Faculty Bibliography

BACKGROUND:Achieving universal health coverage and reducing health inequalities are primary goals for an increasing number of health systems worldwide. Timely and accurate measurements of levels and trends in key health indicators at local levels are crucial to assess progress and identify drivers of success and areas that may be lagging behind. METHODS:We generated estimates of 17 key maternal and child health indicators for Zambia's 72 districts from 1990 to 2010 using surveys, censuses, and administrative data. We used a three-step statistical model involving spatial-temporal smoothing and Gaussian process regression. We generated estimates at the national level for each indicator by calculating the population-weighted mean of the district values and calculated composite coverage as the average of 10 priority interventions. RESULTS:National estimates masked substantial variation across districts in the levels and trends of all indicators. Overall, composite coverage increased from 46% in 1990 to 73% in 2010, and most of this gain was attributable to the scale-up of malaria control interventions, pentavalent immunization, and exclusive breastfeeding. The scale-up of these interventions was relatively equitable across districts. In contrast, progress in routine services, including polio immunization, antenatal care, and skilled birth attendance, stagnated or declined and exhibited large disparities across districts. The absolute difference in composite coverage between the highest-performing and lowest-performing districts declined from 37 to 26 percentage points between 1990 and 2010, although considerable variation in composite coverage across districts persisted. CONCLUSIONS:Zambia has made marked progress in delivering maternal and child health interventions between 1990 and 2010; nevertheless, substantial variations across districts and interventions remained. Subnational benchmarking is important to identify these disparities, allowing policymakers to prioritize areas of greatest need. Analyses such as this one should be conducted regularly and feed directly into policy decisions in order to increase accountability at the local, regional, and national levels.

We considered how participatory syndromic surveillance data can be used to estimate influenza attack rates during the 2012-2013 and 2013-2014 seasons in the United States. Our inference is based on assessing the difference in the rates of self-reported influenza-like illness (ILI, defined as presence of fever and cough/sore throat) among the survey participants during periods of active vs. low influenza circulation as well as estimating the probability of self-reported ILI for influenza cases. Here, we combined Flu Near You data with additional sources (Hong Kong household studies of symptoms of influenza cases and the U.S. Centers for Disease Control and Prevention estimates of vaccine coverage and effectiveness) to estimate influenza attack rates. The estimated influenza attack rate for the early vaccinated Flu Near You members (vaccination reported by week 45) aged 20-64 between calendar weeks 47-12 was 14.7%(95% CI(5.9%,24.1%)) for the 2012-2013 season and 3.6%(-3.3%,10.3%) for the 2013-2014 season. The corresponding rates for the US population aged 20-64 were 30.5% (4.4%, 49.3%) in 2012-2013 and 7.1%(-5.1%, 32.5%) in 2013-2014. The attack rates in women and men were similar each season. Our findings demonstrate that participatory syndromic surveillance data can be used to gauge influenza attack rates during future influenza seasons.

BACKGROUND:Little is known about the experience of chronic pain and the occurrence of illicit drug use behaviors in the population enrolled in methadone maintenance treatment (MMT) programs. METHODS:This is a secondary analysis of longitudinal data from two MMT samples enrolled in a randomized controlled trial of hepatitis care coordination. Patients completed pain, illicit drug use, and other questionnaires at baseline and 3, 9, and 12 months later. Associations were sought over time between the presence or absence of clinically significant pain (average daily pain ≥ 4 or mean pain interference ≥ 4 during the past week) and current illicit drug use (i.e., non-therapeutic opioid, cocaine or amphetamine use identified from self-report or urine drug screening). RESULTS:Of 404 patients providing complete data, within-patient variability in pain and illicit drug use was high across the four assessment periods. While 263 denied pain at baseline, 118 (44.9%) later experienced clinically significant pain during ≥ 1 follow-up assessments. Of 180 patients (44.6%) without evidence of illicit drug use at baseline, only 109 (27.0%) had similar negative drug use at all follow-up assessments. Across four assessment periods, there was no significant association between pain group status and current illicit drug use. CONCLUSIONS:This one-year longitudinal analysis did not identify a significant association between pain and illicit drug use in MMT populations. This finding conflicts with some earlier investigations and underscores the need for additional studies to clarify the complex association between pain and substance use disorders in patients in MMT program settings.

