Impact of community health workers on diabetes management in an urban United States Community with high diabetes burden through the COVID pandemic

Objective

Community Health Worker (CHW) interventions are promising approaches to increasing access to health care, garnering better health outcomes, and decreasing health inequities for historically marginalized populations. This study examines the impact of a health system-based CHW program embedded in the Diabetes Impact Project - Indianapolis Neighborhoods (DIP-IN), a large, place-based, multi-year intervention to reduce diabetes burden. We assessed the CHW program's effectiveness in managing glucose control and reducing diabetes-associated complications across the COVID timeline.

Methods

We examined the association between the CHW intervention and diabetes management in 454 CHW patients and 1,020 propensity score-matched comparison patients. Using electronic medical records for encounters between January 1, 2017, and March 31, 2022, we estimated the CHW program effect using a difference-in-difference approach through generalized linear mixed models.

Results

Participation was associated with a significant reduction (-0.54-unit (95 % CI: -0.73, -0.35) in glycosylated hemoglobin (A1C) on average over time that was beyond the change observed among comparison patients, higher odds of having ≥ 2 A1C measures in a year (OR = 2.32, 95 % CI: 1.79, 3.00), lower odds of ED visits (OR: 0.88; 95 % CI: 0.73, 1.05), and lower odds of hospital admission (OR: 0.81; 95 % CI: 0.60,1.09). When analyses were restricted to a pre-pandemic timeframe, the pattern of results were similar.

Conclusion

This program was effective in improving diabetes management among patients living in diabetes-burdened communities, and the effects were persistent throughout the pandemic timeline. CHW programs offer crucial reinforcement for diabetes management during periods when routine healthcare access is constrained.

Impact of mandatory nucleic acid amplification test (NAAT) testing approval on hospital-onset Clostridioides difficile infection (HO-CDI) rates: A diagnostic stewardship intervention

Misclassification of Clostridioides difficile colonization as hospital-onset C. difficile infection (HO-CDI) can lead to unnecessary treatment of patients and substantial financial penalties for hospitals. We successfully implemented mandatory C. difficile PCR testing approval as a strategy to optimize testing, which was associated with a significant decline in the monthly incidence of HO-CDI rates and lowering of our standardized infection ratio to 0.77 (from 1.03) 18 months after this intervention. Approval request served as an educational opportunity to promote mindful testing and accurate diagnosis of HO-CDI.

Ramifications of Precarious Employment for Health and Health Inequity: Emerging Trends from the Americas

Precarious employment (PE), which encompasses the power relations between workers and employers, is a well-established social determinant of health that has strong ramifications for health and health inequity. In this review, we discuss advances in the measurement of this multidimensional construct and provide recommendations for overcoming continued measurement challenges. We then evaluate recent evidence of the negative health impacts of PE, with a focus on the burgeoning studies from North America and South America. We also establish the role of PE in maintaining and perpetuating health inequities and review potential policy solutions to help alleviate its health burden. Last, we discuss future research directions with a call for a better understanding of the heterogeneity within PE and for research that focuses both on upstream drivers that shape PE and its impacts on health, as well as on the mechanisms by which PE causes poor health. Expected final online publication date for the Annual Review of Public Health, Volume 45 is April 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Differential Employment Quality and Educational Inequities in Mental Health: A Causal Mediation Analysis

BACKGROUND

In the United States, inequities in mental distress between those more and less educated have widened over recent years. Employment quality, a multidimensional construct reflecting the relational and contractual features of employer-employee relationships, may mediate this inequity throughout adulthood, yet no study has examined the extent of this mediation in the United States, or how it varies across racialized and gendered populations.

METHODS

Using the information on working-age adults from the 2001 to 2019 Panel Study of Income Dynamics, we construct a composite measure of employment quality via principal component analysis. Using this measure and the parametric mediational g-formula, we then estimate randomized interventional analogs for natural direct and indirect effects of low baseline educational attainment (≤high school: no/yes) on the end-of-follow-up prevalence of moderate mental distress (Kessler-6 Score ≥5: no/yes) overall and within subgroups by race and gender.

RESULTS

We estimate that low educational attainment would result in a 5.3% greater absolute prevalence of moderate mental distress at the end of follow-up (randomized total effect: 5.3%, 95% CI = 2.2%, 8.4%), with approximately 32% of this effect mediated by differences in employment quality (indirect effect: 1.7%, 95% CI = 1.0%, 2.5%). The results of subgroup analyses across race and gender are consistent with the hypothesis of mediation by employment quality, though not when selecting on full employment (indirect effect: 0.6%, 95% CI = -1.0%, 2.6%).

CONCLUSIONS

We estimate that approximately one-third of US educational inequities in mental distress may be mediated by differences in employment quality.

Continued underrepresentation of historically excluded groups in the neurosurgery pipeline: an analysis of racial and ethnic trends across stages of medical training from 2012 to 2020

OBJECTIVE

US allopathic medical schools have experienced improvements in racial and ethnic diversity among matriculants in the past decade. It is not clear, however, whether better representation of historically excluded racial and ethnic groups at medical school entry impacts subsequent stages of the medical training pipeline leading into a specific field. The aim of this study was to examine these trends as they relate to the neurosurgical medical education pipeline and consider the drivers that sustain barriers for underrepresented groups.

METHODS

Race and ethnicity reports from the American Association of Medical Colleges were obtained on allopathic medical school applicants, acceptees, and graduates and applicants to US neurosurgical residency programs from 2012 to 2020. The representation of groups categorized by self-reported race and ethnicity was compared with their US population counterparts to determine the representation quotient (RQ) for each group. Annual racial composition differences and changes in representation over time at each stage of medical training were evaluated by estimating incidence rate ratios (IRRs) and 95% confidence intervals (CIs) using non-Hispanic Whites as the reference group.

