Sunday, August 01, 2021

Study shows how US immigration policy can have domestic health effects

The Trump administration's "Muslim ban" negatively affected the health of people from targeted nations living in the US

Peer-Reviewed Publication

BROWN UNIVERSITY

PROVIDENCE, R.I. [Brown University] — After a controversial federal order suspending travel to the U.S. from seven Muslim-majority countries was signed in 2017, the number of visits to emergency departments by Minneapolis-St. Paul area residents from those nations increased significantly. And that development followed an already marked increase in primary care visits by members of the same population, which began in November 2016 following an election season characterized by significant anti-immigrant rhetoric.

That’s according to a new JAMA Network Open study led by a Brown University health services researcher in collaboration with a group of public health and health services researchers from across the country. Those changes in health care utilization likely reflected elevated cumulative stress due to an increasingly hostile climate toward Muslims in the U.S., the authors say.

“It’s clear that U.S. immigration policies can have significant effects on the health of people living here in the U.S.,” said Dr. Elizabeth Samuels, corresponding author of the study and an assistant professor of emergency medicine at Brown University’s Warren Alpert Medical School. “In this case, we saw a rise in emergency department visits among people from nations targeted in the ban as well as a rise in missed appointments from people from Muslim majority countries not named in the ban. I think that that's indicative of the kind of rippling health effects these types of policies can have.”

On Jan. 27, 2017, one week after taking office, President Donald Trump issued Executive Order 13769, “Protecting the Nation from Foreign Terrorist Entry into the United States.” Samuels said that when the order took effect, she and other medical colleagues wondered how the immigration policy might affect the health of people from Iran, Iraq, Libya, Somalia, Sudan, Syria and Yemen (the included countries) living in the U.S.

Similar policies have exacerbated levels of discrimination, hostility and “othering” that Muslims in the U.S. experience, she said, and research has shown that increases in hate crimes and hostility directed toward Muslims negatively impacts their health. For example, Samuels notes, after the Sept. 11 attacks, rates of anxiety, depression and low birth weights increased among Arab Americans.

However, because of the way demographic and health data is collected in the U.S., Samuels wasn’t sure if the changing health behaviors of Muslims in the U.S. was even something that could be measured, because health care administrative databases are not mandated to collect information on religious affiliation.

“One of the biggest challenges for those of us who work in Muslim communities is to try to figure out how to find Muslim Americans within U.S. health care databases, because unlike race, ethnicity or even sexual or gender identity, religious identity is not routinely captured or recorded,” said Dr. Aasim I. Padela, a study author and professor of emergency medicine, bioethics, and the medical humanities at the Medical College of Wisconsin. “And in an emotionally-charged post-9-11 environment in which Muslims are often stigmatized, there’s actually a disincentive to offer up this kind of information.”

The result is that while there are smaller studies involving these communities, there is a lack of population-level data. But in researching potential study populations, Samuels discovered that health care provider and insurance company HealthPartners collected country of origin data on patients visiting clinics and hospitals in the Minneapolis-St. Paul area, home to the largest Somali Muslim community in the U.S.

In conducting the study, the researchers analyzed the HealthPartners database and grouped 252,594 patients receiving care between January 2016 and December 2017 into three groups: adults born in one of the nations included in the executive order; adults born in Muslim-majority nations not listed in the order; and U.S.-born non-Latinx adults. They compared changes in primary care and emergency department visits, missed scheduled clinic appointments, and visits they categorized as “stress-responsive,” among individuals from nations included in the executive order from one year before to one year after it was issued.

They found that after the order was issued, there was an immediate increase in emergency department visits among people from the included countries. The study estimates that 232 additional emergency department visits were made by people from Muslim ban-targeted nations in the 360 days after the Muslim ban was issued beyond what would have been estimated if emergency department utilization had followed a trend similar to that seen by U.S.-born non-Latinx adults. This was especially pronounced in the first 30 to 60 days after the ban was issued.

Study results suggested that adults born in Muslim-majority nations not listed in the order missed approximately 101 additional primary care appointments during the time period beyond what they would have expected to miss if following the trend of non-Latinx U.S.-born people.

Some forms of health care utilization were also noted to change even before adoption of the ban. Clinic visits and stress-related diagnoses increased before the executive order was issued, most notably after the 2016 presidential election.

Despite the statistically significant increase in emergency visits, Samuels says she was surprised not to see larger overall health effects, especially related to stress, in the wake of the order. In the study, the researchers discuss why this might be, and how potential changes in health care utilization after the order may have been attenuated by factors specific to Minneapolis-St. Paul. The very factor that made it possible to focus on this population in the study — a concentrated, civically engaged community of Somali-Americans and Muslims — may have also offered protection against political stressors, they note, as the ability to secure benefits through social structures, like community associations or civic organizations, may attenuate the negative health impacts of discrimination.

Padela said that while discrimination is known to impact health care behaviors, measuring the health effects of discrimination in an aggregate fashion, especially for a population that isn’t quantified by health care groups, is tricky.

“This study was able to not only identify a Muslim community within the health care system, but also to analyze their health care behaviors before and after a policy-level decision widely recognized as discriminatory,” he said.

Additional study authors included Dr. Pooja Agrawal, Gregg Gonsalves, Lilla Orr, Dennis Wang and Elizabeth B. White from Yale University; Dr. Altaf Saadi from Massachusetts General Hospital; Dr. Michael Westerhaus from HealthPartners Center for International Health; and Dr. Aarti D. Bhatt from the University of Minnesota.

JOURNAL

JAMA Network Open

DOI

10.1001/jamanetworkopen.2021.18216

METHOD OF RESEARCH

Observational study

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Health Care Utilization Before and After the “Muslim Ban” Executive Order Among People Born in Muslim-Majority Countries and Living in the US

ARTICLE PUBLICATION DATE

30-Jul-2021

Trump’s ‘Muslim ban’ harmed health of Muslim Americans, study finds

Peer-Reviewed Publication

YALE UNIVERSITY

New Haven, Conn. — When former President Donald J. Trump issued an executive order in 2017 banning Muslims from select countries from traveling to the United States, the sweeping decree quickly rippled down to affect health outcomes for Muslim-Americans, Yale researchers say.

