Implications For Population Health Research Articles

Pollen effects in a changing climate: Ragweed pollen exposure and sleepiness in immunotherapy patients of a Southeastern Michigan allergy clinic.

Allergic rhino-conjunctivitis (AR) is a globally relevant health disorder characterized by sneezing, rhinorrhea and sleep disturbance. Ragweed (Ambrosia artemisiifolia) is a plant common to North America and an important allergen. Coarse methods of measuring airborne pollen counts are used to predict seasonal allergy symptoms. This research used a longitudinal study design with a novel, model-based raster of predicted pollen counts to test associations with self-reported symptoms of AR collected from patients receiving immunotherapy for pollen allergies at an allergy clinic. Researchers visited a clinic six times over three weeks. Immunotherapy patients were asked to fill out a brief intake survey on allergic and symptomatic profiles, daytime sleepiness, housing quality, and demographics. Participants responded to a daily, emailed survey on sleepiness and asthma symptoms for 21 days. Using the date and location of responses, ragweed pollen counts were extracted from a prognostic, model based raster (25km pixels). Lag associations of pollen counts with sleepiness were tested using a logistic regression model , adjusted for housing and demographic characteristics, in a distributed lag non-linear model (DLNM) framework. 49 people participated in the study. 26 (52%) were female. The mean age was 37.9 years. Asthma/allergy symptoms were not associated with ragweed pollen but sleepiness was highest two days after exposure (Estimate: 0.33 [0.04,0.62]). Subjects traveled widely during the study period. Intense exposures to ragweed pollen may be associated with daytime sleepiness within small exposure windows. Model-based predicted pollen counts could be used to study health impacts of pollen in people with disease severe enough to receive immunotherapy. Daytime sleepiness can affect productivity and injury risk, and pollen season length and allergenicity may be increasing with climate change. Thus our results may have important implications for population health.

Socioeconomic determinants of cognition among older adults in the Brazilian longitudinal study of aging (ELSI-Brazil): a life-course approach.

The prevalence of cognitive impairment no dementia (CIND) and dementia appears to be higher in low- and middle-income countries (LMICs) compared to high-income economies. Yet few nationally representative studies from Latin American LMICs have investigated life-course socioeconomic factors associated with the susceptibility to these two cognitive conditions. Hence, the present study aimed to examine the associations of early- (education and food insecurity), mid- (employment stability), and late-life (personal income and household per capita income) socioeconomic determinants of CIND and dementia among older adults from Brazil, while simultaneously exploring whether sex plays an effect-modifier role on these associations. This population-based study comprised a nationally representative sample of older adults (N = 5,249) aged 60 years and over from the Brazilian Longitudinal Study of Aging (ELSI-Brazil). We fitted multinomial regressions and estimated odds ratios with the respective 95% confidence intervals (CIs). In multivariate analyses, participants with more years of early-life education (0.89, 95% CI [0.81, 0.97]) and mid-life employment stability (0.97, 95% CI [0.96, 0.99]) and higher late-life household per capita income (0.70, 95% CI [0.51, 0.95) were less likely to have dementia. Regarding CIND, more years of mid-life employment stability (0.97, 95% CI [0.96, 0.98]) was the only determinant to confer protection. Notably, secondary sex-based analyses showed the higher the early-life educational attainment, the lower the odds of dementia in women (0.81, 95% CI [0.75, 0.87]) but not in men (1.00, 95% CI [0.86, 1.16]). These findings may have implications for population health and health policy by advancing our understanding of socioeconomic determinants of CIND and dementia, especially in Latin America.

Recent use of consumer and personal care products and exposures to select endocrine disrupting chemicals among urban children with asthma.

