A Causality Assessment Framework for COVID-19 Vaccines and Adverse Events at the COVID-19 Vaccine Safety Research Center.

During the coronavirus disease 2019 (COVID-19) pandemic, conclusively evaluating possible associations between COVID-19 vaccines and potential adverse events was of critical importance. The National Academy of Medicine of Korea established the COVID-19 Vaccine Safety Research Center (CoVaSC) with support from the Korea Disease Control and Prevention Agency to investigate the scientific relationship between COVID-19 vaccines and suspected adverse events. Although determining whether the COVID-19 vaccine was responsible for any suspected adverse event necessitated a systematic approach, traditional causal inference theories, such as Hill's criteria, encountered certain limitations and criticisms. To facilitate a systematic and evidence-based evaluation, the United States Institute of Medicine, at the request of the Centers for Disease Control and Prevention, offered a detailed causality assessment framework in 2012, which was updated in the recent report by the National Academies of Sciences, Engineering, and Medicine (NASEM) in 2024. This framework, based on a weight-of-evidence approach, allows the independent evaluation of both epidemiological and mechanistic evidence, culminating in a comprehensive conclusion about causality. Epidemiological evidence derived from population studies is categorized into four levels-high, moderate, limited, or insufficient-while mechanistic evidence, primarily from biological and clinical studies in animals and individuals, is classified as strong, intermediate, weak, or lacking. The committee then synthesizes these two types of evidence to draw a conclusion about the causal relationship, which can be described as "convincingly supports" ("evidence established" in the 2024 NASEM report), "favors acceptance," "favors rejection," or "inadequate to accept or reject." The CoVaSC has established an independent committee to conduct causality assessments using the weight-of-evidence framework, specifically for evaluating the causality of adverse events associated with COVID-19 vaccines. The aim of this study is to provide an overview of the weight-of-evidence framework and to detail the considerations involved in its practical application in the CoVaSC.

Association of Neoadjuvant Chemotherapy With Postoperative Outcomes in Immediate Prepectoral Prosthetic Breast Reconstruction.

PURPOSE: Neoadjuvant chemotherapy (NACT) followed by total mastectomy and immediate reconstruction has become an important strategy in the treatment of breast cancer. Although the safety of subpectoral implant-based breast reconstruction with NACT has been extensively evaluated, the safety in prepectoral reconstruction has not been clearly elucidated. We aimed to evaluate the association of NACT with immediate prepectoral breast reconstruction outcomes. METHODS: A retrospective review of patients who underwent total mastectomy and immediate implant-based prepectoral breast reconstruction between May and December 2021 was conducted. Patients were categorized into 2 groups: those receiving NACT and those not receiving it. Postoperative complication rates were compared between the 2 groups. The independent association between NACT and the complication profiles was evaluated. Propensity score matching was also conducted. RESULTS: We analyzed 343 cases, including 85 who received NACT treatment and 258 who did not. Compared with the non-NACT group, the NACT group was younger, had a higher body mass index, and a higher rate of adjuvant radiotherapy. There were no differences in the rates of overall complications or type of complication between the 2 groups. In the multivariable logistic analyses, NACT did not show a significant association with the development of adverse outcomes. Similar results were observed in propensity score matching analyses. CONCLUSIONS: Our results suggest that receiving NACT may not have a significant detrimental effect on the postoperative outcomes of immediate prepectoral prosthetic reconstructions. Conducting prepectoral implant-based reconstruction in the setting of NACT might be safe and provide acceptable outcomes.

Association between metabolic syndrome and gastric cancer risk: results from the Health Examinees Study.

BACKGROUND: Previous studies suggested that metabolic syndrome (MetS) might create a pro-cancer environment and increase cancer incidence. However, evidence on the risk of gastric cancer (GC) was limited. This study aimed to evaluate the association between MetS and its components and GC in the Korean population. METHODS: Included were 108,397 individuals who participated in the large-scale prospective cohort study, the Health Examinees-Gem study during 2004-2017. The multivariable Cox proportional was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) on the association between MetS and its components with GC risk. Age was used as the time scale in the analyses. The stratified analysis was performed to determine the joint effect of lifestyle factors and MetS on GC risk in different groups. RESULTS: During the mean follow-up of 9.1 years, 759 cases of newly diagnosed cancer (408 men and 351 women) were identified. Overall, participants with MetS had a 26% increased risk of GC than those without MetS (HR 1.26; 95% CI 1.07-1.47); the risk increased with the number of MetS components (p for trend 0.01). Hypertriglyceridemia, low HDL-cholesterol, and hyperglycemia were independently associated with the risk of GC. The potential joint effect of MetS and current smokers (p for interaction 0.02) and obesity (BMI ≥ 25.0) (p for interaction 0.03) in GC. CONCLUSIONS: In this prospective cohort study, we found that MetS were associated with an increased risk of GC in the Korean population. Our findings suggest that MetS may be a potentially modifiable risk factor for GC risk.

