Christine L. Gray

Prevalence and Incidence of Traumatic Experiences Among Orphans in Institutional and Family-Based Settings in 5 Low- and Middle-Income Countries: A Longitudinal Study

Contrary to some conventional wisdom, in this large study that randomly sampled orphans and separated children from 5 countries, prevalence of reported traumatic events was no worse among those institutionalized than among those in family-based care. Reported incidence of physical or sexual abuse was actually higher for those in family-based care. Understanding the specific context, and elements contributing to potential harm and benefits in both family-based and institutional care, are essential to promoting the best interest of the child. Contrary to some conventional wisdom, in this large study that randomly sampled orphans and separated children from 5 countries, prevalence of reported traumatic events was no worse among those institutionalized than among those in family-based care. Reported incidence of physical or sexual abuse was actually higher for those in family-based care. Understanding the specific context, and elements contributing to potential harm and benefits in both family-based and institutional care, are essential to promoting the best interest of the child. Background: Policy makers struggling to protect the 153 million orphaned and separated children (OSC) worldwide need evidence-based research on the burden of potentially traumatic events (PTEs) and the relative risk of PTEs across different types of care settings. Methods: The Positive Outcomes for Orphans study used a 2-stage, cluster-randomized sampling design to identify 1,357 institution-dwelling and 1,480 family-dwelling orphaned and separated children in 5 low- and middle-income countries (LMICs) in sub-Saharan Africa and Asia. We used the Life Events Checklist developed by the National Center for Posttraumatic Stress Disorder to examine self-reported PTEs among 2,235 OSC ages 10–13 at baseline. We estimated prevalence and incidence during 36-months of follow-up and compared the risk of PTEs across care settings. Data collection began between May 2006 and February 2008, depending on the site. Results: Lifetime prevalence by age 13 of any PTE, excluding loss of a parent, was 91.0% (95% confidence interval (CI) = 85.6, 94.5) in institution-dwelling OSC and 92.4% (95% CI = 90.3, 94.0) in family-dwelling OSC; annual incidence of any PTE was lower in institution-dwelling (23.6% [95% CI = 19.4, 28.7]) than family-dwelling OSC (30.0% [95% CI = 28.1, 32.2]). More than half of children in institutions (50.3% [95% CI = 42.5, 58.0]) and in family-based care (54.0% [95% CI = 50.2, 57.7]) had experienced physical or sexual abuse by age 13. Annual incidence of physical or sexual abuse was lower in institution-dwelling (12.9% [95% CI = 9.6, 17.3]) than family-dwelling OSC (19.4% [95% CI = 17.7, 21.3]), indicating statistically lower risk in institution-dwelling OSC (risk difference = 6.5% [95% CI = 1.4, 11.7]). Conclusion: Prevalence and incidence of PTEs were high among OSC, but contrary to common assumptions, OSC living in institutions did not report more PTEs or more abuse than OSC living with families. Current efforts to reduce the number of institution-dwelling OSC may not reduce incidence of PTEs in this vulnerable population. Protection of children from PTEs should be a primary consideration, regardless of the care setting.

The Associations between Environmental Quality and Mortality in the Contiguous United States, 2000-2005.

Background: Assessing cumulative effects of the multiple environmental factors influencing mortality remains a challenging task. Objectives: This study aimed to examine the associations between cumulative environmental quality and all-cause and leading cause-specific (heart disease, cancer, and stroke) mortality rates. Methods: We used the overall Environmental Quality Index (EQI) and its five domain indices (air, water, land, built, and sociodemographic) to represent environmental exposure. Associations between the EQI and mortality rates (CDC WONDER) for counties in the contiguous United States (n = 3,109) were investigated using multiple linear regression models and random intercept and random slope hierarchical models. Urbanicity, climate, and a combination of the two were used to explore the spatial patterns in the associations. Results: We found 1 standard deviation increase in the overall EQI (worse environment) was associated with a mean 3.22% (95% CI: 2.80%, 3.64%) increase in all-cause mortality, a 0.54% (95% CI: –0.17%, 1.25%) increase in heart disease mortality, a 2.71% (95% CI: 2.21%, 3.22%) increase in cancer mortality, and a 2.25% (95% CI: 1.11%, 3.39%) increase in stroke mortality. Among the environmental domains, the associations ranged from –1.27% (95% CI: –1.70%, –0.84%) to 3.37% (95% CI: 2.90%, 3.84%) for all-cause mortality, –2.62% (95% CI: –3.52%, –1.73%) to 4.50% (95% CI: 3.73%, 5.27%) for heart disease mortality, –0.88% (95% CI: –2.12%, 0.36%) to 3.72% (95% CI: 2.38%, 5.06%) for stroke mortality, and –0.68% (95% CI: –1.19%, –0.18%) to 3.01% (95% CI: 2.46%, 3.56%) for cancer mortality. Air had the largest associations with all-cause, heart disease, and cancer mortality, whereas the sociodemographic index had the largest association with stroke mortality. Across the urbanicity gradient, no consistent trend was found. Across climate regions, the associations ranged from 2.29% (95% CI: 1.87%, 2.72%) to 5.30% (95% CI: 4.30%, 6.30%) for overall EQI, and larger associations were generally found in dry areas for both overall EQI and domain indices. Conclusions: These results suggest that poor environmental quality, particularly poor air quality, was associated with increased mortality and that associations vary by urbanicity and climate region. Citation: Jian Y, Messer LC, Jagai JS, Rappazzo KM, Gray CL, Grabich SC, Lobdell DT. 2017. Associations between environmental quality and mortality in the contiguous United States, 2000–2005. Environ Health Perspect 125:355–362; http://dx.doi.org/10.1289/EHP119

