Access to global wheat reserves determines country-level vulnerability to conflict-induced Ukrainian wheat supply disruption.

The Russia-Ukraine conflict reduced global wheat supplies, yet the food security implications vary across countries. We identify a 39% decrease in Ukrainian wheat exports in 2022 resulting in >70% import losses in some of the countries most vulnerable to these disruptions, with substantial impacts felt in Egypt, Oman, Saudi Arabia, Libya, Mauritania, Yemen and Lebanon. Differential impacts are a function of access to capital and international trade, suggesting the need for policy measures to defuse the impending food crisis.

Do not transform food systems on the backs of the rural poor.

Even prior to COVID, there was a considerable push for food system transformation to achieve better nutrition and health as well as environmental and climate change outcomes. Recent years have seen a large number of high visibility and influential publications on food system transformation. Literature is emerging questioning the utility and scope of these analyses, particularly in terms of trade-offs among multiple objectives. We build on these critiques of emerging food system transformation approaches in our review of four recent and influential publications from the EAT-Lancet Commission, the IPCC, the World Resources Institute and the Food and Land Use Coalition. We argue that a major problem is the lack of explicit inclusion of the livelihoods of poor rural people in their modeling approaches and insufficient measures to ensure that the nature and scale of the envisioned changes will improve these livelihoods. Unless livelihoods and socioeconomic inclusion more broadly are brought to the center of such approaches, we very much risk transforming food systems to reach environmental and nutritional objectives on the backs of the rural poor.

Prevalence of self-reported memory problems in adults with type 2 diabetes mellitus and cancer in the USA.

PURPOSE: To determine the prevalence of memory problems in individuals with or without a history of DM and cancer and assess possible compounding effects of these diseases on self-reported memory problems (SRMP). METHODS: We used data from the 2009-2018 National Health and Nutrition Examination Survey. We conducted logistic regression analyses to determine the associations among DM, cancer, and SRMP, adjusting for age, sex, race/ethnicity, education, and poverty level. We examined the interaction effects of comorbid DM and cancer on SRMP. We compared participants with both DM and cancer to those with cancer only and to those with no DM or cancer. RESULTS: We included 26,842 adults ≥ 20 years old (N = 3374 with DM, N = 23,468 without DM) and 51.87% female. There were 10,434 Whites, 5730 Blacks, 6795 Hispanics, and 3883 other races/multiracial. More individuals with DM reported memory problems than those without DM (p < 0.0001). More individuals with cancer reported memory problems than those without cancer (p < 0.0001). Of those with both DM and cancer, 14.19% reported memory problems. More individuals with DM had cancer than those without DM (p < 0.0001). Of those with both diseases, 55.75% had DM before the cancer diagnosis. DM (odds ratio[OR] = 1.87, 95%CI, 1.55-2.26) and cancer (OR = 1.81, 95%CI, 1.43-2.30) predicted SRMP. The interaction between DM and cancer was significant, and the likelihood of having both diseases compared to having neither DM nor cancer was OR = 2.09, 95%CI, 1.41 - 3.11. CONCLUSION: Strategies to mitigate SRMP in individuals with comorbid DM and cancer history should consider the impact of both diseases.

Global food systems transitions have enabled affordable diets but had less favourable outcomes for nutrition, environmental health, inclusion and equity.

Over the past 50 years, food systems worldwide have shifted from predominantly rural to industrialized and consolidated systems, with impacts on diets, nutrition and health, livelihoods, and environmental sustainability. We explore the potential for sustainable and equitable food system transformation (ideal state of change) by comparing countries at different stages of food system transition (changes) using food system typologies. Historically, incomes have risen faster than food prices as countries have industrialized, enabling a simultaneous increase in the supply and affordability of many nutritious foods. These shifts are illustrated across five food system typologies, from rural and traditional to industrial and consolidated. Evolving rural economies, urbanization and changes in food value chains have accompanied these transitions, leading to changes in land distribution, a smaller share of agri-food system workers in the economy and changes in diets. We show that the affordability of a recommended diet has improved over time, but food systems of all types are falling short of delivering optimal nutrition and health outcomes, environmental sustainability, and inclusion and equity for all. Six 'outlier' case studies (Tajikistan, Egypt, Albania, Ecuador, Bolivia and the United States of America) illustrate broad trends, trade-offs and deviations. With the integrated view afforded by typologies, we consider how sustainable transitions can be achieved going forward.

