Surveillance for Violent Deaths - National Violent Death Reporting System, 48 States, the District of Columbia, and Puerto Rico, 2021.

Problem/Condition: In 2021, approximately 75,000 persons died of violence-related injuries in the United States. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) on violent deaths that occurred in 48 states, the District of Columbia, and Puerto Rico in 2021. Results are reported by sex, age group, race and ethnicity, method of injury, type of location where the injury occurred, circumstances of injury, and other selected characteristics. This report introduces additional incident and circumstance variables, which now include child victim-specific circumstance information. This report also incorporates new U.S. Census Bureau race and ethnicity categories, which now account for more than one race and Native Hawaiian or other Pacific Islander categories and include updated denominators to calculate rates for these populations. Period Covered: 2021. Description of System: NVDRS collects data regarding violent deaths from death certificates, coroner and medical examiner records, and law enforcement reports. This report includes data collected for violent deaths that occurred in 2021. Data were collected from 48 states (all states with exception of Florida and Hawaii), the District of Columbia, and Puerto Rico. Forty-six states had statewide data, two additional states had data from counties representing a subset of their population (31 California counties, representing 64% of its population, and 13 Texas counties, representing 63% of its population), and the District of Columbia and Puerto Rico had jurisdiction-wide data. NVDRS collates information for each violent death and links deaths that are related (e.g., multiple homicides, homicide followed by suicide, or multiple suicides) into a single incident. Results: For 2021, NVDRS collected information on 68,866 fatal incidents involving 70,688 deaths that occurred in 48 states (46 states collecting statewide data, 31 California counties, and 13 Texas counties), and the District of Columbia. The deaths captured in NVDRS accounted for 86.5% of all homicides, legal intervention deaths, suicides, unintentional firearm injury deaths, and deaths of undetermined intent in the United States in 2021. In addition, information was collected for 816 fatal incidents involving 880 deaths in Puerto Rico. Data for Puerto Rico were analyzed separately. Of the 70,688 deaths, the majority (58.2%) were suicides, followed by homicides (31.5%), deaths of undetermined intent that might be due to violence (8.2%), legal intervention deaths (1.3%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force acting in the line of duty, excluding legal executions), and unintentional firearm injury deaths (<1.0%). The term "legal intervention" is a classification incorporated into the International Classification of Diseases, Tenth Revision, and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement.Demographic patterns and circumstances varied by manner of death. The suicide rate was higher for males than for females. Across all age groups, the suicide rate was highest among adults aged ≥85 years. In addition, non-Hispanic American Indian or Alaska Native (AI/AN) persons had the highest suicide rates among all racial and ethnic groups. Among both males and females, the most common method of injury for suicide was a firearm. Among all suicide victims, when circumstances were known (84.4%), suicide was most often preceded by a mental health, intimate partner, or physical health problem or by a recent or impending crisis during the previous or upcoming 2 weeks. The homicide rate was higher for males than for females. Among all homicide victims, the homicide rate was highest among persons aged 20-24 years compared with other age groups. Non-Hispanic Black or African American (Black) males experienced the highest homicide rate of any racial or ethnic group. Among all homicide victims, the most common method of injury was a firearm. When the relationship between a homicide victim and a suspect was known, the suspect was most frequently an acquaintance or friend for male victims and a current or former intimate partner for female victims. Homicide most often was precipitated by an argument or conflict, occurred in conjunction with another crime, or, for female victims, was related to intimate partner violence. Nearly all victims of legal intervention deaths were male, and the legal intervention death rate was highest among men aged 30-34 years. The legal intervention death rate was highest among AI/AN males, followed by Black males. A firearm was used in the majority of legal intervention deaths. When circumstances were known, the most frequent circumstances reported for legal intervention deaths were as follows: the victim used a weapon in the incident and the victim had a substance use problem (other than alcohol use). Other causes of death included unintentional firearm injury deaths and deaths of undetermined intent. Unintentional firearm injury deaths were most frequently experienced by males, non-Hispanic White (White) persons, and persons aged 15-24 years. These deaths most frequently occurred while the shooter was playing with a firearm and were precipitated by a person unintentionally pulling the trigger. The rate of deaths of undetermined intent was highest among males, particularly among AI/AN and Black males, and among adults aged 30-54 years. Poisoning was the most common method of injury in deaths of undetermined intent, and opioids were detected in nearly 80% of decedents tested for those substances. Interpretation: This report provides a detailed summary of data from NVDRS on violent deaths that occurred in 2021. The suicide rate was highest among AI/AN and White males, whereas the homicide rate was highest among Black males. Intimate partner violence precipitated a large proportion of homicides for females. Mental health problems, intimate partner problems, interpersonal conflicts, and acute life stressors were primary precipitating circumstances for multiple types of deaths examined. Public Health Action: Violence is preventable, and data can guide public health action. NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in developing, implementing, and evaluating programs, policies, and practices to reduce and prevent violent deaths. NVDRS data can be used to enhance prevention efforts into actionable strategies. States or jurisdictions have used their Violent Death Reporting System (VDRS) data to guide suicide prevention efforts and highlight where additional focus is needed. For example, North Carolina VDRS program data have played a significant role in expanding activities related to firearm safety and injury prevention. The program served as a primary data source for partners, which led to the creation of the Office of Violence Prevention in the state, focusing on combatting firearm-related deaths. In Maine, the VDRS provided data on law enforcement officer suicides that were used to help support a bill mandating mental health resiliency and awareness training in the state's law enforcement training academy, along with plans for similar training addressing mental health, substance use, and alcohol problems among corrections officers. In addition, states and jurisdictions have also used their VDRS data to examine factors related to homicide in their state or jurisdiction. For example, Georgia VDRS collaborated with the City of Atlanta Mayor's Office of Violence Reduction to develop two public dashboards that not only offer comprehensive data on violent deaths but also present data on the geographic distribution of populations disproportionately affected by violence to help inform violence prevention interventions.

