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OBJECTIVE: To identify common factors associated with periocular cutaneous malignancies using the National Institutes of Health (NIH) All of Us database. METHODOLOGY: In this case-control study, we extracted electronic health records and sociodemographic data for 385 cases of periocular cutaneous malignancies from the All of Us nationwide database. Controls (N = 1540) were matched to the demographic characteristics of the 2020 United States Census. Bivariate analyses and multivariable logistic regression determined variables significantly associated with increased odds of periocular cutaneous malignancies. We analyzed medical, environmental, and social determinants to evaluate which factors were associated with increased odds of periocular cutaneous malignancies. RESULTS: Among the cases, the mean (standard deviation) age was 66.8 (11.2) years at the time of diagnosis. The majority were male (207, 54%) and white (361, 94%). Periocular cutaneous malignancy was significantly more likely among individuals with high sun exposure (odds ratio [OR] 14.79, 95% confidence interval [CI] 3.35-85.73, P = 0.001), those identifying as white race (OR 3.88, 95% CI 1.06-25.33, P = 0.079), and those with higher socioeconomic status, including higher annual income (OR 1.35, 95% CI 1.25-1.46, P < 0.001). CONCLUSIONS: This study demonstrates similar risk factors for periocular cutaneous malignancies, echoing prior research that showed increased associations with lighter-pigmented skin and higher socioeconomic status. It also sheds light on the positive impact of physician surveillance and health utilization factors in the early detection and treatment of these malignancies, aspects less explored in prior analyses.

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OBJECTIVES: The workplace is an important setting for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposure and transmission. Using data from a large case-control study in Colorado during 2021 and 2022, we aimed to evaluate working outside the home and SARS-CoV-2 infection, the racial and ethnic distribution of workers in occupations associated with infection, and workplace face mask use. METHODS: Cases were Colorado adults with a positive SARS-CoV-2 test by reverse transcription-polymerase chain reaction (RT-PCR) reported to Colorado's COVID-19 surveillance system selected from surveillance data ≤12 days after their specimen collection date. Control participants were randomly selected adult Coloradans with a RT-PCR-confirmed negative SARS-CoV-2 test result reported to the same surveillance system. RESULTS: Working outside the home was associated with infection (odds ratio [OR] = 1.46, 95% confidence interval [CI]: 1.39-1.54). Among participants working outside the home, "Food Preparation and Serving Related" (aOR = 2.35, 95% CI: 1.80-3.06), "Transportation and Material Moving" (aOR = 2.09, 95% CI: 1.62-2.69), "Construction and Extraction" (aOR = 1.88, 95% CI: 1.36-2.59), "Protective Service" (aOR = 1.60, 95% CI: 1.15-2.24), and "Sales and Related" (aOR = 1.44, 95% CI: 1.22-1.69) were occupational categories most strongly associated with infection. American Indian/Alaskan Native, Black, and Hispanic/Latino participants were more likely than others to work in occupational categories with the highest odds of infection (p < 0.05). Cases were less likely than controls to report always wearing a mask (31.9% vs. 41.5%) and wearing a KN95/N95/KF94 mask (16.8% vs. 27.2%) at work. CONCLUSIONS: These findings emphasize the importance of occupation and workplace mask use in the COVID-19 pandemic and its disproportionate racial/ethnic impact on workers.

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BACKGROUND: In the U.S., Black children have disproportionately elevated rates of pediatric morbidity compared with White children, but data are lacking for other countries. We studied the extent to which Black Haitians were at risk of pediatric morbidity in Canada. METHODS: We analyzed a retrospective cohort of 736,498 children born in Quebec between 2008 and 2020. We identified Black Haitians using the mother tongue and birth country of parents. The outcome was mortality or hospitalization for infectious diseases, allergy, cancer, and other morbidity between birth and 12 years of age. We estimated hazard ratios (HR) and 95% confidence intervals (CI) for these outcomes, comparing Haitians with non-Haitians in Cox regression models adjusted for patient characteristics. RESULTS: Compared with non-Haitians, Haitians tended to have a greater risk of pediatric mortality, especially before age 2 years (HR 1.56, 95% CI 1.00-2.45). However, Haitian children had a lower risk of hospitalization than non-Haitian children (HR 0.61, 95% CI 0.59-0.63). Haitians were less likely to be hospitalized for infectious diseases, allergies, appendicitis, cancers, fractures, dental caries, and ophthalmologic conditions. Hospitalization rates were low throughout childhood, even though Haitian children were more likely to be born preterm, develop severe neonatal morbidity, and have other adverse outcomes at birth. CONCLUSION: Haitian children have an elevated risk of neonatal morbidity and early childhood mortality, but lower risk of hospitalization compared with non-Haitians in Canada. The reasons for the disparity are unclear, but greater effort is needed to address potential gaps in healthcare among Black children.

