Publications

Abstract

Key Points A pilot randomized controlled trial of integrated palliative and nephrology care in patients with CKD stage 5 not on dialysis is feasible. A pilot randomized controlled trial of integrated palliative and nephrology care in patients with nondialysis CKD 5 is acceptable. Participants in the integrated care arm had lower symptom burden scores at the end of the trial, whereas the control group had higher scores. Background There has been a call by both patients and health professionals for the integration of palliative care with nephrology care, yet there is little evidence describing the effect of this approach. The objective of this paper is to report the feasibility and acceptability of a pilot randomized controlled trial testing the efficacy of integrated palliative and nephrology care. Methods English speaking patients with CKD stage 5 were randomized to monthly palliative care visits for 3 months in addition to their usual care, as compared with usual nephrology care. Feasibility of recruitment, retention, completion of intervention processes, and feedback on participation was measured. Other outcomes included differences in symptom burden change, measured by the Integrated Palliative Outcome Scale-Renal, and change in quality of life, measured by the Kidney Disease Quality of Life questionnaire and completion of advance care planning documents. Results Of the 67 patients approached, 45 (67%) provided informed consent. Of these, 27 patients completed the study (60%), and 14 (74%) of those in the intervention group completed all visits. We found small improvements in overall symptom burden (-2.92 versus 1.57) and physical symptom burden scores (-1.92 versus 1.79) in the intervention group. We did not see improvements in the quality-of-life scores, with the exception of the physical component score. The intervention group completed more advance care planning documents than controls (five health care proxy forms completed versus one, nine Medical Orders for Life Sustaining Treatment forms versus none). Conclusions We found that pilot testing through a randomized controlled trial of an ambulatory integrated palliative and nephrology care clinical program was feasible and acceptable to participants. This intervention has the potential to improve the disease experience for those with nondialysis CKD and should be tested in other CKD populations with longer follow-up.

Abstract

Background: The concern posed by the confluence of aging and cognitive impairment is growing in importance as the U.S. population rapidly ages. As such, we sought to examine the predictive power of physical functioning (PF) and general health status (GHS) trajectories on mortality outcomes among persons with cognitive impairment (PCIs). Methods: We used group-based trajectory models to identify latent group memberships for PF trajectories in 1,641 PCIs and GHS trajectories in 2,021 PCIs from the National Health and Aging Trends Survey (2011–2018) and applied logistic regressions to predict mortality using these memberships controlling for individual characteristics. Results: We identified six trajectory groups for PF and four groups for GHS. Trajectory group memberships for both outcomes significantly predicted mortality. For PF, group memberships largely captured the average levels over time, and worse trajectories (i.e., lower baselines and faster declines) were associated with higher odds of death. The highest mortality risk was associated with the group experiencing a sharp decline early in its PF trajectory, although its average level across time was not the lowest. For GHS, we observed two groups with comparable average levels across time, but the one with a convex-shape trajectory had much higher mortality risks compared to the one with a concave-shape trajectory. Conclusions: Our findings highlighted that health trajectories predicted mortality among PCIs, not only because of general levels but also because of the shapes of declines. Close monitoring health deterioration of PCIs is crucial to understand the health burden of this population and to make subsequent actions.

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Objective: To examine predictors and consequences of prescription opioid use among a cohort of women living with HIV (WLWH) and women without HIV from 2000 to 2019. Materials and Methods: The Women's Interagency HIV Study is a multisite, prospective cohort study. Cumulative proportion of visits with prescription opioid use was categorized as follows: minimal (0%-9%), intermediate (10%-39%), and chronic (>40%). Logistic regression examined independent predictors, and proportional hazards regression estimated unadjusted and adjusted hazards of all-cause mortality, comparing intermediate and chronic prescription opioid use with minimal use. Results: Annual prevalence of prescription opioid use significantly increased from 12.6% to 19.3% from 2000 to 2019 (p < 0.0001). Prescription opioid use was minimal in 75%, intermediate in 16%, and chronic in 9% of women. WLWH had 56% higher odds of chronic prescription opioid use compared with women without HIV. Even after adjusting for quality-of-life scores including ratings of pain, women with intermediate and chronic prescription opioid use had greater odds of being sexual minorities (lesbian or bisexual), unemployed, and were more likely to report benzodiazepine and nonprescription substance use compared with those with minimal use. Intermediate and chronic prescription opioid use were each associated with an almost 1.5-fold increased risk of all-cause mortality. Conclusions: Despite federally mandated opioid prescribing guidelines, prescription opioid use and related mortality significantly increased in women experiencing physical and psychosocial vulnerabilities. The higher mortality rate found among prescription opioid users may reflect the many underlying chronic medical and psychosocial conditions for which these opioids were prescribed, as well as complications of opioids themselves. Findings underscore the need for non-opioid and nonpharmacological interventions for chronic pain, particularly in sexual minorities and WLWH. Avoiding concurrent use of opioids with benzodiazepines and nonprescription drugs might reduce mortality.