Soybean product consumption decreases risk of gastric cancer: results from the Health Examinees Study.

BACKGROUND: Epidemiological findings on the association between soybean product consumption and gastric cancer risk remain inconsistent. We evaluated the relationship between soybean product consumption and the risk of gastric cancer in a prospective cohort study in Korea. METHODS: This prospective cohort study included a total of 139,267 participants aged 40-69 years from the Health Examinees-Gem (HEXA-G) study between 2004 and 2013. Information on cancer diagnosis was retrieved from the Korea Central Cancer Registry until 31 December 2018. Multivariate hazard ratios (HRs) and 95% of confidence intervals (CIs) for the risk of gastric cancer according to the consumption of soybean products were estimated using Cox proportional hazards models. RESULTS: A total of 767 incident cases of gastric cancer occurred over an average follow-up period of 9.21 years. We found that men who consumed two servings per week had 37% lower risk of gastric cancer compared with who consume those who almost never consumed (HR for tofu consumption of more than two servings/week vs. almost never consumed was 0.63 (95% CI 0.45, 0.89); p for trend = 0.04). Among men with a BMI of less than 25 kg/m2, increased consumption of soybean paste (p for trend = 0.02) and tofu (HR 0.51 (95% CI 0.32, 0.82 for more than two servings/week vs. almost never consumed); p for trend = 0.01) was associated with decreased risk of gastric cancer. CONCLUSION: Our results suggest that a high consumption of soybean products has a protective effect against gastric cancer.

Coverage of radial forearm free flap donor site defect using another free flap.

BACKGROUND: Donor site defects following the radial forearm flap (RFF) harvest have been usually covered with skin grafting, which often lead to suboptimal outcomes and donor morbidities, including delayed healing and scar contractures. The present report aimed to evaluate the outcomes of using another free flap, the domino flap, for coverage of donor site defects following RFFF harvest. METHODS: Five patients (two males and three females) who underwent coverage of donor defects of RFFF using another free flap between 2019 and 2021 were reviewed. Their mean age was 74 years and the mean dimension of the defect of the RFF donor site was 8.7 × 5.6 cm. Four patients used an anterolateral thigh flap and one used a superficial circumflex iliac artery perforator flap. RESULTS: The mean size of the domino flaps were 12.2 × 5.8 cm. Distal stumps of radial vessels adopting retrograde flow were used as recipients in four cases, and proximal ones adopting anterograde in one. The donor site of the domino flaps was primarily closed. All patients recovered well without any postoperative complications. Aesthetically pleasing outcomes with no functional impairment related to scar contractures were observed in the donor site of RFF during the mean follow-up of 15.7 months. CONCLUSIONS: Use of another free flap for coverage of RFFF donor defects may provide rapid wound healing and satisfactory outcomes, and may be considered an alternative option in cases with large-sized defects that are expected to take a long time to achieve complete healing with skin grafting.

The Association of Serum High-Sensitivity C-Reactive Protein Level With the Risk of Site-Specific Cancer Mortality: The Health Examinees (HEXA) Study Cohort.

Few studies have investigated the association between high-sensitivity C-reactive protein (hsCRP) level and site-specific cancer mortality. In this study, we aimed to examine the associations of hsCRP with overall and site-specific cancer mortality among South Koreans using data on the Health Examinees (HEXA) Study cohort (41,070 men and 81,011 women aged ≥40 years). We obtained mortality information from the National Statistical Office of Korea, which provided the dates and causes of all deaths occurring through December 31, 2015, by linking mortality data with each participant's unique national identifier. Cox proportional hazards and restricted cubic spline models were used to assess the association between hsCRP and cancer mortality with adjustment for covariates. An analysis of site-specific cancer mortality was focused on 5 major cancers (lung, liver, gastric, colorectal, and breast/prostate). Median hsCRP levels were 0.77 mg/L and 0.59 mg/L for men and women, respectively. A dose-response association between hsCRP and overall cancer mortality was observed in men but disappeared in women after exclusion of deaths occurring in the first 1 or 2 years of follow-up. Elevated hsCRP levels increased the risks of lung, liver, and gastric cancer mortality in men, but the risks of colorectal and breast cancer mortality were not increased. The dose-response association between hsCRP and cancer mortality was observed differently depending on site-specific cancer mortality by sex.

