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Background: Understanding of the alcohol industry's means of influencing public policy is increasingly well established. Less is known, however, about the specific organisations that lead the political strategies of the alcohol industry. To fill this gap, this paper explores the Distilled Spirits Council of the United States (DISCUS), a key trade association in the United States (US), which also operates internationally. Methods: This study explores how DISCUS is organised and the main political activities it pursues to advance its policy interests. The study triangulates data from several sources, including DISCUS documents, as well as federal lobbying and election expenditure data. Results: This study demonstrates that DISCUS is a key political actor in the US and global alcohol policymaking context. There are identifiable strategies used by DISCUS to shape alcohol policy debates, including framing and lobbying. We also find key synergies between these strategies and identify their operation at varying levels of policy decision-making. Conclusions: Generating more secure inferences about the nature of the alcohol industry's efforts to advance its interests, and with what success and at what cost, requires researchers to investigate other trade associations in different contexts, and use other data sources. [ABSTRACT FROM AUTHOR]

The Melillo et al. article: Reliability and validity of the Veterans Administration Mobility Screening and Solutions Tool (MSST) (Melillo et al, BMC Health Serv Res 22:1323, 2022) introduces the MSST, a derivative flowchart tool in which the Banner Bedside Mobility Assessment Tool (BMAT) is embedded. The authors identify similar goals for the MSST as those for the BMAT, i.e. determine real-time mobility status and choose safe patient handling and mobility (SPHM) equipment to complete transfer and mobility tasks. Further Melillo et al. indicate that goals included "revising and enhancing" and addressing "gaps" in the BMAT, as well as creating instructions for the four BMAT levels (sit and shake, stretch and point, stand, step: march-in-place, advance step and return) that are clear, understandable and comfortable to use. The authors indicate that another goal of the VA MSST is it "enables any healthcare worker at any time to accurately measure and communicate patient mobility and transfer equipment needs." The present article addresses inaccuracies observed in the Melillo et al. article and confusing elements found in the VA MSST flowchart. The present article is based on the author's involvement in developing the BMAT starting in 2003 along with teams from Banner Health and Liko/Hill-Rom which incorporated use of the BMAT by unlicensed assistive personnel (UAP) as a recheck or verification of earlier testing. The 2020 BMAT 2.0 clarified confusing elements identified in BMAT 1.0, i.e. items that needed to be revised or enhanced. BMAT 2.0 covered use of SPHM when testing, when completing care tasks and when progressing patients. The BMAT is primarily a nurse-driven mobility assessment tool created to not be overly prescriptive. BMAT was validated and determined to be reliable based on years of clinical utility studies and research in various settings across the continuum of care. It continues to be supported by a large medical equipment manufacturer who maintains the copyright license. Although the VA MSST flowchart has the four BMAT assessment levels embedded within it, for reasons outlined in this article, it is not feasible to use the VA MSST flowchart alongside or in conjunction with the BMAT 2.0., (© 2024. The Author(s).)

Background: An understanding of the prevalence of gestational diabetes mellitus among pregnant women is essential at local, national and international level so that appropriate health care interventions can be planned, financed and delivered. Methods: A systematic review and meta-analysis of primary research reporting the prevalence of gestational diabetes mellitus in Canada or the United States were carried out according to Meta-analysis of Observational Studies in Epidemiology guidelines. Four electronic databases were systematically searched in June 2023 to identify articles that reported gestational diabetes mellitus prevalence using universal screening in pregnant women from eligible general population samples. Estimates were combined using a random effects model, and the effects of moderator variables analysed. Results: There were 36 separate samples of women or deliveries (total sample size 1,550,917). Overall mean prevalence of gestational diabetes mellitus was 6.9% (95% CI: 5.7–8.3); 13.7% (95% CI: 10.7–17.3) in studies using a one-step screening strategy, and 5.2% (95% CI: 4.4–6.1) in those using a two-step strategy. Heterogeneity in technical methods between studies produced differences in estimates, as did different diagnostic thresholds used. Conclusions: The meta-analysis suggests a slightly higher prevalence of gestational diabetes mellitus in Canada and the United States, compared to Europe, but highlights the need for standardised protocols for estimating gestational diabetes mellitus prevalence. [ABSTRACT FROM AUTHOR]

Contact tracing forms a crucial part of the public-health toolbox in mitigating and understanding emergent pathogens and nascent disease outbreaks. Contact tracing in the United States was conducted during the pre-Omicron phase of the ongoing COVID-19 pandemic. This tracing relied on voluntary reporting and responses, often using rapid antigen tests due to lack of accessibility to PCR tests. These limitations, combined with SARS-CoV-2's propensity for asymptomatic transmission, raise the question "how reliable was contact tracing for COVID-19 in the United States"? We answered this question using a Markov model to examine the efficiency with which transmission could be detected based on the design and response rates of contact tracing studies in the United States. Our results suggest that contact tracing protocols in the U.S. are unlikely to have identified more than 1.65% (95% uncertainty interval: 1.62-1.68%) of transmission events with PCR testing and 1.00% (95% uncertainty interval 0.98-1.02%) with rapid antigen testing. When considering a more robust contact tracing scenario, based on compliance rates in East Asia with PCR testing, this increases to 62.7% (95% uncertainty interval: 62.6-62.8%). We did not assume presence of asymptomatic transmission or superspreading, making our estimates upper bounds on the actual percentages traced. These findings highlight the limitations in interpretability for studies of SARS-CoV-2 disease spread based on U.S. contact tracing and underscore the vulnerability of the population to future disease outbreaks, for SARS-CoV-2 and other pathogens. [ABSTRACT FROM AUTHOR]

Introduction: Share buybacks, when a corporation buys back its own shares, are recognised as having potentially harmful impacts on society. This includes by contributing to economic inequalities, and by impeding investments with the potential to protect and promote the welfare of various stakeholders. Share buybacks, however, have received minimal analytical attention in the public health literature. This paper aimed to explore the potential influence of share buybacks on population health and health inequity using a socio-ecological determinants of health lens. Methods: We conducted a descriptive analysis of share buybacks made by corporations listed on United States (US) stock exchanges between 1982 and 2021, using quantitative data sourced from Compustat. We examined annual trends in share buyback expenditure, including comparisons to dividend, net income, capital expenditure, and research and development expenditure data. We then purposively sampled a set of corporations to provide illustrative examples of how share buybacks potentially influence key socio-ecological determinants of health. The examples were: i) three COVID-19 vaccine manufacturers; ii) five of the world's largest fossil fuel corporations; and iii) US car manufacturer General Motors. For these, we conducted an analysis of data from Compustat, company reports and grey literature materials, focusing on key sources of profits and their allocation to share buybacks and particular investments. Results: US-listed corporations spent an estimated US$9.2 trillion in real terms on share buybacks between 2012 and 2021 (nearly 12 times more than from 1982 to 1991). The contribution of share buybacks to total shareholder 'returns' increased from 11% in 1982 to 55% in 2021, with expenditure on shareholder returns increasing considerably relative to capital, research and development expenditure over this period. The three examples illustrated how some corporations have prioritised the short-term financial interests of their shareholders, including via implementing large share buyback programs, over investments with considerable potential to protect and promote the public's health. Conclusion: The potentially substantial impacts of share buybacks on health warrant increased research and policy attention. Arguably, more must be done to regulate share buybacks as part of efforts to address the corporate drivers of ill-health and inequity. [ABSTRACT FROM AUTHOR]

Background: Respect for patients' autonomy is usually considered to be an important ethical principle in Western countries; privacy is one of the implications of such respect. Healthcare professionals frequently encounter ethical dilemmas during their practice. The past few decades have seen an increased use of courts to resolve intractable ethical dilemmas across both the developed and the developing world. However, Chinese and American bioethics differ largely due to the influence of Chinese Confucianism and Western religions, respectively, and there is a dearth of comparative studies that explore cases of ethical dilemmas between China and the United States.Methods: This paper discusses four typical cases with significant social impact. First, it compares two cases concerning patient privacy: the "Shihezi University Hospital Case", in which a patient was used as a clinical teaching object without her permission, and the "New York-Presbyterian Hospital Case", in which the hospital allowed the filming of a patient's treatment without his consent. Second, it compares two cases regarding patient autonomy and potentially life-saving medical procedures: the "Case of Ms. L", concerning a cohabitant's refusal to sign a consent form for a pregnant woman's caesarean, and the "Case of Mrs. V", concerning a hospital's insistence upon a blood transfusion for a dissenting patient. This paper introduces the supporting and opposing views for each case and discusses their social impact. It then compares and analyses the differences between China and the United States from cultural and legislative perspectives.Conclusions: Ethical dilemmas have often occurred in China due to the late development of bioethics. However, the presence of bioethics earlier in the US than in China has not spared the US of ethical dilemmas. This paper highlights lessons and inspiration from the cases for healthcare professionals and introduces readers to the role and weight of privacy and autonomy in China and in the US from the perspectives of different cultures, religions and laws. [ABSTRACT FROM AUTHOR]

