An Application of Social Vulnerability Index to Infant Mortality Rates in Ohio Using Geospatial Analysis- A Cross-Sectional Study

BACKGROUND

Ohio ranks 43rd in the nation in infant mortality rates (IMR); with IMR among non-Hispanic black infants is three times higher than white infants.

OBJECTIVE

To identify the social factors determining the vulnerability of Ohio counties to IMR and visualize the spatial association between relative social vulnerability and IMR at county and census tract levels.

METHODS

The social vulnerability index (SVICDC) is a measure of the relative social vulnerability of a geographic unit. Five out of 15 social variables in the SVICDC were utilized to create a customized index for IMR (SVIIMR) in Ohio. The bivariate descriptive maps and spatial lag model were applied to visualize the quantitative relationship between SVIIMR and IMR, accounting for the spatial autocorrelation in the data.

RESULTS

Southeastern counties in Ohio displayed highest IMRs and highest overall SVIIMR; specifically, highest vulnerability to poverty, no high school diploma, and mobile housing. In contrast, extreme northwestern counties exhibited high IMRs but lower overall SVIIMR. Spatial regression showed five clusters where vulnerability to low per capita income in one county significantly impacted IMR (p = 0.001) in the neighboring counties within each cluster. At the census tract-level within Lucas county, the Toledo city area (compared to the remaining county) had higher overlap between high IMR and SVIIMR.

CONCLUSION

The application of SVI using geospatial techniques could identify priority areas, where social factors are increasing the vulnerability to infant mortality rates, for potential interventions that could reduce disparities through strategic and equitable policies.

Neighborhood Deprivation and Severe Maternal Morbidity in a Medicaid Population

INTRODUCTION

Few studies have examined whether neighborhood deprivation is associated with severe maternal morbidity (SMM) in already socioeconomically disadvantaged populations. Little is known about to what extent neighborhood deprivation accounts for Black-White disparities in SMM. This study investigated these questions among a statewide Medicaid-insured population, a low-income population with heightened risk of SMM.

METHODS

Data were from Michigan statewide linked birth records and Medicaid claims between 01/01/2016 and 12/31/2019, and were analyzed between 2022 and 2023. Neighborhood deprivation was measured with the Area Deprivation Index at census block group and categorized as low, medium, or high deprivation. Multilevel logistic models were used to examine the association between neighborhood deprivation and SMM. Fairlie nonlinear decomposition was conducted to quantify the contribution of neighborhood deprivation to SMM racial disparity.

RESULTS

People in the most deprived neighborhoods had higher odds of SMM than those in the least deprived neighborhoods (aOR [95% CI]: 1.27 [1.15, 1.40]). Such association was observed in Black (aOR [95% CI]: 1.34 [1.07, 1.67]) and White (aOR [95% CI]: 1.26 [1.12, 1.42]) racial subgroups. Decomposition showed that of 57.5 (cases per 10,000) explained disparity in SMM, neighborhood deprivation accounted for 23.1 (cases per 10,000; 95% CI: 16.3, 30.0) or two-fifths (40.2%) of the Black-White disparity. Analysis on SMM excluding blood transfusion showed consistent but weaker results.

CONCLUSIONS

Neighborhood deprivation may be used as an effective tool to identify at-risk individuals within a low-income population. Community-engaged interventions aiming at improving neighborhood conditions may be helpful to reduce both SMM prevalence and racial inequity in SMM.

Who is most vulnerable? Factors associated with presenting to antenatal care without a male partner in Northern Tanzania

OBJECTIVE

Male engagement in pregnancy care can be beneficial for maternal and child health outcomes. In Tanzania, pregnant women are strongly encouraged to present to their first antenatal care (ANC) appointment with a male partner, where they jointly test for HIV. For some, this presents a barrier to ANC attendance. The objectives of this study were to identify factors associated with presenting to ANC with a male partner using a cross-sectional design and to assess whether women presenting without partners had significantly delayed presentation.

METHODS

Pregnant women (n = 1007) attending a first ANC appointment in Moshi, Tanzania were surveyed. Questions captured sociodemographic characteristics and measures of psychosocial constructs.

RESULTS

Just over half (54%) of women presented to care with a male partner. Women were more likely to present with a male partner if they were younger than 25 years old, married, Muslim, attending ANC for their first pregnancy, and testing for HIV for the first time. Women presenting to ANC with a male partner were significantly more likely to attend ANC earlier in their pregnancy than those presenting without male partners.

CONCLUSION

Policy change allowing women to present to care with other supportive family members could promote earlier presentation to first ANC. Unmarried women may be at a disadvantage in presenting to ANC when policies mandate attendance with a male partner. Male partners of multiparous women should be encouraged to provide pregnancy support even after first pregnancies, and a wholistic emphasis (beyond HIV testing) on first ANC could encourage male engagement beyond the initial appointment.

Mental and social wellbeing trajectory during the pandemic for vulnerable populations

Objectives

We investigated changes over time in mental and social wellbeing indicators for vulnerable population subgroups during the pandemic. These groups were younger people, people with disabilities, low-income groups, unemployed, culturally, and linguistically diverse communities (CaLD), and Aboriginal and Torres Strait Islander peoples.

Methods

A series of four repeated population representative surveys were conducted in June 2020, September 2020, January 2022, and June 2022. Questions included items on psychological distress, financial hardship, social connection, and life satisfaction.

Results

For most groups, social connection and life satisfaction improved in 2022 relative to 2020. Psychological distress and financial hardship showed the opposite pattern, with some groups having worse results in 2022 relative to 2020. People without any vulnerability had better mental health and social wellbeing outcomes at each time point relative to the vulnerable population subgroups.

Conclusion

Pandemic-related policies had differential effects over time and for different population groups. Future policies and research need to closely monitor how they impact population subgroups, and the overall results clearly demonstrate the inequity in mental health and social wellbeing outcomes for vulnerable population cohorts.

Social Risk and Dialysis Facility Performance in the First Year of the ESRD Treatment Choices Model

Importance

The End-Stage Renal Disease Treatment Choices (ETC) model randomly selected 30% of US dialysis facilities to receive financial incentives based on their use of home dialysis, kidney transplant waitlisting, or transplant receipt. Facilities that disproportionately serve populations with high social risk have a lower use of home dialysis and kidney transplant raising concerns that these sites may fare poorly in the payment model.

Objective

To examine first-year ETC model performance scores and financial penalties across dialysis facilities, stratified by their incident patients' social risk.

Design, Setting, and Participants

A cross-sectional study of 2191 US dialysis facilities that participated in the ETC model from January 1 through December 31, 2021.

Exposure

Composition of incident patient population, characterized by the proportion of patients who were non-Hispanic Black, Hispanic, living in a highly disadvantaged neighborhood, uninsured, or covered by Medicaid at dialysis initiation. A facility-level composite social risk score assessed whether each facility was in the highest quintile of having 0, 1, or at least 2 of these characteristics.

Main Outcomes and Measures

Use of home dialysis, waitlisting, or transplant; model performance score; and financial penalization.

Results

Using data from 125 984 incident patients (median age, 65 years [IQR, 54-74]; 41.8% female; 28.6% Black; 11.7% Hispanic), 1071 dialysis facilities (48.9%) had no social risk features, and 491 (22.4%) had 2 or more. In the first year of the ETC model, compared with those with no social risk features, dialysis facilities with 2 or more had lower mean performance scores (3.4 vs 3.6, P = .002) and lower use of home dialysis (14.1% vs 16.0%, P < .001). These facilities had higher receipt of financial penalties (18.5% vs 11.5%, P < .001), more frequently had the highest payment cut of 5% (2.4% vs 0.7%; P = .003), and were less likely to achieve the highest bonus of 4% (0% vs 2.7%; P < .001). Compared with all other facilities, those in the highest quintile of treating uninsured patients or those covered by Medicaid experienced more financial penalties (17.4% vs 12.9%, P = .01) as did those in the highest quintile in the proportion of patients who were Black (18.5% vs 12.6%, P = .001).