Towards food systems transformation-five paradigm shifts for healthy, inclusive and sustainable food systems.

Food systems must serve different societal, public health and individual nutrition, and environmental objectives and therefore face numerous challenges. Considering the integrated performances of food systems, this paper highlights five fundamental paradigm shifts that are required to overcome trade-offs and build synergies between health and nutrition, inclusive livelihoods, environmental sustainability and food system resilience. We focus on the challenges to raise policy ambitions, to harmonize production and consumption goals, to improve connectivity between them, to strengthen food system performance and to anchor the governance of food systems in inclusive policies and participatory institutions. Taken together, these shifts in paradigms shape a new discourse for food system transformation that will be capable to respond to current and future policy challenges.

The household and individual-level productive impacts of cash transfer programs in Sub-Saharan Africa.

Silvio Daidone is a economist and Benjamin Davis is a Strategic Program Leader, both with the Food and Agriculture Organization of the United Nations, Rome, Italy. Sudhanshu Handa is a professor at the University of North Carolina at Chapel Hill. Paul Winters is the Associate Vice-President of the Strategy and Knowledge Department, International Fund for Agricultural Development, Rome, Italy. The research presented in this article has been carried out under the auspices of the "From Protection to Production" (PtoP) project, a collaborative effort of the United Nations Children's Fund, the United Kingdom Department for International Development (DFID) and the Food and Agriculture Organization of the United Nations (FAO). The project has received funding from the DFID Research and Evidence Division, the European Union through the "Improved Global Governance for Hunger Reduction Programme", and the FAO Regular Fund. The authors would like to thank the following: two anonymous reviewers and the journal editor, who have provided excellent comments and significantly contributed to the improvement of the article; Alejandro Grinspun, Fabio Veras Soares, and Marco Knowles for technical review of previous drafts; Ervin Prifti and Noemi Pace for their useful suggestions and comments. The authors are also grateful to participants at the following conferences and workshops: 2017 APPAM International Conference, Brussels; 2016 Transfer Project workshop, Addis Ababa; 2016 IFAD-3IE Designing and implementing high-quality, policy-relevant impact evaluations, Rome; 2015 SASPEN Conference on Social Protection, Johannesburg; 2015 Global Food Security Conference, Ithaca; 2014 IPEA International Seminar "Social protection, entrepreneurship and labor market activation - Evidence for better policies", Brasilia; 2014 University of Florence, Department of Economics & Management Seminars, Florence; 2014 Africa Community of Practice (CoP) on Conditional Cash Transfers and Cash Transfers; 2014 African Union Expert Consultation on Children and Social Protection Systems, Cape Town; 2014 IDS Graduation and Social Protection Conference, Kigali. The authors would also like to remember Josh Dewbre, a founding member of the PtoP team, who passed away in April 2015, who had participated in the fieldwork and in the analysis of several programs included in this study. All mistakes and omissions are those of the authors.

The exclusion from welfare benefits: Resentment and survey attrition in a randomized controlled trial in Mexico.

Public policy programs must often impose limits on who may be eligible for benefits. Despite research on the impact of exclusion in developed countries, there is little evidence on how people react to being excluded from benefits in developing societies. Utilizing repeated waves of data from an experimental evaluation of Mexico's foundational PROGRESA antipoverty program, we examine the impact of exclusion and distinguish two separate forms. "Statistical exclusion" occurs where determination of benefits is based on randomized assignment to a treatment and control group. "Needs-based exclusion" occurs when benefits programs are designed to be selective rather than universal, basing eligibility on characteristics, like relative poverty, that are difficult to measure simply and accurately. Focusing on temporal variation in survey non-response as our behavioral outcome, we show that needs-based exclusion has much greater negative effects on continued participation than statistical exclusion. We also show that these effects are concentrated among the wealthy, that is, those furthest from the eligibility cut-off line. These findings reinforce general concerns about the validity of evaluation studies when incentives are at work. We discuss both the behavioral explanations that might underlie these findings as well as some potential approaches to reduce threats to evaluation validity.

