Measurement of Sex and Gender Identity in the Behavioral Risk Factor Surveillance System Survey, 2014 to 2020.

Effective measurement of sex and gender identity is challenging. Questions measuring gender identity were added as an optional module of the Behavioral Risk Factor Surveillance System (BRFSS) in 2014 and were modified repeatedly in following years. This study examines BRFSS participant responses to gender identity and sex questions, 2014-2020. About 70% of participants who identified as transgender male-to-female reported male sex while 30% reported female sex. Participants who identified as transgender female-to-male reported female sex about 65% of the time and reported male sex 35% of the time. Despite changes in sex question wording, these percentages were consistent over time. Reported sex is used in computing health-related variables and in routing participants to questions about birth control, pregnancy, HPV vaccines, and cancer screenings. Without better measurement, it is challenging to assess health and health risks and inform guidelines, programs, and policies protecting the health of transgender people.

A randomized implementation trial to increase adoption of evidence-informed consent practices.

Introduction: Several evidence-informed consent practices (ECPs) have been shown to improve informed consent in clinical trials but are not routinely used. These include optimizing consent formatting, using plain language, using validated instruments to assess understanding, and involving legally authorized representatives when appropriate. We hypothesized that participants receiving an implementation science toolkit and a social media push would have increased adoption of ECPs and other outcomes. Methods: We conducted a 1-year trial with clinical research professionals in the USA (n = 1284) who have trials open to older adults or focus on Alzheimer's disease. We randomized participants to receive information on ECPs via receiving a toolkit with a social media push (intervention) or receiving an online learning module (active control). Participants completed a baseline survey and a follow-up survey after 1 year. A subset of participants was interviewed (n = 43). Results: Participants who engaged more with the toolkit were more likely to have tried to implement an ECP during the trial than participants less engaged with the toolkit or the active control group. However, there were no significant differences in the adoption of ECPs, intention to adopt, or positive attitudes. Participants reported the toolkit and social media push were satisfactory, and participating increased their awareness of ECPs. However, they reported lacking the time needed to engage with the toolkit more fully. Conclusions: Using an implementation science approach to increase the use of ECPs was only modestly successful. Data suggest that having institutional review boards recommend or require ECPs may be an effective way to increase their use.

Changes in Harm Perception for E-Cigarettes Among Youth in the United States, 2014-2019.

PURPOSE: To evaluate the trend of harm perception for e-cigarettes and the trend of the association between harm perception for e-cigarettes and for cigarettes among US youth from 2014 to 2019. DESIGN, SETTING AND SUBJECTS: The National Youth Tobacco Survey is an annual, cross-sectional, school-based survey done among youth selected using three-stage probability sampling. ANALYSIS: Data were drawn from the 2014 to 2019 Surveys. A Multinomial logistic regression model was used to assess the association between harm perception for e-cigarettes and harm perception for cigarettes for each year. RESULTS: The percentage of youth who perceived e-cigarettes as harmless decreased from 2014 to 2019 (17.2% to 5.8%). From 2015 to 2018, the percentage of smokers who perceived e-cigarettes as a little harmful increased (33.6% to 41.2%). The positive association between harm perception for e-cigarettes and harm perception for cigarettes became stronger with time. In 2014, the odds of perceiving e-cigarettes as harmless relative to very harmful were 19.55 times greater for youth who perceived cigarettes as harmless, compared to those who perceived cigarettes as very harmful (OR = 19.55; 95% CI: 14.19-26.94). These odds increased to 77.65 times in 2019 (OR = 77.65; 95% CI: 41.48-107.85). CONCLUSION: This study suggests a stronger relationship between perceived harm of cigarettes and e-cigarettes with time. Interventions to prevent smoking have the potential to change e-cigarette use.

Exploring Intra and Interorganizational Integration Efforts Involving the Primary Care Sector - A Case Study from Ontario.