Conclusions

In the first year of the Centers for Medicare & Medicaid Services' ETC model, dialysis facilities serving higher proportions of patients with social risk features had lower performance scores and experienced markedly higher receipt of financial penalties.

Trends in Crisis Hotline Call Rates and Suicide Mortality in the United States

OBJECTIVE

Utilization of the 988 Suicide and Crisis Lifeline (Lifeline; formerly called the National Suicide Prevention Lifeline) was analyzed in relation to suicide deaths in U.S. states between 2007 and 2020 to identify states with potential unmet need for mental health crisis hotline services.

METHODS

Annual state call rates were calculated from calls routed to the Lifeline during the 2007-2020 period (N=13.6 million). Annual state suicide mortality rates (standardized) were calculated from suicide deaths reported to the National Vital Statistics System (2007-2020 cumulative deaths=588,122). Call rate ratio (CRR) and mortality rate ratio (MRR) were estimated by state and year.

RESULTS

Sixteen U.S. states demonstrated a consistently high MRR and a low CRR, suggesting high suicide burden and relatively low Lifeline use. Heterogeneity in state CRRs decreased over time.

CONCLUSIONS

Prioritizing states with a high MRR and a low CRR for messaging and outreach regarding the availability of the Lifeline can ensure more equitable, need-based access to this critical resource.

Disparities in refusal of surgery for gynecologic cancer

OBJECTIVE

To identify sociodemographic and clinical factors associated with refusal of gynecologic cancer surgery and to estimate its effect on overall survival.

METHODS

The National Cancer Database was surveyed for patients with uterine, cervical or ovarian/fallopian tube/primary peritoneal cancer treated between 2004 and 2017. Univariate and multivariate logistic regression were used to assess associations between clinico-demographic variables and refusal of surgery. Overall survival was estimated using the Kaplan-Meier method. Trends in refusal over time were evaluated using joinpoint regression.

RESULTS

Of 788,164 women included in our analysis, 5875 (0.75%) patients refused surgery recommended by their treating oncologist. Patients who refused surgery were older at diagnosis (72.4 vs 60.3 years, p < 0.001) and more likely Black (OR 1.77 95% CI 1.62-1.92). Refusal of surgery was associated with uninsured status (OR 2.94 95% CI 2.49-3.46), Medicaid coverage (OR 2.79 95% CI 2.46-3.18), low regional high school graduation (OR 1.18 95% CI 1.05-1.33) and treatment at a community hospital (OR 1.59 95% CI 1.42-1.78). Patients who refused surgery had lower median overall survival (1.0 vs 14.0 years, p < 0.01) and this difference persisted across disease sites. Between 2008 and 2017, there was a significant increase in refusal of surgery annually (annual percent change +1.41%, p < 0.05).

CONCLUSIONS

Multiple social determinants of health are independently associated with refusal of surgery for gynecologic cancer. Given that patients who refuse surgery are more likely from vulnerable, underserved populations and have inferior survival, refusal of surgery should be considered a surgical healthcare disparity and tackled as such.

Lessons Learned from Health Disparities in Coronavirus Disease-2019 in the United States

In the United States, the coronavirus disease-2019 (COVID-19) pandemic has disproportionally affected Black, Latinx, and Indigenous populations, immigrants, and economically disadvantaged individuals. Such historically marginalized groups are more often employed in low-wage jobs without health insurance and have higher rates of infection, hospitalization, and death from COVID-19 than non-Latinx White individuals. Mistrust in the health care system, language barriers, and limited health literacy have hindered vaccination rates in minorities, further exacerbating health disparities rooted in structural, institutional, and socioeconomic inequities. In this article, we discuss the lessons learned over the last 2 years and how to mitigate health disparities moving forward.

Examining neighbourhood-level disparities in Black, Latina/o, Asian, and White physical health, mental health, chronic conditions, and social disadvantage in California

Racial/ethnic minority individuals in the U.S. experience numerous health disparities versus Whites, often due to differences in social determinants. Yet, limited large-scale research has examined these differences at the neighbourhood level. We merged 2021 PLACES Project and 2020 American Community Survey data across 3,211 census tracts (neighbourhoods) defined as majority (>50%) Black, Latina/o, Asian or White. T-tests and hierarchical linear regressions were used to examine differences and associations between neighbourhoods on key health (general health, mental health, obesity, diabetes, cancer, coronary heart disease, chronic obstructive pulmonary disease, stroke), and social outcomes (income, unemployment, age, population density). Results indicated that minority neighbourhoods in California exhibited stark health and social disparities versus White neighbourhoods, displaying worse outcomes on nearly every social and health variable/condition examined; particularly for Black and Latina/o neighbourhoods. Moreover, regression findings revealed that, after considering income, unemployment, and population density, (1) fair/poor mental health and higher percentages of Black, Latina/o and Asian residents in neighbourhoods independently associated with greater neighbourhood fair/poor physical health, and (2) fair/poor mental health significantly associated with greater prevalence of obesity and COPD. This study thus underscores the need to address the profound health and social disparities experienced by minority neighbourhoods for more equitable neighbourhoods.

Huddling with families after disaster: Human resilience and social disparity

Disasters, from hurricanes to pandemics, tremendously impact human lives and behaviors. Physical closeness to family post-disaster plays a critical role in mental healing and societal sustainability. Nonetheless, little is known about whether and how family colocation alters after a disaster, a topic of immense importance to a post-disaster society. We analyze 1 billion records of population-scale, granular, individual-level mobile location data to quantify family colocation, and examine the magnitude, dynamics, and socioeconomic heterogeneity of the shift in family colocation from the pre- to post-disaster period. Leveraging Hurricane Florence as a natural experiment, and Geographic Information System (GIS), machine learning, and statistical methods to investigate the shift across the landfall (treated) city of Wilmington, three partially treated cites on the hurricane’s path, and two control cities off the path, we uncover dramatic (18.9%), widespread (even among the partially treated cities), and enduring (over at least 3 months) escalations in family colocation. These findings reveal the powerful psychological and behavioral impacts of the disaster upon the broader populations, and simultaneously remarkable human resilience via behavioral adaptations during disastrous times. Importantly, the disaster created a gap across socioeconomic groups non-existent beforehand, with the disadvantaged displaying weaker lifts in family colocation. This sheds important lights on policy making and policy communication to promote sustainable family colocation, healthy coping strategies against traumatic experiences, social parity, and societal recovery.

Interprofessional Collaborative Practice Improves Access to Care and Healthcare Quality to Advance Health Equity

ABSTRACT

Healthcare disparites exist in cardiovascular care, including heart failure. Care that is not equitable can lead to higher incidence of heart failure, increased readmissions, and poorer outcomes. The Heart Failure Transitional Care Services for Adults Clinic is an interprofessional collaborative practice that provides guideline-directed medical therapy and education to underserved patients with heart failure. Little is known regarding healthcare equity and quality metrics in relation to interprofessional teams. Thus, the purpose of this study was to examine if an interprofessional collaborative practice care delivery model can affect access to care and healthcare quality outcomes in underserved patients with heart failure. As evidenced by control charts over a two and a half year period, the Heart Failure Transitional Care Services for Adults Clinic was able to show improvements in access to care and quality metrics results without variation. An interprofessional collaborative practice can be an effective delivery model to address health equity and quality of care outcomes.

