Prevalence of Functional Disabilities and Associations Among Disabilities, Violence, and HIV Among Adolescents and Young Adults in Lesotho.

INTRODUCTION: Lesotho has the second-highest prevalence of HIV. Despite progress in achieving HIV epidemic control targets, inequities persist among certain groups, particularly associations between disability, HIV, and violence. We assessed the prevalence of disability and examined associations between disability and HIV and violence using data from the 2018 Lesotho Violence Against Children and Youth Survey (VACS). METHODS: Lesotho VACS was a nationally representative survey of females and males ages 13-24. We assessed the associations between disability status and HIV, sexual risk behaviours, and violence using logistic regression, incorporating survey weights. RESULTS: Weighted functional disability prevalence was 14.1% for females (95% confidence interval [CI] 12.7-15.4) and 7.3% for males (5.3-9.2). Compared with females with no disabilities, females with disabilities had higher odds of being HIV positive (adjusted odds ratio [aOR] 1.92, 1.34-2.76), having transactional sex (aOR 1.79, 1.09-2.95), and experiencing any lifetime violence (aOR 2.20, 1.82-2.65), sexual violence (aOR 1.77, 1.36-2.31), emotional violence (2.02. 1.61-2.53), physical violence (aOR 1.85, 1.54-2.24), witnessing interparental violence (aOR 1.71, 1.46-2.01), and witnessing community violence (aOR 1.52, 1.26-1.84). Males with disabilities had higher odds of having transactional sex (aOR 4.30, 1.35-13.73), having recent multiple sex partners (aOR 2.31, 1.13-4.75), experiencing emotional violence (aOR 2.85, 1.39-5.82), and witnessing interparental violence (aOR 1.78, 1.12-2.84). HIV models for males did not converge due to low numbers. CONCLUSION: Findings emphasize the importance of inclusion and accessibility for adolescents and young adults with disabilities in prevention and services for violence and HIV. Ending HIV in Lesotho depends on addressing the vulnerabilities that lead to potential infection including violence and ensuring equitable services for all.

The Utility of the Behavior Assessment System for Children-2 Behavioral and Emotional Screening System and Strengths and Difficulties Questionnaire in Predicting Mental Disorders in the Project to Learn About Youth-Mental Health.

We examined the predictive utility of the Behavior Assessment System for Children-2 Behavioral and Emotional Screening System (BASC-2-BESS) and Strengths and Difficulties Questionnaire (SDQ) in identifying students with a mental disorder. Data were collected in a two-stage study over 34 months with kindergarten-12th grade (K-12) students (aged 5-19 years) in four U.S. school districts. In Stage 1, teachers completed the BASC-2-BESS and the SDQ. In Stage 2, parents of 1,054 children completed a structured diagnostic interview to determine presence of a mental disorder. Results suggest that teacher versions of the BASC-2-BESS and SDQ have modest utility in identifying children meeting criteria for a mental disorder based on parent report. Area Under the Curve (AUC) statistics representing prediction of any externalizing disorder (.73 for both measures) were higher than the AUCs predicting any internalizing disorder (.58 for both measures). Findings can inform the use of teacher report in mental health screening, specifically the selection of measures when implementing screening procedures.

Clinical Characteristics of Children With Tourette Syndrome With and Without Sleep Disorder.

BACKGROUND: Sleep problems are common in children with Tourette Syndrome (TS). However, research regarding their demographic and clinical profile is limited. METHODS: We examined characteristics of 114 children aged five to 17 years with a lifetime diagnosis of TS and compared children with sleep disorder (n = 32) and without sleep disorder (n = 82). Parent report from the 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome provided demographics and clinical information, other diagnosed disorders, medication use, TS severity, and impairment. RESULTS: More children with TS with sleep disorder were from households with lower parental education (P < 0.01) and poverty (P = 0.04); had other diagnoses (P = 0.03), including obsessive-compulsive disorder (P < 0.01), oppositional defiant disorder or conduct disorder (P < 0.01), attention-deficit/hyperactivity disorder (ADHD) (P = 0.02), and autism (P = 0.03); and had ever used TS medication (P = 0.01) than children with TS without sleep disorder. More children with TS with sleep disorder had severe TS symptoms (P <0.01), tic-related impairment (P<0.01), and severe ADHD symptoms (P < 0.01) compared with children with TS without sleep disorder. CONCLUSIONS: Findings suggest greater parent-reported impact and tic-related interference in children with TS with sleep disorder compared with TS without sleep disorder. Results underscore the importance of monitoring and intervention for TS exacerbations, other diagnosed disorders, and medication use, and consideration of socioeconomic context in sleep disorder management and prevention in children with TS.

