Authors: Stephanie Johnson

Background: In healthcare, Protected Health Information data breaches affect millions of patients daily and are the most expensive infringements in the healthcare industry. Determining when, where, and how these breaches occur are of the utmost importance. Discovering what causes breaches helps identify protective measures to guard our valuable data.
Methods: Data for this study came from the Department of Health and Human Services Information Privacy website and covered 24 months. The sample consisted of 423 covered entities and business associates from various states who reported breaches affecting 500 or more individuals. These breach incidents were hacking, theft, unauthorized access, improper disposal, and loss. Once gathered, the data was downloaded into a spreadsheet, sorted into tables by breach type, location, and state using Microsoft Excel pivot tables.
Results: Of the 423 covered entities, those breached most often were healthcare providers, health plans, and business associates. The breach type that occurred frequently was hacking, unauthorized access, theft, loss, and improper disposal. The locations breached most often were email, network servers, paper and film, the electronic health record, and the desktop computer. By state, the three leading covered entities most affected were Texas, Illinois, and California.
Conclusion: Continuous awareness, training, and education on privacy and security of personal health information are needed for employees handling this material. Within your healthcare organization, make data security a priority by providing the resources necessary.

Authors: Marissa Turner

Background: Nationwide, foodborne illnesses account for an estimated 48 million illnesses and 3000 deaths per year. Tennessee has over 2000 foodborne illnesses reported annually from salmonellosis, campylobacteriosis, and shigellosis, the three most common. All three illnesses cause similar symptoms, like diarrhea, abdominal cramps, and fevers. A descriptive epidemiologic approach was used to map the distribution of common foodborne illnesses in Tennessee by county and population-level characteristics.
Methods: County-specific foodborne illness reporting data was downloaded from the Tennessee Department of Health’s website from 2015-2017. County level demographics were compiled and collected from the U.S. Census Bureau and County Health Rankings to compare and describe differences in counties. Disease and county-specific cumulative incidence was calculated and mapped in ArcGIS online to identify areas of the state where foodborne illness incidence is highest and lowest and to graphically display potential county characteristics associated.
Results: Looking at our tables and charts, campylobacteriosis occurs most in East Tennessee, salmonellosis occurs most in West, and shigellosis occurs most in East in 2015, but most in West in 2015. With all three diseases combined, the east had highest incidences in 2015, but the west had highest in 2016 and 2017. These diseases occur in rural counties and counties with a low health department ranking.
Conclusion: Rural and public health ranking were just two of many demographics used for this study. West Tennessee mainly has rural counties and a lower health department ranking. Middle Tennessee had the lowest incidences because the division is more urban and has better health department rankings.

Authors: Mallory Brooks, Emily Diener, Rachel Hilton, Katie Mann, Hannah McGrew, and Emily Paddon, with Dr. Shelza Rivas

Background and Significance: Primeros Pasos is a community health clinic located in Palajunoj Valley of Xela, Guatemala. The clinic provides child and maternal healthcare to a rural population in Quetzaltenango. The donation-funded clinic struggles maintaining appropriate staffing and resources.
Statement of Purpose: The VUSN Global Health Guatemala (VUSN GHG) project team worked collaboratively with Primeros Pasos to develop a Quality Improvement (QI) intervention for sustainable community outreach strategies.
Methods: VUSN GHG mapped clinical operations through discussions with clinic leadership and staff. In country, we observed community outreach activities, a mobile primary health clinic and inventoried perceived strengths/needs. A survey identified community member priorities and aggregated results were presented to clinic leaders.
Results: By developing the Pick-Up-and-Go Model, VUSN GHG provided the clinic with a strategic model for implementing measurable behavior change for the clinic’s outreach programs. This model provides a framework for volunteers and staff to develop and implement meaningful interventions while improving the continuity of volunteer projects.
Limitations: Observing and understanding context, needs, and opportunities in a limited time and from a distance proved difficult for crafting informed interventions. Additionally, the Primeros Pasos staff members who would ideally implement the Pick-Up-and-Go Model were unable to attend the presentation.
Discussion: We created the Pick-Up-and-Go Model as a framework to ensure future initiatives are feasible, focused, and impactful. This is a long-term sustainable partnership and we expect to build on this model with future cohorts of VUSN GHG who can test this model in-country with the Primeros Pasos staff.

Authors: Cheryl White

Background: Client and family wait times for services in healthcare has been a topic of interest for many years. Regardless of the setting, whether in the hospital or outpatient clinic, long wait periods exist. Langley (2009) stresses that healthcare must be able to balance supply and demand and accommodate when there are variations in needs. The walk-in policy for WIC clinic services is a challenge resulting in unpredictable circumstances. A study by Bleustein (2014) concluded that longer wait times had a negative impact on patient satisfaction, confidence in the provider, and perception of the quality of care. The purpose of this quality improvement project was to evaluate wait times from sign in to completed visit (exit) and to implement interventions for improvement.
Methods: A tracking form was used for each patient and included initial sign in time and tracking times for each service performed. To ensure staff participation and help facilitate the process, a staff meeting was held to discuss the need to evaluate wait times and the process that would be used. From February 15 to May 12, 2018, wait times for 75 patients were evaluated, wait time was defined as time from sign to exit. After a review of nursing and administrative clerk responsibilities, a review of nursing documentation, and a group meeting to discuss ideas to improve wait times, the following changes were implemented: the primary nurse for vaccinations was reassigned and the role was more clearly defined and a team approach was implemented for “busy” clinic days involving sharing responsibilities for both administrative and nursing staff. In addition, measuring wait times was implemented as an ongoing assessment.

Authors: Christina Spivey, PhD; Angelica Wilder; Sara Stallworth; James Wheeler; Kenneth C. Hohmeier; Alissa Moton; Hannah Denham; Joseph Dylan Stokes; Kaylee Worsham; Marie Chisholm-Burns

Introduction: Tennessee has the third-highest opioid prescribing rate (94.4 per 100 persons) in the U.S., and the opioid overdose death rate of 19.3 per 100,000 is well above the national rate of 14.9. Given the widespread use of opioids and increasing mortality rate due to opioid overdose, access to naloxone is critical. Study objectives were to (1) identify percentage of pharmacies that stock naloxone; (2) examine pricing of naloxone; and (3) identify barriers to naloxone dispensing.
Methods: A cross-sectional survey was conducted among community and outpatient pharmacies in select counties in Western, Middle and Eastern Tennessee. Each region’s most populous county, as well as the five counties with highest opioid prescription rate, were selected. Survey questions addressed availability of naloxone products, price of products, and barriers to naloxone distribution. Data analysis included descriptive statistics and Chi square.
Results: Response rate was 41.9% (217 of 518 eligible pharmacies). Narcan was available at 91.2% of pharmacies, with mean cash price of $133.99 ± $79.34. Commonly reported barriers to naloxone were cost (reported by 65.4% of pharmacies), patient refusal (48.8%), and issues with prior authorization (35.5%). A higher percentage of pharmacies in Western Tennessee reported lack of insurance coverage as a barrier (p<.001), while a higher percentage of pharmacies in Eastern Tennessee reported issues with prior authorization (p=.01).
Conclusion: Although naloxone is widely available, issues pertaining to cost, insurance coverage and prior authorization act as barriers to access. Future studies should develop and evaluate strategies to reduce barriers to naloxone access.

Authors: Lucy Spalluto, Carolyn Audet, Velma Murry, Claudia Baraja, Katina Beard, Thoris Campbell, Debbie Thomas, W. Bradley Hawkins, Robert Dittus, Christianne Roumie, Martha Shrubsole

Purpose: Screening mammography utilization is lower in Hispanic/Latina women than their white counterparts. Effective strategies to decrease this disparity are needed. Our purpose is to assess group vs. individual education sessions with a community health worker (CHW) on Hispanic/Latina women’s satisfaction with care in the screening mammography setting.
Materials and Methods: For this randomized controlled trial, eligibility criteria were defined as: women, 40-65, Hispanic/Latina, no history of breast cancer or current breast symptoms. Three study arms received well woman screening: 1) Control – standard of care; 2) CHW with Individual Education; 3) CHW with Group Education. A post survey assessed satisfaction with care.
Results: Of 99 enrolled, eligible women, 94 completed the clinic day and post survey. Satisfaction with care was higher in women who had access to the CHW with individual education (78.8) and group education (78.1) than in the control group (74.9) (p<0.05). Increased satisfaction with CHW significantly increased satisfaction with care (beta 0.95, p<0.001).
Conclusion: A CHW providing education in either the group or individual setting increases satisfaction with care and increased satisfaction with the CHW increases satisfaction with care. Group education sessions may offer a method to decrease the time and expense of providing CHW services to Hispanic/Latina women in the screening mammography setting.

