The PhenX Toolkit: Recommended Measurement Protocols for Social Determinants of Health Research.

Health disparities are driven by unequal conditions in the environments in which people are born, live, learn, work, play, worship, and age, commonly termed the Social Determinants of Health (SDoH). The availability of recommended measurement protocols for SDoH will enable investigators to consistently collect data for SDoH constructs. The PhenX (consensus measures for Phenotypes and eXposures) Toolkit is a web-based catalog of recommended measurement protocols for use in research studies with human participants. Using standard protocols from the PhenX Toolkit makes it easier to compare and combine studies, potentially increasing the impact of individual studies, and aids in comparability across literature. In 2018, the National Institute on Minority Health and Health Disparities provided support for an initial expert Working Group to identify and recommend established SDoH protocols for inclusion in the PhenX Toolkit. In 2022, a second expert Working Group was convened to build on the work of the first SDoH Working Group and address gaps in the SDoH Toolkit Collections. The SDoH Collections consist of a Core Collection and Individual and Structural Specialty Collections. This article describes a Basic Protocol for using the PhenX Toolkit to select and implement SDoH measurement protocols for use in research studies. © 2024 The Authors. Current Protocols published by Wiley Periodicals LLC. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA. Basic Protocol: Using the PhenX Toolkit to select and implement SDoH protocols.

Mental health, chronic and infectious conditions among pregnant persons in US state prisons and local jails 2016-2017.

BACKGROUND: Pregnant individuals in incarcerated settings have unique healthcare needs. Rates of mental health, infectious diseases, and chronic disease are higher among nonpregnant incarcerated women compared with those who are not, but the prevalence of these conditions among pregnant people in custody has not been documented. OBJECTIVES: The objective of this study is to describe the prevalence of metabolic, infectious, and mental health conditions in pregnant people to identify the medical needs of high-risk pregnancies in US state prisons and local jails. STUDY DESIGN: This was a prospective epidemiologic surveillance of a convenience sample of state prisons (n = 20) and local jails (n = 3). METHODS: We used purposive and snowball sampling to recruit a national sample of prisons and jails of a range of sizes and geographies. Reporters submitted to our study database monthly data on selected pregnancy comorbidities for 6 months between 2016 and 2017. Screening, diagnosis, and tracking of these conditions are derived from each facility's medical record and health care delivery systems. RESULTS: Of the 445 newly admitted pregnant people in prisons and 243 in jails, the most prevalent conditions were mental health conditions and hepatitis C. Specifically, 34.1% (n = 152) in prison and 23.5% (n = 57) in jail had a substance use disorder, and 27.4% (n = 122) of those in prison and 17.7% (n = 43) in jail had a psychiatric diagnosis. Finally, 20.2% (n = 91) in prison and 6.6% (n = 16) in jail had hepatitis C. CONCLUSIONS: This study demonstrates that chronic medical and mental health conditions are prevalent among pregnant people in US prisons and jails. However, significant variability in the reported number of cases of these conditions from state to state and between facility types implies a lack of or inadequate screening practices. These data indicate the need for comprehensive screening and appropriate care for the complex needs of pregnant incarcerated people.

OBJECTIVES: The objective of this study is to describe the prevalence of these conditions in pregnant people to identify the medical needs of high-risk pregnancies in US state prisons and local jails. STUDY DESIGN: The study involved ongoing systematic data collection, analysis and interpretation of pregnancy data from a convenience sample of state prisons (n = 20) and local jails (n = 3). METHODS: We intentionally recruited a national sample of prisons and jails of a range of sizes and geographies that house pregnant individuals. Some study facilities were referred from others. Reporters submitted to our study database monthly data on selected pregnancy comorbidities for 6 months between 2016 and 2017. Screening, diagnosis, and tracking of these conditions derived from each facility's medical record and health care delivery systems. RESULTS: Of the 445 newly admitted pregnant people in prisons and 243 in jails, the most prevalent conditions were mental health conditions and hepatitis C. Specifically, 34.1% (n = 152) in prison and 23.5% (n = 57) in jail had a substance use disorder and 27.4% (n = 122) of those in prison and 17.7% (n = 43) in jail had a psychiatric diagnosis. Finally, 20.2% (n = 91) in prison and 6.6% (n = 16) in jail had hepatitisc. CONCLUSIONS: This study demonstrates that chronic medical and mental health conditions are prevalent among pregnant people in US prisons and jails. However, significant variability in the reported number of cases of these conditions from state to state and between facility types implies a lack of or inadequate screening practices. These data indicate the need for comprehensive screening and appropriate care for the complex needs of pregnant incarcerated people.

