Short-term air pollution exposure associated with death from kidney diseases: a nationwide time-stratified case-crossover study in China from 2015 to 2019.

BACKGROUND: Long-term exposure to air pollution has been associated with the onset and progression of kidney diseases, but the association between short-term exposure to air pollution and mortality of kidney diseases has not yet been reported. METHODS: A nationally representative sample of 101,919 deaths from kidney diseases was collected from the Chinese Center for Disease Control and Prevention from 2015 to 2019. A time-stratified case-crossover study was applied to determine the associations. Satellite-based estimates of air pollution were assigned to each case and control day using a bilinear interpolation approach and geo-coded residential addresses. Conditional logistic regression models were constructed to estimate the associations adjusting for nonlinear splines of temperature and relative humidity. RESULTS: Each 10 µg/m3 increment in lag 0-1 mean concentrations of air pollutants was associated with a percent increase in death from kidney disease: 1.33% (95% confidence interval [CI]: 0.57% to 2.1%) for PM1, 0.49% (95% CI: 0.10% to 0.88%) for PM2.5, 0.32% (95% CI: 0.08% to 0.57%) for PM10, 1.26% (95% CI: 0.29% to 2.24%) for NO2, and 2.9% (95% CI: 1.68% to 4.15%) for SO2.  CONCLUSIONS: Our study suggests that short-term exposure to ambient PM1, PM2.5, PM10, NO2, and SO2 might be important environmental risk factors for death due to kidney diseases in China.

Ambient particulate matter and in-hospital case fatality of acute myocardial infarction: A multi-province cross-sectional study in China.

The acute myocardial infarction (AMI) outcomes have been extensively linked with ambient particulate matter (PM). However, whether a smaller particle has greater impact and the consequent attributable burden associated with PM of different sizes remain unclear. We conducted a multi-province cross-sectional study among AMI patients using the inpatient discharge datasets from four Chinese provinces (Shanxi, Sichuan, Guangxi, and Guangdong) from 2014 to 2019. Ambient PM exposure for each patient was assessed using the ChinaHighAirPollutants dataset. We employed the mixed-effects logistic regression models to evaluate the association of PM of different sizes (PM1, PM2.5, PM10) on in-hospital case fatality. The potential reducible fractions in in-hospital case fatality were estimated through counterfactual analyses. Of 177,749 participants, 125,501 (70.6 %) were male and the in-hospital case fatality rate was 4.9%. For short-term (7-day average) exposure, the odds ratios (ORs) for PM1, PM2.5, and PM10 (per 10 µg/m3) were 1.052 (95 % confidence interval [CI], 1.032-1.071), 1.026 (95 % CI, 1.014-1.037), and 1.016 (95% CI, 1.008-1.024), respectively. The estimated ORs for long-term exposure (annual average) were 1.303 (95 % CI, 1.252-1.356) for PM1, 1.209 (95 % CI, 1.178-1.241) for PM2.5, 1.157 (95 % CI, 1.134-1.181) for PM10. Short-term exposure to PM1 showed the highest potential reducible fraction (8.5 %, 95 % CI, 5.0-11.7 %), followed by PM2.5 and PM10, while the greatest potential reducible fraction of long-term exposure was observed in PM10 (30.9 %, 95 % CI, 27.2-34.4%), followed by PM2.5 and PM1. In summary, PM with smaller size had a more pronounced impact on in-hospital AMI case fatality, with PM1 exhibiting greater effects than PM2.5 and PM10. Substantial health benefits for AMI patients could be achieved by mitigating ambient PM exposure.

Association between maternal outdoor physical exercise and the risk of preterm birth: a case-control study in Wuhan, China.