Gender (in) differences in prevalence and incidence of traumatic experiences among orphaned and separated children living in five low- and middle-income countries.

Background. Approximately 153 million children worldwide are orphaned and vulnerable to potentially traumatic events (PTEs). Gender differences in PTEs in low- and middle-income countries (LMIC) are not well-understood, although support services and prevention programs often primarily involve girls. Methods. The Positive Outcomes for Orphans study used a two-stage, cluster-randomized sampling design to identify 2837 orphaned and separated children (OSC) in five LMIC in sub-Saharan Africa and Asia. We examined self-reported prevalence and incidence of several PTE types, including physical and sexual abuse, among 2235 children who were ≥10 years at baseline or follow-up, with a focus on gender comparisons. Results. Lifetime prevalence by age 13 of any PTE other than loss of a parent was similar in both boys [91.7% (95% confidence interval (CI) (85.0–95.5)] and girls [90.3% CI (84.2–94.1)] in institutional-based care, and boys [92.0% (CI 89.0–94.2)] and girls [92.9% CI (89.8–95.1)] in family-based care; annual incidence was similarly comparable between institution dwelling boys [23.6% CI (19.1,−29.3)] and girls [23.6% CI (18.6,−30.0)], as well as between family-dwelling boys [30.7% CI (28.0,−33.6)] and girls [29.3% CI (26.8,−32.0)]. Physical and sexual abuse had the highest overall annual incidence of any trauma type for institution-based OSC [12.9% CI (9.6–17.4)] and family-based OSC [19.4% CI (14.5–26.1)], although estimates in each setting were no different between genders. Conclusion. Prevalence and annual incidence of PTEs were high among OSC in general, but gender-specific estimates were comparable. Although support services and prevention programs are essential for female OSC, programs for male OSC are equally important.

County‐level cumulative environmental quality associated with cancer incidence

Individual environmental exposures are associated with cancer development; however, environmental exposures occur simultaneously. The Environmental Quality Index (EQI) is a county‐level measure of cumulative environmental exposures that occur in 5 domains.

Use of Combination Antihypertensive Therapy Initiation in Older Americans without Prevalent Cardiovascular Disease

To describe new users of antihypertensive medications and identify predictors of combination therapy initiation in older Americans.

Throwing out the baby with the bathwater?: Comparing 2 approaches to implausible values of change in body size.

Background: In childhood obesity research, the appearance of height loss, or “shrinkage,” indicates measurement error. It is unclear whether a common response—excluding “shrinkers” from analysis—reduces bias. Methods: Using data from the National Longitudinal Study of Adolescent Health, we sampled 816 female adolescents (≥17 years) who had attained adult height by 1996 and for whom adult height was consistently measured in 2001 and 2008 (“gold-standard” height). We estimated adolescent obesity prevalence and the association of maternal education with adolescent obesity under 3 conditions: excluding shrinkers (for whom gold-standard height was less than recorded height in 1996), retaining shrinkers, and retaining shrinkers but substituting their gold-standard height. Results: When we estimated obesity prevalence, excluding shrinkers decreased precision without improving validity. When we regressed obesity on maternal education, excluding shrinkers produced less valid and less precise estimates. Conclusion: In some circumstances, ignoring shrinkage is a better strategy than excluding shrinkers.

Why Institutions Matter: Empirical Data from Five Low- and Middle-Income Countries Indicate the Critical Role of Institutions for Orphans

Millions of children orphaned by or separated from their parents are particularly vulnerable to maltreatment. Preventing and mitigating the effects of maltreatment requires understanding the context in which maltreatment occurs. A vastly disproportionate number of the world’s orphans live in South Asia and sub-Saharan Africa, where poverty, civil unrest, and economic insecurity compromise the capacity of family-based care. While studies of children in select destitute orphanages have demonstrated the effects of severe early deprivation, they do not represent the heterogeneity of institution-based care in general or the heterogeneity of institution-based care in low- and middle-income countries (LMICs) specifically. Furthermore, the only large-scale, multi-country study designed to compare average experiences in both institution-based and family-based care indicates the prevalence, and incidence of maltreatment is similar in both types of care. Increasing advocacy for global deinstitutionalization is inconsistent with emerging evidence about institution-based care as compared to family-based care. Furthermore, such sweeping action would remove a critical safety net for many orphans. Long-term positive outcomes are much more likely to come from improved understanding of the essential elements of quality caregiving in all settings, caregiver training and support, and innovative models of orphan care.

