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Among the eight tribes within North Carolina, American Indian communities experience disparate rates of poverty, low education, chronic disease, low access to health care, and low quality of life. Addressing inequities and knowledge gaps will require novel and culturally appropriate approaches designed in partnership with AI communities, and should be underscored by the cultural assets those communities possess.

Objective: Food insecurity (FI) is a growing public health problem. Produce prescriptions are known to improve healthy eating and decrease FI; however, few studies have incorporated community voice prior to its implementation. In this study, we aimed to elicit perspectives of individuals at risk for FI and the potential impact of a fresh food prescription (FFRx) program. Methods: We conducted this qualitative descriptive study through an academic medical center in collaboration with community partners. We conducted focus groups involving Latinx (N = 16) and African-American (N = 8) adults in community settings. Data were interpreted using an inductive thematic analysis. Results: Three overarching themes emerged: (1) fresh food accessibility was limited by cost, household size, and transportation but enhanced by food pantries, budgeting, and education; (2) cooking behaviors were curbed by time constraints and unfamiliarity but propagated by passion, traditions, and communal practices; and (3) health and wellness deterrents included unhealthy diets driven by cultural and familial norms; however, weight loss and awareness of comorbidities were positive motivators. Participants shared their preference for local produce and cooking classes as components of a FFRx program while raising concerns about low participation due to the stigma of receiving aid. Conclusions: Our findings illuminated interest in engaging in a FFRx program and learning ways to prepare healthy foods. A program distributing fresh produce and healthy lifestyle education could close gaps identified in African-American and Latinx communities at risk for FI.

Achieving net zero operational and embodied greenhouse gas (GHG) emissions in the built environment is recognised in Australia and globally as a key strategy to address climate change and achieve the United Nations Sustainable Development Goals (SDGs). However, gaps in the knowledge remain regarding potential national pathways to achieve this outcome in Australia. This study further extends and applies a national-scale integrated macroeconomic simulation model to explore coherent pathways to net zero emissions in the built environment sector by 2050. The scope of the study includes residential and commercial buildings and both operational and embodied emissions. It applies scenario analysis incorporating different levels of climate ambition, including a shift to renewable energy, electrifying buildings, improving energy efficiency and replacing carbon-intensive materials. We find that a high ambition scenario (Scenario 2) delivers a 94% reduction in GHG emissions by 2050 when compared against business-as-usual, placing a net-zero target within reach. Improvements on Australia's SDGs performance are also attained. Through subsequent pathways analysis we find that achieving net zero or even net negative operational and embodied emissions is feasible with more ambitious action in key areas, including increasing the share of mass-timber buildings and reducing end-of-life losses in sequestered carbon.

On January 9, 2018, a catastrophic debris flow devastated Montecito, California. A 30-foot wall of boulders, mud, and debris ran down the hillsides at 15 miles per hour injuring dozens and causing 21 prehospital deaths. A retrospective review was conducted of the victims from the debris flow presenting to Cottage Health. Injury patterns, procedures performed, complications, length of stay, and outcomes were analyzed. Twenty-four patients were evaluated; 15 were admitted. Of the patients admitted, the most common presenting symptoms were soft tissue injuries (100%), hypothermia (67%), craniofacial injuries (67%), corneal abrasions (53%), and orthopedic injuries (47%), as well as loss of an immediate family member during the incident (73%). Procedures included skin irrigation (93%), operative soft tissue debridement (47%), body orifice irrigation due to mud impaction (40%), and orthopedic repair of fractures and ligaments (40%). All survived to discharge. “Debris flow syndrome” can be defined as a pattern of injuries, including soft tissue injuries, hypothermia, craniofacial trauma, corneal abrasions, orthopedic injuries, and mud impaction. Managing the debris flow syndrome requires co-ordinated and specialized care.

Background The Hispanic/Latino population in Forsyth County, North Carolina, is growing quickly and experiencing significant disparities in access to care and health outcomes. Assessing community perceptions and utilization of health care resources in order to improve health equity among Hispanics/Latinos at both the county and state levels is critical. Methods Our community engagement process was guided by the Community Health Assets Mapping Partnerships (CHAMP) approach, which helps identify gaps in health care availability and areas for immediate action to improve access to and quality of health care. Specifically, we invited and encouraged the Hispanic/Latino population to participate in 4 different workshops conducted in Spanish or English. Participants were identified as either health care providers, defined as anyone who provides health care or a related service, or health care seekers, defined as anyone who utilizes such services. Results The most commonly cited challenges to access to care were cost of health care, documentation status, lack of public transportation, racism, lack of care, lack of respect, and education/language. These data were utilized to drive continued engagement with the Hispanic community, and action steps were outlined. Limitations While participation in the workshops was acceptable, greater representation of health care seekers and community providers is needed. Conclusions This process is fundamental to multilevel initiatives under way to develop trust and improve relationships between the Hispanic/Latino community and local health care entities in Forsyth County. Follow-through on recommended action steps will continue to further identify disparities, close gaps in care, and potentially impact local and state policies with regard to improving the health status of the Hispanic/Latino community.