Comparison of the Prevalence of Cardiometabolic Disorders and Comorbidities in Korea and the United States: Analysis of the National Health and Nutrition Examination Survey.

BACKGROUND: Comparison of the prevalence of cardiometabolic disorders (CMDs) and comorbidities in Korea and the United States (US) can be an important indicator for forecasting future risk of cardiovascular events in Korea. This study aimed to estimate and compare the prevalence of hypertension, diabetes mellitus (DM), dyslipidemia, obesity, and metabolic syndrome (MetS) in Korea and the US. METHODS: A total of 15,872 individuals from the US National Health and Nutrition Examination Survey (NHANES) 2003-2014 and 26,492 from the Korea NHANES (KNHANES) 2007-2014 were included. Additionally, 164,339 (139,345 from the Health Examinees-Gem Study and 24,994 from the Cardiovascular Disease Association Study) participants enrolled in the Korea Genome and Epidemiology Study were included to investigate the differences of CMDs between urban and rural regions. To estimate the age-standardized prevalence of CMDs in individuals aged 40-69 years, direct standardization using the World Health Organization standard population was performed. RESULTS: The prevalence of CMDs was lower in Korea than the US (hypertension 49.9% vs. 56.8%; DM 13.4% vs. 14.3%; hypercholesterolemia 16.8% vs. 17.8%; obesity 36.2% vs. 38.6%; and MetS 29.4% vs. 36.5%). According to the median survey years, dyslipidemia has become more prevalent in Korea than in the US since 2010. The prevalence of CMDs was greater in rural than that in urban areas in Korea. CONCLUSION: The prevalence of dyslipidemia in Korea exceeded that of the US after 2010, which was associated with increasing burden of cardiovascular events. The present study suggests that further preventive strategies are needed to mitigate the prevalence of CMDs in Korea.

Development a new chewing problem directory and its validation for Korean elders.

OBJECTIVES: This study aimed to develop a new chewing problem directory (CPD) and validate it with oral health indicators such as total occlusion force, number of natural and rehabilitated teeth (NRT), NRT posterior, natural teeth, natural teeth posterior, and dental status among Korean elders. BACKGROUND: Chewing problem is the main oral health problem in elders. However, there has been no validated tool using both subjective and objective assessment of chewing problem. SUBJECTS AND METHODS: A total of 537 participants aged 65 years or more were randomly assigned into 2 subsamples: developing sample (n = 260) for developing and internally validating the new CPD as the 1st stage and confirmation sample (n = 277) for confirming validation of CPD as the 2nd stage. CPD was developed using three subjective questionnaires (general eating, chewing nuts, and chewing meat problem) and objective NRT. Periodontitis, age, sex, education, smoking, alcohol drinking, metabolic syndrome, and frailty were considered as confounders. Following the development of CPD, CPD was validated using multiple multivariable logistic regression after controlling for confounders in confirmation sample and total sample. RESULTS: The Cronbach's alpha value for three subjective questionnaires of CPD was 0.87. Among oral health indicators, NRT (0-28) showed the highest impact association with subjective chewing problem score (partial r = - 0.276). The chewing problem from the new CPD was associated with all items of oral health indicators. The prevalence of chewing problems by CPD was 57.7% in developing sample. Elders with NRT ≤ 24, compared with those with NRT ≥ 25, showed the highest impact on chewing problems by new CPD (Odds Ratio = 7.3 in the confirmation sample and 5.04 in the total sample, p < 0.05) among oral health indicators. CONCLUSION: This new CPD was developed as a valid tool to evaluate the chewing problem for Korean elders in dental clinics and community-based settings.

Three-year outcome of rapid HIV testing at public health centers in Seoul, Republic of Korea: a short report.