Emerging studies suggest that endocrine disrupting chemicals (EDCs) in personal care and other consumer products are linked with various adverse health effects, including respiratory and reproductive effects. Despite Black persons using more personal care products than other demographic groups and having a high asthma burden, little is known regarding their consumer product use patterns and associated EDC exposures. To examine the association between recent exposure to select EDCs with specific consumer products and behaviors in a cohort of 110 predominantly Black children with asthma, ages 8-17 years, living in Baltimore City, Maryland. We quantified concentrations of bisphenol A (BPA), bisphenol S (BPS), bisphenol F, two dichlorophenols, four parabens, triclosan, benzophenone-3, and triclocarban in spot urine samples. Questionnaires were used to capture recent (last 24-h) consumer product use and behaviors. Associations between EDCs and consumer product uses/behaviors were assessed using multivariable linear regression, adjusting for age, gender, race/ethnicity, and caregiver income level. Effect estimates were expressed as geometric mean ratios of biomarker concentrations of product-users vs non-users. Increased concentrations to select EDCs were associated with recent use of air freshener (ratios; BPA: 1.9, 95%CI 1.4-2; BPS 1.7, 95%CI 1-2.97; propyl paraben: 3.0, 95%CI 1.6-5.6), scented candles (methyl paraben: 2.6, 95%CI 1.1-6.1), and scented carpet powder (2,5-dichlorophenol: 2.8, 95%CI 1.2-6.3). Additionally, consuming canned food was associated with some increased biomarker concentrations (ratios: BPA: 1.7, 95%CI 1.2-2.4; BPS: 2.1, 95% CI: 1.2-3.6). These findings add to the body of evidence suggesting that recent use of select consumer products in Black children contributes to exposure of chemicals of concern and could potentially inform exposure mitigation interventions. Findings have broad potential health implications for pediatric populations and Black children who may face exposure and health disparities. Little is known about how children's personal care product use and consumer behaviors affect their exposures to endocrine disrupting chemicals (EDCs). This is particularly true for Black children who often experience a disparate exposure burden to many EDCs. This is a significant knowledge gap among children that are uniquely vulnerable to EDCs as they undergo critical windows of growth and development. Our findings show associations between consumer products and EDC exposures in predominantly Black children in low-income settings. Identifying EDC exposure determinants has broad health implications as many of these chemicals have been associated with adverse health risks.

Undercounting diagnoses in Australian general practice: a data quality study with implications for population health reporting

BackgroundDiagnosis can often be recorded in electronic medical records (EMRs) as free-text or using a term with a diagnosis code. Researchers, governments, and agencies, including organisations that deliver incentivised primary care quality improvement programs, frequently utilise coded data only and often ignore free-text entries. Diagnosis data are reported for population healthcare planning including resource allocation for patient care. This study sought to determine if diagnosis counts based on coded diagnosis data only, led to under-reporting of disease prevalence and if so, to what extent for six common or important chronic diseases.MethodsThis cross-sectional data quality study used de-identified EMR data from 84 general practices in Victoria, Australia. Data represented 456,125 patients who attended one of the general practices three or more times in two years between January 2021 and December 2022. We reviewed the percentage and proportional difference between patient counts of coded diagnosis entries alone and patient counts of clinically validated free-text entries for asthma, chronic kidney disease, chronic obstructive pulmonary disease, dementia, type 1 diabetes and type 2 diabetes.ResultsUndercounts were evident in all six diagnoses when using coded diagnoses alone (2.57–36.72% undercount), of these, five were statistically significant. Overall, 26.4% of all patient diagnoses had not been coded. There was high variation between practices in recording of coded diagnoses, but coding for type 2 diabetes was well captured by most practices.ConclusionIn Australia clinical decision support and the reporting of aggregated patient diagnosis data to government that relies on coded diagnoses can lead to significant underreporting of diagnoses compared to counts that also incorporate clinically validated free-text diagnoses. Diagnosis underreporting can impact on population health, healthcare planning, resource allocation, and patient care. We propose the use of phenotypes derived from clinically validated text entries to enhance the accuracy of diagnosis and disease reporting. There are existing technologies and collaborations from which to build trusted mechanisms to provide greater reliability of general practice EMR data used for secondary purposes.

Racial disparities among triple negative breast cancer clinical trial enrollees between 2010-2023.