Improving patient-centered communication while using an electronic health record: Report from a curriculum evaluation.

INTRODUCTION: Researchers and clinicians are concerned about the impact of electronic health record use and patient-centered communication. Training about patient-centered clinical communication skills with the electronic health record may help clinicians adapt and remain patient-centered. METHODS: We developed an interactive workshop eliciting challenges and opportunities of working with the electronic health record in clinical practice, introduction of specific patient-centered behaviors and mindful practice techniques, and video demonstrating contrasts in common behavior and "better practices." One hundred thirty-nine resident physicians and faculty supervisors in five residency training programs at the University of Rochester Medical Center participated in the workshops. Participants were asked to complete an 11-item survey of behaviors related to their use of the electronic health record prior to training and after attending training. We used paired t-tests to assess changes in self-reported behavior from pre-intervention to post-intervention. RESULTS: We trained 139 clinicians in the workshops; 110 participants completed the baseline assessment and 39 completed both the baseline and post-intervention assessment. Data from post-curriculum respondents found a statistically significant increase in "I told the patient when turning my attention from the patient to the computer," from 60% of the time prior to the training to 70% of the time after. DISCUSSION: Data from our program evaluation demonstrated improvement in one communication behavior. Sample size limited the detection of other changes; further research should investigate effective training techniques for patient-centered communication while using the electronic health record.

Effect of patient navigation on satisfaction with cancer-related care.

PURPOSE: Despite growing popularity of patient navigation (PN) as a means to improve cancer care quality and reduce cancer-related disparities, there are few well-designed controlled trials assessing the impact of PN on patient outcomes like satisfaction with care. The present controlled study examined effect of PN on satisfaction with cancer-related care. METHODS: Patients who presented with a symptom or abnormal screening test (n = 1788) or definitive diagnosis (n = 445) of breast, cervical, colorectal, or prostate cancer from eight Patient Navigator Research Program sites were included in one of two groups: intervention (PN) or comparison (usual care or usual care plus cancer educational materials). Trained patient navigators met with intervention group participants to help them assess and identify resources to address barriers to cancer diagnostic or treatment care. Using a validated instrument, we assessed participants' satisfaction with their cancer diagnostic or treatment care up to 3 months after diagnostic resolution of a cancer-related abnormality or within 3 months of initiation of cancer treatment. RESULTS: Overall, patients reported high satisfaction with diagnostic care and cancer treatment. There were no statistically significant differences between PN and control groups in satisfaction with cancer-related care (p > 0.05). Hispanic and African American participants were less likely to report high satisfaction with cancer care when compared to White patients. Middle-aged participants with higher education, higher household income, private insurance, owning their own home, working full-time, and those whose primary language is English had higher satisfaction with cancer-related diagnostic care. CONCLUSIONS: PN had no statistically significant effect on patients' satisfaction with cancer-related care. Further research is needed to define the patient populations who might benefit from PN, content of PN that is most useful, and services that might enhance PN. TRIAL REGISTRATIONS: clinicaltrials.gov identifiers: NCT00613275 , NCT00496678 , NCT00375024 , NCT01569672.

Do Lung Cancer Eligibility Criteria Align with Risk among Blacks and Hispanics?