A new study by the Yale School of Public Health and partner institutions found that a significant number of people in the Muslim community in the Minneapolis-St. Paul area skipped their primary care appointments after the ban, and there was also an increase in their visits to the emergency department.

The findings, published July 30 in the journal JAMA Network Open, provides evidence that an abrupt change in federal immigration policy can directly affect health outcomes among people residing in the United States legally. The study is one of the first to measure the causal impact of how policy changes such as these may affect Muslim American immigrant and refugee communities.

Before the ban, primary care visits and diagnoses of stress for individuals from Muslim-majority nations were on the rise, the researchers said. In the year following the ban, however, there were approximately 101 missed primary care appointments beyond what would have been expected among people from Muslim majority countries not named in the ban. There were also approximately 232 more emergency department visits by individuals from nations targeted by the ban than would have been predicted.

“This offers support to the thesis that the Islamophobia fostered by former President Trump affected the health of Muslim-Americans in the United States and that immigration policies can have indirect and unexpected consequences for those targeted by such actions,” said Yale School of Public Health Associate Professor Gregg Gonsalves, the study’s senior author.

Trump issued Executive Order 13769, “Protecting the Nation from Foreign Terrorist Entry into the United States,” shortly after his inauguration to limit the travel of refugees from Iran, Iraq, Libya, Syria, Sudan, and Yemen. The ban was upheld by the U.S. Supreme Court in 2018, only to be revoked by President Joe Biden in January 2021.

For the new study, the researchers examined more than 250,000 adult patients treated at a Minneapolis-St. Paul HealthPartners primary care clinic or in emergency departments in 2016 and 2017. These patients belonged to one of the following three groups: 1) born in a Muslim nation targeted by the ban, 2) born in a Muslim-majority nation not listed in the ban, and 3) non-Hispanic and born in the United States.

The study was co-authored by Pooja Agrawal, assistant professor at Yale School of Medicine, and Elizabeth White, a doctoral student at the Yale School of Public Health, along with researchers and health practitioners from Brown University, Massachusetts General Hospital, Medical College of Wisconsin, HealthPartners Center for International Health, University of Minnesota, Harvard University, and the Yale National Clinician Scholars Program.

JOURNAL

JAMA Network Open

METHOD OF RESEARCH

Data/statistical analysis

SUBJECT OF RESEARCH

People

ARTICLE PUBLICATION DATE

30-Jul-2021

Original Investigation

Public Health

July 30, 2021

Health Care Utilization Before and After the “Muslim Ban” Executive Order Among People Born in Muslim-Majority Countries and Living in the US

Elizabeth A. Samuels, MD, MPH, MHS¹; Lilla Orr, MA²; Elizabeth B. White, BA³; et alAltaf Saadi, MD, MSc⁴; Aasim I. Padela, MD, MSc⁵; Michael Westerhaus, MD, MA⁶; Aarti D. Bhatt, MD⁷; Pooja Agrawal, MD, MPH⁸; Dennis Wang, MD, MPH⁹; Gregg Gonsalves, PhD³

Author Affiliations Article Information

JAMA Netw Open. 2021;4(7):e2118216. doi:10.1001/jamanetworkopen.2021.18216

Key Points

Question Was the 2017 “Muslim ban” executive order associated with changes in health care utilization by people born in Muslim-majority countries living in Minneapolis-St. Paul, Minnesota?

Findings This cohort study of 252 594 patients found that after the executive order was issued, there was an increase in missed primary care appointments and increased emergency department visits among people from Muslim-majority countries living in Minneapolis-St. Paul.

Meaning Changes in health care utilization among people from Muslim-majority countries after the Muslim ban may reflect changes in population health influenced by federal immigration policy.

Abstract

Importance The health effects of restrictive immigration and refugee policies targeting individuals from Muslim-majority countries are largely unknown.

Objective To analyze whether President Trump’s 2017 executive order 13769, “Protecting the Nation from Foreign Terrorist Entry into the United States” (known as the “Muslim ban” executive order) was associated with changes in health care utilization by people born in targeted nations living in the US.

Design, Setting, and Participants This retrospective cohort study included adult patients treated at Minneapolis-St. Paul HealthPartners primary care clinics or emergency departments (EDs) between January 1, 2016, and December 31, 2017. Patients were categorized as (1) born in Muslim ban–targeted nations, (2) born in Muslim-majority nations not listed in the executive order, or (3) non–Latinx and born in the US. Data were analyzed from October 1, 2019, to May 12, 2021.

Exposures Executive order 13769, “Protecting the Nation from Foreign Terrorist Entry into the United States.”

Main Outcomes and Measures Primary outcomes included the number of (1) primary care clinic visits, (2) missed primary care appointments, (3) primary care stress-responsive diagnoses, (4) ED visits, and (5) ED stress-responsive diagnoses. Visit trends were evaluated before and after the Muslim ban issuance using linear regression, and differences between the study groups after the executive order issuance were evaluated using difference-in-difference analyses.

Results A total of 252 594 patients were included in the analysis: 5667 in group 1 (3367 women [59.4%]; 5233 Black individuals [92.3%]), 1254 in group 2 (627 women [50%]; 391 White individuals [31.2%]), and 245 673 in group 3 (133 882 women [54.5%]; 203 342 White individuals [82.8%]). Group 1 was predominantly born in Somalia (5231 of 5667 [92.3%]) and insured by Medicare or Medicaid (4428 [78.1%]). Before the Muslim ban, primary care visits and stress-responsive diagnoses were increasing for individuals from Muslim-majority nations (groups 1 and 2). In the year after the ban, there were approximately 101 additional missed primary care appointments among people from Muslim-majority countries not named in the ban (point estimate [SE], 6.73 [2.90]; P = .02) and approximately 232 additional ED visits by individuals from Muslim ban–targeted nations (point estimate [SE], 3.41 [1.53]; P = .03).