Background: The primary care sector is uniquely positioned to lead the coordination of providers and organizations across health and social care sectors. This study explores whether intraorganizational (professional) integration within a primary care team might be related to interorganizational integration between primary care and other community partners involved in caring for complex patients. Methods: Two care coordination initiatives (Health Links) were selected - one led by a primary care team with a high level of intraorganizational integration as assessed by the Collaborative Practice Assessment Tool (CPAT), and the other led by a primary care team with a low level of intraorganizational integration. A case study design involving a social network approach was used to assess interorganizational integration across six types of relationships including regular contact, perceived level of integration, referrals, information sharing, joint care planning, and shared resources. Results: Compared to the high-CPAT led case, the low-CPAT led case had higher density (more ties among organizations) in terms of regular contact, integration, and sharing of resources, whereas the opposite was true for the referral, information sharing, and joint care planning networks. Network centralization (extent to which network activity is influenced by one or a group of organizations) was higher for the high-CPAT case compared to the low-CPAT case in the integration, referrals, and joint care planning networks, while the low-CPAT case had higher centralization with regard to regular contact, information sharing, and shared resources. Conclusion: The interplay between intra and interorganizational integration remains unclear. We found no consistent differences in the patterns of ties across the six types of networks examined between the two cases. Assessing changes in network metrics for different organizations in each case over time, and supplementing network findings through in-depth interviews with network members are key next steps to consider.

Training Networks of Local Health Departments: A Regional Assessment.

OBJECTIVE: The public health system faces major challenges in 2020, including an aging workforce, reductions in funding, and 2 simultaneous major threats to public health-the coronavirus pandemic and racial injustice. To effectively harness promising new technologies and address these and other public health challenges ahead, public health professionals must be trained on evidence-based practices for protecting and improving public health. This project sought to understand the network of health departments and organizations that provide training in order to inform strategic efforts to fill training gaps and improve access to training for local health departments (LHDs), thereby strengthening the public health system. DESIGN/SETTING/PARTICIPANTS: We conducted a Web-based survey of 501 LHDs in the 6 states constituting Region V of the Department of Health & Human Services. The survey focused on the training relationship between LHDs and state and national organizations that provide public health training, allowing for a social network analysis. We used data visualization and descriptive statistics to examine the network. RESULTS: Of 290 participating health departments (58% response rate), 248 had monthly or more frequent contact with at least 1 organization for the purpose of training. Altogether, the 248 LHDs were connected to 47 state-level organizations and 10 national-level organizations. In 5 of 6 states, more LHDs were connected to the state health department for training than to any other organization type. Universities, national nonprofits, and national membership organizations provided training to the fewest LHDs. Local health department characteristics did not have a clear relationship with its number of training connections. CONCLUSIONS: State health departments may benefit from the support of universities, national nonprofits, and national membership organizations by partnering to offer training or by recommending training from these organizations to LHDs. Additional qualitative information from local and state health departments would be useful to determine the best strategies for universities, national nonprofits, and national membership organizations to participate in training local practitioners to improve LHD capacity.

Examining the extent and factors associated with interprofessional teamwork in primary care settings.

Despite growing emphasis on adopting team-based models of primary care to facilitate patient access to a diverse range of care providers, our understanding of team functioning within primary care teams remains limited. This study examined interprofessional teamwork within primary care practices (Family Health Teams [FHT] and Community Health Centers - [CHC]) in Ontario and explored team-level and organizational factors associated with interprofessional teamwork. Interprofessional teamwork was measured using the Collaborative Practice Assessment Tool (CPAT), which was completed by providers in each participating team. The CPAT responses of 988 providers representing on average 12 professions (sd = 2.1) across 66 teams (44 FHTs and 22 CHCs) were included in the analysis. The average CPAT score was 46.6 (sd = 2.5). CHCs had significantly higher CPAT scores than FHTs (mdiff = 1.7, p = .02). Using diverse communication mechanisms to share information, increasing quality improvement capacities, and age of practice, had a statistically significant positive association with CPAT scores. Increasing team size, using centralized administrative processes, a high level of information exchange, and having a mixed governance board were significantly negatively associated with CPAT score. Findings illustrate factors associated with interprofessional teamwork and offer insight into the comparative performance of two team-based primary care models in Ontario.

An Observational Study of the Association Between Exposure to Vacant Building Demolitions and Elevated Blood Lead Levels in Children Under Six in St Louis City.