Hepatitis B Vaccine Refusal Trends in Washington, DC, Newborns, 2017-2022.

This cross-sectional study evaluates trends in rates of hepatitis B vaccine birth dose refusals in Washington, DC, from 2017 to 2022.

Identifying facilitators and barriers to the uptake of medication for opioid use disorder in Washington, DC: A community-engaged concept mapping approach.

INTRODUCTION: Opioid overdose is a major public health challenge. We aimed to understand facilitators and barriers to engagement in medication for opioid use disorder (MOUD) among persons with OUD in Washington, DC. METHODS: We used a cross-sectional mixed-methods concept mapping approach to explore MOUD engagement between 2021-2022. Community members at-large generated 70 unique statements in response to the focus prompt: "What makes medication for opioid use disorder like buprenorphine (also known as Suboxone or Subutex) difficult to start or keep using?" Persons with OUD (n = 23) and service providers (n = 34) sorted and rated these statements by theme and importance. Data were analyzed with multidimensional scaling and hierarchical cluster analysis, producing thematic cluster maps. Results were validated by our community advisory board. RESULTS: Seven themes emerged in response to the focus prompt: availability and accessibility; hopelessness and fear; unmet basic needs; characteristics of treatment programs; understanding and awareness of treatment; personal motivations, attitudes, and beliefs; and easier to use drugs. "Availability and accessibility," "hopelessness and fear," and "basic needs not being met" were the top three identified barriers to MOUD among consumers and providers; however, the order of these priorities differed between consumers and providers. There was a notable lack of communication and programming to address misconceptions about MOUD's efficacy, side effects, and cost. Stigma underscored many of the statements, showcasing its continued presence in clinical and social spaces. CONCLUSIONS: This study distinguishes itself from other research on MOUD delivery and barriers by centering on community members and their lived experiences. Findings emphasize the need to expand access to treatment, dismantle stigma associated with substance use and MOUD, and address underlying circumstances that contribute to the profound sense of hopelessness and fear among persons with OUD-all of which will require collective action from consumers, providers, and the public.

Fabricating the Black Psyche: Saint Elizabeths Hospital and The Psychoanalytic Review.

Between 1913 and 1917, The Psychoanalytic Review published several studies that argued for a distinct Black psyche. They were edited by the journal's co-founder, William Alanson White, and conducted by the staff at Saint Elizabeths Hospital in Washington, DC, where White served as superintendent. This article provides a brief historical context for better understanding of why and how The Review paid attention to the comparative study of race.