Assessment of a Crisis Standards of Care Scoring System for Resource Prioritization and Estimated Excess Mortality by Race, Ethnicity, and Socially Vulnerable Area During a Regional Surge in COVID-19

IMPORTANCE

Crisis standards of care (CSOC) scores designed to allocate scarce resources during the COVID-19 pandemic could exacerbate racial disparities in health care.

OBJECTIVE

To analyze the association of a CSOC scoring system with resource prioritization and estimated excess mortality by race, ethnicity, and residence in a socially vulnerable area.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort analysis included adult patients in the intensive care unit during a regional COVID-19 surge from April 13 to May 22, 2020, at 6 hospitals in a health care network in greater Boston, Massachusetts. Participants were scored by acute severity of illness using the Sequential Organ Failure Assessment score and chronic severity of illness using comorbidity and life expectancy scores, and only participants with complete scores were included. The score was ordinal, with cutoff points suggested by the Massachusetts guidelines.

EXPOSURES

Race, ethnicity, Social Vulnerability Index.

MAIN OUTCOMES AND MEASURES

The primary outcome was proportion of patients in the lowest priority score category stratified by self-reported race. Secondary outcomes were discrimination and calibration of the score overall and by race, ethnicity, and neighborhood Social Vulnerability Index. Projected excess deaths were modeled by race, using the priority scoring system and a random lottery.

RESULTS

Of 608 patients in the intensive care unit during the study period, 498 had complete data and were included in the analysis; this population had a median (IQR) age of 67 (56-75) years, 191 (38.4%) female participants, 79 (15.9%) Black participants, and 225 patients (45.7%) with COVID-19. The area under the receiver operating characteristic curve for the priority score was 0.79 and was similar across racial groups. Black patients were more likely than others to be in the lowest priority group (12 [15.2%] vs 34 [8.1%]; P = .046). In an exploratory simulation model using the score for ventilator allocation, with only those in the highest priority group receiving ventilators, there were 43.9% excess deaths among Black patients (18 of 41 patients) and 28.6% (58 of 203 patients among all others (P = .05); when the highest and intermediate priority groups received ventilators, there were 4.9% (2 of 41 patients) excess deaths among Black patients and 3.0% (6 of 203) among all others (P = .53). A random lottery resulted in more excess deaths than the score.

CONCLUSIONS AND RELEVANCE

In this study, a CSOC priority score resulted in lower prioritization of Black patients to receive scarce resources. A model using a random lottery resulted in more estimated excess deaths overall without improving equity by race. CSOC policies must be evaluated for their potential association with racial disparities in health care.

Physician Specialties Involved in Thyroid Cancer Diagnosis and Treatment: Implications for Improving Health Care Disparities

CONTEXT

Little is known about provider specialties involved in thyroid cancer diagnosis and management.

OBJECTIVE

Characterize providers involved in diagnosing and treating thyroid cancer.

DESIGN/SETTING/PARTICIPANTS

We surveyed patients with differentiated thyroid cancer from the Georgia and Los Angeles County Surveillance, Epidemiology and End Results registries (N = 2632, 63% response rate). Patients identified their primary care physicians (PCPs), who were also surveyed (N = 162, 56% response rate).

MAIN OUTCOME MEASURES

(1) Patient-reported provider involvement (endocrinologist, surgeon, PCP) at diagnosis and treatment; (2) PCP-reported involvement (more vs less) and comfort (more vs less) with discussing diagnosis and treatment.

RESULTS

Among thyroid cancer patients, 40.6% reported being informed of their diagnosis by their surgeon, 37.9% by their endocrinologist, and 13.5% by their PCP. Patients reported discussing their treatment with their surgeon (71.7%), endocrinologist (69.6%), and PCP (33.3%). Physician specialty involvement in diagnosis and treatment varied by patient race/ethnicity and age. For example, Hispanic patients (vs non-Hispanic White) were more likely to report their PCP informed them of their diagnosis (odds ratio [OR]: 1.68; 95% CI, 1.24-2.27). Patients ≥65 years (vs <45 years) were more likely to discuss treatment with their PCP (OR: 1.59; 95% CI, 1.22-2.08). Although 74% of PCPs reported discussing their patients' diagnosis and 62% their treatment, only 66% and 48%, respectively, were comfortable doing so.

CONCLUSIONS

PCPs were involved in thyroid cancer diagnosis and treatment, and their involvement was greater among older patients and patients of minority race/ethnicity. This suggests an opportunity to leverage PCP involvement in thyroid cancer management to improve health and quality of care outcomes for vulnerable patients.

An exploration of the inverse care law and market forces in Australian primary health care

This paper examines the implications of the second sentence in Tudor Harts statement about inverse care - that its operation was strongest when exposed to market forces. In the Australian context, we briefly review some available evidence for inverse care in three groups - Aboriginal and Torres Strait Islander people and those living in remote and socioeconomically disadvantaged areas. We then discuss the extent to which these examples can be attributed to the operation of supply-and-demand within Australia's hybrid fee-for-service system in general practice. Our analysis suggests disparities in workforce supply and the ability of disadvantaged groups to seek preventive and proactive care are critical factors. These, in turn, suggest the need to fund general practice to be responsible for proactive and preventive care of disadvantaged population groups alongside broader structural reforms in workforce, education and taxation.

Protocol: A mixed methods evaluation of an IPS program to increase employment and well-being for people with long-term experience of complex barriers in Vancouver's downtown and DTES

BACKGROUND

Employment improves mental health and well-being by providing financial security, daily structure, a sense of identity and purpose, and social engagement. However, securing and sustaining employment is exceptionally challenging for vulnerable populations who experience persistent and multiple barriers, such as mental illness, homelessness, food and housing insecurity, and marginalization. Evidence-based supported employment programs, most notably individual placement and support (IPS) are becoming a more common approach for addressing the needs of these high-risk individuals. The aim of this paper is to outline the protocol for evaluating an IPS program in Vancouver's downtown and Downtown Eastside (DTES).

METHODS AND DESIGN

This prospective quasi-experimental study of persons with persistent and multiple barriers to employment will use a mixed-methods approach for evaluating a novel IPS program. The evaluation will consist of survey packages and interviews that will capture outcomes related to employment and well-being, as well as the experiential process of receiving individualized and integrated supports through the IPS program. A mixed-methods approach is appropriate for this study as quantitative data will provide an objective assessment of program impacts on employment and well-being outcomes over time, while qualitative data will provide an in-depth understanding of continued barriers and experiences.

DISCUSSION

The results from this evaluation will contribute evidence within a local British Columbian (BC) context that may increase access to meaningful employment for those with long-term experience of complex barriers to employment. Further, the findings will support continued improvements, and guide decision-making around practices and policy for future implementation of IPS and employment supports across BC.

Developing and evaluating non-invasive healthcare technologies for a group of female participants from a socioeconomically disadvantaged area

When compared to the general population, socioeconomically disadvantaged communities frequently experience compromised health. Monitoring the divide is challenging since standardized biomedical tests are linguistically and culturally inappropriate. The aim of this study was to develop and test a unique mobile biomedical testbed based on non-invasive analysis, as well as to explore the relationships between the objective health measures and subjective health outcomes, as evaluated with the World Health Organization Quality of Life survey. The testbed was evaluated in a socioeconomically disadvantaged neighborhood in Malmö, which has been listed as one of the twelve most vulnerable districts in Sweden. The study revealed that compared to conventional protocols the less intrusive biomedical approach was highly appreciated by the participants. Surprisingly, the collected biomedical data illustrated that the apparent health of the participants from the ethnically diverse low-income neighborhood was comparable to the general Swedish population. Statistically significant correlations between perceived health and biomedical data were disclosed, even though the dependences found were complex, and recognition of the manifest complexity needs to be included in further research. Our results validate the potential of non-invasive technologies in combination with advanced statistical analysis, especially when combined with linguistically and culturally appropriate healthcare methodologies, allowing participants to appreciate the significance of the different parameters to evaluate and monitor aspects of health.

