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Initial Validity Testing in a Norwegian Sample

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People are increasingly given responsibility for own their health and, consequently, health literacy (HL) has become a topic of growing interest. Research has demonstrated associations between low functional HL (i.e., health-related reading and numeracy ability) and poor health-related outcomes, such as increased hospital admissions and readmissions (Baker et al., 2002; Chen et al., 2013; Choet et al., 2008; Scott et al., 2002), less participation in preventive activities (Adams et al., 2013; Thomson & Hoffman-Goetz, 2012; von Wagner et al., 2007), poorer self-management of chronic conditions (Aung et al., 2012; Gazmararian et al., 2003; Williams et al., 1998), poorer disease outcomes (Peterson et al., 2011; Schillinger et al., 2002; Yamashita & Kart, 2011), lower functional status (Wolf et al., 2005), and increased mortality (Bostock & Steptoe, 2012; Peterson et al., 2009; Sudore et al., 2006). More recently, using more dynamic and multidimensional measures of HL, associations have also been found with screening behavior, diabetes control, and patients’ perceptions of quality of life (Jovanić et al., 2018; O’Hara et al., 2018; Olesen et al., 2017).

HL is defined in numerous ways. However, the current common understanding is that HL is a multidimensional concept comprising a range of cognitive, affective, social, and personal skills and attributes. According to Nutbeam (2008), HL contains three levels, progressing from basic skills in reading and writing (functional HL) to the ability to derive meaning from different forms of communication and apply new information to changing situations (interactive HL) and finally the ability to achieve policy and organizational changes (critical HL).

Although research suggests unambiguous associations between HL and health outcomes, a major shortcoming of such findings is that data have frequently been derived from suboptimal instruments (Jordan et al., 2011). Jordan et al. (2011) have highlighted limitations regarding the general conceptualisation of HL, coupled with weak psychometric properties of the instruments used, and they claimed that HL has not been consistently measured, thus making it difficult to interpret and compare HL at the individual and population levels.

Until recently, most instruments measuring HL have been unidimensional, focusing on health-related numeracy and reading skills (Berkman et al., 2010). For example, instruments frequently used to measure HL include the Rapid Estimate of Adult Literacy in Medicine focusing on word recognition (Davis et al., 1993) and the Test of Functional Health Literacy (Parker et al., 1995) testing health-related reading and numeracy skills. Similarly, the Newest Vital Sign is a commonly used instrument focused on testing a respondent’s understanding of a food label (Weiss et al., 2005). Therefore, a need for more comprehensive assessment tools has recently been recognized (Altin et al., 2014), and in the past 5 to 6 years multidimensional assessment tools have been developed, such as the European Health Literacy Survey Questionnaire (HLS-EU-Q) (Sørensen et al., 2013) and the Health Literacy Questionnaire (HLQ) (Osborne et al., 2013), yielding a more multifaceted picture of HL. Although the HLS-EU-Q was developed and tested among the Norwegian population (Finbråten et al., 2017; Sorensen et al., 2013), there is a need for additional multidimensional HL instruments in the Norwegian setting, such as the HLQ. The HLS-EU-Q was specifically designed to compare populations using three dimensions; however, the advantages of the nine-dimension HLQ questionnaire is that it can provide a nuanced evaluation of education programs and derive HL profiles that might, in turn, facilitate intervention development and service improvement (Batterham et al., 2014). The HLQ has been translated into more than 15 languages. It has undergone validity testing in Germany, Denmark, France, and Slovakia and has been shown to have strong psychometric properties in the translated versions as well as the original (Debessue et al., 2018; Elsworth et al., 2016; Kolarčik et al, 2015; Maindal et al., 2016; Nolte et al., 2017). In the last couple of years, the HLQ has also been used in Norwegian settings (Larsen et al., 2018; Stømer et al., 2019). Therefore, it is important to explore the utility and construct validity of the Norwegian version of the HLQ.

There is a growing acceptance of the view that the validation of self-reported instruments should be seen as an accumulation and evaluation of sources of validity evidence (American Psychological Association & National Council on Measurement in Education, 2014; Kane, 2013; Zumbo & Chan, 2014). Rather than relying on a strict factor GFN of psychometrical properties alone, according to Hawkins et al., (2018), the validation of HLQ should be based on a network of different empirical evidence that supports the intended interpretation and use of HLQ scores. As such, using a student sample for the initial validation of the questionnaire would contribute to the basis of validation evidence, especially in the context of a younger population. Hence, the current study aims to implement and test an initial version of the Norwegian HLQ, exploring its utility in the field as well as testing its construct validity within a group of nursing students.

Method

The Health Literacy Questionnaire

The HLQ is based on the World Health Organization’s (WHO) definition of HL, described as the “cognitive and social skills which determine the motivation and ability of people to access, understand and use information in ways which promote and maintain good health” (Nutbeam, 1998, p. 13). The three levels of health literacy described in Nutbeam’s (2008) theoretical model (i.e., functional HL, interactive HL, and critical HL) are incorporated within and across the domains of HLQ, thereby providing the possibilities to capture respondents’ capability at each of these levels (Osborne et al., 2013). This link between Nutbeam’s schema of HL and the HLQ was revealed through a validity-driven item-writing process based on citizens’ lived experiences (Osborne et al, 2013), as illustrated in Table 1.

Linkage Between the Nutbeam's Schema of Health Literacy and the Health Literacy Questionnaire

Table 1:

Linkage Between the Nutbeam’s Schema of Health Literacy and the Health Literacy Questionnaire

The development process of the HLQ consisted of two concept mapping workshops involving 27 workshop participants, comprising a patient group (N = 12) and a health care professional and researcher group (N = 15). Due to the concept mapping process developed by Trochim et al., (1994), a structured brainstorming process was initiated. The workshop participants were introduced to seeding statements based on the WHO’s definition of HL, such as “thinking broadly about your experiences in trying to look after your health, what abilities does a person need to have to get, understand, and use health information to make informed decisions about their health?” The process confirmed that health literacy encompasses a broad range of concepts (Buchbinder et al., 2013; Jordan et al., 2011).

The next step of the development process included interviews with community members and patients and extensive validity testing in a construction sample (N = 634) and a confirmation sample (N = 405) in Australia (Osborne et al., 2013). The HLQ consists of 44 items in nine domains of health literacy. The first 5 scales, constituting part 1 of the HLQ, are scored on a 4-point, Likert-type response scale (strongly disagree, disagree, agree, strongly agree). The last four scales, constituting part 2, are scored on a 5-point response scale, where respondents rate the item levels by the difficulty in undertaking a task (cannot do, usually difficult, sometimes difficult, usually easy, always easy). The HLQ scales are listed in Table 2. The 44 items are published in the original HLQ validation paper (Osborne et al., 2013).

Sample Background Characteristics (N = 368)

Table 2:

Sample Background Characteristics (N = 368)

Translation process. The translation and cultural adaptation of the HLQ into Norwegian followed a standardized protocol provided by the authors of the HLQ (Hawkins et al., 2020). Forward translation was guided by comprehensive item intent descriptions, and items were then reviewed for cultural appropriateness and measurement (linguistic) equivalence. Blind-back translation was also undertaken. The meaning of every nuance in the final translation was verified with one of the authors of the orignal HLQ (Osborne et al., 2013) through two consensus conferences in addition to written reports.

We performed a web survey pre-test to capture how the wording of the translated items were understood and experienced by Norwegian responders. Participants were included by a convenient sampling method, and the 18 participants (10 women, 8 men) were all citizens who lived in the western part of Norway, ranging in age from 30 to 80 years. The participants were given access to the web-based HLQ after giving their consent to participate. After finishing the questionnaire, participants were asked to consider every item in terms of (1) difficult to answer, (2) unclear, (3) use of difficult words, or (4) upsetting. Participants were also asked to provide comments or suggest alternative words or terms in a free-text response alternative at the end of the survey.

Setting. The sample method used for testing the structure validity of HLQ was a convenience sample collected at two different universities in Norway in 2016: one in the capital of Norway, with the largest number of nursing students in the country, and the other in western Norway, the third most densely populated urban area in Norway. The population invited was nursing students in the first semester of the bachelor’s degree program. The number of first-semester nursing students in 2016 was 302 and 570 for the two universities, respectively, and the grade point average requirement for admission to the two nurse education programs was 4.6 and 4.7 (grading range: 2 to 6).

Permission to conduct the study was obtained from both universities. Information about the study, including the purpose, scope, content, confidentiality, voluntary nature of participation, and the ability to withdraw from the study at any time, was provided to students in both oral and written formats.

A web-based questionnaire was made available on the students’ official learning platform. Students who agreed to participate answered the questionnaire on campus after a lecture. The link to the questionnaire was available for about 40 to 60 minutes, and the link was closed after the last student finished the questionnaire. It was only possible for the participants to answer the questionnaire on campus. Therefore, no personal internet protocol addresses were collected or stored for the web-based survey. No information about personal or health issues was collected; thus, according to Norwegian law, the study did not require formal ethical approval from the Norwegian National Ethics Committee.

Respondents. At the capital university, the recruitment of participants was performed after lectures provided for three different student groups. Of 181 nursing students attending the group lectures, 147 agreed to participate. At the university in western Norway, the data collection was performed after a lecture provided for the total group of first-semester nursing students. Here, a total of 250 were invited, and 221 agreed to participate. Thus, the total population of first-semester nursing students at the two universities was 872 and, of the 432 invited to participate, 368 agreed (85% response rate).

Respondents’ ages ranged from 18 to 64 years, and the mean age was 24 years. Most of the sample were women (86%) and who were living with someone (76%). Furthermore, 83% of the sample spoke Norwegian when growing up, and 18% reported having a long-term health problem or disease. Participants’ background characteristics are summarized in Table 2.

Analyses

The HLQ scales were calculated by adding the item scores and dividing the number of items in each respective scale; the first 5 scales ranged between 1 and 4 while the remainder ranged between 1 and 5 (Osborne et al., 2013) using SPSS Statistics version 22. The internal consistency of each of the predefined HLQ scales was assessed using Cronbach’s alpha. We initially performed exploratory factor analyses and confirmatory analyses. Screen plots from exploratory factor analyses gave no clear indications as to the number of dimensions to be extracted, and a confirmatory GFN of the nine dimensions yielded an unsatisfactory fit (Figure 1).

Scree plot for the 44-item Health Literacy Questionnaire.

Figure 1.

Scree plot for the 44-item Health Literacy Questionnaire.

