Journal articles on the topic 'Health Care for the Homeless Program (U.S.)'

Introduction:Spiritual care is an important component of holistic care in nursing. However, health care workers are not unanimous in who is responsible for the spiritual care of patients. It is likely that nurses are best suited to provide spiritual care because of the nature of their work, which requires constant contact with patients. Yet, meeting spiritual needs is not well defined in the role of nurses and is not always taught comprehensively in formal nursing education programmes. The aim of this study was to explore the extent to which nurses working in social care settings implement interventions related to spiritual care in their daily practise, how they perceive their knowledge of spiritual care, and the extent to which this dimension of care was included in their nursing education programmes.Methods:A non-experimental quantitative descriptive research study was used. In April 2020, 214 nurse assistants and registered nurses from 12 nursing homes in Slovenia participated in the study. The questionnaire used in the study included 12 statements related to 3 main areas: i) knowledge of the concepts of spirituality and religion, ii) implementation of spiritual/religious interventions in daily practice, iii) spirituality in nursing education. The individual statements were rated by the respondents on a 5-point Likert scale (1 - strongly disagree to 5 - strongly agree). The questionnaire had adequate internal consistency (Cronbach alpha = 0.857). Data were described using calculated means, Mann-Whitney U test, and Spearman correlation coefficient. A p-value ≤ 0.05 was considered significant.Results:Regular spiritual assessment of nursing home residents is rarely performed by nurses (x̄=2.73, s=1.03). Female nurses (U=2191.500, p=0.008) and nurses who described themselves as religious (U=3314.000, p=0.001) implement spiritual/religious interventions in daily practice to a greater extent; they also expressed higher knowledge of the concepts of spirituality and religion compared to the others (religious/non-religious: U=2920.000, p=0.000; female/male: U=1885.000, p=0.000). The implementation of spiritual/religious interventions in daily practice correlated positively and statistically significantly mainly with self-perceived knowledge of the concepts of spirituality and religion (r=0.495, p=0.000) and the extent to which the content of spiritual care was represented in their nursing education program (r=0.494, p=0.000). However, nurses emphasized that the concept of spirituality and spiritual care tended to be poorly represented in formal nursing education programs (x̄=2.76, s=0.89).Discussion and conclusions:Individual characteristics, particularly self-reported religiosity and gender, appear to have an important influence on the implementation of spiritual/religious interventions in daily practise. In addition, our study suggests that the level of knowledge about the concepts of spirituality and religion influences nurses' willingness to implement spiritual care with their residents. Therefore, nursing educators need to develop curricula that include strategies to increase trainees' awareness of spiritual care. Current international research efforts on perceptions of spirituality and spiritual care in nursing offer important contributions to understanding the role of nursing in relation to spirituality and to developing educational content and approaches for both undergraduate and lifelong learning in nursing.

Early detection of gastrointestinal cancer is an actual public health problem. The implementation of the modern endoscopic diagnostic methods based on the progressive digital technologies significantly reduce the risks of diagnostic errors and contributes to the effective solution of that problem. P u r p o s e : to clarify the possibilities of the early detection of gastrointestinal cancer by equipping the endoscopy unit of the city district hospital with the modern digital endoscopes, including devices with zoom functions – ZOOM. M a t e r i a l s a n d m e t h o d s . The article analyzes the statistical data of the work of the endoscopy unit of Nizniy Tagil State city hospital № 1 from 2013 to 2022 (except 2020–21, when the hospital was completely redesigned as a COVID-hospital). R e s u l t s . A clear relationship between the increase in the number of detected oncopathologies of the gastrointestinal tract and the modern technical equipment of the endoscopic units under the modernization of primary health care program in the Sverdlovsk region in 2021 is presented. Based on risk-based approaches and evidence-based medicine data, the importance expert-class equipment in the routine endoscopic practice in the primary healthcare district hospital for diagnosing gastrointestinal cancer at an early stage is shown. Modern approaches to optical endoscopic diagnostics are analyzed, as well as the potential risks of diagnostic errors associated with technical equipment and possible measures to reduce these risks for further improvement of primary endoscopic diagnostics aimed at detecting gastrointestinal cancer in the early stages are determined, the expediency of equipping endoscopic units of primary care medical organizations with endoscopes inreached magnification functions – ZOOM, as well as photo and video recording of digital images with the possibility of archiving, color printing and further expert analysis of endoscopic images. C o n s e q u e n c e . From the presented statistical data, it is clearly seen how with the improvement of the equipment quality, the detection of gastrointestinal cancer of various localizations is growing.

Abstract Introduction Holistic care for children with chronic diseases including cancer should include psychological support for children and their families. The impact of pediatric malignancies in regard to quality of life (QOL) of parents is poorly described. Objectives We aim to study the QOL of parents of children diagnosed with cancer in physical, psychosocial, environmental, and social domains. Materials and Methods A prospective, cross-sectional study was conducted with 162 parents of children diagnosed with malignancy for 3 months or more. Assessment was done by World Health Organization quality of life (WHOQOL-BREF) questionnaire that includes four domains with a total of 26 questions. Data analysis was done by using Statistical Package for Social Sciences (SPSS) version 20.0; p-value less than 0.05 was considered significant. Results on continuous measurements were presented as “Mean ± SD” and categorical measurements were presented as percentages (%). Differences in the quantitative variables between groups were assessed by unpaired-t-test; comparison between groups by nonparametric Mann–Whitney U test and chi-squared test was used to analyze categorical variables with p-value of < 0.05 using a two-tailed taken as statistically significant. Results Mean raw scores of QOL in physical health, psychological, social, and environmental domains were 20.10, 15.28, 8.10, and 25.24, respectively, with social relationships being the lowest; inadequate or low QOL was noted in 50% study population and it was maximally affected by increased duration of treatment, multimodality treatment, socioeconomic status, rural population, education and occupation status of the parents, and increased cost of care. Type of family or place of residence, family history of psychiatric illness, or malignancy did not influence the QOL of parents of children with cancer. Conclusion Psychological support from the beginning of the treatment along with financial, social support should be offered through a comprehensive care program to improve the QOL.

Introduction Children with cancer are at an increased risk for various physical and cognitive challenges due to their illness and its treatment. A concerning observation is that young cancer patients often lead sedentary or even lying lifestyles, clearly failing to meet the WHO’s recommendation of 60 minutes of moderate-to-vigorous physical activity (PA) daily. This is alarming considering that PA is essential for physical and mental health, e.g., for the development of motor skills and cognitive functions (Bull et al., 2020). However, PA promotion in acute care in Swiss pediatric oncology units is hardly existent. Therefore, the aim of this project is to develop and conduct a physical activity program in a pediatric oncology unit and investigate its effects on cognitive and motor performance. Methods Part A of this project involved a qualitative study conducted at the Inselspital Bern’s pediatric oncology unit, aiming to design a tailored PA therapy program. This part included patient interviews and staff surveys. Part B, which is ongoing, focuses on a forthcoming two-arm multicenter crossover-controlled trial. This trial will compare the exercise therapy and PA counseling (intervention group in Bern, n = 40) with standard treatment (control group in Basel, n = 40). Participants will be aged 6-18 years, newly diagnosed with cancer and undergoing cytotoxictreatment for at least six weeks. The 12-week program will consist of thrice-weekly, 45-minute sessions of individualized exercise, aligned with the SK2-guidelines, NAOK, and international Pediatric Oncology Exercise Guidelines (Götte et al., 2022; Wurz et al., 2021). The sessions will focus on motor skills and cognitively challenging PA. In addition, children will receive 4 exercise counseling sessions. To evaluate the study, there will be three measurement points (once at admission, after twelve weeks of intervention and one follow-up after six months). The outcome measures include motor and cognitive performance, physiological and psychosocial functioning. Results Initial findings from the qualitative study indicate a strong patient and staff interest in exercise therapy. The study also provided valuable insights for developing and implementing the intervention. Discussion/conclusion The results will reveal important insights relevant to research and practice. Adopting a research perspective, the results will shed light on the effects of PA on cognitive performance in acute cancer care. Adopting a more applied perspective, PA has been neglected in Swiss pediatric oncology units so far. Therefore, this study may contribute to proof the effectiveness of PA for childhood cancer patients and thus help implementing it in standard care in the long term. References Bull, F. C., Al-Ansari, S. S., Biddle, S., Borodulin, K., Buman, M. P., Cardon, G., Carty, C., Chaput, J.-P., Chastin, S., Chou, R., Dempsey, P. C., DiPietro, L., Ekelund, U., Firth, J., Friedenreich, C. M., Garcia, L., Gichu, M., Jago, R., Katzmarzyk, P. T., Lambert, E., Leitzmann, M., … & Willumsen, J. F. (2020). World Health Organization 2020 guidelines on physical activity and sedentary behaviour. British Journal of Sports Medicine, 54(24), 1451-1462. https://doi.org/10.1136/bjsports-2020-102955 Götte, M., Gauß, G., Dirksen, U., Driever, P. H., Basu, O., Baumann, F. T., Wiskemann, J., Boos, J., & Kesting, S. V. (2022). Multidisciplinary Network ActiveOncoKids guidelines for providing movement and exercise in pediatric oncology: Consensus-based recommendations. Pediatric Blood & Cancer, 69(11), Article e29953. https://doi.org/10.1002/pbc.29953 Wurz, A., McLaughlin, E., Lategan, C., Chamorro Viña, C., Grimshaw, S. L., Hamari, L., Götte, M., Kesting, S., Rossi, F., van der Torre, P., Guilcher, G. M. T., McIntyre, K., & Culos-Reed, S. N. (2021). The international Pediatric Oncology Exercise Guidelines (iPOEG). Translational Behavioral Medicine, 11(10), 1915-1922. https://doi.org/10.1093/tbm/ibab028

Eating habits develop during the first years of a child's life, children learn what, when, and how much to eat through direct experience with food and by observing the eating habits of others. The aim of this study is to get a clear picture of the Eating program Healthy, starting from the planning, implementation, supervision, and evaluation as a case study of nutrition education; to get information about the advantages, disadvantages and effects of implementing a healthy eating program for children. This research was conducted through a case study with qualitative data analysed using Miles and Huberman techniques. Sample of children in Ananda Islāmic School Kindergarten. The results showed the Healthy Eating program could be implemented well, the diet was quite varied and could be considered a healthy and nutritious food. The visible impact is the emotion of pleasure experienced by children, children become fond of eating vegetables, and make children disciplined and responsible. Inadequate results were found due to the limitations of an adequate kitchen for cooking healthy food, such as cooking activities still carried out by the cook himself at the Foundation's house which is located not far from the school place; use of melamine and plastic cutlery for food; the spoon and fork used already uses aluminium material but still does not match its size; does not involve nutritionists. Keywords: Early Childhood, Eating Healthy Program References: Bandura, A. (1977). Social learning theory. Englewood Cliffs: Prentice-Hall. Bandura, Albert. (2004). Health promotion by social cognitive means. Health Education and Behavior, 31(2), 143–164. https://doi.org/10.1177/1090198104263660 Battjes-Fries, M. C. E., Haveman-Nies, A., Renes, R. J., Meester, H. J., & Van’T Veer, P. (2015). Effect of the Dutch school-based education programme “Taste Lessons” on behavioural determinants of taste acceptance and healthy eating: A quasi-experimental study. 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Abstract Background Infectious diseases (ID) consultation improves SAB readmission rates, compliance with care bundles and mortality. Small community hospitals (SCHs) (which comprise 70% of US hospitals) often lack access to on-site ID physicians. IDt is one way to overcome this barrier, but it is unknown if IDt provides similar clinical benefits to traditional ID consultation. Our study aims to evaluate the impact of IDt on patient outcomes at 15 SCHs (bed range: 16–146) within the Intermountain Healthcare system in Utah. Methods Baseline demographics, Charlson Comorbidity Index (CCI), hospital length of stay (LOS), and mortality (in-hospital, 30- and 90-day) were collected using an electronic health record database and health department vital records on all patients with a positive S. aureus blood culture from January 1, 2009 through December 31, 2018. Data from January 2014 through Sep 2016 were excluded to avoid potential influence of a concurrent antimicrobial stewardship study. Starting in October 2016 an IDt program (staffed by an ID physician and pharmacist) provided consultation for SCH providers and patients using electronic consultation and encrypted two-way audiovisual communication.Statistical analyses were performed using Fisher’s exact test or χ 2 test for categorical variables and Mann–Whitney U test for nonparametric continuous data. Results In total, 625 patients with SAB were identified: 127 (20%) received IDt and 498 (80%) did not (non-IDt). The two groups (IDt vs. non-IDt) were similar in median age (66 vs. 62 years; P = 0.76), percent male (62% vs. 58%; P = 0.35), and median baseline CCI (4 vs. 4; P = 0.54). There were no statistically significant differences in median LOS (5 vs. 5 days; P = 0.93) or in-hospital mortality (2% in both groups). The IDt group had a lower 30-day (9% vs. 15%; P = 0.049) and 90-day mortality (13% vs. 21%; P = 0.034). Conclusion IDt consultation was associated with a decrease in 30- and 90-day mortality for SCH SAB cases. Early transfer of critically ill patients might have affected LOS and in-hospital mortality. Post-discharge care factors might also contribute to 30- and 90-day mortality. While more work is needed to identify other factors associated with the effect of IDt on SAB, these data support the use of IDt to increase access to care and improve SAB outcomes in SCHs. Disclosures All Authors: No reported Disclosures.

Objective: To assess whether to have a steady loving relationship changes sexual desire, level of depression and subjective need for sexual counselling to those patients who have suffered an Acute Coronary Syndrome (ACS) episode within the last year Design and Method: The sample consisted of males under 76, with a diagnosis of ACS episode, from September 1st 2014 to August 31st 2015, within the area of The University Health Care Hospital Complex of Palencia. They were appointed by a telephone call at the local Health Center to hold a personal interview in which they answered an inquiry ad hoc and the validated Beck´s Depression Questionnaire and Sexual Desire and Aversion to Sex (DESEA) Questionnaire. Data were analyzed using the statistical program SPSS Statistics 20.0. Results: 73% of patients in our sample had a partner. When applied non-parametric U-Mann-Whitney and Kruskal-Wallis as statistical contrast, it shows that loving relationships do not have any influence neither on patients’ sexual desire, nor on their demand for greater sexual counselling. It was also found that there is a direct correlation between the parameters of DESEA Questionnaire and de score reached on Beck’s Depression Questionnaire. And finally, that a decreased sexual desire will not influence their request for sexual advice. Conclusions: Sexual desire is a characteristic part of each person and that is confirmed in the participants of our research. Patients continued keeping interest for their sexuality after having suffer an ACS within the last year, regardless of the stability of their sexual relationships.

Objective: To assess whether patients’ sexual activity has worsened after suffering an Acute Coronary Syndrome (ACS). To know whether to consider sex important and to have an active sexual life has any influence on the demand for sexual counselling after the episode. Design and Method: The sample consisted of men aged <76 with diagnosis of ACS episode, from September 1st 2014 to August 31st 2015, within the area of The University Health Care Hospital Complex of Palencia. They were appointed by a telephone call to hold a personal interview in which they answered an inquiry ad hoc and the validated Beck´s Depression Questionnaire and Sexual Desire and Aversion to Sex (DESEA) Questionnaire. Data were analyzed using the statistical program SPSS Statistics 20.0. Results: Only 30.8% of patients in our sample received sexual counselling after an ACS and 86.5% of those considered it insufficient. After an assessment using non-parametric test for dependent samples and U-Mann-Whitney, we noticed that sexual activity after an ACS has worsened and the fact that those patients consider sex important or have an active sexual life doesn’t significantly influence their request for sexual advice. Conclusions: Very few patients have received sexual counselling after an ACS and most of them require more. In our sample of patients, we may guess that this demand could be due to the fact that a significant number of them no longer have a sexually active life. But, considering sex important or having an active sexual life doesn’t have any influence on that demand.

ABSTRAK Masa nifas dimulai dari placenta lahir dan berakhir ketika alat-alat kandungan kembali seperti keadaan sebelum hamil. Ibu nifas akan mengalami banyak perubahan fisik maupun psikologis. Senam nifas merupakan salah satu cara membantu ibu segera pulih, bertujuan memperlancar proses involusi uteri, bermanfaat dari segi kecantikan, mengembalikan kondisi kesehatan dan memperbaiki keregangan otot-otot setelah kehamilan. Pelaksanaan senam nifas dipengaruhi oleh faktor internal dan eksternal. Rumusan masalah berupa terbatasnya pengetahuan dan keterampilan tentang senam nifas di wilayah kerja Puskesmas Talagasari Kabupaten Karawang, dikarenakan belum adanya sosialisasi dan bimbingan tentang senam nifas. Tujuan pengabdian untuk meningkatkan pengetahuan dan keterampilan tentang senam nifas pada ibu nifas menggunakan media modul dan vidio sehingga membantu dalam melakukan senam nifas secara mandiri dan sebagai program tambahan pada kelas ibu hamil. Metode pengabdian dalam kegiatan sosialisasi dan bimbingan senam nifas menggunakan ceramah tanya jawab, diskusi, simulasi dan praktek senam nifas, disertai pre test dan post test. Kegiatan dilaksanakan selama tiga bulan di rumah responden sebanyak 185 orang. Hasil kegiatan sosialisasi dan bimbingan senam nifas ini memberikan implikasi berupa peningkatan pengetahuan ibu nifas hingga sebesar 9,28. Kegiatan telah memberikan manfaat berupa peningkatan pengetahuan dan keterampilan tentang senam nifas bagi seluruh responden. Kesimpulannya bahwa kegiatan sosialisasi dan bimbingan senam nifas memberikan implikasi berupa peningkatan pengetahuan dan kemampuan dalam melakukan gerakan-gerakan senam nifas secara mandiri menggunakan modul dan vidio senam nifas. Selanjutnya puskesmas dapat melanjutkan kegiatan senam nifas tersebut ke dalam materi perawatan nifas pada program kelas ibu hamil. Kata Kunci: Sosialisasi, Bimbingan, Senam , Nifas ABSTRACT The puerperium begins when the placenta is born and ends when the uterine organs return to their pre-pregnancy state. Postpartum mothers will experience many physical and psychological changes. Postpartum gymnastics is one way to help the mother recover soon, aims to expedite the process of uterine involution, is beneficial in terms of beauty, restores health and improves muscle tension after pregnancy. Implementation of postpartum exercise is influenced by internal and external factors. The formulation of the problem is in the form of limited knowledge and skills about postpartum exercise in the working area of the Talagasari Health Center, Karawang Regency, due to the absence of socialization and guidance regarding postpartum exercise. The purpose of the service is to increase knowledge and skills about postpartum exercise for postpartum mothers using modules and video media so that it helps in carrying out postpartum exercise independently and as an additional program for pregnant women classes. The service method in the socialization and guidance of postpartum gymnastics uses question-and-answer lectures, discussions, simulations and practice of postpartum gymnastics, accompanied by pre-tests and post-tests. The activity was carried out for three months in the homes of 185 respondents. The results of this socialization activity and postpartum exercise guidance have implications in the form of increasing the knowledge of postpartum mothers up to 9.28. Activities have provided benefits in the form of increased knowledge and skills about postpartum exercise for all respondents. The conclusion is that postpartum exercise socialization and guidance activities have implications in the form of increasing knowledge and ability to carry out postpartum exercise movements independently using postpartum exercise modules and videos. Furthermore, the health center can continue the postpartum exercise activities in the postnatal care material in the class program for pregnant women. Keywords: Socialization, Guidance, Gymnastics, PostpartumAnggarini, I. A. (2020). Pengaruh Senam Nifas Dan Pijat Oksitosin Terhadap Involusi Uteri Pada Ibu Postpartum. Midwifery Journal: Jurnal Kebidanan Um. Mataram, 5(2), 65. Https://Doi.Org/10.31764/Mj.V5i2.1277Anggarini, I. A., Hakim, M., & Hidayat, A. (2017). Pengaruh Senam Nifas Terhadap Perubahan Maternal Depressive Symptoms Di Rumah Sakit Ibu Dan Anak (Rsia) Sakina Idaman Kabupaten Sleman. Jurnal Unisa Yogya.Ayundya Prameswary1, F. K. (2019). Hubungan Inisiasi Menyusu Dini (Imd), Mobilisasi Dini Dan Senam Nifas Dengan Involusi Uteri. Jurnal Ilmiah Kebidanan Indonesia. Https://Doi.Org/10.33221/Jiki.V7i04.442Azhari, T., & Triana, A. (2022). Percepatan Involusi Uterus Pasca Persalinan Melalui Senam Nifas. Jurnal Kebidanan Tekini, 01(1), 45–55.Bi’i, G. R. M., Folamauk, C. L. H., & Telussa, A. S. (2021). Efektivitas Media Video Terhadap Peningkatan Pengetahuan Tentang Social Distancing Dalam Pencegahan Covid-19 Pada Mahasiswa Baru Universitas Nusa Cendana. Cendana Medical Journal (Cmj), 9(2), 231–239. Https://Doi.Org/10.35508/Cmj.V9i2.5975Brier, J., & Lia Dwi Jayanti. (2020). Application Of Gymnastics Nifas To Afterpains Level In Mother Post Partum In Ponek Room Salatiga City Hospital Lutfaturrohmah1priharyanti. 21(1), 1–9. Http://Journal.Um-Surabaya.Ac.Id/Index.Php/Jkm/Article/View/2203Hutabarat, V., Sitepu, S. A., Sitepu, M. S., & Situmorang, R. B. (2020). Hubungan Tingkat Pengetahuan Ibu Nifas Tentang. Jurnal Keperawatan Komprehensif, 2(2), 58–65.Ineke, S H, Murti Ani, S. S. (2016). Pengaruh Senam Nifas Terhadap Tinggi Fundus Uteri Dan Jenis Lochea Pada Primipara. Jurnal Ilmiah Bidan.Knowledge, I., Public, O., About, M., Exercise, O., Moncongloe, I., & Regency, M. (N.D.). Peningkatan Pengetahuan Ibu Nifas Tentang Senam Otaria Di Desa Moncongloe Kabupaten Maros. 2181–2185.Mindarsih, T., & Pattypeilohy, A. (2020). Pengaruh Senam Nifas Pada Ibu Postpartum Terhadap Involusi Uterus Di Wilayah Kerja The Influence Of Postpartum Exercise On Postpartum Woman To. Jurnal Kesehatan Madani Medika, 11(02), 235–246. Http://Jurnalmadanimedika.Ac.Id/Index.Php/Jmm/Article/View/129/87Mularsih, S. (2017). Studi Komparatif Tentang Minat Praktek Senam Nifas Sebelum Dan Sesudah Di Berikan Penyuluhan Pada Ibu Nifas Di Bidan Praktek Mandiri Wilayah Kota Semarang. Jurnal Penelitian Dan Pengabdian Kepada Masyarakat Unsiq, 4(3), 287–302. Https://Doi.Org/10.32699/Ppkm.V4i3.433Sari, F. N., & Suhertusi, B. (2022). Senam Nifas Upaya Percepatan Involusi Uterus Pada Ibu Postpartum. Jurnal Abdidas, 1(3), 149–156.Sari, V. K., Khairani, N., Kesehatan, F., Kebidanan, P., Fort, U., Bukittinggi, D. K., Kesehatan, F., Kebidanan, P., Fort, U., & Bukittinggi, D. K. (2022). Pengaruh Senam Nifas Terhadap Kualitas Tidur Ibu Nifas Di Praktik Mandiri Bidan R Bukittinggi. Jurnal Endurance, 7(1), 199–208. Http://Publikasi.Lldikti10.Id/Index.Php/Endurance/Article/View/743Savitri, N. P. H., & . S. (2018). Pengaruh Senam Nifas Dalam Peningkatan Produksi Asi. Jurnal Kebidanan, 9(02), 138. Https://Doi.Org/10.35872/Jurkeb.V9i02.315Sayuti, S., Almuhaimin, Sofiyetti, & Sari, P. (2022). Efektivitas Edukasi Kesehatan Melalui Media Video Terhadap Tingkat Pengetahuan Siswa Dalam Penerapan Protokol Kesehatan Di Smpn 19 Kota Jambi. Jurnal Kesmas Jambi, 6(2), 32–39.Siti Noor Hasanah1), Lisda Handayani2), Ainul Fithrah Syahidina3), Agusta Leni4), Dini Indah Purnamasari5), Hema Malinie6), Ratnawiyah7), Rida Ayu Rizki8), Salma Mariesa9), I. F. (2023). Postpartum Exercise In Digital Era In The Working Area Of Guntung. 2(1), 347–354.Sumarni, S., Lasanuddin, H. V., & Annisa, R. (2021). Pendidikan Kesehatan Dan Pelatihan Senam Nifas Agar Ibu Tetap Sehat Dimasa Pandemi Covid-19 Di Akademi Kebidanan Tahirah Al Baeti Bulukumba. Jcs, 3(1), 15–21. Https://Doi.Org/10.57170/Jcs.V3i1.5Victoria, S. I., & Yanti, J. S. (2021). Asuhan Kebidanan Pada Ibu Nifas Dengan Pelaksanaan Senam Nifas, Jurnal Kebidanan Terkini ( Current Midwifery Journal ). 01, 45–55.Widatiningsih, S., Rofi’ah, S., Yuniyanti, B., & Sukini, T. (2018). Pelatihan Senam Nifas Bagi Kader Posyandu Di Desa Ambartawang Kecamatan Mungkid Kabupaten Magelang. Link. Https://Doi.Org/10.31983/Link.V14i1.2955World Health Organization; London School Of Hygiene And Tropical Medicine. (2017). Efektivitas Antara Senam Nifas Versi A Dan Senam Nifas Versi N Terhadap Kelancaran Involusio Uteri Di Puskesmas Binuang Tahun 2017 (Lina Fitriani,S.St.,M.Keb) Salah. Bmc Public Health, 5(1), 1–8. 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Background:Outpatient non-attendance refers to the phenomenon of patients who have a medical appointment but do not show up at the specified date, time, and location without giving previous notice.1In addition to affecting the efficiency and thereby increasing the healthcare total costs, nonattendance might also delay access to care for users on waiting lists.1Nonattendance at health appointments is costly to services, and can risk patient health.2There is very little data on the nonattendance prevalence and impact in Portugal. This knowledge might be fundamental to improve effectiveness of outpatient care in Portugal.Objectives:1) describe patient’s non-attendance rate; 2) assess and characterize the sociodemographic and clinical characteristics among non-attending patients; 3) estimate the economic burden of non-attendance.Methods:Retrospective, cross-sectional and analytical study. We reviewed a one-month Rheumatology consultation period regarding performed medical consultations and non-attended consultations without previous notification from patients. Direct economic costs of non-attended appointments were calculated based on the “Amending Agreement to the ULSAM, EPE Program Agreement”.Results:982 consultations within January 2018 were included. Appointments episodes for therapeutic prescription, medical reports or programmed admissions were excluded. Fifty-seven (5.8%) of scheduled outpatient appointments were non-attended. Subsequent consultations represented 85.2% of attended appointments and 80.7% of non-attended appointments. Female gender was the most prevalent in both groups – 620 (67.0%) among attended consultations and 37 (65.0%) among non-attended consultations. Mean age was 57±15 years in the first group and 54±16 years in the second one. Among attended appointments, mean education level was 8±5 years versus 9±6 years among non-attended appointments. There were no differences between both groups in gender, age, education level, diagnosis, disease duration and activity or appointment type (first or subsequent consultation). A cost of 2,438 euros was estimated regarding non-attended appointments for this period, what could represent a burden of more than 29,000 euros yearly, in direct costs, only.Conclusion:Non-attendance at scheduled appointments in public hospitals seems to be influenced by other factors besides gender, age and education level. The burden of non-attended appointments is undeniable. In addition to the costs estimated in this study, further indirect costs such as poorer patients outcomes, impaired access to medical care and hospital penalties should be taken into account. Implementation of awareness strategies aiming the optimization and effectiveness of healthcare system are required.References:[1]Blæhr EE, Kristensen T, Væggemose U, Søgaard R. The effect of fines on nonattendance in public hospital outpatient clinics: study protocol for a randomized controlled trial.Trials. 2016;17(1):288. doi:10.1186/s13063-016-1420-3[2]Akter S. A qualitative study of staff perspectives of patient non-attendance in a regional primary healthcare setting.Australas Med J. 2014;7(5):218-226. doi:10.4066/AMJ.2014.2056Disclosure of Interests:None declared