Abstract

Objective: To identify if disparate trends in the access and use of nursing home (NH) services among Black and Latino older adults compared with White older adults persist. Access was operationalized as the NHs that served Black, Latino, and White residents. Use was operationalized as the utilization of NH services by Black, Latino, and White residents. Design: This was an observational study analyzing facility-level data from LTCfocus for 2011 to 2017. Setting and Participants: All NH residents present in US NHs participating in the Centers for Medicare and Medicaid Services program on the first Thursday in April in the years 2011 to 2017. NHs with fewer than 4500 bed-days per year are excluded in the LCTfocus dataset. Black, Latino, and White were the racial/ethnic groups of interest. Methods: We calculated the mean percentage of each racial/ethnic group in NHs (Black, Latino, White) annually along with the number of NHs that provided care for these groups. We conducted a simple trend analysis using ordinary least squares to estimate the change in NH access and use by racial/ethnic group over time. Results: Our NH sample ranged from 15,564 in 2011 to 14,956 in 2017. Latino residents' use of NHs increased by 20.47% and Black residents increased by 11.42%, whereas there was a 1.36% decrease in White residents’ use of NHs. In this 7-year span, there was a 4.44% and 6.41% decline in the number of NHs that serve any Black and Latino older adults, respectively, compared with a 2.26% decline in NHs that serve only White older adults (access). Conclusions and Implications: Our findings reveal a continued disproportionate rise in Black and Latino older adults’ use of NHs while the number of NHs that serve this population have declined. This work can inform federal and state policies to ensure access to long-term care services and supports in the community for all older adults and prevent inappropriate NH closures.

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Objectives: To understand dementia care providers’ perspectives on high-quality care for persons living with dementia (PLWD) in long-term care (LTC). Design: A qualitative study using a directed content analysis approach. Setting and Participants: Nine national LTC dementia care providers. Methods: We facilitated 5 listening sessions centered around dementia care philosophies, models, and practices. Two researchers first mapped qualitative data to the Holistic Approach to Transformational Change (HATCh) model for dementia care using a directed content analysis approach. They then identified themes and subthemes emerging from the data using a conventional analysis approach. They coded data iteratively and solicited input from 3 additional researchers to reach consensus where needed. Member checks were performed to ensure the trustworthiness of the data during 2 follow-up listening sessions. Results: The 9 participants described the importance of understanding the experiences of PLWDs in order to provide high-quality dementia care and to deliver such care with the residents and their preferences as the focus. They emphasized experiential education as essential for families and all staff, regardless of role. They noted the need to balance safety with resident choice, as well as the corresponding need for facility leadership and regulators to support such choices. The listening sessions revealed areas to foster person-centered care for PLWD, but also highlighted barriers to implementing this philosophy in LTC settings. Conclusions and Implications: Emergent themes included care practices that center on resident preferences and are supported by staff with the experiential education and communication skills necessary to relate to and support PLWD. These findings provide contextual information for researchers seeking to identify and test interventions that reflect LTC providers’ priorities for PLWD and emphasize the need to align research priorities with provider priorities.