The Community is the Cure: How African American Washington, DC Residents Informed Opioid Treatment Engagement.

BACKGROUND: Recent data indicate rising opioid overdose deaths among African American residents of Washington, DC. OBJECTIVES: We highlight a community-informed approach to assessing attitudes toward opioid use disorder treatment among DC residents (February 2019 to March 2020). METHODS: A listening tour with trusted community leaders led to the formation of a Community Advisory Board (CAB). When the COVID-19 pandemic commenced in March 2020, community dialogues became exclusively virtual. The CAB partnered with academic leaders to co-create project mission and values and center the community's concerns related to opioid use and its causes, treatment structure, and facilitators of effective engagement. RESULTS: Interview guides were created for the engagement of community members, using values highlighted by the CAB. The CAB underscored that in addition to opioid problems, effective engagement must address community experience, collective strengths/resilience, and the role of indigenous leadership. CONCLUSIONS: Engaging community prior to project implementation and maintaining alignment with community values facilitated opioid use disorder assessments. Community-informed assessments may be critical to building community trust.

Widespread exposure to SARS-CoV-2 in wildlife communities.

Pervasive SARS-CoV-2 infections in humans have led to multiple transmission events to animals. While SARS-CoV-2 has a potential broad wildlife host range, most documented infections have been in captive animals and a single wildlife species, the white-tailed deer. The full extent of SARS-CoV-2 exposure among wildlife communities and the factors that influence wildlife transmission risk remain unknown. We sampled 23 species of wildlife for SARS-CoV-2 and examined the effects of urbanization and human use on seropositivity. Here, we document positive detections of SARS-CoV-2 RNA in six species, including the deer mouse, Virginia opossum, raccoon, groundhog, Eastern cottontail, and Eastern red bat between May 2022-September 2023 across Virginia and Washington, D.C., USA. In addition, we found that sites with high human activity had three times higher seroprevalence than low human-use areas. We obtained SARS-CoV-2 genomic sequences from nine individuals of six species which were assigned to seven Pango lineages of the Omicron variant. The close match to variants circulating in humans at the time suggests at least seven recent human-to-animal transmission events. Our data support that exposure to SARS-CoV-2 has been widespread in wildlife communities and suggests that areas with high human activity may serve as points of contact for cross-species transmission.

COVID-19 Incidence, Risk Factors, Impact, and Related Stigma Among a Cohort of Persons With HIV in Washington, DC.

BACKGROUND: Studies on the incidence of COVID-19 among persons with HIV (PWHs) present varied results. Few studies have investigated the impact of COVID-19 infection on health and socioeconomic factors or COVID-19 stigma. We sought to measure the incidence and severity of COVID-19 infection among a cohort of PWHs, characterize associated risk factors and impact, and document perceptions of COVID-19-related stigma. METHODS: Data for this cross-sectional study come from the COVID-19 survey of participants in the DC Cohort longitudinal study from October 30, 2020, through December 31, 2022. Survey results were linked to electronic health records, including HIV laboratory test results and COVID test results. We conducted analyses comparing demographic, socioeconomic, HIV measures, and stigma among those with and without self-reported COVID-19. RESULTS: Of 1972 survey respondents, 17% self-reported COVID-19 infection, with the greatest incidence in the Omicron wave of the pandemic. We found statistically significant differences by age, employment status, essential worker status, education, and household income. Longer duration of HIV diagnosis was associated with greater incidence of COVID-19. PWHs who were overweight or obese had a greater incidence of COVID-19 compared with those who were not. Over 40% of PWHs with COVID-19 reported experiencing at least 1 form of COVID-19-related stigma. CONCLUSION: We observed a high incidence of COVID-19 infection among PWHs in DC. Furthermore, a substantial proportion of PWHs with COVID-19 reported experiencing COVID-19-related stigma. These findings add to the existing literature on COVID-19 coinfection among PWHs and highlight the need for awareness and support for those experiencing COVID-19 stigma.

Health Insurance Coverage Predicts Health Care Use among Latine Immigrants in Two Policy Contexts.

