Regulations and Funding to Create Enterprise Architecture for a Nationwide Health Data Ecosystem.

The COVID-19 pandemic highlighted the United States' lack of a nationwide infrastructure for collecting, sharing, and using health data, especially for secondary uses (e.g., population health management and public health). The federal government is taking several important steps to upgrade the nation's health data ecosystem-notably, the Centers for Disease Control and Prevention's Data Modernization Initiative and the Office of the National Coordinator for Health Information Technology's Trusted Exchange Framework and Common Agreement. However, substantial barriers remain. Inconsistent regulations, infrastructure, and governance across federal and state levels and between states significantly impede the exchange and analysis of health data. Siloed systems and insufficient funding block effective integration of clinical, public health, and social determinants data within and between states. In this analytic essay, we propose strategies to develop a nationwide health data ecosystem. We focus on providing federal guidance and incentives to develop state-designated entities responsible for the collection, integration, and analysis of clinical, public health, social determinants of health, claims, administrative, and other relevant data. These recommendations include a regulatory clearinghouse, federal guidance, model legislation and templated regulation, funding to incentive enterprise architecture, regulatory sandboxes, and a 3-pronged research agenda. (Am J Public Health. 2024;114(2):209-217. https://doi.org/10.2105/AJPH.2023.307477).

The Supreme Court's Rulings on Race Neutrality Threaten Progress in Medicine and Health.

This Viewpoint examines the recent Supreme Court rulings on race neutrality, striking down affirmative action programs in higher education, which will affect efforts to eliminate health inequities in the US.

Equitable allocation of COVID-19 vaccines in the United States.

Many vaccine rationing guidelines urge planners to recognize, and ideally reduce, inequities. In the United States, allocation frameworks are determined by each of the Centers for Disease Control and Prevention's 64 jurisdictions (50 states, the District of Columbia, five cities and eight territories). In this study, we analyzed vaccine allocation plans published by 8 November 2020, tracking updates through to 30 March 2021. We evaluated whether jurisdictions adopted proposals to reduce inequity using disadvantage indices and related place-based measures. By 30 March 2021, 14 jurisdictions had prioritized specific zip codes in combination with metrics such as COVID-19 incidence, and 37 jurisdictions (including 34 states) had adopted disadvantage indices, compared to 19 jurisdictions in November 2020. Uptake of indices doubled from 7 to 14 among the jurisdictions with the largest shares of disadvantaged communities. Five applications were distinguished: (1) prioritizing disadvantaged groups through increased shares of vaccines or vaccination appointments; (2) defining priority groups or areas; (3) tailoring outreach and communication; (4) planning the location of dispensing sites; and (5) monitoring receipt. To ensure that equity features centrally in allocation plans, policymakers at the federal, state and local levels should universalize the uptake of disadvantage indices and related place-based measures.

Secular trends in stillbirth by maternal socioeconomic status in Spain 2007-15: a population-based study of 4 million births.

INTRODUCTION: Stillbirth, one of the urgent concerns of preventable perinatal deaths, has wide-reaching consequences for society. We studied secular stillbirth trends by maternal socioeconomic status (SES) in Spain. METHODS: We developed a population-based observational study, including 4 083 919 births during 2007-15. We estimate stillbirth rates and secular trends by maternal SES. We also evaluated the joint effect of maternal educational attainment and the Human Development Index (HDI) of women's country of origin on the risk of stillbirth. The data and statistical analysis can be accessed for reproducibility in a GitHub repository: https://github.com/migariane/Stillbirth. RESULTS: We found a consistent pattern of socioeconomic inequalities in the risk of delivering a stillborn, mainly characterized by a persistently higher risk, over time, among women with lower SES. Overall, women from countries with low HDIs and low educational attainments had approximately a four times higher risk of stillbirth (RR: 4.44; 95%CI: 3.71-5.32). Furthermore, we found a paradoxical reduction of the stillbirth gap over time between the highest and the lowest SESs, which is mostly due to the significant and increasing trend of stillbirth risk among highly educated women of advanced maternal age. CONCLUSION: Our findings highlight no improvement in stillbirth rates among women of lower SES and an increasing trend among highly educated women of advanced maternal age over recent years. Public health policies developing preventive programmes to reduce stillbirth rates among women with lower SES are needed as well as the necessity of further study to understand the growing trend of age-related stillbirths among highly educated women in Spain.