Health care conditions among pregnant persons in US state prisons and local jails 2016­2017Background: Pregnant individuals in incarcerated settings have unique health care needs. Rates of mental health, infectious diseases, and chronic disease are higher among nonpregnant incarcerated women compared with those who are not, but the prevalence of these conditions among pregnant people in custody has not been documented.

Excess mortality in U.S. prisons during the COVID-19 pandemic.

U.S. prisons were especially susceptible to COVID-19 infection and death; however, data limitations have precluded a national accounting of prison mortality (including but not limited to COVID-19 mortality) during the pandemic. Our analysis of mortality data collected from public records requests (supplemented with publicly available data) from 48 Departments of Corrections provides the most comprehensive understanding to date of in-custody mortality during 2020. We find that total mortality increased by 77% in 2020 relative to 2019, corresponding to 3.4 times the mortality increase in the general population, and that mortality in prisons increased across all age groups (49 and under, 50 to 64, and 65 and older). COVID-19 was the primary driver for increases in mortality due to natural causes; some states also experienced substantial increases due to unnatural causes. These findings provide critical information about the pandemic's toll on some of the country's most vulnerable individuals while underscoring the need for data transparency and standardized reporting in carceral settings.

Racial and Ethnic Differences in Self-Reported COVID-19 Exposure Risks, Concerns, and Behaviors Among Diverse Participants in the Women's Health Initiative Study.

BACKGROUND: Racial and ethnic disparities in coronavirus disease 2019 (COVID-19) risk are well-documented; however, few studies in older adults have examined multiple factors related to COVID-19 exposure, concerns, and behaviors or conducted race- and ethnicity-stratified analyses. The Women's Health Initiative (WHI) provides a unique opportunity to address those gaps. METHODS: We conducted a secondary analysis of WHI data from a supplemental survey of 48 492 older adults (mean age 84 years). In multivariable-adjusted modified Poisson regression analyses, we examined predisposing factors and COVID-19 exposure risk, concerns, and behaviors. We hypothesized that women from minoritized racial or ethnic groups, compared to non-Hispanic White women, would be more likely to report: exposure to COVID-19, a family or friend dying from COVID-19, difficulty getting routine medical care or deciding to forego care to avoid COVID-19 exposure, and having concerns about the COVID-19 pandemic. RESULTS: Asian women and non-Hispanic Black/African American women had a higher risk of being somewhat/very concerned about risk of getting COVID-19 compared to non-Hispanic White women and each was significantly more likely than non-Hispanic White women to report forgoing medical care to avoid COVID-19 exposure. However, Asian women were 35% less likely than non-Hispanic White women to report difficulty getting routine medical care since March 2020 (adjusted relative risk 0.65; 95% confidence interval 0.57, 0.75). CONCLUSIONS: We documented COVID-related racial and ethnic disparities in COVID-19 exposure risk, concerns, and care-related behaviors that disfavored minoritized racial and ethnic groups, particularly non-Hispanic Black/African American women.

Quantifying structural racism in cohort studies to advance prospective evidence.

Calls-to-action in health research have described a need to improve research on race, ethnicity, and structural racism. Well-established cohort studies typically lack access to novel structural and social determinants of health (SSDOH) or precise race and ethnicity categorization, contributing to a loss of rigor to conduct informative analyses and a gap in prospective evidence on the role of structural racism in health outcomes. We propose and implement methods that prospective cohort studies can use to begin to rectify this, using the Women's Health Initiative (WHI) cohort as a case study. To do so, we evaluated the quality, precision, and representativeness of race, ethnicity, and SSDOH data compared with the target US population and operationalized methods to quantify structural determinants in cohort studies. Harmonizing racial and ethnic categorization to the current standards set by the Office of Management and Budget improved measurement precision, aligned with published recommendations, disaggregated groups, decreased missing data, and decreased participants reporting "some other race". Disaggregation revealed sub-group disparities in SSDOH, including a greater proportion of Black-Latina (35.2%) and AIAN-Latina (33.3%) WHI participants with income below the US median compared with White-Latina (42.5%) participants. We found similarities in the racial and ethnic patterning of SSDOH disparities between WHI and US women but less disparity overall in WHI. Despite higher individual-level advantage in WHI, racial disparities in neighborhood resources were similar to the US, reflecting structural racism. Median neighborhood income was comparable between Black WHI ($39,000) and US ($34,700) women. WHI SSDOH-associated outcomes may be generalizable on the basis of comparing across race and ethnicity but may quantitatively (but not qualitatively) underestimate US effect sizes. This paper takes steps towards data justice by implementing methods to make visible hidden health disparity groups and operationalizing structural-level determinants in prospective cohort studies, a first step to establishing causality in health disparities research.