As the critical link between individual building and city, precinct represents an important scale for urban planning, at which low-carbon strategies for urban built environment can be tested and measured. However, previous studies often failed to assess the life cycle greenhouse gas (GHG) emissions from the urban precincts comprehensively and reliably due to methodological and data-related limitations. This study is conceived to bridge this gap by applying a case-specific hybrid life cycle assessment (LCA) to a typical residential precinct including buildings, open spaces, network, on-site energy units and occupant-related mobility. Meanwhile, the corresponding conventional process-based LCA is conducted alongside to quantify the impact of applying different LCA approaches. For the whole precinct, the life cycle GHG emissions from hybrid LCA is 16% higher than its corresponding process-based LCA result, reaching 16.6 t CO2e/inhabitant/year. Embodied emissions, operational emissions and occupant-related transport emissions take up 28%, 32% and 40% of the life cycle GHG emissions, respectively, and the biggest difference between these two LCA approaches is seen in embodied emissions (22%), followed by transport emissions (17%) and operational emissions (11%). Assuming no technology innovation and substantial changes in economic structure, precinct design and lifestyle are involved, twelve GHG emissions mitigation measures are quantified. While process-based LCA suggests a mitigation potential of 35%, hybrid LCA results in a reduction of 31%. The most effective measures are related to reducing transport emissions and operational emissions, but for the embodied emissions, instead of reducing them, the combination of all measures brings about a slight increase both absolutely and relatively. From base case to mitigated case, the differences between two LCA approaches are enlarged and the biggest difference is always seen in embodied emission. This implies the process-based LCA would further underestimate the life cycle GHG emissions in mitigated case, therefore, the use of hybrid LCA is more favourable for the purpose of providing a comprehensive and reliable assessment.

It is increasingly important for faculty to teach deliberately and provide timely, detailed, and formative feedback on surgical trainee performance. We initiated a multicenter study to improve resident evaluative processes and enhance teaching and learning behaviors while engaging residents in their education.Faculty from 7 US postgraduate training programs rated resident operative performances using the perioperative briefing, intraoperative teaching, debriefing model, and rated patient visits/academic performances using the entrustable professional activities model via a web-based platform. Data were centrally analyzed and iterative changes made based on participant feedback, individual preferences, and database refinements, with trends addressed using the Plan, Do, Check, Act improvement methodology.Participants (92 surgeons, 150 residents) submitted 3,880 assessments during July 2014 through September 2017. Evidence of preoperative briefings improved from 33.9% ± 2.5% to 95.5% ± 1.5% between April and September 2014 compared with April and September 2017 (p0.001). Postoperative debriefings improved from 10.6% ± 2.7% to 90.2% ± 2.5% (p0.001) for the same period. Meaningful self-reflection by residents improved from 28.6% to 67.4% (p0.001). The number of assessments received per resident during a 6-month period increased from 6.4 ± 6.2 to 13.4 ± 10.1 (p0.003). Surgeon-entered assessments increased from 364 initially to 685 in the final period, and the number of resident assessments increased from 308 to 445. We showed a 4-fold increase in resident observed activities being rated.By adopting recognized educational models with repeated Plan, Do, Check, Act cycles, we increased the quality of preoperative learning objectives, showed more frequent, detailed, and timely assessments of resident performance, and demonstrated more effective self-reflection by residents. We monitored trends, identified opportunities for improvement and successfully sustained those improvements over time, applying a team-based approach.

Background: Cigarette smoking has been reported to be high among Lesbian, Gay, Bisexual, Transgendered and Queer (LGBTQ) populations. However, in-depth information on perception, knowledge, attitudes and behaviors, is limited. Methods: We analyzed 2016 data from the AHA-Tobacco Regulatory Addiction Center (A-TRAC) study on multi-ethnic LGBTQ groups living primarily in Chicago and New York City, ages 18-64, smokers and non-smokers. Twenty-nine focus groups and 99 individual surveys were conducted to obtain socio-demographic-economic characteristic and in-depth information on tobacco use, including cigarette smoking. Atlas.ti and SAS 9.4 were used for data analyses. Results: Of 99 participants, 58.8% of LGBTQ individuals reported smoking 100+ cigarettes during their life time; 49.5% (n=49) reported current cigarette smoking; and 17% reported frequent or occasional use of e-cigarette, e-hookah and/or other types of vaping. Age (25+) and low household income ( Conclusions: Cigarette smoking was high among the LGBTQ individuals in our sample and they seems unlikely to quit. Social stressors appear to be a strong contributing factor. Educational efforts and culturally appropriate messages to this population, are critical.