BACKGROUND: China had the second largest proportion of preterm birth (PTB) internationally. However, only 11% of pregnant women in China meet international guidelines for maternal physical activity, a significantly lower proportion than that in Western countries. This study aims to examine the association between outdoor physical exercise during pregnancy and PTB among Chinese women in Wuhan, China. METHODS: A case-control study was conducted among 6656 pregnant women (2393 cases and 4263 controls) in Wuhan, China from June 2011 to June 2013. Self-reported measures of maternal physical exercise (frequency per week and per day in minutes) were collected. Adjusted odds ratios were estimated using Bayesian hierarchical logistic regression and a generalized additive mixed model (GAMM). RESULTS: Compared to women not involved in any physical activity, those who participated in physical exercise 1-2 times, 3-4 times, and over five times per week had 20% (aOR: 0.80, 95% credible interval [95% CI]: 0.68-0.92), 30% (aOR: 0.70, 95% CI: 0.60-0.82), and 32% (aOR: 0.68, 95% CI: 0.59-0.78) lower odds of PTB, respectively. The Bayesian GAMM showed that increasing physical exercise per day was associated with lower risk of PTB when exercise was less than 150 min per day; however, this direction of association is reversed when physical exercise was more than 150 min per day. CONCLUSION: Maternal physical exercise, at a moderate amount and intensity, is associated with lower PTB risk. More data from pregnant women with high participation in physical exercise are needed to confirm the reported U-shape association between the physical exercise and risk of preterm birth.

Association between ambient air pollution and hyperuricemia in traffic police officers in China: a cohort study.

To evaluate the association between ambient air pollution and hyperuricemia, we prospectively followed 1748 traffic police officers without hyperuricemia at baseline (2009-2014) from 11 districts in Guangzhou, China. We calculated six-year average PM10, SO2 and NO2 concentrations using data collected from air monitoring stations. The hazard ratios for hyperuricemia per 10 µg/m3 increase in air pollutants were 1.46 (95% CI: 1.28-1.68) for PM10, 1.23 (95% CI: 1.00-1.51) for SO2, and 1.43 (95% CI: 1.26-1.61) for NO2. We also identified changes in the ratio of serum uric acid to serum creatinine concentrations (ua/cre) per 10 µg/m3 increase in air pollutants as 11.54% (95% CI: 8.14%-14.93%) higher for PM10, 5.09% (95% CI: 2.76%-7.42%) higher for SO2, and 5.13% (95% CI: 2.35%-7.92%) higher for NO2, respectively. Long-term exposure to ambient air pollution was associated with a higher incidence of hyperuricemia and an increase in ua/cre among traffic police officers.

Investigation of simple, objective, and effective indicators for predicting acute paraquat poisoning outcomes.

Initial symptoms of paraquat (PQ) toxicity are often not obvious, and the lack of advanced testing equipment and medical conditions in the primary hospital make it difficult to provide early diagnosis and timely treatment. To explore simple, objective, and effective indicators of prognosis for primary clinicians, we retrospectively analyzed acute PQ poisoning in 190 patients admitted to our hospital from 2008 to 2017. Based on their condition at the time of discharge, patients were categorized into either the survival group (n = 71) or the mortality group (n = 119). Age, PQ ingested amount, urinary PQ, urinary protein, white blood cell (WBC), and serum creatinine (Cr) were the key factors associated with the prognosis for PQ poisoning. We identified specific diagnostic thresholds for these key indicators of PQ poisoning: PQ ingested amount (36.50 mL), urinary PQ (semiquantitative result "++"), urinary protein (semiquantitative result "±"), WBC (16.50 × 109/L), and serum Cr (102.10 µmol/L). Combining these five indicators to identify poisoning outcomes was considered objective, accurate, and convenient. When the combined score was <1, the predicted probability of patient death was 6%. When the combined score was ≥3, the predicted probability of patient death was 96%. These findings provide metrics to assist primary clinicians in predicting outcomes of acute PQ poisoning at earlier stages, a basis for administering treatment.

Long-term exposure to ambient fine particles associated with asthma: A cross-sectional study among older adults in six low- and middle-income countries.