Conditions of Confinement in U.S. Carceral Facilities During COVID-19: Individuals Speak-Incarcerated During the COVID-19 Epidemic.

Objectives: We aimed to describe conditions of confinement among people incarcerated in the United States during the coronavirus disease 2019 (COVID-19) pandemic using a community-science data collection approach. Methods: We developed a web-based survey with community partners to collect information on confinement conditions (COVID-19 safety, basic needs, support). Formerly incarcerated adults released after March 1, 2020, or nonincarcerated adults in communication with an incarcerated person (proxy) were recruited through social media from July 25, 2020 to March 27, 2021. Descriptive statistics were estimated in aggregate and separately by proxy or formerly incarcerated status. Responses between proxy and formerly incarcerated respondents were compared using Chi-square or Fisher's exact tests based on α=0.05. Results: Of 378 responses, 94% were by proxy, and 76% reflected state prison conditions. Participants reported inability to physically distance (≥6 ft at all times; 92%), inadequate access to soap (89%), water (46%), toilet paper (49%), and showers (68%) for incarcerated people. Among those receiving prepandemic mental health care, 75% reported reduced care for incarcerated people. Responses were consistent between formerly incarcerated and proxy respondents, although responses by formerly incarcerated people were limited. Conclusions: Our findings suggest that a web-based community-science data collection approach through nonincarcerated community members is feasible; however, recruitment of recently released individuals may require additional resources. Our data obtained primarily through individuals in communication with an incarcerated person suggest COVID-19 safety and basic needs were not sufficiently addressed within some carceral settings in 2020-2021. The perspectives of incarcerated individuals should be leveraged in assessing crisis-response strategies.

Economic burden related to fistulas or strictures among commercially insured patients with Crohn's disease in the United States.

BACKGROUND: Crohn's disease (CD) is a chronic, progressive, immune-mediated gastrointestinal condition that can lead to fistulizing or stricturing complications. OBJECTIVE: To quantify the burden of illness related to fistulas and/or strictures in patients with CD. METHODS: Using the Optum Research Database from October 2015 to December 2019, patients with CD were classified according to 1 of 3 condition cohorts: CD with fistula (CD-F), CD with stricture (CD-S), or CD with fistula and stricture (CD-FS). Each cohort was matched to a nonfistula, nonstricture CD cohort. Postdiagnosis per patient per year (PPPY) costs and health care resource utilization were assessed, accounting for variable lengths of follow-up periods. Multivariable generalized linear models were used to estimate the adjusted mean costs in each cohort. RESULTS: The CD-F, CD-S, and CD-FS cohorts included 1,317; 4,650; and 894 patients, respectively. The mean age of patients within the CD-S and their comparator cohorts was higher than in the CD-F or CD-FS cohorts (59.9 vs 49.5 vs 49.6 years). At baseline, cardiovascular disease was the most common comorbidity across all condition and comparator cohorts. Condition cohorts had 2-4 times more inpatient visits, 5-8 times more surgical visits, and 2-3 times more endoscopies PPPY than comparator cohorts. Compared with their respective comparator cohort, patients in the 3 condition cohorts had higher medication, medical, and total health care costs. CONCLUSIONS: This study demonstrates a significant economic burden related to fistulas and/or strictures among patients with CD, highlighting the importance of prevention, early recognition, and appropriate management of CD-related complications. DISCLOSURES: Yanni Fan, Ling Zhang, Jennifer S Thompson, and Kimberly G Brodovicz are employees of Boehringer Ingelheim. Rhonda L Bohn, Monik C Jiménez, and Stephani Gray (Bohn Epidemiology, LLC) are paid consultants to Boehringer Ingelheim. Gil Y Melmed reports receiving grants from Pfizer; consulting fees from Boehringer Ingelheim, AbbVie, Arena, BMS, Celgene, Entasis, Ferring Lilly, Fresenius Kabi, Medtronic, Samsung Bioepis, Janssen, Takeda, Pfizer, Prometheus Labs, and TechLab. We conducted a retrospective study using administrative claims data from the Optum Research Database, a database of a commercially insured population in the United States. All patient data were anonymized and deidentified; therefore, informed consent was not necessary. Restrictions apply to the availability of these data because of a contract between Optum and Boehringer Ingelheim, and data are thus unavailable to the public. For enquiries on the dataset analyzed in this study, please contact Optum (https://www.optum.com).

