Maryland Counties Research Articles

Evaluating implementation of Diabetes Self-Management Education in Maryland County, Liberia: protocol for a pilot prospective cohort study

IntroductionAchieving glycaemic targets for people living with diabetes (PLWD) is challenging, especially in settings with limited resources. Programmes need to address gaps in knowledge, skills and self-management. Diabetes Self-Management Education...

Relationship between Infant Mortality, Household Income and Race in Maryland Counties: A Short Communication

We used the data collected by the Centers for Disease Control and Prevention, National Center for Health Statistics to analyze infant crude death rate data in Maryland counties between 1999 and 2020 and compared this data to household income data collected by the US Census in the same Maryland counties. We found a significant inverse relationship and correlation between infant deaths and household income in Maryland counties. It is likely that low income plays a role in low birth weight in these infants and therefore may be related to the major cause of infant mortality.

Psychometric properties of two mental health screening tools in southeast Liberia: The Liberian Distress Screener and Patient Health Questionnaire.

Evidence suggests that locally developed and/or adapted screening tools for mental ill-health can have higher validity than directly translated tools developed in other settings. We administered the locally developed Liberian Distress Screener (LDS) and the Liberian-adapted Patient Health Questionnaire-9 (PHQ-9L) to a random sample of 142 outpatients at a regional hospital in Maryland County, Liberia. In the LDS, seven items demonstrated poor model fit and were excluded, resulting in an 11-item screener (LDS-11). Exploratory factor analysis of the 11-item screener (LDS-11) showed a single latent variable construct with significant factor loadings. Cronbach's alpha revealed good internal consistency (α = 0.81). Rasch analyses showed that "brain hot" and "heart fall down" were the most difficult idioms of distress to endorse while "things playing on the mind" was the easiest. All LDS-11 elements were associated with elevated function impairment, with "things playing on the mind," "worry too much," "head is hurting," and "heart cut/beat fast" achieving statistical significance. One item in the PHQ-9L demonstrated poor model fit and was excluded from psychometric analyses. The resultant eight-item PHQ demonstrated internal consistency (α = 0.76) and Rasch analysis revealed that "moving/talking too slowly/fast" was the most difficult item to endorse, while "not happy when doing things" was the easiest. Twelve items were significantly associated with functional impairment. Exploratory analyses reveal items that demonstrate ease and appropriateness of use for assessing mental distress in this population. Implementation research is needed to incorporate idioms of distress and screeners into Liberia's mental healthcare system.

On the Effectiveness of Government Policy on Gender Based Violence in Maryland County, Harper City, Halfman Station Case Study of Republic of Liberia

This paper presents the numerical analysis of the effectiveness of Government Policy on Gender Based Violence in Harper City, Maryland County. Data used were collected from the case study area and was analysed. The study revealed that there is a great effect on the Government Policy on Gender based violence in the case study of this article.

Understanding Racial Inequities in the Implementation of Harm Reduction Initiatives.

Objectives. To elucidate a structurally oriented theoretical framework that considers legacies of racism, trauma, and social exclusion and to interrogate the "unmet obligations" of the institutionalization of the harm reduction infrastructure to provide equitable protections to Black and Latinx people who use drugs (PWUD) in Maryland. Methods. In 2019, we conducted a rapid ethnographic assessment of and qualitative interviews with PWUD (n = 72) and stakeholders (n = 85) in 5 Maryland counties. We assessed PWUD's experiences, service gaps in as well as barriers and facilitators to accessing services, and the potential to expand harm reduction programs. Results. The unmet obligations we found included enforcement and punitive governance of syringes, naloxone, and other drug use equipment; racism and racialization, social exclusion, and legacies of trauma; and differential implications of harm reduction for populations experiencing racialized criminalization. Conclusions. The implementation of harm reduction policies are a first step, but assessment of structural dynamics are needed for diverse communities with unique histories. This research illuminates a key paradox: progressive policy is implemented, yet the overdose crisis escalates in communities where various forms of racialized exclusions are firmly entrenched. (Am J Public Health. 2022;112(S2):S173-S181. https://doi.org/10.2105/AJPH.2022.306767).

Online Pilot Grocery Intervention among Rural and Urban Residents Aimed to Improve Purchasing Habits.

