Kala Mehta

Objective To date, there are no studies of COVID-19 cases and deaths in the Navajo Nation, US. The primary objective of this manuscript is to understand whether counties with a higher proportion of Navajo (Diné) population also had higher cases and deaths of COVID-19 and whether these dropped with vaccination. Method We undertook a cross-sectional analysis of county level data from March 16, 2020—May 11, 2021. Data were obtained from public repositories and the US Census for the Navajo Nation, including northeastern Arizona, southeastern Utah, and northwestern New Mexico. The primary outcome measure is the number of individuals with confirmed cases or deaths of COVID-19. A secondary outcome was COVID-19 vaccinations. Results The 11 counties in Navajo Nation have a wide variation in the percent Navajo population, the resources available (ICU beds and occupancy), and COVID-19 outcomes. Overall, there was a substantial increase in the number of cases from March 16 –July 16, 2020 (the h...

IntroductionEconomic groups, such as microfinance or self-help groups are widely implemented in low-income and middle-income countries (LMICs). Women’s groups are voluntary groups, which aim to improve the well-being of members through activities, such as joint savings, credit, livelihoods development and/or health activities. Health interventions are increasingly added on to existing women’s economic groups as a public health intervention for women and their families. Here, we present the protocol for a mixed-methods systematic review we will conduct of the evidence on integrated economic and health interventions on women’s groups to assess whether and how they improve health-related knowledge, behaviour and outcomes in LMICs.Methods and analysisWe will search seven electronic databases for published literature, along with manual searches and consultation. The review will include (1) randomised trials and non-randomised quasiexperimental studies of intervention effects of integrate...

BackgroundSocial innovations in health are inclusive solutions to address the healthcare delivery gap that meet the needs of end users through a multi-stakeholder, community-engaged process. While social innovations for health have shown promise in closing the healthcare delivery gap, more research is needed to evaluate, scale up, and sustain social innovation. Research checklists can standardize and improve reporting of research findings, promote transparency, and increase replicability of study results and findings.Methods and findingsThe research checklist was developed through a 3-step community-engaged process, including a global open call for ideas, a scoping review, and a 3-round modified Delphi process. The call for entries solicited checklists and related items and was open between November 27, 2019 and February 1, 2020. In addition to the open call submissions and scoping review findings, a 17-item Social Innovation For Health Research (SIFHR) Checklist was developed based...

While social innovations in health have shown promise in closing the healthcare delivery gap, especially in low- and middle-income countries (LMICs), more research is needed to evaluate, scale up, and sustain social innovations. Research checklists can standardize and improve reporting of research findings, promote transparency, and increase replicability of study results and findings. This article describes the development of a 17-item social innovation in health research checklist to assess and report social innovation projects and provides examples of good reporting. The checklist is adapted from the TIDieR checklist and will facilitate more complete and transparent reporting and increase end user engagement.Summary pointsWhile many social innovations have been developed and shown promise in closing the healthcare delivery gap, more research is needed to evaluate social innovationThe Social Innovation in Health Research Checklist, the first of its kind, is a 17-item checklist to ...

Whether requiring Graduate Record Examinations (GRE) results for doctoral applicants affects the diversity of admitted cohorts remains uncertain. This study randomized applications to 2 population-health doctoral programs at the University of California San Francisco to assess whether masking reviewers to applicant GRE results differentially affects reviewers’ scores for underrepresented minority (URM) applicants from 2018–2020. Applications with GRE results and those without were randomly assigned to reviewers to designate scores for each copy (1–10, 1 being best). URM was defined as self-identification as African American/Black, Filipino, Hmong, Vietnamese, Hispanic/Latinx, Native American/Alaska Native, or Native Hawaiian/Other Pacific Islander. We used linear mixed models with random effects for the applicant and fixed effects for each reviewer to evaluate the effect of masking the GRE results on the overall application score and whether this effect differed by URM status. Revie...

