Introduction: Homelessness is a complex and systemic problem within the United States, made more complicated by distributing federal funding to address this crucial issue. Regional Continuums of Care (CoC) is the primary method of designating organizational units by geography responsible for addressing homelessness within a given area. The primary duties of each CoC are to oversee the operation for the designated region, to maintain the Homeless Management Information System (HMIS), and plan for the CoC. The size and scope of CoCs can vary within some states, indicating larger or smaller groups of counties responsible for addressing homelessness in a given area. However, some states have entities known as Balance of the State (BoS) CoCs, which cover large geographic areas. The extent to which the smaller CoC model or the larger BoS model is associated with the overall effectiveness of addressing homelessness within a given state has not been examined and is the focus of this study. Methods: A cross-sectional study examining CoC structure and homelessness was used for this project. Per capita rates of homelessness were the primary outcome variable of interest. Per capita homeless was derived from general population numbers reported by the US Census Bureau in 2022 by PIT count per state as reported by HUD in the same year. States organizational structure as defined by the number of CoCs in a state was the independent variable of interest. To examine this potential relationship further, as well as the impact of other known factors that impact homelessness, an OLS regression was performed. Results: Overall, the number of CoCs ranged from 1 to 44. Overall the OLS regression model including three variables (CoC, state geographic location, and rurality) was statistically significant, F(6, 43)=4.406, p Conclusion: The initial examination of the relationship between homelessness per capita and the number of CoCs in a state suggests that other elements to account for effectiveness of CoC within a community setting need to be considered. Further explorations such as policy implications, weather patterns, and funding may need to be considered in seeing a reduction of homelessness per capita. A more comprehensive analysis of the relationship between states with exclusively CoCs and those BoS occupying large geographic areas indicates a need for standardization of data collection, distribution of federal funding, and culturally competent strategic planning for the reduction of homelessness.

LGBT+ patients, medical students, and healthcare providers have been shown to experience significant health disparities and poor health outcomes, to less frequently seek out healthcare, and to often face discrimination in healthcare settings. Researchers suggest the lack of high quality and in-depth training on LGBT+ health and communication skills may contribute to hostile clinic cultures and reinforce implicit and explicit biases towards LGBT+ patients. Despite the growing body of research and interest in curriculum reforms, there has not been an up to date, comprehensive review of LGBT+ health trainings and resources at U.S. medical schools since 2015. We conducted a systematic review of available information on the presence of LGBT+ trainings, support groups, and resources for medical students, residents, and faculty at all M.D.-granting institutions who are part of the Association of American Medical Colleges (AAMC). The systematic review was conducted between May and September 2020 through Google using pre-determined keyword search strategies. Collected information included type of programming, targeted audience, and length of training among others that was built into an easily accessible online database of LGBT+ health curriculums and resources. Similar to 2015, most U.S. medical schools (52%) do not have or do not provide easily accessible information about LGBT+ trainings for their students. Even fewer medical schools (39%) report that they require their students to take some form of LGBT+ health training, and almost no information is easily available on LGBT+ trainings for residents and medical school faculty. Our findings suggest that medical schools have made some progress in creating more inclusive curricula and training environments compared to 2015. However, there has not been a consensus in how medical students should be trained to be more aware of and to address biases, discrimination, and poor health outcomes affecting their LGBTQ+ patients and colleagues.