Online grocery shopping has the potential to improve access to food, particularly among low-income households located in urban food deserts and rural communities. The primary aim of this pilot intervention was to test whether a three-armed online grocery trial improved fruit and vegetable (F&V) purchases. Rural and urban adults across seven counties in Kentucky, Maryland, and North Carolina were recruited to participate in an 8-week intervention in fall 2021. A total of 184 adults were enrolled into the following groups: (1) brick-and-mortar “BM” (control participants only received reminders to submit weekly grocery shopping receipts); (2) online-only with no support “O” (participants received weekly reminders to grocery shop online and to submit itemized receipts); and (3) online shopping with intervention nudges “O+I” (participants received nudges three times per week to grocery shop online, meal ideas, recipes, Facebook group support, and weekly reminders to shop online and to submit itemized receipts). On average, reported food spending on F/V by the O+I participants was USD 6.84 more compared to the BM arm. Online shopping with behavioral nudges and nutrition information shows great promise for helping customers in diverse locations to navigate the increasing presence of online grocery shopping platforms and to improve F&V purchases.

Borrelia burgdorferi (Spirochaetales: Spirochaetaceae) Infection Prevalence and Host Associations of Ticks Found on Peromyscus spp. in Maryland.

Lyme disease, caused by Borrelia burgdorferi sensu stricto and most commonly transmitted by Ixodes scapularis Say (Ixodida: Ixodidae), is the most common tick-borne disease in Maryland. Because B. burgdorferi s.s. is maintained in enzootic cycles among wild mice (Peromyscus spp) and Ixodes spp ticks, differing patterns of parasitism of ticks on mice could impact the infection prevalence with B. burgdorferi. We determined the infection prevalence of Peromyscus spp as well as questing and partially engorged nymphal ticks collected at six sites on private land in five counties in Maryland from May to August 2020. Questing nymph infection prevalence (NIP) was 14%. We trapped 1258 mice and collected 554 ticks and 413 ear tissue samples. The prevalence of infested Peromyscus spp varied based on host age and sex, with older and male mice more likely to be infested. We detected a significant difference amongst the proportion of attached Ixodes and the location of trapping. Similarly, the prevalence of B. burgdorferi infected Peromyscus spp mice varied between locations (average mouse infection prevalence was 40%), with the highest prevalence in locations where Ixodes were the most commonly found ticks. The B. burgdorferi infection prevalence in partially engorged I. scapularis nymphs retrieved from Peromyscus spp was ~36% which lends further support to the host infection prevalence. Local differences in distribution of infected vectors and reservoirs are important factors to consider when planning interventions to reduce Lyme disease risk.

School desegregation, school re-zoning, and growth management in two Maryland counties

This article examines how school and non-school policies interact to reinforce or disrupt school segregation in the context of suburban communities and how these systems are maintained by structural and institutional mechanisms. Methodologically, we use a case study approach to delve deeply into the interpretation and implementation of school attendance zone redesign and non-school policies, specifically land use policies and tools. We draw on neo-institutionalist theory and Ray’s (2019) framework of racialized organizations to make sense of school districts, planning agencies, and their policies. We find that school district rezoning policies provide a weak regulatory framework for desegregating schools because school zoning decisions are not made in a vacuum but rather are shaped by policies and actions taken by other actors in a multi-level governance structure. School zoning policies themselves prioritized capacity over desegregation, and regulations and norms governing the public engagement processes privilege opposition to desegregation. Our study points to the importance of greater coordination across governmental levels and policy arenas, and underscores how desegregation policy is part of a political and relational process between advocates, elected leaders, families, and youth across policy sectors.

The Role of Family Medicine Training in Addressing Workforce Challenges in Rural Liberia - Early Implementation Experience.