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The Health Equity Leadership & Exchange Network states that "health equity exists when all people, regardless of race, sex, sexual orientation, disability, socioeconomic status, geographic location, or other societal constructs, have fair and just access, opportunity, and resources to achieve their highest potential for health." It is clear from the wide discrepancies in maternal and infant mortalities, by race, ethnicity, location, and social and economic status, that health equity has not been achieved in pregnancy care. Although the most obvious evidence of inequities is in low-resource settings, inequities also exist in high-resource settings. In this presentation, based on the Global Pregnancy Collaboration Workshop, which addressed this issue, the bases for the differences in outcomes were explored. Several different settings in which inequities exist in high- and low-resource settings were reviewed. Apparent causes include social drivers of health, such as low income, inadequate housing, suboptimal access to clean water, structural racism, and growing maternal healthcare deserts globally. In addition, a question is asked whether maternal health inequities will extend to and be partially due to current research practices. Our overview of inequities provides approaches to resolve these inequities, which are relevant to low- and high-resource settings. Based on the evidence, recommendations have been provided to increase health equity in pregnancy care. Unfortunately, some of these inequities are more amenable to resolution than others. Therefore, continued attention to these inequities and innovative thinking and research to seek solutions to these inequities are encouraged.

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SETTING: Public health measures enacted during the COVID-19 pandemic significantly impacted Nova Scotians experiencing food insecurity. Public Health (PH), Nova Scotia Health, created a provincial Housing Isolation Program (HIP) which addressed barriers to isolation, including food access, for COVID-19 cases and contacts being followed by PH. INTERVENTION: HIP worked with partners to coordinate and respond to urgent food needs of isolating clients by providing grocery and meal delivery options. HIP also made referrals to government and community partners for income and food supports. This program was intended to minimize the spread of COVID-19 by facilitating isolation while meeting basic needs for people with no other means of support. OUTCOMES: From December 2020 to March 2022, HIP completed grocery and meal deliveries for 579 clients, 1351 referrals to a provincial Income Support Program, and 231 referrals to external food supports. HIP staff worked with clients to manage potential perceptions of stigma. Challenges reported included the urgency of food needs, lack of social supports, and availability and accessibility constraints in rural communities, as well as difficulty accessing culturally appropriate foods and special diets. IMPLICATIONS: This intervention demonstrates the importance of addressing food insecurity during emergency preparedness, planning, and response. During emergencies, planning and mobilizing food access requires an equity-oriented approach to overcome stigma. Broadly, continued reliance on charitable responses creates significant vulnerability during emergencies and addressing root causes of food insecurity through social policy will provide longer-term protection.

RéSUMé: CONTEXTE: Les mesures de santé publique adoptées pendant la pandémie de COVID-19 ont eu un important impact sur la population néo-écossaise en situation d'insécurité alimentaire. Les Services de santé publique de Santé Nouvelle-Écosse ont créé un programme provincial d'hébergement en isolement (Housing Isolation Program - HIP) qui s'est attaqué aux obstacles à l'isolement, y compris l'accès à la nourriture, pour les cas de COVID-19 et les contacts suivis par la Santé publique. INTERVENTION: Le programme d'hébergement en isolement (HIP) a travaillé avec des partenaires pour assurer la coordination et répondre aux besoins alimentaires urgents de la clientèle isolée en proposant des solutions de livraison d'épicerie et de repas. Le HIP a également orienté la clientèle vers des partenaires gouvernementaux et communautaires pour qu'elle bénéficie d'un soutien au revenu et d'une aide alimentaire. Ce programme visait à minimiser la propagation de la COVID-19 en rendant l'isolement plus facile tout en répondant aux besoins fondamentaux des personnes qui n'ont pas d'autre source de soutien. RéSULTATS: De décembre 2020 à mars 2022, le HIP a effectué des livraisons d'épicerie et de repas pour 579 personnes; 1 351 aiguillages vers un programme provincial de soutien au revenu; et 231 aiguillages vers des soutiens alimentaires externes. Le personnel du HIP a travaillé avec la clientèle pour gérer les perceptions potentielles de stigmatisation. Parmi les difficultés signalées, citons l'urgence des besoins alimentaires, le manque de soutien social, les contraintes de disponibilité et d'accessibilité dans les communautés rurales, ainsi que la difficulté d'accès à des aliments culturellement adaptés et à des régimes alimentaires particuliers. IMPLICATIONS: Cette intervention démontre l'importance de la prise en compte de l'insécurité alimentaire lors de la préparation, de la planification et de l'intervention en cas d'urgence. Dans les situations d'urgence, la planification et la mobilisation de l'accès à la nourriture nécessitent une approche axée sur l'équité afin de surmonter la stigmatisation. D'une manière générale, le fait de continuer à s'appuyer sur des réponses d'ordre caritatif crée une vulnérabilité importante dans les situations d'urgence. S'attaquer aux causes profondes de l'insécurité alimentaire au moyen d'une politique sociale permettra d'assurer une protection à plus long terme.

