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Homelessness remains a pervasive, long-standing problem in the United States and is poised to increase as a result of the COVID-19 pandemic. Individuals experiencing homelessness bear a higher burden of complex medical and mental health illnesses and often struggle to obtain quality and timely health care. The United States desperately needs to train a workforce to confront this large and growing crisis, but few health professional schools currently devote curricula to the clinical needs of people experiencing homelessness. This article discusses educational and curricular strategies for health professional students. Understanding the health needs of--and the social influences on the lives of--people experiencing homelessness is crucial for addressing this health equity challenge. [ABSTRACT FROM AUTHOR] Copyright of AMA Journal of Ethics is the property of American Medical Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

In this commentary, we review the evidence concerning associations between religious service attendance and subsequent health and wellbeing outcomes. The evidence base for a link between religious service attendance and health has increased substantially over the past 2 decades. The interpretation and implications of this research require careful consideration (Am J Epidemiol. 2022;191(1):20–30). It would be inappropriate to universally promote service attendance solely on the grounds of the associations with health. Nevertheless, a more nuanced approach, within both clinical care and public health, may be possible—one that encouraged participation in religious community for those who already positively self-identified with a religious or spiritual tradition and encouraged other forms of community participation for those who did not. Discussion is given to potential future research directions and the challenges and opportunities for promotion efforts by the public health community.

There exists no coherent national strategy for the early detection or prevention of gastric cancer in the United States (US), even among identified high-risk groups such as Asian Americans, African Americans, Hispanic Americans, and Alaska Native/American Indian peoples. As a result, patients with gastric cancer in the US are diagnosed at later stages and demonstrate worse overall survival compared to nations of East Asia with established screening programs (Table 1). The under-recognition of gastric cancer risk within minority communities is a significant unaddressed healthcare disparity.

The prevalence of opioid use and misuse has provoked a staggering number of deaths over the past two and a half decades. Much attention has focused on individual risks according to various characteristics and experiences. However, broader social and contextual domains are also essential contributors to the opioid crisis such as interpersonal relationships and the conditions of the community and society that people live in. Despite efforts to tackle the issue, the rates of opioid misuse and non-fatal and fatal overdose remain high. Many call for a broad public health approach, but articulation of what such a strategy could entail has not been fully realised. In order to improve the awareness surrounding opioid misuse, we developed a social-ecological framework that helps conceptualise the multivariable risk factors of opioid misuse and facilitates reviewing them in individual, interpersonal, communal and societal levels. Our framework illustrates the multi-layer complexity of the opioid crisis that more completely captures the crisis as a multidimensional issue requiring a broader and integrated approach to prevention and treatment.

This cohort study assesses the association of frequent religious service attendance with deaths related to drugs, alcohol, and suicide (referred to as deaths from despair) among US health care professionals., Key Points Question Is frequent religious service attendance associated with a lower risk of deaths related to drugs, alcohol, and suicide (referred to as deaths from despair) among US health care professionals? Findings In this cohort study of 66 492 female registered nurses and 43 141 male health care professionals in the US, attendance at religious services at least once per week was associated with a 68% lower hazard of death from despair among women and a 33% lower hazard among men compared with never attendance. Meaning The findings suggest that frequent attendance at religious services is associated with lower subsequent risk of deaths from despair., Importance The increase in deaths related to drugs, alcohol, and suicide (referred to as deaths from despair) has been identified as a public health crisis. The antecedents associated with these deaths have, however, seldom been investigated empirically. Objective To prospectively examine the association between religious service attendance and deaths from despair. Design, Setting, and Participants This population-based cohort study used data extracted from self-reported questionnaires and medical records of 66 492 female registered nurses who participated in the Nurses’ Health Study II (NHSII) from 2001 through 2017 and 43 141 male health care professionals (eg, dentist, pharmacist, optometrist, osteopath, podiatrist, and veterinarian) who participated in the Health Professionals Follow-up Study (HPFS) from 1988 through 2014. Data on causes of death were obtained from death certificates and medical records. Data analysis was conducted from September 2, 2018, to July 14, 2019. Exposure Religious service attendance was self-reported at study baseline in response to the question, “How often do you go to religious meetings or services?” Main Outcomes and Measures Deaths from despair, defined specifically as deaths from suicide, unintentional poisoning by alcohol or drug overdose, and chronic liver diseases and cirrhosis. Cox proportional hazards regression models were used to estimate the hazard ratio (HR) of deaths from despair by religious service attendance at study baseline, with adjustment for baseline sociodemographic characteristics, lifestyle factors, psychological distress, medical history, and other aspects of social integration. Results Among the 66 492 female participants in NHSII (mean [SD] age, 46.33 [4.66] years), 75 incident deaths from despair were identified (during 1 039 465 person-years of follow-up). Among the 43 141 male participants in HPFS (mean [SD] age, 55.12 [9.53] years), there were 306 incident deaths from despair (during 973 736 person-years of follow-up). In the fully adjusted models, compared with those who never attended religious services, participants who attended services at least once per week had a 68% lower hazard (HR, 0.32; 95% CI, 0.16-0.62) of death from despair in NHSII and a 33% lower hazard (HR, 0.67; 95% CI, 0.48-0.94) of death from despair in HPFS. Conclusions and Relevance The findings suggest that religious service attendance is associated with a lower risk of death from despair among health care professionals. These results may be important in understanding trends in deaths from despair in the general population.