Sharenting is a habit of using social media to share content that disseminates pictures, videos, information, and parenting styles for their children. The purpose of this article is to describe the sharenting phenomenon that occurs among young parents, and the importance of parenting programs, rather than protecting children's privacy. Writing articles use a qualitative approach as a literature review method that utilizes various scientific articles describing the sharenting phenomenon in various countries. The findings show that sharenting behaviour can create the spread of children's identity openly on social media and tends not to protect children's privacy and even seems to exploit children. Apart from that, sharenting can also create pressure on the children themselves and can even have an impact on online crime. 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This research aims to analyze environmental-based education to increase environmental literacy and naturalistic intelligence. This research uses a qualitative descriptive method with interviews, observation, and document analysis as data collection techniques. Informants were selected using purposive sampling techniques. The criteria for selecting informants are teachers who have a minimum of five years of teaching experience and the ability to make environment-based learning plans. The sampling results were 15 teachers from five kindergartens in the coastal area. The research results show that Environment-Based Education (EBE) can increase children's eco-literacy and naturalistic intelligence which focuses on four main dimensions, such as knowledge, understanding, skills, values ​​, and attitudes. Increasing children's positive attitudes and behavior towards the environment can increase awareness of coastal environmental preservation. Results also show increased acquisition of practical knowledge, skills, and positive attitudes towards the preservation and sustainability of the coastal environment. The findings of the above studies allow recommendations for understanding the long-term impact of such teaching on environmental literacy in children that requires long-term studies. A more organized learning model that other educational institutions may employ, and includes the creation of unique curricula, including outdoor education programs, and efforts in environmental initiatives. Keywords: eco-literacy, naturalistic intelligence, environmental-based education, coastal ECCE References: Alfianto, A. B., Karyanto, P., & Harlita. (2019). Learning management system for eco literacy enhancement: The effectiveness of adopting Lewinshon indicators as an additional standard of competence. AIP Conference Proceedings, 2194. https://doi.org/10.1063/1.5139734 Amalric, M., & Cantlon, J. F. (2023). Entropy, complexity, and maturity in children’s neural responses to naturalistic video lessons. Cortex, 163, 14–25. https://doi.org/10.1016/j.cortex.2023.02.008 Anjari, T. Y., & Purwanta, E. (2019). Effectiveness of the Application of Discovery Learning to the Naturalist Intelligence of Children About the Natural Environment in Children Aged 5-6 Years. 296(Icsie 2018), 356–359. https://doi.org/10.2991/icsie-18.2019.65 Bater, M. L., Gould, J. F., Collins, C. T., Anderson, P. J., & Stark, M. J. (2024). Child development education in the Neonatal Unit: Understanding parent developmental literacy needs, priorities and preferences. Patient Education and Counseling,119(November 2023), 108058. https://doi.org/10.1016/j.pec.2023.108058 Biber, K., Cankorur, H., Güler, R. S., & Demir, E. (2023). Investigation of environmental awareness and attitudes of children attending nature centred private kindergartens and public kindergartens. Australian Journal of Environmental Education, 39(1), 4–16. https://doi.org/10.1017/aee.2022.1 Collado, S., Rosa, C. D., & Corraliza, J. A. (2020). The effect of a nature-based environmental education program on children’s environmental attitudes and behaviors: A randomized experiment with primary schools. Sustainability (Switzerland), 12(17). https://doi.org/10.3390/SU12176817 Ernst, J., & Burcak, F. (2019). Young children’s contributions to sustainability: The influence of nature play on curiosity, executive function skills, creative thinking, and resilience. Sustainability (Switzerland), 11(15). https://doi.org/10.3390/su11154212 Flanagan, R. M., & Symonds, J. E. (2022). Children’s self-talk in naturalistic classroom settings in middle childhood: A systematic literature review. Educational Research Review, 35(December 2021). https://doi.org/10.1016/j.edurev.2022.100432 Gauvain, M. (2020). Vygotsky’s Sociocultural Theory. Encyclopedia of Infant and Early Childhood Development, November 2018, 446–454. https://doi.org/10.1016/B978-0-12-809324-5.23569-4 Giorgi, R., & Mariotti, G. (2019). WebriSC-V: A web-based education-oriented RISC-V pipeline simulation environment. Proceedings of the Workshop on Computer Architecture Education, WCAE 2019. https://doi.org/10.1145/3338698.3338894 Hermawan, I. M. S., Arjaya, I. B. A., & Diarta, I. M. (2022). Be-Raise: a Blended-Learning Model Based on Balinese Local Culture To Enhance Student’S Environmental Literacy. Jurnal Pendidikan IPA Indonesia, 11(4), 552–566. https://doi.org/10.15294/jpii.v11i4.39475 Hilmi, M. I., Lutfiansyach, D. Y., Hufad, A., Kamil, M., & Wahyudin, U. (2020). Eco-Literacy: Fostering Community Behavior Caring for the Environment. The First Transnational Webinar on Adult and Continuing, 548(Traced 2020), 118–121. Hong, S., & Lee, J. Y. (2022). Evaluation of therapeutic communication education for nursing students based on constructivist learning environments: A systematic review. Nurse Education Today, 119(August), 105607. https://doi.org/10.1016/j.nedt.2022.105607 Hutton, J., Children, C., Dewitt, T. G., Children, C., Horowitz-kraus, T., & Children, C. (2021). Development of an Eco-Biodevelopmental Model of Emergent Literacy Before Kindergarten: A Review. May. https://doi.org/10.1001/jamapediatrics.2020.6709 Istiana, R., Rahmayanti, H., & Sumargo, B. (2021). Marine environmental education learning system recommendation model based on student needs analysis in Indonesian coastal areas. Cypriot Journal of Educational Sciences, 16(5), 2236–2247. https://doi.org/10.18844/cjes.v16i5.6305 Juhriati, I., Rachman, I., & Yayoi, K. (2021). The best practice of ecoliteracy based on social culture. IOP Conference Series: Earth and Environmental Science, 802(1). https://doi.org/10.1088/1755-1315/802/1/012012 Kadarisman, I., & Pursitasari, I. D. (2023). Eco-literacy in Science Learning: A Review and Bibliometric Analysis. Jurnal Pendidikan Indonesia Gemilang, 3(2), 134–148. https://doi.org/10.53889/jpig.v3i2.197 Kim, B. J., & Chung, J. B. (2023). Is safety education in the E-learning environment effective? Factors affecting the learning outcomes of online laboratory safety education. Safety Science, 168(May), 106306. https://doi.org/10.1016/j.ssci.2023.106306 Kofi, A., & Asemnor, F. (2024). Play-Based Pedagogy in Ghanaian Basic Schools : A Review of Related Literature. 18(3), 17–28. https://doi.org/10.9734/AJARR/2024/v18i3611 Kos, M., Jerman, J., Anžlovar, U., & Torkar, G. (2016). Preschool children’s understanding of pro-environmental behaviours: Is it too hard for them? International Journal of Environmental and Science Education, 11(12), 5554–5571. 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User experiences of college students using mental health applications to improve self-care: Implications for improving engagement. Internet Interventions, 34(May), 100676. https://doi.org/10.1016/j.invent.2023.100676 Nattel, J., & Akullian, D. (2021). An argument for the naturalistic study of collective intelligence. The Lancet Planetary Health, 5(5), e247–e248. https://doi.org/10.1016/S2542-5196(21)00077-2 Ningtyas, L. D. (2019). Pengaruh Naturalistic Intelligence dan New Environmental Paradigm terhadap Environmental Sensitivity. IJEEM - Indonesian Journal of Environmental Education and Management, 4(2), 82–94. https://doi.org/10.21009/ijeem.042.01 Nurwidodo, N., Amin, M., Ibrohim, I., & Sueb, S. (2020). The role of eco-school program (Adiwiyata) towards environmental literacy of high school students. European Journal of Educational Research, 9(3), 1089–1103. https://doi.org/10.12973/EU-JER.9.3.1089 Park, A. T., Richardson, H., Tooley, U. A., McDermott, C. L., Boroshok, A. 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Starting from growth that supports development, in the end growth and development go hand in hand. An important period in a child's growth and development begins in infancy because basic growth is what will influence and determine the child's subsequent development. The aim of this research is to detect deviations in the development of early childhood children aged 2-3 years at the ECCE Rahmah El Yunusiyyah Padang Panjang through the Stimulation, Detection and Early Intervention of Child Growth and Development (SDICGD) instruments in the Android feature. This research was conducted using a cross-sectional approach. Participants in this study were 26 children aged 2-3 years using a consecutive sampling technique of 10 children whose growth and development were monitored using the SDICGD android application. The results of this study showed that several partisipants experienced malnutrition, one partisipant out of nine normal partisipants. The Developmental Pre-Screening Questionnaire (DPSQ) instrument of the ten child participants contained nine children (90%) who were according to the developmental stage aged 24-36 months, and one child was not according to the developmental stage. The results of the Attention Deficit and Hyperactivity Disorder (ADHD) test showed that three children (60%) were normal, and two children (40%) were hyperactive. Early detection of children's growth and development must be carried out regularly every month, and according to the child's age. For further research, it is hoped that early detection will also be carried out on the development of children's mental health, not just growth and development which is common and widely researched. Schools and parents must play an active role in children's growth and development so that no developmental stages are missed, and children grow and develop according to their age. 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BackgroundDuring the COVID-19 pandemic, the patients with rheumatic disease in the biopsychosocial perspective have been adversely affected by social isolation, uncertainty, and the thought that their chronic disease will worsen and increase in their symptoms. ACR/EULAR (American College of Rheumatology / European League Against Rheumatism) defines recommendations about continuing current pharmacotherapy and the significance of the biopsychosocial approach and exercise for patients with rheumatic diseases during a COVID-19 infection 1, 2.ObjectivesThis study aims to investigate the effectiveness of the biopsychosocial exercise performed by telerehabilitation on biopsychosocial status, general health status, and anxiety-depression levels in the patients with inflammatory and non-inflammatory rheumatic diseases.MethodsFourteen patients with inflammatory rheumatic diseases (rheumatoid arthritis: 4; ankylosing spondylitis: 4; sjogren’s syndrome: 3; polymyalgia rheumatica: 2; and vasculitis: 1) and eight patients with non-inflammatory rheumatic diseases (fibromyalgia: 6; and osteoarthritis: 2) performed a biopsychosocial-based exercise model (named as “Bilişsel Egzersiz Terapi Yaklaşimi”-(BETY) in original; “Cognitive Exercise Therapy Approach” in English) via telerehabilitation continued for three sessions per week for 12 months 3. Outcome measures were Health Assessment Questionnaire (HAQ), Hospital Anxiety and Depression Scale (HADS), and BETY-Biopsychosocial Questionnaire (BETY-BQ) 4. All outcomes were measured baseline and at the 12th month. The Wilcoxon’s test was used for statistical analysis.ResultsAll of the 22 patients were female. The mean age was 57.4 and 55.8 years in the inflammatory and non-inflammatory rheumatic diseases groups respectively, and they had a mean BMI of 25.9 and 25.3 kg/m2. There was no significant difference by time for HAQ score (p = 0.125), HADS anxiety and depression (p = 0.916 and p = 0.663, respectively), and BETY-BQ score (p = 0.753) between the baseline and at the 12th month follow-up in the patients with inflammatory rheumatic diseases. Similarly, in the patients with non-inflammatory rheumatic diseases, there was no significant difference by time for HAQ score (p = 0.546), HADS anxiety and depression (p = 0.343 and p = 0.527, respectively), and BETY-BQ score (p = 0.068) between the baseline and at the 12th month follow-up.ConclusionThis study showed that biopsychosocial-based exercise through real-time telerehabilitation was able to maintain their conditions before pandemic in biopsychosocial status, general health, and anxiety-depression levels on the patients with inflammatory and non-inflammatory rheumatic diseases during COVID-19 pandemic period in one-year follow-up.References[1]England BR, Barber CE, Bergman M, Ranganath VK, Suter LG, Michaud K. Brief Report: adaptation of American College of Rheumatology Rheumatoid Arthritis Disease Activity and functional status measures for telehealth visits. Arthritis Care Res (Hoboken). 2020.[2]Landewé RB, Machado PM, Kroon F, Bijlsma HW, Burmester GR, Carmona L, Combe B, Galli M, Gossec L, Iagnocco A. EULAR provisional recommendations for the management of rheumatic and musculoskeletal diseases in the context of SARS-CoV-2. Ann Rheum Dis. 2020;79(7):851-8.[3]Kisacik P, Unal E, Akman U, Yapali G, Karabulut E, Akdogan A. Investigating the effects of a multidimensional exercise program on symptoms and antiinflammatory status in female patients with ankylosing spondylitis. Complementary therapies in clinical practice. 2016;22:38-43.[4]Edibe Ü, Gamze A, KARACA NB, KİRAZ S, AKDOĞAN A, KALYONCU U, ERTENLİ Aİ, BİLGEN ŞA, KARADAĞ Ö, ERDEN A. Romatizmali hastalar için bir yaşam kalitesi ölçeğinin geliştirilmesi: madde havuzunun oluşturulmasi. Journal of Exercise Therapy and Rehabilitation. 2017;4(2):67-75.Disclosure of InterestsNone declared

The ability to recognize the concept of early numbers in early childhood is very important to develop so that children are ready to take part in learning mathematics at a higher level. This study aims to determine the effect of mathematics learning approaches and self-regulation to recognize the concept of early numbers ability in kindergarten. The study used an experimental method with a treatment design by level 2x2. The sample used was 32 children. Score data, ability to recognize number concepts, analyzed and interpreted. The results showed that: (1) The Realistic Mathematics Education approach is better than the Open Ended Approach in improving the ability to recognize children's number concepts; (2) There is an interaction effect between mathematics learning approaches and Self-Regulation to recognize the concept of early numbers ability; (3) The Realistic Mathematics Education approach is more suitable for children with high self-regulation, (4) The Open Ended approach is more suitable for children with low self-regulation. Subsequent experiments are expected to find mathematics learning approaches for children whose self-regulation is low on recognizing the concept of early numbers ability. Keywords: mathematics learning approach, self-regulation, early number concept ability References: Adjie, N., Putri, S. U., & Dewi, F. (2019). Penerapan Pendidikan Matematika Realistik (PMR) dalam Meningkatkan Pemahaman Konsep Bilangan Cacah pada Anak Usia Dini. 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Parents play a crucial role in shaping the character of their children, and the character of children is closely tied to the involvement of both parents. This study aims to examine how parents function as educators, motivators, role models, controllers, and providers (facilitators) in cultivating character values, discipline, and responsibility in children. The research was conducted using qualitative methods with a sequential and phenomenological approach. Photovoice, combined with thematic analysis, served as the type and source of data. Data collection involved interviews and observations, with six pairs of parents with 5-6-year-old children participating in the study. The analysis revealed that parents, through their various roles, internalize the development of independent, disciplined, and responsible character values in their children. The study concludes that children aged 5-6 exhibit character values learned through a process of observation and imitation. Future research is encouraged to utilize these findings as a reference for instilling character values in children. Keywords: character value, early childhood, parental role References: Adawiah, A., Asmini, A., Umar, A., & Abdu, W. J. (2023). The Influence of Parenting Styles and Managerial Elements on School Readiness in Kindergarten-Aged Children within a Community. Jurnal Obsesi : Jurnal Pendidikan Anak Usia Dini, 7(5). https://doi.org/10.31004/obsesi.v7i5.5154 Andhika, M. R. (2021). Peran Orang Tua Sebagai Sumber Pendidikan Karakter. At-Ta’dib: Jurnal Ilmiah Prodi Pendidikan Agama Islam, 13(1), 73–81. Anggraeni, R. N., Fakhriyah, F., & Ahsin, M. N. (2021). Peran orang tua sebagai fasilitator anak dalam proses pembelajaran online di rumah. Jurnal Ilmiah Pendidikan Dasar, 8(2), 105. https://doi.org/10.30659/pendas.8.2.105-117 Boiliu, E. R. (2023). Dimensi Pengembangan Pendidikan Karakter bagi Anak Usia Dini. 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SOSIOHUMANIORA: Jurnal Ilmiah Ilmu Sosial Dan Humaniora, 6(2), 13–24. https://doi.org/10.30738/sosio.v6i2.6781 Epstein, J. L. (2018). School, family, and community partnerships: Preparing educators and improving schools, second edition. In School, Family, and Community Partnerships: Preparing Educators and Improving Schools, Second Edition. https://doi.org/10.4324/9780429494673 Eslava, M., Deaño, M., Alfonso, S., Conde, Á., & García-Señorán, M. (2016). Family context and preschool learning. Journal of Family Studies, 22(2). https://doi.org/10.1080/13229400.2015.1063445 Ferdiansyah, S., Supiastutik, & Angin, R. (2020). Thai students’ experiences of online learning at indonesian universities in the time of the covid-19 pandemic. Journal of International Students, 10(Special Issue 3), 58–74. https://doi.org/10.32674/jis.v10iS3.3199 Fiskerstrand, A. (2022). Literature review – Parent involvement and mathematic outcome. 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Parent Cooperative Early Childhood Settings: Empowering Family Strengths and Family Engagement for All Young Children. International Journal of Contemporary Education, 4(1). https://doi.org/10.11114/ijce.v4i1.5143 Hart, P. (2022). Reinventing character education: the potential for participatory character education using MacIntyre’s ethics. Journal of Curriculum Studies, 54(4). https://doi.org/10.1080/00220272.2021.1998640 Hidayat, M., Rozak, R. W. A., Hakam, K. A., Kembara, M. D., & Parhan, M. (2022). Character education in Indonesia: How is it internalized and implemented in virtual learning? Cakrawala Pendidikan, 41(1). https://doi.org/10.21831/cp.v41i1.45920 Holiseh, H., Satispi, E., & Gusman, D. T. (2023). Strategi Komunikasi BKKBN (Badan Koordinasi Keluarga Berencana Nasional) Melalui Program Keluarga Berencana. Jurnal Akuntan Publik, 1(2). Ihmeideh, F., AlFlasi, M., Al-Maadadi, F., Coughlin, C., & Al-Thani, T. (2020). Perspectives of family–school relationships in Qatar based on Epstein’s model of six types of parent involvement. Early Years, 40(2). https://doi.org/10.1080/09575146.2018.1438374 Liana, H., Rahardjo, B., & Sjamsir, H. (2018). Implementasi Pembelajaran Karakter Anak Usia Dini Di Paud Anak Kita Preschool Samarinda. Pendas Mahakam : Jurnal Pendidikan Dan Pembelajaran Sekolah Dasar, 3(1), 8–19. Retrieved from https://jurnal.fkip-uwgm.ac.id/index.php/pendasmahakam/article/view/222 Marliyanti, Rahardjo, B., & Rozie, F. (2020). Penerapan Penanaman Nilai-Nilai Karakter Melalui 9 Pilar Karakter Anak Usia 5-6 Tahun di TK Hidayah Samarinda. Jendela Bunda, 7(2). Mayasari, A., Sopian, A., Ridwan, W., Hasanah, A., & Arifin, B. S. (2022). Pengembangan Model Evaluasi Pendidikan Karakter dalam Pembelajaran di Sekolah. JIIP - Jurnal Ilmiah Ilmu Pendidikan, 5(7). https://doi.org/10.54371/jiip.v5i7.676 Mubarok, M. N. (2021). Manajemen Internalisasi Nilai Karakter Anak Usia Dini di Lingkungan Keluarga. 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Early childhood teacher education programs must figure out how to effectively educate the workforce as classrooms become more diverse due to children varied cultural backgrounds and skills. This study aims to analyse student involvement in the Strengthening of Early Childhood Educators Teaching Skills course in distance education. The research method used is descriptive qualitative. The research participants were 405 students of the Department of Early Childhood Education, consisting of 90% women aged between 20-55 years and an average age of 31 years. The research findings show that at the level of academic challenge, most students agree that the ECE Educators Teaching Skills Strengthening (TSS) course brings new ideas and certain experiences and is very helpful in applying theory or concepts to practical problems. Indicators of active/collaborative learning indicate that hands-on experiences help students work more effectively with others. Meanwhile, the student-faculty interaction component shows that they have carried out two-way discussions regarding material assessment and practice. Additionally, online tutorials have provided quick feedback on assignments and guidance in compiling practice reports. The student learning experience is greatly helped by the TSS course. Students acquire new knowledge and skills to support their profession as teachers. Keywords: early childhood educators, engagement, teaching skill, distance education References: Ackerman, D. J. (2004). What do teachers need? Practitioners’ perspectives on early childhood professional development. Journal of Early Childhood Teacher Education, 24(4), 291–301. https://doi.org/10.1080/1090102040240409 Bolliger, D. U., & Martin, F. (2018). Instructor and student perceptions of online student engagement strategies. Distance Education, 39(4), 568–583. https://doi.org/10.1080/01587919.2018.1520041 Cherrington, S., & Thornton, K. (2013). 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Background: Although sleep has been identified as an important modifiable risk factor for sports injury, the effect of decreased sleep on sports injuries in adolescents is poorly studied. Purpose: To systematically review published literature to examine if a lack of sleep is associated with sports injuries in adolescents and to delineate the effects of chronic versus acute lack of sleep. Methods: PubMed and EMBASE databases were systematically searched for studies reporting statistics regarding the relationship between sleep and sports injury in adolescents aged <19 years published between 1/1/1997 and 12/21/2017. From included studies, the following information was extracted: bibliographic and demographic information, reported outcomes related to injury and sleep, and definitions of injury and decreased sleep. Additionally, a NOS (Newcastle-Ottawa Scale) assessment and an evaluation of the OCEM (Oxford Center for Evidence-Based Medicine) level of evidence for each study was conducted to assess each study’s individual risk of bias, and the risk of bias across all studies. Results: Of 907 identified articles, 7 met inclusion criteria. Five studies reported that adolescents who chronically slept poorly were at a significantly increased likelihood of experiencing a sports or musculoskeletal injury. Two studies reported on acute sleep behaviors. One reported a significant positive correlation between acutely poor sleep and injury, while the other study reported no significant correlation. In our random effects model, adolescents who chronically slept poorly were more likely to be injured than those who slept well (OR 1.58, 95% CI 1.05 to 2.37, p = 0.03). OCEM criteria assessment showed that all but one study (a case-series) were of 2b level of evidence—which is the highest level of evidence possible for studies which were not randomized control trials or systematic reviews. NOS assessment was conducted for all six cohort studies to investigate each study’s individual risk of bias. Five out of six of these studies received between 4 to 6 stars, categorizing them as having a moderate risk of bias. One study received 7 stars, categorizing it as having a low risk of bias. NOS assessment revealed that the most consistent source of bias was in ascertainment of exposure: all studies relied on self-reported data regarding sleep hours rather than a medical or lab record of sleep hours. Conclusions: Chronic lack of sleep in adolescents is associated with greater risk of sports and musculoskeletal injuries. Current evidence cannot yet definitively determine the effect of acute lack of sleep on injury rates. 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ABSTRAK Kemisikinan merupakan suatu permasalahan yang harus ditemukan cara mengentaskannya. Islam agama yang sempurna telah memberikan solusi melalui instrument zakat, infak, dan sedekah. Tujuan dari penelitian ini adalah untuk menilai dampak zakat, infak, sedekah di LAZNAS LMI (Lembaga Manajemen Infaq) dengan Pendekatan CIBEST. Metode penelitian yang digunakan adalah kuantitatif dengan uji beda antara kondisi material dan spiritual mustahik sebelum dibantu dengan setelah disalurkan dana ZIS. Hasil analisis dari 355 penerima manfaat menunjukkan bahwa pada kuadran I, penerima manfaat yang dikategorikan sejahtera bertambah 28% sesudah dibantu. Pada kuadran II, penerima manfaat yang dikategorikan miskin secara material menurun sebesar 27,7%. Selain itu pada kuadran IV penerima manfaat yang dikategorikan miskin secara absolut, juga ikut menurun sebesar 0,3%. Hasil Uji Beda juga menunjukan ada perbedaan indeks spiritual maupun indeks material penerima manfaat antar sebelum dan sesudah pemberian dana ZIS dibuktikan dengan Uji Beda Wilcoxon untuk indeks material value, dan Uji T berpasangan untuk indeks spiritual value.. Dengan adanya hasil penilaian kaji dampak ini diharapkan dampak dari bantuan yang diberikan bisa terukur dan juga menjadi bahan evaluasi serta perencanaan untuk program-program yang akan datang. Implikasi temuan penelitian ini dapat memberikan refrensi terkait manfaat zakat, infak, sedekah dalam membantu mengetaskan kemiskinan yang dilakukan oleh lembaga amil zakat nasional. Secara praktik, Lembaga Manajemen Infaq perlu memberikan perhatian khusus kepada mustahik yang berada di kategori miskin absolut, dengan memberikan intervensi ekonomi dan pembinaan secara spiritual. Kata Kunci: Kaji Dampak, ZIS, Kemiskinan, CIBEST, Lemabga Amil Zakat, Lembaga Manajemen Infaq. ABSTRACT Poverty is a problem that must find a way to eradicate. Islam, the perfect religion, has provided a solution through the instruments of zakat, infaq, and shadaqah. The purpose of this study was to assess the impact of Zakat, Sedekah, and Infaq in Lembaga Manajemen Infaq with the CIBEST Approach. The method used is quantitative by distributing questionnaires and testing the difference between the material and spiritual conditions of the mustahik before being assisted with after the ZIS funds are distributed. The results of the analysis of 355 beneficiaries showed that in quadrant I, beneficiaries categorized as prosperous increased by 28% after being assisted. In quadrant II, beneficiaries categorized as materially poor decreased by 27.7%. In addition, in quadrant IV, beneficiaries who are categorized as absolute poor also decreased by 0.3%. The results of the Difference Test also show that there are differences in the spiritual index and material index of beneficiaries between before and after the provision of ZIS funds, as evidenced by the Wilcoxon Difference Test for the material value index, and the paired T-test for the spiritual value index. The assistance provided can be measured and can also be used as material for evaluation and planning for future programs. The implications of the findings of this study can provide a reference regarding the benefits of zakat, shadaqah, and infaq in helping to alleviate poverty carried out by the national amil zakat institution. In practice, Amil Zakat Organization needs to pay special attention to mustahik who are in the absolute poor category, by providing economic intervention and spiritual guidance. Keywords: Assessment of Impact, ZIS, Poverty, CIBEST, Amil Zakat Organization, Lembaga Manajemen Infaq. DAFTAR PUSTAKA Ahmed, B. O., Johari, F., & Wahab, K. A. (2017). 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Jurnal Ekonomi Syariah Teori dan Terapan, 7(6), 1060-1073. https://doi.org/10.20473/vol7iss20206pp1060-1073 Rijal, K., Zainuri, A., & Azwari, P. C. (2020). Impact analysis of the zakat, infaq and shadaqah funds distribution to the poverty level of mustahik by using Cibest method Indonesia. Fikri: Jurnal Kajian Agama,Sosial dan Budaya, 5(1), 145-158. https://doi.org/10.25217/jf.v5i1.982 Rozalinda. (2014). Ekonomi Islam: Teori dan aplikasinya pada aktivitas ekonomi. Jakarta: Rajagrafindo. Saad, R. A. J., Farouk, A. U., & Abdul Kadir, D. (2020). Business zakat compliance behavioral intention in a developing country. Journal of Islamic Accounting and Business Research, 11(2), 511–530. https://doi.org/10.1108/JIABR-03-2018-0036 Saad, R. A. J., & Haniffa, R. (2014). Determinants of (Islamic tax) compliance behavior. Journal of Islamic Accounting and Business Research, 5(2), 182–193. https://doi.org/10.1108/JIABR-10-2012-0068 Salam, A., & Nisa, R. (2021). Analisis pengaruh pendistribusian dana zakat terhadap mustahik ditinjau dengan menggunakan metode CIBEST. Jurnal Ekonomi Syariah Indonesia, 9(1), 67–73. https://doi.org/10.21927/jesi.2021.11(1).67-73 Sanrego, & Taufik. (2016). Fiqih tamkin (Fiqih pemberdayaan). Jakarta: QisthiPress. Sudarmanto, E., Revida, E., Zaman, N., Simarmata, M. M. T., Purba, S., Syafrizal, S., Bachtiar, E., Faried, A. I., Nasrullah, N., Marzuki, I., Hastuti, P., Jamaludin, J., Kurniawan, I., Mastutie, F., Susilawaty, A. (2020). Konsep Dasar Pengabdian Kepada Masyarakat: Pembangunan dan Pemberdayaan. Medan: Yayasan Kita Menulis. Sugiyono. (2015). Metode penelitian pendidikan (Pendekatan kuantitatif, kualitatif, dan R&D). Bandung: CV. Alfabeta. Suharto, E. (2005). Membangun masyarakat memberdayakan rakyat kajian strategis pembangunan kesejahteraan sosial dan pekerja sosial. Bandung: PT. Revika Aditama. Sumantri, R., Iswati, S., & Mufrodi, A. (2019). The effectiveness of distribution of zakat funds on ZDC South Sumatra. Opción, Año 35(20), 1572–1588. Widyaningsih, N., Hafidhuddin, D., & Beik, I. S. (2016). Studi dampak zakat di Sulawesi Selatan dengan model CIBEST. Jurnal Ekonomi Islam Republika, 28. Retrieved from https://fem.ipb.ac.id/d/iqtishodia/2016/Iqtishodia_20160128.pdf Yacoub, Y. (2012). Pengaruh tingkat pengangguran terhadap tingkat kemiskinan kabupaten/kota di Provinsi Kalimantan Barat. Jurnal Eksos, 8(3), 176-185.

