Improving Sexual Assault and Sexual Harassment Prevention from the Bottom-up: a Pilot of Getting To Outcomes in the US Military.

While the Department of Defense (DoD) has given increased attention and priority to preventing sexual assault and sexual harassment (SA/SH), it remains a problem. To build its prevention capacity, DoD piloted Getting To Outcomes® (GTO®) from 2019 to 2022 at 10 military installations. GTO is an evidence-based planning and implementation support that has been used in many civilian contexts but has only recently been adapted for military SA/SH. The purpose of this study was to describe GTO use, identify its benefits and challenges, and discuss lessons the GTO effort yielded for prevention more broadly using a framework of organizational and program-level capacities needed for successful prevention in the military context, called the Prevention Evaluation Framework (PEF). GTO was piloted with 10 military installations ("sites") representing all Military Services, plus the Coast Guard and National Guard. GTO is comprised of a written guide, training, and ongoing coaching. The pilot's goal was for each site to use GTO to implement a SA/SH prevention program twice. Participants from each site were interviewed and data was collected on GTO steps completed, whether GTO spurred new evaluation activities and collaborations, and the degree of leadership support for GTO. Most sites completed all GTO steps at least once. Interviews showed that DoD participants believe GTO improved prevention understanding, planning, and evaluation capacity; strengthened confidence in chosen programs; and helped sites tailor programs to the military context. Barriers were the complexity of GTO, DoD personnel turnover, and the disruption that the COVID pandemic caused in sexual assault prevention program delivery. Many respondents were unsure if they would continue all of GTO after the coaching ended, but many believed they would continue at least some parts. According to the PEF, the GTO pilot revealed several additional prevention system gaps (e.g., need for leadership support) and changes needed to GTO (e.g., stronger leader and champion engagement), to support quality prevention. The military and other large organizations will need to focus on these issues to ensure prevention implementation and evaluation are conducted with quality.

Drivers of differential views of health equity in the U.S.: is the U.S. ready to make progress? Results from the 2018 National Survey of Health Attitudes.

OBJECTIVES: The public health sector has long recognized the role of the social determinants of health in health disparities and the importance of achieving health equity. We now appear to be at an inflection point, as we hear increasing demands to dismantle structures that have perpetuated inequalities. Assessing prevailing mindsets about what causes health inequalities and the value of health equity is critical to addressing larger issues of inequity, including racial inequity and other dimensions. Using data from a nationally representative sample of adults in the United States, we examined the factors that Americans think drive health outcomes and their beliefs about the importance of health equity. METHODS: Using data from the 2018 National Survey of Health Attitudes, we conducted factor analyses of 21 survey items and identified three factors from items relating to health drivers-traditional health influencers (THI), social determinants of health (SDoH), and sense of community health (SoC). Health equity beliefs were measured with three questions about opportunities to be healthy. Latent class analysis identified four groups with similar patterns of response. Factor mixture modeling combined factor structure and latent class analysis into one model. We conducted three logistic regressions using latent classes and demographics as predictors and the three equity beliefs as dependent variables. RESULTS: Nearly 90% of respondents comprised one class that was characterized by high endorsement (i.e., rating the driver as having strong effect on health) of THI, but lower endorsement of SDoH and SoC. Logistic regressions showed that respondents endorsing (i.e., rated it as a top priority) all three health equity beliefs tended to be female, older, Black or Hispanic, more educated, and have lower incomes. The class of respondents that endorsed SDoH the most was more likely to endorse all three equity beliefs. CONCLUSIONS: Results suggested that people historically impacted by inequity, e.g., people of color and people with low incomes, had the most comprehensive understanding of the drivers of health and the value of equity. However, dominant beliefs about SDoH and health equity are still generally not aligned with scientific consensus and the prevailing narrative in the public health community.

Are Publicly Funded Health Databases Geographically Detailed and Timely Enough to Support Patient-Centered Outcomes Research?