Association of the Affordable Care Act Medicaid Expansion with Trauma Outcomes and Access to Rehabilitation among Young Adults: Findings Overall, by Race and Ethnicity, and Community Income Level

BACKGROUND

Low-income young adults disproportionately experience traumatic injury and poor trauma outcomes. This study aimed to evaluate the effects of the Affordable Care Act's Medicaid expansion, in its first 4 years, on trauma care and outcomes in young adults, overall and by race, ethnicity, and ZIP code-level median income.

STUDY DESIGN

Statewide hospital discharge data from 5 states that did and 5 states that did not implement Medicaid expansion were used to perform difference-in-difference (DD) analyses. Changes in insurance coverage and outcomes from before (2011-2013) to after (2014-2017) Medicaid expansion and open enrollment were examined in trauma patients aged 19 to 44 years.

RESULTS

Medicaid expansion was associated with a decrease in the percentage of uninsured patients (DD -16.5 percentage points; 95% CI, -17.1 to -15.9 percentage points). This decrease was larger among Black patients but smaller among Hispanic patients than White patients. It was also larger among patients from lower-income ZIP codes (p < 0.05 for all). Medicaid expansion was associated with an increase in discharge to inpatient rehabilitation (DD 0.6 percentage points; 95% CI, 0.2 to 0.9 percentage points). This increase was larger among patients from the lowest-compared with highest-income ZIP codes (p < 0.05). Medicaid expansion was not associated with changes in in-hospital mortality or readmission or return ED visit rates overall, but was associated with decreased in-hospital mortality among Black patients (DD -0.4 percentage points; 95% CI, -0.8 to -0.1 percentage points).

CONCLUSIONS

The Affordable Care Act Medicaid expansion, in its first 4 years, increased insurance coverage and access to rehabilitation among young adult trauma patients. It also reduced the socioeconomic disparity in inpatient rehabilitation access and the disparity in in-hospital mortality between Black and White patients.

Exposure, hazard, and vulnerability all contribute to Schistosoma haematobium re-infection in northern Senegal

Background

Infectious disease risk is driven by three interrelated components: exposure, hazard, and vulnerability. For schistosomiasis, exposure occurs through contact with water, which is often tied to daily activities. Water contact, however, does not imply risk unless the environmental hazard of snails and parasites is also present in the water. By increasing reliance on hazardous activities and environments, socio-economic vulnerability can hinder reductions in exposure to a hazard. We aimed to quantify the contributions of exposure, hazard, and vulnerability to the presence and intensity of Schistosoma haematobium re-infection.

Methodology/Principal findings

In 13 villages along the Senegal River, we collected parasitological data from 821 school-aged children, survey data from 411 households where those children resided, and ecological data from all 24 village water access sites. We fit mixed-effects logistic and negative binomial regressions with indices of exposure, hazard, and vulnerability as explanatory variables of Schistosoma haematobium presence and intensity, respectively, controlling for demographic variables. Using multi-model inference to calculate the relative importance of each component of risk, we found that hazard (Ʃw_{i =} 0.95) was the most important component of S. haematobium presence, followed by vulnerability (Ʃw_i = 0.91). Exposure (Ʃw_i = 1.00) was the most important component of S. haematobium intensity, followed by hazard (Ʃw_i = 0.77). Model averaging quantified associations between each infection outcome and indices of exposure, hazard, and vulnerability, revealing a positive association between hazard and infection presence (OR = 1.49, 95% CI 1.12, 1.97), and a positive association between exposure and infection intensity (RR 2.59–3.86, depending on the category; all 95% CIs above 1)

Conclusions/Significance

Our findings underscore the linkages between social (exposure and vulnerability) and environmental (hazard) processes in the acquisition and accumulation of S. haematobium infection. This approach highlights the importance of implementing both social and environmental interventions to complement mass drug administration.

While the impacts of natural hazards tend to be described in terms of social determinants such as exposure and vulnerability, the risk for infectious disease is often expressed in terms of environmental determinants without fully considering the socio-ecological processes that put people in contact with infective agents of disease. In the case of schistosomiasis, risk is determined by human interactions with freshwater environments where schistosome parasites circulate between people and aquatic snails. In this study, we quantified the relative contributions of exposure, hazard, and vulnerability to schistosome re-infection among schoolchildren in an endemic region of northern Senegal. We find that hazard and vulnerability influence whether a child becomes infected, while exposure and hazard influence the burden of worms once infection is acquired. Increasing numbers of worms is known to be positively associated with increasing severity of disease. Our findings underscore the importance of evaluating social and environmental determinants of disease simultaneously; omitting measures of exposure, hazard or vulnerability may limit our understanding of risk.

Environmental Influences Measured by Epigenetic Clock and Vulnerability Components at Birth Impact Clinical ASD Heterogeneity

Although Autism Spectrum Disorders (ASD) is recognized as being heavily influenced by genetic factors, the role of epigenetic and environmental factors is still being established. This study aimed to identify ASD vulnerability components based on familial history and intrauterine environmental stress exposure, explore possible vulnerability subgroups, access DNA methylation age acceleration (AA) as a proxy of stress exposure during life, and evaluate the association of ASD vulnerability components and AA to phenotypic severity measures. Principal Component Analysis (PCA) was used to search the vulnerability components from 67 mothers of autistic children. We found that PC1 had a higher correlation with psychosocial stress (maternal stress, maternal education, and social class), and PC2 had a higher correlation with biological factors (psychiatric family history and gestational complications). Comparing the methylome between above and below PC1 average subgroups we found 11,879 statistically significant differentially methylated probes (DMPs, p < 0.05). DMPs CpG sites were enriched in variably methylated regions (VMRs), most showing environmental and genetic influences. Hypermethylated probes presented higher rates in different regulatory regions associated with functional SNPs, indicating that the subgroups may have different affected regulatory regions and their liability to disease explained by common variations. Vulnerability components score moderated by epigenetic clock AA was associated with Vineland Total score (p = 0.0036, adjR² = 0.31), suggesting risk factors with stress burden can influence ASD phenotype.

Association Between Housing Insecurity, Psychological Distress, and Self-rated Health Among US Adults During the COVID-19 Pandemic

This survey study examines association of housing insecurity with psychological distress and self-rated health among US adults during the COVID-19 pandemic.

Impact of essential workers in the context of social distancing for epidemic control

New emerging infectious diseases are identified every year, a subset of which become global pandemics like COVID-19. In the case of COVID-19, many governments have responded to the ongoing pandemic by imposing social policies that restrict contacts outside of the home, resulting in a large fraction of the workforce either working from home or not working. To ensure essential services, however, a substantial number of workers are not subject to these limitations, and maintain many of their pre-intervention contacts. To explore how contacts among such "essential" workers, and between essential workers and the rest of the population, impact disease risk and the effectiveness of pandemic control, we evaluated several mathematical models of essential worker contacts within a standard epidemiology framework. The models were designed to correspond to key characteristics of cashiers, factory employees, and healthcare workers. We find in all three models that essential workers are at substantially elevated risk of infection compared to the rest of the population, as has been documented, and that increasing the numbers of essential workers necessitates the imposition of more stringent controls on contacts among the rest of the population to manage the pandemic. Importantly, however, different archetypes of essential workers differ in both their individual probability of infection and impact on the broader pandemic dynamics, highlighting the need to understand and target intervention for the specific risks faced by different groups of essential workers. These findings, especially in light of the massive human costs of the current COVID-19 pandemic, indicate that contingency plans for future epidemics should account for the impacts of essential workers on disease spread.

