Toward a Comprehensive Measure of Drug-Attributable Harm.

This Viewpoint from authors at the Harvard T.H. Chan School of Public Health summarizes approaches to addressing substance use in the US; challenges posed by metrics such as overdose deaths; and more informative metrics, such as quality-adjusted life-years, to promote health equity and improve length and quality of life and health outcomes at all levels.

Spirituality As A Determinant Of Health: Emerging Policies, Practices, And Systems.

Reimagining public health's future should include explicitly considering spirituality as a social determinant of health that is linked to human goods and is deeply valued by people and their communities. Spirituality includes a sense of ultimate meaning, purpose, transcendence, and connectedness. With that end in mind, we assessed how recommendations recently issued by an expert panel for integrating spiritual factors into public health and medicine are being adopted in current practice in the United States. These recommendations emerged from a systematic review of empirical evidence on spirituality, serious illness, and population health published between 2000 and 2022. For each recommendation, we reviewed current federal, state, and local policies and practices recognizing spiritual factors, and we considered the ways in which they reflected the panel's recommendations. In this article, we highlight opportunities for broader application and scale while also noting the potential harms and benefits associated with incorporating these recommendations in various contexts. This analysis, while respecting the spiritual and religious diversity of the US population, identifies promising approaches for strengthening US public health by integrating spiritual considerations to inform person- and community-centered policy and practice.

First Decade of Supportive Services for Veteran Families Program and Homelessness, 2012-2022.

As homelessness remains an urgent public health crisis in the United States, specific programs in the US Department of Veterans Affairs (VA) system may serve as a roadmap for addressing it. We examine lessons learned from the first decade (2012-2022) of the Supportive Services for Veteran Families (SSVF) program, a cornerstone in the VA continuum of homeless services aimed at both preventing homelessness among those at risk and providing rapid rehousing for veterans and their families who are currently experiencing homelessness. Drawing on information from annual reports and other relevant literature, we have identified 3 themes of SSVF that emerged as features to comprehensively deliver support for homeless veterans and their families: (1) responsiveness and flexibility, (2) coordination and integration, and (3) social resource engagement. Using these strategies, SSVF reached nearly three quarters of a million veterans and their families in its first decade, thereby becoming one of the VA's most substantial programmatic efforts designed to address homelessness. We discuss how each feature might apply to addressing homelessness in the general population as well as future research directions. (Am J Public Health. 2024;114(6):610-618. https://doi.org/10.2105/AJPH.2024.307625).

Widening Gender Gap in Life Expectancy in the US, 2010-2021.

This cross-sectional study systematically examines the contributions of COVID-19 and other underlying causes of death to the widened gender life expectancy gap from 2010 to 2021.

Learning from COVID-19: government leaders' perspectives to improve emergency risk communication.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic highlighted the challenges of effective emergency risk communication (ERC) to protect public health, including the difficulty in tackling the spread of inaccurate information. This study aimed to understand those challenges and potential solutions by interviewing leading government spokespersons and their advisors from around the world with experience during large scale emergencies. Interviews were conducted with 27 individuals representing governments from 19 countries across five continents. Thematic analysis, using both a deductive and inductive approach, organized and identified salient themes and patterns that emerged from the interview data. RESULTS: The thematic analysis of the interviews' data led to the identification of 9 principles of communication: 1) Timeliness, 2) Transparency, 3) Coordination, 4) Accuracy and Consistency, 5) Accountability and Integrity, 6) Independence from politics, 7) Responsiveness, 8) Equity, 9) Trust and Empathy. We also developed 36 recommendations actionable by government agencies to enhance the practice of the 9 principles. Examples include the need for: proactive communication strategies, permanent communication task forces integrated into preparedness and response efforts, robust processes to enhance open discussion of controversial topics within government agencies, clarification of how various branches of government coordinate to oversee specific aspects of the overall communication, and development of relationships across public and private entities ahead of a crisis. CONCLUSIONS: Our findings suggest key practical recommendations for leaders of government agencies to enhance ERC capabilities going forward. Before a crisis, they must constantly review internal processes and integrate ERC functions into overall communication planning efforts. During a crisis, they must coordinate roles and responsibilities across branches of governments, strive to communicate to a range of populations to uphold equity, maintain transparency by avoiding information voids on controversial issues and build trust by building relationships with a variety of community leaders. After a crisis, government agencies should continue the practice of social listening to hear more about the public's informational needs, strengthen civic participation processes, and understand how an always evolving information environment can best be leveraged during future crises.