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BACKGROUND: Mobile Integrated Health-Community Paramedicine (MIH-CP) is a novel approach that may reduce the rural-urban disparity in vaccination uptake in the United States. MIH-CP providers, as physician extenders, offer clinical follow-up and wrap-around services in homes and communities, uniquely positioning them as trusted messengers and vaccine providers. This study explores stakeholder perspectives on feasibility and acceptability of community paramedicine vaccination programs. METHODS: We conducted semi-structured qualitative interviews with leaders of paramedicine agencies with MIH-CP, without MIH-CP, and state/regional leaders in Indiana. Interviews were audio recorded, transcribed verbatim, and analyzed using content analysis. RESULTS: We interviewed 24 individuals who represented EMS organizations with MIH-CP programs (MIH-CP; n = 10), EMS organizations without MIH-CP programs (non-MIH-CP; n = 9), and state/regional administrators (SRA; n = 5). Overall, the sample included professionals with an average of 19.6 years in the field (range: 1-42 years). Approximately 75% (n = 14) were male, and all identified as non-Hispanic white. MIH-CPs reported they initiated a vaccine program to reach underserved areas, operating as a health department extension. Some MIH-CPs integrated existing services, such as food banks, with vaccine clinics, while other MIH-CPs focused on providing vaccinations as standalone initiatives. Key barriers to vaccination program initiation included funding and vaccinations being a low priority for MIH-CP programs. However, participants reported support for vaccine programs, particularly as they provided an opportunity to alleviate health disparities and improve community health. MIH-CPs reported low vaccine hesitancy in the community when community paramedics administered vaccines. Non-CP agencies expressed interest in launching vaccine programs if there is clear guidance, sustainable funding, and adequate personnel. CONCLUSIONS: Our study provides important context on the feasibility and acceptability of implementing an MIH-CP program. Findings offer valuable insights into reducing health disparities seen in vaccine uptake through community paramedics, a novel and innovative approach to reduce health disparities in rural communities.

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Objective: This study systematically reviews evidence of socioeconomic health disparities in Costa Rica, a middle-income country, to elucidate the relationship between socioeconomic status and health outcomes. Methods: Published studies were identified through a systematic review of PubMed (English) and Scielo (Spanish) databases from December 2023 to January 2024, following PRISMA guidelines. Search terms included socioeconomic status, social determinants, social gradient in health, and health inequalities. Results: Of 236 identified references, 55 met the inclusion criteria. Findings were categorized into health inequalities in mortality (among the general population, infants, and older adults), life expectancy, cause-specific mortality, and health determinants or risk factors mediating the association between the social environment and health. The studies indicate higher mortality among the most disadvantaged groups, including deaths from respiratory diseases, violence, and infections. Higher socioeconomic status was associated with lower mortality rates in the 1990s, indicating a positive social gradient in health (RII = 1.3, CI [1.1-1.5]). Disparities were less pronounced among older adults. Urban areas exhibited concentrated wealth and increased risky behaviors, while rural areas, despite greater socioeconomic deprivation, showed a lower prevalence of risky behaviors. Regarding smoking, people living in rural areas smoked significantly less than those in urban areas (7% vs. 10%). Despite the relatively equitable distribution of public primary healthcare, disparities persisted in the timely diagnosis and treatment of chronic diseases. Cancer survival rates post-diagnosis were positively correlated with the wealth of districts (1.23 [1.12-1.35] for all cancers combined). Conclusion: The study highlights the existence of social health inequalities in Costa Rica. However, despite being one of the most unequal OECD countries, Costa Rica shows relatively modest social gradients in health compared to other middle and high-income nations. This phenomenon can be attributed to distinctive social patterns in health behaviors and the equalizing influence of the universal healthcare system.