Educational attainment is an important social determinant of maternal, newborn, and child health1–3. As a tool for promoting gender equity, it has gained increasing traction in popular media, international aid strategies, and global agenda-setting4–6. The global health agenda is increasingly focused on evidence of precision public health, which illustrates the subnational distribution of disease and illness7,8; however, an agenda focused on future equity must integrate comparable evidence on the distribution of social determinants of health9–11. Here we expand on the available precision SDG evidence by estimating the subnational distribution of educational attainment, including the proportions of individuals who have completed key levels of schooling, across all low- and middle-income countries from 2000 to 2017. Previous analyses have focused on geographical disparities in average attainment across Africa or for specific countries, but—to our knowledge—no analysis has examined the ...

Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2—to end preventable child deaths by 2030—we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000–2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geograp...

IntroductionIn underserved populations, the contribution of community health workers (CHWs) is vital to the healthcare systems. Attrition of these workers causes critical breakdowns in the delivery of essential services to these populations. Literature on reasons for attrition is limited, although some have been identified in studies on sustainability of CHW programmes. These factors are, however, likely to be influenced by context. We measured CHW attrition and its predictors in a rural area in Kenya.MethodsWe conducted a nested case–control study and focus group discussions among CHWs involved in a maternal and child health project. A training register of 1005 CHWs was used to sample and follow CHWs for attrition. Incidence of CHW attrition was calculated using a Poisson model. Separately, we used logistic regression to determine predictors of CHW attrition.ResultsOf the 1005 CHWs, 498 (49.6%) had left the project by the time of the study. The incidence of attrition was 46.8/1000 ...

Detailed assessments of mortality patterns, particularly age-specific mortality, represent a crucial input that enables health systems to target interventions to specific populations. Understanding how all-cause mortality has changed with respect to development status can identify exemplars for best practice. To accomplish this, the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) estimated age-specific and sex-specific all-cause mortality between 1970 and 2016 for 195 countries and territories and at the subnational level for the five countries with a population greater than 200 million in 2016. We have evaluated how well civil registration systems captured deaths using a set of demographic methods called death distribution methods for adults and from consideration of survey and census data for children younger than 5 years. We generated an overall assessment of completeness of registration of deaths by dividing registered deaths in each location-year by ...

Although predictions of the future are usually difficult and frequently temporary, it is relatively safe to assume that the future will see growing importance of the field of ethnogeriatrics. As healthcare institutions attempt to cope with the rapidly growing older population in the context of the growing hyperdiversity of populations with which they are faced [1], there seems little doubt that issues discussed in the previous chapters of this volume become increasingly salient for providers, planners, patients, and families.

End-stage renal disease disproportionately affects black Americans. However, the impact of residential segregation by race-a prominent feature of many U.S. cities--on outcomes of patients receiving dialysis and on facility performance has not been evaluated. To examine the relationship among racial composition of ZIP codes in metropolitan areas, outcomes of patients receiving dialysis, and characteristics of dialysis facilities. Retrospective cohort study of patients receiving dialysis and cross-sectional study of dialysis facilities. U.S. metropolitan ZIP codes with differing percentages of black residents. Black and non-Hispanic white patients who initiated long-term dialysis between 1 January 1995 and 31 December 2002 (n = 399,424) and dialysis facilities in operation in December 2004 (n = 3244). Mortality and time to transplantation among patients receiving dialysis, and performance of dialysis facilities on the basis of quality indicators (anemia management, dialysis adequacy, and facility-level mortality rates). Most black patients (50.3%) but few white patients (5%) lived in the 3% (n = 769) of ZIP codes in which most residents were black. In analyses adjusted for patient and ZIP code characteristics, mortality rates were higher among white patients but not among black patients living in areas with a higher percentage of black residents (adjusted hazard ratio for ZIP codes with > or =75% black residents vs. <10% black residents, 1.14 [95% CI, 1.07 to 1.21] for white patients and 1.02 [CI, 0.99 to 1.06] for black patients). Time to transplantation was longer among both black and white patients (adjusted hazard ratio for ZIP codes with > or =75% black residents vs. <10% black residents, 0.84 [CI, 0.78 to 0.92] and 0.63 [CI, 0.57 to 0.71] for black patients and white patients, respectively). Dialysis facilities located in areas with a higher percentage of black residents were more likely to have higher-than-expected mortality rates and were less likely to meet performance targets. Patient-level analyses were restricted to black and non-Hispanic white patients. Patient-level and facility-level analyses focused only on the percentage of black residents in each ZIP code. The racial composition of urban residential areas is associated with time to transplantation and dialysis facility performance on standard quality measures. Closer scrutiny of care provided to patients receiving dialysis who live in predominantly black residential areas and to dialysis facilities operating in these areas may be warranted.

