education, where higher levels are linked to better job opportunities and health literacy, affects SES.
• Occupation influences exposure to workplace hazards, stability, and employer-sponsored health benefits.

Screening for Health-Related Social Needs

• Increased screening may not improve health outcomes due to burden on overworked providers, lack of resources/expertise, and uncertain impact on health outcomes.
• PCPs already experience burnout/time constraints, and SDoH screenings could reduce direct medical care time.
• Many primary care settings lack social services, expertise, and funding for identified social needs.
• Evidence on whether primary care-based interventions improve long-term health outcomes is limited.

Unbalanced Confounding Variables

• Unbalanced confounding variables create alternative explanations for observed differences between study groups.
• They are independent variables influencing the outcome variable.
• They are unevenly distributed across levels of exposure in the outcome variable.

Statistical Significance

• An independent t-test compares the sample means of two groups (baseline vs. most extreme group).
• If p < 0.05, the difference between the two groups is statistically significant.
• For interval data, use a two standard error screening test, and if positive, run an independent t-test.
• For counts, use the same screening test and get mean estimates.
• For sample proportions, calculate the raw numbers and use the total sample size to find averages across groups, using the same screening test.

Research Article Appraisal

• Study results cannot be confidently generalized if the balancing of confounders was not properly reported.
• Differences in key confounding variables mean results are not applicable to all populations.
• The risk ratio for night shift work and breast cancer could be overestimated or underestimated, depending on how confounders influenced each group.
• Without proper adjustments the study fails to account for alternative explanations, which reduces confidence in its conclusions.

PTSD in Refugee Populations

• PTSD results from exposure to traumatic events, leading to dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis.
• Increased amygdala activity and decreased prefrontal cortex regulation results in heightened fear responses.
• Chronic stress may lead to altered neurotransmitter levels, including serotonin and norepinephrine.
• Cultural presentation in refugee populations include submissiveness, fearfulness, and emotional withdrawal.
• Some may feel overwhelmed and physically affected by trauma, which is referred to as a "wind attack".
• Excessive rumination leads to distress.
• Sleep paralysis and weak heart may also be a sign, and some may seek spiritual healing instead of psychiatric care.
• Diagnostic criteria (DSM-5) include intrusion symptoms, avoidance symptoms, negative mood/cognition, arousal/reactivity symptoms, and dissociative subtype.
• First-line therapy includes trauma-focused cognitive behavioral therapy (CBT).
• Pharmacological management may include SSRIs and Prazosin for PTSD-related nightmares.
• Consider community/spiritual support, engagement with Buddhist monks, meditation, and culturally specific healing practices.

Cultural Barriers to Western Medicine

• Cultural barriers impacts adherence and outcomes, and culturally competent care can improve medication adherence and health outcomes
• Historical trauma/trust issues may be a barrier, and Khmer Rouge survivors may distrust government-related institutions like healthcare.
• Language barriers can be a factor, and low English proficiency leads to misunderstandings in medical instructions.
• Beliefs are another factor, and Western medicine is seen as complementary to traditional methods.
• Some refugees may prefer herbal remedies, coining therapy, or spiritual healing over prescribed treatments
• Mental illness is seen as a result of spiritual imbalance or bad karma in some cultures.
• Medications are perceived as short-term symptom reliefs rather than long-term management.
• Sharing medications among family members is common.
• Limited finances, transportation difficulties, and social isolation hinder healthcare access.
• They may also fear discrimination which leads to avoidance of medical professionals.
• Strategies for improving medication adherence and health outcomes involve culturally competent care.
• You should incorporate traditional healing practices into treatment plans.
• Medical practices may train healthcare providers on Cambodian cultural perspectives.
• Education and communication by providing translated educational materials is also helpful.
• You may use visual aids and oral instructions for those with low literacy
• To build trust you must acknowledge cultural beliefs without dismissing them.
• Adapting treatment plans by combining traditional Cambodian methods with Western therapy (mindfulness meditation and CBT) can be beneficial.