Before 2014, the only test used for anonymous voluntary human immunodeficiency virus (HIV) screening at public health centers (PHCs) in the Republic of Korea was an enzyme-linked immunosorbent assay (ELISA), which takes around 3 days to obtain results. In 2014, to encourage voluntary anonymous HIV screening tests, the Seoul Metropolitan Government adopted a rapid HIV screening test at PHCs. The rapid HIV screening test was introduced at four PHCs in 2014 and all 25 PHCs after 2015. We compared the numbers of HIV screening tests and confirmed positive individuals before and after introduction of the rapid HIV screening test. In 2012-2013, before the introduction of rapid HIV screening test, an average of 330 HIV screening tests were performed monthly (355 in 2012 and 305 in 2013) and 69 individuals were confirmed to have HIV in 2012 and 93 in 2013. After the introduction of the rapid HIV screening test, anonymous voluntary HIV screening increased to a monthly average of 447 tests in 2014, 2099 in 2015, and 2409 in 2016. These identified 38 new cases in 2014, 116 in 2015, and 143 in 2016. Adoption of the rapid HIV screening test has increased the number of HIV screening tests and confirmed cases.

Relative Effects of Demographic, Psychological, Behavioral, and Social Factors on the Initiation and Maintenance of Leisure-time Physical Activity: Results From a Confirmatory Path Analysis in a Longitudinal Study.

BACKGROUND: There is a lack of evidence of the complicated pathways of underlying determinants in the phases of physical activity. The purpose of this study was to evaluate simultaneously a set of potential determinants on the initiation and maintenance phases of leisure-time physical activity (LTPA). METHODS: The longitudinal data of 54,359 Korean adults aged 40-69 years from the Health Examinees study were used. The median follow-up duration was 4.2 years. The self-reported durations per week of LTPA was repeatedly assessed. Based on previous longitudinal studies, the potential determinants were selected, and hypothetical models were constructed that consider the complex associations between the determinants. The standardized coefficients for direct and indirect effects were estimated using path analysis to differentiate contributions of mediation from the total effects. RESULTS: In the total population, age, education, chronic diseases, smoking, depression symptoms, and self-rated health were significantly associated with both initiation and maintenance phases. Income (B = 0.025) and social supports (B = 0.019) were associated only with the initiation phase. Waist-to-hip ratio (B = -0.042) and stress (B = -0.035) were associated only with the maintenance phase. After stratifying by sex, the significant effects of education, chronic diseases, and smoking were found only in men. The initiation phase-specific effects of income and social supports and the maintenance phase-specific effects of stress were found only in women. It was estimated that indirect effects contributed approximately 15% of the total effect. CONCLUSION: The findings suggested that there were initiation- or maintenance-specific determinants of leisure-time physical activity according to sex.

Salivary flow rate and the risk of cognitive impairment among Korean elders: a cross-sectional study.

BACKGROUND: Salivary function has been suggested to be associated with cognitive impairment. However, the effect of salivary flow rate (SFR) on cognitive impairment remains unclear. This study aimed to investigate whether SFR is associated with cognitive impairment among Korean elders. METHODS: This cross-sectional study included 649 elders aged 65 and older in the Korean community-dwelling population. Cognitive impairment was assessed using the Mini-Mental Status Examination. Unstimulated SFR was measured and dichotomized. Denture status, age, sex, education level, smoking, drinking, diabetes, hypertension, and obesity were considered confounders. Multivariable logistic regression analysis was applied to assess the adjusted association. Stratified analysis by sex and denture status was performed to clarify the effect modification. RESULTS: Participants without cognitive impairment showed a higher SFR level than those with cognitive impairment (0.81 mL/min for non-cognitive impairment versus 0.52 mL/min for cognitive impairment, p < 0.001). After controlling for confounders, participants with low SFR (< 0.3 mL/min) were more likely to have cognitive impairment by 1.5 times than participants with normal SFR (odds ratio [OR] = 1.5, confidence interval [CI] = 1.05-2.10). The association of low SFR with cognitive impairment was higher in women and dentate participants: about 10% higher in women (OR = 1.63, CI = 1.07-2.50) and about 22% higher in dentate participants (OR = 1.82, CI = 1.41-2.90). CONCLUSIONS: Salivary flow rate is independently associated with cognitive impairment among Korean elders. The association was modified in females and dentate elders. Physicians and dentists should consider low SFR and cognitive impairment as a risk factor between them in clinics.

