Arizona Community Research Articles

Abstract B128: Underlying factors influencing kidney cancer surgical treatment disparities: Patients, non-patient community members and urologists’ perspectives

Abstract Background: Racial and ethnic minority patients often delay or forgo kidney cancer (KCa) surgical treatment and have an invasive surgical treatment. This study aimed to understand the underlying factors of KCa surgical treatment disparities through interviews with KCa patients and non-patients from racial and ethnic minority communities in Arizona and online surveys with urologists who practice in the U.S. Methods: We conducted phone interviews with KCa patients (n=13) and interviews at health events with community members without KCa (n=61). Online surveys were conducted with urologists (n=54). Results: Many interview participants had healthcare access issues with 22% reporting not having a primary care doctor and 12% reporting that there was a time when they could not see a doctor because of cost. Almost 50% reported that they had delayed care because they could not get an appointment soon enough. Among 10 patients who responded to a question about diagnosis delay, 4 answered that they waited over a year to see their doctor when they had health issues before their diagnosis. A quarter of community participants (25%) and about a third of patients (31%) reported that cultural values or religious beliefs influenced their choice of treatment. When community participants were asked what they knew about KCa symptoms and treatments, many did not provide relevant or correct information. Only 51% of non-patients reported that they trusted their doctor’s judgements about their medical care, but 92% of patients reported that they trusted their doctor’s judgement. About 30% of urologists reported that patients from racial and ethnic minority backgrounds often have healthcare access challenges, but only 9% responded that NHW patients often have challenges. They did not report that racial and ethnic differences in treatment exist. About 10% of urologists reported socioeconomic backgrounds of patients affect treatment decision and timeliness often or all the time. Only 46% reported that they refer patients to necessary services all the time, when patients express concerns of finance and healthcare access challenges. Many urologists strongly or slightly agreed that treatment decisions should be made by the treating clinicians (82%) and based on clinical information (87%). Many also strongly or slightly agreed that patients and their family members should contribute to decision-making (98%), while 46% strongly or slightly agreed that patients’ cultural and religious backgrounds often affect their treatment choices. In open-ended questions, urologists responded that work and family obligations, healthcare access, and health literacy rather than race and ethnicity are factors influencing treatment, while mistrust was identified as one of factors influencing treatment delay. Conclusions: Barriers to healthcare access, lack of knowledge, and mistrust before diagnosis may be underlying factors among patients, while urologists view healthcare access, social and economic factors, and mistrust influence KCa surgical treatment decision and delay. Citation Format: Ken Batai, Alex Cruz, Juan Adrover, Daphne Larose, D'Andre Gomez, Francine C. Gachupin, Jacquanette R. Slowtalker, Benjamin R. Lee, Juan Chipollini. Underlying factors influencing kidney cancer surgical treatment disparities: Patients, non-patient community members and urologists’ perspectives [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B128.

Limited Awareness of Long COVID Despite Common Experience of Symptoms Among African American/Black, Hispanic/Latino, and Indigenous Adults in Arizona.

Communities of color might disproportionately experience long-term consequences of COVID-19, known as Long COVID. We sought to understand the awareness of and experiences with Long COVID among African American/Black (AA/B), Hispanic/Latino (H/L), and Indigenous (Native) adults (18 + years of age) in Arizona who previously tested positive for COVID-19. Between December 2022 and April 2023, the Arizona Community Engagement Alliance (AZCEAL) conducted 12 focus groups and surveys with 65 AA/B, H/L and Native community members. Data from focus groups were analyzed using thematic analysis to identify emerging issues. Survey data provided demographic information about participants and quantitative assessments of Long COVID experienceswere used to augment focus group data. Study participants across all three racial/ethnic groups had limited to no awareness of the term Long COVID, yet many described experiencing or witnessing friends and family endure physical symptoms consistent with Long COVID (e.g., brain fog, loss of memory, fatigue) as well as associated mental health issues (e.g., anxiety, worry, post-traumatic stress disorder). Participants identified a need for Long COVID mental health and other health resources, as well as increased access to Long COVID information. To prevent Long COVID health inequities among AA/B, H/L, and Native adults living in AZ, health-related organizations and providers should increase access to culturally relevant, community-based Long COVID-specific information, mental health services, and other health resources aimed at serving these populations.

