Welcome to the IUPUI Center for Translating Research Into Practice monthly Conversation with our scholar of the Month. My name is Steve Veg. I'm the Associate Director of the Center, and it's a pleasure to welcome you here for our monthly opportunity to talk with one of our esteemed scholars. Today, we're delighted to share with you. A conversation with doctor Herardo Mal Pome. But before we get started, we have several things we'd like to share. First, we'd like to remind you that the idea of the Center for translating for research into practice is the brain child of Professor Emeritus Sandra Petrono, who is a translational scholar herself, now in retirement, and she was married at the time, still is married to our Chancellor Emeritus Charles Bands. And the two of them had the vision that there should be a center on our campus that would identify, highlight, and promote research that is translational. So we're indebted to their thoughts and ideas about making this happen. They created a couple of awards for this and have promoted this kind of work on our campus, and we are glad to continue to do this, including with these monthly conversations. We're all used to Zoom, but just a reminder, please stay muted during this time, but later we'll ask you to unmute turn on your cameras when we have a conversation. But you're welcome to use the chat to put down ideas, questions that you have. We will be recording this session today if you want to see it later or have a friend or colleague that you'd like to see this. And reminder, you will receive one of those post evaluation e mails from us an opportunity to give some feedback about the presentation today, the discussion, as well as other ideas for future events that the center could promote. You want to keep in touch with us and learn more things. You can get continuing education for this series. If you're interested, you can visit expand IU dot EDU and look for the Center for translating research into practice. We hope that you'll not only check us out on our website at trip dot pU but follow us on social media. That's how you can keep up to date on the great things that are happening here on campus. Pick your choice of the things that you like. This work is not possible without support the Vance Community Fellow Award. There's a research fund that helps support that work. So if you or a colleague might be interested, please consider adding this to your list of philanthropic opportunities, so we can continue this great work. We are really appreciative of our partnership with the library here on campus. And their work in promoting what they call scholar work. So if you go to our website, example today, you could go to the page and click on doctor Mal Pome. You could see more about his work. And then you can see right there after a description of the exciting work that he does, a list of the easily accessible journal publications that are available on Scholar work. So all you have to do is click on the link. You can also go down to the bottom to the Scholar Works link and see the entire Scholar works collection at the library. This is doctor Mal Pome page, but you can see how easy it is to link to see his journal work. October is a busy month for us here. Next coming up in the center for translating research into practice. We hope that you'll join us on Friday, October 13 for something special called a spotlight. We're featuring our inaugural fellow, doctor Susan Hyatt, and we're calling that Sue and the City. Adventures in translational research in Indianapolis learn more about her work. And then our scholar of the month will be doctor Susana Marie Sk, and that'll be on the October 27, where again, we'll have our regular monthly conversation. We're also in October hosting our annual Trip Awards and fall showcase. So come and learn about this year's fellow and scholar awardees, as well as the Bans Petronio trip awardee, Holly Cusack McVay, who will be sharing some of her work on that Wednesday, October 11, 230-5 in the campus center. We'll also be showcasing some other IUPUI translational scholars. They'll be just pointing out some of their work so that you can learn more about what they do. It's a great opportunity to find out what's happening here at IUPUI. We're interested in knowing more about what you'd like us to do. So our research endeavors here in the center are going to ask you a few brief questions. So Nuri is going to lead you through and we're going to ask you to go ahead and please answer some questions using the Zoom pole chat. So Nuria, bring it on. Thank you for taking a moment to give us some feedback as we get started today. Well, today, as I mentioned, we are super excited to have with us doctor Herardo Mal Pome, who is a professor at the Fairbank School of Public Health and involved in the Campus CTSI project in a variety of ways. As mentioned earlier, the Vance Petroneo Duo created the Vance Petrono, translating research into Practice Award, and doctor Mapome was the 2021 recipient. Today, he's going to talk to us. Give us some thinking about the first wave of COVID and its influence on social media. And so we are very excited to have him here with us, and I'm going to invite him to turn on his camera. And I need to get back to, Where did it go? Here we go. So he can turn on his camera and get us started. So over here. There you go. You are ready to go, doctor Mal Pome, and welcome. We can't wait to hear what you have to share. Thank you so much. Let me see if I can find the correct sharing screen process. It seems to be, yeah. I think I survived this one. Well, thank you very much. Can you see my slides? Can you hear me okay? Yes, we can. All right. Well, first and foremost, I want to again mention again the magnificent role that Charles and Sandra had in keeping this adventure alive. I love the idea. I love the people here, and that certainly includes for Shar Stepan Nuri. It's been a real pleasure to work with all of them in different opportunities that I had. And today, I'm going to talk about something that is perhaps a new spin on my longstanding