The need for epidemiological research on eating disorders in Africa and the Caribbean.

The eating disorders field acknowledges the need to include diverse populations in research. Although global diversity has increased in epidemiologic research, there is still a significant lack of research in Africa and the Caribbean. The objectives of this article are to highlight knowledge gaps in these regions and make recommendations to improve future research. We searched the literature about the epidemiology of eating disorders in Africa and the Caribbean and provided a brief summary of research findings and measures used to identify cases. There is a large knowledge gap about the epidemiology of eating disorders across African and Caribbean nations. Knowledge about the cultural appropriateness of measurement instruments and screening tools is also lacking. Inadequate information about the epidemiology of eating disorders in Africa and the Caribbean inhibits the eating disorders research field from identifying who is affected. Further, measures and screening instruments with uncertain cultural validity inhibit the ability to understand case presentations and treatment targets. We recommend that the field advocate for the inclusion of eating disorders in larger population health research and that future research should evaluate the appropriateness of measurement instruments to capture eating disorder cases in African and Caribbean countries. PUBLIC SIGNIFICANCE: There is a lack of eating disorder research in African and Caribbean countries. The limited studies that do exist show evidence of eating disorders in African and Caribbean countries. Research is needed to develop culturally relevant measures for screening and case identification, and to calculate incidence and prevalence.

Eating disorders and oral health: a scoping review.

BACKGROUND: Screening and treatment guidance for somatic sequalae of eating disorders typically include specifics such as laboratory testing, observable physical signs, and treatment interventions. Oral health guidance is notably sparse or absent from many guidelines. Often, the only mention of oral health is the potential erosion caused by self-induced vomiting and suggests a referral to an oral health professional. The guidelines generally do not include information about education and training of oral health professionals. OBJECTIVE: The objective of this research was to explore the literature on eating disorders and oral health including the effects of eating disordered behaviors on oral health and training of oral health professionals to increase their capacity to recognize and appropriately address clinical care needs of individuals with eating disorders. METHODS: A comprehensive scoping review was conducted to investigate what is known about the relationship between eating disorders and oral health and training provided to oral health professionals in recognition and treatment of individuals with eating disorders. The search was completed using PubMed, Embase, Science Direct, Google Scholar, and the Journal of the American Dental Association. RESULTS: Of 178 articles returned in the initial search, 72 full texts were read, and 44 were included based on eligibility criteria. The retained articles were categorized thematically into articles related to (1) oral health professional education and training, (2) the oral health effects of eating disorders, and (3) patient experiences of oral health care. CONCLUSION: Most of the research on the relationship between eating disorders and oral health examines the impact of eating disordered behaviors. There is a significantly smaller literature on the knowledge and training of oral health professionals related to eating disorders and individuals with eating disorders' experiences of oral health care. Research on education and training of oral health professionals should be expanded globally, taking into consideration the suitability of interventions for diverse models of oral health education and service delivery. Further, there is an opportunity for eating disorder professionals and professional organizations to improve understanding and care of eating disorders by building relationships with oral health providers and professional organizations in their local communities.

Oral health professionals, including dentists and dental hygienists, are well positioned to observe signs of eating disordered behaviors during routine oral health care. To gain an understanding of what is known about the relationship between eating disorders and oral health, we reviewed research studies that discussed any aspect of this relationship. We identified 44 studies meeting our criteria. Most of the extant research focuses on the impact of eating disorders on oral health. Smaller portions of the literature discussed education and training of oral health professionals and patients' oral health behaviors (including routine oral health care). Educational interventions to increase oral health professionals' knowledge of eating disorders and confidence in raising concerns with patients are effective, but evidence about whether they are being implemented in training programs is lacking. Further, many studies indicated the need to connect oral health professionals to eating disorder treatment providers. Additional research is needed to develop guidance and best practices for collaboration between fields.

Factors Affecting State-Level Enforcement of the Federal Mental Health Parity and Addiction Equity Act: A Cross-Case Analysis of Four States.