Latent Tuberculosis (TB)

• TB bacteria remains dormant in the body and is kept in check by the immune system.
• Reactivation risk increases with immunosuppression (HIV, diabetes, immunosuppressive drugs).
• The BCG vaccine is given in many countries to prevent severe TB in children, including Cambodia.
• The BCG vaccine does NOT cause false positives of QuantiFERON-TB GOLD (QFT) or T-SPOT TB tests.
• Risk factors for reactivation of latent TB include HIV/AIDS, diabetes, immunosuppressive therapy, chronic kidney disease, malnutrition, and cancer.
• You should take routine vaccinations before travel for MMR, TDaP, Polio, Influenza, Hep A and B, and Typhoid.
• You should consider Japanese encephalitis, meningococcal, and rabies vaccinations (if rural travel is expected).
• Malaria prophylaxis and Dengue prevention (avoid mosquito bites use insect repellents) can prevent infectious diseases.

Refugee and Immigrant Health

• Refugees apply for asylum before leaving their home country due to persecution based on race, religion, nationality, political opinion, or membership in a social group.
• Asylees are already in the US or a port of entry when they apply for asylum, and must prove they cannot return home due to a well-founded fear of persecution.
• Migrants leave their country for reasons not related to persecution like economic opportunities, environmental disasters, or better living conditions.
• Immigrants (including refugees and asylees) make up 13% of US residents.
• The common regions of origin include Syria, Afghanistan, Ukraine, Venezuela, and parts of sub-Saharan Africa.
• Economic migrants often seek better economic opportunities from Latin America, South Asia, and Africa.
• Resettlement process is described by the UNHCR (the United Nations High Commission on Refugees)
• Overseas medical exam is required under US immigration law (Title IV) that identifies class A and B conditions.
• A domestic medical exam includes a physical, mental health screening, and infectious disease testing (TB, Hep B/C, HIV, STDs) and vaccinations.
• Refugees receive legal and social support like assistance from resettlement agencies
• Refugee receive assistance for Housing, access to employment, and enrollment into the healthcare system

Health Screening for Immigrants

• Key conditions to screen for include mental health (PTSD, depression, trauma), Latent TB, malnutrition, anemia, vitamin deficiencies, Hepatitis B/C, and STDs.
• Always screen for Parasitic infections and vaccine-preventable diseases.
• Barriers to care include fear of deportation, language barriers, financial concerns, and cultural differences (distrust of Western medicine, gender-based healthcare preferences).
• Health disparities and problems with social determinants include higher rates of chronic diseases due to stress, lower access to care, and changes in diet
• Limited preventative care due to lack of insurance and healthcare literacy
• There may also bee gender-based violence issues.

Impact of Immigration Status on Healthcare

• Refugees and asylees qualify for Medicaid upon arrival.
• Undocumented immigrants do not qualify but may receive emergency medical care.
• Immigrants applying for a green card may be denied if they use public assistance for 12 out of 36 months, discouraging healthcare use.

Cultural Sensitivity

• It is recommended to avoid hospitals due to fear of ICE.
• PCP's can ask about immigration status, but should do so sensitively and only when medically relevant
• The LEARN Model is a set of guidelines used in the medical field to help doctors use cultural sensitivity with their patients
  • Listen
  • Explore
  • Acknowledge
  • Recognize
  • Negotiate
• Explanatory model:
  • ask the patient what their understanding of their condition is and how it is treated in their home country.
• Cultural Competency Techniques
  • Use culturally appropriate dietary recommendations and inquire about herbal remedies
  • Recognize that family decision-making may differ

Amyotrophic Lateral Sclerosis (ALS)

• ALS is a neurodegenerative disorder that affects upper and lower motor neurons.
• UMN findings include weakness with slow movements, hyperreflexia, and spasticity.
• LMN findings include weakness, atrophy, and fasciculations.
• It is caused by mutations in the SOD-1 gene (Cu/Zn dismutase) and a gene coding for a protein involved in RNA processing.
• The progression is the following: it leads to progressive muscle weakness, atrophy, and eventually paralysis leading to inability to walk, use hands/ arms, speak, swallow, and eventually breath
• No cure for ALS exists, and no treatment stops the neuronal loss.
• Average survival time after diagnosis is 2-5 years (varies widely).
• To help with the disease, help manage symptoms and improve the quality of life
• Riluzole decreases glutamate levels to help reduce the toxic levels to motor neurons