ABSTRAK Kemisikinan merupakan suatu permasalahan yang harus ditemukan cara mengentaskannya. Islam agama yang sempurna telah memberikan solusi melalui instrument zakat, infak, dan sedekah. Tujuan dari penelitian ini adalah untuk menilai dampak zakat, infak, sedekah di LAZNAS LMI (Lembaga Manajemen Infaq) dengan Pendekatan CIBEST. Metode penelitian yang digunakan adalah kuantitatif dengan uji beda antara kondisi material dan spiritual mustahik sebelum dibantu dengan setelah disalurkan dana ZIS. Hasil analisis dari 355 penerima manfaat menunjukkan bahwa pada kuadran I, penerima manfaat yang dikategorikan sejahtera bertambah 28% sesudah dibantu. Pada kuadran II, penerima manfaat yang dikategorikan miskin secara material menurun sebesar 27,7%. Selain itu pada kuadran IV penerima manfaat yang dikategorikan miskin secara absolut, juga ikut menurun sebesar 0,3%. Hasil Uji Beda juga menunjukan ada perbedaan indeks spiritual maupun indeks material penerima manfaat antar sebelum dan sesudah pemberian dana ZIS dibuktikan dengan Uji Beda Wilcoxon untuk indeks material value, dan Uji T berpasangan untuk indeks spiritual value.. Dengan adanya hasil penilaian kaji dampak ini diharapkan dampak dari bantuan yang diberikan bisa terukur dan juga menjadi bahan evaluasi serta perencanaan untuk program-program yang akan datang. Implikasi temuan penelitian ini dapat memberikan refrensi terkait manfaat zakat, infak, sedekah dalam membantu mengetaskan kemiskinan yang dilakukan oleh lembaga amil zakat nasional. Secara praktik, Lembaga Manajemen Infaq perlu memberikan perhatian khusus kepada mustahik yang berada di kategori miskin absolut, dengan memberikan intervensi ekonomi dan pembinaan secara spiritual. Kata Kunci: Kaji Dampak, ZIS, Kemiskinan, CIBEST, Lemabga Amil Zakat, Lembaga Manajemen Infaq. ABSTRACT Poverty is a problem that must find a way to eradicate. Islam, the perfect religion, has provided a solution through the instruments of zakat, infaq, and shadaqah. The purpose of this study was to assess the impact of Zakat, Sedekah, and Infaq in Lembaga Manajemen Infaq with the CIBEST Approach. The method used is quantitative by distributing questionnaires and testing the difference between the material and spiritual conditions of the mustahik before being assisted with after the ZIS funds are distributed. The results of the analysis of 355 beneficiaries showed that in quadrant I, beneficiaries categorized as prosperous increased by 28% after being assisted. In quadrant II, beneficiaries categorized as materially poor decreased by 27.7%. In addition, in quadrant IV, beneficiaries who are categorized as absolute poor also decreased by 0.3%. The results of the Difference Test also show that there are differences in the spiritual index and material index of beneficiaries between before and after the provision of ZIS funds, as evidenced by the Wilcoxon Difference Test for the material value index, and the paired T-test for the spiritual value index. The assistance provided can be measured and can also be used as material for evaluation and planning for future programs. The implications of the findings of this study can provide a reference regarding the benefits of zakat, shadaqah, and infaq in helping to alleviate poverty carried out by the national amil zakat institution. In practice, Amil Zakat Organization needs to pay special attention to mustahik who are in the absolute poor category, by providing economic intervention and spiritual guidance. Keywords: Assessment of Impact, ZIS, Poverty, CIBEST, Amil Zakat Organization, Lembaga Manajemen Infaq. DAFTAR PUSTAKA Ahmed, B. O., Johari, F., & Wahab, K. A. (2017). 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Parents play an important role in the development of their children. This research reflects the role of parents in developing children. Through four stages of identification, screening, eligibility, and acceptable results, this method uses a systematic literature review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) method. The findings from the fourteen articles examined show that parenting skills play an important role in a child's growth and development from birth to death. The determining factor in the development of physical, motoric, moral, language, social-emotional, and life skills aspects is the role of both parents as important teachers for children from birth to adulthood. Parents can also use a variety of parenting strategies and skills, many of which they have learned throughout their lives and passed on to their children, to help their children grow. 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Hamsters were exposed to sodium arsenite (173 mg As/L) in drinking water for 6 days. Equal amounts of proteins from urinary bladder or liver extracts of control and arsenic-treated hamsters were labeled with Cy3 and Cy5 dyes, respectively. After differential in gel electrophoresis and analysis by the DeCyder software, several protein spots were found to be down-regulated and several were up regulated. Our experiments indicated that in the bladder tissues of hamsters exposed to arsenite, transgelin was down-regulated and GST-pi was up-regulated. The loss of transgelin expression has been reported to be an important early event in tumor progression and a diagnostic marker for cancer development [29-32]. Down-regulation of transgelin expression may be associated with the carcinogenicity of inorganic arsenic in the urinary bladder. In the liver of arsenite-treated hamsters, ornithine aminotransferase was up-regulated, and senescence marker protein 30 and fatty acid binding protein were down-regulated. The volume ratio changes of these proteins in the bladder and liver of hamsters exposed to arsenite were significantly different than that of control hamsters. Introduction Chronic exposure to inorganic arsenic can cause cancer of the skin, lungs, urinary bladder, kidneys, and liver [1-6]. The molecular mechanisms of the carcinogenicity and toxicity of inorganic arsenic are not well understood [7-9). Humans chronically exposed to inorganic arsenic excrete MMA(V), DMA(V) and the more toxic +3 oxidation state arsenic biotransformants MMA(III) and DMA (III) in their urine [10, 11], which are carcinogen [12]· After injection of mice with sodium arsenate, the highest concentrations of the very toxic MMA(III) and DMA(III) were in the kidneys and urinary bladder tissue, respectively, as shown by experiments of Chowdhury et al [13]. Many mechanisms of arsenic toxicity and carcinogenicity have been suggested [1, 7, 14] including chromosome abnormalities [15], oxidative stress [16, 17], altered growth factors [18], cell proliferation [19], altered DNA repair [20], altered DNA methylation patterns [21], inhibition of several key enzymes [22], gene amplification [23] etc. Some of these mechanisms result in alterations in protein expression. Methods for analyzing multiple proteins have advanced greatly in the last several years. In particularly, mass spectrometry (MS) and tandem MS (MS/MS) are used to analyze peptides following protein isolation using two-dimensional (2-D) gel electrophoresis and proteolytic digestion [24]. In the present study, Differential In Gel Electrophoresis (DIGE) coupled with Mass Spectrometry (MS) has been used to study some of the proteomic changes in the urinary bladder and liver of hamsters exposed to sodium arsenite in their drinking water. Our results indicated that transgelin was down-regulated and GST-pi was up-regulated in the bladder tissues. In the liver tissues ornithine aminotransferase was up-regulated, and senescence marker protein 30, and fatty acid binding protein were down-regulated. Materials and Methods Chemicals Tris, Urea, IPG strips, IPG buffer, CHAPS, Dry Strip Cover Fluid, Bind Silane, lodoacetamide, Cy3 and Cy5 were from GE Healthcare (formally known as Amersham Biosciences, Uppsala, Sweden). Thiourea, glycerol, SDS, DTT, and APS were from Sigma-Aldrich (St. Louis, MO, USA). Glycine was from USB (Cleveland, OH, USA). Acrylamide Bis 40% was from Bio-Rad (Hercules, CA, USA). All other chemicals and biochemicals used were of analytical grade. All solutions were made with Milli-Q water. Animals Male hamsters (Golden Syrian), 4 weeks of age, were purchased from Harlan Sprague Dawley, USA. Upon arrival, hamsters were acclimated in the University of Arizona animal care facility for at least 1 week and maintained in an environmentally controlled animal facility operating on a 12-h dark/12-h light cycle and at 22-24°C. They were provided with Teklad (Indianapolis, IN) 4% Mouse/Rat Diet # 7001 and water, ad libitum, throughout the acclimation and experimentation periods. Sample preparation and labelling Hamsters were exposed to sodium arsenite (173 mg) in drinking water for 6 days and the control hamsters were given tap water. On the 6th day hamsters were decapitated rapidly by guillotine. Urinary bladder tissues and liver were removed, blotted on tissue papers (Kimtech Science, Precision Wipes), and weighed. Hamster urinary bladder or liver tissues were homogenized in lysis buffer (30mMTris, 2M thiourea, 7M urea, and 4% w/w CHAPS adjusted to pH 8.5 with dilute HCI), at 4°C using a glass homogenizer and a Teflon coated steel pestle; transferred to a 5 ml acid-washed polypropylene tube, placed on ice and sonicated 3 times for 15 seconds. The sonicate was centrifuged at 12,000 rpm for 10 minutes at 4°C. Small aliquots of the supernatants were stored at -80°C until use (generally within one week). Protein concentration was determined by the method of Bradford [25] using bovine serum albumin as a standard. Fifty micrograms of lysate protein was labeled with 400 pmol of Cy3 Dye (for control homogenate sample) and Cy5 Dye (for arsenic-treated urinary bladder or liver homogenate sample). The samples containing proteins and dyes were incubated for 30 min on ice in the dark. To stop the labeling reaction, 1uL of 10 mM lysine was added followed by incubation for 10 min on ice in the dark. To each of the appropriate dye-labeled protein samples, an additional 200 ug of urinary bladderor liver unlabeled protein from control hamster sample or arsenic-treated hamster sample was added to the appropriate sample. Differentially labeled samples were combined into a single Microfuge tube (total protein 500 ug); protein was mixed with an equal volume of 2x sample buffer [2M thiourea, 7M urea, pH 3-10 pharmalyte for isoelectric focusing 2% (v/v), DTT 2% (w/v), CHAPS 4% (w/v)]; and was incubated on ice in the dark for 10 min. The combined samples containing 500 ug of total protein were mixed with rehydration buffer [CHAPS 4% (w/v), 8M urea, 13mM DTT, IPG buffer (3-10) 1% (v/v) and trace amount of bromophenol blue]. The 450 ul sample containing rehydration buffer was slowly pipetted into the slot of the ImmobilinedryStripReswelling Tray and any large bubbles were removed. The IPG strip (linear pH 3-10, 24 cm) was placed (gel side down) into the slot, covered with drystrip cover fluid (Fig. 1), and the lid of the Reswelling Tray was closed. The ImmobillineDryStrip was allowed to rehydrate at room temperature for 24 hours. First dimension Isoelectric focusing (IEF) The labeled sample was loaded using the cup loading method on universal strip holder. IEF was then carried out on EttanIPGphor II using multistep protocol (6 hr @ 500 V, 6 hr @ 1000 V, 8 hr @ 8000 V). The focused IPG strip was equilibrated in two steps (reduction and alkylation) by equilibrating the strip for 10 min first in 10 ml of 50mM Tris (pH 8.8), 6M urea, 30% (v/v) glycerol, 2% (w/v) SDS, and 0.5% (w/v) DTT, followed by another 10 min in 10 ml of 50mM Tris (pH 8.8), 6M urea, 30% (v/v) glycerol, 2% (w/v) SDS, and 4.5% (w/v) iodoacetamide to prepare it for the second dimension electrophoresis. Second dimension SDS-PAGE The equilibrated IPG strip was used for protein separation by 2D-gel electrophoresis (DIGE). The strip was sealed at the top of the acrylamide gel for the second dimension (vertical) (12.5% polyacrylamide gel, 20x25 cm x 1.5 mm) with 0.5% (w/v) agarose in SDS running buffer [25 mMTris, 192 mM Glycine, and 0.1% (w/v) SDS]. Electrophoresis was performed in an Ettan DALT six electrophoresis unit (Amersham Biosciences) at 1.5 watts per gel, until the tracking dye reached the anodic end of the gel. Image analysis and post-staining The gel then was imaged directly between glass plates on the Typhoon 9410 variable mode imager (Sunnyvale, CA, USA) using optimal excitation/emission wavelength for each DIGE fluor: Cy3 (532/580 nm) and Cy5 (633/670 nm). The DIGE images were previewed and checked with Image Quant software (GE Healthcare) where all the two separate gel images could be viewed as a single gel image. DeCyde v.5.02 was used to analyze the DIGE images as described in the Ettan DIGE User Manual (GE Healthcare). The appropriate up-/down regulated spots were filtered based on an average volume ratio of ± over 1.2 fold. After image acquisition, the gel was fixed overnight in a solution containing 40% ethanol and 10% acetic acid. The fixed gel was stained with SyproRuby (BioRad) according to the manufacturer protocol (Bio-Rad Labs., 2000 Alfred Nobel Drive, Hercules, CA 94547). Identification of proteins by MS Protein spot picking and digestion Sypro Ruby stained gels were imaged using an Investigator ProPic and HT Analyzer software, both from Genomic Solutions (Ann Arbor, MI). Protein spots of interest that matched those imaged using the DIGE Cy3/Cy5 labels were picked robotically, digested using trypsin as described previously [24] and saved for mass spectrometry identification. Liquid chromatography (LC)- MS/MS analysis LC-MS/MS analyses were carried out using a 3D quadrupole ion trap massspectrometer (ThermoFinnigan LCQ DECA XP PLUS; ThermoFinnigan, San Jose, CA) equipped with a Michrom Paradigm MS4 HPLC (MichromBiosources, Auburn, CA) and a nanospray source, or with a linear quadrupole ion trap mass spectrometer (ThermoFinnigan LTQ), also equipped with a Michrom MS4 HPLC and a nanospray source. Peptides were eluted from a 15 cm pulled tip capillary column (100 um I.D. x 360 um O.D.; 3-5 um tip opening) packed with 7 cm Vydac C18 (Vydac, Hesperia, CA) material (5 µm, 300 Å pore size), using a gradient of 0-65% solvent B (98% methanol/2% water/0.5% formic acid/0.01% triflouroacetic acid) over a 60 min period at a flow rate of 350 nL/min. The ESI positive mode spray voltage was set at 1.6 kV, and the capillary temperature was set at 200°C. Dependent data scanning was performed by the Xcalibur v 1.3 software on the LCQ DECA XP+ or v 1.4 on the LTQ [27], with a default charge of 2, an isolation width of 1.5 amu, an activation amplitude of 35%, activation time of 50 msec, and a minimal signal of 10,000 ion counts (100 ion counts on the LTQ). Global dependent data settings were as follows: reject mass width of 1.5 amu, dynamic exclusion enabled, exclusion mass width of 1.5 amu, repeat count of 1, repeat duration of a min, and exclusion duration of 5 min. Scan event series were included one full scan with mass range of 350-2000 Da, followed by 3 dependent MS/MS scans of the most intense ion. Database searching Tandem MS spectra of peptides were analyzed with Turbo SEQUEST, version 3.1 (ThermoFinnigan), a program that allows the correlation of experimental tandem MS data with theoretical spectra generated from known protein sequences. All spectra were searched against the latest version of the non redundant protein database from the National Center for Biotechnology Information (NCBI 2006; at that time, the database contained 3,783,042 entries). Statistical analysis The means and standard error were calculated. The Student's t-test was used to analyze the significance of the difference between the control and arsenite exposed hamsters. P values less than 0.05 were considered significant. The reproducibility was confirmed in separate experiments. Results Analysis of proteins expression After DIGE (Fig. 1), the gel was scanned by a Typhoon Scanner and the relative amount of protein from sample 1 (treated hamster) as compared to sample 2 (control hamster) was determined (Figs. 2, 3). A green spot indicates that the amount of protein from sodium arsenite-treated hamster sample was less than that of the control sample. A red spot indicates that the amount of protein from the sodium arsenite-treated hamster sample was greater than that of the control sample. A yellow spot indicates sodium arsenite-treated hamster and control hamster each had the same amount of that protein. Several protein spots were up-regulated (red) or down-regulated (green) in the urinary bladder samples of hamsters exposed to sodium arsenite (173 mg As/L) for 6 days as compared with the urinary bladder of controls (Fig. 2). In the case of liver, several protein spots were also over-expressed (red) or under-expressed (green) for hamsters exposed to sodium arsenite (173 mg As/L) in drinking water for 6 days (Fig. 3). The urinary bladder samples were collected from the first and second experiments in which hamsters were exposed to sodium arsenite (173 mg As/L) in drinking water for 6 days and the controls were given tap water. The urinary bladder samples from the 1st and 2nd experiments were run 5 times in DIGE gels on different days. The protein expression is shown in Figure 2 and Table 1. The liver samples from the 1st and 2nd experiments were also run 3 times in DIGE gels on different days. The proteins expression were shown in Figure 3 and Table 2. The volume ratio changed of the protein spots in the urinary bladder and liver of hamsters exposed to arsenite were significantly differences than that of the control hamsters (Table 1 and 2). Protein spots identified by LC-MS/MS Bladder The spots of interest were removed from the gel, digested, and their identities were determined by LC-MS/MS (Fig. 2 and Table 1). The spots 1, 2, & 3 from the gel were analyzed and were repeated for the confirmation of the results (experiments; 173 mg As/L). The proteins for the spots 1, 2, and 3 were identified as transgelin, transgelin, and glutathione S-transferase Pi, respectively (Fig. 2). Liver We also identified some of the proteins in the liver samples of hamsters exposed to sodium arsenite (173 mg As/L) in drinking water for 6 days (Fig. 3). The spots 4, 5, & 6 from the gels were analyzed and were repeated for the confirmation of the results. The proteins for the spots 4, 5, and 6 were identified as ornithine aminotransferase, senescence marker protein 30, and fatty acid binding protein, respectively (Fig. 3) Discussion The identification and functional assignment of proteins is helpful for understanding the molecular events involved in disease. Weexposed hamsters to sodium arsenite in drinking water. Controls were given tap water. DIGE coupled with LC-MS/MS was then used to study the proteomic change in arsenite-exposed hamsters. After electrophoresis DeCyder software indicated that several protein spots were down-regulated (green) and several were up-regulated (red). Our overall results as to changes and functions of the proteins we have studied are summarized in Table 3. Bladder In the case of the urinary bladder tissue of hamsters exposed to sodium arsenite (173 mg As/L) in drinking water for 6 days, transgelin was down-regulated and GST-pi was up-regulated. This is the first evidence that transgelin is down-regulated in the bladders of animals exposed to sodium arsenite. Transgelin, which is identical to SM22 or WS3-10, is an actin cross linking/gelling protein found in fibroblasts and smooth muscle [28, 29]. It has been suggested that the loss of transgelin expression may be an important early event in tumor progression and a diagnostic marker for cancer development [30-33]. It may function as a tumor suppressor via inhibition of ARA54 (co-regulator of androgen receptor)-enhanced AR (androgen receptor) function. Loss of transgelin and its suppressor function in prostate cancer might contribute to the progression of prostate cancer [30]. Down-regulation of transgelin occurs in the urinary bladders of rats having bladder outlet obstruction [32]. Ras-dependent and Ras-independent mechanisms can cause the down regulation of transgelin in human breast and colon carcinoma cell lines and patient-derived tumorsamples [33]. Transgelin plays a role in contractility, possibly by affecting the actin content of filaments [34]. In our experiments loss of transgelin expression may be associated or preliminary to bladder cancer due to arsenic exposure. Arsenite is a carcinogen [1]. In our experiments, LC-MS/MS analysis showed that two spots (1 and 2) represent transgelin (Fig. 2 and Table 1). In human colonic neoplasms there is a loss of transgelin expression and the appearance of transgelin isoforms (31). GST-pi protein was up-regulated in the bladders of the hamsters exposed to sodium arsenite. GSTs are a large family of multifunctional enzymes involved in the phase II detoxification of foreign compounds [35]. The most abundant GSTS are the classes alpha, mu, and pi classes [36]. They participate in protection against oxidative stress [37]. GST-omega has arsenic reductase activity [38]. Over-expression of GST-pi has been found in colon cancer tissues [39]. Strong expression of GST-pi also has been found in gastric cancer [40], malignant melanoma [41], lung cancer [42], breast cancer [43] and a range of other human tumors [44]. GST-pi has been up-regulated in transitional cell carcinoma of human urinary bladder [45]. Up-regulation of glutathione – related genes and enzyme activities has been found in cultured human cells by sub lethal concentration of inorganic arsenic [46]. There is evidence that arsenic induces DNA damage via the production of ROS (reactive oxygen species) [47]. GST-pi may be over-expressed in the urinary bladder to protect cells against arsenic-induced oxidative stress. Liver In the livers of hamsters exposed to sodium arsenite, ornithine amino transferase was over-expressed, senescence marker protein 30 was under-expressed, and fatty acid binding protein was under-expressed. Ornithine amino transferase has been found in the mitochondria of many different mammalian tissues, especially liver, kidney, and small intestine [48]. Ornithine amino transferase knockdown inhuman cervical carcinoma and osteosarcoma cells by RNA interference blocks cell division and causes cell death [49]. It has been suggested that ornithine amino transferase has a role in regulating mitotic cell division and it is required for proper spindle assembly in human cancer cells [49]. Senescence marker protein-30 (SMP30) is a unique enzyme that hydrolyzes diisopropylphosphorofluoridate. SMP30, which is expressed mostly in the liver, protects cells against various injuries by stimulating membrane calcium-pump activity [50]. SMP30 acts to protect cells from apoptosis [51]. In addition it protects the liver from toxic agents [52]. The livers of SMP30 knockout mice accumulate phosphatidylethanolamine, cardiolipin, phosphatidyl-choline, phosphatidylserine, and sphingomyelin [53]. Liver fatty acid binding protein (L-FABP) also was down- regulated. Decreased liver fatty acid-binding capacity and altered liver lipid distribution hasbeen reported in mice lacking the L-FABP gene [54]. High levels of saturated, branched-chain fatty acids are deleterious to cells and animals, resulting in lipid accumulation and cytotoxicity. The expression of fatty acid binding proteins (including L-FABP) protected cells against branched-chain saturated fatty acid toxicity [55]. Limitations: we preferred to study the pronounced spots seen in DIGE gels. Other spots were visible but not as pronounced. Because of limited funds, we did not identify these others protein spots. In conclusion, urinary bladders of hamsters exposed to sodium arsenite had a decrease in the expression of transgelin and an increase in the expression of GST-pi protein. Under-expression of transgelin has been found in various cancer systems and may be associated with arsenic carcinogenicity [30-33). Inorganic arsenic exposure has resulted in bladder cancer as has been reported in the past [1]. Over-expression of GST-pi may protect cells against oxidative stress caused by arsenite. In the liver OAT was up regulated and SMP-30 and FABP were down regulated. These proteomic results may be of help to investigators studying arsenic carcinogenicity. The Superfund Basic Research Program NIEHS Grant Number ES 04940 from the National Institute of Environmental Health Sciences supported this work. Additional support for the mass spectrometry analyses was provided by grants from NIWHS ES06694, NCI CA023074 and the BIOS Institute of the University of Arizona. Acknowledgement The Author wants to dedicate this paper to the memory of his former supervisor Dr. H. VaskenAposhian who passed away in September 6, 2019. He was an emeritus professor of the Department of Molecular and Cellular Biology at the University of Arizona. 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Método para la implementación de sistemas solares activos en establecimientos hospitalarios, estudio de caso en el hospital clínico del sur, Concepción, Chile. En Proceedings of the 3rd International Congress on Sustainable Construction and Eco-Efficient Solutions. Sevilla. 2017; 451-464. Disponible: https://idus.us.es/xmlui/handle/11441/58969. [24]Compañía General de Electricidad, Tarifa de Suministro. 2018 Disponible: http://www.cge.cl/wp-content/uploads/2019/08/Publicacion-CGE-2019-08-01-Suministro-electrico.pdf. [25]Ministerio de Desarrollo Social, Precio Social del Carbono. 2018. Disponible: http://sni.ministeriodesarrollosocial.gob.cl/download/precio-social-co2-2017/?wpdmdl=2406.

THE ROLE OF POSYANDU CADRES IN EFFORTS TO IMPROVE THE NUTRITIONAL STATUS OF TODDLERS IN SUKA MAKMUR VILLAGE, PATILANGGIO DISTRICT Ripanwati Aridi1), Titin Dunggio2), Novian S. Hadi3) 1.2.3)University Of Bina Mandiri Gorontalo, Gorontalo E-Mail: Aridiripanwati@gmail.com ABSTRACT The Integrated Health Post is a community role that is managed by cadres, generally who manages the Posyandu in their respective regions voluntarily. The success of Posyandu can be seen from the maternal mortality rate, infant mortality rate, and under-five mortality rate. Posyandu's specific goal is to increase community participation in the implementation of basic health efforts (primary health care), increase the role of cross-sector, and increase the reach of basic health services. The purpose of this study was to find out the role of Posyandu cadres in improving the nutritional status of toddlers in Suka Makmur Village, Patilanggio District. This research was conducted in Suka Makmur Village, Patilanggio District. The method in this study is quantitative using a cross-sectional approach with a point time approach design. The population in this study was mothers who have children aged 1 to 5 years in Suka Makmur Village, Patilanggio District. The sampling technique was taken by total sampling. The results of the study about the role of cadres in Suka Makmur Village, Patilanggio District, the best roles were 25 people (83.3%). The increase in the nutritional status of toddlers in Suka Makmur Village, Patilanggio District, the most with good nutritional status was 26 respondents (86.7%). The results of statistical tests with Fisher's Exact Test correction obtained p-value = 0.048 <á (0.05), thus there is a significant relationship between the role of Posyandu cadres in efforts to improve the nutritional status of toddlers in Suka Makmur Village, Patilanggio District. Keyword: The Role of Cadres, improved Nutritional Status, Toddle INTRODUCTION Posyandu is a Community Based Health Efforts (UKBM) which is managed, by, for, and with the community to empower the community and provide facilities for the community in obtaining basic health services. The Integrated Health Post is a community role that is managed by cadres, generally, these cadres manage posyandu in their respective areas voluntarily [1]. If the Posyandu is programmed thoroughly the problems of malnutrition in children under five, malnutrition, edema, and other health problems related to the health of mothers and children will be easily avoided because remembering that Posyandu is also one of the places for public health services that directly interact with the community. The Success of Posyandu can be seen from the maternal mortality rate, infant mortality rate, under-five mortality rate, and also coverage of other Posyandu programs such as immunization [2]. RPJMN policy direction for health 2020-2024 Improves health services towards universal health coverage, especially strengthening primary health care by encouraging increased promotional and preventive efforts, supported by innovation and the use of technology. RPJMN Strategy 2020-2024 to Improving maternal and child health, family planning, and reproductive health, accelerating community nutrition improvement, increased disease control, strengthening the Healthy Living Community Movement (Germas), Strengthening Health Systems, Drug and Food Control. Ministry of Health Strategic (2020-2024) Increasing quality universal health coverage, Improving public health status through a life cycle approach, increasing the culture of healthy living people through community empowerment and health mainstreaming, increased disease prevention and control and management of public health emergencies, increased health resources, improved good governance [3]. Village Community Health Development (PKMD) is an activity carried out by the community, from the community, and for the community. One of the operational forms of community participation or UKBM (community-based health efforts) namely with the posyandu. Posyandu is one of the means in health service efforts carried out by, from, and with the community, to empower the community and provide facilities for the community to obtain maternal and child health, which is the main objective of posyandu. Posyandu's specific goal is to increase community participation in the implementation of primary health care, increasing the role across sectors, and increasing the reach of basic health services [4]. Posyandu is held for the benefit of the community so that the community itself is actively involved in forming, organizing, and making the best use of posyandu. Community participation is needed in utilizing posyandu. In carrying out their duties, previous health cadres will be given the training to support the smooth implementation of activities to improve the nutritional status of children under five [5]. Nationally, the nutritional status of children in various regions in Indonesia is still a problem. The amount of people with malnutrition in the world reaches 104 million children, and malnutrition is the cause of one-third of all causes of child deaths worldwide. Indonesia is among a group of 36 countries in the world that contribute 90% of the world's nutritional problems [6]. Cadres are the central point in implementing posyandu activities. It is hoped that participation and activeness will be able to drive community participation. However, the presence of cadres is relatively unstable because their participation is voluntary, so there is no guarantee that they will continue to carry out their functions properly as expected. If there are family interests or other interests, the posyandu will be abandoned [7]. In 2017, the total of Posyandu in Indonesia was 291,447 but only 164,487 were active with the percentage of active Posyandu 56.57% [8]. In Gorontalo Province in 2017, the highest proportion of Posyandu was Posyandu Madya 48.5%, then Posyandu Purnama 39%, Posyandu Pratama 10.7%, and Posyandu with Independent strata only 1.9%. According to data from the health office of Gorontalo Province, in 2017 the highest of posyandu was in the Gorontalo Regency area, namely 442 posyandu and the least in the Gorontalo City is 128 posyandu [9]. The development of posyandu in Gorontalo Province aims to provide services to the community, especially improving the nutritional status of children under five. Based on data from the Health Office of Gorontalo Provincial. The results of nutritional surveillance through a survey of monitoring nutritional status (PSG) in 2015 in all areas of Gorontalo province involving the Poltekes of the Ministry of Health found that the prevalence of underweight/malnutrition in Gorontalo province is 24.4%, consisting of 18.8% malnourished toddlers and 5.6% malnutrition. Then the prevalence of stunting / short and very short was 36.5% consisting of 22.4% short and very short toddlers and 14.1%. The prevalence of wasting / thin and very thin children was 13.4% consisting of thin children 9.0% and 4.4% very thin. In 2015 the number of cases of malnutrition in Pohuwato Regency reached 105 cases, in 2016 it decreased to 57 cases and in 2017 totaled 57 cases of malnutrition, this shows that there is still a lack of health services provided by health workers and the role of cadres, especially in improving the nutritional status of children under five [9]. From the results of observations in the work area of Puskesmas Patilanggio, there are 21 posyandu with 30 cadres active in implementing posyandu. Although all of them are active, their roles are still not optimal. There are those whose participation is good and those that are lacking. From 30 cadres, it was found that 60% of their roles were motivators, 70% were administrators, and 60% were educators. After the researcher saw the implementation of posyandu activities carried out by cadres based on the implementation of the Vtable system, it did not implement properly. The implementation is limited to table II (weighing) and table III (recording in KMS). The counseling that should be provided by cadres is, in fact, in the field most cadres are still very dependent on health workers. Cadres only weigh children under five and if there is a scale that is less or more, cadres do not provide health education to mothers who bring a toddler. From the results of interviews conducted by researchers with 5 cadres, 2 cadres said that besides being active in implementing the posyandu, the cadres also do house visits to invite mothers with toddlers to come to the posyandu and take time to discuss with mothers who the house is close to each other. Meanwhile, 3 cadres said that their activities were limited to implementing posyandu. Based on the monthly reports of Puskesmas Patillanggio, in March 2020 the total of all toddlers was 120 people, with 1 person with malnutrition status, 23 people deficient nutrition, 1 person over nutrition, and 95 good nutrition. Meanwhile, in the Sukamakmur village in April 2020 the total of all toddlers was 167 people, with a malnutrition status of 15 people, over-nutrition 2 people, and good nutrition 143 people. The background above encourages researchers to research “The Role of Posyandu Cadres in Improving the Nutritional Status of Toddlers in Suka Makmur Village, Patilanggio District. RESEARCH METHODS This type of research is quantitative using a cross-sectional approach with a point time approach design. This research was conducted from June 2020 to August 2020. The location of this research was in Suka Makmur Village, Patillanggio District. The population in this research was mothers who have children aged 1 to 5 years in Suka Makmur village, Patilanggio district, with a total of 167 mothers of children under five. The sampling of this research using the Slovin formula, where the results obtained that the number of samples of 30 mothers who have toddlers 1 - 5 years old adjusted to the number of samples (cadres). Samples were taken by random sampling. The research analysis used univariate and bivariate analysis, where the bivariate analysis used the chi-square statistical test. RESEARCH RESULTS Univariate Analysis Age distribution of respondents Table 1. Distribusi umur responden Mother's age N % 20 - 25 Years 11 36,7 26 – 30 Years 7 23,3 31 – 35 Years 6 20,0 > 36 Years 6 20,0 Jumlah 30 100,0 Source: Processed data (2020) Based on table 1 above, it can be seen that it shows that from 30 respondents (100%), the most respondents were aged 20-25 years as much as 11 people (36.7%). Distribution of respondents' education Table. 2 Distribution of respondents' education Education N % SD SMP SMA Diploma/Sarjana 19 6 3 2 63,3 20,0 10,0 6,7 Total 30 100,0 Source: Processed data (2020) Based on table 2 above, it can be seen that from the 30 respondents (100%), most of them had primary school education as much as 19 respondents (63.3%). Distribution of respondents' work Table 3. Distribution of respondents' work Pekerjaan N % Housewife Entrepreneur PNS 28 1 1 93,3 3,3 3,3 Total 30 100,0 Source: Processed data (2020) Based on table 3 above, it can be seen that from the 30 respondents (100%) the most respondents have IRT jobs totaling 28 people (93.3%). Child sex distribution Table 4. Child sex distribution Jenis kelamin N % Man Woman 11 19 36,7 63,3 Total 30 100,0 Source: Processed data (2020) Based on table 4 above, it can be seen that from the 30 respondents (100%), most respondents were female, as much as 19 people (63.3%). Age distribution of children under five Table 5. Age distribution of children under five Toddler’e Age N % 12 – 18 Month 19 – 26 Month 27 – 43 Month 51 – 60 Month 8 7 10 5 26,6 23,3 33,5 16,6 Total 30 100,0 Source: Processed data (2020) Based on table 5 above, it can be seen that from the 30 respondents (100%), most respondents were aged 27 - 43 months, totaling 10 people (33.5%). Distribution of cadre roles Table 6. Distribution of cadre roles Cadres’ Role N % Poor Good 5 25 16,7 83,3 Total 30 100,0 Source: Processed data (2020) Based on table 6 above, it can be seen that from the 30 respondents (100%), most respondents had a good role as many as 25 people (83.3%). Distribution of Nutritional Status Table 7. Distribution of Nutritional Status Nutrition Status N % Good Poor Fat 26 3 1 86,7 10,0 3,3 Total 30 100,0 Source: Processed data (2020) Based on table 7 above, it can be seen that from the 30 respondents (100%), most respondents with good nutritional status were 26 respondents (86.7%). Bivariate Analysis Table 8. The relationship between cadres of posyandu cadres and nutritional status of toddler Cadres’ Roler Nutrition Status Total Sig. Good Poor Fat Poor Good 3 (10,0%) 23 (76,7%) 1 (3,3%) 2 (6,7%) 1 (3,3%) 0 (0%) 5 (16,7%) 25 (83,3%) p= 0,048 Total 26 (86,7%) 3 (10,0%) 1 (3,3%) 30 (100,0%) Source: Processed data (2020) The results of statistical analysis using the chi-square test at the level of significance á = 0.05 or the confidence interval p <0.05. The results of statistical tests with the Fisher's Exact Test correction obtained p value = 0.048 <á (0.05), thus it can be said that there is a relationship between the role of Posyandu cadres in improving the nutritional status of toddlers in Suka Makmur Village, Patilanggio District. DISCUSSION The Role of Cadre Based on the results of this research, according to the data obtained, it shows that most of the roles of cadres in Suka Makmur Village have a good role, as much as 25 people (83.3%). The results of this research are in line with research conducted by Onthonhie in Sangihe, whose research results found that most of the cadres (86.9%) had carried out their duties well as cadres in carrying out posyandu activities both as motivators, administrators, and educators [10]. The role of cadres is very important because cadres are responsible for implementing the posyandu program. If the cadres are not active, the implementation of posyandu will also not run smoothly and as a result, the nutritional status of infants and toddlers (under five years old) cannot be detected early clearly [11]. The role of cadres as a motivator can improve the quality of Posyandu, especially in handling health problems. Cadres play a role in implementing posyandu activities and mobilizing maternal activity in posyandu activities. Cadres as implementers at posyandu are tasked with filling in the KMS for toddlers. The completeness and correctness of filling in KMS are very important as information on the status of toddler growth and development. If the role of cadres is lacking, monitoring of toddler growth and development will increase [12]. The role of cadres as educators in providing maximum understanding to mothers of toddlers is very much needed for the progress of children's development and nutritional status. The role of cadres as educators, among others, can explain the KMS data for each toddler or the condition of the child based on the weight gain data depicted in the KMS graph, hold group discussion activities with mothers whose houses are close together, and home visit activities [12]. Nutritional status of children under five Based on the results of this research, according to the data obtained, it shows that most of the nutritional status of a toddler in Suka Makmur Village has a good nutritional status of as many as 26 people (86.7%). The factors that influence the nutritional status of a toddler in Suka Makmur village are in terms of good health services and the role of cadres in increasing education of food consumption for toddlers. The results of this research are in line with the research conducted by Onthonie, most of the results (85.2%) had a good nutritional status [10]. The problem of poor nutrition is caused by various causes in children, namely the result of the consumption of bad food so that the energy entering and leaving is not balanced. The body needs good food choices so that nutritional needs are met and the body functions properly [13]. Lack of knowledge of mothers about nutrition results in low spending, food and quality budgets, as well as less food diversity, besides the ability of mothers to apply information about nutrition in their daily life [14]. Nutrition activities in posyandu are one of the main activities and are generally a priority in the implementation of Posyandu activities and are carried out by cadres [15]. The relationship between the role of cadres on the nutritional status of toddler The results of this research indicate that there is a relationship between the role of posyandu cadres in improving the nutritional status of a toddler. This research is in line with the research conducted by Purwanti et al, which states that there is a relationship between the role of cadres and the nutritional status of children under five [16]. Fitriah's research also states that there is a relationship between the role of cadres and the nutritional status of children under five [17]. The duties of cadres in activities at the posyandu are to conduct early detection of abnormalities in under-fives weight, providing additional food, and how to prevent diarrhea in a toddler. Posyandu cadres are health providers that are close to the targeted posyandu activities. The frequency of meeting with cadres is more frequent than other health workers. Therefore, cadres must be active in various activities, not only in implementation but also in management matters such as planning activities, recording, and reporting of cadre meetings [15]. The role of cadres can help the community in reducing the number of malnutrition, besides, role cadres also help in reducing maternal and toddler mortality rates, by utilizing the expertise and other supporting facilities related to improving the nutritional status of a toddler, so it can be concluded that the role of cadres affects the nutritional status of a toddler, If the role of cadres is higher, the rate of reduction of malnutrition among toddler also high [16]. Based on the results of the research above, the researchers assumed that the role of cadres would be better in carrying out their roles in posyandu activities and helping health workers because cadres had the duties and responsibilities to help improve the nutritional health of toddler. Thereby, the role of a good cadre can affect the nutritional status of children where the better the role of the cadres, the higher rate of good nutrition in toddler and can improve the quality of posyandu, especially in handling toddler health problems so that malnutrition can be resolved quickly through prevention and rapid handling. Besides, the role of good cadres tends to motivate mothers of toddlers to always pay attention to things that can improve the nutrition of their children and motivate mothers to routinely bring toddlers to posyandu to monitor their health. In this research using anthropometric indicators of weight/height because height can provide an overview of the growth function seen from the thin and short stature and height is also very good for seeing past nutritional conditions, especially those related to low birth weight and underweight conditions and nutrition in toddlerhood. Height is expressed in the form of Index TB / U (height for age), or also index weight/height (weight for height) is rarely done because changes in height are slow and usually only done once a year. CONCLUSION The role of cadres in Suka Makmur Village, Patilanggio District is mostly cadres who have a good role. The nutritional status of toddlers in Suka Makmur Village, Patilanggio District has increased with good nutritional status. There is a significant relationship between the role of Posyandu cadres in efforts to improve nutritional status, the better the role of cadres, the better the reduction in malnutrition in a toddler in Suka Makmur village, Patilanggio district. Therefore, it is hoped that cadres will further improve their knowledge and skills by attending regular meetings at every meeting held by the Puskesmas, to further improve themselves in participating actively in posyandu programs. REFERENCES [1] Kemenkes RI. 2012 Pusat Promosi Kesehatan Tahun 2012 tentang Buku Saku Posyandu. [2] Adisasmito W, 2016. Sistem Kesehatan. [3] Kemenkes RI. 2020. Rencana Strategis Kementerian Kesehatan Tahun 2020 - 2024. Jakarta [4] Kemenkes RI. 2013. Laporan Akuntabilitas Kinerja Kementerian Kesehatan. Jakarta. [5] Depkes RI. 2012. Buku Paket Pelatihan Kader Kesehatan. Jakarta. [6] World Health Organization. The Global Burden Of Disease : Geneva: WHO Library. [7] Syafei, A. 2010. Faktor – Faktor Yang Berhubungan Dengan Partisipasi Kader Dalam Kegiatan Gizi Posyandu Di Kelurahan Rengas Kecamatan Ciputat Timur Kota Tangerang Selatan. Jakarta: Universitas Islam Negeri Syarif Hidayatullah [8] Kemenkes RI. 2018. Data dan Informasi Profil Kesehatan Indonesia 2017. Jakarta [9] Dinas Kesehatan Provinsi Gorontalo. 2017. Profil Kesehatan Provinsi Gorontalo. [10] Ontonhie. 2014. Hubungan Peran Serta Kader Posyandu dengan Status Gizi Balita di Wilayah Kerja Puskesmas Manganitu Kabupaten Kepulauan Sangihe. E-Journal Keperawatan. Program Studi Ilmu keperawatan Fakultas Kedokteran Universitas Samratulangi. [11] Isaura, V. 2011. Faktor – Faktor Yang Berhubungan Dengan Kinerja Kader Posyandu Di Wilayah Kerja Puskesmas Tarusan Kecamatan Koto XI Tarusan Kabupaten Pesisir Selatan. Padang: Universitas Andalas [12] Anondo. 2007. Kualitas Kader Rendah, Peran Posyandu Melemah [13] Almatsier. 2009. Prinsip Dasar Ilumu Gizi. Jakarta. [14] Ernawati A., 2006. Hubungan Faktor Sosial Ekonomi, Higiene Sanitasi Lingkungan, Tingkat Konsumsi dan Infeksi dengan Status Gizi Anak Usia 2-5 tahun di Kabupaten Semarang Tahun 2003. Tesis. Universitas Diponegoro. [15] Wahyutomo, A. H. 2010. Hubungan Karakteristik Dan Peran Kader Posyandu Dengan Pemantauan Tumbuh Kembang Balita Di Puskesmas Kalitidu-Bojonegoro. Surakarta: Universitas Sebelas Maret [16] Purwanti, D., Pajeriaty., & Rasyid, A. 2014. Faktor Yang Berhubungan Dengan Status Gizi Balita Di Wilayah Kerja Puskesmas Madello Kabupaten Barru. Jurnal Ilmiah Kesehatan Diagnosis Volume 5 Nomor 1 [17] Fitriah, R. 2012. Faktor – Faktor Yang Berhubungan Dengan Peningkatan Gizi Balita Di Wilayah Kerja Puskesmas Dasan Cermen Kecamatan Sandubaya. Mataram: Politeknik Kesehatan.