BACKGROUND: Ambient PM2.5 is considered harmful to the respiratory system. However, little has been shown about the long-term association between ambient PM2.5 and asthma. METHODS: A survey from 2007 to 2010 was conducted among adults over 50 years of age in six low- and middle- income countries (including China, India, Ghana, Mexico, Russia, and South Africa), which belonged to one part of a prospective cohort study - the Study on global AGEing and adult health. The yearly mean PM2.5 concentrations of the residential communities of participants were estimated from remote sensing data. A mixed effects model was applied to investigate the association between ambient PM2.5 and asthma. RESULTS: A total of 4553 asthma patients were identified among the 29,249 participants in this study, producing a prevalence of 15.57%. For each 10 µg/m3 increase in PM2.5, the adjusted prevalence ratio of asthma was 1.05 (95% Confidence Interval: 1.01, 1.08) after controlling for the effects of sex, age, BMI, education attainment, smoking status, alcohol consumption, and occupational exposure. Further analyses showed that males and smokers might be particularly vulnerable populations. Additionally, it was estimated that about 5.12% of the asthma cases in the study population (95% Confidence Interval: 1.44%, 9.23%) could be attributed to long-term PM2.5 exposure. CONCLUSION: Long-term exposure to PM2.5 might be an important risk factor of asthma. Effective air pollution reduction measures should be taken to reduce PM2.5 concentrations in order to reduce the associated asthma cases and disease burden.

Ambient PM1 air pollution, blood pressure, and hypertension: Insights from the 33 Communities Chinese Health Study.

No evidence exists concerning the association between blood pressure and ambient particles with aerodynamic diameter ≤ 1.0 µm (PM1), a major component of PM2.5 (≤ 2.5 µm) particles, and potentially causing more hazardous health effects than PM2.5. We aimed to examine the associations of blood pressure in adults with both PM1 and PM2.5 in China. In 2009, we randomly selected 24,845 participants aged 18-74 years from 33 communities in China. Using a standardized mercuric-column sphygmomanometer, we measured blood pressure. Long-term exposure (2006-08) to PM1 and PM2.5 were estimated using a spatial statistical model. Generalized linear mixed models were used to evaluate the associations between air pollutants and blood pressure and hypertension prevalence, controlling for multiple covariates. A 10-µg/m3 increase in PM1 was significantly associated with an increase of 0.57 (95% CI 0.31-0.83) mmHg in systolic blood pressure (SBP), 0.19 (95% CI 0.03-0.35) mmHg increase in diastolic blood pressure (DBP), and a 5% (OR=1.05; 95% CI 1.01-1.10) increase in odds for hypertension. Similar associations were detected for PM2.5. Furthermore, PM1-2.5 showed no association with blood pressure or hypertension. In summary, both PM1 and PM2.5 exposures were associated with elevated blood pressure levels and hypertension prevalence in Chinese adults. In addition, most of the pro-hypertensive effects of PM2.5 may come from PM1. Further longitudinal designed studies are warranted to validate our findings.

Household water treatment and the nutritional status of primary-aged children in India: findings from the India human development survey.

BACKGROUND: Poor water quality, one of the leading causes of diarrhea, is an issue for most developing countries. Although the health burden of poor-quality water has been studied extensively, there is a paucity of research regarding the impact of household water treatment (HWT) on children's nutritional status using data from large-scale surveys. In this research, we study the effect of HWT on the nutritional status of primary-aged children in India using a secondary data set consisting of 20,315 children between the ages of 6 and 14 (10,523 males and 9,792 females) in 12,839 households from the second wave of the India Human Development Survey (IHDS-II). METHODS: The IHDS-II is a nationally representative, household-based, comprehensive, and face-to-face survey. Households were selected using stratified random sampling, and a team consisting of one male and one female interviewer visited each household between November 2011 and October 2012. A knowledgeable member, typically the male head of household, was interviewed about the socioeconomic condition of the household. An ever-married woman between the ages of 15 and 49, typically the wife of the male head of household, answered questions related to education and health. The height and weight of all eligible household members were measured by interviewers. Correlation between HWT and nutritional status was computed first, and the estimation of a generalized simultaneous equation model, in which a binary indicator of HWT and other covariates was included, was carried out afterward. RESULTS: Bivariate analysis shows a negative association between the nutritional status of children and HWT. Additionally, findings from the generalized simultaneous equation model demonstrate that HWT increases the probability of producing normal-weighted primary-aged children by 1.7 %, while it decreases the probability of primary-aged children being thin by 2.5% and being severely thin by 1.7% in India. CONCLUSIONS: This study indicates that HWT has the potential to advance the nutritional status of primary school-aged children in India.