CONTEXT: The Mental Health Parity and Addiction Equity Act (MHPAEA) requires coverage for mental health and substance use disorder (MH/SUD) benefits to be no more restrictive than for medical/surgical benefits in commercial health plans. State insurance departments oversee enforcement for certain plans. Insufficient enforcement is one potential source of continued MH/SUD treatment gaps among commercial insurance enrollees. This study explored state-level factors that may drive enforcement variation. METHODS: The authors conducted a four-state multiple-case study to explore factors influencing state insurance offices' enforcement of MHPAEA. They interviewed 21 individuals who represented state government offices, advocacy organizations, professional organizations, and a national insurer. Their analysis included a within-case content analysis and a cross-case framework analysis. FINDINGS: Common themes included insurance office relationships with other stakeholders, policy complexity, and political priority. Relationships between insurance offices and other stakeholders varied between states. MHPAEA complexity posed challenges for interpretation and application. Policy champions influenced enforcement via priorities of insurance commissioners, governors, and legislatures. Where enforcement of MHPAEA was not prioritized by any actors, there was minimal state enforcement. CONCLUSIONS: Within a state, enforcement of MHPAEA is influenced by insurance office relationships, legal interpretation, and political priorities. These unique state factors present significant challenges to uniform enforcement.

Enforcement of the Mental Health Parity and Addiction Equity Act: State Insurance Commissioners' Statutory Capacity.

OBJECTIVE: State insurance departments enforce the federal Mental Health Parity and Addiction Equity Act (MHPAEA) for fully insured employer-sponsored health plans and plans on the individual marketplace. Variable enforcement among states may drive patients' difficulties in accessing behavioral health treatment. This study explored insurance commissioners' statutory capacity for enforcing the MHPAEA. METHODS: Legal mapping of insurance office powers and responsibilities was conducted for MHPAEA-enforcing states. Relevant state laws and regulations were gathered from the Westlaw database. Sections were coded in the categories commissioner selection, frequency of examinations, fines, licenses, subpoenas, investigations and hearings, rehabilitation or liquidation of insurers, and initiation of legal actions. RESULTS: The sample included 450 sections of states' codes and regulations. The 46 states that enforced the MHPAEA showed only small differences in the powers and responsibilities of insurance commissioners. CONCLUSIONS: Similarities across states in statutory capacity of commissioners suggest that it is not a primary source of variation in MHPAEA enforcement.

US Adults' Beliefs About Harassing or Threatening Public Health Officials During the COVID-19 Pandemic.

Importance: The rise in attacks on public health officials has weakened the public health workforce and complicated COVID-19 mitigation efforts. Objective: To examine the share of US adults who believed harassing or threatening public health officials because of COVID-19 business closures was justified and the factors shaping those beliefs. Design, Setting, and Participants: The Johns Hopkins University COVID-19 Civic Life and Public Health Survey was fielded from November 11 to 30, 2020, and July 26 to August 29, 2021. A nationally representative cohort of 1086 US adults was included. Main Outcomes and Measures: Respondents were asked how much they believed that threatening or harassing public health officials for business closures to slow COVID-19 transmission was justified. Adjusted differences in beliefs regarding attacks on public health officials were examined by respondent sociodemographic and political characteristics and by trust in science. Results: Of 1086 respondents who completed both survey waves, 565 (52%) were women, and the mean (SE) age was 49 (0.77) years. Overall, 177 respondents (16%) were Hispanic, 125 (11%) were non-Hispanic Black, 695 (64%) were non-Hispanic White, and 90 (8%) were non-Hispanic and another race. From November 2020 to July and August 2021, the share of adults who believed harassing or threatening public health officials because of business closures was justified rose from 20% (n = 218) to 25% (n = 276) (P = .046) and 15% (n = 163) to 21% (n = 232) (P = .01), respectively. In multivariable regression analysis, respondents who trusted science not much or not at all were more likely to view threatening public health officials as justified compared with who trusted science a lot (November 2020: 35% [95% CI, 21%-49%] vs 7% [95% CI, 4%-9%]; P < .001; July and August 2021: 47% [95% CI, 33%-61%] vs 15% [95% CI, 11%-19%]; P < .001). There were increases in negative views toward public health officials between November 2020 and July and August 2021, among those earning $75 000 or more annually (threatening justified: 7 [95% CI, 1-14] percentage points; P = .03), those with some college education (threatening justified: 6 [95% CI, 2-11] percentage points; P = .003), those identifying as politically independent (harassing justified: 9 [95% CI, 3-14] percentage points; P = .01), and those trusting science a lot (threatening justified: 8 [95% CI, 4-13] percentage points; P < .001). Conclusions and Relevance: While antagonism toward public health officials was concentrated among those doubting science and groups most negatively affected by the pandemic (eg, those with lower income and less education), the findings of this study suggest that there has been a shift toward such beliefs within more economically advantaged subgroups and those more trusting of science. Restoring public trust in public health officials will require nuanced engagement with diverse groups.