interest in social networks, in this case of Hispanics. What I'm going to do is to explain why we had this amazing opportunity to expand our knowledge about social networks and situations that were really exceptional or extreme, such as the COVID 19 pandemic. What I want to do? Let me see if I can have this working? Yeah. So here there. The most important thing perhaps is that under normal circumstances, there will be some challenges in getting under represented minority groups to participate in research. But that became even more challenging when we started looking at a situation whereby some community groups were affected more than others during the COVID 19 epidemic, we're going to talk specifically about the 2020 impacts. And I want to make sure that we look first as some personal community networks parallels. We want to see how they have a role in health. Then we are going to have this notion of networks maybe protective because they provide support or resources, but also damaging because they perpetrate unhealthy behaviors and practices. Then we want to look specifically a situation with the effect the impact of the COVID 19 pandemic and then see how the networks may have been affected. The idea here is that we want to look at the health issues, not from the point of view of the individuals. That is important, of course, and most of the research in health has largely been either the individual or large groups of people in population health research, for example. But what we're doing with a social network perspective is to understand that there is a degree of interdependence between actors in one group. And we tend to use those social norms as a way to decide what you see that is acceptable, what do you see that prompts us to have some sort of action implemented. But most importantly, we can measure quantitatively those interactions, the flow of information, and how different factors, the interactions, and the systems change over time. We really have a great opportunity with social dwork analysis. Now it also happens that have a group, a very strong group in social network analysis research in Bloomington. And I have learned a lot from the likes of Bernie Pescosoldo, Bria Peri, A Macrany, and Edri Wright, who is no longer in IU. But they really spent a good chunk of time trying to get me somewhat familiar with the concepts, and I fell in love with them because they're really very interesting in how these links across actors really help have better or wor health, more effective and less effective tools to address health problems. The idea here is that not only the information flows in a way that provides information, but also there is a social regulation of health behaviors. For example, if I have a friend or a group of friends that think that Saud is to drink a couple of all bottles of tequila, well, my health outcomes are going to be different if I go to another place where mother drinking is more likely to be the social norm. That regulation of behavior help us decide when health care or preventive efforts are necessary and how it to be affecting the person individually or the group. So what we really do here is understand that there is a volition element in how we see the social norms, how we act. But there is always an overlay of social, commercial, industrial determinants of health where we live. The idea here is in this diagram by Lisa Berkman, excellent piece of work already a couple of decades old. Is that we have the far left, the social structural conditions that condition a lot of what we do. This will be a natural home for the social industrial commercial determinants of health. When we start moving closer to the individual in the social networks column, this is where we have the social network structure because we have the size, the density, how close they are, how reachable are those actors. And we can measure these characteristics of network ties. We can measure a number of things that will help us understand what the networks is doing for the individual and what he's doing for the network itself and other connections. So the idea here is that this type of analysis is extremely useful when you have to design preventive or clinical interventions, for example, because you know where to get in if you can identify the entry points in a network where you will have the right kind of response. For example, We have some of the Mexican community or the Central American community have a little use for seeking the first point of advice, the same point of deciding whether healthcare is needed from professionals, and that is simply because the social regulation is that there will be some Hispanic specific a member of that community that will help them understand that, this is serious enough to do something. Example is having a non licensed nurse from Salvador who happens to be here, and they don't provide care. But they do provide orientation and when a person approaches them, I said, you know, Dona Maria, what do you think about this kind of situation? My son has been having this problem for a long time and I'm not sure what to do well. Something usually taken to the hospital or to the clinic because this looks like important that is not resolving by itself. That kind of thing really is what places the intermediate level of factors in the perspective of what we want to do in medical sociology. We can address not only the network pieces, total social support, social, social engagement, person to person contact, and access to material resources and goods. We want to concentrate our attention for the time being in the middle levels, the two columns of the middle levels, but we're going to have an opportunity to examine the individual impact later on. I'm going to borrow from this image that was created by my friend and colleague, Bria Perry. The idea here is that the distribution of impacts in catastrophic situation is not equal. You can see this on the left hand side, that there are not only racial ethnic weld gaps, but after the greater session, those differences became more marked. And you can see that