Health Insurance Literacy and Medical Care Avoidance Among International Students: A Case Study.

Objectives: This research examines the health insurance literacy and healthcare utilization of international students attending a university in the US Midwest. Methods: One hundred and forty-three undergraduate and graduate students attending a midsize metropolitan university in the Midwest completed an online survey in early 2022. Results: Many students surveyed could not identify the definitions of basic terms, such as copay. Furthermore, about 80% of students surveyed could not determine their financial responsibilities in two medical settings. Regression results show that the continent they are from and the length of their stay in the United States significantly predict their understanding of key health insurance terms. More than half of the international students surveyed indicated they often feel confused about their health insurance (57.34%). Only about 20% have delayed or skipped care due to unfamiliarity with the health insurance system. Conclusion: The health insurance literacy of most international students at the midwestern university we surveyed is not ideal. This and possibly other universities in the United States should take more initiatives to help their international students understand the health insurance system.

The impact of healthcare industry convergence on the performance of the public health system: a geospatial modeling study of provincial panel data from China.

Objective: This paper examines the impact of healthcare industry convergence on the performance of the public health system in the eastern, central, and western regions of China. Methods: Public health performance was measured by a composite index of three standards: average life expectancy at birth, perinatal mortality, and maternal mortality. The healthcare industry convergence was measured using a coupling coordination degree method. The spatial lag, spatial error, and spatial Durbin models were used to estimate the effect of healthcare industry convergence on public health system performance and this effect's spatial dependence and heterogeneity across eastern, central, and western China using panel data from 30 Chinese provinces from 2002 to 2019. Results: The convergence of the healthcare industry significantly promotes regional public health [ß =0.576, 95% CI: (0.331,0.821)]. However, the convergence does not have a spatial spillover effect on the public health system at the national level. Additionally, analysis of regional heterogeneity shows that the direct effects of healthcare industry convergence on public health are positive and statistically significant for Eastern China, statistically insignificant for Central China, and positive and statistically significant for Western China. The indirect effects are negative, statistically significant, positive, statistically significant, and statistically insignificant for these three regions, respectively. Conclusion: Policy efforts should strengthen the convergence between the healthcare industry and relevant industries. It can produce more current healthcare services to improve public health and reduce regional health inequality.

Factors associated with food insecurity among the chronically ill population during the COVID-19 pandemic in the United States.

Introduction: Little is known about food insecurity among Americans with chronic diseases, one of the vulnerable groups in health care. Factors influencing food insecurity among this population group are especially poorly understood. Methods: Using data from the COVID Impact Survey, this cross-sectional study sought to examine food insecurity among adults with chronic diseases in the United States and to identify factors associated with their risks for food insecurity during the COVID-19 pandemic. Results: Nearly 28% of the national and 32% of the regional samples from the COVID Impact Survey were at risk for food insecurity. The logistic regressions show that chronically ill US adults with one of the following characteristics have higher odds of being at risk for food insecurity: younger than 60 years, having financial stress, unemployed, having received food from a food pantry, without health insurance, having a household income lower than $100,000, and without a college degree. Discussion: Targeted policies and programs are warranted to address underlying determinants of food insecurity that adults with chronic illnesses experience.

Self-esteem and weight status of young adults: Findings from a pilot study.

BACKGROUND: Researchers have examined the association between self-esteem and obesity in past studies. However, most studies have focused on pediatric or adolescent populations. In this pilot study, we aim to explore the association of self-esteem with weight status in young adults, a group of individuals in a significant and pivotal period of their lives whose needs and challenges have received little attention in previous studies. MATERIALS AND METHODS: Exactly 127 college juniors and seniors in the Midwest participated in late 2017. For our survey, we collected the following information: body weight, height, self-esteem score from the state self-esteem scale, grade point average, risk of eating disorders, sleep quality, nutritional behavior, lifestyle (smoking, frequency of exercise, alcohol drinking, average daily time watching television, playing video games, and social media use), and demographic and socioeconomic background. We used logistic regression for our analysis. RESULTS: The logistic regression indicates that a one-point increase in the self-esteem score was negatively associated with a young adult's odds of having an unhealthy weight (being overweight or obese) by approximately 3%. Furthermore, soda drinking is a statistically significant factor associated with weight status. CONCLUSIONS: This finding suggests self-esteem is positively associated with a healthy weight in young adults. A larger-scale study should be conducted in the future to validate this relationship and better understand young adults' needs.