An argument for renewed focus on epidemiology for public health

PURPOSE Although epidemiology has an indispensable role in serving public health, the relative emphasis of applications of epidemiology often tend toward individual-level medicine over public health in terms of resources and impact. METHODS We make distinctions between public health and medical applications of epidemiology to raise awareness among epidemiologists, many of whom came to the field with public health in mind. We discuss reasons for the overemphasis on medical epidemiology and suggest ways to counteract these incentives. RESULTS Public health epidemiology informs interventions that are applied to populations or that confer benefits beyond the individual, whereas medical epidemiology informs interventions that improve the health of treated individuals. Available resources, new biomedical technologies, and existing epidemiologic methods favor medical applications of epidemiology. Focus on public health impact and methods suited to answer public health questions can create better balance and promote population-level improvements in public health. CONCLUSIONS By deliberately reflecting on research motivations and long-term goals, we hope the distinctions presented here will facilitate critical discussion and a greater consciousness of our potential impact on both individual and population-level health. Renewed intentions towards public health can help epidemiologists navigate potential projects and ultimately contribute to an epidemiology of consequence.

The association between physical inactivity and obesity is modified by five domains of environmental quality in U.S. adults: A cross-sectional study

Physical inactivity is a primary contributor to the obesity epidemic, but may be promoted or hindered by environmental factors. To examine how cumulative environmental quality may modify the inactivity-obesity relationship, we conducted a cross-sectional study by linking county-level Behavioral Risk Factor Surveillance System data with the Environmental Quality Index (EQI), a composite measure of five environmental domains (air, water, land, built, sociodemographic) across all U.S. counties. We estimated the county-level association (N = 3,137 counties) between 2009 age-adjusted leisure-time physical inactivity (LTPIA) and 2010 age-adjusted obesity from BRFSS across EQI tertiles using multi-level linear regression, with a random intercept for state, adjusted for percent minority and rural-urban status. We modelled overall and sex-specific estimates, reporting prevalence differences (PD) and 95% confidence intervals (CI). In the overall population, the PD increased from best (PD = 0.341 (95% CI: 0.287, 0.396)) to worst (PD = 0.645 (95% CI: 0.599, 0.690)) EQI tertile. We observed similar trends in males from best (PD = 0.244 (95% CI: 0.194, 0.294)) to worst (PD = 0.601 (95% CI: 0.556, 0.647)) quality environments, and in females from best (PD = 0.446 (95% CI: 0.385, 0.507)) to worst (PD = 0.655 (95% CI: 0.607, 0.703)). We found that poor environmental quality exacerbates the LTPIA-obesity relationship. Efforts to improve obesity through LTPIA may benefit from considering this relationship.

Starting the Conversation: Are Campus Sexual Assault Policies Related to the Prevalence of Campus Sexual Assault?

One goal of university campus sexual assault (CSA) policies is to help prevent CSA. Federal guidance in the 2014 White House Task Force to Protect Students From Sexual Assault Checklist for Campus Sexual Misconduct Policies suggests 10 elements for inclusion in CSA policies (e.g., Policy Introduction, Grievance/Adjudication), and outlines policy topics to be included within each element (Policy Introduction includes two topics: statement of prohibition against sex discrimination including sexual misconduct and statement of commitment to address sexual misconduct). However, no research has examined whether CSA policies impact CSA prevalence. To begin addressing this gap, we studied 24 universities participating in the 2015 Association of American Universities Campus Climate Survey on Sexual Assault and Sexual Misconduct. We linked 2014-2015 data from these universities’ CSA policies and their CSA prevalence findings from the 2015 Association of American Universities (AAU) survey. To test whether the comprehensiveness of schools’ CSA policies was related to schools’ CSA prevalence, we examined the degree to which the CSA policies included recommended policy content from the aforementioned Checklist. Policies were characterized as more comprehensive if they included greater numbers of Checklist topics. We then correlated the number of topics within the policies with school-level CSA prevalence. We also explored whether there was lower CSA prevalence among schools with policies containing particular topics. Results suggested that greater comprehensiveness of schools’ entire CSA policies was negatively correlated with CSA prevalence; however, these findings did not approach statistical significance. The number of negative correlations observed between schools’ CSA policy elements and CSA prevalence among undergraduate women was greater than expected by chance alone, suggesting a possible connection between comprehensive CSA policies and CSA prevalence. Schools with policies that included a topic on their sexual assault response team had the lowest CSA prevalence for both women and men, and schools that included topics describing grievance/adjudication procedures had lower CSA prevalence. This study provides a novel examination of CSA and could inform needed research related to the impact of CSA policies on CSA.