Post-transplant diabetes mellitus (PTDM) is a common problem among solid organ transplant recipients contributing to morbidity and affecting patient as well as graft survival adversely. It can occur at any period following transplantation, but maximum incidence is observed in the first few months, with a second peak after a few years after transplantation. The pathogenesis is complex and poorly understood, however, it is associated with both dysfunctional beta-cells and insulin resistance. Both nonpharmacologic and antidiabetic therapies are important for adequate glycemic control. This point of view article provides a short review on PTDM in solid organ transplantation (SOT) recipients from a general physician’s perspective. Solid organ transplantation is currently the best choice of treatment for most patients suffering from end-stage organ failure. Successful organ transplantation offers enhanced quality and duration of life with lower morbidity and mortality. Innovations in SOT, advances in surgical techniques, progress in immunosuppressive regimens, and critical care have greatly improved both the patient and graft survival in last several decades. The discovery of calcineurin inhibitors (CNIs) represents a milestone event in the history of immunosuppression and it has revolutionized transplant medicine; further breakthrough in immunosuppressive regimens is the cornerstone for existing successful transplant program. The current 5-year graft survival is about 80% for kidney and heart transplants, and 70% for liver and lung transplants (UNOS-OPTN and SRTR registry data). Cardiovascular disease (CVD), infections, and drug toxicity play an important role in the long-term morbidity and mortality of this patient population. This risk is not only due to presence of underlying pre-existing comorbidities, but also results from adverse effects of the immunosuppressive drugs such as hypertension, dyslipidemia, and PTDM. The risk of PTDM after SOT varies from 10 to 40% during the first 1 year. This risk depends on several factors including the type of transplanted organ [10–20% of kidney transplant recipients (KTRs) and 20–40% of patients with heart, liver, and lung transplants]. Post-transplant diabetes mellitus is widely studied in KTRs, but the risk factors and pathophysiology seem to be similar in all kinds of SOT. Post-transplant diabetes mellitus [previously termed, new-onset diabetes mellitus after transplantation (NODAT)] results in a remarkable proportion of SOT recipients and contributes to increased risk of CVD and infections, leading to significant mortality and morbidity. The pathogenesis is complex and poorly understood, however, it is associated with both dysfunctional beta-cells as well as reduced sensitivity to insulin. Consensus guidelines and proceedings from international consensus meeting on PTDM updated its recommendations in 2014, preferred to call it as PTDM rather than NODAT, as few patients could have undiagnosed diabetes prior to transplantation. New-onset diabetes mellitus after transplantation simply indicates exclusion of pretransplant diabetes and it is found that around 10% of KTRs have undetected diabetes prior to transplantation.1 Hence, PTDM represents timing of diagnosis in post-transplant period rather than time of occurrence of disease. The gold standard method to diagnose PTDM is the oral glucose tolerance test (OGTT). Post-transplant diabetes mellitus typically presents with postprandial hyperglycemia [impaired glucose tolerance (IGT)] rather than impaired fasting glucose (IFG). International consensus guidelines for PTDM recommend standard diagnostic criteria by American Diabetes Association (ADA) and World Health Organization (WHO) for the diagnosis of PTDM and these are almost same as to those used for type II diabetes mellitus (T2DM) in the general population with few exceptions (Table 1).2 Following transplantation, there is increased turnover of red blood cells due to perioperative blood loss and regain of renal function in case of kidney transplantation with normal erythropoietin production. The immunosuppressant drugs can have a negative effect on red cell proliferation in the bone marrow. Hence the glycated hemoglobin (HbA1c) can be erratic and accurate interpretation is not possible in the first 2–3 months, and is not a recommended test to identify PTDM in early post-transplant period. After 3 months post-transplant, HbA1c is reliable and ADA cut-off can be followed to diagnose PTDM. As per ADA guidelines, “prediabetes” is diagnosed with OGTT if fasting plasma glucose is 100–125 mg/dL (IFG) or 2-hour plasma glucose is 140–199 mg/dL (IGT). American Diabetes Association and WHO criteria differ with respect to normal ranges of fasting plasma glucose. American Diabetes Association criteria are more sensitive in detecting transplant candidates at risk for PTDM as its threshold value is lower.3 Impaired fasting glucose is diagnosed if fasting plasma glucose is ≥100 mg/dL by the ADA and ≥110 mg/dL by the WHO. Oral glucose tolerance test is more sensitive for detecting prediabetes as IGT is more commonly seen than IFG. The incidence of PTDM is higher in the first year, with a second peak after a few years following transplantation. Early peak is usually the result of metabolic adverse effects of immunosuppressive drugs, whereas late peak is due to post-transplant weight gain, obesity, metabolic syndrome, and insulin resistance. There is a great variability in the prevalence and incidence rates in the published literature. This is due to differences in the proposed diagnostic criteria, definitions used, organs transplanted, timing from transplantation, follow-up duration, population genetics, geographical differences, immunosuppressive drug regimens, and other risk factors. The prevalence of PTDM varied from 15 to 55% in the literature.4–8 It is identified that up to one-third of nondiabetic KTRs develop impaired glucose metabolism by 6 months following transplantation. Currently, the prevalence of PTDM appears to be reducing, mainly due to use of lower doses of immunosuppressive drugs targeting lower trough levels to prevent drug toxicity.9 Transient hyperglycemia is highly prevalent in the early post-transplant period; it can be identified in ~90% of KTRs in the first few weeks. It can result from use of higher doses of immunosuppressive drugs, antirejection therapy, stress, infections, sepsis, and other critical conditions. While detecting transient post-transplantation hyperglycemia is crucial as it is a predisposing factor for consequent PTDM, universally labeling all of them as PTDM in the early post-transplant setting is not acceptable. The diagnosis of PTDM should be delayed until the recipient is clinically stable, with stable allograft function, and is on lower doses of immunosuppression without acute infections. To avoid overdiagnosis, few authors proposed to define PTDM as a long-term (usually more than 3 months) need for antihyperglycemic therapy. The common predisposing factors for the occurrence of PTDM are side effects of immunosuppression and their effect on glucose metabolism, infections especially due to certain viruses, and hypomagnesemia, along with traditionally identified predisposing factors seen with T2DM (Table 2). Risk factors for PTDM should be analyzed during the pretransplant period to prevent or delay the development of PTDM. Some of these include older age, high-risk race or ethnic groups, obesity or metabolic syndrome, prediabetes prior to transplant, gestational diabetes, first degree relative with diabetes, nonalcoholic steatohepatitis, polycystic kidney disease, higher human leukocyte antigen (HLA)—mismatches, acute rejection episodes, cadaver donor, cytomegalovirus (CMV) and hepatitis C virus (HCV) infections, and use of immunosuppression.8 Induction with basiliximab may predispose patients to PTDM as concluded in a study from North India.10 Glucocorticoids induced PTDM seems to be dose-dependent. It is characterized mainly by insulin resistance and higher postprandial blood glucose levels. Although, it could be dose-dependent, there is no evidence that steroid withdrawal prevents or reduces PTDM incidence.11,12 Calcineurin inhibitors have toxic effect on islet cells of pancreas and alter insulin secretion pattern.13 Calcineurin inhibitors by causing hypomagnesemia, precipitate PTDM. Diabetes Incidence after Renal Transplantation: Neoral C Monitoring Versus Tacrolimus (DIRECT) study observed a greater risk of PTDM with tacrolimus than cyclosporine (CsA).14 In the Efficacy Limiting Toxicity Elimination (ELITE) study, low-dose tacrolimus (8.4%) was more diabetogenic at 1 year than standard-dose CsA (6%), low-dose CsA (4.2%), and low-dose sirolimus (6.6%).15 Various meta-analyses also concluded that tacrolimus is more diabetogenic than CsA.16,17 Mammalian target of rapamycin (mTOR) inhibitors such as sirolimus can also induce PTDM. Conversion from one of the CNIs (either tacrolimus or CsA) to sirolimus resulted in worsening of glycemic control and insulin resistance as shown in a study.18 Antimetabolites such as mycophenolate mofetil (MMF) and azathioprine seem to be nondiabetogenic and may not contribute to the pathogenesis of PTDM. The combination immunosuppressive drug regimens were assessed in some s t u d i e s . O n e s t u d y f o u n d t h a t t h e combination of CNI and sirolimus has a greater risk of PTDM than the combination of CNI and MMF.19 Some other drugs such as renin-angiotensin-aldosterone system (RAAS) blockers [angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB)], co-trimoxazole and statins may reduce the risk of PTDM.20,21 Hepatitis C virus infection was associated with almost fourfold higher risk of acquiring PTDM than those who were not infected in a meta-analysis among KTRs. 22 The pathogenesis of HCV-induced PTDM seems to be multifactorial including abnormal glucose metabolism, insulin resistance, and beta-cell dysfunction. Anti-HCV treatment and sustained virological remission in pretransplant period may prevent the development of PTDM. A large North Indian retrospective study compared long-term outcomes of HCV-infected and noninfected KTRs and concluded greater risk of PTDM in the HCV-infected group (~40 vs 19%). In the same study, anti-HCV therapy was given to all infected recipients before transplantation.23 Hepatitis C virus-associated PTDM is usually noticed in liver transplant recipients, especially in cases with hepatic steatosis. Association of PTDM with CMV infection is unclear. There was a fourfold greater risk of PTDM in patients with asymptomatic CMV infection in a study.24 Prediabetes before transplantation can predispose to PTDM. A percentage of 35% of KTRs with PTDM had pretransplant IGT in one study.25 Risk adaptive approach and tailoring of immunosuppression seems to be the fundamental concept to delay and prevent the occurrence of PTDM, especially in those with greater risk for PTDM. Transient hyperglycemia is widely prevalent in early post-transplant period; though it can predispose the recipient to PTDM, it should not be considered as an expression of PTDM. The contribution of transient hyperglycemia to the risk of PTDM was assessed in the past. Around 29% of recipients with postoperative transient hyperglycemia progressed to develop PTDM within 1 year, in a study.26 In another similar study, 46.7% of recipients with early transient hyperglycemia developed PTDM. There was a fourfold higher risk of PTDM in patients with transient hyperglycemia.27 Post-transplant diabetes mellitus, due to its predisposition to infections and CVD, adversely affects graft and overall patient survival. Cardiovascular disease is the most common cause of death and poor patient survival in SOT recipients, and PTDM has a correlation with CVD mortality.28 There is also an adverse effect of PTDM on graft survival independent from excessive mortality. Various factors implicate in death-censored graft loss due to PTDM. Some of these include development of de novo diabetic nephropathy in the renal allograft, excessive risk for infections such as pneumonia, urinary tract infection, and viral infections including CMV.29 Also it could be due to reduced immunosuppression for glycemic control resulting in excessive risk for graft rejection and ultimately graft loss. The treatment of PTDM should be multidisciplinary as it predisposes to various complications including CVD and it is usually associated with other post-transplant complications. The risk for PTDM needs to be assessed during pretransplant assessment by taking thorough history, physical examination, evaluating for metabolic syndrome and prediabetes, and assessing for any other associated cardiovascular risk factors. All SOT recipients should be closely monitored for glycemic control postoperatively while on immunosuppression. Generally, blood sugars are monitored at regular intervals such as every week for initial 4 weeks, then at 3 and 6 months, and annually thereafter. Glycated hemoglobin is not reliable in early post-transplant period, but can be advised 3 months after transplant. Stringent glycemic control is not advisable in majority of SOT recipients as they are at high risk for CVD. Hence, management should target at achieving fair control of blood sugars to near normal glycemic targets without increasing risk for hypoglycemia. Glycated hemoglobin target of <7.5% is acceptable in majority, especially in elderly and those who have CVD. Treatment includes both nonpharmacological and antidiabetic therapies. Diet, exercise, lifestyle modification, control of obesity, and weight reduction constitute main components of nonpharmacologic therapy. Along with PTDM, control of hypertension, dyslipidemia, and other cardiovascular risk factors is also crucial to reduce CVD risk. Kidney Disease: Improving Global Outcomes (KDIGO) and other guidelines suggest statin therapy to all cardiac and renal SOT recipients. For liver and lung transplant recipients, statin therapy should be individualized. The risk of rejection should be analyzed and must be weighted for the potential usefulness of modifying immunosuppression for glycemic control. The doses of glucocorticoids can be cut down, however complete withdrawal can precipitate rejection. Tacrolimus to CsA switching can be considered in patients with PTDM refractory to therapy despite reduction in doses of tacrolimus targeting lower trough levels. In one North-Indian randomized open-label prospective study involving KTRs, there was significant control of PTDM in CsA switching arm vs tacrolimus continuation arm.30 Another randomized controlled trial (RCT) in KTRs also showed easy reversal of PTDM at 12 months after switching from tacrolimus to CsA in comparison with continued treatment with tacrolimus.31 Switching to sirolimus in PTDM is not advisable as it may further aggravate glycemic control. Most patients in initial few months require insulin therapy with or without OHA (single drug or combination OHAs). The preferred therapy for initial few weeks following transplantation is insulin. Intensified therapy with basal insulin-containing regimen for initial few months showed to reduce the risk of development of PTDM at 12 months after transplantation probably due to beta-cell protection mediated by early insulin therapy.32 The concept of “beta-cell rest” was proposed which states that early insulin therapy preserves beta-cell function over the long term. The principle is that early insulin therapy prevents glucotoxicity and stimulation of vulnerable beta-cells whereas OHAs induce overstimulation of beta-cells causing their exhaustion. Oral hypoglycemic agents might be preferred after first 1–2 months of transplantation, and this sequence of therapy (insulin followed by oral agents) is the converse of what is recommended in the management of T2DM. Most of the SOT recipients requiring insulin might not need it after the early post-transplant period. Conversion to oral agents is usually successful when the daily need for insulin dose is less than 20 units. Among OHAs, biguanides (metformin), sulfonylureas, m e glitinides, gliptins [dipeptidyl peptidase-4 (DPP-4) inhibitors], and thiazolidinediones (pioglitazone) have been evaluated for treatment of PTDM in SOT recipients. These are found to be safe and effective with no significant interaction with the immunosuppressive drugs. These classes of OHAs are the preferred agents currently for the treatment of PTDM. Some of the oral drugs need renal dose modification as per glomerular filtration rate (GFR) level. A significant proportion of long-term SOT recipients who are on CNIs develop nephrotoxicity with a drop in GFR level from baseline. Metformin is an age-old drug for management of T2DM. It is considered as first-line drug, especially in patients with obesity and insulin resistance. It can precipitate lactic acidosis in high-risk subgroup of patients, especially in the presence of renal dysfunction. Majority of the reported cases of lactic acidosis have been identified in patients who were already on RAAS blockers (ACEI or ARB) in the presence of renal dysfunction. It can be initiated safely in patients with an estimated glomerular filtration rate (eGFR) up to 45 mL/min/1.73 m2 . It is not recommended to start metformin once eGFR is less than 45 mL/min/1.73 m2 and is currently contraindicated if eGFR of <30 mL/min/1.73 m2 , although data are emerging on its metabolic benefits even in patients with advanced CKD. Due to its safet y concerns, it is necessary to monitor renal function closely while on metformin therapy. It can also aggravate gastrointestinal (GI) side effects of immunosuppressive drugs. Gliclazide, glipizide, and glimepiride are preferred among sulfonylureas in patients with renal dysfunction. Meglitinides, such as repaglinide, due to their short duration of action, may be preferred over sulfonylureas in the presence of low GFR as the latter drugs are associated with significant risk of hypoglycemia. However, there are no strong data supporting the use of repaglinide or nateglinide among SOT recipients, as the studies performed were short-term. But they were considered safe and efficacious. Dipeptidyl peptidase-4 inhibitors or gliptins inhibit DPP-4 enzyme which is responsible for degradation of endogenous incretins leading to restoration of insulin secretion and inhibition of glucagon release. They are weight neutral (do not induce weight gain), have glucose-dependent action with lesser risk for hypoglycemia, and are considered to be safe along with immunosuppressive drugs due to least interactions. They may be considered as the potential first-line OHAs to manage PTDM. The studies performed on the available gliptins such as sitagliptin and vildagliptin are of small sample size with short-term follow-up, however, they documented their safety and efficacy in SOT recipients. In T2DM, long-term safety data are available for sitagliptin but not for vildagliptin.33 Vildagliptin was considered as safe and effective in KTRs as concluded in a double-blind RCT.34 There is some drug interaction between sitagliptin and CNIs especially CsA with regard to prolongation of QT interval in the combination group. Linagliptin was found to be safe and effective for PTDM management as concluded in one Indian study. As it is nonrenally eliminated, it does not require dose adjustment in renal failure.35 Thiazolidinediones are considered as the last resort of therapy in SOT recipients with PTDM due to their side effect profile as these patients generally suffer from multiple comorbidities. These drugs can worsen post-transplant mineral bone disease and bone loss, precipitate congestive heart failure, and lead to anemia, fluid overload, and weight gain. Drug interaction with CNIs is observed as they predispose to CNI toxicity. Alpha-glucosidase inhibitors such as acarbose and miglitol are not recommended if eGFR is <30 mL/min/1.73 m2 and they can aggravate GI side effects of MMF. Incretin mimetics [glucagon-like peptide 1 (GLP1) receptor agonists] such as exenatide, liraglutide, lixisenatide, and semaglutide, have not been evaluated for their safety in SOT recipients except for a few small studies. Physicians should be cautious against using GLP1 receptor agonists due to risk of GI tract side effects and precipitation of prerenal acute kidney injury in SOT recipients having GFR <30 mL/min/1.73 m2 . Recent clinical trials with GLP1 receptor agonists in nontransplant population showed their potential benefit on adverse cardiovascular as well as renal outcomes in high-risk CVD patients; the data in SOT recipients are still awaited. The data are emerging for the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors in SOT recipients with PTDM. Important drugs include canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin. They have been evaluated in large clinical trials in nontransplant population and found to significantly reduce the risk of major adverse cardiovascular and renal outcomes. They are now considered as first choice therapies for both cardiovascular and renal protection in patients with heart failure with reduced ejection fraction, diabetic kidney disease, and proteinuric nondiabetic kidney diseases, and this benefit was observed irrespective of presence of diabetes. Their efficacy and safety in patients with kidney and other SOT recipients are not known as these patients were excluded from large clinical trials. The only concern with these drugs is increased predisposition to genital, fungal and lower urinary tract infections, and this could be life-threatening in immunosuppressed SOT recipients. The antihyperglycemic effect of these drugs diminishes once GFR is <60 mL/min/1.73 m2 and is practically nil at GFR <30 mL/min/1.73 m2 . In an RCT that included KTRs with PTDM who were randomized to either SGLT2 inhibitor or placebo found that empagliflozin is safe and efficacious for treatment of PTDM, and moderate weight loss was also observed in the treatment arm.36 A pilot study from India also concluded that canagliflozin use resulted in better glycemic control with lower HbA1c level, body weight, and blood pressure reduction. The requirement of other OHAs was also reduced, with no adverse effects including hypoglycemia in the treatment arm.37 There is an immense need for a large-scale intervention trials in SOT recipients with PTDM with these newer hypoglycemic agents, that is, GLP1 receptor agonists and SGLT2 inhibitors that have been proved to have pleiotropic benefits and lower major adverse cardiovascular and renal events in high-risk patients with T2DM.

Introduction: People experiencing unsheltered homelessness (PEUH) have higher disease burden yet limited access to healthcare. COVID-19 introduced even greater risk for PEUH aged 65+ years with an underlying chronic health condition and were temporarily housed in hotels/motels for Project RoomKey (PRK). This study aimed to characterize a PRK cohort who received primary care from a street medicine program. Methods: This observational case series study included a sample of 35 PRK participants receiving primary care from a street medicine team at a single site from July to September 2020. We used the HOUSED BEDS assessment tool for taking history on PEUH. Results: Participants were 63% male, 40% Hispanic/Latino/a, 40% white, 94% English-speaking, and 73% had chronic health conditions. Assessment revealed: average Homelessness (H) of 4 years; 76% had no prior social service Outreach (O); average Utilization (U) was 4 emergency department visits in prior 6-months; 68% received Salary (S) from government income; Food access or Eat (E) was commonly purchased (29%) or donated (26%); clean water to Drink (D) for 59% of participants; 86% had access to a Bathroom (B); Encampment (E) was varied and 38% reported safety concerns; Daily routine (D) showed 76% could access a telephone, 32% received social support from family; 79% reported past or current Substance use (S). No participants contracted COVID-19 during study period. Conclusions: This study describes health and demographic characteristics of PRK participants in Southern California. Findings inform policies to continue PRK that includes onsite healthcare such as via street medicine.

Background: There is a need for oral health awareness among future clinicians and for dental services for homeless men. This quality improvement project aimed to: 1) improve oral health knowledge among physician assistant (PA), medical, and undergraduate student clinic managers; 2) determine the oral health needs of homeless men; and 3) establish a dental referral program for patients at a student-run free clinic.Methods: The project was conducted at a student-run free clinic embedded in a men’s homeless shelter in Dallas, Texas. Student managers underwent a training program that included a PowerPoint presentation and practice oral exams. Pre- and post-tests were used to assess their knowledge of different oral health topics. Patients of the clinic were surveyed for dental concerns at intake, and oral exams and referrals to a student-run dental clinic were done if indicated.Results: Student clinic managers (N=16) demonstrated improved knowledge on the recognition and treatment of some but not all dental conditions. Of the patients surveyed (N=13), most reported a history of dental caries (77%), had loose or missing teeth (62%), and brushed their teeth <2 times per day (69%). Although 65% of patients were referred to the dental clinic, only 9% went to their appointment.Conclusions: The manager training provided additional information and experience for clinic managers around oral health. The increased awareness made it easier for clinic managers to refer appropriate patients to the dental clinic. The newly implemented referral service provided a resource for the clinic to send patients that warrant higher level of dental care.

A new management method in the public health care system is project management. A i m . Improving the quality of medical care in a public health care institution for patients with neurological disorders of the face through organizational measures using project management. M a t e r i a l s a n d m e t h o d s . The state medical organization has implemented an original program of assistance to patients with neurological disorders in the face in several stages. Used project management. There was no restructuring of medical departments or hiring of new employees. R e s u l t s . At the Sklifosovsky Research Institute, in total for the period 2021–2022, 865 offline (over the year, the growth rate of consultations increased by 2.5) and 48 online consultations with neurologists were conducted, there were 139 MRIs, 180 electrodiagnostic procedures, surgical treatment was performed on 101 patients, and 161 botulinum therapy procedures were performed. Scientific research included the development of protocols for magnetic resonance imaging and electrodiagnostics, an algorithm for making decisions about surgical care was described, and new methods of physical rehabilitation were proposed. 28 scientific articles were published, the results were reported at scientific and practical conferences and congresses. A team of specialists has developed a postgraduate educational program. Provided patient education. The Face Clinic project is recognized as socially important. C o n c l u s i o n s . For a specific group of patients, in order to quickly achieve results, it is better to organize work through project management. It is necessary to teach doctors management tools.

In the healthcare system in Russian Federation, in recent decades, standards of medical care have been formed, which are tabular forms indicating medical services, medicines, medical devices implanted in the human body, blood components and clinical nutrition (components), indicating average frequency indicators. P u r p o s e – a comparative analysis of the standards of medical care for adults in the oncology profile, approved by orders of the Ministry of Health of Russia in the period from 2012 to 2018, and the standards developed on the basis of clinical guidelines and approved in the period from 2019 to 2022, with a view to the possibility of planning a state guarantee program based on them. M a t e r i a l s a n d m e t h o d s . The comparison was performed by comparing the standards of medical care in the context of types of medical care, the conditions for providing medical care, localizations and nosological forms according to ICD‑10 blocks, types of medical interventions and assessing consistency with planning units of the state guarantees program. R e s u l t s . The standards of medical care in the oncology profile, approved in the period from 2012 to 2018, were developed in the context of the types of medical interventions and were not coordinated either with the planning units of the state guarantees program or with the methods of payment by diagnosis-related group. The introduction of a methodology for the formation of standards of medical care based on clinical guidelines using standardized modules of medical care made it possible to revise the principle of the formation of standards for the oncology profile and harmonize them with the planning units of the state guarantees program and methods of payment by diagnosis-related group. F i n d i n g s . Structuring the process of developing medical care standards based on clinical guidelines and developing a methodology for their formation makes it possible to realize the economic function of medical care standards.