1093 Background: Despite the social construct of race lacking biological significance, it plays a significant role in health disparities and necessitates examination to address social stratification and health inequities. Not reporting race in medical research neglects the reality of social stratification, injustices, and implications for population health. Additionally, excluding racial demographic data from research publications may conceal health disparities. This study focuses on Triple Negative Breast Cancer (TNBC) clinical trials, aiming to meta-analyze the inclusion of racial data and assess racial representation. Methods: A meta-analysis of 81 completed TNBC trials (2011-2023) from ClinicalTrials.gov was conducted. Demographic data on race and sex were extracted and analyzed using Microsoft Excel. Two independent reviewers extracted study-level data for a random-effects analysis. The primary outcome was identifying the prevalence of studies lacking racial data. The secondary outcomes are the prevalence of each racial category (White, Black, Asian, Hispanic/Latino, and Combined Other) among all TNBC clinical trials that reported demographic information. The Combined Other category includes American Indian, Native Hawaiian, more than one race, and unknown/unreported. Results: Of 81 trials, 29.63% did not report racial data. The remaining 57 trials (8,196 participants) revealed 73.98% White, 10.29% Asian, 7.85% Black, 8.02% Hispanic/Latino, and 4.12% "combined other" participants. U.S.-based trials (36 studies, 3,348 participants) showed 77.96% White, 12.03% Black, 4.51% Asian, and 4.96% Hispanic/Latino participants. Moreover, we conducted a comparative analysis between the racial distribution in U.S. clinical trials and the prevalence of TNBC in the U.S. population, utilizing the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Public Use Datasets (2010-2019). The analysis revealed a significant discrepancy with White (p<.001) participants being overrepresented, and Black (p<.001), Asian (p<.001), Hispanic/Latino (p<.001), American Indian (p<.001), more than one race (p<.02), and Other/Unknown (p<.001) populations being underrepresented. Conclusions: Globally, 29.63% of TNBC trials did not report racial data, raising concerns about generalizability. U.S.-based studies exhibited overrepresentation of White participants and underrepresentation of Black, Asian, Hispanic/Latino, American Indian, Native Hawaiian, and other categories. Notably, Black and Hispanic/Latino individuals, comprising a substantial portion of TNBC patients, were underrepresented. These findings underscore racial/ethnic disparities in breast cancer trial participation, warranting further investigation into recruitment barriers for equitable participation.

Association between antibiotic use and mortality among older persons receiving first-line immune checkpoint inhibitors for non-small cell lung cancer (NSCLC).

e14607 Background: There is biologic plausibility that antibiotics (ABX) may reduce the effectiveness of cancer therapy, most notably immune checkpoint inhibitors (ICI). As ABX are commonly prescribed to older persons and more than a third of US persons with cancer are eligible for ICIs, use of ABX has important population health implications. We assess the association between ABX use and mortality among persons with NSCLC who receive first-line (1L) treatment. Methods: Using SEER-Medicare, we assembled a cohort of persons ≥66 years with NSCLC who received 1L treatment with platinum-based chemotherapy (PLT) or ICI (PLT without ICI, PLT with ICI, and ICI monotherapy) within one year of cancer diagnosis between 2017-2019. We assessed overall ABX exposure from 1 month to 1 year prior to treatment initiation and by ABX class. Primary outcome was all cause deaths within three years of treatment initiation or until 12/31/2020. Multivariable Cox proportional hazard models adjusting for individual-level characteristics (demographics, time-to-treatment, comorbidities, healthcare use, SEER registry, and neighborhood socioeconomic status) and landmark analyses of 1-6 months after cancer treatment were used to assess the association between ABX exposure and mortality. Results: Among 4,182 persons (mean age 75 years, 85% white, 68% chemo-immunotherapy within 2 months of NSCLC diagnosis), 63%, 18%, and 18% received PLT, PLT+ICI, and ICI, respectively. ICI+/-PLT increased in prevalence from 20% of treatments (2017) to 55% (2019). The mean age of persons who received ICI alone (78 years old) was higher than PLT or PLT+ICI. Prior to 1L treatment, 22% and 72% of persons received ABX within 30 days and 1 year prior to cancer treatment, respectively. The three most common ABX classes were fluoroquinolones (48%), penicillins (21%), and macrolides (18%). The cohort was followed for 3,274 person-years and included 2,958 deaths within 1 year and 4,144 deaths within 3 years of follow-up. Compared with persons who did not receive ABX within 3 months of cancer treatment, ABX use was associated with higher risk of death within 3 years for ICI alone [HR 1.24 (1.05-1.46) but not for PLT alone or PLT+ICI. Fluoroquinolones were associated with an elevated risk of mortality among persons who received ICI alone HR 1.41(95%CI: 1.1-1.8) and PLT alone HR 1.18 (95%CI: 1.05-1.32) but not PLT+ICI. Our findings were similar across definitions of ABX exposure (30 days to 1 year prior to treatment) and analytic landmarks after treatment initiation. Conclusions: Among patients with NSCLC who received 1L treatment, we identified an association between ABX exposure prior to treatment and increased mortality among persons who received ICI monotherapy but not PLT+ICI. As ICIs expand to more cancer types and earlier stages, ABX use may have a significant impact on outcomes and population health.