Exploring the spiritual foundations of public health leadership.

The Covid-19 pandemic has laid bare the challenges of public health leadership. Faced with criticism, threats, and even violence, many public health leaders have left the field. A healthier future for the nation may well rest on training aspiring public health leaders to build deeper capacity for perseverance, healing, and resilience. Reflecting the growing experience of a team of public health educators at the Harvard T.H. Chan School of Public Health (Harvard Chan), this article offers recommendations for public health schools to recognize, and incorporate into leadership education, themes of spirituality-ie, the way people seek ultimate meaning and purpose and deep connectedness to something larger than themselves. Doing so can serve as a foundation for the lifelong journey of leadership. Over the past decade, Harvard Chan has incorporated meaning, purpose, and connectedness themes to complement more traditional coursework addressing research and translation. While many established leadership frameworks address the "what" and "how" of career development, the spirituality framework can support aspiring leaders to more fully understand their "why" and its alignment with challenging work. Such a deeply personal topic, traditionally kept private, has been shared and nurtured in Harvard Chan classrooms through a range of pedagogical strategies including personal reflection, one-on- one coaching, experiential learning, case discussions, and candid conversations with public health leaders. By encouraging a values-based foundation for decision-making in crises and difficult leadership moments, such grounding can help aspiring leaders navigate the challenges of public health leadership that inevitably lie ahead.

E-cigarette use behaviors of Asian American, Native Hawaiian, and Pacific Islander youth in the contiguous United States: Insights from the Monitoring the Future Study (2018-2019).

This study examines e-cigarette use behaviors of Asian American, Native Hawaiian, and Pacific Islander (AANHPI) youth, in relation to other racial/ethnic groups in the United States. Data were obtained from the 2018 and 2019 Monitoring the Future surveys, which include a random, probability-based sample of youth in 8th, 10th, and 12th grades surveyed annually across the contiguous United States. Respondents provided information on race/ethnicity and e-cigarette use (n = 42,980). Measures of e-cigarette use included current (1 + of past 30 days) and regular use (10 + of past 30 days). Chi-square tests were used to determine differences in e-cigarette use by race/ethnicity. Associations between race/ethnicity, other sociodemographic factors, and e-cigarette use were explored using logistic regression analyses. Approximately 5.1% (n = 2,410) of the sample identified as AANHPI. A greater proportion of Native Hawaiian and Pacific Islanders reported current e-cigarette use (NHPI, 28.0%), relative to Asian American (AA, 10.3%), Black (9.5%), Hispanic or Latino (15.0%), American Indian or Alaskan Native (AIAN, 16.5%), multiracial (22.3%), and non-Hispanic White (25.2%) youth. Regular e-cigarette use was highest among non-Hispanic White (12.3%), followed by multiracial (10.7%), AIAN (7.8%), Hispanic or Latino (5.0%), AA (4.3%), and Black (3.0%) youth. Associations between race/ethnicity and e-cigarette use remained significant, after controlling for other sociodemographic factors. Continued monitoring of e-cigarette use is needed among AANHPI, a historically underrepresented population in tobacco research. Special attention should be paid to NHPI, who reported the highest rates of e-cigarette use.

Overcome Health Inequities to Eliminate Viral Hepatitis.

This Viewpoint outlines the progress made toward eliminating hepatitis B and C but emphasizes the work that remains to prioritize diagnosis and treatment of populations disproportionately affected by viral hepatitis, including ensuring that there are systems in place to treat those infected and care for those at risk.

The Exodus Of State And Local Public Health Employees: Separations Started Before And Continued Throughout COVID-19.

Understanding the size and composition of the state and local governmental public health workforce in the United States is critical for promoting and protecting the health of the public. Using pandemic-era data from the Public Health Workforce Interests and Needs Survey fielded in 2017 and 2021, this study compared intent to leave or retire in 2017 with actual separations through 2021 among state and local public health agency staff. We also examined how employee age, region, and intent to leave correlated with separations and considered the effect on the workforce if trends were to continue. In our analytic sample, nearly half of all employees in state and local public health agencies left between 2017 and 2021, a proportion that rose to three-quarters for those ages thirty-five and younger or with shorter tenures. If separation trends continue, by 2025 this would represent more than 100,000 staff leaving their organizations, or as much as half of the governmental public health workforce in total. Given the likelihood of increasing outbreaks and future global pandemics, strategies to improve recruitment and retention must be prioritized.