BACKGROUND: Black patients have higher lung cancer risk despite lower pack years of smoking. We assessed lung cancer risk by race, ethnicity, and sex among a nationally representative population eligible for lung cancer screening based on Medicare criteria. METHODS: We used data from the National Health and Nutrition Examination Survey, 2007-2012 to assess lung cancer risk by sex, race and ethnicity among persons satisfying Medicare age and pack-year smoking eligibility criteria for lung cancer screening. We assessed Medicare eligibility based on age (55-77 years) and pack-years (≥ 30). We assessed 6-year lung cancer risk using a risk prediction model from Prostate, Lung, Colorectal and Ovarian Cancer Screening trial that was modified in 2012 (PLCOm2012). We compared the proportions of eligible persons by sex, race and ethnicity using Medicare criteria with a risk cut-point that was adjusted to achieve comparable total number of persons eligible for screening. RESULTS: Among the 29.7 million persons aged 55-77 years who ever smoked, we found that 7.3 million (24.5%) were eligible for lung cancer screening under Medicare criteria. Among those eligible, Blacks had statistically significant higher (4.4%) and Hispanics lower lung cancer risk (1.2%) than non-Hispanic Whites (3.2%). At a cut-point of 2.12% risk for lung screening eligibility, the percentage of Blacks and Hispanics showed statistically significant changes. Blacks eligible rose by 48% and Hispanics eligible declined by 63%. Black men and Hispanic women were affected the most. There was little change in eligibility among Whites. CONCLUSION: Medicare eligibility criteria for lung cancer screening do not align with estimated risk for lung cancer among Blacks and Hispanics. Data are urgently needed to determine whether use of risk-based eligibility screening improves lung cancer outcomes among minority patients.

Assessing Health Literacy in Deaf American Sign Language Users.

Communication and language barriers isolate Deaf American Sign Language (ASL) users from mass media, health care messages, and health care communication, which, when coupled with social marginalization, places them at a high risk for inadequate health literacy. Our objectives were to translate, adapt, and develop an accessible health literacy instrument in ASL and to assess the prevalence and correlates of inadequate health literacy among Deaf ASL users and hearing English speakers using a cross-sectional design. A total of 405 participants (166 Deaf and 239 hearing) were enrolled in the study. The Newest Vital Sign was adapted, translated, and developed into an ASL version (ASL-NVS). We found that 48% of Deaf participants had inadequate health literacy, and Deaf individuals were 6.9 times more likely than hearing participants to have inadequate health literacy. The new ASL-NVS, available on a self-administered computer platform, demonstrated good correlation with reading literacy. The prevalence of Deaf ASL users with inadequate health literacy is substantial, warranting further interventions and research.

Preliminary validation of a scale to measure patient perceived similarity to their navigator.

OBJECTIVE: A central premise in deployment of community health workers (CHW) is that CHWs share key characteristics with their patients. We sought to develop a scale to measure this construct called the Perceived Navigator Similarity (PNS) questionnaire. METHODS: We adopted items from a similarly developed scale, patient perceived similarity to their physicians, and examined its psychometric properties among 51 patients who were navigated for cancer care by a CHW. RESULTS: Principal component analysis revealed two main factors: personal and ethnic. The scale was associated with greater satisfaction with navigation (p < 0.005) and cancer care (p < 0.05). CONCLUSION: The PNS shows promise for further validation in larger samples assessing navigator-patient similarity from the patient perspective.

Emergency Department utilization among Deaf American Sign Language users.

BACKGROUND: Deaf American Sign Language (ASL) users comprise a linguistic minority population with poor health care access due to communication barriers and low health literacy. Potentially, these health care barriers could increase Emergency Department (ED) use. OBJECTIVE: To compare ED use between deaf and non-deaf patients. METHOD: A retrospective cohort from medical records. The sample was derived from 400 randomly selected charts (200 deaf ASL users and 200 hearing English speakers) from an outpatient primary care health center with a high volume of deaf patients. Abstracted data included patient demographics, insurance, health behavior, and ED use in the past 36 months. RESULTS: Deaf patients were more likely to be never smokers and be insured through Medicaid. In an adjusted analysis, deaf individuals were significantly more likely to use the ED (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.11-3.51) over the prior 36 months. CONCLUSION: Deaf American Sign Language users appear to be at greater odds for elevated ED utilization when compared to the general hearing population. Efforts to further understand the drivers for increased ED utilization among deaf ASL users are much needed.

Process Evaluation of Practice-based Diabetes Prevention Programs: What Are the Implementation Challenges?