RESULTS

On average, Asian and White individuals most frequently applied and were accepted to medical school, had the highest graduation rates, and applied to neurosurgery residency programs more often than other racial groups. The medical school application and acceptance rates for Black individuals increased from 2012 to 2020 relative to Whites by 30% (95% CI 1.23-1.36) and 42% (95% CI 1.31-1.53), respectively. During this same period, however, inequities in neurosurgical residency applications grew across all non-Asian racialized groups relative to Whites. While the incidence of active Black neurosurgery residents increased from 2012 to 2020 (0.6 to 0.7/100,000 Black US inhabitants), the prevalence of White neurosurgery residents grew in the active neurosurgery resident population by 16% more.

CONCLUSIONS

The increased racial diversity of medical school students in recent years is not yet reflected in racial representation among neurosurgery applicants. Disproportionately fewer Black relative to White US medical students apply to neurosurgery residency, which contributes to declining racial representation among all active neurosurgery resident physicians. Hispanic individuals are becoming increasingly represented in neurosurgery residency but continue to remain underrepresented relative to the US population. Ongoing efforts to recruit medical students into neurosurgery who more accurately reflect the diversity of the general US population are necessary to ensure equitable patient care.

A cross-sectional analysis of work schedule notice and depressive symptoms in the United States

The implementation of last-minute work scheduling practices, including fluctuations in work hours, shift cancellations, and short notice, reflects a new norm in employment in the United States. This study aimed to investigate whether work schedule notice of ≤2 weeks was associated with high depressive symptoms. We used data from the 2019 cycle of the National Longitudinal Survey of Youth 1997 (N = 4963 adults aged 37-42 years). Using adjusted gender-stratified modified Poisson models, we tested the association between schedule notice (≤2 weeks, >2 weeks, consistent scheduling) and high depressive symptoms. Presence of high depressive symptoms was assessed using the 7-item Center for Epidemiologic Studies Depression (CES-D) Short-Form scale and defined as CES-D-SF ≥8. Respondents reporting >2 weeks schedule notice (versus ≤2 weeks) were disproportionately non-Hispanic Black or Hispanic and resided in the South and/or in a rural area. High depressive symptoms were 39% more prevalent among women with schedule notice of ≤2 weeks compared to those with >2 weeks notice (Prevalence Ratio [PR]: 1.39, 95% Confidence Interval (CI): 1.07, 1.80). We did not observe an association among men (PR: 1.06, 95% CI: 0.75, 1.50). Schedule notice of ≤2 weeks was associated with a greater burden of high depressive symptoms among US women. Policies to reduce precarious work scheduling practices should be further evaluated for their impacts on mental health.

Maternal precarious employment and child overweight/obesity in the United States

Precarious employment has increased in the United States and is now recognized as an important social determinant of health. Women are disproportionately employed in precarious jobs and are largely responsible for caretaking, which could deleteriously affect child weight. We utilized data from the National Longitudinal Survey of Youth adult and child cohorts (1996-2016; N = 4453) and identified 13 survey indicators to operationalize 7 dimensions of precarious employment (score range: 0-7, 7 indicating the most precarious): material rewards, working-time arrangements, stability, workers' rights, collective organization, interpersonal relations, and training. We estimated the association between maternal precarious employment and incident child overweight/obesity (BMI ≥85th percentile) using adjusted Poisson models. Between 1996 and 2016, the average age-adjusted precarious employment score among mothers was 3.7 (Standard Error [SE] = 0.02) and the average prevalence of children with overweight/obesity was 26.2% (SE = 0.5%). Higher maternal precarious employment was associated with a 10% higher incidence of children having overweight/obesity (Confidence Interval: 1.05, 1.14). A higher incidence of childhood overweight/obesity may have important implications at the population-level, due to the long-term health consequences of child obesity into adulthood. Policies to reduce employment precariousness should be considered and monitored for impacts on childhood obesity.

A tutorial on a marginal structural modeling approach to mediation analysis in occupational health research: Investigating education, employment quality, and mortality

Life expectancy inequities between more- and less-educated groups have grown by 1 to 2 years over the last several decades in the United States. Simultaneously, employment conditions for many workers have deteriorated. Researchers hypothesize that these adverse conditions mediate educational inequities in mortality. However, methodological barriers have impeded research on the role of employment conditions and other hazards as mediating factors in health inequities. Indeed, traditional mediation analysis methods are often biased in occupational health settings, including in those with exposure-mediator interactions and mediator-outcome confounders that are caused by exposure. In this paper, we outline-and provide code for-a marginal structural modeling (MSM) approach for estimating total effects and controlled direct effects originally proposed elsewhere, which can be applied to common mediation analysis settings in occupational health research. As an example, we apply our approach to assess the extent to which disparities in employment quality (EQ)-a multidimensional construct characterizing the terms and conditions of the worker-employer relationship-explained educational inequities in mortality in a 1999-2015 US Panel Study of Income Dynamics sample of workers with mortality follow-up through 2017. Under certain strong assumptions described in the text, our estimates suggest that over 70% of the educational inequity in mortality would have been eliminated if EQ had been at the 80^th percentile (100^th  = best) across exposure groups.

Association between precarious employment and BMI in the United States

OBJECTIVE

There is growing recognition that precarious employment is an important determinant of health, which may increase BMI through multiple mechanisms, including stress. It was investigated whether increases in precarious employment were associated with changes in BMI in the United States.

METHODS

Data were from the National Longitudinal Survey of Youth adult cohort (1996-2016) (N = 7280). Thirteen indicators were identified to operationalize seven dimensions of precarious employment (range: 0-7, 7 indicating most precarious): material rewards, working-time arrangements, stability, workers' rights, collective organization, interpersonal relationships, and training. The precarious employment-BMI association was estimated using linear regression models and an instrumental variables approach; state- and individual-level firm sizes were the instruments for precarious employment. Models also included individual and year fixed effects and controlled for age, marital status, education, region, and industry.

