Purpose: The purpose of this report from the field is to describe the process by which an multidisciplinary workgroup, selected by the CDC Foundation in partnership with maternal health experts, developed a definition of racism that would be specifically appropriate for inclusion on the Maternal Mortality Review Information Application (MMRIA) form. Description: In the United States Black women are nearly 4 times more likely to experience a pregnancy-related death. Recent evidence points to racism as a fundamental cause of this inequity. Furthermore, the CDC reports that 3 of 5 pregnancy related deaths are preventable. With these startling facts in mind, the CDC created the Maternal Mortality Review Information Application (MMRIA) for use by Maternal Mortality Review Committees (MMRC) to support standardized data abstraction, case narrative development, documentation of committee decisions, and analysis on maternal mortality to inform practices and policies for preventing maternal mortality. Assessment: Charged with the task of defining racism and discrimination as contributors to pregnancy related mortality, the work group established four goals to define their efforts: (1) the desire to create a product that was inclusive of all forms of racism and discrimination experienced by birthing people; (2) an acknowledgement of the legacy of racism in the U.S. and the norms in health care delivery that perpetuate racist ideology; (3) an acknowledgement of the racist narratives surrounding the issue of maternal mortality and morbidity that often leads to victim blaming; and (4) that the product would be user friendly for MMRCs. Conclusion: The working group developed three definitions and a list of recommendations for action to help MMRC members provide suggested interventions to adopt when discrimination or racism were contributing factors to a maternal death. The specification of these definitions will allow the systematic tracking of the contribution of racism to maternal mortality through the MMRIA and allow a greater standardization of its identification across participating jurisdictions with MMRCs that use the form.

Racist policies and practices that restrict Black, as compared to white workers, from employment may drive racial inequities in birth outcomes among workers. This study examined the association between structural racism in labor markets, measured at a commuting zone where workers live and commute to work, and low-birthweight birth. We found the deleterious effect of structural racism in labor markets among US-born Southern Black pregnant people of working age, but not among African- or Caribbean-born counterparts in any US region. Our analysis highlights the intersections of structural racism, culture, migration, and history of racial oppression that vary across regions and birth outcomes of Black workers.

COVID-19 mortality increases dramatically with age and is also substantially higher among Black, Indigenous, and People of Color (BIPOC) populations in the United States. These two facts introduce tradeoffs because BIPOC populations are younger than white populations. In analyses of California and Minnesota--demographically divergent states--we show that COVID vaccination schedules based solely on age benefit the older white populations at the expense of younger BIPOC populations with higher risk of death from COVID-19. We find that strategies that prioritize high-risk geographic areas for vaccination at all ages better target mortality risk than age-based strategies alone, although they do not always perform as well as direct prioritization of high-risk racial/ethnic groups. One-sentence summary Age-based COVID-19 vaccination prioritizes white people above higher-risk others; geographic prioritization improves equity.

Substantial racial and ethnic disparities in COVID-19 mortality have been observed at the state and national levels. However, less is known about how race and ethnicity and neighborhood-level disad...

Before, during, and after their immigration to the United States, immigrants face stressful life circumstances that may render them at risk for depressive symptoms. However, there is a dearth of re...

Veterans often experience challenges related to processing traumatic experiences and community reintegration, yet there is a dearth of research on promising community-driven approaches. This paper describes core processes and outcomes of Vets & Friends (V&F), a community-based support program that promotes veteran reintegration by healing trauma and moral injury using a communalization of trauma (CoT) approach. We conducted focus groups with 23 V&F group members. A mix of inductive and deductive codes were generated during thematic analysis. Critical themes identified included processes such as sharing narratives, connecting emotionally with experiences, feeling heard and accepted by group members, and listening as others shared their experiences. Outcomes included restoration of trust, connection with group members, building skills to manage trauma, and community acceptance and engagement. V&F shows promise in meeting veteran-specific needs by employing CoT approaches that offer opportunities to restore community trust and acceptance.