Legumes of Arizona: An Illustrated Flora and Reference

The Fabaceae is one of the most ecologically, economically, and agriculturally important plant families in the world. These plants are particularly significant in Arizona as many species are native and adapted to arid lands. Desert-adapted plants will become increasingly important as water issues of the state become more critical. Additionally, legumes are important and sometimes dominant components of the many biotic communities in Arizona. This manual meets a critical need for a reference on these plants in Arizona.

Associations of Sleep Quality and Physical Activity with Diabetes Quality of Life in Korean Americans with Type 2 Diabetes: A Cross-Sectional Study.

The cross-sectional study aimed to examine the associations of sleep quality and physical activity with diabetes quality of life in Korean Americans with type 2 diabetes. A total of 119 Korean American adults with type 2 diabetes were recruited from Korean communities in Arizona, USA. The Pittsburgh Sleep Quality Index for sleep quality, the International Physical Activity Questionnaire for physical activity, and the Diabetes Quality of Life (DQOL) for quality of life were assessed. Descriptive statistics, bivariate correlations, and multiple linear regressions were conducted. The mean score of the total DQOL was 1.85 (SD = 0.28). Approximately 70% of those had poor sleep quality and a third showed low physical activity. The findings demonstrated that both sleep quality and low physical activity were independent predictors of overall DQOL scores, indicating that poor sleep quality and low physical activity are associated with reduced Diabetes Quality of Life in this demographic. Specifically, the satisfaction subscale of DQOL showed significant associations with low physical activity levels, suggesting that enhancing physical activity could potentially improve satisfaction within DQOL. Furthermore, the impact subscale was positively related to sleep quality, suggesting that better sleep quality might significantly lower the perceived negative impact of diabetes on daily life. No significant associations were found between sleep quality, physical activity, and the worry subscale of DQOL in the adjusted models. The study indicates that addressing sleep quality and promoting physical activity are essential components of diabetes management strategies aimed at improving the quality of life for Korean Americans with type 2 diabetes. This underlines the need for tailored interventions that consider cultural preferences and individual needs to enhance diabetes outcomes and quality of life in this population.

Novel signals and polygenic score for height are associated with pubertal growth traits in Southwestern American Indians.

Most genetic variants associated with adult height have been identified through large genome-wide association studies (GWASs) in European-ancestry cohorts. However, it is unclear how these variants influence linear growth during adolescence. This study uses anthropometric and genotypic data from a longitudinal study conducted in an American Indian community in Arizona between 1965-2007. Growth parameters (i.e. height, velocity, and timing of growth spurt) were derived from the Preece-Baines growth model, a parametric growth curve fitted to longitudinal height data, in 787 participants with height measurements spanning the whole period of growth. Heritability estimates suggested that genetic factors could explain 25% to 71% of the variance of pubertal growth traits. We performed a GWAS of growth parameters, testing their associations with 5 077 595 imputed or directly genotyped variants. Six variants associated with height at peak velocity (P < 5 × 10-8, adjusted for sex, birth year and principal components). Implicated genes include NUDT3, previously associated with adult height, and PACSIN1. Two novel variants associated with duration of growth spurt (P < 5 × 10-8) in LOC105375344, an uncharacterized gene with unknown function. We finally examined the association of growth parameters with a polygenic score for height derived from 9557 single nucleotide polymorphisms (SNPs) identified in the GIANT meta-analysis for which genotypic data were available for the American Indian study population. Height polygenic score was correlated with the magnitude and velocity of height growth that occurred before and at the peak of the adolescent growth spurt, indicating overlapping genetic architecture, with no influence on the timing of adolescent growth.

Optimizing Postpartum Care in Rural Communities: Insights from Women in Arizona and Implications for Policy

ObjectivesOptimal postpartum care promotes healthcare utilization and outcomes. This qualitative study investigated the experiences and perceived needs for postpartum care among women in rural communities in Arizona, United States.MethodsWe conducted in-depth interviews with thirty childbearing women and analyzed the transcripts using reflexive thematic analysis to gauge their experiences, needs, and factors affecting postpartum healthcare utilization.ResultsExperiences during childbirth and multiple structural factors, including transportation, childcare services, financial constraints, and social support, played crucial roles in postpartum care utilization for childbearing people in rural communities. Access to comprehensive health information and community-level support systems were perceived as critical for optimizing postpartum care and utilization.Conclusions for PracticeThis study provides valuable insights for policymakers, healthcare providers, and community stakeholders in enhancing postpartum care services for individuals in rural communities in the United States.