Background. American Indian (AI) youth have the highest rates of suicide among racial/ethnic minority groups in the United States. Community-based strategies are essential to address this issue, and community-based participatory research (CBPR) offers a model to engage AI communities in mental health promotion programming. Objectives. This article describes successes and challenges of a CBPR, mixed-method project, The Lumbee Rite of Passage (LROP), an academic-community partnership to develop and implement a suicide prevention program for Lumbee AI youth in North Carolina. Method. LROP was conducted in two phases to (1) understand knowledge and perceptions of existing mental health resources and (2) develop, implement, and evaluate a cultural enrichment program as a means of suicide prevention. Discussion/Results. LROP implemented an effective community–academic partnership by (1) identifying and understanding community contexts, (2) maintaining equitable partnerships, and (3) implementing a culturally tailored research design targeting multilevel changes to support mental health. Strategies formed from the partnership alleviated challenges in each of these key CBPR concept areas. Conclusions. LROP highlights how a CBPR approach contributes to positive outcomes and identifies opportunities for future collaboration in a tribal community. Using culturally appropriate CBPR strategies is critical to achieving sustainable, effective programs to improve mental health of AI youth.

Objective This study explored influences on intention to adhere to highly active antiretroviral therapy (HAART) among immigrant Latinos living with HIV/AIDS in the southeastern USA. Methods Our community-based participatory research (CBPR) partnership completed individual in-depth interviews with 25 immigrant Latinos, based on the theory of planned behavior (TPB), to explore beliefs toward HAART adherence and HIV testing. Results Participants identified (a) seven outcomes of treatment adherence (e.g., “feeling good” and “controlling the virus”), (b) six groups of persons influencing adherence (e.g., family, partner/spouse), and (c) nine impediments to adherence (e.g., appointment scheduling, side effects of treatment). Fear of deportation, perceived costs of services, and barriers to communication emerged as impediments to both HAART adherence and HIV testing. Conclusion The findings suggest the utility of TPB in identifying factors to enhance HAART adherence among immigrant Latinos. Future research should explore the extent to which these identified TPB components quantitatively influence adherence intention and immunological and virological outcomes. Practice implications Culturally congruent interventions for immigrant Latinos may need to focus on facilitators of adherence, influential referent groups, and destigmatizing HIV/AIDS.

Few creative methodologies have been used in minority and underserved communities to elucidate the health challenges they face. Photovoice is a qualitative method that enables individuals to share their experiences with a given topic, such as chronic illness, through photography and inspires positive community action. Voices of African American Health was a photovoice project in which 24 African Americans living in the Piedmont Triad region of North Carolina took photographs and journaled about their experiences with chronic disease over a four-week period. Stories and photos that emerged from this program fell into four broad themes: limited health care access and perceived poor quality of care; religion and spirituality; expression and release of emotion; and coping mechanisms. This project used artistic means to enable community members to portray their experiences with chronic disease as a means to increase awareness of minority health. A traveling art exhibit showcases participants' photographs and j...

Information regarding the prevalence and determinants of cardiac structure and function (systolic and diastolic) among the various Hispanic background groups in the United States is limited.The Echocardiographic Study of Latinos (ECHO-SOL) ancillary study recruited 1,824 participants through a stratified-sampling process representative of the population-based Hispanic Communities Health Study - Study of Latinos (HCHS-SOL) across four sites (Bronx, NY; Chicago, Ill; San Diego, Calif; Miami, Fla). The HCHS-SOL baseline cohort did not include an echo exam. ECHO-SOL added the echocardiographic assessment of cardiac structure and function to an array of existing HCHS-SOL baseline clinical, psychosocial, and socioeconomic data and provides sufficient statistical power for comparisons among the Hispanic subgroups. Standard two-dimensional (2D) echocardiography protocol, including M-mode, spectral, color and tissue Doppler study was performed. The main objectives were to: 1) characterize cardiac structure and function and its determinants among Hispanics and Hispanic subgroups; and 2) determine the contributions of specific psychosocial factors (acculturation and familismo) to cardiac structure and function among Hispanics.We describe the design, methods and rationale of currently the largest and most comprehensive study of cardiac structure and function exclusively among US Hispanics. ECHO-SOL aims to enhance our understanding of Hispanic cardiovascular health as well as help untangle the relative importance of Hispanic subgroup heterogeneity and sociocultural factors on cardiac structure and function.

Although bullying has been linked to suicide among youth, little is known about bullying in American Indians, a population at high risk for suicide. Qualitative data from focus groups with Lumbee Indian youth (N = 31, 16 males, 15 females, 12-17 years of age) and in-depth interviews with gatekeepers in the Lumbee community revealed that bullying is common, and is perceived to contribute to depression and suicide. Youth expressed powerlessness to overcome bullying. Survey data (N = 79, 32 males, 47 females, 11-18 years of age) showed that bullied youth (11.5%) had lower self-esteem and higher levels of depressive symptoms. Interventions are needed to address this behavior that contributes to poor psychosocial health in Lumbee youth.