Association of Non-Pharmaceutical Interventions to Reduce the Spread of SARS-CoV-2 With Anxiety and Depressive Symptoms: A Multi-National Study of 43 Countries.

Objectives: To examine the association of non-pharmaceutical interventions (NPIs) with anxiety and depressive symptoms among adults and determine if these associations varied by gender and age. Methods: We combined survey data from 16,177,184 adults from 43 countries who participated in the daily COVID-19 Trends and Impact Survey via Facebook with time-varying NPI data from the Oxford COVID-19 Government Response Tracker between 24 April 2020 and 20 December 2020. Using logistic regression models, we examined the association of [1] overall NPI stringency and [2] seven individual NPIs (school closures, workplace closures, cancellation of public events, restrictions on the size of gatherings, stay-at-home requirements, restrictions on internal movement, and international travel controls) with anxiety and depressive symptoms. Results: More stringent implementation of NPIs was associated with a higher odds of anxiety and depressive symptoms, albeit with very small effect sizes. Individual NPIs had heterogeneous associations with anxiety and depressive symptoms by gender and age. Conclusion: Governments worldwide should be prepared to address the possible mental health consequences of stringent NPI implementation with both universal and targeted interventions for vulnerable groups.

Eating disorders in the U.S. Medicare population.

OBJECTIVE: The social and economic burden of eating disorders is significant and often financially devastating. Medicare is the largest public insurer in the United States and provides coverage for older adults and some disabled individuals. This study explores prevalence, sociodemographic and clinical characteristics, and health care spending for Medicare enrollees with eating disorders. METHOD: A cross-sectional study was conducted with the nationally representative 20% sample of 2016 Medicare inpatient, outpatient, carrier, and home health fee-for-service claims and Medicare Advantage encounter records. Sociodemographic characteristics and comorbid somatic conditions were compared between individuals with versus without an eating disorder diagnosis. Mean spending was compared overall and separately for inpatient, outpatient, home health, and pharmacy claims. RESULTS: The sample included 11,962,287 Medicare enrollees of whom 0.15% had an eating disorder diagnosis. Compared to those without a 2016 eating disorder diagnosis, a greater proportion of individuals with an eating disorder were female (73.8% vs. 54.3%), under age 65 (41.6% vs. 15.5%), and dually eligible for Medicaid due to disability or low-income qualification (48.0% vs. 19.6%). Individuals with eating disorders had higher rates of comorbid conditions, with the greatest differences in cardiac arrythmias (35.3% vs. 19.9%), arthritis (40.1% vs. 26.6%), and thyroid conditions (32.2% vs. 19.4%). Spending was higher for enrollees with eating disorders compared to those without overall ($29,456 vs. $7,418) and across settings. DISCUSSION: The findings establish that eating disorders occur in the Medicare population, and that enrollees with these illnesses have risk factors associated with significant healthcare spending and adverse health outcomes.

Improving Physical Health Among People With Serious Mental Illness: The Role of the Specialty Mental Health Sector.