Conclusions and Relevance Results of this cohort study suggest that after issuance of the Muslim ban executive order, missed primary care appointments and ED visits increased among people from Muslim-majority countries living in Minneapolis-St. Paul.

Introduction

The 2016 US presidential election was marked by anti-Muslim and anti-immigrant rhetoric, and the subsequent Trump administration introduced multiple restrictive immigration policies targeting individuals from Muslim-majority and Latin American countries.¹ On January 27, 2017, President Trump issued executive order 13769, “Protecting the Nation from Foreign Terrorist Entry into the United States,”² commonly referred to as the “Muslim ban.” The first iteration of the Muslim ban suspended the US Refugee Resettlement Program and prevented citizens from 7 Muslim-majority countries (Iraq, Syria, Iran, Libya, Somalia, Sudan, and Yemen) from traveling or immigrating to the US. The ban underwent multiple legal challenges but was upheld by the US Supreme Court in 2018.³ On January 20, 2021, President Biden repealed the Muslim ban by executive order.⁴

Policies like the Muslim ban exacerbate heightened levels of discrimination, hostility, and “othering” that US Muslims experience.⁵ Over the past 2 decades, there has been an increase in hate crimes⁶ and social hostility⁷^,8 directed toward US Muslims—experiences that negatively affect health. Following the September 11 attacks, Arab Americans, including Muslim Arab Americans, experienced increased rates of anxiety, depression, and low birth weights.⁵^,9^-12 Islamophobia and restrictive entry policies have been associated with worse health outcomes among migrants, placing Muslim American immigrants and refugees at increased vulnerability as they are additionally targeted by immigration and refugee policy changes, above and beyond discrimination faced by US Muslims more broadly.¹³^-15 Recent research has shown increased incidence of preterm birth among people from Muslim-majority countries after the Muslim ban was issued.¹⁶ However, it is largely unknown and can be difficult to measure how health and health care utilization in Muslim American immigrant and refugee communities changes in response to shifting sociopolitical climates due to several methodological challenges. National health and health care surveys, as well as administrative data sets, do not routinely capture religious affiliation, and naming and country-of-origin algorithms are not precise enough to distinguish people who are Muslim.¹⁷^,18

To describe changes in health care utilization of people from Muslim-majority countries after enactment of the Muslim ban, we examined changes in primary care and emergency department (ED) utilization by people from Muslim ban–targeted nations living in the Minneapolis-St. Paul, Minnesota, metropolitan area, which is home to the largest Somali Muslim community in the US.¹⁹

Methods

Study Design

We conducted a retrospective, cohort study documenting trends in primary care and ED utilization, missed scheduled appointments, and stress-responsive conditions among individuals from Muslim ban–targeted nations living in Minneapolis-St. Paul 1 year before (January 1, 2016) to 1 year after (December 31, 2017) issuance of the ban. For outcomes with similar visit and diagnosis trends before the ban was issued, we used a difference-in-difference analysis to compare differences in utilization trends between people born in Muslim ban–targeted nations and non–Latinx US-born citizens. Supplementary analyses compared trends among people born in a Muslim-majority nation not listed in the Muslim ban to non–Latinx US-born citizens. Patient demographic, visit, and diagnosis data were extracted from the HealthPartners electronic health record (EHR) by a HealthPartners data analyst. HealthPartners and the institutional review board of Yale University approved this study and waived the need for patient informed consent. All records were deidentified and assigned a unique study identification number before secure filing from HealthPartners to the Yale analytic team. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.²⁰

Study Setting and Population

The Minneapolis-St. Paul metropolitan area has 3.63 million residents and the largest Somali Muslim population in the US. In 2017, approximately 252 000 area residents (59.3%) were White non-Latinx individuals, 81 900 (19.3%) were Black non-Latinx individuals, 26 800 (6.3%) were Asian non-Latinx individuals, and 40 900 (9.6%) were Latinx individuals.²¹ In 2016, there were approximately 17 889 people born in Muslim ban–targeted nations living in Minneapolis-St. Paul, of whom 15 808 (88.4%) were born in Somalia.²¹

We analyzed EHR data from HealthPartners, one of Minneapolis-St. Paul’s largest health care and insurance organizations, serving over 1.2 million patients at 55 primary care centers, 22 acute care centers, and 8 hospitals. Although religion is not recorded in the EHR, the HealthPartners EHR is unique in that it includes nation of origin information. This allowed us to characterize patients receiving care from January 1, 2016, to December 31, 2017, into 3 groups: (1) adults born in a country listed in the executive order (group 1) (Table 1; eTable 1 in the Supplement); (2) adults born in Muslim-majority nations not listed in the executive order (group 2) (Table 1, eTable 2 in the Supplement); and (3) US-born non–Latinx adults (Group 3) (Table 1). We excluded US-born Latinx patients (persons who identify as Latino, Latina, or Hispanic, or having lineage from Mexico or any nation in Central or South America) as they have been subject to distinct anti-immigrant rhetoric and policies that have important effects on their health and health care utilization.²²^,23

Outcomes

We hypothesized that after issuance of the Muslim ban, we would observe increased health care visits for stress-responsive diagnoses, increased primary care missed appointments, and increased ED visits. Primary outcomes included the number of (1) primary care visits, (2) missed primary care appointments, (3) primary care stress-responsive diagnoses, (4) ED visits, and (5) ED stress-responsive diagnoses.

Primary Care Utilization

Primary care visits, missed appointments, and stress-responsive diagnoses were analyzed as counts per 1000 people. Kept and missed visit trends were examined overall, regardless of diagnosis, and stress-responsive diagnoses were analyzed separately. We identified stress-responsive diagnoses through literature review and opinion by study team members with expertise in Muslim, immigrant, and refugee health and who provide primary care to people from Muslim-majority countries living in Minneapolis-St.Paul.⁹^,23^-30 Diagnoses considered to be stress responsive were agreed upon by consensus (eTable 3 in the Supplement) and included 138 International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), codes in 6 categories: mental health, sleep disorders, gastrointestinal symptoms, neurologic symptoms, food-related disorders, and pain syndromes.