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To achieve cardiovascular health (CVH) equity in the United States, an understanding of the social and structural factors that contribute to differences and disparities in health is necessary. The Asian American population is the fastest-growing racial group in the United States but remains persistently underrepresented in health research. There is heterogeneity in how individual Asian American ethnic groups experience CVH and cardiovascular disease outcomes, with certain ethnic groups experiencing a higher burden of adverse social conditions, disproportionately high burden of suboptimal CVH, or excess adverse cardiovascular disease outcomes. In this scientific statement, upstream structural and social determinants that influence CVH in the Asian American population are highlighted, with particular emphasis on the role of social determinants of health across disaggregated Asian American ethnic groups. Key social determinants that operate in Asian American communities include socioeconomic position, immigration and nativity, social and physical environments, food and nutrition access, and health system-level factors. The role of underlying structural factors such as health, social, and economic policies and structural racism is also discussed in the context of CVH in Asian Americans. To improve individual-, community-, and population-level CVH and to reduce CVH disparities in Asian American ethnic subgroups, multilevel interventions that address adverse structural and social determinants are critical to achieve CVH equity for the Asian American population. Critical research gaps for the Asian American population are given, along with recommendations for strategic approaches to investigate social determinants of health and intervene to reduce health disparities in these communities.

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Introduction: Homelessness is a phenomenon of social exclusion and poverty that has increased alarmingly during recent years. Homeless people (HP) experience violations of several basic human rights or needs that impact their well-being. Therefore, the aim of this research was to assess the health status and self-perceived health of HP and examining the impact of homelessness on their health. Methods: We used an explanatory sequential mixed-methods approach that integrated a quantitative cross-sectional study within critical social and ethno-sociological qualitative frameworks. Data were collected in Palma, Spain, from December 1, 2020, to January 1, 2023. A total of 198 HP were recruited from the streets and public areas. Basic human needs (Virginia Henderson model), medical diagnoses, substance abuse (DAST-10), diet quality (IASE), depression (PHQ-9), and social support (SSQ-6) were assessed. Then, 17 semi-structured interviews were conducted and were analyzed using thematic content and discourse analysis. Quantitative and qualitative data were integrated and jointly analyzed. Results: The 79.3% of the participants were men, mean age of 47.8 ± 12.2 years. The 76.4% were Spanish. The participants reported severe difficulties in accessing the labor market, and that this greatly affected their self-esteem and mental health. The 48.9% of the participants suffered from one or more chronic diseases, and 50.3% were diagnosed with a mental health disorder. The participants generally did not consider health problems as a central concern. The health needs that most affected the participants were related to food, safety, and social support. HP frequently felt unsafe, fearfully, and anxious. Conclusion: Homelessness, unemployment, and social exclusion have significant negative impacts on the health and wellbeing of HP. Precarious work conditions and deficiencies in the welfare system contribute significantly to homelessness. These results highlight the need for systemic solutions that extend beyond short-term housing initiatives.

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Few studies examine how high-achieving Black women navigate chronic reproductive health morbidities. Black women are disproportionately more likely to experience uterine fibroids, with earlier onset and more severe symptoms. This study leverages a national mixed-methods data set of Black women academics to examine how they describe symptomatic fibroids impacting their careers and lives. We find that participants (1) actively coped by engaging in superwoman schema, (2) postponed treatment due to the demands of their tenure-track position, and (3) normalized pain. Our findings suggest a potentially high prevalence of uterine fibroids among Black women faculty, that symptomatic fibroids were an impediment to some women's careers, and that women with symptomatic fibroids often identified expectations of their careers as an impediment to seeking timely treatment. We provide insights for how highly educated, successful Black women cope and navigate career stress coupled with challenges resulting from chronic reproductive health morbidities.

