OBJECTIVE:Recreation time provides important opportunities for physical activity, time outdoors, and stress reduction during incarceration, yet little is known about how recreation time policies are documented and implemented in US jails. We documented recreation time policies in Arizona county jails and assessed the degree to which written policies align with operational practices. METHODS:Using a modified policy surveillance approach, we abstracted recreation‑related policies from 14 Arizona jail handbooks. We documented operational practices through structured interviews with administrators from 10 Arizona jails and calculated policy-practice agreements for each county and recreation domain. RESULTS:All handbooks and all interviewed facilities indicated that recreation time was provided. However, detailed policy content varied widely. Recreation time frequency was documented in only 43% of handbooks but was reported in 90% of interviews. Similarly, the duration of recreation time was documented in only 36% of handbooks compared with 100% of interviews. Policy-practice agreement ranged from 100% for recreation availability and location to 10% for equipment availability. No handbook documented physical activity programs, and only 2 facilities reported offering them. CONCLUSIONS:Recreation time policies in Arizona jails are inconsistently documented and often omit essential details, limiting transparency. Improving policy clarity and alignment with practice may enhance equitable access to recreation opportunities for incarcerated individuals.
OBJECTIVES:According to the Centers for Disease Control and Prevention, opioid-related deaths in the United States have increased steadily during the past 20 years, contributing to a major public health emergency. In Nebraska's most populous county, Douglas County, the drug overdose mortality rate nearly doubled from 2015 to 2021. This study assessed the current needs, barriers, and priorities related to opioid use and overdose in Douglas County to inform local response strategies. METHODS:We used a mixed methods explanatory sequential design that included (1) surveys of people with lived and living experience of substance use and their family members or support people and (2) interviews with leaders and staff of community-based organizations in Douglas County. RESULTS:Seventy-three people completed surveys, and 8 community partners participated in qualitative interviews. The main service needs identified were (1) specific treatment options for women with children, (2) primary care providers offering medication-assisted therapy, and (3) peer-run services. In addition, individuals who were recently incarcerated had distinct challenges. A cross-cutting theme was the need for community understanding and education about substance use, particularly as it relates to stigma as a barrier to treatment and to obtaining naloxone. Both survey and qualitative results indicated a need to improve access to naloxone and to strengthen community-level understanding of its use. Unmet social needs, including unstable housing, food insecurity, and transportation barriers, were identified as contributing factors to substance use and to difficulties accessing treatment. CONCLUSIONS:This study identified current community needs and barriers in addressing the opioid crisis in Douglas County. The findings provide guidance for ongoing efforts to reduce opioid-related overdose deaths.
OBJECTIVES:Although smoking is a risk factor for suicide, the role of nicotine dependence is unclear. We evaluated whether the Heavy Smoking Index (HSI) could serve as a brief screening tool to identify Korean adults at elevated risk of suicidal ideation, suicide planning, and suicide attempts in population health settings. METHODS:We analyzed data from the 2019 and 2022 Korea National Health and Nutrition Examination Survey using multivariable logistic regression to estimate adjusted odds ratios (AORs) for suicidal ideation, suicide planning, and suicide attempts by smoking status and HSI-defined nicotine dependence. RESULTS:Among 9321 participants aged ≥19 years, 4.7% reported suicidal ideation, 1.1% had a suicide plan, and 0.5% had attempted suicide. Compared with nonsmokers, smokers had higher odds of suicidal ideation (AOR = 1.75; 95% CI, 1.33-2.31) and suicide planning (AOR = 3.33; 95% CI, 1.99-5.58); the odds of suicide attempts were not significantly higher (AOR = 1.17; 95% CI, 0.53-2.59). Among current smokers, higher HSI-defined nicotine dependence was associated with greater risk of suicidal ideation and suicidal planning, consistent with a dose-response relationship across dependence levels. CONCLUSIONS:Nicotine dependence influenced suicidal behaviors beyond smoking status alone, supporting the integration of targeted cessation programs into national suicide prevention frameworks. Future longitudinal studies with biochemical assessment should clarify the underlying causal pathways.
