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Introduction: Cardiovascular health (CVH), measured using the AHA’s Life’s Simple 7, is linked to mortality. Associations of AHA’s Life’s Essential 8 (LE8), an enhanced approach to defining CVH, with mortality risk have not yet been evaluated in a nationally representative sample of US adults. Hypothesis: Lower CVH will be associated with higher risk for all-cause, CVD, and cancer mortality. Methods: We included 21,164 adults (mean age: 48y, 51% female, 11% Black, 15% Hispanic, 65% White) from the 2011-2018 NHANES whose mortality through 2019 was determined via linkage to the National Death Index. The CVH score (range: 0-100, high: 80-100, moderate: 50-79, low: 0-49) and component scores were computed consistent with the LE8 framework. The Kaplan-Maier method and multivariable Cox proportional hazards models were used to evaluate the CVH score and its component scores in relation to all-cause mortality (primary outcome) as well as CVD and cancer mortality (secondary outcomes), accounting for the complex stratified survey design of NHANES. Results: During a median follow-up of 5y, there were 1,397 deaths, including 414 and 329 deaths from CVD and cancer, respectively. Low vs. high CVH was related to 3-fold higher risk for all-cause mortality and >3-fold higher risk of CVD and cancer mortality, and a linear trend across CVH categories was detected (Figure). Lower scores for the diet, physical activity, nicotine exposure, sleep health, BMI, blood glucose, and blood pressure components predicted 25% to 2-fold higher mortality risk, and a gradient in risk was observed. Associations did not vary by sex, but there were differences by race and ethnicity (p-interaction Conclusions: CVH measured using the enhanced LE8 is a strong predictor of all-cause, CVD, and cancer mortality in US adults, with evidence of a dose-response relationship. Improving CVH could result in substantial population-level reductions in mortality.

Introduction: The US has the largest immigrant population globally, with a record high ~47 million foreign-born residents in 2022. Immigrants endure social and structural factors that may adversely influence their cardiovascular health (CVH). Hypothesis: Overall and individual metrics of CVH will vary by immigration status (US-born vs. foreign-born) and among foreign-born sub-populations. Methods: The analytic sample included 13,471 adults (19% foreign-born), ages 20-79 y (not pregnant or institutionalized) and free of CVD, from the 2013-2018 NHANES. We calculated the CVH score (range 0-100, low CVH: Results: Compared to US-born adults, foreign-born adults had higher overall CVH, diet, nicotine exposure, BMI, and blood pressure scores, but lower physical activity, glucose, and cholesterol scores (p Conclusions: While US immigrants have higher overall CVH compared to US-born persons, CVH status is complex and varies across immigrant sub-populations. Understanding immigration as a SDOH is essential for effective public health initiatives aimed at improving CVH in the heterogeneous US immigrant population.

Indoor dining is one of the potential drivers of COVID-19 transmission. We used the heterogeneity among state government preemption of city indoor dining closures to estimate the impact of keeping indoor dining closed on COVID-19 incidence.We obtained case rates and city or state reopening dates from March to October 2020 in 11 US cities. We categorized cities as treatment cities that were allowed by the state to reopen but kept indoor dining closed or comparison cities that would have kept indoor dining closed but that were preempted by their state and had to reopen indoor dining. We modeled associations using a difference-in-difference approach and an event study specification. We ran negative binomial regression models, with city-day as the unit of analysis, city population as an offset, and controlling for time-varying nonpharmaceutical interventions, as well as city and time fixed effects in sensitivity analysis and the event study specification.Keeping indoor dining closed was associated with a 55% (IRR = 0.45; 95% confidence intervals = 0.21, 0.99) decline in the new COVID-19 case rate over 6 weeks compared with cities that reopened indoor dining, and these results were consistent after testing alternative modeling strategies.Keeping indoor dining closed may be directly or indirectly associated with reductions in COVID-19 spread. Evidence of the relationship between indoor dining and COVID-19 case rates can inform policies to restrict indoor dining as a tailored strategy to reduce COVID-19 incidence. See video abstract at, http://links.lww.com/EDE/B902.