RESULTS

The average precarious employment score (PES) was 3.49 (95% CI: 3.46-3.52). The PES was the highest among Hispanic (4.04; 95% CI: 3.92-4.15) and non-Hispanic Black (4.02; 95% CI: 3.92-4.12) women with lower education. A 1-point increase in the PES was associated with a 2.18-point increase in BMI (95% CI: 0.30-4.01).

CONCLUSIONS

Given that even small changes in weight affect chronic disease risk, policies to improve employment quality warrant consideration.

The association between household and neighborhood characteristics and COVID-19 related ICU admissions

Introduction

Approaches to COVID-19 mitigation can be more efficiently delivered with a more detailed understanding of where the severe cases occur. Our objective was to assess which demographic, housing and neighborhood characteristics were independently and collectively associated with differing rates of severe COVID-19.

Methods

A cohort of patients with SARS-CoV-2 in a single health system from March 1, 2020 to February 15, 2021 was reviewed to determine whether demographic, housing, or neighborhood characteristics are associated with higher rates of severe COVID-19 infections and to create a novel scoring index. Characteristics included proportion of multifamily homes, essential workers, and ages of the homes within neighborhoods.

Results

There were 735 COVID-19 ICU admissions in the study interval which accounted for 61 percent of the state's ICU admissions for COVID-19. Compared to the general population of the state those admitted to the ICU with COVID-19 were disproportionately older, male sex, and were more often Black, Indigenous, People of Color. Patients disproportionately resided in neighborhoods with three plus unit multifamily homes, homes built before 1940, homes with more than one person to a room, homes of lower average value, and in neighborhoods with a greater proportion of essential workers. From this our COVID-19 Neighborhood Index value was comparatively higher for the ICU patients (61.1) relative to the population of Rhode Island (49.4).

Conclusion

COVID-19-related ICU admissions are highly related to demographic, housing and neighborhood-level factors. This may guide more nuanced and targeted vaccine distribution plans and public health measures for future pandemics.

The inequitable burden of the COVID-19 pandemic among marginalized older workers in the United States: an intersectional approach

Objectives

The COVID-19 pandemic has profoundly affected the lives of people globally, widening long-standing inequities. We examined the COVID-19 pandemic’s impact on employment conditions by race/ethnicity, gender, and educational attainment and the association between such conditions and well-being in older adults in the United States.

Methods

Using data from the Health and Retirement Study respondents interviewed between May 2020 and May 2021 when they were ≥55 years of age, we examined intersectional patterns in COVID-19-related changes in employment conditions among 4,107 participants working for pay at the start of the pandemic. We also examined the compounding nature of changes in employment conditions and their association with financial hardship, food insecurity, and poor self-rated health.

Results

Relative to non-Hispanic White men with greater than high school education (>HS), Black and Latinx men and women were more likely to experience job loss irrespective of education; among those who did not experience job loss, men with ≤HS reporting Black, Latinx, or “other” race were >90% less likely to transition to remote work. Participants who experienced job loss with decreased income or continued in-person employment with decreased income/shift changes had greater prevalence of financial hardship, food insecurity, and poor/fair self-rated health than others.

Discussion

The impact of COVID-19 on employment conditions is inequitably patterned and is associated with financial hardship, food insecurity, and adverse health in older adults. Policies to improve employment quality and expand social insurance programs among this group are needed to reduce growing inequities in well-being later in life.

Association of Treatment with Remdesivir and 30-day Hospital Readmissions in Patients Hospitalized with COVID-19

Background

Since the beginning of COVID-19 pandemic, there has been a widespread use of remdesivir in adults and children. There is little known information about remdesivir's role in reducing 30-day readmissions after hospitalization with COVID-19. This study aimed to determine whether treatment with remdesivir was associated with reduced risk of 30-day readmission after index hospitalization with COVID-19.

Methods

The study was a multi-center cohort study in Rhode Island, USA. Patients included all adults that were discharged after hospital treatment for COVID-19 between April 1^st and December 31^st, 2020. The main study outcomes were length of hospital stay, 30-day readmission, and post-discharge 30 days mortality.

Results

A total of 2,062 patients (2,279 hospitalizations) were included in the analytic sample. Patients were less likely to be readmitted within 30 days if they received remdesivir relative to not receiving remdesivir; associations were strongest for those with mild disease (RR: 0.31; 95% CI: 0.13,0.75). Remdesivir treatment was associated with reduction in all-cause mortality (HR: 0.65; 95% CI: 0.49,0.85) and an increase in length of stay (estimated average increase of 3.27 days; 95% CI: 2.11,4.44). Limitation: Unmeasured factors such as time-to-treatment and severity of disease prior to initiation of remdesivir.

Conclusions

Remdesivir may be an effective strategy for reducing progression to severe COVID-19 disease and limiting morbidity associated with readmission to hospital. Larger prospective studies are justified to study the role of remdesivir in mild or early COVID-19 with high risk of disease progression and readmission to hospital within 30 days.

Beyond Hours Worked and Dollars Earned: Multidimensional EQ, Retirement Trajectories and Health in Later Life

The working lives of Americans have become less stable over the past several decades and older adults may be particularly vulnerable to these changes in employment quality (EQ). We aimed to develop a multidimensional indicator of EQ among older adults and identify EQ and retirement trajectories in the United States. Using longitudinal data on employment stability, material rewards, workers' rights, working-time arrangements, unionization, and interpersonal power relations from the Health and Retirement Study (HRS), we used principal component analysis to construct an EQ score. Then, we used sequence analysis to identify late-career EQ trajectories (age 50-70 years; N = 11,958 respondents), overall and by sociodemographics (race, gender, educational attainment, marital status). We subsequently examined the sociodemographic, employment, and health profiles of these trajectories. We identified 10 EQ trajectories; the most prevalent trajectories were Minimally Attached and Wealthy (13.9%) and Good EQ to Well-off Retirement (13.7%), however, 42% of respondents were classified into suboptimal trajectories. Those in suboptimal trajectories were disproportionately women, people of color, and less-educated. Individuals in the Poor EQ to Delayed and Poor Retirement and Unattached and Poor clusters self-reported the greatest prevalence of poor health and depression, while individuals in the Wealthy Business Owners and Great EQ to Well-off Retirement clusters self-reported the lowest prevalence of poor health and depression at baseline. Trajectories were substantially constrained for women of color. Although our study demonstrates EQ is inequitably distributed in later life, labor organizing and policy change may afford opportunities to improve EQ and retirement among marginalized populations.