here, you have over the years, the wealth in the white population remain pre more constant or so, but in the case of Black sa went down, and if you look at Hispanics is the same sort of thing. Now, looking at the right hand side of the slide, we see that only upper income families have median and wealth greater than prior to the great recession. What really have is that you have the upper income has actually increased their income or their wealth. Whereas if you look at middle income that hasn't happened and lower income is pre evident that there hasn't really been an opportunity for them to become better prepared to address adversity. Another example that Bria put together for another is the Hurricane Katrina kind of situation. This is actually fascinating. On the left hand side, we have African Americans are more likely than Whites to report financial employment problems. What we have the in the blue The blue bars, the African Americans, the orange the white group. And then you find that problems with credit card debt or other personal debt, there's almost double the impact for African Americans. Someone in household had overtime regular hours cut back again. Same thing. Fall behind in paying rent or mortgage, this is actually pretty clear that this kind of thing happens. And so on and so forth. We have on the right hand side, the Katrina experiences compared by income. We have those that those household that make less than $20,000 a year, and those that make 50 or more. Again, on similar or different elements of precarity of having a problem during the Katrina event is that you're more likely as a poorer person to be concerned about elderly family members living in the path of the hurricane, fear for your life, almost twice as likely for those that were poor compared to those that were better off, separated for at least a day from family members. When without food for at least a day, which is pretty clear that there is a differential impact without drinking water for at least a day, spent at least one night in an emergency shelter. The idea here is that the more we become familiar with the general elements of living conditions of different groups, we can have a better sense of what kind of impact we can anticipate and perhaps design interventions to try and address those things. So Bernie Pez Cosolo came up with this idea probably three or 4-years-old to conducting a person to person health interview survey. And what she did together with a large group was to collect information about those factors that shape health in Indiana. And they use a stratified probability sample of households across the state. Usually, this is a bit problematic because Hispanic households tend to have a 30% under representation because some of these households do not figure in driver's license rosters, for example, or in tax return rosters or some of the things that are clearly identifiable. So we cannot say that we identify all the Hispanics in the state because there is a good chunk of them who happens to be underground. Now, person to person, p2p, the excellent data collection, the study continues to a very lg extent, and then COVID happened. And then besides collecting all of this information, What Bria did was to create a rapid response kind of study went to the Sage Foundation and say I need money to do this kind of thing. They gave her the money and around April, if I'm not mistaken, April and May, when people were already hunkered down in their houses, there was a phone interview to assess how those living conditions and social factors may have affected may have been affected by the pandemic. And with that, Bria and Bernice created a pandemic precarity index, which essentially summarized the food housing and financial insecurity indicators very much along the lines of the images I shared for Katrina and for other catastrophic situations. What they found, and this is published in the proceedings of the National Academies of Science is that there is a clear gradation between the precarious sitation in terms of housing in security, food in security, financial insecurity, and being fired or unemployed, from those that are traditionally better off compared with those are traditionally less well off. We can see that this happens not only across racial disparities, but also along educational disparities. We have obvious impacts in the groups that are less likely to be in a position to address this kind of challenge. Now, again, I make the point that the Hispanics here are those including the official sampling frameworks. Now, what Brian and I did is to address this kind of situation by looking at those Hispanics living in Indiana, who are the more likely candidates for not being part of a statewide sampling framework. So what we did was to look at the resources that I have been doing the Vida Santa story funded NAH. And what we're doing here is following a cohort of Hispanic immigrants to track health social and economic well being for those people who have been in Indiana six months or less, and those that the established who are parts of the network of those new immigrants. We collected the face to face information certainly for the baseline, and I will explain this later. And we follow that at 6:12 and 18 months. The idea was to see how the networks of those persons that are newly arrived will evolve over time, and with that, the ability to meet the challenges in a better or worse situation, For those recent immigrants. The idea here is, how much of the networks and the recreation of the networks is helping you to have resources that will address oral oral mental general well being health. Now, exactly in the same fashion that Bria created this rapid response study from the P to P. Bria and I came up with this Hispanic rapid response study that took us back to the Via Sana cohort, and we elicited information in August of November and 2020, and we were asking very much the same sort of questions that the COVID study for the general population did. But we had to put that in the context of the Hispanic experiences. So what we have