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OBJECTIVES: Adolescence is a crucial life stage that can lead to excess weight and body dissatisfaction. Social inequalities in these issues may have been exacerbated by the COVID-19 pandemic. We aimed to analyze the presence of socioeconomic inequalities and their changes in these inequalities stratified by sex in 13- to 19-year-olds in a large Mediterranean city (Barcelona, Spain). STUDY DESIGN: Cross-sectional population-based study. METHODS: We used data from the 2016 and 2021 editions of the FRESC survey, which is a representative citywide survey that captures various aspects of adolescent health. Excess weight was determined by objective body mass index measurements. Body dissatisfaction was defined as the discrepancy between perceived and desired body shape. Socioeconomic status was divided into five pseudo-quintiles by using the Family Affluence Scale. We calculated the corresponding prevalence estimates and fitted robust Poisson regression models to estimate both simple and complex measures of inequality, including relative and absolute differences between the two survey years. RESULTS: The overall prevalence of excess weight increased from 25.3% [23.9-26.6] to 29.8% [28.2-31.4] between 2016 and 2021. Similarly, body dissatisfaction increased from 44.2% [42.6-45.8] to 60.4% [58.7-62]. Socioeconomic inequalities in excess weight significantly increased in girls (adjusted ratio of the relative index of inequalities = 1.72 [1.08; 2.74] but not in boys. No significant changes were detected in body dissatisfaction in either girls or boys. CONCLUSIONS: Our findings highlight the presence of a sex-specific change in socioeconomic inequalities in adolescent well-being regarding excess weight and body dissatisfaction. These results underscore the need for local public policies to improve social equity in adolescent health.

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BACKGROUND: The Oncotype DX Genomic Prostate Score (ODX-GPS) is a gene expression assay that predicts disease aggressiveness. The objective of this study was to identify sociodemographic and regional factors associated with ODX-GPS uptake. METHODS: Data from Surveillance Epidemiology and End Results registries on men with localized prostate cancer with a Gleason score of 3 + 3 or 3 + 4, PSA ≤20 ng/mL, and stage T1c to T2c disease from 2013 through 2017 were linked with ODX-GPS data. Census-tract level neighborhood socioeconomic status (nSES) quintiles were constructed using a composite socioeconomic score. Multivariable logistic regression was used to estimate the associations of ODX-GPS uptake with age at diagnosis, race and ethnicity, nSES, geographic region, insurance type, and marital status, accounting for National Comprehensive Cancer Network risk group, year of diagnosis, and clustering by census tract. RESULTS: Among 111,434 eligible men, 5.5% had ODX-GPS test uptake. Of these, 78.3% were non-Hispanic White, 9.6% were Black, 6.7% were Hispanic, and 3.6% were Asian American. Black men had the lowest odds of ODX-GPS uptake (odds ratio, 0.70; 95% confidence interval [CI], 0.63-0.76). Those in the highest versus lowest quintile of nSES were 1.64 times more likely (95% CI, 1.38-2.94) to have ODX-GPS uptake. The odds of ODX-GPS uptake were statistically significantly higher among men residing in the Northeast, West, and Midwest compared to the South. CONCLUSIONS: Disparities in ODX-GPS uptake by race, ethnicity, nSES, and geographical region were identified. Concerted efforts should be made to ensure that this clinical test is equitably available.

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INTRODUCTION/OBJECTIVES: Exposure to adverse social determinants of health (SDoH) in childhood is associated with poorer long-term health outcomes. Within structurally marginalized populations, there are disproportionately high rates of developmentally vulnerable children. The RICHER (Responsive, Intersectoral, Child and Community Health, Education and Research) social pediatric model was designed to increase access to care in marginalized neighborhoods. The purpose of this study was to describe the children and youth engaged with the RICHER model of service and characterize the needs of the population. METHODS: A retrospective chart review was conducted on children and youth who accessed primary care services through the program between January 1, 2018 and April 30, 2021. Basic descriptive data analysis was done using Stata v15.1. RESULTS: A total of 210 charts were reviewed. The mean age in years at initial assessment was 6.32. Patients most commonly identified their race/ethnicity as Indigenous (33%) and 15% were recent newcomers to Canada. Evidence of at least 1 adverse SDoH was noted in 41% of charts; the most common included material poverty (34%), food insecurity (11%), and child welfare involvement (20%). The median number of diagnoses per patient was 4. The most frequently documented diagnoses were neurodevelopmental disorders (50%) including developmental delay (39%), ADHD (32%), and learning disability (26%). The program referred 72% of patients to general pediatricians and/or other subspecialists; 34% were referred for tertiary neuropsychological assessments and 35% for mental health services. CONCLUSIONS: Our data suggests that this low-barrier, place-based primary care RICHER model was able to reach a medically, developmentally, and socially complex population living in disenfranchised urban neighborhoods. Half of the patients identified in our review had neurodevelopmental concerns and a third had mental health concerns, in contrast to an estimated 17% prevalence for mental health, behavioral, or developmental disorders in North American general pediatric aged populations. This highlights the impact adverse SDoH can have on child health and the importance of working with community partners to identify developmentally vulnerable children and support place-based programs in connecting with children who may be missed, overlooked, or disadvantaged through traditional models of care.

