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During 2021, nearly 150,000 unaccompanied children (UCs) were apprehended at the US-Mexican border. Most are leaving Guatemala, Honduras, and El Salvador, motivated by poverty, climate change, and violence. UCs are most often apprehended by the Border Patrol and then transferred to the Office of Refugee Resettlement (ORR), the Department of Health and Human Services. ORR is responsible for ensuring that the child is released to a parent or sponsor in the United States capable of providing an adequate home. Advocacy must not only address a complex system of legal and custodial care but also confront a troubled political environment.

Low- and middle-income countries account for over 90% of burns worldwide. Though mission trips, public health interventions and educational strategies have been introduced in recent years, a disparity remains in treatment provided between high- and low -income countries. This analysis aims to review available literature pertaining to strategies for training in burns management, with a focus on those applicable to low-income countries.Mesh terms including "burns", "burns care", "burns management", "training", "teaching" and "education" were inputted into Medline and EMBase. Studies were included on the basis that they include an educational intervention to train doctors to provide surgical burns care in low-income countries. Included literature was analysed using scoring tools then a critical appraisal was performed.Fourteen studies were included in this analysis. These describe e-learning (n = 1), video-based teaching (n = 1), lecture-based teaching (n = 1), simulation training (n = 8) and hospital-based training achieved through collaborative efforts between high and low-income countries such as mission trips and fellowship programmes (n = 3). The strategies described have been summarised and presented.Burns care training should be accessible at a global scale and so, involve training methods including simulation, courses and fellowship programmes that are affordable and accessible to surgeons in low-income countries.

Background We use the Global Multidimensional Poverty Index (MPI) to explore how different dimensions of poverty more directly linked to young people are associated with depressive symptoms among South African youth. Methods Data came from the 2017 wave of the nationally-representative National Income Dynamics Study (NIDS) in South Africa. We focused on a sample of 15-24-year-olds whose depressive symptoms were assessed using an adapted version of the 10-item Centre for Epidemiological Studies Depression Scale. We examine how individual dimensions and indicators of the MPI relate to depression, in comparison to more conventional measures, including household income, subjective social standing, overcrowding and personal assets. Cross-sectional analyses were adjusted for clustering to account for sampling design. Results The MPI index was not associated with probable depression (OR=1.02, 95%CI 0.81-1.29). Only lack of access to the labour market emerged as a key individual dimension associated with probable depression (OR=5.29, 95%CI 1.70-16.47), a relationship driven by an increased odds for those not in employment, education or training. Lack of household assets, living in an informal dwelling and lower perceived social standing were also associated with increased odds for depression. No gender differences were noted. Limitations The study is cross-sectional and not suitable to examine the causal nature of the association between multidimensional poverty and depression. Conclusions Poverty dimensions that measure youth’s access to employment or training have a strong association with depression. Further research is needed to assess whether improved access to employment or training contributes to improving mental health among young South Africans.

Barriers in access to pediatric surgical care are common in low- and middle-income countries (LMICs), but also exist in high-income countries, particularly in urban and rural areas.This article describes "Disparities in Access to Care"-held within the Social Injustice Symposium at the 2020 American Pediatric Surgical Association (APSA) Annual Meeting.This symposium outlined disparities in access to care, illustrated by examples from pediatric trauma and neonatal surgery in U.S. urban, U.S. rural, and non-U.S. global locations (LMICs). Geographic and financial challenges were common to families from the rural U.S. and LMICs. In contrast, families in U.S. urban settings generally do not face geographic barriers, but are often economically and racially diverse and many face complex societal factors leading to poor outcomes. Systemic processes must be changed to improve pediatric surgical health outcomes.A comprehensive health system with an equal emphasis on supportive care and surgery is required in all settings. Global collaboration and partnerships can provide an avenue for advocacy and strategic innovation to improve quality of care.Ⅴ.

Burn injury risk, severity, and outcomes have been associated with socioeconomic status. Limited data exist to evaluate health access-related influences at a structural population level. This study evaluated factors at the Census-tract level, specifically evaluating food access and social vulnerability in pediatric scald burns.A single-institution retrospective review using the trauma registry and electronic medical record was conducted of pediatric burns between 2016 and 2020. Home address was coded to the Census-tract level and bulk analyzed. Socioeconomic metrics of the home environment were evaluated from publicly available databases, the United States Food and Drug Administration Food Access Research Atlas, and the Centers for Disease Control's Social Vulnerability Index.There were 840 patients that met inclusion criteria (49.8% scald, N = 418). The mean total body surface area for scalds was 6.6% with an age of 10.2 years; 76% (n = 317) of scalds had Medicaid, and 15% (n = 63) were due to hot noodles. Scalds occurred more in females (45.7%, N = 191 vs 28.0%, N = 118; Plt; .0001), non-White race (62.7%, N = 262 vs 29.1%, N = 123; Plt; .0001), and low-income and low-food access populations (39.8%, N = 147 vs 30.4%, N = 116; P = .007). Low-food access Black populations showed increased scald injury (18% [interquartile range 6-35] vs 10% [interquartile range 4-25]), whereas all other populations showed no association. The patients with scalds had a higher overall social vulnerability index (0.67 vs 0.62, P = .008).Often related to poverty, health access, and health equity, population-level social determinants of health like social vulnerability and food access have significant impact on health care and should influence health outreach and systems improvement.

We are facing a global water crisis. However, because most water indicators assess physical availability or infrastructure in aggregate, knowing which sociodemographic groups experience water insecurity is difficult. We aimed to assess the prevalence of water insecurity across low-income and middle-income countries (LMICs) and examine how it varies by sociodemographic characteristics and exposure to life disruptions due to the COVID-19 pandemic across and within countries.In this observational study, we used Individual Water Insecurity Experiences (IWISE) scale data from a cross-sectional, nationally representative sample of individuals aged 15 years and older (defined as adults) in 31 LMICs. The IWISE scale range is 0-36, and water insecurity was defined as a score of 12 or higher. We used multivariable linear regression models to assess how individual-level experiences with water insecurity related to sociodemographic characteristics in each country, region, and the pooled sample.45 555 individuals from 31 LMICs completed the IWISE module between Sept 4, 2020, and Feb 24, 2021, and were included in the 2020 Gallup World Poll (GWP) database; 45 365 individuals had sufficient data to estimate the prevalence of water insecurity. 42 918 individuals from 30 LMICs had sufficient data to assess sociodemographic characteristics associated with water insecurity, and 39 161 individuals in 29 countries had sufficient data to assess how IWISE scale scores covaried with life disruptions due to the COVID-19 pandemic. The overall prevalence of water insecurity in 2020 was 14·2%, ranging by region from 36·1% in the sub-Saharan Africa region to 9·1% in the Asia region, and by country from 63·9% in Cameroon to 3·6% in China. In the pooled model including sociodemographic and COVID-19 factors, difficulty getting by on household income (vs no difficulty getting by: β 2·76 [95% CI 2·45-3·07]), living in the outskirts of a city (vs living in a large city: 0·85 [0·29-1·41]), and being greatly affected by the COVID-19 pandemic (vs not being affected: 2·36 [1·96-2·77]) were strongly associated with higher IWISE scores. In country and regional models, the sociodemographic factors most consistently associated with higher IWISE scores were difficulty getting by on household income and life disruptions due to the COVID-19 pandemic, but the strength of these associations varied across countries and regions.Through extrapolation of these nationally representative data, we estimate that hundreds of millions of people had life-altering experiences with water insecurity globally in 2020, and that their sociodemographic characteristics vary by country and region. Additional individual-level measurements globally could help pinpoint the characteristics of those who are most water insecure, thereby guiding the development of context-specific policy and interventions that will best serve those most affected.Carnegie Corporation, Northwestern University, and USAID.

To understand how families receiving benefits from the Supplemental Nutrition Assistance Program (SNAP) conceptualize healthy eating and its relationship to child development.This study is a secondary analysis of in-depth, in-home qualitative interviews. 30 caregivers with children between the ages of 4 and 10 years old participating in SNAP in Baltimore, MD, were asked about food purchasing resources and strategies. Two independent coders re-analyzed primary data using an iterative process to identify a priori themes related to caregivers' conceptualization of healthy eating and emergent themes related to the ways families use SNAP benefits. Themes were identified via content analysis and revised until consensus was reached.Participants demonstrated knowledge of nutritious food groups, specific unhealthy nutrients, and the importance of food in managing chronic conditions. However, the importance of nutrition was balanced with the need for ready-made foods that children could safely prepare on their own, shelf stable goods, and low-cost foods. Emergent themes identified caregivers' views of health-related impacts of food beyond nutrition, including the role of food as: a parenting tool to support child socialization and development, a means of creating experiences unique to childhood, and a mechanism for promoting family cohesion.This study suggests families receiving SNAP use benefits to best serve children's well-being while conceptualizing the child health benefits of food as extending beyond nutrition. Future policy interventions aimed at optimizing SNAP should address the potential for nutrition assistance to foster positive child social and emotional development among low-income families while meeting nutritional needs.