Abstract

Introduction: Effective communication is essential to good health care, and hearing loss disrupts patient-provider communication. For the more than 2 million veterans with severe hearing loss, communication is particularly challenging in noisy health care environments such as emergency departments. The purpose of this qualitative study was to describe patient and provider perspectives of feasibility and potential benefit of providing a hearing assistance device, a personal amplifier, during visits to an emergency department in an urban setting affiliated with the Department of Veterans Affairs. Methods: This qualitative descriptive study was conducted in parallel with a randomized controlled study. We completed a semistructured interview with 11 veterans and 10 health care providers to elicit their previous experiences with patient-provider communication in the ED setting and their perspectives on hearing screening and using the personal amplifier in the emergency department. Interview data were analyzed using content analysis and Atlas.ti V8.4 software (Scientific Software Development GmbH, Berlin, Germany). Results: The veteran sample (n = 11) had a mean age of 80.3 years (SD = 10.2). The provider sample included 7 nurses and 3 physicians. In the ED setting, hearing loss disrupts patient-provider communication. Screening for hearing loss in the emergency department was feasible except in urgent/emergent cases. The use of the personal amplifier made communication more effective and less effortful for both veterans and providers. Discussion: Providing the personal amplifier improved the ED experience for veterans and offers a promising intervention that could improve health care quality and safety for ED patient populations.

Abstract

Background: Dementia is a global public health priority due to rapid growth of the aging population. As China has the world’s largest population with dementia, this debilitating disease has created tremendous challenges for older adults, family caregivers, and health care systems on the mainland nationwide. However, public awareness and knowledge of the disease remain limited in Chinese society. Objective: This study examines online public discourse and sentiment toward dementia among the Chinese public on a leading Chinese social media platform Weibo. Specifically, this study aims to (1) assess and examine public discourse and sentiment toward dementia among the Chinese public, (2) determine the extent to which dementia-related discourse and sentiment vary among different user groups (ie, government, journalists/news media, scientists/experts, and the general public), and (3) characterize temporal trends in public discourse and sentiment toward dementia among different user groups in China over the past decade. Methods: In total, 983,039 original dementia-related posts published by 347,599 unique users between 2010 and 2021, together with their user information, were analyzed. Machine learning analytical techniques, including topic modeling, sentiment analysis, and semantic network analyses, were used to identify salient themes/topics and their variations across different user groups (ie, government, journalists/news media, scientists/experts, and the general public). Results: Topic modeling results revealed that symptoms, prevention, and social support are the most prevalent dementia-related themes on Weibo. Posts about dementia policy/advocacy have been increasing in volume since 2018. Raising awareness is the least discussed topic over time. Sentiment analysis indicated that Weibo users generally attach negative attitudes/emotions to dementia, with the general public holding a more negative attitude than other user groups. Conclusions: Overall, dementia has received greater public attention on social media since 2018. In particular, discussions related to dementia advocacy and policy are gaining momentum in China. However, disparaging language is still used to describe dementia in China; therefore, a nationwide initiative is needed to alter the public discourse on dementia. The results contribute to previous research by providing a macrolevel understanding of the Chinese public’s discourse and attitudes toward dementia, which is essential for building national education and policy initiatives to create a dementia-friendly society. Our findings indicate that dementia is associated with negative sentiments, and symptoms and prevention dominate public discourse.

Abstract

Objective: This study aimed to evaluate the implementation of the long-term care insurance (LTCI) pilot program in China through an examination of public trust in the system and its associated factors of insurance awareness and satisfaction with the LTCI policy. Method: An online survey was used to collect data from 786 participants in the city of Guangzhou, one of the pilot sites of the LTCI. Ordinal logistic regression models were used to investigate the related factors of public trust in the LTCI. Structural equation modeling (SEM) was conducted to test the mediating effect of satisfaction with LTCI policy on the relationship between insurance awareness and public trust. Results: More than 60% of participants gave a positive evaluation of the LTCI pilot program. More than 70% of the participants recognized the important role of the program. Both an understanding of insurance and satisfaction with LTCI policies were associated with public trust. The proportion of the indirect effect with regard to the total effect of satisfaction on trust was 70.133%, greater than the direct effect of 29.867%. Conclusions: Our findings supported the hypothesis that satisfaction with the LTCI policy plays a mediating role between insurance awareness and public trust. Optimalization of the LTCI policy was recommended to improve public trust in the LTCI program.