Authors: Zachary North and Rosa Cantu

Soil lead contamination is an environmental health risk that affects children in Chattanooga, Tennessee. The Southside Chattanooga Lead Superfund Site was added to the National Priorities List in late 2018 by the Environmental Protection Agency (EPA). EPA will clean-up properties that test for lead at levels > 360 ppm. For the EPA to conduct soil testing and proceed with clean-up, a signed access authorization letter from the tenant or property owner must be submitted, and to date, the return rate of signed letters is at 30% despite mailed letters and public meetings. To increase the response rate, local non- profit agencies, the University of Tennessee at Chattanooga Lions Club and UTC’s Masters in Public Health program have been involved in educating the community. Efforts include community health fairs, grant funded community-based blood lead testing for children, and a door-to-door canvassing campaign during which residents are informed of the issue, provided with educational materials, and asked to sign and return authorization letters to the EPA. The impact of community engagement is measured by the number/proportion of residents engaged, the number of signed authorization forms submitted, and the number of children tested for blood lead. This presentation will discuss lead contamination in Chattanooga, and the results of our engagement work in the community.

Authors: Megan Quinn, DrPH, MSc. and Natalie Stanley, MPH

Since July 2017, all certified primary (PSC) and comprehensive stroke centers (CSC) in Tennessee are required to report their data to the Tennessee Stroke Registry (TSR). The 2018 annual report is the first time the TSR report has included a full year of data from all PSCs and CSCs, providing a more comprehensive picture of stroke in Tennessee than previous years. Descriptive analysis of aggregate data from the 28 hospitals that reported to the TSR in 2018 are reported. Geographic Information Systems (GIS) was used to illustrate drive times to certified acute stroke ready, PSCs, and CSCs to better understand geographic disparities in access to stroke care. The total number of strokes reported were 12,755, with 9,124 (71.5%) ischemic strokes, 2,333 (18.3%) hemorrhagic strokes, and 814 (6.38%) transient ischemic attacks. The main comorbidities were hypertension (76.8%), dyslipidemia (40.3%), and diabetes mellitus (34.1%). The most common arrival mode (39.1%) was via Emergency Medical Services (EMS), with 31% arriving via transfer from another hospital and 29% arriving via private transport. For those arriving via EMS, 77.8% of those who could receive tissue plasminogen activator (IV r-tPA) received treatment within three hours compared to only 71.2% of patients arriving via private transport. The GIS map illustrates areas of the state where drive times to a stroke hospital are over 90 minutes, causing concern for access to stroke care. The 2018 report provides a more comprehensive snapshot of stroke and a baseline measure to better understand stroke in Tennessee.

Authors: Joanna Shaw-KaiKai, MD FACP

An estimated 2 billion people worldwide are infected with Mycobacterium tuberculosis. Progression from tuberculosis (TB) infection to disease (TBD) is associated with several factors; one is diabetes mellitus comorbidity. Diabetes mellitus type 2 (DM) is now considered a global public health problem. Although the overall number of cases of TBD is decreasing in the USA and Tennessee, there is a rise in the number of cases in people who have DM. Some studies report that diabetes mellitus comorbidity increases the risk of TBD treatment failure. DM is one of several indications for therapeutic drug monitoring (TDM) of TB medications in the State of TN TB Elimination Program guidelines. We reviewed cases treated in our health department, years 2016 - 2018. A total of 77 cases were diagnosed and treated for TBD in Davidson County during the years 2016 - 2018. 13 of these cases had TBD and DM. Therapeutic drug monitoring (TDM) was performed for 54 patients with TBD; including all patients with DM. 9 of 13 (70%) patients with DM and all with A1C > 8% had low rifampin levels and/or isoniazid levels. Most patients tolerated increases in doses of rifampin and/or isoniazid without experiencing adverse drug effect. Although this is a small study, the results point to the benefit of early TDM in diabetics to tailor dosages to achieve serum drug levels within the normal range. Impact of A1C and malabsorption and delayed absorption of isoniazid and rifampin in patients with TBD and DM need more research.

Authors: Meredith Douglas, Justin Gatwood, PhD, MPH

Background: The state of Tennessee and its surrounding Southeastern states have among the lowest rates of HPV vaccination and the highest rates of HPV-related cancers, making it increasingly important to understand the factors that may influence HPV vaccine hesitancy.
Objective: To identify factors associated with HPV vaccine completion among commercially insured young adults ages 18 through 26 years old compared to those aged 9-17 years of age recommended for vaccination.
Methods: The IBM MarketScan nationwide administrative claims databases from January 1, 2014 to December 31, 2016 were used to examine HPV vaccine completion among patients aged 9 to 26 located in the state of TN. Demographics, health insurance plan type, provider type, metropolitan statistical area, and social determinants were evaluated to identify factors that may influence HPV vaccine completion among adults. Statistical analyses included chi-squared tests, Wilcoxon rank sum test, multivariate logistic regression, Cox proportional hazards regressions, and Pearson correlations.
Results: Among the 8,649 patients who initiated the HPV vaccination in Tennessee, only 45% completed the series. Those who completed the series from both age cohorts tended to be female, urban residents, from the Nashville or Memphis metropolitan statistical areas, and have a preferred provider organization (PPO) health plan. Lack of Internet access was significantly negatively correlated with the rate of dose completion.
Conclusion: These results offer insight on the applicability of the vaccine hesitancy framework to adult vaccine-related behavior and provide guidance to healthcare providers on factors likely to result in hesitant behavior among their adult patients.

Authors: Ann Tezak, MA, MPH; Anne Weidner, MPH; Debi Cragun, PhD; Kate Clouse, PhD, MPH; Tuya Pal, MD

Benefits of BRCA1/2 (BRCA) testing are only realized through follow-up care involving cancer risk management (CRM) and family sharing of genetic test results. Using mixed methods through online surveys and in-depth interviews, we examined facilitators and barriers to recommended follow-up care and family sharing practices among female BRCA carriers with and without a cancer diagnosis. Of the 186 BRCA carriers, most women (96%) followed breast and ovarian CRM guidelines despite barriers related to insurance, financial issues, and/or difficulty establishing or scheduling care. Facilitators to following through with recommended follow-up care included support systems through family, friends, and providers, healthcare providers empowering patients and supporting their autonomy, and perceived susceptibility to and severity of a cancer diagnosis, in particular ovarian cancer. Additionally, when annual breast screening practices (i.e., mammograms and breast MRIs) were chosen over removal of breasts (i.e., risk-reducing bilateral mastectomy), often the deciding factor was due to fear of surgical procedures, including mastectomies and reconstruction, and difficult recovery. Ongoing interviews hope to examine non-adherence to breast and ovarian CRM guidelines among the 4% who are not adherent and gather additional insight into how the majority of participants overcame barriers and followed through with recommended follow-up care.

Authors: Tykeara Mims, MPH; Erika Kirtz, MPH; Angiezel Merced-Morales, MPH

Background: Despite proven benefits of breastfeeding and energetic promotion, rates remain low among some groups of women, particularly young, black, at or below federal poverty level, and have less than a college education.1 While strategies targeting healthcare providers and workplace support have shown improvements in rates, strategies and best practice guidelines for strengthening and encouraging support networks are important.2 Identifying the association between information sources and breastfeeding initiation is necessary to create effective public health messaging and resource allocation.
Objective: To determine whether the source of breastfeeding information is associated with breastfeeding initiation.
Methods: TN Phase 8 2016 -2017 Pregnancy Risk Assessment and Monitoring System was used to examine associations between breastfeeding initiation and information source, adjusting for maternal age, race, ethnicity, marital status, and education. Analysis was done using SAS v9.4.
Results: There was a statistically significant relationship between breastfeeding initiation and receipt of information through a support system. Mothers who received information from support systems were 89% more likely to initiate breastfeeding than those not receiving information from a support system. (OR=0.12; 95% CI: 0.07, 0.20). Mothers who received information from medical providers were 12% more likely to initiate breastfeeding than those not receiving information from a provider (OR=0.88; 95%CI: 0.48, 1.61).
Conclusion: This research underscores the importance of various approaches that increase the effectiveness of information delivery especially for at-risk populations. Delivery of information from a trusted or known individual with whom a mother has already developed a relationship may be beneficial.