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Kidney services worldwide are increasingly using digital health technologies to deliver care. This includes kidney electronic patient-reported outcome (ePRO) systems: ambulatory digital technologies that enable the capture of PRO data electronically from people with kidney disease remotely and in real time to be shared with their kidney care team. Current kidney ePRO systems commonly aim to support the monitoring and management of symptoms in patients with kidney disease. The majority have thus far only been implemented in research settings and are not yet routinely used in clinical practice, leaving their readiness for real-world implementation largely unknown. Compared with paper-based PRO collection, ePRO systems have certain advantages, which we categorize as efficiency benefits (e.g., lower administrative burden), direct patient care benefits (e.g., automated PRO-based patient education), and health system and research benefits (e.g., collecting ePRO data once for multiple purposes). At the same time, kidney ePRO systems come with drawbacks, such as their potential to exacerbate existing inequities in care and outcomes and to negatively affect staff burden and patients' experience of kidney care. Areas that hold promise for expediting the development and uptake of kidney ePRO systems at the local, organizational, and national level include harnessing national kidney registries as enabling infrastructures; using novel data-driven technologies (e.g., computerized adaptive test systems, configurable dashboards); applying implementation science and action research approaches to enhance translation of ePRO research findings into clinical practice; and engaging stakeholders, including patients and carers, health care professionals, policymakers, payers, ePRO experts, technology providers, and organizations that monitor and improve the quality of kidney services.

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We examined the link between discrimination and self-rated mental health (SRMH) among immigrants and Canadian-born individuals, stratified according to an individual's identification as racialized or white. Using data from Canada's General Social Survey (2014) (weighted N = 27,575,000) with a novel oversample of immigrants, we estimated the association of perceived discrimination with SRMH separately among immigrants and Canadian-born individuals and stratified by racialized status. Among immigrants, we also investigated whether age-at-arrival attenuated or strengthened associations. The prevalence of discrimination was higher among racialized compared to white immigrants (18.9% versus 11.8%), and among racialized compared to white non-immigrants (20.0% versus 10.5%). In the adjusted model with immigrants, where white immigrants not reporting discrimination were the referent group, both white (adjusted prevalence odds ratio [aPOR] 6.11, 95% confidence interval [CI] 3.08, 12.12) and racialized immigrants (aPOR 2.28, 95% CI 1.29, 4.04) who experienced discrimination reported poorer SRMH. The associations were weaker among immigrants who immigrated in adulthood. In the adjusted model with non-immigrants, compared to unexposed white respondents, Canadian-born white respondents who experienced discrimination reported poorer SRMH (aPOR 3.62, 95% CI 2.99, 4.40) while no statistically significant association was detected among racialized respondents (aPOR 2.24, 95% CI 0.90, 5.58). Racialized respondents experienced significant levels of discrimination compared to white respondents irrespective of immigrant status. Discrimination was associated with poor SRMH among all immigrants, with some evidence of a stronger association for white immigrants and immigrants who migrated at a younger age. For Canadian-born individuals, discrimination was associated with poor SRMH among white respondents only.