Intersectional trends in employment quality in older adults in the United States

Americans' working lives have become more precarious over the past several decades. Worsening employment quality has been linked to poorer physical and mental health and may disproportionately impact marginalized working populations. We examined differences in the quality and character of worker-employer relationships among older workers in the United States (US) across intersecting gender-racial/ethnic-educational subgroups. Using longitudinal data on employment stability, material rewards, workers' rights, working-time arrangements, unionization, and interpersonal power relations from the Health and Retirement Study (1992-2016), we used principal components analysis to construct an employment quality (EQ) score. We estimated intersectional differences in EQ, overall and over time, using generalized estimating equations. Overall, EQ was greatest for white men with college degrees and poorest for Latinx women with < high school degrees. Over time, EQ tended to remain unchanged or slightly worsen across intersectional strata; the greatest EQ reduction was for Latinx women with college degrees, while the greatest improvement was for white women with high school degrees. There are enduring and growing inequities in EQ for older marginalized adults in the US, which may contribute to growing health inequities.

Factors Related to Prescription Drug Monitoring Program Queries for Veterans Receiving Long-Term Opioid Therapy

Objective

State prescription drug monitoring programs (PDMPs) identify controlled medications dispensed across providers and systems. Department of Veterans Affairs (VA) policy requires electronic health record documentation of PDMP queries at least annually for VA patients receiving controlled medications; however, queries are not uniformly conducted. We examined factors associated with PDMP queries for veterans receiving long-term opioid therapy.

Methods

Veterans with a VA provider who received long-term opioid therapy between August 2015 and August 2016 within a four-state region were identified; 9,879 were due for a PDMP query between August 2016 and February 2017. Likelihood of veterans’ PDMP queries during this follow-up period was modeled as a function of patient, provider, and facility characteristics of interest in mixed-effects modified Poisson models estimating relative risk and 95% confidence intervals. Multivariable models controlled for potential confounders identified through the use of directed acyclic graphs.

Results

PDMP queries were documented for 62.1% of veterans that were due for a PDMP query. Veterans were more likely to be queried if they were Hispanic or if they received methadone, had average daily milligram morphine equivalents &gt;20, or received urine drug screening during the studied period. Veterans were less likely to be queried if they had a rural address, mail order medication, or cancer diagnosis. Likelihood of PDMP queries was also lower for veterans whose opioid-prescribing provider was an oncologist or working in a low-complexity facility.

Conclusions

Adherence to PDMP query policy within the VA varied by patient, clinician, and facility factors. Mechanisms to standardize the conduct of PDMP queries may be needed.

Changes in precarious employment in the United States: A longitudinal analysis

Objective:

This longitudinal study aimed to measure precarious employment in the US using a multidimensional indicator.

Methods:

We used data from the National Longitudinal Survey of Youth (1988–2016) and the Occupational Information Network database to create a longitudinal precarious employment score (PES) among 7568 employed individuals over 18 waves (N=101 290 observations). We identified 13 survey indicators to operationalize 7 dimensions of precarious employment, which we included in our PES (range: 0–7, with 7 indicating the most precarious): material rewards, working-time arrangements, stability, workers’ rights, collective organization, interpersonal relations, and training. Using generalized estimating equations, we estimated the mean PES and changes over time in the PES overall and by race/ethnicity, gender, education, income, and region.

Results:

On average, the PES was 3.17 [standard deviation (SD) 1.19], and was higher among women (3.34, SD 1.20), people of color (Hispanics: 3.24, SD 1.23; non-Hispanic Blacks: 3.31, SD 1.23), those with less education (primary: 3.99, SD 1.07; high school: 3.43, SD 1.19), and with lower-incomes (3.84, SD 1.08), and those residing in the South (3.23, SD 1.17). From 1988 to 2016, the PES increased by 9% on average [0.29 points; 95% confidence interval (CI) 0.26–0.31]. While precarious employment increased over time across all subgroups, the increase was largest among males (0.35 points; 95% CI 0.33–0.39), higher-income (0.39 points; 95% CI 0.36–0.42) and college-educated (0.37 points; 95% CI 0.33–0.41) individuals.

Conclusions:

Long-term decreases in employment quality are widespread in the US. Women and those from racialized and less-educated populations remain disproportionately precariously employed; however, we observed large increases among men, college graduates and higher-income individuals.

Life-course trajectories of employment quality and health in the U.S.: A multichannel sequence analysis

The organization of employment in the U.S. has changed dramatically since the 1970s, causing decreased power and security for workers across many dimensions of the employment relationship. Multidimensional employment-quality (EQ) measures can be used to capture these changes and test their association with health. However, most public-health EQ studies have used cross-sectional, unidimensional data. We addressed these limitations using a longitudinal, multidimensional EQ measure and data on 2779 1985-2017 Panel Study of Income Dynamics respondents. First, using a multichannel sequence-analysis approach, we identified gender-specific clusters of mid-career (ages 29-50) EQ trajectories based on respondents' employment stability, material rewards, working-time arrangements, collective organization, and power relations. Next, we examined cross-cluster variation in respondent characteristics. Finally, we estimated the gender-specific associations between cluster-membership and post-sequence-analysis-period prevalence of poor/fair self-rated health (SRH) and moderate mental illness (Kessler-K6≥5). We identified five clusters among women and seven among men. Respondents in poor-EQ clusters were disproportionately people of color and less-educated; they also tended to report worse health. For example, among women, the prevalence of poor/fair SRH and moderate mental illness was lowest among standard-employment-relationship-like-non-union workers and the becoming self-employed, and greatest among minimally-attached, returning-to-the-labor-force, and precariously-employed workers. Meanwhile, among men, the prevalence of the outcomes was lowest among stably-high-wage workers and the wealthy self-employed, and greatest among exiting-the-labor-force and precariously-employed workers. Given the potential role of EQ in health inequities, researchers and practitioners should consider EQ in their work.

