Public Health Commons^™

Comparison Of Routine Health Screening Rates Between Two Emr Systems, Lauren M. Cancio, Caleb J. Berta

Longitudinal Scholar's Project

An EMR, electronic medical record, system refers to the software widely adopted by medical practitioners to reduce the use of hard-copy files, and improve the documentation, storage, and retrieval of patient information. Some EMR systems can generate automatic alerts reminding providers when patients are due for certain preventive services or meet the criteria for various screening measures. Epic, one of the leading EMR systems in use today, contains this additional feature. The screening recommendations built into Epic are derived from a committee of USPSTF, U.S. Preventive Services Task Force, medical experts whose focus is to improve patient health across the …

Three Essays About Preventing Mental And Behavioral Disorders, Snehal Lopes

All Dissertations

Prevention efforts in the public health field operate at various levels, including primary prevention among those without a disease of interest, secondary prevention among persons at high risk or showing early signs of the disease, and tertiary prevention among persons with the disease. The three essays presented in this dissertation are centered around the theme of prevention, and taken together, have implications for prevention at the primary, secondary, and tertiary levels. Specifically, the essays focus on the prevention of depressive disorders and the prevention of behavioral and mental health correlates for depression in the context of various populations (general adult, …

Overview Of Transition Care Clinics And Patient No-Shows, Manul Awasthi

Electronic Theses and Dissertations

Introduction

Transition care clinics (TCCs) have proven to be effective in meeting the time-sensitive needs of patients in the post-discharge period and ensuring smooth transitions of patients from hospital to home. These clinics have led to lower readmissions, lower emergency department visits, cost savings, and lower rates of other adverse events following discharge. However, TCCs, including the East Tennessee State University Family Medicine (ETSU-FM) TCC have been facing high rates of patient no-shows.

Aim

The aim of this dissertation is to identify the different components and outcomes of TCC based on the literature. We further aim to analyze the TCC …

When The Costs Outweigh The Benefits: Examining Variations In Nulliparous, Term, Singleton, Vertex And Elective Cesarean Delivery Rates Across The United States, 2016-2020, Kathleen Tatro

Electronic Theses and Dissertations

The overutilization of cesarean deliveries is a major public health issue in the United States (U.S.). The rates of cesarean deliveries have increased substantially from the mid 1990s. Low-risk, defined as nulliparous, term, singleton, vertex (NTSV) pregnancies with no medical indication of need, and elective cesarean deliveries have been implicated as drivers of these increases. Elective cesarean deliveries are NTSV cesarean deliveries in which no trial of labor was attempted. There is a lack of clear rationale as to the noted increases in cesarean delivery rates as the evidence shows that these procedures provide no additional health benefits to mothers …

Final Evaluation Of La Door: Proposition 47 Grant Program, Melissa M Labriola, Danielle Sobol, Stephanie Brooks Holliday, Heather Sims

Faculty, Staff and Student Publications

The Los Angeles Diversion, Outreach, and Opportunities for Recovery program (LA DOOR) was designed by the Los Angeles City Attorney's Office (LACA) to provide a comprehensive, health-focused, preventative approach that proactively engages individuals at elevated risk of returning to LACA on a new misdemeanor offense related to substance use, mental illness, or homelessness. LA DOOR was funded through the grant program of Proposition 47. Programs funded through Proposition 47 are intended to serve individuals with a history of criminal justice involvement and mental health issues or substance use disorders and to offer mental health services, substance use disorder treatment, and …

Examining The Roles Of Acculturative Stressors And Cultural Factors In Major Health And Safety Issues Among Hispanic/Latino Farmworkers, Brenda Berumen-Flucker

Health Services Research Dissertations

Statement of the problem: Hispanic/Latino farmworkers are at increased risk of adverse health and safety outcomes. Heightened levels of acculturative stress and the unique cultural characteristics and beliefs reported by this group increase workers’ vulnerability for adverse outcomes.

