School of Public Health

California’s state government, employers and households are concerned about the future affordability of healthcare. We use health expenditure data from the Centers for Medicare & Medicaid Services’ Office of the Actuary to forecast California’s health expenditures from 2013 to 2022 and identify factors driving expenditure increases. Real health expenditures per capita (2013$) are forecasted to increase from $8,398 to $11,421 (or 36%), resulting in health expenditures increasing from 14.5% to 16.0% of California’s economy. Expenditure increases are mostly driven by gains in real income per capita (40-60%), followed by medical-specific inflation (23%), an aging population (14%), and insurance coverage gains (8%). The -4% to 16% residual is attributable to changes in the volume and mix of services and technology. Several innovations could potentially dampen these increases, such as shared-risk, value-based payment models, practice redesign initiatives, lower cost settings and healthcare professionals, many of which are found in accountable care organizations.

Adult salmon that stray when they escape into non-natal streams to spawn is a natural phenomenon that promotes population growth and genetic diversity, but excessive stray rates impede adult abundance restoration efforts. Adult San Joaquin River (SJR) Basin fall-run Chinook salmon (Oncorhynchus tshawytscha) that return to freshwater to spawn migrate through the San Francisco Bay and Sacramento–San Joaquin River Delta (Delta). The Delta has been heavily affected by land development and water diversion. During the fall time-period for the years 1979 to 2007 Delta pumping facilities diverted on average 340% of the total inflow volume that entered the Delta from the SJR. The hypothesis tested in this paper is that river flow and Delta exports are not significantly correlated with SJR salmon stray rates. Adult coded-wire-tagged salmon recoveries from Central Valley rivers were used to estimate the percentage of SJR Basin salmon that strayed to the Sacramento River Basin. SJR salmon stray rates were negatively correlated (P = 0.05) with the average magnitude of pulse flows (e.g., 10 d) in mid- to late-October and positively correlated (P = 0.10) with mean Delta export rates. It was not possible to differentiate between the effects of pulse flows in October and mean flows in October and November on stray rates because of the co-linearity between these two variables. Whether SJR-reduced pulse flow or elevated exports causes increased stray rates is unclear. Statistically speaking the results indicate that flow is the primary factor. However empirical data indicates that little if any pulse flow leaves the Delta when south Delta exports are elevated, so exports in combination with pulse flows may explain the elevated stray rates. For management purposes, we developed two statistical models that predict SJR salmon stray rate: (1) flow and export as co-independent variables; and (2) south Delta Export (E) and SJR inflow (I) in the form of an E:I ratio.

In this article, we describe an elective course using readers’ theater with students in the health care professions and the arts. Readers' theater is a technique used for the performance of literature in which texts are staged with minimal production values and scripts are not fully memorized. These techniques are drawn upon more commonly in theater and performance studies classrooms, but we found them to be effective as tools for connecting future health care providers with their local communities. With a central theme of age and aging, we chose non-dramatic works of literature and adapted them for dramatic readings at retirement communities in Berkeley and Oakland, California.

Extreme weather events, including wildfires, are becoming more intense, frequent, and expansive due to climate change, thus increasing negative health outcomes. However, such effects can vary across space, time, and population subgroups, requiring methods that can handle multiple exposed units, account for time-varying confounding, and capture heterogeneous treatment effects. In this article, we proposed an approach based on staggered generalized synthetic control methods to study heterogeneous health effects, using the 2018 California wildfire season as a case study. This study aimed to estimate the effects of the November 2018 California wildfires, one of the states deadliest and most destructive wildfire seasons, on respiratory and circulatory health, document heterogeneity in health impacts, and investigate drivers of this heterogeneity. We applied a two-stage generalized synthetic control method to compare health outcomes in exposed (from 8 November to 5 December 2018) versus unexposed counties and used random-effects meta-regression to evaluate the effect modification of county-level socioeconomic variables on the observed health effects of the November 2018 wildfires. We observed an increase in respiratory hospitalizations for most exposed counties when compared with unexposed counties, with significant increases in Fresno, San Francisco, San Joaquin, San Mateo, and Santa Clara counties. No effect on circulatory hospitalizations was observed. County-level sociodemographic characteristics seem to not modulate the effects of wildfire smoke on respiratory hospitalizations. This novel two-stage framework can be applied in broader settings to understand spatially and temporally compounded health impacts of climate hazards. We provide codes in R for reproducibility and replication purposes.