This study analyzed electronic health record (EHR) data from 2016 through 2019 from a federally qualified health center (FQHC) serving predominantly low-income Latine immigrants in the Washington, D.C. metropolitan area to examine how changes in health insurance coverage relate to changes in health care use. Federally qualified health center clients were insured for an average of 59% to 63% of their annual visits, but about one-third had no coverage throughout the year. Findings from descriptive regression and within-client fixed effects models indicate that in years with higher proportions of insured visits, clients averaged more medical visits and interpreter services but fewer mental health and care coordination visits. Latine immigrant clients in D.C., a city with a universal health insurance option, had health insurance coverage for 89% of their visits, and averaged more medical and fewer coordination visits relative to those in a neighboring county in a state without a universal insurance option.

Designing and Developing a Medical-Legal Partnership to Address Cancer Patients' Health-Harming Legal Needs.

The Georgetown University's Cancer Legal Assistance and Well-being Project launched in 2020 as a medical-legal partnership that works with health care providers at a Washington, D.C. safety-net hospital to treat the health-harming legal needs of historically and intentionally marginalized patients with cancer.

Neighborhood Inequities in Tobacco Product Descriptors, Washington, DC, 2018-2019.

BACKGROUND: The tobacco industry uses product descriptors to communicate reduced harm and increase appeal. This cross-sectional study assessed store-level racial, ethnic, and socioeconomic inequities in the distribution of retail tobacco product descriptors in a convenience sample of retailers in Washington, DC. METHODS: Young adults (n = 146) who did not currently use tobacco reported real-time store visits over 14 days. Trained data collectors took high-resolution photographs of all tobacco (including e-cigarette) marketing in each store (n = 96) participants visited. We coded text descriptors on tobacco product advertisements and displays into descriptor categories (eg, fruit, sweet, concept). We fit multilevel models to examine relationships between store neighborhood census tract-level racial, ethnic, and socioeconomic characteristics and tobacco product descriptors in stores. As a supplementary analysis, we used geospatial methods to model predicted patterns of descriptors at the census tract level. RESULTS: Stores located in census tracts with the highest versus lowest percentage of Black residents had a greater count of fruit, sweet or dessert, alcohol, and concept descriptors (p < .05), similar to findings from the geospatial approach. Adjusted models also indicated some inequities in stores in census tracts with higher percentages of Hispanic or Latino residents for fruit, alcohol, and concept descriptors; however, tract-level models showed opposite results for concept flavors. CONCLUSIONS: In this convenience sample, fruit, alcohol, sweet/dessert, and concept FTP descriptors were prevalent in stores in neighborhoods with more Black residents demonstrated through two analytic approaches. Surveillance using representative samples of tobacco retailers could improve the ability to track the extent of this inequity. IMPLICATIONS: We document inequities in the amount of fruit, sweet or dessert, alcohol, and concept flavor descriptors in stores across neighborhoods in Washington, DC. Federal, state, and local regulatory action is needed to reduce inequities in flavored tobacco product availability and marketing, including for concept flavors.

A cross-sectional survey of clinical trials knowledge, participation, and perspectives in an underserved community of Washington, DC.

The inclusion of participants from underrepresented and underserved groups is lagging in dermatology clinical trials. Through dissemination of a pilot survey at a community skin health fair, knowledge, participation, and perspectives of clinical trials were evaluated in an urban, medically underserved community in Washington, DC. Clinical trial-related questions were derived from the Health Information National Trends Survey 5 Cycle 4. This cross-sectional survey analyzed responses from 39/55 attendees (71% response rate). Most respondents were female (23/37 [62.2%]), between the ages of 25 and 54 (19/38, [50.0%]), and self-identified as non-white (35/39 [89.7%]) with a majority self-identifying as Black (16/31 [41%]). Most respondents self-reported knowing "little" to "nothing" about clinical trials (26/35 [74.3%]), and even more were unaware of the federal resource clinicaltrials.gov (30/37 [81.1%]). Few respondents discussed clinical trials as a treatment option with their healthcare provider (8/35 [22.9%]), yet having a discussion was significantly correlated with clinical trial participation (p = 0.0302). Self-reported level of knowledge was not significantly associated with participation in a clinical trial (p = 0.3035). Healthcare providers were the preferred first source of clinical trial information, followed by an internet search. Respondents rarely cited mistrust or skepticism as a barrier to participation (2/34 [5.9%]). Subjective positive healthcare experiences were significantly correlated to positive expectations with clinical trial participation (p = 0.0242). The findings of this study suggest the essential role healthcare providers, including dermatologists, play in clinical trial education and recruitment of underrepresented populations, and that patient mistrust may be present but is a rarely cited barrier to clinical trial participation.