Method: The first project consisted of a systematic review examining threats to the health and safety of Hispanic/Latino agricultural workers attributable to climate change, focusing specifically on their risk for heat-related illnesses (HRI) and cultural factors and beliefs increasing workers’ vulnerability for HRI. The second project was a secondary data analysis focused on identifying potential relationships between acculturative stressors, cultural factors, and …

Social Contributors For The Rise Of Covid-19 Infections In South Asia: A Large Cross-Sectional Survey, Zouina Sarfraz, Azza Sarfraz, Muzna Sarfraz, Nishwa Azeem, Namrata Hange, Miguel Felix, Ivan Cherrez-Ojeda

Department of Paediatrics and Child Health

Background: The ongoing global coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was first reported in South Asia on 30th January 2020 in India. Ever since, certain countries have witnessed multiple waves of COVID-19, requiring attention by public health experts and strategists in the region. The objectives of this study are to assess social contributors to the recurrent waves of COVID-19 in South Asia including first demographic traits, second household characteristics and social measures, third workplace trends and personal protective equipment use, and fourth satisfaction and attitudes concerning public health measures and vaccination status. …

Men’S Stories: An Account Of Translating Vaccine Decision Narratives From Young Men In The U.S. Into A Targeted Public Health Intervention, Michelle Miller-Day, Erin S. Craw, Diana Harris, Michael L. Hecht

Communication Faculty Articles and Research

Effective interventions to promote human papillomavirus (HPV) vaccination are needed for all young adults across the globe. Yet, most public health efforts focus on HPV-related risks for females. Unfortunately, HPV-related cancers in men are also a concern, as is the potential for men to spread HPV to their partners. The HPV vaccine is highly effective in reducing risks related to these cancers. Yet, vaccination rates among young males are low and their vaccination concerns are not well understood. This project conducted 15 in-depth qualitative interviews with U.S. males aged 18–22 to hear their vaccine decision stories. Themes of HPV vaccination …

Covid-19 Pandemic Impact On Essential Public Health Services And Online Health Communication—Appalachian Kentucky, March–December 2020, Margaret A. Riggs, Kenny Ortiz-Jurado, Keith Klein

Journal of Appalachian Health

Introduction: The COVID-19 pandemic posed many challenges for local health departments (LHDs). This study examines how stay-at-home orders impacted the provision of essential public health services and subsequent increased use of online health communication by LHDs for rural populations in Appalachian Kentucky during the first year of the COVID-19 pandemic.

Methods: A survey to gather information about provision of essential public health services was administered to five LHDs representing 13 counties between June 2020 and December 2020. Additionally, demographic and health-outcome data from LHD, state health department, and CDC websites were reviewed, alongside health communications posted on LHD social media …

Performance Of Machine Learning Classifiers In Classifying Stunting Among Under-Five Children In Zambia, Obvious Nchimunya Chilyabanyama, Roma Chilengi, Roma Chilengi, Michelo Simuyandi, Caroline C. Chisenga, Masuzyo Chirwa, Kalongo Hamusonde, Rakesh Kumar Saroj, Najeeha Talat Iqbal, Innocent Ngaruye

Department of Paediatrics and Child Health

Stunting is a global public health issue. We sought to train and evaluate machine learning (ML) classification algorithms on the Zambia Demographic Health Survey (ZDHS) dataset to predict stunting among children under the age of five in Zambia. We applied Logistic regression (LR), Random Forest (RF), SV classification (SVC), XG Boost (XgB) and Naïve Bayes (NB) algorithms to predict the probability of stunting among children under five years of age, on the 2018 ZDHS dataset. We calibrated predicted probabilities and plotted the calibration curves to compare model performance. We computed accuracy, recall, precision and F1 for each machine learning algorithm. …

Congregational Leaders And Covid-19: Human Flourishing And Future Directions For Research, Isaac Voss

Essays

No abstract provided.

Asking The Question ‘What Matters To You?’ In A London Intensive Care Unit, Harriet Pittaway, Laura White, Karen Turner, Angelique Mcgillivary

Journal of Patient-Centered Research and Reviews

Purpose: At the heart of the paradigm shift in approach to patient care from paternalism toward shared decision-making lies the international “What Matters To You?” (WMTY) movement. However, WMTY principles are not frequently applied to the critical care setting. The aim of this quality improvement project work was to design and integrate a tool for all patients admitted to the intensive care unit (ICU) that helped answer WMTY.