Chronic parental stress may negatively impact health among both parents and children. Adverse neighborhood social conditions like crime may increase stress while a supportive neighborhood may buffer stress and promote well-being. Our objective was to examine associations between neighborhood social factors and stress among mothers of young children.We surveyed 300 mothers/female caregivers of Medicaid-enrolled 2 to 4-year-old children in Philadelphia. Maternal stress was measured via the 10-item Perceived Stress Scale (range 0-40). Mothers' perceived neighborhood safety and collective efficacy were assessed using validated scales. Addresses were geocoded to link census tract-level violent crime rates. We used multivariable linear regression to examine associations of neighborhood safety, collective efficacy, and crime with maternal stress, adjusted for demographics, household socioeconomic status, and neighborhood poverty.Among mothers (mean age 31, 60% Black/African American), higher perceived neighborhood safety and collective efficacy were associated with lower stress scores after adjustment for covariates. Each 1-point increase (on a 5-point scale) in perceived neighborhood safety was associated with a 2.30-point decrease in maternal stress (95% CI: -3.07, -1.53). Similarly, each 1-point increase in perceived collective efficacy was associated with a 3.08-point decrease in maternal stress (95% CI: -4.13, -2.02). Police-recorded violent crime rates were not associated with maternal stress.Mothers of young children who perceive their neighborhood social environment more favorably report less stress compared to those who feel their neighborhood environment is less safe and cohesive. Future work is warranted to investigate whether interventions that increase perceived neighborhood safety and collective efficacy reduce stress.

To describe state agencies' implementation of the Supplemental Nutrition Assistance Program (SNAP) during the first year of the coronavirus disease of 2019 (COVID-19) pandemic, barriers and facilitators to SNAP implementation, and recommendations to improve SNAP implementation.Qualitative methodology guided by Bullock's determinants of policy implementation framework using 7 semistructured, virtual focus groups in April 2021.Twenty-six states representing all 7 US Department of Agriculture Food and Nutrition Service regions.Four focus groups with state-level SNAP administrators and 3 focus groups with state-level SNAP supportive services (Supplemental Nutrition Assistance Program-Education, EmploymentTraining, and Outreach) supervisors (n = 62).Supplemental Nutrition Assistance Program implementation during the COVID-19 pandemic.Thematic analysis using a phronetic iterative approach.Six primary themes emerged: the policy response, technology needs, collaboration, participant communication, funding realities, and equity. Implementation challenges included the design of waivers in the early pandemic response, inadequate federal guidance and funding, outdated technology, and prepandemic regulations limiting state authority. Modernized technology systems, availability of virtual programming, partnerships, and enhanced benefits facilitated SNAP implementation.Supplemental Nutrition Assistance Program administrators adapted their programs to deliver services virtually during the COVID-19 pandemic. These experiences highlighted the importance of certain policy determinants, such as modernized technology and streamlined application processes, to improve outcomes for SNAP participants and staff.

BackgroundHousehold food insecurity persists in the United States and has important implications for health and well-being. Food insecurity in female-identified caregivers is particularly concerning, given its association with their mental health and adverse health outcomes for their children. Food insecurity is associated with disordered eating but, to our knowledge, no prior studies have examined an association between food insecurity and food addiction.ObjectiveOur aim was to examine whether food insecurity is associated with higher food addiction symptom endorsement in low-income female adults.DesignSecondary analysis of baseline data from a quasi-experimental study of a mindfulness-based intervention on gestational weight gain among low-income pregnant individuals and an observational study of low-income families.Participants/settingParticipants in study 1 (n= 208) were English-speaking, low-income pregnant individuals with overweight or obesity, recruited in California from 2011 to 2013. Participants in study 2 (n= 181) were English-speaking, low-income female caregivers for children aged 8 through 10 years, recruited in Michigan from 2018 to 2019. Both studies recruited participants from community health clinics, social service agencies, and online advertisements.Main outcome measuresThe primary outcome measure was food addiction symptoms, assessed by the Yale Food Addiction Scale.Statistical analysisMultivariate Poisson regression was used to examine the association between household food insecurity and food addiction symptoms in each sample, adjusted for sociodemographic characteristics.ResultsIn study 1, pregnant individuals in food-insecure households reported 21% higher food addiction symptoms than pregnant individuals in food-secure households (incidence rate ratio 1.21; 95% CI 1.00 to 1.47; P= .047). In study 2, caregivers in food-insecure households had 56% higher food addiction symptoms than caregivers in food-secure households (incidence rate ratio 1.56; 95% CI 1.01 to 2.40; P= .045).ConclusionsThese findings provide preliminary support for a relationship between household food insecurity and food addiction. Future research should examine potential mechanisms and whether interventions to reduce food insecurity lower risk of food addiction.

To characterize the prevalence of food insecurity among men who have sex with men (MSM) and assess its associations with sexual health measures and substance use, as compared to poverty status.In 2017, 10,049 US MSM were recruited online and completed the American Men's Internet Survey. The survey assessed food insecurity, annual household income and past-year behaviors: condomless anal intercourse, exchange sex, any illicit substance use other than marijuana, use of methamphetamine, alkyl nitrites or gamma-hydroxybutyrate (GHB), HIV testing, and sexually transmitted infection testing and diagnosis. We tested associations between behavioral outcomes and food insecurity or poverty, controlling for demographic characteristics.The prevalence of food insecurity among AMIS participants was 15.8%. Food insecurity nonresponse was 2.5% while income nonresponse was 19.0%. Food insecurity was significantly and positively associated with all behavioral outcomes, while poverty was significantly and positively associated only with exchange sex, any illicit substance use, methamphetamine, and GHB use. In models that included both food insecurity and poverty as exposures, food insecurity remained independently positively associated with all behavioral outcomes and the associations for poverty level were null for all outcomes except methamphetamine and GHB use.Assessing food insecurity in sexual health and substance use survey research may provide a more robust indicator of economic deprivation and provide insight for HIV and STI prevention interventions.

To examine the interactive association of neighborhood and family socio-economic characteristics (SEC) on children's sleep.Secondary data analyses were completed on the 2014 Ontario Child Health Study, a cross-sectional sample of 10,802 children aged 4-17.Children (aged 4-11, 50% male; N = 6264) with available sleep outcome data.Multilevel modeling was used to assess the interactive relationship between family- and neighborhood-level poverty in relation to child sleep outcomes (problems falling asleep, problems staying asleep, weekday and weekend time in bed), above the associations of variables known to be related to sleep at the child (ie, child age, sex, internalizing problems, externalizing problems, chronic illness), family (ie, negative parenting behaviors, family structure, parent mental health, years lived in neighborhood, parent education level), and neighborhood levels (ie, neighborhood size, antisocial behavior).Neighborhood poverty (plt; .01, ß = -0.001, 95% confidence interval [-0.007, -0.002]) was significantly related to shorter weekday time in bed and the interactive association of family and neighborhood poverty was significantly related to weekend time in bed (plt; .05, ß = 0.012, 95% confidence interval [0.004, 0.021]). Children living in low poverty neighborhoods with families of higher SEC backgrounds, and children living in high poverty neighborhoods with families of lower SEC backgrounds had the shortest weekend time in bed (9.7 hours).There is a compound relationship of family and neighborhood poverty on children's sleep above and beyond family- and child-level risk factors.