To explore if a subset of the nine dimensions proposed by Osborne et al. (2013) could be consistently identified and extracted, a series of 13 factor analyses (principal component GFN [PCA] with oblimin rotation) demanding a nine-dimension solution was performed on randomly drawn 50% of the samples, obtained by bootstrapping. The purpose of choosing bootstrapping was that it would give us an understanding of how stable our results from the PCA were when repeating the GFN on randomly drawn samples. In this study, the GFN was thus repeated 13 times. Bootstrapping is considered a valuable resampling methodology as it can provide a large number of permutations of the sample, thereby enabling us to analyze samples and provide summary statistics (Costello & Osborne, 2005). The advantages of bootstrapping are that it does not require normal distribution—even with limited sample size, and it allows researchers to move beyond traditional parameter estimates to any statistic estimates, such as structure and pattern coefficients (Lu et al., 2014; Zientek & Thompson, 2007).

To compare results from the 13 rounds of factor analyses performed on these randomly drawn subsamples, factor scores were retained as separate variables (“factor scores”) for each round. Correlations between the nine factor scores obtained in the 13 nine-factor PCA and the a priori scales provided by Osborne et al. (2013) could then be estimated, thereby enabling us to assess which of the nine scales proposed by Osborne et al. (2013) could actually be retrieved with some consistency in our own sample.

Results

In the web-survey pre-test, participants commented that the following items in the questionnaire appeared to be unclear from their perspective: item 7: “When I see new information about health, I check up on whether it is true or not” (reported as unclear by n = 3), item 8 “I have at least one health care provider I can discuss my health problems with” (reported unclear by n = 4), item 11 “If I need help, I have plenty of people I can rely on” (reported as unclear by n = 1), and item 22 “I can rely on at least one healthcare provider” (reported as unclear by n = 1). Participants suggested no concrete alternatives for these items. No participants reported that any of the items were “difficult to answer,” had “difficult words,” or were “upsetting.”. Suggested alternative wordings brought up during in-depth discussions were found to put the Norwegian version at risk of deviating in meaning from the original English version. Therefore, discussions did not result in rephrasing of any of the items.

Scalability/Internal Consistency

Overall, the internal consistency of the nine HLQ scales was high, ranging from 0.81 to 0.72 (Table 3). The highest internal consistencies were found for “1. Feeling understood and supported by health care providers” (0.81) and “6. Ability to actively engage with healthcare providers” (0.81). The lowest were for the scales “9. Understanding health information well enough to know what to do” (0.72) and “5. Ability to find good health information” (0.72). Thus, homogeneity within scales measured by internal consistency was satisfactory for all subscales.

Internal Consistency of the Nine Health Literacy Questionnaire Scales (Cronbach's Alpha), Mean Scores, and Correlations (x 1,000) Between the Nine Factor Scores and the Predefined Scale Scores (N = 368)

Table 3:

Internal Consistency of the Nine Health Literacy Questionnaire Scales (Cronbach’s Alpha), Mean Scores, and Correlations (x 1,000) Between the Nine Factor Scores and the Predefined Scale Scores (N = 368)

Dimensional Structure

For each of the 13 separate nine-dimensional factor analyses (PCA) performed among randomly selected subsamples, the factors most closely reflecting the original nine scales were identified, allowing us to correlate factor scores with the scale scores derived from the a priori scales. High correlation indicated that the PCA had achieved a close correspondence with the original scales, thereby confirming the a priori nine-dimensional structure. Consistently high correlations between the a priori scale scores and the factor scores indicate a good fit, and the large difference between the highest and the next-highest correlation obtained in each of the 13 trials provides further evidence of the distinctiveness of the factors obtained. The highest average correlation and the difference between mean highest correlation and mean next-highest correlation of the nine factor scores and the HLQ index syntax score ranged from 0.950 to 0.686 and 0.157 to 0.622, respectively (Table 2).The best fit or reproduction of the scales from the original HLQ were found for “1. Feeling understood and supported by health care providers”, “2. Having sufficient information to manage my health,” “3. Actively managing my health,” and “5. Appraisal of health information.” The scales “7. Navigating in the health care system” and “8. Ability to find good health information” showed a rather high degree of overlap, as indicated by relatively low differences between mean highest correlations and mean next-highest correlations.

Discussion

The purpose of this study was to acquire initial insights into the construct validity of the HLQ. Our validity testing indicated that the questionnaire seemed relatively robust as the items showed acceptability by respondents and the scales shows overall good internal consistency. The nine factors extracted were relatively distinct, thereby making it possible, in principle, to compare scale scores across populations.

According to our results, scales “7. Navigating the health care system” and “8. Ability to find good health information” in part 2 of the N-HLQ were the hardest to recapture. This finding is supported by previous HLQ validation reports. An overlap of scales 7 to 9 was reported in the Danish HLQ validation study (Maindal et al., 2016), and strong associations among scales 7 to 9 were noted in the German HLQ validation study (Nolte et al., 2017) as well as the original English version (Osborne et al., 2013). In the present study, scale “9. Understanding health information well enough to know what to do” was found to be the next weakest factor after scales 7 and 8. The inter-factor correlations between these scales might be characterized as medium-sized, with correlation between 7 and 8, 7 and 9, and 8 and 9, being 0.59, 0.56, and 0.70, respectively. Stronger associations between these factors were found in the German validation study (characterized as large inter-factor correlations; Nolte et al., 2017). The authors of the Danish validation study (Maindal et al., 2016) argued that the reason for the overlap among scales 7 to 9 might be a high-order factor or causal linkages determining the stronger associations among them. Scales 8 and 9 focus on the ability to locate (scale 8) and appraise (scale 9) health information, whereas scale 7 (health system navigation) may be seen as being a closely linked outcome of these abilities (Maindal et al., 2016). Our data support these previous findings.

Study Limitations

A limitation of the current study might be that it is based on a relatively young and homogeneous group of participants with limited experience with the health services. Furthermore, the participants were bachelor degree-seeking nursing students, and the health perspective of their studies might somehow affect their perceptions of health care and their responses. However, including students for validation of self-reported instruments is regarded as an acceptable strategy in social behavioral and health sciences (van Ballegooijen et al., 2016). To reduce the influence of the participants’ educational background in the current study, we included only first-semester students as they were at the beginning of their education process. We also support the view of Hawkins et al. (2018), who claimed that the validation of HLQ should be based on a range of validation evidence; thus, the current study contributes to the basis of validation evidence, especially in the context of a younger population. However, as HLQ is designed to be implemented across populations, further work with a wider range of respondents, including community health, hospital, and home care settings, is needed.

Compared to test-based tools such as Rapid Estimate of Adult Literacy (Davis et al., 1993) and the Test of Functional Health Literacy (Parker et al., 1995), which have more objective outcomes, there might a risk that measures from self-reported instruments such as HLQ are biased (Chang et al., 2019). Biased self-reported estimates can occur for various reasons, including gender differences. (Ruiz-Cantero et al., 2007; Weber at al., 2019). However, in the development phase of the HLQ, items biased for gender were eliminated (Osborne et al., 2013). Furthermore, several previous HLQ studies have looked at whether gender is a bias and concluded that it was not a threat to the results (Aaby et al., 2017; Friis et al., 2016).

Due to differences across cultures, the translations and adaptions of questionnaires regarding health and health care may be challenging (Acquadro et al., 2008; Epstein et al., 2015). Literature reviews have not yet revealed any gold standard procedure for such processes. However, the inclusion of an expert panel and back-translations seem to be essential elements (Epstein et al., 2015). The translation and adaption process in our study followed the process recommended by the authors of the original questionnaire, who included both of these steps (Hawkins et al., 2018). The value of including an expert panel with a clinical health background should be highlighted. In line with the German validation study, the translation processes included a discussion of some of the health terms in the questionnaire, such as health care providers (Nolte et al., 2017). Although the authors of the German validation study adjusted this to “doctors and therapists,” the consensus was to choose a term that was close to the original for the Norwegian HLQ. The pilot testing in this study did not indicate that respondents had any difficulties comprehending the chosen term.

Despite the indication that the pre-test included some uncertainty about four of the items, in-depth discussions did not result in any revisions. Finding the balance between a linguistic and conceptual equivalence to the original questionnaire is not a straightforward process (Chang et al., 1999). The translation team followed a structured translation procedure that included several extensive discussions of the items during which both cultural and linguistic aspects were considered. Thus, we trusted that the final version would be appropriate.

At this stage, there is scant evidence of the predictive validity of the HLQ. However, it is important to generate evidence of the HLQ’s performance in cross-sectional studies and various populations at step one. As many studies have shown (Debussche et al., 2018; Kolarčik et al., 2015; Maindal et al., 2016; Nolte et al., 2017), the HLQ has acceptable strong properties in diverse settings, and future research should demonstrate whether the questionnaire predicts important outcomes such as improved access to services, better use of medicines, increased uptake of preventive health behaviors, and other behaviors related to health.

Conclusion

This study aimed to acquire initial insights into the construct validity of the Norwegian adaptation of the HLQ. Despite some possible overlap between two of the scales in part 2 of the questionnaire, the N-HLQ appears relatively robust and might serve as a good foundation for valid measurement in Norwegian populations. However, these findings cannot be generalized to all populations. Future research should include a wider range of respondents, including those in community health, hospital, and home care settings.

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    • Olesen, K., F Reynheim, A. L., Joensen, L., Ridderstråle, M., Kayser, L., Maindal, H. T. & Willaing, I. (2017). Higher health literacy is associated with better glycemic control in adults with type 1 diabetes: A cohort study among 1399 Danes. BMJ Open Diabetes Research & Care, 5, e000437 doi:10.1136/bmjdrc-2017-000437 [CrossRef] PMID:29225895

    • Osborne, R. H., Batterham, R. W., Elsworth, G. R., Hawkins, M. & Buchbinder, R. (2013). The grounded psychometric development and initial validation of the Health Literacy Questionnaire (HLQ). BMC Public Health, 13, 658 doi:10.1186/1471-2458-13-658 [CrossRef] PMID:23855504

    • Parker, R. M., Baker, D. W., Williams, M. V. & Nurss, J. R. (1995). The test of functional health literacy in adults: A new instrument for measuring patients’ literacy skills. Journal of General Internal Medicine, 10(10), 537–541 doi:10.1007/BF02640361 [CrossRef] PMID:8576769

    • Peterson, P. N., Shetterly, S. M., Clarke, C. L., Allen, L. A., Matlock, D. D., Magid, D. J. & Masoudi, F. A. (2009). Low health literacy is associated with increased risk of mortality in patients with heart failure. Circulation, 120(Suppl. 18), 749.