What every clinician needs to know about chronic kidney disease: Detection, classification and epidemiology.

Chronic kidney disease (CKD) is a major healthcare challenge, affecting >800 million people worldwide. Implications for population health result from the strong associations of CKD with increased rates of cardiovascular disease, heart failure, progressive CKD leading to kidney failure, acute kidney injury (AKI), and mortality. In addition to a single disease perspective, CKD commonly coexists alongside other long-term conditions, in particular type 2 diabetes and cardiovascular disease. CKD is therefore an important component of multimorbidity that influences individual management and impacts prognosis. CKD is defined by abnormalities of kidney structure or function of any cause with implications for health that are present for longer than 3 months. The diagnosis is usually made on the basis of an abnormal glomerular filtration rate (GFR < 60 mL/min/1.73 m2) and/or the presence of proteinuria (urine albumin to creatinine ratio > 30 mg/g or >3 mg/mmol). GFR is usually estimated from serum creatinine concentration using a variety of validated equations. However, serum creatinine is closely related to muscle mass and may therefore not be an accurate marker of GFR in people with high or low muscle mass (sarcopaenia). Cystatin C is an alternative endogenous marker of GFR that is increasingly being used but also has limitations. An estimate of GFR based on both creatinine and cystatin C is the most accurate. Diagnosis should be followed by classification and risk stratification to guide the development of a risk-based, personalized care plan. Improved detection and widespread implementation of optimal CKD management has the potential to bring major benefits to population health.

Population health implications of exposure to pervasive military aircraft noise pollution.

While the adverse health effects of civil aircraft noise are relatively well studied, impacts associated with more intense and intermittent noise from military aviation have been rarely assessed. In recent years, increased training at Naval Air Station Whidbey Island, USA has raised concerns regarding the public health and well-being implications of noise from military aviation. This study assessed the public health risks of military aircraft noise by developing a systematic workflow that uses acoustic and aircraft operations data to map noise exposure and predict health outcomes at the population scale. Acoustic data encompassing seven years of monitoring efforts were integrated with flight operations data for 2020-2021 and a Department of Defense noise simulation model to characterize the noise regime. The model produced contours for day-night, nighttime, and 24-h average levels, which were validated by field monitoring and mapped to yield the estimated noise burden. Established thresholds and exposure-response relationships were used to predict the population subject to potential noise-related health effects, including annoyance, sleep disturbance, hearing impairment, and delays in childhood learning. Over 74,000 people within the area of aircraft noise exposure were at risk of adverse health effects. Of those exposed, substantial numbers were estimated to be highly annoyed and highly sleep disturbed, and several schools were exposed to levels that place them at risk of delay in childhood learning. Noise in some areas exceeded thresholds established by federal regulations for public health, residential land use and noise mitigation action, as well as the ranges of established exposure-response relationships. This study quantified the extensive spatial scale and population health burden of noise from military aviation.We employed a novel GIS-based workflow for relating mapped distributions of aircraft noise exposure to a suite of public health outcomes by integrating acoustic monitoring and simulation data with a dasymetric population density map. This approach enables the evaluation of population health impacts due to past, current, and future proposed military operations. Moreover, itcanbemodified for application to other environmental noise sources and offers an improved open-sourcetool to assess the population health implications of environmental noise exposure, inform at-risk communities, and guide efforts in noise mitigation and policy governing noise legislation, urban planning, and land use.