Emergency Department Utilization

Overall ED visits and ED stress-responsive diagnoses were also analyzed as counts per 1000 people. As previously described, ED stress-responsive diagnoses were identified through literature review and expert opinion, were agreed upon by consensus, and included 27 ICD-10 codes for acute coronary syndrome, assault, suicide attempt, and syncope (eTable 4 in the Supplement)⁹^,23^-32 as well as ambulatory sensitive conditions. Ambulatory sensitive conditions are conditions for which an ED visit or hospitalization is considered preventable through outpatient interventions and can be exacerbated by social stressors and inequalities.³¹^,33 Ambulatory sensitive diagnoses included 21 ICD-10 codes for angina, asthma, congestive heart failure, chronic obstructive pulmonary disease, diabetes complications, and hypertension (eTable 4 in the Supplement).³¹^,33

Statistical Analyses

We used local linear regression to characterize visit and diagnosis trends in 2016 and 2017 and fit separate models for all outcomes: primary care visits, missed primary care appointments, primary care stress-responsive diagnoses, ED visits, and ED stress-responsive diagnoses. After documenting changes over time, we identified outcomes for which trends appeared to be similar among non–Latinx US-born individuals and individuals from Muslim ban–targeted nations in the preintervention period by examining the interaction between study group and time (30-day periods) in linear regression models. For outcomes that followed approximately parallel trends before the ban was issued, we conducted difference-in-difference analyses.

The primary difference-in-difference analyses estimated the change in outcomes between pre- and post-ban periods among individuals from Muslim ban–targeted nations above and beyond the change observed among non–Latinx US-born individuals. For the difference-in-difference analyses, we fit the linear regression model described in equation 1:

Y = β₀ + (β₁Muslim ban targeted) + (β₂Muslim ban targeted × post-Muslim ban) + (β_t period) + ε.

We compared the 360 days before and after the ban was issued, divided into 24 distinct, 30-day periods. Each outcome Y is a count per person per 30-day time period. The designations Muslim ban targeted and Muslim ban targeted × post-Muslim ban represent being from a Muslim ban–targeted nation and being from a Muslim ban–targeted nation after the ban was issued, respectively. For each model, we estimated the average difference in differences (β₂) over increasing time intervals centered on the ban issuance date, beginning with 30 days before and after the ban was issued and increasing by 30-day increments to 360 days before and after issuance.

Demographic details were not included in the primary analysis because they do not vary over time. However, it is important to account for demographic details, because there are important differences between study groups that could influence health care utilization. In order to account for different characteristics between study groups and assess robustness, we compared changes in health care utilization by individuals from Muslim ban–targeted nations to 2 subgroups of non–Latinx US-born individuals demographically similar to individuals in group 1 (Muslim ban-targeted): a matched comparison group and a synthetic control. First, we matched on age, sex, race/ethnicity, and insurance type (Medicaid or Medicare, or commercial) to reweight members of group 3 (non–Latinx, US born) and identify a subset of group 3 with similar characteristics as group 1 (Muslim ban–targeted). We used the R package MatchIt, version 3.6.1, (R Core Team) to identify this reference group, then fit a weighted version of the model described in equation 1 (eTable 10 in the Supplement).³⁴ Second, we used a generalized synthetic control method to reweight members of group 3 to produce a reference group with demographic characteristics and pre–Muslim ban outcomes more similar to those observed in group 1. Models were fit using the R package gsynth with parametric bootstrap standard errors.³⁵ These robustness checks are reported in eTables 8-10 and in the eFigure in the Supplement. All P values were 2-sided, and P < .05 was considered significant. Data were analyzed from October 1, 2019, to May 12, 2021.

READ ON

Health Care Utilization Before and After the “Muslim Ban” Executive Order Among People Born in Muslim-Majority Countries and Living in the US | Emergency Medicine | JAMA Network Open | JAMA Network

Personally addressed emails designed with behavioral science can increase COVID-19 vaccine registration among vaccine-hesitant healthcare workers

Behavioral scientists at Geisinger’s Steele Institute for Health Innovation report findings from randomized trial

Peer-Reviewed Publication

GEISINGER HEALTH SYSTEM

DANVILLE, Pa. – A research letter published today in JAMA Network Open reports that individually addressed email reminders designed with behavioral science increased registration for a COVID-19 vaccination more than two-fold among healthcare workers who had not received a vaccine, compared with those who did not receive an email.

In one of the first real-world tests of an intervention to increase COVID-19 vaccination, members of the Behavioral Insights Team at Geisinger’s Steele Institute for Health Innovation used a combination of behavioral science principles, such as highlighting how many people have already been vaccinated, comparing the risk of a vaccine to that of COVID-19, and embedding a link to the registration portal, to develop the email messages.

The rate of COVID-19 vaccination is slowing in the United States, with some states having vaccination rates far below the target of 70%. Meanwhile, the increasing prevalence of the Delta variant, the threat of other COVID-19 variants, and the possibility that some or all vaccinated people will need to return for a booster shot highlight the importance of testing ways to increase vaccination.

“The evidence for easily scalable interventions for COVID-19 vaccination, like a well-designed email, has largely been limited to laboratory experiments that only measure intentions for getting a vaccine, which may or may not translate into actual behavior,” said Henri Santos, Ph.D., staff scientist in Geisinger’s Behavioral Insights Team and first author of the paper. “Although we focused on encouraging vaccination among healthcare workers—one of the first groups to gain access to COVID-19 vaccines—these messages could be adapted by other organizations and sent to other kinds of employees, students, or patients.”

Employees of Geisinger, a large, integrated health system in central and northeast Pennsylvania, began to access COVID-19 vaccines in mid-December. Between then and when the project was conducted in mid-January, the health system sent at least 36 COVID-19 vaccine-related emails to employees. At that point, employees were randomly assigned to one of three groups: one receiving an individually addressed “social norms” email, another receiving an individually addressed “reframing risks” email, or a delayed control group who received one of the two emails three days later. Those who received the social norms email were told that millions of U.S. residents and most of their fellow employees had been vaccinated or had scheduled a vaccination. Those who received the reframing risks email were presented with a comparison of the side effects of a vaccine against the much more serious known and unknown complications of COVID-19. Both emails were sent from the chief of infectious diseases and requested that the employee make a yes-or-no decision about receiving a vaccine.