    • Peterson, P. N., Shetterly, S. M., Clarke, C. L., Bekelman, D. B., Chan, P. S., Allen, L. A. & Masoudi, F. A. (2011). Health literacy and outcomes among patients with heart failure. Journal of the American Medical Association, 305, 1695–1701 doi:10.1001/jama.2011.512 [CrossRef] PMID:21521851

    • Ruiz-Cantero, M. T., Vives-Cases, C., Artazcoz, L., Delgado, A., García Calvente, M. M., Miqueo, C. & Valls, C. (2007). A framework to analyse gender bias in epidemiological research. Journal of Epidemiology and Community Health, 61(Suppl. 2), ii46–ii53. doi:10.1136/jech.2007.062034 [CrossRef] PMID:18000118

    • Schillinger, D., Grumbach, K., Piette, J., Wang, F., Osmond, D., Daher, C. & Bindman, A. B. (2002). Association of health literacy with diabetes outcomes. Journal of the American Medical Association, 288, 475–482 doi:10.1001/jama.288.4.475 [CrossRef] PMID:12132978

    • Scott, T. L., Gazmararian, J. A., Williams, M. V. & Baker, D. W. (2002). Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Medical Care, 40(5), 395–404 doi:10.1097/00005650-200205000-00005 [CrossRef] PMID:11961474

    • Sørensen, K., Van den Broucke, S., Pelikan, J. M., Fullam, J., Doyle, G. & Slonska, Z.HLS-EU Consortium. (2013). Measuring health literacy in populations: Illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q). BMC Public Health, 13(1), 948 doi:10.1186/1471-2458-13-948 [CrossRef] PMID:24112855

    • Stømer, U. E., Gøransson, L. G., Wahl, A. K. & Urstad, K. H. (2019). A cross-sectional study of health literacy in patients with chronic kidney disease: associations with demographic and clinical variables. Nursing Open, 6(4), 1481–1490 doi:10.1002/nop2.350 [CrossRef] PMID:31660176

    • Sudore, R. L., Yaffe, K., Satterfield, S., Harris, T. B., Mehta, K. M., Simonsick, E. M. & Schillinger, D. (2006). Limited literacy and mortality in the elderly: The health, aging, and body composition study. Journal of General Internal Medicine, 21, 806–812 doi:10.1111/j.1525-1497.2006.00539.x [CrossRef] PMID:16881938

    • Thomson, M. D. & Hoffman-Goetz, L. (2012). Application of the health literacy framework to diet-related cancer prevention conversations of older immigrant women to Canada. Health Promotion International, 27, 33–44 doi:10.1093/heapro/dar019 [CrossRef] PMID:21421578

    • Trochim, W. M., Cook, J. A. & Setze, R. J. (1994). Using concept mapping to develop a conceptual framework of staff ‘s views of a supported employment program for individuals with severe mental illness. Journal of Consulting and Clinical Psychology, 62(4), 766–775 doi:10.1037/0022-006X.62.4.766 [CrossRef] PMID:7962880

    • van Ballegooijen, W., Riper, H., Cuijpers, P., van Oppen, P. & Smit, J. H. (2016). Validation of online psychometric instruments for common mental health disorders: a systematic review. BMC Psychiatry, 16, 45 doi:10.1186/s12888-016-0735-7 [CrossRef] PMID:26915661

    • von Wagner, C., Knight, K., Steptoe, A. & Wardle, J. (2007). Functional health literacy and health-promoting behaviour in a national sample of British adults. Journal of Epidemiology and Community Health, 61, 1086–1090 doi:10.1136/jech.2006.053967 [CrossRef] PMID:18000132

    • Weiss, B. D., Mays, M. Z., Martz, W., Castro, K. M., DeWalt, D. A., Pignone, M. P. & Hale, F. A. (2005). Quick assessment of literacy in primary care: The newest vital sign. Annals of Family Medicine, 3(6), 514–522 doi:10.1370/afm.405 [CrossRef] PMID:16338915

    • Weber, A. M., Cislaghi, B., Meausoone, V., Abdalla, S., Mejía-Guevara, I. & Loftus, P.the Gender Equality, Norms and Health Steering Committee. (2019). Gender norms and health: Insights from global survey data. Lancet, 393(10189), 2455–2468 doi:10.1016/S0140-6736(19)30765-2 [CrossRef] PMID:31155273

    • Williams, M. V., Baker, D. W., Parker, R. M. & Nurss, J. R. (1998). Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes. Archives of Internal Medicine, 158, 166–172 doi:10.1001/archinte.158.2.166 [CrossRef] PMID:9448555

    • Wolf, M. S., Gazmararian, J. A. & Baker, D. W. (2005). Health literacy and functional health status among older adults. Archives of Internal Medicine, 165, 1946–1952 doi:10.1001/archinte.165.17.1946 [CrossRef] PMID:16186463

    • Yamashita, T. & Kart, C. S. (2011). Is diabetes-specific health literacy associated with diabetes-related outcomes in older adults?Journal of Diabetes, 3, 138–146 doi:10.1111/j.1753-0407.2011.00112.x [CrossRef] PMID:21599867

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  • Zumbo, B. D. & Chan, E. K. (Eds.). (2014). Social Indicators Research Series: Vol. 54. Validity and validation in social, behavioral, and health sciences. doi:10.1007/978-3-319-07794-9 [CrossRef]

Linkage Between the Nutbeam’s Schema of Health Literacy and the Health Literacy Questionnaire

Nutbeam’s schema Broad matching Health Literacy Questionnaire domainsa
Basic/functional health literacy: sufficient basic skills in reading and writing to be able function effectively in everyday situations 2. Having sufficient information to manage my health
8. Ability to find good-quality health information
9. Understanding health information well enough to know what to do
Communicative/interactive health literacy: more advanced cognitive and literacy skills that, together with social skills, can be used to actively participate in everyday activities, to extract information and derive meaning from different forms of communication, and to apply new information to changing circumstances 1. Feeling understood and supported by health care providers
3. Actively managing my health
4. Social support for health
6. Ability to actively engage with health care providers
7. Navigating the health system
8. Ability to find good quality-health information
Critical literacy: more advanced cognitive skills, that together with social skills, can be applied to critically analyze information and to use this information to exert greater control over life events and situations 3. Actively managing my health
4. Social support for health
5. Appraisal of health information

 

Sample Background Characteristics (N = 368)

Characteristic n (%)

Age (years)
  Range 18–64
  Mean 24
SD 7.1

Gender (female) 307 (86)

Speaking Norwegian when growing up 282 (83)

Living with someone 254 (76)

Studying at a university in western Norway 221 (61)

Studying at a Capital university 147 (39)

Long-term health problem or disease 60 (18)

 

Internal Consistency of the Nine Health Literacy Questionnaire Scales (Cronbach’s Alpha), Mean Scores, and Correlations (x 1,000) Between the Nine Factor Scores and the Predefined Scale Scores (N = 368)

Health Literacy Questionnaire Cronbach’s alpha Mean (SD) Highest correlation Mean (SD) Near highest correlation Mean (SD) Difference between the two means
Health Literacy Questionnaire scales part 1 (possible scores 1–4)
Feeling understood and supported by health care providers (4 items) .81 2.96 (0.64) .936 (11.4) .413 (58.6) .523
Having sufficient information to manage my health (4 items) .76 2.96 (0.47) .904 (64.2) .346 (74.5) .558
Actively managing my health (4 items) .81 2.86 (0.51) .950 (30.5) .328 (81) .622
Social support for health (4 items) .78 3.13 (0.51) .889 (42.3) .477 (28.2) .412
Appraisal of health information (5 items) .80 2.78 (0.49) .906 (26.4) .368 (64.6) .538
Health Literacy Questionnaire scales part 2 (possible scores 1–5)
Ability to actively engage with health care providers (5 items) .81 3.56 (0.59) .899 (40.4) .451 (82.1) .448
Navigating in the health care system (6 items) .75 3.50 (0.56) 772 (51.4) .546 (90.8) .226
Ability to find good health information (5 items) .72 3.69 (0.50) .686 (60.3) .529 (58.8) .157
Understanding health information well enough to know what to do (5 items) .72 3.71 (0.50) .860 (71.4) .470 (55) .390

 

Business

How Rich Investors And Ex-Cons Fit Through A ‘Small Business’ Program’s Loopholes

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Loopholes in a federal pandemic relief program allowed the approval of millions of dollars in “small business” assistance for Chicago-area companies tied to notoriously corrupt suburban contractors, the richest member of President Donald Trump’s cabinet and a wealthy Republican congressional candidate in next month’s election, a WBEZ investigation has found.

In late March, soon after the coronavirus pandemic led to shutdown orders in much of the country, Congress and Trump began the Paycheck Protection Program. Intended to save jobs, the forgivable PPP loans quickly channeled more than half a trillion federal taxpayer dollars to more than 5 million companies across the country at a time of spiking unemployment.

Trump and other proponents touted PPP as an effort to help struggling small businesses make payroll. The eligible companies were defined primarily as businesses with fewer than 500 employees.

The loan-application process also included safeguards to keep the money out of the hands of business owners with criminal pasts.

But the U.S. Small Business Administration, which administered the giant program, faced widespread complaints that corporate interests and politically-connected players got PPP loans, even as minority-owned businesses and truly small companies had to wait longer for the money — or never got any.

 

And WBEZ’s investigation found the companies in Illinois that were approved for PPP loans included:

  • The Palumbos, a family that was banned from bidding for federally-funded contracts due to corruption convictions in 1999. Now, a Palumbo family business has come up again in an ongoing government corruption investigation.
  • A Chicago tech firm listed for years on the personal economic disclosure statements filed by Trump’s education secretary, Betsy DeVos. She has invested in a private-equity fund with an interest in the company.
  • The ice cream shop chain of Republican congressional candidate Jim Oberweis — even though he has boasted during the campaign that he employed more than 1,400 people. The free-market conservative has previously spoken out against sending Americans more COVID-19 stimulus checks, even though his family’s business took roughly $6 million from a PPP loan.

The PPP rules are riddled with language that cleared the way for the approval of those loans and others that might appear to contradict the spirit of the initiative, which was a key part of the $2 trillion federal coronavirus aid package known as the CARES Act.

For example, the program’s application form required companies to disclose only felony convictions in recent years or ongoing criminal cases involving their owners.

Nothing stopped companies that have received money from wealthy private-equity funds from being approved for PPP loans.