Background Most medical educational programs emphasize clinical observation or clinical skill acquisition, fewer focus upon research. The Danish-American Research Exchange (DARE) program, sponsored by the Lundbeck Foundation, is unique in that the medical student initiates biomedical research collaboration between Danish and US medical institutions. To achieve this, Danish medical students (DARE students) conduct binational mentored research projects while based in the United States for 10 months. In addition, DARE students are introduced to interdisciplinary thinking about how to develop ultra-low-cost healthcare interventions through the ‘$10 Challenge’. Methods We conducted a cross-sectional study of DARE alumni over five consecutive years (2015–2020, n = 24). Research metrics included completion of a research project, primary authorship, and co-authorship of publications. The number of publications, prior to and after the DARE program were enumerated. For the first four cohorts,...

IntroductionAs part of an investment by the Bill & Melinda Gates Foundation to support the Government of Bihar to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) statewide, BBC Media Action implemented multiple communication tools to support front-line worker (FLW) outreach. We analyse the impacts of a package of mHealth audio messaging and paper-based job aids used by FLWs during government-sponsored village health, sanitation and nutrition days (VHSNDs) on knowledge and practices of childbearing women across the RMNCHN continuum of care.MethodsData from two surveys collected between July and September 2016 were analysed using logistic regression to compare health-related knowledge and behaviours between women who had been exposed at VHSNDs to the mHealth GupShup Potli (GSP) audio recordings or interpersonal communication (IPC) tools versus those who were unexposed.ResultsExposure to GSP recordings (n=2608) was associated with improved knowledge acro...

Background Light-to-moderate alcohol consumption reduces the risk of coronary heart disease and stroke. Because vascular disease is associated with cognitive impairment and dementia, we hypothesised that alcohol consumption might also affect the risk of dementia. Methods We examined the relation between alcohol consumption and risk of dementia in individuals taking part in the Rotterdam Study—a prospective population-based study of 7983 individuals aged 55 years and older. We studied all participants who did not have dementia at baseline (1990–93) and who had complete data on alcohol consumption (n=5395). Through follow-up examinations in 1993–94 and 1997–99 and an extensive monitoring system, we obtained nearly complete follow-up (99·7%) until the end of 1999. We used proportional hazards

INTRODUCTION This study was conducted to address a lack of information in the literature regarding the frequency and consequences of specific types of torture and abuse among Eritreans seeking asylum in the United States. METHODS Cross-sectional study of Eritreans seeking asylum in the United States presenting to a human rights clinic for forensic medical and psychological evaluations based on Istanbul Protocol. Reports were eligible for inclusion if subjects: 1) immigrated from Eritrea 2) reported torture and abuse in Eritrea, 3) were 18 or older. 59 reports met inclusion criteria. Demographic features of individuals, reported history and specific types of torture, and physical and psychological sequelae were analyzed. RESULTS Over 300 instances of torture were reported, an average of about 6 per person. The primary forms of torture reported were beating (87.7%) and forced positioning (57.9%). 90% of asylum seekers examined had physical findings which were consistent with the tortu...