Emerging health care research paradigms such as comparative effectiveness research (CER), patient-centered outcome research (PCOR), and precision medicine (PM) share one ultimate goal: constructing evidence to provide the right treatment to the right patient at the right time. We argue that to succeed at this goal, it is crucial to have both timely access to individual-level data and fine geographic granularity in the data. Existing data will continue to be an important resource for observational studies as new data sources are developed. We examined widely used publicly funded health databases and population-based survey systems and found four ways they could be improved to better support the new research paradigms: (1) finer and more consistent geographic granularity, (2) more complete geographic coverage of the US population, (3) shorter time from data collection to data release, and (4) improved environments for restricted data access. We believe that existing data sources, if utilized optimally, and newly developed data infrastructures will both play a key role in expanding our insight into what treatments, at what time, work for each patient.

Cognitive ability in childhood and the chronicity and suicidality of depression.

BACKGROUND: There is inconsistent evidence regarding the influence of general cognitive abilities on the long-term course of depression. AIMS: To investigate the association between general childhood cognitive abilities and adult depression outcomes. METHOD: We conducted a cohort study using data from 633 participants in the New England Family Study with lifetime depression. Cognitive abilities at age 7 were measured using the Wechsler Intelligence Scale for Children. Depression outcomes were assessed using structured diagnostic interviews administered up to four times in adulthood between ages 17 and 49. RESULTS: In analyses adjusting for demographic factors and parental psychiatric illness, low general cognitive ability (i.e. IQ<85 v. IQ>115) was associated with recurrent depressive episodes (odds ratio (OR) = 2.19, 95% CI 1.20-4.00), longer episode duration (rate ratio 4.21, 95% CI 2.24-7.94), admission to hospital for depression (OR = 3.65, 95% CI 1.34-9.93) and suicide ideation (OR = 3.79, 95% CI 1.79-8.02) and attempt (OR = 4.94, 95% CI 1.67-14.55). CONCLUSIONS: Variation in cognitive abilities, predominantly within the normal range and established early in childhood, may confer long-term vulnerability for prolonged and severe depression. The mechanisms underlying this vulnerability need to be established to improve the prognosis of depression among individuals with lower cognitive abilities.

A prospective study of positive early-life psychosocial factors and favorable cardiovascular risk in adulthood.

BACKGROUND: The American Heart Association's national goals for cardiovascular health promotion emphasize that cardiovascular risk originates early in life, but little is known about childhood factors that may increase the likelihood of having a favorable cardiovascular risk (FCR) in adulthood. We examined the prospective association between positive childhood factors and the likelihood of midlife FCR. We also considered pathways through which childhood factors may influence FCR. METHODS AND RESULTS: We studied 415 adults (mean age=42.2 years) of the Collaborative Perinatal Project, a national cohort initiated in 1959 to 1966. We examined 3 positive childhood factors assessed at age 7 years: attention regulation (ability to stay focused), cognitive ability, and positive home environment. Of these adults, 10.6% had FCR in midlife. Adjusting for demographics and childhood cardiovascular health, a 1-unit increase in childhood attention regulation, cognitive ability, and positive home environment was associated with 2.4 (95% confidence interval, 1.1-4.7), 1.8 (95% confidence interval, 1.1-2.9), and 1.3 (95% confidence interval, 1.1-1.6) higher respective odds of having midlife FCR. The association with childhood attention regulation was maintained when accounting for adulthood factors; education and diet in part explained the associations with childhood cognitive ability and home environment. The effect of each attribute was additive as those with high levels of each childhood factor had 4.3 higher odds (95% confidence interval, 1.01-18.2) of midlife FCR in comparison with those low in all factors. CONCLUSIONS: Positive childhood psychosocial factors may promote healthy adult cardiovascular functioning. Primordial prevention efforts aimed at preventing the development of cardiovascular risk should consider building on childhood psychosocial resources.

Levels of naturally occurring radioisotopes in local and imported bottled drinking water available in Québec City, Canada.