The Collaborative Cohort of Cohorts for COVID-19 Research (C4R) is a national prospective study of adults at risk for coronavirus disease 2019 (COVID-19) comprising 14 established United States (US) prospective cohort studies. For decades, C4R cohorts have collected extensive data on clinical and subclinical diseases and their risk factors, including behavior, cognition, biomarkers, and social determinants of health. C4R will link this pre-COVID phenotyping to information on SARS-CoV-2 infection and acute and post-acute COVID-related illness. C4R is largely population-based, has an age range of 18-108 years, and broadly reflects the racial, ethnic, socioeconomic, and geographic diversity of the US. C4R is ascertaining severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and COVID-19 illness using standardized questionnaires, ascertainment of COVID-related hospitalizations and deaths, and a SARS-CoV-2 serosurvey via dried blood spots. Master protocols leverage existing robust retention rates for telephone and in-person examinations, and high-quality events surveillance. Extensive pre-pandemic data minimize referral, survival, and recall bias. Data are being harmonized with research-quality phenotyping unmatched by clinical and survey-based studies; these will be pooled and shared widely to expedite collaboration and scientific findings. This unique resource will allow evaluation of risk and resilience factors for COVID-19 severity and outcomes, including post-acute sequelae, and assessment of the social and behavioral impact of the pandemic on long-term trajectories of health and aging.

Background: Travel distance to care facilities may shape urban-rural cancer survival disparities by creating barriers to specific treatments. Guideline-supported treatment options for women with early stage breast cancer involves considerations of breast conservation and travel burden: Mastectomy requires travel for surgery, whereas breast-conserving surgery (BCS) with adjuvant radiation therapy (RT) requires travel for both surgery and RT. This provides a unique opportunity to evaluate the impact of travel distance on surgical decisions and receipt of guideline-concordant treatment. Materials and Methods: We included 61,169 women diagnosed with early stage breast cancer between 2004 and 2013 from the Surveillance Epidemiology and End Results (SEER)-Medicare database. Driving distances to the nearest radiation facility were calculated by using Google Maps. We used multivariable regression to model treatment choice as a function of distance to radiation and Cox regression to model survival. Results: Women living farthest from radiation facilities (>50 miles vs. <10 miles) were more likely to undergo mastectomy versus BCS (odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.22-1.79). Among only those who underwent BCS, women living farther from radiation facilities were less likely to receive guideline-concordant RT (OR: 1.72, 95% CI: 1.32-2.23). These guideline-discordant women had worse overall (hazards ratio [HR]: 1.50, 95% CI: 1.42-1.57) and breast-cancer specific survival (HR: 1.44, 95% CI: 1.29-1.60). Conclusions: We report two breast cancer treatments with different clinical and travel implications to show the association between travel distance, treatment decisions, and receipt of guideline-concordant treatment. Differential access to guideline-concordant treatment resulting from excess travel burden among rural patients may contribute to rural-urban survival disparities among cancer patients.

Data are needed on the use of oral anticoagulation in patients with atrial fibrillation (AF) in rural versus urban areas, including the initiation of direct oral anticoagulants (DOACs). We used Medicare data to examine rural/urban differences in anticoagulation use in patients with AF. We identified incident AF in a 20% sample of fee-for-service Medicare beneficiaries (aged ≥&nbsp;65&nbsp;years) from 2011 to 2016 and collected ZIP code and covariates at the time of AF. We identified the first anticoagulant prescription filled, if any, following AF diagnosis. We categorized beneficiaries into four rural/urban areas using rural–urban commuting area codes and used Poisson regression models to compare anticoagulant use. We included 447,252 patients with AF (mean age 79&nbsp;±&nbsp;8&nbsp;years), of which 82% were urban, 9% large rural, 5% small rural, and 4% isolated. The percentage who initiated an anticoagulant rose from 34% in 2011 to 53% in 2016, paralleling the uptake of DOACs. In a multivariable-adjusted analysis, those in rural areas (vs. urban) were more likely to initiate an anticoagulant. However, rural beneficiaries (vs. urban) were less likely to initiate a DOAC; those in isolated areas were 17% less likely (95% confidence interval [CI] 13–20), those in small rural areas were 12% less likely (95% CI 9–15), and those in large rural areas were 10% less likely (95% CI 8–12). Among Medicare beneficiaries with AF, anticoagulation use was low but increased over time with the introduction of DOACs. Rural beneficiaries were less likely to receive a DOAC.