Pregnancy Outcomes and Documentation Status Among Latina Women: A Systematic Review

Purpose: The impression that Latinas experience paradoxically good pregnancy outcomes in the United States persists, despite evidence showing that these outcomes are not enjoyed by all Latina subgroups. We conducted this systematic literature review to examine the relationship between documentation status and pregnancy outcomes among Latinas.

Methods: This review synthesizes empirical evidence on this relationship; examines how these studies define and operationalize documentation status; and makes recommendations of how a more comprehensive methodological approach can guide public health research on the impact of documentation status on Latina immigrants to the United States. We searched the literature within PubMed, Web of Science, Academic Search Premier, and Google Scholar in 2017 for relevant studies.

Results: Based on stringent inclusion criteria, we retained nine studies for analysis.

Conclusion: We found that evidence for the impact of documentation status on pregnancy outcomes among Latinas is not conclusive. We believe the divergence in our findings is, in part, due to variation in: conceptualization of how documentation status impacts pregnancy outcomes, sample populations, definitions of exposures and outcomes, and contextual factors included in models. Specific analytic challenges around sampling, measurement, and data analysis are identified. Suggestions for future research are offered regarding measurement of documentation status. Findings highlight the need for increased attention to documentation as an influence on Latina pregnancy outcomes.

The tipping point: could increasing the subminimum wage reduce poverty-related antenatal stressors in U.S. women?

PURPOSE

Tipped workers, primarily women of reproductive-age, can be paid a "subminimum wage" 71% lower than the federal minimum wage, contributing to economic hardship. Poverty-related antenatal stress has deleterious health effects for women and their children. The purpose of this study was to investigate the effects of increasing the state-level subminimum wage (currently $2.13 per hour) on poverty-related antenatal stress for women in the United States.

METHODS

Utilizing a difference-in-differences approach comparing state wage policies over time, we estimated the impact of increases in the subminimum wage on poverty-related antenatal stress using data from 35 states participating in the Pregnancy Risk Assessment Monitoring System between 2004 and 2014, linked to state-level wage laws, census, and antipoverty policy data.

RESULTS

The effect of increasing the subminimum wage on poverty-related stress differed by year and sociodemographics. Wage increases in 2014 were associated with the largest decreases in stress for unmarried women of color with less than a college degree, a population that we estimated would have experienced a 19.7% reduction in stress from 2004 to 2014 if subminimum wage was equivalent to the federal minimum wage.

CONCLUSIONS

Increasing the subminimum wage can reduce poverty-related stress and may be a potential intervention for reducing poor health outcomes.

A nationwide investigation of the impact of the tipped worker subminimum wage on infant size for gestational age

Tipped workers, primarily women of reproductive-age, can be paid a "subminimum wage" 71% lower than the federal minimum wage. We estimated the effects of increasing the state-level tipped worker subminimum wage (federally, $2.13 per hour) on infant size for gestational age in the US as infants born small or large are at risk for poor health across the lifecourse. Utilizing unconditional quantile regression and difference-in-differences analysis of data from 2004 to 2016 Vital Statistics Natality Files (N = 41,219,953 mother-infant dyads), linked to state-level wage laws, census, and antipoverty policy data, we estimated the effect of increasing the subminimum wage on birthweight standardized for gestational age (BWz). Smallest and largest infants are defined as those in the 5th and 95th BWz percentiles, respectively. Increases in the subminimum wage affected the BWz distribution. When compared to a static wage of $2.13 for the duration of the study period, wage set to 100% of the federal minimum ($5.15-$7.25) was associated with an increase in BWz of 0.024 (95% CI: 0.004, 0.045) for the smallest infants and a decrease by 0.041 (95% CI: -0.054, -0.029) for the largest infants. Increasing the subminimum wage may be one strategy to promote healthier birthweight in infants.

Analyzing Policies Through a DOHaD Lens: What Can We Learn?

Social, health, and environmental policies are critical tools for providing the conditions needed for healthy populations. However, current policy analyses fall short of capturing their full potential impacts across the life course and from generation to generation. We argue that the field of Developmental Origins of Health and Disease (DOHaD), a conceptual and research framework positing that early life experiences significantly affect health trajectories across the lifespan and into future generations, provides an important lens through which to analyze social policies. To illustrate this point, we synthesized evidence related to policies from three domains-family leave, nutrition, and housing-to examine the health implications for multiple generations. We selected these policy domains because they represent increasing distance from a reproductive health focus, each with a growing evidence base to support a potential impact on pregnant women and their offspring. Each of these examples represents an opportunity to extend our understanding of policy impact using a DOHaD lens, taking into account the potential life course and intergenerational effects that have previously been overlooked.

Associations of Tipped and Untipped Service Work With Poor Mental Health in a Nationally Representative Cohort of Adolescents Followed Into Adulthood

Precarious work is concentrated in the service industry in the United States and is a risk factor for poor mental health. Service occupations in which workers receive tips are potentially more precarious due to unstable schedule and income, and lack of benefits. We tested hypotheses that individuals working in tipped service occupations have greater odds of experiencing poor mental health (as indicated by self-reported depression, sleep problems, and/or greater perceived stress) relative to individuals in untipped service and nonservice occupations, using cross-sectional data from wave IV of the National Longitudinal Study of Adolescent to Adult Health data set (2007-2008; age range, 24-33 years). To improve comparability of occupation types, propensity scores were computed as a function of childhood factors, then used to construct a sample of 2,815 women and 2,586 men. In gender-stratified multivariable regression, women in tipped service had greater odds of reporting a depression diagnosis or symptoms relative to women in nonservice work (odds ratio = 1.61; 95% confidence interval: 1.11, 2.34). Associations of similar magnitude for sleep problems and perceived stress were observed among women but were not statistically significant; all associations were close to the null among men. Additional research is necessary to understand the factors that underlie differences in poor mental health in tipped and untipped service versus nonservice workers.