The New York Neurotrauma Consortium (NYNC) is a nascent multidisciplinary research and advocacy organization based in the New York Metropolitan Area (NYMA). It aims to advance health equity and optimize outcomes for traumatic brain and spine injury patients. Given the extensive racial, ethnic, and socioeconomic diversity of the NYMA, global health frameworks aimed at eliminating disparities in neurotrauma may provide a relevant and useful model for the informing research agendas of consortia like the NYNC. In this review, we present a comparative analysis of key health disparities in traumatic brain injury (TBI) that persists in the NYMA as well as in low- and middle-income countries (LMICs). Examples include (a) inequitable access to quality care due to fragmentation of healthcare systems, (b) barriers to effective prehospital care for TBI, and (c) socioeconomic challenges faced by patients and their families during the subacute and chronic postinjury phases of TBI care. This review presents strategies to address each area of health disparity based on previous studies conducted in both LMIC and high-income country settings. Increased awareness of healthcare disparities, education of healthcare professionals, effective policy advocacy for systemic changes, and fostering racial diversity of the trauma care workforce can guide the development of trauma care systems in the NYMA that are free of racial and related healthcare disparities.

Alcohol is a leading risk factor for over 200 conditions and an important contributor to socioeconomic health inequalities. However, little is known about the associations between individuals' socioeconomic circumstances and alcohol consumption, especially heavy episodic drinking (HED; ≥5 drinks on one occasion) in low-income or middle-income countries. We investigated the association between individual and household level socioeconomic status, and alcohol drinking habits in these settings.In this pooled analysis of individual-level data, we used available nationally representative surveys-mainly WHO Stepwise Approach to Surveillance surveys-conducted in 55 low-income and middle-income countries between 2005 and 2017 reporting on alcohol use. Surveys from participants aged 15 years or older were included. Logistic regression models controlling for age, country, and survey year stratified by sex and country income groups were used to investigate associations between two indicators of socioeconomic status (individual educational attainment and household wealth) and alcohol use (current drinking and HED amongst current drinkers).Surveys from 336 287 participants were included in the analysis. Among males, the highest prevalence of both current drinking and HED was found in lower-middle-income countries (L-MICs; current drinking 49·9% [95% CI 48·7-51·2] and HED 63·3% [61·0-65·7]). Among females, the prevalence of current drinking was highest in upper-middle-income countries (U-MIC; 29·5% [26·1-33·2]), and the prevalence of HED was highest in low-income countries (LICs; 36·8% [33·6-40·2]). Clear gradients in the prevalence of current drinking were observed across all country income groups, with a higher prevalence among participants with high socioeconomic status. However, in U-MICs, current drinkers with low socioeconomic status were more likely to engage in HED than participants with high socioeconomic status; the opposite was observed in LICs, and no association between socioeconomic status and HED was found in L-MICs.The findings call for urgent alcohol control policies and interventions in LICs and L-MICs to reduce harmful HED. Moreover, alcohol control policies need to be targeted at socially disadvantaged groups in U-MICs.Deutsche Forschungsgemeinschaft and the National Center for Advancing Translational Sciences of the US National Institutes of Health.

Implementation science is a useful tool to consider ways in which we can introduce improvements to burn services in low-and-middle income countries (LMICs), where the majority of the burden of burn injury is now experienced. This paper outlines the development of the Delivery Assessment Tool (DAT), a method for facilitating quality improvement in burn services in LMICs. We used a participatory approach that ensured that local clinicians and experts were fully involved in piloting the tool. The DAT is based on internationally agreed operational standards for burn care service delivery and has undergone an iterative process of improvement and refinement through an initial three-year project in Nepal and Bangladesh. The DAT, a 50-item tool organised into 10 subsections, is used to assess a service through a participatory focus group discussion (FGD) with a mixed, multidisciplinary team of staff working at the burn service, typically 6-10 participants. This usually lasts 2 to 3hours. The staff in the unit then select priority areas for quality improvement programmes that are within their control to achieve, which starts a cycle of audit and review. The final version of the tool was used in a further three-year project to evaluate 11 hospitals in Nepal and Bangladesh. Education and training are key components of this work; both were provided by Interburns as part of on-going support for the clinical teams. At the end of the project a >19% improvement in scores was demonstrated using the final version of the DAT in both Nepal and Bangladesh; this achievement is remarkable given the continued difficulties in service provision where patient numbers far outstrip the resources available to care for them. As a result of this work, we have made a digital version of the tool available free of charge.

PURPOSE: The Developmental Psychobiological Model of Experiential Canalization (DPMEC) proposes that conditions of poverty-related adversity influence child self-regulation through parental caregiving, stress hormones, and the child’s genetics. However, empirical findings investigating these relationships with prolonged stress hormones are mixed. Further, the relationships among conditions of adversity with prolonged stress hormones have seldom been investigated in toddlers living in poverty. Guided by the DPMEC, we examined the relationships among maternal caregiving, prolonged stress, and self-regulation in toddlers living in poverty in the United States, to include examining whether toddler prolonged stress mediated relations between maternal caregiving and child self-regulation. DESIGN AND METHODS: Participants were mothers and toddlers (20 to 24 months of age) living in poverty, who provided hair samples to measure four months of average cortisol concentration to estimate prolonged stress. We used observational measures to examine maternal caregiving and indirect report to measure children’s self-regulation. RESULTS: Findings did not support the role of toddler prolonged stress in mediating the relationship between maternal caregiving and toddler self-regulation. However, multiple linear regression models showed that higher levels of maternal emotionally supportive caregiving significantly predicted better toddler soothability (b = 0.90; p = .03; 95% CI [0.10, 1.69]; partial correlation = .26). CONCLUSIONS: This study adds partial support for the DPMEC to represent associations between maternal caregiving and toddler self-regulation for mothers and toddlers experiencing poverty. PRACTICE IMPLICATIONS: While these data come from an observational study, pediatric nurses may consider assessing maternal supportive caregiving upon reports of poor toddler soothability.

The Supplemental Nutrition Assistance Program; Free/Reduced Priced Lunch Program; and Special Supplemental Nutrition Program for Women, Infants, and Children reduce food insecurity for millions of Americans with lower incomes. However, critics have questioned whether they increase obesity. This study examined whether program participation was associated with BMI z-score from kindergarten to fifth grade.Data from 4,457 primary-grade students whose household incomes were equal to or below 200% of the federal poverty level from kindergarten to fifth grade as part of the Early Childhood Longitudinal Study, Kindergarten Class of 2010‒2011 were analyzed. Marginal structural models with inverse probability of treatment/censoring weights were used to estimate associations between Supplemental Nutrition Assistance Program/Free and Reduced Priced Lunch participation over time and fifth-grade BMI z-score, accounting for lost-to-follow-up and time-varying confounders. Weighted generalized estimating equations were used to examine associations between Special Supplemental Nutrition Program for Women, Infants, and Children participation and BMI z-score trends. All analyses incorporated sampling weights. The Early Childhood Longitudinal Study, Kindergarten Class of 2010‒2011 data were collected from 2010-2016; analyses were conducted in 2021 and 2022.At baseline, 2,419 (54.3%) respondents participated in the Supplemental Nutrition Assistance Program, 3,993 (89.6%) participated in Free/Reduced Priced Lunch, and 3,755 (84.2%) reported past participation in the Special Supplemental Nutrition Program for Women, Infants, and Children. No associations were found between any program and fifth-grade BMI z-score or between Special Supplemental Nutrition Program for Women, Infants, and Children participation and BMI z-score trend.Previous findings of relationships between program participation and BMI may have been because of weaker study designs and uncontrolled confounding. Participation in the Supplemental Nutrition Assistance Program; Free/Reduced Priced Lunch; and Special Supplemental Nutrition Program for Women, Infants, and Children was not associated with increased risk of childhood obesity in this recently conducted longitudinal study.

2·6 billion people rely on solid fuels for cooking or heating. Accelerating access to cleaner solutions is crucial to reduce the negative effects of solid fuel use. Despite abundant evidence on how to implement these solutions, previous attempts have been disappointing. An overview of the evidence is missing and the translation of the evidence into practice is poor. We conducted an umbrella review using eight databases to: consolidate evidence on the factors that influence the implementation of improved solid fuel cookstoves and clean fuels in low-income and middle-income countries; weigh the level of confidence in existing evidence; and develop two practical implementation strategy tools. We identified 31 relevant reviews (13 systematic reviews and 18 narrative reviews) that covered over 479 primary studies. We found 15 implementation factors supported by the highest level of evidence. Regarding improved solid fuel cookstoves, these factors included: cost; knowledge and beliefs about the innovation; and compatibility. For clean fuels these factors included: cost; knowledge and beliefs about the innovation; and external policy and incentives. The factors were synthesised into the Cleaner Cookstove Implementation Tool and the Clean Fuel Implementation Tool. These tools can be used to optimise the implementation of cleaner cooking solutions, thereby improving health, environmental, climate, and gender equity outcomes.