Aedes mosquitoes, as vectors of medically important arthropod-borne viruses (arboviruses), constitute a major public health threat that requires entomological and epidemiological surveillance to guide vector control programs to prevent and reduce disease transmission. In this study, we present the collaborative effort of 1 year of Aedes ageypti (Linnaeus, 1762) mosquito-based arbovirus surveillance in 2 geographically distinct regions of Latin America (Nicaragua and Ecuador). Adult female mosquitoes were collected using backpack aspirators in over 2,800 randomly selected households (Nicaragua, Ecuador) and 100 key sites (Nicaragua) from 8 distinct communities (Nicaragua: 2, Ecuador: 6). A total of 1,358 mosquito female pools were processed for RNA extraction and viral RNA detection using real-time reverse transcription-polymerase chain reaction. Ten positive dengue virus (DENV) pools were detected (3 in Nicaragua and 7 in Ecuador), all of which were found during the rainy season and matched the serotypes found in humans (Nicaragua: DENV-1 and DENV-4; Ecuador: DENV-2). Infection rates ranged from 1.13 to 23.13, with the Nicaraguan communities having the lowest infection rates. Our results demonstrate the feasibility of detecting DENV-infected Aedes mosquitoes in low-resource settings and underscore the need for targeted mosquito arbovirus sampling and testing, providing valuable insights for future surveillance programs in the Latin American region.

Antibiotics can trigger antimicrobial resistance and microbiome alterations. Reducing pathogen exposure and undernutrition can reduce infections and antibiotic use. We assess effects of water, sanitation, handwashing (WSH) and nutrition interventions on caregiver-reported antibiotic use in Bangladesh and Kenya, longitudinally measured at three timepoints among birth cohorts (ages 3-28 months) in a cluster-randomized trial. Over 50% of children used antibiotics at least once in the 90 days preceding data collection. In Bangladesh, the prevalence of antibiotic use was 10-14% lower in groups receiving WSH (prevalence ratio [PR] = 0.90 (0.82-0.99)), nutrition (PR = 0.86 (0.78-0.94)), and nutrition+WSH (PR = 0.86 (0.79-0.93)) interventions. The prevalence of using antibiotics multiple times was 26-35% lower in intervention arms. Reductions were largest when the birth cohort was younger. In Kenya, interventions did not affect antibiotic use. In this work, we show that improving WSH and nutrition can reduce antibiotic use. Studies should assess whether such reductions translate to reduced antimicrobial resistance.

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Gender norms have been posited to impact intimate partner violence (IPV), but there is scant evidence of the longitudinal association between community-level gender norms and IPV. Using longitudinal data on 3,965 married girls surveyed in India, we fitted mixed-effects ordinal and binary logistic regression models for physical IPV intensity and occurrence of sexual IPV. We found a 26% increase in the odds that women experience frequent physical IPV per one unit increase in greater community-level equitable gender norms. We did not find an association between community-level equitable gender norms and sexual IPV. Findings suggest that the relationship between gender norms and physical and sexual IPV differs, indicating the need for tailored interventions for different types of IPV.

Natural disasters and extreme weather events are increasing in frequency and intensity, in part due to climate change. These events can have severe impacts, including on maternal health. We review the existing research on natural disasters, environmental hazards, and maternal health outcomes – focusing specifically on relevant conceptual frameworks and termination of pregnancy as an outcome of these events – published between January 2004 and May 2024. We retrieved eight frameworks and 26 additional research articles. None of the frameworks identified pregnancy termination as an outcome of natural disasters, though there is ample evidence to suggest that pregnancy termination and related outcomes must be included in these frameworks. We propose a new, comprehensive framework in which all reproductive outcomes with the potential to affect maternal morbidity or mortality, including pregnancy termination (i.e., induced abortion), are considered. We hope that the Natural disasters, Environmental hazards, and Maternal Outcomes (NEMO) framework will inform emergency response planning to improve service delivery that empowers individuals to make informed reproductive health choices in the wake of these crises.