BACKGROUND AND OBJECTIVES: The reported percent of nursing home residents suffering adverse outcomes decreased dramatically since Nursing Home Compare began reporting them, but the validity of scores is questionable for nursing homes that score well on measures using facility-reported data but poorly on inspections. Our objective is to assess whether nursing homes with these "discordant" scores are meaningfully better than nursing homes that score poorly across domains. RESEARCH DESIGN AND METHODS: We used a convergent mixed-methods design, starting with quantitative analyses of 2012-2016 national data. We conducted in-depth interviews and observations in 12 nursing homes in 2017-2018, focusing on how facilities achieved their Nursing Home Compare ratings. Additional quantitative analyses were conducted in parallel to study performance trajectories over time. Quantitative and qualitative results were interpreted together. RESULTS: Discordant facilities engage in more quality improvement strategies than poor performers, but do not seem to invest in quality improvement in resource-intensive, broad-based ways that would spill over into other domains of quality and change their trajectory of improvement. Instead, they focus on lower-resource improvements related to data quality, staff training, leadership, and communication. In contrast, poor-performing facilities seemed to lack the leadership and continuity of staff required for even these low-resource interventions. DISCUSSION AND IMPLICATIONS: High performance on the quality measures using facility-reported data is mostly meaningful rather than misleading to consumers who care about those outcomes, although discordant facilities still have quality deficits. The quality measures domain should continue to have a role in Nursing Home Compare.

Given the high prevalence of overweight/obesity and the low prevalence of engaging in physical activity in children, it is important to identify barriers that impede child physical activity. One potential barrier is parental stress. The current study examined the association between parental stress levels and girls' and boys' moderate to vigorous physical activity. Children aged 5-7 years and their families (n = 150) from 6 racial/ethnic groups (n = 25 each Black, Hispanic, Hmong, Native American, Somali, andWhite families) were recruited for the Family Matters mixed-methods study in 2015 through primary care clinics in Minneapolis and St Paul, MN. Two in-home visits were carried out with families 10 days apart for data collection, with an 8-day observational period in between when children wore accelerometers. Higher parental stress levels were associated with fewer minutes of moderate to vigorous physical activity in girls (P < .05) compared with boys. On average, girls with a parent reporting a stress rating of 10 engaged in 24 minutes less of physical activity per day than girls with a parent with a stress rating of 1. The results suggest that parental stress may reduce girls' engagement in physical activity. The implications of these results include targeting parental stress and coping skills in future physical activity interventions. In addition, when addressing child physical activity in health care visits with parents and daughters, providers may want to focus their anticipatory guidance on parental stress and coping skills in addition to providing resources to help parents manage stress.