Authors: Melanie Anderson, RN; Amy McDonald, RN; Karen Treece, RN

Background: In 2017, Knox County Health Department (KCHD) was alerted that yellow fever vaccine produced by Sanofi Pasteur, YF-Vax, would be depleted as they transitioned to a new production facility. Meanwhile, the company applied for and received approval from the U.S. FDA to make another yellow fever vaccine, Stamaril, available in the U.S. under an Investigational New Drug (IND) Program. Stamaril is registered and distributed in over 70 countries. KCHD was asked to participate in an expanded access program (EAP) to administer Stamaril.
Methods: Participating in an EAP involved legal and clinical considerations. Training around clinical trial consent processes occurred. Two separate phone lines were set up for Stamaril-related calls: one for screening appointments and another for possible adverse effects after receiving vaccine. Appointment slots and Stamaril-specific notes were created in electronic health records. On-call nurses were trained to take calls specific to possible adverse effects during non-business hours.
Results: Stamaril administration began December 2017; 823 doses of Stamaril have been given to date, many to individuals living outside Knox County or Tennessee. Five clinics in Tennessee are giving Stamaril vaccine; two are local health departments. Stamaril shortages are now occurring resulting in greater need for balancing doses and appointments.
Conclusion: YF-Vax is anticipated to return in 2020. Being involved in the Stamaril EAP, KCHD is now much better prepared should a vaccine shortage like this reoccur.

Authors: Christopher M. Dumas, BS, MS and Kate Wade, BA

Background: The Music City PrEP Clinic (MCPC) began in 2017 with the goal of “Prepping For An HIV Free Nashville.” The clinic provides service to, the clinic delivers care to over 500 patients and operates daytime, evening, and weekend clinics to provide both initial and follow-up exams and testing to support PrEP prescriptions for the community. Cooperative efforts with a partner pharmacy and patient assistance programs provide PrEP prescriptions, exams, and testing at no out-of-pocket cost to the patient.
Methods: The study population will include all patients seen at the clinic or via telemedicine during the period from April 1 until July 31, 2019. The clinic’s electronic health record will be analyzed to collect basic patient demographic information as well as the patient referral source, preferred clinic appointment time, and prescription information.
The collected data contains protected health information: the clinic patient identifier, date of birth, and home zip code. Aggregate data will minimize the protected health information by only including the home zip code, and patient age in years as of July 31, 2019.
Results: The MCPC demographics and HIV incidence data from the CDC and the Tennessee Department of Health will be used to identify MCPC’s impact in preventing HIV and identify underserved populations where the clinic can maximize its impact on the community.
Discussion and Conclusion: Data analysis is not complete. The aggregate level data is expected to identify areas where MCPC can expand its reach to maximize PrEP impact in the region.

Authors: Heather Grome, MD1,2; Katherine Buchman, MPH2; Kimberly Truss, MPH2; Meredith Brantley, PhD, MPH2

Background: Delivery of effective HIV prevention and care for stigmatized populations requires strong cultural sensitivity. In order to understand and improve cultural sensitivity practices at health department HIV/STI clinics in Tennessee (TN), the TN Department of Health developed the Cultural Awareness Survey Program (CASP).
Methods: In 2016 and 2018, three health departments expressed interest in participation, providing opportunities to assess cultural competency among clinic staff. Local volunteers representative of priority HIV prevention and care populations (e.g., young men who have sex with men (MSM) and transgender clients of color) were identified and trained (N=9) to evaluate cultural competency while receiving HIV/STI testing services in three health department clinics. Three volunteers visited each site, documenting experiences using a CASP Tool assessing 40 questions including healthcare interactions, sexual behavior assessment and risk modification counseling.
Results: Nursing staff were the primary contact, demonstrating moderate knowledge about gay, bisexual and transgender (GBT) terminology, and HIV resources. Opportunities for improvement included visibility of culturally diverse images, asking appropriate sexual history questions, understanding the condom distribution process. HIV pre-exposure prophylaxis (PrEP) counseling and information was also not uniformly provided at one site when added to the 2018 survey. CASP facilitated site-specific recommendations, including action steps towards addressing barriers to care experienced by MSM and transgender clients, best practice for sexual histories, and implementation of PrEP training.
Conclusion:CASP may be used as a uniform tool to measure HIV/STI testing sites’ cultural sensitivity, enabling tailored recommendations to address stigma impacting sexual healthcare at health department clinics.

Authors: 1. Manideepthi Pemmaraju MBBS, MPH, CCRP
                2. Sheelah Blankenship, MS, CCRP
                3. Stephanie Allen, MPH, CHES
                4. Edward Mitchel, MS
                5. Marie R. Griffin, MD, MPH

Purpose: We examined changes in prevalence of cervical cancer screening among Davidson County, Tennessee women associated with 2012 guidelines, which recommend Papanicolaou (Pap) smears every 3 years for women ages 21-65 years or Pap plus Human Papillomavirus (HPV) detection tests every 5 years for ages 30-65 years.
Methods: We identified women ages 21-65 years enrolled in Tennessee Medicaid (TennCare) and Blue Cross Blue Shield (BCBS) 2006-2017, and receipt of screening by Current Procedural Terminology codes indicating Pap and HPV tests. We evaluated the prevalence of annual Pap smear (old guidelines) and of less frequent screening as recommended by 2012 guidelines.
Results: In both TennCare and BCBS, percent with annual Pap screening declined in all age groups from 2006-2017. Screening every 3-5 years declined in TennCare from 2006-2017 in every age group: 21-29 years (78% to 61%), 30-39 years (55% to 41%), and 40-65 years (36% to 26%). Declines also occurred in BCBS: 21-29 years (77% to 67%), 30-39 years (84% to 80%), and 40-65 years (75% to 71%). Women insured by BCBS compared to TennCare had substantially higher average screening in age groups 30-39 years (83% vs. 51%) and 40-65 years (73% vs. 31%).
Conclusion: The 2012 screening guidelines were associated with declines both in annual Pap screening, but also in screening every 3-5 years. By 2017, fewer than half of women ages 30-65 years insured with TennCare were appropriately screened, resulting in large disparities in screening frequency by type of insurance.

Authors: 1.Manideepthi Pemmaraju MBBS, MPH, CCRP
                2.Sheelah Blankenship, MS, CCRP
                3.Stephanie Allen, MPH, CHES
                4.Marie R. Griffin, MD, MPH

Purpose: To determine if area-level characteristics have an influence on the proportion of incident precancerous lesions (cervical intraepithelial neoplasia grades 2, 3 and adenocarcinoma in-situ, also known as CIN 2+ lesions) that are high-grade (CIN3) among Davidson County, Tennessee women.
Methods: The data for this analysis includes Davidson County, Tennessee (Nashville) women ages 18 years and older diagnosed with CIN2+, 2008-2017. Their addresses were assigned a Federal Information Processing Standards (FIPS) code and the Integrated Public Use Microdata Series (IPUMS) GeoMarker database generated area-level data for the census tract associated with the FIPS code, including proportion population in poverty, proportion single woman households, and proportion of adults who completed high school. This analysis identified the proportion of women with CIN2+ that were classified as CIN3 lesions. The variables analyzed were age (18-29, 30-39, and 40+ years) and area-level data that were organized into approximate quintiles for analysis.
Results: The proportion of women with CIN2+ that were classified as CIN3 increased with age: 32% for 18-29 years, 39% for 30-39 years, and 47% for 40+ years. Across each age group, these proportions were stable throughout all quintiles of the 3 area-level factors examined including: poverty, single woman household status, and education.
Conclusion: The proportion of women with CIN3 progression was strongly-associated with age, but unrelated to area-level factors. Almost 50% of women 40 years and older with cervical pre-cancer presented with CIN3. It is important for all women to adhere to current cervical cancer screening guidelines to prevent progression to cervical cancer.