Background:Liberia has a severe shortage in the health workforce, which is amplified in rural areas. Many talented Liberians leave the country for post-graduate education; those physicians who do stay are concentrated in Monrovia.Objective:We initiated a family medicine specialty training program (FMSTP) to increase the number of well-trained physicians who have the knowledge, skills, and commitment to meet the health needs of the Liberian people.Methods:The Liberian College of Physicians and Surgeons (LCPS) family medicine program is a three-year post-graduate course that follows the West African College of Physician (WACP) curriculum. The program has a longitudinal rural training component supported by Partners in Health in Maryland county, where residents gain experience in a remote and under-served region. The program is evaluated through resident evaluations and ultimately bench-marked by accreditation and exam pass rates.Findings:The FMSTP commenced in July 2017, and the first rural rotation was in January 2018. To-date 13 residents have completed a total of 43 rotations in Maryland. Residents surveyed highly rated the faculty and their rural rotations. They identify more hands-on involvement in patient care, exposure to community health, and one-on-one time with faculty as the greatest assets of the rural training experience. Accreditation from the WACP was granted in December 2018. One of the graduating residents from the first class in 2020 is now serving as the first Liberian family medicine specialist in Maryland County.Discussion:Investing in a strong rural training component in our FMSTP has not only strengthened the program but has also built the infrastructure to establish our rural site as an attractive teaching hospital for intern doctors and nursing students. As the program continues to grow, success will be measured by the proportion of Liberian medical students entering the family medicine training program, retention of family medicine physicians in rural areas, and ultimately progress towards universal health coverage (UHC).

Coronary Calcium Scanning and Cardiovascular Risk Assessment Among Firefighters

Sudden cardiac death is the main cause of death among firefighters. The goal of this study is to identify firefighters at risk for cardiovascular disease using coronary artery calcium screening. Asymptomatic firefighters aged ≥40 years without known cardiovascular disease or diabetes (N=487) were recruited from fire departments in 3 Maryland counties from 2016 to 2018, with data analysis from 2018 to 2019. The cardiovascular disease prevention program included an evaluation of blood pressure, cholesterol, BMI, fasting glucose, medications, and a coronary calcium scan. A subset (n=100) was evaluated in more detail, including family history, metabolic syndrome, diet, exercise, smoking, and atherosclerotic cardiovascular disease risk score. Results indicated that 191 (39%) firefighters had a coronary artery calcium score >0, of which 91% were above the average for age, sex, and ethnicity. On univariable logistic regression, older age, male sex, hypertension, BMI, and glucose were significantly (p<0.05) associated with a higher likelihood of having any coronary artery calcium. Multiple logistic regression found that older age; male sex; taking lipid-lowering or antihypertensive medications; and higher low-density lipoprotein cholesterol, BMI, and fasting blood glucose were significantly associated with a higher likelihood of having coronary artery calcium. Of those with coronary artery calcium, 141 (74%) were not on lipid-lowering medication. In addition, 47 (94%) of those on lipid-lowering medication had a low-density lipoprotein cholesterol >70 mg/dL. In the detailed subset, 30 (30%) had coronary artery calcium. Among these, 28 (93%) had an atherosclerotic cardiovascular disease risk score <7.5%. Thus, if atherosclerotic cardiovascular disease scores alone were used to assess risk in this subset, an opportunity would have been missed to identify and treat firefighters who may have benefited from more aggressive treatment. A coronary artery calcium scan may identify the firefighters at increased risk for cardiovascular disease. A comprehensive cardiovascular disease prevention program implemented early in a firefighter's career may help reduce cardiovascular disease risk and thus death and disability in this high-risk population.

COVID-19-related knowledge, attitudes and practices: a mixed-mode cross-sectional survey in Liberia

ObjectivesTo examine the knowledge, attitudes and practices (KAP) of COVID-19 of rural and urban residents in Liberia to inform the development of local social and behaviour change communication strategies.DesignCross-sectional, mixed-mode...

The Value of Community Health Literacy Assessments: Health Literacy in Maryland.

Community health assessments have typically not measured health literacy at the community level. We developed the Community Health Literacy Assessment (CHLA) framework to describe county and regional health literacy activities, assets, gaps, and opportunities in Maryland. We implemented the CHLA framework in Maryland from January to August 2018. We conducted an environmental scan of Maryland's 24 counties to identify community resources, health indicators, and organizations. We targeted local health improvement coalitions and health departments for interviews in each county. We conducted qualitative interviews to understand what key community organizations throughout Maryland are doing to implement health literacy best practices and policies. We used summative content analysis to review, quantify, and interpret interview data. We conducted 57 interviews with participants from 56 organizations representing all 24 counties in Maryland. We captured data on multiple dimensions of health literacy and identified 3 main themes: health literacy assets and activities, health literacy gaps, and health literacy opportunities. The most cited asset was collecting data to inform health literacy practices, the most cited gap was using jargon with community members, and the most cited opportunity was increasing public awareness of existing health programs through improved outreach and teaching health information-seeking behaviors. A systematic community health literacy assessment is a feasible way to collect a large amount of health literacy data, which can inform strategic planning, determine community interventions, and ultimately lead us toward a health-literate society. We recommend that others replicate the CHLA framework to operationalize health literacy as a health indicator and include it as a community health assessment measure.