Abstract

Objectives: Our study documented communication workflows across adult day care centers (ADCs) and primary care providers (PCPs) around complex needs of persons living with dementia (PLWD). We also identified barriers and facilitators to productive communication in clinical decision support and clinical information systems. Materials and Methods: We conducted 6 focus groups with ADC staff (N=33) and individual semistructured interviews with PCPs (N=22) in California. The eHealth Enhanced Chronic Care Model was used to frame the directed qualitative content analysis. Results: Our results captured cumbersome and ineffective workflows currently used to exchange information across PCPs and ADCs. Stakeholders characterized current communication as (1) infrequent, (2) delayed, (3) incomplete, (4) unreliable, (5) irrelevant, and (6) generic. Conversely, communication that was bidirectional, relevant, succinct, and interdisciplinary was needed to elevate the standard of care for PLWD. Discussion and Conclusion: ADCs possess a wealth of information that can support clinical decision-making across community-based providers involved in the care of PLWD, especially PCPs. However, effective information exchange is mired by complicated workflows that rely on antiquated technologies (eg, facsimile) and standard templates. Current information exchange largely focuses on satisfying regulatory guidelines rather than supporting clinical decision-making. Integrating community-based services into the health care continuum is a necessary step in elevating the standard of care for PLWD. In the absence of interoperable electronic health records, which may not be financially viable for ADCs, other options, such as mobile health, should be explored to facilitate productive information exchange of personalized relevant information.

Abstract

As centenarians are the most vulnerable social group among older adults, their quality of life (QoL) is of great significance for the realization of healthy aging and a harmonious society. The purpose of this cross-sectional study was to propose a multidimensional analysis of centenarians’ QoL to examine the factors associated with QoL. In the study, a factor analysis method, including exploratory factor analysis and confirmatory factor analysis, was used to uncover the latent structure of QoL and to monitor the dimension, reliability, and validity of the measurement scale. Structural equation model was performed to test the proposed hypotheses. Based on Lawton’s “the good life” theoretical framework, we constructed our QoL model with four dimensions: physical health, mental health, family and social relationships, and socioeconomic status. After the factor analysis, three main hypotheses were presented. The results of the final QoL model revealed that two hypotheses of the relationships between QoL and “physical health” and “socioeconomic status” were supported. This paper suggests that interventions related to improving functional health and living standard could enhance the QoL for centenarians.

Abstract

Background: Hypertrophic cardiomyopathy (HCM) is a common and clinically heterogeneous inherited cardiac disease. Quality of life (QOL) and physical functioning are important clinically but are underexplored in diverse populations with HCM. Objectives: To examine predictors for and compare QOL and physical functioning in Black and White adults with HCM. Methods: We analyzed a sub-sample from a longitudinal prospective study on HCM. Eligibility criteria included self-identified Black and White adults (≥18 years) with clinical HCM. QOL was measured with the Minnesota Living with Heart Failure Questionnaire (MLWHF);physical functioning included age-adjusted exercise capacity and NYHA class. Covariates included HCM structural characteristics and common comorbidities. We analyzed data from 434 individuals, 57 (13.1%) of whom self-identified as Black/African American. Results: In this sample, the Black cohort had higher MLWHF scores, 31.2 (27.2) v. 23.9 (22.1), p=0.042, signifying worse QOL, but there were no intergroup differences when QOL was dichotomized. Mean metabolic equivalents (METs) on symptom-limited stress testing were similar, though the Black cohort was younger, 54.6 (13.4) v.62.5 (14.8) years, p=0.001. No one from the Black cohort achieved an “excellent-for-age” exercise capacity, and 64.1% had a “below-average-for-age” exercise capacity vs 47% in the White cohort, though this was not statistically significant, p=0.058. There was no difference between groups in advanced NYHA class. Female gender was associated with worse QOL and physical functioning irrespective of covariates. Conclusions: This study is a starting point that underscores the need for a more comprehensive examination of well-being and physical functioning in Black populations with HCM.