Mental health among healthcare workers and other vulnerable groups during the COVID-19 pandemic and other coronavirus outbreaks: A rapid systematic review

INTRODUCTION

Although most countries and healthcare systems worldwide have been affected by the COVID-19 pandemic, some groups of the population may be more vulnerable to detrimental effects of the pandemic on mental health than others. The aim of this systematic review was to synthesise evidence currently available from systematic reviews on the impact of COVID-19 and other coronavirus outbreaks on mental health for groups of the population thought to be at increased risk of detrimental mental health impacts.

MATERIALS AND METHODS

We conducted a systematic review of reviews on adults and children residing in a country affected by a coronavirus outbreak and belonging to a group considered to be at risk of experiencing mental health inequalities. Data were collected on symptoms or diagnoses of any mental health condition, quality of life, suicide or attempted suicide. The protocol for this systematic review was registered in the online PROSPERO database prior to commencing the review (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=194264).

RESULTS

We included 25 systematic reviews. Most reviews included primary studies of hospital workers from multiple countries. Reviews reported variable estimates for the burden of symptoms of mental health problems among acute healthcare workers, COVID-19 patients with physical comorbidities, and children and adolescents. No evaluations of interventions were identified. Risk- and protective factors, mostly for healthcare workers, showed the importance of personal factors, the work environment, and social networks for mental health.

CONCLUSIONS

This review of reviews based on primary studies conducted in the early months of the COVID-19 pandemic shows a lack of evidence on mental health interventions and mental health impacts on vulnerable groups in the population.

Food insecurity during COVID-19 pandemic: A genuine concern for people from disadvantaged community and low-income families in Province 2 of Nepal

BACKGROUND

Food insecurity is a serious social and public health problem which is exacerbated by the COVID-19 pandemic especially in resource-poor countries such as Nepal. However, there is a paucity of evidence at local levels. This study aims to explore food insecurity among people from the disadvantaged community and low-income families during the COVID-19 pandemic in Province-2 of Nepal.

METHODS

The semi-structured qualitative interviews were conducted virtually among purposively selected participants (n = 41) from both urban and rural areas in eight districts of Province 2 in Nepal. All the interviews were conducted in the local language between July and August 2020. The data analysis was performed using thematic network analysis in Nvivo 12 Pro software.

RESULTS

The results of this study are grouped into four global themes: i) Impact of COVID-19 on food security; ii) Food insecurity and coping strategies during the COVID-19 pandemic, iii) Food relief and emergency support during the COVID-19 pandemic, and iv) Impact of COVID-19 and food insecurity on health and wellbeing. Most participants in the study expressed that families from low socioeconomic backgrounds and disadvantaged communities such as those working on daily wages and who rely on remittance had experienced increased food insecurity during the COVID-19 pandemic. Participants used different forms of coping strategies to meet their food requirements during the pandemic. Community members experienced favouritism, nepotism, and partiality from local politicians and authorities during the distribution of food relief. The food insecurity among low-income and disadvantaged families has affected their health and wellbeing making them increasingly vulnerable to the COVID-19 infection.

CONCLUSION

Food insecurity among low-income and disadvantaged families was found to be a serious problem during the COVID-19 pandemic. The study suggests that the relief support plan and policies should be focused on the implementation of immediate sustainable food security strategies to prevent hunger, malnutrition, and mental health problems among the most vulnerable groups in the community.

Time-varying associations between COVID-19 case incidence and community-level sociodemographic, occupational, environmental, and mobility risk factors in Massachusetts

BACKGROUND

Associations between community-level risk factors and COVID-19 incidence have been used to identify vulnerable subpopulations and target interventions, but the variability of these associations over time remains largely unknown. We evaluated variability in the associations between community-level predictors and COVID-19 case incidence in 351 cities and towns in Massachusetts from March to October 2020.

METHODS

Using publicly available sociodemographic, occupational, environmental, and mobility datasets, we developed mixed-effect, adjusted Poisson regression models to depict associations between these variables and town-level COVID-19 case incidence data across five distinct time periods from March to October 2020. We examined town-level demographic variables, including population proportions by race, ethnicity, and age, as well as factors related to occupation, housing density, economic vulnerability, air pollution (PM2.5), and institutional facilities. We calculated incidence rate ratios (IRR) associated with these predictors and compared these values across the multiple time periods to assess variability in the observed associations over time.

RESULTS

Associations between key predictor variables and town-level incidence varied across the five time periods. We observed reductions over time in the association with percentage of Black residents (IRR = 1.12 [95%CI: 1.12-1.13]) in early spring, IRR = 1.01 [95%CI: 1.00-1.01] in early fall) and COVID-19 incidence. The association with number of long-term care facility beds per capita also decreased over time (IRR = 1.28 [95%CI: 1.26-1.31] in spring, IRR = 1.07 [95%CI: 1.05-1.09] in fall). Controlling for other factors, towns with higher percentages of essential workers experienced elevated incidences of COVID-19 throughout the pandemic (e.g., IRR = 1.30 [95%CI: 1.27-1.33] in spring, IRR = 1.20 [95%CI: 1.17-1.22] in fall). Towns with higher proportions of Latinx residents also had sustained elevated incidence over time (IRR = 1.19 [95%CI: 1.18-1.21] in spring, IRR = 1.14 [95%CI: 1.13-1.15] in fall).

CONCLUSIONS

Town-level COVID-19 risk factors varied with time in this study. In Massachusetts, racial (but not ethnic) disparities in COVID-19 incidence may have decreased across the first 8 months of the pandemic, perhaps indicating greater success in risk mitigation in selected communities. Our approach can be used to evaluate effectiveness of public health interventions and target specific mitigation efforts on the community level.

Deterioration of mental health and insufficient Covid-19 information among disadvantaged immigrants in the greater Paris area

OBJECTIVES

The aim of this study is to provide information on changes in mental health among disadvantaged immigrants from Sub-Saharan Africa in the Greater Paris area and their level of information about Covid-19.

METHODS

Prior to the Covid-19 epidemic, the Makasi community-based cohort followed 850 immigrants from sub-Saharan Africa in the Greater Paris area. Between the 1st of April and the 7th of June 2020, all participants scheduled for a follow-up survey were systematically included into an additional COVID-19-related wave of data collection (N = 100). We compared participants' type of housing, level of food insecurity, work and mental health (PHQ9) before and during the first COVID-19-related lockdown, using paired-Mc Nemar chi-2 tests. We next described their level of information on Covid-19 and policy measures, broken down by sex.

RESULTS

Among the 100 participants, 68% had no legal residence permit. Food insecurity was more often reported during lockdown than before (62% vs 52%). 9% of participants had a score indicative of severe depression (PHQ9) before lockdown and 17% afterwards (p = 0.17). Only 51% knew about the possibility of asymptomatic transmission of the COVID-19 virus.

CONCLUSIONS

This study brings original information on a hard-to-reach population group. Our results suggest that the lockdown had a detrimental impact on various economic and mental health aspects among disadvantaged migrants residing in the Greater Paris area.

Comparison of hospitalized patients with COVID-19 who did and did not live in residential care facilities in Montréal: a retrospective case series

BACKGROUND

As in other jurisdictions, the demographics of people infected with SARS-CoV-2 changed in Quebec over the course of the first COVID-19 pandemic wave, and affected those living in residential care facilities (RCFs) disproportionately. We evaluated the association between clinical characteristics and outcomes of hospitalized patients with COVID-19, comparing those did or did not live in RCFs.