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Despite Vietnam's overall progress on maternal health indicators, marginalized ethnic minorities in remote areas face lower access to antenatal care and higher maternal mortality rates relative to the Kinh (majority ethnic group). Last year, we conducted fieldwork for 2 qualitative research projects that aimed to address maternal health inequities among pregnant ethnic minority women in rural Northern Vietnam. Although not the focus of our research, the use of ultrasonography services at for-profit private clinics was ubiquitous in participants' healthcare-seeking accounts. Ultrasound scans from for-profit clinics were a major component of ethnic minority women's antenatal care: many purchased 8 to 10 scans during pregnancy at $6.15 US dollars per scan, despite their limited agricultural income of $120 to $205 per month. Women were unaware of how many scans were recommended and their medically indicated scheduling, but purchased frequent scans to assuage pregnancy anxieties and access what they experienced as the highest-quality antenatal service. In tandem, for-profit ultrasonography providers offered broader opening hours, immediate results, and rich technological scans, which seemed to deliver poor families the most tangible "value" for their hard-earned money. Previous literature documented the concerning overuse of ultrasonography among Kinh women in urban Vietnam: What are the implications of this trend extending to affect rural-dwelling ethnic minority women who face lower education, economic marginalization, and a 4-fold higher maternal mortality rate? Our findings raise concerns related to safety, financial vulnerability and provider-induced demand, and broader health policy questions regarding healthcare commodities in low-resource settings. Critically, there is no evidence of the effect of obstetrical ultrasound on reducing maternal mortality in low- and middle-income countries, and its excess use could burden available resources and detract from evidence-based services. Our findings suggest that health system gaps are driving poor women toward frequent purchases of a single insufficient maternal health commodity: this will not improve their pregnancy outcomes or health equity for marginalized ethnic minorities. We argue that addressing this overuse of ultrasonography due to provider-induced demand requires a multipronged response that meets women's growing expectations. Our findings highlight the need for investment in health education, health promotion, and reliable high-quality public maternal healthcare for ethnic minority communities in Vietnam.

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PURPOSE: Family physicians are increasingly more likely to encounter transgender and gender-diverse (TGD) patients requesting gender-affirming care. Given the significant health inequities faced by the TGD community, this study aimed to assess changes in military-affiliated clinicians' perspectives toward gender-affirming care over time. METHODS: Using a serial cross-sectional survey design of physicians at the 2016 and 2023 Uniformed Services Academy of Family Physicians conferences, we studied participants' perception of, comfort with, and education on gender-affirming care using Fisher's Exact tests and logistic regression. RESULTS: Response rates were 68% (n = 180) and 69% (n = 386) in 2016 and 2023, respectively. Compared to 2016, clinicians in 2023 were significantly more likely to report receiving relevant education during training, providing care to >1 patient with gender dysphoria, and being able to provide nonjudgmental care. In 2023, 26% reported an unwillingness to prescribe gender-affirming hormones (GAH) to adults due to ethical concerns. In univariable analysis, female-identifying participants were more likely to report willingness to prescribe GAH (OR = 2.6, 95%CI = 1.7-4.1) than male-identifying participants. Willingness to prescribe was also associated with ≥4 h of education (OR = 2.2, 95%CI = 1.1-4.2) compared to those with fewer than 4 h, and those who reported the ability to provide nonjudgmental care compared to those who were neutral (OR = 0.09, 95%CI = 0.04-0.2) or disagreed (OR = 0.11, 95%CI = 0.03-0.39). Female-identifying clinicians were more likely to agree additional training would benefit their practice (OR = 5.3, 95%CI = 3.3-8.5). CONCLUSIONS: Although military-affiliated family physicians endorsed more experience with and willingness to provide nonjudgmental gender-affirming care in 2023 than 2016, profound gaps in patient experience may remain based on the assigned clinician. Additional training opportunities should be available, and clinicians unable to provide gender-affirming care should ensure timely referrals. Future research should explore trends across clinical specialties.