Factors Associated With Disparities in Hospital Readmission Rates Among US Adults Dually Eligible for Medicare and Medicaid.

Importance: Low-income older adults who are dually eligible (DE) for Medicare and Medicaid often experience worse outcomes following hospitalization. Among other federal policies aimed at improving health for DE patients, Medicare has recently begun reporting disparities in within-hospital readmissions. The degree to which disparities for DE patients are owing to differences in community-level factors or, conversely, are amenable to hospital quality improvement, remains heavily debated. Objective: To examine the extent to which within-hospital disparities in 30-day readmission rates for DE patients are ameliorated by state- and community-level factors. Design Setting and Participants: In this retrospective cohort study, Centers for Medicare & Medicaid Services (CMS) Disparity Methods were used to calculate within-hospital disparities in 30-day risk-adjusted readmission rates for DE vs non-DE patients in US hospitals participating in Medicare. All analyses were performed in February and March 2019. The study included Medicare patients (aged ≥65 years) hospitalized for acute myocardial infarction (AMI), heart failure (HF), or pneumonia in 2014 to 2017. Main Outcomes and Measures: Within-hospital disparities, as measured by the rate difference (RD) in 30-day readmission between DE vs non-DE patients following admission for AMI, HF, or pneumonia; variance across hospitals; and correlation of hospital RDs with and without adjustment for state Medicaid eligibility policies and community-level factors. Results: The final sample included 475 444 patients admitted for AMI, 898 395 for HF, and 1 214 282 for pneumonia, of whom 13.2%, 17.4%, and 23.0% were DE patients, respectively. Dually eligible patients had higher 30-day readmission rates relative to non-DE patients (RD >0) in 99.0% (AMI), 99.4% (HF), and 97.5% (pneumonia) of US hospitals. Across hospitals, the mean (IQR) RD between DE vs non-DE was 1.00% (0.87%-1.10%) for AMI, 0.82% (0.73%-0.96%) for HF, and 0.53% (0.37%-0.71%) for pneumonia. The mean (IQR) RD after adjustment for community-level factors was 0.87% (0.73%-0.97%) for AMI, 0.67% (0.57%-0.80%) for HF, and 0.42% (0.29%-0.57%) for pneumonia. Relative hospital rankings of corresponding within-hospital disparities before and after community-level adjustment were highly correlated (Pearson coefficient, 0.98). Conclusions and Relevance: In this cohort study, within-hospital disparities in 30-day readmission for DE patients were modestly associated with differences in state Medicaid policies and community-level factors. This suggests that remaining variation in these disparities should be the focus of hospital efforts to improve the quality of care transitions at discharge for DE patients in efforts to advance equity.

State-Level Estimates of the Prevalence of Parent-Reported ADHD Diagnosis and Treatment Among U.S. Children and Adolescents, 2016 to 2019.

OBJECTIVE: To provide state-level estimates of diagnosed ADHD and associated treatment among children in the United States in 2016 to 2019. METHOD: This study used the National Survey of Children's Health to produce national and state-level estimates of lifetime diagnosis and current ADHD among all children aged 3 to 17 years (n=114,476), and national and state-level estimates of medication and behavioral treatment use among children with current ADHD. RESULTS: The state-level estimates of diagnosed ADHD ranged from 6.1% to 16.3%. Among children with current ADHD, state-level estimates of ADHD medication usage ranged from 37.8% to 81.4%, and state-level estimates of behavioral treatment ranged from 38.8% to 61.8%. CONCLUSION: There was substantial state-level variation for indicators of ADHD diagnosis and associated treatment. These state-level results can be used by policymakers, public health practitioners, health care providers, and other stakeholders to help address the service needs of children with ADHD in their states.

Factors Associated With Bullying Victimization and Bullying Perpetration in Children and Adolescents With ADHD: 2016 to 2017 National Survey of Children's Health.