Underlying Factors of Health Insurance Use Among Blacks and Hispanics With Ambulatory Care-Sensitive Conditions.

This study examined satisfaction with and confidence in understanding health insurance use among Blacks and Hispanic Americans with ambulatory care-sensitive conditions. Using the 2013-2016 Health Reform Monitoring Survey data sets, descriptive statistics and ordinary least-square regressions estimated the association between satisfaction and confidence scores and racial or ethnic groups with ambulatory care-sensitive conditions. Compared with their White counterparts, Black (ß = -.13; 95% confidence interval [CI], -0.19 to -0.06) and Hispanic (ß = -0.41; 95% CI, -0.48 to -0.33) participants' standardized confidence scores were significantly lower. Research is needed to identify factors that may enhance this population's confidence level.

The Chasm in Percutaneous Coronary Intervention and In-Hospital Mortality Rates Among Acute Myocardial Infarction Patients in Rural and Urban Hospitals in China: A Mediation Analysis.

Objectives: To determine to what extent the inequality in the ability to provide percutaneous coronary intervention (PCI) translates into outcomes for AMI patients in China. Methods: We identified 82,677 patients who had primary diagnoses of AMI and were hospitalized in Shanxi Province, China, between 2013 and 2017. We applied logistic regressions with inverse probability weighting based on propensity scores and mediation analyses to examine the association of hospital rurality with in-hospital mortality and the potential mediating effects of PCI. Results: In multivariate models where PCI was not adjusted for, rural hospitals were associated with a significantly higher risk of in-hospital mortality (odds ratio [OR]: 1.19, 95% confidence interval [CI]: 1.03-1.37). However, this association was nullified (OR: 0.94, 95% CI: 0.81-1.08) when PCI was included as a covariate. Mediation analyses revealed that PCI significantly mediated 132.3% (95% CI: 104.1-256.6%) of the effect of hospital rurality on in-hospital mortality. The direct effect of hospital rurality on in-hospital mortality was insignificant. Conclusion: The results highlight the need to improve rural hospitals' infrastructure and address the inequalities of treatments and outcomes in rural and urban hospitals.

Population attributable fraction of lung cancer due to genetic variants, modifiable risk factors, and their interactions: a nationwide prospective cohort study.

BACKGROUND: Genetic variants and modifiable risk factors (including environmental exposure and lifestyle) greatly contribute to the development of lung cancer. The population attributable fraction (PAF) of these risk factors, especially their interactive effects, has not been well quantified. METHODS: A total of 398,577 participants were included in this analysis. There were 2504 incident lung cancer cases identified over an average 10.4-year follow-up. We applied Cox proportional hazards models to examine the associations between risk factors and incident lung cancer. We further developed a polygenic risk score and evaluated whether environmental factors modified the effect of genetic risk on incident lung cancer. Furthermore, we calculated the PAF for each risk factor, as well as their gene-environment additive interaction, and then combined them to create a weighted PAF that takes into consideration participants with overlapping risk factors. RESULTS: Our analysis showed that smoking was the leading risk factor for lung cancer with a PAF of 63.73%. We observed additive interactions between smoking, PM2.5, NOx, and genetic risk, with PAFs of 17.85% (smoking-high genetic risk interaction), 10.79% (smoking-intermediate genetic risk interaction), 5.30% (NOx-high genetic risk interaction), 6.55% (PM2.5-high genetic risk interaction), and 4.99% (PM2.5-intermediate genetic risk interaction). We estimated that 73.46% of lung cancer cases could be attributable to potentially modifiable risk factors after adjusting for the correlation between them. CONCLUSION: High genetic risk and several modifiable factors may increase the risk of incident lung cancer. Participants with a high genetic risk may be more vulnerable to developing lung cancer if exposed to smoking and/or high air pollution. Our findings provide evidence that the majority of incident lung cancer cases could be prevented by eliminating modifiable risk factors.