Abstract

Objective This study aimed to assess whether racial disparities in nulliparous, term, singleton, vertex cesarean delivery rates vary among hospitals of different type (academic vs. nonacademic), setting (urban vs. rural), delivery volume, and patient population. Study Design This is a retrospective cohort study including singleton term vertex live births in nulliparous Black and non-Hispanic White birthing people in California between 2011 and 2017. Cesarean delivery rates were obtained using birth certificate data and International Classification of Diseases, 9th/10th Revision codes. Risk of cesarean delivery was compared among Black versus White birthing people by hospital type (academic, nonacademic), setting (rural, suburban, urban), volume (< 1,200, 1,200-2,300, 2,400-3,599, ≥3,600 deliveries annually), and patient population (proportion Black-serving). Federal Information Processing codes were used to designate hospital setting. Risks were calculated using univariable and multivariable logistic regression and adjusted for birthing person age, body mass index, medical comorbidities, gestational age, labor type (spontaneous vs. induction), and infant birthweight. Results The sample included 59,441 Black (cesarean delivery rate: 30.2%) and 363,624 White birthing people (cesarean delivery rate: 26.1%). Black birthing people were significantly more likely than White birthing people to have a cesarean delivery across nearly all hospital-level factors considered with adjusted relative risks ranging from 1.1 to 1.3. The only exception was rural settings in which the adjusted relative risk was 1.3 but did not reach statistical significance. Conclusion Black-White disparities in nulliparous, term, singleton, vertex cesarean delivery rates were persistent across all hospital-level factors we considered: academic status, rurality, delivery volume, and patient population. Furthermore, disparities existed at roughly the same magnitude regardless of hospital characteristics. These global increased risks likely reflect structural inequities in care, which contribute to disparities in pregnancy-related morbidity and mortality. These data should encourage providers, hospital systems, and quality collaboratives to further investigate racial disparities in cesarean delivery rates and develop strategies for eliminating them. Key Points Nulliparous Black birthing people are more likely than White to undergo cesarean delivery. This persists across hospitals of all academic status, rurality, delivery volume, and patient population. These findings likely reflect structural rather than institutional inequities in obstetric care.

Abstract

Background: Birthing people of color are more likely to deliver low birthweight and preterm infants, populations at significant risk of morbidity and mortality. Birthing people of color are also at higher risk for mental health conditions and emergency mental healthcare utilization postpartum. Although this group has been identified as high risk in these contexts, it is not known whether racial and ethnic disparities exist in mental healthcare utilization among birthing people who have delivered preterm. Objective: We sought to determine if racial and ethnic disparities exist in postpartum mental healthcare-associated emergency department visits or hospitalizations for birthing people with preterm infants in a large and diverse population. Study design: This population-based historic cohort study used a sample of Californian live-born infants born between 2011 and 2017 with linked birth certificates and emergency department visit and hospital admission records from the California Statewide Health Planning and Development database. The sample was restricted to preterm infants (<37 weeks’ gestation). Self-reported race and ethnicity groups included Hispanic, non-Hispanic Black, non-Hispanic Asian, non-Hispanic White, and non-Hispanic others. Mental health diagnoses were identified from the International Classification of Diseases Ninth and Tenth revision codes recorded in emergency department and hospital discharge records. Logistic regression analysis was used to estimate the association between mental health-related emergency department visits and rehospitalizations by race or ethnicity compared with non-Hispanic White birthing people and controlling for the following characteristics and health condition covariates: age, parity, previous preterm birth, body mass index, smoking, alcohol use, hypertension, diabetes, previous mental health diagnosis, and prenatal care. Results: Of 204,539 birthing people who delivered preterm infants in California, 1982 visited the emergency department and 836 were hospitalized in the first year after preterm birth for a mental health-related illness. Black birthing people were more likely to have a mental health-related emergency department visit and hospitalization (risk ratio, 1.8; 95% confidence interval, 1.5–2.0 and risk ratio, 1.9; 95% confidence interval, 1.5–2.3, respectively) within the first postpartum year than White birthing people. Hispanic and Asian birthing people were less likely to have mental health-related emergency department visits (adjusted risk ratio, 0.7; 95% confidence interval, 0.7–0.8 and adjusted risk ratio, 0.2; 95% confidence interval, 0.2–0.3, respectively) and hospitalizations (adjusted risk ratio, 0.6; 95% confidence interval, 0.5–0.7 and adjusted risk ratio, 0.2; 95% confidence interval, 0.1–0.3, respectively). When controlling for birthing people with a previous mental health diagnosis and those without, the disparities remained the same. Conclusion: Racial and ethnic disparities exist in emergency mental healthcare escalation among birthing people who have delivered preterm infants. Our findings highlight a need for further investigation into disparate mental health conditions, exacerbations, access to care, and targeted hospital and legislative policies to prevent emergency mental healthcare escalation and reduce disparities.