We measured asset-based and education-based inequity in utilization of 2 cancer screening tests, Pap tests and mammograms, using nationally representative surveys conducted in 2003, 2008, and 2013. Utilization of Pap tests (ages 25-59 years) and mammograms (ages 50-69 years) increased over time. Asset-based and education-based inequities declined significantly for both screening tests, particularly among women who reported a doctor visit in the previous year. This decline coincided with increases in the coverage of primary health care in Brazil. However, barriers persisted; in 2013, college-educated women were still 2.27 times more likely to have a mammogram than those who were illiterate.

Description, The scaling of mortality in cities of the Americas varies widely by cause and region., We explored how mortality scales with city population size using vital registration and population data from 742 cities in 10 Latin American countries and the United States. We found that more populated cities had lower mortality (sublinear scaling), driven by a sublinear pattern in U.S. cities, while Latin American cities had similar mortality across city sizes. Sexually transmitted infections and homicides showed higher rates in larger cities (superlinear scaling). Tuberculosis mortality behaved sublinearly in U.S. and Mexican cities and superlinearly in other Latin American cities. Other communicable, maternal, neonatal, and nutritional deaths, and deaths due to noncommunicable diseases were generally sublinear in the United States and linear or superlinear in Latin America. Our findings reveal distinct patterns across the Americas, suggesting no universal relation between city size and mortality, pointing to the importance of understanding the processes that explain heterogeneity in scaling behavior or mortality to further advance urban health policies.

The concept of the ‘social cross-over’ in cardiovascular disease (CVD) mortality was first described in 1978 by Marmot et al .1 By analysing mortality trends between 1931 and 1971 in England and Wales, Marmot et al found that the pattern of mortality from coronary heart disease changed over the years, from being more common among middle-class and upper-class men and women to being more common among working-class men and women.1 Underlying this change was a steep increase in CVD mortality among the working-class group starting in the 1950s for men and in the 1960s for women, concurrent with increases in smoking rates and dietary changes.1 In the study by Mallinson and colleagues, the authors describe the absence of a social cross-over in CVD mortality in Brazil.2 The study used cross-sectional data for 2010 from states at various degrees of economic development to proxy the changes in economic development experienced by high-income countries over time. Mallinson et al found no support for the social cross-over hypothesis. Instead, they found that education-based inequalities in CVD mortality were actually widest in the least developed states, meaning that CVD mortality was highest among the population with the lowest levels of educational attainment.2 Previous studies on the social cross-over have relied on longitudinal samples to examine how inequalities in CVD change over time. Mallinson et al instead leverage intracountry heterogeneity in social development. The use of cross-sectional data from one country has two important advantages: (1) uniformity of the vital statistics system across the country, which reduces inconsistencies in the quality of the data often present in cross-country comparisons, and (2) consistency of coding, one of the biggest issues in studies using historical data.2 The authors also addressed issues of variation in the quality of data across states and …

ObjectiveIndoor dining is one of the potential key drivers of COVID-19 transmission. We leverage the heterogeneity in state government preemption of city indoor dining closures, to estimate the impact of keeping indoor dining closed on COVID-19 incidence.MethodsWe obtained case rates and city/state re-opening dates from March to October 2020 in 11 U.S. cities. We categorized cities as (treatment) cities that were allowed by the state to reopen but kept indoor dining closed; and (comparison) cities that would have kept indoor dining closed but were preempted by their state and had to reopen indoor dining.ResultsKeeping indoor dining closed was associated with a 43% (IRR=0.57, 95% CI 0.46 to 0.69) decline in COVID-19 incidence over 4-weeks compared with cities that reopened indoor dining. These results were consistent after testing alternative modeling strategies.ConclusionsKeeping indoor dining closed contributes to reductions in COVID-19 spread.Policy ImplicationsEvidence of the relationship between indoor dining and COVID-19 incidence can inform state and local decisions to restrict indoor dining as a tailored strategy to reduce COVID-19 incidence.

