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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.

The scope of pharmacy practice in global health has expanded over the past decade creating additional education and training opportunities for students, residents and pharmacists. There has also been a shift from short-term educational and clinical experiences to more sustainable bidirectional partnerships between high-income countries (HICs) and low- to middle-income countries (LMICs). As more institutional and individual partnerships between HICs and LMICs begin to form, it is clear that there is a lack of guidance for pharmacists on how to build meaningful, sustainable, and mutually beneficial programs. The aim of this paper is to provide guidance for pharmacists in HICs to make informed decisions on global health partnerships and identify opportunities for engagement in LMICs that yield mutually beneficial collaborations. This paper uses the foundations of global health principles to identify five pillars of global health engagement when developing partnerships: (a) sustainability, (b) shared leadership, (c) mutually beneficial partnerships, (d) local needs-based care and (e) host-driven experiential and didactic education. Finally, this paper highlights ways pharmacists can use the pillars as a framework to engage and support health care systems, collaborate with academic institutions, conduct research, and interface with governments to improve health policy.

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.

In 2001, The Institute of Medicine published its recommendations for bringing high quality care to all people of the United Sates. That solution involved fulfilling criteria expressed in the acronym, STEEEP. Care must be: Safe, Timely, Effective, Efficient, Equitable and Patient Centered (Institute of Medicine 2001). While improvements were made in terms of infant mortality, longevity, and deaths amenable to quality care, healthcare in the United States has remained fragmented with much work yet to be done. This leaves many uninsured individuals without access to affordable healthcare. Despite the implementation of policies such as the Affordable Care Act and the American Rescue Plan, which have expanded Medicaid and given access to many, it still falls short. Approximately 24.9 million people remain uninsured. The rising costs of healthcare in the U.S. have led to both insured and uninsured patients being exposed to medical debt, lower health status, and limited access to care. Safety net clinics, such as free clinics, have become essential for many uninsured individuals who rely on them to receive medical care. Free clinics are an example of safety nets that give medical access to the uninsured. These clinics have positive results on health outcomes and help to lower healthcare expenditures, particularly in emergency room visits. Studies have shown that uninsured individuals are more likely to use emergency services, which results in higher healthcare costs. Free clinics provide preventative care and early interventions that can help prevent costly emergency visits and hospitalizations. Moreover, free clinics serve as a place for volunteers to grow their skills and become better providers of medicine. Volunteers include physicians, nurses, medical students, and other healthcare professionals who dedicate their time and expertise to help those in need. Volunteers at free clinics are provided with a unique opportunity to enhance their skills by working with a diverse patient population that often has complex medical conditions. Free clinics are essential safety nets that provide medical access to the uninsured and underserved communities. Without these clinics, many uninsured individuals would be left without access to care, leading to poor health outcomes and higher healthcare costs. The importance of free clinics cannot be overstated, and unless there is a change in the current healthcare system, free clinics should be given the place they deserve, including more volunteer and funding support. As the U.S. healthcare system continues to evolve, it is critical to recognize the value of free clinics and the role they play in ensuring access to care for all individuals, regardless of their insurance status.