METHODS

We conducted a retrospective case series of all consecutive adults (≥ 18 yr) admitted to the Jewish General Hospital in Montréal with laboratory-confirmed SARS-CoV-2 infection from Mar. 4 to June 30, 2020, with in-hospital follow-up until Aug. 6, 2020. We collected patient demographics, comorbidities and outcomes (i.e., admission to the intensive care unit, mechanical ventilation and death) from medical and laboratory records and compared patients who did or did not live in public and private RCFs. We evaluated factors associated with the risk of in-hospital death with a Cox proportional hazard model.

RESULTS

In total, 656 patients were hospitalized between March and June 2020, including 303 patients who lived in RCFs and 353 patients who did not. The mean age was 72.9 (standard deviation 18.3) years (range 21 to 106 yr); 349 (53.2%) were female and 118 (18.0%) were admitted to the intensive care unit. The overall mortality rate was 23.8% (156/656), but was higher among patients living in RCFs (36.6% [111/303]) compared with those not living in RCFs (12.7% [45/353]). Increased risk of death was associated with age 80 years and older (hazard ratio [HR] 2.39, 95% confidence interval [CI] 1.35-4.24), male sex (HR 1.74, 95% CI 1.25-2.41), the presence of 4 or more comorbidities (HR 2.01, 95% CI 1.18-3.42) and living in an RCF (HR 1.62, 95% CI 1.09-2.39).

INTERPRETATION

During the first wave of the COVID-19 epidemic in Montréal, more than one-third of RCF residents hospitalized with SARS-CoV-2 infection died during hospitalization. Policies and practices that prevent future outbreaks of SARS-CoV-2 infection in this setting must be implemented to prevent high mortality in this vulnerable population.

The impact of humanitarian assistance on post-disaster social vulnerabilities: some early reflections on the Nepal earthquake in 2015

Every year, thousands of people around the world who face unequal access to political and social power and resources lose their lives and/or livelihoods in natural hazard events. As a result, the reduction of vulnerability has become a central concern of humanitarian actors. This paper analyses the impact of humanitarian assistance on vulnerabilities in Nepal following the Gorkha earthquake on 25 April 2015. The causes and manifestations of vulnerability before and after the disaster are determined through the application of the Pressure and Release model and the adoption of a mixed-methods research approach. The findings of the study reveal that 20 months after the earthquake, humanitarian assistance had not had any long-term positive influences on the root causes of the phenomenon, and that vulnerabilities at the micro level could be resolved in part. To diminish the extent of disasters in the future, however, the fundamental reasons for the vulnerability have to be addressed better.

'She come like a sister to me': a qualitative study of volunteer social support for disadvantaged women in the transition to motherhood in England

This qualitative study explores the ways in which disadvantaged women benefit from social support from a trained volunteer during pregnancy and the postnatal period, using the theoretical frameworks of stress and coping and a multi-dimensional model of social support. Forty-seven mothers took part in semi-structured interviews. The mothers, who had received social support through nine volunteer projects in England, faced many potentially stressful challenges besides having a baby (such as poverty, poor housing, histories of abuse, motherhood at a young age, living with physical or mental health difficulties, migration and insecure immigration status). Analysis was in two distinct stages: first, an inductive thematic analysis of mothers' experiences, and second, mapping of the results onto the theoretical frameworks chosen. Volunteers built relationships of trust with mothers and gave skilled emotional support, positive appraisal support, informational support and practical support according to mothers' individual needs, thereby assisting mothers exposed to multiple stressors with problem-focused, emotion-focused and perception-focused coping. This helped to reduce social isolation, increase effective access to services and community resources, and build mothers' confidence, self-esteem and self-efficacy. Volunteer social support may have particular salience for mothers who lack structural support and need skilled functional support. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

COVID-19 vaccine prioritization of incarcerated people relative to other vulnerable groups: An analysis of state plans

BACKGROUND

Carceral facilities are epicenters of the COVID-19 pandemic, placing incarcerated people at an elevated risk of COVID-19 infection. Due to the initial limited availability of COVID-19 vaccines in the United States, all states have developed allocation plans that outline a phased distribution. This study uses document analysis to compare the relative prioritization of incarcerated people, correctional staff, and other groups at increased risk of COVID-19 infection and morbidity.

METHODS AND FINDINGS

We conducted a document analysis of the vaccine dissemination plans of all 50 US states and the District of Columbia using a triple-coding method. Documents included state COVID-19 vaccination plans and supplemental materials on vaccine prioritization from state health department websites as of December 31, 2020. We found that 22% of states prioritized incarcerated people in Phase 1, 29% of states in Phase 2, and 2% in Phase 3, while 47% of states did not explicitly specify in which phase people who are incarcerated will be eligible for vaccination. Incarcerated people were consistently not prioritized in Phase 1, while other vulnerable groups who shared similar environmental risk received this early prioritization. States' plans prioritized in Phase 1: prison and jail workers (49%), law enforcement (63%), seniors (65+ years, 59%), and long-term care facility residents (100%).

CONCLUSIONS

This study demonstrates that states' COVID-19 vaccine allocation plans do not prioritize incarcerated people and provide little to no guidance on vaccination protocols if they fall under other high-risk categories that receive earlier priority. Deprioritizing incarcerated people for vaccination misses a crucial opportunity for COVID-19 mitigation. It also raises ethical and equity concerns. As states move forward with their vaccine distribution, further work must be done to prioritize ethical allocation and distribution of COVID-19 vaccines to incarcerated people.

Perceived structural vulnerabilities among detained noncitizen immigrants in Minnesota

Across several decades there has been an unprecedented increase in immigration enforcement including detention and deportation. Immigration detention profoundly impacts those experiencing detention and their family members. An emerging area of research has found that immigrants experience a number of challenges which constrain and limit their decisions, choices, and options for security and integration in the United States due to social, political and structural determinants. These determinants lead to greater structural vulnerabilities among immigrants. The purpose of the current study was to illuminate the perceived vulnerabilities of detained noncitizen immigrants as they are raised and described while attending case hearings at the Bloomington, Minnesota immigration court. Through conducting a thematic analysis of notes derived from third party immigration court observers, three areas of perceived vulnerability were identified. These perceived vulnerabilities include 1) migration and motivations to migrate, 2) structural vulnerabilities (e.g., discrimination, financial insecurity, social ties and family support, stable or fixed residence, English language proficiency, health and mental health) in the US, and 3) challenges in navigating immigration detention. These findings demonstrate that noncitizen immigrants who are undergoing immigration detention are experiencing multiple intersecting vulnerabilities which profoundly impact their lives. Collaborative efforts across sectors are needed to work towards comprehensive immigration reforms including both short-term and long-term solutions to address pressing issues for noncitizens undergoing immigration detention.