Both the social norms and reframing risks emails led to more than twice as many registrations within three days (6.5% and 6.9% of recipients, respectively) compared with the delayed control group who had not yet received an email (3.2%)—an average absolute increase in vaccination registration of 3.5 percentage points. However, there was no significant difference between those who received the social norms and reframing risks emails.

“Like many lightweight behavioral interventions—sometimes called ‘nudges’—tested in the real world, ours had a modest impact, increasing the vaccination rate in our sample by 3.5 percentage points,” said Michelle Meyer, faculty co-director of the Behavioral Insights Team, assistant professor in Geisinger’s Research Institute, and the senior author of the paper. “On the other hand, these emails can be quickly sent to large numbers of people for free, and in some places, 3.5 percentage points might be the difference between reaching and failing to reach herd immunity. Our results suggest that some people who have been hesitant about the vaccine, even after a great deal of prior communication, can still be reached, at virtually no cost.”

About Geisinger
Geisinger is committed to making better health easier for the more than 1 million people it serves. Founded more than 100 years ago by Abigail Geisinger, the system now includes nine hospital campuses, a health plan with more than half a million members, a Research Institute, and the Geisinger Commonwealth School of Medicine. With nearly 24,000 employees and more than 1,600 employed physicians, Geisinger boosts its hometown economies in Pennsylvania by billions of dollars annually. Learn more at geisinger.org or connect with us on Facebook, Instagram, LinkedIn and Twitter.

JOURNAL

JAMA Network Open

DOI

10.1001/jamanetworkopen.2021.18702

METHOD OF RESEARCH

Randomized controlled/clinical trial

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Effect of Targeted Behavioral Science Messages on COVID-19 Vaccination Registration Among Employees of a Large Health System

ARTICLE PUBLICATION DATE

28-Jul-2021

What’s behind people’s hesitancy towards vaccination?

Peer-Reviewed Publication

THE POLISH ASSOCIATION OF SOCIAL PSYCHOLOGY

In the context of the COVID-19 pandemic, it becomes essential to understand why people refuse or indefinitely delay vaccination. A new Polish study, conducted at the Jagiellonian University (Krakow, Poland) and the SWPS University of Social Sciences and Humanities (Wroclaw, Poland) and published in the peer-reviewed scholarly journal Social Psychological Bulletin, brings up the impact of the active spread of attention-grabbing anti-vaccine arguments, as well as the overall distrust in the Big Pharma, science and health providers.

In their study, using data from a total of 492 participants, who have self-identified as either ambiguous towards or opposing vaccination, the research team, led by Dr Katarzyna Stasiuk, conclude that vaccine deniers are mostly led by a generalised negative attitude to vaccines.

The arguments were collected during a conference, where people opposing the vaccination presented their stand on the subject. Curiously, even though they often reported their stance to be founded in their own or observed negative experience with vaccines, when asked about their reasoning, they were rather vague in their explanations. Many reported that they didn’t remember the source of information, while others attributed autism, allergies or children being sick to vaccines, despite the missing evidence of correlation.

Such instances can be explained with people’s tendency to remember negative reports, even if those have simply been read online.

“Confirmation bias consists of an individual actively seeking information consistent with their pre-existing hypothesis, and avoiding information indicative of alternative explanations,” say the researchers. “Therefore, a pre-existing negative attitude toward vaccines may cause individuals to interpret negative symptoms as consequences of vaccines, further reinforcing the negative attitude.”

The research team also reminds that when given similar information from multiple sources, people tend to forget how they have learned it, often confusing it with their own experience or those of their close ones. As a result, they could turn into yet another source of misinformation.

All in all, vaccine deniers believe that vaccines lead to serious negative side effects, don’t protect the individual and the society against infectious diseases, and are not sufficiently tested before introduction. Further, they are convinced that anti-vaccination leaders are better informed about vaccines than physicians, and that it is rather the former that act in the public interest.

Interestingly, when compared to the group who self-reported as vaccine-hesitant, opponents of vaccines were more inclined to believe that modern medicine is able to handle an epidemic.

Meanwhile, the vaccine-ambiguous participants in the survey were mostly confident in the efficacy of vaccines, as well as them being properly researched. However, they were still susceptible to the anti-vaccine movement’s statements about side effects and the “Big Pharma conspiracy”. Moreover, if presented with well-prepared arguments, they are likely to become vaccine deniers.

In conclusion, the scientists note that existing evidence is quite pessimistic about the possibility of changing the attitudes of vaccine opponents, and thus recommend that efforts need to be focused on persuading the vaccine-ambiguous group, so that their concerns about negative effects are reduced. They also suggest that they need to be presented with prosocial arguments about why medical professionals recommend vaccines, in order to strengthen the positive points of their attitude.

###

Original source:

Stasiuk, K., Maciuszek, J., Polak, M., & Doliński, D. (2021). Profiles of Vaccine Hesitancy: The Relation Between Personal Experience With Vaccines, Attitude Towards Mandatory Vaccination, and Support for Anti-Vaccine Arguments Among Vaccine Hesitant Individuals. Social Psychological Bulletin, 16(2), 1-20. https://doi.org/10.32872/spb.6525

JOURNAL

Social Psychological Bulletin

DOI

10.32872/spb.6525

METHOD OF RESEARCH

Experimental study

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Profiles of Vaccine Hesitancy: The Relation Between Personal Experience With Vaccines, Attitude Towards Mandatory Vaccination, and Support for Anti-Vaccine Arguments Among Vaccine Hesitant Individuals

ARTICLE PUBLICATION DATE

29-Jul-2021

COI STATEMENT

n/a

Could residential heat pumps be part of the climate solution?