Authors: 1. Emmanuel Sackey, MB ChB
                2. Manideepthi Pemmaraju MBBS, MPH, CCRP
                3. Stephanie Allen, MPH, CHES
                4. Sheelah Blankenship, MS, CCRP
                5. Gail Hughett, RN, CCRP
                6. Marie R. Griffin, MD, MPH

Purpose: The annual incidence of cervical cancer per 100,000 women is 8.0 in the United States, 8.4 in Tennessee, and 6.2 in Davidson County. We reviewed medical records of Davidson County women who developed cervical cancer to determine screening patterns and social barriers that may have contributed to their diagnoses.
Methods: We identified 350 Davidson County women ages 18 and older with cervical cancer from 2008-2018 through the Tennessee Cancer Registry. Using a convenience sample of 22 women to pilot a medical record review, we classified women into three categories: failure to be screened (no Papanicolaou [Pap] test in 3 years or no Pap and HPV co-test in 5 years prior to diagnosis), failure of follow-up (>1-year lapse between abnormal screening test and follow-up), and failure of the screening test (appropriate screening and/or follow-up yielded false-negative results). We also reviewed social barriers that may have prevented women from being screened or followed-up.
Results: Of the 22 women, 17 had no evidence of screening within the recommended interval, and 5 had no follow-up within a year of an abnormal screening test. Eleven had one or more social barriers that may have contributed to their development of cancer including: substance abuse, serious mental illness, history of lack of health insurance, language barriers, morbid obesity, and incarceration.
Conclusion: Overall, failure of timely screening and/or follow-up contributed to cervical cancer progression; these may also include social barriers. These results emphasize the importance of routine screening and education on cervical cancer screening guidelines.

Authors: Tamaecia Moore, MPH and Jamaica Glover, MPH

Background: Sizzurp, Purple Drank, Dirty Sprite, and Lean are all code names for an opioid-based drink consisting of clear soda, hard fruity candy and codeine, which is an opioid. Lean is often misused recreationally among youth. Excessive use of lean can lead to negative health consequences, including addiction and death. Despite its lethality, there has been little effort to raise awareness regarding this issue.
Intervention: The Shelby County Health Department (SCHD) developed a Campaign titled “Kick the Cup,” targeting youth, to raise awareness regarding the addictive nature of lean and discourage its use.
The campaign’s overall intended messages are
    1. Opioid addiction can happen to anyone
    2. Lean which is made of codeine is addictive
    3. Opt either not to begin using lean or to stop using lean
Method: Foundational elements of the campaign were developed through an internet search. Based on the research and the intended messages, a local graphic design firm developed mock images. The SCHD partnered with Shelby County Coordinated School Health to conduct 3 focus groups with 9-12th graders at a local high school to help with imagery and message refinement.
Results: The “Kick the Cup” campaign is the first youth driven campaign in Tennessee that focuses solely on lean use. The images have been used in various ways to include city bus wraps, social media, and youth focused presentations. Working with the youth to develop a campaign that sends a direct message for their peers has been the driving force behind the campaign’s success.

Authors: Emmanuel Sackey
                Tyler Nelson
                Doreen Achieng Awino Baraza
                Joseph Wambua Mulinge
                Winny Cherono

Background: Strengthening health systems in low- and middle-income countries remains an essential catalyst towards the attainment of universal health coverage (UHC). The Lwala Community Alliance (a non-profit organization, located in the Rongo sub-county of Kenya) as part of its efforts to improve the health outcomes of the sub-county’s inhabitants, rolled out a quality improvement (QI) project in six partnering health facilities to enhance the quality of health care services delivery.
Methods: The QI initiative, guided by the six building blocks of the WHO health systems framework, commences with each facility undergoing a baseline health facility assessment (HFA) followed by the implementation of the Health Improvement QI model using tools (e.g. case observation guidelines, data quality audits, patient and staff satisfaction surveys) to identify and address gaps for improvement in service delivery. The potential impact of the QI interventions is assessed biannually through the HFA.
Results: Results revealed a mean baseline HFA score of 21.6% (S.D. ; 5.60) across the health facilities and a mean HFA score of 38.8% (S.D. ; 3.96) 1-year post-baseline assessment. This represents a mean increase of 17.2% (95% CI: 11.22 – 23.18) in facility service delivery indicators.
Conclusion: QI interventions remain an important driver of improvement in health services’ delivery and can be effectively applied in resource-limited settings facilitated through the efforts and expertise- leveraging capabilities of non-profit organizations such as Lwala. Such projects aid towards the attainment of UHC and goal targets under the Sustainable Development Goal 3 (Ensure good health and well-being).

Authors: Poliala M. Dickson, PhD CHES, Moesha Overstreet, Charity Whitehead, Dimanté Givens, Kelly Ford, Dominique McDonald, & Emmonnie Henderson

Introduction: Intimate Partner Violence (IPV) includes physical, psychological, and sexual abuse by men and women toward romantic partners. These occurrences can have lasting emotional and psychological impact and often is an intergenerational occurrence. Thus, identifying risks and providing a framework for early intervention is vital. The purpose of this study is to determine risk factors for experiencing IPV based on variables addressed in the 2017 YRBS.
Methods: Data from the 2017 Tennessee Youth Risk Behavior Survey (TNYRBS) were analyzed. Complex Sample Methods logistic regression was used to calculate odds ratios and determine the variables that increase risk for experiencing IPV.
Results: A total of 2,043 students participated in the 2017 TNYRBS with 10.8% (N = 142) reporting they that have experienced intimate partner violence. We identified three significant variables in our model. Odds ratios were as followed: students who have ever drank alcohol 2.6 (95% CI: 1.3 – 5.3), students who were threatened with a weapon on school property 2.4 (95% CI: 1.4– 4.0), and students who got in a physical fight 2.1 (95% CI: 1.3 – 3.7).
Discussion: Overall, the YRBS is a great tool to analyze the extent to which adolescents experience IPV, but with the cross-sectional analysis the YRBS lacks key variables needed to assess overall risk factors of IPV. Although TN offers prevention programs for IPV, consideration should be taken to implement a more comprehensive IPV surveys in adolescents to assist in the determination of risk factors for IPV.

Authors: Jacquelyn Favours, MPH; Barbara Clinton, MSW, LAPSW; Muna Muday, MPH(c); Elisa Friedman, MS

Background: Globally recognized to improve population health and reduce healthcare expenditures, the national interest of community health workers (CHW) has grown. Many states have established statewide advocacy organizations, leveraging CHW programs to improve population health outcomes and transform care delivery. Tennessee (TN) is one of the states in the country that has yet to establish an official statewide advocacy organization. In 2016, the Meharry-Vanderbilt Alliance began a collaborative approach to explore standardizing the CHW role in TN.
Methods: To date, the TN CHW Collaborative has conducted a National Scan of Statewide CHW Associations, launched the TN CHW Statewide Survey using a snowball sampling approach and hosted a statewide meeting to establish a foundation for the collaborative.
Results: Twenty-seven (27) statewide CHW associations were examined for mission, services and organizational base advantages and disadvantages. Sixty-seven (67) organizational responses were received to the statewide survey. Ninety-six (96) CHW stakeholders attended the statewide convening, providing implications for the TN CHW Collaborative.
Conclusion: Although TN still needs to develop a statewide advocacy organization for CHWs, a collective effort to standardize the role in TN may allow for improvements in training, educating and integrating the CHW role into the healthcare system. Implications for the TN CHW Collaborative include identifying mechanisms for statewide funding and reimbursement models, as well as developing a statewide advocacy organization.

Authors: Cristina S. Barroso, DrPH
                 Eugene Fitzhugh, PhD
                 Liliana Burbano Bonilla, MS
                 Cheryl Hill, MS-MPH, RDN, LDN
                 Kelley Wilds, BSE
                 Michelle Moyers, MPH

People who are active, or who become active, have much lower risk for hypertension, type 2 diabetes, heart disease, stroke, cancer, depression, and falls with injuries. Local parks are important spaces for physical activities, and residents living in closer proximity to a park have a higher likelihood of using the par for physical activity. A collaborative effort was needed to understand how people interact with their parks and recreation environment. The University of Tennessee at Knoxville and the Knox County Health Department (KCHD) examined how Knoxville, Tennessee residents, particularly those living in at-risk areas for chronic, interact with their local park and recreation system.
A mix-methods approach consisting of both qualitative methods, which included key informant and focus group interviews and quantitative methods (such as telephone and web-based surveys, environmental audits of parks, and direct observation of physical activity behavior was used to examine how city residents interact with their neighborhood park. Males (53.8%) utilized the parks more than females (46.2%). Minority residents use the parks at a much higher proportion (33.5%) than compared to the Knoxville census (24.8%). However, residents underutilize parks, especially in low-income areas. Furthermore, people in the City of Knoxville, especially low-income residents, perceive park quality inequity.
Active use of a park can provide immediate physical and psychological benefits to person, while communities and neighborhoods benefit socially, economically, and environmentally. By promoting active visits to parks, the KCHD can help citizens engage in health-enhancing physical activity, including those living with chronic diseases.