CONTEXT: St Louis City has been demolishing vacant buildings at an increasing rate. Demolition can cause lead dust spread, and childhood lead exposure can have negative effects on cognition, growth, and development. Previous studies show an association between exposure to multiple demolitions and elevated blood lead levels (EBLLs) in children, but St Louis City does not monitor the effects of demolitions on children's blood lead levels. OBJECTIVES: The purpose of this study was to measure the association between exposure to demolitions and EBLLs in children younger than 6 years in St Louis City from 2017 to 2020. DESIGN/SETTING/PARTICIPANTS: We analyzed blood lead testing data for children 0 to 72 months of age (n = 22 192) and proximity to demolitions. Exposure was the presence of demolitions within 400 ft of a child's address in the 33 days before their first lead test. MAIN OUTCOME MEASURE: We used logistic regression to test the association between proximity to demolition and EBLLs (≥5 µg/dL). RESULTS: The percentage of children living in proximity to 1 or more demolitions was slightly higher among those with EBLLs (n = 21; 1.3%) than among those without EBLLs (n = 250; 1.2%). However, after adjusting for age, sex, year home was built, season, neighborhood socioeconomic percentile, and neighborhood racial composition, the odds of EBLLs were not significantly different for children exposed to 1 or more demolitions (OR = 0.82; 95% CI, 0.5-1.25) compared with exposed to zero demolitions. CONCLUSIONS: Although this study found no association between exposure to demolitions and EBLLs, results should be interpreted with caution, given numerous limitations. Given the consequences of childhood lead exposure, it is recommended that St Louis City conduct a similar analysis on demolitions conducted after 2020 using systematically collected demolition dates. Targeted testing or soil and air monitoring could also be informative.

Transgender Identity and Cardiovascular Disease.

Objectives: As of 2016, 1.4 million people in the United States were identified as transgender. Transgender people face health disparities and may be at high risk for cardiovascular disease (CVD). The objective of this study was to examine the odds of CVD for those who report a transgender identity compared with cisgender. Methods: We used logistic regression to examine whether transgender identity was associated with CVD after accounting for factors commonly associated with CVD. Data were obtained from the Behavioral Risk Factor Surveillance Survey for the years 2015 through 2019. Results: Of the participants, 93.1% reported no CVD and 6.9% reported CVD. For participants with female sex recorded at birth, those identifying as transgender had 2.66 times higher odds of CVD (95% confidence interval [CI]: 1.60-4.41) than those identifying as cisgender. For participants with male sex recorded at birth, the odds of CVD were not statistically significantly different for transgender identity compared with cisgender identity; however, those who were gender nonconforming had 2.21 times higher odds of CVD (95% CI: 1.04-4.70) compared with those with cisgender identity. Additional significant predictors of CVD were age, race, body mass index, alcohol consumption, exercise, and smoking status. Conclusion: Participants who were female sex recorded at birth had statistically significant increased odds of CVD for those reporting transgender identity compared with cisgender identity. However, transgender identity did not change the odds of CVD compared with cisgender identity for participants who were male sex recorded at birth.

Primer on binary logistic regression.

Family medicine has traditionally prioritised patient care over research. However, recent recommendations to strengthen family medicine include calls to focus more on research including improving research methods used in the field. Binary logistic regression is one method frequently used in family medicine research to classify, explain or predict the values of some characteristic, behaviour or outcome. The binary logistic regression model relies on assumptions including independent observations, no perfect multicollinearity and linearity. The model produces ORs, which suggest increased, decreased or no change in odds of being in one category of the outcome with an increase in the value of the predictor. Model significance quantifies whether the model is better than the baseline value (ie, the percentage of people with the outcome) at explaining or predicting whether the observed cases in the data set have the outcome. One model fit measure is the count- [Formula: see text], which is the percentage of observations where the model correctly predicted the outcome variable value. Related to the count- [Formula: see text] are model sensitivity-the percentage of those with the outcome who were correctly predicted to have the outcome-and specificity-the percentage of those without the outcome who were correctly predicted to not have the outcome. Complete model reporting for binary logistic regression includes descriptive statistics, a statement on whether assumptions were checked and met, ORs and CIs for each predictor, overall model significance and overall model fit.

'Falsehood flies, and the truth comes limping after it': social media and public health.