Supported by National Science Foundation (NSF), International Society of Intelligent Biological Medicine (ISIBM), International Journal of Computational Biology and Drug Design and International Journal of Functional Informatics and Personalized Medicine, IEEE 7th Bioinformatics and Bioengineering attracted more than 600 papers and 500 researchers and medical doctors. It was the only synergistic inter/multidisciplinary IEEE conference with 24 Keynote Lectures, 7 Tutorials, 5 Cutting-Edge Research Workshops and 32 Scientific Sessions including 11 Special Research Interest Sessions that were designed dynamically at Harvard in response to the current research trends and advances. The committee was very grateful for the IEEE Plenary Keynote Lectures given by: Dr. A. Keith Dunker (Indiana), Dr. Jun Liu (Harvard), Dr. Brian Athey (Michigan), Dr. Mark Borodovsky (Georgia Tech and President of ISIBM), Dr. Hamid Arabnia (Georgia and Vice-President of ISIBM), Dr. Ruzena Bajcsy (Berkeley and Member of United States National Academy of Engineering and Member of United States Institute of Medicine of the National Academies), Dr. Mary Yang (United States National Institutes of Health and Oak Ridge, DOE), Dr. Chih-Ming Ho (UCLA and Member of United States National Academy of Engineering and Academician of Academia Sinica), Dr. Andy Baxevanis (United States National Institutes of Health), Dr. Arif Ghafoor (Purdue), Dr. John Quackenbush (Harvard), Dr. Eric Jakobsson (UIUC), Dr. Vladimir Uversky (Indiana), Dr. Laura Elnitski (United States National Institutes of Health) and other world-class scientific leaders. The Harvard meeting was a large academic event 100% full-sponsored by IEEE financially and academically. After a rigorous peerreview process, the committee selected 27 high-quality research papers from 600 submissions. The committee is grateful for contributions from keynote speakers Dr. Russ Altman (IEEE BIBM conference keynote lecturer on combining simulation and machine learning to recognize function in 4D), Dr. Mary Qu Yang (IEEE BIBM workshop keynote lecturer on new initiatives of detecting microscopic disease using machine learning and molecular biology, http:// ieeexplore.ieee.org/servlet/opac?punumber=4425386) and Dr. Jack Y. Yang (IEEE BIBM workshop keynote lecturer on data mining and knowledge discovery in translational medicine) from the first IEEE Computer Society BioInformatics and BioMedicine (IEEE BIBM) international conference and workshops, November 2-4, 2007, Silicon Valley, California, USA. [ABSTRACT FROM AUTHOR]

This analysis presents a detailed defense of my epidemiologic research in the May 17, 2003 British Medical Journal that found no significant relationship between environmental tobacco smoke (ETS) and tobacco-related mortality. In order to defend the honesty and scientific integrity of my research, I have identified and addressed in a detailed manner several unethical and erroneous attacks on this research. Specifically, I have demonstrated that this research is not "fatally flawed," that I have not made "inappropriate use" of the underlying database, and that my findings agree with other United States results on this relationship. My research suggests, contrary to popular claims, that there is not a causal relationship between ETS and mortality in the U.S. responsible for 50,000 excess annual deaths, but rather there is a weak and inconsistent relationship. The popular claims tend to damage the credibility of epidemiology. In addition, I address the omission of my research from the 2006 Surgeon General's Report on Involuntary Smoking and the inclusion of it in a massive U.S. Department of Justice racketeering lawsuit. I refute erroneous statements made by powerful U.S. epidemiologists and activists about me and my research and I defend the funding used to conduct this research. Finally, I compare many aspect of ETS epidemiology in the U.S. with pseudoscience in the Soviet Union during the period of Trofim Denisovich Lysenko. Overall, this paper is intended to defend legitimate research against illegitimate criticism by those who have attempted to suppress and discredit it because it does not support their ideological and political agendas. Hopefully, this defense will help other scientists defend their legitimate research and combat "Lysenko pseudoscience." [ABSTRACT FROM AUTHOR]

Background: It is widely acknowledged that there is a global divide on health care and health research known as the 10/90 divide. Methods: A retrospective survey of articles published in the BMJ, Lancet, NEJM, Annals of Internal Medicine & JAMA in a calendar year to examine the contribution of the developing world to medical literature. We categorized countries into four regions: UK, USA, Other Euro-American countries (OEAC) and (RoW). OEAC were European countries other than the UK but including Australia, New Zealand and Canada. RoW comprised all other countries. Results: The average contribution of the RoW to the research literature in the five journals was 6.5%. In the two British journals 7.6% of the articles were from the RoW; in the three American journals 4.8% of articles were from RoW. The highest proportion of papers from the RoW was in the Lancet (12%). An analysis of the authorship of 151 articles from RoW showed that 104 (68.9%) involved authorship with developed countries in Europe or North America. There were 15 original papers in these journals with data from RoW but without any authors from RoW. Conclusions: There is a marked under-representation of countries in high-impact general medical journals. The ethical implications of this inequity and ways of reducing it are discussed. [ABSTRACT FROM AUTHOR]

Background: Since spring 2013, periodic emergence of avian influenza A(H7N9) virus in China has heightened the concern for a possible pandemic outbreak among humans, though it is believed that the virus is not yet human-to-human transmittable. Till June 2017, A(H7N9) has resulted in 1533 laboratory-confirmed cases of human infections causing 592 deaths. The aim of this paper is to present disease burden estimates (measured by infection attack rates (IAR) and number of deaths) in the event of a possible pandemic outbreak caused by human-to-human transmission capability acquired by A(H7N9) virus. Even though such a pandemic will likely spread worldwide, our focus in this paper is to estimate the impact on the United States alone.Method: The method first uses a data clustering technique to divide 50 states in the U.S. into a small number of clusters. Thereafter, for a few selected states in each cluster, the method employs an agent-based (AB) model to simulate human A(H7N9) influenza pandemic outbreaks. The model uses demographic and epidemiological data. A few selected non-pharmaceutical intervention (NPI) measures are applied to mitigate the outbreaks. Disease burden for the U.S. is estimated by combining results from the clusters applying a method used in stratified sampling.Results: Two possible pandemic scenarios with R 0 = 1.5 and 1.8 are examined. Infection attack rates with 95% C.I. (Confidence Interval) for R 0 = 1.5 and 1.8 are estimated to be 18.78% (17.3-20.27) and 25.05% (23.11-26.99), respectively. The corresponding number of deaths (95% C.I.), per 100,000, are 7252.3 (6598.45-7907.33) and 9670.99 (8953.66-10,389.95).Conclusions: The results reflect a possible worst-case scenario where the outbreak extends over all states of the U.S. and antivirals and vaccines are not administered. Our disease burden estimations are also likely to be somewhat high due to the fact that only dense urban regions covering approximately 3% of the geographic area and 81% of the population are used for simulating sample outbreaks. Outcomes from these simulations are extrapolated over the remaining 19% of the population spread sparsely over 97% of the area. Furthermore, the full extent of possible NPIs, if deployed, could also have lowered the disease burden estimates. [ABSTRACT FROM AUTHOR]

Background: Access to clinicians competent in transgender health remains a significant barrier and contributor toward health inequity for transgender people. Studies on access and barriers to care have predominantly evaluated transgender patients' perceptions, but scant research has included the perspectives of clinicians.Aims: We conducted a qualitative study to explore how clinicians (meaning physicians and advanced practice providers, in this paper) in the United States: (1) attain and utilize information, (2) perceive barriers and facilitators, and (3) understood gaps in their professional training, in regard to practicing transgender health care.Methods: A Qualitative Descriptive approach guided our conventional content analysis of field notes and interviews with clinicians within a parent study that explored health care access among transgender adults. Transcripts were coded into meaning units that were iteratively abstracted into themes. Standard measures were performed to promote the trustworthiness of the analysis and reduce bias.Results: Participants (n = 13) consisted of physicians (n = 8), physician assistants (n = 3), and nurse practitioners (n = 2). The majority were women (n = 11), identified as White (n = 9), cisgender (n = 13), and ages ranged from 31 - 58 years. Five main themes were identified: (1) Knowledge Acquisition: Formal and Informal Pathways to Competency; (2) Perceived Challenges and Barriers: I didn't know what I was doing; (3) Power to Deny: Prescriptive Authority and Gatekeeping; (4) Stigma: This is really strange, and I can't really understand it; (5) Reflections: Strategies for Success, Rewards, and Personal Motivations.Discussion: Clinicians gained a sense of comfort and competence with mentorship, self-directed learning, clinical experience, and person-centered, harm-reduction approaches. Stigma, bias, and structural-level factors were barriers to providing care. This study offers a unique perspective of clinicians' motivations and strategies for providing gender-affirming care and elucidates how stigma impacts the delivery of gender-affirming care. [ABSTRACT FROM AUTHOR]

This paper examines demographic differences in flourishing, defined as "complete well-being" and consisting of six domains: emotional health, physical health, purpose, character strengths, social connectedness, and financial security. Results are based on a random, cross-sectional sample of 2363 survey respondents drawn from employees of a large, national, self-insured employer based in the United States. We found that well-being across domains tends to increase with age, although there are some variations. Results are similar across most domains for men and women, although women score higher on character strengths, while men had higher scores on financial security. Racial and ethnic differences were striking. Black employees score higher than the reference group (White employees) on the emotional, purpose, and character strengths domains, but considerably lower on financial security. Hispanics also score lower on financial security (though not as low as Blacks), but higher than Whites on purpose, character strengths, and social connectedness. Asians reported higher well-being than Whites across all domains except purpose. [ABSTRACT FROM AUTHOR]