Background This study examined the variation in city-level amenable mortality, i.e. mortality due to conditions that can be mitigated in the presence of timely and effective healthcare, in 363 Latin American cities and measured associations between amenable-mortality rates and urban metrics. Methods We used death records from 363 cities with populations of >100 000 people in nine Latin American countries from 2010 to 2016. We calculated sex-specific age-adjusted amenable-mortality rates per 100 000. We fitted multilevel linear models with cities nested within countries and estimated associations between amenable mortality and urban metrics, including population size and growth, fragmentation of urban development and socio-economic status. Results Cities in Mexico, Colombia and Brazil had the highest rates of amenable mortality. Overall, >70% of the variability in amenable mortality was due to between-country heterogeneity. But for preventable amenable mortality, those for which the healthcare system can prevent new cases, most of the variability in rates occurred between cities within countries. Population size and fragmentation of urban development were associated with amenable mortality. Higher fragmentation of urban development was associated with lower amenable mortality in small cities and higher amenable mortality in large cities. Population growth and higher city-level socio-economic status were associated with lower amenable mortality. Conclusions Most of the variability in amenable mortality in Latin American cities was due to between-county heterogeneity. However, urban metrics such as population size and growth, fragmentation of urban development and city-level socio-economic status may have a role in the distribution of amenable mortality across cities within countries.

Opioid misuse is a public health crisis in the United States. The origin of this crisis is associated with a sharp increase in opioid analgesic prescribing. We used the urban scaling framework to analyze opioid prescribing patterns in US commuting zones (CZs), i.e., groups of counties based on commuting patterns. The urban scaling framework postulates that a set of scaling relations can be used to predict health outcomes and behaviors in cities. We used data from the Drug Enforcement Administration’s Automated Reports and Consolidated Ordering System (ARCOS) to calculate counts of oxycodone/hydrocodone pills distributed to 607 CZs in the continental US from 2006 to 2014. We estimated the scaling coefficient of opioid pill counts by regressing log(pills) on log(population) using a piecewise linear spline with a single knot at 82,363. Our results show that CZs with populations below the knot scaled superlinearly (β = 1.36), i.e., larger CZs had disproportionally larger pill counts compared to smaller CZs. On the other hand, CZs with populations above the knot scaled sublinearly (β = 0.92), i.e., larger CZs had disproportionally smaller pill counts compared to smaller CZs. This dual scaling pattern was consistent across US census regions. For CZs with population below the knot, the superlinear scaling of pills is consistent with the explanation that an increased number of successful matches between prescribers and users will lead to higher prescribing rates. The non-linear scaling behavior observed could be the result of a combination of factors, including stronger health care systems and prescribing regulation in largely populated commuting zones, as well as high availability of other opioids such as heroin in these commuting zones. Future research should explore potential mechanisms for the non-linearity of prescription opioid pills.

The 2003 revision of the US Standard Certificate of Live Birth (birth certificate) and Pregnancy Risk Assessment Monitoring System (PRAMS) are important for maternal weight research and surveillance. We examined quality of prepregnancy body mass index (BMI), gestational weight gain, and component variables from these sources.Data are from a PRAMS data quality improvement study among a subset of New York City and Vermont respondents in 2009. We calculated mean differences comparing prepregnancy BMI data from the birth certificate and PRAMS (n = 734), and gestational weight gain data from the birth certificate (n = 678) to the medical record, considered the gold standard. We compared BMI categories (underweight, normal weight, overweight, obese) and gestational weight gain categories (below, within, above recommendations), classified by different sources, using percent agreement and the simple κ statistic.For most maternal weight variables, mean differences between the birth certificate and PRAMS compared with the medical record were less than 1 kg. Compared with the medical record, the birth certificate classified similar proportions into prepregnancy BMI categories (agreement = 89%, κ = 0.83); PRAMS slightly underestimated overweight and obesity (agreement = 84%, κ = 0.73). Compared with the medical record, the birth certificate overestimated gestational weight gain below recommendations and underestimated weight gain within recommendations (agreement = 81%, κ = 0.69). Agreement varied by maternal and pregnancy-related characteristics.Classification of prepregnancy BMI and gestational weight gain from the birth certificate or PRAMS was mostly similar to the medical record but varied by maternal and pregnancy-related characteristics. Efforts to understand how misclassification influences epidemiologic associations are needed.