A Harmful Scene: Vicarious Exposure to Racism and Negative Affect Among Undergraduate Students in the Context of the George Floyd Tragedy

ABSTRACT Evidence of vicarious exposure to racism has primarily been garnered from in-group racial-ethnic samples to convey its harmful psychological impacts on individuals who share identities with those who are directly experiencing the racist act being observed. The extent to which this evidence applies to out-group members exposed to vicarious racism is underexamined. The present study investigated the extent to which vicarious exposure to racialized violence in policing leading to the death of George Floyd predicted negative affect among a sample of undergraduate students when accounting for other factors that may contribute to negative affect. A sample (N = 683) of nonhomogeneous racial-ethnic (67% People of Color; 33% White) undergraduate students aged 18 to 41 completed an online survey assessing demographic characteristics, vicarious racism exposure, everyday discrimination exposure, and affect during the summer and fall of 2020. Bivariate analyses indicated racial-ethnic disparities in negative affect among the sample. After controlling for race-ethnicity, gender identity, sexual identity, and everyday discrimination, a hierarchical linear regression analysis indicated that exposure to vicarious racialized violence in policing significantly predicted increased levels of negative affect. These findings provide vital insight into the harmful psychological impacts of vicarious exposure to racialized violence on individuals in the U.S. which has individual, population, and public health implications.

A reassessment of trends and rural–urban/regional differences in the total fertility rate in China, 2000–2020: analyses of the 2020 national census data

The decline in the total fertility rate (TFR) is a key driver of population change and has important implications for population health and social development. However, China’s TFR has been a considerable controversy due to a lack of high-quality data. Therefore, this study used the 2020 national population census of China (NPCC) data and reverse survival method to reassess temporal trends in the TFRs and to reexamine rural–urban differences and regional variations in TFRs from 2000 to 2020 in China. Overall, there were significant gaps between the estimated and reported TFRs before 2020, and the estimated TFRs based on the 2020 NPCC data remained higher than the reported TFRs from government statistics. Although TFRs rebounded shortly in the years after the two-child policy, they have shown a wavelike decline since 2010. Additionally, the estimated TFRs fluctuated below 1.5 children per woman in urban areas compared to above 1.8 in rural areas, but the rural–urban differences continued to decrease. Regarding geographic regional variations, the estimated TFRs in all regions displayed a declining trend during 2010–2020, especially in rural areas. Large decreases of over 25% in TFRs occurred in the north, east, central, and northwest regions. In addition to changing the birth policy, the government and society should adopt comprehensive strategies, including reducing the costs of marriage, childbearing, and child education, as well as promoting work-family balance, to encourage and increase fertility levels.

Assessing diet quality and associated environmental impacts: A cross-sectional analysis in a middle- to older-aged Irish population

Current dietary patterns have implications for both population and planetary health, giving dietary shifts the potential to reduce these impacts. However, higher quality diets are not inherently of lower environmental impact. This paper examines the association between diet quality, defined using the Dietary Approaches to Stop Hypertension (DASH) diet, Mediterranean (MED) diet and Healthy Eating Index 2015 (HEI-2015) , and environmental impacts among middle- to older-aged adults. The cross-sectional analysis used a random sample of 1862 males and females aged 46–73 years. Diet quality scores (DQS) were derived from a validated food frequency questionnaire (FFQ). The impact of food production was estimated using greenhouse gas emissions (GHGE) and blue water use (BWU) environmental impact indicators from secondary data sources. Relationships between food groups, DQS and environmental impacts were evaluated via correlation and regression analyses. The food group red meat & offal was found to be the largest contributor to dietary GHGE and caffeinated beverages to BWU for all DQS and across all quartiles of adherence. The cumulative contribution of discretionary foods and beverages requires attention given they are superfluous to human health. In fully adjusted regression analyses, higher diet quality was associated with lower GHGE for all DQS. Conversely, higher diet quality was positively associated with water use (DASH and MED only). Encompassing principles of the DASH and MED diets in future dietary recommendations may reduce diet-related disease in later life and dietary GHGE. However, the increase of BWU as diets become healthier is a concern. Advocating for plant-based diets must be coordinated with sustainable production and supply. National solutions to increase self-sufficiency and reduce impacts and reliance on climate vulnerable countries is warranted. The population dietary shifts required for health and planet can only be realised by multi-level structural changes to food systems through policy, and not through sole expectation of individual change.