Over 90% of the annual 1·35 million worldwide deaths due to road traffic injuries (RTIs) occur in low-income and middle-income countries (LMICs). For this Series paper, our aim was two-fold. Firstly, to review evidence on effective interventions for victims of RTIs; and secondly, to estimate the potential number of lives saved by effective trauma care systems and clinical interventions in LMICs. We reviewed all the literature on trauma-related health systems and clinical interventions published during the past 20 years using MEDLINE, Embase, and Web of Science. We included studies in which mortality was the primary outcome and excluded studies in which trauma other than RTIs was the predominant injury. We used data from the Global Status Report on Road Safety 2018 and a Monte Carlo simulation technique to estimate the potential annual attributable number of lives saved in LMICs. Of the 1921 studies identified for our review of the literature, 62 (3·2%) met the inclusion criteria. Only 28 (1·5%) had data to calculate relative risk. We found that more than 200 000 lives per year can be saved globally with the implementation of a complete trauma system with 100% coverage in LMICs. Partial system improvements such as establishing trauma centres (145 000 lives saved) and instituting and improving trauma teams (115 000) were also effective. Emergency medical services had a wide range of effects on mortality, from increasing mortality to saving lives (200 000 excess deaths to200 000 lives saved per year). For clinical interventions, damage control resuscitation (60 000 lives saved per year) and institution of interventional radiology (50 000 lives saved per year) were the most effective interventions. On the basis of the scarce evidence available, a few key interventions have been identified to provide guidance to policy makers and clinicians on evidence-based interventions that can reduce deaths due to RTIs in LMICs. We also highlight important gaps in knowledge on the effects of other interventions.

Although Medicaid expansion aims to eliminate financial barriers to health care for low-income people in the United States, health care accessibility cannot be guaranteed without clinicians who provide health care to Medicaid recipients. This study examined the characteristics of Indiana dentists that are associated with the likelihood of participating in Medicaid after expansion in 2015.This study included Indiana-licensed dentists who renewed their licenses in 2018 and provided supplemental data elements related to demographics, education and training, and professional characteristics. Dentists' Medicaid engagement behavior was categorized on the basis of when claims were submitted from 2014 through 2017. Statistical analyses included the χOverall, 2,037 Indiana-licensed dentists were included in the study. Of these, 802 (39.4%) were continually active in Medicaid during the study period, and 116 (5.7%) became active after expansion. Dentists had a greater likelihood of engaging in Medicaid after expansion if they were female, specialized in oral and maxillofacial surgery, practiced in a group practice, and were located in a rural county.This study shows that dentists with certain demographic and practice characteristics had a greater likelihood of participation in Indiana Medicaid after expansion in 2015. Several findings from this study are consistent with previous research regarding the emerging trends in workforce diversity and show the impact of expansion policies on the dental safety net.This study presents an effective framework for the use of administrative and regulatory data sources for state-level analysis of the Medicaid safety net.

To estimate the number and geographic distribution of children and adolescents in the United States who reside in counties with neither child and adolescent psychiatrists nor sufficient Internet broadband to support telepsychiatry services.This analysis combined data from the Health Resources and Services Administration's Area Health Resource Files on child psychiatrist workforce with Federal Communications Commission information on broadband coverage to generate a composite of in-person and digital access to child psychiatric services throughout the United States. Using multivariable fixed-effects Poisson regression analysis, we estimated the number of children and adolescents (aged 5-19 years) without access to psychiatric services and examined disparities across counties in the United States.We estimate that 6,035,402 children and adolescents in the United States (approximately 10%) have inadequate in-person and digital availability of child psychiatric services within their counties. Although this was true for only 3% of children and adolescents in urban counties, this applied to more than half (51%) in rural counties (adjusted odds ratio [AOR] = 2.71; 95% CI = 1.94, 3.78; p .001). Likewise, only 3% of children and adolescents in high-income counties had insufficient digital and physical access, compared to more than 4 in 10 children and adolescents (41%) in low-income counties (AOR = 0.43; 95% CI = 0.30-0.61; p .001). Counties with a higher density of Black and Hispanic residents had greater likelihood of service availability (p 0.001), potentially a function of living in metropolitan communities.Although telehealth holds promise for promoting access to child and adolescent psychiatric services, large disparities in overall access to services persists in rural and low-income communities.

Background: Infertility and intimate partner violence (IPV) are of serious concern globally, yet the prevalence of IPV against infertile women has not been quantified at the regional or global level. We aimed to estimate the prevalence of IPV against infertile women and its variation in low-income and middle-income countries (LMICs). Methods: We did a systematic literature search of 11 databases for articles published between database inception and Sept 30, 2021, and performed meta-analyses to estimate the pooled prevalence and 95% CI of IPV against infertile women in LMICs. We used subgroup analyses and meta-regressions to explore variation in the prevalence by study period (2010 and before vs after 2010), study region (Africa, west Asia, south Asia, and east Asia), type of infertility (primary or secondary), risk of bias (high, moderate, or low), sample size (continuous variable), and measuring tools (the modified Abuse Assessment Screen, the WHO Violence Against Women instrument, or the revised Conflict Tactics Scales). This study is registered with PROSPERO, CRD42021248448. Findings: Of 2661 references identified (2637 via database searches and 24 via secondary searches), 120 full-text articles were reviewed, and we identified 30 relevant studies conducted in nine LMICs between 2000 and 2019. 25 studies met the inclusion criteria for meta-analysis, with a total sample size of 7164 participants. The 12-month prevalence of IPV among infertile women was 36·0% (95% CI 20·4–55·2), compared with a lifetime prevalence of 47·2% (31·7–63·3). The most common type of IPV was psychological violence, with a prevalence of 24·6% (11·3–45·6) over 12 months and 51·5% (38·8–64·0) over a lifetime (slightly higher than the pooled overall rate due to different data sources), respectively; followed by physical violence (11·9% [5·2–25·1] and 20·2% [12·1–31·7]); sexual violence (8·7% [2·6–25·0] and 11·5% [6·1–20·7]); and economic coercion (2·6% [0·4–13·7] and 9·8% [5·7–16·5]). Significant variations of lifetime prevalence estimates were presented by study period (R2=39·46%), region (R2=50·95%), and measuring tools (R2=54·27%). Interpretation: A high prevalence of IPV against infertile women is evident despite heterogeneity across studies. IPV screening, counselling, and structural interventions should be tailored to address this urgent issue at multiple levels of society. Funding: China Medical Board and WHO.

Adverse and positive childhood experiences have a profound impact on lifespan health and well-being. However, their incorporation into ongoing population-based surveillance systems has been limited. This paper outlines critical steps in building a comprehensive approach to adverse and positive childhood experiences surveillance, provides examples from the Preventing Adverse Childhood Experiences: Data to Action cooperative agreement, and describes improvements needed to optimize surveillance data for action. Components of a comprehensive approach to adverse and positive childhood experiences surveillance include revisiting definitions and measurement, including generating and using uniform definitions for adverse and positive childhood experiences across data collection efforts; conducting youth-based surveillance of adverse and positive childhood experiences; using innovative methods to gather and analyze near real-time data; leveraging available data, including from administrative sources; and integrating data on community- and societal-level risk and protective factors for adverse childhood experiences, including social and health inequities such as racism and poverty, as well as policies and conditions that create healthy environments for children and families. Comprehensive surveillance data on adverse and positive childhood experiences can inform data-driven prevention and intervention efforts, including focusing prevention programming and services to populations in greatest need. Data can be used to evaluate progress in reducing the occurrence of adverse childhood experiences and bolstering the occurrence of positive childhood experiences. Through expansion and improvement in adverse and positive childhood experiences surveillance-including at federal, state, territorial, tribal, and local levels-data-driven action can reduce children's exposure to violence and other adversities and improve lifelong health and well-being.

Despite health gains over the past 30 years, children and adolescents are not reaching their health potential in many low-income and middle-income countries (LMICs). In addition to health systems, social systems, such as schools, communities, families, and digital platforms, can be used to promote health. We did a targeted literature review of how well health and social systems are meeting the needs of children in LMICs using the framework of The Lancet Global Health Commission on high-quality health systems and we reviewed evidence for structural reforms in health and social sectors. We found that quality of services for children is substandard across both health and social systems. Health systems have deficits in care competence (eg, diagnosis and management), system competence (eg, timeliness, continuity, and referral), user experience (eg, respect and usability), service provision for common and serious conditions (eg, cancer, trauma, and mental health), and service offerings for adolescents. Education and social services for child health are limited by low funding and poor coordination with other sectors. Structural reforms are more likely to improve service quality substantially and at scale than are micro-level efforts. Promising approaches include governing for quality (eg, leadership, expert management, and learning systems), redesigning service delivery to maximise outcomes, and empowering families to better care for children and to demand quality care from health and social systems. Additional research is needed on health needs across the life course, health system performance for children and families, and large-scale evaluation of promising health and social programmes.