Optimal cutoff values for anthropometric indices of obesity as discriminators of metabolic abnormalities in Korea: results from a Health Examinees study.

BACKGROUND: Obesity is well known as a risk factor for cardiovascular disease. We aimed to determine the performance of and the optimal cutoff values for obesity indices to discriminate the presence of metabolic abnormalities as a primary risk factor for cardiovascular diseases in a Health Examinees study (HEXA). METHODS: The current study analyzed 134,195 participants with complete anthropometric and laboratory information in a Health Examinees study, consisting of the Korean population aged 40 to 69 years. The presence of metabolic abnormality was defined as having at least one of the following: hypertension, hyperglycemia, or dyslipidemia. The area under the receiver operating characteristic curve (AUC) and 95% confidence intervals (CIs) were calculated for body mass index, waist to hip ratio, waist to height ratio, waist circumference, and conicity index. RESULTS: The AUC of metabolic abnormalities was the highest for waist-to-height ratio (AUC [95% CIs], 0.677 [0.672-0.683] among men; 0.691 [0.687-0.694] among women), and the lowest for the C index (0.616 [0.611-0.622] among men; 0.645 [0.641-0.649] among women) among both men and women. The optimal cutoff values were 24.3 kg/m2 for the body mass index, 0.887 for the waist-to-hip ratio, 0.499 for the waist-to-height ratio, 84.4 cm for waist circumference and 1.20 m3/2/kg1/2 for the conicity index among men, and 23.4 kg/m2 for the body mass index, 0.832 for the waist-to-hip ratio, 0.496 for the waist-to-height ratio, 77.0 cm for the waist circumference and 1.18 m3/2/kg1/2 for the conicity index among women. CONCLUSION: The waist-to-height ratio is the best index to discriminate metabolic abnormalities among middle-aged Koreans. The optimal cutoff of obesity indices is lower than the international guidelines for obesity. It would be appropriate to use the indices for abdominal obesity rather than general obesity and to consider a lower level of body mass index and waist circumference than the current guidelines to determine obesity-related health problems in Koreans.

Changes in exercise frequency and cardiovascular outcomes in older adults.

AIMS: Little is known about the association of changes in moderate to vigorous physical activity (MVPA) level with cardiovascular disease (CVD), especially in older adults whose ability to engage in frequent MVPA naturally wanes as they age. We aimed to examine the association of changes in MVPA and CVD in older adults. METHODS AND RESULTS: In a nationwide cohort study of older adults aged 60 years or older, we identified more than 1.1 million subjects without previous history of CVD at baseline who underwent two consecutive national health screening from 2009 to 2012. We prospectively assessed the risk of CVD occurred between 2013 and 2016 according to changes in frequency of MVPA by initial MVPA status. Compared to those who were continuously physically inactive, those who increased their frequency of MVPA from physically inactive to 1-2 times per week [0.7/1000 person-years (PY) decrease in incidence rate (IR); adjusted hazard ratio (aHR) 0.95; 95% confidence interval (CI) 0.92-0.99], 3-4 times per week (1.5/1000 PY decrease in IR; aHR 0.89; 95% CI 0.84-0.94), ≥5 times per week (0.4/1000 PY decrease in IR; aHR 0.91; 95% CI 0.85-0.97) had a significantly reduced risk for total CVD (P for trend <0.001). Older adults who became physically inactive from engaging in more than 1-2 times of MVPA per week had a higher CVD risk compared to those who maintained their frequency of MVPA. CONCLUSION: Among older adults, engaging in higher frequency of MVPA or maintaining MVPA level was associated with reduced risk of CVD.

Changes in socio-economic patterns of energy consumption and insufficient energy intake across India from 1993-94 to 2011-12.