Post-Acute Care: Advancing Population Health Interventions, Risk Assessment, and Implications for Readmissions and Cost-Effectiveness through Telehealth

Post-Acute Care: Advancing Population Health Interventions, Risk Assessment, and Implications for Readmissions and Cost-Effectiveness through Telehealth

Healthcare workforce equity for health equity: An overview of its importance for the level of primary health care.

Healthcare workforce crises often stem from healthcare workers' inequities. This study provides an overview of the main PHC workforce policy questions related to health equity, offering examples of evidence necessary to support the implementation of policies and strategies that increase equity in the health workforce and access to the PHC workforce and services. The equity-related policies in PHC and workforce were linked with the indicators listed in the Global Health Workforce Network Data and Evidence Hub and guidelines for health workforce management. The policy-relevant questions in PHC cover many workforce issues such as the optimal size, equitable distribution, relevant competencies to ensure equitable healthcare access, and equitable approaches for retention, training, recruitment, benefits and incentive schemes and governance. This will require intersectionality evidence of the optimised staffing to PHC workload, that PHC practitioners' training demonstrates evidence-based knowledge aligned with locally relevant expertise. Critical for equitable PHC access and health equity is the establishment of efficient measurement of PHC workforce equity and its implications for population health. Using indicators that measure health and workforce equity in research, policy, and practices may improve recruitment and retention, and respond more effectively to the PHC workforce crises.

Bedsharing among breastfeeding physicians: Results of a nationwide survey.

Bedsharing is common but advised against by the American Academy of Pediatrics. It is unknown if breastfeeding physicians bedshare more or less than the general population. To determine the prevalence of bedsharing among physicians, their reasons for bedsharing or not, and whether bedsharing was associated with a longer duration of breastfeeding. An online survey was adapted from surveys administered by the Centers for Disease Control and Prevention. The survey was administered to physicians and medical students who birthed children from October 2020 through August 2021. Respondents were asked to report on a singleton birth, and questions centered around sleep practices and breastfeeding. Survival analysis was used to examine the association between bedsharing and breastfeeding duration. Of 546 respondents with bedsharing data, 68% reported some history of bedsharing, and 77% were in specialties that involved caring for pregnant people and/or infants. Those who bedshared breastfed an average of four months longer than those who never bedshared (18.08 versus 14.08 months p<0.001). The adjusted risk of breastfeeding cessation was markedly lower for those who bedshared compared to those who did not (Hazard Ratio 0.57, 95% Confidence Interval 0.45, 0.71). The primary reason for bedsharing was to breastfeed (73%); the primary reason for not bedsharing was safety concerns (92%). Among those who bedshared (n = 373), 52% did not inform their child's healthcare provider. Bedsharing is common among our sample of mainly breastfeeding physicians, including those who care for pregnant people and/or infants. It is also associated with a longer duration of breastfeeding, which has implications for population health. Practicing bedsharing implies cognitive dissidence and may affect how physicians counsel about bedsharing. Additionally, lack of disclosure of bedsharing practices has implications for practical guidance about having open non-judgmental conversations and may be a missed opportunity to counsel on bedsharing safety.

Expansion of Comprehensive Sexuality Education

School-based sex education has always been and continues to be controversial and mired in politics, and gaps persist in the content and skills that children and adolescents receive about sexual health. State policies dictate whether sex and HIV education are mandated, medically accurate, or include life skills such as providing consent to sexual activity, and these policies have important implications for population health. In this column, I review research findings about abstinence only versus sex education or comprehensive sexuality education, identify gaps in research and content related to sex education programs, review state sex education policies, and provide recommendations from professional organizations on expanding school-based programming to include comprehensive sexuality education.