Many clinicians have limited knowledge about the challenges of living in poverty, leading to stigma and differential treatment in healthcare settings. A poverty simulation event may help clinicians gain empathy and knowledge about the ways that poverty impacts health and well-being.This study evaluated the impact of a poverty simulation and the effect of personal characteristics on clinicians' attitudes towards poverty.Using a prospective longitudinal mixed-methods study design, a convenience sampling of clinicians from a freestanding children's hospital was recruited to participate in a poverty simulation event. The 21-item Attitudes Towards Poverty (ATP) tool was administered pre- and post-simulation and at 3 follow-up time points. Multiple linear regression analysis and linear mixed effects models were used to analyze ATP data. Qualitative data were analyzed to identify broad themes.Mean scores in the ATP domains of stigma and structural perspective increased post-simulation, but only stigma scores demonstrated sustained improvement. Scores in the personal deficiency domain remained unchanged. Being male, White, and having Liberal political views were associated with lower ATP scores in our data. Qualitative data show participants felt the simulation generated feelings of compassion and empathy.Simulation participation improved ATP scores in two domains immediately post-event, suggesting the simulation positively impacted clinicians' attitudes towards poverty. Follow-up data suggest the impact of the simulation may be temporary.Experiential learning activities, like poverty simulations, help foster awareness and empathy among clinicians but may not have long-term impact. Ongoing education is needed to create a workforce sensitized and equipped to care for families from all backgrounds.

The burden of surgical disease in children from low and middle-income countries (LMICs) is becoming more recognized as significant and undertreated. We recently reviewed our health system's experience with providing quaternary-level surgical care to children from LMICs through a partnership with World Pediatric Project (WPP), a not-for-profit organization.A retrospective review was performed of all WPP-sponsored patients who received surgical care at our children's hospital from LMICs in the Caribbean and Central America from July 2000 to August 2018.Two hundred and fifty-five patients (average age: 5.9 ± 5.3 years; range:1-18 years) from 14 countries received a total of 371 moderately to significantly complex operations from 10 pediatric surgical subspecialties, with cardiac, neurosurgery, craniofacial and general/thoracic surgical subspecialties being the most common. The average length of hospital stay was 10.7 ± 18.9 days. All patients had the opportunity to follow-up with local providers and/or visiting WPP-sponsored surgical teams. 227 patients (93.8%) were seen by WPP providers or released to an in-country physician partnering with WPP. There were 21 (8.2%) total, minor and major, postoperative complications. Five deaths (2.0%) occurred at our institution and 7 from disease progression, after returning to their home country.Providing complex surgical care to LMIC children in the US may help address a significant global burden. This care can be provided by multiple subspecialists with excellent outcomes, good follow-up, and low complication and mortality rates. Having a supportive health care system, volunteer surgeons, and an organization that manages logistics and provides financial support is essential.Clinical research, retrospective review LEVEL OF EVIDENCE: Level IV.

Objective To examine the effects of parental Medicaid eligibility on parental health, parenting practices, and child development in low-income families. Methods Longitudinal analysis using data from the Early Child Longitudinal Study-Kindergarten: 2011 to 2016. Outcomes included parental self-rated health, parental depressive symptoms, parents’ communication and warmth toward children, and children's social skills and externalizing and internalizing behaviors. We estimated 2-way (individual and year) fixed effects models using Medicaid eligibility as a continuous variable, controlling for changing economic conditions, changes in family structure, and state-specific trends. We then estimated triple difference models comparing lower income families to those with higher incomes. Finally, we estimated difference-in-difference models and used entropy weights in order to account for differences in trends prior to 2014 for some outcomes. Results In fixed effects models, expanding Medicaid eligibility by 100% of the federal poverty line is associated with a 12.7 percentage point reduction in parents’ report of having fair or poor health (95% confidence interval [CI], -23.9, -1.5) and a 1.15-point improvement on a 12-point scale of parental warmth towards children (95% CI, 0.15, 2.16). Results were substantively similar in entropy-balanced difference-in-differences models. In triple difference models, expanded Medicaid eligibility is associated with a 0.46 point improvement in warmth (95% CI, 0.10, 0.83) but not improved parental health. No significant effects for child behavior or other outcomes were detected. Conclusions Expanding Medicaid for parents may have implications for intergenerational family functioning that could lead to broader social benefits.

OBJECTIVE: To identify longitudinal bidirectional associations between unique sleep trajectories and obesity and hypertension among Black, adolescent girls. DESIGN, SETTING, AND PARTICIPANTS: Longitudinal data were from a randomized controlled trial (2009–2013) implemented in schools serving low-income communities aimed at preventing obesity among adolescent girls (mean age = 12.2 y (SD ± 0.72). MEASURES: Nocturnal sleep data were extracted from accelerometers at T1 (enrollment, n = 470), T2 (6-month, n = 348), and T3 (18-month follow-up, n = 277); height and weight were measured at T1–T3; and systolic/diastolic blood pressure (SDBP) at T1 and T3 using an oscillometric monitor. Multilevel models examined longitudinal associations. Finite mixture models identified sleep trajectory groups. Structural equation models examined whether T1 chronic disease risk predicted sleep profiles, and conversely, if sleep trajectories predicted T3 chronic disease risk. Data were analyzed in 2021. RESULTS: For each additional hour of sleep and 1% increase in efficiency there was a 7% lower risk of overweight/obesity at T1 and 6% lower risk at T2, but not at T3. Four sleep trajectories emerged: Worsened, Irregular, Improved, and Regular, with no demographic or metabolic differences between the trajectories. Improved sleep trajectory predicted lower diastolic percentile at T3 (b = −8.81 [95% CI −16.23, −1.40]). CONCLUSIONS: Group-based trajectories of sleep duration and quality provide information on modifiable factors that can be targeted in interventions to evaluate their impact on reducing chronic diseases and addressing disparities. Additional research is needed on samples beyond those recruited in the context of an intervention study.

The COVID-19 pandemic has underscored the need to strengthen national surveillance systems to protect a globally connected world. In low-income and middle-income countries, zoonotic disease surveillance has advanced considerably in the past two decades. However, surveillance efforts often prioritise urban and adjacent rural communities. Communities in remote rural areas have had far less support despite having routine exposure to zoonotic diseases due to frequent contact with domestic and wild animals, and restricted access to health care. Limited disease surveillance in remote rural areas is a crucial gap in global health security. Although this point has been made in the past, practical solutions on how to implement surveillance efficiently in these resource-limited and logistically challenging settings have yet to be discussed. We highlight why investing in disease surveillance in remote rural areas of low-income and middle-income countries will benefit the global community and review current approaches. Using semi-arid regions in Kenya as a case study, we provide a practical approach by which surveillance in remote rural areas can be strengthened and integrated into existing systems. This Viewpoint represents a transition from simply highlighting the need for a more holistic approach to disease surveillance to a solid plan for how this outcome might be achieved.

To understand the specific ways in which champions lead efforts to obtain and sustain buy-in for immediate postpartum long-acting reversible contraception (LARC) programs.We conducted a qualitative study with 60 semistructured interviews at 3 teaching hospitals in Texas with physicians, nurses, administrators and other staff who participated in the implementation of immediate postpartum LARC. Physicians self-identified as champions and identified other champion physicians and administrators. Two researchers analyzed and coded interview transcripts for content and themes.We found that champions draw on institutional knowledge and relationships to build awareness and support for immediate postpartum LARC implementation. To obtain buy-in, champions needed to demonstrate financial sustainability, engage key stakeholders from multiple departments, and obtain nurse buy-in. Champions also created buy-in by communicating goals for the service that focused on expanding reproductive autonomy, improving maternal health, and improving access to postpartum contraception. Some staff, especially nurses, identified reasons for the program that run counter to reproductive justice principles: reducing birth rates, poverty, and/or unplanned pregnancy among young women and high-parity women. Respondents at 2 hospitals noted that not all women had equitable access to immediate postpartum LARC.Physician and non-physician champions must secure long-term support across multiple hospital departments to successfully implement an immediate postpartum LARC program. For programs to equitably serve all women in need of postpartum contraceptive care, champions and other program leaders need to implement strategies to address access issues. They should also explicitly focus on reproductive justice principles during program introduction and training.Successfully implementing immediate postpartum long-acting reversible contraception programs requires champions with institutional networking connections, administrative and nursing support, and clearly communicated goals. Champions need to address access issues and focus on reproductive justice principles during program introduction and training to equitably serve all women in need of postpartum contraceptive care.