Conducting mixed methods research is critical for healthcare researchers to understand attitudes, behaviors, and experiences on health-related topics, such as vaccine acceptance. As the COVID-19 pandemic has made it difficult to employ traditional, face-to-face qualitative methodologies, this paper describes the use of a virtual platform to conduct person-centered research. To overcome these challenges and better understand the attitudes and behaviors of vaccine-eligible individuals in the United States, an online health community called the Virtual Engagement Research Community (VERC) was designed and implemented. Using the Health Belief Model as a framework, the VERC employed a mixed methods approach to elicit insights, which included discussion topics, rapid polls, and surveys. Throughout the initial enrollment period of April–October 2021, continuous improvement efforts were made to bolster recruitment and member engagement. This agile research strategy was successful in utilizing mixed methods to capture community sentiments regarding vaccines. While this community focused on vaccination, the methodology holds promise for other areas of health research such as obesity, HIV, mental health disorders, and diabetes. Plain English summary: The COVID-19 pandemic has made it difficult to conduct research in person, but qualitative and quantitative data remain critical for developing research design. To gather and understand vaccine perceptions, opinions, and behaviors in a real time manner, The Virtual Engagement Research Community (VERC) was launched. As of October 2021, the VERC had 72 members who had the opportunity to participate in research events such as surveys, polls, discussion topics, and moderated chats in a private, invitation-only virtual community. The online format offered researchers the opportunity to adapt the types and frequency of engagements, fine-tune the research questions based on community responses and current events, and adjust the analysis and reporting methodology as needed to increase participation and maximize the value of the VERC. The success of the VERC and the lessons learned support the use of online communities to enhance mixed methods research as a valuable strategy for other health researchers. [ABSTRACT FROM AUTHOR]

The blood levels of most vitamins decrease during pregnancy if un-supplemented, including vitamins A, C, D, K, B1, B3, B5, B6, folate, biotin, and B12. Sub-optimal intake of vitamins from preconception through pregnancy increases the risk of many pregnancy complications and infant health problems. In the U.S., dietary intake of vitamins is often below recommended intakes, especially for vitamin D, choline and DHA. Many studies suggest that insufficient vitamin intake is associated with a wide range of pregnancy complications (anemia, Cesarean section, depression, gestational diabetes, hypertension, infertility, preeclampsia, and premature rupture of membranes) and infant health problems (asthma/wheeze, autism, low birth weight, congenital heart defects, intellectual development, intrauterine growth restriction, miscarriage, neural tube defects, orofacial defects, and preterm birth). The primary goal of this paper is to review the research literature and propose evidence-based recommendations for the optimal level of prenatal supplementation for each vitamin for most women in the United States. A secondary goal was to compare these new recommendations with the levels of vitamins in over 180 commercial prenatal supplements. The analysis found that prenatal supplements vary widely in content, often contained only a subset of essential vitamins, and the levels were often below our recommendations. This suggests that increasing prenatal vitamin supplementation to the levels recommended here may reduce the incidence of many pregnancy complications and infant health problems which currently occur. [ABSTRACT FROM AUTHOR]

Background: Both the consumption of breastmilk in infancy and a person's season of birth influences his or her health, educational, professional, and behavioral outcomes. Further, season of birth effects differ by sex. However, current research, for the most part, neglects to examine if season of birth and breastfeeding are related. This paper examines the impact of sex-based variations in season of birth on breastfeeding likelihood and duration in the U.S. Methods: Using data from children born to female respondents of the National Longitudinal Survey of Youth 1979 (born between 1970 and 2012), this study examines with Probit, Negative Binomial, and Ordinary Least Squares (OLS) regressions if a child's season of birth and sex are correlated with breastfeeding incidence and duration. The breastfeeding incidence and duration data are self-reported by the mother. Results: Season of birth has a small but statistically significant impact on the incidence and duration of breastfeeding, which varies depending on the sex of the infant. Mothers giving birth to sons in the spring are 13.5% less likely to breastfeed than those giving birth to sons in the winter (with a p - value of 0.0269). Mothers with daughters born in the summer or fall (autumn) breastfeed slightly longer than mothers with daughters born in the spring. On average, mothers of summer-born daughters breastfeed 4.1% longer (with a 95% confidence interval of 0.3 - 7.8) and those with fall-born daughters 3.8% longer (with a 95% confidence interval of 0 - 7.5). Mothers giving birth to daughters in the spring are also significantly less likely to reach the breastfeeding six-week duration target (compared to fall and winter births) and the one-year duration target (compared to fall births). Conclusions: These findings suggest that the costs and benefits of breastfeeding an infant vary with the season of birth and the sex of the child. This finding could explain some of the season of birth effects previously identified in the literature. Further, policymakers seeking to increase breastfeeding rates should consider the reduced breastfeeding rates and durations for children born in the spring. [ABSTRACT FROM AUTHOR]

Background: Since COVID-19 first appeared in the United States (US) in January 2020, US states have pursued a wide range of policies to mitigate the spread of the virus and its economic ramifications. Without unified federal guidance, states have been the front lines of the policy response.Main Text: We created the COVID-19 US State Policy (CUSP) database ( https://statepolicies.com/ ) to document the dates and components of economic relief and public health measures issued at the state level in response to the COVID-19 pandemic. Documented interventions included school and business closures, face mask mandates, directives on vaccine eligibility, eviction moratoria, and expanded unemployment insurance benefits. By providing continually updated information, CUSP was designed to inform rapid-response, policy-relevant research in the context of the COVID-19 pandemic and has been widely used to investigate the impact of state policies on population health and health equity. This paper introduces the CUSP database and highlights how it is already informing the COVID-19 pandemic response in the US.Conclusion: CUSP is the most comprehensive publicly available policy database of health, social, and economic policies in response to the COVID-19 pandemic in the US. CUSP documents widespread variation in state policy decisions and implementation dates across the US and serves as a freely available and valuable resource to policymakers and researchers. [ABSTRACT FROM AUTHOR]

Background: Equal-tailed confidence intervals that maintain nominal coverage (0.95 or greater probability that a 95% confidence interval covers the true value) are useful in interval-based statistical reliability standards, because they remain conservative. For age-adjusted death rates, while the Fay–Feuer gamma method remains the gold standard, modifications have been proposed to streamline implementation and/or obtain more efficient intervals (shorter intervals that retain nominal coverage). Methods: This paper evaluates three such modifications for use in interval-based statistical reliability standards, the Anderson–Rosenberg, Tiwari, and Fay–Kim intervals, when data are sparse and sample size-based standards alone are overly coarse. Initial simulations were anchored around small populations (P = 2400 or 1200), the median crude all-cause US mortality rate in 2010–2019 (833.8 per 100,000), and the corresponding age-specific probabilities of death. To allow for greater variation in the age-adjustment weights and age-specific probabilities, a second set of simulations draws those at random, while holding the mean number of deaths at 20 or 10. Finally, county-level mortality data by race/ethnicity from four causes are selected to capture even greater variation: all causes, external causes, congenital malformations, and Alzheimer disease. Results: The three modifications had comparable performance when the number of deaths was large relative to the denominator and the age distribution was as in the standard population. However, for sparse county-level data by race/ethnicity for rarer causes of death, and for which the age distribution differed sharply from the standard population, coverage probability in all but the Fay–Feuer method sometimes fell below 0.95. More efficient intervals than the Fay–Feuer interval were identified under specific circumstances. When the coefficient of variation of the age-adjustment weights was below 0.5, the Anderson–Rosenberg and Tiwari intervals appeared to be more efficient, whereas when it was above 0.5, the Fay–Kim interval appeared to be more efficient. Conclusions: As national and international agencies reassess prevailing data presentation standards to release age-adjusted estimates for smaller areas or population subgroups than previously presented, the Fay–Feuer interval can be used to develop interval-based statistical reliability standards with appropriate thresholds that are generally applicable. For data that meet certain statistical conditions, more efficient intervals could be considered. [ABSTRACT FROM AUTHOR]

Background: Mindfulness based stress reduction (MBSR) is increasingly being used to improve outcomes such as stress and depression in a range of long-term conditions (LTCs). While systematic reviews on MBSR have taken place for a number of conditions there remains limited information on its impact on individuals with Parkinson's disease (PD).Methods: Medline, Central, Embase, Amed, CINAHAL were searched in March 2016. These databases were searched using a combination of MeSH subject headings where available and keywords in the title and abstracts. We also searched the reference lists of related reviews. Study quality was assessed based on questions from the Cochrane Collaboration risk of bias tool.Results: Two interventions and three papers with a total of 66 participants were included. The interventions were undertaken in Belgium (n = 27) and the USA (n = 39). One study reported significantly increased grey matter density (GMD) in the brains of the MBSR group compared to the usual care group. Significant improvements were reported in one study for a number of outcomes including PD outcomes, depression, mindfulness, and quality of life indicators. Only one intervention was of reasonable quality and both interventions failed to control for potential confounders in the analysis. Adverse events and reasons for drop-outs were not reported. There was also no reporting on the costs/benefits of the intervention or how they affected health service utilisation.Conclusion: This systematic review found limited and inconclusive evidence of the effectiveness of MBSR for PD patients. Both of the included interventions claimed positive effects for PD patients but significant outcomes were often contradicted by other results. Further trials with larger sample sizes, control groups and longer follow-ups are needed before the evidence for MBSR in PD can be conclusively judged. [ABSTRACT FROM AUTHOR]