Examining COVID-19 mortality rates by race and ethnicity among incarcerated people in 11 U.S. state prisons (March-October 2021).

Background: Populations who are incarcerated have experienced disproportionately high coronavirus disease 2019 (COVID-2019) mortality rates compared to the general population. However, mortality rates by race/ethnicity from federal, state, and local carceral settings are largely unavailable due to unregulated reporting; therefore, racial/ethnic inequities have yet to be examined. We aimed to estimate coronavirus disease 2019 (COVID-19) mortality rates among individuals incarcerated in U.S. state prisons by race and ethnicity (RE). Methods: Public records requests to state Departments of Corrections were used to identify deaths from COVID-19 among incarcerated adults occurring from March 1-October 1, 2020. We requested race, ethnicity, and age specific data on deaths and custody populations; sufficient data to calculate age-adjusted rates were obtained for 11 state systems. Race and ethnic specific unadjusted deaths rates per 100,000 persons were calculated overall and by state, based on March 1, 2020 custody populations. Rate ratios (RR) and 95% confidence intervals (95%CI) compared aggregated age-adjusted death rates by race and ethnicity, with White individuals as the reference group. Results: Of all COVID-related deaths in U.S. prisons through October 2020, 23.35% (272 of 1165) were captured in our analyses. The average age at COVID-19 death was 63 years (SD = 10 years) and was significantly lower among Black (60 years, SD = 11 years) compared to White adults (66 years, SD = 10 years; p < 0.001). In age-standardized analysis, COVID-19 death rates were significantly higher among Black (RR = 1.93, 95% CI: 1.25-2.99), Hispanic (RR = 1.81, 95% CI: 1.10-2.96) and those of Other racial and ethnic groups (RR = 2.60, 95% CI: 1.01-6.67) when compared to White individuals. Conclusions: Age-standardized death rates were higher among incarcerated Black, Hispanic and those of Other racial and ethnic groups compared to their White counterparts. Greater data transparency from all carceral systems is needed to better understand populations at disproportionate risk of COVID-19 morbidity and mortality.

Differences in Metabolomic Profiles Between Black and White Women and Risk of Coronary Heart Disease: an Observational Study of Women From Four US Cohorts.

BACKGROUND: Racial differences in metabolomic profiles may reflect underlying differences in social determinants of health by self-reported race and may be related to racial disparities in coronary heart disease (CHD) among women in the United States. However, the magnitude of differences in metabolomic profiles between Black and White women in the United States has not been well-described. It also remains unknown whether such differences are related to differences in CHD risk. METHODS: Plasma metabolomic profiles were analyzed using liquid chromatography-tandem mass spectrometry in the WHI-OS (Women's Health Initiative-Observational Study; 138 Black and 696 White women), WHI-HT trials (WHI-Hormone Therapy; 156 Black and 1138 White women), MESA (Multi-Ethnic Study of Atherosclerosis; 114 Black and 219 White women), JHS (Jackson Heart Study; 1465 Black women with 107 incident CHD cases), and NHS (Nurses' Health Study; 2506 White women with 136 incident CHD cases). First, linear regression models were used to estimate associations between self-reported race and 472 metabolites in WHI-OS (discovery); findings were replicated in WHI-HT and validated in MESA. Second, we used elastic net regression to construct a racial difference metabolomic pattern (RDMP) representing differences in the metabolomic patterns between Black and White women in the WHI-OS; the RDMP was validated in the WHI-HT and MESA. Third, using conditional logistic regressions in the WHI (717 CHD cases and 719 matched controls), we examined associations of metabolites with large differences in levels by race and the RDMP with risk of CHD, and the results were replicated in Black women from the JHS and White women from the NHS. RESULTS: Of the 472 tested metabolites, levels of 259 (54.9%) metabolites, mostly lipid metabolites and amino acids, significantly differed between Black and White women in both WHI-OS and WHI-HT after adjusting for baseline characteristics, socioeconomic status, lifestyle factors, baseline health conditions, and medication use (false discovery rate <0.05); similar trends were observed in MESA. The RDMP, composed of 152 metabolites, was identified in the WHI-OS and showed significantly different distributions between Black and White women in the WHI-HT and MESA. Higher RDMP quartiles were associated with an increased risk of incident CHD (odds ratio=1.51 [0.97-2.37] for the highest quartile comparing to the lowest; Ptrend=0.02), independent of self-reported race and known CHD risk factors. In race-stratified analyses, the RDMP-CHD associations were more pronounced in White women. Similar patterns were observed in Black women from the JHS and White women from the NHS. CONCLUSIONS: Metabolomic profiles significantly and substantially differ between Black and White women and may be associated with CHD risk and racial disparities in US women.