here is that some of these datasets from either two, three, or four studies were put together. In this case, what we have is a comparison of the immigrant experience in Indiana, is not about income, this is a about education. Let's talk about the reasons of immigrant. You find that the probability of losing a job was about the same between immigrant groups compared with a non immigrant. Probability of being laid off and hos with us, again, it was more marked in the immigrant recent or not than compared with a non immigrant. But some of these features actually turn out to be somewhat worrisome because you see that the probability of COVID affecting food security was far more marked in the new immigrant situation and the safe for housing security. This actually replicates in hard numbers, what we saw during that year and the following year that there was definitely hunger in the Hispanic community in the deprived area. Central Indianapolis that I know for a fact, but I have references that the same anecdotal reports come from other parts of the state. Now, let's talk about the Vasa study sequence, and one of the reasons why with this data collection, not only addressed the issue of what was the impact. But because we were doing a survey that had four data collection points. The interesting thing is that we knew that there will be some sort of impact from COVID 19 when it came to this sort of obitation. As you can see, the first interview took place in August 2017 for the Vida Santo. And then that person started going through the first interview, second interview, third interview and finished the fourth interview later. But while we collected all the data at baseline, face to face, we had already prepared to have data collection through a mix of phone interviews and Internet based answer options. And the reason for that is that the very recent immigrant tends to relocate very quickly. Following probably the opportunity to work in areas that have more work available to them. So it is not uncommon that they relocate. They arrive in Indianapolis, but then they have a closing in Philadelphia. There's there's a lot of construction here, you should come over here. I mean, you stay at home. So that person goes away, but we still track where they went and how they were doing. The role point here is that we needed to ascertain which factors affected viarables over time, in particular those vis modifying the evolution of networks. We as was about the evolution of network. How things change over time. And immigration is a major reset point for networks because you move to another country is like going to jail, getting out of jail, getting married, getting a divorce, you lose part of those networks and you recreate those networks, or you simply let go of them. In this case, it is an essential element of immigration when you move because you still have connections with the old country. But there are a lot of things that you have to address in the day to day basis in order to make sure that you function within the social group of what is being done in your daily life. Now, we addressed all of the Dasana variables in the cleaning to ascertain the impact of COVID in evolution networks. But in doing so, we created a number of papers that were carried out by the people doing a lot of the work in terms of data collection, or in terms of people doing the analysis from a social network perspective. I have to mention here these papers stress and alcohol intake among Hispanic adult immigrants in the US Midwest. This is the first part of a contrast that we have made because using the audit, system to ascertain alcohol intake and alcohol use disorder. We were able to show that they were Some people that were drinking a lot and a large proportion that abstained from drinking. This is for the established and the new immigrants. But the levels of the stress as measured in a separate variable, did not have an obvious impact on alcohol intake or alcohol use dissolve. Interestingly enough, there was no difference between the new immigrants and established immigrants and usually recent immigrants tend to drink less. Lack of a difference here probably suggests that the recent immigrants actually increased the alcohol intake to be about the same as established immigrants. This is Jackie Rodriguez and Cindy Rodriguez who led this study. Now this is another one that I'm doing with Caroline Brooks is not on the review. Is going to be e published probably next week. And what we did here is to take a look at some specific areas of dental health. We were asking, have you ever had apply to your teeth? Have you had dental feelings? How often do you use dental flows? And then we looked at a standard social support measurement And what we found is that the higher social support made dental outcomes better for Mexicans, but had no effect or was detrimental for Central American. That is counter intuitive. But what we find is that the country of origin and level of education we important factors in predicting less favorable outcomes for dental health. But the recency of immigration didn't really quite matter as much within the very recent time that people have migrated. This is not surprising. Sicilia Me Heber has found that Central American immigrants have social networks that may be favorable or not favorable depending on the valance of the relationship that may be very close, but very negative. In fact, the social relationships may not be not only a network of help and support, but also source of burdens and constraints, and that reflects into the health impacts that we find. Their migration difference between the Mexican and Central American participants in the study. And Denise Ambriz and the rest of the group on Brea Peris gang, so to speak, we looked at the context of exit for those Latin ex immigrants, and he actually corroborated what we found because when you have higher pre migration adversity, you had high levels of stress, worries about COVID 19 and had more mat insecurity during the pandemic after controlling for a whole bunch of vir. So We conclude