Methods: Using Plan-Do-Study-Act (PDSA) methodology across 8 cycles, a multidisciplinary team designed and integrated a bedside poster into the ICU. Quantitative and qualitative data were collected via a bedside audit process on …

Can Variables From The Electronic Health Record Identify Delirium At Bedside?, Ariba Khan, Kayla Heslin, Michelle Simpson, Michael L. Malone

Journal of Patient-Centered Research and Reviews

Delirium, a common and serious disorder in older hospitalized patients, remains underrecognized. While several delirium predictive models have been developed, only a handful have focused on electronic health record (EHR) data. This prospective cohort study of older inpatients (≥ 65 years old) aimed to determine if variables within our health system’s EHR could be used to identify delirium among hospitalized patients at the bedside. Trained researchers screened daily for delirium using the 3-minute diagnostic Confusion Assessment Method (3D-CAM). Patient demographic and clinical variables were extracted from the EHR. Among 408 participants, mean age was 75 years, 60.8% were female, and …

Abstracts From The 2022 Health Care Systems Research Network (Hcsrn) Annual Conference

Journal of Patient-Centered Research and Reviews

The Health Care Systems Research Network (HCSRN) is comprised of 20 health systems with embedded research units. The network’s annual conference serves as a forum for research teams from member institutions to disseminate scientific findings, explore new collaborations, and share insights about conducting research in real-world care delivery settings. Abstracts accepted for presentation at HCSRN 2022 are published in this supplement of Journal of Patient-Centered Research and Reviews, the official journal of HCSRN’s annual conference proceedings.

Gis Automated Delineation And Analysis Of Cancer Service Areas In The United States, Changzhen Wang

LSU Doctoral Dissertations

Delineating a meaningful and reliable geographic unit pertaining to cancer care is essential in examining geographic variations in cancer care for better analysis, management, and planning. Public health researchers have devoted great efforts to defining various service areas, which; however, lack scientific rigor or are unrepresentative of the highly specialized cancer care markets, and their methods have become obsolete in the era of big data and high geo-computation. This study develops the “Spatially Constrained Leiden (ScLeiden)” method, a network community detection algorithm in Geographic Information Systems (GIS), and applies it to delineate a series of coherent cancer service …

Virtual Behavioral Health Treatment Satisfaction And Outcomes Across Time, Mindy R. Waite, Sara Diab, James Adefisoye

Journal of Patient-Centered Research and Reviews

Purpose: The COVID-19 pandemic continues to have major and long-lasting impacts on health care delivery and mental health. As health care shifted to telehealth, legislation was adjusted to expand telehealth allowances, creating a unique opportunity to elucidate outcomes. The aim of this study was to assess long-term patient and clinician satisfaction and outcomes with virtual behavioral health.

Methods: Data were obtained over 16 months from surveys to patients and clinicians receiving/providing virtual treatment. Outcomes data also were collected from medical records of adults receiving in-person and virtual behavioral health treatment. Data were summarized using descriptive statistics. Groups were compared using …

Is Home Blood Pressure Monitoring Effective At Controlling Hypertension In African American Patients? A Clin-Iq, Rebecca Nye, Wilhelm Lehmann, Deborah Simpson

Journal of Patient-Centered Research and Reviews

African Americans are disproportionately affected by hypertension, a modifiable contributor to multiple chronic diseases and premature death. Primary care physicians play an important role in hypertension control. Home blood pressure monitoring (HBPM) is an evidence-based method for confirming diagnosis and monitoring hypertension over time. Some studies have found that HBPM may lead to clinically relevant reductions in blood pressure when combined with additional interventions, but few studies have focused specifically on African American populations. Evidence of effectiveness could increase clinical recommendation of HBPM. This clinical inquiry examined whether HBPM improves blood pressure control in African Americans with uncontrolled hypertension. Reviewed …

Real-World Third Covid-19 Vaccine Dosing And Antibody Response In Patients With Hematologic Malignancies, Michael A. Thompson, Sigrun Hallmeyer, Veronica E. Fitzpatrick, Yunqi Liao, Michael P. Mullane, Stephen C. Medlin, Kenneth Copeland, James L. Weese

Journal of Patient-Centered Research and Reviews

Purpose: This study sought to describe the changes in immune response to a third dose of either Pfizer’s or Moderna’s COVID-19 mRNA vaccine (3V) among patients with hematologic malignancies, as well as associated characteristics

Methods: This retrospective cohort study analyzed pre-3V and post-3V data on 493 patients diagnosed with hematologic malignancies across a large Midwestern health system between August 28, 2021, and November 1, 2021. For antibody testing, S1 spike antigen of the SARS-CoV-2 virus titer was used to determine serostatus.