Consumption of local and imported bottled water in Canada has greatly increased during the past three decades. While the presence of natural radioactivity is often overlooked when dealing with the water quality of these bottled products, it could contribute substantially to the uptake of radionuclides especially when sourced from regions with higher radioactivity levels compared to where it is consumed. In this study, the activity of several naturally occurring radionuclides (i.e., 210Po, 226,228Ra, 230,232Th, 234,235,238U) were measured in bottled water available in Québec, Canada after sample pretreatment and analysis by either radiometric or mass spectrometry approaches. 230,232Th and 228Ra concentrations were below minimum detectable activity levels in all samples tested. Analytical results for 234U, 235U, 238U, and 226Ra showed concentrations that ranged from 0.38 to 115 mBq/L, (2.2-313) x 10-2 mBq/L, 0.48-58.4 mBq/L, and 1.1-550 mBq/L, respectively. 210Po was detected in only 5 samples and its activity ranged from 2 to 26 mBq/L. To determine variability in activity within brands, the same brands of bottled water were purchased during two consecutive years and analyzed. The possible radiological impact of the consumption of these types of water was assessed based on different drinking habit scenarios. Some of the imported water brands showed higher activity concentrations than local sources or tap water, suggesting that individuals drinking predominantly imported bottled water would receive a higher radiation dose than those who drink mainly local water.

What drives health mindset and expectations in the United States?

Health mindset is a group of beliefs or assumptions that individuals hold about the causes of health and well-being. Strengthening our understanding of factors that shape mindset and how mindset shapes expectations for who can and should be responsible for health can inform the success and sustainability of solutions to current health crises including the COVID-19 pandemic, ongoing disparities in health outcomes, and gun violence. We first examined associations between personal characteristics and experiences with health mindset. Next, we examined the association between mindset and the belief that government involvement can help address pressing health questions, using obesity as an example of a health outcome that is shaped both by personal choices and factors outside one's control. Going forward, it will be important to consider health mindset in broader transformations of the health system and population approaches to improving health.

Has COVID-19 changed how people think about the drivers of health? If so, does it matter?

Background: Could the COVID-19 pandemic prompt shifts in Americans' basic views on health mindset and policy solutions to health crises? Methods: A sample of 1,637 individuals rated the extent to which items (e.g., the role of environmental vs. individual factors) "may affect people's health and wellbeing," both before (2018) and during the pandemic. In summer 2020 and fall 2021 they responded to questions about vaccination status and perceptions of COVID-19 related policies. We assessed changes in health mindset using repeated measures logistic regression, and used cross-sectional logistic regressions to assess whether variations in mindset explain COVID-19 related attitudes and behavior. Results: Between 2018 and 2021 respondents gave increasing weight to where people live and genetic factors and less weight to the role of individual health choices. Views on the importance of access to healthcare did not change appreciably. Those who reported that health care and place have a strong effect on health and wellbeing were significantly more likely to get vaccinated. Moreover, those who strongly believed that place is important were significantly less likely to agree that their local government went too far in restricting their freedom and that the local economy should have been left alone. Conclusion: Respondents were more likely in 2021 than in 2018 to recognize social determinants of health, and this is associated with a greater openness to pandemic-control measures. It remains to be seen, however, whether the changes in health mindset will persist over time and contribute to changes in policy and practice.

Equity as a Guiding Principle for the Public Health Data System.

The growing centering of equity in health has elevated a conversation about how those interests should translate within the systems and sectors that influence health. In particular, the public health data system has been relatively limited in capturing the drivers and consequences of health inequity as well as the varying dimensions of equity. This article examines what it means to use equity as a guiding principle throughout the components and functions of a modern public health data system. As with other articles in this supplement, this article builds from a literature review, environmental scan, and deliberations from the National Commission to Transform Public Health Data Systems to summarize current gaps to integrate equity throughout the system. It outlines opportunities for the technology and data science sectors specifically to engage given the access that these sectors have to information that would illuminate and frame the nuances and impacts of health inequity.

What Data Should Be Included in a Modern Public Health Data System.