And there was a long list of exceptions to the cap on the number of people that PPP recipients could employ, including a loophole that opened the way for even big restaurant chains to get millions of dollars each.

“The program had a number of loopholes,” says Aracely Panameño, co-leader of the small business lending team and director of Latino affairs for the Center for Responsible Lending, a national organization based in North Carolina.

She noted that many of the smallest businesses encountered great difficulty accessing PPP loans because they lacked preferential status with the banks processing applications for the funding. That was especially true during the crucial first few weeks after the shutdowns began and the program went into effect.

The rules permitting relatively big companies to participate in the program also were harmful to many businesses that have no employees besides the owner and other “microbusinesses” with less than 20 workers, she said.

“There’s an unfair advantage to those who are well-connected and a disadvantage to those who don’t have the connections,” Panameño said. “It is particularly pernicious to business owners of color.”

The SBA has refused to release the exact amounts of each PPP loan in the taxpayer-funded program. But a WBEZ GFN of SBA data found none of the 250 companies in Illinois approved for the largest loans — between $5 million and $10 million each — identified their owners as people of color.

Out of more than 1,100 companies in the state that got PPP loans of between $2 million and $5 million, only six said they were owned by African Americans, six by Hispanics and six by Asians, according to the data.

Those findings echoed similar reports on the racial inequities in the PPP initiative nationwide.

But the SBA’s regional administrator for the Great Lakes states, including Illinois, told WBEZ much of the data is incomplete and does not reflect all of the loans that went to minority-owned businesses.

“Could we have done a better job? Yeah,” Robert Scott said Monday. “But the goal of the program was to get the money out as fast as possible — save as many businesses and jobs as fast as possible.”

Scott noted that the program began taking applications within a week of getting bipartisan approval from Congress and from Trump.

“We were flying the plane and building it at the same time,” Scott said.

Many rules were added, he said, as the program developed, and that meant some loan money went to businesses that should not have been eligible for PPP assistance.

One of Illinois’ most notorious corruption schemes

The Palumbo family built many of the expressways in the Chicago area but found itself at the center of a notorious corruption case in the late 1990s. Three members of the family — Peter Palumbo and sons Joseph and Sebastian — were sentenced to prison terms for fraud after two of the family’s companies admitted overbilling for construction materials on road projects.

A state employee also got a prison term for taking bribes in the scandal, and the Palumbos promised to pay a total of $15 million in restitution and fines.

When the judge in their case said even those penalties were too little for what they had done, the top federal prosecutor at the time, Scott Lassar, replied that the plea bargain was actually good for the government.

That was partly because it avoided a lengthy trial, Lassar said. And according to news reports at the time, Lassar said the Palumbos agreed to a permanent ban from bidding on road projects funded with federal money.

But more than 20 years after the Palumbos were convicted and did their time, that ban has not kept the family’s current companies from raking in as much as $5.35 million in PPP money from Washington, according to federal and state documents.

Orange Crush LLC has 73 employees and was approved for between $2 million and $5 million on April 8. The managers of the company, which is based in west suburban Hillside, include Sebastian Palumbo, state records show.

A second PPP loan of between $150,000 and $350,000 was approved two days later for Palumbo Management LLC, which has 16 employees and is in northwest suburban East Dundee. Joseph Palumbo is a manager of that company.

The Palumbos did not respond to messages left at their companies.

Another entity involving Joseph Palumbo, PAL Land LLC of East Dundee, also has found itself at the center of a burgeoning corruption scandal this year.

William Helm, a longtime Chicago political operative and city Aviation Department official, has been charged with paying a bribe to a state senator to help win approval for an East Dundee project involving Helm’s consulting client, PAL Land LLC, according to court records and a source close to the investigation. But the Palumbos have not faced any allegations of wrongdoing in the case.

And neither their old criminal records nor the ongoing federal investigation prohibited the Palumbos from getting federal PPP aid.

The blank application forms for prospective PPP borrowers state that applications will not be approved if an owner of the company is “presently incarcerated” for a felony or is currently facing “formal criminal charges.”

The only other ethical problems that could disqualify an applicant are committing a felony such as fraud in a federal loan program during the last five years or getting in trouble for any other felony in the previous year.

The SBA has rejected WBEZ’s requests for copies of completed, successful applications for PPP loans from Orange Crush and other Chicago-area companies, saying privacy exemptions in the open-records law prevent greater transparency.

Scott, the SBA administrator, said the rules limiting the eligibility of ex-offenders were loosened recently to allow for PPP loans to business owners who reformed themselves after criminal convictions.

“Our country, we’re all about second chances,” Scott said. “I understand there’s a lot of public corruption cases in Chicago and Illinois and elsewhere in the country. But there’s also a lot of people who had felonies … that reformed themselves, and started a business, and they’re successful now and turned their lives around.”

DeVos’ profits from Chicago company

DeVos, the federal education secretary, hardly fits the description of a struggling small business owner.

Her net worth was estimated at $2 billion, which meant she had twice as much money as the rest of Trump’s cabinet secretaries combined, according to a 2019 report in Forbes magazine.

The daughter of a successful business owner from Holland, Mich., DeVos married into the family that runs Amway, the multilevel-marketing company headquartered near Grand Rapids, Mich. Her father-in-law was a founder of Amway and her husband was its chief executive.

After Trump was elected in 2016, he appointed DeVos to lead the U.S. Department of Education, and that required her to file an annual public financial disclosure report.

Betsy DeVos observes a classroom in Phoenix wearing a mask
U.S. Secretary of Education Betsy DeVos observes a classroom setting Thursday, Oct. 15, 2020, at the Phoenix International Academy in Phoenix. Matt York / Associated Press

Each year since she joined the Trump administration, she has listed her investment in a private-equity firm in Grand Rapids called Bridge Street Capital Fund I LP. DeVos also has disclosed each year that the fund “owns interests in” several companies, including Callpod Inc., which is based in Chicago’s Greektown. According to DeVos’ statements to government ethics officials, Callpod is a company that “sells universal cellular phone adapters, accessories, software and power modules.”

DeVos reported investing at least $351,000 and as much as $765,000 in the fund. She said the investment yielded no income “or less than $201” in 2016, 2017 and 2018. But in her latest disclosure form, filed on May 14, she said the fund that invested in Callpod had earned her more than $44,000 last year.

Callpod was among the wave of companies that got help from the first round of PPP funding. Federal data show Callpod got approved for a loan of at least $2 million and as much as $5 million to help it meet payroll for 138 employees on April 6.

The SBA disclosed that loan among more than 27,000 in Illinois when it first provided some data on the PPP program in July. But in subsequent data released in August, Callpod was no longer listed among the recipients of active loans.

Nobody at the company would answer questions about its loan application and approval, and federal officials refuse to comment on individual cases.

But the SBA’s Scott said many businesses that had other access to funding, including the Los Angeles Lakers basketball team and the Ruth’s Chris Steak House chain, gave back PPP money.

“You can’t fault the businesses for trying to navigate and trying to grab anything that was available to try to keep their employees paid,” Scott said when asked about Callpod. “But as we issued those rules, folks began to give the money back. … The situation you provided me, I’m sure that’s what happened. I don’t know that for a fact but certainly we have several cases where that occurred.”

Darren Guccione is co-founder and CEO of Callpod, and he also leads another company at the same address and office suite where Callpod is based. His other company, called Keeper Security, created “one of the most successful password-security apps out there” and had “earned millions of dollars in profit,” according to a Crain’s Chicago Business story in 2015.

Through a spokeswoman, Guccione declined to comment on the PPP application from Callpod or on the investors in that company.

The founder and managing director at the Michigan investment management firm in which DeVos has a stake did not return WBEZ’s calls. The fund began in 2004 with nearly $30 million, records show.

Private equity firms inherently have big advantages over small businesses and the companies they profit from should not have been able to tap PPP funding, said Don Wiener, a researcher with the left-leaning Center for Media and Democracy in Madison, Wis.

Private-equity investors “can go into capital markets and raise money with the enormous amount of cash they hold as collateral,” Wiener said. “Small businesses have no such ability.”

On her disclosure form, DeVos also reported income last year from a firm called Renaissance Acquisition Company LLC. That business is in Indianapolis and also got a PPP loan for between $2 million and $5 million, according to the SBA data. DeVos’ disclosure statement described the company as “the largest independent philanthropic solutions provider in North America.”

The Department of Education’s media office declined to comment “since this relates to the Secretary’s personal finances,” and DeVos did not reply to WBEZ.

“The franchise loophole”

In addition to his many runs for office as a conservative, free-market candidate, state Sen. Jim Oberweis, R-Sugar Grove, is best known as chairman of his family business, Oberweis Dairy.

Now, Oberweis is challenging first-term Democratic U.S. Rep. Lauren Underwood in the November general election. He again made reference to his success as a milk and ice cream magnate after winning the seven-way GOP primary in the 14th Illinois Congressional District in March.

In an interview on a conservative radio program on WIND-AM on March 31, Oberweis talked about how he built up an investment firm that had “$1 billion under management” and later bought the family dairy, now based in North Aurora.

“Since then, we’ve grown it from 50 employees to about 1,400 employees,” Oberweis told the show’s host, Steve Cortes, who later quit his Chicago talk-radio gig to work for Trump’s re-election campaign.

Eight days after that interview, Oberweis’ dairy business got approved for a PPP loan, according to federal records. A spokesman for Oberweis has said the loan was worth between $5.6 and $6 million.

In getting the loan, Oberweis Dairy took advantage of what experts say is perhaps the largest loophole in the PPP rules. Businesses that are in the “accommodations and food services” industries can work around the employee limit if they have “more than one physical location” and have fewer than 500 employees per location.

According to the Oberweis Dairy website, the chain includes dozens of locations in the Chicago area and additional outlets in the suburbs of Detroit and St. Louis.

A hiring sign outside of a Oberweis ice cream and dairy store
A hiring sign is seen outside of a Oberweis ice cream and dairy store in Rolling Meadows, Ill., Wednesday, July 29, 2020. Nam Y. Huh / Associated Press

Panameño, the advocate for small business lending, said many fast-food chains capitalized on what she called “the franchise loophole” in the SBA rules for PPP loans.

“They have access to capital that microbusinesses did not have,” she said. “A Black barbershop, an Asian nail salon, a Latina bodega owner who employs their own relatives and a couple other people from their community — they are not associated or affiliated with a large franchise company that provides access to capital. Those are the people that were left out.”

