Residential social vulnerability among healthcare personnel with and without severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection in Five US states, May-December 2020.

OBJECTIVE: To characterize residential social vulnerability among healthcare personnel (HCP) and evaluate its association with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection. DESIGN: Case-control study. SETTING: This study analyzed data collected in May-December 2020 through sentinel and population-based surveillance in healthcare facilities in Colorado, Minnesota, New Mexico, New York, and Oregon. PARTICIPANTS: Data from 2,168 HCP (1,571 cases and 597 controls from the same facilities) were analyzed. METHODS: HCP residential addresses were linked to the social vulnerability index (SVI) at the census tract level, which represents a ranking of community vulnerability to emergencies based on 15 US Census variables. The primary outcome was SARS-CoV-2 infection, confirmed by positive antigen or real-time reverse-transcriptase- polymerase chain reaction (RT-PCR) test on nasopharyngeal swab. Significant differences by SVI in participant characteristics were assessed using the Fisher exact test. Adjusted odds ratios (aOR) with 95% confidence intervals (CIs) for associations between case status and SVI, controlling for HCP role and patient care activities, were estimated using logistic regression. RESULTS: Significantly higher proportions of certified nursing assistants (48.0%) and medical assistants (44.1%) resided in high SVI census tracts, compared to registered nurses (15.9%) and physicians (11.6%). HCP cases were more likely than controls to live in high SVI census tracts (aOR, 1.76; 95% CI, 1.37-2.26). CONCLUSIONS: These findings suggest that residing in more socially vulnerable census tracts may be associated with SARS-CoV-2 infection risk among HCP and that residential vulnerability differs by HCP role. Efforts to safeguard the US healthcare workforce and advance health equity should address the social determinants that drive racial, ethnic, and socioeconomic health disparities.

Using a web platform for equitable distribution of COVID-19 monoclonal antibodies: a case study in resource allocation.

While medical countermeasures in COVID-19 have largely focused on vaccinations, monoclonal antibodies (mAbs) were early outpatient treatment options for COVID-positive patients. In Minnesota, a centralized access platform was developed to offer access to mAbs that linked over 31,000 patients to care during its operation. The website allowed patients, their representative, or providers to screen the patient for mAbs against Emergency Use Authorization (EUA) criteria and connect them with a treatment site if provisionally eligible. A validated clinical risk scoring system was used to prioritize patients during times of scarcity. Both an ethics and a clinical subject matter expert group advised the Minnesota Department of Health on equitable approaches to distribution across a range of situations as the pandemic evolved. This case study outlines the implementation of this online platform and clinical outcomes of its users. We assess the impact of referral for mAbs on hospitalizations and death during a period of scarcity, finding in particular that vaccination conferred a substantially larger protection against hospitalization than a referral for mAbs, but among unvaccinated users that did not get a referral, chances of hospitalization increased by 4.1 percentage points.

Life Course Assessment of Area-Based Social Disadvantage: A Systematic Review.

Area-based social disadvantage, which measures the income, employment, and housing quality in one's community, can impact an individual's health above person-level factors. A life course approach examines how exposure to disadvantage can affect health in later life. This systematic review aimed to summarize the approaches used to assess exposure to area-based disadvantage over a life course, specifically those that define the length and timing of exposure. We reviewed the abstracts of 831 articles based on the following criteria: (1) whether the abstract described original research; (2) whether the study was longitudinal; (3) whether area-based social disadvantage was an exposure variable; (4) whether area-based social disadvantage was assessed at multiple points; and (5) whether exposure was assessed from childhood to older adulthood. Zero articles met all the above criteria, so we relaxed the fifth criterion in a secondary review. Six studies met our secondary criteria and were eligible for data extraction. The included studies followed subjects from childhood into adulthood, but none assessed disadvantages in late life. The approaches used to assess exposure included creating a cumulative disadvantage score, conducting a comparison between life course periods, and modeling the trajectory of disadvantage over time. Additional research was needed to validate the methodologies described here, specifically in terms of measuring the impact of area-based social disadvantage on health.

Developing an Ethics Framework for Allocating Remdesivir in the COVID-19 Pandemic.