PURPOSE OF REVIEW: To highlight the various uses of social media by public health practitioners and organizations, with special emphasis on how social media has been successfully applied and where applications have struggled to achieve the desired effects. RECENT FINDINGS: Social media has been used effectively in improving the timeliness and accuracy of public health surveillance. Social media has also been used to communicate information between public health organizations and reinforce consistent messaging about enduring threats to public health. It has been applied with some success to coordinate of disaster response and for keeping the public informed during other emergency situations. However, social media has also been weaponized against the public health community to spread disinformation and misinformation, and the public health community has yet to devise a successful strategy to mitigate this destructive use of social media. SUMMARY: Social media can be an effective tool for public health practitioners and organizations who seek to disseminate information on a daily basis, rapidly convey information in emergent situations, and battle misinformation. Social media has been uniquely valuable and distinctly destructive when it comes to protecting and improving public health.

Cost-Related Nonadherence and Mortality in Patients With Chronic Disease: A Multiyear Investigation, National Health Interview Survey, 2000-2014.

INTRODUCTION: Prescription costs are rising, and many patients with chronic illnesses have difficulty paying for prescriptions. Missing or delaying medication because of financial concerns is common; however, the effects of cost-related nonadherence (CRN) on patient outcomes have not been described. Our objective was to determine if CRN is associated with higher all-cause and disease-specific mortality among patients living with diabetes and cardiovascular disease in a representative sample of US adults. METHODS: We ascertained CRN, vital status, and cause of death for 39,571 patients with diabetes, 61,968 patients with cardiovascular disease, and 124,899 patients with hypertension in the 2000 through 2014 releases of the National Health Interview Survey. We used adjusted Cox proportional hazards models to estimate associations between CRN and all-cause mortality and CRN and disease-specific mortality. RESULTS: On average, 15% of the sample reported CRN in the year before interview. After adjusting for confounders, CRN was associated with 15% to 22% higher all-cause mortality rates for all conditions (diabetes hazard ratio [HR] = 1.18; 95% CI, 1.1-1.3; cardiovascular disease [CVD] HR = 1.15; 95% CI, 1.1-1.2; hypertension HR = 1.22; 95% CI, 1.2-1.3). Relative to no CRN, CRN was associated with 8% to 18% higher disease-specific mortality rates (diabetes HR = 1.18; 95% CI, 1.0-1.4; CVD HR = 1.09; 95% CI, 1.0-1.2; hypertension HR = 1.08; 95% CI, 0.9-1.3). CONCLUSION: Relative to full adherence, CRN is associated with higher mortality rates for patients with diabetes, cardiovascular disease, and hypertension, although associations may have weakened since 2011. Policies that increase prescription affordability may decrease mortality for patients experiencing CRN.

Diversify the syllabi: Underrepresentation of female authors in college course readings.

Emerging evidence demonstrates that female-authored publications are not well represented in course readings in some fields, resulting in a syllabi gender gap. Lack of representation may decrease student awareness of opportunities in professional fields and disadvantage the career success of female academics. We contribute to the evidence on the syllabi gender gap by: 1) quantifying the extent to which female authors are represented in assigned course readings; 2) examining representation of female authors by gender of instructor and discipline; and 3) comparing female representation in syllabi with the workforce and with representation as authors of peer-reviewed journal articles. From a list of courses offered in 2018-2019 at Washington University in St. Louis, we selected a stratified random sample of course syllabi from four disciplines (humanities; social science; science, technology, engineering, and mathematics; and other). We coded the gender of course instructors and course reading authors using the genderize application programming interface. We examined representation of female authors at the reading, course, and discipline level using descriptive statistics and data visualization. The final sample included 2435 readings from 129 unique courses. The mean percentage of female authors per reading was 34.1%; 822 (33.8%) of readings were female-led (i.e., a female first or sole author). Female authorship varied by discipline, with the highest percentage of female-led readings in social science (40%). Female instructors assigned a higher percentage of readings with female first authors and readings with higher percentages of females on authorship teams. The representation of female authors on syllabi was lower than representation of females as authors in the peer-reviewed literature or in workforce. Adding to evidence of the syllabi gender gap, we found that female authors were underrepresented as sole and first authors and as members of authorship teams. Since assigned readings promote academic scholarship and influence workforce diversity, we recommend several strategies to diversify the syllabi through increasing awareness of the gap and improving access to female-authored publications.

