Public Health Reports®

In Colorado, legalization of recreational marijuana in 2014 increased public access to marijuana and might also have led to an increase in emergency department (ED) visits. We examined the validity of using syndromic surveillance data to detect marijuana-associated ED visits by comparing the performance of surveillance queries with physician-reviewed medical records.

We developed queries of combinations of marijuana-specific International Classification of Diseases, Tenth Revision (ICD-10) diagnostic codes or keywords. We applied these queries to ED visit data submitted through the Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE) syndromic surveillance system at 3 hospitals during 2016-2017. One physician reviewed the medical records of ED visits identified by ≥1 query and calculated the positive predictive value (PPV) of each query. We defined cases of acute adverse effects of marijuana (AAEM) as determined by the ED provider’s clinical impression during the visit.

Of 44 942 total ED visits, ESSENCE queries detected 453 (1%) as potential AAEM cases; a review of 422 (93%) medical records identified 188 (45%) true AAEM cases. Queries using ICD-10 diagnostic codes or keywords in the triage note identified all true AAEM cases; PPV varied by hospital from 36% to 64%. Of the 188 true AAEM cases, 109 (58%) were among men and 178 (95%) reported intentional use of marijuana. Compared with noncases of AAEM, cases were significantly more likely to be among non-Colorado residents than among Colorado residents and were significantly more likely to report edible marijuana use rather than smoked marijuana use (P < .001).

ICD-10 diagnostic codes and triage note keyword queries in ESSENCE, validated by medical record review, can be used to track ED visits for AAEM.

Despite increased awareness of obesity-related health risks and myriad treatment options, obesity still affects more than one-third of persons in the United States and is a substantial public health problem. Studies show that physicians play a key role in obesity prevention and treatment. The objective of this study was to examine the extent to which obesity is diagnosed and treated at the level of patient-physician interaction.

We used data from the National Ambulatory Medical Care Survey (NAMCS), a nationally representative data set of US physician office visits. We estimated the number of obesity diagnoses and prescriptions of weight-loss management solutions (exercise counseling, diet counseling, or weight-loss drugs) in clinical practice from 1996 through 2014. We also calculated rates of obesity diagnosis and compared these rates with national rates of obesity based on body mass index data from the Behavioral Risk Factor Surveillance System (BRFSS) for the same period.

The estimated number of weight gain–related physician office visits increased from 2.3 million in 1996 to a peak of 7.6 million in 2012, and then fell to 4.5 million in 2014. National estimates of obesity diagnoses resulting from physician office visits ranged from 7.1 million in 1996 to 12.7 million in 2014 and substantially outnumbered the estimates for weight gain–related physician office visits throughout the study period. Estimates of exercise counseling and diet counseling and weight-loss medication prescriptions resulting from physician office visits fluctuated over time but never exceeded obesity diagnoses. When compared with national rates of obesity from the BRFSS, rates of obesity diagnoses resulting from physician office visits were substantially lower in the NAMCS (17%-30% vs 1%). National trends for weight-loss medication prescriptions closely mirrored those of weight gain–related physician office visits, even though fluctuations were substantial.

Our results suggest that obesity is largely underdiagnosed and undertreated in clinical encounters. Future studies should investigate the structural changes needed to better engage physicians in obesity prevention and care. Practitioners should also reflect on their biases in treating obesity as a chronic disease.

Social distancing is the practice of restricting contact among persons to prevent the spread of infection. This study sought to (1) identify key features of preparedness and the primary concerns of local public health officials in deciding to implement social distancing measures and (2) determine whether any particular factor could explain the widespread variation among health departments in responses to past outbreaks.

We conducted an online survey of health departments in the United States in 2015 to understand factors influencing health departments’ decision making when choosing whether to implement social distancing measures. We paired survey results with data on area population demographic characteristics and analyzed them with a focus on broad trends.

Of 600 health departments contacted, 150 (25%) responded. Of these 150 health departments, 63 (42%) indicated that they had implemented social distancing in the past 10 years. Only 10 (7%) health departments had a line-item budget for isolation or quarantine. The most common concern about social distancing was public health impact (n = 62, 41%). Concerns about law, politics, finances, vulnerable populations, and sociocultural issues were each identified by 7% to 10% of health departments. We were unable to clearly predict which factors would influence these decisions.

Variations in the decision to implement social distancing are likely the result of differences in organizational authority and resources and in the primary concerns about implementing social distancing. Research and current social distancing guidelines for health departments should address these factors.

The quantity and quality of dietary intake among women of reproductive age has important public health implications for nutritional status during pregnancy. We described dietary intake during the year before pregnancy among a large, diverse group of US mothers.

We examined data from 11 109 mothers who gave birth from 1997 through 2011 and participated in a population-based case-control study, the National Birth Defects Prevention Study, as controls (mothers who had babies without major birth defects). We examined whether subgroups of mothers at elevated risk of adverse pregnancy outcomes were more likely than their reference groups to have high dietary intake (>90th percentile of intake) or low dietary intake (<10th percentile of intake). We examined dietary intake of 22 nutritional factors, which were estimated from responses to a food frequency questionnaire.

Participants who were aged <20, were nulliparous, had <high school diploma or <$20 000 annual household income, were non-Hispanic black, were underweight or obese, did not intend to become pregnant, did not take folic acid–containing vitamin supplements, or smoked had worse dietary intakes than their reference groups. For example, 17.5% of participants aged <20 had a low score on the diet quality index and 5.3% had a high score (vs expected values of 10%). Participants who were aged ≥35, were Hispanic, or had prepregnancy diabetes tended to have better dietary intakes than their reference groups. Maternal overweight and prepregnancy hypertension had few significant associations.