Abstract

Objective: To determine whether individuals from a historically underrepresented racial group have a higher cardiometabolic risk than historically represented individuals with type 1 diabetes (T1D) considering socioeconomic deprivation. Methods: We used the multivariable logistic and linear regression models to examine socioeconomic deprivation (upper 10th percentile) by race/ethnicity interaction for each cardiometabolic risk factor and cardiometabolic risk burden score, respectively, across 6320 zip code tabulation areas. We also determined the age-adjusted prevalence of low, moderate, and high cardiometabolic risks defined as 0, 1 to 2, and 3 or more risk factors for hypertension, obesity, dyslipidemia, and off-target glycemia for non-Hispanic White (n = 15 746), non-Hispanic Black (n = 1019), Hispanic (n = 1115), and other (n = 887), respectively. Results: The sample comprised 18 767 adolescents and adults with T1D. Those identifying as non-Hispanic Black were more likely to have a high cardiometabolic risk profile, including a 4.5-fold increase in the odds of off-target glycemia, a twofold increase in the odds of systolic hypertension, and 0.29 (unadjusted) and 0.46 (adjusted) increases in a higher cardiometabolic risk burden compared with non-Hispanic White individuals (P < .01). Those identifying as Hispanic had a 3.4-fold increase in the odds of off-target glycemia but were less likely to be overweight/obese or have systolic hypertension compared with non-Hispanic White. However, the lower likelihood of overweight/obesity and hypertension did not persist after considering covariates. Conclusion: There is a need to investigate additional determinants of racially/ethnically underrepresented cardiometabolic health, including structural racism and implicit bias in cardiometabolic care for individuals with T1D.

Abstract

Objectives: COVID-19 disproportionately affects racial/ethnic minorities and vaccine can help mitigate infection and transition, decrease rate of hospitalization, lower mortality rate, and control the pandemic. This study aims to examine disparities in COVID-19 vaccination rate by age among Whites, Hispanics, Blacks, and Asian Americans, and the modification effects by gender and education. Methods: We used seven waves of biweekly surveys from the Household Pulse Survey collected between July 21, 2021, and October 11, 2021. Results: Asians reported the highest, Blacks reported the lowest vaccination rate, and gender differences were minimal. Increasing age was associated with higher vaccination rate except for the oldest age group. The decline was from 84.4% (70-79 years) to 41.1% (80-88 years: 41.1%) among Hispanics and 92.8% to 69.6% among Asians. Educational effect was the most salient among younger adults with the largest gaps observed in Blacks. Among 18-29-year Black participants, the vaccination rates were 31.1% (confidence interval [95% CI]: 25.7-37.1) for high school or lower, 58.9% (95% CI: 54.2-63.5) for some college or associate degree, and 74.2% (95% CI: 69.4-78.5) for bachelor or higher degrees, leaving a 43.1% gap between the lowest and the highest education levels. The gaps in this age group were 33.7% among Whites, 32.1% among Hispanics, and 20.5% among Asian Americans. Conclusion: Our study advances the existing literature on COVID-19 vaccination by providing empirical evidence on the dynamic race/ethnic-age-education differences across racial/ethnic groups. The findings from our study provide scientific foundation for the development of more strategies to improve vaccination rate for the minority populations.

Abstract

Despite long-existing calls to address alarming racial/ethnic gaps in severe maternal morbidity (SMM), research that considers the impact of intersecting social inequities on SMM risk remains scarce. Invoking intersectionality theory, we sought to assess SMM risk at the nexus of racial/ethnic marginalization, weathering, and neighborhood/individual socioeconomic disadvantage. We used birth hospitalization records from California across 20 years (1997–2017, N = 9,806,406) on all live births ≥20 weeks gestation. We estimated adjusted average predicted probabilities of SMM at the combination of levels of race/ethnicity, age, and neighborhood deprivation or individual socioeconomic status (SES). The highest risk of SMM was observed among Black birthing people aged ≥35 years who either resided in the most deprived neighborhoods or had the lowest SES. Black birthing people conceptualized to be better off due to their social standing (aged 20–34 years and living in the least deprived neighborhoods or college graduates) had comparable and at times worse risk than White birthing people conceptualized to be worse off (aged ≥35 years and living in the most deprived neighborhoods or had a high-school degree or less). Our findings highlight the need to explicitly address structural racism as the driver of racial/ethnic health inequities and the imperative to incorporate intersectional approaches.