Introduction Research on risk factors for prenatal depression is critical to improve the understanding, prevention, and treatment of women's psychopathology. The current study examines the relation between experiences of racial discrimination and trajectories of depression symptoms over the course of pregnancy. Method Participants completed standardized measures regarding symptoms of depression at four timepoints during pregnancy and reported on experiences of racial discrimination at one timepoint. Latent growth curve modeling was used to examine the relation between discrimination and initial levels (intercept) and trajectories (slope) of depression symptoms over pregnancy. Results Participants were 129 pregnant individuals recruited from obstetric clinics and oversampled for elevated depression symptoms. Thirty-six percent of the participants were living at or below 200% of the federal poverty line. Fifty-four percent of the sample identified as non-Latinx White, 26% as Latinx, and 13% as non-Latinx Black. An unconditional latent growth curve modeling revealed a negative quadratic trajectory of depression symptoms during pregnancy. When women's report of discrimination was added as a predictor of depression trajectories, discrimination predicted the initial value (intercept) of depression symptoms, but not change over the course of pregnancy (slope). Specifically, higher levels of experiences of discrimination were associated with higher levels of depression symptoms. When sociodemographic and contextual covariates were included in the model, a low family income-to-needs ratio was also related to higher levels of depression symptoms. Conclusions These findings provide evidence that women's experiences of racial discrimination and family financial strain are risk factors for prenatal depression, with implications for screening, treatment, and policy.

Introduction This study connects the aggregate strength of public health policies taken in response to the COVID-19 pandemic in the U.S. states to the governors’ party affiliations and to state-level outcomes. Understanding the relationship between politics and public health measures can better prepare American communities for what to expect from their governments in a future crisis and encourage advocacy for delegating public health decisions to medical professionals. Methods The public health Protective Policy Index captures the strength of policy response to COVID-19 at the state level. The authors estimated a Bayesian model that links the rate of disease spread to Protective Policy Index. The model also accounted for the possible state-specific undercounting of cases and controls for state population density, poverty, number of physicians, cardiovascular disease, asthma, smoking, obesity, age, racial composition, and urbanization. A Bayesian linear model with natural splines of time was employed to link the dynamics of Protective Policy Index to governors’ party affiliations. Results A 10–percentage point decrease in Protective Policy Index was associated with an 8% increase in the expected number of new cases. Between late March and November 2020 and at the state-specific peaks of the pandemic, the Protective Policy Index in the states with Democratic governors was about 10‒percentage points higher than in the states with Republican governors. Conclusions Public health measures were stricter in the Democrat-led states, and stricter public health measures were associated with a slower growth of COVID-19 cases. The apparent politicization of public health measures suggests that public health decision making by health professionals rather than by political incumbents could be beneficial.

Limited literature explores the impact that poverty-focused educational simulations can have on practicing clinicians. This study used a poverty simulation, specifically created to resemble the lives of Medicare patients, to sensitize practicing pharmacists to the situations faced by people living in poverty. The study evaluated how a poverty-focused educational program impacted practicing pharmacists' actual knowledge gain, intention to assist patients with limited income, and satisfaction with the educational program.A quasi-experimental one-group pre-/posttest design of practicing pharmacists was utilized. The intervention was a live continuing educational (CE) program at a pharmacy alumni event and a pharmacy convention. The CE program was delivered in person and included a Medicare poverty simulation and a 75-min didactic lecture. Pre- and posttests were used to assess outcomes. The primary outcome was change in knowledge as measured by test scores. Secondary outcomes included intention to assist future low-income patients and participant satisfaction with the educational program.Eighty-nine pharmacists participated in the educational program. Participants' mean knowledge increased from 2.76 (SD = 0.97) to 3.61 (SD = 1.21) (P .001) out of 5. The majority (88.3%) agreed they were interested in assisting patients with limited income in the future. Most participants strongly agreed that the program was satisfactory and contributed to their learning.This is the first identifiable study that incorporated a poverty simulation into an educational program for practicing pharmacists. The study may help inform the development of future educational programs for practicing pharmacists.

Background Gross motor skills are postulated to have a bidirectional relationship with physical activity (PA); however, no study has tested this relationship before and after a summer break. The purpose of this study was to examine the bidirectional relationships between school PA and gross motor skills in children before and after a summer break. Methods Participants were a sample of 440 children recruited from 3 low-income schools (mean age = 8.9 ± 1.2 years, mean ± SD). PA was assessed as average school-day step counts using Yamax DigiWalker (Yamasa Tokei Keiki, Tokyo, Japan) pedometers worn for 5 consecutive school days. Gross motor skills were assessed using the Test for Gross Motor Development, 3rd edition. Data were collected at 2 timepoints: at the end of spring semester (T1) and at the beginning of the subsequent fall semester (T2). An age- and body mass index-adjusted cross-lagged model was employed to relate T1 school step counts with T2 gross motor skills and T1 gross motor skills with T2 school step counts. Results T1 gross motor skills significantly predicted T2 school step counts (β = 0.24, 95%CI: 0.08 to 0.40, p = 0.003); however, T1 school step counts did not predict T2 gross motor skills (β = 0.04, 95%CI: –0.06 to 0.14, p = 0.445). The model explained 35.4% and 15.9% of the variances of T2 gross motor skills and T2 school step counts, respectively. Additional analyses indicated that these relationships were driven primarily by ball skills. Conclusion The relationship between gross motor skills and school PA was not bidirectional; however, higher gross motor skills, specifically ball skills, predicted higher school PA after a 3-month summer break.

UN member states have committed to achieving the Sustainable Development Goals (SDGs) by 2030. This Review examines the published evidence on how improving eye health can contribute to advancing the SDGs (beyond SDG 3). We identified 29 studies that showed direct benefits from providing eye health services on SDGs related to one or more of poverty (SDGs 1, 2, and 8), education (SDG 4), equality (SDGs 5 and 10), and sustainable cities (SDG 11). The eye health services included cataract surgery, free cataract screening, provision of spectacles, trichiasis surgery, rehabilitation services, and rural community eye health volunteers. These findings provide a comprehensive perspective on the direct links between eye health services and advancing the SDGs. In addition, eye health services likely have indirect effects on multiple SDGs, mediated through one of the direct effects. Finally, there are additional plausible links to other SDGs, for which evidence has not yet been established.

Background Health inequities and socio-economic disadvantage are causes for concern in Aotearoa New Zealand. Becoming pregnant can increase a woman’s vulnerability to poverty, with the potential for an increase in multiple stressful life events. Providing midwifery care to women living in socio-economic deprivation has been found to add additional strains for midwives. Exploring the perspectives of the midwives providing care to women living with socio-economic deprivation can illuminate the complexities of maternity care. Aim To explore the impact on midwives when providing care for socio-economically disadvantaged women in Aotearoa New Zealand. Method Inductive thematic analysis was used to analyse an open-ended question from a survey that asked midwives to share a story around maternal disadvantage and midwifery care. Findings A total of 214 stories were received from midwives who responded to the survey. Providing care to disadvantaged women had an impact on midwives by incurring increased personal costs (time, financial and emotional), requiring them to navigate threats and uncertainty and to feel the need to remedy structural inequities for women and their wider families. These three themes were moderated by the relationships midwives held with women and affected the way midwives worked across the different maternity settings. Conclusion Midwives carry a greater load when providing care to socio-economically deprived women. Enabling midwives to continue to provide the necessary support for women living in socio-economic deprivation is imperative and requires additional resources and funding.