Context The Patient Protection and Affordable Care Act increases healthcare access and includes provisions that directly impact access to and cost of evidence-based colorectal cancer screening. The Affordable Care Act's removal of cost sharing for colorectal cancer screening as well as Medicaid expansion have been hypothesized to increase screening and improve other health outcomes. However, since its passage in 2010, there is little consensus on the Affordable Care Act's impact. Evidence acquisition Data from March 2010 to June 2019 were reviewed and 21 relevant studies were identified; 19 studies examined colorectal cancer screening with most finding increased screening rates. Evidence synthesis Eleven studies found significant increases, 5 found nonsignificant increases, 3 found nonsignificant decreases, and 1 study found a significant decrease in colorectal cancer screening. Three studies examined the impact on colorectal cancer incidence and stage of diagnosis, where a significant 2.4% increase in early diagnosis was found in one and a nonsignificant increase in incidence in another. However, survival improved after Medicaid expansion. Conclusions Free preventive colorectal cancer screening and Medicaid expansion because of passage of the Affordable Care Act have been, in general, positively associated with modest improvements in screening rates across the country. Future studies are needed that investigate the longer-term impact of the Affordable Care Act on colorectal cancer morbidity and mortality rates, as screening is only the first step in treatment of cancerous and precancerous lesions, preventing them from progressing. Moreover, more studies examining subpopulations are needed to better assess where gaps in care remain.

To determine how low-income Asian American, Native Hawaiian, and Pacific Islander (AANHPI) adults gained health insurance coverage-specifically, via Medicaid or private insurance-under the Affordable Care Act, we used a difference-in-differences approach to compare uninsurance rates in 2010-13 and 2015-16. In Medicaid expansion states, adjusted Medicaid coverage gains were 9.67 percentage points larger than in nonexpansion states; however, adjusted private coverage gains in expansion states were 10.19 percentage points lower. These results indicate that, in contrast to the case for other racial/ethnic groups, for AANHPI the Medicaid coverage increases in expansion states were of similar magnitude to the private insurance coverage increases in nonexpansion states. Reasons for this may include differences in willingness to enroll in public versus private coverage, barriers related to language or citizenship status, or other factors. Future studies are needed to understand these patterns and promote health equity for this population.

Epilepsy is more common among children and adults living in households at lowest incomes. Like those living with any complex chronic condition, people with epilepsy need quality healthcare to improve their health and social outcomes. The purpose of this study was to use the latest national data to provide updated estimates of the percentages of adults aged 18–64 years with active epilepsy who were uninsured in 2010, 2013, 2015, and 2017 and to examine changes in health insurance coverage during these years. We analyzed nationally representative samples of adults (aged 18–64 years) from the 2010, 2013, 2015, and 2017 National Health Interview Survey (NHIS). We used a validated epilepsy surveillance case definition to classify adults as having active epilepsy during 2010 and 2013 (n = 507) and during 2015 and 2017 (n = 582). We used the NHIS recode variables available in each year that account for a series of questions posed to respondents to confirm coverage and that ultimately classify respondents with different healthcare coverage types. Overall, the percentage of uninsured adults among respondents aged 18–64 years with active epilepsy decreased by more than half (59%), from 17.7% (95% confidence interval [CI] = 13.6%–22.7%) in 2010 and 2013 to 7.3% (95% CI = 4.8%–10.7%) in 2015 and 2017. The decrease in the percentage of uninsured adults with active epilepsy after 2010 and 2013 was balanced by a similar increase in public insurance coverage and private insurance coverage in 2015 and 2017. Epilepsy stakeholders can ensure that all uninsured adults with epilepsy obtain access to health insurance coverage. National Health Interview Survey data on epilepsy, when available, can be used to monitor trends in insurance status in the new decade.