Polysubstance Overdose Deaths in the Fentanyl Era: A Latent Class Analysis.

To elucidate the main latent classes of substances detected among overdose decedents, and latent class associations with age, sex, race, and jurisdiction of death in Maryland. We used toxicology data from the Office of the Chief Medical Examiner of Maryland for all decedents. We analyzed all cases of drug overdose deaths that occurred from 2016 to 2018 (N = 6566) using latent class analysis and regression. Drug overdose deaths were concentrated in 2 of 24 counties in Maryland (Baltimore City and County). Fentanyl was involved in 71% of all drug overdose deaths, and the majority (76%) of these deaths included multiple substances. Three latent classes emerged: (1) fentanyl/heroin/cocaine (64%); (2) fentanyl/alcohol (18%); and (3) prescription drugs including opioids, benzodiazepines and antidepressants (18.0%). The fentanyl/heroin/cocaine class members were significantly younger (<30 years), female and White compared to the fentanyl/alcohol class, but more male and non-White than the prescription drugs class (all P < 0.05). Deaths in Baltimore City/County were more likely than in other locations to involve fentanyl/alcohol (P < 0.05). The majority of fentanyl-involved overdose deaths in Maryland involved multiple substances, and several demographic and geographic differences in these patterns emerged. Geographically-targeted interventions that are tailored to reduce the harms associated with polysubstance use (including cocaine, alcohol, and prescription drugs) for different demographic groups are warranted.

Growing pains in local food systems: a longitudinal social network analysis on local food marketing in Baltimore County, Maryland and Chester County, Pennsylvania

Local food systems are growing, and little is known about how the constellation of farms and markets change over time. We trace the evolution of two local food systems (Baltimore County, Maryland and Chester County, Pennsylvania) over six years, including a dataset of over 2690 market connections (edges) between 1520 locations (nodes). Longitudinal social network analysis reveals how the architecture, actor network centrality, magnitude, and spatiality of these supply chains shifted during the 2012–2018 time period. Our findings demonstrate that, despite growth in the number of farmers’ markets, grocery stores, farms and restaurants in both counties, each local food system also experienced high turnover rates. Over 80% of the market connections changed during the study period. Farms, farmers’ markets, and grocery stores showed a 40–50% ‘survival’ rate, indicating their role in sustaining local food systems over longer time periods. Other actors, such as restaurants, had a much higher turnover rate within the network. Both food systems became more close-knit and consolidated as the center of gravity for both local food systems pulled away from urban areas toward rural farmland. Evidence of both growth and decay within local food systems provides a new understanding of the social networks behind local food markets.

Monkeypox Outbreak, Harper District, Maryland County, Liberia, December 2017

Introduction: Monkeypox is a viral zoonotic disease caused by orthopoxyvirus. In Liberia, one confirmed case of monkeypox constitutes an outbreak. A District Surveillance Officer (DSO) of Harper District, Maryland County reported a suspected case of monkeypox on December 5, 2017. We investigated to verify the diagnosis, identify the source of the disease, assess the magnitude of the outbreak, and implement evidence-based control measures. Methods: We interviewed family and community members, and health workers to identify additional cases and contacts, and to obtain information on the source of the illness. We collected samples (whole blood and lesion swabs) for confirmation of the disease. We monitored the contacts for 21 days for signs and symptoms of monkeypox signs. We also conducted environmental assessment on source of the infection. Results: We identified one confirmed case of monkeypox in a 5-year old male from Tenken Community Maryland County in Liberia, who tested positive for West African strain of monkeypox virus. The case-patient had no history of direct contact with wild animals nor consumption of bush, and no travel history or contact with a sick person. The patient was isolated and recovered after three weeks of treatment on analgesics and antibiotics. We identified 35 contacts, none of whom developed signs and symptoms during 21 days of follow up. Conclusions: This was a confirmed monkeypox outbreak in Maryland County. Laboratory confirmation was delayed, and the source of infection remained unknown.