The public is inundated with data, both in where data are ubiquitously collected and in how organizations are using data to drive public sector and commercial decisions. The public health data system is no exception to this flood of data, both in growing data volume and variety. However, what are collected and analyzed about the health status of the nation, how particular data and measures are prioritized for parsimony, and how those data provide a signal for where to invest to address health inequities are in dire need of a reboot. As with other articles in this supplement, this article builds from a literature review, an environmental scan, and deliberations from the National Commission to Transform Public Health Data Systems. The article summarizes what data should be included and identifies where the technology and data sectors can contribute to fill current gaps to measure equity, positive health, and well-being.

The Issues of Interoperability and Data Connectedness for Public Health.

An unprecedented amount of data is being collected across a diversity of sectors, which, if harnessed, could transform public health decision-making. Yet significant challenges stand in the way of such a vision, including the need to establish standards of data sharing and interoperability, the need for innovation in both methodological approaches and workforce models, and the need for data stewardship and governance models to ensure the protection and integrity of the public health data system. As with other articles in this supplement, this article builds from a literature review, environmental scan, and deliberations from the National Commission to Transform Public Health Data Systems. The article summarizes some of the challenges around data sharing and reuse and identifies where the technology and data sectors can contribute to fill current gaps to promote interoperability and data stewardship.

Technology and Data Implications for the Public Health Workforce.

Achieving a modern equity-oriented public health system requires the development of a public health workforce with the skills and competencies needed to generate findings and integrate knowledge using diverse data. Yet current workforce capabilities and infrastructure are misaligned with what is needed to harness both new and older forms of data and to translate them into information that is equity contextualized. As with other articles in this supplement, this article builds from a literature review, environmental scan, and deliberations from the National Commission to Transform Public Health Data Systems. The article summarizes some of the challenges around current workforce capabilities and pipeline. The article identifies where the technology and data sectors can contribute skills, expertise, and assets in support of innovative workforce models and augment the development of public health workforce competencies.

Literacy skills and calculated 10-year risk of coronary heart disease.

BACKGROUND: Coronary heart disease (CHD) is a leading cause of morbidity and mortality. Reducing the disease burden requires an understanding of factors associated with the prevention and management of CHD. Literacy skills may be one such factor. OBJECTIVES: To examine the independent and interactive effects of four literacy skills: reading, numeracy, oral language (speaking) and aural language (listening) on calculated 10-year risk of CHD and to determine whether the relationships between literacy skills and CHD risk were similar for men and women. DESIGN: We used multivariable linear regression to assess the individual, combined, and interactive effects of the four literacy skills on risk of CHD, adjusting for education and race. PARTICIPANTS: Four hundred and nine English-speaking adults in Boston, MA and Providence, RI. MEASURES: Ten-year risk of coronary heart disease was calculated using the Framingham algorithm. Reading, oral language and aural language were measured using the Woodcock Johnson III Tests of Achievement. Numeracy was assessed through a modified version of the numeracy scale by Lipkus and colleagues. KEY RESULTS: When examined individually, reading (p = 0.007), numeracy (p = 0.001) and aural language (p = 0.004) skills were significantly associated with CHD risk among women; no literacy skills were associated with CHD risk in men. When examined together, there was some evidence for an interaction between numeracy and aural language among women suggesting that higher skills in one area (e.g., aural language) may compensate for difficulties in another resulting in an equally low risk of CHD. CONCLUSIONS: Results of this study not only provide important insight into the independent and interactive effects of literacy skills on risk of CHD, they also highlight the need for the development of easy-to use assessments of the oral exchange in the health care setting and the need to better understand which literacy skills are most important for a given health outcome.

Patients' literacy skills: more than just reading ability.

Limited literacy contributes to suboptimal care and outcomes for patients. The Institute of Medicine noted that future work in health literacy should consider multiple literacy skills. However, lacking empirical evidence of the relationship between different literacy skills, reading skills are often used as proxies of literacy in research and practice. Using a community-based sample of 618 individuals residing in Boston, Massachusetts, and Providence, Rhode Island, the authors conducted a principal component analysis on measures of four literacy skills--reading, numeracy, oral (speaking), and aural (listening)--to examine whether and to what extent literacy can, or should, be represented by a single measure. The first principal component represented overall literacy and could only explain 60% of the total variation in literacy skills among individuals. The second principal component differentiated between numeracy/reading and the oral/aural exchange. While reading and numeracy best represent overall literacy, patients' relative strengths may vary. Those with moderate reading ability may have high oral and aural language skills. Conversely, people who have difficulties speaking with or understanding a provider may read well. Effective communication with patients should rely on the oral exchange and written health information, and not rely on a single literacy skill.