Socioeconomic determinants of cognition among older Brazilian adults: A life‐course approach

AbstractBackgroundThe prevalence of cognitive impairment is higher in low‐ and middle‐income countries compared to high‐income economies. Yet few nationally representative studies from Latin America have investigated life‐course socioeconomic factors related to the susceptibility to age‐associated cognitive impairment. In this study, we examined the associations of early‐ (education and food insecurity), mid‐ (employment stability), and late‐life (any personal income, household per capita income, and self‐perceived income) socioeconomic indicators with the risk of cognitive impairment, while simultaneously exploring whether gender plays an effect‐modifier role on these associations.MethodThe study population comprised Brazilian adults aged 50 years and over (N = 8710) from the Brazilian Longitudinal Study of Aging. Those with ≤ 1.5 SD on a global composite measure of cognition (N = 1005) were assigned to the cognitive impairment group. Unadjusted and mutually adjusted logistic regressions estimated odds ratios with 95% confidence intervals.ResultHigher midlife employment stability and late‐life household per capita income were positively associated with the health of adult cognition. Moreover, secondary analyses performed separately for males and females showed the higher the early‐life educational attainment, the lower the likelihood of impaired cognition among females but not among males. Conversely, having a source of income in old age showed a buffering role against cognitive impairment in males, but this association was not observed in females. No significant associations were noted for early‐life food insecurity or late‐life self‐perceived income.ConclusionThese findings may have implications for population health and health policy by advancing our understanding of socioeconomic determinants of mid‐to‐late‐adulthood cognition.

“What’s the damage? Give it to me!”: Type 2 diabetes mellitus and obesity management in primary care with implications for biomedical science, clinical practice and population health

Type 2 diabetes mellitus (T2DM) is a condition that defines medicine in the 21st century. Multifactorial individual and environmental causes have given rise to a non-communicable disease that challenges traditional prevention and treatment paradigms. In this report, the author explores the case of one patient with T2DM he met during his general practice placement in South Auckland. He argued that in the face of such interwoven challenges, an understanding spanning from the pathophysiology to the pathological environment—and an ability to bridge these understandings in the clinical context—is essential in supporting patients with this complex condition.

A Sugar-Sweetened Beverage Excise Tax in California: Projected Benefits for Population Obesity and Health Equity

Amid the successes of local sugar-sweetened beverage (SSB) taxes, interest in state-wide policies has grown. This study evaluated the cost effectiveness of a hypothetical 2-cent-per-ounce excise tax in California and its implications for population health and health equity. Using the Childhood Obesity Intervention Cost-Effectiveness Study microsimulation model, tax impacts on health, health equity, and cost effectiveness over 10 years in California were projected, both overall and stratified by race/ethnicity and income. Expanding on previous models, differences in the effect of intake of SSBs on weight by BMI category were incorporated. Costing was performed in 2020, and analyses were conducted in 2021-2022. The tax is projected to save $4.55 billion in healthcare costs, prevent 266,000 obesity cases in 2032, and gain 114,000 quality-adjusted life years. Cost-effectiveness metrics, including cost/quality-adjusted life year gained, were cost saving. Spending on SSBs was projected to decrease by $33 per adult and $26 per child overall in the first year. Reductions in obesity prevalence for Black and Hispanic Californians were 1.8 times larger than for White Californians, and reductions for adults with lowest incomes (<130% Federal Poverty Level) were 1.4 times the reduction among those with highest incomes (>350% Federal Poverty Level). The tax is projected to save $112 in obesity-related healthcare costs per $1 invested. A state-wide SSB tax in California would be cost saving, lead to reductions in obesity and improvement in SSB-related health equity, and lead to overall improvements in population health. The policy would generate more than $1.6 billion in state tax revenue annually that can also be used to improve health equity.