Implementing best practice guidelines for diabetes and cardiovascular comorbidities is important to reduce the risk of complications for people with type 2 diabetes. The T1D Exchange Quality Improvement Collaborative (T1DX-QI) established a type 2 diabetes quality improvement (T2D-QI) program to reduce cardiovascular risk for people with type 2 diabetes by improving glucose, blood pressure, and lipid management initiation. The program began in 2019 with an adult endocrine center in the Northeast and a primary care center on the West Coast. In 2023, a new equity-focused type 2 diabetes intervention began with 3 adult endocrine centers on the East Coast, with an aim to increase access to and use of continuous glucose monitors. In 2023, 4 primary care centers focused on improving screening measures for adults with type 2 diabetes, prioritizing glycated hemoglobin A1 c , blood pressure, lipid, and urine albumin-to-creatinine ratio. Each clinic received training in quality improvement (QI) methodology and coaching from QI consultants to develop initiatives tailored to the needs of their clinics. Lessons gathered through qualitative interviews and reports included the importance of training the clinical team in QI methodology; adopting lower effort, higher impact interventions to build momentum and cultivate confidence and engagement among clinical teams; obtaining timely data updates; and engaging partners who could champion the work, influence practice, and navigate system complexities. The expansion of T1DX-QI to include type 2 diabetes demonstrated that standardized QI training and interventions developed through a data-driven iterative process and delivered through multidisciplinary teams can be successful.
Objectives: Numerous nonclinical health factors such as housing and access to services shape public health outcomes and are essential for understanding and addressing population needs. National initiatives, including the United States Core Data for Interoperability (USCDI), aim to standardize data collection and improve data sharing across health care and public health systems. Dataset quality is critical for reliable decision-making and patient care. However, challenges in limited validation, fragmentation, and integration issues remain. This study assessed the quality of national public health datasets and evaluated their alignment with USCDI. Methods: An interdisciplinary public health informatics team analyzed 5 datasets across social, economic, education, physical, and health services domains during 2024-2025. The research team examined data quality using 6 metrics: completeness, uniqueness, accuracy, timeliness, consistency, and conformity. Results: The analysis revealed high levels of completeness (100%) and uniqueness (100%) for a subset of USCDI-mapped elements across most datasets; however, other data quality metrics (accuracy, timeliness, and conformity) could not be uniformly assessed because of dataset characteristics and limited gold-standard reference values. We developed a publicly accessible toolkit to support informaticists and data scientists in creating dataset quality metrics and advancing alignment. Conclusion: This study underscores the role of data standards in strengthening public health data quality through improved alignment. The toolkit may serve as a practical resource for aligning datasets with USCDI and enhancing reliability for public health analysis. Future research linking public health and clinical data could advance interoperability and promote health equity.
Objectives: Most people with opioid use disorder (OUD) do not receive effective treatments despite their existence. The OUD cascade of care framework can be used to inform quality improvement efforts to address this gap, but data access and linkage requirements may limit its use. We sought to adapt the framework under the constraints of electronic health record data and identify patient populations at risk for OUD treatment discontinuity. Materials and Methods: We extracted data on patients with OUD from the Los Angeles County Department of Health Services from July 2022 through June 2023. We adapted the cascade of care to include probable OUD diagnosis, receipt of naloxone prescription, and receipt of ≥1 and ≥2 buprenorphine prescriptions. We then stratified and conducted statistical analyses for associations by sex, race and ethnicity, and facility type (inpatient, primary care, emergency, or urgent care). Results: Of 3881 patients identified with probable OUD, 49% received a naloxone prescription and 30% and 17% had ≥1 and ≥2 buprenorphine prescriptions, respectively, in 1 year. Non-Hispanic Black and Hispanic patients were less likely to receive buprenorphine prescriptions than were non-Hispanic White patients and patients of other or unknown race and ethnicity. We observed larger gaps in care between receipt of ≥1 and ≥2 buprenorphine prescriptions for patients using urgent care and emergency departments compared with patients in other settings. Practice Implications: This study illustrates substantial gaps between OUD diagnosis and treatment. This adapted framework for the OUD cascade of care can serve as a quality-monitoring tool to aid clinicians and health care administrators in narrowing the treatment gap for people with OUD.