Patient activation and advocacy: which literacy skills matter most?

Attention to the effect of a patient's literacy skills on health care interactions is relatively new. So, too, are studies of either structural or personal factors that inhibit or support a patient's ability to navigate health services and systems and to advocate for their own needs within a service delivery system. Contributions of the structural environment, of interpersonal dynamics, and of a variety of psychological and sociological factors in the relationship between patients and providers have long been under study. Less frequently examined is the advocacy role expected of patients. However, the complex nature of health care in the United States increasingly requires a proactive stance. This study examined whether four literacy skills (reading, numeracy, speaking, and listening) were associated with patient self-advocacy--a component of health literacy itself--when faced with a hypothetical barrier to scheduling a medical appointment. Although all literacy skills were significantly associated with advocacy when examined in isolation, greater speaking and listening skills remained significantly associated with better patient advocacy when all four skills were examined simultaneously. These findings suggest that speaking and listening skills and support for such skills may be important factors to consider when developing patient activation and advocacy skills.

Microscopic examination of dog chews: correlation of histological findings to product labeling.

The purpose of this study was to use routine morphologic-based staining techniques to examine the histology of commercially labeled rawhide and rawhide-free dog chew products and compare the results to the product labeling. Ten dog chew products were examined by light microscopy using hematoxylin and eosin and Masson's trichrome stains. The products were labeled by the manufacturer as rawhide, beef hide, beef chew/rawhide free, and rawhide free. Four of the products were composed of two separate materials, a main chew roll and a second substance (filler) which was coated on or between the layers of the main chew roll. These materials were processed independently. Microscopically, a variety of tissues and materials were identified including collagen, skeletal muscle, fat, plant material, and starch. The products and their fillers were separated into four distinct groups based on microscopic appearance. The components identified in eight of the products appeared consistent with the product labeling. Two products labeled as rawhide free appeared similar to the dermis and this was inconsistent with product labeling. Masson's trichrome stain was not helpful in distinguishing tissue types in the tested products and this may have been due to the heat processing the products underwent during manufacturing. Bacteria and/or fungi were identified by microscopy in the H&E stained sections in four rawhide-free products.

Fetal growth and the lifetime risk of generalized anxiety disorder.

BACKGROUND: Anxiety disorders are thought to have their origins in early childhood, though they have not yet been studied as a potential outcome of impaired fetal growth, which has been implicated in the developmental etiologies of many psychopathologies. This study investigated the association between indicators of fetal growth and the development of generalized anxiety disorder (GAD). METHODS: Indicators of fetal growth, including birth weight (BW) and ponderal index (PI), were assessed among 682 offspring of participants in Providence, Rhode Island, site of the Collaborative Perinatal Project. Participants were interviewed as adults, and their lifetime histories of GAD were assessed using the Diagnostic Interview Schedule. We used Cox regression to estimate the association between fetal growth indicators and development of GAD. RESULTS: The lifetime risk of GAD differed between infants in the highest category of BW, PI, and all others. Newborns with birth weights below 3.5 kg (hazard ratio, HR: 2.38; CI=1.25, 4.55), in the lowest four BW Z-score quintiles (HR=2.49; CI=1.14, 5.45) or a PI in the lowest four quintiles (HR=2.33; CI=1.04, 5.00) had higher lifetime risks of GAD. CONCLUSION: In contrast to earlier studies on psychiatric outcomes in relation to fetal growth, there was no linear relationship between birth weight and GAD. Although these results generally support the hypothesis that a healthy nutritional fetal uptake, as indicated by BW and PI, is associated with better lifetime mental health, further work is needed to characterize the nature of the association between fetal growth and subsequent psychopathology.