En la region de America Latina y Caribe (ALC), la mayoria de los paises buscan reformar sus sistemas de salud para lograr la cobertura universal y mejorar la eficiencia de sus gastos sanitarios, al tiempo que cumplen con las expectativas cada vez mayores de los ciudadanos acerca de la calidad de la atencion. El papel de la atencion primaria de salud (APS) destaca como clave para lograr esos objetivos de forma integrada. Por ello, el Banco Interamericano de Desarrollo llevo a cabo, entre 2012 y 2014, la Encuesta sobre Acceso, Experiencia y Coordinacion de la Atencion Primaria de Salud en America Latina y el Caribe, en poblaciones adultas de Colombia, Mexico, Brasil, El Salvador, Panama y Jamaica, buscando contribuir al diseno de politicas publicas de salud, y considerando especialmente el punto de vista de los pacientes. Los dos primeros capitulos del presente libro presentan el contexto y desafios de los sistemas de salud de la region y describen el marco conceptual y la metodologia del estudio. Los capitulos tres al ocho tratan, por separado, de cada uno de los seis paises estudiados, con resultados sobre las experiencias de los pacientes con la atencion primaria de salud y su integracion con los demas niveles de atencion. El capitulo nueve cierra el libro con un analisis comparativo entre los seis paises de ALC y extiende la comparacion a 11 paises de altos ingresos de la OCDE, donde se evidencian las brechas persistentes en los indicadores de acceso, experiencia y coordinacion en la APS entre los paises de ALC y los de la OCDE. Un analisis multivariado con los 17 paises demuestra que los principales atributos observados de la APS estan directamente vinculados a las percepciones de los pacientes acerca de la necesidad de cambios fundamentales en los sistemas de salud y de la calidad de los servicios utilizados.

Sample characteristics using individual datasets (PNAD 2008 and PNS 2013) vs. combined dataset. (DOCX 139 kb)

Predicted probability of four outcomes showing the interaction between a poverty indicator and type of coverage. (DOCX 27 kb)

Background Innovative and sustainable strategies to strengthen districts and other sub-national health systems and management are urgently required to reduce child mortality. Although highly effective evidence-based and affordable child survival interventions are well-known, at the district level, lack of data, motivation, analytic and planning capacity often impedes prioritization and management weaknesses impede implementation. The Community and District Empowerment for Scale-up (CODES) project is a complex management intervention designed to test whether districts when empowered with data and management tools can prioritize and implement evidence-based child survival interventions equitably. Methods The CODES strategy combines management, diagnostic, and evaluation tools to identify and analyze the causes of bottlenecks to implementation, build capacity of district management teams to implement context-specific solutions, and to foster community monitoring and social accountability to increase demand for services. CODES combines UNICEF tools designed to systematize priority setting, allocation of resources and problem solving with Community dialogues based on Citizen Report Cards and U-Reports used to engage and empower communities in monitoring health service provision and to demand for quality services. Implementation and all data collection will be by the districts teams or local Community-based Organizations who will be supported by two local implementing partners. The study will be evaluated as a cluster randomized trial with eight intervention and eight comparison districts over a period of 3 years. Evaluation will focus on differences in uptake of child survival interventions and will follow an intention-to-treat analysis. We will also document and analyze experiences in implementation including changes in management practices. Discussion By increasing the District Health Management Teams’ capacity to prioritize and implement context-specific solutions, and empowering communities to become active partners in service delivery, coverage of child survival interventions will increase. Lessons learned on strengthening district-level managerial capacities and mechanisms for community monitoring may have implications, not only in Uganda but also in other similar settings, especially with regard to accelerating effective coverage of key child survival interventions using locally available resources. Trial registration number ISRCTN15705788, Date of registration; 24 July 2015.

The rapid demographic and epidemiological transitions occurring in Latin America and the Caribbean have led to high levels of noncommunicable diseases in the region. In addition to reduced risk factors for chronic conditions, a strong health system for managing chronic conditions is vital. This study assessed the extent to which populations in six Latin American and Caribbean countries receive high-quality primary care, and it examined the relationship between experiences with care and perceptions of health system performance. We applied a validated survey on access, use, and satisfaction with health care services to nationally representative samples of the populations of Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama. Respondents reported considerable gaps in the ways in which primary care is organized, financed, and delivered. Nearly half reported using the emergency department for a condition they considered treatable in a primary care setting. Reports of more primary care problems were associated with worse perceptions of health system performance and quality and less receipt of preventive care. Urgent attention to primary care performance is required as the region's population continues to age at an unprecedented rate.