Impact of the affordable care act dependent coverage provision on young adult cancer patient insurance coverage by sociodemographic and economic characteristics.

PURPOSE: To evaluate the impact of the Affordable Care Act Dependent Care Provision by sociodemographic and economic characteristics in young adult cancer patients. METHODS: The National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) 18 database were queried for young adult cancer cases diagnosed during 2007-2014. Using a difference-in-differences approach, we examined insurance coverage in different subgroups of policy-eligible 19-25 year-olds versus policy-ineligible 27-29 year-olds from the pre- (2007-2009) to post- (2011-2014) Dependent Care Provision period. RESULTS: Across subgroups and study populations, insurance coverage increased significantly following the Provision enactment in the policy-eligible versus policy-ineligible group across most subgroups (range in NCDB: 1.83 to 6.38% for low and mid-low education areas, respectively; range in SEER: 1.43 to 6.18 for Non-Hispanic Others and Hispanics, respectively). Heterogenous impacts were observed by sex with a larger impact in males (NCDB: 5.14%, 95% CI 3.59-6.69; SEER: 4.46, 2.12-6.8) than females (NCDB: 2.51%, 95% CI 1.39-3.62; SEER: 2.50, 0.82-4.18). We observed no other statistical evidence for Dependent Care Provision subgroup heterogeneity except for a smaller impact in individuals from low education areas in NCDB. CONCLUSIONS: Our results indicate a positive Dependent Care Provision impact on insurance coverage in young adults with cancer across subgroups, with evidence for a smaller impact in females relative to males and in low relative to high education areas.

Impacts of the Affordable Care Act Dependent Coverage Provision on Young Adults With Cancer.

INTRODUCTION: Evidence through 2012 suggests that the 2010 Affordable Care Act Dependent Coverage Provision, extending dependent insurance coverage eligibility to age 26years, increased young adult insurance coverage and decreased cancer diagnosis stage in young adult cancer patients. This study examines Dependent Coverage Provision-associated changes in insurance coverage and diagnosis stage through 2014 in young adult cancer patients. METHODS: Using a quasi-experimental study design, analyses were conducted in 2017-2018 using 2007 to 2014 data from the Surveillance, Epidemiology, and End Results (SEER) 18 and the National Cancer Database (NCDB). Using difference-in-differences analyses applied to linear probability models, changes in the percentage of policy-eligible individuals aged 19-25years versus ineligible individuals aged 27-29years who were insured (excluding Medicaid) and diagnosed at early (Stages 0 and 1) or late (Stage 4) stages following Dependent Coverage Provision enactment were estimated. RESULTS: A total of 36,901 and 92,358 young adults were included from SEER and NCDB. Consistent increases in the percentage insured (SEER: 3.45 percentage points, 95% CI=2.04, 4.87; NCDB: 3.72 percentage points, 95% CI=2.80, 4.64); variable increases in early-stage diagnoses (2.25 percentage points, 95% CI=0.40, 4.10; 0.69 percentage points, 95% CI= -0.65, 2.02); and decreases in late-stage diagnoses (-1.74 percentage points, 95% CI= -3.10, -0.38; -0.58 percentage points, 95% CI= -1.46, 0.30) were observed in young adults aged 19-25 versus 27-29years. CONCLUSIONS: These results provide clear evidence for a Dependent Coverage Provision-associated impact on insurance coverage in young adult cancer patients; however, clear impacts on diagnosis stage are less evident.

Examining the Reproducibility of 6 Published Studies in Public Health Services and Systems Research.