Peer-Reviewed Publication

UNIVERSITY OF MICHIGAN

FACULTY Q&A

ANN ARBOR—Deploying residential heat pumps more widely across the United States has the potential to help reduce carbon pollution while also saving homeowners money, according to a new study by a University of Michigan researcher and colleagues.

However, in most parts of the country the electricity grid will have to get cleaner and electric heat pumps will have to get cheaper before these devices become both environmentally and financially compelling, says Parth Vaishnav of the Center for Sustainable Systems at U-M's School for Environment and Sustainability.

The study was published online July 28 in the journal Environmental Research Letters.

The other authors are Thomas Deetjen of the University of Texas and Liam Walsh of Carnegie Mellon University.

What is a residential heat pump? I've seen them described as essentially an air conditioner that is slightly modified so that it can run in two directions, cooling the home in the summer and providing heat in the winter. Is that correct?

That's exactly right. Heat naturally flows from hot places to cold places, just as a car will roll downhill. During the summer, air conditioners move heat from a cold place (the inside of your home) to a hot place (the outside). During the winter, air conditioners can operate as a heat pump and do the same thing, except that the cold place is the outside and the hot place is your home. Just as you need to do some work to push a car uphill, you need to do some work to push heat from a cold to a hot place. What makes heat pumps efficient is that you usually can transfer two or more units of heat for every unit of work.

Heat pumps are widely discussed as tools to help fight climate change. How could electric heat pumps help reduce fossil fuel emissions, and what is the potential for their widespread adoption across the United States?

Most homes in the U.S. are heated by burning a carbon-containing fuel (natural gas, propane or oil) within the house. Doing this emits greenhouse gases. There is no easy way of eliminating the GHGs from this combustion. For example, it would be very expensive to capture small amounts of carbon dioxide from hundreds of millions of homes and sequester it permanently. However, heat pumps run on electricity, and there are many good and relatively inexpensive ways to decarbonize the electrical grid.

Our study shows that, if we assume moderate decarbonization of the grid over the lifetime of a heat pump installed today, heat pumps would cut greenhouse gas emissions everywhere. We should, however, keep two things in mind. One, heat pumps would raise heating costs for some houses, especially if we did not tax fossil fuels for the harm that they do to human health and the environment.

Second, electricity generation from coal and natural gas also produces harmful pollutants like oxides of nitrogen, fine particulate matter and sulfur dioxide. In some parts of the country, the electrical generation mix is dirty enough that emissions of these pollutants do enough damage to overwhelm the benefits of reducing carbon dioxide emissions.

Accounting for all this, our study suggests that switching about 30% of single-family homes to heat pumps right now would cut harms to the environment and human health and save households money. We ought to begin by switching from resistive electric heating, oil and propane to natural gas. The best places to start are the parts of the country that have a moderate climate.

We also ought to clean up the grid as fast as possible. If we commit to doing that, our previous studies show that heat pumps can reduce environmental and human health harms virtually everywhere in the country.

How was the Environmental Research Letter study done, and what was the most important finding?

We used a database called ResStock, developed by the National Renewable Energy Laboratory, to simulate 400 houses in each of 55 U.S. cities, for a total of 22,000 houses. Each set of houses was chosen to be representative of the housing stock in that city. We then used the U.S. Department of Energy's EnergyPlus model to simulate the hourly energy use for each of those 22,000 houses. We ran two versions of this analysis: one with heat pumps, and another with whatever heating fuel the house currently had. We compared these two runs to work out the benefits and costs of a switch to heat pumps.

To assess damages to human health, we used integrated air quality models developed by researchers at Carnegie Mellon. To assess harms from the environment, we used the social cost of carbon.

The most important finding was that you could save money and reduce social harms—right now—by doubling the proportion of homes that have heat pumps.

What percentage of U.S. houses could benefit financially—in the form of reduced utility bills—from installing an electric heat pump, and what percentage of those homes could reduce greenhouse gas emissions by installing a heat pump?

About a third of single-family homes would benefit financially, after accounting for the extra cost of installing heat pumps relative to a gas furnace. All of those homes would reduce greenhouse gas emissions.

What are some of the main impediments to achieving widespread heat pump adoption across the United States?

From the point of view of a homeowner, the key barrier is the perceived higher cost of installing heat pumps. I say perceived because in many parts of the country, heat pumps would more than pay for themselves over their lifetimes. Also, if a homeowner needed to replace a furnace and an air conditioner, installing a heat pump—which can heat and cool—might be the cheapest option. Another key barrier is that installers may not know enough about heat pumps to inform customers adequately.

What is the potential for residential heat pump adoption in a cold weather state like Michigan?

In the long term, very good. In terms of their ability to "do the job," heat pumps have gotten much better at working reliably and efficiently in cold climates. They will continue to improve. As the summers get warmer, the fact that heat pumps can also serve as efficient air conditioners will become more and more valuable.

That said, we ought to continue to invest in making heat pumps cheaper and more efficient. We also ought to invest in making our housing stock more efficient by supporting weatherization. Apart from the cold climate, one of the challenges is that the electrical grid in the Midwest is still too dependent on coal and natural gas. We ought to either shift to sources that do not produce carbon dioxide emissions at all, or we ought to capture emissions from coal and gas plants and permanently sequester them.

Study: U.S. residential heat pumps: The private economic potential and its emissions, health, and grid impact (doi.org/10.1088/1748-9326/ac10dc)

JOURNAL

Environmental Research Letters

DOI

10.1088/1748-9326/ac10dc

Trauma Informed Care can help break the cycle of violence

Multidisciplinary American College of Surgeons ISAVE group proposes strategies for trauma centers to address root causes of violence

Peer-Reviewed Publication

AMERICAN COLLEGE OF SURGEONS

Author video — VIDEO: ROCHELLE A. DICKER, MD, FACS, DISCUSSES HOW TRAUMA CENTERS CAN HELP ADDRESS ROOT CAUSES OF VIOLENCE, IMPROVE HEALTH, AND REDUCE INEQUITIES IN MARGINALIZED COMMUNITIES. view more
CREDIT: AMERICAN COLLEGE OF SURGEONS

Key takeaways

Trauma Informed Care accounts for both the mental and physical aspects of trauma.
Trauma centers and hospitals should invest directly in at-risk communities to create opportunities for financial and educational inclusion.
Engaging at-risk communities can help address structural racism and social determinants of health and create a solutions-based narrative.