Effects of Objective and Perceived Social Isolation on Cardiovascular and Brain Health: A Scientific Statement From the American Heart Association.

Background Social isolation, the relative absence of or infrequency of contact with different types of social relationships, and loneliness (perceived isolation) are associated with adverse health outcomes. Objective To review observational and intervention research that examines the impact of social isolation and loneliness on cardiovascular and brain health and discuss proposed mechanisms for observed associations. Methods We conducted a systematic scoping review of available research. We searched 4 databases, PubMed, PsycInfo, Cumulative Index of Nursing and Allied Health, and Scopus. Findings Evidence is most consistent for a direct association between social isolation, loneliness, and coronary heart disease and stroke mortality. However, data on the association between social isolation and loneliness with heart failure, dementia, and cognitive impairment are sparse and less robust. Few studies have empirically tested mediating pathways between social isolation, loneliness, and cardiovascular and brain health outcomes using appropriate methods for explanatory analyses. Notably, the effect estimates are small, and there may be unmeasured confounders of the associations. Research in groups that may be at higher risk or more vulnerable to the effects of social isolation is limited. We did not find any intervention studies that sought to reduce the adverse impact of social isolation or loneliness on cardiovascular or brain health outcomes. Conclusions Social isolation and loneliness are common and appear to be independent risk factors for worse cardiovascular and brain health; however, consistency of the associations varies by outcome. There is a need to develop, implement, and test interventions to improve cardiovascular and brain health for individuals who are socially isolated or lonely.

Association of Reproductive Life Span and Age at Menopause With the Risk of Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND AND OBJECTIVES: Subarachnoid hemorrhage from cerebral aneurysm remains a devastating disease with high mortality and morbidity. Cerebral aneurysm and its rupture are more prevalent in postmenopausal women and have been postulated to be hormonally influenced. The goal of this study was to investigate the associations of female-specific factors, including reproductive life span, age at menarche, and age at menopause, with the incidence of aneurysmal subarachnoid hemorrhage (aSAH) in women. METHODS: Participants in the Nurses' Health Study were followed up from 1980 or the time of reaching menopause until 2018. Only women with natural menopause or surgical menopause due to bilateral oophorectomy were included. Reproductive life span was defined by subtracting the age at menarche from the age at menopause. Multivariable-stratified proportional hazards models were used to study reproductive life span, age at menarche, and age at menopause with the incidence of aSAH. Multivariable models were adjusted for age, race, smoking, hysterectomy, hypertension, hyperlipidemia, body mass index, hormone therapy use, oral contraceptive use, and parity. RESULTS: A total of 97,398 postmenopausal women with reproductive life span data were included; 138 participants developed aSAH, which was confirmed on medical record review by a physician. A shorter reproductive life span (≤35 years) was associated with a 2-fold higher incidence of aSAH after multivariable adjustment (hazard ratio [HR] 2.0 [95% CI 1.4-2.8]). Early age at menopause (age <45 years) was similarly associated with a higher risk of aSAH (HR 2.1 [95% CI 1.4-3.1]), but age at menarche was not. Use of oral contraceptives and postmenopausal hormone therapy was not associated with the incidence of aSAH. DISCUSSION: An earlier age at menopause and a shorter reproductive life span duration (≤35 years) were associated with a higher risk of incident aSAH in women. No associations were noted for age at menarche, parity, oral contraceptive use, or postmenopausal therapy use.