Context: The prevalence of opioid use and misuse has provoked a staggering number of deaths over the past two and a half decades. Much attention has focused on individual risks according to various characteristics and experiences. However, broader social and contextual domains are also essential contributors to the opioid crisis, as interpersonal relationships and the conditions of the community and society people live in. Despite efforts to tackle the issue, the rates of opioid misuse, non-fatal overdose, and overdose death remain high. Many call for a broad public health approach, but articulation of what such a strategy could entail has not been fully realized. Broader systems policies, especially those that emphasize prevention, could more effectively intervene in this crisis. Methods: In order to improve the awareness surrounding opioid misuse, we developed a social-ecological framework that helps conceptualize the multivariable risk factors of opioid misuse and facilitates reviewing them in individual, interpersonal, communal, and societal levels. Findings: Our framework illustrates the multi-layer complexity of the opioid crisis that more completely captures the crisis as a multidimensional issue requiring a broader and integrated approach to prevention and treatment. Conclusions: Future research can elucidate the interconnections among the risk factors as well as leverage systems science tools (e.g., simulation modeling) to uncover the complexities of the crisis, and help evaluate, analyze, and forecast the effectiveness of ongoing and new policy interventions. We explain and call for the need for more systems science approaches in opioid research.

Working in government can be a remarkable life experience for anyone but particularly for those who have trained in the worlds of medicine and public health. This article describes some lessons learned from a physician initially based in academic medicine and public health who has since spent more than a decade serving in leadership positions at the state and federal levels. Many of the described themes about policy making can guide health professionals who wish to understand and ultimately contribute to the public sector. Certainly, the challenges and risks are noteworthy. However, for those willing and able to take the leap, government service can offer extraordinary opportunities not only for tremendous personal growth but also for making broader contributions to public health.

To summarize the results of the major management review of the U.S. Public Health Service Commissioned Corps (2009-2010) and note related outcomes.Narrative from the U.S. Assistant Secretary for Health, who directed and oversaw the management review.The management review led to 46 recommendations, all of which have since been implemented. The subsequent organizational and operational changes have unified reporting structures, streamlined the administrative Corps organizational structure, and transferred support services to providers with expertise in uniformed services to create a new integrated personnel and payroll system. Related processes have also prompted a systematic billet review as well as establishment of explicit criteria for eligibility to become a Corps officer. Corps leaders report improvements in recruiting talented officers, increased selectivity from the candidate pool, and enhanced matching of incoming officers with agency assignments. Furthermore, Corps activity has grown in both traditional and innovative ways.The Corps has enjoyed heightened activity and outcomes in the era of health reform. The management review and its implementation have strengthened the Corps, helping officers to do their job and achieve their mission.

This cohort study analyzed the extent of post–Affordable Care Act (ACA) health insurance coverage gains for Asian Americans, Native Hawaiians, and Pacific Islanders and whether disparities in coverage have narrowed over time.

In this study, Global Burden of Disease investigators characterize trends in mortality, life expectancy, and prevalence associated with most common diseases and disease and mortality risk factors in the United States between 1990 and 2016.

Improving health outcomes relies on patients' full engagement in prevention, decision-making, and self-management activities. Health literacy, or people's ability to obtain, process, communicate, and understand basic health information and services, is essential to those actions. Yet relatively few Americans are proficient in understanding and acting on available health information. We propose a Health Literate Care Model that would weave health literacy strategies into the widely adopted Care Model (formerly known as the Chronic Care Model). Our model calls for first approaching all patients with the assumption that they are at risk of not understanding their health conditions or how to deal with them, and then subsequently confirming and ensuring patients' understanding. For health care organizations adopting our model, health literacy would then become an organizational value infused into all aspects of planning and operations, including self-management support, delivery system design, shared decision-making support, clinical information systems to track and plan patient care, and helping patients access community resources. We also propose a measurement framework to track the impact of the new Health Literate Care Model on patient outcomes and quality of care.

Implementing the Affordable Care Act (ACA) requires a new commitment to “person-centeredness” as a central feature of health care. Person-centered health care means people have both the knowledge r...