On May 1, 2020, the US Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) to allow use of the antiviral drug remdesivir to treat patients with severe coronavirus disease-2019 (COVID-19). Remdesivir is an investigational drug studied in clinical trials for COVID-19 and is available to children and pregnant women through compassionate-use access but is not yet FDA approved. In early May, the US Department of Health and Human Services began to distribute remdesivir, donated by Gilead Sciences, Inc., to hospitals and state health departments for emergency use; multiple shipments have since been distributed. This process has raised questions of how remdesivir should be allocated. The Minnesota Department of Health has collaborated with the Minnesota COVID Ethics Collaborative and multiple clinical experts to issue an Ethical Framework for May 2020 Allocation of Remdesivir in the COVID-19 Pandemic. The framework builds on extensive ethical guidance developed for public health emergencies in Minnesota before the COVID-19 crisis. The Minnesota remdesivir allocation framework specifies an ethical approach to distributing the drug to facilities across the state and then among COVID-19 patients within each facility. This article describes the process of developing the framework and adjustments in the framework over time with emergence of new data, analyzes key issues addressed, and suggests next steps. Sharing this framework and the development process can encourage transparency and may be useful to other states formulating and refining their approach to remdesivir EUA allocation.

A mystery shopper study identifying practice-level barriers to adolescent IUD access in western Pennsylvania.

OBJECTIVE(S): To identify practice-level barriers that adolescents experience when seeking a hormonal intrauterine device (IUD). STUDY DESIGN: We secret-shopped gynecological practices within a health system using a script targeting potential practice-level barriers. RESULTS: We assessed 50 of a targeted 50 practices; only 8 (16%) would schedule a contraceptive appointment that permitted same-day IUD placement. Twenty-eight (56%) respondents stateda parent must accompany the adolescent. CONCLUSION: Practice-level barriers toadolescentIUD access exist that are inconsistent with best-practice guidelines and Pennsylvania state law. IMPLICATIONS: Practice staff and providers need more medical and legal education regarding IUD provision to adolescents.

An investigation of prepregnancy body mass index, ethnicity and health-related quality of life as predictors of breastfeeding exclusivity during early postpartum period: Cross sectional survey.

BACKGROUND: Identifying and understanding the determinants of breastfeeding exclusivity during early postpartum period are crucial for sustainable breastfeeding. Few researchers have examined the association among prepregnancy body mass index, ethnicity and exclusive breastfeeding. As a result, whether or not these factors exhibit different relationship patterns across body mass index groups remains unclear. OBJECTIVES: This study was performed to: (1) test the relationships among prepregnancy body mass index, ethnicity, health-related quality of life, maternal and obstetric characteristics and exclusive breastfeeding; and (2) compare the relationships among these study variables for two body mass index groups. DESIGN: Exploratory cross-sectional research design. SETTING: Two postnatal wards of a university-affiliated hospital. PARTICIPANTS: A total of 715 postpartum multi-ethnic women in Singapore. METHODS: We used structural equation modelling with multigroup analysis to examine our hypothetical model, which integrated the concepts of breastfeeding initiation and health-related quality of life conceptual models. A 12-item short form health survey was used to assess the health-related quality of life. RESULTS: The structural equation modelling showed that women with following factors were significantly less likely to initiate exclusive breastfeeding: being Chinese (ß = -0.10, p < 0.05), having high body mass index (ß = -0.11, p < 0.01), living with low household income (ß = -0.08, p < 0.05) and exhibiting poor health-related quality of life scores (ß = 0.17, p < 0.001). Multigroup analysis showed no difference (critical ratio = 0.061) between the parameter estimates of health-related quality of life on exclusive breastfeeding in the two body mass index groups. Health-related quality of life (ß = 0.17, p < 0.001) and monthly household incomes (ß = -0.11, p < 0.05) were the only significant factors in the normal body mass index group. All structural equation modelling values satisfactorily fitted the data (Goodness of Fit Index = 0.937-0.954, Incremental Fit Index = 0.937-0.945, Tucker-Lewis Index = 0.906-0.917, Comparative Fit Index = 0.936-0.942 and Root Means Square Error of Approximation = 0.027-0.040). CONCLUSIONS: Enhancing postpartum health-related quality of life and prepregnancy weight management are crucial to initiate exclusive breastfeeding. Our findings can guide the development of promising health promotion strategies among Chinese women with low household income.

Psychometric Evaluation of 5- and 4-Item Versions of the LATCH Breastfeeding Assessment Tool during the Initial Postpartum Period among a Multiethnic Population.