Introduction: Healthcare organisations serve clients from diverse Indigenous and other ethnic and racial groups on a daily basis, and require appropriate client-centred systems and services for provision of optimal healthcare. Despite advocacy for systems-level approaches to cultural competence, the primary focus in the literature remains on competency strategies aimed at health promotion initiatives, workforce development and student education. This paper aims to bridge the gap in available evidence about systems approaches to cultural competence by systematically mapping key concepts, types of evidence, and gaps in research. Methods: A literature search was completed as part of a larger systematic search of evaluations and measures of cultural competence interventions in health care in Canada, the United States, Australia and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched from 2002 to 2015. Overall, 109 studies were found, with 15 evaluating systems-level interventions or describing measurements. Thematic analysis was used to identify key implementation principles, intervention strategies and outcomes reported. Results: Twelve intervention and three measurement studies met our inclusion criteria. Key principles for implementing systems approaches were: user engagement, organisational readiness, and delivery across multiple sites. Two key types of intervention strategies to embed cultural competence within health systems were: audit and quality improvement approaches and service-level policies or strategies. Outcomes were found for organisational systems, the client/practitioner encounter, health, and at national policy level. Discussion and implications: We could not determine the overall effectiveness of systems-level interventions to reform health systems because interventions were context-specific, there were too few comparative studies and studies did not use the same outcome measures. However, examined together, the intervention and measurement principles, strategies and outcomes provide a preliminary framework for implementation and evaluation of systems-level interventions to improve cultural competence. Identified gaps in the literature included a need for cost and effectiveness studies of systems approaches and explication of the effects of cultural competence on client experience. Further research is needed to explore the extent to which cultural competence improves health outcomes and reduces ethnic and racially-based healthcare disparities. [ABSTRACT FROM AUTHOR]

Background: Over the past 20 years, various authors have addressed the question of the future of chiropractic. Most were positive about the future, with some advocating evidence-based practice and integration with mainstream healthcare, some advocating continued separation with an emphasis on subluxation-based care or the traditional/ historical paradigm of chiropractic, and some calling for tolerance and unity. No papers were found specifically inquiring about the future of chiropractic radiology. Methods: The study population consisted of all current members of the American Chiropractic College of Radiology (ACCR), estimated at 190 people, known as chiropractic radiologists or Diplomates of the American Chiropractic Board of Radiology (DACBRs). An internet-based, anonymous survey using SurveyMonkey was implemented, supplemented by hard copies distributed at a conference. The main point of interest for this paper is the final item of the overall questionnaire. This item inquired about the future of chiropractic radiology. Thematic analysis was used on the responses, coded in both constructionist and inductive ways to extract both a general outlook and more specific themes. The inductive themes were also assigned secondarily to a SWOT (strengths, weaknesses, opportunities, and threats) analysis. Results: The overall response rate to the survey was 38% (73/190); within the group of respondents, 71 of 73 (98%) answered the item that is the subject of this paper. Opinions on the outlook for chiropractic radiology in the future were more negative than positive, with 14 respondents giving a positive outlook, 26 negative, and 14 non-committal. 28 respondents advocated integration with the wider healthcare community, 11 recommended emphasising separateness or a focus on working within chiropractic, and 15 did not express an opinion on this issue. Ten strengths were noted, 11 weaknesses, 57 opportunities, and 30 threats. Conclusions: The increasing necessity of demonstrating evidence for diagnostic and therapeutic procedures in healthcare makes it likely that chiropractic radiologists and the wider chiropractic profession will need to take a more active position on evidence-based practice. Re-evaluation of guidelines and legislation as well as enforcement policies and practices will be necessary. The consequences of failing to do so may include increased marginalisation and reduced viability as a profession. [ABSTRACT FROM AUTHOR]

Background: Health information systems are central to strong health systems. They assist with patient and program management, quality improvement, disease surveillance, and strategic use of information. Many donors have worked to improve health information systems, particularly by supporting the introduction of electronic health information systems (EHIS), which are considered more responsive and more efficient than older, paper-based systems. As many donor-driven programs are increasing their focus on country ownership, sustainability of these investments is a key concern. This analysis explores the potential sustainability of EHIS investments in Malawi, Zambia and Zimbabwe, originally supported by the United States President's Emergency Plan for AIDS Relief (PEPFAR).Methods: Using a framework based on sustainability theories from the health systems literature, this analysis employs a qualitative case study methodology to highlight factors that may increase the likelihood that donor-supported initiatives will continue after the original support is modified or ends.Results: Findings highlight commonalities around possible determinants of sustainability. The study found that there is great optimism about the potential for EHIS, but the perceived risks may result in hesitancy to transition completely and parallel use of paper-based systems. Full stakeholder engagement is likely to be crucial for sustainability, as well as integration with other activities within the health system and those funded by development partners. The literature suggests that a sustainable system has clearly-defined goals around which stakeholders can rally, but this has not been achieved in the systems studied. The study also found that technical resource constraints - affecting system usage, maintenance, upgrades and repairs - may limit EHIS sustainability even if these other pillars were addressed.Conclusions: The sustainability of EHIS faces many challenges, which could be addressed through systems' technical design, stakeholder coordination, and the building of organizational capacity to maintain and enhance such systems. All of this requires time and attention, but is likely to enhance long-term outcomes. [ABSTRACT FROM AUTHOR]

Background: The Implementation Research Institute (IRI) provides two years of training in mental health implementation science for 10 new fellows each year. The IRI is supported by a National Institute of Mental Health (NIMH) R25 grant and the Department of Veterans Affairs (VA). Fellows attend two annual week-long trainings at Washington University in St. Louis. Training is provided through a rigorous curriculum, local and national mentoring, a 'learning site visit' to a federally funded implementation research project, pilot research, and grant writing. Methods: This paper describes the rationale, components, outcomes to date, and participant experiences with IRI. Results: IRI outcomes include 31 newly trained implementation researchers, their new grant proposals, contributions to other national dissemination and implementation research training, and publications in implementation science authored by the Core Faculty and fellows. Former fellows have obtained independent research funding in implementation science and are beginning to serve as mentors for more junior investigators. Conclusions: Based on the number of implementation research grant proposals and papers produced by fellows to date, the IRI is proving successful in preparing new researchers who can inform the process of making evidencebased mental healthcare more available through real-world settings of care and who are advancing the field of implementation science. [ABSTRACT FROM AUTHOR]

The article discusses different presentations made at the ninth annual conference of the MidSouth Computational Biology and Bioinformatics Society, held in Oxford, Mississippi, on February 17-18, 2012. At the event, keynote speaker Michael Gribskov, from Purdue University, delivered the opening address, "After the Deluge: Bioinformatics meets big data." William Slikker, director at the U.S. Food & Drug Administration, talked about the progress in Regulatory Science.

Background: Assessing the consequences of research is an increasingly important task in research and innovation policy. This paper takes a broader view of those consequences than the conventional economic approach, placing researchers and their activities in the centre of the assessment process and examining results for professional practice and general education as well as contributions to knowledge.Methods: The paper uses historical and documentary analysis to illustrate the approach, focusing on U.S. biomedicine over the past century. At aggregate level, the analysis attributes portions of the change in aggregate health indicators to research and research-based institutions, through several available types of logic: either through correlations between timing of institutional changes and changes in the indicators or through direct or indirect causal connections.Results: The analysis shows that while biomedical research has certainly contributed to improved health in the United States, other factors have also contributed. In some ways the institutional structure of science-based medicine has worked against creating benefits for some groups in U.S. society.Conclusions: The paper concludes with a call for more strategic attention to dimensions of impact other than knowledge outcomes and for participatory planning for research. [ABSTRACT FROM AUTHOR]

As the recent collection of papers from the Quality Enhancement Research Initiative (QUERI) Series indicates, knowledge is leading to considerable action in the United States (U.S.) Department of Veterans Affairs (VA). The QUERI Series offers clinical researchers, implementation scientists, health systems, and health research funders from around the globe a unique window into the both the practice and science of implementation or knowledge translation (KT) in the VA. By describing successes and challenges as well as setbacks and disappointments, the QUERI Series is all the more useful. From the vantage point of Canadian KT researchers and officials at a national health research funding agency, we offer a number of observations and lessons that can be learned from QUERI. "Knowledge, if it does not determine action, is dead to us." Plotinus (Roman philosopher 205AD-270AD) [ABSTRACT FROM AUTHOR]

Background: United States academic medical centers are increasingly incorporating electronic health records (EHR) into teaching settings. We report third year medical students' attitudes towards clinical learning using the electronic health record in ambulatory primary care clinics. Methods: In academic year 2005-06, 60 third year students were invited to complete a questionnaire after finishing the required Ambulatory Medicine/Family Medicine clerkship. The authors elicited themes for the questionnaire by asking a focus group of third year students how using the EHR had impacted their learning. Five themes emerged: organization of information, access to online resources, prompts from the EHR, personal performance (charting and presenting), and communication with patients and preceptors. The authors added a sixth theme: impact on student and patient follow-up. The authors created a 21-item questionnaire, based on these themes that used a 5-point Likert scale from "Strongly Agree" to "Strongly Disagree". The authors emailed an electronic survey link to each consenting student immediately following their clerkship experience in Ambulatory Medicine/Family Medicine. Results: 33 of 53 consenting students (62%) returned completed questionnaires. Most students liked the EHR's ability to organize information, with 70% of students responding that essential information was easier to find electronically. Only 36% and 33% of students reported accessing online patient information or clinical guidelines more often when using the EHR than when using paper charts. Most students (72%) reported asking more history questions due to EHR prompts, and 39% ordered more clinical preventive services. Most students (69%) reported that the EHR improved their documentation. 39% of students responded that they received more feedback on their EHR notes compared to paper chart notes. Only 64% of students were satisfied with the doctor-patient communication with the EHR, and 48% stated they spent less time looking at the patient. Conclusion: Third year medical students reported generally positive attitudes towards using the EHR in the ambulatory setting. They reported receiving more feedback on their electronic charts than on paper charts. However, students reported significant concerns about the potential impact of the EHR on their ability to conduct the doctor-patient encounter. [ABSTRACT FROM AUTHOR]