Evaluating Physical Activity Resources to Support Health Equity in Arizona

We evaluated physical activity (PA) resources in lower-income Arizona communities to support the Supplemental Nutrition Assistance Program – Education (SNAP-Ed) in pursuing equitable policy, systems, and environment (PSE) interventions. In 2017, 71 PA resources across 10 counties (65% parks) were rated using the Physical Activity Resource Assessment (PARA) tool. Accessibility was high, but condition scores and attractiveness varied across resources, with no rural/urban differences. Results suggest that Extension SNAP-Ed staff can be agents of change by assessing resource condition where physical activity health inequities may exist and then convening partners to begin to address needed changes.

Education for sustainable development: Societal benefits of a community garden project in Tucson, Arizona

Education for sustainable development is gaining traction in sustainability discourses and policies to bridge the gap between the theory and practice of climate change mitigation and adaptation. In the United States, university-led initiatives are being promoted to provide experiential learning platforms to empower students for climate action. One such example is community gardens. This paper examined the societal benefits derived by a group of university students from engaging in community-based learning through the University of Arizona Community Garden (UACG). Based on interviews, participant observation, and students-based activities, the findings revealed that the community garden provided psychosocial benefits such as social interaction, and connection with nature. The findings highlight the co-benefits of integrating community garden projects into community-based learning pedagogies to realize psychosocial and environmental benefits. Scaling up such interventions through collaboration with community organizations can advance the role of higher education in the achievement of the SDGs.

Gender-Based Salary Differentials Among Administrators in Arizona Community Colleges

Objective: This research study examined gender wage equality among administrators across Arizona’s ten community college districts comprising 19 colleges. Method: Both descriptive and inferential statistics were used to analyze salary data. Results: All 19 college campuses evidenced differences in median income between 12-month, full-time women and men. However, when disaggregated by job category, median income of women and men was equal in a number of job categories in several institutions, illustrating the complexity of measuring gender wage equality using descriptive statistics. A multiple regression analysis revealed that only three of the 19 community colleges had gender-based salary differentials. Thus, gender wage equality prevails in most Arizona community colleges despite inconsistent salary schedules among the college districts and no state-level oversight. Contributions: Community colleges provide learning opportunities to a heterogeneous population of 5.4 million students annually. Understanding gender-based salary differentials among community college administrators can provide insights into diversity, equity, inclusion, and social justice in higher education.

Community‐driven science and science education: Living in and navigating the edges of equity, justice, and science learning

Community‐driven science and science education: Living in and navigating the edges of equity, justice, and science learning

Co‐created environmental health science: Identifying community questions and co‐generating knowledge to support science learning

AbstractSocial, political, and cultural complexities observed in environmental justice (EJ) communities require new forms of investigation, science teaching, and communication. Defined broadly, participatory approaches can challenge and change inequity and mistrust in science. Here, we describe Project Harvest and the partnership building and co‐generation of knowledge alongside four EJ communities in Arizona. From 2017 to 2021, Project Harvest centered learning around these communities and the participant experience drove the data sharing practice. The framework of sense‐making is used to analyze how community scientists (CS) are learning within the context of environmental pollution and (in)justice. The environmental health literacy (EHL) framework is applied to document the acquisition of skills that enable protective decision‐making and the capacity of CS to move along the EHL continuum. Using data from surveys, focus groups, and semi‐structured interviews, we are asking how did: (1) Personal connections and local relevancy fuel sense‐making? (2) Data sharing make pollution visible and connect to historical knowledge to either reinforce or modify their existing mental map around pollution? and (3) The co‐creation process build data literacy and a relationship science? Results indicate that due to the program framing, CS personally connected with, and made sense of their data based on use and experience. CS synthesized and connected their pollution history and lived experiences with their data and evaluated contaminant transport. CS saw themselves as part of the process, are taking what they learned and the evidence they helped produce to adopt protective environmental health measures and are applying these skills to new contexts. Here, co‐created science nurtured a new/renewed relationship with science. This science culture rooted in co‐creation, fosters action, trust, and supports ongoing science engagement. The science learning that stems from co‐created efforts can set the pace for social transformation and provide the foundation for structural change.