OBJECTIVES:Cardiovascular health during adolescence can shape cardiovascular disease risk later in life. We examined the association between frequent social media use and cardiovascular health among US high school students. METHODS:We used data from the 2023 national Youth Risk Behavior Survey to create cardiovascular health metrics based on the American Heart Association's Life's Essential 8 construct (range, 0-100), with a higher score representing better cardiovascular health. Metrics included diet, physical activity, nicotine exposure, sleep health, body mass index, and an overall cardiovascular health score. We dichotomized social media use as frequent social media use versus infrequent social media use/nonuse. Linear regression estimated the association between social media use and cardiovascular health metrics by sex, adjusting for grade and race and ethnicity. RESULTS:Frequent social media use was associated with significantly lower mean scores for overall cardiovascular health (female: β = -5.3; 95% CI, -7.5 to -3.1; male: β = -3.6; 95% CI, -5.3 to -1.9), diet (female: β = -9.3; 95% CI, -12.1 to -6.5; male: β = -6.4; 95% CI, -9.2 to -3.5), and nicotine exposure (female: β = -11.9; 95% CI, -17.1 to -6.8; male: β = -10.7; 95% CI, -14.8 to -6.6) compared with infrequent/nonuse. Among male students only, frequent social media use was associated with a significantly higher mean physical activity score (β = 4.4; 95% CI, 0.6 to 8.2) but a lower mean sleep health score (β = -4.8; 95% CI, -8.3 to -1.3). CONCLUSIONS:Future studies could examine the mechanisms linking frequent social media use with cardiovascular health among adolescents to better inform prevention strategies.
OBJECTIVES:Homelessness is a complex issue associated with numerous health inequalities, including eye impairments, yet the prevalence of cataract among adults experiencing homelessness is poorly understood. We determined the prevalence of cataract among people experiencing homelessness, with a primary focus on adults, and summarized key demographic characteristics of the study populations. METHODS:We conducted a systematic review on the prevalence of cataract among adults experiencing homelessness. We searched 4 databases-MEDLINE, Scopus, Web of Science, and CINAHL-for studies conducted worldwide and published from 1960 through 2024. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and used predefined search terms related to homelessness and cataract. RESULTS:The final review included 10 studies in which cataract prevalence was assessed through either full ophthalmologic screening or clinical examination. The reported prevalence of cataract ranged from 1.0% (1 of 100) in a UK-based study to 28.6% (26 of 91) in a US-based study. Of the 10 included studies, 9 were cross-sectional and 1 was a cohort study, with mean participant ages ranging from 30.3 to 55.1 years. CONCLUSION:This systematic review summarizes the available evidence on cataract among people experiencing homelessness. Findings highlight gaps in the literature and directions for future research to improve eye health in this population.
Excessive alcohol use is a leading cause of preventable morbidity and mortality in the United States, causing 117 000 deaths from chronic causes and 61 000 deaths from acute causes each year. Local health departments may find it challenging to assess the local impacts of excessive alcohol use, limiting their ability to mount an effective public health response to mitigate related harms. We leveraged the Centers for Disease Control and Prevention's Alcohol-Related Disease Impact (ARDI) application (app) to estimate the average annual number of alcohol-attributable deaths (AADs) and resulting years of potential life lost (YPLL) by age group, sex, and race and ethnicity in Franklin County, Ohio, from 2022 through 2024. The ARDI app allows users to create and upload custom prevalence and mortality datasets to estimate local alcohol-attributable fractions, AADs, and YPLL for 58 underlying causes of death related to excessive alcohol use. On average, there were 680 deaths and 17 597 YPLL per year in Franklin County from 2022 through 2024. The average annual mortality rate per 100 000 residents for AADs was 50.7, which was similar to the mortality rate for drug overdoses in Franklin County in 2023 (51.6). These findings provide important context for local public health professionals and policymakers and provide a foundation for further assessment and public health response. Our use of the ARDI app at the local level may also be of interest to other local health departments that wish to study the impact of excessive alcohol use in their jurisdictions.
OBJECTIVES:Medical debt is a challenge for US veterans. Depending on eligibility, some veterans receive care outside the US Department of Veterans Affairs (VA) system through private health care providers, where out-of-pocket costs may be higher. We examined whether access to VA health care and TRICARE coverage (vs other types of health coverage) was associated with lower rates of medical debt and cost avoidance among veterans. METHODS:This cross-sectional study used data from the 2022 National Health Interview Survey and binomial logistic regression models to examine whether access to VA care and TRICARE was associated with a lower likelihood of medical debt or cost avoidance than other types of health coverage. Models controlled for health insurance coverage, income to poverty ratio, urban or rural status, service-related disability, and overall health condition. RESULTS:VA and TRICARE programs (vs other types of health coverage) were associated with a significantly lower likelihood of not seeing a physician (odds ratio [OR] = 0.53 and 0.23, respectively; P < .05), rationing prescriptions (OR = 0.44 and 0.22, respectively; P < .05), and not filling prescriptions (OR = 0.39 and 0.26, respectively; P < .01), but TRICARE performed significantly better and was the only program significantly associated with lower medical debt (OR = 0.37; P = .03). CONCLUSIONS:These findings suggest that health insurance-based coverage may be more effective than direct care at reducing financial barriers for veterans. Policymakers should consider expanding TRICARE eligibility or piloting new VA health insurance programs to address the financial burden veterans face when seeking care outside the VA system.