Results: Among 493 participants, 274 (55.6%) were seropositive both pre- and post-3V (+/+) while 115 (23.3%) seroconverted to positive …

Partnering To Advance Health Equity And A Welcome Opportunity To Gather: Proceedings From The 28th Annual Conference Of The Health Care Systems Research Network, Robert T. Greenlee

Journal of Patient-Centered Research and Reviews

In April 2022, the Health Care Systems Research Network (HCSRN) — a consortium of 20 research institutions affiliated with large health systems spread across the United States (and one in Israel) — held its 28th annual conference in Pasadena, California, with 275 researchers, health care colleagues, and external academic partners in attendance. With a conference theme of “Promoting Collaboration and Partnerships to Advance Health Equity,” the scientific program was assembled by a multisite planning committee with input from representatives of informal local host Kaiser Permanente Southern California. Objectives of the annual conference are to showcase scientific findings from HCSRN projects …

Increasing Naloxone Co-Prescribing Among At-Risk Individuals: Evaluation Of A Quality Improvement Project In A Large Health System, Sarah Hemphill Ba, Kristen Silvia Md, Marc D. Kimball Md

Journal of Maine Medical Center

Background: Naloxone availability and early administration is key in preventing death following opioid overdose. The CDC advises that naloxone should be made available to all at-risk individuals. In 2017, providers at Maine Medical Center noted that only 6% of at-risk patients had naloxone prescriptions

Methods: Included in this study were all patients of MaineHealth, a health system comprising 9 hospitals and 30 primary care practices, serving approximately 1.1 million patients. Between 2017 and 2020, we implemented several system-wide quality improvement interventions to increase rates of naloxone co-prescribing among at-risk individuals. Risk factors included prescribed opioids ≥50 morphine milligram equivalents, concurrent …

Describing And Assessing A New Method Of Approximating Categorical Individual-Level Income Using Community-Level Income From The Census (Weighting By Income Probabilities), Uriel Kim, Siran M. Koroukian, Kurt C. Stange, James C. Spilsbury, Weichuan Dong, Johnie Rose

Faculty Scholarship

Objective: To assess a new approach (weighting by “income probabilities [IP]”) that uses US Census data from the patients' communities to approximate individual-level income, an important but often missing variable in health services research. Data Sources: Community (census tract level) income data came from the 2017 5-year American Community Survey (ACS). The patient data included those diagnosed with cancer in 2017 in Ohio (n = 65,759). The reference population was the 2017 5-year ACS Public Use Microdata Sample (n = 564,357 generalizing to 11,288,350 Ohioans). Study Design/Methods: We applied the traditional approach of income approximation using median census tract income …

Evaluasi Sistem Informasi Surveilans Malaria (Sismal) Di Wilayah Kerja Dinas Kesehatan Kota Malang, Muhammad Irvan Indrayana, Iwan Ariawan

Jurnal Biostatistik, Kependudukan, dan Informatika Kesehatan

Malaria merupakan salah satu penyakit menular yang memiliki potensi tinggi dalam penyebarluasan penyakit. Berdasarkan dari Badan Pusat Statistik, Jawa Timur memiliki 7.256 kasus malaria suspek dan di kota Malang memiliki 11 kasus suspek pada tahun 2020 dan mayoritas berasal dari kasus impor dimana pasien berasal atau pernah melakukan perjalanan di luar wilayah Kota Malang yang kemudian merasakan gejala dan melakukan pemeriksaan di Kota Malang. Sistem Informasi Surveilans Malaria (SISMAL) adalah instrumen guna melakukan kegiatan pencatatan, pelaporan dan untuk meningkatkan validitas dan kelengkapan dalam pelaporan data malaria yang merupakan salah satu hal penting untuk mendukung terselenggaranya sistem Surveilans yang baik. Sistem …

Validitas Dan Reliabilitas Kuesioner Chinese Positive Youth Development Scales (Cpyds) Mengukur Keterampilan Hidup Pelajar Smp Di Babakan Madang Kabupaten Bogor 2019, Rahastiwi Fadilah Utami, Sabarinah Prasetyo, Dion Zein Nurizin