OBJECTIVE: To assess whether disparities in energy consumption and insufficient energy intake in India have changed over time across socio-economic status (SES). DESIGN: This cross-sectional, population-based survey study examines the relationship between several SES indicators (i.e. wealth, education, caste, occupation) and energy consumption in India at two time points almost 20 years apart. Household food intake in the last 30 d was assessed in 1993-94 and in 2011-12. Average dietary energy intake per person in the household (e.g. kilocalories) and whether the household consumed less than 80 % of the recommended energy intake (i.e. insufficient energy intake) were calculated. Linear and relative risk regression models were used to estimate the relationship between SES and average energy consumed per day per person and the relative risk of consuming an insufficient amount of energy. SETTING: Rural and urban areas across India. PARTICIPANTS: A nationally representative sample of households. RESULTS: Among rural households, there was a positive association between SES and energy intake across all four SES indicators during both survey years. Similar results were seen for energy insufficiency vis-à-vis recommended energy intake levels. Among urban households, wealth was associated with energy intake and insufficiency at both time points, but there was no educational patterning of energy insufficiency in 2011-12. CONCLUSIONS: Results suggest little overall change in the SES patterning of energy consumption and percentage of households with insufficient energy intake from 1993-94 to 2011-12 in India. Policies in India need to improve energy intake among low-SES households, particularly in rural areas.

Association between social trust and the risk of cardiovascular disease in older adults in Korea: a nationwide retrospective cohort study.

BACKGROUND: Although social capital has been shown to be one of the important social determinants of health, the association between social trust and the risk of cardiovascular disease (CVD) is not clear yet. We aimed to investigate the association of social trust with CVD risk using a large Korean population based data. METHODS: The data of this study was derived from the Korean National Health Insurance Service database. Community-level social trust was determined from the Korean Community Health Survey. The study population consisted of 2,156,829 participants. According to social trust index measured in the area of residence during 2011, participants were followed-up from 1 January 2012 to 31 December 2016. Multivariate Cox proportional hazards regression was used to determine the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for CVD risk according to quintiles of social trust. RESULTS: Compared to participants with the lowest quintile of social trust, those within the highest quintile had lower risk for CVD (aHR 0.91, 95% CI = 0.89 to 0.93), CHD (aHR 0.92, 95% CI = 0.89 to 0.95), and stroke (aHR 0.90, 95% CI = 0.87 to 0.93). The risk-reducing association of high social trust on CVD risk was preserved after additional adjustments for lifestyle behaviors including smoking, alcohol consumption, and physical activity. CONCLUSION: Higher social trust was associated with reduced risk of CVD even after considering lifestyle behaviors. Social trust in a community level is an important determinant of CVD and enhancing social trust may lead to reduced risk of CVD.

Association of community level social trust and reciprocity with mortality: a retrospective cohort study.

BACKGROUND: Whether community level social capital is associated with mortality within an Asian population is yet unclear. METHODS: The study population was derived from the Korean National Health Insurance Service-National Sample Cohort. A total of 636,055 participants were followed-up during 2012-2013 for deaths from all causes, cardiovascular disease (CVD), cancer, and other causes. Community level social trust and reciprocity at the administrative district level were derived from the Korean Community Health Survey. Cox proportional hazards regression was used to determine the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for mortality according to levels of community level social trust and reciprocity. RESULTS: Compared to participants who reside in areas within the lower half of community level social trust, those who reside in areas within the upper half had lower risk of death from all causes (aHR 0.84, 95% CI 0.78-0.89), CVD (aHR 0.82, 95% CI 0.67-0.99), and cancer (aHR 0.85, 95% CI 0.73-0.98). Similarly, residing in areas in the upper half of community level social reciprocity was associated with reduced risk for all-cause mortality (aHR 0.80, 95% CI 0.75-0.86). The protective association of high community level social trust and reciprocity on mortality remained after additional adjustments for smoking, alcohol intake, and physical activity. CONCLUSIONS: Residing in areas with high community level social trust and reciprocity may be associated with better population health status.

Maternal, neonatal, and child health systems under rapid urbanization: a qualitative study in a suburban district in Vietnam.

BACKGROUND: Vietnam has been successful in increasing access to maternal, neonatal, and child health (MNCH) services during last decades; however, little is known about whether the primary MNCH service utilization has been properly utilized under the recent rapid urbanization. We aimed to examine current MNCH service utilization patterns at a district level. METHODS: The study was conducted qualitatively in a rural district named Quoc Oai. Women who gave a birth within a year and medical staff at various levels participated through 43 individual in-depth interviews and 3 focus group interviews. RESULTS: Primary MNCH services were underutilized due to a failure to meet increased quality needs. Most of the mothers preferred private clinics for antenatal care and the district hospital for delivery due to the better service quality of these facilities compared to that of the commune health stations (CHSs). Mothers had few sociocultural barriers to acquiring service information or utilizing services based on their improved standard of living. A financial burden for some services, including caesarian section, still existed for uninsured mothers, while their insured counterparts had relatively few difficulties. CONCLUSIONS: For the improved macro-efficiency of MNCH systems, the government needs to rearrange human resources and/or merge some CHSs to achieve economies of scale and align with service volume distribution across the different levels.