OBJECTIVES:The rapidly evolving overdose crisis often involves polydrug use. The Toxicology Investigators Consortium (ToxIC) Drug Overdose Toxico-Surveillance (DOTS) Reporting Program aimed to inform the epidemiology of opioid and stimulant overdoses presenting to the emergency department (ED) using structured patient interviews, medical record reviews, and the collection of blood specimens for qualitative analysis and quantitative drug concentrations. MATERIALS AND METHODS:ToxIC implemented DOTS at 17 medical centers in the United States during 2022-2024. ED patients (aged ≥13 y) who presented with a severe or life-threatening opioid and/or stimulant overdose were screened for eligibility and approached for informed consent. The Center for Forensic Science Research and Education conducted analyses using a panel of >1200 substances through liquid chromatography quadrupole time-of-flight mass spectrometry and quantitative measurements using liquid chromatography tandem quadrupole mass spectrometry. We computed descriptive statistics to summarize main outcomes. RESULTS:During the 2-year sentinel surveillance program, 995 patients were included. Seventy percent (n = 694) of patients presented with a clinically suspected opioid overdose, 13.3% (n = 132) with a suspected stimulant overdose, and 17.0% (n = 169) with an undifferentiated overdose. Fentanyl was detected in most (86%; n = 600) patients with an opioid overdose presentation and 35% (n = 46) of patients with a suspected stimulant presentation. The median (range) fentanyl blood concentration in nonfatal overdoses was 4.5 (1.0-140.0) ng/mL. Mortality was 1.0% (n = 10). PRACTICE IMPLICATIONS:The DOTS Reporting Program addressed a gap in public health overdose data by obtaining quantitative blood concentrations and information on the patient's drug use history that are often not captured in traditional surveillance systems. Future work should consider incorporating patient interviews and quantitative concentrations into overdose data collection to elucidate which drug(s) contribute to the overdose.
The Association of Public Health Laboratories, the Centers for Disease Control and Prevention, and Quest Diagnostic Laboratories collaborated to implement a scalable, extensible model for public health reporting that increased electronic laboratory reporting (ELR) for Quest from 3 million reports in 2015 to 17.5 million reports in 2023. This volume represented a 15% increase in US ELR coverage, from 75% to 90% nationwide from 2015 to 2023. As of early 2026, Quest had sent >200 million ELR messages through the Association of Public Health Laboratories Informatics Messaging Services (AIMS) platform. AIMS is a public health data exchange intermediary that performs shared services, translation, and transformation and maintains connections with state public health agencies (PHAs) and public health laboratories. Using the AIMS platform to validate and route ELR messages reduced the point-to-point connections that Quest must maintain and the onboarding time to connect to each PHA. By using a single messaging standard to exchange data with >50 PHAs, Quest can maintain these feeds with minimal overhead. In 2020, Quest leveraged this existing connection with AIMS to quickly add COVID-19 to the data feed; as a result, Quest became one of the first private laboratories to send COVID-19 data to state PHAs, the Centers for Disease Control and Prevention, and the US Department of Health and Human Services. We describe this crucial milestone in ELR and the lessons learned through the early stages of the project. This successful public-private partnership has been replicated for other use cases and establishes AIMS as the centralized health information exchange network for public health.
OBJECTIVES:The World Trade Center (WTC) Health Program (hereinafter, Program) provides medical monitoring and treatment for WTC-related health conditions to eligible individuals affected by 9/11. We identified Program members with a respiratory disease (RD) certification and described their characteristics, certifications, and related health care use during 2011-2024. METHODS:We analyzed administrative data on member enrollment, certifications, and medical claims from July 2011 through December 2024. We identified members certified for RD, including WTC-related health conditions within the corresponding care suites of obstructive airway disease, upper respiratory disease, and interstitial lung disease, and we examined related claims to assess health care use and cost. RESULTS:Of 139 970 enrolled Program members, 90 529 (65%) received certification for ≥1 WTC-related health condition, and 53 444 (38%) received certification for RD. Of 39 058 RD-certified responder members, upper respiratory disease was the most common RD certification (82%), while of 14 386 RD-certified survivor members, obstructive airway disease was the most common RD certification (65%). More than 80% of RD-certified members were also certified for other non-RD WTC-related conditions. Since 2016, about 58% of RD-certified members had Program-paid diagnosis or treatment services annually, and 38% to 49% had RD-related diagnosis or treatment services during 2013-2024. Annual overall health care costs increased more rapidly than RD-related health care costs among RD-certified members. CONCLUSIONS:Comorbidity prevalence and health care costs increased among this population of responders and survivors with RD certifications. Ongoing medical monitoring and data collection will help guide policies and interventions.