OBJECTIVE: The authors evaluated Project TEACH (PT), a statewide training and consultation program for pediatric primary care providers (PCPs) on identification and treatment of mental health conditions. METHODS: An intervention group of 176 PCPs who volunteered for PT training was compared with a stratified random sample of 200 PCPs who did not receive PT training. Data on prescription practices, diagnoses, and follow-up care were from New York State Medicaid files (2009-2013) for youths seen by the trained (N=21,784) and untrained (N=46,607) PCPs. RESULTS: The percentage of children prescribed psychotropic medication increased after PT training (9% to 12%, p<.001), a larger increase than in the untrained group (4% to 5%, p<.001) (comparison, p<.001). Fewer differences were noted in diagnoses and in medication use and follow-up care among children with depression. CONCLUSIONS: This intervention may have an impact on providers' behaviors, but further research is needed to clarify its effectiveness.

BACKGROUND: Synthetic cannabinoids are marketed as "legal highs" and have similar effects to cannabis (marijuana). Although prevalence of synthetic cannabinoid use is now declining in the US, use has been associated with tens of thousands of poisonings and hospitalizations, particularly among teens. It is important to examine which teens are at highest risk for use of these new, potentially deleterious drugs as they are understudied and continue to emerge. METHODS: Data were analyzed from a nationally representative sample of high school seniors in the Monitoring the Future study (2011-2013; Weighted N=11,863; modal age: 18). Bivariable and multivariable models were used to delineate correlates of recent (12-month) synthetic cannabinoid use. RESULTS: Ten percent reported any recent use and 3% reported more frequent use (used >/=6 times). Females were at low odds for use and going out 4-7 evenings per week for fun consistently increased odds of use. Black and religious students were at low odds of use until controlling for other drug use, and higher income increased odds of use until controlling for other drug use. Lifetime use of alcohol, cigarettes and other illicit drugs all robustly increased odds of use, but frequency of lifetime marijuana use was the strongest correlate with more frequent use further increasing odds of synthetic cannabinoid use. Only 0.5% of non-marijuana users reported use of synthetic cannabinoids. CONCLUSIONS: This is among the first national studies to delineate correlates of synthetic cannabinoid use. Results can inform national and local efforts to prevent use and adverse consequences resulting from use.

BACKGROUND: In light of the current sentencing disparity (18:1) between crack and powder cocaine possession in the United States, we examined socioeconomic correlates of use of each, and relations between use and arrest, to determine who may be at highest risk for arrest and imprisonment. METHODS: We conducted secondary data analyses on the National Survey on Drug Use and Health, 2009-2012. Data were analyzed for adults age >/=18 to determine associations between use and arrest. Socioeconomic correlates of lifetime and annual use of powder cocaine and of crack were delineated using multivariable logistic regression and correlates of frequency of recent use were examined using generalized negative binomial regression. RESULTS: Crack users were at higher risk than powder cocaine users for reporting a lifetime arrest or multiple recent arrests. Racial minorities were at low risk for powder cocaine use and Hispanics were at low risk for crack use. Blacks were at increased risk for lifetime and recent crack use, but not when controlling for other socioeconomic variables. However, blacks who did use either powder cocaine or crack tended to use at higher frequencies. Higher education and higher family income were negatively associated with crack use although these factors were sometimes risk factors for powder cocaine use. CONCLUSIONS: Crack users are at higher risk of arrest and tend to be of lower socioeconomic status compared to powder cocaine users. These findings can inform US Congress as they review bills (e.g., The Smarter Sentencing Act), which would help eliminate cocaine-related sentencing disparities.

Urban food swamps are typically situated in low-income, minority communities and contribute to overweight and obesity. Changing the food landscape in low income and underserved communities is one strategy to combat the negative health consequences associated with the lack of access to healthy food resources and an abundance of unhealthy food venues. In this paper, we describe Proyecto MercadoFRESCO (Fresh Market Project), a corner store intervention project in East Los Angeles and Boyle Heights in California that used a multi-level approach with a broad range of community, business, and academic partners. These are two neighboring, predominantly Latino communities that have high rates of overweight and obesity. Located in these two communities are approximately 150 corner stores. The project used a community-engaged approach to select, recruit, and convert four corner stores, so that they could become healthy community assets in order to improve residents' access to and awareness of fresh and affordable fruits and vegetables in their immediate neighborhoods. We describe the study framework for the multi-level intervention, which includes having multiple stakeholders, expertise in corner store operations, community and youth engagement strategies, and social marketing campaigns. We also describe the evaluation and survey methodology to determine community and patron impact of the intervention. This paper provides a framework useful to a variety of public health stakeholders for implementing a community-engaged corner store conversion, particularly in an urban food swamp.