Oral Antiviral Therapy Utilization Among Adults with Recent COVID-19 in the United States.

BACKGROUND: This is the first study, to our knowledge, to assess uptake of oral antiviral treatment (OAV) for COVID-19 in the US and assess whether it is reaching recommended groups. OBJECTIVE: The study evaluated uptake among persons of all ages, with emphasis on utilization among individuals ages 65 + who comprise 75% of all COVID-19 deaths. To maximize public health outreach and benefit, we sought to understand reasons for use and non-use of OAV among individuals 65 + with at least mild COVID-19 symptoms. DESIGN: Data were collected from phase 3.5 of the US Census Household Pulse Survey, during three 2022 time periods: June 1-13, June 29-July 11, and July 27-August 8. PARTICIPANTS: Respondents (n = 12,299) were ages 18 + with active or resolved COVID-19 within the last 4 weeks of their survey participation. MAIN MEASURE(S): Comparisons of demographic variables were made for OAV uptake using the chi-square test of independence. A logistic regression was conducted to identify characteristics of participants independently associated with receipt of an OAV. Comparisons were made with chi-square testing, between those ages 65 + with at least mild symptoms who endorsed one of a number of specific reasons for not using OAV. KEY RESULTS: Utilization was low-17.9% of all respondents, 20.5% of respondents ages 50-64, and 33.9% of respondents 65 years and older received guideline-concordant treatment for their infection. Receipt did not differ by income or sex. The average response across the three phases was 5.4%. Most common reasons for not receiving treatment included having minimal symptoms, not thinking that they needed treatment, and not receiving a recommendation from their healthcare provider. CONCLUSIONS: A minority of increased-risk US residents have accessed early therapy for COVID-19 despite being made available without cost. Responses suggest that efforts to improve patient and provider knowledge could improve utilization to mitigate future COVID-19 hospitalizations.

Establishing Academic Homes for Homelessness: A Call to Action.

Although homelessness ranks as one of society's most pressing and visible health equity challenges, the academic community has not actively addressed its health impacts, root causes, and potential solutions. Few schools and programs of public health even offer a basic course for students. In the COVID-19 pandemic era, academia must demonstrate urgency to address homelessness and educate learners, motivate fledgling researchers, inform policy makers, offer community-engaged and evidence-based studies, and join in the growing national debate about best approaches. At a minimum, every public health student should understand the interdisciplinary challenges of homelessness, its implications for health equity, and opportunities to address the crisis. We call for academia, particularly schools and programs of public health, to engage more fully in national partnerships to care for members of society who are most marginalized, in terms of health and behavioral health outcomes, quality of life, and connectedness.

The Tobacco Industry and Harm Reduction.

This Viewpoint discusses the ways in which the tobacco industry can advance their stated goals of harm reduction and a smoke-free future.

Spirituality in Serious Illness and Health.

Importance: Despite growing evidence, the role of spirituality in serious illness and health has not been systematically assessed. Objective: To review evidence concerning spirituality in serious illness and health and to identify implications for patient care and health outcomes. Evidence Review: Searches of PubMed, PsycINFO, and Web of Science identified articles with evidence addressing spirituality in serious illness or health, published January 2000 to April 2022. Independent reviewers screened, summarized, and graded articles that met eligibility criteria. Eligible serious illness studies included 100 or more participants; were prospective cohort studies, cross-sectional descriptive studies, meta-analyses, or randomized clinical trials; and included validated spirituality measures. Eligible health outcome studies prospectively examined associations with spirituality as cohort studies, case-control studies, or meta-analyses with samples of at least 1000 or were randomized trials with samples of at least 100 and used validated spirituality measures. Applying Cochrane criteria, studies were graded as having low, moderate, serious, or critical risk of bias, and studies with serious and critical risk of bias were excluded. Multidisciplinary Delphi panels consisting of clinicians, public health personnel, researchers, health systems leaders, and medical ethicists qualitatively synthesized and assessed the evidence and offered implications for health care. Evidence-synthesis statements and implications were derived from panelists' qualitative input; panelists rated the former on a 9-point scale (from "inconclusive" to "strongest evidence") and ranked the latter by order of priority. Findings: Of 8946 articles identified, 371 articles met inclusion criteria for serious illness; of these, 76.9% had low to moderate risk of bias. The Delphi panel review yielded 8 evidence statements supported by evidence categorized as strong and proposed 3 top-ranked implications of this evidence for serious illness: (1) incorporate spiritual care into care for patients with serious illness; (2) incorporate spiritual care education into training of interdisciplinary teams caring for persons with serious illness; and (3) include specialty practitioners of spiritual care in care of patients with serious illness. Of 6485 health outcomes articles, 215 met inclusion criteria; of these, 66.0% had low to moderate risk of bias. The Delphi panel review yielded 8 evidence statements supported by evidence categorized as strong and proposed 3 top-ranked implications of this evidence for health outcomes: (1) incorporate patient-centered and evidence-based approaches regarding associations of spiritual community with improved patient and population health outcomes; (2) increase awareness among health professionals of evidence for protective health associations of spiritual community; and (3) recognize spirituality as a social factor associated with health in research, community assessments, and program implementation. Conclusions and Relevance: This systematic review, analysis, and process, based on highest-quality evidence available and expert consensus, provided suggested implications for addressing spirituality in serious illness and health outcomes as part of person-centered, value-sensitive care.