Sustainable procurement of medical devices in an international context

Background and Objectives Sustainability is a working principle included in the United Nations (UN) procurement processes with the adoption of the Sustainable Development Goals (SDGs) in 2015. In the context of internationally funded projects in developing countries for procuring health-related goods during and following the COVID-19 pandemic, this article further investigates what sustainable procurement means when applied to purchasing medical devices (MDs), considering its impact on health services. It also proposes a reflection on the concepts of sustainability and quality assurance as guiding principles for technical teams during the process of MD procurement. Material and Methods This article aims to identify how sustainability can be implemented during the execution of a project based on the analysis of principles that guide procurement actions in the four UN agencies with the highest volume of MD procurement. The concept of sustainability is also explored from a macrosystemic point of view as the ratio between the impact of a procurement project on healthcare services and its investment. Its implications for population health and wealth is also discussed. Based on the experience of the authors in implementing purchasing processes of MDs, a framework for the specific technical activity is then proposed. Results In the UN system, sustainable procurement focuses on the social, economic, and environmental quality of the equipment and on the conditions of its production to guarantee that a sustainable good is procured. Not being enough, the focus should also be on the benefit of a procurement project, not as the possession of a new MD, but as the utility of the device: an instrument to provide healthcare services of the beneficiary country. Procuring sustainable goods should include planning their future use as an essential component for a sustainable positive impact on the health and wealth of the beneficiary population. Thus, the intended use of the procured devices should be defined, planned, and measured. In the proposed framework, sustainability is a ratio between an MD’s social, economic, and environmental costs and the benefits of its use. When neglecting the essential factor of sustainable use of MDs, the risk of purchasing equipment that will not be properly and efficiently used is relevant. To guarantee the sustainable use of a MD, it is essential to assess the needs, the local conditions, and the conditions for its lifelong use. Further evolution of the concept of sustainability is developed towards the possibility of modulating the project’s objective from procuring sustainable MDs to improving the sustainability of the health services by procuring MDs. Conclusion Sustainable procurement of MDs is a key factor in supporting the sustainable development of health services and health systems toward the SDGs. Post-pandemic investments to strengthen the resilience of health services in developing countries shall consider sustainable procurement, including the essential quality assurance process. This process, led by an expert clinical engineer, shall be centered on the future use of the equipment and not be limited to its quality as a material good.

Effects of the COVID-19 Pandemic on Primary Health Care for Chronic Conditions in Canada: Protocol for a Retrospective Pre-Post Study Using National Practice-Based Research Network Data.

Since the COVID-19 pandemic began, there have been concerns that interruptions to the health care system may have led to changes in primary care, especially for care of chronic conditions such as diabetes and heart failure. Such changes may have longer term implications for population health. This study aims to describe the impacts of the COVID-19 pandemic on indicators of primary care access, comprehensiveness, and appropriateness among adult patients, as well as on specific indictors of chronic conditions. Additionally, this study aims to determine whether any identified changes were associated with patient sociodemographic characteristics and multimorbidity. This is a retrospective, single-arm, pre-post study using Canadian Primary Care Sentinel Surveillance Network (CPCSSN) data. CPCSSN is a research network supported by a primary care electronic medical record database, comprising over 1500 physicians and nearly 2 million patients. We are examining changes in care (eg, frequency of contacts, laboratory tests and investigations, referrals, medications prescribed, etc) among adults. We will also examine indicators specific to evidence-based recommendations for care in patients with diabetes and those with heart failure. We will compare rates of outcomes during key periods of the pandemic between March 13, 2020, and December 31, 2022, with equal time periods before the pandemic. Differences will be examined among specific subgroups of adults, including by decade of age, number of comorbidities, and socioeconomic status. Regression models appropriate to outcome distributions will be used to estimate changes, adjusting for potential confounders. This analysis is part of a mixed-methods study with a qualitative component investigating how patients with diabetes with or without concurrent heart failure perceived the impact of the pandemic on access to primary care and health care-related decisions. This study was approved by the Hamilton Integrated Research Ethics Board (14782-C). The start date of this study was October 5, 2022, and the prospective end date is January 31, 2024. As of May 2023, the study cohort (n=875,934) is defined, data cleaning is complete, and exploratory analyses have begun. Extended analyses using 2022 data are planned once the new data becomes available. We will disseminate results through peer-reviewed publications and academic conference, as well as creating evidence briefs, infographics, and a video for policy maker and patient audiences. This study will investigate whether the COVID-19 pandemic has resulted in changes in the provision of primary care in Canada and whether these potential changes have led to gaps in care. This study will also identify patient-level characteristics associated with changes in care patterns across the COVID-19 pandemic. Indicators specific to chronic conditions, namely diabetes and heart failure, will also be explored to determine whether there were changes in care of these conditions. ClinicalTrials.gov NCT05813652; https://clinicaltrials.gov/ct2/show/NCT05813652. RR1-10.2196/49131.