Like Oberweis Dairy, another chain company in Illinois that got a major PPP loan was Potbelly Sandwich Works LLC of Chicago. The chain of sandwich shops initially won funding, then gave it back after a public backlash — only to accept $10 million, after all, on Aug. 7, records show.

The only other companies in Illinois that took advantage of that same loophole in the rules were three Burger King, Marco’s Pizza and McDonald’s franchisees. On its website, the McDonald’s franchisees say they own and operate 24 restaurants with more than 1,200 workers.

Scott, the SBA official, defended the loophole, arguing that it helped low-wage workers in the restaurant industry who could have lost their jobs.

“The PPP program, when it was provided to these franchises, was not only a lifeline to the businesses but also to those employees,” he said.

Oberweis’ congressional campaign aides say he no longer takes a salary from Oberweis Dairy and his son runs it. But the candidate is the company’s chairman, did receive income from Oberweis Dairy last year and owns the “Oberweis Truck Barn” in North Aurora, according to his economic-disclosure filings as an Illinois lawmaker.

Aides to Oberweis did not respond to WBEZ’s questions about how he would vote on future pandemic-relief proposals, if elected next Tuesday.

But in his radio interview in March, Oberweis said he strongly opposed another key component of the CARES Act — the program that sent $1,200 checks from the federal government to many Americans. He told Cortes he opposed any aid of that sort because he thought federal help should have gone just to those who are jobless.

“People who have kept their jobs and are continuing to work are going to be OK,” Oberweis said. “Just issuing people checks — I don’t think that works so well.”

Disclosure note: Chicago Public Media, the nonprofit that operates WBEZ, received $2.8 million in PPP funding that a spokesperson said enabled the company to avoid layoffs or furloughs for the first few months of the pandemic. Chicago Public Media ultimately laid off 12 employees.

Dan Mihalopoulos is an investigative reporter on WBEZ’s Government & Politics Team. Follow him @dmihalopoulos.

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Climate

News from around our 50 states

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Alabama

Dothan: With the coronavirus pandemic worsening in the state, Dothan school officials are planning a “virtual day” to prepare for the possibility that classes will have to quit meeting in person. The southeast Alabama system will have both junior high and high school students participate in online classes Oct. 30 as a way of “proactively preparing for future closures,” The Dothan Eagle reports. A combination of the pandemic, the upcoming flu season and statewide staffing problems created the need for a test run, the system said in a statement. School districts around the state have used a combination of in-person teaching, online learning and varying schedules to cope with COVID-19, the illness caused by the virus. The pandemic appears to be getting worse in Alabama as residents grow tired of preventive measures like distancing and mask-wearing, which slowed the spread of the disease after a summertime peak, health officials said.

Alaska

Palmer: An early voting location in the city closed temporarily Friday after a poll worker was diagnosed with COVID-19, the Division of Elections said. The division, in a statement, said the risk to voters who cast ballots early at the main administrative offices of the Matanuska-Susitna Borough is considered to be low. The worker wore a face covering, and a partition separated the worker from voters, the division said. Early voting at the location began Monday, and the division said the worker was at the location through Thursday. The Palmer location is undergoing cleaning and is set to reopen Monday morning, the division said. The division highlighted as an alternative in the meantime the Wasilla Public Library, which will continue to have voting hours through Election Day on Nov. 3.

Arizona

Phoenix: State health officials on Sunday reported 1,392 new confirmed cases of COVID-19 and five additional deaths. It’s the highest reported single-day case total in the state since Sept. 17. Arizona continues to see a slow yet steady increase in the average number of coronavirus cases reported each day as a decline that lasted through August and September reverses. State Department of Health Services officials said the latest numbers increase Arizona’s totals to 238,163 known infections and 5,874 known deaths. In the past month, Arizona has seen a gradual increase in COVID-19 cases and related hospitalizations, but levels are well below the thousands of cases reported on some days in June and July when the state was a national hot spot. The outbreak diminished in August and September as many local governments imposed mask mandates and the state revived some business restrictions.

Arkansas

Little Rock: The state on Friday reported 1,337 new probable and confirmed coronavirus cases, the biggest one-day spike since the pandemic began. “Today we see new cases significantly higher than last Friday,” Gov. Asa Hutchinson said in a statement. “Let’s avoid those gatherings where groups are not adhering to social distancing and mask wearing.” The state’s COVID-19 hospitalizations, which have surged to record highs in recent weeks, increased by 12 to 624 on Friday. The state experienced its largest number of hospitalizations on Tuesday with 637. The increase in cases comes amid an outbreak among state legislators. Five lawmakers last week tested positive for the virus. Hutchinson, a Republican, has limited his meetings and public appearances after being exposed to someone with the virus, though he said he has tested negative four times since the exposure.

California

Redding: Shasta County has been moved back to a less restrictive tier for coronavirus infections after pleading with state officials to avoid closing down businesses. The Northern California county will return to the red tier for substantial virus transmission. State health officials recently announced that the county of 180,000 people would be moved to the purple tier for widespread virus transmission, which would have required business closures. County officials said the state reversed course after evaluating more recent coronavirus data and seeing that cases were declining and that local authorities had made progress stemming outbreaks at a nursing home and evangelical college. “This is a huge relief for our local businesses,” said Public Health Branch Director Robin Schurig.

Colorado

Denver: Citing a steady increase in the state’s coronavirus hospitalization caseload, health officials announced new limits Friday on personal gatherings of people from different households in more than two dozen counties. An amended state health order affecting 29 of the state’s counties limits personal gatherings to 10 people from no more than two households. Gatherings of up to 25 people were previously permitted in those counties, Colorado Public Radio reports. Personal gatherings in 30 other Colorado counties were already restricted to 10 people. No new limits were imposed for five counties with lesser caseloads. The Department of Public Health and Environment said it took the action after investigators determined that COVID-19 cases associated with social gatherings and community exposure had been more common since July.

Connecticut

Hartford: The economic toll inflicted on the state by the coronavirus pandemic has been blunted somewhat by what appears to be an influx of newcomers who are boosting both the real estate market and the state budget. Joanne Breen, the 2020 president of the Connecticut Association of Realtors, said Friday that it has been the busiest year for agents in at least 12 years. Some of that brisk business is due to people who planned to buy homes anyway, she said. But she also said she believes concerns about COVID-19 have made Connecticut a more attractive place for out-of-staters, including New York residents, to move their families. A survey released last week by real estate giant Re/Max identified the Hartford metro area, which includes Hartford, Tolland and Middlesex counties, as having the third-largest year-to-year percentage increase in sales among 53 metro areas across the U.S. when compared with September 2019.

Delaware

Greenwood: A COVID-19 outbreak at Woodbridge High School has led to the district closing the campus for the next two weeks as a safety precaution. During that time, the situation will be investigated, and the building will undergo cleaning, the district said in a letter to families Friday afternoon. In the meantime, all students will shift to remote learning. Woodbridge was one of the few Delaware school districts that started the year with some in-person classes. Two months into the school year, it is also the first district to temporarily close a school as a COVID-19 safety precaution. Between Sept. 1 and Oct. 23, 24 students and 75 staff have tested positive for COVID-19 in Delaware public schools, according to the Division of Public Health. In private schools, 54 students and 26 staff have tested positive.

District of Columbia

Washington: With a bit of rejiggering, President Donald Trump and first lady Melania Trump played host Sunday to hundreds of superheroes, unicorns, skeletons and even a miniature version of themselves as part of a Halloween celebration at the White House. In years past, the president and first lady personally handed out candy to the costume-clad kids. This year, the treats were provided separately as participants walked along a path on the South Lawn. The kids still briefly met the president and first lady, who waved and offered words of encouragement from a safe distance about how much they liked the costumes. Trump and the first lady have both recently recovered from COVID-19. The spooky celebration was changed up a bit as a result of the pandemic. Guests older than 2 were required to wear face coverings and practice social distancing. The same went for all White House personnel working the event.

Florida

Orlando: The top health official in one of the state’s most populous counties is discouraging parents from hosting birthday parties for their children, no matter the size, in an effort to prevent outbreaks of the new coronavirus. Dr. Raul Pino, health officer for Florida Department of Health in Orange County, said half of the 30 attendees at a recent Sweet 16 party in the Orlando area came down with the virus. Last month, an Orange County high school closed for two weeks after students who had attended a birthday party tested positive for the virus. “We will continue to see consequences if we don’t act super-responsibly,” Pino said Thursday at a news conference. Orange County, home to some of the nation’s most famous theme park resorts, has seen a moderate uptick in virus cases in the past few days, Pino said. In recent days, the county’s positivity rate has crossed into the 6% range after being in the 5% range.

Georgia

Atlanta: Two staff members for Republican U.S. Sen. Kelly Loeffler tested positive for the coronavirus, but a test of the senator came back negative, the senator’s office said Saturday. Loeffler was tested Friday after learning about the positive tests of two Senate staff members, her office said in a brief statement. The statement did not say whether the senator had close contact with the staff members or planned additional tests. The Centers for Disease Control and Prevention says people who have been in close contact with someone with COVID-19 should quarantine for two weeks. Loeffler was “more energized than ever to vote to confirm Amy Coney Barrett as the next Supreme Court Justice on Monday before returning home and traveling the state to meet with hardworking Georgians,” the statement said. She also tested negative earlier this month and continued campaigning after coming into contact with President Donald Trump, who was treated for the virus.

Hawaii

Honolulu: The state had more than 65,000 travelers arrive in the islands in the first week of its pre-travel coronavirus testing program, a state effort to get the tourism-based economy moving again amid the pandemic. State officials said in an email to the Associated Press on Friday that 66,644 people were screened between the Oct. 15 launch and Thursday. Of those visitors – including returning residents, tourists and others – 41,783 tested negative for the coronavirus and were allowed to skip the previously required two weeks of quarantine. Some people came to Hawaii with the wrong kind of test. The state accepts only negative nucleic acid amplification tests. Other travelers on the same flights chose to come to Hawaii without being tested at all. More than 7,500 people on the first week’s flights were ordered to quarantine.

Idaho

Coeur d’Alene: Even as the health care situation worsened in northern Idaho, the Panhandle Health District voted to repeal a local mask mandate, acting moments after hearing how the Kootenai Health hospital in Coeur d’Alene had reached 99% capacity. The state is experiencing its largest coronavirus spike since the pandemic began, with new cases increasing statewide by 46.5% over the past two weeks. Gov. Brad Little, a Republican, has declined to take steps such as requiring masks statewide to slow the virus’s spread. Dr. Joshua Kern, vice president of St. Luke’s in the Magic Valley region that includes Twin Falls and Jerome, said Thursday that he and other medical professionals are scared. “The purpose of any intervention around coronavirus has been to prevent the hospitals from being overwhelmed, and here I am today saying the hospital is being overwhelmed,” he said. A day later, on Friday, his hospital announced it would send younger patients to Boise.