ADA and SSA Definitions of Disability

• ADA definition: someone who has a physical or mental impairment that substantially limits one or more major life activities.
• Requires employers to provide reasonable accommodations to qualified employees with disabilities, unless doing so would impose an undue hardship on the employer.
• There are a multitude of reasonable accommodations like: changes in the workplace that enable people with disabilities to perform the essential functions of their jobs
• SSA definition: inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months
• It provides social security disability insurance and supplemental security income
• Social Security disability insurance (SSDI) is for workers who have paid social security taxes and are now unable to work due to a disability
• SSI is for low-income individuals with disabilities who have imited a lack of work history

Legal and Ethical Considerations Regarding End-of-Life Care

• Advanced directives allow individuals to express their wishes regarding their future care, including end-of-life decisions.
• A living will states whether a person wishes to have life-sustaining treatment if they have a terminal condition or are permanently unconscious.
• A Healthcare representative allows patients to appoint a trusted individual to make healthcare decisions on their behalf.
• A Voluntary designation of conservator enables individuals to designate a conservator to manage their medical or personal decisions if they become incapable.

Guardianship

• Guardianship ensures minors are cared for and their assets are managed
• Guardianship of the person involves responsibility for the care of a minor.
• Guardianship of the estate involves managing the assets of a minor.
• Temporary Guardianship is done through probate court and needs to be renewed every 12 months.
• Post-death Guardianship is a permanent guardianship that is assigned after the death of a parent.

Capacity Evaluation

• it is important to communicate a clear choice: must clearly express a preferred tx option or decision, and frequent reversals of choice may indicate impaired capacity
• Must be able to understand the information: must grasp the fundamental aspects of their medical condition, tx options, and risks/ benefits
• Acknowledge the situation and consequence: must acknowledge their medical condition and understand the likely outcomes of their decision, and risks of refusing tx
• Use reason to choose the correct options: must be able to compare options logically and provide rationale for their decision

Conservatorship

• Conservator of person manages personal affairs such as food, shelter, safety, and medical care.
• Conservator of estate manages finances, property, and financial decisions.
• Special limited conservators are appointed for short-term purposes, such as consenting to psychiatric medication for a person in a psychiatric hospital.
• Temporary conservators are appointed in emergencies to prevent immediate and irreparable harm.
• Voluntary conservators are appointed as an individual request without a finding of incapacity.
• There are also several legal protections in place

Abuse of Conservatorship Process

• Misuse or misappropriation of assets under court supervision
• Failure to audit conservatorship finances systematically
• Negligence: Removal due to misconduct
• Local courts lack tracking and judicial oversight

Ethical Principles in Conservatorship

• Respect Autonomy: individuals should maintain as much control over their own decisions as possible, and CT law prioritizes the least restrictive measures.
• Beneficence: if an individual is unable to make safe decisions, a conservator may be necessary to act in their best interest
• Nonmaleficence: courts and healthcare providers must ensure that conservators do not harm or exploit the individuals under their care
• Distributive justice: courts must ensure equitable treatment and protect individuals from undue influence or abuse by conservators

Wearable Health Technology

• Wearable health technology can be worn on the body and perform some function for a wearer and/or caregiver
• Healthcare has specialized sensor(s) that sense, measure, collect and present different health and fitness metrics like fitness and sleep tracking
• To collect data, these wearables use specialized sensors to track physiological and environmental parameters like a heart rate monitor, ECG, pulse oximeter, and temperature sensor
• You then send some data to: Sensing → signal processing → algorithms → data communication → cloud storage/ local storage

Wearable Health Technology Risks

• Potential Inaccuracies: the most common sources of inaccuracies for various classes of wearable technology
• Unknown Benefits: unclear evidence that wearable technology changes health outcomes Most study designs may be limited to truly detect effects over time
• Constant
• Unrestrictive
• Predatory pricing
• Sustainability
• Electronic waste

Wearable Technology Epidemiology

• India has the highest ownership rate of wearable tech (the US is in 7th)
• 28-41% of the US population uses wearable technology
• US demographics:
  • Young to middle-aged
  • Affluent
  • high education level
  • urban location
  • Female
  • Private insurance
  • Good health
• New Barrier: Need better FDA regulation of data quality and increased diversity of study recruitment