Background: Several unsuccessful attempts have been made to reach a cross-disciplinary consensus on issues fundamental to the field of eating disorders in the United States (U.S.). In January 2020, 25 prominent clinicians, academicians, researchers, persons with lived experience, and thought leaders in the U.S. eating disorders community gathered at the Legacy of Hope Summit to try again. This paper articulates the points on which they reached a consensus. It also: (1) outlines strategies for implementing those recommendations; (2) identifies likely obstacles to their implementation; and (3) charts a course for successfully navigating and overcoming those challenges. Methods: Iterative and consensual processes were employed throughout the Summit and the development of this manuscript. Results: The conclusion of the Summit culminated in several consensus points, including: (1) Eating disorder outcomes and prevention efforts can be improved by implementing creative health education initiatives that focus on societal perceptions, early detection, and timely, effective intervention; (2) Such initiatives should be geared toward parents/guardians, families, other caretakers, and frontline healthcare providers in order to maximize impact; (3) Those afflicted with eating disorders, their loved ones, and the eating disorders community as a whole would benefit from greater accessibility to affordable, quality care, as well as greater transparency and accountability on the part of in-hospital, residential, and outpatient health care providers with respect to their qualifications, methodologies, and standardized outcomes; (4) Those with lived experience with eating disorders, their loved ones, health care providers, and the eating disorders community as a whole, also would benefit from the establishment and maintenance of treatment program accreditation, professional credentialing, and treatment type and levels of care guidelines; and (5) The establishment and implementation of effective, empirically/evidence-based standards of care requires research across a diverse range of populations, adequate private and government funding, and the free exchange of ideas and information among all who share a commitment to understanding, treating, and, ultimately, markedly diminishing the negative impact of eating disorders. Conclusions: Widespread uptake and implementation of these recommendations has the potential to unify and advance the eating disorders field and ultimately improve the lives of those affected. Plain English summary: A cross-disciplinary group of eating disorder professionals, thought leaders, and persons with lived experience have come together and reached a consensus on issues that are fundamental to the battle against the life-threatening and life-altering illnesses that are eating spectrum disorders. Those issues include: (1) the need for early detection, intervention, prevention, and evidenced-based standards of care; (2) the critical need to make specialized care more accessible and affordable to all those in need; (3) the importance of developing uniform, evidenced-based standards of care; (4) the need for funding and conducting eating spectrum disorder research; and (5) the indispensability of advocacy, education, and legislation where these illnesses are concerned. During the consensus process, the authors also arrived at strategies for implementing their recommendations, identified likely obstacles to their implementation, and charted a course for successfully navigating and overcoming those challenges. Above all else, the authors demonstrated that consensus in the field of eating spectrum disorders is possible and achievable and, in doing so, lit a torch of hope that is certain to light the path forward for years to come. [ABSTRACT FROM AUTHOR]

Background: An increasing number of HIV cure trials involve combining multiple potentially curative interventions. Until now, considerations for designing and implementing complex combination HIV cure trials have not been thoroughly considered. Methods: We used a purposive method to select key informants for our study. Informants included biomedical HIV cure researchers, regulators, policy makers, bioethicists, and community members. We used in-depth interviews to generate ethical and practical considerations to guide the design and implementation of combination HIV cure research. We analyzed the qualitative data using conventional content analysis focused on inductive reasoning. Results: We interviewed 11 biomedical researchers, 4 community members, 2 regulators, 1 policy researcher, and 1 bioethicist. Informants generated considerations for designing and implementing combination interventions towards an HIV cure, focused on ethical aspects, as well as considerations to guide trial design, benefit/risk determinations, regulatory requirements, prioritization and sequencing and timing of interventions, among others. Informants also provided considerations related to combining specific HIV cure research modalities, such as broadly neutralizing antibodies (bNAbs), cell and gene modification products, latency-reversing agents and immune-based interventions. Finally, informants provided suggestions to ensure meaningful therapeutic improvements over standard antiretroviral therapy, overcome challenges of designing combination approaches, and engage communities around combination HIV cure research. Conclusion: The increasing number of combination HIV cure trials brings with them a host of ethical and practical challenges. We hope our paper will inform meaningful stakeholder dialogue around the use of combinatorial HIV cure research approaches. To protect the public trust in HIV cure research, considerations should be periodically revisited and updated with key stakeholder input as the science continues to advance. [ABSTRACT FROM AUTHOR]

Background: Researchers investigating health outcomes for populations over age 65 can utilize Medicare claims data, but these data include no direct information about individuals' health prior to age 65 and are not typically linkable to files containing data on exposures and behaviors during their worklives. The current paper is a proof-of-concept, of merging employers' administrative data and private, employment-based health claims with Medicare data. Characteristics of the linked data, including sensitivity and specificity, are evaluated with an eye toward potential uses of such linked data. This paper uses a sample of former manufacturing workers from an industrial cohort as a test case. The dataset created by this integration could be useful to research in areas such as social epidemiology and occupational health.Methods: Medicare and employment administrative data were linked for a large cohort of manufacturing workers (employed at some point during 1996-2008) who transitioned onto Medicare between 2001-2009. Data on work-life health, including biometric indicators, were used to predict health at age 65 and to investigate the concordance of employment-based insurance claims with subsequent Medicare insurance claims.Results: Chronic diseases were found to have relatively high levels of concordance between employment-based private insurance and subsequent Medicare insurance. Information about patient health prior to receipt of Medicare, including biometric indicators, were found to predict health at age 65.Conclusions: Combining these data allows for evaluation of continuous health trajectories, as well as modeling later-life health as a function of work-life behaviors and exposures. It also provides a potential endpoint for occupational health research. This is the first harmonization of its kind, providing a proof-of-concept. The dataset created by this integration could be useful for research in areas such as social epidemiology and occupational health. [ABSTRACT FROM AUTHOR]

Background: Self-rated health (SRH) is one of the most commonly used summary measures of overall health and well-being available to population scientists due to its ease of administration in large-scale surveys and to its efficacy in predicting mortality. This paper assesses the extent to which SRH is affected by its placement before or after questions about bodyweight on a survey, and whether differences in placement on the questionnaire affects SRH's predictive validity. Methods: I assessed the validity of SRH in predicting the risk of mortality by comparing outcomes of sample members who were asked to rate their health before reporting on their bodyweight (the control group) and sample members who were asked to rate their health after reporting on their bodyweight (the treatment group). Both the control and treatment group were randomly assigned via an experiment administered as a module in a nationally representative sample of adults in the USA in 2019 (N = 2523). Results: The odds of reporting a more favorable appraisal of health are 30% lower for sample members who were in the treatment group when compared with the control group. Additionally, the SRH of treatment group members is significantly associated with their risk of mortality, while the SRH of control group members is not. Conclusion: The findings from this study suggest that for researchers to maximize the utility of SRH, closer attention needs to be paid to the context of the survey within which it asked. SRH is highly sensitive to the questions that precede it, and this sensitivity may in turn mischaracterize the true health of the population that the survey is intending to measure. [ABSTRACT FROM AUTHOR]

Background: In 2010, the first comprehensive National HIV/AIDS Strategy for the United States was released and included three goals: (1) reducing the number of people who become infected with HIV, (2) increasing access to care and improving health outcomes for people living with HIV, and (3) reducing HIV-related health disparities and health inequities. In 2013, as part of its effort to help address the National HIV/AIDS Strategy, the National Institute on Drug Abuse (NIDA) funded a type 2 effectiveness-implementation hybrid trial titled the Substance Abuse Treatment to HIV Care (SAT2HIV) Project. Aim 1 of the SAT2HIV Project tests the effectiveness of a motivational interviewing-based brief intervention (MIBI) for substance use as an adjunct to usual care within AIDS Service Organizations (ASOs) as part of its MIBI Experiment. Aim 2 of the SAT2HIV Project tests the effectiveness of implementation and sustainment facilitation (ISF) as an adjunct to the Addiction Technology Transfer Center (ATTC) model for training staff in motivational interviewing as part of its ISF Experiment. The current paper describes the study protocol for the ISF Experiment. Methods: As part of a multisite randomized controlled trial, individuals with comorbid HIV/AIDS and problematic substance use are randomized to receive either the ASOs'; usual care (control condition) or usual care plus a MIBI for substance use (experimental condition) delivered by trained ASO case-management staff. Primary outcome measures are reductions in days of primary substance use, number of substance-related problems, times engaging in risky behaviors, days of non-adherence to HIV medications, and increases in substance use treatment. As part of this paper, we describe the trial protocol in accordance with the Standard Protocol Items: Recommendations for Interventional Trials guidelines. Discussion: If successfully able to implement MIBI as an effective adjunct to usual care, the current trial may have a significant impact on increasing the capacity of ASOs to address problematic substance use among individuals living with HIV/AIDS. Reducing the prevalence of problematic substance use among individuals living with HIV/AIDS within the United States may lead to significant improvements on key performance measures (i.e., the HIV Care Continuum and the 90-90-90 target). [ABSTRACT FROM AUTHOR]