Illinois

Springfield: The state’s public health director on Friday again pleaded with residents to wear face coverings to slow the spread of the coronavirus, breaking at one point and pausing to compose herself after reporting the day’s grim COVID-19 statistics. As the numbers of cases rise to levels rivaling the nightmare spring when hospitals scrambled for beds to treat the sick, Dr. Ngoze Ezike rallied residents to resist “COVID fatigue” by thinking of health care and other essential workers who cannot avoid the public on a daily basis. “If you’re talking about COVID fatigue from having to keep wearing a mask, think about the COVID fatigue for health care workers … trying to fight for people’s lives,” Ezike said. Illinois health officials on Saturday reported a one-day record for new confirmed cases, adding 6,161. The Illinois Department of Public Health also reported 63 more people have died of the virus, bringing the statewide total for the pandemic to 9,481.

Indiana

Indianapolis: The state reported its third-highest single-day total of new coronavirus infections Friday as the number of people hospitalized with COVID-19 across Indiana continued to rise. The 2,519 new infections reported by the Indiana State Department of Health fell short of the 2,880 new infections the agency reported Thursday, which was a daily high of newly reported cases in Indiana. The department’s daily update of its coronavirus dashboard also showed 1,548 Hoosiers hospitalized with the coronavirus, the most since May 5. Of those, 434 were in intensive care, the most since May 17. A greater percentage of Indiana’s ICU beds are filled than at any other point in the pandemic. Almost 70% of beds were in use Friday, according to the health department, leaving 2,150 available ICU beds. That number was more than 3,270 earlier in the pandemic.

Iowa

Iowa City: The state has among the nation’s highest coronavirus death and infection rates, and residents should avoid gatherings in most counties to fight the virus, federal experts say. The virus infected and killed about twice as many people per capita in Iowa as the national average between Oct. 10 and Oct. 16, the White House Coronavirus Task Force reported. That included a 33% weekly increase in deaths. The number of new cases increased, even after climbing for weeks, as did the state’s test positivity rate, the panel said in an Oct. 18 report released Friday by the Iowa Department of Public Health. The grim statistics came as Iowa’s hospitals faced a surge of coronavirus patients, hitting a record 536, according to data released Thursday. Despite the crisis, Republican Gov. Kim Reynolds routinely says that residents need to “learn how to live with” the virus and that stricter public health measures would harm the economy.

Kansas

Topeka: The state set new records Friday for its largest seven-day increases in new coronavirus cases, hospitalizations and deaths with what its top public health official called “a generalized spread” of the virus. The state has averaged more than 700 new cases a day this month, and the figure was a record 768 for the seven days ending Friday, beating the previous high mark of 757 for the seven days ending Wednesday. The state Department of Health and Environment reported 1,774 new confirmed and probable coronavirus cases since Wednesday, an increase of 2.4% that brought the total for the pandemic to 76,230. Dr. Lee Norman, the state health department’s head, said the generalized spread of the virus in Kansas has resulted from resistance to wearing masks in public, continuing to have mass gatherings, crowded school athletic events, and bringing students back to college and university campuses.

Kentucky

U.S. Rep. Thomas Massie, R-Ky., speaks at a Second Amendment rally outside the Kentucky State Capitol building in Frankfort on Jan. 31.
U.S. Rep. Thomas Massie, R-Ky., speaks at a Second Amendment rally outside the Kentucky State Capitol building in Frankfort on Jan. 31.

Louisville: A member of Congress says he won’t be receiving the coronavirus vaccine when it becomes available. Republican U.S. Rep. Thomas Massie tweeted Thursday that he hopes a vaccine is developed soon, but he doesn’t plan to use it. When asked about it, Massie said in a statement that he didn’t see the vaccine as necessary for him. “I’m not in a high/risk category and I trust my natural immune system response over a pharmaceutically stimulated response,” he said. Massie’s tweet came after President Donald Trump said during a presidential debate with former Vice President Joe Biden that a vaccine could come within weeks. Nurse practitioner Alexandra Owensby, who is running against Massie in the Nov. 3 election, said in a statement that “the problem is people feel like the vaccine has been rushed.” Owensby said she hopes at some point most Americans will trust the vaccine enough to get it.

Louisiana

Baton Rouge: Republicans in the state House filed a petition Friday to revoke Gov. John Bel Edwards’ coronavirus restrictions for a week, as lawmakers finished a special session in which they sought more power over the Democratic governor’s emergency actions but appeared likely to see that effort vetoed. Republicans are invoking a never-before-used process outlined in state law that allows a majority of House lawmakers to nullify the governor’s public health emergency declaration – and all restrictions tied to it – with a petition. House Speaker Clay Schexnayder said Edwards refused to address legislative concerns about his virus rules “in any substantive way.” The petition sent to Edwards was signed by 65 of the House’s 68 Republicans. The governor lashed out at them as ignoring the risks of the virus outbreak for an “unconscionable” partisan political ploy. “Burying heads in the sand and just pretending COVID isn’t a problem isn’t going to help,” he said.

Maine

Alfred: County officials said Friday that a coronavirus outbreak that sickened more than 80 people at a jail is over. The outbreak at York County Jail in Alfred was connected to a larger outbreak centered on a northern Maine wedding and reception. An employee of the jail attended the wedding, the Maine Center for Disease Control and Prevention has said. The outbreak linked to the Aug. 7 wedding event sickened a total of 178 people and killed eight. The case total includes the cases from the Alfred jail. The County Commissioners of York County said in a statement Friday that no inmates at the Alfred jail are currently receiving treatment and that all staff have returned to work. An inquiry by an outside examiner continues, the commissioners said. A Maine CDC spokesperson confirmed the jail facility met the criteria to close an outbreak investigation Oct. 12. The Maine CDC has said its investigation into the wedding is also closed.

Maryland

Baltimore: Voters can begin to cast ballots in person this week at dozens of sites statewide. Early voting centers open Monday morning and will operate daily until Nov. 2. Maryland has allowed early in-person voting since 2010, but it wasn’t offered during the June primary due to the COVID-19 pandemic. Many early voting center locations have changed, with senior centers and privately owned buildings replaced by empty schools to protect health, The Baltimore Sun reports. Local election directors decided on what safety measures to utilize, but socially distanced lines, plastic glass shields and frequent sanitizing of equipment are expected. More than 1.6 million Maryland residents already requested mail-in ballots by a deadline earlier this month. More than 45% of those residents have returned them.

Massachusetts

Boston: The state has ordered the shutdown of every indoor ice skating facility in Massachusetts for two weeks in response to several COVID-19 clusters linked to ice hockey games and practices. The order took effect Friday and lasts until Nov. 7, according to the state Department of Public Health. At least 30 clusters of COVID-19 have been associated with organized ice hockey activities involving residents from more than 60 cities and towns in the state, the department said. Each includes two or more confirmed or probable COVID-19 cases, for a total of 108 confirmed cases. “This pause will allow for the development of stronger COVID-19 protocols to further protect players, families, coaches, arena staff and other participants, as well as communities surrounding hockey rinks,” the agency said in a statement. College and professional programs are exempt from the order.

Michigan

Lansing: More than 3,000 new confirmed cases of the coronavirus – the most yet during the pandemic – were reported Saturday amid what a top health official called “alarming increases” in infections around the state. The 3,338 new COVID-19 cases reported by the Michigan Department of Health and Human Services surpassed the state’s previous single-day record of 2,030 new cases set Oct. 15. That earlier record had topped the previous record of 1,953 from early April. The state agency also reported 35 more deaths from COVID-19, raising Michigan’s pandemic toll to 7,182 deaths. Dr. Joneigh Khaldun, Michigan’s chief medical executive, said in a statement that “if rates continue like this, we risk overwhelming our hospitals and having many more Michiganders die.” She said Michigan is continuing to see coronavirus infection clusters associated with facilities, programs and schools.

Minnesota

Minneapolis: The state reported one of its largest one-day tallies of new coronavirus cases Saturday as 2,268 people tested positive. The number of new cases is the second-highest reported during the pandemic, just below the 2,297 cases reported Oct. 16. The positivity rate of testing has also climbed in recent days, an indication that infections are increasing. The seven-day average positivity rate was 6.53%, according to date from the COVID Tracking Project. Health officials have said the uptick in cases is due to more infections spreading among people rather than increased testing showing more cases. The upward trend in new cases has been followed by an uptick in deaths from COVID-19, with the seven-day average number of deaths above 14. The Minnesota Department of Health reported 14 more deaths Saturday, with nine of those in long-term care and assisted-living facilities, bringing the state’s death toll to 2,328.

Mississippi

Mississippi State Health Officer Dr. Thomas Dobbs expresses concern at the public's lack of mask-wearing at Gov. Tate Reeves' COVID-19 press briefing in Jackson, Miss., on July 8.
Mississippi State Health Officer Dr. Thomas Dobbs expresses concern at the public’s lack of mask-wearing at Gov. Tate Reeves’ COVID-19 press briefing in Jackson, Miss., on July 8.

Jackson: State Health Officer Dr. Thomas Dobbs and other health officials said COVID-19 is starting to affect more young and white residents in Mississippi as the number of new cases continues to grow. “We’ve seen a pretty dramatic shift where early on, (cases were) two-thirds African American, and now it’s kinda moved to two-thirds Caucasian,” he said during a news conference Friday. Dobbs said even though there are more white residents in the state, things have gotten to the point where the virus is disproportionately affecting that segment of the total population. He encouraged residents to take precautions seriously. “Let’s learn the lessons from the past, and let’s all just be careful,” he said. State epidemiologist Dr. Paul Byers said younger people, especially the school-age population, are the fastest-growing segment among reported cases. Residents in the 50-59 age range and those over 65 are also seeing higher numbers, he said.

Missouri

St. Louis: Gov. Mike Parson’s coronavirus diagnosis came about a week after he visited a state office building despite being warned about an outbreak among workers, emails show. The emails obtained by the St. Louis Post-Dispatch show that a public relations officer at the Department of Commerce and Insurance asked Parson’s spokeswoman whether the governor wanted to move forward with Sept. 16 event at the Harry S Truman State Office Building in Jefferson City “given the building situation.” Parson, a Republican, was diagnosed with COVID-19 on Sept. 23. Parson made numerous other in-person visits elsewhere in the days before he tested positive, including a visit to the Mount Vernon Veterans Home, which subsequently logged its first case of the virus. Though some photographs show Parson wearing a mask during this time, others show him without a mask.