Jurnal Biostatistik, Kependudukan, dan Informatika Kesehatan

Masa remaja merupakan masa di mana individu mengalami peralihan dari anak-anak menjadi dewasa. Pada masa ini ada rasa keingintahuan yang besar dan banyak perubahan yang terjadi, akibatnya tidak sedikit remaja menghadapi berbagai masalah. Salah satu upaya untuk mempersiapkan remaja sehingga siap dan mampu menghadapi masalah adalah dengan membekali remaja keterampilan hidup. Pada tahun 2019, tim Pengabdian kepada Masyarakat FKM UI menerjemahkan kuesioner Chinese Positive Youth Development Scales (CPYDS) ke dalam bahasa Indonesia untuk mengukur keterampilan hidup siswa SMP di Babakan Madang. Data tersebut kemudian dianalisis lebih lanjut untuk tujuan melihat validitas dan reliabilitasnya. Validitas dinilai dengan korelasi point-biserial dan analisis …

Evaluasi Sistem Surveilans Tuberkulosis Di Dinas Kesehatan Kabupaten Banyumas Berdasarkan Pendekatan Sistem, Nadia Hasnanisa, Sabarinah Prasetyo, Arif Burhanudin

Jurnal Biostatistik, Kependudukan, dan Informatika Kesehatan

Kabupaten Banyumas sebagai wilayah dengan jumlah kasus TB tertinggi di Provinsi Jawa Tengah mengalami penurunan angka pelaporan kasus TB. Tujuan penelitian ini adalah mengetahui gambaran dan kesesuaian pelaksanaan surveilans TB dari segi input, proses, dan output di wilayah kerja Dinas Kesehatan Kabupaten Banyumas berdasarkan pedoman yang ada. Penelitian kualitatif deskriptif menggunakan data primer melalui wawancara, observasi, dan dokumentasi, dengan jumlah informan sebanyak 2 orang yang dipilih dengan metode purposive sampling. Beberapa komponen surveilans yang belum memenuhi standar yaitu jumlah petugas (Man), pelatihan bagi petugas (Man), pendanaan (Money), sarana transportasi (Material), alat TCM (Material), sarana kepustakaan (Material), …

Hubungan Aktivitas Fisik, Konsumsi Buah Dan Sayur, Serta Cek Kesehatan Rutin Terhadap Kejadian Hipertensi Pada Siswa/I Sma Sederajat Di Wilayah Kerja Puskesmas Sawangan, Kota Depok, Milla Herdayati, Andito Yahya, Anggi Anitia, Anna Yulianti, Maulidyah Ananda, Meita Chairunnisa, Meliana Putri, Nabilah Huwaida, Nafa Shahira Anglila S, Nafikhatul Khikmah, Rofiq Firzatullah, Rouli Felicia

Jurnal Biostatistik, Kependudukan, dan Informatika Kesehatan

Hipertensi adalah salah satu penyakit tidak menular tanpa gejala dengan kematian tertinggi yang mulai berkembang pada remaja. Studi CDC menunjukkan 1 dari 25 remaja usia 12 hingga 19 tahun menderita Hipertensi. Sementara di Indonesia, terdapat 34,11% dengan usia di atas 18 tahun terdiagnosis hipertensi oleh dokter. Pada tingkat lebih kecil, dalam penelitian di kota Depok ditemukan 57,1% kasus hipertensi pada remaja di usia 12-25 tahun. Studi ini bertujuan untuk menganalisis faktor-faktor perilaku yang berhubungan dengan kejadian hipertensi di wilayah kerja puskesmas Sawangan. Metode penelitian menggunakan desain studi cross sectional dengan teknik cluster random sampling. Sampel penelitian adalah hasil randomisasi pada …

Hubungan Beban Kerja Tenaga Kesehatan Dengan Kelelahan Kerja Di Puskesmas Kecamatan Sukmajaya Kota Depok Selama Pandemi, Herma Krisdiana, Jaslis Iljas, Dumilah Ayuningtyas, Eny Juliati