The tremendous need for comprehensive healthcare among underserved populations has been well documented. Most of the healthcare resources have been allocated to major metropolitan areas and largely populated cities. In Massachusetts alone, 500,000 people are not serviced by proper healthcare because they are unemployed or underinsured. They do not have a home base for their needs, most visit emergency rooms or minute clinics for care. They lack continuity of care. For minorities and underserved populations, there is a gap in the healthcare system. Statistics have shown that the lower your socioeconomic status, the more advanced the disease has progressed before it is diagnosed, leading to fewer treatment options and poorer outcomes. This is often due to Healthcare Deserts / Health Professions Shortage Areas in the US where there is a true lack of access to healthcare resources. One effective system for healthcare belongs to the Cuban government. Since the revolution in 1949, one of the main goals of the Cuban government was to provide primary care to all its population. The system before the revolution was centralized in the cities and was available mostly to the wealthy and urban populations while the remaining population was left with a substandard and underfunded system like many developed and undeveloped countries. In this paper, we will explore the success of the Cuban system and extrapolate some aspects of its system to use in the underserved populations that inhabit Healthcare Deserts. Implementation of systems will create an Oasis of providers that will naturally improve the well-being of populations leading to the well-being of federally funded state and local resources. The Cuban system divided the country into a grid system and each grid was subsequently divided into even smaller areas with a population of approximately one thousand. A primary care team consisting of a doctor and a nurse was assigned to each grid, including a dental component, and charged with the health and well-being of the population. This system was so successful that it was exported to other countries such as Venezuela, and it was adopted by the World Health Organization as the healthcare model standard to be followed in their world efforts. These programs have been implemented in Latin America, Africa, and Asia with different levels of success due to resource availability and financial constraints. In Venezuela during the Chavez administration, the system was implemented and achieved its highest level of success by benefiting the poor and underserved while Chavez was in power, creating thousands of clinics and improving the healthcare of the population. In Africa, Tanzania adopted the primary care approach at its new dental school and is producing strong clinicians versed with this approach. In Asia, the WHO has made progress in some areas; however, success has proven dependent on the country’s political and financial situation. The primary care approach that the system embraces, emphasizes prevention and education at a very early stage. This is key, and the data proves the success of campaigns even with limited resources provided there is the involvement of the local population. In contrast, United States resources are concentrated on the coasts and urban locations such that the rural areas have the least resources, and people in rural locations often travel long distances to access healthcare. A few states in the US have implemented programs that have been successful – Colorado, North Carolina, and New Mexico. If we successfully transplant teams of healthcare providers, including doctors, dentists, nurses, pharmacist, optometrist, obstetrics /gynecology, pediatricians, and a complete and sustainable health center into empty grids, slowly a series of Oasis will be created and access to care will improve. This change needs to happen at multiple levels, it is a task that must be taken collectively, from the teaching institutions exposing healthcare students to the need for providers in these rural and underserved areas, increasing funding to provide more scholarships and programs that funnel recent graduates into these areas with a sustainable and self-replenishing model, and most important, emphasizing education and prevention in dental school curriculum as the key to improving healthcare, and creating Oases in the current deserts.

The primary purpose of this study is to determine if certain lifestyle and health behaviors (e.g. smoking, physical activity, diet) in the medically underserved population have any influence on particular health statuses. This study also looked to determine if these health behaviors resulted in particular medical aliments being more prevalent or specific to this community. The secondary purpose of this study aims to gain information that may help health care providers practicing in this community to earlier identify risk factors in patients before a medical problem becomes more severe, difficult and expensive to treat. A survey, adapted from the CDC's Behavioral Risk Factor Surveillance System (BRFSS), was created to allow for the collection of descriptive statistical data. The survey contains questions on the various topics of diet, physical activity, chronic diseases, and self-perception of overall health status. The survey was distributed to 20 older adult participants at Hebni Nutrition, LLC, all from disadvantaged backgrounds. Descriptive statistics were used to analyze the data. Of the 20 surveys collected, about half of the respondents reported consuming close to the recommended fruit and vegetable servings and participating in regular physical activity. Furthermore, the participants reported rates of diabetes and hypertension well above average. This study's results were inconclusive as to whether any specific health behaviors among medically underserved individuals influence the prevalence of chronic diseases in this population; more likely a combination of many factors and overall poorer health habits that persist over a lifetime are contributors to chronic diseases among the medically underserved population.

Cancer is one of the main causes of death in the US. Lung cancer remains the highest killing form of cancer. Lung screening rates are low amongst the general population and even lower in minority populations. It is not well known what the barriers are for lung cancer screening. In order to investigate barriers, I created questions to add onto an existing questionnaire survey for an ongoing lung cancer screening research project. These questions focused on social determinants of health and the survey was administered to patients who were non-adherent to lung cancer screening. Patients reported cost concerns for screening, potential medical care costs, and ability to attend medical appointments as barriers to lung cancer screening. Both non-white and female patients reported more difficulties attending appointments than their white and male counterparts. Patient physician relationship and perceived racial discrimination were not barriers to lung cancer screening in the patient population surveyed. Further research needs to investigate specific details on these barriers to create interventions to increase lung cancer screening rates. / Urban Bioethics