PURPOSE: The purpose of this report is to describe lessons learned about the feasibility of recruitment and implementation of low-income adults with prediabetes in primary care clinics into diabetes prevention programs. METHODS: Mixed methods process evaluation of a pragmatic 2-group pilot comparative effectiveness study of a community-developed Healthy Living Program (HLP) and a Diabetes Prevention Program (DPP) with 58 adults. RESULTS: Of the total (n = 1215) assessed for eligibility, 7% (n = 92) were randomized, 58 completed the baseline assessment, and 31 completed the intervention. The process evaluation identified difficulty in systematically screening potentially eligible patients. There were several logistic and staffing challenges with program planning and initial start-up. CONCLUSIONS: Addressing challenges to feasibility is required for successful translation of evidence-based programs to clinical settings.

Improving breast and colon cancer screening rates: a comparison of letters, automated phone calls, or both.

PURPOSE: Low-cost interventions to improve cancer screening among primary care patients are needed. The comparative effectiveness of personalized letters, automated telephone calls, and both on breast cancer (BC) and colorectal cancer (CRC) screening is not known. METHODS: A pragmatic, randomized, controlled trial was conducted in 2011 to 2012. Eligible primary care patients were women ages 50 to 74 years who were past due for mammography and men or women who were past due for mammography or CRC screening of any kind (>12 months since last fecal occult blood test, >5 years since last sigmoidoscopy/double-contrast barium enema, or >10 years since last colonoscopy), respectively. Participants were randomized to 1 of 3 interventions: personalized mailed letters, automated telephone calls, or both. The primary outcome was medical record documentation of a completed mammogram or CRC screening within 36 weeks of randomization. We estimated the costs of each intervention and calculated the marginal cost-effectiveness per person screened. RESULTS: The crude screening rates for BC were 19%, 22%, and 37% and for CRC were 17%, 14%, and 24% for the letter, automated call, and combined (letter/automated call) groups, respectively. The combined intervention group had a statistically higher screening rate (P < .05) compared with either of the single intervention groups (letter only or automated call) for both BC and CRC in both the crude and adjusted analyses. The combined intervention costs $5.11 per additional person screened for BC and $13.14 per additional person screened for CRC. CONCLUSION: In a primary care practice, letters plus automated telephone calls are better than either alone in increasing cancer screening rates among patients who are overdue for screening. These findings suggest the promise of a relatively inexpensive intervention to improve cancer screening.

Do clinicians recommend aspirin to patients for primary prevention of cardiovascular disease?

BACKGROUND: The United States Preventive Services Task Force (USPSTF) released updated guidelines in 2009 recommending aspirin to prevent myocardial infarction among at-risk men and stroke among at-risk women. OBJECTIVE: Our aim was to examine clinician aspirin recommendation among eligible persons based on cardiovascular risk scores and USPSTF cutoffs. DESIGN: We used across-sectional analysis of a current nationally representative sample. PARTICIPANTS: Participants were aged 40 years and older, and in the National Health and Nutrition Examination Survey (NHANES) (2011-2012). MAIN MEASURES: We determined aspirin eligibility for cardiovascular disease (CVD) prevention for each participant based on reported and assessed cardiovascular risk factors. We assessed men's risk using a published coronary heart disease risk calculator based on Framingham equations, and used a similar calculator for stroke to assess risk for women. We applied the USPSTF risk cutoffs for sex and age that account for offsetting risk for gastrointestinal hemorrhage. We assessed clinician recommendation for aspirin based on participant report. RESULTS: Among men 45-79 years and women 55-79 years, 87 % of men and 16 % of women were potentially eligible for primary CVD aspirin prevention. Clinician recommendation rates for aspirin among those eligible were low, 34 % for men and 42 % for women. Rates were highest among diabetics (63 %), those 65 to 79 years (52 %) or those in poor health (44 %). In contrast, aspirin recommendation rates were 76 % for CVD secondary prevention. After accounting for patient factors, particularly age, eligibility for aspirin prevention was not significantly associated with receiving a clinician's recommendation for aspirin (AOR 0.99 %; CI 0.7-1.4). CONCLUSIONS: Despite an "A recommendation" from the USPSTF for aspirin for primary prevention of CVD, the majority of men and women potentially eligible for aspirin did not recall a clinical recommendation from their clinician.