Suicide risk assessment: examining transitions in suicidal behaviors among pregnant women in Perú.

The goals of this research were to characterize suicidal behavior among a cohort of pregnant Peruvian women and identify risk factors for transitions between behaviors. The World Health Organization Composite International Diagnostic Interview suicide questionnaire was employed to assess suicidal behavior. Discrete-time survival analysis was used to study the cumulative age-of-onset distribution. The hazard function was calculated to assess the risk of onset of each suicidal behavior. Among 2062 participants, suicidal behaviors were endorsed by 22.6% of participants; 22.4% reported a lifetime history of suicidal ideation, 7.2% reported a history of planning, and 6.0% reported attempting suicide. Childhood abuse was most strongly associated with suicidal behavior, accounting for a 2.57-fold increased odds of suicidal ideation, nearly 3-fold increased odds of suicide planning, and 2.43-fold increased odds of suicide attempt. This study identified the highest prevalence of suicidal behavior in a population of pregnant women outside the USA. Diverse populations of pregnant women and their patterns of suicidal behavior transition must be further studied. The association between trauma and suicidal behavior indicates the importance of trauma-informed care for pregnant women.

Maternal pre-pregnancy body mass index and circulating microRNAs in pregnancy.

BACKGROUND: Maternal pre-pregnancy overweight and obese status has been associated with a number of pregnancy complications and adverse offspring outcomes. Mechanisms for observed associations, however, are largely unknown. We investigated associations of pre-pregnancy body mass index with early-mid pregnancy epigenetic biomarkers, circulating microRNAs. METHODS: Peripheral blood was collected from participants (16-27 weeks gestation) of two multi-racial pregnancy cohorts, the Omega Study and the Pregnancy Outcomes and Community Health Study. Plasma miRNA expression was characterised using epigenome-wide (319 miRNAs) profiling among 20 pregnant women in each cohort. Cohort-specific linear regression models that included the predictor (pre-pregnancy body mass index), the outcome (microRNA expression), and adjustment factors (maternal age, gestational age at blood collection, and race) were fit. RESULTS: Expression of 27 miRNAs was positively associated with pre-pregnancy body mass index in both cohorts (p-values <0.05). A number of these differentially expressed miRNAs have previously been associated with adipogenesis (e.g. let-7d*, miR-103-2*, -130b, -146b-5-p, -29c, and -26b). Identified miRNAs as well as their experimentally validated targets participate in pathways that involve organismal injury, reproductive system disease, connective tissue disorders, cancer, cellular development, growth and proliferation. CONCLUSION: Pre-pregnancy body mass index is associated with circulating miRNAs in early-mid pregnancy.

Suicidal behavior-related hospitalizations among pregnant women in the USA, 2006-2012.

Suicide is one of the leading causes of maternal mortality in many countries, but little is known about the epidemiology of suicide and suicidal behavior among pregnant women in the USA. We sought to examine trends and provide nationally representative estimates for suicidal behavior (including suicidal ideation and suicide and self-inflicted injury) among pregnant women from 2006 to 2012 in the USA. Pregnant women aged 12-55 years were identified through pregnancy- and delivery-related hospitalization records from the National (Nationwide) Inpatient Sample. Suicidal behavior was identified by the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Annual, nationwide estimates and trends were determined using discharge and hospital weights. The prevalence of suicidal ideation more than doubled from 2006 to 2012 (47.5 to 115.0 per 100,000 pregnancy- and delivery-related hospitalizations), whereas the prevalence of suicide and self-inflicted injury remained stable. Nearly 10 % of suicidal behavior occurred in the 12-18-year group, showing the highest prevalence per 100,000 pregnancy- and delivery-related hospitalizations (158.8 in 2006 and 308.7 in 2012) over the study period. For suicidal ideation, blacks had higher prevalence than whites; women in the lowest income quartile had the highest prevalence. Although the prevalence of suicidal behavior was higher among hospitalizations with depression diagnoses, more than 30 % of hospitalizations were for suicidal behavior without depression diagnoses. Our findings highlight the increasing burden and racial differences in suicidal ideation among US pregnant women. Targeted suicide prevention efforts are needed for high-risk pregnant women including teens, blacks, and low-income women.