Centella asiatica triterpenes for diabetic neuropathy: a randomized, double-blind, placebo-controlled, pilot clinical study

BACKGROUND

Diabetic neuropathy (DN), a common complication of diabetes mellitus, results from hyperglycemia, poor microcirculation and attendant nerve damage. Currently available treatments relieve symptoms, but do not modify the neurodegeneration underlying DN. Centella asiatica (CA) triterpenes improved microcirculation in earlier clinical studies, and showed neurotropic effects in preclinical models suggesting a potential disease modifying effect in DN. This 52-week, randomized, double-blind, placebo-controlled trial examined the effects of CAST, a standardized CA extract containing triterpenes, on neuropathy symptoms in Type II diabetic subjects.

PATIENTS AND METHODS

The study enrolled patients with a history of Type II diabetes, with evidence of symptomatic symmetrical DN with total symptom score (TSS) ≥4, and stable HbA1c level <8. The primary outcome measure was TSS, which assessed intensity and frequency of parasthesia, numbness, pain and burning symptoms self-reported by patients. Secondary measures were nerve conduction, neurological impairment score, and quantitative sensory testing.

RESULTS

Comparing CAST (n=21) and Placebo (n=22) groups, significant reductions from baseline for TSS (p<0.01) and paresthesia (p<0.01) were seen only in CAST treated groups. Numbness increased from baseline only in the Placebo group (p<0.05) and was significantly higher than for the CAST group (p<0.001). Burning sensation was reduced in both groups (p<0.01). Plasma triterpene levels in patients treated with CAST mirrored neurotropic concentrations in vitro.

CONCLUSIONS

CAST is a potential oral treatment for diabetic neuropathy, as it is well tolerated and effective in reducing the severity of DN symptoms in patients with Type II diabetes.

Weighing in on Bariatric Surgery: Effectiveness Among Medicaid Beneficiaries-Limited Evidence and Future Research Needs

INTRODUCTION

In the general population, bariatric surgery is well documented as the most effective obesity treatment for sustained weight loss and remission of comorbidities. Characterization of the patient populations most likely to benefit from surgical intervention is needed, but the heterogeneity of treatment effects across payer groups has not been reviewed.

METHODS

A systematic review of published studies focusing on bariatric surgery outcomes among Medicaid beneficiaries was conducted. By using PubMed and Scopus, this study searched for studies that quantitatively compared clinical or social bariatric surgery outcomes for United States adult Medicaid recipients and commercially insured patients.

RESULTS

Of the 568 titles reviewed, 21 met inclusion criteria. Weight loss and the remission of comorbidities at 1 or 2 years postoperatively were similar between groups despite differences in baseline health status. Short-term health care utilization and mortality outcomes were worse in Medicaid recipients; for instance, Medicaid patients had an average length of stay that was 2 days longer and experienced three more deaths in the first postoperative year.

CONCLUSIONS

The critical research gaps in the evidence base needed to improve treatment guidelines for Medicaid patients undergoing bariatric surgery include an understanding of the causes of the baseline health differences and how these differences contribute to postoperative outcomes.

High birth weight modifies association between adolescent physical activity and cardiometabolic health in women and not men

Recent evidence suggests that adverse prenatal development alters physiological response to physical activity, but longitudinal epidemiologic evidence is scant. This study tested the hypothesis that lower physical activity during adolescence and young adulthood is more strongly associated with later cardiovascular disease (CVD) risk and diabetes or prediabetes (DM/PDM) in women and men who were born with high or low birth weight (HBW, LBW), compared to normal birth weight (NBW). We analyzed data from the National Longitudinal Study of Adolescent to Adult Health, a cohort study of US adolescents followed into adulthood (1994-2009). Using sex-stratified multivariable regression, 30-year CVD risk score (calculated using objective measures; n=12,775) and prevalent DM/PDM (n=15,138) at 24-32years of age were each modeled as a function of birth weight category, self-reported moderate-to-vigorous physical activity frequency in adolescence (MVPA1) and young adulthood (MVPA3), and MVPA-birth weight interactions. Greater MVPA1 was associated with lower 30-year CVD risk score and DM/PDM risk in HBW women but not NBW or LBW women. Associations between MVPA1 and 30-year CVD risk or DM/PDM were not modified by HBW in men; or by LBW in women or men. Additionally, birth weight did not modify estimated effects of MVPA3. Findings suggest that frequent MVPA in adolescence may be a particularly important cardiometabolic risk reduction strategy in girls born HBW; however, we found no evidence that birth weight and MVPA interact in cardiometabolic disease risk in men, for MVPA in adulthood, or for LBW.

Does the association between early life growth and later obesity differ by race/ethnicity or socioeconomic status? A systematic review

PURPOSE

Rapid growth during infancy predicts higher risk of obesity later in childhood. The association between patterns of early life growth and later obesity may differ by race/ethnicity or socioeconomic status (SES), but prior evidence syntheses do not consider vulnerable subpopulations.

METHODS

We systemically reviewed published studies that explored patterns of early life growth (0-24 months of age) as predictors of later obesity (>24 months) that were either conducted in racial/ethnic minority or low-SES study populations or assessed effect modification of this association by race/ethnicity or SES. Literature searches were conducted in PubMed and SocINDEX.