that the early disadvantages in the migration triectory, can lead to additional risk as immigrants transition to the US. Therefore, you offers some information for us to understand that the issue here is not simply thinking that, all Hispanic, Latino, all of them are the same. In actual fact there has a lot of nuances, depending on what was the origin, the time in the US, the kind of work that they do, and several of these viable really lend themselves to the kind of intervention entry points that we should be looking in the future. We also ask this paper was led by Emily Ecko, who, together with Caroline Brooks did a lot, a lot of the Ty analysis for many of these papers. And here we ask How did they get the information that were specific to co 19 information and resources, safe distance, use gloves, wear a mask, consistently that kind of thing. They were differences across gender, country of origin and level of schooling. But the one thing that we confirmed because we need that from prior research, is that the first contact that these immigrants have in seeking advice is not with professionals. You see that the doctors here on the left hand side, they actually not all that will put that inability for some of the immigrants. Family and friends, Internet, and so on so for play different roles. Now, using the same index of pandemic precety that Bria and Bernese developed a few years ago, Melissa Garcia ran this study and Here we found that in terms of the gender social expectations, there were differential effects in terms of the family having children, and in terms of the gender of the parent that we're talking about, Some of you know that, for example, this concept of self sacrifice and femininity is what is called Marans in many cultures, not only Hispanic culture, where the mother is the center of the family. They sacrifice everything for the kids. They are always super interested in that. In actual fact, this is one of the reasons why many of the interventions, as long as we have a good reason to believe that is the case, should really address the mothers because they actually make a lot more things happen than we imagine if you look at the family just for us. The differential effects with that for men. Any family time was an increasing precarity. If they were single, they were not too bad. They had a spouse or the precarity, the worry went up. If you had children, it was even worse. In the case of women, only having children increase the precarity, while having being married, decrease the precarity for that woman, which is a very interesting thing to do, and again, important information on how to disseminate our work. This is a more network of the analysis led by Nix Meat and it's being published in social racial ethnicity. What we find here is that immigrants and any kind of person, but certainly the case of immigrants, the beauty is that because they are fresh and they start developing these networks, it is easy to measure how they evolve and how they Expand. So like any human being, we engage in deliberate and selective activation of networks. For example, I call my mom to ask for a cooking recipe. She is my network, go to person. We have a very close relationship in terms of cooking. Another one is my sister, my youngest sister. But there are certain things that I don't talk with my mom, which is probably my romantic life or my sexual life for very simple reasons that we all understand. But that essentially means that all networks are function specific and the immigrants are not different. The issue here is that because they are in a resource constrained environment, they fall back on the community to get resources they want. One thing that is well established is that ethnic enclaves may offer access to cultural resources and supportive community networks, but they may also reproduce gations that are simply not conducted to better health. Classical example is Hispanic Latinos. They come to Indiana and they continue buying bottled water or water large containers because they don't throw the tap water, because in Mexico, certainly in Central America, if you drink from the tab, basically you're nuts you going to get sick. But by buying water, those minority groups are not getting the fluoride that is included in the community fluoridation that exists in Indiana. So they have already something against them of dental health. So some of this is a lot more versatile than that, but this is a good example of how being an enclave doesn't quite help you to make the most of the opportunis resources that are available to you. So let me approach the end by saying that we have some take home messages. The impacts of Hispanic healthnee is where multiple were severe and for the first year, they were the group that was more negatively affected, more than African Americans and American Indians. Then things changed as the pandemic progressed, and African Americans Americans actually took the dubious honor of being the groups that were most affected. Now, there are a lot of variations when it comes to Hispanic health, and it has to do with how well created is the network where that person comes from and where they arrive. This is a beautiful book by Bashi called the survival of the Nite. And it goes to show using Caribbean immigrants to London and to the US. Now there are different characteristics, but it always revolve around what are the features of the network where they arrive. Now, as I said before, there are caveats to adopting a single monolithic lens to interpret Hispanic health, clan oriented, positive, protection of the elderly, the importance of the kids. Yeah, Those exist, but they are not perfect because some of these interactions are less positive, as you will expect. And I think is not only something near, is being a very important element of social network studies is that if you're going to do something about those characteristics, you need to take into account what is the network doing for that person and doing for the community and doing for you when you design an intervention. This distinction really flotate