Authors: W. Bradley Hawkins, Ph.D., M.P.H., Annie Smart, Rebecca Mohr, Marie Griffin, M.D., M.P.H.

The Vanderbilt University Master of Public Health (MPH) Program recently developed a new interprofessional education (IPE) requirement for all students. Through the combination of a didactic foundation provided through the credit-bearing course Public Health Practice and a practical experience, students learn the roles that other professionals play in providing public health services along with methods of communicating effectively with colleagues from other professions.
For the practical experience, the MPH Program works with collaborators from the university and community to establish opportunities for students to engage in on interprofessional teams. Examples include emergency preparedness exercises with local and state health departments, case competitions, service-learning courses, and other activities. Additionally, students may propose other activities to fulfill their requirement. Preceptors assess the student’s interprofessional competency through direct observation and review of the student’s report, which describes the IPE activity and how their team worked together to address a public health challenge.
The MPH Program uses REDCap (Research Electronic Data Capture) to document and track student progress toward meeting the IPE practical experience requirement. Developed at Vanderbilt University, REDCap is an open-source, secure web platform for building and maintaining online databases and surveys. Students use REDCap to choose, manage, and report their IPE activities. Preceptors use REDCap to provide student assessments. REDCap offers a collection of tools that can be tailored to virtually any type of data collection and it is available at no charge to organizations and institutions that join the REDCap Consortium.

Authors: Taylor Dula, Denise Chavez-Reyes, Dr. Katie Baker, Dr. Debbi Slawson, Lee Cutshaw, Dr. Claudia Kozinetz, Dr. Mildred Maisonet

Background: Chronic Obstructive Pulmonary Disease (COPD) is the fourth leading cause of death in the U.S. Tennessee COPD death and prevalence rates are higher than the national average with Northeast Tennessee counties exhibiting the highest prevalence. The COPD National Action Plan encourages engaging local stakeholders to support COPD awareness. Evaluating stakeholder connectedness can enhance COPD research and community-based programming outcomes and inform best practices for productive, positive stakeholder interactions.
Objectives: A COPD research team assessed stakeholder engagement using Himmelman’s Collaboration for Change model to categorize collaboration levels.
Methods: Himmelman’s model provides guidance on steps to improve efficacy and trust within partnerships by moving stakeholders through four levels: networking, coordinating, cooperating, and collaborating. Organizations are characterized by increasing engagement levels from exchanging information (networking), altering activities for common purposes (coordinating), altering activities and sharing resources (cooperating), and enhancing mutual capacity (collaborating).
Results: Thirteen stakeholders were categorized into collaboration levels: 3 networking (clinics), 7 coordinating (community-based organizations, specialist), 1 cooperating (clinic), and 2 collaborating (support group, engagement team). Preliminary results suggest networking stakeholders exchanged information by distributing study flyers. Coordinating stakeholders distributed flyers and offered educational programming to participants/clients, enhancing access to services/resources. Cooperating stakeholders extended multiple educational opportunities, increasing partnership trust and responsibility sharing. Collaborating stakeholders coordinated mutually beneficial activities and action plans.
Conclusion: These preliminary findings serve to enhance understanding and effective engagement in shared activities and action plans with stakeholders for mutual benefit. Utilizing Himmelman’s model, the research team can target communication and action towards higher levels of collaboration.

Authors: Katherine E. Hamilton, Pharm.D., Timothy Zaske, Pharm.D., Hope Randle, Pharm.D., Christopher Wilson, Pharm.D., Erica Schlensinger, Pharm.D., Wesley Gemin, Pharm.D., Tracy M. Hagemann, Pharm.D.

Background: Anecdotal reports from student pharmacists have indicated that some community pharmacies refuse to dispense buprenorphine to patients with a valid prescription. Currently, little information on student perceptions of this conduct exists. This study explores student pharmacists' perceptions and experiences concerning dispensing buprenorphine-containing prescriptions to patients with substance use disorder
Methods: An online survey was distributed to student pharmacists at The University of Tennessee Health Science Center College of Pharmacy. Descriptive statistics were used to quantify perceptions.
Results: Two hundred thirty-five (33.5%) students completed the questionnaire. Approximately 30% indicated that they had been encouraged by a precepting pharmacist to lie to a patient about buprenorphine stock, and 60% were encouraged to lie to patients about stock of any controlled substance. About 68% of students agreed with the statement that chemical dependency is a disease not a moral weakness and 28.5% felt confident in their ability to offer substance abuse services to their patient population. Interestingly, 54.5% of our students indicated that they had a family member or a close friend with a substance use disorder.
Conclusion: This study provides insights into students’ experiences and perceptions of buprenorphine dispensation in community pharmacies in Tennessee. Overall, UTHSC student pharmacists are acutely aware of the issues associated with substance use disorders in the community setting and many have been personally affected through family and friends. These results reveal a need to improve pharmacy education in substance use disorders and to employ teaching methods that discourage negative stigma surrounding it’s treatment.

Authors: Michael Schmidt, PhD and Satish Kedia, PhD, Social and Behavioral Sciences Division, The University of Memphis School of Public Health

Domestic violence can lead to severe injury, physical health problems, mental trauma, and psychological disorders. Survivors often rely on support from family, friends, and professionals to identify resources to end abuse and facilitate recovery. Our study explored how minority women survivors acquired information to locate and utilize agency services to escape abuse and recover from trauma. In-depth interviews were conducted with minority women survivors (n=29) who were in counseling. Data were analyzed using grounded theory methodology. The findings revealed that information from friends, family, neighbors, and faith leaders helped survivors find services. For others, police were critical in directing them to crime victims’ and domestic violence agencies. Still other women sought information independently while evading their abusers’ monitoring. Prior to receiving services, survivors knew little about various forms of domestic violence, other than physical assault, or types of help available. Participants reported little exposure to public health campaigns for domestic violence awareness or available services and only found one or two trusted supporters with such knowledge. While survivors’ need more information, so do their supporters—people to whom survivors often turn for information. Furthermore, it is important survivors be assured that law enforcement and service agencies’ primary responsibilities are to serve them, not take their children away or deport them. These participants also provided their perspective on messaging, media selection, and placement for awareness campaigns. Effective media campaigns should employ radio, TV, and bus wraps and place materials in food pantries, clothes closets, health departments, and SNAP offices.

Authors: Crowe, J., Powers, P., Houze, G.

Background: As of June 21, 2019, Tennessee Department of Health (TDH) has identified 1,791 cases of hepatitis A in TN, including 80 in Knox County. In order to stem the outbreak, KCHD mobilized our HCV Program and clinical teams to organize offsite vaccine clinics. Because our HCV Program has been engaged in robust public health outreach since 2016, community partnerships and individual patient relationships built over the past three years have greatly facilitated the response to this outbreak.
Methods Since April 2018, KCHD has administered 3,278 hepatitis A vaccines at 112 community clinics in jails, homeless shelters, street outreach, food banks, alcohol/drug treatment programs, methadone clinics, syringe services programs, and other locations. These clinics provide an opportunity to engage community members who may not otherwise come to a health department. In addition to outreach, patients screened in KCHD clinics are being offered hepatitis A vaccine. Over 6,300 doses of hepatitis A vaccine have been given to adults in Knox County Since April 2018, a 400% from 2017. Conclusions Through offsite vaccine clinics, KCHD has curbed the hepatitis A outbreak in Knox County, provided public health education to thousands of community members, and strengthened partnerships. When public health takes it to the streets, we build trust with patients who are difficult to reach due to poverty, homelessness, substance misuse, and other issues. Engaging with these populations and the agencies that serve them on their turf demonstrates that public health must take a proactive approach to meeting the needs of the community.