PURPOSE: To determine whether periodontal disease is positively associated with incident diabetes across the continuum of body mass levels (BMI) and test the hypothesis that the periodontal risk for incident diabetes is modified by BMI. METHODS: We included 5569 diabetes-free participants from Visit 4 (1996-1998) of the Atherosclerosis Risk in Communities (ARIC) Study and followed them until 2018. Periodontal disease status was classified by periodontal profile class (PPC)-Stages and incident diabetes was based on participant report of physician diagnosis. We estimated the hazard ratios (HR) for diabetes using a competing risk model for each PPC-Stage. We assessed multiplicative interactions between periodontal disease and BMI (as a continuous variable) on risk of diabetes. RESULTS: During a median time of 19.4 years of follow-up, 1,348 incident diabetes cases and 1,529 deaths occurred. Compared to &quot;healthy/incidental disease&quot; Stage , participants with PPC-&quot;severe periodontal disease&quot; or &quot;severe tooth loss&quot; Stage and lower BMI had elevated risk for diabetes adjusting for demographic, smoking, education and biological variables when accounting for death as a competing risk with HRs 1.76 (95%CI 1.10-2.80) and 2.11 (95% CI 1.46-3.04), respectively. The interaction between PPC-stages and BMI was significant (p= 0.01). No significant associations of PPC-Stages with incident diabetes were present when BMI was above 31 kg/m 2. CONCLUSION: Periodontal disease was associated with incident diabetes, especially in non-obese participants. Dentists should be aware that periodontal disease is associated with incident diabetes but the association may be modified for patient&#039;s at higher BMI levels.

The Census Bureau plans a new approach to disclosure control for the 2020 census that will add noise to every statistic the agency produces for places below the state level. The Bureau argues the new approach is needed because the confidentiality of census responses is threatened by "database reconstruction," a technique for inferring individual-level responses from tabular data. The Census Bureau constructed hypothetical individual-level census responses from public 2010 tabular data and matched them to internal census records and to outside sources. The Census Bureau did not compare these results to a null model to demonstrate that their success in matching would not be expected by chance. This is analogous to conducting a clinical trial without a control group. We implement a simple simulation to assess how many matches would be expected by chance. We demonstrate that most matches reported by the Census Bureau experiment would be expected randomly. To extend the metaphor of the clinical trial, the treatment and the placebo produced similar outcomes. The database reconstruction experiment therefore fails to demonstrate a credible threat to confidentiality. 2

<h3>Importance</h3><p>Police contact may have negative psychological effects on pregnant people, and psychological stress has been linked to preterm birth (ie, birth at &lt;37 weeks’ gestation). Existing knowledge of racial disparities in policing patterns and their associations with health suggest redesigning public safety policies could contribute to racial health equity.</p><h3>Objective</h3><p>To examine the association between community-level police contact and the risk of preterm birth among White pregnant people, US-born Black pregnant people, and Black pregnant people who were born outside the US.</p><h3>Design, Setting, and Participants</h3><p>This cross-sectional study used medical record data of 745 White individuals, 121 US-born Black individuals, and 193 Black individuals born outside the US who were Minneapolis residents and gave birth to a live singleton at a large health system between January 1 and December 31, 2016. Data were analyzed from March 2019 to October 2020.</p><h3>Exposures</h3><p>Police contact was measured at the level of the census tract where the pregnant people lived. Police incidents per capita (ie, the number of police incidents divided by the census tract population estimate) were dichotomized into high if the value was in the fourth quartile and low for the remaining three quartiles.</p><h3>Main Outcomes and Measures</h3><p>Preterm birth status was based on the<i>International Statistical Classification of Diseases and Related Health Problems, 10th revision, Clinical Modification </i>(<i>ICD-10-CM</i>) code. Preterm infants were those with<i>ICD-10-CM</i>codes P07.2 and P07.3 documented in their charts.</p><h3>Results</h3><p>Of 1059 pregnant people (745 [70.3%] White, 121 [11.4%] US-born Black, 193 [18.2%] Black born outside the US) in the sample, 336 White individuals (45.1%) and 62 Black individuals who were born outside the US (32.1%) gave birth between the ages of 30 and 34 years, while US-born Black individuals gave birth at younger ages, with 49 (40.5%) aged 25 years or younger. The incidence of preterm birth was 6.7% for White individuals (50 pregnant people), 14.0% for US-born Black individuals (17 pregnant people), and 5.7% for Black individuals born outside the US (11 pregnant people). In areas with high police contact vs low police contact, the odds of preterm birth were 90% higher for White individuals (odds ratio [OR], 1.9; 95% CI, 1.9-2.0), 100% higher for US-born Black individuals (OR, 2.0; 95% CI, 1.8-2.2), and 10% higher for Black individuals born outside the US (OR, 1.1; 95% CI, 1.0-1.2). Secondary geospatial analysis further revealed that the proportion of Black residents in Minneapolis census tracts was correlated with the number of police incidents reported between 2012 and 2016 (<i>P</i> = .001).</p><h3>Conclusions and Relevance</h3><p>In this study, police contact was associated with preterm birth for both Black and White pregnant people. Predominantly Black neighborhoods had greater police contact than predominantly White neighborhoods, indicating that Black pregnant people were more likely to be exposed to police than White pregnant people. These findings suggest that racialized police patterns borne from a history of racism in the United States may contribute to racial disparity in preterm birth.</p>