Abstract: Social Determinants of Health in Belize Free Clinic Introduction: To determine the most appropriate ways to serve patients in rural Belize through medical mission work, it is important to assess social determinants of health (SDOH). It has long been agreed that a variety of factors affect health, including environment, community and social context, access to healthcare, stress, income, mental health, education, and transportation. Many people in Roaring Creek, Belize, a village with a population of approximately 2,000, use Body and Soul Ministries, a nonprofit that invites medical teams from all over to deliver medical care, as their primary source of healthcare. During one of these trips, a medical team from East Tennessee State University (ETSU) provided medical care and employed the TeamCare survey, already used in several clinics in east Tennessee to assess the SDOH needs of the patient population in Roaring Creek. The purpose of this study was to use a survey that assesses several SDOH to determine better ways to address health needs in the community of Roaring Creek as well as connect patients with resources to meet those needs. Methods: A team of ETSU medical students, a resident, and five physicians served in a free clinic in Roaring Creek, Belize in October 2017. The team saw approximately 500 patients. Some patients were randomly selected to take the TeamCare survey to assess for six SDOH, including literacy, financial needs, drug use, abuse, transportation, and mental health. Based on the results of the survey, patients were connected with their local community health worker to assist in locating resources for patients. Using SPSS, results from the survey were arranged for frequencies and measures of central tendency. Results: Overall, a total of 106 patients responded to the TeamCare survey. Based on the survey results, 83.2% of patients responded “yes” to at least one question regarding needs related to SDOH. In fact, 7.9% of patients answered “yes” to five questions. Of note, 53.5% of patients responded positively for financial need, 46.5% positive for mental health needs, 37.6% positive for environmental alcohol or drug abuse, and 32.7% positive for transportation needs. More women stated positively for physical or verbal abuse compared to men (-1.48, p=0.001). Discussion and Conclusion: Roaring Creek, Belize is a rural community that illustrates how SDOH can impact health outcomes. There has been a recent effort for clinicians to address SDOH, especially in rural areas, but perhaps not enough globally. One way this can be done is by surveying for SDOH at clinic visits and then linking patients with relevant community resources. However, resources are not always readily available in Roaring Creek, Belize. Many patients are positive for SDOH, but with an overall lack of resources, it is important to do more research to determine how global health efforts can best serve these populations. Perhaps the best way for SDOH needs to be addressed is for Body and Soul to collaborate with community health workers and mission teams to establish ongoing programs and longstanding resources for the community.

BACKGROUND AND SIGNIFICANCE. Various studies have identified physical risk factors for musculoskeletal disorders (MSDs) associated with hand harvesting of crops, due to repetitive motions, lifting or carrying of heavy loads, and working in flexed trunk postures. A paucity of research exists on ergonomic risks to tomato farmworkers. The available studies have estimated risk based on self-reports of injury and semi-quantitative measures. METHODS. A partnership between East Tennessee State University (ETSU) and a migrant health center (Rural Medical Services) has identified some of the occupational health needs of this population. With the aid of surface electromyography (sEMG), an objective-quantitative tool, a more refined understanding of ergonomic health risks for this population will be developed. The purpose of this study is to evaluate the muscle load and fatigue induced on the anterior deltoid and upper trapezius muscles during three tasks: driving stakes into the ground, tying of tomatoes to stakes, and hoisting of a 35-pound bucket full of tomatoes. Space for a mock test plot, where the study will be conducted, is available at the ETSU’s Valleybrook facility. Muscle activity recordings will be obtained from 15 tomato farmworkers. Spectral analysis and the amplitude probability distribution function (APDF) will be used to assess fatigue and muscle load respectively. A repeated measures ANOVA will be employed in the study. ANTICIPATED RESULTS. Findings of this study should show that localized muscle loading increases muscle fatigue. Neuromuscular demand should vary, depending on the type of task performed. Stake pounding may show a higher neuromuscular demand than the other tasks. AIM 1. Evaluate the magnitude of muscle activity during three simulated tomato-field tasks and measure the intensity of movement during the stake pounding task. AIM 2. Compare estimates of muscle fatigue and muscle load induced on the anterior deltoid and upper trapezius muscles during three simulated tomato-field tasks.

