Public Health Reports®

Organizational health equity capacity assessments (OCAs) provide a valuable starting point to understand and strengthen an organization’s readiness and capacity for health equity. We conducted a scoping review to identify and characterize existing OCAs.

We searched the PubMed, Embase, and Cochrane databases and practitioner websites to identify peer-reviewed and gray literature articles and tools that measure or assess health equity–related capacity in public health organizations. Seventeen OCAs met the inclusion criteria. We organized primary OCA characteristics and implementation evidence and described them thematically according to key categories.

All identified OCAs assessed organizational readiness or capacity for health equity, and many aimed to guide health equity capacity development. The OCAs differed in regard to thematic focus, structure, and intended audience. Implementation evidence was limited.

By providing a synthesis of OCAs, these findings can assist public health organizations in selecting and implementing OCAs to assess, strengthen, and monitor their internal organizational capacity for health equity. This synthesis also fills a knowledge gap for those who may be considering developing similar tools in the future.

Parental leave and breastfeeding breaks influence the ability to initiate and continue breastfeeding. We investigated how eligibility criteria in the Family and Medical Leave Act (FMLA) and Affordable Care Act (ACA) affect access to unpaid parental leave and breastfeeding breaks and assessed affordability and alternative policy models.

We used family income data to assess the affordability of unpaid leave by race and ethnicity. We used 2017-2018 US Current Population Survey data to determine the percentage of private sector workers aged 18-44 years who met the minimum hour (1250 hours of work during a 12-month period), tenure (12 months), and firm size (≥50 employees) requirements of FMLA and ACA. We analyzed eligibility by gender, race and ethnicity, and age. We also examined parental leave and breastfeeding break policies in 193 countries.

Most Latinx (66.9%), Black (60.2%), and White (55.3%) workers were ineligible and/or unlikely to be able to afford to take unpaid FMLA leave. Of 69 534 workers, more women (16.9%) than men (10.3%) did not meet the minimum hour requirement. Minimum tenure excluded 23.7% of all workers and 42.2% of women aged 18-24 years. Minimum firm size excluded 30.3% of all workers and 37.7% of Latinx workers. Of 27 520 women, 28.8% (including 32.9% of Latina women) were excluded from ACA breastfeeding breaks because of firm size. Nearly all other countries guaranteed mothers paid leave regardless of firm size or minimum hours and guaranteed ≥6 months of paid leave or breastfeeding breaks.

Adopting a comprehensive, inclusive paid parental leave policy and closing gaps in breastfeeding break legislation would remove work-related barriers to breastfeeding; reduce racial, ethnic, and gender inequities; and align US national policies with global norms.

To help understand whether decreased emergency medical services (EMS) utilization due to the COVID-19 pandemic contributed to increased accidental fatal drug overdoses, we characterized recent EMS utilization history among people who had an accidental opioid-involved fatal drug overdose in Rhode Island.

We identified accidental opioid-involved fatal drug overdoses among Rhode Island residents that occurred from January 1, 2018, through December 31, 2020. We linked decedents by name and date of birth to the Rhode Island EMS Information System to obtain EMS utilization history.

Among 763 people who had an accidental opioid-involved fatal overdose, 51% had any EMS run and 16% had any opioid overdose–related EMS run in the 2 years before death. Non-Hispanic White decedents were significantly more likely than decedents of other races and ethnicities to have any EMS run (P < .001) and any opioid overdose–related EMS run (P = .05) in the 2 years before death. Despite a 31% increase in fatal overdoses from 2019 through 2020, corresponding with the onset of the COVID-19 pandemic, EMS utilization in the prior 2 years, prior 180 days, or prior 90 days did not vary by time frame of death.

In Rhode Island, decreased EMS utilization because of the COVID-19 pandemic was not a driving force behind the increase in overdose fatalities observed in 2020. However, with half of people who had an accidental opioid-involved fatal drug overdose having an EMS run in the 2 years before death, emergency care is a potential opportunity to link people to health care and social services.

Reports on recent mortality trends among adults aged ≥65 years are lacking. We examined trends in the leading causes of death from 1999 through 2020 among US adults aged ≥65 years.