A randomized controlled trial evaluating the effects of nurse-led triage of 911 calls.

To better connect non-emergent 911 callers to appropriate care, Washington, DC, routed low-acuity callers to nurses. Nurses could provide non-emergent transportation to a health centre, recommend self-care or return callers to the traditional 911 system. Over about one year, 6,053 callers were randomized (1:1) to receive a business-as-usual response (ncontrol = 3,023) or further triage (ntreatment = 3,030). We report on seven of nine outcomes, which were pre-registered ( https://osf.io/xderw ). The proportion of calls resulting in an ambulance dispatch dropped from 97% to 56% (ß = -1.216 (-1.324, -1.108), P < 0.001), and those resulting in an ambulance transport dropped from 73% to 45% (ß = -3.376 (-3.615, -3.137), P < 0.001). Among those callers who were Medicaid beneficiaries, within 24 hours, the proportion of calls resulting in an emergency department visit for issues classified as non-emergent or primary care physician (PCP) treatable dropped from 29.5% to 25.1% (ß = -0.230 (-0.391, -0.069), P < 0.001), and the proportion resulting in the caller visiting a PCP rose from 2.5% to 8.2% (ß = 1.252 (0.889, 1.615), P < 0.001). Over the longer time span of six months, we failed to detect evidence of impacts on emergency department visits, PCP visits or Medicaid expenditures. From a safety perspective, 13 callers randomized to treatment were eventually diagnosed with a time-sensitive illness, all of whom were quickly triaged to an ambulance response. These short-term effects suggest that nurse-led triage of non-emergent calls can safely connect callers to more appropriate, timely care.

Predictors of PrEP Retention and Attrition in an Urban Publicly Funded Safety-net Specialty Clinic.

Pre-exposure prophylaxis (PrEP) is an effective tool for human immunodeficiency virus (HIV) prevention. The purpose of this study is to identify correlates of PrEP retention using patient data from an urban, publicly funded safety-net clinic in Washington, DC. Cox proportional hazards regression, logistical regression, and survival curves were used to assess the association of age, gender, race/ethnicity, insurance, number of partners, and sexually transmitted infection (STI) diagnosis at PrEP initiation with time on PrEP. From August 2016-December 2020, 1,126 people were prescribed PrEP - patients were mostly Black (44.8%) or Latinx (30.4%) and identified as cisgender men (84.6%). Half had no insurance (49.1%), with the remaining patients reporting private (28.9%) or public (21.5%) insurance. Age at PrEP prescription ranged from 15 to 66 with 80% being 20 to 39 years. For the 87.7% (n = 987) of patients who discontinued PrEP, mean PrEP time was 158 days and median was 28 days. The highest rates of discontinuation were observed within the first month with 44.3% discontinuing by day 30, 52.3% by 3 months, and 73.2% by 1 year. Cisgender women, transgender persons, and those younger than 30 years were more likely to discontinue PrEP. Latinx and patients with less than 3 male partners in the last 90 days were less likely to discontinue PrEP. We demonstrated a high level of PrEP uptake among populations disproportionally affected by HIV. Future analyses are needed to examine ways of reducing barriers to PrEP initiation and improving PrEP adherence.

Risk of Chronic Obstructive Pulmonary Disease and Receipt of a Breathing Test in 26 States and the District of Columbia, 2017-2018.

We estimated the prevalence of respiratory symptoms, chronic obstructive pulmonary disease (COPD) risk level, and receipt of a breathing test among adults without reported COPD in 26 states and the District of Columbia by using 2017-2018 Behavioral Risk Factor Surveillance System data. Among adults without reported COPD, the 3 respiratory symptoms indicating COPD (chronic cough, phlegm or mucus production, shortness of breath) were common (each >10%). About 15.0% were at higher COPD risk (based on the number of symptoms, age, and smoking status); 41.4% of adults at higher risk reported receipt of a breathing test. Patient-provider recognition and communication of risk symptoms, appropriate screening, and follow-up are important for early diagnosis and treatment.