Preferences for intervention among Peruvian women in intimate partner violence relationships.

We sought to identify what abused Peruvian women want or need as intervention strategies. We conducted five focus groups with 30 women with prior or current experience with intimate partner violence. Participants noted that abused women need compassionate support, professional counseling, and informational and practical (e.g., work skills training, employment, shelter, financial support) interventions. We propose a 2-tiered intervention strategy that includes community support groups and individual professional counseling. This strategy is intended to offer broad coverage, meeting the needs of large groups of women who experience abuse, whereas providing specialized counseling for those requiring intensive support. Respect for each woman's autonomy in the decision-making process is a priority. Interventions targeted toward women and men should address structural factors that contribute to violence against women.

Smoking and perceived stress in relation to short salivary telomere length among caregivers of children with disabilities.

Telomere length (TL), the length of repeated DNA sequence that forms protective caps at the end of chromosomes, has emerged as a novel biomarker of cell aging and oxidative stress. There is increasing research exploring the associations of smoking and perceived stress with TL, and the results are inconsistent. This study aimed to examine whether smoking and perceived stress were associated with shortened salivary TL among primary caregivers of children with disabilities. Using a quantitative polymerase chain reaction method, salivary TL was assessed among 89 caregivers aged 19-69 years (87% were women) who took care of disabled children in the Patagonia Region, Chile. Interviewer-administered questionnaires were used to collect information on sociodemographic and lifestyle factors. The 14-item Perceived Stress Scale was used to assess perceived stress. Mean relative TL was 0.92 (standard error = 0.03). Smokers had age-adjusted mean TL that was 0.07 units lower (ß = -0.07, standard error = 0.03; p = 0.012) than non-smokers. Smokers were 2.17 times more likely to have shorter TL ( < 0.73, the lowest quartile of TL) than non-smokers (odds ratio = 3.17; 95% confidence interval = 1.05-9.52) with adjustment for age and perceived stress. Caregivers with higher perceived stress were 2.13 times more likely to have shorter TL (odds ratio = 3.13; 95% confidence interval = 1.03-9.55) than caregivers with lower perceived stress after adjustment for age and smoking. This study provides the first evidence of strong associations between smoking and perceived stress and shortened salivary TL among caregivers of children with disabilities. Larger studies with detailed information on smoking status are warranted to confirm our findings.

Plasma vitamin D is associated with fasting insulin and homeostatic model assessment of insulin resistance in young adult males, but not females, of the Jerusalem Perinatal Study.

OBJECTIVE: To examine cross-sectional relationships between plasma vitamin D and cardiometabolic risk factors in young adults. DESIGN: Data were collected from interviews, physical examinations and biomarker measurements. Total plasma 25-hydroxyvitamin D (25(OH)D) was measured using LC-tandem MS. Associations between 25(OH)D and cardiometabolic risk factors were modelled using weighted linear regression with robust estimates of standard errors. SETTING: Individuals born in Jerusalem during 1974-1976. SUBJECTS: Participants of the Jerusalem Perinatal Study (n 1204) interviewed and examined at age 32 years. Participants were oversampled for low and high birth weight and for maternal pre-pregnancy obesity. RESULTS: Mean total 25(OH)D concentration among participants was 21·7 (sd 8·9) ng/ml. Among males, 25(OH)D was associated with homeostatic model assessment of insulin resistance (natural log-transformed, ß=-0·011, P=0·004) after adjustment for BMI. However, these associations were not present among females (P for sex interaction=0·005). CONCLUSIONS: We found evidence for inverse associations of 25(OH)D with markers of insulin resistance among males, but not females, in a healthy, young adult Caucasian population. Prospective studies and studies conducted on other populations investigating sex-specific effects of vitamin D on cardiometabolic risk factors are warranted.

Hair cortisol in relation to sociodemographic and lifestyle characteristics in a multiethnic US sample.