Background: Nicotine vaping products (NVPs) are increasingly popular worldwide. They may provide public health benefits if used as a substitute for smoking, but may create public health harms if used as a gateway to smoking or to discourage smoking cessation. This paper presents the Smoking and Vaping Model (SAVM), a user-friendly model which estimates the public health implications of NVPs in the USA. Methods: SAVM adopts a cohort approach. We derive public health implications by comparing smoking- and NVP-attributable deaths and life-years lost under a No-NVP and an NVP Scenario. The No-NVP Scenario projects current, former, and never smoking rates via smoking initiation and cessation rates, with their respective mortality rates. The NVP Scenario allows for smoking- and NVP-specific mortality rates, switching from cigarette to NVP use, separate NVP and smoking initiation rates, and separate NVP and smoking cessation rates. After validating the model against recent US survey data, we present the base model with extensive sensitivity analyses. Results: The SAVM projects that under current patterns of US NVP use and substitution, NVP use will translate into 1.8 million premature smoking- and vaping-attributable deaths avoided and 38.9 million life-years gained between 2013 and 2060. When the NVP relative risk is set to 5%, the results are sensitive to the level of switching and smoking cessation rates and to a lesser extent smoking initiation rates. When the NVP relative risk is raised to 40%, the public health gains in terms of averted deaths and LYL are reduced by 42% in the base case, and the results become much more sensitive to variations in the base case parameters. Discussion: Policymakers, researchers, and other public health stakeholders can apply the SAVM to estimate the potential public health impact of NVPs in their country or region using their own data sources. In developing new simulation models involving NVPs, it will be important to conduct extensive sensitivity analysis and continually update and validate with new data. Conclusion: The SAVM indicates the potential benefits of NVP use. However, given the uncertainty surrounding model parameters, extensive sensitivity analysis becomes particularly important. [ABSTRACT FROM AUTHOR]

Background: Unfortunately, racism and discrimination against Ethnic minority (EM) has been globalized, universally infecting industries worldwide, and the field of nursing has not been spared. In the United States (US), overt and institutionalized racism (IR) still permeates the fields of nursing, nursing leadership, and nursing education. Programs to address these disparities, and efforts by nursing professional societies and nursing education policymaking bodies to address racism in the nursing field, specifically with nursing leadership and education, have met with little success. Objective: The purpose of this paper is to illustrate the existence and magnitude of racism and its impact on the fields of nursing, nursing leadership, and nursing education, and to make evidence-based recommendations for an agenda for reforming nursing education in the US. Methods: A narrative literature review was conducted with a focus on pulling together the strongest evidence on which to base policy recommendations. Results: Based on the available literature, we put forth five recommendations aimed at modifying nursing education in the US as a strategy to counter IR in the US in the nursing field. Conclusions: Recommendations to address IR in nursing focus on nursing education, and involve implementing programs to address the lack of opportunity for both EM students and faculty in nursing, developing an anti-discriminatory pedagogy, and incorporating diversity initiatives as key performance indicators (KPIs) in the process of approval and accreditation of nursing programs. [ABSTRACT FROM AUTHOR]

Background: US Latinos report high levels of emotional distress. Having positive familial and friend social support buffers emotional distress among US Latinos, but thus far no research has been done on social support and ataque de nervios in that population, or on social strain and emotional distress. Methods: This paper assesses social support and strain across three relationship types (partner, family, and friends) with three measures of emotional distress (depression, anxiety, and ataque de nervios). The sample for partner, family, and friend support included 508 Latino adults 21 and older. Multivariate logistic regression models were used to assess the association of social support and strain with each outcome. Results: As all social support types increased, the odds of emotional distress symptoms decreased. Conversely, as each unit of partner and family strain increased, the odds of emotional distress symptoms increased. Increased friend strain was associated with greater odds of depressive and anxiety symptoms only. Conclusion: Social support in all three network types (partner, family, and friend) was associated with a decrease in the odds of emotional distress, assessed as symptoms of depression, anxiety, and ataque de nervios. [ABSTRACT FROM AUTHOR]

Background: In the U.S., strong ethnic/racial, socioeconomic, demographic, and geographic breastfeeding (BF) inequities persist, and African American and Hispanic women are less likely to meet their breastfeeding goals compared to White women. This systematic review (SR) was designed to answer the question: What is the impact of breastfeeding interventions targeting ethnic/racial minority women in the U.S. on improving BF initiation, duration and exclusivity rates? Methods: The SR was conducted following the Institute of Medicine Guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The study protocol was developed and registered a priori in PROSPERO (ID#CRD42020177764). The electronical databases searched was MEDLINE All (Ovid). Search strategies were led by the team's expert public health librarian using both controlled vocabulary and free text queries and were tested against a validated set of relevant papers included in existing reviews. The GRADE methodology was used to assess the quality of the studies. Results: We included 60 studies that had randomized (n = 25), observational (n = 24), quasi-experimental (n = 9), or cross-sectional (n = 2) designs. The studies focused on populations that were multi-ethnic/racial (n = 22), only Hispanic (n = 24), only Black (n = 13), and only American Indian (n = 1). The study interventions were classified following the socioecological model: macrosystem/policy level (n = 6); community level (n=51), which included healthcare organizations (n = 34), The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (n = 9), and community organizations/public health institutions (n = 8); and interpersonal level (n = 3). Conclusions: Policy and community level interventions delivered through WIC, healthcare facilities, and community agencies) are likely to improve BF outcomes among women of color. The combination of interventions at different levels of the socioecological model has not been studied among minority women in the U.S. Implementation science research is needed to learn how best to scale up and sustain effective BF interventions, taking into account the needs and wants of minority women. Thus, it is strongly recommended to conduct large scale implementation research studies addressesing how to strengthen the different health and social environments surrounding women of color in the U.S. to improving their BF outcomes. [ABSTRACT FROM AUTHOR]

Background: Prescription medication (PM) misuse/abuse has emerged as a national crisis in the United States, and social media has been suggested as a potential resource for performing active monitoring. However, automating a social media-based monitoring system is challenging-requiring advanced natural language processing (NLP) and machine learning methods. In this paper, we describe the development and evaluation of automatic text classification models for detecting self-reports of PM abuse from Twitter.Methods: We experimented with state-of-the-art bi-directional transformer-based language models, which utilize tweet-level representations that enable transfer learning (e.g., BERT, RoBERTa, XLNet, AlBERT, and DistilBERT), proposed fusion-based approaches, and compared the developed models with several traditional machine learning, including deep learning, approaches. Using a public dataset, we evaluated the performances of the classifiers on their abilities to classify the non-majority "abuse/misuse" class.Results: Our proposed fusion-based model performs significantly better than the best traditional model (F1-score [95% CI]: 0.67 [0.64-0.69] vs. 0.45 [0.42-0.48]). We illustrate, via experimentation using varying training set sizes, that the transformer-based models are more stable and require less annotated data compared to the other models. The significant improvements achieved by our best-performing classification model over past approaches makes it suitable for automated continuous monitoring of nonmedical PM use from Twitter.Conclusions: BERT, BERT-like and fusion-based models outperform traditional machine learning and deep learning models, achieving substantial improvements over many years of past research on the topic of prescription medication misuse/abuse classification from social media, which had been shown to be a complex task due to the unique ways in which information about nonmedical use is presented. Several challenges associated with the lack of context and the nature of social media language need to be overcome to further improve BERT and BERT-like models. These experimental driven challenges are represented as potential future research directions. [ABSTRACT FROM AUTHOR]

Background: Increasing numbers of primary care practitioners in refugee resettlement countries are providing care to refugees. Access to trained interpreters is a priority for these practitioners, but there are many barriers to the implementation of interpreted consultations in routine care. There is a lack of international, theoretically informed research. The purpose of this paper is to understand barriers to interpreter use in primary care consultations in four resettlement countries using Normalisation Process Theory. Method: We conducted a cross-sectional online survey with networks of primary care practitioners (PCPs) who care for refugees in Australia, Canada, Ireland and the US (n = 314). We analysed qualitative data from the survey about barriers to interpreter use (n = 178). We completed an inductive thematic analysis, iteratively developed a Normalisation Process Theory (NPT)-informed coding frame and then mapped the emergent findings onto the theory's construct about enacting interpreted consultations. Results: In all four countries, the use of an interpreter presented communication and interaction challenges between providers and patients, which can impede the goals of primary care consultations. Primary care practitioners did not always have confidence in interpreted consultations and described poor professional practice by some interpreters. There was variation across countries, and inconsistency within countries, in the availability of trained interpreters and funding sources. Conclusion: There are shared and differential barriers to implementation of interpreted consultations in a consistent and sustained way in the four countries studied. These findings can be used to inform country-specific and international level policies and interventions focusing on improving skills and resources for interpreted consultations to improve implementation of interpreted primary care consultations. [ABSTRACT FROM AUTHOR]

Background: Over the past few decades, numerous forecasting methods have been proposed in the field of epidemic forecasting. Such methods can be classified into different categories such as deterministic vs. probabilistic, comparative methods vs. generative methods, and so on. In some of the more popular comparative methods, researchers compare observed epidemiological data from the early stages of an outbreak with the output of proposed models to forecast the future trend and prevalence of the pandemic. A significant problem in this area is the lack of standard well-defined evaluation measures to select the best algorithm among different ones, as well as for selecting the best possible configuration for a particular algorithm.Results: In this paper we present an evaluation framework which allows for combining different features, error measures, and ranking schema to evaluate forecasts. We describe the various epidemic features (Epi-features) included to characterize the output of forecasting methods and provide suitable error measures that could be used to evaluate the accuracy of the methods with respect to these Epi-features. We focus on long-term predictions rather than short-term forecasting and demonstrate the utility of the framework by evaluating six forecasting methods for predicting influenza in the United States. Our results demonstrate that different error measures lead to different rankings even for a single Epi-feature. Further, our experimental analyses show that no single method dominates the rest in predicting all Epi-features when evaluated across error measures. As an alternative, we provide various Consensus Ranking schema that summarize individual rankings, thus accounting for different error measures. Since each Epi-feature presents a different aspect of the epidemic, multiple methods need to be combined to provide a comprehensive forecast. Thus we call for a more nuanced approach while evaluating epidemic forecasts and we believe that a comprehensive evaluation framework, as presented in this paper, will add value to the computational epidemiology community. [ABSTRACT FROM AUTHOR]