Association between maternal family history of hypertension and preterm birth: modification by noise exposure and multivitamin intake.

OBJECTIVE: To measure the effect of maternal family history of hypertension on preterm birth (PTB) and to identify factors that modified this association. METHODS: A case-control study was nested in a prospective cohort of the entire pregnant population in Wuhan, China, from 2011 to 2013. Home-visit interviews were scheduled for all PTBs and their controls, to collect extensive information on maternal exposures to behavioral, environmental, and intergenerational risk factors of PTB. The effects of maternal family history of hypertension on PTB were measured by logistic regression analyses, controlling for potential confounders. Potential effect modifiers were examined using stratified analyses. RESULTS: There were 2393 PTBs and 4263 full-term births out of all eligible births. A positive association was observed between maternal family history of hypertension and PTB, after adjusted for potential confounders (adjusted odds ratio: 1.17 [1.03, 1.33]). A higher effect was observed when mothers were exposed to certain noise during pregnancy (adjusted odds ratio: 1.37 [1.14, 1.65]) and/or when they did not take multivitamins during pregnancy (adjusted odds ratio: 1.46 [1.20, 1.78]), whereas, this association was weaker and no longer significant when mothers took multivitamins during pregnancy (adjusted odds ratio: 1.00 [0.84, 1.19]) and/or when they were not exposed to certain noise during pregnancy (adjusted odds ratio: 1.01 [0.85, 1.12]). The modification effect from maternal multivitamin intake was significant on both spontaneous and medically indicated PTBs, and the modification effect from maternal exposure to certain noise was only significant on spontaneous PTB. CONCLUSIONS: Increased PTB risk was observed for pregnant women with a family history of hypertension in Wuhan, China. This effect was stronger when pregnant women did not take multivitamin and/or exposed to certain noise during pregnancy, than those who took multivitamin and/or unexposed to certain noise.

Cigarette taxes and respiratory cancers: new evidence from panel co-integration analysis.

Using a set of state-level longitudinal data from 1954 through 2005, this study investigates the "long-run equilibrium" relationship between cigarette excise taxes and the mortality rates of respiratory cancers in the United States. Statistical tests show that both cigarette excise taxes in real terms and mortality rates from respiratory cancers contain unit roots and are co-integrated. Estimates of co-integrating vectors indicated that a 10 percent increase in real cigarette excise tax rate leads to a 2.5 percent reduction in respiratory cancer mortality rate, implying a decline of 3,922 deaths per year, on a national level in the long run. These effects are statistically significant at the one percent level. Moreover, estimates of co-integrating vectors show that higher cigarette excise tax rates lead to lower mortality rates in most states; however, this relationship does not hold for Alaska, Florida, Hawaii, and Texas.

Association between socioeconomic welfare and depression among older adults: Evidence from the China health and Retirement Longitudinal Study.

This study aims to examine the association between province-level socioeconomic welfare factors and depression symptoms among older adults in China. Province-level socioeconomic characteristics were merged with microdata for respondents over 65 years from the 2018 China Health and Retirement Longitudinal Study (CHARLS) Wave 4 (N = 6657). Principal component analysis (PCA) was used to extract three socioeconomic welfare factors constructed from 14 province-level variables. A Bayesian mixed-effects logistic model was applied to measure the association between the three socioeconomic welfare factors and depression symptoms while controlling for socio-demographic variables. The PCA showed that economic welfare, medical resource welfare, and social service welfare together explained 72.2 percent of the total variance of the 14 province-level variables. It was found that increasing economic welfare was significantly associated with a lower probability of depression symptoms (OR = 0.806, 95%CI: [0.674, 0.967]), while medical facilities were associated with a higher probability of depression symptoms (OR = 1.181, 95%CI: [1.029, 1.354]) among Chinese older adults. Uncertainty existed as to whether having access to social welfare (OR = 0.941, 95%CI: [0.835, 1.060]) was associated with prevalence of depression. Thus, improved socioeconomic welfare systems for older adults (which possibly require an increase in spending) are necessary to contribute further to reduced depression risk in China. Policymakers should also improve the utilization of medical resources to mitigate the incidence of depression among the elderly in China.