Progress in Reducing Disparities in Premature Mortality in the USA: a Descriptive Study.

BACKGROUND: Eliminating health disparities among different segments of the US population is an overarching goal of the US Healthy People 2020 objectives. OBJECTIVE: Examine changes in educational, rural-urban, and racial disparities in premature mortality during the past 10 years. DESIGN AND PARTICIPANTS: Descriptive analysis of US mortality data from 2007 to 2017. MAIN MEASURES: Relative and absolute rural-urban, educational attainment, and Black-White disparities in premature mortality for all-cause and top 10 causes of death among persons ages 25-74 years, estimated as rate ratios and rate differences between ≤12 and ≥16 years of education, rural versus urban, and non-Hispanic Black (Black) versus non-Hispanic White (White), respectively, in 2007 and 2017. KEY RESULTS: During 2007-2017, mortality rates in persons aged 25-74 years in the USA increased for several leading causes of death, especially in persons with <16 years of education, rural residents, and White people. As a result, disparity in mortality between 2007 and 2017 widened on both relative and absolute scales for all-cause and for 6 of the top 10 causes of death by education and for all-cause and for 9 of the top 10 causes by rural/urban residence. In contrast, Black-White disparities narrowed for all-cause and for all 7 causes that Black people had a higher rate than White people. For all-cause mortality for example, absolute disparities in the number of deaths per 100,000 person-years between 2007 and 2017 increased from 454.0 (95%CI, 446.0-462.1) to 542.7 (535.6-549.7) for educational attainment and from 85.8 (82.8-88.8) to 140.5 (137.6-143.4) for rural versus urban; in contrast, absolute Black-White disparity decreased from 315.3 (311.0-319.7) to 221.7 (218.1-225.3). CONCLUSIONS: Educational and rural-urban disparities in premature mortality widened, whereas Black-White disparities narrowed in the USA between 2007 and 2017, though overall rates remained considerably higher in Black people.

Prioritizing Asian Americans, Native Hawaiians, and Pacific Islanders in the U.S. Health Equity Agenda.

Asian American, Native Hawaiian, and Pacific Islander (AANHPI) populations are growing rapidly in the United States, yet AANHPIs remain understudied, overlooked, and misunderstood. During the COVID-19 pandemic, themes from the tragic history of anti-Asian bias and marginalization have resurfaced in a surge of renewed bigotry and xenophobic violence against AANHPIs. In this commentary, the authors discuss the role of medical schools in combating anti-Asian sentiment as an important step toward achieving health equity. Based on their collective expertise in health disparities research, medical education, and policy, they offer suggestions about how to disrupt the pattern of invisibility and exclusion faced by AANHPI populations. They consider ways that representative data, leadership in medical education, research funding, national policies, and broad partnerships can help address AANHPI health disparities.

Invited Commentary: Religious Service Attendance and Implications for Clinical Care, Community Participation, and Public Health.

In this commentary, we review the evidence concerning associations between religious service attendance and subsequent health and wellbeing outcomes. The evidence base for a link between religious service attendance and health has increased substantially over the past 2 decades. The interpretation and implications of this research require careful consideration (Am J Epidemiol. 2022;191(1):20-30). It would be inappropriate to universally promote service attendance solely on the grounds of the associations with health. Nevertheless, a more nuanced approach, within both clinical care and public health, may be possible-one that encouraged participation in religious community for those who already positively self-identified with a religious or spiritual tradition and encouraged other forms of community participation for those who did not. Discussion is given to potential future research directions and the challenges and opportunities for promotion efforts by the public health community.