We used data from the National Vital Statistics System mortality files to identify the 10 leading causes of death among adults aged ≥65 years. We calculated overall and cause-specific age-adjusted death rates and then calculated the average annual percentage change (AAPC) in death rates from 1999 through 2020.

The overall age-adjusted death rate decreased on average by 0.5% (95% CI, −1.0% to −0.1%) per year from 1999 through 2020. Although rates for 7 of the top 10 causes of death decreased significantly, the rates of death from Alzheimer disease (AAPC = 3.0%; 95% CI, 1.5% to 4.5%) and from unintentional injuries (AAPC = 1.2%; 95% CI, 1.0% to 1.4%), notably falls (AAPC = 4.1%; 95% CI, 3.9% to 4.3%) and poisoning (AAPC = 6.6%; 95% CI, 6.0% to 7.2%), increased significantly.

Public health prevention strategies and improved chronic disease management may have contributed to decreased rates in the leading causes of death. However, longer survival with comorbidities may have contributed to increased rates of death from Alzheimer disease and unintentional falls.

Mammography is a screening tool for early detection of breast cancer. Uptake in screening use in states can be influenced by Medicaid coverage and eligibility policies, public health outreach efforts, and the Centers for Disease Control and Prevention–funded National Breast and Cervical Cancer Early Detection Program. We described state-specific mammography use in 2020 and changes as compared with 2012.

We estimated the proportion of women aged ≥40 years who reported receiving a mammogram in the past 2 years, by age group, state, and demographic and socioeconomic characteristics, using 2020 Behavioral Risk Factor Surveillance System data. We also compared 2020 state estimates with 2012 estimates.

The proportion of women aged 50-74 years who received a mammogram in the past 2 years was 78.1% (95% CI, 77.4%-78.8%) in 2020. Across measures of socioeconomic status, mammography use was generally lower among women who did not have health insurance (52.0%; 95% CI, 48.3%-55.6%) than among those who did (79.9%; 95% CI, 79.3%-80.6%) and among those who had a usual source of care (49.4%; 95% CI, 46.1%-52.7%) than among those who did not (81.0%; 95% CI, 80.4%-81.7%). Among women aged 50-74 years, mammography use varied across states, from a low of 65.2% (95% CI, 61.4%-69.0%) in Wyoming to a high of 86.1% (95% CI, 83.8%-88.3%) in Massachusetts. Four states had significant increases in mammography use from 2012 to 2020, and 8 states had significant declines.

Mammography use varied widely among states. Use of evidence-based interventions tailored to the needs of local populations and communities may help close gaps in the use of mammography.

Before the 2017-2018 school year, Pennsylvania shortened the grace period for provisional entrants—kindergarteners who are not up-to-date on vaccination and do not have medical or nonmedical exemption—from 8 months to 5 days. We analyzed the impact of this change on school-entry vaccination status.

Using data from the Pennsylvania Department of Health for school years 2015-2016 through 2018-2019, we examined state-level trends in Pennsylvania kindergarteners’ vaccination status, including the percentage who were up-to-date on each required vaccine, provisionally enrolled, medically exempted from vaccination, and nonmedically exempted from vaccination. Using the Spearman correlation coefficient, we assessed associations at the school level among changes in kindergarteners’ vaccination status after the grace period was shortened.

From 2016-2017 to 2017-2018, the provisional entrance rate of kindergarteners in Pennsylvania decreased substantially after the change in the grace period (from 8.1% to 2.2%), the medical exemption rate remained stable, and the nonmedical exemption rate increased slightly (from 1.8% to 2.5%). The percentage of kindergarteners up-to-date on required vaccines increased or remained stable across the study period except for polio, which decreased from 97.9% in 2015-2016 to 96.2% in 2018-2019. The change in provisional entrance rate was negatively associated with change in kindergarteners up-to-date on required vaccines (ρ range, −0.30 to −0.70) but not with change in medical or nonmedical exemptions (ρ range, −0.01 to −0.08).

Efforts to reduce provisional entrants may increase the percentage of kindergarteners up-to-date on vaccinations at school entry without a corresponding increase in exemptions.