Abstract Background Compared to the general population, individuals experiencing homelessness are at greater risk of excess morbidity and mortality from COVID-19 but have been vaccinated at lower rates. The U.S. Department of Veterans Affairs (VA)’s Homeless Patient Aligned Care Team (HPACT) program integrates health care and social services for Veterans experiencing homelessness to improve access to and utilization of care. Methods This study explores the vaccination uptake behavior and attitudes through a qualitative comparative case study of two HPACT clinics, one in California (CA) and one in North Dakota (ND). Semi-structured telephone interviews were conducted with Veterans enrolled in the two VA HPACT clinics from August to December 2021 with 20 Veterans (10 at each clinic). Results Four themes emerged from the interviews: (1) Vaccination uptake and timing— While half of the Veterans interviewed were vaccinated, ND Veterans were more likely to be vaccinated and got vaccinated earlier than CA Veterans; (2) Housing— Unsheltered or precariously housed Veterans were less likely to be vaccinated; (3) Health Care— Veterans reporting positive experiences with VA health care and those who trusted health providers were more likely to vaccinate than those with negative or nuanced satisfaction with health care; (4) Refusers’ Conspiracy Theories and Objectivity Claims— Veterans refusing the vaccine frequently mentioned belief in conspiracy theories while simultaneously asserting their search for objective information from unbiased sources. Conclusions These findings amplify the importance of improving access to population-tailored care for individuals experiencing homelessness by reducing patient loads, expanding housing program enrollment, and increasing the provider workforce to ensure personalized care. Health care providers, and housing providers, social workers, and peers, who offer information without discrediting or criticizing Veterans’ beliefs, are also key to effectively delivering vaccine messaging to this population.

Objective This study aimed to assess trends and correlates of severe maternal morbidity at delivery among active duty women in the U.S. military, all of whom are guaranteed health care and full employment. Study Design Linked military personnel and medical encounter data from the Department of Defense Birth and Infant Health Research program were used to identify a cohort of delivery hospitalizations among active duty military women from January 2003 through August 2015. Cases of severe maternal morbidity were identified by applying 21- and 20-condition algorithms (with and without blood transfusion) developed by the Centers for Disease Control and Prevention. Rates (per 10,000 delivery hospitalizations) were reported overall and by specific condition. Multivariable Poisson regression models estimated associations with demographic, clinical, and military characteristics. Results Overall, 187,063 hospitalizations for live births were included for analyses. The overall 21- and 20-condition severe maternal morbidity rates were 111.7 (n = 2089) and 37.4 (n = 699) per 10,000 delivery hospitalizations, respectively. The 21-condition rate increased by 184% from 2003 to 2015; the 20-condition rate increased by 40%. Compared with non-Hispanic White women, the adjusted 21-condition rate of severe maternal morbidity was higher for Hispanic (adjusted rate ratio [aRR] = 1.28, 95% confidence interval [CI]: 1.13–1.46), non-Hispanic Black (aRR = 1.34, 95% CI: 1.21–1.49), Asian/Pacific Islander (aRR = 1.35, 95% CI: 1.13–1.61), and American Indian/Alaska Native (aRR = 1.39, 95% CI: 1.06–1.82) women. Rates also varied by age, clinical factors, and deployment history. Conclusion Active duty U.S. military women experienced an increase in severe maternal morbidity from 2003 to 2015 that followed national trends, despite protective factors such as stable employment and universal health care. Similar to other populations, military women of color were at higher risk for severe maternal morbidity relative to non-Hispanic White military women. Continued surveillance and further investigation into maternal health outcomes are critical for identifying areas of improvement in the Military Health System. Key Points

Advance care planning (ACP) is a conversation about values, future treatment choices, and designation of a surrogate decision-maker, held in advance of a health crisis. ACP protocols are established by home health agencies (HHAs) to support the staff in talking about patients’ future treatment choices, which can include opting against acute care use. In 2016, Medicare implemented an experimental incentive program called Home Health Value-Based Purchasing (HHVBP) in 9 regionally representative states. These agencies were required to compete on value, where reimbursement rates were tied to outcomes in a Total Performance Score (TPS). With home health’s aim of avoiding unplanned acute care use, in-patient hospitalization was weighted the heaviest as a poor outcome, followed by emergency department (ED) use. The purpose of this quasi-interventional study was to determine the relationship between advance care planning protocols and ED use among HHAs in the U. S. by the status of participation HHVBP intervention group. The Advance Care Planning Protocol (ACPP) score was measured by scoring survey questions. Our findings show (1) ACPP score intensity was higher in states that participated in the HHVBP program; (2) high measurement reliability for the ACPP scores; (3) no significant relationship between ACPP and ED use overall; but (4) the relationship between ACPP intensity and ED use was equal-and-opposite for the HHVBP and non-HHVBP groups. These findings suggest that the HHVBP intervention altered the influence of ACPP intensity on ED use. Recommendations are made for the HHVBP program regarding ACP’s role in goal-concordant care.

BEATdiabetes is based on Joslin Diabetes Center’s Why WAIT program, a 12-week program designed to help improve weight and diabetes glycemia, incorporating structured diet, learning sessions and individualized exercises. The Why WAIT program has demonstrated effectiveness virtually. Endpoints included weight, BMI, and A1c. The program employed a version of BEATdiabetes app (developed by Healthimation Inc®, licensed by Nemaura Medical) and utilized gamification to engage users. In addition, participants shared 2-hour, weekly virtual visits to review food logs, exercise sessions, and CGM data with diabetes medications adjusted accordingly. This initial pilot study uses the BEATdiabetes app and seeks to identify if results can be replicated in a real-world environment (RWE) without virtual visits, CGM data and program medication adjustment. The APRN, CDCES live coach had phone calls with users weekly for the first 4 weeks, then 4-week intervals for the next 8 weeks with more touchpoints available (emails, in-app chat, phone calls) . Self-reported endpoints showed users remained engaged utilizing the app 70/84 days, completed 74% of 7 daily tasks, and positively received education, resulting in weight loss, reduction in BMI and waist circumference, and improvement/maintenance in glycemia all during the holiday season. Based upon pilot study learnings changes were identified for next steps in RWE. Disclosure S. L. Horvat: Consultant; Nemaura Medical, Employee; W5 Insights, LLC. L. M. Novak: Advisory Panel; Novo Nordisk, Provention Bio, Inc., Xeris Pharmaceuticals, Inc., Consultant; Abbott Diabetes, Novo Nordisk, Xeris Pharmaceuticals, Inc., Speaker’s Bureau; Abbott Diabetes, Eli Lilly and Company, Novo Nordisk, Xeris Pharmaceuticals, Inc. V. Valentine: Advisory Panel; Abbott Diabetes, Xeris Pharmaceuticals, Inc., Consultant; Nemaura, Pendulum, Zealand Pharma A/S, Speaker’s Bureau; Lilly Diabetes. B. P. Childs: Consultant; W5 Insight LLC, Other Relationship; Sanofi-Aventis U. S., Research Support; Abbott Diabetes. R. Barry: Consultant; W5 Insights, LLC. J. Warner: Consultant; Nemaura Medical, Tandem Diabetes Care, Inc.

Aim: After periodic implementation of the Home and sELf care Program (HELP, a pilot project supported by the ministry of health and welfare of the Korean government) in patients with T1DM, we evaluated the long-term effects on glycemic control. Methods: We included 120 T1DM patients aged 15 years or older. Structured educations, including physician consultation as well as nursing and nutrition education, were provided to the subjects up to four times a year, and remote support using digital apps and phones was provided between educations. Patients were followed up at average intervals of 2 to 4 months, up to a maximum of 24 months. The primary endpoint was mean HbA1c of subjects at f/u visit. Results: Patients who received at least one structured education had a mean HbA1c reduction of more than 1.0% from baseline, even after adjusting for confounders [%, from 8.52 ± 2.11(SD) to 7.31 ± 1.20 at 1st f/u visit (p &lt; 0.001); 7.42 (after adjustment, 7.29-7.54, 95% CI), from 8.50 ± 2.12 to 7.37 ± 1.32 at 7th f/u visit (p &lt; 0.001); 7.42 (after adjustment,7.31-7.53, 95% CI)]. TIR was maintained at least 55% or more on average for 24 months, and TBR (70 & 54) also gradually improved to the recommended range (&lt;5% & &lt;1%, 18 - 24 moths). Conclusion: The effect of HELP on glycemic control in patients with T1DM was found to be a significant improvement, as well as an improvement in CGM-based indices. Disclosure D. Koo: None. L. Dayeon: None. J. Ko: None. S. Moon: None. C. Park: None.

Introduction & Objective: Patients with type 2 diabetes (T2D) have an increased risk of sustaining a fracture, and risks of nonunion, impaired fracture healing, and post-fracture complications are higher in T2D. It is largely unknown how T2D affects the cost of fractures. This study aims to estimate the cost of fractures in T2D compared to persons without diabetes, and secondly to analyze potential drivers of fracture costs. We hypothesized that cost of fractures in patients with T2D are higher than in the nondiabetic background population. Methods: This study analyses patients in Denmark aged 18+ with a hip, humerus, forearm, foot, or ankle fracture in the period 2011-2015. Persons with polycystic ovary syndrome (PCOS), with other types of diabetes, with T2D diagnosed after fracture, and persons emigrating within the follow-up period were excluded. Patients with T2D were matched with patients without diabetes based on fracture site, sex, age, and Charlson Comorbidity Index (CCI) Score. The direct healthcare costs of fractures for T2D and controls were estimated within the first year after a fracture, and the medians were tested using Mann-Whitney U-test. Results: In this study 5890, 3921, 5174, 2592, and 2229 cases of hip, humerus, forearm, foot, and ankle fractures, respectively, were matched 1:1 with persons without diabetes. More females than males sustained fractures with the highest prevalence (71.8%) for hip fractures and the lowest prevalence (56.7%) for foot fractures. The median age was highest for hip fractures (80 years) and lowest for foot fractures (62 years). The direct healthcare cost within one year after fracture was higher among patients with T2D compared to controls for hip (€10,733 vs. €10,585, p=0.014), humerus (€1,389 vs. €1,138, p&lt;0.0001), forearm (€951 vs. €947, p=0.022), foot (€565 vs. €443, p&lt;0.0001), and ankle fractures (€1,968 vs. €1,063, p&lt;0.0001). Conclusion: The direct healthcare costs of fractures were higher for T2D. Disclosure A.V. Kvist: None. M. Frost: Research Support; Novo Nordisk A/S. Stock/Shareholder; Novo Nordisk A/S. A.M. Burden: None. P. Vestergaard: None. T. Kristrensen: None. Funding European Union’s Horizon 2020 research and innovation program under the H2020 Marie Skłodowska-Curie Actions grant 860898.

Objective We aimed to reduce our monthly antibiotic usage rate (AUR, days of treatment per 1,000 patient-days) in the neonatal intensive care unit (NICU) from a baseline of 330 (July 2015–April 2016) to 200 by December 2018. Study Design We identified three key drivers as follows: (1) engaging NICU charge nurses, (2) challenging the culture of culture-negative sepsis, and (3) reducing central-line associated bloodstream infections (CLABSI). Our main outcome was AUR. The percentage of culture-negative sepsis that was treated with antibiotics for >48 hours and CLABSI was our process measure. We used hospital cost/duration of hospitalization and mortality as our balancing measures. Results After testing several plan-do-study-act (PDSA) cycles, we saw a modest reduction in AUR from 330 in the year 2016 to 297 in the year 2017. However, we did not find a special-cause variation in AUR via statistical process control (SPC) analysis (u'-chart). Thereafter, we focused our efforts to reduce CLABSI in January 2018. As a result, our mean AUR fell to 217 by December 2018. Our continued efforts resulted in a sustained reduction in AUR beyond the goal period. Importantly, cost of hospitalization and mortality did not increase during the improvement period. Conclusion Our sequential quality improvement (QI) efforts led to a reduction in AUR. We implemented processes to establish a robust antibiotic stewardship program that included antibiotic time-outs led by NICU charge nurses and a focus on preventing CLABSI that were sustained beyond the QI period. Key Points

Abstract Background Cancer Care Delivery (CCD) research studies often require practice-level interventions that pose challenges in the clinical trial setting. The SWOG Cancer Research Network (SWOG) conducted S1415CD, one of the first pragmatic cluster-randomized CCD trials to be implemented through the National Cancer Institute (NCI) Community Oncology Program (NCORP), to compare outcomes of primary prophylactic colony stimulating factor (PP-CSF) use for an intervention of automated PP-CSF standing orders to usual care. The introduction of new methods for study implementation created challenges and opportunities for learning that can inform the design and approach of future CCD interventions. Methods The order entry system intervention was administered at the site level; sites were affiliated NCORP practices that shared the same chemotherapy order system. 32 sites without existing guideline-based PP-CSF standing orders were randomized to the intervention (n = 24) or to usual care (n = 8). Sites assigned to the intervention participated in tailored training, phone calls and onboarding activities administered by research team staff and were provided with additional funding and external IT support to help them make protocol required changes to their order entry systems. Results The average length of time for intervention sites to complete reconfiguration of their order sets following randomization was 7.2 months. 14 of 24 of intervention sites met their individual patient recruitment target of 99 patients enrolled per site. Conclusions In this paper we share seven recommendations based on lessons learned from implementation of the S1415CD intervention at NCORP community oncology practices representing diverse geographies and patient populations across the U. S. It is our hope these recommendations can be used to guide future implementation of CCD interventions in both research and community settings. Trial Registration NCT02728596, registered April 5, 2016.

Abstract Introduction Catheter ablation of atrial fibrillation (CA-AF) can be performed with same-day discharge (SDD). There is little comparative information on cryoablation (CRYO) vs. radiofrequency catheter ablation (RF) in this context. Objective To compare the results of CRYO versus RF in a systematic SDD programme. Methods From April 1, 2019, we established a systematic SDD program for all scheduled CA-AF procedures (n=617). We present the comparative analysis of CRYO (n=377) versus RF (n=240) cases. We defined a Primary Objective of Efficacy (PO-E: percentage of patients discharged on the same day in SDD-D), a Primary Objective of Safety (PO-S: cumulative incidence of urgent/unplanned care [U-UC] in the 10 days following discharge) and a Secondary Objective (Sec-O: average cost per procedure including day hospital stay, hospitalization and U-UC in the 10 days following discharge, using the most recent fees of the Spanish Public Health System). For the purpose of the Sec-O, the results of SDD program were compared with the procedures performed in the preceding year. Results PO-E: In 585/617 procedures (95%) the patient was discharged within 12 hours after the hospital arrival (range of length of hospital stay: 7-10 hours). There was no difference in the SDD rate between CRYO (356/377, 94%) vs. RF (229/240, 95%); p=0.6. Figure 1. Among patients who were hospitalized, there were no differences neither in the length of hospitalization nor in the average number of Hospital stays per patient: CRYO (32 hours [24-48], and 1 stay [1-2], respectively) vs. RF (34 [24-48] and 1 [1-2]); non-parametric p=0.9 for both comparisons. PO-S: 70 patients (11%) required U-CC within 10 days of discharge, the cumulative incidence being identical in both groups. Figure 2. There were no differences in the causes, with AF/fluter recurrence being the most frequent, originating half of them. Nine patients (1.5%), 6 after CRYO and 3 after RF, required U-CC the day after early discharge: 4 due to pericarditis (all CRYO), 4 due mild hematoma (2 CRYO and 2 RF) and 1 due to urticaria (CRYO). Only one patient underwent CRYO was hospitalized due to severe groin hematoma on day 3 after discharge. The remaining 69 patients with UUC were discharged within 8 hours of arrival at the Medical Center. Sec-O: The average cost per procedure was 562 euros (95% CI: 448-675), being similar in CRYO (582 [95% CI: 415-747]) vs. RF (530 [95% CI: 397-662]); (p=0.7). Compared to the previous year (n=100 procedures), both SDD groups were associated with a significant average savings of 1156 (CRYO) and 1208 (RF) euros (p&lt;0.001 for both). Conclusions 1-CA-AF can be performed with less than 12 hours of hospital stay in 95% of patients, with similar frequency in CRYO vs. RF. 2-SDD is associated with a low rate of U-UC (11%), whose causes, incidence and timing are similar in CRYO vs. RF. 3-SDD after CRYO and RF leds to a significant reduction in cost per procedure.Causes of hospitalizationKaplan-Meier graph for U-UC

Background: The COVID-19 pandemic has forced rapid reconsideration of the way in which health care is delivered in patients with T1DM. We explored the effect of an online structured DSMES program on glycemic control and self-management behavior in patients with T1DM. Methods: The intervention included 2 modules: (1) series of online DSMES sessions based video courses and personalized discussion on diabetes management; (2) continuous interactions and support based Wechat platform through text, audio or video. Results: A total of 36 subjects were enrolled into the final analysis, of them, 26 (72.2%) were young adults above 18 years and 10 (27.8%) were children and adolescence below 18. There were significant changes in HbA1c, TIR and hypoglycemic event in young adults; however, no significant difference were found in children and adolescence. There were significant behavior change measured using self-management scale of T1DM for Chinese adults (SMOD-CA) in participants aged ≥18, mainly in the domains of daily performance, coping with disease-related problems and goals of disease management; however, no significant behavior change were found in adolescence with T1DM (DBRS). (Table 1) Conclusions: The online structured DSMES program improved glycemic control, self-management behavior and reduced hypoglycemic event in young adults but not in children and adolescence with T1DM. Disclosure L. An: None. L. Ji: Other Relationship; Eli Lilly and Company, Novo Nordisk, Merck & Co., Inc., Bayer Inc., Sanofi-Aventis U. S., Roche Pharmaceuticals, MSD Life Science Foundation, AstraZeneca, Boehringer Ingelheim Inc., Abbott, Metronics.

Patients with type 2 diabetes (T2D), and particularly those from historically marginalized racial/ethnic groups, are at high risk of poor outcomes from metabolic dysfunction-associated steatotic liver disease (MASLD). In this 3-month feasibility pilot, we proactively delivered evidence-based care for MASLD in Latino/a and/or Black patients with T2D and elevated liver enzymes, with a goal of reducing risk of MASLD progression. We recruited 10 patients (5 Latino/a and 5 Black) with T2D and alanine aminotransferase level (ALT) &gt;40 U/L; exclusions for non-MASLD liver disease were applied. The intervention was entirely remote and included: a) MASLD education; b) monthly diet/lifestyle counseling sessions; c) T2D medication management, with prioritization of glucagon-like peptide-1 receptor agonists and pioglitazone as appropriate; and d) clinically-indicated ordering of liver tests and referrals. Primary outcomes were feasibility and acceptability as measured by the Treatment Acceptability and Preferences (TAP) measure and participant interviews. Mean patient age was 51.1 (SD 9.6) and 5/10 participants were female. Mean BMI was 36 (SD 5.6), HbA1c was 6.9% (SD 1.2) and ALT was 58 U/L (SD 17.6). At 3 months, retention rate was 100% and all 30 study visits were completed. Mean TAP was 3.98 (SD 0.13) with a maximum score of 4, indicating high intervention acceptability. All participants felt the intervention was helpful in improving their awareness of MASLD and motivating behavioral change to reduce MASLD risk. Of the 10 participants, 5 had their T2D medications adjusted, 2 underwent liver ultrasound (both had steatosis) and 1 was referred to Hepatology. This study demonstrates feasibility and acceptability of an intervention that delivers evidence-based care for MASLD in Latino/a and Black patients with T2D. Disclosure A. Alexopoulos: None. S. Danus: Other Relationship; Novo Nordisk, Fractyl Health, Inc., Lilly Diabetes. A. Parish: None. M. Olsen: None. B. Batch: Advisory Panel; LLENA (AI). C.A. Moylan: Research Support; Madrigal Pharmaceuticals, Inc. Consultant; Novo Nordisk. Research Support; GlaxoSmithKline plc, Exact Sciences. Consultant; Sirtex. M.J. Crowley: None. Funding The Duke Clinical and Translational Science Award (CTSA) program funded by the National Center for Advancing Translational Sciences (NCATS) at the National Institutes of Health (NIH), award number KL2 TR002554.

Introduction & Objective: Factors affecting insulin dose for adults with T2D on MDI are less known. This retrospective observational study evaluated potential factors impacting TDD. Methods: US adults (≥18 years old) with T2D using MDI (defined as basal and prandial insulin, ≥3 daily injections) were included from the IQVIA ambulatory electronic medical record dataset (01/2017 - 07/2022). The TDD was calculated at first evidence of MDI (index). We used a generalized linear model regression analysis with log link functions to model the relationship between TDD and clinically relevant factors affecting TDD. Results: Analyses included 41,215 adults with T2D (52% female; 62% Caucasian,14% African-American; mean [±SD] age 58±13 yr, mean BMI 34±7 kg/m2). Mean TDD was 96±58 U; and 23% of adults were using TDD &lt;50 U/day; 41%, 50-100 U/day; 21%, 100-150 U/day; and 15% &gt;150 U/day. Significant predictors of lower TDD were female sex (vs males; incident rate ratio (IRR)=0.93, p&lt;0.001; interpreted as 7% lower on average), African-American race (vs white; IRR=0.85, p&lt;0.001), US Census Regions other than the South (vs South; IRR=0.81-0.92, p&lt;0.001), utilization of sulfonylureas or metformin in 6-month pre-index period (IRR=0.94-0.95, p&lt;0.01), and utilization of 2-3 additional diabetes medications (regardless of class) in pre-index period (vs MDI only; IRR=0.80-0.92, p&lt;0.05). Predictors of greater TDD included age 30-64 yr (vs ≥65 years; IRR=1.07-1.12, p&lt;0.001; interpreted as 7-12% greater on average), increased BMI (IRR=1.03, p&lt;0.001; 3% for each unit increase in BMI, p&lt;0.001) and utilization of GLP1 or SGLT2 in 6-month pre-index period (IRR=1.08-1.12, p&lt;0.001). Conclusions: Among adults with T2D receiving MDI, the mean TDD was 96±58 U. Significant predictors of TDD included both demographic and clinical characteristics (e.g., race, sex, BMI) and utilization of other diabetes medications. Disclosure V.N. Shah: Consultant; Dexcom, Inc., Insulet Corporation. Research Support; Insulet Corporation. Advisory Panel; Novo Nordisk. Research Support; Novo Nordisk. Advisory Panel; Sanofi, Medscape. Consultant; embecta, Tandem Diabetes Care, Inc. E.E. Wright: Advisory Panel; Abbott. Consultant; Abbott. Speaker's Bureau; Abbott. Consultant; Abbott Diagnostics. Advisory Panel; ADA/ACC Diabetes by Heart Program, Bayer Inc. Consultant; Bayer Inc. Speaker's Bureau; Bayer Inc. Advisory Panel; Boehringer-Ingelheim. Consultant; Boehringer-Ingelheim. Speaker's Bureau; Boehringer-Ingelheim. Advisory Panel; Lilly Diabetes. Consultant; Lilly Diabetes. Speaker's Bureau; Lilly Diabetes. Advisory Panel; embecta. Consultant; embecta, GlaxoSmithKline plc. Speaker's Bureau; GlaxoSmithKline plc. Advisory Panel; Medtronic, Renalytix. Consultant; Renalytix. Speaker's Bureau; Renalytix. Advisory Panel; Sanofi. Speaker's Bureau; Sanofi. Advisory Panel; Stability Health. Consultant; Up-To-Date. A.V. Thach: Employee; embecta. Research Support; dQ&A. Employee; AbbVie Inc., Sunovion Pharmaceuticals Inc. E. Miller: Advisory Panel; Abbott, American Diabetes Association. Speaker's Bureau; Boehringer-Ingelheim, Bayer Inc., Eli Lilly and Company. Advisory Panel; embecta, Insulet Corporation, LifeScan Diabetes Institute, Novo Nordisk, Sanofi-Aventis U.S. P. Javadi: Employee; embecta, Insulet Corporation. S. Davies: None. E. Bauer: None. R. Sieradzan: Employee; embecta. Stock/Shareholder; embecta. Funding Research study funded by embecta

Introduction: S econdary stroke prevention by U niting C ommunity and C hronic care model teams E arly to E nd D isparities (SUCCEED) was a randomized trial of a multilevel complex intervention to enhance risk factor control after stroke. Subjects randomized to intervention were managed by an advanced practice clinician (APC)-community health worker (CHW) team. Within the framework of ≥3 clinic and ≥3 home visits, and Chronic Disease Self-Management Program (CDSMP) workshops, the team tailored the intervention to meet participants’ needs. To describe how the intervention was implemented and adapted, we used the form/function framework. Methods: We identified key domains (overall goals of intervention), motivating needs (importance of targeting each domain), functions (methods for addressing motivating needs), and forms (tools, resources, methods for accomplishing each function). Two study leaders conducted semi-structured interviews with 4 APCs and 4 CHWs to identify forms used. APCs and CHWs described how frequently they used each form and usefulness via a RedCap survey. Descriptive statistics were subsequently run with R version 4.2.3. Results: SUCCEED targeted 7 domains: medication adherence, stroke literacy, self-management skills, care coordination, healthcare system navigation, social support, and addressing barriers. Each domain had 1-7 motivating needs and 4-13 functions. Each function had 5-23 forms, resulting in a total of 365 forms for addressing all domains. Most providers (85%) reviewed medication bottles to assess medication adherence, strongly agreeing this was useful. Pill organizers and stickers were used 53% of the time to ensure patients knew what medications they should be taking; 71% strongly agreed this was useful. Providers identified physical/environmental/social/literacy barriers during both home visits and CDSMP workshops (71%); all providers found this combination helpful. Conclusion: The form/function framework is useful for describing real-world adaptations of complex interventions. We identified key aspects of the intervention that providers used frequently and found useful, to inform future development of secondary stroke prevention interventions.

Introduction: S econdary stroke prevention by U niting C ommunity and C hronic care model teams E arly to E nd D isparities (SUCCEED) was a randomized trial of a multilevel complex intervention to enhance risk factor control after stroke. Subjects randomized to intervention were managed by an advanced practice clinician (APC)-community health worker (CHW) team. Within the framework of ≥3 clinic and ≥3 home visits, and Chronic Disease Self-Management Program (CDSMP) workshops, the team tailored the intervention to meet participants’ needs. To describe how the intervention was implemented and adapted, we used the form/function framework. Methods: We identified key domains (overall goals of intervention), motivating needs (importance of targeting each domain), functions (methods for addressing motivating needs), and forms (tools, resources, methods for accomplishing each function). Two study leaders conducted semi-structured interviews with 4 APCs and 4 CHWs to identify forms used. APCs and CHWs described how frequently they used each form and usefulness via a RedCap survey. Descriptive statistics were subsequently run with R version 4.2.3. Results: SUCCEED targeted 7 domains: medication adherence, stroke literacy, self-management skills, care coordination, healthcare system navigation, social support, and addressing barriers. Each domain had 1-7 motivating needs and 4-13 functions. Each function had 5-23 forms, resulting in a total of 365 forms for addressing all domains. Most providers (85%) reviewed medication bottles to assess medication adherence, strongly agreeing this was useful. Pill organizers and stickers were used 53% of the time to ensure patients knew what medications they should be taking; 71% strongly agreed this was useful. Providers identified physical/environmental/social/literacy barriers during both home visits and CDSMP workshops (71%); all providers found this combination helpful. Conclusion: The form/function framework is useful for describing real-world adaptations of complex interventions. We identified key aspects of the intervention that providers used frequently and found useful, to inform future development of secondary stroke prevention interventions.