PURPOSE: We investigated the feasibility of obtaining hair samples from men and women at community-based barbershops and hair salons for analysis of cortisol and assessed sociodemographic and lifestyle correlates of hair cortisol concentrations (HCCs). A total of 102 participants completed the study. METHODS: Research staff interviewed participants using a structured questionnaire, and samples of hair were collected. HCCs were determined using liquid chromatography-tandem mass spectrometry. Age- and sex-adjusted linear regression models were used to evaluate the association of HCC with covariates. RESULTS: Analyses by race/ethnicity showed highest median HCC in blacks (12.5 [6.9-29.3]) pg/mg) followed by Hispanics (10.7 [5.8-14.9] pg/mg), whites (5.0 [3.8-10.8] pg/mg), and other participants (4.2 [3.3-15.7] pg/mg), P < .01. Current smokers had significantly higher median HCC (11.7 [8.8-18.9] pg/mg) compared with former smokers (4.6 [3.5-14.6] pg/mg) and those who had never smoked (6.9 [4.7-12.8] pg/mg), P = .04. After adjustment for age and sex, geometric mean HCC was 0.72 pg/mg lower in dyed hair compared with hair that was not dyed (ß = -0.72, standard error = 0.30, 95% confidence interval, -1.29 to -0.15, P = .02). CONCLUSIONS: HCC can be assessed in community-based studies. Future HCC studies should consider cosmetic hair treatment, cigarette smoking, and the potential role of psychosocial stressors in the association between race/ethnicity and HCC.

Associations of allostatic load with sleep apnea, insomnia, short sleep duration, and other sleep disturbances: findings from the National Health and Nutrition Examination Survey 2005 to 2008.

PURPOSE: To examine whether allostatic load (AL), a measure of cumulative physiologic dysregulation across biological systems, was associated with sleep apnea, insomnia, and other sleep disturbances. METHODS: Data from the National Health and Nutrition Examination Survey 2005-2008 were used. AL was measured using nine biomarkers representing cardiovascular, inflammatory, and metabolic system functioning. A total of 3330 US adults aged 18 years and older were included in this study. RESULTS: The prevalence of high AL (AL score ≥3) was the highest among African Americans (26.3%), followed by Hispanic Americans (20.3%), whites (17.7%), and other racial/ethnic group (13.8%). After adjustment for sociodemographic and lifestyle factors, high AL was significantly associated with sleep apnea (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.40-2.63), snoring (OR, 2.20; 95% CI, 1.79-2.69), snorting/stop breathing (OR, 2.16; 95% CI, 1.46-3.21), prolonged sleep latency (OR, 1.42; 95% CI, 1.08-1.88), short sleep duration (<6 hours) (OR, 1.35; 95% CI, 1.00-1.82), and diagnosed sleep disorder (OR, 2.26; 95% CI, 1.66-3.08). There was no clear evidence that observed associations varied by sociodemographic characteristics. CONCLUSIONS: This study suggests significant associations of high AL with sleep apnea, sleep apnea symptoms, insomnia component, short sleep duration, and diagnosed sleep disorder among US adults.

Sleep characteristics and health-related quality of life among a national sample of American young adults: assessment of possible health disparities.

PURPOSE: The aim of the study is to examine the associations of sleep characteristics with health-related quality of life (HRQOL) and sleep health disparities among US young adults using national survey data. METHODS: The study sample consisted of 2,391 young adults aged 20-39 years from the National Health and Nutrition Examination Survey 2005-2008. HRQOL was assessed using the Centers for Disease Control and Prevention's HRQOL-4 scale. Multivariable logistic regression models were applied to evaluate the sleep-HRQOL associations. Stratified analyses were conducted to examine whether the associations varied by sociodemographic characteristics. RESULTS: Approximately 35.6 % of young adults slept <7 h, 41.9 % had insomnia, 4.4 % had sleep disorder, and 8.5 % had sleep apnea. More females had insomnia than males (48.6 vs. 35.9 %, P < 0.001). US-born young adults had more sleep disturbances than their foreign-born counterparts. Compared with those sleeping 7-8 h, the adjusted odds ratio of poor general health was 1.60 (95 % confidence interval, 1.08-2.35) for individuals sleeping 6-7 h and 1.88 (1.23-2.86) for those sleeping <6 h. Similar results were found for low mental HRQOL and overall HRQOL. Insomnia, long sleep latency, troubling falling asleep, daytime sleepiness, and frequent sleeping pill use were significantly associated with low mental HRQOL and overall HRQOL. The associations between sleep disturbances and low HRQOL varied little by sex, race/ethnicity, and country of birth. CONCLUSIONS: Sleep disturbances are common among US young adults and are significantly associated with low HRQOL. Objective measures of sleep are warranted to confirm our findings.