Monkeypox Outbreak, Harper District, Maryland County, Liberia, December 2017

Introduction: Monkeypox is a viral zoonotic disease caused by orthopoxyvirus. In Liberia, one confirmed case of monkeypox constitutes an outbreak. A District Surveillance Officer (DSO) of Harper District, Maryland County reported a suspected case of monkeypox on December 5, 2017. We investigated to verify the diagnosis, identify the source of the disease, assess the magnitude of the outbreak, and implement evidence-based control measures. Methods: We interviewed family and community members, and health workers to identify additional cases and contacts, and to obtain information on the source of the illness. We collected samples (whole blood and lesion swabs) for confirmation of the disease. We monitored the contacts for 21 days for signs and symptoms of monkeypox signs. We also conducted environmental assessment on source of the infection. Results: We identified one confirmed case of monkeypox in a 5-year old male from Tenken Community Maryland County in Liberia, who tested positive for West African strain of monkeypox virus. The case-patient had no history of direct contact with wild animals nor consumption of bush, and no travel history or contact with a sick person. The patient was isolated and recovered after three weeks of treatment on analgesics and antibiotics. We identified 35 contacts, none of whom developed signs and symptoms during 21 days of follow up. Conclusions: This was a confirmed monkeypox outbreak in Maryland County. Laboratory confirmation was delayed, and the source of infection remained unknown.

Literacy is power: structural drivers of child malnutrition in rural Liberia

BackgroundIn Liberia, an estimated 32% of children under 5 are stunted. Malnutrition and hunger worsened during the country’s civil war and were further exacerbated by the 2014–2016 outbreak of Ebola...

A Failed Cardiac Surgery Program in an Underserved Minority Population County Reimagined: The Power of Partnership.

BackgroundPrince George's County Maryland, historically a medically underserved region, has a population of 909 327 and a high incidence of cardiometabolic syndrome and hypertension. Application of level I evidence practices in such areas requires the availability of highly advanced cardiovascular interventions. Donabedian principles of quality of care were applied to a failing cardiac surgery program. We hypothesized that a multidisciplinary application of this model supported by partnership with a university hospital system could result in improved quality care outcomes.Methods and ResultsA 6‐month assessment and planning process commenced in July 2014. Preoperative, intraoperative, and postoperative protocols were developed before program restart. Staff education and training was conducted via team simulation and rehearsal sessions. A total of 425 patients underwent cardiac surgical procedures. Quality tracking of key performance measures was conducted, and 323 isolated coronary artery bypass grafting procedures were performed from July 2014 to December 2019. Key risk factors in our patient demographic were higher than the Society of Thoracic Surgeons national mean. Risk‐adjusted outcome data yielded a mortality rate of 0.3% versus 2.2% nationally. The overall major complication rate was lower than expected at 7.1% compared with 11.5% nationally. Readmission rate was less than the Society of Thoracic Surgeons mean for isolated coronary artery bypass grafting (4.0% versus 10.1%, P<0.0001). Significant differences in 6 key performance outcomes were noted, leading to a 3‐star Society of Thoracic Surgeons designation in 7 of 8 tracking periods.ConclusionsExcellent outcomes in cardiac surgery are attainable following program renovation in an underserved region in the setting of low volume. The principles and processes applied have potential broad application for any quality improvement effort.

Home visiting: A lifeline for families during the COVID-19 pandemic

Home visiting: A lifeline for families during the COVID-19 pandemic

The effect of farmers’ market access on residential property values

Improving farmers' market accessibility is increasingly being used as a mechanism to promote healthy food consumption. Previous studies about farmers’ markets largely focused on describing either the demographics of market patrons or the impact of market participation on fruit and vegetable intake. Thus, little empirical research has examined how market accessibility impacts nearby communities.The goal of this study is to assess whether consumers value farmers' market accessibility by exploiting preferences revealed through housing purchases. Using residential sales data from 2007 to 2012 in five Central Maryland counties, we tested whether farmers' market accessibility is associated with housing prices by estimating hedonic models with temporal and neighborhood fixed effects. The results suggest an inverse association between housing prices and distance to the closest farmers’ market, a relationship that remains statistically significant when using matching and instrumental variables estimators. The results also suggest that the association between market accessibility and housing prices is stronger in areas with poor-quality food environments.The findings are important to policy makers and planners because they suggest that farmers' market accessibility is valued by consumers in nearby communities and that consumers with limited access to food stores are willing to pay a premium for houses with access to farmers’ markets. Assessing the mechanisms driving this association is an important area for future research.