Background: End-of-life decision making constitutes a major challenge for bioethical deliberation and political governance in modern democracies: On the one hand, it touches upon fundamental convictions about life, death, and the human condition. On the other, it is deeply rooted in religious traditions and historical experiences and thus shows great socio-cultural diversity. The bioethical discussion of such cultural issues oscillates between liberal individualism and cultural stereotyping. Our paper confronts the bioethical expert discourse with public moral attitudes.Methods: The paper is based on a qualitative study comprising 12 focus group discussions with religious and secular persons in the USA, Germany, and Israel (n = 82). Considering the respective socio-political and legal frameworks, the thematic analysis focuses on moral attitudes towards end-of-life decision making and explores the complex interplay between individual preferences, culture, and religion.Results: Our findings draw attention to the variety and complexity of cultural and religious aspects of end-of-life decision making. Although there is local consensus that goes beyond radical individualism, positions are not neatly matched with national cultures or religious denominations. Instead, the relevance of the specific situatedness of religious beliefs and cultural communities becomes visible: Their status and role in individual situations, for example, as consensual or conflicting on the level of personal perspectives, family relationships, or broader social contexts, e.g., as a majority or minority culture within a political system.Conclusions: As the group discussions indicate, there are no clear-cut positions anchored in "nationality," "culture," or "religion." Instead, attitudes are personally decided on as part of a negotiated context representing the political, social and existential situatedness of the individual. Therefore, more complex theoretical and practical approaches to cultural diversity have to be developed. [ABSTRACT FROM AUTHOR]

Background: Doulas have been instrumental in providing breastfeeding support to nursing mothers before and during the COVID-19 pandemic, as they can significantly impact a mother's ability to initiate and maintain breastfeeding. However, the COVID-19 pandemic, subsequent lockdowns, and social isolation created challenges for nursing mothers to access doulas' services, usually provided in person. In this study, we examined the role of doulas in providing breastfeeding support during the COVID-19 pandemic, exploring adaptation to COVID-19 guidelines and the challenges doulas face in providing breastfeeding support during the pandemic. Methods: A systematic review was conducted following the PRISMA guidelines. Thirteen scientific databases and twenty peer-reviewed journals were searched for journal articles published in English between January 2020 and March 2022 using key search terms (e.g., Doula, Breastfeeding, COVID-19). Studies evaluating the role of doulas in providing breastfeeding support during COVID-19, and the impact of COVID-19 Guidelines on doula services, were included. Two reviewers independently performed the risk of bias assessment and data extraction. Summative content analysis was used to analyze the data. Results: The majority of studies were conducted in developed nations. This systematic review includes eight articles, four qualitative, one survey, two mixed-methods studies, and one prospective research study. Seven of the eight studies were conducted in the United States, and the eighth was conducted in multiple countries. These studies have three main themes: (1) virtual breastfeeding support provided by doulas during the pandemic; (2) remote social support provided by doulas to breastfeeding mothers during the pandemic; and (3) barriers to doula service delivery due to COVID-19 restrictions, primarily the exclusion of doulas as essential workers. The eight studies showed that doulas found innovative ways to serve the needs of birthing and nursing mothers during the difficulties brought on by the pandemic. Conclusion: Doulas provided breastfeeding support during the COVID-19 pandemic by utilizing innovative service delivery methods while navigating changes in COVID-19 guidance. However, system-level integration of doulas' work and the acknowledgment of doulas as essential healthcare providers are needed to enhance doula service delivery capacity, especially during a pandemic, to help improve maternal health outcomes. [ABSTRACT FROM AUTHOR]

Background: An opinion currently shared by taxonomists and non taxonomists alike is that the work of inventorying biodiversity is unbalanced: firstly, in favour of countries in which taxonomy has been studied for a long time, and, secondly, in favour of vertebrates. In the current context of threats of species extinction, access for taxonomists to biological material and information becomes crucial if the scientific community really aims at a better knowledge of biological diversity before it is severely and irreversibly impoverished. We performed an analysis of 748 papers published in Zootaxa in 2006 and 2007, as well as 434 questionnaires sent to their authors to test these opinions. A generalization of these results to zoological taxonomy as a whole is discussed. Discussion: We found that the disequilibrium is not exactly what it usually considered to be. The USA, China and Brazil are currently the three leading countries in zoological taxonomy. Each of them presents, however, a different pattern. Taxonomists from Asia and South America are younger and mainly work in universities, not museums. A bias in favour of vertebrates still exists if we refer to the effort invested in each group to produce taxonomic data, but not to the number of papers. Finally, we insist on the idea that "describing a species" is very different from "knowing a species". Summary: The taxonomic involvement of a country, in terms of manpower and funding, appears to be a key factor in the development of fruitful taxonomic research. This message seems to have been understood by the countries that recently decided to increase considerably their taxonomic involvement. It still has to be received by those who did not. [ABSTRACT FROM AUTHOR]

In December 2008, the US Commission on the Prevention of Weapons of Mass Destruction Proliferation and Terrorism, released a report, World At Risk. The Report points to the fact that, not only is the use of a weapon of mass destruction in a terrorist attack before the end of 2013, more likely than not, but also to the fact that terrorists are more likely to be able to obtain and use biological weapons than nuclear. This paper examines the recommendations of the report in the context of the historic and geopolitical changes, in particular globalization. The authors highlight the "dual-use" dilemma, as described in the report, as the paradoxical use of technology developed for the benefit of mankind being used for sinister purposes. The mitigation of such a threat lies in broad stakeholder involvement and cooperation, including non-state actors, governments and the bio-tech industry itself. The importance of vigilance measures within the life science community is emphasized and, the authors propose, could include a web-based didactic course in bioterrorism and weapons of mass destruction identification. The site could outline safety protocols, have detailed disaster management tutorials, and could be specifically tailored for different subsets of industry and health professionals. The paper concludes with an endorsement of a multi-pronged approach including strong international guidelines and intelligence cooperation and preparatory measures such as the wide-spread use of detection systems as well as diagnostic decision support systems for bioterrorism detection at the local level. [ABSTRACT FROM AUTHOR]

Background: Studies on differences between immigrant and non-immigrant groups in health care utilization vary with respect to the extent and direction of differences in use. Therefore, our study aimed to provide a systematic overview of the existing research on differences in primary care utilization between immigrant groups and the majority population. Methods: For this review PubMed, PsycInfo, Cinahl, Sociofile, Web of Science and Current Contents were consulted. Study selection and quality assessment was performed using a predefined protocol by 2 reviewers independently of each other. Only original, quantitative, peer-reviewed papers were taken into account. To account for this hierarchical structure, logistic multilevel analyses were performed to examine the extent to which differences are found across countries and immigrant groups. Differences in primary care use were related to study characteristics, strength of the primary care system and methodological quality. Results: A total of 37 studies from 7 countries met all inclusion criteria. Remarkably, studies performed within the US more often reported a significant lower use among immigrant groups as compared to the majority population than the other countries. As studies scored higher on methodological quality, the likelihood of reporting significant differences increased. Adjustment for health status and use of culture-/language-adjusted procedures during the data collection were negatively related to reporting significant differences in the studies. Conclusion: Our review underlined the need for careful design in studies of differences in health care use between immigrant groups and the majority population. The results from studies concerning differences between immigrant and the majority population in primary health care use performed within the US might be interpreted as a reflection of a weaker primary care system in the US compared to Europe and Canada. [ABSTRACT FROM AUTHOR]

Background: The misuse of legal and illegal substances has led to an increase in substance use disorder (SUD) in the United States. Although primary prevention strategies have been successfully used to target chronic physical diseases, these strategies have been less effective with SUD, given misconceptions of SUD, shortages in behavioral health professionals, and the population-based focus on specific substances. A developmental approach to the identification and primary prevention of SUD that does not fully rely upon behavioral health workers is needed. The purpose of this paper was to examine age related risk factors for developing SUD and present a novel individualized approach to SUD prevention.Methods: A literature search was conducted to identify risk factors for SUD among children, young adults, adults, and older adults. We searched CINAHL, PsycINFO, and PubMed between the years 1989-2019, and extracted data, analyzing similarities and differences in risk factors across life stages. Broader categories emerged that were used to group the risk factors.Results: More than 370 articles were found. Across all age groups, risk factors included adverse childhood experiences, trauma, chronic health diseases, environmental factors, family history, social determinants, and grief and loss. Despite the similarities, the contextual factors and life challenges associated with these risks varied according to the various life stages. We proposed an approach to primary prevention of SUD based on risk factors for developing the disease according to different age groups. This approach emphasizes screening, education, and empowerment (SEE), wherein individuals are screened for risk factors according to their age group, and screening results are used to customize interventions in the form of education and empowerment. Given that trained persons, including non-healthcare providers, close to the at-risk individual could conduct the screening and then educate and mentor the individual according to the risk level, the number of people who develop SUD could decrease.Conclusions: The risk factors for developing SUD vary across the various life stages, which suggests that individualized approaches that do not overtax behavioral healthcare workers are needed. Using SEE may foster early identification and individualized prevention of SUD. [ABSTRACT FROM AUTHOR]