Racial disparities in short sleep duration by occupation and industry.

Short sleep duration, which is associated with increased morbidity and mortality, has been shown to vary by occupation and industry, but few studies have investigated differences between black and white populations. By using data from a nationally representative sample of US adult short sleepers (n = 41,088) in the National Health Interview Survey in 2004-2011, we estimated prevalence ratios for short sleep duration in blacks compared with whites for each of 8 industry categories by using adjusted Poisson regression models with robust variance. Participants' mean age was 47 years; 50% were women and 13% were black. Blacks were more likely to report short sleep duration than whites (37% vs. 28%), and the black-white disparity was widest among those who held professional occupations. Adjusted short sleep duration was more prevalent in blacks than whites in the following industry categories: finance/information/real estate (prevalence ratio (PR) = 1.44, 95% confidence interval (CI): 1.30, 1.59); professional/administrative/management (PR = 1.30, 95% CI: 1.18, 1.44); educational services (PR = 1.39, 95% CI: 1.25, 1.54); public administration/arts/other services (PR = 1.30, 95% CI: 1.21, 1.41); health care/social assistance (PR = 1.23, 95% CI: 1.14, 1.32); and manufacturing/construction (PR = 1.14, 95% CI: 1.07, 1.20). Short sleep generally increased with increasing professional responsibility within a given industry among blacks but decreased with increasing professional roles among whites. Our results suggest the need for further investigation of racial/ethnic differences in the work-sleep relationship.

Validity of the Patient Health Questionnaire-9 for depression screening and diagnosis in East Africa.

Depression is often underdiagnosed and undertreated in primary care settings, particularly in developing countries. This is, in part, due to challenges resulting from lack of skilled mental health workers, stigma associated with mental illness, and lack of cross-culturally validated screening instruments. We conducted this study to evaluate the reliability and validity of the Patient Health Questionnaire-9 (PHQ-9) as a screen for diagnosing major depressive disorder among adults in Ethiopia, the second most populous country in sub-Saharan Africa. A total of 926 adults attending outpatient departments in a major referral hospital in Ethiopia participated in this study. We assessed criterion validity and performance characteristics against an independent, blinded, and psychiatrist administered semi-structured Schedules for Clinical Assessment in Neuropsychiatry (SCAN) interview. Overall, the PHQ-9 items showed good internal (Cronbach's alpha=0.81) and test re-test reliability (intraclass correlation coefficient=0.92). A factor analysis confirmed a one-factor structure. Receiver Operating Characteristics (ROC) analysis showed that a PHQ-9 threshold score of 10 offered optimal discriminatory power with respect to diagnosis of major depressive disorder via the clinical interview (sensitivity=86% and specificity=67%). The PHQ-9 appears to be a reliable and valid instrument that may be used to diagnose major depressive disorders among Ethiopian adults.

Washington State exhibits wide regional variation in proportion of Medicaid-eligible children who get needed mental health care.

In Washington State, mental health care for Medicaid-eligible children is delivered through thirteen regional support networks. The estimated statewide prevalence rate for serious emotional disturbances in children up to age seventeen is 7 percent; analysis found, however, that the proportion of Medicaid-eligible children who received mental health care ranged from 2.91 percent in the North Central network to 8.16 percent in the Southwest network. The variation was not linked to the racial or ethnic makeup of the local population or the rural or urban nature of the region. Instead, interviews with network administrators indicated a substantial contributor to this regional care variation was the state's Access to Care Standards, which restrict network mental health services to children with the most severe disorders. Other factors contributing to the regional variation included funding, the networks' geographic size, and availability of providers. With the Affordable Care Act expected to bring more children with mental health care needs into the Medicaid system, our findings and recommendations offer policy makers timely information on how to improve children's access to mental health care.