Background In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries. Methods GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution. Findings Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990–2010 time period, with the greatest annualised rate of decline occurring in the 0–9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10–24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10–24 years were also in the top ten in the 25–49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50–74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI. Interpretation As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and development investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve. Funding Bill & Melinda Gates Foundation

IntroductionWe evaluated the impact of a ‘Team-Based Goals and Incentives’ (TBGI) intervention in Bihar, India, designed to improve front-line (community health) worker (FLW) performance and health-promoting behaviours related to reproductive, maternal, newborn and child health and nutrition.MethodsThis study used a cluster randomised controlled trial design and difference-in-difference analyses of improvements in maternal health-related behaviours related to the intervention’s team-based goals (primary), and interactions of FLWs with each other and with maternal beneficiaries (secondary). Evaluation participants included approximately 1300 FLWs and 3600 mothers at baseline (May to June 2012) and after 2.5 years of implementation (November to December 2014) who had delivered an infant in the previous year.ResultsThe TBGI intervention resulted in significant increases in the frequency of antenatal home visits (15 absolute percentage points (PP), p=0.03) and receipt of iron-folic acid...

Childhood obesity is increasing especially in Latinos and early intervention is essential to prevent later obesity complications. Latino children (n = 201) recruited at two San Francisco hospitals were assessed at birth including infant anthropometrics and feeding practices and followed to age 9 with annual anthropometric assessments. We evaluated the relationship between perinatal risk factors and obesity at age 9 and chronic obesity (obesity at both 5 and 9 years). Higher birthweight [odds ratio (OR) 2.48, 95% confidence interval (CI) 1.06-5.81] and maternal pre-pregnancy body mass index (BMI) (OR 1.09, 95% CI 1.00-1.18) were associated with increased risk for obesity at 9 years. Higher maternal pre-pregnancy BMI (OR 1.10, 95% CI 1.01-1.20) was associated with chronic obesity. Additionally, prenatal depression symptoms were protective (OR 0.33, 95% CI 0.11-0.94) against chronic obesity. We found no association between maternal age and education, exclusive breastfeeding at 4-6 week...

Dementia has a huge physical, psychological, social and economic impact upon caregivers, families and societies at large. There has been a growing impetus to utilize Internet interventions given the potential scalability, and presumed cost-effectiveness and accessibility. In this paper, we describe the design of a randomized controlled trial (RCT) aiming to study the impact of online self-help programs on caregivers of people with dementia in India. The experimental group will receive an interactive training and support program and the comparison group will receive an education-only e-book. It will be among the first online support intervention RCTs for a mental health condition in a lower-middle income country. Two hundred and eight participants are expected to be recruited via several strategies (email, Internet and social media, telephone and face-to-face) starting in the Bangalore region of India. The inclusion criteria for participation in the trial are: (1) being 18 years or o...

Duration of acute kidney injury (AKI) has been recognized a risk factor for adverse outcomes following AKI. We sought to examine the relationship of AKI duration and recurrent AKI with short-term outcomes in critically ill patients who were mechanically ventilated and met criteria for the acute respiratory distress syndrome. Participants in the NHLBI ARDS Network SAILS multicenter trial who developed AKI were included in this analysis and divided into groups based on AKI duration. Differences in outcomes were evaluated using t test and Chi-square test. Competing risks regression and Cox regression were used to evaluate factors associated with resolving AKI and recurrent AKI. In total, 238 patients were included in the study. Seventy-seven patients had short duration AKI (1-2 days), 47 medium duration AKI (3-7 days), 87 persistent AKI (> 7 days) and 38 died during their AKI episode. Persistent AKI was associated with worse outcomes including increased ICU length of stay, time on t...

Beta-blockers vary in pharmacodynamics and pharmacokinetic properties. It is unknown whether specific types are associated with increased perioperative risks. We evaluated perioperative risks associated with beta-blocker subtypes, overall and in patient subgroups. We performed a Danish Nationwide cohort study, 2005-2011, of patients treated chronically with beta blocker (atenolol, bisoprolol, carvedilol, metoprolol, propranolol, or other) prior to non-cardiac surgery. Risks of 30-day all-cause mortality (ACM) and 30-day major adverse cardiovascular events (MACE) were estimated using adjusted logistic regression models and odds ratios with 95% confidence intervals. We identified 61 660 patients, most frequently treated with metoprolol (67% of patients, mean age 69 years, 49% males), atenolol (10% of patients, mean age 68 years, 36% males), or carvedilol (9% of patients, mean age 68 years, 60% males). The crude incidences of ACM and MACE were 4.1 and 3.5% in patients with metoprolol, ...