OBJECTIVE: To identify characteristics associated with bullying involvement in pediatric ADHD. METHODS: Data from the 2016 to 2017 National Survey of Children's Health for children aged 6 to 17 years with ADHD were evaluated to assess the association between parent-reported bullying victimization or perpetration and the following potential predictors: demographic characteristics, family factors, school factors, and child conditions/behaviors. RESULTS: Among children with ADHD, 46.9% were bullying victims and 16.2% were perpetrators. Factors associated with victimization included having family financial strain, developmental delay or intellectual disability, friendship difficulties, and school reports about problems. Factors linked to perpetration included being male, receiving government assistance, lack of school engagement, school reports about problems, and having difficulties with friendships, staying calm, and arguing. CONCLUSIONS: Children with ADHD frequently were bullying victims and sometimes bullying perpetrators. Factors related to family financial strain, developmental disabilities, emotional regulation, peer relationships, and school functioning may help to identify risk for bullying and opportunities for anti-bullying interventions.

Bullying Victimization and Perpetration Among US Children with and Without Tourette Syndrome.

OBJECTIVE: Tourette syndrome (TS) and co-occurring mental, behavioral, and developmental disorders (MBDDs) have been shown to affect peer relationships. This study provides nationally representative estimates of diagnosed TS prevalence and the prevalence of parent-reported bullying victimization and perpetration among US children with and without TS. METHODS: This study included 2016-2017 National Survey of Children's Health data on children aged 6 to 17 years (N = 51,001) with parent-reported responses about TS diagnosis and their child's experiences with bullying victimization and perpetration. We calculated weighted prevalence estimates of diagnosed TS and of bullying indicators among children ever diagnosed with TS compared with peers without TS. We conducted a logistic regression analysis to estimate adjusted prevalence ratios of bullying involvement by TS status, controlling for age, sex, and co-occurring MBDDs. RESULTS: By parent report, 0.3% of US children had ever received a diagnosis of TS; most children with a TS diagnosis (83.2%) had a co-occurring MBDD. Among children with TS, 56.1% experienced bullying victimization, 20.7% experienced bullying perpetration, and 15.9% experienced both, compared with 21.6%, 6.0%, and 4.1% for children without TS, respectively. After adjusting for age, sex, and co-occurring MBDDs, only the association between TS and bullying victimization remained statistically significant. CONCLUSION: Compared with children without TS, children with TS overall experience more bullying victimization and perpetration. Health care professionals treating children with TS could assess challenges with peer relationships and co-occurring disorders to provide targeted support and referral.

Coronavirus Disease Case Definitions, Diagnostic Testing Criteria, and Surveillance in 25 Countries with Highest Reported Case Counts.

We compared case definitions for suspected, probable, and confirmed coronavirus disease (COVID-19), as well as diagnostic testing criteria, used in the 25 countries with the highest reported case counts as of October 1, 2020. Of the identified countries, 56% followed World Health Organization (WHO) recommendations for using a combination of clinical and epidemiologic criteria as part of the suspected case definition. A total of 75% of identified countries followed WHO recommendations on using clinical, epidemiologic, and diagnostic criteria for probable cases; 72% followed WHO recommendations to use PCR testing to confirm COVID-19. Finally, 64% of countries used testing eligibility criteria at least as permissive as WHO. We observed marked heterogeneity in testing eligibility requirements and in how countries define a COVID-19 case. This heterogeneity affects the ability to compare case counts, transmission, and vaccine effectiveness, as well as estimates derived from case surveillance data across countries.

Psychometric Assessment of Pilot Language and Communication Items on the 2018 and 2019 National Survey of Children's Health.

OBJECTIVE: Until recently, normative data on language and communication development among children in the United States have not been available to inform critical efforts to promote language development and prevent impairments. This study represents the first psychometric assessment of nationally representative data derived from a National Survey of Children's Health (NSCH) pilot measure of language and communication development among children ages 1 to 5 years. METHODS: We analyzed 14,573 parent responses to language and communication items on the 2018 and 2019 NSCH to evaluate whether the newly added 11 items represent a single latent trait for language and communication development and to determine normative age of success on each item. We applied weighted, one-parameter Item Response Theory to rate and cluster items by difficulty relative to developmental language ability. We examined differential item functioning (DIF) using weighted logistic regression by demographic factors. RESULTS: Together, exploratory factor analysis resulting in a single factor > 1 and explaining 93% of the variance and positive correlations indicated unidimensionality of the measure. Item characteristic curves indicated groupings were overall concordant with proposed milestone ages and representative of an approximate 90% success cut-point by child age. Indicated normative age cut-points for 3 of the items differed slightly from proposed milestone ages. Uniform DIF was not observed and potential nonuniform DIF was observed across 5 items. CONCLUSIONS: Results have the potential to enhance understanding of risk and protective factors, inform efforts to promote language and communication development, and guide programmatic efforts on early detection of language delays.