Interprofessional collaboration in healthcare is vital to the nation’s health and interprofessional education is of significant interest in the current academic climate and practice environment. Remote Area Medical is a non-profit healthcare organization that partners with community hosts to provide dental, vision, and medical services to medically underserved patients in remote areas of the United States and abroad. RAM mobile clinics have served over 785,000 people since their founding in 1985, providing vital healthcare services free of charge through the volunteer services of healthcare professionals. RAM mobile clinics provide an excellent opportunity for interprofessional collaboration and interprofessional education as learners partner with volunteer professionals to serve the community. The RAM mobile clinic in Gray, Tennessee was first established in 2017 and implemented the innovate utilization of undergraduate and graduate health professional students from the East Tennessee State University Academic Health Sciences Center in student teams. Interprofessional student teams along with precepting faculty are flexible in location and services offered to best serve the needs of the mobile clinic at any given time. Interprofessional student teams work to improve patient utilization of services offered at the event and assist with medication histories and health screens while growing student interprofessional patient care skills in the process. The objective of this research is to describe the impact of interprofessional student teams on patient care at the Gray, Tennessee RAM mobile clinic during the first two years. Data was collected from the years 2017 and 2018 by the student volunteer coordinator then analyzed by student researchers. The interprofessional student teams consisted of 87 student volunteers that were training in Clinical and Rehabilitative Sciences, Medicine, Nursing, Public Health, or Pharmacy over the course of the three-day mobile clinic in 2017 and 109 different student volunteers in 2018. Student teams were precepted by interprofessional faculty and logged 2,332 interventions in 2017 and 1,130 interventions in 2018. The top two interventions in 2017 were Medication Histories and Blood Glucose Screens while the top two interventions in 2018 were Medication Histories and Health Screens. Variation in number of interventions logged and type of interventions logged can be explained by event characteristics that differed between the two years. Student participants commented positively on their engagement with one another and discussions they had to better understand each other’s professions between patient encounters. This research attempts to demonstrate that the impact of interprofessional student teams at a RAM mobile clinic is worth the investment of faculty resources in planning and execution to engage student learning while benefitting the patient population being served. This research also provided a hypothesis for additional research to be conducted around the 2019 Gray, Tennessee RAM mobile clinic.

ABSTRACT OBJECTIVES: The objectives of this project are to review current literature regarding conjunctivitis including the pathogens that cause conjunctivitis, how to diagnose and differentiate between viral and bacterial conjunctivitis, and the different modalities to treating the disease with limited resources in rural communities. Then examine an outbreak of viral hemorrhagic conjunctivitis in rural Belize in October of 2017. This includes examining data collected by ETSU Family Medicine Department during health outreach clinics regarding diagnosis made, treatment provided, and comparing this information to a survey collected about social determinants of health. Finally, discuss the importance of disseminating public health education regarding how to limit the spread of contagious infections to a rural population with limited health literacy and access to resources. METHODS: In October of 2017 East Tennessee State University (ETSU) Quillen College of Medicine medical students, primary care physicians, and residents traveled to rural Belize to provide free primary care. The clinics consisted of seeing patients at both an established clinic in Roaring Creek, Belize and at remote health clinics in even more rural locations. Many of the patients who presented to the clinics had similar complaints of itchy, red, and productive eyes. Quantitative data was recorded from patient charts regarding their presenting symptoms, diagnosis, and the treatment. The data was organized utilizing microsoft excel and evaluated using SPSS and measures of central tendency. Qualitative data was also collected from interactions with patients and newspaper articles published in Belize about the conjunctivitis outbreak. RESULTS: The results showed that a total of 431 patients received care and 52% of them were diagnosed with conjunctivitis. 46.9% of the patients were determined to have viral conjunctivitis, while 2.8% of them had bacterial conjunctivitis. It was discovered that many patients utilized one reusable cloth to wipe their children's eyes repeatedly thus spreading the disease across and throughout the rural communities. It was found through careful conversations with patients that they were putting urine and breast milk into their eyes in hopes that it would help their pink eye. The Belize Ministry of Health Reported that there were 5,343 cases of pink eye countrywide, with a viral strain being more predominant than bacterial. CONCLUSION: In conclusion, extremely contagious diseases like conjunctivitis are dangerous in rural developing countries because of lack of education about hygiene and limited resources necessary to contain such diseases. While medication is not effective for viral conjunctivitis, it can have devastating consequences (e.g blindness) if a superinfection is not caught early in the course. Education can be the best medicine especially in cases of viral diseases. Patients were also provided with resources to wash their hands often, sterilized water to flush their eyes, and single use towels. A lesson on conjunctivitis, its complications, and how to prevent the spread of the disease was aired on public television. This reports provides examples of both practice creative ways to spread health literacy in rural populations with limited access to resources.