Purpose: For reproductive-age women, medications for opioid use disorder (OUD) decrease risk of overdose death and improve outcomes but are underutilized. Our objective was to provide a qualitative description of reproductive-age women's experiences of seeking an appointment for medications for OUD. Methods: Trained female callers placed telephone calls to a representative sample of publicly listed opioid treatment clinics and buprenorphine providers in Florida, Kentucky, Massachusetts, Michigan, Missouri, North Carolina, Tennessee, Virginia, Washington, and West Virginia to obtain appointments to receive medication for OUD. Callers were randomly assigned to be pregnant or non-pregnant and have private or Medicaid-based insurance to assess differences in the experiences of access by these characteristics. The callers placed 28,651 uniquely randomized calls, 10,117 to buprenorphine-waivered prescribers and 754 to opioid treatment programs. Open-ended, qualitative data were obtained from the callers about the access experiences and were analyzed using a qualitative, iterative inductive-deductive approach. From all 28,651 total calls, there were 17,970 unique free-text comments to the question “Please give an objective play-by-play of the description of what happened in this conversation.” Findings: Analysis demonstrated a common path to obtaining an appointment. Callers frequently experienced long hold times, multiple transfers, and difficult interactions. Clinic receptionists were often mentioned as facilitating or obstructing access. Pregnant callers and those with Medicaid noted more barriers. Obtaining an appointment was commonly difficult even for these persistent, trained callers. Conclusions: Interventions are needed to improve the experiences of reproductive-age women as they enter care for OUD, especially for pregnant women and those with Medicaid coverage.

Students of color are disproportionately affected by exposure to adverse childhood experiences (ACEs), racial trauma, and traumatic stress. Trauma-informed interventions in schools can promote healing among ACE-impacted students of color. These interventions require collaboration with family members to decide upon services and referrals; however, educators commonly face challenges with engaging families. The study purpose is to understand barriers and facilitators to engaging families in trauma-informed mental health interventions for ACE-impacted students of color. As part of a larger school-based trauma-informed trial (Link for Equity), 6 focus groups were conducted with parents/guardians of color and school staff (n = 39) across 3 Midwestern school districts. Participants were asked open-ended questions about trauma, discrimination, school supports, and family engagement. Transcripts were coded by two team members, and thematic analysis was used to identify barriers/facilitators to family involvement. Results indicated that families of ACE-impacted students of color commonly experienced racism including microaggressions and stereotypes from the school community, which deterred engagement and prevented trusting relationships between families and school staff. Parents highlighted feeling excluded from decisions related to their child’s education and that their voices were not heard or understood. Participants discussed the need for schools to consider how family obstacles (such as mental health and trauma) may prevent families from engaging with staff, and they recommended structural changes, such as anti-racism trainings for educators. Findings highlight the need for anti-racist work that addresses interpersonal and structural racism in schools, in order to promote family engagement in trauma-informed mental health interventions.

Background and Objectives: Prevalence of nursing home residents with Alzheimer's