RESULTS

Ten studies met the inclusion criteria. Faster growth during the first 2 years of life was consistently associated with later obesity irrespective of definition and timing of exposure and outcome measures. Associations were strongest in populations composed of greater proportions of racial/ethnic minority and/or low-SES children. For example, ORs ranged from 1.17 (95% CI: 1.11, 1.24) in a heterogeneous population to 9.24 (95% CI: 3.73, 22.9) in an entirely low-SES nonwhite population.

CONCLUSIONS

The impact of rapid growth in infancy on later obesity may differ by social stratification factors such as race/ethnicity and family income. More robust and inclusive studies examining these associations are needed.

Brief gatekeeper training for suicide prevention in an ethnic minority population: a controlled intervention

BACKGROUND

Suicide is a critical public health problem around the globe. Asian populations are characterized by elevated suicide rates and a tendency to seek social support from family and friends over mental health professionals. Gatekeeper training programs have been developed to train frontline individuals in behaviors that assist at-risk individuals in obtaining mental health treatment. The purpose of this study is to assess the efficacy of a brief, multi-component gatekeeper intervention in promoting suicide prevention in a high-risk Asian community in the United States.

METHODS

We adapted an evidence-based gatekeeper training into a two-hour, multi-modal and interactive event for Japanese-Americans and related stakeholders. Then we evaluated the intervention compared to an attention control using mixed methods.

RESULTS

A sample of 106 community members participated in the study. Intervention participants (n = 85) showed significant increases in all three types of intended gatekeeper behavior, all four measures of self-efficacy, and both measures of social norms relevant to suicide prevention, while the control group (n = 48) showed no significant improvements. Additional results showed significantly higher satisfaction and no adverse experiences associated with the gatekeeper training. The separate collection of qualitative data, and integration with the quantitative survey constructs confirmed and expanded understanding about the benefits of the intervention.

CONCLUSIONS

A brief, multi-modal gatekeeper training is efficacious in promoting positive gatekeeper behaviors and self-efficacy for suicide prevention in an at-risk ethnic minority population of Japanese Americans.

Social Support and Health Service Use in Depressed Adults: Findings From the National Health and Nutrition Examination Survey

OBJECTIVE

We investigated the relationship between social support and health service use among men and women with depression.

METHODS

Participants were 1379 adults with symptoms of depression (Patient Health Questionnaire-9 score ≥ 5) in the National Health and Nutrition Examination Survey. Using the framework of the Andersen Behavioral Model of Health Services Use, multivariable regression models used social support, stratified by depression severity, to estimate association with utilization of mental health and nonmental health services. Partial F-tests examined a priori interactions between social support and gender.

RESULTS

Among those with adequate social support, odds of seeing a nonmental health provider were much higher when depression was moderate [Odds Ratio (OR): 2.6 (1.3-5.3)] or severe [OR: 3.2 (1.2-8.7)], compared to those lacking social support. Conversely, odds of mental health service use were 60% lower among those with moderate depression [OR: 0.4 (0.2-1.0)] when social support was adequate as opposed to inadequate. Social support was unrelated to service use when depression was mild. Gender moderated the relationship between social support and health service use among individuals with severe depression.

CONCLUSIONS

Social support has opposite associations with mental and nonmental health service use among adults with clinically significant depression. This association is largely attributable to the effect of male gender on the relationship between social support and health service use.

Does Mode of Contact with Different Types of Social Relationships Predict Depression in Older Adults? Evidence from a Nationally Representative Survey

OBJECTIVES

To determine associations between use of three different modes of social contact (in person, telephone, written or e-mail), contact with different types of people, and risk of depressive symptoms in a nationally representative, longitudinal sample of older adults.

DESIGN

Population-based observational cohort.

SETTING

Urban and suburban communities throughout the contiguous United States.

PARTICIPANTS

Individuals aged 50 and older who participated in the Health and Retirement Survey between 2004 and 2010 (N = 11,065).

MEASUREMENTS

Frequency of participant use of the three modes of social contact with children, other family members, and friends at baseline were used to predict depressive symptoms (measured using the eight-item Center for Epidemiologic Studies Depression Scale) 2 years later using multivariable logistic regression models.

RESULTS

Probability of having depressive symptoms steadily increased as frequency of in-person-but not telephone or written or e-mail contact-decreased. After controlling for demographic, clinical, and social variables, individuals with in-person social contact every few months or less with children, other family, and friends had a significantly higher probability of clinically significant depressive symptoms 2 years later (11.5%) than those having in-person contact once or twice per month (8.1%; P < .001) or once or twice per week (7.3%; P < .001). Older age, interpersonal conflict, and depression at baseline moderated some of the effects of social contact on depressive symptoms.

CONCLUSION

Frequency of in-person social contact with friends and family independently predicts risk of subsequent depression in older adults. Clinicians should consider encouraging face-to-face social interactions as a preventive strategy for depression.

Effect of expectancy and personality on cortical excitability in Parkinson's disease

Our previous studies in Parkinson's disease have shown that both levodopa and expectancy of receiving levodopa reduce cortical excitability. We designed this study to evaluate how degree of expectancy and other individual factors modulate placebo response in Parkinson's patients. Twenty-six Parkinson's patients were randomized to 1 of 3 groups: 0%, 50%, and 100% expectancy of receiving levodopa. All subjects received placebo regardless of expectancy group. Subjects completed the NEO-Five Factor Inventory, General Perceived Self-Efficacy Scale, and Perceived Stress Scale. Cortical excitability was measured by the amplitude of motor-evoked potential (MEP) evoked by transcranial magnetic stimulation. Objective physical fatigue of extensor carpi radialis before and after placebo levodopa was also measured. Responders were defined as subjects who responded to the placebo levodopa with a decrease in MEP. Degree of expectancy had a significant effect on MEP response (P < .05). Subjects in the 50% and 100% expectancy groups responded with a decrease in MEP, whereas those in the 0% expectancy group responded with an increase in MEP (P < .05). Responders tended to be more open to experience than nonresponders. There were no significant changes in objective physical fatigue between the expectancy groups or between responders and nonresponders. Expectancy is associated with changes in cortical excitability. Further studies are needed to examine the relationship between personality and placebo effect in Parkinson's patients. © 2013 Movement Disorder Society.

