The current fragmented delivery of health care has contributed to unplanned hospital readmissions as a leading problem in the United States. Reducing readmissions to urban teaching hospitals is difficult. Many patients living in urban communities face social, economic, language, and transportation barriers to maintaining their health. Both the patient and the medical center experience the burden of readmission and are challenged with addressing SDoH and social injustices at several levels. Medicare views hospital readmissions as a marker representing lower quality of health care delivery to penalize hospitals providing care to the poor. This thesis addresses multiple social and economic factors associated with hospital readmissions, explores the interrelated components of readmissions at the personal and hospital system level, and delves into the interactions of bioethical principles associated with urban living. Hospital readmissions remain a serious issue nationwide and in order to reduce the rates of re-hospitalization the social and economic inequalities contributing to hospital readmissions are significant and must be addressed. / Urban Bioethics

Low health literacy is highly prevalent in the United States and can significantly impact health outcomes for patients. Prior research has shown that communication is a major mediator between health literacy and health outcomes. However, there has been limited investigation into the quality of communication of patients who attend clinics staffed by medical residents. The patient population attending the resident clinic at Temple University Hospital is made up mostly of African Americans from lower-income neighborhoods of North Philadelphia. This investigation aims to gather data regarding the relationship between health literacy and communication in this previously under-studied patient population. Using a rapidly self-administered health literacy screening tool, the quantitative data reveals a high prevalence of low health literacy in this patient population. Additionally, using a semi-structured interview with a two-staged coding process, the qualitative data describes several ways in which limited health literacy can diminish optimal patient-provider communication. The patients in this study population express a high desire for information about their health status, as incomplete communication was a potential source of anxiety. Suggestions from patients in this population focus on increasing active participation in clinic visits. Study subjects agreed that interventions targeted towards medical residents would help to improve communication with low health literacy patients. Novel approaches to educating medical trainees about health literacy should be investigated in the future. / Urban Bioethics

Childhood trauma greatly impacts the lives of patients and their future health outcomes. Since the discovery of the utility of the Adverse Childhood Experiences (ACEs) screening tool in the 1990s, many providers have attempted to screen and intervene on these past experiences of trauma with mixed results. ACEs have an outsized impact on adult health. There is considerable literature documenting the changing state of screening for ACEs in adult populations, and the compelling rationales for doing so. There are also a number of interventions available currently, but providers face challenges to use them. Ethical considerations and issues with the current state of screening for ACEs exist, due to some of these challenges and differential availability of interventions between populations. Here, I use the principles of urban bioethics to explain the ethical obligation of screening for ACEs despite these challenges and to dispute previous discussions on this topic. This article will show that there are general strategies that providers can take to implement ACEs screening in an ethical manner and specifically discusses trauma-informed care’s utility to help achieve these strategies. Through this discussion, I hope to encourage providers to reconsider ACEs screening and give them strategies to do so. / Urban Bioethics

The physician-patient dichotomy is reinforced continuously in medical education and medical practice. The physician possesses knowledge that will be used to help the patient in some way. However, as human beings, physicians are subject to the illnesses and diseases that affect their patients. Physicians moved by this role-reversal may feel compelled to record their experiences, leading to an accumulation of “physician-as-patient literature.” Five examples of “physician-as-patient” literature illustrate five fundamental lessons that can be adapted by physicians: relating to patient vulnerability, fostering hope for patients, mobilizing support systems, recognizing physical consequences of disease, and appreciating patient quality of life. By generalizing these individual stories, it is not necessary for physicians to experience the exact disease or illness they treat. Rather, they can draw from their unique life experiences to practice empathy. The concept of empathetic medicine can be introduced in medical school training by integrating empathy education into scientific curriculum. Current practitioners can benefit from narrative exercises, reflection and physician self-disclosure in efforts to promote empathy. Medical practice requires solid relationships between human beings, physicians and patients. This basic principle is further emphasized in “physician-as-patient” literature and concerted efforts by institutions and individual physicians can lead to a foundation for a culture of empathy. / Urban Bioethics