People with serious mental illness die 10-20 years earlier, compared with the overall population, and the excess mortality is driven by undertreated physical health conditions. In the United States, there is growing interest in models integrating physical health care delivery, management, or coordination into specialty mental health programs, sometimes called "reverse integration." In November 2019, the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness convened a forum of 25 experts to discuss the current state of the evidence on integrated care models based in the specialty mental health system and to identify priorities for future research, policy, and practice. This article summarizes the group's conclusions. Key research priorities include identifying the active ingredients in multicomponent integrated care models and developing and validating integration performance metrics. Key policy and practice recommendations include developing new financing mechanisms and implementing strategies to build workforce and data capacity. Forum participants also highlighted an overarching need to address socioeconomic risks contributing to excess mortality among adults with serious mental illness.

Association Between Enrollment in Maryland's Behavioral Health Homes and Use of Outpatient Mental Health Services.

OBJECTIVE: This study examined the association between enrollment in Maryland's behavioral health home (BHH) program and use of outpatient mental health services among people with serious mental illness. METHODS: The study sample, drawn from Maryland Medicaid administrative claims data from 2012 through 2017, included 12,232 individuals ages 21-64 with a serious mental illness who were enrolled in a BHH (N=3,319) or never enrolled (N=8,913). A marginal structural modeling approach with inverse probability of treatment weighting was used to examine the association between BHH enrollment and outpatient mental health utilization, measured as the number of visits per 3-month period. RESULTS: BHH enrollment was associated with 0.8 additional outpatient mental health visits per 3-month period, or approximately three additional visits annually. CONCLUSIONS: A specialty mental health system-based health home model with a primary goal of improving access to general medical care was associated with increased use of outpatient mental health services.

Change Over Time in Public Support for Social Distancing, Mask Wearing, and Contact Tracing to Combat the COVID-19 Pandemic Among US Adults, April to November 2020.

Objectives. To examine how sociodemographic, political, religious, and civic characteristics; trust in science; and fixed versus fluid worldview were associated with evolving public support for social distancing, indoor mask wearing, and contact tracing to control the COVID-19 pandemic.Methods. Surveys were conducted with a nationally representative cohort of US adults in April, July, and November 2020.Results. Support for social distancing among US adults dropped from 89% in April to 79% in July, but then remained stable in November 2020 at 78%. In July and November, more than three quarters of respondents supported mask wearing and nearly as many supported contact tracing. In regression-adjusted models, support differences for social distancing, mask wearing, and contact tracing were most pronounced by age, partisanship, and trust in science. Having a more fluid worldview independently predicted higher support for contact tracing.Conclusions. Ongoing resistance to nonpharmaceutical public health responses among key subgroups challenge transmission control.Public Health Implications. Developing persuasive communication efforts targeting young adults, political conservatives, and those distrusting science should be a critical priority.

Cancer Screening Among Adults With and Without Serious Mental Illness: A Mixed Methods Study.

BACKGROUND: Persons with serious mental illness (SMI) die 10-20 years earlier than the general population; cancer is the second leading cause of death. Differences in cancer screening between SMI and the general population are not well understood. OBJECTIVES: To describe receipt of cancer screening among individuals with versus without SMI and to explore clinicians' perceptions around cancer screening for people with SMI. METHODS: Mixed-methods study using 2010-2017 MarketScan commercial insurance administrative claims data and semi-structured clinician interviews. In the quantitative analyses, we used multivariate logistic regression analyses to calculate the likelihood of receiving cervical, breast, colorectal, or prostate cancer screening among people with versus without SMI, defined as schizophrenia or bipolar disorder. We conducted semi-structured interviews with 17 primary care physicians and 15 psychiatrists. Interview transcripts were coded using a hybrid deductive/inductive approach. RESULTS: Relative to those without SMI, individuals with SMI were less likely to receive screening for cervical cancer [adjusted odds ratio (aOR): 0.80; 95% confidence interval (CI): 0.80-0.81], breast cancer (aOR: 0.79; 95% CI: 0.78-0.80), colorectal cancer (aOR: 0.90; 95% CI: 0.89-0.91), and prostate cancer (aOR: 0.85; 95% CI: 0.84-0.87). Clinicians identified 5 themes that may help explain the lower rates of cancer screening in persons with SMI: access to care, available support, prioritization of other issues, communication, and patient concerns. CONCLUSIONS: People with SMI were less likely to receive 4 common types of cancer screening. Improving cancer screening rates in the SMI population will likely require a multidisciplinary approach to overcome barriers to screening.