Health Insurance Literacy and Medical Debt in Middle-Age Americans.

BACKGROUND: Health insurance literacy (HIL) may influence medical financial burden among people who are sick and the most vulnerable. OBJECTIVE: This study examined the relationships between HIL, health insurance factors, and medical debt among middle-age Americans, a population with an increasing prevalence of illnesses. METHODS: Linear and generalized linear regression analyses were conducted on data drawn from the 2015-2016 waves of the Health Reform Monitoring Survey, a national, internet-based sample of Americans age 18 to 64 years. The analytical sample included 8,042 people age 50 to 64 years. KEY RESULTS: Adjusted mean HIL scores did not differ by private versus public insurance or by out-of-pocket costs. Mean HIL scores were lower with higher deductibles; however, differences in mean scores were small. Higher HIL was associated with lower medical debt (odds ratio = 0.97; 95% confidence interval [0.96, 0.98]), but at the highest HIL score, the risk of having medical debt was still 13.8%. Public coverage, higher annual deductibles, and out-of-pocket costs were associated with higher risks of having medical debt. CONCLUSIONS: The findings suggest that HIL plays an important role in medical debt burden. However, with the shift toward high cost-sharing insurance plans, addressing health care affordability issues along with HIL are critical to eliminate medical debt problems. [HLRP: Health Literacy Research and Practice. 2021;5(4):e319-e332.] Plain Language Summary: Understanding and using health insurance (also defined as health insurance literacy) may influence the ability to pay medical bills among people who are sick and vulnerable. This study examined the relationships among health insurance literacy, health insurance factors, and difficulty paying medical bills (i.e., medical debt) in Americans age 50 to 64 years using data from the Health Reform Monitoring Survey. People with higher health insurance literacy reported lower medical debt. Type of insurance coverage did not influence medical debt. Those with annual deductibles and out-of-pocket health care costs were more likely to report having medical debt.

Maternal PM2.5 exposure associated with stillbirth: A large birth cohort study in seven Chinese cities.

BACKGROUND: Maternal exposure to fine particulate matter (PM2.5) has been associated with a few adverse birth outcomes. However, its effect on stillbirth remains unknown in China, especially the susceptible windows and potential modifiers. OBJECTIVE: This study aimed to evaluate the associations between maternal PM2.5 exposure and stillbirth in seven Chinese cities. METHODS: We used birth cohort data of 1,273,924 mother-and-birth pairs in seven cities in southern China between 2014 and 2017 to examine these associations. Pregnant women were recruited in the cohort at their first visit to a doctor for pregnancy, and stillbirths were recorded at the time of birth. Air pollution exposures were assessed through linking daily air pollutant concentrations from nearby monitoring stations to the mother's residential community. Cox regression models were applied to determine the associations between PM2.5 and stillbirth for different gestational periods. RESULTS: Among the participants, 3150 (2.47‰) were identified as stillbirth cases. The hazard ratio (HR) of stillbirths was 1.52 (95% CI: 1.42, 1.62) for each 10 µg/m3 increase in PM2.5 during the entire pregnancy after controlling for some important covariates. Relatively stronger associations were observed during the second trimester [adjusted HR = 1.67 (95% CI: 1.57, 1.77)] than trimesters 1 [HR = 1.44 (95% CI: 1.37, 1.52)] and trimester 3 [HR = 1.23 (95% CI: 1.16, 1.30)]. Stratified analyses also showed a stronger association among pregnant women without previous pregnancy and previous delivery experiences. CONCLUSION: The study indicates that maternal exposure to PM2.5, especially during the midpoint period of pregnancy, might increase the risk of stillbirths. Maternal previous pregnancy and delivery may modify this association.