Ensemble machine learning of factors influencing COVID-19 across US counties

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) the causal agent for COVID-19, is a communicable disease spread through close contact. It is known to disproportionately impact certain communities due to both biological susceptibility and inequitable exposure. In this study, we investigate the most important health, social, and environmental factors impacting the early phases (before July, 2020) of per capita COVID-19 transmission and per capita all-cause mortality in US counties. We aggregate county-level physical and mental health, environmental pollution, access to health care, demographic characteristics, vulnerable population scores, and other epidemiological data to create a large feature set to analyze per capita COVID-19 outcomes. Because of the high-dimensionality, multicollinearity, and unknown interactions of the data, we use ensemble machine learning and marginal prediction methods to identify the most salient factors associated with several COVID-19 outbreak measure. Our variable importance results show that measures of ethnicity, public transportation and preventable diseases are the strongest predictors for both per capita COVID-19 incidence and mortality. Specifically, the CDC measures for minority populations, CDC measures for limited English, and proportion of Black- and/or African-American individuals in a county were the most important features for per capita COVID-19 cases within a month after the pandemic started in a county and also at the latest date examined. For per capita all-cause mortality at day 100 and total to date, we find that public transportation use and proportion of Black- and/or African-American individuals in a county are the strongest predictors. The methods predict that, keeping all other factors fixed, a 10% increase in public transportation use, all other factors remaining fixed at the observed values, is associated with increases mortality at day 100 of 2012 individuals (95% CI [1972, 2356]) and likewise a 10% increase in the proportion of Black- and/or African-American individuals in a county is associated with increases total deaths at end of study of 2067 (95% CI [1189, 2654]). Using data until the end of study, the same metric suggests ethnicity has double the association as the next most important factors, which are location, disease prevalence, and transit factors. Our findings shed light on societal patterns that have been reported and experienced in the U.S. by using robust methods to understand the features most responsible for transmission and sectors of society most vulnerable to infection and mortality. In particular, our results provide evidence of the disproportionate impact of the COVID-19 pandemic on minority populations. Our results suggest that mitigation measures, including how vaccines are distributed, could have the greatest impact if they are given with priority to the highest risk communities.

The Epidemiological Impact of STIs among General and Vulnerable Populations of the Amazon Region of Brazil: 30 years of Surveillance

Sexually transmitted infections (STIs) represent a worldwide public health problem and, although many of them are curable, they continue to be neglected, especially in areas with a low human development index, such as in the northern region of Brazil. This review describes the results of 30 years of studies at the Virus Laboratory at the Federal University of Pará, including the prevalence and molecular epidemiology of HIV-1, HTLV-1/2, HPV, HBV, Treponema pallidum and Chlamydia trachomatis among urban and non-urban populations, and also in vulnerable groups in the Brazilian Amazon. Control strategies and challenges in preventing STIs are discussed considering this immense geographic region, where essential health services are unable to reach the entire population, especially the most vulnerable, such as female sex workers, people who use illicit drugs, remnants of quilombolos and indigenous communities.

Childhood food insecurity and incident diabetes: A longitudinal cohort study of 34 042 children in Ontario, Canada

AIM

To examine the association between childhood food insecurity and incident diabetes.

METHODS

Using health administrative databases linked to the Canadian Community Health Survey, we conducted a population-based cohort study of children aged <18 years from Ontario, Canada. Children without diabetes who had a household response to the Canadian Community Health Survey Household Food Security Survey Module were followed for a median of 9.5 years for incident diabetes. Multivariable Cox proportional hazards models were used to examine the association between childhood food insecurity and incident diabetes, adjusted sequentially for important clinical and socio-economic risk factors.

RESULTS

We included 34 042 children, of whom 5.3% lived in food-insecure households. There were 184 new cases of diabetes, diagnosed at a median age of 16 and 18.5 years in food-secure and food-insecure children, respectively. In unadjusted analysis, childhood food insecurity was associated with an increased risk of incident diabetes (hazard ratio 1.69, 95% CI 1.01 to 2.81). When adjusted for clinical and socio-economic confounders, the relationship was no longer statistically significant (hazard ratio 1.55, 95% CI 0.91 to 2.66, adjusted for clinical confounders; hazard ratio 1.30, 95% CI 0.72 to 2.37, adjusted for clinical/socio-economic confounders). Our results remained robust in sensitivity analyses.

CONCLUSIONS

Although food-insecure children are a medically and socially vulnerable population, they do not appear to be at increased risk of incident diabetes over a median of 9.5 years.

Neighborhood Disadvantage Measures and COVID-19 Cases in Boston, 2020

OBJECTIVE

Understanding the pattern of population risk for coronavirus disease 2019 (COVID-19) is critically important for health systems and policy makers. The objective of this study was to describe the association between neighborhood factors and number of COVID-19 cases. We hypothesized an association between disadvantaged neighborhoods and clusters of COVID-19 cases.

METHODS

We analyzed data on patients presenting to a large health care system in Boston during February 5-May 4, 2020. We used a bivariate local join-count procedure to determine colocation between census tracts with high rates of neighborhood demographic characteristics (eg, Hispanic race/ethnicity) and measures of disadvantage (eg, health insurance status) and COVID-19 cases. We used negative binomial models to assess independent associations between neighborhood factors and the incidence of COVID-19.

RESULTS

A total of 9898 COVID-19 patients were in the cohort. The overall crude incidence in the study area was 32 cases per 10 000 population, and the adjusted incidence per census tract ranged from 2 to 405 per 10 000 population. We found significant colocation of several neighborhood factors and the top quintile of cases: percentage of population that was Hispanic, non-Hispanic Black, without health insurance, receiving Supplemental Nutrition Assistance Program benefits, and living in poverty. Factors associated with increased incidence of COVID-19 included percentage of population that is Hispanic (incidence rate ratio [IRR] = 1.25; 95% CI, 1.23-1.28) and percentage of households living in poverty (IRR = 1.25; 95% CI, 1.19-1.32).

CONCLUSIONS

We found a significant association between neighborhoods with high rates of disadvantage and COVID-19. Policy makers need to consider these health inequities when responding to the pandemic and planning for subsequent health needs.

Community Characteristics and COVID-19 Outcomes: A Study of 159 Counties in Georgia, United States

BACKGROUND

The COVID-19 pandemic affects population groups differently, worsening existing social, economic, and health inequities.

PURPOSE

This study examined 159 counties within Georgia to identify community characteristics associated with county-level COVID-19 case, hospitalization, and death rates.

METHODS

Data from the 2020 County Health Rankings, the 2010 US Census, and the Georgia Department of Public Health COVID-19 Daily Status Report were linked using county Federal Information Processing Standard codes and evaluated through multivariable linear regression models.

RESULTS

The percentages of children in poverty, severe housing problems, and people not proficient in the English language were significant predictors associated with increases in case, hospitalization, and death rates. Diabetic prevalence was significantly associated with increases in the hospitalization and death rates; in contrast, the percentages of people with excessive drinking and female were inversely associated with hospitalization and death rates. Other independent variables showing an association with death rate included the percentages of people reporting fair or poor health and American Indian/Alaska Native.

IMPLICATION

Local authorities' proper allocation of resources and plans to address community social determinants of health are essential to mitigate disease transmission and reduce hospitalizations and deaths associated with COVID-19, especially among vulnerable groups.

Trajectories of Depressive Symptoms Experienced by Older People: Effects of Time, Hurricane Sandy, and the Great Recession

OBJECTIVES

To examine depressive symptom trajectories as a function of time and exposure to Hurricane Sandy, accounting for the effects of the Great Recession.

METHODS

We analyzed 6 waves of data from a 12-year panel using latent class growth models and multinomial logistic regression.

RESULTS

We identified 4 groups of people experiencing different trajectories of depressive symptoms. The groups differed on baseline characteristics (gender, age, education, income, race), history of diagnosed depression, and initial level of depressive symptoms. The group with the highest levels of depressive symptoms reported greater levels of peri-traumatic stress exposure to Hurricane Sandy.

DISCUSSION

Depressive symptoms increased as a function of the Great Recession, but exposure to Hurricane Sandy was not associated with subsequent increases in depressive symptoms for any of the 4 groups. People who consistently experienced high levels of depressive symptoms over time reported the highest levels of peri-traumatic stress during Hurricane Sandy. Findings highlight the importance of accounting for historical trends when studying the effects of disaster, identify people likely to be at risk during a disaster, and provide novel information about the causal relationship between exposure to disaster and depressive symptoms.