Montana

Kalispell: State and county health officials have started cracking down on businesses that aren’t enforcing Gov. Steve Bullock’s mask mandate, which was put in place in July to reduce the spread of COVID-19. The Montana Department of Public Health and Human Services sought court approval in Flathead County to force four businesses to come into compliance with the mandate, the Flathead Beacon reports. The state is seeking temporary restraining orders against Sykes Diner and Mercantile in Kalispell, Remington Bar and Casino in Whitefish, Your Lucky Turn Tavern in Bigfork and Ferndale Market. The governor’s mandate requires face coverings to be worn in all indoor spaces open to the public in counties that have four or more current cases of COVID-19. It also requires businesses to take “reasonable measures” to ensure customers, employees and others follow the mandate.

Nebraska

Lincoln: State public health officials confirmed another 977 coronavirus cases Thursday, bringing the state’s total to 61,285, according to its tracking portal. The number tracks with a recent surge in cases that led Gov. Pete Ricketts to reimpose some social distancing restrictions to avoid overwhelming Nebraska’s hospitals. State officials say 559,625 people in Nebraska have gotten tested since the pandemic began, and 498,023 have tested negative. They’ve confirmed 587 virus-related deaths so far. Nebraska’s hospitals still have 1,336 beds available for patients, about 29% of their total capacity. They also have 198 intensive care beds available, accounting for 31% of the total supply, and 632 ventilators that can be used, roughly 77% of the total.

Nevada

Sex worker Alice Little stands outside the closed Bunny Ranch brothel in Carson City, Nev.
Sex worker Alice Little stands outside the closed Bunny Ranch brothel in Carson City, Nev.

Reno: Brothels remain closed under state restrictions imposed because of the pandemic, but a rural county is allowing brothels to offer non-sexual escort services. The Lyon County Board of Commissioners approved the new authorization for the four brothels in the county Oct. 15. Because the brothels remain closed, the sex workers must meet customers elsewhere for escort services authorized under the ordinance. More than 500 people were unemployed due to the brothel closings, brothel owner Suzette Cole told the board. Lyon County Manager Jeffery Page said the closures have hurt the local economy. The authorization for escort services will allow brothels to stay in business and provide income for owners and workers, he said. Sex worker Alice Little said many workers, who are considered independent contractors, left the industry to work elsewhere, but she said that is difficult because of the stigma attached to the work.

New Hampshire

Concord: Anyone who went to five restaurants in Portsmouth, Concord and Peterborough on certain days this month should get tested for the coronavirus, state health officials said Friday. The Department of Health and Human Services said at least four people who have tested positive visited Daniel Street Tavern in Portsmouth while potentially infectious, and anyone who was in the bar area Oct. 9, 14 or 15 should get tested. At least one person has tested positive who visited the Goat Bar and Grill in Portsmouth on Oct. 15. In Concord, at least five people who have tested positive visited the Draft Sports Bar and Grill on Oct. 9 and 11 and Oct. 14-18. And at the Barley House Restaurant and Tavern, potential exposure via two people may have occurred Oct. 12, 13, 14 and 16. Exposure also may have occurred Oct. 13 at the Bantam Grill in Peterborough, where at least one person has tested positive.

New Jersey

Red Bank: Gov. Phil Murphy signed two bills into law Friday aimed at addressing staffing shortages and residents’ isolation at the state’s long-term care facilities, two areas of vulnerability exposed during the coronavirus pandemic. The bills signed Friday were an outgrowth of a consultant’s report released in June. More than 7,000 people have died from COVID-19 in New Jersey’s long-term care facilities, about half of the state’s total deaths. In May, the Democratic governor was forced to send the National Guard to nursing homes hit hard by the new coronavirus. The state’s largest facility, in Andover, was fined more than $200,000 by federal health authorities for putting residents in its care at risk. In April, police acting on an anonymous tip found 18 bodies in a makeshift morgue at the home.

New Mexico

Albuquerque: One of the oldest Roman Catholic dioceses in the nation will again be foregoing Sunday Mass indefinitely as the state marks its latest surge of COVID-19 cases. Archbishop John C. Wester is directing churches within the northern New Mexico diocese to cease regular Mass schedules and encouraging Masses to be streamed online or recorded so they can be accessed at home. He’s also calling for funeral services and weddings to be delayed. The guidance comes as state officials have been pushing people to stay home and adhere to the provisions of an amended public health order that took effect Friday. That includes limiting retail hours and temporarily closing businesses the state determines are hot spots for the virus. Wester pointed to data that shows the demographics of cases migrating toward the younger ages and the uptick of hospitalizations, saying there are concerns about the state’s health care system’s capacity.

New York

New York: The number of people hospitalized in the state because of the coronavirus has climbed back over 1,000, officials said Friday. The figure has increased in the past month but is still far below the peak level of the spring. Gov. Andrew Cuomo said there were 1,023 hospitalizations around the state as of Thursday. That’s more than double the number that were hospitalized month ago and the first time since late June that the state has seen that many people in hospitals with the virus. At the pandemic’s peak in April, nearly 19,000 people were hospitalized. As is happening around the country to different degrees, New York is seeing an uptick in virus cases as more places like schools and businesses have been opening up. Statewide, 1,637 people tested positive with the virus Thursday, on par with where levels have been for the month.

North Carolina

Charlotte: A state health official on Saturday ordered a large church to close its doors temporarily because of concerns it is helping spread the coronavirus by disregarding social distancing measures. Mecklenburg County Health Director Gibbie Harris ordered the United House of Prayer for All People to close all its buildings and said the church has not cooperated with efforts to stem the virus’s spread, the Charlotte Observer reports. Harris said at least three deaths and more than 121 confirmed cases of the virus have been linked to the church, which held a weeklong church event earlier this month. The county said the church has continued to hold large gatherings despite recommendations not to do so and has failed to implement social distancing measures. The church did not immediately return a request for comment. On Friday, North Carolina set a new record for a single-day increase in reported COVID-19 cases.

North Dakota

Bismarck: National Guard soldiers have helped to notify 800 people who tested positive for COVID-19 but initially weren’t told, officials said. The notification backlog, which was due to a recent sharp increase in coronavirus cases, was resolved Thursday largely through shifting the role last week of 50 North Dakota National Guard soldiers, health officials said. The soldiers had been informing people they may have been exposed to COVID-19 and should monitor their health for signs and symptoms of the virus. On Tuesday, health officials announced the soldiers would instead notify those who test positive for the virus. The North Dakota Department of Health expects the change in contact tracing to be temporary. As part of the new process, public health officials will no longer reach out to close contacts of individuals who test positive for COVID-19. Instead, those testing positive will be instructed to self-notify their close contacts.

Ohio

Columbus: Small businesses, bars and restaurants, low-income renters, arts groups, and colleges and universities are among those eligible for $429 million in federal pandemic dollars being released by the state this week, Gov. Mike DeWine and his fellow Republican legislative leaders announced Friday. The aid package, which the governor has promised for several weeks, is scheduled to go before a bipartisan state legislative spending panel Monday. Its passage is assured with the backing of House Speaker Bob Cupp and Senate President Larry Obhof, who joined the governor at Friday’s virtual news conference. The announcement came on a day when the Ohio Health Department reported 2,518 probable and confirmed cases of the coronavirus, marking the third consecutive day of record-high daily cases in the state.

Oklahoma

Oklahoma City: A one-day record increase of more than 1,800 newly confirmed coronavirus cases was reported Saturday by the state health department. The Oklahoma State Department of Health report came one day after Gov. Kevin Stitt again extended a state of emergency due to the pandemic. Stitt on Friday extended for 30 days his emergency order first issued March 15. The health department reported 1,829 new cases for a total of 115,685 since the start of the pandemic and 924 people hospitalized due to the virus, down from a record high of 956 hospitalizations Friday. An additional 11 people have died from COVID-19, the illness caused by the virus, for a death toll of 1,245. The true number of coronavirus cases in Oklahoma is likely higher because many people have not been tested, and studies suggest people can be infected and not feel sick.

Oregon

Salem: The Oregon Health Authority reported 550 new confirmed COVID-19 cases Friday, the state’s largest daily total since the start of the pandemic. Health officials called the number of cases “troubling” and said that based on current COVID-19 modeling, if Oregon remains on the same path, it could reach capacity in its hospitals by mid-December. The previous daily case count record in Oregon, which also occurred this month, was 484. Officials called Friday’s record-breaking number of new cases “a reminder that Oregonians cannot let their guards down.” Shimi Sharief, the Oregon Health Authority senior health adviser, said health officials “remain cautious” about giving a single day’s total “too much weight.” “That said, we believe this increase is due to continued community transmission from social gatherings, as well as household clusters,” Sharief said.

Pennsylvania

Harrisburg: State officials on Friday announced the highest single-day total of new cases of COVID-19 since the start of the pandemic and a rise in the number of young people getting sick with the virus. The Pennsylvania Department of Health reported 2,219 new positive cases of the novel coronavirus Friday. That number is almost as high as the two-day total released Monday and tops the state’s previous high count of 2,060 on April 8. “Seeing the highest percent positivity we have seen in several months is concerning. Seeing the highest number of new cases since the pandemic started in Pennsylvania on March 6 is also concerning,” said Nate Wardle, spokesman for the Department of Health. “Nothing is good right now regarding COVID.” State officials are comparing the rate of transmission of the virus to April, when it moved unbidden through nursing homes. But this time, the virus is infecting younger patients.

Rhode Island

Providence: The two highest single-day totals of new confirmed coronavirus cases in Rhode Island since the pandemic began came last week, but the state is conducting more tests than ever. The state Department of Health on Friday said there were 449 new cases confirmed the previous day out of nearly 14,100 tests, a 3.2% positivity rate. The department also adjusted Wednesday’s new confirmed cases up to 470, out of almost 18,000 tests. The previous one-day high was 412 on April 23, but that was out of fewer than 3,000 people tested. The seven-day rolling average of the positivity rate in Rhode Island has now surged over the past two weeks from more than 1.5% on Oct. 8 to more than 2.4% on Thursday, according to the Johns Hopkins University Center for Systems Science and Engineering. The new confirmed cases over the two days push the state’s total to more than 30,000.