Timely data on drug overdose deaths can help identify community needs, evaluate the effectiveness of interventions, and allocate resources. We identified variations in death investigation and reporting systems within and between states that affect the timeliness and accuracy of death certificate information.

The HEALing Communities Study (HCS) is a community-engaged, data-driven approach to combating the opioid crisis in 67 communities in 4 states: Kentucky, Massachusetts, New York, and Ohio. HCS conducted a survey of coroners and medical examiners to understand variability in drug overdose death data. We compared survey results in Massachusetts, New York, and Ohio with national data to investigate the completeness of provisional death counts by type of death investigation system.

Communities in each HCS state had different ways of collecting and reporting mortality data. Completion of death certificates for drug overdoses ranged from <2 weeks in 23% (7 of 31) of those surveyed to more than 3 months in 10% (3 of 31) of those surveyed. Variabilities in the timeliness of reporting drug overdose deaths were not associated with type of coroner or medical examiner office in each state, urban versus rural setting, or specificity of drug information on the death certificate.

Having specific drug information on the death certificate may increase death certificate quality, comparability, and accuracy. We recommend the following: (1) all coroners and medical examiners should be trained on conducting death investigations, interpreting toxicology reports, and completing death certificates; (2) 1 office in each state should oversee all coroners and medical examiners to increase data consistency; and (3) communities should identify and address barriers to timely death certification.

On September 23, 2019, the North Carolina Division of Public Health identified a legionellosis increase in western North Carolina; most patients had recently attended the North Carolina Mountain State Fair. We conducted a source investigation.

Cases were fair attendees with laboratory-confirmed legionellosis and symptom onset within 2 to 14 days (Legionnaires’ disease) or ≤3 days (Pontiac fever). We conducted a case-control study matching cases to non-ill fair attendees as control participants and an environmental investigation, and we performed laboratory testing (Legionella bacteria culture and polymerase chain reaction) of 27 environmental samples from fairgrounds and hot tubs and 14 specimens from case patients. We used multivariable unconditional logistic regression models to calculate adjusted odds ratios for potential Legionella exposure sources and risk factors.

Of 136 people identified with fair-associated legionellosis, 98 (72%) were hospitalized and 4 (3%) died. Case patients were more likely than control participants to report walking by hot tub displays (adjusted odds ratio = 10.0; 95% CI, 4.2-24.1). Complete hot tub water treatment records were not kept, precluding evaluation of water maintenance conducted on display hot tubs. Legionella pneumophila sequence types (STs) were consistent among 10 typed clinical specimens (ST224) but distinct from the only positive environmental sample from the fair (ST7 and ST8).

Hot tub displays were identified as the most likely outbreak source, making this the largest hot tub–associated Legionnaires’ disease outbreak worldwide. Following the investigation, the North Carolina Division of Public Health and the Centers for Disease Control and Prevention released guidance on mitigating risk of Legionella exposure from hot tub displays. Results highlight the importance of properly maintaining equipment that aerosolizes water, including hot tubs intended for display purposes only.

The opioid epidemic has led to a surge in diagnoses of neonatal opioid withdrawal syndrome (NOWS). Many states track the incidence of NOWS by using the P96.1 International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code for “neonatal withdrawal symptoms from maternal use of drugs of addiction.” In October 2018, an ICD-10-CM code for neonatal opioid exposure (P04.14) was introduced. This code can be used when an infant is exposed to opioids in utero but does not have clinically significant withdrawal symptoms. We analyzed the effect of the P04.14 code on the incidence rate of NOWS (P96.1) and “other” neonatal drug exposure diagnoses (P04.49).

We used private health insurance data collected for infants in the United States from the first quarter of 2016 through the third quarter of 2021 to describe incidence rates for each code over time and examine absolute and percentage changes before and after the introduction of code P04.14.