Smoking and cessation behaviors in patients at federally funded health centers - United States, 2014

BACKGROUND

Federally funded health centers (HCs) provide care to the most vulnerable populations in the U.S., including populations with disproportionately higher smoking prevalence such as those with lower incomes.

METHODS

This study compared characteristics of adult HC patients, by cigarette smoking status, and assessed smoking cessation-related behaviors using 2014 Health Center Patient Survey data; analysis was restricted to adults with data on cigarette smoking status (n = 5583). Chi-square and logistic regression analyses were conducted.

RESULTS

Overall, 28.1 % were current smokers and 19.2 % were former smokers. Current smokers were more likely to report fair/poor health (48.2 %) and a high burden of behavioral health conditions (e.g., severe psychological distress 23.9 %) versus former and never smokers. Most current smokers reported wanting to quit in the past 12 months (79.0 %) and receiving advice to quit from a healthcare professional (78.7 %). In a multivariable model, age <45, non-white race, COPD diagnosis, and past 3-month marijuana use were significantly associated with desire to quit. Few former smokers (15.2 %) reported using cessation treatment, though use was higher among those who quit within the previous year (30.6 %).

CONCLUSIONS

Although most current smokers reported a desire to quit, low uptake of evidence-based treatment may reduce the number who attempt to quit and succeed. Given the burden of tobacco use, future efforts could focus on identifying and overcoming unique personal, healthcare professional, or health system barriers to connecting them with cessation treatments. Increasing access to cessation treatments within HCs could reduce smoking-related disparities and improve population health.

A scoping review of sources of mercury and its health effects among Pakistan's most vulnerable population

Mercury and methyl mercury are poisonous to human body. In the recent times, exposure to mercury has been anthropogenic in nature. Within the past several decades, many incidences of mercury poisoning have been documented in several countries including Pakistan. Mercury has been ingested where it has been used to preserve crops, through the point and non-point source discharge into the surface water, and consequently entering the food chain. We conducted this scoping review of mercury and its health effects in Pakistan in order to raise the flag to a silent ongoing Minamata disease in the country. We conducted a systematic search of the available literature in Google Scholar, PubMed, and grey literature of unpublished theses and reports of various universities across the country. We found that in the northern Pakistan, suspended sediments were the major pathway of the riverine mercury transport. Sediments of Hunza and Gilgit River were found high in mercury concentrations. Gold mining leads to an increase in mercury concentration in soil and river waters flowing in this region. High concentrations up to 108 ng/L were found in Shimsal River. It is suspected that that high level of mercury transport may be leading to accumulation of mercury in major water bodies and lakes downstream. Occupational exposure to mercury and other heavy metals is common in an unregulated private sector of the country. Goldsmiths burn the amalgamated gold without personal protective measures. Direct exposure to the fumes of mercury leads to respiratory, dermatological, systemic and neurological ailments specific to mercury poisoning. We found good evidence of bioaccumulation of mercury in fish and fish products in Pakistan. The untreated waste water discharge is responsible to not only afflicted the fish but also the birds which feed on this fish. Further, the same untreated waste water from factories and agriculture runoffs affect vegetables grown in it. Studies looking at the biomarkers for mercury in humans have shown increased and even toxic levels of mercury among the most vulnerable populations of the country. Other sources of mercury exposure included mercury in traditional medicines and cigarette products. Though no evidence was found for its presence in drinking water, its existence in the food chain and occupational exposure pose great threat to the humans as well as animals.

Spatial and temporal trends in social vulnerability and COVID-19 incidence and death rates in the United States

BACKGROUND

Socially vulnerable communities may be at higher risk for COVID-19 outbreaks in the US. However, no prior studies examined temporal trends and differential effects of social vulnerability on COVID-19 incidence and death rates. Therefore, we examined temporal trends among counties with high and low social vulnerability to quantify disparities in trends over time.

METHODS

We conducted a longitudinal analysis examining COVID-19 incidence and death rates from March 15 to December 31, 2020, for each US county using data from USAFacts. We classified counties using the Social Vulnerability Index (SVI), a percentile-based measure from the Centers for Disease Control and Prevention, with higher values indicating more vulnerability. Using a Bayesian hierarchical negative binomial model, we estimated daily risk ratios (RRs) comparing counties in the first (lower) and fourth (upper) SVI quartiles, adjusting for rurality, percentage in poor or fair health, percentage female, percentage of smokers, county average daily fine particulate matter (PM2.5), percentage of primary care physicians per 100,000 residents, daily temperature and precipitation, and proportion tested for COVID-19.

RESULTS

At the outset of the pandemic, the most vulnerable counties had, on average, fewer cases per 100,000 than least vulnerable SVI quartile. However, on March 28, we observed a crossover effect in which the most vulnerable counties experienced higher COVID-19 incidence rates compared to the least vulnerable counties (RR = 1.05, 95% PI: 0.98, 1.12). Vulnerable counties had higher death rates starting on May 21 (RR = 1.08, 95% PI: 1.00,1.16). However, by October, this trend reversed and the most vulnerable counties had lower death rates compared to least vulnerable counties.

CONCLUSIONS

The impact of COVID-19 is not static but can migrate from less vulnerable counties to more vulnerable counties and back again over time.

Hepatitis C Among High-Risk Alabamians: Disease Burden and Screening Effectiveness

BACKGROUND

The effectiveness of hepatitis C testing and linkage-to-care (LTC) is poorly characterized in low-resource jurisdictions facing gaps in harm reduction, including illegality of syringe exchange services. Effectiveness of a community-based test/LTC program was evaluated in Alabama.

METHODS

In 2016-2018, shelters, drug treatment centers (DTCs), AIDS organizations, and Federally Qualified Health Centers (FQHCs) engaged in screening/LTC. A coordinator navigated individuals to confirm viremia and link to substance use treatment or primary care with hepatitis C prescribers.

RESULTS

Point-of-care (POC) tested 4293 individuals (10% [427] antibody-positive, 71% [299/419] RNA performed, 80% [241/299] viremia confirmed) and 93% linked to care (225/241). Electronic medical record (EMR)-based reflex strategy screened 4654 (15% [679] antibody positive, 99% [670/679] RNA performed, 64% [433/679] viremia confirmed) and 85% linked to care (368/433). We observed higher odds of RNA confirmation in EMR-based reflex versus POC (OR, 2.07; P < .0001) and higher odds of LTC in EMR-based reflex versus POC (OR, 1.51; P < .0001). Overall, 53% individuals tested were nonbaby boomers.

CONCLUSIONS

In Alabama, screening at high-risk settings identified significant hepatitis C burden and reflex testing outperformed point-of-care linkage indicators. Colocating testing in DTCs and treatment in FQHCs provided key LTC venues to at-risk younger groups.

Supporting Graduate Nursing Education for Students From Disadvantaged Backgrounds

BACKGROUND

There is a lack of diversity in the master's prepared nursing workforce. One nursing school implemented a scholarship program for students from disadvantaged backgrounds enrolled in the Family Nurse Practitioner and Adult Gerontology Primary Nurse Practitioner tracks.

METHOD

Awardees were required to be full-time students from disadvantaged backgrounds with financial need. Each student was matched with a faculty member for regular mentorship. Student progress was evaluated every three months, with follow-up 1 year after graduation.

RESULTS

A total of 45 students received the Scholarship for Disadvantaged Students (SDS) over 2 consecutive years. Of the 45 students, 26 (58%) identified themselves as Hispanic and 11 (24%) as black. A total of 42 (93%) of 45 SDS students completed the original plan of study and passed the national certification board.

CONCLUSION

The SDS serves as a model of an effective mentorship program to assist nurse practitioner students from disadvantaged backgrounds. [J Nurs Educ. 2020;59(5):287-290.].