South Carolina

Charleston: More than 71,000 idled workers in the state already have used up their eligibility for state unemployment benefits as the coronavirus pandemic continues, federal statistics show. The Post and Courier reports that the number of people exhausting their 20 weeks of state unemployment eligibility shows many workers who were laid off in the spring don’t have jobs to which to return even though the number of new layoffs has declined. People without additional eligibility can no longer receive money from the state’s unemployment trust fund, which is managed by the S.C. Department of Employment Workforce. But they can claim benefits from two other federal programs that provide as much as 23 weeks of additional financial support. The most recent employment survey estimated there were 65,000 fewer people employed in South Carolina in September than there were in March, when the pandemic was declared.

South Dakota

The entrance to the Pine Ridge Indian Reservation in South Dakota.
The entrance to the Pine Ridge Indian Reservation in South Dakota.

Pine Ridge: The Oglala Sioux Tribe has locked down the Pine Ridge Indian Reservation in response to a surging number of COVID-19 cases in the state. The lockdown began at 10 p.m. Friday and lasts until 6 a.m. Oct. 30. During that time, all noncritical travel is barred. The tribe said nonessential businesses should close to the public, and travel to nonessential work to or from the reservation should stop. The tribe also said nonemergency medical appointments that require travel to or from the reservation should be rescheduled. Tribes nationwide have taken an aggressive approach to preventing infections amid fears that Native Americans could be particularly vulnerable to the coronavirus – and this isn’t the first time the Oglala Sioux Tribe has imposed a lockdown since the pandemic began.

Tennessee

Columbia: A hospital is suspending all elective procedures requiring an overnight stay due to a surge in patients hospitalized with COVID-19. As of Friday evening, Columbia’s Maury Regional Medical Center was treating 50 COVID-19 inpatients, 20 of whom were in the medical center’s 26-bed intensive care unit. In response, the hospital is suspending elective surgical procedures that require an overnight stay for two weeks, beginning Monday, it announced Friday. “The time has long passed for our community to take this virus seriously,” Alan Watson, CEO of Maury Regional Health, said in a Friday statement. “We are seeing the impact of our community letting down their guard, and we must make every effort to mitigate the spread of this virus so that it does not further tax health care providers across Middle Tennessee and the entire state.”

Texas

More than 200 vehicles lined up for drive-thru COVID-19 testing in far East El Paso, Texas, on Oct. 14. Many of those waiting for testing said they waited for three hours or more to get tested at the mobile test collection site at the Socorro ISD Student Activities Complex.
More than 200 vehicles lined up for drive-thru COVID-19 testing in far East El Paso, Texas, on Oct. 14. Many of those waiting for testing said they waited for three hours or more to get tested at the mobile test collection site at the Socorro ISD Student Activities Complex.

El Paso: The surge in coronavirus in this border city continued Saturday with a record 1,216 new cases, nearly 20% of the state’s daily count, according to city-county health officials. The city reported 3,346 cases in the previous three days and more than 5,800 in the prior week, according to city-county health reports. El Paso has reported 38,554 total cases since the pandemic began in March. “Now, we need our community to help us by doing their part and staying home, if and when possible, for the next two weeks in order to stop the rapid the spread of the virus,” public health director Angela Mora said in a statement. Gov. Greg Abbott has sent medical equipment and about 500 medical personnel to the region to help fight the virus. President Donald Trump downplayed the toll of the coronavirus during Thursday’s final debate with Joe Biden, claiming that “there was a very big spike in Texas, it’s now gone.”

Utah

Salt Lake City: The state hit another ominous record Friday by tallying the highest number of confirmed coronavirus cases in a single day as the state struggles to slow a monthlong surge of COVID-19 that is filling intensive care beds at hospitals. After the state reported 1,960 new cases, Gov. Gary Herbert warned in a statement that the state is “on the brink” and once again pleaded with people to adhere to mask mandates in place in 21 of the state’s 29 counties. The Republican governor said people should wear masks anytime they are with people outside their immediate family, even extended family or friends. Capacity at the state’s intensive care units reached 76%, with more people hospitalized last week for COVID-19 than at any other time during the pandemic, state figures show. Four more deaths recorded Friday bring the total to 567. Utah had the seventh-highest rate of newly confirmed infections per capita Friday, according to data from Johns Hopkins.

Vermont

Montpelier: A coronavirus outbreak connected to recreational hockey and broomball at an indoor ice rink has grown to 43 cases, including cases at seven schools in various counties, seven workplaces, two colleges and two hospitals, Vermont Health Commissioner Dr. Mark Levine said Friday. The cases linked to the Central Vermont Memorial Civic Center are not within a single community, and people who played those sports live in counties across the state, he said during the governor’s twice-weekly virus briefing. The number of close contacts to the people infected now likely exceeds 240, Levine said. Vermont reported 28 new coronavirus cases Friday, its second-highest number since early June, with Levine saying half of the newest cases are associated with three outbreaks. At least seven positive virus cases have been linked to a wedding held in Cambridge on Oct. 10, the Health Department said.

Virginia

Radford: Another fraternity at Radford University is facing consequences for allegedly violating pandemic-related safety guidelines. TV station WDBJ reports the school’s Kappa Alppha Psi chapter was placed on an interim suspension and is being afforded a conduct hearing after university officials said the fraternity hosted an off-campus party. Radford University administered 270 COVID-19 tests last week, 59 of which were positive, the station reports. University officials said half of the cases were attributed to the party. “We can do better, and we must do better,” university spokeswoman Caitlyn Scaggs said. The fraternity’s national office did not immediately respond to a message from the station seeking comment. The school suspended a different fraternity in August, also in connection with off-campus gatherings.

Washington

Seattle: Seattle Public Schools Superintendent Denise Juneau said Friday that the district will remain in a remote learning model for the rest of the current semester because of an increase in COVID-19 cases. Most students will continue to participate in school virtually through January 2021, Juneau said in a news release. The only exception will be for students who receive special education services that require in-person instruction. Officials made the decision because of a recent increase in COVID-19 cases in King County and after consultation with the district’s Re-entry Leadership Team. Juneau said the team – composed of representatives of the School Board, Seattle Education Association, Seattle Council PTSA, the Principals’ Association of Seattle Schools, and students – will meet regularly to talk about next steps.

West Virginia

Charleston: A teachers union lost its bid Friday to stop the state from using its color-coded map to decide whether counties can hold in-person public school classes and athletic competitions amid the pandemic. Judge Carrie Webster denied the West Virginia Education Association’s request for a preliminary injunction after Gov. Jim Justice’s attorney argued the court lacked jurisdiction and said the union did not have evidence that the map is not a rational approach tailored to West Virginia, WCHS-TV reports. The union’s president, Dale Lee, testified that 67% of teachers surveyed had compromising health issues and fears or relatives who were home sick. After the ruling, Lee said the WVEA was disappointed in the outcome. “By choosing to use the lesser of the infection rate or the percentage of positive tests, WVEA and its members believe the governor’s color-coded map changes have created a false picture of COVID spread,” Lee said in a statement.

Wisconsin

Madison: An appeals court on Friday temporarily blocked Gov. Tony Evers’ restrictions on indoor public gatherings pending appeal, dealing the Democratic governor a setback in his efforts to slow the spread of the coronavirus. The ruling from the 3rd District Court of Appeals follows Evers’ administration issuing an emergency order Oct. 6 that limited indoor public gatherings to 25% of a building or room’s capacity or 10 people in places without an occupancy limit. The order also came as COVID-19 cases surged in Wisconsin, which last week was among the worst states in the nation in daily new cases per capita, and its hospitals are near capacity. But the powerful Tavern League of Wisconsin argued the capacity limits amount to a “de facto closure” order for bars and restaurants and sued to strike down the order.

Wyoming

Cody: Yellowstone National Park officials have proposed an earlier opening date and later closure during the winter at an entrance for snowmobiles and snow coaches. Park officials announced plans to open the East Entrance from Dec. 15 to March 15, The Billings Gazette reports. The East Entrance is currently allocated two commercially guided snowmobile trips, one non-commercially guided trip and one commercial snow coach on each day of the winter season. The updated dates for opening the gate located west of Cody would coincide with the park’s two other winter gates, the West Entrance near West Yellowstone, Montana, and the South Entrance near Jackson, Wyoming. Access to the park at the North Entrance near Mammoth Hot Springs, Wyoming, is the only gate open to automobiles for the entire year. The maximum number of snowmobiles currently allowed in the park from all entrances in a day is 480.

From USA TODAY Network and wire reports

This article originally appeared on USA TODAY: Brothel loophole, ice rink outbreaks: News from around our 50 states

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Coronavirus not slowing Hamilton’s growth and upbeat mood, residents say

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And coronavirus is “just a speed bump,” not a wall, when it comes to that progress, he said.

In the past week, the state has set daily records for coronavirus cases multiple times, which has raised concerns among some about how life might change if future government action is taken. The Journal-News spent time this weekend talking with people for their thoughts on the current state of the virus and their daily lives.

Dalton Lubbers, a tap manager at the downtown brewery, said things are moving back closer to life prior to the onset of the coronavirus in March.

“We are getting pretty cheery crowds. But with some of the newer downtown businesses than us it (coronavirus) may have taken more of a toll,” said Lubbers.

He in part credited the city’s DORA district (Downtown Outdoor Refreshment Area), which allows downtown visitors to carry locally purchased alcohol-based drinks around the central business district and across the river into the Main Street business area.

Other business owners also pointed to the city’s Alive After 5 events, most recently happening last Friday evening, for helping attract visitors downtown to local shops, restaurants, art galleries and pubs.

ExploreDowntown Hamilton event will support 22 local businesses with Halloween theme today

Maria Peckinpaugh, co-owner of Sara’s House décor and gifts shop in the High Street business district, said coronavirus brought challenges but also some opportunities.

“It’s helped us create more of an online perspective and work to flourish our business in different ways that we never expected before,” said Peckinpaugh.

The mood among customers and residents is “resilient,” she said.

“They are happy that shops are still open and restaurants are open and they are able to spend time around Hamilton,” she said. “They (businesses) have created a safe and helpful environment for all the shoppers.”

Among those shoppers Saturday was city native Shawna Neeley, who said the city’s progress has happened without sacrificing “it’s small-town vibe.”

The impact of coronavirus on the city also has an unexpected benefit, said Neeley.

“Honestly, everyone has been a lot nicer. It really brought together that small-town hospitality that we have here even though things have really changed and you have to wear masks and everything,” she said.

“A lot of people here are optimistic and we’re all kind of hoping for a better next year and that everything will be worked out and figured out by then.”

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