Few Prison Systems Release Individual Death Data: Death in Custody Reporting Act Completeness, Speed, and Compliance.

The United States has one of the largest incarcerated populations per capita. Prisons are dangerous environments, with high in-prison and postrelease mortality. The Death in Custody Reporting Acts (DCRAs) of 2000 and 2013 require deaths of people in correctional custody or caused by law enforcement to be reported to the Bureau of Justice Assistance. These deaths must be reported within 3 months of the death and include 10 required fields (eg, age, cause of death). There is no public reporting requirement. Our Third City Mortality project tracks near-real-time data about individual deaths released publicly and prison system metadata, including data completeness and release speed, across (N = 54) US state, federal (N = 2; Bureau of Prisons, Immigration and Customs Enforcement), Washington, District of Columbia, and Puerto Rico prison systems. Twenty-one (38%) systems release no individual death data; 13 systems release incomplete data slower than 1 year; 19 release timely, but incomplete, death data; and only one system (Iowa) releases complete and timely data. Incomplete, untimely, public prison mortality data limit protective community responses and epidemiology.

Enrollment and use of a peer counselor mHealth texting program to support breastfeeding in low-income people: A pilot study in the District of Columbia.

OBJECTIVE: To describe the characteristics of postpartum people who did and did not enroll in a breastfeeding peer-counselor mobile health (mHealth) texting program as well as the issues raised through 2-way texting with peer counselors. DESIGN: Pilot intervention study involving two Special Supplemental Nutrition Programs for Women Infants and Children (WIC) sites in the District of Columbia over 1 year. SAMPLE: WIC recipients. MEASUREMENTS: Descriptive statistics, comparison of recipients who enrolled or not and qualitative content analysis of text messages. INTERVENTION: A breastfeeding peer counselor texting program entitled BfedDC involving routine 1-way programmed messages and 2-way texting capacity for recipients to engage with peer counselors. RESULTS: Among our sample (n = 1642), nearly 90% initiated breastfeeding. A total of 18.5% (n = 304) enrolled in the BfedDC texting program, of whom 19.7% (n = 60) utilized the 2-way texting feature. Message content covered seven content themes and included inquiries about expressing human milk, breastfeeding difficulties, breastfeeding frequency and duration, appointments and more. CONCLUSIONS: Although enrollment was relatively low in BfedDC, benefits included 1-way supportive texts for breastfeeding and the ability to 2-way text with peer counselors. This program aligns with the Surgeon General's Call to Action to Support Breastfeeding and promotes breastfeeding equity in low-income people.

Legislative Health Notes: Preliminary Learnings From Piloting a New Policy Analysis Tool.

CONTEXT: In 2018, the Health Impact Project (the Project) developed and tested a new health in all policies (HiAP) tool called "legislative health notes" to provide state and local legislators with peer-reviewed evidence, public health data, and local data that illustrate potential positive and negative health and equity effects of proposed bills. OBJECTIVES: The Project sought to refine the health note methodology while piloting the tool in the Colorado and Indiana General Assemblies, and with the Council of the District of Columbia, and worked with affiliates to introduce them in North Carolina, Ohio, and California. DESIGN AND PARTICIPANTS: External partners solicited feedback on health notes via semistructured interviews and surveys from legislators, legislative staff, and expert reviewers who were familiar with health notes in each of these jurisdictions. RESULTS: Respondents shared that health notes were nonpartisan, were easy for nonexperts to understand, and would be more effective if delivered earlier in the legislative process. CONCLUSION: In response to informant feedback, practitioners can explore adding high-level summaries, increasing focus on health equity implications and the potential to work with legislators during the policy formulation phase. Data from this pilot suggest that legislative health notes are a promising nonpartisan and standardized tool to better understand the health and equity implications of proposed legislation.

Association Between Park Use and Moderate-to-Vigorous Activity During COVID-19 Years among a Cohort of Low-Income Youth.