Predicted probability of three outcomes showing the interaction between health need and type of coverage. (DOCX 24 kb)

© 2015 Macinko et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. This study uses data from a nationally representative household survey (the 2013 National Health Survey, n = 62,986) to describe patterns of alcohol consumption and related behaviors among Brazilian adults. Analyses include descriptive and multivariable Poisson regression for self-reports in the past 30 days of: drinking any alcohol, binge drinking, binge drinking 4 or more times, and driving after drinking (DD); as well as age of alcohol consumption initiation. Results show that current drinking prevalence was 26%, with an average age of initiation of 18.7 years. Binge drinking was reported by 51% of drinkers, 43% of whom reported binge drinking 4 or more times. Drinking and driving was reported by nearly one quarter of those who drive a car/motorcycle. Current drinking was more likely among males, ages 25-34, single, urban, and those with more education. Binge drinking was more likely among males, older age groups, and people who started drinking before 18. Drinking and driving was higher among males, those with more education, and rural residents. Those who binge-drink were nearly 70% more likely to report DD. All behaviors varied significantly among Brazilian states. Given their potential health consequences, the levels of injurious alcohol behaviors observed here warrant increased attention from Brazilian policymakers and civil society.

OBJETIVOS: avaliar a qualidade da informação sobre óbitos de menores de um ano notificados ao Sistema de Informação da Atenção Básica (SIAB). MÉTODOS: estudo avaliativo da qualidade dos dados do SIAB realizado no município do Recife. Procedeu-se a análise do comportamento dos dados do SIAB, comparativamente aos do sistema de informação sobre mortalidade no período de 2000 a 2006, utilizando as bases municipal e federal disponível no site do DATASUS. Para 2006, os óbitos de menores de um ano notificados ao SIAB municipal foram individualizados e a partir de entrevistas semiestruturadas com os agentes comunitários de saúde (ACS) as notificações foram confirmadas ou descartadas, identificando erros, e fragilidades no processo de produção dos dados do SIAB. RESULTADOS: existem diferenças entre as bases de dados federal e municipal do SIAB. Apenas 34,0% dos óbitos notificados pelos ACS, foram confirmados. Entre os erros que levaram a notificação excessiva de óbitos no SIAB destacam-se os relacionados à definição do evento (4,6%), os de preenchimento (33,8%), consolidação (7,3%) e digitação (21,4%) dos dados. CONCLUSÕES: apesar da disponibilidade de indicadores e reconhecimento quanto às potencialidades do SIAB para o monitoramento e avaliação da atenção primária, este permanece com fragilidades no processo de produção da informação, necessitando de investimentos para garantir maior confiabilidade dos dados.

Introduction Perceived discrimination is related to poor health and has been offered as one explanation for the persistence of health inequalities in some societies. In this study, we explore the prevalence and correlates of perceived discrimination in a large, multiracial Brazilian metropolitan area. Methods The study uses secondary analysis of a regionally representative household survey conducted in 2010 (n=12,213). Bivariate analyses and multiple logistic regression assess the magnitude and statistical significance of covariates associated with reports of any discrimination and with discrimination in specific settings, including when seeking healthcare services, in the work environment, in the family, in social occasions among friends or in public places, or in other situations. Results Nearly 9% of the sample reported some type of discrimination. In multivariable models, reports of any discrimination were higher among people who identify as black versus white (OR 1.91), higher (OR 1.21) among women than men, higher (OR 1.33) among people in their 30’s and lower (OR 0.63) among older individuals. People with many health problems (OR 4.97) were more likely to report discrimination than those with few health problems. Subjective social status (OR 1.23) and low social trust (OR 1.27) were additional associated factors. Perceived discrimination experienced while seeking healthcare differed from all other types of discrimination, in that it was not associated with skin color, social status or trust, but was associated with sex, poverty, and poor health. Conclusions There appear to be multiple factors associated with perceived discrimination in this population that may affect health. Policies and programs aimed at reducing discrimination in Brazil will likely need to address this wider set of interrelated risk factors across different populations.