The exclusive use of code P96.1 declined from an incidence rate per 1000 births of 1.08 in 2016-2018 to 0.70 in 2019-2021, a −35.7% (95% CI, −47.6% to −23.8%) reduction. Use of code P04.49 only declined from an incidence rate of 2.34 in 2016-2018 to 1.64 in 2019-2021, a −30.0% (95% CI, −36.4% to −23.7%) reduction. Use of multiple codes during the course of treatment increased from an average incidence per 1000 births of 0.56 in 2016-2018 to 0.79 in 2019-2021, a 45.5% (95% CI, 24.8%-66.1%) increase.

The introduction of ICD-10-CM code P04.14 altered the use of other neonatal opioid exposure codes. The use of multiple codes increased, indicating that some ambiguity may exist about which ICD-10-CM code is most appropriate for a given set of symptoms.

Inpatient vaccination is an opportunity to increase vaccine uptake among patients at high risk for severe COVID-19 illness. We designed and implemented a hospital-based COVID-19 vaccination program with the aim of increasing documentation of vaccine eligibility and COVID-19 vaccination to eligible inpatients before discharge.

We integrated a templated note into the electronic medical records and trained health care personnel to screen inpatients and document COVID-19 vaccine eligibility at the Atlanta Veterans Affairs Medical Center. Vaccination staff deployed to inpatient wards administered the vaccine to eligible and consenting patients at the bedside. We calculated the number of inpatients whose vaccine eligibility was assessed and documented during a 4-week period after health care personnel were trained. We used the Wald χ² test to compare the proportion of eligible patients who were vaccinated before discharge 4 weeks before (March 29–April 23, 2021) and 4 weeks after (May 3-28, 2021) the training period.

During the 4 weeks before the training period, COVID-19 vaccine eligibility was not routinely assessed and documented. Of 793 inpatients discharged during the 4 weeks after the training period, 470 (59%) had COVID-19 vaccine eligibility documented. Of 86 patients who were eligible for vaccination, 61 (71%) received COVID-19 vaccination before discharge. COVID-19 vaccination rates during hospitalization increased significantly from 16 of 769 inpatients (2%) during the 4 weeks before training to 61 of 793 inpatients (8%) during the 4 weeks after training (P < .001).

An inpatient vaccination program that integrated COVID-19 vaccination into discharge planning increased vaccine screening and uptake. Future studies are needed to identify barriers to vaccination and strategies to increase vaccine uptake among those who are hesitant.

Public health agencies have a critical role in providing effective messaging about mitigation strategies during a public health emergency. The objectives of this study were (1) to understand perceptions of COVID-19 vaccines, including concerns about side effects, safety, and effectiveness and how these perceptions influence vaccine decision-making among US adults and (2) to learn what messages might motivate vaccine uptake.

In April and May 2021, we conducted 14 online focus groups with non-Hispanic English-speaking and English- and Spanish-speaking Hispanic adults (N = 99) not vaccinated against COVID-19. We oversampled adults aged 18-39 years and rural residents and systematically assessed 10 test messages. Researchers used a standardized guide and an a priori codebook for focus group discussions, coding transcripts, and thematic analysis.

Vaccine hesitancy factors included fear of the unknown; long-term side effects, including infertility; and beliefs that the vaccines were developed too quickly and were not sufficiently effective. Motivating factors for receiving vaccination included the ability to safely socialize and travel. Health care providers were considered important trusted messengers. Participants were critical of most messages tested. Messages that came across as “honest” about what is not yet known about COVID-19 vaccines were perceived more positively than other messages tested. Messages were seen as ineffective if perceived as vague or lacking in data and specificity.

Messages that were simple and transparent about what is unknown about vaccines relative to emerging science were viewed most favorably. Health care providers, friends, and family were considered influential in vaccination decision-making. Findings underscore the benefits of research-informed strategies for developing and disseminating effective messages addressing critical issues in a public health emergency.

The COVID-19 pandemic led to widespread fear of infection, with many people expanding their use of cleaning products and trying unproven prevention and treatment strategies. We described shifts in reported exposures related to COVID-19 home interventions.

This study considered suspected toxicity exposures involving household cleaning products (bleach, peroxide, disinfectants), antimalarials (hydroxychloroquine and chloroquine), and ivermectin reported to the California Poison Control System from 2015 through 2021 and assessed trends in exposures by using interrupted time-series analyses.