This dissertation explores the bioethical construction of pregnancy as site of risk and argues that pregnancy is best characterised as sitting in a constant state of tension, as simultaneously healthy-normal-natural and risky. This tension and how it is acknowledged or ignored is a significant factor in many ethical issues centered upon pregnancy. Using a genealogical analysis, this study identifies features of the social discourse around pregnancy that impede clinical research during pregnancy despite both policy changes and educational campaigns emphasising the benefits and importance of such research. The first major finding of the project is the identification of stigma about pregnancy and pharmaceuticals arising out of the mid twentieth century pharmaceutical scandals. This stigma continues to distort the perception of risk during pregnancy, such that the risk of inaction during pregnancy is significantly undervalued and the risk of actions—particularly pharmaceutical interventions—is overestimated. This is related to both the exclusion of pregnant women from pharmaceutical research, and an accompanying tendency towards medical over-intervention in childbirth. The second major finding is how narratives of health and risk construct pregnancy as women’s initiation into ‘responsible motherhood’ and the corresponding surveillance, pressures and expectations that align with the narrative. Pregnant women’s desire to act in their child’s best interest and the knowledge that not only acting or choosing ‘wrong’ may harm their child, make women less inclined to both take risks and/or act outside of conventional norm. This thesis recommends that successful, stakeholder education needs to widen to include a broader range of issues including the effect of stigma upon risk perception, the broader bias towards inaction, and the normative strength of social narratives of good mothering and maternal responsibility. / Thesis / Doctor of Philosophy (PhD) / This dissertation explores the idea of pregnancy as site of risk. It argues that pregnancy is best characterised as a state that is simultaneously healthy and at risk. The tension between these two ways of understanding pregnancy is central to many ethical issues related to pregnancy. This study identifies ideas about pregnancy that impede clinical research during pregnancy. The first major finding of the project is the identification of stigma about pregnancy and pharmaceuticals arising out of the mid twentieth century pharmaceutical scandals. The second major finding is how ideas of health and risk construct pregnancy as women’s initiation into ‘responsible motherhood’ and the corresponding surveillance, pressures and expectations that align with the narrative. This thesis recommends that stakeholder education needs to include a broader range of issues including the effect of stigma, the bias towards inaction, and the role of social narratives of good mothering and maternal responsibility.

This dissertation explores the pragmatic implications of judicial rhetoric found in a 1988 Supreme Court decision, i.e., this is a dissertation about public administration using constitutional law to illuminate an administrative question. My viewpoint is a legal/constitutional one which uses the law as pedagogue to inform public administration and to offer a useful message for the public administration practitioner. That message deals with a legal/constitutional distinction between publicness and privateness and the implications of that distinction. Quincy West was sentenced to prison in 1973 for armed robbery. While in prison he suffered a torn Achilles tendon for which he received inadequate medical care. After numerous attempts to obtain medical care, West filed suit against the prison physician contractor in federal courts for cruel and unusual punishment. This dissertation uses the story of West's legal efforts and the Supreme Court's decision in his case to discuss the broad implications of that decision for the public administration practitioner and government contractors. The lens is a constitutional one. The framework is John Rohr's schema for understanding a Supreme Court case: viewing that case from the institutional, concrete, dialectical, and pertinent perspectives. The specifics of West's allegations against his physician invite discussions of bioethical topics such as informed consent and medical legal topics such as malpractice and patient abandonment. The Court's determination of state action in West v. Atkins (1988) requires discussion of the administrative areas of contracts and grants administration as well as risk management. The complex responsibilities of the public administration practitioner are examined, as is his or her need to follow and independently learn from the messages included in the courts' interpretation of the law. This historic story illustrates that there is no bright line between law and policy. The Court's dialogue with itself is not merely interpretation and development of the law - it is policy reformulation. For this reason, among others, the conscientious administrator must monitor the Court's ongoing dialogue and listen attentively to its messages of import for our field and our practice. / Ph. D.

The United States has the highest incarceration rate in the world. The millions of people in prison across the country experience numerous health disparities and injustices despite having a constitutional right to health care. In chapter 1, the issues surrounding health inequity in prison are highlighted through two case studies on patient autonomy. From a bioethical standpoint, patient autonomy is integral to a person’s health, yet it is frequently violated in prison in multiple ways, including a lack of informed consent and the censorship of health literature. Greater awareness and advocacy efforts are needed to safeguard patient health within the carceral system.Chapter 2 highlights the importance of incorporating prison health into medical education, where currently few opportunities exist. In recent years, medical school curricula have placed increasing emphasis on the social determinants of health, which include prison health. Service-learning offers a potential means for incorporating prison health education into medical school curricula, as it represents an experiential learning modality that facilitates the formation of relationships between medical students and the surrounding community. The Lewis Katz School of Medicine’s prison health service-learning program was established in collaboration with Prison Health News and serves as one example for how students can learn about the social determinants of health and play a direct role in advocating for marginalized patient populations. / Urban Bioethics