Neighborhood parks are important venues to support moderate-to-vigorous (MVPA) activity. There has been a noticeable increase promoting physical activity among youth in neighborhood parks. This paper aims to assess the association between park use and MVPA among low-income youth in a large urban area. We recruited a cohort of 434 youth participants during the COVID pandemic years (2020-2022) from low-income households in Washington, D.C. We collected multiple data components: accelerometry, survey, and electronic health record data. We explored the bivariate relationship between the accelerometer-measured daily MVPA time outcome and survey-based park use measures. A mixed-effect model was fitted to adjust the effect estimate for participant-level and time-varying confounders. The overall average daily MVPA time is 16.0 min (SD = 12.7). The unadjusted bivariate relation between daily MVPA time and frequency of park visit is 1.3 min of daily MVPA time per one day with park visits (p < 0.0001). The model-adjusted estimate is 0.7 daily MVPA minutes for 1 day with park visit (p = 0.04). The duration of a typical park visit is not a significant predictor to daily MVPA time with or without adjustments. The initial COVID outbreak in 2020 resulted in a significant decline in daily MVPA time (- 4.7 min for 2020 versus 2022, p < 0.0001). Park visit frequency is a significant predictor to low-income youth's daily MVPA time with considerable absolute effect sizes compared with other barriers and facilitators. Promoting more frequent park use may be a useful means to improve low-income youth's MVPA outcome.

"It's different than a doctor saying 'You're making the right choice'": A qualitative study of chaplains' experience caring for patients undergoing abortion in Washington DC, Maryland, and Virginia.

OBJECTIVES: Health care chaplains are faith providers with theological education, pastoral experience, and clinical training who provide spiritual care to patients, their families, and medical staff. This study sought to characterize chaplains' experiences providing spiritual care for patients experiencing abortion and pregnancy loss and to explore how chaplains gain competency and comfort in providing pastoral care for this patient population. STUDY DESIGN: Researchers conducted in-depth, semistructured, qualitative interviews with currently-practicing chaplains recruited via convenience sampling in the Washington DC, Maryland, and Virginia region. We analyzed interviews using directed content analysis and coded using both inductive and deductive coding. RESULTS: We interviewed 13 chaplains. The majority were Protestant and identified as Democrats. Participants often personally struggled with the acceptability of abortion but emphasized the importance of spiritual care for this patient population. They recognized that religious stigma regarding abortion prevented referrals to chaplaincy. Though desiring to contribute, chaplains reported little formal education in pregnancy support counseling. They relied on foundational pastoral care skills, like holding space, values clarification, connecting with patients' spirituality, words of comfort, ritualistic memorialization, and resource provision. All desired more training specific to abortion and pregnancy loss in chaplaincy education. CONCLUSIONS: Chaplains from varied faith backgrounds have a diverse set of skills to support patients experiencing abortion or pregnancy loss, but feel underutilized and lacking in formal training. Though not all patients require pastoral support, chaplains can be critical members of the care team, particularly for those patients experiencing spiritual distress. IMPLICATIONS: Chaplains have a paucity of training in supporting patients experiencing abortion and pregnancy loss. Chaplains want to be involved with patients experiencing abortion but feel excluded by both patients and practitioners. Standardization of pastoral care training is important to ensure adequate spiritual support for patients who desire such services.

Tuberculosis - United States, 2023.

After 27 years of declining U.S. tuberculosis (TB) case counts, the number of TB cases declined considerably in 2020, coinciding with the COVID-19 pandemic. For this analysis, TB case counts were obtained from the National TB Surveillance System. U.S. Census Bureau population estimates were used to calculate rates overall, by jurisdiction, birth origin, race and ethnicity, and age group. Since 2020, TB case counts and rates have increased each year. During 2023, a total of 9,615 TB cases were provisionally reported by the 50 U.S. states and the District of Columbia (DC), representing an increase of 1,295 cases (16%) as compared with 2022. The rate in 2023 (2.9 per 100,000 persons) also increased compared with that in 2022 (2.5). Forty states and DC reported increases in 2023 in both case counts and rates. National case counts increased among all age groups and among both U.S.-born and non-U.S.-born persons. Although TB incidence in the United States is among the lowest in the world and most U.S. residents are at minimal risk, TB continues to cause substantial global morbidity and mortality. This postpandemic increase in U.S. cases highlights the importance of continuing to engage communities with higher TB rates and their medical providers in TB elimination efforts and strengthening the capacity in public health programs to carry out critical disease control and prevention strategies.