Strategies are needed to ensure optimal nutrition among all childbearing women.

Researchers have identified associations between neighborhood-level factors (eg, income level, tobacco retailer density) and smoking behavior, but few studies have assessed these factors in urban environments. We explored the effect of tobacco retailer density, neighborhood poverty, and housing type (multiunit and public) on smoking in a large urban environment (New York City).

We used data on smoking prevalence and individual sociodemographic characteristics from the 2011-2013 New York City Community Health Survey, data on tobacco retailers from the 2012 New York City Department of Consumer Affairs, data on neighborhood sociodemographic characteristics and population density from the 2009-2013 American Community Survey, and data on multiunit and public housing from the 2012 New York City Primary Land Use Tax Lot Output data set. We used aggregate neighborhood-level variables and ordinary least squares regression, geographic weighted regression, and multilevel models to assess the effects of tobacco retailer density and neighborhood poverty on smoking prevalence, adjusting for sociodemographic characteristics (age, sex, race/ethnicity, and education) and neighborhood population density. We also assessed interactions between tobacco retailer density and poverty and each housing type on smoking.

Neighborhood poverty positively and significantly modified the association between tobacco retailer density and prevalence of neighborhood smoking (β = 0.003, P = .01) when we controlled for population density, sociodemographic characteristics, and types of housing. Neighborhood poverty was positively associated with the prevalence of individual smoking (β = 0.0099, P < .001) when we adjusted for population density, sociodemographic characteristics, and type of housing.

More research is needed to determine all the environmental factors associated with smoking prevalence in a densely populated urban environment.

The objectives of this study were (1) to obtain data on the current status of public health workforce training and the use of the Training Finder Real-Time Affiliate Network (TRAIN), a public health learning management platform, in state health departments, and (2) to use the data to identify organizational features that might be affecting training and to determine barriers to and opportunities for improving training.

We conducted structured interviews in 2014 with TRAIN administrators and performance improvement managers (n = 14) from 7 state health departments that were using TRAIN to determine training practices and barriers to training. We determined key organizational features of the 7 agencies, including training structure, required training, TRAIN administrators’ employment status (full time or part time), barriers to the use and tracking of core competencies in TRAIN, training needs assessment methods, leadership support of training and staff development, and agency interest in applying for Public Health Accreditation Board accreditation.

We identified 4 common elements among TRAIN-affiliated state health departments: (1) underuse of TRAIN as a training tool, (2) inadequate ownership of training within the organization, (3) insufficient valuation of and budgeting for training, and (4) emerging collaboration and changing perceptions about training stimulated by agency preparation for accreditation.

Public health leaders can increase buy-in to the importance of training by giving responsibility for training to a person, centralizing training, and setting expectations for the newly responsible training leader to update training policy and require the use of TRAIN to develop, implement, evaluate, monitor, and report on agency-wide training.

Much of the research on the effects of childhood adversity on mental health has focused on adults. The objective of our study was to examine the individual and cumulative effect of childhood adversity on mental health service use among children.

We used data from the 2011-2012 National Survey of Children’s Health (n = 79 834) to determine the use of mental health services in the past 12 months among children aged 2-17. The independent variables of interest were experiencing any 1 of 9 adverse family experiences (AFEs). We used logistic regression models to determine if each AFE was associated with mental health service use. We also examined AFEs as a continuous measure, representing the number of AFEs (ranging from 0 to 9) that summed them individually, and we examined age-by-AFE and age-by-need interaction terms. We adjusted all models for confounders.

Compared with not experiencing an AFE, experiencing all AFEs was associated with higher odds of mental health service use. Neighborhood violence was associated with the greatest increase in odds of mental health service use (adjusted odds ratio [aOR] = 2.35; 95% confidence interval [CI], 2.00-2.77). When measured as a continuous scale, each additional AFE was associated with higher odds of mental health service use (aOR = 1.33; 95% CI, 1.28-1.37). The effect of AFEs on mental health service use decreased with age.

The observed association between AFEs and use of mental health services may be attributable to more severe or poorly managed mental illness among these children. Efforts are needed to increase access to and quality of mental health care among children affected by AFEs.

Implementation science provides useful tools for guiding and evaluating the integration of evidence-based interventions with standard practice. The objective of our study was to demonstrate the usefulness of applying an implementation science framework—the Consolidated Framework for Implementation Research (CFIR)—to increase understanding of implementation of complex statewide public health initiatives, using the example of Medicaid immediate postpartum long-acting reversible contraception (LARC) policies.

We conducted semistructured telephone interviews with the 13 state teams participating in the Immediate Postpartum LARC Learning Community. We asked teams to describe the implementation facilitators, barriers, and strategies in 8 focus areas of the Learning Community. We audio-recorded and transcribed interviews and then coded each interview according to the domains and constructs (ie, theoretical concepts) of the CFIR.

Cosmopolitanism (ie, networking with external organizations) was the most frequently coded construct of the framework. A related construct was networks and communications (ie, the nature and quality of social networks and formal and informal communications in an organization). Within the construct of cost, state teams identified barriers that were often unable to be overcome. Trialability (ie, ability to test the intervention on a small scale) and engaging champions (ie, attracting and involving persons who dedicate themselves to supporting the intervention in an organization) were among the most salient constructs of the framework and were the sources of many implementation strategies.

State leaders and program staff members may benefit from considering the CFIR domains and constructs in the planning, implementation, and evaluation of complex statewide public health initiatives.