Background: Primary open angle glaucoma (POAG) is the most common form of glaucoma in the United States and is the leading cause of irreversible blindness in African Americans. Although this is the case, there are no current primary care screening guidelines for this condition. The USPSTF cites that there is insufficient evidence to assess the balance of benefits and harms of screening for POAG in adults. This condition disproportionately affects African American and Hispanic patients. A systematic review performed earlier this year highlighted disparities in research participation among POAG clinical trials. No similar studies have been pursued outside of clinical trials. This is problematic because screening guidelines are heavily influenced by the literature related to the topic. Methods: A rapid scoping review of the literature will be performed with a particular focus on demographic data. Data was sourced from the included studies used in the systematic review performed in 2022 to inform the current USPSTF guidelines. Data collection will consist of the compilation of demographic data within each of the studies on a spreadsheet and will subsequently be analyzed according to subgroup corresponding to study type. Results: A total pooled sample of 16659 participants was obtained from the 16 included studies. After exclusion of an outlier study, total research participation across all studies was 27.9% and 5.5% for Black and Hispanic individuals, respectively. In clinical trials, 26.9% and 6.9% were Black and Hispanic individuals, respectively. Lastly, among nonclinical trials, 28.7% and 3.3% were Black and Hispanic individuals, respectively. Conclusions: Primary open angle glaucoma is a public health issue. The current recommendations for POAG screening are based on the currently available literature. However, it has been previously shown that disparities exist in research participation among Black and Latino individuals in clinical trials. The findings within this study corroborate those findings as well as highlight that disparities in research participation and representation persist among nonclinical trial research studies. This thesis underscores the ongoing need for equitable efforts in POAG research across all studies. With these efforts, recommendations for screening may be properly elucidated to inform more equitable care and identification of this disease. / Urban Bioethics

Diversifying the physician workforce is crucial for addressing healthcare disparities. Despite efforts to promote diversity, residency programs still have low representation of Black/African Americans. Our research, drawn from articles in the Temple University Libraries Database and Google Scholar Database up to March 2024, highlights differences in perceptions of program culture and racial diversity between URIM and non-URIM applicants. URIM applicants consider factors such as the authenticity of diversity, equity, and inclusion (DEI) efforts, as well as the racial climate when evaluating programs. Additionally, representation of URIM faculty and residents along with post-interview communication and events are important factors when assessing residency programs. There is limited literature on how Black/African American applicants' preferences influence diversity recruitment efforts. It is imperative for programs to incorporate feedback from URIM applicants to develop effective recruitment strategies and foster cultural shifts. By doing so, we can contribute to a more diverse and inclusive physician workforce capable of more effectively addressing health disparities that disproportionately affect Black/African Americans. / Urban Bioethics

With food and nutrition insecurity driving diet-related chronic health conditions in urban settings, strategies that facilitate access to fresh fruits and vegetables are imperative. Food is Medicine is a philosophy that embraces the integration of nutrition education and food subsidies into health care. This thesis describes one example of a Food is Medicine program, food prescription programs (FRx), in chronic disease management. While FRx programs vary in length, there are no studies to our knowledge addressing the reasons why patients adhere to FRx long-term. Using a positive deviance approach, we sought to understand positive deviant patient (PDP) practices and characteristics influencing consistent, long-term participation in Temple University's Farm to Families (F2F) fruit and vegetable prescription program. Prior to introducing this case study, I share from an Urban Bioethics lens my reflections on study design, my positionality coordinating research with community members, and how Urban Bioethical principles relate to FRx. I present the F2F case study: we conducted semi-structured, in-depth interviews among 13 PDPs who participated for over three months between 2016 and 2021. Interview transcripts were coded for most common themes. Seven of the 13 PDPs opted to participate in photovoice interviews. I then examine lessons learned from the F2F case study. Lastly, I discuss the sustainability of FRx from an Urban Bioethics lens, starting with considerations of resource allocation of FRx, and ending with integrating FRx into clinical practice and health systems. Despite the complexity of risk factors and sociopolitical forces contributing to food and nutrition insecurity in the United States, food justice is both necessary and achievable. How we as Urban Bioethicists and clinicians choose to approach food insecurity determines our capacity to challenge the status quo and reconstruct the narratives that have perpetuated this issue for far too long. Through a collaborative effort that embraces the experiences of our patients and community members, my aspiration is for food justice to become a reality. / Urban Bioethics