Reports of Forgone Medical Care Among US Adults During the Initial Phase of the COVID-19 Pandemic.

Importance: The coronavirus disease 2019 (COVID-19) pandemic has caused major disruptions in the US health care system. Objective: To estimate frequency of and reasons for reported forgone medical care from March to mid-July 2020 and examine characteristics of US adults who reported forgoing care. Design, Setting, and Participants: This survey study used data from the second wave of the Johns Hopkins COVID-19 Civic Life and Public Health Survey, fielded from July 7 to July 22, 2020. Respondents included a national sample of 1337 individuals aged 18 years or older in the US who were part of National Opinion Research Center's AmeriSpeak Panel. Exposures: The initial period of the COVID-19 pandemic in the US, defined as from March to mid-July 2020. Main Outcomes and Measures: The primary outcomes were missed doses of prescription medications; forgone preventive and other general medical care, mental health care, and elective surgeries; forgone care for new severe health issues; and reasons for forgoing care. Results: Of 1468 individuals who completed wave 1 of the Johns Hopkins COVID-19 Civic Life and Public Health Survey (70.4% completion rate), 1337 completed wave 2 (91.1% completion rate). The sample of respondents included 691 (52%) women, 840 non-Hispanic White individuals (63%), 160 non-Hispanic Black individuals (12%), and 223 Hispanic individuals (17%). The mean (SE) age of respondents was 48 (0.78) years. A total of 544 respondents (41%) forwent medical care from March through mid-July 2020. Among 1055 individuals (79%) who reported needing care, 544 (52%) reported forgoing care for any reason, 307 (29%) forwent care owing to fear of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission, and 75 (7%) forwent care owing to financial concerns associated with the COVID-19 pandemic. Respondents who were unemployed, compared with those who were employed, forwent care more often (121 of 186 respondents [65%] vs 251 of 503 respondents [50%]; P = .01) and were more likely to attribute forgone care to fear of SARS-CoV-2 transmission (78 of 186 respondents [42%] vs 120 of 503 respondents [24%]; P = .002) and financial concerns (36 of 186 respondents [20%] vs 28 of 503 respondents [6%]; P = .001). Respondents lacking health insurance were more likely to attribute forgone care to financial concerns than respondents with Medicare or commercial coverage (19 of 88 respondents [22%] vs 32 of 768 respondents [4%]; P < .001). Frequency of and reasons for forgone care differed in some instances by race/ethnicity, socioeconomic status, age, and health status. Conclusions and Relevance: This survey study found a high frequency of forgone care among US adults from March to mid-July 2020. Policies to improve health care affordability and to reassure individuals that they can safely seek care may be necessary with surging COVID-19 case rates.

Public Support for Social Safety-Net Policies for COVID-19 in the United States, April 2020.

Objectives. To examine public support for health insurance, income support, and unemployment policies during the initial phase of disease transmission and economic distress following the coronavirus disease 2019 (COVID-19) outbreak and to assess varying public support based on beliefs about the role of government.Methods. We fielded a nationally representative survey of US adults (n = 1468) from April 7, 2020, to April 13, 2020.Results. Of US adults, 77% supported paid sick leave, and a majority also supported universal health insurance, an increased minimum wage, and various unemployment support policies. Public support for an active government role in society to improve citizens' lives increased by 10 percentage points during this initial pandemic response relative to September 2019. Belief in a strong governmental role in society was associated with greater support for social safety-net policies.Conclusions. During the initial phase of the COVID-19 pandemic in early April 2020, most US adults favored a range of safety-net policies to ameliorate its negative health and economic consequences. For most safety-net policies, public support was highest among those favoring a stronger governmental role in society.