In patients with atherosclerotic cardiovascular disease (ASCVD), barriers related to transportation may impair access to care, with potential implications for prognosis. Although few studies have explored transportation barriers among patients with ASCVD, the correlates of delayed care due to transportation barriers have not been examined in this population. We aimed to examine this in U.S. patients with ASCVD using nationally representative data.Using data from the 2009-2018 National Health Interview Survey, we estimated the self-reported prevalence of delayed medical care due to transportation barriers among adults with ASCVD, overall and by sociodemographic characteristics. Logistic regression was used to examine the association between various sociodemographic characteristics and delayed care due to transportation barriers.Among adults with ASCVD, 4.5% (95% CI; 4.2, 4.8) or ∼876,000 annually reported delayed care due to transportation barriers. Income (low-income: odds ratio [OR] 4.43, 95% CI [3.04, 6.46]; lowest-income: OR 6.35, 95% CI [4.36, 9.23]) and Medicaid insurance (OR 4.53; 95% CI [3.27, 6.29]) were strongly associated with delayed care due to transportation barriers. Additionally, younger individuals, women, non-Hispanic Black adults, and those from the U.S. South or Midwest, had higher odds of reporting delayed care due to transportation barriers.Approximately 5% of adults with ASCVD experience delayed care due to transportation barriers. Vulnerable groups include young adults, women, low-income people, and those with public/no insurance. Future studies should analyze the feasibility and potential benefits of interventions such as use of telehealth, mobile clinics, and provision of transportation among patients with ASCVD in the U.S.

BACKGROUND Over the past 2 decades there has been an increased emphasis on added sugars intake in the Dietary Guidelines for Americans (DGA), which has been accompanied by policies and interventions aimed at reducing intakes, particularly among children, adolescents and teens. OBJECTIVE The present study provides a comprehensive time trends analysis of added sugars intake and contributing sources in the diets of U.S. children, adolescents and teens (2-18 y) from 2001-2018, focusing on variations according to sociodemographic factors (age, sex, race and ethnicity, income), food assistance and health-related factors (physical activity, body weight status). METHODS Data from 9 consecutive 2-y cycles of the National Health and Nutrition Examination Survey (NHANES) were combined and regression analyses were conducted to test for trends in added sugars intake and sources from 2001-2018 for the overall age group (2-18 y) and for 2 age subgroups (2-8 and 9-18 y). Trends were also examined on subsamples stratified by sex, race and ethnicity (Hispanic, non-Hispanic Asian, non-Hispanic Black, non-Hispanic White), income (household poverty income ratio), food assistance, physical activity and body weight status. RESULTS From 2001-2018, added sugars intake decreased significantly (P

Background Food insecurity has been identified as an important social determinant of health and is associated with many health issues prevalent in Medicaid members. Despite this, little research has been done around food insecurity within Medicaid populations. Objective Our objective was to estimate the prevalence of household food insecurity and identify factors associated with experiencing food insecurity in Iowa’s Medicaid expansion population. Design We conducted a cross-sectional telephone survey between March and May of 2019. Participants Our sample was drawn from Medicaid members enrolled in Iowa’s expansion program at least 14 months, stratified by Federal Poverty Level (FPL) category. Members who did not have valid contact information were excluded. We selected one individual per household to reduce the interrelatedness of responses. We sampled 6,000 individuals and had 1,349 respondents in the analytic sample. Main outcome measure Our main outcome was whether a respondent’s household experienced food insecurity in the previous year, using the Hunger Vital Sign screening tool. Statistical analyses performed We weighted responses to account for the sampling design and differential nonresponse between strata. We estimated the prevalence of food insecurity and used logistic regression to model food insecurity as a function of demographic (age, FPL category, gender, employment, education, race, rurality, and Supplemental Nutrition Assistance Program [SNAP] participation) and health-related (self-rated health, self-rated oral health, health literacy) factors. Results The estimated prevalence of experiencing food insecurity was 51.3%. Race, gender, education, employment, health literacy, and self-rated health were all significantly associated with food insecurity. Conclusions Our findings show that food insecurity is prevalent in Iowa’s Medicaid expansion population. Food insecurity should be more widely measured as a critical social determinant of health in Medicaid populations. Policymakers and clinicians should consider interventions that connect households experiencing food insecurity to food resources (eg, produce prescriptions and food pantry referrals) and policies that increase food access. Abbreviations Iowa Wellness Plan (IWP); Federal Poverty Level (FPL); Healthy Behavior Program (HBP); Supplemental Nutrition Assistance Program (SNAP)

Economic outcomes reflect an intricate mixture of people's internal dispositions and external circumstances that are beyond their control. How, then, do people make sense of wealth and poverty? I suggest that attributions of economic outcomes are susceptible to various influences that can be grouped into two broad categories—who people are (i.e. personal influences) and what people see in the world (i.e. societal influences). Personal influences include people's ideological leanings and worldviews, socioeconomic standing, and experiences of economic success or failure. Societal influences include macroeconomic circumstances, cultural narratives, structural prejudices, and salient consumption behaviors by the rich and the poor. I discuss how these influences shape (and distort) attributions of economic outcomes and lay beliefs about wealth and poverty.

Background In 2020, the United States had approximately 85,000 new diagnoses of Hodgkin and Non-Hodgkin lymphoma. Food insecurity is both a direct and indirect detriment to health outcomes. The rate and risk factors for food insecurity among lymphoma patients are unknown, as the unemployment rate soars far above pre-COVID19 pandemic levels further heightening the economic stresses of a lymphoma diagnosis. Methods Data regarding the food security status were obtained from the cross-sectional National Health Interview Survey (NHIS) conducted by the Centers for Disease Control and Prevention. A raw score compiled from a series of 10 food security questions was used to determine the Food Secure and Food Insecure groups. Respondents who reported a history of lymphoma from 2011 to 2019 were included in the analysis. Results Of the 921 patients reporting a history of lymphoma 9.06% were considered Food Insecure. The sociodemographic subgroups with the highest risk of being Food Insecure included respondents living below 100% of the Federal Poverty Level, non-US citizens, the uninsured, and those on Medicare. Conclusion Food insecurity is common among lymphoma patients. Therefore, oncologists across the country should be aware of the sociodemographic risk factors for food insecurity in order to assist in mediation, maximizing the efficacy of treatments. Research regarding the impact of food insecurity on therapy compliance and patient outcomes is warranted in future studies.

More than 98% of infant deaths occur in low- and middle-income countries (LMICs). Breastfeeding improves infant survival and protects against certain illnesses, such as diarrhea and pneumonia, which are leading causes of deaths in those5 years of age in LMICs. The World Health Organization (WHO) recommends early initiation of breastfeeding within 1 hour of birth, exclusive breastfeeding up to 6 months of age, and continued breastfeeding up to 2 years of age. However, fewer than half of infants in LMICs are breastfed optimally to these standards. The objectives of this article are to describe the global epidemiology and health benefits of breastfeeding with particular focus on LMICs.We searched PubMed to identify original research articles on breastfeeding in LMICs and reviews related to the benefits of breastfeeding, with particular focus on articles published in the past 5 years. We used reports and data published by the WHO and the United Nations Children's Fund (UNICEF) related to global breastfeeding rates, targets, and programmatic initiatives. We used the Lives Saved Tool to estimate mortality related to breastfeeding practices.Less than half of infants globally receive early, exclusive, or continued breastfeeding. Certain high-risk groups, such as premature or HIV-exposed infants, face particular challenges and benefits related to breastfeeding. The WHO, UNICEF, and other global partners have developed a multipronged strategy to promote global breastfeeding, ranging from government-level advocacy to grassroots community support groups. Using the Lives Saved Tool, we estimate that nearly 200,000 lives of those5 years of age could be saved in LMICs from 2020 to 2030 if early, exclusive, and continued breastfeeding rates were linearly increased from current rates to meet the WHO 2030 goals of 60% to 80% coverage. If this goal were exceeded and near-universal coverage were achieved, the number of lives would increase even further such that820,000 lives per year could potentially be saved by universal breastfeeding. In this review, we delineate the health and economic benefit of breastfeeding in LMICs, discuss breastfeeding epidemiology in the global context, and describe targeted strategies to improve breastfeeding uptake.