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BACKGROUND/OBJECTIVES: Urban-rural inequities in health and mortality exist in Korea, a highly centralized developed country. The potential impact of multiple health-related lifestyle behaviors on mortality and difference between urban and rural areas is not fully understood. This study aimed to investigate the effect of high-risk health behaviors on all-cause mortality among residents living in urban and rural in Korea. SUBJECTS/METHODS: Cross-sectional analyses were conducted on 8,298 adults aged 40 yrs and older from the Korea National Health and Nutrition Examination Survey 2013-2015. High-risk behaviors were defined as having poor diet quality, current smoking, high-risk drinking, or insufficient physical activity. Mortality status was linked to the Cause of Death data followed up to December 31, 2019. The associations between all-cause mortality and high-risk behaviors were evaluated using Cox proportional hazard regression models adjusted for age, sex, education, income, and survey year. Population attributable fractions (PAFs) were calculated, and effect modification analysis was conducted. Participants were stratified by residential area (urban or rural). RESULTS: During the follow-up (median: 5.4 yrs), 313 deaths occurred. A higher proportion of rural residents than urban residents engaged in multiple high-risk behaviors (28.9% vs. 22.6%; P < 0.0001). As individual factors, a greater risk of mortality was associated with poor diet quality, current smoking, and inadequate physical activity, and these tendencies persisted in rural residents, especially for diet quality. Multiple high-risk behaviors were positively associated with a higher risk of mortality in Koreans living in urban and rural areas. PAF (95% confidence interval) was 18.5% (7.35-27.9%) and 29.8% (16.1-40.2%) in urban and rural residents, respectively. No additive or multiplicative effect of the region was observed. CONCLUSION: The higher prevalence of multiple high-risk lifestyle behaviors in rural residents may explain the higher mortality in rural areas compared to urban areas. Comprehensive public health policies to improve health-related behaviors in rural populations may be needed.

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BACKGROUND: The increasing life expectancy of individuals with Down syndrome has led to a growing awareness of mid- and late-life conditions. METHODS: Based on the Disease Analyser database (IQVIA), this retrospective cohort study compared adults ≥18 years of age with Down syndrome (ICD-10: Q90) in general practices in Germany with a propensity score-matched cohort without Down syndrome. The outcome was the first diagnosis of a fracture within 5 years of the index date. The cumulative incidence of fractures over a 5-year period was presented using Kaplan-Meier curves. Univariable Cox regression analyses by age group and sex were performed to assess the association between Down syndrome and fractures. RESULTS: A total of 2547 individuals with Down syndrome and 12 735 individuals without Down syndrome were included in the study. A significantly higher cumulative fracture incidence within 5 years was observed in the age group 51-60 years (9.3% Down syndrome vs. 4.8% without Down syndrome, P = 0.003) as well as in the age group >60 years (20.3% Down syndrome vs. 8.6% without Down syndrome, P < 0.001) compared with the cohort without Down syndrome. Regression analysis showed a significant association between Down syndrome and fracture risk in women with Down syndrome aged 51-60 years (hazard ratio [HR] = 1.60; 95% confidence interval [CI]: 1.13-2.26), and in those aged 51-60 years (HR = 2.08; 95% CI: 1.27-3.41) and >60 years (HR = 2.98; 95% CI: 1.87-4.73)), but not in men. When comparing fractures in individuals with and without Down syndrome, shoulder and arm fractures were most common in the Down syndrome cohort. CONCLUSION: The results of our study indicate a positive association between individuals with Down syndrome and subsequent fractures in women and those aged >50 years. Prevention of falls appears to be particularly important in these populations. However, future studies should clarify the extent to which socio-economic factors, such as housing, play a role in this context.

RESUMEN

BACKGROUND: Caries is an important public health concern. Dental sealants are effective in preventing caries; however, their uptake is suboptimal and little is known about second molar (2M) sealants. The authors examined the prevalence of 2M sealants among US adolescents and investigated the factors associated with their presence. METHODS: The authors conducted a cross-sectional analysis of 2011-2016 National Health and Nutrition Examination Survey data on adolescents aged 12 through 19 years with complete sealant data (n = 3,636). Race and ethnicity, income, and first molar (1M) sealant were primary variables of interest. The logistic regression models were used to estimate the factors associated with 2M sealants. All analyses used survey weights and accounted for complex survey design. RESULTS: Only 34.6% of adolescents (95% CI, 31.2% to 38.0%) had 2M sealants. Approximately 89.0% of adolescents (95% CI, 86.1% to 92.0%) with 2M sealants and 19.6% (95% CI, 17.1% to 22.2%) without 2M sealants had 1M sealants. In the adjusted models, race and ethnicity were strongly associated with 2M sealant presence, but the association did not hold when 1M sealant was included in the model. 1M sealants were the most significant factor explaining the presence of 2M sealants (odds ratio, 0.03; 95% CI, 0.02 to 0.04). CONCLUSIONS: Two of 3 adolescents lacked 2M sealants, with considerable disparities in their presence. To improve adolescent oral health, clinical and community programs should increase delivery of 2M sealants. PRACTICAL IMPLICATIONS: Study findings highlight the need to evaluate adolescent sealant delivery programs to improve the uptake of 2M sealants.