Effects of Estimated Community-Level Health Literacy on Treatment Initiation and Preventive Care Among Older Adults with Newly Diagnosed Diabetes.

PURPOSE: Individual measures of health literacy are not feasible for administration on a large scale, yet estimates of community-level health literacy in the US recently became available. We sought to investigate whether community-level health literacy estimates are associated with the initiation of oral antihyperglycemic agents (OHA) and the use of standard preventive care services among older adults with newly diagnosed diabetes. PATIENTS AND METHODS: We conducted a retrospective cohort study of 169,758 patients, ≥65 years old with hypertension and newly diagnosed type 2 diabetes using 2007-2011 data from the Center for Medicare and Medicaid Services Chronic Conditions Warehouse. We examined the relationship between community-level health literacy estimates and initiation of OHA, receipt of flu shots, eye exams, Hemoglobin A1c tests, and lipid tests within 12 months post diabetes diagnosis. RESULTS: Patients living in communities with above basic health literacy (vs. basic/below basic) were 15% more likely to initiate OHA (Hazard Ratio=1.15; 95% CI 1.12 to 1.18). After classifying the health literacy distribution as quintiles, the analysis revealed a dose-response relationship with OHA initiation that plateaued at the third and fourth quintiles and declined at the fifth quintile. Individuals residing in communities with higher health literacy were more likely to participate in preventive care services (relative risk ranged from 1.09 for lipid test [95% CI 1.07-1.11] to 1.43 for flu shot [95% CI 1.41-1.46]). CONCLUSION: Community-level health literacy estimates were associated with the initiation of OHA and uptake of standard preventive care services in older adults. Community-level health literacy may help to inform targeted diabetes education and support efforts.

Developing predictive models of health literacy.

INTRODUCTION: Low health literacy (LHL) remains a formidable barrier to improving health care quality and outcomes. Given the lack of precision of single demographic characteristics to predict health literacy, and the administrative burden and inability of existing health literacy measures to estimate health literacy at a population level, LHL is largely unaddressed in public health and clinical practice. To help overcome these limitations, we developed two models to estimate health literacy. METHODS: We analyzed data from the 2003 National Assessment of Adult Literacy (NAAL), using linear regression to predict mean health literacy scores and probit regression to predict the probability of an individual having 'above basic' proficiency. Predictors included gender, age, race/ethnicity, educational attainment, poverty status, marital status, language spoken in the home, metropolitan statistical area (MSA) and length of time in U.S. RESULTS: All variables except MSA were statistically significant, with lower educational attainment being the strongest predictor. Our linear regression model and the probit model accounted for about 30% and 21% of the variance in health literacy scores, respectively, nearly twice as much as the variance accounted for by either education or poverty alone. CONCLUSIONS: Multivariable models permit a more accurate estimation of health literacy than single predictors. Further, such models can be applied to readily available administrative or census data to produce estimates of average health literacy and identify communities that would benefit most from appropriate, targeted interventions in the clinical setting to address poor quality care and outcomes related to LHL.

Early manifestations of personality and adult health: a life course perspective.

OBJECTIVE: The aim of this study is to investigate whether individual personality or temperamental qualities that emerge early and persist over the life course, predict adult midlife health. Specific childhood personality attributes considered include distress proneness, behavioral inhibition, and ability to stay focused on a task. DESIGN: Prospective data are from 569 individuals followed from birth into adulthood. MAIN OUTCOME MEASURES: Outcomes include two different measures of adult health: self-rated general health, and number of illnesses in adulthood. RESULTS: Childhood personality attributes related to attention and distress were significantly associated with adult health, with stronger effects evident among women. Children with high attention reported better self-rated health (b = 0.12, p < .05) and fewer illnesses (b = -0.09, p < .01) as adults; more distress-prone children reported worse self-rated health (b = -0.15, p < .05) and more illnesses (b = 0.07, p < .09) as adults. CONCLUSION: Associations between child personality attributes with both general self-rated health and number of illnesses in adulthood were maintained after taking account of childhood social environment and child health. Findings indicate that early emerging personality and related processes influence adult physical health, and suggest the potential value of interventions targeting early life development.