Although numerous definitions of mentoring exist in the professional literature, traditionally it is a process through which a senior, experienced faculty member (mentor) provides guidance and support for a junior or less experienced colleague (mentee). Mentoring is a critical element for faculty career advancement in academic medicine,1–5 and mentors can play a variety of roles in helping mentees delineate and accomplish their career goals.1,6 Ideally, mentors can enable junior faculty to enhance productivity and can provide education about the written and unwritten rules that govern the academic environment.1 Faculty members with mentors express more confidence than their peers,7 report experiencing higher career satisfaction,8,9 are more likely to have productive careers,10,11 and feel greater support for their research careers.12 Unfortunately, many early-career faculty members, particularly those from underrepresented racial and ethnic minority (URM) groups, are often unaware of the significance of mentoring or cannot find mentors committed to their career success.13,14 Ironically, laudable traits such as self-reliance that helped URM early-career faculty to navigate graduate and medical school may actually isolate them and hinder them from achieving further success.15,16 Numerous studies have reported that URM faculty typically receive less mentoring than their nonminority peers.17–19 Mentoring programs designed to address unique challenges faced by URM faculty are critically needed. These challenges include marginalization, overt and covert racism, and a disproportionate share of activities that do not advance careers (e.g., serving on numerous committees; participation in community outreach endeavors; advising minority students, postdoctoral fellows, and residents).17–19 Finally, URM faculty often treat more financially marginalized patients who generate less revenue but whose clinical care requires more time.15,20 Two recent reports provide troubling evidence with regard to reversing these disparities and achieving the goal of enhancing successful career trajectories of URMs in academic health centers (AHCs). A 2010 report from the Association of American Medical Colleges (AAMC)21 indicated that nonwhite faculty are less likely to be promoted than white faculty. Another study, based on National Institutes of Health data (2000–2006), indicated that African American scientists are about 10% less likely than their white peers to obtain R01 grants.22 In a follow-up article that discussed the potential reasons for this disparity, Tabak and Collins23 hypothesized that variability in access to mentoring may be a causal factor. Leaders of several AHCs in the United States have acknowledged the relative paucity of URM faculty and are attempting to increase the diversity of students, trainees, and faculty.24 The AAMC has stated that enhancing the diversity of AHC faculty is a significant component in the overall strategy to reduce health care disparities in the United States.25 Over the last decade, a few AHCs have designed mentoring programs specifically for URM faculty to address these various disparities24,26; however, the pace of progress has been glacial, and it has yielded mixed results. We conducted a systematic review of the published literature with a focus on outcomes of mentoring programs designed for URM faculty employed in AHCs. This article extends the descriptive review of mentoring programs by Daley and colleagues26 for URM faculty in AHCs and includes the updated literature with a focus on published programmatic outcomes. We used the RE-AIM framework27 to synthesize and describe the primary components of the programs. From these publications, we gleaned “promising practices” that can be widely disseminated to other AHCs, and we suggest ways to enhance efforts to increase and sustain faculty diversity at AHCs.

La Clinica del Pueblo, a health education collaboration between the Maya Angelou Center for Health Equity at Wake Forest University School of Medicine and Que Pasa Media, Inc., disseminates culturally appropriate health information to the North Carolina (NC) Latino community. The program includes a weekly radio show and corresponding newspaper column addressing four areas: childhood health, adult health, safety, and utilization. The radio show format includes a didactic presentation followed by a call-in question and answer period. Over 200 consecutive weeks of programming have been completed, averaging 11 calls per show. A Latino healthcare resource guide and hotline also provide resource information. Participant demographic information indicates that 50% of the target population comes from Mexico, 60% are women, and 70% of the community is younger than 38 years. There was an increase in the use of the media as a source of health information over the course of the project, from an initial 33% of respondents to 58% in the last survey. Listenership to La Clinica del Pueblo displayed a pronounced increase (18% initial survey to 55% in last survey, P < 0.05). We also observed a statistically significant increase in medical knowledge from initial survey to the last survey (P < 0.001). By multiple regression analysis, we identified 4 predictors of medical knowledge: order of surveys (1 < 3, P < 0.001), education level (P < 0.0001), female gender (P < 0.01) and radio listenership (P < 0.05). The first three variables predicted higher scores; however, radio listening recognition of our radio program was more common among individuals who had lower scores. In conclusion, La Clinica del Pueblo is a model for a novel approach that can reach the Latino community to improve medical knowledge and possibly affect health behaviors in a positive manner.