Authors: Angiezel Merced-Morales, Generosa Kakoti, Uvonne Leverett

Background: Experiencing stressful life events during pregnancy has negative consequences for both mother and infant, and may increase the likelihood of Postpartum Depressive Symptoms (PDS). This study examines whether prenatal stress and adverse birth outcomes are associated with PDS.
Objective: To determine the influence of prenatal stressors and whether mothers with adverse birth outcomes are more likely to experience PDS when compared to those without.
Methods: Using weighted data from the Tennessee Pregnancy Risk Assessment Monitoring System (2012 to 2015), mothers were categorized into two groups: those with adverse birth outcomes (having a low birthweight baby (< 2500 grams) or having a pre-term delivery (gestation<37 weeks)) and those without. Multivariate logistic regression was utilized to study the association between PDS and prenatal stressors (economic, relationship, and traumatic), history of depression and other demographic characteristics of the mothers in the two groups.
Results: Overall logistic regression showed that mothers with adverse birth outcomes were 33.0% more likely to experience PDS compared to those without (OR 1.33, 95%CI: 1.01–1.76).
Mothers from both groups were more likely to experience PDS if they had history of depression or economic stressors.
Mothers without adverse birth outcomes were more likely to experience PDS if they had relationship stressors (OR 1.99, 95%CI: 1.41, 2.78).
Conclusion: Mothers with adverse birth outcomes are more likely to experience PDS when compared to those without. However, results suggest that all women should be routinely screened during pregnancy for a range of stressors and encouraged to seek help for PDS.

Authors: Aubrey Ray and Laurie L. Meschke

Background: The Centers for Disease Control and Prevention endorse a series of evidence-based sexual violence prevention programs through their STOP SV technical package including Coaching Boys into Men, Safe Dates, and Shifting Boundaries. Ongoing outcome evaluation of these programs is essential to ensuring that participants are achieving the intended learning objectives. Further, it is critical that the evaluation measures reflect the learning objectives, curricular activities, and constraints of time and setting.
Objective: We describe the systematic process and outcome of identifying and prioritizing validated measures for a state-wide evaluation of Coaching Boys into Men, Safe Dates, and Shifting Boundaries.
Methods: Our identification and prioritization steps include the following: (1) Develop table of learning objectives by session and activity; (2) Review evaluation measures included with curricula; (3) Obtain measures from first authors of published evaluations; (4) Identify relevant, validated measures from the literature; (5) Prioritize measures based on relevance, administration time, and repetition of learning objectives across sessions; and (6) Incorporate curriculum facilitators’ feedback.
Results: Each curriculum includes 1-12 sessions with 2-7 learning objectives per session. Final selection of evaluation measures includes an average of 14 measures per session related to curriculum learning objectives and activities (range: 6-18 measures per session).
Conclusion: Identifying and prioritizing validated measures for program evaluation can benefit from a systematic approach. Tools, strategies, and challenges of this process provide an opportunity to enhance the accuracy and validity of outcome evaluation.

Authors: Aubrey Ray, Laurie L. Meschke, Kristina Kintziger, Soghra Jarvandi

Background: Over 80% of Appalachian counties have higher rates of diabetes than the national average. Diabetes self-management challenges in Appalachia have been associated with poor healthcare access, low education, high poverty rates, and cultural factors (e.g., calorie-dense diets and resistance to seeking support). In turn, Appalachian residents with diabetes face increased risk of complications. We sought to identify evaluated type 2 diabetes self-management programs in Appalachia and analyze them for delivery method, structure, content, and outcomes.
Methods: We conducted a systematic review in six databases. Selection criteria included diabetes self- management education programs for adults with type 2 diabetes (T2D) in Appalachian counties. Initial searches identified 141 articles and seven met the inclusion criteria.
Results: Delivery method reflected a combination of individual sessions, group sessions, and telephone calls. Program facilitators included pharmacists, nurses, dietitians, counselors, and diabetes educators. Sessions focused on behavior modification (e.g. diet, physical activity), medication management, connection to resources, and scheduling clinic visits. Evaluation designs were randomized trial, nonrandomized trial, and cohort study. Five programs significantly improved participants’ lifestyle behaviors, glycemic control, diabetes knowledge, and/or self-efficacy regarding self-management behaviors.
Discussion: Most of the educational programs were effective in supporting the self-management efforts of adults with T2D in Appalachia. Despite the documented need for diabetes education in Appalachia, very few studies on the effectiveness of these programs exist. Future research should assess programs in other parts of Appalachia and identify program characteristics that most contribute to improved health for Appalachian people.

Authors: Brook McKelvey, MA, MPH, Abraham Mukolo, PhD, Justin Gatebuke, MPH, Anh Ngo, MD, PhD

Objectives: This analysis describes the trend in smoking among pregnant women with reference to the Baby & Me Tobacco Free Program (BMTF) implemented since January 2016 in Davidson County, Tennessee.
Methods: Maternal smoking was abstracted from birth records for Davidson County from 2013 through 2017. The annual rate was calculated as a percentage of pregnant women who smoked in any trimester during pregnancy over the total live births, stratified by maternal age, race/ethnicity, maternal education, and parity. Percent change in the smoking rate between 2013 and 2015 (before the intervention) and between 2015 and 2017 (after the intervention roll-out) was compared.
Results: Overall, the percent of mothers who smoked during at least one trimester of pregnancy declined steadily from 8.5% in 2013 to 6.1% in 2017. The decline was greater between 2015 and 2017 (18.3%) than between 2013 and 2015 (12.6%), coinciding with the time of the intervention roll-out. The decline varied substantially by maternal age, race/ethnicity, education, and parity. Between 2015 and 2017, the decline in maternal smoking in Davidson County (18.3%) was significantly greater than the decline for the State of Tennessee (11%) and for the United States (8%).
Conclusion: While the decrease in the prevalence of maternal smoking in Davidson County precedes the implementation of the BMTF program, the decline was stronger following the intervention roll-out. This is suggestive, but not conclusive, of intervention impact. The declining smoking rate needs to be further monitored to see if it is sustained in 2018 and beyond.

Authors: Rachel Depperschmidt

Effective chronic disease management for the uninsured and underserved population is missionally important to Church Health. This study sought to characterize demographic risk factors associated with uncontrolled diabetes within the Church Health diabetic patient panel. A patient’s diabetes was considered uncontrolled if their most recent HbA1c reading was greater than 9.0%, as measured from January to December of 2018. The proportion of prevalence, uncontrolled disease rates, and uncontrolled odds ratios, and 95% confidence intervals (CI) were calculated across the demographic characteristics of race, gender, age, and insurance status. Chi-squared analysis showed race, age, and insurance status may be related to diabetes diagnosis. Non-Hispanic Blacks were more likely to have poorly controlled diabetes when compared to Non-Hispanic Whites after adjusting for gender, age, and insurance status [AOR: 1.54 (1.13-2.10 95% CI]. Age groups of 45-64 and 65+ had less risk for uncontrolled disease when compared to those age 18-44 [AOR: 0.65 (0.49 – 0.86 95% CI)]; [AOR: 0.29 (0.19-0.44 95% CI)], respectively. Some Church Health patient demographic subgroups may be at higher risk for uncontrolled diabetes including those age 18-44 and Non-Hispanic Blacks. Odds of uncontrolled diabetes did not differ across insurance status after adjusting for race, age, and gender, reflecting and effective care model for uninsured patients at Church Health.

Authors: Brett Eaton, Brittany Jackson, Johanna Krygsman, Cole Powers, DNP, FNP-BC

Background and Significance: Females in substance use disorder recovery have an increased risk of sleep impairment due to prior substance abuse and rigors of the recovery process. Poor sleep quality can adversely impact mental and physical health outcomes, as well as the recovery process.
Statement of Purpose: VUSN students aimed to improve sleep satisfaction, as defined by quality and quantity, and increase confidence in applying knowledge or improving sleep satisfaction. The projected outcome was an average decrease of two points on the Pittsburgh Sleep Quality Index (PSQI) and an average confidence increase of 30% for each intervention.
Methods: Eight bi-weekly interventions focused on health topics relevant to improving sleep quality, utilizing PowerPoints, educational games, and teach back. Sleep quality was measured prior to the first and following the final intervention using the PSQI. Confidence in applying knowledge was measured by pre and post surveys each intervention.
Results: An average of nine females, age 20 to 45 years old, participated during each bi-weekly session, with a reported average increase of 29.8% in confidence to apply knowledge.
Limitations: A lack of consistency in participants throughout the project posed difficulty in tracking longitudinal data. Potential confounding factors impacted confidence outcomes, i.e. co-occurring recovery.
Discussion: Sleep satisfaction was affected negatively by history of substance use disorder, supporting the implementation of interventions to improve sleep. Over the course of the project participant- reported confidence to implement sleep improvement interventions increased. Future projects should address weekly, rather than longitudinal change in sleep quality.