We found a significant increase in exposures reported to the California Poison Control System related to household cleaning products and ivermectin during the COVID-19 pandemic. As of January 1, 2015, the baseline level of reported exposures to household cleaning products was 707.33 per month and was declining at a rate of 1.71 (95% CI, –2.87 to –0.56) per month through February 29, 2020. In March 2020, an increase of 466.57 (95% CI, 328.08-605.07) reported exposures above baseline occurred, after which exposures to cleaning products decreased at a rate of 23.40 (95% CI, –32.48 to –14.32) per month. The number of reported exposures to antimalarials did not change significantly before or during the pandemic. The number of reported ivermectin exposures before December 2020 was initially stable at 14.50 per month and then increased by 2.05 per month through December 2021.

Our observations suggest that while some dangerous home prevention and treatment efforts resolve over time, further interventions may be needed to reduce the public health effects related to attempts to self-treat COVID-19 with ivermectin.

Substantial data on COVID-19–related morbidity and mortality among medically underserved populations are available, yet data on the social impact of the COVID-19 pandemic among immigrants in the United States are limited. We identified COVID-19–related health and social disparities among US immigrants.

We analyzed predictors of COVID-19–related health and social outcomes (including ever had or thought had COVID-19, vaccine uptake, risk-reduction behaviors, job loss, childcare difficulties, and difficulty paying rent) during the pandemic by citizenship status, using data from the 2021 California Health Interview Survey. The overall sample size included 24 453 US-born citizens, naturalized citizens, and noncitizens aged ≥18 years. We examined relationships between sociodemographic variables, including immigration-related factors, and COVID-19–related health and social outcomes using descriptive, bivariate, and multivariate logistic regression analysis.

When accounting for sociodemographic characteristics, noncitizens had higher odds than naturalized and US-born citizens of experiencing challenges during the COVID-19 pandemic, including difficulty paying rent (adjusted odds ratio [aOR] = 1.54; 95% CI, 1.47-2.42) and job loss (aOR = 1.43; 95%, CI, 1.14-1.79). At the bivariate level, noncitizens had the highest rate of ever had or thought had COVID-19 (24.7%) compared with US-born citizens (20.8%) and naturalized citizens (16.8%; all P < .001). Noncitizens also had a significantly higher likelihood of risk-reduction behaviors (eg, always wearing a face covering, getting vaccinated if available) than US-born citizens (P < .001).

These findings reveal the disproportionate impact of the COVID-19 pandemic among noncitizens and reflect limited socioeconomic resources, limited access to health care, and precarious employment among noncitizens in California during the pandemic. Citizenship status should be considered a critical immigration-related factor when examining disparities among immigrant populations.

Program evaluation is an essential function for public health professionals that is necessary to acquire funding for public health programs and support evidenced-based practice, but coverage of program evaluation principles and methodology within the master of public health (MPH) curriculum is inconsistent and may not adequately prepare students to conduct program evaluation activities postgraduation, especially on culturally responsive program evaluation. We examined the effectiveness of an online training course on program evaluation topics.

In July 2021, we recruited current and recently graduated MPH students from accredited US universities to measure the effectiveness of a 1-hour online training course in program evaluation. We distributed pre- and postsurveys to eligible participants. We assessed program evaluation skills on a 4-point Likert scale to determine improvements in knowledge (from 4 = extremely knowledgeable to 1 = not knowledgeable), attitudes (from 4 = strongly agree to 1 = strongly disagree), and self-efficacy (from 4 = strongly agree to 1 = strongly disagree).

Among 80 MPH students who completed the survey, respondents indicated mean (SD) increases from presurvey to postsurvey in knowledge (from 2.13 [0.66] to 3.24 [0.54]) and attitudes (from 3.61 [0.51] to 3.84 [0.30]) toward program evaluation and in self-efficacy in conducting program evaluation (from 2.92 [0.71] to 3.44 [0.52]).

The course may be an effective approach for training public health professionals about program evaluation. Our results provide a basis for revising the way program evaluation is taught and practical recommendations for integrating program evaluation competencies within public health curricula, such as by incorporating a self-paced training course for continuing education.