Patient navigation moderates emotion and information demands of cancer treatment: a qualitative analysis.

PURPOSE: Patient navigation is increasingly employed to guide patients through cancer treatment. We assessed the elements of navigation that promoted patients' involvement in treatment among patients with breast and colorectal cancer that participated in a navigation study. METHODS: We conducted qualitative analysis of 28 audiotaped and transcribed semi-structured interviews of navigated and unnavigated cancer patients. RESULTS: Themes included feeling emotionally and cognitively overwhelmed and desire for a strong patient-navigator partnership. Both participants who were navigated and those who were not felt that navigation did or could help address their emotional, informational, and communicational needs. The benefits of logistical support were cited less often. CONCLUSIONS: Findings underscore the salience of personal relationships between patients and navigators in meeting patients' emotional and informational needs.

Impact of patient navigation on timely cancer care: the Patient Navigation Research Program.

BACKGROUND: Patient navigation is a promising intervention to address cancer disparities but requires a multisite controlled trial to assess its effectiveness. METHODS: The Patient Navigation Research Program compared patient navigation with usual care on time to diagnosis or treatment for participants with breast, cervical, colorectal, or prostate screening abnormalities and/or cancers between 2007 and 2010. Patient navigators developed individualized strategies to address barriers to care, with the focus on preventing delays in care. To assess timeliness of diagnostic resolution, we conducted a meta-analysis of center- and cancer-specific adjusted hazard ratios (aHRs) comparing patient navigation vs usual care. To assess initiation of cancer therapy, we calculated a single aHR, pooling data across all centers and cancer types. We conducted a metaregression to evaluate variability across centers. All statistical tests were two-sided. RESULTS: The 10521 participants with abnormal screening tests and 2105 with a cancer or precancer diagnosis were predominantly from racial/ethnic minority groups (73%) and publically insured (40%) or uninsured (31%). There was no benefit during the first 90 days of care, but a benefit of navigation was seen from 91 to 365 days for both diagnostic resolution (aHR = 1.51; 95% confidence interval [CI] = 1.23 to 1.84; P < .001)) and treatment initiation (aHR = 1.43; 95% CI = 1.10 to 1.86; P < .007). Metaregression revealed that navigation had its greatest benefits within centers with the greatest delays in follow-up under usual care. CONCLUSIONS: Patient navigation demonstrated a moderate benefit in improving timely cancer care. These results support adoption of patient navigation in settings that serve populations at risk of being lost to follow-up.

Clinician-targeted intervention and patient-reported counseling on physical activity.

INTRODUCTION: Limited time and lack of knowledge are barriers to physical activity counseling in primary care. The objective of this study was to examine the effectiveness of a clinician-targeted intervention that used the 5As (Ask, Advise, Agree, Assist, Arrange) approach to physical activity counseling in a medically underserved patient population. METHODS: Family medicine clinicians at 2 community health centers were randomized to Group 1 or Group 2 intervention. Both clinician groups participated in 4 training sessions on the 5As for physical activity counseling; Group 2 training took place 8 months after Group 1 training. Both groups were trained to refer patients to a community exercise program. We used a pre-post analysis to evaluate the effectiveness of the intervention on clinician use of 5As. Eligible patients (n = 319) rated their clinicians' counseling skills by using a modified Physical Activity Exit Interview (PAEI) survey. Clinicians (n = 10) self-assessed their use of the 5As through a survey and interviews. RESULTS: Both patient and clinician groups had similar sociodemographic characteristics. The PAEI score for both groups combined increased from 6.9 to 8.6 (on a scale of 0-15) from baseline to immediately postintervention (P = .01) and was 8.2 (P = .09) at 6-month follow-up; most of the improvement in PAEI score was due to increased use of 5As skills by Group 2 clinicians. Group 1 reported difficulty with problem solving, whereas Group 2 reported ease of referral to the community exercise program. CONCLUSION: A clinician training intervention showed mixed results for 5As physical activity counseling.