The opioid epidemic in the United States has had a devastating impact on millions of people as well as on their families and communities. The increased prevalence of opioid misuse, use disorder and overdose in recent years has highlighted the need for improved public health approaches for reducing the tremendous harms of this illness. In this paper, we explain and call for the need for more systems science approaches, which can uncover the complexities of the opioid crisis, and help evaluate, analyse and forecast the effectiveness of ongoing and new policy interventions. Similar to how a stream of systems science research helped policy development in infectious diseases and obesity, more systems science research is needed in opioids. [ABSTRACT FROM AUTHOR]

Background: Chronic musculoskeletal pain (MSP) affects more than 40% of adults aged 50 years and older and is the leading cause of disability in the USA. Older adults with chronic MSP are at risk for analgesic-related side effects, long-term opioid use, and functional decline. Recognizing the burden of chronic MSP, reducing the transition from acute to chronic pain is a public health priority. In this paper, we report the protocol for the Brief EducaTional Tool to Enhance Recovery (BETTER) trial. This trial compares two versions of an intervention to usual care for preventing the transition from acute to chronic MSP among older adults in the emergency department (ED).Methods: Three hundred sixty patients from the ED will be randomized to one of three arms: full intervention (an interactive educational video about pain medications and recovery-promoting behaviors, a telecare phone call from a nurse 48 to 72 h after discharge from the ED, and an electronic communication containing clinical information to the patient's primary care provider); video-only intervention (the interactive educational video but no telecare or primary care provider communication); or usual care. Data collection will occur at baseline and at 1 week and 1, 3, 6, and 12 months after study enrollment. The primary outcome is a composite measure of pain severity and interference. Secondary outcomes include physical function, overall health, opioid use, healthcare utilization, and an assessment of the economic value of the intervention.Discussion: This trial is the first patient-facing ED-based intervention aimed at helping older adults to better manage their MSP and reduce their risk of developing chronic pain. If effective, future studies will examine the effectiveness of implementation strategies.Trial Registration: ClinicalTrials.gov NCT04118595 . Registered on 8 October 2019. [ABSTRACT FROM AUTHOR]

Background: Cancer is a leading cause of death in the United States. Primary care providers (PCPs) juggle patient cancer prevention and screening along with managing acute and chronic health problems. However, clinical decision support (CDS) may assist PCPs in addressing patients' cancer prevention and screening needs during short clinic visits. In this paper, we describe pre-implementation study design and cancer screening and prevention CDS changes made to maximize utilization and better fit a healthcare system's goals and culture. We employed the Consolidated Framework for Implementation Research (CFIR), useful for evaluating the implementation of CDS interventions in primary care settings, in understanding barriers and facilitators that led to those changes.Methods: In a three-arm, pragmatic, 36 clinic cluster-randomized control trial, we integrated cancer screening and prevention CDS and shared decision-making tools (SDMT) into an existing electronic medical record-linked cardiovascular risk management CDS system. The integrated CDS is currently being tested within a predominately rural upper Midwestern healthcare system. Prior to CDS implementation, we catalogued pre-implementation changes made from 2016 to 2018 based on: pre-implementation site engagement; key informant interviews with healthcare system rooming staff, providers, and leadership; and pilot testing. We identified influential barriers, facilitators, and changes made in response through qualitative content analysis of meeting minutes and supportive documents. We then coded pre-implementation changes made and associated barriers and facilitators using the CFIR.Results: Based on our findings from system-wide pre-implementation engagement, pilot testing, and key informant interviews, we made changes to accommodate the needs of the healthcare system based on barriers and facilitators that fell within the Intervention Characteristics, Inner Setting, and Outer Setting CFIR domains. Changes included replacing the expansion of medical assistant roles in one intervention arm with targeted SDMT, as well as altering cancer prevention CDS and study design elements.Conclusions: Pre-implementation changes to CDS may help meet healthcare systems' evolving needs and optimize the intervention by being responsive to real-world implementation barriers and facilitators. Frameworks like the CFIR are useful tools for identifying areas where pre-implementation barriers and facilitators may result in design changes, both to research studies and CDS systems.Trial Registration: NCT02986230. [ABSTRACT FROM AUTHOR]

Background: Intimate partner violence (IPV) against women in the United States (US) remains a complex public health crisis. Women who experience IPV are among the most vulnerable patients seen in primary care. Screening increases the detection of IPV and, when paired with appropriate response interventions, can mitigate the health effects of IPV. The Department of Veterans Affairs (VA) has encouraged evidence-based IPV screening programs since 2014, yet adoption is modest and questions remain regarding the optimal ways to implement these practices, which are not yet available within the majority of VA primary care clinics.Methods/design: This paper describes the planned evaluation of VA's nationwide implementation of IPV screening programs in primary care clinics through a randomized implementation-effectiveness hybrid type 2 trial. With the support of our VA operational partners, we propose a stepped wedge design to compare the impact of two implementation strategies of differing intensities (toolkit + implementation as usual vs. toolkit + implementation facilitation) and investigate the clinical effectiveness of IPV screening programs. Using balanced randomization, 16-20 VA Medical Centers will be assigned to receive implementation facilitation in one of three waves, with implementation support lasting 6 months. Implementation facilitation in this effort consists of the coordinated efforts of the two types of facilitators, external and internal. Implementation facilitation is compared to dissemination of a toolkit plus implementation as usual. We propose a mixed methods approach to collect quantitative (clinical records data) and qualitative (key informant interviews) implementation outcomes, as well as quantitative (clinical records data) clinical effectiveness outcomes. We will supplement these data collection methods with provider surveys to assess discrete implementation strategies used before, during, and following implementation facilitation. The integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework will guide the qualitative data collection and analysis. Summative data will be analyzed using the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework.Discussion: This research will advance national VHA efforts by identifying the practices and strategies useful for enhancing the implementation of IPV screening programs, thereby ultimately improving services for and health of women seen in primary care.Trial Registration: NCT04106193. Registered on 23 September 2019. [ABSTRACT FROM AUTHOR]

Background: Synthesis of psychometric properties of substance use measures to identify patterns of use and substance use disorders remains limited. To address this gap, we sought to systematically evaluate the psychometric properties of measures to detect substance use and misuse.Methods: We conducted a systematic review and meta-analysis of literature on measures of substance classes associated with HIV risk (heroin, methamphetamine, cocaine, ecstasy, alcohol) that were published in English before June 2016 that reported at least one of the following psychometric outcomes of interest: internal consistency (alpha), test-retest/inter-rater reliability (kappa), sensitivity, specificity, positive predictive value, and negative predictive value. We used meta-analytic techniques to generate pooled summary estimates for these outcomes using random effects and hierarchical logistic regression models.Results: Findings across 387 paper revealed that overall, 65% of pooled estimates for alpha were in the range of fair-to-excellent; 44% of estimates for kappa were in the range of fair-to-excellent. In addition, 69, 97, 37 and 96% of pooled estimates for sensitivity, specificity, positive predictive value, and negative predictive value, respectively, were in the range of moderate-to-excellent.Conclusion: We conclude that many substance use measures had pooled summary estimates that were at the fair/moderate-to-excellent range across different psychometric outcomes. Most scales were conducted in English, within the United States, highlighting the need to test and validate these measures in more diverse settings. Additionally, the majority of studies had high risk of bias, indicating a need for more studies with higher methodological quality. [ABSTRACT FROM AUTHOR]

Background: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has been shown to have positive effects in promoting healthy birth outcomes in the United States. We explored whether such effects held prior to and during the most recent Great Recession to improve birth outcomes and reduce differences among key socio-demographic groups.Methods: We used a pooled cross-sectional time series design to study pregnant women and their infants with birth certificate data. We included Medicaid and uninsured births from Washington State and Florida (n = 226,835) before (01/2005-03/2007) and during (12/2007-06/2009) the Great Recession. Interactions between WIC enrollment and key socio-demographic groupings were analyzed for binary and continuous birth weight outcomes.Results: Our study found beneficial WIC interaction effects on birth weight. For race, prenatal care, and maternal age we found significantly better birth weight outcomes in the presence of WIC compared to those without WIC. For example, being Black with WIC was associated with an increase in infant birth weight of 53.5 g (baseline) (95% CI = 32.4, 74.5) and 58.0 g (recession) (95% CI = 27.8, 88.3). For most groups this beneficial relationship was stable over time.Conclusions: This paper supports previous research linking maternal utilization of WIC services during pregnancy to improved birth weight (both reducing LBW and increasing infant birth weight in grams) among some high-disadvantage groups. WIC appears to have been beneficial at decreasing disparity gaps in infant birth weight among the very young, Black, and late/no prenatal care enrollees in this high-need population, both before and during the Great Recession. Gaps are still present among other social and demographic characteristic groups (e.g., for unmarried mothers) for whom we did not find WIC to be associated with any detectable value in promoting better birth weight outcomes. Future research needs to examine how WIC (and/or other maternal and child health programs) could be made to work better and reach farther to address persistent disparities in birth weight outcomes. Additionally, in preparation for future economic downturns it will be important to determine how to preserve and, if possible, expand WIC services during times of increased need.Trial Registration: Not applicable, this article reports only on secondary retrospective data (no health interventions with human participants were carried out). [ABSTRACT FROM AUTHOR]