The objective of the study is was investigate the association between hearing impairment and anxiety. We conducted a cross-sectional analysis of 1,732 community-based adults aged 76 to 85 years who participated in the Health Aging and Body Composition (ABC) study. Logistic regression models were adjusted for demographic and cardiovascular risk factors. Hearing impairment was defined by the speech-frequency pure tone average. Anxiety was defined as reporting two symptoms of at least "a little" or one symptom "quite a bit" on the three-item Hopkins Symptom Checklist. Compared with individuals with no hearing impairment, the odds of prevalent anxiety were higher among individuals with mild hearing impairment (odds ratio [OR] = 1.32, 95% confidence interval [CI] = [1.01, 1.73]) and moderate or greater hearing impairment (OR = 1.59, 95% CI = [1.14, 2.22]). Hearing aid use was not significantly associated with lower odds of anxiety. Hearing impairment is independently ...

To better understand the potential impact of hearing impairment (HI) and hearing aid use on emotional vitality and mental health in older adults. We investigated the cross-sectional association of HI with emotional vitality in 1,903 adults aged 76-85 years in the Health ABC study adjusted for demographic and cardiovascular risk factors. Hearing was defined by the speech frequency pure tone average (no impairment < 25 dB, mild impairment 25-40 dB, and moderate or greater impairment > 40 dB). Emotional vitality was defined as having a high sense of personal mastery, happiness, low depressive symptomatology, and low anxiety. Compared with individuals with no HI, participants with moderate or greater HI had a 23% lower odds of emotional vitality (odds ratio [OR] = 0.77; 95% confidence interval [CI]: 0.59-0.99). Hearing aid use was not associated with better emotional vitality (OR = 0.98; 95% CI: 0.81-1.20). HI is associated with lower odds of emotional vitality in older adults. Fu...

Up-to-date evidence about levels and trends in disease and injury incidence, prevalence, and years lived with disability (YLDs) is an essential input into global, regional, and national health policies. In the Global Burden of Disease Study 2013 (GBD 2013), we estimated these quantities for acute and chronic diseases and injuries for 188 countries between 1990 and 2013. Estimates were calculated for disease and injury incidence, prevalence, and YLDs using GBD 2010 methods with some important refinements. Results for incidence of acute disorders and prevalence of chronic disorders are new additions to the analysis. Key improvements include expansion to the cause and sequelae list, updated systematic reviews, use of detailed injury codes, improvements to the Bayesian meta-regression method (DisMod-MR), and use of severity splits for various causes. An index of data representativeness, showing data availability, was calculated for each cause and impairment during three periods globally...

Differential item functioning (DIF) occurs when a test item has different statistical properties in subgroups, controlling for the underlying ability measured by the test. DIF assessment is necessary when evaluating measurement bias in tests used across different language groups. However, other factors such as educational attainment can differ across language groups, and DIF due to these other factors may also exist. How to conduct DIF analyses in the presence of multiple, correlated factors remains largely unexplored. This study assessed DIF related to Spanish versus English language in a 44-item object naming test. Data come from a community-based sample of 1,755 Spanish- and English-speaking older adults. We compared simultaneous accounting, a new strategy for handling differences in educational attainment across language groups, with existing methods. Compared to other methods, simultaneously accounting for language- and education-related DIF yielded salient differences in some ...

Accurate neuropsychological assessment of older individuals from heterogeneous backgrounds is a major challenge. Education, ethnicity, language, and age are associated with scale level differences in test scores, but item level bias might contribute to these differences. We evaluated several strategies for dealing with item and scale level demographic influences on a measure of executive abilities defined by working memory and fluency tasks. We determined the impact of differential item functioning (DIF). We compared composite scoring strategies on the basis of their relationships with volumetric magnetic resonance imaging (MRI) measures of brain structure. Participants were 791 Hispanic, white, and African American older adults. DIF had a salient impact on test scores for 9% of the sample. MRI data were available on a subset of 153 participants. Validity in comparison with structural MRI was higher after scale level adjustment for education, ethnicity/language, and gender, but item...