Assessing the impact of rainwater harvesting infrastructure and gardening trends on microbial indicator organism presence in harvested rainwater and garden soils.

To assess the microbial water quality of harvested rainwater infrastructure used to supplement household water uses for homegrown produce. Using a co-created community science methodology, between 2017 and 2020, a total of 587 harvested rainwater samples and 147 garden soil samples irrigated with harvested rainwater were collected from four Arizona communities and analyzed for coliform, Escherichia coli, and/or Salmonella. Participants also completed a home description survey regarding their home and surrounding area, water harvesting infrastructure, and gardening habits. Chi-Square tests revealed that the quality of harvested rainwater is affected by proximity to a waste disposal or incineration facility, animal presence, cistern treatment, and cistern age (P<0.05), while soil samples were associated with community (P<0.05). Coliform and E. coli concentrations in both sample types were greater in the monsoon season.

Adolescent Growth Spurt and Type 2 Diabetes Risk in Southwestern American Indians.

Early puberty onset is associated with higher risk of diabetes, but most studies have not accounted for childhood factors that may confound the association. Using data from a study conducted in an Indigenous community in Arizona (1965-2007), we examined associations of timing and velocity of the adolescent growth spurt with type 2 diabetes, and whether these associations are mediated by childhood body mass index and insulinemia. Adolescent growth parameters were derived from the Preece-Baines growth model, a parametric growth curve fitted to longitudinal height data, for 861 participants with height measurements spanning the whole period of growth. In males, older age at take-off, age at peak velocity, and age at maturation were associated with decreased prevalence of diabetes (odds ratio (OR)= 0.43 per year, 95% confidence interval (CI): 0.27, 0.69; OR= 0.50, 95% CI: 0.35, 0.72; OR= 0.58, 95% CI: 0.41, 0.83, respectively), while higher velocity at take-off was associated with increased risk (OR= 3.47 per cm/year, 95% CI: 1.87, 6.42) adjusting for age, birth year, and maternal diabetes. Similar results were observed with incident diabetes. Our findings suggest that an early and accelerated adolescent growth spurt is a risk factor for diabetes, at least in males. These associations are only partially explained by measures of adiposity and insulinemia.

Patterns of contamination and burden of lead and arsenic in rooftop harvested rainwater collected in Arizona environmental justice communities

As climate change exacerbates water scarcity, rainwater harvesting for household irrigation and gardening becomes an increasingly common practice. However, the use and quality of harvested rainwater are not well studied, and the potential pollutant exposures associated with its use are generally unknown. There are currently no federal standards in the United States to assess metal(loid)s in harvested rainwater. Project Harvest, a community science research project, was created to address this knowledge gap and study the quality of harvested rainwater, primarily used for irrigation, in four environmental justice communities in Arizona, USA. Community scientists collected 577 unique rooftop harvested rainwater samples from 2017 to 2020, which were analyzed for metal(loid)s, where arsenic (As) concentrations ranged from 0.108 to 120 μg L−1 and lead (Pb) concentrations ranged from 0.013 to 350 μg L−1 and compared to relevant federal/state standards/recommendations. Community As and Pb concentrations decreased as: Hayden/Winkelman > Tucson > Globe/Miami > Dewey-Humboldt. Linear mixed models were used to analyze rooftop harvested rainwater data and results indicated that concentrations of As and Pb in the summer monsoon were significantly greater than winter; and contamination was significantly greater closer to extractive industrial sites in three of the four study communities (ASARCO Hayden Plant Superfund Alternative site in Hayden/Winkelman, Davis-Monthan United States Air Force Base in Tucson - Pb only, and Freeport McMoRan Copper and Gold Mine in Globe/Miami). Based on models, infrastructure such as proximity to roadway, roof material, presence of a cistern screen, and first-flush systems were not significant with respect to As and Pb when controlling for relevant spatiotemporal variables; whereas, cistern age was associated with Pb concentrations. These results however, indicate that concentrations vary seasonally and by proximity to industrial activity, not by decisions made regarding collection system infrastructures at the individual home level. This study shows that generally, individuals are not responsible for environmental contamination of rooftop harvested rainwater, rather activities and decisions of government and corporate industries control contaminant release.