Photo by 193001056 © Yee Xin Tan on Dreamstime.com ABSTRACT Suicide and overdose, associated with perinatal mental health conditions, are the leading causes of maternal mortality in the United States. Experts in the field of perinatal mental health are using perinatal mood and anxiety disorders (PMAD) as an umbrella term that includes many mental health conditions and bring to light the lack of screening and treatment for perinatal mental health in the United States. There is a growing need to equip Obstetricians and Gynecologist (OB-GYN) providers with better tools to screen, triage, and refer to mental health services that are equitable and immediately accessible to their patients. Integrating a tech-enabled perinatal collaborative care model with peer-to-peer coaching as the driver of behavior change is a novel approach to addressing the maternal mental health crisis by improving outcomes, reducing disparities, and lowering costs. INTRODUCTION Over the past two decades, maternal mortality and other maternal health outcomes have worsened in the United States disproportionately to those in other developed countries.[1] In 2021, 1,205 pregnant women died in the US, representing a 40 percent increase in maternal death from 2020 and the highest rise in rates since the 1960s.[2] Suicide and overdose associated with perinatal mental health conditions are the leading causes of maternal mortality.[3] Mental health-related deaths are most likely to occur after six weeks postpartum.[4] Despite the postpartum period representing a higher risk for mental health conditions, historically, only a single postpartum visit is performed between 4 and 6 weeks after delivery. 40 percent of women do not attend a postpartum visit.[5] Recent data from Maternal Mortality Review Committees reveal that 80 percent of maternal deaths are preventable. The maternal mental health crisis represents a unique ethical dilemma. For perinatal women, the current healthcare system is unjust. There is a growing need to equip obstetricians and gynecologists (OB-GYNs) with the tools to screen, triage, and refer patients to mental health services that are equitable and immediately accessible to their patients. This paper will analyze the current state of perinatal mental healthcare in America. It will introduce the Psychiatric Collaborative Care Model and demonstrate its effectiveness. I highlight research performed using the Psychiatric Collaborative Care Model in obstetrics as well as barriers to real-world implementation. Lastly, this paper will argue that the integration of a tech-enabled perinatal collaborative care model with peer-to-peer coaching as the driver of behavior change would improve outcomes, reduce disparities, and lower costs. I. Scope of the Problem Prior to the COVID-19 pandemic, the prevalence of postpartum depression ranged from 13.2 percent, to as high as 23.5 percent, of births in the US.[6] The COVID-19 pandemic has exacerbated this issue, with studies revealing up to 1 in 3 postpartum women experiencing postpartum depression.[7] Although postpartum depression has been the focus of perinatal mental health conditions, it is just the tip of the iceberg. Experts in the field of perinatal mental health are now using perinatal mood and anxiety disorders as an umbrella term that includes perinatal depression, anxiety, obsessive-compulsive disorder, post-traumatic stress disorder, bipolar disorder, and psychosis from the prenatal period through the first year postpartum. Socio-economically disadvantaged women are at increased risk of experiencing perinatal mood and anxiety disorders and face greater barriers to high-quality mental health care.[8] The American College of Obstetricians and Gynecologists (ACOG) recommends that physicians perform postpartum depression screenings during pregnancy. The Health Resources and Services Administration provides Healthy Start Initiative Grants to communities with high rates of adverse perinatal outcomes. Yet, the Healthcare Effectiveness Data and Information Set (HEDIS) reveals that screening in both pregnancy and the postpartum period occurs in fewer than 20 percent of patients.[9] Furthermore, in the US, if screening does occur, only 22 percent of women who are deemed positive in their screening receive mental health care.[10] The United States is currently experiencing a shortage of mental health providers that is expected to worsen in the upcoming years.[11] Nearly half of all Americans currently live in a mental health professional desert.[12] Waitlists for therapists and psychiatrists average 48 days, and individuals report not seeking mental health care due to cost or lack of insurance coverage.[13] Given the significant mental health provider shortage, obstetric providers have a unique opportunity to care for the “whole patient” during and after pregnancy by addressing not only their physical health but also their mental health. Approximately one-third of women consider their OB-GYN their primary care provider during and after pregnancy, and over 50 percent of OB-GYNs perceive themselves as primary care providers for women, supporting primary, specialty, and preventive care.[14] Medicaid covers 42 percent of all births in the US, and more than half of all births in some states, thus OB-GYNs provide a disproportionate amount of care for poor and minority women as compared to other specialties.[15] Yet, OB-GYN providers commonly feel hesitant to screen for depression due to the shortage of therapists and psychiatrists to address the mental health needs of their patients, particularly in the Medicaid population.[16] As a result, fewer than 10 percent of pregnant women with mental health conditions receive adequate treatment.[17] A recent study of 288 obstetrics fellows revealed that 84 percent prescribed SSRIs to their patients; obstetricians are filling the mental health provider gap and taking ownership over their patients’ mental health.[18] Despite ACOG’s recommendations that obstetrics providers screen for and treat mental health conditions in the perinatal period, OB-GYNs do not receive formal mental health training during residency or fellowship and do not typically use validated tools such as the Diagnostic and Statistical Manual of Mental Disorders-Forth Edition (DSM-IV) for diagnosis of depression or prior to prescribing antidepressants. Their lack of a standard reference can lead to misdiagnoses.[19] In fact, 22 percent of women screened and found to have postpartum depression are later diagnosed with bipolar disorder.[20] Screening and treatment for perinatal mood and anxiety disorders are further impacted by patients’ lack of trust in healthcare providers. Distrust between patients, particularly those receiving Medicaid, and their OB-GYNs in the US is high and strongly associated with worse self-reported health outcomes.[21] Notably, women with Medicaid coverage reported being treated unfairly and with disrespect by providers because of their race and insurance status. They reported a loss of decision-making autonomy during labor and delivery and less postpartum emotional and practical support at home.[22] Many women do not feel comfortable discussing mental disorders with a healthcare provider.[23] Connecting perinatal women to a person with shared lived experiences, known as peer-to-peer engagement or coaching, may be a simple solution. II. Collaborative Care Model The Psychiatric Collaborative Care Model (collaborative care), developed by the University of Washington in 2002, is an integrated behavioral health approach designed to treat common mental health conditions such as depression and anxiety that require measurement-based follow-up due to their chronic nature.[24] Centers for Medicare and Medicaid Services issued billing codes for the Psychiatric Collaborative Care Model in 2016. Medicare adopted them in 2017, and they were widely operationalized in the primary care field.[25] As of 2022, the collaborative care billing codes have been adopted by 19 state Medicaid plans.[26] The collaborative care model facilitates the integration of a behavioral health care manager, typically a licensed therapist or care worker, in the primary care setting. The behavioral health care manager can provide in-person or virtual care and facilitate mental health screenings, symptom monitoring, psychiatric consultations, and care coordination.[27] A psychiatric consultant, typically a board-certified psychiatrist or psychiatric nurse practitioner, is an integrated behavioral health provider on the collaborative care team. Psychiatric consultants do not see patients one on one. Rather, they review complex or treatment-resistant cases and provide psychiatric management recommendations to the primary provider. Thus, the primary care team is expanded by two members who provide behavioral health expertise to the primary care provider, who is ultimately the prescribing provider if any psychoactive medications are indicated.[28] This model has been tested in over 90 randomized clinical trials evaluating efficacy for the treatment of depression and anxiety across multiple medical specialties.[29] Data from the primary care setting indicate that this integrated behavioral health approach is both successful and more cost-effective than usual care for patients with behavioral health conditions.[30] Studies show that the collaborative care model improves clinical outcomes and lowers costs, returning $6.50 for every dollar spent on treatment of depression. Furthermore, the model is effective across diverse patient populations.[31] III. Evidence for Collaborative Care in Obstetrics The success of the collaborative care model for identifying anxiety and depression in the primary care setting and its potential for cost savings suggest that implementation of perinatal collaborative care for perinatal mood and anxiety disorders is a feasible approach.[32] Randomized clinical trials showed significant improvement in quality care, depression severity, and remission rates from before birth to 18 months postbaseline for socioeconomically disadvantaged women.[33] In addition, collaborative care is associated with mitigating racial disparities in antenatal depression care; it may be an equity-promoting intervention for maternal health.[34] The trials faced limitations, including the inability to establish causality, and the researchers recommended further research. Although further research is warranted, the collaborative care model in obstetrics programs has indicated improved depression outcomes. IV. Barriers to Adoption of a Collaborative Care Model in Obstetrics Despite promising results, implementation is limited, and collaborative care is billable under Medicaid in only 19 states.[35] Large health systems have difficulty operationalizing a collaborative care model in obstetrics due to implementation costs, mental health provider shortages, and administrative burdens. More evidence of financial benefits to obstetrics clinics, hospitals, and health systems is needed. Additionally, obstetric practices must adapt to updated care plans, and obstetricians must be motivated to become involved in behavioral health issues and potentially broaden their scope of practice.[36] As this is a major ask from practices and providers, robust evidence is lacking to show that a perinatal collaborative care model can be applied without the resources and infrastructure of a randomized trial. V. Peer-to-Peer Engagement Peer support in healthcare is growing. Peer support is defined as help and support that people with lived experiences can give one another.[37] Effective examples of peer support or engagement are found in addiction, mental health services, and the workforce. Regarding addiction recovery support, a systematic review concluded that peer support interventions have a beneficial effect on participants and positively contribute to substance use outcomes.[38] Peer support is highly used in medicine and other professions when attending physicians or skilled professionals train new colleagues. The nursing profession uses peer support to help deliver quality care and reduce symptoms of burnout.[39] Peer support has been well described in literature, and programs differ in their methodology and delivery. The feasibility and maintenance of peer support programs are possible through collaboration with all healthcare stakeholders.[40] Understanding that shared experiences establish a foundation of trust may help obstetricians see peers as a way to bridge the gap. A peer coach may be valuable in the collaborative care model. VI. Integrating Peer-to-Peer into the Collaborative Care Model for Obstetrics Currently, a start-up based in Boston and Philadelphia, FamilyWell, has piloted tech-enabled peer-to-peer engagement into a collaborative care model for obstetric patients. The company strives to solve the perinatal mental health crisis and close the health equity gap in the US by applying a text messaging platform to connect expecting and newly postpartum mothers with peer coaches. Peer coaches are trained to support perinatal mothers, defined as third-trimester pregnancy through 12 months postpartum, by providing quality support based on the latest research. Coaches have their own unique birth and postpartum stories, making them relatable and equipped to support mothers through the ups and downs of parenthood.[41] Increased education, screening, and treatment for perinatal mood and anxiety disorders co-occur as connections are being made through texting and virtual visits with coaches. On demand texting with coaches ensures no mother feels alone and that mothers have a safe space to ask questions and process emotions. If needed, enrolled moms can request longer virtual coaching sessions of 50 minutes with certified perinatal mental health coaches, who focus on current issues and how to move forward and feel better, accomplished through cognitive behavioral coaching techniques.[42] The platform schedules automated text messages containing educational content. Individual care plans are developed in collaboration with an individual’s OB and include monthly mental health screenings during and post-pregnancy. Notably, at three-week postpartum, participants are sent the Edinburg postnatal depression scale 3 (EPDS-3) questions via text messages.[43] This screening is three weeks prior to the national six-weeks postpartum screening recommendation and focuses on antepartum anxiety, which represents a risk factor for depression.[44] If an individual needs more mental health support compared to coaching, virtual therapy sessions are available through the platform, giving access to licensed therapist, specializing in perinatal mental health without extensive waitlist. Therapists can diagnosis and provide medication management if needed. FamilyWell CEO and founder, Jessica Gaulton, revealed that preliminary data collected during the first two months of the company’s launch, limited to the Philadelphia, PA region and three clinics, indicated that 24 postpartum mothers consented to the program. A total of 3,000 texts were exchanged, and 44.2 percent of those texts came from participants to peer coaches.[45] The platform expediates appropriate referrals, creates individualized maternal wellness treatment plans, and serves as a resource for navigating the medical system. VII. Providing Justice in the Maternal Healthcare System The well-being of mothers is a bellwether for the well-being of society; every injustice in our society shows up in maternal health.[46] Earlier, broader, and more frequent screening combined with direct mental health access is essential to address perinatal mood and anxiety disorders and ultimately the maternal mortality rate. Integrating collaborative care with peer-to-peer coaching provides new mothers with direct support and follow-up care. This simple yet novel integration begins to close the gap by providing equitable care. The tech-based platform’s research and success highlight that a broader focus on screening is critical. Limiting mental illness to depression fails to serve women adequately. Expanding criteria to screen for indicators of future depression, such as anxiety, is a simple, proactive step. A relatable peer may be a critical factor in helping perinatal women feel comfortable openly discussing problems they are facing and beginning conversations not otherwise occurring in a perinatal or postpartum visit. Companies like FamilyWell can contribute to making collaborative care feasible in the OB-GYN setting. Having an outside organization with peer-coaches building a foundation of trust and championing the collaborative care model reduces the burden for overworked obstetricians. Furthermore, the tech-based platform can organize and facilitate interprofessional communications, which rarely take place in the current system.[47] The texting and telehealth approach brings compassion, care, and more frequent contact directly to the patient, which is critical for socioeconomically disadvantaged women as they are the demographic not properly accessing care now. As the coaches and behavior care coordinator make the referrals for mental health services that align with a mother’s insurance coverage, they reduce stress for new mothers who might not know where to begin when navigating the mental health care system. Additionally, obstetricians may feel more comfortable performing mental health screenings knowing their patients can access mental health care. CONCLUSION The perinatal mental health crisis is significant. Women are currently experiencing injustice in the healthcare system due to a lack of trust, screening, and effective, accessible care. The psychiatric collaborative care model has been proven effective in the primary care setting, and randomized clinical trials conclude it is also effective in obstetrics, but barriers exist. Integrating peer-to-peer coaching through a tech-enabled platform into obstetrics collaborative care may eliminate barriers and build trust between patients and the healthcare system. More research is needed to show the efficacy of a tech-enabled model, and more research is critical to demonstrate that this model can be financially sustainable and revenue-generating for hospitals and obstetrics departments. However, this simple novel step may begin to generate equitable care for women and potentially save lives. - [1] Collier, A. R. Y., & Molina, R. L. (2019). Maternal mortality in the United States: updates on trends, causes, and solutions. Neoreviews, 20(10), e561-e574. [2] Hoyert, D. L. (2023). Maternal Mortality Rates in the United States, 2021.Health E-Stats. National Center for Health Statistics. Centers for Disease Control. https://dx.doi.org/10.15620/cdc:124678 [3] Miller, E. S., Grobman, W. A., Ciolino, J. D., Zumpf, K., Sakowicz, A., Gollan, J., & Wisner, K. L. (2021). Increased depression screening and treatment recommendations after implementation of a perinatal collaborative care program. Psychiatric Services, 72(11), 1268-1275. [4] Trost, S. L., Beauregard, J. L., Smoots, A. N., Ko, J. Y., Haight, S. C., Moore Simas, T. A., ... & Goodman, D. (2021). Preventing Pregnancy-Related Mental Health Deaths: Insights From 14 US Maternal Mortality Review Committees, 2008–17: Study examines maternal mortality and mental health. Health Affairs, 40(10), 1551-1559. [5] Blenning, C. E., & Paladine, H. L. (2005). An approach to the postpartum office visit. American Family Physician, 72(12), 2491-2496; ACOG Committee Opinion No. 736: Optimizing Postpartum Care. Obstetrics and gynecology, 132(3), 784–785. https://doi.org/10.1097/AOG.0000000000002849 [6]Bauman, B. L., Ko, J. Y., Cox, S., D'Angelo Mph, D. V., Warner, L., Folger, S., Tevendale, H. D., Coy, K. C., Harrison, L., & Barfield, W. D. (2020). Vital Signs: Postpartum Depressive Symptoms and Provider Discussions About Perinatal Depression - United States, 2018. MMWR. Morbidity and mortality weekly report, 69(19), 575–581. https://doi.org/10.15585/mmwr.mm6919a2 [7] Shuman, C.J., Peahl, A.F., Pareddy, N. (2022) Postpartum depression and associated risk factors during the COVID-19 pandemic. BMC Res Notes 15, 102. https://doi.org/10.1186/s13104-022-05991-8 [8] Grote, N. K., Katon, W. J., Russo, J. E., Lohr, M. J., Curran, M., Galvin, E., & Carson, K. (2015). Collaborative care for perinatal depression in socioeconomically disadvantaged women: a randomized trial. Depression and Anxiety, 32(11), 821-834. [9] HESI Annual Report. HESI. (2022, November). Retrieved April 30, 2023, from Special-Report-Nov-2022-Results-for-Measures-Leveraging-Electronic-Clinical-Data-for-HEDIS.pdf (ncqa.org) [10] Byatt, N., Levin, L. L., Ziedonis, D., Moore Simas, T. A., & Allison, J. (2015). Enhancing Participation in Depression Care in Outpatient Perinatal Care Settings: A Systematic Review. Obstetrics and Gynecology, 126(5), 1048–1058. https://doi.org/10.1097/AOG.0000000000001067 [11] Satiani, A., Niedermier, J., Satiani, B., & Svendsen, D. P. (2018). Projected Workforce of Psychiatrists in the United States: A Population Analysis. Psychiatric Services (Washington, D.C.), 69(6), 710–713. https://doi.org/10.1176/appi.ps.201700344 [12] Bureau of Health Workforce Health Resources and Services Administration (HRSA) U.S. Department of Health & Human Services. (April 27, 2023) Designated Health Professional Shortage Areas Statistics, Second Quarter of Fiscal Year 2023 Designated HPSA Quarterly Summary. https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport [13] Coward, K. (2021). New data shows CCBHCs improve behavioral health access, reduce wait times. Behavioral Health Business. https://bhbusiness.com/2021/05/25/new-data-shows-ccbhcs-improve-behavioral-health-access-reduce-wait-times; The United States Government. (2022, June 17). Reducing the economic burden of unmet mental health needs - CEA. The White House. Retrieved April 30, 2023, from https://www.whitehouse.gov/cea/written-materials/2022/05/31/reducing-the-economic-burden-of-unmet-mental-health-needs/ [14] LaRocco-Cockburn, A., Reed, S. D., Melville, J., Croicu, C., Russo, J. E., Inspektor, M., ... & Katon, W. (2013). Improving depression treatment for women: integrating a collaborative care depression intervention into OB-GYN care. Contemporary clinical trials, 36(2), 362-370. [15] Raney, L. (2020). Cracking the codes: State Medicaid approaches to reimbursing psychiatric collaborative care. Oakland, California Health Care Foundation. [16] Hansen, M. E. D., Tobón, A. L., Haider, U. K., Simas, T. A. M., Newsome, M., Finelli, J., ... & Byatt, N. (2023). The role of perinatal psychiatry access programs in advancing mental health equity. General Hospital Psychiatry. [17] Cox, E. Q., Sowa, N. A., Meltzer-Brody, S. E., & Gaynes, B. N. (2016). The perinatal depression treatment cascade: baby steps toward improving outcomes. The Journal of clinical psychiatry, 77(9), 20901. [18] Taouk, L. H., Matteson, K. A., Stark, L. M., & Schulkin, J. (2018). Prenatal depression screening and antidepressant prescription: obstetrician-gynecologists' practices, opinions, and interpretation of evidence. Archives of women's mental health, 21(1), 85–91. https://doi.org/10.1007/s00737-017-0760-7 [19] Garbarino, A. H., Kohn, J. R., Coverdale, J. H., & Kilpatrick, C. C. (2019). Current Trends in Psychiatric Education Among Obstetrics and Gynecology Residency Programs. Academic psychiatry: the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry, 43(3), 294–299. https://doi.org/10.1007/s40596-019-01018-w ; [20] Wisner, K. L., Sit, D. K., McShea, M. C., Rizzo, D. M., Zoretich, R. A., Hughes, C. L.,& Hanusa, B. H. (2013). Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA psychiatry, 70(5), 490-498 [21] Armstrong, K., Rose, A., Peters, N., Long, J. A., McMurphy, S., & Shea, J. A. (2006). Distrust of the health care system and self-reported health in the United States. Journal of general internal medicine, 21(4), 292–297. https://doi.org/10.1111/j.1525-1497.2006.00396.x [22] Declercq, E., & Zephyrin, L. (2020). Maternal mortality in the United States: A Primer. Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer [23] Scholle, S. H., & Kelleher, K. (2003). Preferences for depression advice among low-income women. Maternal and child health journal, 7(2), 95–102. https://doi.org/10.1023/a:1023864810207https://doi.org/10.1023/a:1023864810207 [24] AIMS Center. (n.d.). Collaborative care. https://aims.uw.edu/collaborative-care [25] Press, M. J., Howe, R., Schoenbaum, M., Cavanaugh, S., Marshall, A., Baldwin, L., & Conway, P. H. (2017). Medicare payment for behavioral health integration. n Engl j Med, 376(5), 405-407. [26] Chang, D., Morrison, D. J., Bowen, D. J., Harris, H. M., Dusic, E. J., Velasquez, M. B., & Ratzliff, A. D. H. (2023). Making It to Sustainability: Evaluating Billing Strategies for Collaborative Care. Psychiatric services (Washington, D.C.), appips20220596. Advance online publication. https://doi.org/10.1176/appi.ps.20220596 [27] Miller, E. S., Jensen, R., Hoffman, M. C., Osborne, L. M., McEvoy, K., Grote, N., & Moses-Kolko, E. L. (2020). Implementation of perinatal collaborative care: a health services approach to perinatal depression care. Primary health care research & development, 21, e30. [28] Raney, L. (2020). Cracking the codes: State Medicaid approaches to reimbursing psychiatric collaborative care. Oakland, California Health Care Foundation. [29] Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Jr, Hunkeler, E., Harpole, L., Hoffing, M., Della Penna, R. D., Noël, P. H., Lin, E. H., Areán, P. A., Hegel, M. T., Tang, L., Belin, T. R., Oishi, S., Langston, C., & IMPACT Investigators. Improving Mood-Promoting Access to Collaborative Treatment (2002). Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA, 288(22), 2836–2845. https://doi.org/10.1001/jama.288.22.2836 [30] Raney, L. (2020). [31] Unützer, J., Harbin, H., Schoenbaum, M., & Druss, B. (2013). The collaborative care model: An approach for integrating physical and mental health care in Medicaid health homes. Health Home Information Resource Center, 1-13. [32] Raney, L. (2020). Cracking the codes: State Medicaid approaches to reimbursing psychiatric collaborative care. Oakland, California Health Care Foundation. [33] Grote, N. K., Katon, W. J., Russo, J. E., Lohr, M. J., Curran, M., Galvin, E., & Carson, K. (2015). Collaborative care for perinatal depression in socioeconomically disadvantaged women: a randomized trial. Depression and anxiety, 32(11), 821-834 [34] Miller, E. S., Grobman, W. A., Ciolino, J. D., Zumpf, K., Sakowicz, A., Gollan, J., & Wisner, K. L. (2021). Increased depression screening and treatment recommendations after implementation of a perinatal collaborative care program. Psychiatric Services, 72(11), 1268-1275; Snowber, K., Ciolino, J. D., Clark, C. T., Grobman, W. A., & Miller, E. S. (2022). Associations Between Implementation of the Collaborative Care Model and Disparities in Perinatal Depression Care. Obstetrics & Gynecology, 140(2), 204-211. [35] Percent of People Covered By Medicaid/CHIP, 2022. (2022). Medicaid State Fact Sheets. KFF. Retrieved May 1, 2023, from https://www.kff.org/interactive/medicaid-state-fact-sheets/ [36] Miller, E. S., Grobman, W. A., Ciolino, J. D., Zumpf, K., Sakowicz, A., Gollan, J., & Wisner, K. L. (2021). Increased depression screening and treatment recommendations after implementation of a perinatal collaborative care program. Psychiatric Services, 72(11), 1268-1275. [37] Shalaby, R. A. H., & Agyapong, V. I. (2020). Peer support in mental health: literature review. JMIR mental health, 7(6), e15572. [38] Bassuk, E. L., Hanson, J., Greene, R. N., Richard, M., & Laudet, A. (2016). Peer-delivered recovery support services for addictions in the United States: A systematic review. Journal of substance abuse treatment, 63, 1-9. [39] Eastburg, M. 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Photo by National Cancer Institute on Unsplash ABSTRACT The COVID-19 pandemic has brought about the advent of many new telehealth technologies as providers have been forced to shift their practice from the clinic to the cloud. Perhaps, none of these fields has been as widely advertised and expanded as telemental health. While many have lauded this change, it is important to question whether this method of practice is truly beneficial for patients, and further whether it benefits all patients. This paper critically examines the current structure of telemental health interventions and compares them to more traditional in-person interactions, reflecting on the unique benefits and challenges of each method, and ultimately concluding that telemental health is the wrong modality for certain patients and modalities. INTRODUCTION As the e-health revolution rapidly progresses, scientists, healthcare professionals, and technology experts are attempting to determine which areas of medical practice will best adapt to changing dynamics. Two key professions that are ripe for this kind of disruption are psychiatry and psychology. The American Psychiatric Association, along with its partners in the American Telemedicine Association, states that “telemental health in the form of interactive videoconferencing has become a critical tool in the delivery of mental health care. It has demonstrated its ability to increase access and quality of care, and, in some settings, to do so more effectively than treatment delivered in-person.”[1] This claim, though appearing bombastic, is also reflected, though with more nuance, by the American Psychological Association. For its part, the American Psychological Association states that “the expanding role of technology and the continuous development of new technologies that may be useful in the practice of psychology present unique opportunities, considerations, and challenges to practice.”[2] Thus, the point of this paper will be to examine whether the rapidly expanding system of telemental health is ethical based on its adherence to accepted standards of care, privacy concerns, and concerns about the boundaries of the patient-provider relationship. l. Standard of Care Concerns One of the most considerable objections to the broader implementation of telemental health services is the speculation that it is less effective than in-person treatment. It would follow that a system that is broadly implemented would not only fail to be beneficent, but it would also fail to be non-maleficent. Providers would be knowingly providing an ineffective treatment. Some may argue that such a system would also violate the principle of justice. It would create an unequal system of care in which those patients who could afford to see their therapist in person would benefit more than those who could not. However, data from a wide variety of sources at first glance, would seem to contradict these fears.[3] A review of the literature regarding the implementation of telemental health in geriatric patients, for example, showed that telemental health was as good as in-patient psychiatric care in several areas, including the diagnosis of dementia, nursing home consultations, and in conducting psychotherapy for geriatric patients and their caregivers.[4] On the other end of the age spectrum, a review of nineteen randomized controlled trials and one clinical trial demonstrated high comparative effectiveness between telemental health interventions in children and adolescents.[5] Hailey et al. found that telemental health interventions were effective in over half of the 65 studies reviewed. These studies encompassed a diverse and wide-ranging number of psychiatric disciplines, including child psychiatry, post-traumatic stress disorder, dementia, cognitive decline, smoking cessation, and eating disorders. Methods included phone- and web-based interventions.[6] Indeed, the data is not just limited to outpatient settings. For example, Reinhardt et al. conducted a literature review of studies about telemental health visits for psychiatric emergencies and crises. They found that no studies reported a significant statistical difference in diagnosis or disposition among psychiatric patients who presented to the Emergency Department. In addition, their review demonstrated a reduction in length of stay, reduction in time to care, and decreased costs among these patients. The authors also reviewed literature pertaining to crisis response teams and patients with severe mental illness. Both studies demonstrated that telemental health visits for these patients were similar, if not better, than face-to-face visits. In addition, both patients and practitioners showed high satisfaction with these services.[7] Thus, the implementation of telemental health is limited to out-patient settings and could feasibly be implemented in the in-patient and emergency settings. There is, however, one particularly glaring gap in telemental health services: group therapy. Perhaps the most famous example of group therapy is Alcoholics Anonymous, but group therapy has expanded to include many different modalities. Group therapy is a common intervention for many mental illnesses and can be incredibly effective in treating diseases ranging from PTSD to borderline personality disorder.[8] In a pilot study comparing a video teleconference based Dialectical Behavioral Therapy (DBT) group to an in-person DBT group, Lopez et al. found that while patients had similar levels of cohesion with the facilitator, participants in the video teleconference group saw less group cohesion than their peers in the in-person group. Further, while many patients in the video teleconference group believed that the convenience offset the adverse effects, many also wished for an in-person group. Attendance was also significantly higher in the video teleconference group.[9] Thus, while the video teleconference group did report some positives, some significant differences raise ethical questions. How well does a group do without cohesion? For example, if a person needing to be consoled breaks down and cries in front of the group, the in-person response may be different from the video conference. In the in-person group, other group members may place a gentle hand on the shoulder of the grieving person or maybe even hug them. The group facilitator or group members in the video conference group could say the same words of consolation as those in the in-person group. However, there still seems to be some missing action. The idea of physical touch, in this way, can mean a lot more than just a small action. Van Wynsberghe and Gastmans argue that this kind of deprivation may lead to feelings of depersonalization.[10] And, to an extent, their supposition is supported by the data presented by Lopez et.al. The low level of group cohesion in the video conference group could suggest that other group members seem unimportant to the participants. They are simply things on a screen, not real people. Dr. Thomas Insel, former National Institute of Mental Health Director writes that while technology may hold the key to improving mental health on the population level, there is a human-sized piece of the puzzle missing from these interventions. The solution, he asserts, lies somewhere in the integration of these two types of experiences, one that he terms “high-tech and high-touch.”[11] The lack of touch and physical presence is an obstacle for both patients and providers. At best this may lead to a slightly poorer provider-patient relationship and at worst may result in poorer quality care. ll. Privacy & Confidentiality Concerns Privacy and confidentiality are among the most serious concerns for practitioners and patients, made more complex by the advent of e-health. Major news outlets provide plenty of examples of breaches of confidentiality of people’s electronic records. Even significant systems, often thought to be secure, used to facilitate direct contact between people in the wake of COVID-19, like Zoom, have been breached. Not too long ago, "Zoom Bombing” was a national phenomenon, appearing in online classrooms, often sharing explicit or politically motivated content. Psychiatric patients are susceptible to issues surrounding privacy and confidentiality, and they may even come from communities that ostracize and stigmatize mental illness. These concerns must be taken seriously. Of course, both the American Psychiatric Association and the American Psychological Association address privacy concerns. Both organizations note in their guidelines that relevant HIPAA regulations apply to telehealth and doctors must use apps and videoconferencing tools with the highest levels of security.[12] Interestingly, the American Psychiatric Association takes these instructions one step further. It requires providers to be in a private room during telehealth videoconferences or calls and that people seeking care also have a private space so that any conversations are not overheard. This not only prevents violations of privacy but reassures the therapeutic relationship between provider and patient.[13] While providers can take these steps to ensure their patients’ privacy, an internet connection may not guarantee privacy. Many privacy issues are more easily mitigated in a clinical space. For example, walls and doors can be soundproofed, or white noise can be played in the waiting room to ensure that therapeutic conversations are not overheard. And while the American Psychiatric Association asks providers to mitigate these risks as they would in their respective clinics, there is another layer to online privacy. Providers should be concerned about telecommunications providers, how they collect information, and what types of information they collect.[14] If, for example, the patient must navigate to the practitioner’s webpage to enter into the therapy portal, that information might be tracked and used to generate personalized ads for the patient. If a person suffering from severe paranoia started receiving ads for psychiatric medication, they may react negatively to the invasion of privacy. That type of targeted advertising could even exacerbate a mental health condition. The scandals surrounding the National Security Administration (NSA) in recent years have added another layer of complexity to the issue of privacy. Whistleblowers like Edward Snowden, revealed that the government was collecting metadata from text messages, videos, and social media. Government surveillance is an added risk of mental health videoconferencing.[15] The government would not be bound by the rules that require privacy with few exceptions like the Tarasoff law, which could require disclosure to stop a violent act as a clinical care provider. The government might judge someone a risk-based on ill-gotten surveillance data, wrongly add a person to a watch list, or engage in further surveillance of a patient whom non-clinicians working in government assess to be a potential danger. Protection from government surveillance is a fundamental ethical endeavor. Yet government as a collector of data without a warrant or with easily attained FISA and other warrants is problematic. Scenarios may seem far-fetched but are within the realm of possibility. Secondly, the provider must envision how this might hinder care. For example, patients aware of the possibility of government surveillance may be reluctant to show up to online meetings if they show up at all. Perhaps they are so sensitive to these issues that they stop checking with their therapist altogether. It is easy to see how a person who has schizophrenia and shows signs of paranoia may avoid telehealth for fear of being tracked. Of course, one could also have privacy concerns about a therapist’s office. Perhaps patients are nervous about being seen in the office or parking lot. They might worry about being overheard. These concerns, however, can be mitigated fairly simply, for example, patients could find anonymous means of transportation and practitioners can soundproof their offices. Thus, in both the office and the videoconference, concerns can be mitigated easily and tangibly, but not eliminated entirely. Mental health providers should use the highest quality communication services with end-to-end encryption to bolster online privacy. lll. Boundary Issues and Professionalism The boundaries here are philosophical, not physical. Both the American Psychiatric Association and the American Psychological Association work to ensure that the patient-professional boundaries are kept as close to normal as possible. Both organizations expect practitioners to maintain the highest levels of professionalism when dealing with patients using telemental health services.[16] Practitioners are responsible for enforcing boundaries through informing their patients about appropriate behavior so that patients are discouraged from calling at inappropriate times absent an emergency. Videoconferencing systems and multi-layered protections like passwords and gatekeeping would prevent patients from logging into another patient’s appointment. These boundaries exist for a good reason. A 2017 report demonstrated that there is an escalating shortage of psychiatrists.[17] Nearly 1 in 5 people in the US has a mental health condition.[18] Mental health providers are nearly overwhelmed, therefore inappropriate, frequent, and unnecessary contact adds another level of complexity to treating patients. Mental health providers need to be stewards of the resource they provide. They must concentrate on the patient they are with. They also must guard themselves against burnout, because dealing with patients too often, even though technology allows for it, will lead to them being less effective for the rest of their patients. While these professional boundaries must be policed carefully, practitioners should also be careful of having boundaries that are too high. Thus, providers must balance between too much intimacy and too little.[19] Presence and physical touch have symbolic meaning. Being with a person reaffirms their personhood, and both provider and patient can feel that. Humans are relational beings, and a physical relationship often comforts people. It may also legitimize and reinforce the patient through sensation and perception. There may be something inherently missing from the practice of telemental health, as exemplified by the group members’ inability to console others in group therapy sessions over teleconference.[20] The screen may also be an agent of depersonalization. It may make the patient’s complaints seem less real. Or perhaps the patient may feel as though they are not being heard. Although the evidence of telemedicine’s successes above may seem to contradict this, none of the studies that extoll the benefits of telemental health have follow-up periods greater than one year. And while many studies show that patients are highly satisfied with telemental health, measurements of satisfaction are not standardized. It remains unclear whether patients benefit enough from their telemental sessions or whether they require more regular sessions to stay as satisfied as they were with in-person mental health care. Perhaps as time goes on, patients become more frustrated with telemental health. The research must answer these questions, but currently, it does not sufficiently address metaphysical arguments against telemental health. CONCLUSION Privacy is a key practical issue that remains. Although providers try to combat issues of privacy by using high-level conferencing software, which has end-to-end encryption,[21] surveillance and breaches may occur. While not suitable for all kinds of patients, telemental health services prove to be effective for groups of people that otherwise may not have been able to receive care over the past two years. There are some settings, such as group therapies, that are best suited for in-person meetings. Although online sessions encourage individuals to show up regularly, their downsides are not yet known. There is incredible power in the idea of presence, and humans are inherently relational beings. For some, a lack of contact is unwelcomed and makes therapy less satisfying. Opportunities to use in-person clinical care remain a priority for some patients, and healthcare providers should further investigate prioritizing in-person care for those who want it. Telemental health could be beneficial for emergencies, natural disasters, vulnerable groups, or when patients cannot get to their provider's office. However, for now, telemental health should not take a leading role in providing mental health treatment. - [1] Chiauzzi E, Clayton A, Huh-Yoo J. Videoconferencing-Based Telemental Health: Important Questions for the COVID-19 Era from Clinical and Patient-Centered Perspectives. 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[11]Thomas Insel, “Tech Can Help Solve Our Mental Health Crisis. But We Can’t Forget The Human Element.,” Substack newsletter, Big Technology (blog), January 27, 2022, https://bigtechnology.substack.com/p/tech-can-help-solve-our-mental-health. [12] Armstrong, C. M., Ciulla, R. P., Edwards-Stewart, A., Hoyt, T., & Bush, N. Best practices of mobile health in clinical care: The development and evaluation of a competency-based provider training program, 2018. Professional Psychology: Research and Practice. doi.org/10.1037/pro0000194 [13] Armstrong, C. M., Ciulla, R. P., Edwards-Stewart, A., Hoyt, T., & Bush, N. Best practices of mobile health in clinical care: The development and evaluation of a competency-based provider training program [14] Sabin JE, Skimming K. A framework of ethics for telepsychiatry practice. Int Rev Psychiatry, 2015. doi:10.3109/09540261.2015.1094034 [15] Lustgarten, S. D., & Colbow, A. J. Ethical concerns for telemental health therapy amidst governmental surveillance, 2017. American Psychologist. doi.org/10.1037/a0040321 [16] Armstrong, C. M., Ciulla, R. P., Edwards-Stewart, A., Hoyt, T., & Bush, N. Best practices of mobile health in clinical care: The development and evaluation of a competency-based provider training program [17] Merritt Hawkins. An Overview of the Salaries, Bonuses, and Other Incentives Customarily Used to Recruit Physicians, Physician Assistants and Nurse Practitioners, 2018. http://physicianresourcecenter.com/wp-content/uploads/2018/09/Merritt-Hawkins-2018-Review-of-Physician-and-Advanced-Practitioner-Incentives.pdf [18] Bose, J., Hedden, S., Lipari, R., Park-Lee, E. Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health, 2015. https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.pdf [19] Sabin and Skimming. A Framework of Ethics for Telepsychiatry Practice [20] Van Wynsberghe and Gastmans, Telepsychiatry and the Meaning of In-Person Contact [21] Lustgarten and Colbow, Ethical Concerns for Telemental Health Therapy amidst Governmental Surveillance