someplace between the social causes of health impacts, the context where people live, and the social values that determine the distribution of such cases, which essentially social class and socioeconomic status. So with this I finish, I do appreciate your time. I am not terribly late. And I really have this long list of people that have honored me with their collaborations and I have learned a lot from them, and I'm probably forgetting a couple of them. I do apologize for that. But I've been blessed with amazing project managers, students, and community collaborators, interviewers and certainly co investigators in doing this. Thank you. Well, thank you, doctor Ma Pome, for sharing a lot of information for us to think about. And as we like to do, at this point in our conversations is to open up the floor and invite you, the audience to turn on your camera and join the conversation and to propose questions for discussion or to dig deeper into any of the topics that were presented by doctor Ma Pome. So does anybody have something they'd like to ask about or to get clarification on or to encourage some conversation? Well, as your question. Oh, go ahead. Go ahead. Okay. Well, one question I had was, thank you again, doctor Maam for your presentation. Is very informative. One question I had is I'm not sure if I missed it or not, but how did you, initially identify the new immigrants for the study? And was it easy for you to develop trust with them for them to open up and give you their contact information and Those are actually key questions to doing this type of research because we have enough of a presence with parishes and community organizations so that we go to the parish on the Spanish language mass on a Sunday morning and just ask, he, you know, how you do any appartment? Glad to see you here. Do you know any person that might have arrived from outside within the last six months? Oh, yeah, look at the parses over there. They have a cousin that just arrived and that kind of thing that established the first element. But the most important thing is the issue of trust. And I think that just because we have been working on this for ten, 15 years, there is a brand name that people in the Hispanic communities, Oh, yes, this is Herardo again. That's fine. I go to the priests Can you give me the opportunity to speak from the pulpit during the Parish announcements. And things of the like that created the type of presence that will allow people to trust you at least at a minimum level, and those newcomers, if they're coming from Salvador and they're probably running for their life. They are really very scared of having this kind of interaction with the outside world. Let me remind you that we did this research. The entire collection of data was done during the Trump administration and a good chunk during the pandemic years. So I take a special pride in saying that we have an 81.7% retention rate. At the end of the fourth follow up, and that is not a small thing. We had trouble getting new people into the study. But once that they were in the study, they were retained very effectively. And since we have Cindy Rodriguez here, in the audience, I want to draw attention to the fact that some project managers did support this effort, but Cindy was really at the forefront of this kind of component of the study I was particularly difficult at the time that Hispanic immigration was demonized by the Federal administration. Now, the interesting thing about all of this is that that great retention rate really had to do with our techniques to maintain contact with them, showing up in the parish, send Bertmon cards, making sure that we knew, hey, where is Joseperez? I cannot find him. He actually moved to Kentucky. Okay. Can you ask him if it's okay to have his phone number, or they have the same phone number. So we know where to find that person and had to arrange for the data collection taking place in some more convoluted situations. In fact, we even we didn't have that many people being deported. But we conducted the final data collection with one person in Reno in the Mexican border, another Tua Mala Honduras, I don't remember well. But that essentially meant that we were able to track them down to a very high level of sophistication. Any other questions? Hello. Yes, go ahead, Mika Oh. Go ahead. You were starting to you were starting to speak, Mr. Hutcheson, then we'll have Michael go after you. All right. My apologies. Thank you for your presentation. I wanted to find out a little bit more about the precarity measure, security index, how you went about identifying the variable or just motivation for developing an index of that nature. And can you see something like that being used for other areas for other populations as well. And particular thinking about policy development policy. Considering the time constraints we have now, I wouldn't get into the details of that. That research was led by Bria Perry, and she is a medical sociologist who took whatever kind of techniques to see which variables hung together and then create the index. My suggestion is you go to the Bria Perry at Al proceedings of the National Academy of Science. That's a paper I came out in 2021, if I'm not mistaken. And it describes the entire development of the index. And now you're completely right. This precarity index perhaps was even more significant because we had information about precarity food, employment, housing, pd kando thing. We had before the COVID 19 pandemic and during the COVID 19 pandemic. So it was actually easy to see how the changes could have been attributed to the COVID 19 pandemic. And I think you make an excellent point, I will point out to the paper by Bria because it really makes a great case for that index. Thank you, Michael. Go ahead, Michael. Thank you very much, Harada. Thank you. Very interesting, as always, you educate me. Um just curious. The immigrants knew or established? Did you have information of where they came from in those countries? And what I'm thinking there is a rural versus an urban or you know, capital city