Clinical characteristics and outcomes in hospitalized patients with respiratory viral co-infection during the 2009 H1N1 influenza pandemic

Background

The clinical consequences of co-infection with two or more respiratory viruses are poorly understood. We sought to determine if co-infection with pandemic 2009–2010 influenza A H1N1 (pH1N1) and another respiratory virus was associated with worse clinical outcomes.

Methods

A retrospective cohort study was performed of all hospitalized patients with a positive respiratory viral panel (RVP) for two or more viruses within 72 hours of admission at our institution from October 2009 to December 2009. We compared patients infected with one respiratory virus to those with respiratory viral co-infection.

Results

We identified 617 inpatients with a positive RVP sample with a single virus and 49 inpatients with a positive RVP sample for two viruses (i.e. co-infection). Co-infected patients were significantly younger, more often had fever/chills, tachypnea, and they more often demonstrated interstitial opacities suggestive of viral pneumonia on the presenting chest radiograph (OR 7.5, 95% CI 3.4–16.5). The likelihood of death, length of stay, and requirement for intensive care unit level of care were similar in both groups, but patients with any respiratory virus co-infection were more likely to experience complications, particularly treatment for a secondary bacterial pneumonia (OR 6.8, 95% CI 3.3–14.2). Patients co-infected with pH1N1 and another respiratory virus were more likely to present with chest radiograph changes suggestive of a viral pneumonia, compared to mono-infection with pH1N1 (OR 16.9, 95% CI 4.5–62.7). By logistic regression using mono-infection with non-PH1N1 viruses as the reference group, co-infection with pH1N1 was the strongest independent predictor of treatment for a secondary bacterial pneumonia (OR 17.8, 95% CI 6.7–47.1).

Conclusion

Patients with viral co-infection, particularly with pH1N1, were more likely to have chest radiograph features compatible with a viral pneumonia and complications during their hospital course, particularly treatment for secondary bacterial pneumonia. Despite this, co-infection was not associated with ICU admission.

Distinguishing characteristics between pandemic 2009-2010 influenza A (H1N1) and other viruses in patients hospitalized with respiratory illness

Background

Differences in clinical presentation and outcomes among patients infected with pandemic 2009 influenza A H1N1 (pH1N1) compared to other respiratory viruses have not been fully elucidated.

Methodology/Principal Findings

A retrospective study was performed of all hospitalized patients at the peak of the pH1N1 season in whom a single respiratory virus was detected by a molecular assay targeting 18 viruses/subtypes (RVP, Luminex xTAG). Fifty-two percent (615/1192) of patients from October, 2009 to December, 2009 had a single respiratory virus (291 pH1N1; 207 rhinovirus; 45 RSV A/B; 37 parainfluenza; 27 adenovirus; 6 coronavirus; and 2 metapneumovirus). No seasonal influenza A or B was detected. Individuals with pH1N1, compared to other viruses, were more likely to present with fever (92% & 70%), cough (92% & 86%), sore throat (32% & 16%), nausea (31% & 8%), vomiting (39% & 30%), abdominal pain (14% & 7%), and a lower white blood count (8,500/L & 13,600/L, all p-values<0.05). In patients with cough and gastrointestinal complaints, the presence of subjective fever/chills independently raised the likelihood of pH1N1 (OR 10). Fifty-five percent (336/615) of our cohort received antibacterial agents, 63% (385/615) received oseltamivir, and 41% (252/615) received steroids. The mortality rate of our cohort was 1% (7/615) and was higher in individuals with pH1N1 compared to other viruses (2.1% & 0.3%, respectively; p = 0.04).

Conclusions/Significance

During the peak pandemic 2009–2010 influenza season in Rhode Island, nearly half of patients admitted with influenza-like symptoms had respiratory viruses other than influenza A. A high proportion of patients were treated with antibiotics and pH1N1 infection had higher mortality compared to other respiratory viruses.

Comparison of five assays for detection of Clostridium difficile toxin

Performance characteristics of five assays for detection of Clostridium difficile toxin were compared using fresh stool samples from patients with C. difficile infection (CDI). Assays were performed simultaneously and according to the manufacturers' instructions. Patients were included in the study if they exhibited clinical symptoms consistent with CDI. Nonmolecular assays included glutamate dehydrogenase antigen tests, with positive findings followed by the Premier Toxin A and B Enzyme Immunoassay (GDH/EIA), and the C. Diff Quik Chek Complete test. Molecular assays (PCR) included the BD GeneOhm Cdiff Assay, the Xpert C. difficile test, and the ProGastro Cd assay. Specimens were considered true positive if results were positive in two or more assays. For each method, the Youden index was calculated and cost-effectiveness was analyzed. Of 81 patients evaluated, 26 (32.1%) were positive for CDI. Sensitivity of the BD GeneOhm Cdiff assay, the Xpert C. difficile test, the ProGastro Cd assay, C. Diff Quik Chek Complete test, and two-step GDH/EIA was 96.2%, 96.2%, 88.5%, 61.5%, and 42.3%, respectively. Specificity of the Xpert C. difficile test was 96.4%, and for the other four assays was 100%. Compared with nonmolecular methods, molecular methods detected 34.7% more positive specimens. Assessment of performance characteristics and cost-effectiveness demonstrated that the BD GeneOhm Cdiff assay yielded the best results. While costly, the Xpert C. difficile test required limited processing and yielded rapid results. Because of discordant results, specimen processing, and extraction equipment requirements, the ProGastro Cd assay was the least favored molecular assay. The GDH/EIA method lacked sufficient sensitivity to be recommended.