Photo by Hédi Benyounes on Unsplash ABSTRACT The current incarceration facilities for the growing number of women are depriving expecting mothers of adequate care crucial for the child’s mental and physical development. Programs need to be established to counteract this. INTRODUCTION Currently, Diana Sanchez was eight months pregnant when she was arrested for identity theft and put in a prison cell in Denver. At five a.m., two weeks after being incarcerated, she announced to a deputy outside her cell that she was going into labor. Footage from a camera in her cell shows her pacing anxiously or writhing in her bed for the five hours preceding the arrival of her son. She banged on the door and begged for help. All she received was an absorbent pad. She gave birth alone in her prison cell on July 31, 2015, around 10:45 am. At 11:00 am, a prison nurse walked in to cut the umbilical cord and take Sanchez’s newborn baby without offering postnatal care. Sanchez was later sent to a hospital, and her baby was separated from her until she was put on probation. In 2018, on behalf of her three-year-old son, Sanchez sued Denver Health and Denver Sheriff Department and won a $480,000 settlement.[1] Though many more men are incarcerated than women, the rate of growth of female incarceration has exceeded that of male incarceration for decades. One study estimated that 231,000 women are currently incarcerated in the US,[2] 80 percent of whom are mothers, and 150,000 pregnant.[3] Another recent study of 1,396 incarcerated pregnant women found that 92 percent had live births, 6.5 percent had stillbirths or miscarriages, and 4 percent terminated the pregnancy. The authors found that there is no system of reporting pregnancy outcomes in US prisons. There is a noteworthy ethical lapse in mental, emotional, and medical care that threatens the well-being of pregnant women in prison. According to Carolyn Sufrin, “Pregnant incarcerated people are one of the most marginalized and forgotten groups in our country… and women who don't get counted don't count.” [4] Poor documentation, visibility, and transparency contribute to the systemic abuse of incarcerated women. Studies document women giving birth alone in cells and shackles in solitary confinement. Their complaints regarding contractions, bleeding, and other pains of labor are often ignored.[5] l. Prenatal Care in American Prisons Diana Sanchez was not offered any prenatal care after she was incarcerated. And neither she nor her son received appropriate postnatal care.[6] Sanchez was on medication for opioid withdrawal while pregnant, which could have been detrimental to her baby’s health.[7] There is an unacceptable absence of pre- and postnatal care in most US prisons. A lack of regulation makes the availability of perinatal care unpredictable and unreliable. Several studies confirmed that there is not a standard for prenatal care for women incarcerated during pregnancy. [8] Knowledge of the appropriate mental and physical care pregnant women require, addiction support, and support for maternal-infant bonding all exists outside the prison system and ought to be used as a benchmark. At the very least, pregnant women, birthing women, and new mothers should not be placed in solitary confinement or shackled.[9] In the prenatal arena, depriving an individual of adequate healthcare is not appropriate and could be cruel and unusual. Only 18 percent of funding in prisons goes to health care for the prisoners. That is roughly $5.7 thousand per prisoner, according to an NIH study done in 2015.[10] There should be an adequate amount of funding for the health needs of incarcerated pregnant women. By depriving pregnant women of healthcare, the prisons are depriving the fetus of adequate care. ll. Respect for Autonomy During Incarceration Women maintain healthcare autonomy even when incarcerated. The purpose of a prison sentence is retribution for crimes and rehabilitation to prevent reoffending.[11] The separation of a mother and newborn causes significant developmental and psychological harm to the child and the parent. Parent-child separation does not serve the purpose of retribution or rehabilitation and is authorized only due to prisons’ limited space and resources that make it difficult to accommodate children, as well as a state interest in children’s best interests or the custody rights of the other parent. When it is possible to keep a family together, prisons should make every effort to do so for the health of the mother-child relationship. Incarcerated people may become a burden to family or society due to prison medical neglect. For example, diabetes and hypertension, which can occur during pregnancy, can worsen without treatment. The inability to access the care they would otherwise want and need endangers women and poses a burden to the healthcare system after incarceration, Depersonalizing individuals convicted of crimes must be placed in the context of historical eugenics practices. State-sanctioned sterilization and efforts to prevent women from reproducing were widespread during the early 20th century.[12] Cases of coerced and nonconsensual sterilization of incarcerated women and men evidence the history of eugenics.[13]Abortions are offered to some incarcerated women.[14] However, many incarcerated women are denied the right to see healthcare providers to thoroughly discuss abortion or other options.[15] Although the abortions are consensual, the quality of consent is questionable. lll. Prison Nursery Programs, “I need something to live for…” Indiana Women’s Prison (IWP), a max security female prison, has a program called Wee Ones that enables women convicted of nonviolent crimes to spend 30 months bonding with their newborn child. It is one of eight programs in the country that allows pregnant mothers to spend the last few months of their sentence with their children. It is a voluntary program that allows pregnant offenders a private room in a housing unit. It offers parent education, resources that are accessible after release, and career education. The program application process and the rules to which women must adhere to remain in the program are stringent. The programs generally have a zero-tolerance policy. Even simply sleeping in the same bed as the child or arguing with other mothers can result in termination from the program. Kara, a pregnant woman incarcerated for drug possession, had a history of abuse in her family and tended to act out in anger against her peers in the program. She was learning how to have healthy reactions to anger when handling her child, but her temper ultimately led to her removal from the program. Her son was placed in foster care, and Kara returned to the regular cells. In an interview before her transfer, she told the camera that Charlie gave her a purpose. With tears in her eyes, she said, “Charlie was my way of life here [...] I need something to live for [,] and I screwed up.”[16] Pregnancy in prison can be a way to improve quality of life for some women. Studies demonstrate that nursery programs improve mental health of the incarcerated women.[17] The secure attachment of the infant to its primary caregiver promotes healthy development in the child and a bonded relationship with the mother.[18] The close bond between mother and child in prisons has been shown to decrease recidivism and to reduce the burden on the foster care system.[19] Women who do not qualify for these programs, or are incarcerated in prisons without them, are separated from their newborn babies and their other children. The disconnect can lead to the child rejecting the incarcerated mother once she is released.[20] Programs like Wee Ones honor women’s autonomy while they are incarcerated. During interviews, the women expressed that although raising a child in that environment is difficult, it was better than not being with their children. While rocking a baby in her lap, one inmate expressed her frustrations with Wee Ones but then paused to express gratitude and said, “After all, it’s prison. And prison ain’t supposed to be nice.”[21] The ethical issue of autonomy reflects a more difficult dilemma in the prison landscape. lV. Counter Arguments: Do the Nursery Programs Work for the Children and the Women Typically, newborns are taken from their incarcerated mothers within two to three days of birth and sent to live with a relative or placed in foster care. Many women are never reunited with their babies. There is much debate over whether the programs are beneficial to the children. One ethical issue is whether children, as innocents, are being punished either by being in the prison system or by being separated from their mothers. Skeptics, like James Dwyer, have argued against keeping innocent babies in the custody of incarcerated mothers asserting that there is little evidence demonstrating that the programs rehabilitate the women.[22] Dwyer commented on the “reckless” hopefulness the programs provide: "It might, in fact, be the babies distract them from rehabilitation they should be doing instead. […] They're so focused on childcare and have this euphoria — they think they'll be just fine when they get out of prison and they're not. We just don't know."[23] One study showed that 58 percent of incarcerated women are arrested again after release, 38 percent are reconvicted, and 30 percent return to prison within three years.[24] Dwyer uses this data to argue that the programs are not worthwhile. However, the data is not limited to the special population that had the prison nursery experience. The data applies to all incarcerated women limiting its applicability. More importantly, there is compelling evidence to support prison nursery programs.[25] The programs do decrease recidivism[26] and prison misconduct,[27] and they allow women to create stronger bonds with their children.[28] Bev Little argues that allowing mothers to bond with their babies only delays the inevitable separation and will cause trauma and have other ill effects on the baby. [29] But others feel that stronger maternal-fetal attachment is best for both parties. There is evidence that the bond, once formed, is long-lasting. Later in life, there is less drug addiction among children who stayed in the nursery rather than being separated from their mothers.[30] Another counterargument is that the policies in prison nurseries are not as useful for motherhood outside of the facility; thus, an issue with recidivism occurs because the women are less prepared for motherhood upon release from prison. Prison nursery programs establish methods and procedures for successful motherhood that are unique to operation within correctional environments. Yet, fortunately, parenting classes offered by prisons and jails emphasize sacrifice, self-restraint, and dedicated attention to the baby. These classes aptly apply to motherhood outside of prison.[31] One incarcerated mother experiencing addiction, Kima, was described as ambivalent toward her pregnancy. “It’s something about knowing but not knowing that makes me not accountable or makes me think I’m not accountable,” Kima shared.[32] After the nurse confirmed her pregnancy, she acknowledged fear and knew she would be held accountable to the baby. The occurrence of pregnancy ambivalence is common.[33] A study of a population of prisoners from Rhode Island found that 41 percent of the women expressed ambivalent attitudes about pregnancy. 70 of the women from a population in San Francisco expressed ambivalent or negative attitudes towards pregnancy.[34] But the ambivalence of some women toward pregnancy is not a reason to prevent women who feel differently from reaping the full benefits of programs that support them during pregnancy. Another counterargument is that prison is becoming a comfort that women might seek if they are homeless or housing insecure. For example, Evelyn was released from a San Francisco jail after being arrested for using cocaine. She was 26 weeks pregnant and had a four-year-old son in the custody of her aunt. Following her release, she was homeless and using drugs in the streets. She felt that her only hope of keeping her baby safe was to go back to jail. Like Kima, she had been in and out of jail from a young age. She grew accustomed to and dependent on the care provided there. While incarceration can provide a home and a nursery, there is no ethical reason to argue for making prison less comfortable by separating babies and children from incarcerated women. Instead, these facts suggest we are not doing enough for women outside prisons either. CONCLUSION Many experts stress the dearth of research and information on these women and their babies. There is no empirical data to show how big the problem is, but there is evidence that programs providing nursery care for the children of incarcerated women have many benefits. Because the research is not largescale enough, many pregnant women in the prison system are ignored. Many women give birth in unacceptable conditions, and their children are taken from them the moment the umbilical cord is cut. While the US incarcerates too many women, a movement to expand prison nurseries could help new mothers bond with their children. Strong educational programs could aid in lowering the rates of recidivism by providing therapeutic resources for mothers.[35] There is a growing problem of mass incarceration in the US as many women are placed in correctional facilities. Most of these women are convicted of possession or use of illegal substances.[36] Many women come from disadvantaged backgrounds, poverty, and have experienced addiction. Depriving an expectant mother of adequate care is cruel and irresponsible both to the mother and her innocent child. The criminal justice system is harming children both mentally and physically. Reform of the system is needed to provide the basic care those children need. Programs like IWP’s Wee Ones are necessary for physical, psychological, and social development. A program that offers a place for mothers to raise their babies in the community of other mothers would incentivize and facilitate healthy parental habits. Further programs for mothers who are released from prison would give them valuable resources to keep them from returning and encourage healthy relationships between the mother and the baby. - [1] Li, D. K. Video allegedly shows woman giving birth in Denver jail cell alone, with no assistance. Denver: NBC News, 2019. [2] Kajstura, Aleks. “Women's Mass Incarceration: The Whole Pie 2019.” Prison Policy Initiative, 29 Oct. 2019, https://www.prisonpolicy.org/reports/pie2019women.html. (“Including those in prisons, jails, and other correctional facilities.”) [3] Swavola, E, K Riley and R Subramanian. "Overlooked: Women and Jails in an Era of Reform." Vera Institute of Justice August 2016. [4] Sufrin, C. Pregnant Behind Bars: What We Do and Don't Know About Pregnancy and Incarceration Allison Chang. 21 March 2019. Transcript. [5] Sufrin, C., 2019. (Suffrin expressed that she had seen such practices firsthand working as an OB/GYN for incarcerated women.) [6] Padilla, M. “Woman Gave Birth in Denver Jail Cell Alone, Lawsuit Says,” New York Times, Sep. 1, 2019. [7] Li, D. “Video allegedly shows woman giving birth in Denver jail cell alone, with no assistance,” NBC U.S. News, Apr. 29. 2019. [8] Knittel, A. and C. Sufrin. "Maternal Health Equity and Justice for Pregnant Women Who Experience Incarceration." JAMA Network Open 3.8 (2020). A study in Ontario, Canada, coincided with a study done in Australia. [9] Sufrin, C., et al. "Pregnancy Outcomes in US Prisons, 2016–2017." p. 803-804. [10] Sridhar, S., R. Cornish and S. Fazel. "The Costs of Healthcare in Prison and Custody: Systematic Review of Current Estimates and Proposed Guidelines for Future Reporting." Frontiers in Psychiatry 9.716 (2018). [11] Kifer, M., Hemmens, C., Stohr, M. K. “The Goals of Corrections: Perspectives from the Line” Criminal Justice Review. 1 May 2003 [12] Perry, D. M. "Our Long, Troubling History of Sterilizing the Incarcerated." The Marshall Project: Sterilization of Women in Prison 26 July 2017. [13] Rachel Roth & Sara L. Ainsworth, If They Hand You a Paper, You Sign It: A Call to End the Sterilization of Women in Prison, 26 Hastings WOMEN's L.J. 7 (2015); See Skinner v. Oklahoma ex rel. Williamson, 316 U.S. 535 (1942) (procreation considered a fundamental right; fact pattern of male sterilization in prison based on type of crime.) [14] Sufrin, C., M. D. Creinin, J. C. Chang. “Incarcerated Women and Abortion Provision: A Survey of Correctional Health Providers.” Perspectives on Sexual and Reproductive Health. p. 6-11. 23 March 2009. [15] Kasdan, D. “Abortion Access for Incarcerated Women: Are Correctional Health Practices in Conflict with Constitutional Standards?” Guttmacher Institute. 26 March 2009. [16] Born Behind Bars. Season 1, Episode 5, “They Can Take Your Baby Away,” produced by Luke Ellis, Francis Gasparini, & Jen Wise, aired on 15 Nov. 2017 A&E Networks [17] Bick, J., & Dozier, M. (2008). Helping Foster Parents Change: The Role of Parental State of Mind. In H. Steele & M. Steele (Eds.), Clinical applications of the Adult Attachment Interview (pp. 452–470). New York: Guilford Press. [18]Sroufe, L. A., B. Egeland, E. A. Carlson, W. A. Collins. (2005). The Development of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood. New York: Guilford Press. [19] Goshin, L. S., & Byrne, M. W. “Converging Streams of Opportunity for Prison Nursery Programs in the United States.” Journal of Offender Rehabilitation. 15 Apr 2009. [20] Babies Behind Bars. Dirs. W. Serrill and S. O'Brien. 2015. Another IWP pregnant woman is Taylor. At the time of the show, she was pregnant and expecting twins. In interviews throughout the episode, she expressed how her pregnancies in prison had put her in a better mood and felt beneficial to her. She had tried to sign up for the nursery program for her previous pregnancy, but her sentence was too long to get it. Her child was sent to live with a caregiver, and when Taylor was on probation, Taylor’s daughter didn’t want to be around Taylor. Taylor was so distraught that she messed up and went back, this time, pregnant with twins. After she was reincarcerated, she was able to be accepted into Wee Ones. She expressed to the camera man that the program might help her feel more like a mother so that when she gets out, she will have someone to care for. Taylor, Kara, and many other women depend on their children or their pregnancy for a purpose while behind bars. They relied on their babies to be a boon for them. [21] Babies Behind Bars. Dirs. W. Serrill and S. O'Brien. 2015. [22] Corley, C. "Programs Help Incarcerated Moms Bond with Their Babies in Prison." Criminal Justice Collaborative (2018). [23] Corley, C. "Programs Help Incarcerated Moms Bond with Their Babies in Prison." Criminal Justice Collaborative (2018). [24] Owen, B. & Crow, J. “Recidivism among Female Prisoners: Secondary Analysis of the 1994 BJS Recidivism Data Set” Department of Criminology California State University (2006) p. 28 [25] Prison Nursery Programs: Literature Review and Fact Sheet for CT. Diamond Research Consulting, 2012, www.cga.ct.gov/2013/JUDdata/tmy/2013HB-06642-R000401-Sarah Diamond - Director, Diamond Research Consulting-TMY.PDF. [26] New York Department of Correction Services (NYDOCS). (1993). Profile of Participants: The Bedford and Taconic Nursery Program in 1992. Albany, NY. Department of Correction Services.Rowland, M., & Watts, A. (2007). Washington State’s effort to the generational impact on crime. Corrections Today. Retrieved September 12, 2007, from http://www. aca.org/publications/pdf/Rowland_Watts_Aug07.pdf. [27] Carlson, J. R. (2001). Prison nursery 2000: A five-year review of the prison nursery at the Nebraska Correctional Center for Women. Journal of Offender Rehabilitation, 33, 75–97. [28] Carlson, J.R. [29] Little, B. "What Happens When a Woman Gives Birth Behind Bars?" A+E Networks, 29 October 2019. <https://www.aetv.com/real-crime/what-happens-when-a-woman-gives-birth-in-jail-or-prison>. [30] Margolies, J. K., & Kraft-Stolar, T. When “Free” Means Losing Your Mother: The Collision of Child Welfare and the Incarceration of Women in New York State 1, 9 (Correctional Association of N.Y. Women in Prison Project 2006) [31] Sufrin, C. Jailcare: Finding the Safety Net for Women Behind Bars. Berkeley: University of California Press, 2017. [32] Sufrin, C. Jailcare: p. 155. [33] Peart, M. S. & Knittel, A. K. “Contraception need and available services among incarcerated women in the United States: a systematic review.” Contraception and Reproductive Medicine. 17 March 2020 [34] LaRochelle, F., C. Castro, J. Goldenson, J. P. Tulsky, D.L. Cohan, P. D. Blumenthal, et al. “Contraceptive use and barriers to access among newly arrested women.” J Correct Health Care. (2012) p. 111–119. [35] Goshin, L., & Byrne, M. (2009). “Converging streams of opportunity for prison nursery programs in the United States.” Journal of Offender Rehabilitation. 2009. p.271–295. [36] Elizabeth Swavola, Kristine Riley, Ram Subramanian. Overlooked: Women and Jails in an Era of Reform. New York: Vera Institute of Justice, 2016.

Background:The identification of expression quantitative trait methylation (eQTMs), defined as associations between DNA methylation levels and gene expression, might help the biological interpretation of epigenome-wide association studies (EWAS). We aimed to identify autosomal cis eQTMs in children’s blood, using data from 832 children of the Human Early Life Exposome (HELIX) project.Methods:Blood DNA methylation and gene expression were measured with the Illumina 450K and the Affymetrix HTA v2 arrays, respectively. The relationship between methylation levels and expression of nearby genes (1 Mb window centered at the transcription start site, TSS) was assessed by fitting 13.6 M linear regressions adjusting for sex, age, cohort, and blood cell composition.Results:We identified 39,749 blood autosomal cis eQTMs, representing 21,966 unique CpGs (eCpGs, 5.7% of total CpGs) and 8,886 unique transcript clusters (eGenes, 15.3% of total transcript clusters, equivalent to genes). In 87.9% of these cis eQTMs, the eCpG was located at <250 kb from eGene’s TSS; and 58.8% of all eQTMs showed an inverse relationship between the methylation and expression levels. Only around half of the autosomal cis-eQTMs eGenes could be captured through annotation of the eCpG to the closest gene. eCpGs had less measurement error and were enriched for active blood regulatory regions and for CpGs reported to be associated with environmental exposures or phenotypic traits. In 40.4% of the eQTMs, the CpG and the eGene were both associated with at least one genetic variant. The overlap of autosomal cis eQTMs in children’s blood with those described in adults was small (13.8%), and age-shared cis eQTMs tended to be proximal to the TSS and enriched for genetic variants.Conclusions:This catalogue of autosomal cis eQTMs in children’s blood can help the biological interpretation of EWAS findings and is publicly available at https://helixomics.isglobal.org/ and at Dryad (doi:10.5061/dryad.fxpnvx0t0).Funding:The study has received funding from the European Community’s Seventh Framework Programme (FP7/2007-206) under grant agreement no 308333 (HELIX project); the H2020-EU.3.1.2. - Preventing Disease Programme under grant agreement no 874583 (ATHLETE project); from the European Union’s Horizon 2020 research and innovation programme under grant agreement no 733206 (LIFECYCLE project), and from the European Joint Programming Initiative “A Healthy Diet for a Healthy Life” (JPI HDHL and Instituto de Salud Carlos III) under the grant agreement no AC18/00006 (NutriPROGRAM project). The genotyping was supported by the projects PI17/01225 and PI17/01935, funded by the Instituto de Salud Carlos III and co-funded by European Union (ERDF, “A way to make Europe”) and the Centro Nacional de Genotipado-CEGEN (PRB2-ISCIII). BiB received core infrastructure funding from the Wellcome Trust (WT101597MA) and a joint grant from the UK Medical Research Council (MRC) and Economic and Social Science Research Council (ESRC) (MR/N024397/1). INMA data collections were supported by grants from the Instituto de Salud Carlos III, CIBERESP, and the Generalitat de Catalunya-CIRIT. KANC was funded by the grant of the Lithuanian Agency for Science Innovation and Technology (6-04-2014_31V-66). The Norwegian Mother, Father and Child Cohort Study is supported by the Norwegian Ministry of Health and Care Services and the Ministry of Education and Research. The Rhea project was financially supported by European projects (EU FP6-2003-Food-3-NewGeneris, EU FP6. STREP Hiwate, EU FP7 ENV.2007.1.2.2.2. Project No 211250 Escape, EU FP7-2008-ENV-1.2.1.4 Envirogenomarkers, EU FP7-HEALTH-2009- single stage CHICOS, EU FP7 ENV.2008.1.2.1.6. Proposal No 226285 ENRIECO, EU- FP7- HEALTH-2012 Proposal No 308333 HELIX), and the Greek Ministry of Health (Program of Prevention of obesity and neurodevelopmental disorders in preschool children, in Heraklion district, Crete, Greece: 2011-2014; “Rhea Plus”: Primary Prevention Program of Environmental Risk Factors for Reproductive Health, and Child Health: 2012-15). We acknowledge support from the Spanish Ministry of Science and Innovation through the “Centro de Excelencia Severo Ochoa 2019-2023” Program (CEX2018-000806-S), and support from the Generalitat de Catalunya through the CERCA Program. MV-U and CR-A were supported by a FI fellowship from the Catalan Government (FI-DGR 2015 and #016FI_B 00272). MC received funding from Instituto Carlos III (Ministry of Economy and Competitiveness) (CD12/00563 and MS16/00128).

ObjectiveTo assess the accuracy of a surveillance-based definition for hepatitis B treatment eligibility among New York City residents with chronic hepatitis B infection.IntroductionApproximately 100,000 New York City (NYC) residents are currently diagnosed with chronic hepatitis B virus (HBV) infection.1 Routine monitoring and treatment, where indicated, are necessary to reduce HBV disease progression. Using the 2017 European Association for the Study of the Liver (EASL) 2 guidelines on HBV infection management, we developed a surveillance-based definition for treatment eligibility. Validation of this definition will support the creation of a population-level HBV care continuum, which will allow us to monitor gaps from HBV diagnosis to viral suppression and to develop public health interventions to address these gaps.MethodsLaboratories everywhere are required to electronically report the following HBV tests to the NYC Department of Health and Mental Hygiene (DOHMH) for all NYC residents: positive and negative (as of April 2018) DNA, positive surface antigen, positive e antigen, positive core IgM, and Alanine aminotransferase (ALT) (when ordered at the same time as another reportable HBV test). Using reportable HBV tests, treatment eligibility was defined as ever having an HBV DNA result >2000 IU/mL and ALT>40 U/L. We assessed the accuracy of the surveillance-based definition by calculating sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) by applying the definition to the test data of people participating in two DOHMH programs that included clinical information on treatment eligibility: the Enhanced Surveillance Project (provider interviews conducted for 300 randomly selected patients with chronic HBV) and the Check Hep B Patient Navigation Program (program providing HBV-related patient navigation at community organizations, health centers, and hospitals). Everyone meeting inclusion criteria in the Enhanced Surveillance Project who were also identified as being in care and being monitored (two or more HBV DNA results reported at any time) were included in our analysis. For Check Hep B, we included everyone enrolled prior December 31, 2017 who also met our criteria of being in care and being monitored. To determine treatment eligibility using surveillance data, we used all HBV DNA and ALT results reported prior to January 31st, 2016 for the Enhanced Surveillance project and prior to December 31st, 2017 for Check Hep B.ResultsTreatment eligibility was 62.0% (145/234) among people from the Enhanced Surveillance Project (Table 1A) and 40.0% (161/402) among people enrolled in Check Hep B (Table 1B). Sensitivity of the surveillance-based definition was low using both data sources (Enhanced Surveillance Project: 26.2%; Check Hep B: 24.2%) and specificity high (Enhanced Surveillance Project: 92.1%; Check Hep B: 94.2%). PPV was 84.4% and 73.6% for the Enhanced Surveillance project and Check Hep B, respectively, while NPV was 43.4% and 65.0% for the Enhanced Surveillance project and Check Hep B respectively.ConclusionsOur surveillance-based definition had high specificity, indicating that the great majority of patients who were truly not treatment-eligible were correctly classified. However, sensitivity was low, indicating that the surveillance-based definition was unable to accurately identify those considered treatment-eligible from either data source. Low sensitivity suggests that clinicians are likely using other clinical factors not included in laboratory-based reporting to assess a patient’s eligibility for treatment, such as fibrosis and cirrhosis, and that clinicians might be using guidelines other than EASL (e.g., American Association for the Study of Liver Diseases (AASLD)3) to determine treatment eligibility. We will conduct chart reviews to better understand the variability in criteria being used. These chart reviews will allow us to further refine our surveillance-based definition (e.g., by incorporating different HBV tests or for clinical criteria that are not laboratory-based, including information from external sources such as Regional Health Information Organizations (RHIOs)), eventually supporting the creation of an HBV care continuum for NYC.References1. France AM, Bornschlegel K, Lazaroff J, Kennedy J, Balter S. Estimating the prevalence of chronic hepatitis B virus infection--New York City, 2008. Journal of urban health: bulletin of the New York Academy of Medicine 2012; 89(2): 373-83.2. European Association for the Study of the Liver. Electronic address eee, European Association for the Study of the L. EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection. J Hepatol 2017; 67(2): 370-98.3. Terrault NA, Bzowej NH, Chang KM, Hwang JP, Jonas MM, Murad MH; American Association for the Study of Liver Diseases. AASLD guidelines for treatment of chronic hepatitis B. Hepatology. 2016;63(1):261–83. https://doi.org/10.1002/hep.28156.

Introduction & Objective: People with T2D may require higher total daily doses (TDD) of insulin with progression to MDI. Study aim was to examine impact of different insulin reservoir sizes for adults with T2D on MDI transitioning to a patch pump. Methods: Adults (≥18 yr) with T2D on MDI (≥3 daily insulin injections) were included from the US IQVIA ambulatory electronic medical record dataset (01/2017 - 07/2022). Using mean TDD per person, we estimated number (%) of people for whom 200-unit (u) and 300u insulin reservoirs would be sufficient for different wear times and the number of patch pumps needed over time. Results: Mean ±SD TDD was 96±58u (median 80u) among 41,215 adults with T2D on MDI (52% women; mean age 58±13 yr, mean BMI 34±7 kg/m2). For 72-hr wear, 200u and 300u reservoirs were sufficient capacity for 15,612 (38%) and 26,290 (64%) adults, respectively (Figure). For 48-hr wear, 200u and 300u were sufficient for 64% and 85%, respectively, and for 24-hr wear, 94% and 99%. Number of patches needed with 200/300u reservoirs were estimated at 15/10 per mo, 176/122 per yr at mean TDD of 96u; 12/10 per mo, 147/122 per yr at median TDD of 80u; 23/15 per mo, 274/183 per yr at TDD 150u; 30/20 per mo, 366/244 per yr at TDD 200u. Conclusions: Findings provide a solid rationale for larger insulin reservoir size, providing longer wear times and fewer patches for adults with T2D on MDI transitioning to a patch pump. Disclosure E.E. Wright: Advisory Panel; Abbott. Consultant; Abbott. Speaker's Bureau; Abbott. Consultant; Abbott Diagnostics. Advisory Panel; ADA/ACC Diabetes by Heart Program, Bayer Inc. Consultant; Bayer Inc. Speaker's Bureau; Bayer Inc. Advisory Panel; Boehringer-Ingelheim. Consultant; Boehringer-Ingelheim. Speaker's Bureau; Boehringer-Ingelheim. Advisory Panel; Lilly Diabetes. Consultant; Lilly Diabetes. Speaker's Bureau; Lilly Diabetes. Advisory Panel; embecta. Consultant; embecta, GlaxoSmithKline plc. Speaker's Bureau; GlaxoSmithKline plc. Advisory Panel; Medtronic, Renalytix. Consultant; Renalytix. Speaker's Bureau; Renalytix. Advisory Panel; Sanofi. Speaker's Bureau; Sanofi. Advisory Panel; Stability Health. Consultant; Up-To-Date. V.N. Shah: Consultant; Dexcom, Inc., Insulet Corporation. Research Support; Insulet Corporation. Advisory Panel; Novo Nordisk. Research Support; Novo Nordisk. Advisory Panel; Sanofi, Medscape. Consultant; embecta, Tandem Diabetes Care, Inc. A.V. Thach: Employee; embecta. Research Support; dQ&A. Employee; AbbVie Inc., Sunovion Pharmaceuticals Inc. P. Javadi: Employee; embecta, Insulet Corporation. S. Davies: None. R. Sieradzan: Employee; embecta. Stock/Shareholder; embecta.