Authors: Fatimah B. Ali, MCHES, MPH, Ph.D, Walden University
                Kimberly G. Dawson-Lawson, Ph.D., MD, University of Phoenix.
                Patrick Tschida, MPH, DrPH, The John Hopkins University.
                Vasileios Margaritis PhD, National and Kapodistrian University of Athens.

Low-income immigrants in the United States experience declining health with increasing length of stay in the country. Their declining health over time has been associated with increased smoking, obesity prevalence, and higher risk for developing diabetes and heart disease. How immigrants perceive their body weight and size, influenced by social interaction, culture, gender, and acculturation is also significant to healthy weight maintenance. Not knowing one’s healthy weight could result in body weight misperception and resistance to attaining a healthy weight. The aim of this qualitative study, based on the social constructivist framework, was to understand Nigerian women immigrants’ (NWI’s) body weight self-perceptions (BWSPs), their experiences with weight changes after immigration, and what it meant to them within their historical, immigration, and cultural contexts. Data were collected from audio recorded interviews of 8 purposefully selected NWIs living in Middle Tennessee. After a process of content analysis of transcribed interviews using NVivo, participants’ BWSPs were described and interpreted using hermeneutic phenomenology. The key findings of this research were that participants perceived themselves overweight compared to when they had just immigrated to the United States; believed that age, marriage, change in environment and food contributed to their weight gain; and were not accepting of their weight gain, which led them to eating healthier and moving more in order to lose weight. Findings from this research have social change implications. Health disparities could be reduced by disseminating timely health information to immigrants to educate them about nutrition and physical activity behaviors.

Authors: Zach S. Farley and Andrew Bailey

Background: Attention Restoration Theory (ART) states that natural environments induce a mentally- restorative, stress-reducing psychological response. Advancement of mobile electroencephalogram (EEG) allow for observation of cortical correlates (CCs) of ART as individual(s) interact with external environments. There is limited research using CCs to observe changes in emotional state while in urban settings. We seek confirmation that passive interaction with green space can induce cognitive benefits during a routine walk through an urban environment.
Methods: A convenience sample (n=33) completed brief (<20-minute) walking routes in an urban setting while wearing mobile EEG headsets and activity bands. CCs, heart rate, and geospatial location were continuously collected throughout the walk. This allowed for tracking of CCs in relation to location within the urban environment. Raw EEG data were transformed into four mental states: focus, motivation, arousal, and inward attention and compared to geospatial location. The data were Z-scored for standardization to allow for Geographic Information System input and analysis.
Results: Preliminary results provide evidence of lower focus and arousal, and increased inward attention (meditative state) and motivation (valence) when encountering green space. This trend is reversed when encountering elements of the built environment (e.g. roads, traffic noise, etc.). These findings are consistent across various walking routes in accordance with ART.
Conclusion: Our findings aid the advocacy of urban green space as a mentally-restorative and mood- enhancing in passive reflection. This provides preliminary evidence for incorporating urban green space planning as a part of a comprehensive strategy to enhance population mental health.

Authors: Kadi Bliss, PhD, CHES and Kristen Brewer, MS, Doctoral Candidate

With 82% of American households using the internet to obtain information and the massive amount of false health-related information on the internet (U.S. Census Bureau, 2018), it is imperative for public health students to learn how to properly evaluate information on the World Wide Web. This presentation will discuss a collaborative approach to teaching health literacy and information evaluation by utilizing two undergraduate public health courses; communication and advocacy, and consumer health. During the fall 2018 semester, students in communication and advocacy were assigned a project whereby they hosted a health fair on campus. As part of the health fair, student groups were required to develop infographics and interactive educational materials on topics such as sexually transmitted infections, suicide prevention, healthy eating, physical activity, and sleep. Materials had to be targeted to the undergraduate population, and students conducted research to obtain current, reliable, relevant sources on their topic. Research proposals containing multiple sources were shared with peers in the consumer health class, and proposals were evaluated for clarity of topic addressed, justification of any facts or statistics included, active hyperlinks for web sources, and whether or not sources used were current, valid and reliable. Peer feedback was then sent back to communication and advocacy students and health fair materials were created based on resource reliability feedback. During this presentation, project details will be shared and lessons learned will be discussed.

Authors: Annabel Henley; Nichol Ooten; Letha Hancock, NP; Libby Spoon, RN

Background: There are very few clinical guidelines available that outline reproductive health needs for males. Public health efforts have not focused on engaging this population. In 2018, the Knox County Health Department (KCHD) decided to use suggestions from a National Family Planning Training Center toolkit to develop a modified version of a male friendly clinic. The modifications were designed to more successfully engage their population.
Methods: KCHD decided to offer family planning services to males in the Communicable Disease Clinic (CDC). Using project management principles, clinic managers met with administrators, outlined the program and received support and encouragement. The main objective was to integrate reproductive education into the STI visit. Specific goals included referring males to a no cost vasectomy program and providing written information/education about partner-based options. A short history form specifically for men was created along with a specific visit note. Training needs were determined and scheduled. A specific RN was identified to pilot and champion the program.
Results: Audits indicated a successful pilot. The program was expanded to all providers in the CDC. In ten months, average monthly male family planning visits increased from 0 to 90. Vasectomy referrals increased by 25%.
Conclusion: The initial program was expanded to include all Knox area clinics. A new program designed to offer men more in-depth reproductive health visits with Nurse Practitioners is in the planning/development phase. The program was presented at the 2019 Statewide Spring Update and is now being implemented in health departments across the state.

Authors: Umar Kabir, DVM, MPH, Ph.D.(c)

Existing research about the effects of Psychological Distress (PD) on breast cancer screening has been mixed. Early studies suffered from various limitations, while subsequent studies designed to address these limitations dichotomized PD into Severe Psychologically Distress (SPD) or No Psychological Distress (NPD), and thus failed to capture individuals with Moderate Psychological Distress (MPD). New evidence suggests that individuals with MPD, who typically were included among individuals with NPD in prior studies, have healthcare utilization patterns that are comparable to individuals with SPD. We examined the use of mammography among individuals with PD using both the dichotomous and trichotomous classifications of PD.
Methods: The study population comprised 58,495 women aged 40 years or older who participated in the National Health Interview Survey from 2013 to 2017. The Kessler-6 PD index score (0-24) was dichotomized (0-12 NPD; >13 SPD) and trichotomized (0-5: NPD; 5-12: MPD; >13 SPD). Two multivariate logistic regressions were conducted for the dichotomous and trichotomous PD categories. Andersen's Behavioral Model of Health Services Use guided the choice of covariates. Data analysis was conducted using SAS version 9.4.
Results: Our study showed 4.7% had SPD and 17.9% had MPD. The latter MPD group was included in the NPD group in the dichotomous analysis. In the dichotomous analysis, women with SPD (adjusted-odds ratio(AOR): 0.81; 95% CI: 0.73-0.89) were less likely to have received a mammogram than those with NPD. In the trichotomous regression, women with SPD (AOR:0.8; 95% CI: 0.72-0.88) and MPD (AOR: 0.93; 95% CI: 0.87-0.99) were both less likely to have had a mammogram than those with NPD.
Conclusion: Prior studies that included individuals with MPD among those with NPD underestimate the effect of SPD on mammography. Moreover, these studies underestimate the importance of efforts to enhance mammography uptake among both women with MPD and SPD.

Authors: Michael Booth, Leah Branam, Naomi Chan, Emily Friedman, Carrie Plummer, Kate Reidy, Jillian Scott, Molly Shine, Rachael Tanner-Smith, Nathaniel Whelton

Background: The Clinic at Mercury Courts (CMC) is a nurse-managed, community health center serving low-income patients experiencing homelessness. In 2017, 68% of CMC patients lived 200% below the poverty threshold and 38% experienced extended periods of homelessness. These patients also report health-harming legal needs (HHLNs), which currently are beyond the scope of CMC.
Purpose: To investigate how best to integrate a medical-legal partnership (MLP) into CMC.
Methods: Students established relationships with key stakeholders, including: 1) CMC leadership, staff, and patients; 2) Belmont Law faculty, and; 3) Legal Aid. After obtaining IRB approval students conducted a patient focus group to identify commonly experienced HHLNs. Qualitative data was transcribed, coded, and analyzed for emergent themes.
Results: Twelve participants identified tangible (lack of transportation, mobility limitations) and structural (powerlessness, lack of dignity) barriers to accessing care, as well as HHLNs, including: lack of health insurance, disability, and records expungement. Participants highlighted the need for continuity and follow-through to establish a sense of community, compassion, and trustworthiness.
Limitations: Focus group format necessitated a small sample size and was limited to English-speaking patients.
Discussion: Analysis of the focus group data identified patient interest in and need for specific medical- legal services. Given the importance of continuity and follow-through for patients, a continuous and structured leadership team will provide stability as students cycle through each academic year.