BACKGROUND In response to the first U.S. National HIV/AIDS Strategy released in July 2010, we assessed how HIV/AIDS funding is spent by the Department of Health and Human Services (HHS) and how these resources align geographically with the HIV/AIDS epidemic according to various measures. METHODS Estimated FY2010 spending information was gathered from HHS agencies, including state/territory-level spending by prevention, care, and treatment services of the Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration (HRSA), and Substance Abuse and Mental Health Services Administration (SAMHSA) - as well as Centers for Medicare and Medicaid Services (CMS). HHS funding is presented descriptively by state in the context of living HIV and AIDS case numbers and rates. RESULTS Nearly US$16 billion went to discretionary and entitlement spending, 77% of which supported or provided care and treatment by CMS (Medicare, Medicaid) and HRSA; the remainder to research, prevention, and other activities. For states and territories overall, funding was highly correlated with living AIDS case numbers (R(2) = .88) as well as living HIV case numbers (R(2) = .84); funding was far less correlated with case rates (per 100,000 population) for AIDS (R(2) = .35) or HIV (R(2) = .42). CONCLUSIONS HHS HIV/AIDS funding, overall, is well correlated with the number of HIV/AIDS cases in each state/territory. Future assessments should capture information on who is being served, where, and how.

Health literacy is the capacity to understand basic health information and make appropriate health decisions. Tens of millions of Americans have limited health literacy--a fact that poses major challenges for the delivery of high-quality care. Despite its importance, health literacy has until recently been relegated to the sidelines of health care improvement efforts aimed at increasing access, improving quality, and better managing costs. Recent federal policy initiatives, including the Affordable Care Act of 2010, the Department of Health and Human Services' National Action Plan to Improve Health Literacy, and the Plain Writing Act of 2010, have brought health literacy to a tipping point-that is, poised to make the transition from the margins to the mainstream. If public and private organizations make it a priority to become health literate, the nation's health literacy can be advanced to the point at which it will play a major role in improving health care and health for all Americans.

The escalating problem of multiple chronic conditions (MCC) among Americans is now a major public health and medical challenge, associated with suboptimal health outcomes and rising health-care expenses. Despite this problem's growth, the delivery of health services has continued to employ outmoded “siloed” approaches that focus on individual chronic diseases. We describe an action-oriented framework—developed by the U.S. Department of Health and Human Services with additional input provided by stakeholder organizations—that outlines national strategies for maximizing care coordination and for improving health and quality of life for individuals with MCC. We note how the framework's potential can be optimized through some of the provisions of the new Patient Protection and Affordable Care Act, and through public-private partnerships.

The US health care system has undertaken concerted efforts to improve the quality of care that Americans receive, using well-documented strategies and new incentives found in the Affordable Care Act of 2010. Applying quality concepts to public health has lagged these efforts, however. This article describes two reports from the Department of Health and Human Services: Consensus Statement on Quality in the Public Health System and Priority Areas for Improvement of Quality in Public Health. These reports define what is meant by public health quality , establish quality aims, and highlight priority areas needing improvement. We describe how these developments relate to the Affordable Care Act and serve as a call to action for ensuring a better future for population health. We present real-world examples of how a framework of quality concepts can be applied in the National Vaccine Safety Program and in a state office of minority health.

To meet the dynamic and evolving challenges of public health in the 21st century, our society should foster the next generation of public health leaders. We offer a vision for doing so, by introducing prevention literacy and education from the earliest possible starting point and then broadening these concepts throughout the educational ladder. Making this societal commitment now to nurture such future leaders should make the country healthier by 2020 and beyond.

Too many people in our country are not reaching their full potential for health because of preventable conditions. Moreover, Americans receive only about half of the preventive services that are recommended1 — a finding that highlights the national need for improved health promotion. The 2010 Affordable Care Act2 responds to this need with a vibrant emphasis on disease prevention. Many of the 10 major titles in the law, especially Title IV, Prevention of Chronic Diseases and Improving Public Health, advance a prevention theme through a wide array of new initiatives and funding. As a result, we believe that the Act . . .

Dr. Howard Koh writes that the Healthy People initiative aims to unify national dialogue about health, motivate action, and encourage new directions in health promotion, providing a public health roadmap and compass for the country.