Assessing Impact of COVID-19 Pandemic on Receipt and Timeliness of Newborn Hearing Screening and Diagnostic Services Among Infants Born in Four States.

The study compares receipt and timeliness of newborn hearing screening and follow-up diagnostic services between the pre-pandemic birth cohort and the pandemic birth cohort in four participating states. Findings from this study will help inform state Early Hearing Detection and Intervention (EHDI) programs in the future should a major public health event occur again.

How Medicaid and States Could Better Meet Health Needs of Persons Experiencing Homelessness.

An estimated 580 000 people experienced homelessness on any single night in the United States in 2020. This article argues that, to address these persons' unmet needs, Medicaid should collaborate with clinicians and state programs to provide permanent supportive housing and housing support services to individuals experiencing homelessness. Access to shelter can improve health outcomes for individuals experiencing homelessness and reduce overall health care costs.

Community-Based Prevalence of Externalizing and Internalizing Disorders among School-Aged Children and Adolescents in Four Geographically Dispersed School Districts in the United States.

The Project to Learn About Youth-Mental Health (PLAY-MH; 2014-2018) is a school-based, two-stage study designed to estimate the prevalence of selected mental disorders among K-12 students in four U.S.-based sites (Colorado, Florida, Ohio, and South Carolina). In Stage 1, teachers completed validated screeners to determine student risk status for externalizing or internalizing problems or tics; the percentage of students identified as being at high risk ranged from 17.8% to 34.4%. In Stage 2, parents completed a structured diagnostic interview to determine whether their child met criteria for fourteen externalizing or internalizing disorders; weighted prevalence estimates of meeting criteria for any disorder were similar in three sites (14.8%-17.8%) and higher in Ohio (33.3%). PLAY-MH produced point-in-time estimates of mental disorders in K-12 students, which may be used to supplement estimates from other modes of mental disorder surveillance and inform mental health screening and healthcare and educational services.

Factors Associated with Self-regulation in a Nationally Representative Sample of Children Ages 3-5 Years: United States, 2016.

OBJECTIVE: The aim of the present study was to describe self-regulation (the ability to influence or control one's thoughts or behavior in response to situational demands and social norms) in children ages 3-5 years using a nationally representative sample and examine risk and protective factors to identify opportunities to support children and families. METHODS: Using a cross-sectional design, we examined data from a parent-reported pilot measure of self-regulation from the 2016 National Survey of Children's Health (NSCH). We compared U.S. children aged 3-5 years who were described by parents as "on track" with self-regulation development with children who were not. In addition, we described how health care and developmental services, community, family, and child health and development factors are associated with children's self-regulation. RESULTS: The majority of children (4 of 5) were described by their parents to be developmentally on track with self-regulation. Compared to children described as not on track, children described as on track more often lived in financially and socially advantaged environments and less often experienced family adversity. They also had other positive health and development indicators, whether or not they were receiving developmental services. However, only half of children not on track received developmental surveillance, and only 1 in 4 children described as not on track received educational, mental health, or developmental services. CONCLUSION: The findings are a step towards using self-regulation as an indicator of healthy child development and as a potential strategy to identify groups of children who may need additional support.

Personal exposure to NO2 and benzene in the Cape Town region of South Africa is associated with shorter leukocyte telomere length in women.

Air pollution exposure is a major global health concern and has been associated with molecular aging. Unfortunately, the situation has not received much attention in the African region. The aim of this study was to investigate whether current personal ambient NO2 and benzene, toluene, ethyl-benzene and xylenes (ortho (o)-, meta (m)- and para (p)-xylene (BTEX) exposure is associated with leukocyte telomere length (LTL), a marker of molecular ageing, in apparently healthy women (mean ± SD age: 42.5 ± 13.4 years) residing in the Cape Town region of South Africa. The repeated measures study collected data from 61 women. Seven-day median (interquartile range (IQR)) personal NO2 and BTEX exposure levels were determined via compact passive diffusion samplers carried on the person prior to baseline (NO2: 14.2 (9.4-17.2) µg/m³; Benzene: 3.1 (2.1-5.3) µg/m³) and 6-month follow-up (NO2: 10.6 (6.6-13.6) µg/m³; Benzene: 2.2 (1.3-4.9) µg/m³) visits. LTL was measured at baseline and follow-up using a real-time PCR method. Multiple linear mixed model analyses (adjusting for age, body mass index, smoking, employment status, level of education and assessment visit) showed that each IQR increment increase in NO2 (7.0 µg/m³) and benzene (3.3 µg/m³) was associated with -7.30% (95% CI: -10.98 to -3.46%; p < 0.001) and -6.78% (95% CI: -11.88 to -1.39%; p = 0.015) difference in LTL, respectively. The magnitude of these effects of NO2 and benzene corresponds to the effect of an increase of 10.3- and 6.0-year in chronological age on LTL. Our study shows that personal exposures to NO2 and benzene are associated with molecular ageing as indicated by LTL in healthy women residing in the Cape Town region.