Abstract

Introduction: Maternal morbidity and mortality rates are on the rise in the United States, particularly among Black populations. Recently, there has been an uptick in research funding to identify and address root causes, particularly among at-risk groups. However, given the historical trauma experienced by Black populations in research settings, novel approaches built firmly on ethical principles and grounded in a framework of reproductive justice are necessary to minimize harm and center the research process on maintaining the dignity and respect of research participants. Methods: Ethical principles as outlined by the American Nurses Association, Black Mamas Matter Alliance, and federal research guidelines are reviewed within the context of conducting maternal mortality-focused research. In addition, community developed research frameworks and methodologies are presented and discussed within the research context. Conclusions: Black pregnant people have reported mistreatment during clinical encounters; therefore, intentional protections to promote safety must be considered in the research setting. Ethical principles must be considered when designing and implementing research initiatives focused on addressing maternal mortality risk in Black communities.

Abstract

Precision nutrition is an emerging concept that aims to develop nutrition recommendations tailored to different people's circumstances and biological characteristics. Responses to dietary change and the resulting health outcomes from consuming different diets may vary significantly between people based on interactions between their genetic backgrounds, physiology, microbiome, underlying health status, behaviors, social influences, and environmental exposures. On 11-12 January 2021, the National Institutes of Health convened a workshop entitled "Precision Nutrition: Research Gaps and Opportunities" to bring together experts to discuss the issues involved in better understanding and addressing precision nutrition. The workshop proceeded in 3 parts: part I covered many aspects of genetics and physiology that mediate the links between nutrient intake and health conditions such as cardiovascular disease, Alzheimer disease, and cancer; part II reviewed potential contributors to interindividual variability in dietary exposures and responses such as baseline nutritional status, circadian rhythm/sleep, environmental exposures, sensory properties of food, stress, inflammation, and the social determinants of health; part III presented the need for systems approaches, with new methods and technologies that can facilitate the study and implementation of precision nutrition, and workforce development needed to create a new generation of researchers. The workshop concluded that much research will be needed before more precise nutrition recommendations can be achieved. This includes better understanding and accounting for variables such as age, sex, ethnicity, medical history, genetics, and social and environmental factors. The advent of new methods and technologies and the availability of considerably more data bring tremendous opportunity. However, the field must proceed with appropriate levels of caution and make sure the factors listed above are all considered, and systems approaches and methods are incorporated. It will be important to develop and train an expanded workforce with the goal of reducing health disparities and improving precision nutritional advice for all Americans.

Abstract

Background: While pollution from vehicle sources is an established risk factor for preterm birth, it is unclear whether distance of residence to the nearest major road or related measures like major road density represent useful measures for characterising risk. Objective: To determine whether major road proximity measures (including distance to major road, major road density and traffic volume) are more useful risk factors for preterm birth than other established vehicle-related measures (including particulate matter <2.5 μm in diameter (PM2.5) and diesel particulate matter (diesel PM)). Methods: This retrospective cohort study included 2.7 million births across the state of California from 2011–2017; each address at delivery was geocoded. Geocoding was used to calculate distance to the nearest major road, major road density within a 500 m radius and major road density weighted by truck volume. We measured associations with preterm birth using risk ratios adjusted for target demographic, clinical, socioeconomic and environmental covariates (aRRs). We compared these to the associations between preterm birth and PM2.5 and diesel PM by census tract of residence. Results: Findings showed that whereas higher mean levels of PM2.5 and diesel PM by census tract were associated with a higher risk of preterm birth, living closer to roads or living in higher traffic density areas was not associated with higher risk. Residence in a census tract with a mean PM2.5 in the top quartile compared with the lowest quartile was associated with the highest observed risk of preterm birth (aRR 1.04, 95% CI 1.04, 1.05). Conclusions: Over a large geographical region with a diverse population, PM2.5 and diesel PM were associated with preterm birth, while measures of distance to major road were not, suggesting that these distance measures do not serve as a proxy for measures of particulate matter in the context of preterm birth.