Organic micropollutants measured in roof-harvested rainwater from rural and urban environmental justice communities in Arizona

Due to global water scarcity and population growth, multiple solutions are needed to conserve and collect water, especially in arid and semi-arid regions of the planet. As the practice of harvesting rainwater grows, it is important to assess the quality of roof-harvested rainwater (RHRW). This study measured twelve organic micropollutants (OMPs) in RHRW samples collected between 2017 and 2020 by community scientists, with approximately two hundred RHRW samples and corresponding field blank analyzed annually. The OMPs analyzed were atrazine, pentachlorophenol (PCP), chlorpyrifos, 2,4-dichlorophenoxyacetic acid (2,4-D), prometon, simazine, carbaryl, nonylphenol (NP), perfluorooctanoic acid (PFOA), perfluorooctane sulfonic acid (PFOS), perfluorobutane sulfonic acid (PFBS), and perfluorononanoic acid (PFNA). OMP concentrations measured in RHRW were below the following existing standards: US EPA Primary Drinking Water Standard, Arizona Department of Environmental Quality (ADEQ) Partial Body Contact for Surface Waters, and ADEQ Full Body Contact for Surface Waters for analytes in this study. At the time the study was conducted, 28 % of RHRW samples exceeded the non-enforceable US EPA Lifetime Health Advisory (HA) of 70 ng L−1 for the combined sum of PFOS and PFOA with a mean exceedance concentration of 189 ng L−1. When comparing PFOA and PFOS to the June 15, 2022 interim updated HAs of 0.004 ng L−1 and 0.02 ng L−1, respectively, all samples exceeded these values. No RHRW samples exceeded the final proposed HA of 2000 ng L−1 for PFBS. The limited number of state and federal standards established for the contaminants highlighted in this study indicate potential regulatory gaps and that users need to be aware that OMPs may be present in RHRW. Based on these concentrations, domestic activities and intended uses should be carefully considered.

Evolution of COVID-19 Health Disparities in Arizona.

COVID-19 burdens are disproportionally high in underserved and vulnerable communities in Arizona. As the pandemic progressed, it is unclear if the initial associated health disparities have changed. This study aims to elicit the dynamic landscape of COVID-19 disparities at the community level and identify newly emerging vulnerable subpopulations. Findings from this study can inform interventions to increase health equity among minoritized communities in the Southwest, other regions of the US, and globally. We compiled biweekly COVID-19 case counts of 274 zip code tabulation areas (ZCTAs) in Arizona from October 21, 2020, to November 25, 2021, a time spanning multiple waves of COVID-19 case growth. Within each biweekly period, we tested the associations between the growth rate of COVID-19 cases and the population composition in a ZCTA including race/ethnicity, income, employment, and age using multiple regression analysis. We then compared the associations across time periods to discover temporal patterns of health disparities. The association between the percentage of Latinx population and the COVID-19 growth rate was positive before April 2021 but gradually converted to negative afterwards. The percentage of Black population was not associated with the COVID-19 growth rate at the beginning of the study but became positive after January 2021 which persisted till the end of the study period. Young median age and high unemployment rate emerged as new risk factors around mid-August 2021. Based on these findings, we identified 37 ZCTAs that were highly vulnerable to future fast escalation of COVID-19 cases. As the pandemic progresses, vulnerabilities associated with Latinx ethnicity improved gradually, possibly bolstered by culturally responsive programs in Arizona to support Latinx. Still communities with disadvantaged social determinants of health continued to struggle. Our findings inform the need to adjust current resource allocations to support the design and implementation of new interventions addressing the emerging vulnerabilities at the community level.

Community Engagement Alliance (CEAL) Against COVID-19 Disparities: Academic-community partnership to support workforce capacity building among Arizona community health workers.

The COVID-19 pandemic has both highlighted and worsened existing health inequities among communities of color and structurally vulnerable populations. Community Health Workers, inclusive of Community Health Representatives (CHW/Rs) have entered the spotlight as essential to COVID-19 prevention and control. To learn about community experiences and perspectives related to COVID-19 and inform CHW/R workforce capacity building efforts, a series of focus groups were conducted with CHW/Rs throughout Arizona at two time points in 2021. Throughout the data collection and analysis process, researchers and community partners engaged in ongoing and open dialogue about what CHW/Rs on the ground were reporting as priority community concerns, needs, and challenges. Thus, CHW/Rs informed the development of culturally and linguistically relevant health education messages, materials, and training for CHW/Rs. In this community case study, we detail the efforts of partnership between a statewide CHW professional association and an academic research team that facilitated rapid decision-making and knowledge sharing to create community-grounded tools and resources supportive of CHW/R workforce capacity building in the context of the COVID-19 pandemic.