Twenty years ago, a seminal study on adverse childhood experiences (ACEs) and subsequent increased health risks catapulted ACEs into the zeitgeist of research and application. Though a validated construct, the questionnaire, particularly the child sexual abuse (CSA) item is not without limitation and yet is used by the Centers for Disease Control and state agencies to quantify need and allocate resources to services accordingly. Currently, CSA is counted only when the perpetrator is 5-years or older than the victim. This requirement makes neglect of sibling and peer assault very likely. Accordingly, this study aimed to assess whether individuals with CSA experiences within an age gap smaller than 5 years are missed by the 5-year modifier embedded in CSA assessment wording and whether this missed group would otherwise qualify for services if detected. The study also aimed to assess whether this missed group has equivalently poor health outcomes to CSA groups currently captured by the 5-year modifier and whether outcomes for all CSA groups were higher than those who did not have a CSA history. An international sample of 974 women aged 18 to 50 completed an online survey hosted by Reddit regarding their substance use, multiple domains of current health, and CSA history using the original ACEs questionnaire and an experimental version of the CSA item without the 5-year modifier. All statistical analyses were completed in R. Results indicated there was a group of survivors with CSA experiences missed by the 5-year modifier and this had implications for reducing their total ACE scores. This group was nearly equal in size to CSA groups captured by the 5-year modifier and demonstrated equivalently poor health and substance use outcomes. On nearly all variables, CSA groups demonstrated poorer health outcomes than those who had never experienced CSA. These findings suggest the language of how CSA is assessed must be thoughtfully revised to include all CSA experiences as all are equally at risk for adverse outcomes and thus all warrant consideration for services currently afforded those with CSA histories and high ACE scores.

Purpose The Johnson City Downtown Day Center (JCDDC) provides integrated inter-professional primary care, mental health, and social work case management services to homeless and under-served persons who have difficulty accessing traditional systems. Because of the exponential rise in substance abuse in the Appalachian region, the JCDDC providers and staff initiated SBIRT as recommended standard of care, as endorsed by SAMHSA, United States Public Health Services Task Force, and the National Institute on Alcohol Abuse and Alcoholism. The JCDDC has two mechanisms by which patients can choose to participate in substance abuse treatment: SMART Recovery, and psychiatric nurse practitioner (NP) referrals. The purpose of the project evaluates use of SBIRT at the JCDDC by determining process of (1) referral and (2) follow-up rates of those who received SBIRT; analyzing outcomes by measuring numbers of: (1) screens administered; (2) brief interventions; (3) positive screens; (4) referrals to either SMART Recovery or to the psychiatric NP; (5) participation in one follow-up. Review of Literature: Approximately 6.4 million people, or 2.4% of the U.S. population 12 years and older, currently misuse prescription medications. There is an undeniable and tangible correlation between the chronic disease of substance use disorder and unstable housing or homelessness (de Chesnay & Anderson, 2016). Similarly, substance use disorder was found to be much more common in people facing homelessness than in people who had stable housing (National Coalition for the Homeless, 2009). Substance Abuse and Mental Health Services Administration (SAMHSA) has been the most significant funding source for SBIRT proliferation in the United States. Despite a demonstrated need for substance abuse services among this vulnerable population, people who are homeless have substantially greater barriers to obtaining treatment and often go without. Summary of Innovation or Practice The current SBIRT process includes use of DAST-10 and AUDIT tools. Evaluating clinic processes and outcomes in vulnerable populations who have inconsistent erratic follow-up is challenging. However, new ways of understanding patterns and incremental outcomes is essential to addressing clinic practice that can impact outcomes in vulnerable groups. Implications for NPs The heterogeneity of the homeless population is often precipitated by a host of complicating factors including co-occurring mental illness, multiple chronic conditions, unstable income, and lack of transportation. Therefore, the importance of finding effective, cost-conscious processes that are population specific and patient-centered is essential for future research and policy. The inter-professional model of care also informs future practice by evaluating the feasibility of administering all of the elements of SBIRT in a single facility.