Introduction:As Hurricane Katrina bore down on New Orleans in August 2005, the city's mandatory evacuation prompted the exodus of an estimated 80% of its 485,000 residents. According to estimates from the US Centers for Disease Control and Prevention (CDC), at least 18 states subsequently hosted >200,000 evacuees.Hypothesis/Problem:In this case study, “Operation Helping Hands” (OHH), the Massachusetts health and medical response in assisting Hurricane Katrina evacuees is described. Operation Helping Hands represents the largest medical response to evacuees in recent Massachusetts history.Methods:The data describing OHH were derived from a series of structured interviews conducted with two leading public health officials directing planning efforts, and a sample of first responders with oversight ofoperations at the evacuation site. Also, a literature review was conducted to identify similar experiences, common challenges, and lessons learned.Results:Activities and services were provided in the following areas: (1) administration and management;(2) medical and mental health; (3) public health; and (4) social support. This study adds to the knowledge base for future evacuation and shelter planning, and presents a conceptual framework that could be used by other researchers and practitioners to describe the process and out comes of similar operations.Conclusions:This study provides a description of the planning and implementation efforts of the largest medical evacuee experience in recent Massachusetts history, an effort that involved multiple agencies and partners. The conceptual framework can inform future evacuation and shelter initiatives at the state and national levels, and promotes the overarching public health goal of the highest attainable standard of health for all.

Background: Chronic Obstructive Pulmonary Disease (COPD) causes a huge economic burden and >80% of COPD cases are attributable to smoking. Massachusetts introduced a comprehensive Tobacco Control Program (MTCP) in January 1993. A trend analysis of COPD hospitalization rates might indirectly reflect the potential impact of such comprehensive tobacco control programs. Methods: Age-adjusted COPD hospitalization rates/100 000 was abstracted from the Massachusetts Community Health Information Profile Database between 1989 and 2005. Joinpoint Regression Analyses program was employed to estimate annual percent changes (APC) in COPD rates by age, sex and race. Results: In 1989, 265/100 000 age-adjusted COPD hospitalization rates were reported that increased to 423/100 000 in 1993, and then declined to 329/100 000 in 2005. A significant annual decline of 5.6 percentage points was observed in overall COPD rates from 1993 onwards. A similar temporal pattern, with an age-gradient and a slower annual decline in female COPD rates relative to male COPD rates, was observed. COPD rates in both Blacks and Whites were similar to the general overall pattern. Such consistent annual declines in COPD hospitalization rates from 1993 onwards in Massachusetts also closely correspond to the introduction of the MTCP in January 1993. Conclusion: The findings indirectly suggest that smoking cessation should remain the cornerstone strategy for the prevention and control of COPD burden. However, additional studies across different population settings are essential for a definitive conclusion with regard to the immediate impact of a comprehensive tobacco control program on COPD hospitalization rates showing possible gender susceptibility.

Although widespread support favors prospective planning for altered standards of care during mass casualty events, the literature includes few, if any, accounts of groups that have formally addressed the overarching policy considerations at the state level. We describe the planning process undertaken by public health officials in the Commonwealth of Massachusetts, along with community and academic partners, to explore the issues surrounding altered standards of care in the event of pandemic influenza. Throughout 2006, the Massachusetts Department of Public Health and the Harvard School of Public Health Center for Public Health Preparedness jointly convened a working group comprising ethicists, lawyers, clinicians, and local and state public health officials to consider issues such as allocation of antiviral medications, prioritization of critical care, and state seizure of private assets. Community stakeholders were also engaged in the process through facilitated discussion of case scenarios focused on these and other issues. The objective of this initiative was to establish a framework and some fundamental principles that would subsequently guide the process of establishing specific altered standards of care protocols. The group collectively identified 4 goals and 7 principles to guide the equitable allocation of limited resources and establishment of altered standards of care protocols. Reviewing and analyzing this process to date may serve as a resource for other states. (Disaster Med Public Health Preparedness. 2009;3(Suppl 2):S132–S140)

Atlanta; Sue Grinnell, Office Director, Community Wellness and Prevention, of the Washington State Department of Health; David Guzick, Dean of the University of Rochester School of Medicine and Dentistry in Rochester, New York; Robert Meenan, Dean of Boston University School of Public Health in Boston; Randy Schwartz, Senior Vice President for Strategic Health Initiatives, American Cancer Society, New England Division; Harrison Spencer, President and CEO of ASPH; Ciro Sumaya, Cox Endowed Chair in Medicine and former dean of Texas A&M Health Science Center School of Rural Public Health in