To evaluate the utilization of brachytherapy and duration of treatment on overall survival for locally advanced cervical cancer.The National Cancer Database (NCDB) was queried to identify stage II-IVA cervical cancer patients diagnosed in the United States between 2004 and 2015 who were treated with definitive chemoradiation therapy. We defined standard of care (SOC) treatment as receiving external beam radiation therapy (EBRT) and concurrent chemotherapy, brachytherapy (BT), and completing treatment within 8 weeks, and compared SOC treatment to non-SOC. The primary outcome was overall survival (OS). We also evaluated the effect of sociodemographic and clinical variables on receiving SOC.We identified 10,172 women with locally advanced cervical cancer primarily treated with chemotherapy and concurrent EBRT of which 6047 (59.4%) patients received brachytherapy, and only 2978 (29.3%) completed treatment within 8 weeks (SOC). Receipt of SOC was associated with significantly improved overall survival (median OS 131.0 mos vs 95.5 mos, 78.1 mos, 49.2 mos; p 0.0001). Furthemore, in patients whose treatment extended beyond 8 weeks, brachytherapy was still associated with an improved survival (median OS 95.5 vs 49.2 mos, p 0.0001). More advanced stage, Non-Hispanic Black race, lower income, lack of insurance or government insurance, less education, and rural residence were associated with decreased likelihood of receiving SOC.Completing standard of care concurrent chemoradiation therapy and brachytherapy in the recommended 8 weeks was associated with a superior overall survival. Patients who received brachytherapy boost show superior survival to patients receiving EBRT alone, regardless of treatment duration. Disparities in care for vulnerable populations highlight the challenges and importance of care coordination for patients with cervical cancer.

Highlights • An effective and affordable injectable rotavirus vaccine may be attractive to LMICs. • Co-administering oral and injectable vaccines is acceptable to many stakeholders. • Oral vaccine with a birth dose is favored over a higher cost, standalone injectable. • Providing rotavirus vaccine in a DTP combination is the most preferred option., Background Currently available live, oral rotavirus vaccines (LORVs) have significantly reduced severe rotavirus hospitalizations and deaths worldwide. However, LORVs are not as effective in low- and middle-income countries (LMIC) where rotavirus disease burden is highest. Next-generation rotavirus vaccine (NGRV) candidates in development may have a greater public health impact where they are needed most. The feasibility and acceptability of possible new rotavirus vaccines were explored as part of a larger public health value proposition for injectable NGRVs in LMICs. Objective To assess national stakeholder preferences for currently available LORVs and hypothetical NGRVs and understand rationales and drivers for stated preferences. Methods Interviews were conducted with 71 national stakeholders who influence vaccine policy and national programming. Stakeholders from Ghana, Kenya, Malawi, Peru, Senegal, and Sri Lanka were interviewed using a mixed-method guide. Vaccine preferences were elicited on seven vaccine comparisons involving LORVs and hypothetical NGRVs based on information presented comparing the vaccines’ attributes. Reasons for vaccine preference were elicited in open-ended questions, and the qualitative data were analyzed on key preference drivers. Results Nearly half of the national stakeholders interviewed preferred a highly effective standalone, injectable NGRV over current LORVs. When presented as having similar efficacy to the LORV, however, very few stakeholders preferred the injectable NGRV, even at substantially lower cost. Similarly, a highly effective standalone injectable NGRV was generally not favored over an equally effective oral NGRV following a neonatal-infant schedule, despite higher cost of the neonatal option. An NGRV-DTP-containing combination vaccine was strongly preferred over all other options, whether delivered alone with efficacy similar to current LORVs or co-administered alongside an LORV (LORV + NGRV-DTP) to increase efficacy. Conclusion Results from these national stakeholder interviews provide valuable insights to inform ongoing and future NGRV research and development.

Purpose Given that the relationships between higher BMI and adverse health outcomes are nonconstant and most pronounced at either ends of the BMI distribution, we assess the association between neighborhood poverty and BMI at multiple points along the BMI distribution. Methods Using data from the 1999 to 2015 Panel Study of Income Dynamics of Black and White adults in the United States, we estimate quantile regression models while jointly applying a marginal structural modeling approach to account for time-varying individual-level factors that may be simultaneously mediators as well as confounders. Results Neighborhood poverty was not found to be associated with bodyweight at any point along the BMI distribution for Black or White males. However, high neighborhood poverty, compared to low neighborhood poverty, predicted increases in bodyweight for Black females at the lower end of the BMI distribution and for White females at the higher end of the BMI distribution. No association was found between neighborhood poverty and BMI at the mean. Conclusions Results identify the most vulnerable subgroups, suggesting that White females at the higher end of the BMI distribution as well as Black females at the lower end of the BMI distribution are particularly sensitive to obesogenic environments.

Summary Background & aims South Africa's inequitable history has contributed to a malnourished population, further aggravated by high levels of violence and economic uncertainty culminating in a population suffering the sequelae of poverty. The perceived notion is that malnutrition places the South African population at greater risk for development of refeeding syndrome. This study aimed to identify the incidence of refeeding syndrome in the South African population. Methods All patients admitted into the surgical intensive care unit from 1 November 2019 to 30 September 2020, were screened using the National Institute for Health and Care Excellence (NICE) refeeding risk criteria. Patients started on artificial feeds with one or more risk factors were included in the study. The syndrome was confirmed using the King's College criteria and compared with the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria for refeeding syndrome. Results 200 Patients were included in this study. The median age of the sample population was 41 years (IQR 30–58) with a male predominance (63%). All patients included had one or more risk factors and 62 (31%) of patients fulfilled the NICE criteria. The sensitivity of the NICE criteria was 33% and specificity was 70%. The most common risk factors identified were little or no nutritional intake for >5 days (55%) followed by a history of alcohol abuse, drugs including insulin, chemotherapy, diuretics or antacids (18%). Specificity values for all risk factors were >80% apart from little or no nutritional intake for >5 days which had a specificity of 64.2%. Sensitivity values for all risk factors were low. 84.5% of patients received artificial nutritional support in the form of enteral feeds, 9% parenteral and 6.5% both enteral and parenteral feeds. A total of 146 patients required electrolyte supplementation. Three patients fulfilled the King's College criteria and one subsequently died. In comparison, 25 patients fulfilled the ASPEN criteria and 3 demised. Conclusion Due to the low sensitivity and specificity of the NICE criteria, we advise that it be used merely as a guideline to identify patients at risk of refeeding syndrome and one should remain vigilant in patients with any risk factors present. Due to the small number of patients who fulfilled the King's College criteria and significant difference in incidence when compared to the ASPEN definition, a conclusion regarding the accuracy of both diagnostic criteria could not be made. We recommend a review of the current definition and a global adoption of an agreed criteria for the estimation of the true prevalence.

Purpose Despite many programs aiming to delay girls' marriage and pregnancy over the last 2 decades, there is no consensus yet concerning the effectiveness of different approaches and the contexts in which they are implemented. We focus on different social contexts within Bangladesh and Zambia and investigate how literacy, poverty, and community characteristics impact the effectiveness of interventions. Methods We utilize data sets from two randomized controlled trials conducted by the Population Council in Bangladesh and Zambia. Within each respective country, we estimate the impacts of the interventions on marriage and pregnancy among adolescent girls using the analysis of covariance estimator by different social contexts based on community-level variables. Results In Bangladesh, providing academic skill training had a significant impact on discouraging child marriage in the villages where girls' paid-work participation rate was relatively high, whereas in low paid-work participation villages, providing gender-awareness skill training had an impact. In Zambia, providing empowerment intervention and safe spaces had a significant impact on delaying pregnancy especially for illiterate girls in the communities where premarital sex was relatively common. Conclusions In Bangladesh, where girls' paid-work participation is limited, premarital sex is uncommon, and marriage is subject to collective decision-making; the effectiveness of a program may depend on girls' agency and the availability of acceptable working opportunities. In Zambia where premarital sex is common, pregnancy may precede marriage, and marriage entails the nature of individual decision-making; empowering the most vulnerable girls seems to be more effective in delaying marriage/pregnancy.

Adverse childhood experiences such as abuse, neglect, and poverty, profoundly alter neurobehavioral development in a manner that negatively impacts health across the lifespan. Adults who have been exposed to such adversities exhibit premature and more severe age-related declines in brain health. Unfortunately, it remains unclear whether the negative effects of early life adversity (ELA) on brain health can be remediated through intervention in adulthood. Physical activity may represent a low-cost behavioral approach to address the long-term consequences of ELA on brain health. However, there has been limited research examining the impact of physical activity on brain health among adults with a history of ELA. Accordingly, the purpose of this review is to (1) review the influence of ELA on brain health in adulthood and (2) highlight evidence for the role of neurotrophic factors, hypothalamic-adrenal-pituitary axis regulation, inflammatory processes, and epigenetic modifications in mediating the effects of both ELA and physical activity on brain health outcomes in adulthood. We then propose a theoretical framework to guide future research in this area.