OBJECTIVE: Research replication, or repeating a study de novo, is the scientific standard for building evidence and identifying spurious results. While replication is ideal, it is often expensive and time consuming. Reproducibility, or reanalysis of data to verify published findings, is one proposed minimum alternative standard. While a lack of research reproducibility has been identified as a serious and prevalent problem in biomedical research and a few other fields, little work has been done to examine the reproducibility of public health research. We examined reproducibility in 6 studies from the public health services and systems research subfield of public health research. DESIGN: Following the methods described in each of the 6 papers, we computed the descriptive and inferential statistics for each study. We compared our results with the original study results and examined the percentage differences in descriptive statistics and differences in effect size, significance, and precision of inferential statistics. All project work was completed in 2017. RESULTS: We found consistency between original and reproduced results for each paper in at least 1 of the 4 areas examined. However, we also found some inconsistency. We identified incorrect transcription of results and omitting detail about data management and analyses as the primary contributors to the inconsistencies. RECOMMENDATIONS: Increasing reproducibility, or reanalysis of data to verify published results, can improve the quality of science. Researchers, journals, employers, and funders can all play a role in improving the reproducibility of science through several strategies including publishing data and statistical code, using guidelines to write clear and complete methods sections, conducting reproducibility reviews, and incentivizing reproducible science.

Network influences on the development and implementation of active transportation policies in six U.S. cities.

Many communities have prioritized policy and built environment changes to promote active transportation (AT). However, limited information exists on the partnerships and processes necessary to develop and implement such policy and environmental changes, particularly among organizations in non-health sectors. Within the transportation sector, metropolitan planning organizations (MPOs) are increasingly recognized as organizations that can support AT policies. This study examined inter-organizational relationships among MPOs and their partners working to advance AT policies in six U.S. cities. In fall 2015, an average of 22 organizations in each city participated in an online survey about partnerships with MPOs and other organizations developing and implementing AT policies. Measures included organizational characteristics and relational attributes including: level of AT policy collaboration, information transmission, resource sharing, and perceived decisional power. Descriptive network analysis and exponential random graph modeling were used to examine organizational attributes and relational predictors associated with inter-organizational collaboration in each network. MPOs served as collaborative intermediaries, connecting other organizations around AT policies, in half of the cities examined. Organizations in each city were more likely to collaborate around AT policies when partners communicated at least quarterly. In half of the cities, the probability of AT policy collaboration was higher when two agencies exchanged resources and when organizations had perceived decisional authority. Network analysis helped identify factors likely to improve partnerships around AT policies. Results may contribute to best practices for collaboration among researchers, practitioners, policymakers, and advocates across diverse sectors seeking to promote population-level physical activity.

Use of reproducible research practices in public health: A survey of public health analysts.

OBJECTIVE: Use of reproducible research practices improves the quality of science and the speed of scientific development. We sought to understand use of reproducible research practices in public health and associated barriers and facilitators. METHODS: In late 2017, we surveyed members of the American Public Health Association Applied Public Health Statistics section and others; 247 of 278 who screened eligible answered the survey, and 209 answered every applicable question. The survey included questions about file management, code annotation and documentation, reproducibility of analyses, and facilitators and barriers of using reproducible practices. RESULTS: Just 14.4% of participants had shared code, data, or both. Many participants reported their data (33%) and code (43.2%) would be difficult for colleagues to find if they left their institution. Top reported barriers to using reproducible practices were data privacy (49.8%) and lack of time (41.7%). Participants suggested training (50.9%) and requirements by journals (44.4%) and funders (40.2%) to increase use of reproducible research practices. CONCLUSIONS: Increasing use of reproducible research practices is important for public health and requires action from researchers, training programs, funders, and journals.

Evaluating the Implementation of a Twitter-Based Foodborne Illness Reporting Tool in the City of St. Louis Department of Health.

Foodborne illness is a serious and preventable public health problem affecting 1 in 6 Americans with cost estimates over $50 billion annually. Local health departments license and inspect restaurants to ensure food safety and respond to reports of suspected foodborne illness. The City of St. Louis Department of Health adopted the HealthMap Foodborne Dashboard (Dashboard), a tool that monitors Twitter for tweets about food poisoning in a geographic area and allows the health department to respond. We evaluated the implementation by interviewing employees of the City of St. Louis Department of Health involved in food safety. We interviewed epidemiologists, environmental health specialists, health services specialists, food inspectors, and public information officers. Participants viewed engaging innovation participants and executing the innovation as challenges while they felt the Dashboard had relative advantage over existing reporting methods and was not complex once in place. This study is the first to examine practitioner perceptions of the implementation of a new technology in a local health department. Similar implementation projects should focus more on process by developing clear and comprehensive plans to educate and involve stakeholders prior to implementation.