Abstract

Objective: Evaluate the risk of preterm (<37 weeks) or early term birth (37 or 38 weeks) by body mass index (BMI) in a propensity score-matched sample. Design: Retrospective cohort analysis. Setting: California, USA. Population: Singleton live births from 2011–2017. Methods: Propensity scores were calculated for BMI groups using maternal factors. A referent sample of women with a BMI between 18.5 and <25.0 kg/m2 was selected using exact propensity score matching. Risk ratios for preterm and early term birth were calculated. Main outcome measures: Early birth. Results: Women with a BMI <18.5 kg/m2 were at elevated risk of birth of 28–31 weeks (relative risk [RR] 1.2, 95% CI 1.1–1.4), 32–36 weeks (RR 1.3, 95% CI 1.2–1.3), and 37 or 38 weeks (RR 1.1, 95% CI 1.1–1.1). Women with BMI ≥25.0 kg/m2 were at 1.2–1.4-times higher risk of a birth <28 weeks and were at reduced risk of a birth between 32 and 36 weeks (RR 0.8–0.9) and birth during the 37th or 38th week (RR 0.9). Conclusion: Women with a BMI <18.5 kg/m2 were at elevated risk of a preterm or early term birth. Women with BMI ≥25.0 kg/m2 were at elevated risk of a birth <28 weeks. Propensity score-matched women with BMI ≥30.0 kg/m2 were at decreased risk of a spontaneous preterm birth with intact membranes between 32 and 36 weeks, supporting the complexity of BMI as a risk factor for preterm birth. Tweetable abstract: Propensity score-matched women with BMI ≥30 kg/m2 were at decreased risk of a late spontaneous preterm birth.

Abstract

Although adolescent females with asthma are at increased risk for bullying, relationships between bullying at school and electronic bullying and demographics, mental health issues, and substance use have not specifically been studied in these young women. The purpose of this research was to examine such relationships among adolescent females with asthma. Complex sampling software was used to extrapolate frequencies and χ2 analyses to adolescent females with asthma. In this U.S. sample of adolescent females with asthma (n = 1,634), younger age, mental health issues, and substance use were significantly related to bullying at school and electronic bullying, while race/ethnicity and grade in school were significantly related only to bullying at school. In general, findings are consistent with previous research regarding relationships between bullying and risk factors among all U.S. adolescent females. Guidance by school nurses is needed to create effective supports for victimization reduction in this vulnerable group.

Abstract

Objectives: Among childbearing women, insurance coverage determines degree of access to preventive and emergency care for maternal and infant health. Maternal-infant dyads with dual burden of severe maternal morbidity and preterm birth experience high physical and psychological morbidity, and the risk of dual burden varies by insurance type. We examined whether sociodemographic and perinatal risk factors of dual burden differed by insurance type. Methods: We estimated relative risks of dual burden by maternal sociodemographic and perinatal characteristics in the 2007–2012 California birth cohort dataset stratified by insurance type and compared effects across insurance types using Wald Z-statistics. Results: Dual burden ranged from 0.36% of privately insured births to 0.41% of uninsured births. Obstetric comorbidities, multiple gestation, parity, and birth mode conferred the largest risks across all insurance types, but effect magnitude differed. The adjusted relative risk of dual burden associated with preeclampsia superimposed on preexisting hypertension ranged from 9.1 (95% CI 7.6–10.9) for privately insured to 15.9 (95% CI 9.1–27.6) among uninsured. The adjusted relative risk of dual burden associated with cesarean birth ranged from 3.1 (95% CI 2.7–3.5) for women with Medi-Cal to 5.4 (95% CI 3.5–8.2) for women with other insurance among primiparas, and 7.0 (95% CI 6.0–8.3) to 19.4 (95% CI 10.3–36.3), respectively, among multiparas. Conclusions: Risk factors of dual burden differed by insurance type across sociodemographic and perinatal factors, suggesting that care quality may differ by insurance type. Attention to peripartum care access and care quality provided by insurance type is needed to improve maternal and neonatal health.