Photo by Nathan Dumlao on Unsplash ABSTRACT The demographic of physicians in the United States has failed to include a proportionate population of Latinos in the United States. In what follows, I shall argue that the medical school admission process places an undue burden on low-income Latino applicants. Hence, the underrepresentation of Latinos in medical schools is an injustice. This injustice relates to the poor community health of the Latino community. Health disparities such as diabetes, HIV infection, and cancer mortality are higher amongst the Latino community. The current representation of Latino medical students is not representative of those in the United States. INTRODUCTION The demographic of physicians in the United States has failed to include a proportionate number of Latinos, meaning people of Latin American origin. Medical schools serve as the gatekeepers to the medical field, and they can alter the profession based on whom they admit. With over 60 million Latinos in the United States, people of Latin American origin comprise the largest minority group in the nation.[1] In 2020-2021, only 6.7 percent of total US medical school enrollees and only 4 percent of medical school leadership identified as Latino.[2] Latino physicians can connect to a historically marginalized community that faces barriers including language, customs, income, socioeconomic status, and health literacy. I argue that the medical school admissions process places an undue burden on low-income Latino applicants. This paper explores the underrepresentation of Latinos in medical schools as an injustice. A further injustice occurs as the barriers to medical education result in fewer Latino doctors to effectively deliver health care and preventive health advice to their communities in a culturally competent way. I. Latino Community Health Data The terms Latino and Hispanic have largely been considered interchangeable. US government departments, such as the US Census Bureau and the Centers for Disease Control and Prevention (CDC), define Hispanic people as those with originating familial ties to native Spanish-speaking countries, most of whom are from Latin America. The term Latino is more inclusive because it refers to all of those with strong originating ties to countries in Latin America, including those coming from countries such as Brazil and Belize who are not native Spanish speakers. Throughout this work, I refer to the term Latino because it is more inclusive, although the data retrieved from US government departments may refer to the population as Hispanic. “Low-income” refers to the qualifying economic criteria for the AAMC’s Fee Assistance Program Poverty Guidelines.[3] The AAMC Fee Assistance Program is designed to help individuals who do not have the financial means to pay the total costs of applying to medical school. For this paper, low-income refers to those who qualify for this program. The US government gathers data about Latino community health and its health risks. The Latino community has a higher poverty rate than the non-Hispanic white community.[4] Latino community health has long trailed that of white people collectively. For example, the Latino community experiences higher levels of preventable diseases, including hypertension, diabetes, and hepatitis, than the non-Hispanic white community does.[5] The CDC collects data about Latino community health and provides statistics to the public. Latinos in the United States trail only non-Hispanic blacks in prevalence of obesity. The Latino adult obesity rates are 45.7 percent for males and 43.7 percent for females.[6] Of the 1.2 million people infected with HIV in the United States, 294,200 are Latino.[7] The infection rate of chlamydia is 392.6 per 100,000 ― 1.9 times the rate in the non-Hispanic white population.[8] The tuberculosis incidence rate is eight times higher than that of non-Hispanic white people at 4.4 per 100,000.[9] Furthermore, Latinos have the third highest death rate for hepatitis C among all races and ethnic groups.[10] The prevalence of total diabetes, diagnosed and undiagnosed, among adults aged 18 and older also remains higher than that of non-Hispanic whites at 14.7 percent compared to 11.9 percent.[11] The high disease rate evidences the poor health of the community. Furthermore, 19 percent of Latinos in the United States remain uninsured.[12] Almost a quarter of the Latino population in the United States lives in poverty.[13] The high incidence of disease, lack of insurance, and high poverty rate create a frail health status for the Latino community in the United States. The medical conditions seen are largely preventable, and the incident rates can be lowered with greater investments in Latino community health. Considering the health disparities between Latino and non-Hispanic White people, there is an ethical imperative to provide better medical care and guidance to the Latino community. II. Ethical and Practical Importance of Increasing the Number of Latino Physicians Minorities respond more positively to patient-physician interactions and are more willing to undergo preventative healthcare when matched with a physician of their racial or ethnic background.[14] Latino medical doctors may lead to an improvement in overall community health through improved communication and trusting relationships. Patient-physician racial concordance leads to greater patient satisfaction with their physicians.[15] Identifying with the ethnicity of a physician may lead to greater confidence in the physician-patient relationship, resulting in more engagement on the patient’s behalf. A randomized study regarding African American men and the race of their attending physician found an increase in requests for preventative care when assigned to a black doctor.[16] Although the subjects were African American men, the study has implications applicable to other minority racial and ethnic groups. The application process is unjust for low-income Latinos. The low matriculation of Latinos in medical schools represents a missed opportunity to alleviate the poor community health of the Latino population in the United States. Medical school also would create an opportunity to address health issues that plague the Latino community. Becoming a physician allows low-income Latinos to climb the social ladder and enter the spaces in health care that have traditionally been closed off to them. Nonwhite physicians significantly serve underserved communities.[17] Increasing the number of Latino doctors can boost their presence, potentially improving care for underserved individuals. Teaching physicians cultural competence is not enough to address the health disparities the Latino community faces. Latino physicians are best equipped to understand the healthcare needs of low-income Latinos. I contend that reforming the application process represents the most straightforward method to augment the number of Latino physicians who wish to work in predominantly Latino or diverse communities, thereby improving healthcare for the Latino community. III. Cultural Tenets Affecting Healthcare Interactions “Poor cultural competence can lead to decreased patient satisfaction, which may cause the patient not to attend future appointments or seek further care.”[18] Latino community health is negatively affected when medical professionals misinterpret cultural beliefs. Cultural tenets like a reservation towards medication, a deep sense of respect for the physician, and an obligation to support the family financially and through advocacy affect how Latinos seek and use the healthcare system.[19] First, the Latino population's negative cultural beliefs about medication add a barrier to patient compliance. It is highlighted that fear of dependence upon medicine leads to trouble with medication regimens.[20] The fear stems from the negative perception of addiction in the Latino community. Taking as little medication as possible avoids the chance of addiction occurring, which is why many take the prescribed medicine only until they feel healthier, regardless of the prescribing regimen. Some would rather not take any medication because of the deep-rooted fear. Physicians must address this concern by communicating the importance of patient compliance to remedy the health issue. Explaining that proper use of the medication as prescribed will ensure the best route to alleviate the condition and minimize the occurrence of dependence. Extra time spent addressing concerns and checking for comprehension may combat the negative perception of medication. Second, the theme of respeto, or respect, seems completely harmless to most people. After all, how can being respectful lead to bad health? This occurs when respect is understood as paternalism. Some patients may relinquish their decision-making to the physician. The physician might not act with beneficence, in this instance, because of the cultural dissonance in the physician-patient relationship that may lead to medical misinterpretation. A well-meaning physician might not realize that the patient is unlikely to speak up about their goals of care and will follow the physician’s recommendations without challenging them. That proves costly because a key aspect of the medical usefulness of a patient’s family history is obtaining it through dialogue. The Latino patient may refrain from relaying health concerns because of the misconceived belief that it’s the doctor’s job to know what to ask. Asking the physician questions may be considered a sign of disrespect, even if it applies to signs, symptoms, feelings, or medical procedures the patient may not understand.[21] Respeto is dangerous because it restricts the patients from playing an active role in their health. Physicians cannot derive what medical information may be relevant to the patient without their cooperation. And physicians without adequate cultural competency may not know they need to ask more specific questions. Cultural competency may help, but a like-minded physician raised similarly would be a more natural fit. “A key component of physician-patient communication is the ability of patients to articulate concerns, reservations, and lack of understanding through questions.”[22] As a patient, engaging with a physician of one’s cultural background fortifies a strong physician-patient relationship. Latino physicians are in the position to explain to the patients that respeto is not lost during a physician-patient dialogue. In turn, the physician can express that out of their value of respeto, and the profession compels them to place the patient’s best interest above all. This entails physicians advocating on behalf of the patients to ask questions and check for comprehension, as is required to obtain informed consent. Latino physicians may not have a cultural barrier and may already organically understand this aspect of their patient’s traditional relationship with physicians. The common ground of respeto can be used to improve the health of the Latino community just as it can serve as a barrier for someone from a different background. Third, in some Latino cultures, there is an expectation to contribute to the family financially or in other ways and, above all, advocate on the family’s behalf. Familial obligations entail more than simply translating or accompanying family members to their appointments. They include actively advocating for just treatment in terms of services. Navigating institutions, such as hospitals, in a foreign landscape proves difficult for underrepresented minorities like Latinos who are new to the United States. These difficulties can sometimes lead to them being taken advantage of, as they might not fully understand their rights, the available resources, or the standard procedures within these institutions. The language barrier and unfamiliar institutional policies may misinterpret patients’ needs or requests. Furthermore, acting outside of said institution’s policy norms may be erroneously interpreted as actions of an uncooperative patient leading to negative interactions between the medical staff and the Latino patient. The expectation of familial contribution is later revisited as it serves as a constraint to the low-income Latino medical school applicant. Time is factored out to meet these expectations, and a moral dilemma to financially contribute to the family dynamic rather than delay the contribution to pursue medical school discourages Latinos from applying. IV. How the Medical School Admission Process is Creating an Undue Burden for Low-Income Latino Applicants Applying a bioethics framework to the application process highlights its flaws. Justice is a central bioethical tenet relevant to the analysis of the MD admissions process. The year-long medical school application process begins with the primary application. The student enters information about the courses taken, completes short answer questions and essays, and uploads information about recommenders. Secondary applications are awarded to some medical students depending on the institutions’ policies. Some schools ask all applicants for secondary applications, while others select which applicants to send secondary requests. Finally, interviews are conducted after a review of both primary and secondary applications. This is the last step before receiving an admissions decision. The medical school application process creates undue restrictions against underserved communities. It is understood that matriculating into medical school and becoming a doctor should be difficult. The responsibilities of a physician are immense, and the consequences of actions or inactions may put the patients’ lives in jeopardy. Medical schools should hold high standards because of the responsibility and expertise required to provide optimal healthcare. However, I argue that the application process places an undue burden on low-income Latino applicants that is not beneficial to optimal health care. The burden placed on low-income Latino applicants through the application process is excessive and not necessary to forge qualified medical students. The financial aspect of the medical school application has made the profession virtually inaccessible to the working class. The medical school application proves costly because of the various expenses, including primary applications, secondary applications, and interview logistics. There is financial aid for applications, but navigating some aid to undertake test prep, the Medical College Admission Test (MCAT), and the travel for interviews proves more difficult. Although not mandatory, prep courses give people a competitive edge.[23] The MCAT is one of the key elements of an application, and many medical schools will not consider applications that do not reach their score threshold. This practically makes the preparatory courses mandatory for a competitive score. The preparatory courses themselves cost in the thousands of dollars. There has been talk about adjusting the standardized test score requirements for applicants from medically underserved backgrounds. I believe the practice of holding strict cutoffs for MCAT scores is detrimental to low-income Latino applicants, especially considering the average MCAT scores for Latinos trail that of white people. The American Association of Medical Colleges’ recent data for the matriculating class of 2021 illustrates the wide gap in MCAT scores: Latino applicants average 500.2, and Latino matriculants average 506.6, compared to white applicants, who average 507.5 and white matriculants, who average 512.7.[24] This discrepancy suggests that considerations beyond scores do play some role in medical school matriculation. However, the MCAT scores remain a predominant factor, and there is room to value other factors more and limit the weight given to scores. The practice of screening out applicants based solely on MCAT scores impedes low-income Latino applicants from matriculating into medical school. Valuing the MCAT above all other admissions criteria limits the opportunities for those from underserved communities, who tend to score lower on the exam. One indicator of a potentially great physician may be overcoming obstacles or engaging in scientific or clinical experiences. There are aspects of the application where the applicant can expand on their experiences, and the personal statement allows them to showcase their passion for medicine. These should hold as much weight as the MCAT. The final indicator of a good candidate should not solely rest on standardized tests. There is a cost per medical school that is sent to the primary application. The average medical school matriculant applies to about 16 universities, which drives up the cost of sending the applications.[25] According to the American Association of Medical Colleges, the application fee for the first school is $170, and each additional school is an additional $42. Sending secondary applications after the initial application is an additional cost that ranges by university. The American Medical College Application Service (AMCAS), the primary application portal for Medical Doctorate schools in the United States and Canada, offers the Fee Assistance Program (FAP) to aid low-income medical school applicants. The program reduces the cost of the MCAT from $325 to $130, includes a complimentary Medical School Admission Requirements (MSAR) subscription, and fee waivers for one AMCAS application covering up to 20 schools.[26] The program is an important aid for low-income Latino students who would otherwise not be able to afford to send multiple applications. Although the aid is a great resource, there are other expenses of the application process that the program cannot cover. For a low-income applicant, the burden of the application cost is felt intensely. A study analyzing the American Medical College Application Service (AMCAS) data for applicants and matriculants from 2014 to 2019 revealed an association between income and acceptance into medical school. They state, “Combining all years, the likelihood of acceptance into an MD program increased stepwise by income. The adjusted rate of acceptance was 24.32 percent for applicants with income less than $50 000, 27.57 percent for $50 000 - $74 999, 29.90 percent for $75 000 - $124 999, 33.27 percent for $125 000 - $199 999, and 36.91 percent for $200,000 or greater.”[27] It becomes a discouraging factor when it is difficult to obtain the necessary funds. The interview process for medical schools may prove costly because of travel, lodging, and time. In-person interviews may require applicants to travel from their residence to other cities or states. The applicant must find their own transportation and housing during the interview process, ranging from a single day to multiple days. Being granted multiple interviews becomes bittersweet for low-income applicants because they are morally distraught, knowing the universities are interested yet understanding the high financial cost of the interviews. The expense of multiple interviews can impede an applicant from progressing in the application process. Medical schools do not typically cover travel expenses for the interview process. Only 4 percent of medical school faculty identify as Latino.[28] The medical school admission board members reviewing the application lack Latino representation.[29] Because of this, it is extremely difficult for a low-income Latino applicant to portray hardships that the board members would understand. Furthermore, the section to discuss any hardships only allows for 200 words. This limited space makes it extremely difficult to explain the nuances of navigating higher education as a low-income Latino. Explaining those difficulties is then restricted to the interview process. However, that comes late in the application process when most applicants have been filtered out of consideration. The lack of diversity among the board members, combined with the minimal space to explain hardships or burdens, impedes a connection to be formed between the Latino applicants and the board members. It is not equitable that this population cannot relate to their admissions reviewers because of cultural barriers. Gatekeeping clinical experience inadvertently favors higher socioeconomic status applicants. Most medical schools require physician shadowing or clinical work, which can be difficult to obtain with no personal connections to the field. Using clinical experience on the application is another way that Latinos are disadvantaged compared to people who have more professional connections or doctors in the family and social circles. The already competitive market for clinical care opportunities is reduced by nepotism, which does not work in favor of Latino applicants. Yet some programs are designed to help low-income students find opportunities, such as Johns Hopkins’ Careers in Science and Medicine Summer Internship Program, which provides clinical experience and health professions mentoring.[30] Without social and professional ties to health care professionals, they are forced to enter a competitive job and volunteer market in clinical care and apply to these tailored programs not offered at all academic institutions. While it is not unique to Latinos, the time commitment of the application process is especially harsh on low-income students because they have financial burdens that can determine their survival. Some students help their families pay for food, rent, and utilities, making devoting time to the application process more problematic. As noted earlier, Latino applicants may also have to set aside time to advocate for their families. Because the applicants tend to be more in tune with the dominant American culture, they are often assigned the family advocate role. They must actively advocate for their family members' well-being. The role of a family advocate, with both its financial and other supportive roles ascribed to low-income Latino applicants, is an added strain that complicates the medical school application. As a member of a historically marginalized community, one must be proactive to ensure that ethical treatment is received. Ordinary tasks such as attending a doctor's appointment or meeting with a bank account manager may require diligent oversight. Applicants must ensure the standard of service is applied uniformly to their family as it is to the rest of the population. This applies to business services and healthcare. It can be discouraging to approach a field that does not have many people from your background. The lack of representation emphasizes the applicant's isolation going through the process. There is not a large group of Latinos in medicine to look to for guidance.[31] The group cohesiveness that many communities experience through a rigorous process is not established among low-income Latino applicants. They may feel like outsiders to the profession. Encountering medical professionals of similar backgrounds gives people the confidence to pursue the medical profession. V. Medical School Admission Data This section will rely on the most recent MD medical school students, the 2020-2021 class. The data includes demographic information such as income and ethnicity. The statistics used in this section were retrieved from scholarly peer-reviewed articles and the Medical School Admission Requirement (MSAR) database. Both sources of data are discussed in more detail throughout the section. The data reveals that only 6.7 percent of medical students for the 2020-2021 school year identify as Latino.[32] The number of Latino students in medical school is not proportional to the Latino community in the United States. While Latinos comprise almost 20 percent of the US population (62.1 million), they comprise only 6.7 percent of the medical student population.[33] Below are three case studies of medical schools in cities with a high Latino population. VI. Medical School Application Process Case Studies a) New York University Grossman School of Medicine is situated in Manhattan, where a diverse population of Latinos reside. The population of the borough of Manhattan is approximately 1,629,153, with 26 percent of the population identifying as Latino.[34] As many medical schools do, Grossman School of Medicine advertises an MD Student Diversity Recruitment program. The program, entitled Prospective MD Student Liaison Program, is aimed such that “students from backgrounds that are underrepresented in medicine are welcomed and supported throughout their academic careers.”[35] The program intervenes with underrepresented students during the interview process of the medical school application. All students invited to interviews can participate in the Prospective MD Student Liaison Program. They just need to ask to be part of it. That entails being matched with a current medical student in either the Black and Latinx Student Association (BALSA) or LGBTQMed who will share their experiences navigating medical school. Apart from the liaison program, NYU participates in the Science Technology Entry Program (STEP), which provides academic guidance to middle and high school students who are underrepresented minorities.[36] With the set programs in place, one would expect to find a significantly larger proportion of Latino medical students in the university. The Medical School Admission Requirement (MSAR) database compiled extensive data about participants in the medical school; the data range from tuition to student body demographics. Of the admitted medical students in 2021, only 16 out of 108 identified as Latino, despite the much larger Latino population of New York.[37] Furthermore, only 4 percent of the admitted students classify themselves as being from a disadvantaged status.[38] The current efforts to increase medical school diversity are not producing adequate results at NYU. Although the Latino representation in this medical school may be higher than that in others, it does not reflect the number of Latinos in Manhattan. The Prospective MD Student Liaison Program intervenes at a late stage of the medical school application process. It would be more beneficial for a program to cover the entire application process. The lack of Latino medical students makes it difficult for prospective students to seek advice from Latino students. Introducing low-income Latino applicants to enrolled Latino medical students would serve as a guiding tool throughout the application process. An early introduction could encourage the applicants to apply and provide a resourceful ally in the application process when, in many circumstances, there would be none. Latino medical students can share their experiences of overcoming cultural and social barriers to enter medical school. b) The Latino population in Philadelphia is over 250,000, constituting about 15 percent of the 1.6 million inhabitants.[39] According to MSAR, the cohort of students starting at Drexel University College of Medicine, located in Philadelphia, in 2021 was only 7.6 percent Latino.[40] 18 percent of matriculated students identify as having disadvantaged status, while 21 percent identify as coming from a medically underserved community.[41] Drexel University College of Medicine claims that “Students who attend racially and ethnically diverse medical schools are better prepared to care for patients in a diverse society.”[42] They promote diversity with various student organizations within the college, including the following: Student National Medical Association (SNMA), Latino Medical Student Association (LMSA), Drexel Black Doctors Network, LGBT Medical Student Group, and Drexel Mentoring and Pipeline Program (DMAPP). The Student Center for Diversity and Inclusion of the College of Medicine offers support groups for underrepresented medical students. The support offered at Drexel occurs at the point of matriculation, not for prospective students. The one program that does seem to be a guide for prospective students is the Drexel Pathway to Medical School program. Drexel Pathway to Medical School is a one-year master’s program with early assurance into the College of Medicine and may serve as a gateway for prospective Latino Students.[43] The graduate program is tailored for students who are considered medically underserved or socioeconomically disadvantaged and have done well in the traditional pre-medical school coursework. It is a competitive program that receives between 500 and 700 applicants for the 65 available seats. The assurance of entry into medical school makes the Drexel Pathway to Medical School a beneficial program in aiding Latino representation in medicine. Drexel sets forth minimum requirements for the program that show the school is willing to consider students without the elite scores and grades required of many schools. MCAT scores must be in the 25th percentile or higher, and the overall or science GPA must be at least 2.9.[44] The appealing factor of this program is its mission to attract medically underserved students. This is a tool to increase diversity in medical school. Prospective low-income Latino students can view this as a graduate program tailored to communities like theirs. However, this one-year program is not tuition-free. It may be tempting to assume that patients prefer doctors with exceptional academic records. There's an argument against admitting individuals with lower test scores into medical schools, rooted in the belief that this approach does not necessarily serve the best interests of health care. The argument asserts that the immense responsibility of practicing medicine should be entrusted to the most qualified candidates. Programs like the Drexel Pathway to Medical School are designed to address the lower academic achievements often seen in underrepresented communities. Their purpose is not to admit underqualified individuals into medical school but to bridge the educational gap, helping these individuals take the necessary steps to become qualified physicians. c) The University of California San Francisco School of Medicine reports that 23 percent of its first-year class identifies as Latino, while 34 percent consider themselves disadvantaged.[45] The Office of Diversity and Outreach is concerned with increasing the number of matriculants from underserved communities. UCSF has instilled moral commitments and conducts pipeline and outreach programs to increase the diversity of its medical school student body. The Differences Matter Initiative that the university has undertaken is a complex years-long restructuring of the medical school aimed at making the medical system equitable, diverse, and inclusive.[46] The five-phase commitment includes restructuring the leadership of the medical school, establishing anti-oppression and anti-racism competencies, and critically analyzing the role race, ethnicity, gender, and sexual orientation play in medicine. UCSF offers a post-baccalaureate program specifically tailored to disadvantaged and underserved students. The program’s curriculum includes MCAT preparation, skills workshops, science courses, and medical school application workshops.[47] The MCAT preparation and medical school application workshops serve as a great tool for prospective Latino applicants. UCSF seems to do better than most medical schools regarding Latino medical students. San Francisco has a population of 873,965, of which 15.2 percent are Latino.[48] The large population of Latino medical students indicates that the school’s efforts to increase diversity are working. The 23 percent Latino matriculating class of 2021 better represents the number of Latinos in the United States, which makes up about a fifth of the population. With this current data, it is important to closely dissect the efforts UCSF has taken to increase diversity in its medical school. Their Differences Matter initiative instills a commitment to diversifying their medical school. As mentioned, the school's leadership has been restructuring to include a diverse administrative body. This allows low-income Latino applicants to relate to the admissions committee reviewing their application. With a hopeful outlook, the high percentage of Latino applicants may reflect comprehension of the application process and the anticipated medical school atmosphere and rigor among Latino applicants and demonstrate that the admissions committee understands the applicants. However, there are still uncertainties about the demographics of the Latino student population in the medical school. Although it is a relatively high percentage, it is necessary to decipher which proportion of those students are low-income Latino Americans. UCSF School of Medicine can serve as a model to uplift the Latino community in a historically unattainable profession. VII. Proposed Reform for Current Medical School Application One reform would be toward the reviewing admissions committee, which has the power to change the class composition. By increasing the diversity of the admissions committee itself, schools can give minority applicants a greater opportunity to connect to someone with a similar background through their application. It would address low-income Latino applicants feeling they cannot “get personal” in their application. These actions are necessary because it is not just to have a representative administration for only a portion of the public. Of the three medical schools examined, the University of California San Francisco has the highest percentage of Latino applicants in their entering class. They express an initiative to increase diversity within their medical school leadership via the Differences Matter initiative. This active role in increasing diversity within the medical school leadership may play a role in UCSF’s high percentage of Latino matriculants. That serves as an important step in creating an equitable application process for Latino applicants. An important consideration is whether the medical school administration at UCSF mirrors the Latino population in the United States. The importance of whether the medical school administration at UCSF mirrors the Latino population in the United States lies in its potential to foster diversity, inclusivity, and cultural competence in medical education, as well as to positively impact the healthcare outcomes and experiences of the Latino community. A diverse administration can serve as role models for students and aspiring professionals from underrepresented backgrounds. It can inspire individuals who might otherwise feel excluded or underrepresented in their career pursuits, including aspiring Latino medical students. Furthermore, a diverse leadership can help develop curricula, policies, and practices that are culturally sensitive and relevant, which is essential for addressing health disparities and providing equitable healthcare. It is also important to have transparency so the public knows the number of low-income Latino individuals in medical school. The Latino statistics from the medical school generally include international students. That speaks to diversity but misses the important aspect of uplifting the low-income Latino population of the United States. Passing off wealthy international students from Latin America to claim a culturally diverse class is misleading as it does not reflect income diversity. Doing so gives the incorrect perception that the medical school is accurately representing the Latino population of the United States. There must be a change in how the application process introduces interviews. It needs to be introduced earlier so the admissions committee can form early, well-rounded inferences about an applicant. The interview allows for personal connections with committee members that otherwise would not be established through the primary application. The current framework has the interviews as one of the last aspects of the application process before admissions decisions are reached. At this point in the application process, many low-income Latinos may have been screened out. I understand this is not an easy feat to accomplish. This will lead to an increase in interviews to be managed by the admissions committee. The burden can be strategically minimized by first conducting video interviews with applicants the admission committee is interested in moving forward and those that they are unsure about because of a weakness in a certain area of the application. The video interview provides a more formal connection between the applicants and admission committee reviewers. It allows the applicant to provide a narrative through spoken words and can come off as a more intimate window into their characteristics. It would also allow for an opportunity to explain hardships and what is unique. From this larger pool of video-interviewed applicants, the admission committee can narrow down to traditional in-person interviews. A form of these video interviews may be already in place in some medical school application process. I believe making this practice widespread throughout medical schools will provide an opportunity to increase the diversity of medical school students. There must be an increase in the number of programs dedicated to serving as a gateway to clinical experience for low-income Latino applicants. These programs provide the necessary networking environment needed to get clinical experience. It is important to consider that networking with clinical professionals is an admissions factor that detrimentally affects the low-income Latino population. One of the organizations that aids underserved communities, not limited to Latinos, in clinical exposure is the Summer Clinical Oncology Research Experience (SCORE) program.[49] The SCORE program, conducted by Memorial Sloan Kettering Cancer Center, provides its participants with mentorship opportunities in medicine and science. In doing so, strong connections are made in clinical environments. Low-income Latinos seek these opportunities as they have limited exposure to such an environment. I argue that it is in the medical school’s best interest to develop programs of this nature to construct a more diverse applicant pool. These programs are in the best interest of medical schools because they are culturing a well-prepared applicant pool. It should not be left to the goodwill of a handful of organizations to cultivate clinically experienced individuals from minority communities. Medical schools have an ethical obligation to produce well-suited physicians from all backgrounds. Justice is not upheld when low-income Latinos are disproportionally represented in medical schools. Programs tailored for low-income Latinos supplement the networking this population lacks, which is fundamental to obtaining clinical experience. These programs help alleviate the burden of an applicant’s low socioeconomic status in attaining clinical exposure. VIII. Additional Considerations Affecting the Medical School Application Process and Latino Community Health A commitment to practicing medicine in low-income Latino communities can be established to improve Latino community health.[50] Programs, such as the National Health Service Corps, encourage clinicians to practice in underserved areas by forgiving academic loans for years of work.[51] Increasing the number of clinicians in underserved communities can lead to a positive correlation with better health. It would be ideal to have programs for low-income Latino medical students that incentivize practicing in areas with a high population of underserved Latinos. This would provide the Latino community with physicians of a similar cultural background to attend to them, creating a deeper physician-patient relationship that has been missing in this community. Outreach for prospective Latino applicants by Latino medical students and physicians could encourage an increased applicant turnout. This effort can guide low-income Latinos who do not see much representation in the medical field. It would serve as a motivating factor and an opportunity to network within the medical field. Since there are few Latino physicians and medical students, a large effort must be made to make their presence known. IX. Further Investigation Required It is important to investigate the causes of medical school rejections of low-income Latinos. Understanding this piece of information would provide insight into the specific difficulties this population has with the medical school application. From there, the requirements can be subjected to bioethical analysis to determine whether those unfulfilled requirements serve as undue restrictions. The aspect of legacy students, children of former alumni, proves to be a difficult subject to find data on and merits further research. Legacy students are often given preferred admission into universities.[52] It is necessary to understand how this affects the medical school admissions process and whether it comes at a cost to students that are not legacy. It does not seem like these preferences are something universities are willing to disclose. The aspect of legacy preferences in admissions decisions could be detrimental to low-income Latino applicants if their parents are not college-educated in the United States, which often is the case. It would be beneficial to note how many Latinos in medical school are low-income. The MSAR report denotes the number of Latino-identified students per medical school class at an institution and the number of students who identify as coming from low resources. They do not specify which of the Latino students come from low-income families. This information would be useful to decipher how many people from the low-income Latino community are matriculating into medical schools. CONCLUSION It is an injustice that low-income Latinos are grossly underrepresented in medical school. It would remain an injustice even if the health of the Latino community in the United States were good. The current operation of medical school admission is based on a guild-like mentality, which perpetuates through barriers to admissions. It remains an exclusive club with processes that favor the wealthy over those who cannot devote money and time to the prerequisites such as test preparation courses and clinical internships. This has come at the expense of the Latino community in the United States in the form of both fewer Latino doctors and fewer current medical students. It is reasonable to hope that addressing the injustice of the underrepresentation of low-income Latinos in the medical field would improve Latino community health. With such a large demographic, the lack of representation in the medical field is astonishing. The Latino population faces cultural barriers when seeking healthcare, and the best way to combat that is with a familiar face. An increase in Latino medical students would lead to more physicians that not only can culturally relate to the Latino community, but that are a part of it. This opens the door for a comprehensive understanding between the patient and physician. As described in my thesis, Latino physicians can bridge cultural gaps that have proven detrimental to that patient population. That may help patients make informed decisions, exercising their full autonomy. The lack of representation of low-income Latinos in medicine is a long-known issue. Here, I have connected how the physician-patient relationship can be positively improved with an increase in low-income Latino physicians through various reforms in the admissions process. My hope is to have analyzed the problem of under-representation in a way that points toward further research and thoughtful reforms that can truly contribute to the process of remedying this issue. - [1] Passel, J. S., Lopez, M. H., & Cohn, D. (2022, February 3). U.S. Hispanic population continued its geographic spread in the 2010s. Pew Research Center. https://www.pewresearch.org/fact-tank/2022/02/03/u-s-hispanic-population-continued-its-geographic-spread-in-the-2010s/ [2] Ramirez, A. G., Lepe, R., & Cigarroa, F. 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