OBJECTIVES: The aim of this study was to evaluate the internal consistency, structural validity, sensitivity and specificity of the 5- and 4-item versions of the LATCH assessment tool among a multiethnic population in Singapore. METHODS: The study was a secondary analysis of a subset of data (n = 907) from our previous breastfeeding survey from 2013 to 2014. The internal consistency of the LATCH was examined using Cronbach's alpha. The structural validity was assessed using an exploratory factor analysis (EFA), and the proposed factors were confirmed by confirmatory factor analysis (CFA) using separate samples. Receiver operating characteristic analysis was used to evaluate the sensitivity and specificity of the LATCH score thresholds for predicting non-exclusive breastfeeding. RESULTS: The Cronbach's alpha values of the 5- and 4-item LATCH assessments were 0.70 and 0.74, respectively. The EFA demonstrated a one-factor structure for the 5- and 4-item LATCH assessments among a randomized split of 334 vaginally delivered women. Two CFA of the 4-item LATCH demonstrated better fit indices of the models compared to the two CFA of the 5-item LATCH among another randomized split of 335 vaginally delivered women and 238 cesarean delivered women. Using cutoffs of 5.5 and 3.5 were recommended when predicting non-exclusive breastfeeding for 5- and 4-item versions of the LATCH assessment among vaginally delivered women (n = 669), with satisfactory sensitivities (94% and 95%), low specificities (0% and 2%), low positive predictive values (25%) and negative predictive values (20% and 47%). A cutoff of 5.5 was recommended to predict non-exclusive breastfeeding for 5- and 4-item versions among cesarean delivered women (n = 238) with satisfactory sensitivities (93% and 98%), low specificities (4% and 9%), low positive predictive values (41%) and negative predictive values (65% and 75%). Therefore, the tool has good sensitivity but poor specificity, positive and negative predictive values. CONCLUSIONS: We found that the 4-item version demonstrated sound psychometric properties compared to the 5-item version. Health professionals can use the 4-item LATCH as a clinical tool because it is a concise, easy-to-use and valid tool for assessing breastfeeding techniques among a multiethnic population.

Maternal, Infant Characteristics, Breastfeeding Techniques, and Initiation: Structural Equation Modeling Approaches.

OBJECTIVES: The aim of this study was to examine the relationships among maternal and infant characteristics, breastfeeding techniques, and exclusive breastfeeding initiation in different modes of birth using structural equation modeling approaches. METHODS: We examined a hypothetical model based on integrating concepts of a breastfeeding decision-making model, a breastfeeding initiation model, and a social cognitive theory among 952 mother-infant dyads. The LATCH breastfeeding assessment tool was used to evaluate breastfeeding techniques and two infant feeding categories were used (exclusive and non-exclusive breastfeeding). RESULTS: Structural equation models (SEM) showed that multiparity was significantly positively associated with breastfeeding techniques and the jaundice of an infant was significantly negatively related to exclusive breastfeeding initiation. A multigroup analysis in the SEM showed no difference between the caesarean section and vaginal delivery groups estimates of breastfeeding techniques on exclusive breastfeeding initiation. Breastfeeding techniques were significantly positively associated with exclusive breastfeeding initiation in the entire sample and in the vaginal deliveries group. However, breastfeeding techniques were not significantly associated with exclusive breastfeeding initiation in the cesarean section group. Maternal age, maternal race, gestations, birth weight of infant, and postnatal complications had no significant impacts on breastfeeding techniques or exclusive breastfeeding initiation in our study. Overall, the models fitted the data satisfactorily (GFI = 0.979-0.987; AGFI = 0.951-0.962; IFI = 0.958-0.962; CFI = 0.955-0.960, and RMSEA = 0.029-0.034). CONCLUSIONS: Multiparity and jaundice of an infant were found to affect breastfeeding technique and exclusive breastfeeding initiation respectively. Breastfeeding technique was related to exclusive breastfeeding initiation according to the mode of birth. This relationship implies the importance of early effective interventions among first-time mothers with jaundice infants in improving breastfeeding techniques and promoting exclusive breastfeeding initiation.

Inpatient versus home-based rehabilitation for older adults with musculoskeletal disorders: a systematic review.

OBJECTIVE: To review and summarize available evidence to compare the outcomes of home-based rehabilitation to inpatient rehabilitation for older patients with musculoskeletal conditions. DATA SOURCES: Relevant articles published prior to August 2011 were identified using MEDLINE, CINAHL and the Cochrane Central Register of Controlled Trials databases. REVIEW METHODS: English-language articles that compared patient outcomes of home-based and inpatient rehabilitation for older adults were included. Outpatient care was not included as home-based or inpatient rehabilitation. Methodological quality of included studies was evaluated by two reviewers using the PEDro scale. RESULTS: A systematic search yielded eight randomized controlled trials and four cohort studies. Older adults who received rehabilitation in the home had equal or higher gains than the inpatient group in function, cognition, and quality of life; they also reported higher satisfaction. CONCLUSION: Home-based rehabilitation may be an effective alternative for treating older patients with musculoskeletal conditions.