Authors: Genoa Clark, MPPA
                Lindy Clapp, MD
                Ashley Myrick, BSSW
                Greg Stafford, BSN, RN
                Lesly-Marie Buer, PhD, MPH

Choice Health Network (CHN) founded one of the first three legal syringe access programs in Tennessee after the 2017 passage of the Safe Syringe Act. The syringe access program began service delivery via a mobile unit in April 2018 and introduced a second site in August 2018. In 2019, CHN expanded services under the harm reduction model to address more of the physical, mental, and social needs of our friends and neighbors who use drugs. Between January and May 2019, CHN saw 1,986 unique participants, provided 2,526 naloxone doses, and performed 436 point-of-care HIV and HCV tests. In the spring of 2019, the harm reduction team added an onsite nurse who performs phlebotomy for confirmatory (RNA) HCV testing, a service nearly 100 participants used in the first two months of testing. The HIV positivity rate for those tested at the mobile unit is 1% and the HCV positivity rate (both Ab+ and RNA+) is 63%. Because they use drugs, many of our most vulnerable community members have been stigmatized, ignored, and forgotten by traditional healthcare institutions. With help from likeminded community partners at the state, local, and neighborhood level, the CHN harm reduction program has created a nonjudgmental space for people who use drugs to address their health needs. Making screening routine, accessible, and integrated into syringe access has shown the desire and willingness of the community to educate and take care of one another.

Authors: Brian L. Winbigler, Pharm.D., MBA

Objectives: Provide elementary school children with knowledge and information on tobacco and the harmful effects on our health and the environment.
Methods: This is a structured course utilizing puppets to offer children positive alternatives to tobacco in a practical and engaging format. The six 30-minute sessions were delivered in schools over six weeks by the health department, community volunteers, and pharmacy students. Six jungle puppets illustrate a world where tobacco can impact their lives. Each lesson aims to influence a specific value or perception related to tobacco use. Pre and post surveys addressing six questions were given to participants before and after completing the six week program. A pooled t-test was used to minimize bias and analyze survey results for statistical significance. Funding for the Tobacco Tales curriculum which included hand puppets, song, coloring page and a certificate of accomplishment was provided by a local community coalition. Coordination with local schools, scheduling, and general administration of the program is facilitated via the local health department.
Results: To date 268 students have participated in the Tobacco Tales program with an additional 150 expected to finish at the end of this month. The preliminary data shows statically significant changes in perception related to tobacco and smoking across all six values measured. The program has been well received by school administration, teaching staff, and child participants.
Conclusion: Presenting educational materials in a fun, interactive, familiar way to elementary school children can help form, change, and strengthen health knowledge and understanding.

Authors: Karen Squier, OD, MS

Patient understanding of his or her diagnosis is the first step in vision rehabilitation(1). Patient awareness of resources or self-identification of having “low vision” may also limit a patient’s choice to pursue low vision rehabilitation (2,3) . The aim of this study was to assess patient understanding of low vision in a Memphis Low Vision Clinic.
Methods: 50 patients (27 females, 23 males) from the Low Vision Service in The Eye Center at Southern College of Optometry consented to a survey administered before and after their low vision exams. Descriptive statistics were used to analyze the respondents’ answers.
Results: 28% of patients stated they did not know the purpose of their low vision examination upon arrival to the clinic. 28% stated they did not know what the term “low vision” meant, however 92% patients felt they had low vision when the definition of low vision was read to them. Posttest, all patients stated they understand the purpose of a low vision exam, and only 86% felt they would be classified as “low vision patients” after their examination.
Conclusion: This study suggests that patients suffering from visual impairment may not know services that are called “low vision” may be appropriate avenues to receive vision rehabilitation. Further assessment into health literacy and patient education may help to improve these outcomes.

Authors: Kimberly DeCosta and Tara M. Prairie

Introduction: The purpose of this study is to determine to what extent playing multiple sports decreases the likelihood of an athlete getting injured.
Methods: Data was collected utilizing a quasi-experimental mixed methods approach with a quantitative survey and phenomenological semi-structured interview questions.
Results: The results of a chi-square test for independence (with Yates Continuity Correction) revealed a significant association between playing multiple sports in high school and a decrease of future injuries, x2 (8, n = 31) = .58, p = .001, phi = .58. Of the athletes that had no injuries during their college career, 50% of them were those that played 5 or more sports during high school, 26.9% played 2 to 3 sports in high school, and 23.1% played 1 to 2 sports in high school. Specific to the interview (n = 1), advantages of being a multisport athlete as noted by a physical therapist include prevention of overuse injuries and increased coordination. However, the interviewee could not pinpoint when it would be safest for a child to start specializing in one sport.
Conclusion/Policy Implications: Based on preliminary findings, playing multiple sports may be beneficial to overuse injury prevention. Next steps for this project involve a validity and reliability study to determine content validity and internal consistency of the measurement. Policy implications could include recommending high school athletes explore other options other than their specialized sport.

Authors: Olanrewaju, Folawiyo; Vanhook, Patricia*; McKenzie, Stacey W

Purpose of Study: The prevalence of Hepatitis C Virus (HCV) in the US is estimated at 3.5 million with 18,153 deaths in 2016. The incidence of HCV in Tennessee exceeds the Healthy People 2020 goal (2.3 per 100,000). This descriptive study ascertains the HCV prevalence and usefulness of screening in medical outreach settings (MO) compared to indigent healthcare clinics (IHC) in northeast Tennessee.
Methods Used: Between April 2017 – February 2019, routine, opt-out HCV testing of adults (n=250) was performed at 4 IHC and 3 MO sites in the Tri-Cities, TN region. During screening, demographic information was collected and the de-identified data was analyzed using Statistical Analysis System (SAS 9.3).
Summary of Results: A total of 250 clients were screened for HCV. The majority of clients screened were non-Hispanic whites 228 (91.20%); females 136 (54.40%); young adults 131 (52.40%) and at IHC clinics 187 (74.80%). Screening showed HCV antibody prevalence of 14.8%. The majority of positive cases were young, female, non-Hispanic whites. The prevalence at the IHC clinics and MO settings were 36 (97.30%; P=0.0006) and 1(2.70%) respectively.
Conclusion: This analysis shows higher yield of targeted HCV screening at IHC clinics. Focused HCV screening is critical in this era of opioid epidemic. The use of case control or cohort study designs to establish causality is recommended for improving focused HCV screening.

Authors: Chaitra Subramanya, MPH ¹, Melody Evans, MBA², David Sweat, MPH³, Courtney Tipper, MHA4, Cedric Robinson, MHA5, Shelby County Health Department, Memphis, TN

Background: Tennessee has reported an outbreak of Hepatitis A disease since May 2018. The Shelby County Health Department’s STD Clinic vaccinated less than 1% (N = 198) of all patients seen between May 2018-March 2019. A Quality Improvement (QI) project was initiated to improve Hepatitis A vaccine (HAV) uptake among patients seeking services at STD clinic.
Objective: To increase HAV uptake among at-risk Shelby County patients visiting STD clinic for services during April – May 2019.
Methods: In March 2019, the QI Team worked with the STD clinic staff to create standard operating procedures and a revised workflow process with the marketing strategy of asking patients multiple times if they are interested in receiving HAV. Patient consent form (Acceptance/Declination) and Clinical Staff form (Patient Screening Tool) were created to document data.
Results: In April, 506 (71.9%) patients were in need of HAV and among them, a total of 114 (22.5%) patients were administered HAV. In May, around 585 (74.4%) patients were in need of vaccination among them a total of 113 (19.3%) patients were administered HAV. Results show a significant increase in HAV numbers from baseline.
Conclusion: With standardized processes, increased marketing, training, and timely data collection, our efforts to increase Hepatitis A vaccination uptake among at-risk patients visiting Packer Clinic was successful and we have “ADOPTED” it.