Personal NO2 and Volatile Organic Compounds Exposure Levels are Associated with Markers of Cardiovascular Risk in Women in the Cape Town Region of South Africa.

Exposure to ambient NO2 and benzene, toluene ethyl-benzene and m+p- and o-xylenes (BTEX) is associated with adverse cardiovascular effects, but limited information is available on the effects of personal exposure to these compounds in South African populations. This 6-month follow-up study aims to determine 7-day personal ambient NO2 and BTEX exposure levels via compact passive diffusion samplers in female participants from Cape Town, and investigate whether exposure levels are associated with cardiovascular risk markers. Overall, the measured air pollutant exposure levels were lower compared to international standards. NO2 was positively associated with systolic and diastolic blood pressure (SBP and DBP), and inversely associated with the central retinal venular equivalent (CRVE) and mean baseline brachial artery diameter. o-xylene was associated with DBP and benzene was strongly associated with carotid intima media thickness (cIMT). Our findings showed that personal air pollution exposure, even at relatively low levels, was associated with several markers of cardiovascular risk in women residing in the Cape Town region.

Cost-effectiveness of HIV Prevention Interventions in Sub-Saharan Africa: A Systematic Review.

BACKGROUND: Sub-Saharan Africa carries the highest HIV burden globally. It is important to understand how interventions cost-effectively fit within guidelines and implementation plans, especially in low- and middle-income settings. We reviewed the evidence from economic evaluations of HIV prevention interventions in sub-Saharan Africa to help inform the allocation of limited resources. METHODS: We searched PubMed, Web of Science, Econ-Lit, Embase, and African Index Medicus. We included studies published between January 2009 and December 2018 reporting cost-effectiveness estimates of HIV prevention interventions. We extracted health outcomes and cost-effectiveness ratios (CERs) and evaluated study quality using the CHEERS checklist. FINDINGS: 60 studies met the full inclusion criteria. Prevention of mother-to-child transmission interventions had the lowest median CERs ($1144/HIV infection averted and $191/DALY averted), while pre-exposure prophylaxis interventions had the highest ($13,267/HIA and $799/DALY averted). Structural interventions (partner notification, cash transfer programs) have similar CERs ($3576/HIA and $392/DALY averted) to male circumcision ($2965/HIA) and were more favourable to treatment-as-prevention interventions ($7903/HIA and $890/DALY averted). Most interventions showed increased cost-effectiveness when prioritizing specific target groups based on age and risk. INTERPRETATION: The presented cost-effectiveness information can aid policy makers and other stakeholders as they develop guidelines and programming for HIV prevention plans in resource-constrained settings.

Measuring hospital-specific disparities by dual eligibility and race to reduce health inequities.

OBJECTIVE: To propose and evaluate a metric for quantifying hospital-specific disparities in health outcomes that can be used by patients and hospitals. DATA SOURCES/STUDY SETTING: Inpatient admissions for Medicare patients with acute myocardial infarction, heart failure, or pneumonia to all non-federal, short-term, acute care hospitals during 2012-2015. STUDY DESIGN: Building on the current Centers for Medicare and Medicaid Services methodology for calculating risk-standardized readmission rates, we developed models that include a hospital-specific random coefficient for either patient dual eligibility status or African American race. These coefficients quantify the difference in risk-standardized outcomes by dual eligibility and race at a given hospital after accounting for the hospital's patient case mix and proportion of dual eligible or African American patients. We demonstrate this approach and report variation and performance in hospital-specific disparities. PRINCIPAL FINDINGS: Dual eligibility and African American race were associated with higher readmission rates within hospitals for all three conditions. However, this disparity effect varied substantially across hospitals. CONCLUSION: Our models isolate a hospital-specific disparity effect and demonstrate variation in quality of care for different groups of patients across conditions and hospitals. Illuminating within-hospital disparities can incentivize hospitals to reduce inequities in health care quality.