Increasing varicella incidence rates among children in the Republic of Korea: an age-period-cohort analysis.

In the Republic of Korea, despite the introduction of one-dose universal varicella vaccination in 2005 and achieving a high coverage rate of 98.9% in 2012, the incidence rate has been increased sevenfold. This study aimed to investigate time trends of varicella incidence rate, assessing the age, period and birth cohort effects. We used national data on the annual number of reported cases from 2006 to 2017. A log-linear Poisson regression model was used to estimate age-period-cohort effects on varicella incidence rate. From 2006 to 2017, the incidence of varicella increased from 22.5 cases to more than 154.8 cases per 100 000. Peak incidence has shifted from 4 to 6 years old. The estimated period and cohort effects showed significant upward patterns, with a linear increasing trend by net drift. There has been an increase in the incidence among the Korean population regarding period and cohort despite the universal vaccination of varicella vaccine. Our data suggest the need for additional studies to address the current gap in herd immunity.

Trends and Correlates of High-Risk Alcohol Consumption and Types of Alcoholic Beverages in Middle-Aged Korean Adults: Results From the HEXA-G Study.

BACKGROUND: We aimed to report the prevalence and correlates of high-risk alcohol consumption and types of alcoholic beverages. METHODS: The baseline data of the Health Examinees-Gem (HEXA-G) study participants, including 43,927 men and 85,897 women enrolled from 2005 through 2013, were used for analysis. Joinpoint regression was performed to estimate trends in the age-standardized prevalence of alcohol consumption. Associations of demographic and behavioral factors, perceived health-related effects, social relationships, and the diagnostic history of diseases with alcohol consumption were assessed using multinomial logistic regression. RESULTS: The prevalence of alcohol consumption remained higher in men during the study period and increased in women. The amount of alcohol consumed has increased in women, especially that from beer and makgeolli, a traditional Korean fermented rice wine. Older participants were less likely to be high-risk drinkers (men and women who drink more than 40 or 20 g/day of alcohol, respectively) and drink Soju, a distilled liquor, and beer, and more likely to drink makgeolli. Educational level was negatively associated with high-risk drinking. However, it was positively associated with the consumption of strong spirits and wine. Smoking was associated with high-risk drinking and the consumption of soju and strong spirits. Engaging in regular exercise and having stress were associated with drinking all types of beverages except for soju. CONCLUSIONS: Sex-specific trends in alcohol consumption were influenced by demographic, behavioral, and perceived health-related factors. The findings will help improve the understanding of alcohol-related problems and provide evidence for establishing country-specific policies and campaigns in Korea.

Is there a female disadvantage in child undernutrition in South India?: Exploring gender differences in height in infancy, childhood, and adolescence in Andhra Pradesh and Telangana.

OBJECTIVE: The aim of this study was to investigate whether gender-based disparities in health and well-being extend to a female disadvantage in height in infancy, childhood, and adolescence in Andhra Pradesh and Telangana. METHODS: Using longitudinal data from the Young Lives study in Andhra Pradesh and Telangana, India, linear mixed effects and linear regression models examined associations between gender and height and the modifying influences of birth order and older siblings' gender composition. RESULTS: In the younger cohort, at 6-18 months, girls were 0.17-SDs of height for age z-scores (HAZ) taller than boys (P = .01). In the same cohort, the girls' advantage in HAZ was attenuated to 0.02 (P = .58) by 11-12 years. In the older cohort, the difference in HAZ between girls and boys was 0.04 (P = .61) at the beginning of the study when they were 7-8 years old; by 18-19 years of age, the difference had switched, with boys being 0.22-SD (P = .05) taller. There was no difference by birth order except in the younger cohort in which children with 2 or more siblings experienced height deficits compared with only children at 7-8 and 11-12 years. There was no differential effect of gender by birth order nor by the gender composition of siblings. CONCLUSION: A female disadvantage in undernutrition, as manifest in differences between girls and boys in HAZ, did not appear until later ages. Identifying how and why gendered disparities in standardized height emerge in late adolescence will help target more resources to improve conditions for girls and women in south India.