CHICAGO (July 30, 2021): Trauma surgeons are often the first point of contact with the health care system for victims of violence. However, their role can extend beyond caring for a patient’s physical injuries. Trauma centers can help address root causes of violence, improve health, and reduce inequities in marginalized communities, according to the American College of Surgeons (ACS) Improving Social Determinants to Attenuate Violence (ISAVE) workgroup. The ISAVE workgroup published four strategies to help break the cycle of violence in an article published on the Journal of the American College of Surgeons website in advance of print.

“Violence, in and of itself, is very much the end result of social determinants of health, structural racism, and structural barriers in our country that have existed for a long time,” said Rochelle A. Dicker, MD, FACS, of the division of trauma and critical care, University of California at Los Angeles Geffen School of Medicine. “The strategies we propose are very action-oriented. Trauma is not just about the physical injury but has a broader definition. We need to be more comprehensive and aware of that as we treat our patients.”

Four strategies to address the root causes of violence

The ISAVE workgroup proposes four strategies to improve health and health care for marginalized communities that are disproportionally impacted by violence:

Development and Implementation of Trauma Informed Care in All Trauma Centers
Integrating Social Care into Trauma Care
The Trauma Center’s Role in Investing in At-Risk Communities
Advocacy

These strategies form ISAVE’s vision of the future of care for victims of violence. These efforts extend beyond the confines of trauma centers, reaching into communities plagued by this violence epidemic.

A key feature of the ISAVE strategies is the Trauma Informed Care (TIC) curriculum. The authors note that trauma has traditionally had two definitions:

From the mental health perspective, a deeply distressing and disturbing experience
From the perspective of trauma surgery and emergency medical services, an acute physical injury

The authors note that having two different definitions of trauma can lead to a fragmentation of care. The TIC curriculum takes into account the full scope of trauma and can “foster a sense of empowerment, autonomy, and partnership in the injured person to help patients thrive, not just survive.”

Focusing on at-risk communities

The authors address violence and the social determinants of health with a broad lens, noting the risk of perpetuating a cycle of inequity, disparity, and inequality if underlying causes of death and ill health are not addressed. The authors suggest a strategy to invest directly in at-risk communities to treat patients with a full scope of understanding the underlying factors.

“It is important that people have access to trauma centers, but the other piece is hospitals investing in their communities,” Dr. Dicker said. “For example, putting in place vocational training programs so that the community is part of the employment process in a hospital itself. Also, whether the hospital uses local vendors for food; that’s an investment in the local community. Investment truly is the ability to put dollars into the communities that are in such great need.”

Health and wealth are inextricably tied to one another, the authors note. “Black and Brown communities suffer heavily from a racial wealth gap relative to white communities, although rural white Americans are also deeply impacted by this gap and share a common lack of access to mechanisms to build financial security,” they write. “Creating opportunities for financial and educational inclusion may not be seen on the surface as a health-related matter but, in fact, it is at its core.”

Advocacy is the overarching theme that informs the strategies proposed by ISAVE. The authors note that it is an intrinsic duty for trauma center personnel to use advocacy to address the social determinants of health that lead to violence. Specific policy suggestions include engaging hospital and health system administrators to leverage the Affordable Care Act’s Community Health Needs Assessment to encourage hospitals to engage in addressing poverty and unemployment.

“Physical trauma leads to psychological trauma and psychological trauma predisposes to physical trauma. Optimally addressing one, requires addressing the other,” the authors conclude. “Although complex, effective interventions for violence are not as complex as those required to combat a novel corona virus pandemic, and as the COVID-19 pandemic has plainly demonstrated, we are all in this together. What affects one of us, affects all of us.”

CAPTION

Four ways for trauma centers to address root causes of violence.

CREDIT

American College of Surgeons

The ISAVE workgroup was established in 2019 by the ACS Committee on Trauma (COT) and first outlined steps the medical community must take to understand and address the root causes of firearm violence at a panel presentation during the 2020 ACS Clinical Congress virtual. The ACS COT has been working to prevent firearm related injury, death, and disability by working together to address the root causes of violence and simultaneously making firearm ownership as safe as possible. Learn more about the ACS COT’s efforts that focus on treating firearm violence as a public health problem.

Article coauthors with Dr. Dicker are Arielle Thomas, MD, MPH; Eileen M. Bulger, MD, FACS; Ronald M. Stewart, MD, FACS; Stephanie Bonne, MD, FACS; Tracy A. Dechert, MD, FACS; Randi Smith, MD, FACS; Altovise Love-Craighead, MS; Fatimah Dreier, MA; Meera Kotagal, MD, FACS; Tamara Kozyckyj, MPH; and Holly Michaels, MPH.

The article authors have no relevant financial relationships to disclose.

“FACS” designates that a surgeon is a Fellow of the American College of Surgeons.

Citation: Strategies for Trauma Centers to Address the Root Causes of Violence: Recommendations from the Improving Social Determinants to Attenuate Violence (ISAVE) Workgroup of the American College of Surgeons Committee on Trauma. Journal of the American College of Surgeons. DOI: doi.org/10.1016/j.jamcollsurg.2021.06.016.

About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 82,000 members and is the largest organization of surgeons in the world. For more information, visit www.facs.org.