Jurnal Biostatistik, Kependudukan, dan Informatika Kesehatan

Beban kerja merupakan salah satu faktor risiko yang menyebabkan terjadinya kelelahan. Situasi pandemi saat ini memberikan dampak nyata khususnya pada sektor kesehatan. WHO menetapkan COVID-19 sebagai pandemi pada tahun 2020. Dampak pandemi COVID-19 menyebabkan tenaga kesehatan sebagai sumberdaya penyedia layanan kesehatan dihadapkan pada situasi berbeda, salah satunya terjadi peningkatan pada tuntutan pekerjaan. Tingginya tuntutan pekerjaan yang diterima tenaga kesehatan akan menjadi penyebab beban kerja menjadi tinggi sehingga lebih berisiko mengalami kelelahan kerja. Penelitian ini bertujuan untuk mengetahui hubungan antara beban kerja dengan kelelahan kerja di Puskesmas Kecamatan Sukmajaya selama masa pandemi. Desain penelitian yang digunakan adalah cross sectional dengan pengumpulan …

Mental Health, Chronic Disease, And Substance Use: Findings From Rural Texas, Subi Gandhi, Ryan Glaman, Elizabeth Wachira, Muna Bashir, Sushma Sharma, Chelsea Mowles, Jasmine Luttrell

Journal of Social, Behavioral, and Health Sciences

There are vital links among mental health conditions, chronic diseases, and substance use disorders. Simultaneous examination of the relationship among these three conditions is essential for providing well-integrated care to rural residents who have limited resources and for representing medically underserved areas. We aimed to assess the burden of behavioral health conditions and chronic diseases from a rural Texas community to garner context-specific insights and inform effective health promotion strategies in similar communities. We conducted a cross-sectional study among 181 residents from various zip codes in a rural Texas county. A self-administered, 18-item health-needs questionnaire was used to collect data …

Disparities In Adult Critical Care Resources Across Pakistan: Findings From A National Survey And Assessment Using A Novel Scoring System, Mustafa Ali Khan, Hamna Shahbaz, Ali Aahil Noorali, Anam Noor Ehsan, Mareeha Zaki, Fahham Asghar, Mohammed Moizul Hassan, Haroon Muhammad Arshad, Muhammad Sohaib, Adil H. Haider

Medical College Documents

Background: In response to the COVID-19 pandemic, concerted efforts were made by provincial and federal governments to invest in critical care infrastructure and medical equipment to bridge the gap of resource-limitation in intensive care units (ICUs) across Pakistan. An initial step in creating a plan toward strengthening Pakistan's baseline critical care capacity was to carry out a needs-assessment within the country to assess gaps and devise strategies for improving the quality of critical care facilities.
Methods: To assess the baseline critical care capacity of Pakistan, we conducted a series of cross-sectional surveys of hospitals providing COVID-19 care across the country. …

Development Of A Digital Health Capability Framework For Allied Health Practitioners: An Australian First, Nikki Littlewood, Sharon Downie, Abbey Sawyer, Kath Feely, Dhruv Govil, Brit Gordon

Internet Journal of Allied Health Sciences and Practice

Background: The value of digital health technologies and their contribution to high-quality and safe clinical care and enhanced health patient experience and outcomes is well established. Digital health technologies are increasingly being used by Victorian allied health professionals (AHPs) in routine service delivery, the uptake of which has been significantly accelerated by the impact of the coronavirus (COVID-19) pandemic. Objectives: This case study outlines the development of a capability framework to support Victorian AHPs, health services, other employers, and university training partners to measure and expand digital health capability at individual practitioner and workforce levels. Methods: A mixed-methods approach to …

Increased Rates Of Death From Unintentional Injury Among Non-Hispanic White, American Indian/Alaska Native, And Non-Metropolitan Communities, Lindsey R. Hammerslag, Jeffery Talbert, Tyrone F. Borders

Rural & Underserved Health Research Center Publications

Overview of Key Findings

• Living in a nonmetropolitan area is associated with an increase in the age-adjusted death rate from unintentional injuries, from 46.2 in metropolitan areas to 59.2 in nonmetropolitan areas in 2018, with all races/ethnicity groups affected except for non-Hispanic Black.
• The ratio of unintentional injury deaths in nonmetropolitan areas, compared to metropolitan areas, was 1.28 overall, ranging from 1.05 to 1.56 depending on race and ethnicity.
• American Indians and Alaska Natives have the highest rate of living in nonmetropolitan areas (39.5%), and this group has the greatest increase in death from unintentional injury associated with living in …