Taking action to advance the study of race and ethnicity: the Women's Health Initiative (WHI).

"Race" and "ethnicity" are socially constructed terms, not based on biology - in contrast to biologic ancestry and genetic admixture - and are flexible, contested, and unstable concepts, often driven by power. Although individuals may self-identify with a given race and ethnic group, as multidimensional beings exposed to differential life influencing factors that contribute to disease risk, additional social determinants of health (SDOH) should be explored to understand the relationship of race or ethnicity to health. Potential health effects of structural racism, defined as "the structures, policies, practices, and norms resulting in differential access to goods, services, and opportunities of society by "race," have been largely ignored in medical research. The Women's Health Initiative (WHI) was expected to enroll a racially and ethnically diverse cohort of older women at 40 U.S. clinical centers between 1993 and 1998; yet, key information on the racial and ethnic make-up of the WHI cohort of 161,808 women was limited until a 2020-2021 Task Force was charged by the WHI Steering Committee to better characterize the WHI cohort and develop recommendations for WHI investigators who want to include "race" and/or "ethnicity" in papers and presentations. As the lessons learned are of relevance to most cohorts, the essence of the WHI Race and Ethnicity Language and Data Interpretation Guide is presented in this paper. Recommendations from the WHI Race and Ethnicity Language and Data Interpretation Guide include: Studies should be designed to include all populations and researchers should actively, purposefully and with cultural-relevance, commit to recruiting a diverse sample; Researchers should collect robust data on race, ethnicity and SDOH variables that may intersect with participant identities, such as immigration status, country of origin, acculturation, current residence and neighborhood, religion; Authors should use appropriate terminology, based on a participant's self-identified "race" and "ethnicity", and provide clear rationale, including a conceptual framework, for including race and ethnicity in the analytic plan; Researchers should employ appropriate analytical methods, including mixed-methods, to study the relationship of these sociocultural variables to health; Authors should address how representative study participants are of the population to which results might apply, such as by age, race and ethnicity.

Association of Individual and Familial History of Correctional Control With Health Outcomes of Patients in a Primary Care Center.

Importance: Research has shown that experiences of incarceration, probation, and parole are associated with worse health outcomes for incarcerated individuals and their families. Objectives: To quantify the proportion of patients in an urban primary care clinic with an individual or family history of incarceration, probation, and/or parole and to evaluate how correctional control is associated with subjective and objective health outcomes. Design, Setting, and Participants: This cross-sectional, mixed-methods study used patient surveys and retrospective medical record review to assess the experience of correctional control among 200 English-speaking adult patients presenting for care at the Rhode Island Hospital Center for Primary Care between July 9, 2019, and January 10, 2020. Main Outcomes and Measures: Patient surveys included closed and open-ended questions pertaining to personal or familial experiences of incarceration, probation, and parole, as well as health outcomes associated with these experiences. Medical record review abstracted key health indicators and health care use data. Results: In this cross-sectional study of 200 adult patients (1 participant was removed from the full analytic sample owing to missing ethnicity data; 113 of 199 men [56.8%]; mean [SD] age, 51.2 [14.0] years) presenting for primary care, 78 of 199 (39.2%) had a history of incarceration, 32 of 199 (16.1%) were on probation or parole at the time of the study, and 92 of 199 (46.2%) reported having a family member with a history of incarceration. Of the 199 patients, 62 (31.2%) identified as non-Hispanic Black, 93 (46.7%) identified as non-Hispanic White, and 44 (22.1%) identified as belonging to another race (American Indian and Alaska Native, Asian, Native Hawaiian and Other Pacific Islander, or other nonspecified). Compared with participants without a history of correctional control, those with a personal history of incarceration were at greater odds of having an emergency department visit that did not result in hospitalization in models adjusted for age, sex, and race and ethnicity (odds ratio, 2.87; 95% CI, 1.47-5.75). Conclusions and Relevance: This cross-sectional study suggests that primary care clinicians should screen for correctional control as a prevalent social determinant of health.

Pregnancy Prevalence and Outcomes in 3 United States Juvenile Residential Systems.