Triggering rainfall intensities for post-wildfire debris flows in the Sonoran Desertscrub plant community

Wildfire makes landscapes more vulnerable to debris flows by reducing soil infiltration capacity and decreasing vegetation cover. The extent to which fire affects debris-flow processes depends on the severity of the fire, the climatology of intense rainfall, the pre-fire plant community, and sediment supply, among other factors. As fire expands into new plant communities and geographic regions, there is a corresponding need to expand efforts to document fire-induced changes and their impacts on debris-flow processes. In recent years, several large wildfires have impacted portions of the Sonoran Desertscrub plant community in Arizona, USA, a plant community where fire has been historically infrequent. Following two of these fires, we monitored debris-flow activity at the watershed scale and quantified wildfire-driven changes in soil hydraulic properties using in-situ measurements with mini disk tension infiltrometers. Results indicate that rainfall intensity-duration thresholds for the initiation of post-fire debris flows in recently burned watersheds within the Sonoran Desertscrub plant community are substantially greater than those in nearby areas dominated by other plant communities, such as chaparral. Results provide insight into the impact of fire on debris-flow processes in a plant community where it is likely to be more impactful in the future and help expand existing post-fire debris flow databases into a plant community where there is a paucity of observations.

Drinking water and health assessment in a Northern Arizona community

Arizona is a mineral rich state that relies on a mix of surface and ground water supplies for drinking water requirements. Small, rural water systems relying on groundwater frequently encounter elevated metal(loid) measures, particularly inorganic arsenic (As +3, +5). Such contaminant occurrences can be associated with adverse health outcomes including cancers. The Hopi Environmental Health Project examined drinking water quality and water consumption behaviors from 76 homes on Hopi lands over a four-year period. Water samples were analyzed for 28 elements and compared to US Environmental Protection Agengy (EPA) maximum contaminant levels (MCL). Only municipal/piped water had a mean arsenic concentration (11.01 µg/L) exceeding the MCL (10.0 µg/L). All other water types and elements occurred below MCL when detected. A lifetime cancer and hazard quotient associated with arsenic consumption through each water type was performed and piped/municipal water was found to carry the greatest risks (9.96 cases per 10,000 people). Results from this study showed the potential for multiple contaminants to be present in drinking water from Hopi lands and the need for further health assessment of routine exposure to low doses of contaminant mixtures through drinking water.

Morbidity and Functional Outcomes Following Rocky Mountain Spotted Fever Hospitalization-Arizona, 2002-2017.

Rocky Mountain spotted fever (RMSF) is a deadly tickborne disease disproportionately affecting Arizona tribal communities. While the acute clinical effects of RMSF are well-documented, more complete understanding of the long-term health consequences is needed to provide guidance for providers and patients in highly impacted areas. We performed a retrospective review of hospitalized RMSF cases from 2 tribal communities in Arizona during 2002-2017. Medical records from acute illness were abstracted for information on clinical presentation, treatment, and status at discharge. Surviving patients were interviewed about disease recovery, and patients reporting incomplete recovery were eligible for a neurologic examination. Eighty hospitalized cases of RMSF met our inclusion criteria and were reviewed. Of these, 17 (21%) resulted in a fatal outcome. Among surviving cases who were interviewed, most (62%) reported full recovery, 15 (38%) reported ongoing symptoms or reduced function following RMSF illness, and 9 (23%) had evidence of neurologic sequelae at the time of examination. Sequelae included impaired cognition, weakness, decreased deep tendon reflexes, seizures, and cranial nerve dysfunction. Longer hospitalization (25.5 days vs 6.2 days, P < .001), a higher degree of disability at discharge (median modified Rankin score 1 vs 0, P = .03), and delayed doxycycline administration (6.2 days vs 4.1 days, P = .12) were associated with long-term sequelae by logistic regression. Although the etiology of sequelae is not able to be determined using this study design, life-altering sequelae were common among patients surviving severe RMSF illness. Delayed administration of the antibiotic doxycycline after day 5 was the strongest predictor of morbidity.