community? Somebody coming from San Salvador instead of La Libertad or Guatemala City, instead of utapa, as you know, I spent a lot of time in that part of the world, and I know that you know, there's a different exposure of those people necessarily to the option for healthcare while they are still at home as it were before they came here. Does that make sense? Yes, it does. And I think you're completely right in appreciating how this works in terms of where people come from. In fact, we have variables for both established and recent immigrants, where we ask them, do you come from a capital city, a large city, small city, village and a small ranch. And that allows us to have to create an index of rurality. There are several tops, and we're not going to create something new, but we have the information for both established and recent m that information. I have one of my students, Dylan Jones, we're looking at the rurality effect to see if some of these key outcomes were governed or affected by how rural was the community where the person came from. It is an absolute distinction when it comes to Hispanic Latino immigration because it really speaks to where in the acculturation trajectory that person inserts. For example, in my case, a college educated, middle class kid from Mexico City, Parents reading Parma, a lot of newspapers and magazines in English. By the time I came to the US, I was far more westernized and more in tune with social values that some of them were American, some of them were simply middle class. If you contrast what I do for health, compared with a person that comes from a Rancheria, a small ranch in the Middle of Nowhere in Wahaca, that person has probably had a couple of years of formal education. They have some of them have some sort of literacy. Some others the just semi functional literacy, and their ability to understand the American world and how to deal with nuances, for example, navigating the medical or dental care, just happened to be a different type of challenge. In fact, another spin of the da Sana is we created a navigation manual for Central American immigrants to explain to them what was the deal with with teeth around here. So what were the expectations of the dentists, what the kinds of rights and resources you had, where to go where you needed cheap or free dental care. What are the basic elements that lead to toca to parental disease, and also some sort of a very empathic empowerment with Art Novell a photo novela kind of description, inviting people to be part of that because Manuel, sees Jose and Jose didn't make it to work yesterday because hetero toothache went to the dentists and the dentist has $5,000. And then Manuel explains well, this is what you have to do. You need to understand the difference between episodic dental care in other parts, but you have the right to solicit to seek a resolution of problems that don't start with the $5,000 in right off the path. So you're completely right. As soon as I have a study from Dylan and I, I will share it with the group because it is extremely interesting, and you're completely right. The rurality is a major issue here. Any other question? Comments? I'm wondering about a couple of things that really intrigued me about your presentation. O A the rurality question because there's a lot of similarities, perhaps to our own state of Indiana where we're largely a rural state. And so it makes me wonder about the application of what you're learning in this area and how it applies to Indiana and your discussion about social networks and how important that is. Again, and how that might apply to in general in our state around health outcomes. So what do you think about that? I think that there is a difference between the different types of residents location. I don't think it is necessarily a major education cask as it happens in the Hispanic population and even more in those countries that have a more limited type of educational offerings. Say, for example, Central America, In Indiana, you probably have access to some education, some formal schooling will take you to high school. There are things that you will learn there. What really matters in terms of the realty when it comes to Indiana is having a closely placed access to CarePoint. Because if you live in a place that you have to drive a couple of hours to get to the next Dentist. So even worse in New Mexico, Arizona, that literally in order for you to get from here to there to see the dentists to drive. So and then you have to return because they have to do something else like four or five days later. So the issue of accessibility is confounded by realty. I wouldn't know how to use this at this specific time, but I am pretty sure that Bria has information about the realty from the p2p study. Wow. Great. I do want to call people's attention to the chat in Zoom because there's a whole bunch of resources that doctor M Pam has provided if you want to dig deeper into a variety of sources that he was sharing. So there's links right there. And those will also be shared out later. If you don't have time and you don't want to be able to connect those. We will send those out in a follow up e mail to you so that you'll have that at your fingertips along with that link asking you to take a moment. And give us some feedback about the session today and your ideas about other events. So I want to take a pause here at about 10 minutes of the hour to thank doctor Mal Pome for his time today and getting us to think about this in a deeper way. And for those that need to carry on because you have appointments at the top of the hour, we understand that you may need to leave. And so we want to give a big round of applause and appreciation for the great work of doctor M Palme on our campus and understanding more about translational research in the ways that he's presented. And those who would like to to stay for a little bit longer will hang out for the opportunity to just continue some conversation for those that need to quick reminder, we have several events coming up in the next month. Please check us out.