JOURNAL

Journal of the American College of Surgeons

DOI

10.1016/j.jamcollsurg.2021.06.016

ARTICLE TITLE

Strategies for Trauma Centers to Address the Root Causes of Violence: Recommendations from the Improving Social Determinants to Attenuate Violence (ISAVE) Workgroup of the American College of Surgeons Committee on Trauma

ARTICLE PUBLICATION DATE

30-Jul-2021

Army award-winning research to transform Soldier-robot communication

Grant and Award Announcement

U.S. ARMY RESEARCH LABORAT

Army award-winning research to transform Soldier-robot communication — IMAGE: ARMY RESEARCHERS DEVELOP GROUND-BREAKING TECHNOLOGY THAT WILL ENHANCE HOW SOLDIERS AND ROBOTS COMMUNICATE AND CARRY OUT TASKS IN TACTICAL ENVIRONMENTS. view more
CREDIT: NEIL ADAMS

PHILADELPHIA, Md. -- Army researchers developed ground-breaking technology that will enhance how Soldiers and robots communicate and carry out tasks in tactical environments.

This research sets out to develop a natural language understanding, or NLU, pipeline for robots that would be easily ported over to any computational system or agent and incrementally tames the variation that we see in natural language, said Army researcher Dr. Claire Bonial from the U.S. Army Combat Capabilities Development Command, known as DEVCOM, Army Research Laboratory.

This means that regardless of how a Soldier chooses to express him or herself to the robot, the underlying intent of that language is understood and can be acted on, given both the current conversational and environmental or situational context.

To do this, the NLU pipeline first automatically parses the input language into Abstract Meaning Representation, or AMR, which captures the basic meaning of the content of the language, Bonial said. It then converts and augments the AMR into Dialogue-AMR, which captures additional elements of meaning needed for two-way human robot dialogue in particular, such as what the person is trying to do with the utterance in the conversational context, for example give a command, ask a question, state a fact about the environment, etc.

“This is unique in comparison to other NLU components within dialogue systems, many of which forego any kind of semantic representation in favor of a deep-learning approach,” Bonial said.

This research was presented at the 14th International Conference on Computational Semantics, or IWCS 2021, where it received the Outstanding Paper Award.

The award citation noted that “The authors are not afraid of using old-fashined hand-written rules when they do the job, something which is lacking in much current work in NLP,“ and that “Anyone who wants to work on human-robot dialogue will want to see this first go at parsing in this new domain.”

“This award was incredibly gratifying for several reasons,” Bonial said. “First, this paper represents research efforts that were planted and have been growing since I was a doctoral student. I was part of the first group of researchers establishing what has become one of the most widely used semantic representations in natural language processing, AMR.”

Bonial started work with this group in 2010, and has been actively involved in refining and extending the representation ever since. Thus, this paper represents a body of research spanning over a decade for Bonial.

This includes work to represent language expressed through semi-idiomatic constructions, for example “the higher you fly, the harder you’ll fall!,” and most recently extending AMR so that it can better capture two-way dialogue, and specifically task-oriented, situated dialogue between people and robots, in an augmented version of the representation called Dialogue-AMR, she said.

Efforts to develop Dialogue-AMR started in 2018 with dialogue expert Dr. David Traum as part of the University Affiliated Research Center previously established between DEVCOM ARL and the Institute for Creative Technologies at the University of Southern California.

Dialogue-AMR draws upon ARL and ICT’s Bot Language research collaboration focused on robot dialogue systems, which was initiated by one of the IWCS paper’s co-authors, Dr. Clare Voss, in 2012.

Second, Bonial said, this paper reports on a critical step in the research trajectory: the researchers’ experiments to robustly and critically evaluate Dialogue-AMR as a computational semantic representation, as well as the NLU pipeline used to automatically obtain the correct Dialogue-AMR representation when given unconstrained natural language input.

These experiments were also done in collaboration with Traum of ICT, as well as an ARL student intern and recent graduate of Georgetown University, Mitchell Abrams. Abrams was recently selected as a Department of Defense Science, Mathematics, And Research For Transformation scholar, and will be coming back to the lab after completing his fully-funded doctoral program.

This evaluation is significant because the researchers evaluate in two problem domains: first, the domain of human-robot dialogue for collaborative search and navigation tasks, and second the domain of human-human dialogue in the virtual Minecraft gaming environment, where participants are collaboratively building blocks structures.

The Minecraft dialogue data that made this comparative evaluation possible was obtained from Dr. Martha Palmer of the University of Colorado, Boulder, and Dr. Julia Hockenmaier of the University of Illinois at Urbana-Champaign.

Evaluating in these two domains gets at a key question regarding the utility of such a representation and the NLU pipeline in general.

Bonial questioned how efficiently and with what accuracy the pipeline and representation can be applied in one problem domain, and then transferred and refined to a new problem domain. Or, in other words, how feasible is it for us to use this approach for communicating with a robot when that robot needs to tackle new problems and environments?

“Any Army application requires a system that can efficiently and flexibly act in dynamic circumstances,” Bonial said. “Our evaluation demonstrates that our NLU pipeline can obtain human-level performance in the first, human-robot dialogue domain, such that the output Dialogue-AMR representations agree with, or are similar to, human gold-standard representations at a rate similar to representations manually created by different humans.”

Further their evaluation demonstrates that with just a small amount of additional training data (several hours’ worth of annotation work amounting to about 200 additional training instances for the machine learning elements of the pipeline), the NLU pipeline obtains promising performance in the second domain of human-human dialogue in the Minecraft domain, she said.

The researchers noted that while the performance is somewhat lower than performance on the original human-robot dialogue domain, it is comparable or better than the performance of other automatic semantic parsers for other semantic representations and language domains.

“These promising results demonstrate that this NLU pipeline leverages a valid approach for communicating with robots in collaborative tasks across multiple domains,” Bonial said. “I am very excited for the promise of this research to provide transformational overmatch in our computational systems’ ability to understand the underlying meaning of Soldiers’ instructions, despite difference in their dialects, accents and other types of noise sure to arise in Army-relevant applications.”

In the research team’s next steps, they are connecting the output semantic representation with a system that grounds the pieces of the representation to both entities in the environments and the executable behaviors of the robot in joint work with Dr. Thomas Howard of the University of Rochester.

“We are optimistic that the deeper semantic representation will provide the structure needed for superior grounding of the language in both the conversational and physical environment such that robots can communicate and act more as teammates to Soldiers, as opposed to tools,” Bonial said.

Visit the laboratory's Media Center to discover more Army science and technology stories