Cardiovascular disease (CVD) contributes to substantial health and economic burdens. In the United States, nearly half of the adult population (127.9 million in 2020) has 1 or more CVD-related conditions. Effective evidence-based approaches to prevent and treat CVD exist, yet it can take several years to incorporate scientific findings into practice. As a result, many practitioners are unaware of these public health and clinical strategies. To address this gap and reduce the lag between science and practice, the Centers for Disease Control and Prevention launched the Best Practices Clearinghouse for Heart Disease and Stroke Prevention and Management (BPC). The BPC facilitates the widespread implementation of 18 effective strategies for heart disease and stroke prevention and management, and the platform remains flexible and responsive to new evidence as it emerges. To demonstrate the functionality of the BPC and highlight key features of the platform, we present content from 2 strategies as examples: (1) Lifestyle Modification Programs to Control Hypertension, which helps patients increase healthy behaviors and reduce the risk of further complications or declining cardiovascular health, and (2) Cardiac Rehabilitation to Support Recovery From Cardiac Events, which combines physical activity, health education, and counseling to help patients recover after a cardiac event. The BPC uses a unique approach that supports CVD prevention and management by summarizing evidence for strategy effectiveness, policy and law considerations for strategy implementation, the ability to foster user engagement and information sharing through forms to submit feedback and resources, and clear examples of all 18 strategies in action.
An updated varicella case definition and classification from the Council of State and Territorial Epidemiologists became effective in 2024, emphasizing laboratory confirmation by requiring that confirmed cases be laboratory confirmed or epidemiologically linked to a laboratory-confirmed case, in addition to meeting clinical criteria. We assessed the impact of the changes using varicella reports in Minnesota from January 1, 2024, through May 31, 2025. Of 737 reports, 61.2% (n = 451) met the new definition and 61.9% (n = 456) met the old definition; 12.1% (n = 89) changed classifications. The proportion of cases classified as confirmed decreased by 17.5%, while those classified as probable increased by 28.0%; changes were primarily driven by the requirement to link reports to a laboratory-confirmed case. Reports not classified (ie, undefined; 26.9%; n = 198) mostly lacked rash descriptions. The updated definition improves jurisdictions' ability to classify cases accurately, thus strengthening national surveillance by reflecting current varicella epidemiology. Improved reporting of rash description, epidemiologic information, and increased laboratory testing are needed to improve surveillance.
OBJECTIVE:Adolescent substance use is an important public health concern associated with suicidal behaviors. Although parental cohabitation is considered protective, limited is known about its role in the relationship between substance use and suicidality. This study examined differences in suicidal behaviors according to substance use experience and parental cohabitation among Korean adolescents. METHODS:We analyzed data from the 2023 Korea Youth Risk Behavior Web-based Survey (N = 52 880). Participants were categorized by lifetime substance use (ever user vs nonuser) and parental cohabitation (living with parents vs not living with parents). Multivariable logistic regression was used to estimate adjusted odds ratios (AORs) and 95% CIs for suicidal ideation, planning, and attempts, controlling for sociodemographic and behavioral factors. RESULTS:Compared with nonusers living with parents, nonusers not living with parents showed increased odds of suicidal ideation, planning, and attempts (AOR = 1.40, 1.92, and 2.91, respectively). Ever users living with parents also had elevated odds (AOR = 2.67, 6.44, and 11.04, respectively). The highest risks were observed among ever users not living with parents (AOR = 3.46, 8.86, and 37.92, respectively). The prevalence of suicide attempts ranged from 3.0% among nonusers living with parents to 61.9% among ever users not living with parents. CONCLUSION:Substance use and absence of parental cohabitation were independently and jointly associated with increased odds of suicidal behaviors. Adolescents with both risk factors exhibited the greatest vulnerability, highlighting the importance of family support and substance use prevention in suicide prevention efforts.