STUDY OBJECTIVE: To describe the number of admissions of pregnant adolescents to US juvenile residential systems (JRS) and the outcomes of pregnancies that ended while in custody. DESIGN: Prospective study. SETTING: Three nonrandomly selected JRS in 3 US states. PARTICIPANTS: Designated reporter at each JRS reporting aggregate data on various pregnant admissions, outcomes, and systems' policies. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Monthly number of pregnant people admitted, pregnant people at the end of the month, births, preterm births, cesarean deliveries, miscarriages, induced abortions, ectopic pregnancies, maternal and newborn deaths, and administrative policies. RESULTS: There were 71 admissions of pregnant adolescents reported over 12 months from participating JRS. At the time of the census, 6 of the 183 female adolescents (3.3%) were pregnant. Eight pregnancies ended while in custody. Of these, 1 pregnancy was a live full-term birth, 4 were miscarriages, and 3 were induced abortions. There were no newborn deaths or maternal deaths. Administrative policies and services varied among the JRS. For example, all JRS had a prenatal care provider on-site, whereas 2 JRS helped cover the costs of abortions. CONCLUSION: To our knowledge, this study is the first to report the estimates of pregnancy and pregnancy outcomes among justice-involved youth in JRS. Our findings indicate that there are pregnant adolescents in JRS and most return to their communities while pregnant, highlighting the importance of continuity of care. More work is needed to understand the complexities of health care needs of justice-involved pregnant youth during and after their incarceration.

Ten-Year Differences in Women's Awareness Related to Coronary Heart Disease: Results of the 2019 American Heart Association National Survey: A Special Report From the American Heart Association.

BACKGROUND: High awareness that cardiovascular disease is the leading cause of death (LCOD) among women is critical to prevention. This study evaluated longitudinal trends in this awareness among women. METHODS AND RESULTS: Online surveys of US women (≥25 years of age) were conducted in January 2009 and January 2019. Data were weighted to the US population distribution of sociodemographic characteristics. Multivariable logistic regression was used to evaluate knowledge of the LCOD. In 2009, awareness of heart disease as the LCOD was 65%, decreasing to 44% in 2019. In 2019, awareness was greater with older age and increasing education and lower among non-White women and women with hypertension. The 10-year awareness decline was observed in all races/ethnicities and ages except women ≥65 years of age. The greatest declines were among Hispanic women (odds ratio of awareness comparing 2019 to 2009, 0.14 [95% CI, 0.07-0.28]), non-Hispanic Black women (odds ratio, 0.31 [95% CI, 0.19-0.49]), and 25- to 34-year-olds (odds ratio, 0.19 [95% CI, 0.10-0.34]). In 2019, women were more likely than in 2009 to incorrectly identify breast cancer as the LCOD (odds ratio, 2.59 [95% CI, 1.86-3.67]), an association that was greater in younger women. Awareness of heart attack symptoms also declined. CONCLUSIONS: Awareness that heart disease is the LCOD among women declined from 2009 to 2019, particularly among Hispanic and non-Hispanic Black women and in younger women (in whom primordial/primary prevention may be most effective). An urgent redoubling of efforts by organizations interested in women's health is required to reverse these trends.

The association between weight-promoting medication use and weight gain in postmenopausal women: findings from the Women's Health Initiative.

OBJECTIVE: With the rise in obesity, there has been a concomitant increase in prescription medications associated with weight gain. The objective of this study is to quantify the magnitude of association between putative weight-promoting medications and 3-year weight change in a diverse cohort of postmenopausal women in the Women's Health Initiative (WHI). METHODS: This is a prospective observational cohort study, considering 40 sites in the WHI and a cohort of seventy six thousand two hundred fifty-two postmenopausal women aged 50-79 years, with weight measured at both baseline and 3 years, in the WHI-Observational Study. Body mass index (BMI) and waist circumference (WC) were measured at baseline and 3 years. An in-clinic medication inventory identified prescribed medications, including antidepressants, beta-blockers, insulin, and/or glucocorticosteroids. Generalized linear models evaluated if intermittent or persistent use of weight-promoting drugs was associated with increased BMI and WC during a 3-year follow up. RESULTS: Women with overweight or obesity at baseline were more likely to be taking antidepressants, beta-blockers, and/or insulin. Taking at least one putative weight-promoting medication was associated with a greater increase in BMI (0.37 vs 0.27 kg/m, P = 0.0045) and WC (1.10 cm vs 0.89 cm, P = 0.0077) over the course of 3 years compared to women not on these medications. Both BMI and WC increased with the number of weight-promoting drugs prescribed (P for trend per medication used < 0.00001 for both variables). Those who took either antidepressants or insulin, or a combination of antidepressants and beta-blockers, were most likely to have a significant increase in BMI compared to nonusers. CONCLUSIONS: Antidepressants, beta-blockers, and insulin were associated with weight gain in postmenopausal women. This information may help to inform clinical decision-making and efforts to mitigate medication-related weight gain. : Video Summary:http://links.lww.com/MENO/A617.