Tennessee is a state in the United States South region, which is disproportionately burdened with higher levels of chronic disease and mental health disorders. Despite its unique cultural heritage and close-knit communities, the region faces a range of challenges related to access to mental health services, stigma, social and economic factors that can negatively impact mental health outcomes. Racial disparities in mental health among Black people are a significant challenge in the region that requires urgent attention. There is a need for increased funding for mental health initiatives in rural and underserved areas of Tennessee. The proposed study examines the association between physical health and depression among Blacks in Tennessee. We used cross-sectional data from the 2021 Behavioral Risk Factor Surveillance System a nationally representative U.S. telephone-based survey of adults aged 18 years and extracted data for participants who self-identified as race/ethnicity Black, and who reside in Tennessee (n=476). Logistic regression analyses were conducted to test the association number of past month physically unhealthy days and depression (outcome). We controlled for income, race/ethnicity, educational status, gender, health insurance status, and age. Results indicate that 19.9% (n=195) reported having been diagnosed with depression, while 25.0% (n=119) reported 1-14 physically unhealthy days in the past month, and 15.3% (n=73) reported 15-30 unhealthy days. Our logistic regression analysis revealed that 15-30 physically unhealthy days (OR=4.47, 95% CI, 2.37, 8.40), 1-14 physically unhealthy days (OR=3.59, 95% CI, 2.07, 6.24), and female gender (OR=2.00, 95% CI, 1.14, 3.49). The findings reveal a strong association between physically unhealthy days and depression among Black people in Tennessee. Greater efforts to address both poor physical health and mental health among Blacks are essential. Efforts to improve access to mental health services, reduce mental health stigma, and address social and economic factors that can negatively impact mental health outcomes are essential to addressing this challenge, particularly among Blacks in Tennessee.

Home visits are a required training component of many Family Medicine residency programs in the United States. However, they are becoming less popular due to such factors as increasing resident responsibilities, decreasing reimbursement, and a decline in resident intention to incorporate home visits into future practice. This study’s aims are: (1) to evaluate the current practices of one Family Medicine residency training program’s time and resource expenditure to conduct home visits, and (2) to evaluate resident and faculty experiences of home visits. Residents and faculty in a Family Medicine training program were provided with a 12- question survey immediately after completing a home visit. A total of 19 surveys from residents and faculty were collected and analyzed. Average reported time spent per home visit was 90 minutes (range = 50-180 minutes), and the home visit teams included an average of 4 members (range = 2-6 members). The providers felt that they knew their patients and the patients’ circumstances better after the home visit with a score of 4.1 (on a 1-5 scale with 5 being a positively framed statement). Resident opinions were neutral (average score 3.1 on a 1-5 scale) regarding whether they found home visits to be educational to their residency training in Family Medicine. Residents also had mixed feelings (average score 2.9) regarding whether they would perform more home visits during their residency training if given the opportunity. Most faculty members (5/7) indicated they had done home visits during their residency training and all faculty (7/7) felt that home visits added value to their training in Family Medicine. Finally, qualitative recommendations were collected from respondents which may allow this training program to improve home visits in the future. Overall, significant time is currently being spent conducting home visits, with a difference in perceived efficacy between residents and faculty. Future research may include a cost analysis to quantify financial value, as well as expanding data collection to other Family Medicine residency training programs to improve generalizability.