Video Summary:http://links.lww.com/MENO/A617.

Plasma Estradiol and Testosterone Levels and Ischemic Stroke in Postmenopausal Women.

Background and Purpose- Although exogenous hormone therapy (HT) use has been associated with increased risk of ischemic stroke in postmenopausal women, it remains unknown whether sex hormone levels contribute to ischemic stroke risk. We aimed to estimate associations between plasma sex hormone levels and ischemic stroke risk, by HT status, in a nested case-control study of postmenopausal women from the NHS (Nurses' Health Study). Methods- Women with confirmed incident ischemic stroke (n=419) were matched with controls (n=419) by age, HT use, and other factors. Plasma estradiol and testosterone levels were measured using liquid chromatography tandem mass spectrometry; SHBG (sex hormone-binding globulin) was assayed by electrochemiluminescence immunoassay. Associations of total and free estradiol and testosterone, the estradiol/testosterone ratio, and SHBG with ischemic stroke were estimated using conditional logistic regressions stratified by HT status with adjustment for matching and cardiovascular risk factors. Results- Current HT users had different hormone profiles from never/past users. No clear linear trends were observed between estradiol (total or free) levels or the estradiol/testosterone ratio and ischemic stroke risk among either current users (Ptrend>0.1) or never/past users (Ptrend>0.6). For both current and never/past users, the associations between some of the sex hormones and ischemic stroke differed by body mass index categories (Pinteraction≤0.04). For women with a body mass index <25 kg/m2, a higher estradiol/testosterone ratio was associated with significantly elevated ischemic stroke risk among current users (Ptrend=0.01), and higher levels of total and free estradiol were significantly associated with higher ischemic stroke risk among never/past users (Ptrend≤0.04). Testosterone and SHBG were not associated with ischemic stroke in either current or never/past users. Conclusions- Our findings do not support a role of sex hormone levels in mediating ischemic stroke risk among postmenopausal women. Replications in additional larger studies are required.

Racial Variation in Stroke Risk Among Women by Stroke Risk Factors.

Background and Purpose- In the United States, black Americans exhibit a greater risk of stroke and burden of stroke risk factors than whites; however, it is unclear whether these stroke risk factors influence stroke risk differently across racial groups. Methods- In total, 126 018 participants of the Women's Health Initiative (11 389 black and 114 629 white women), free of stroke and coronary heart disease at baseline (1994-1998), were followed through 2010. Participants completed baseline clinical exams with standardized measurements of blood pressure and anthropometrics, medication inventory and self-reported questionnaires on sociodemographics, behaviors/lifestyle, and medical history. Incident total, ischemic and hemorrhagic strokes were updated annually through questionnaires with medical record confirmation. Rate differences (per 100 000 person-years) and hazard ratios (HR) based on multivariable Cox models and were estimated. Results- Over a median of 13 years, 4344 stroke events were observed. Absolute incidence rates were higher in black than white women in each age group. In age-adjusted analyses, the risk of stroke was significantly higher among black compared with white women (HR=1.47, 95% CI, 1.33-1.63); adjustment for stroke risk factors, which may be on the causal pathway, attenuated the estimate. Racial disparities were greatest among women 50 to <60 years (HR=3.48; 95% CI, 2.31-5.26; rate difference =99) and diminished with increasing age (60 to <70 HR=1.80; 95% CI, 1.50-2.16; rate difference =107; ≥70 years: HR=1.26; 95% CI, 1.10-1.43; rate difference =87; Pinteraction <0.001). Black women 50 to <60 years remained at significantly higher risk than white women after adjustment for stroke risk factors (HR=1.76; 95% CI, 1.09-2.83). Conclusions- There was a moderately greater risk of total stroke among black compared with white women; however, racial disparities were greatest among women aged 50 to <60 years. Interventions targeted at younger black women may provide the greatest benefit in reducing disparities.