Characterization of Healthy Housing in Africa: Method,Profiles, and Determinants

Housing is a key social determinant of health with implications for both physical and mental health. The measurement of healthy housing and studies characterizing the same in sub-Saharan Africa (SSA) are uncommon. This study described a methodological approach employed in the assessment and characterization of healthy housing in SSA using the Demographic and Health Survey (DHS) data for 15 countries and explored healthy housing determinants using a multiple survey-weighted logistic regression analysis. For all countries, we demonstrated that the healthy housing index developed using factor analysis reasonably satisfies both reliability and validity tests and can therefore be used to describe the distribution of healthy housing across different groups and in understanding the linkage with individual health outcomes. We infer from the results that unhealthy housing remains quite high in most SSA countries. Having a male head of the household was associated with decreased odds of healthy housing in Burkina Faso (OR = 0.80, CI = 0.68–0.95), Cameroon (OR = 0.65, CI = 0.57, 0.76), Malawi (OR = 0.70, CI = 0.64–0.78), and Senegal (OR = 0.62, CI = 0.51–0.74). Further, increasing household size was associated with reducing odds of healthy housing in Kenya (OR = 0.53, CI = 0.44–0.65), Namibia (OR = 0.34, CI = 0.24–0.48), Nigeria (OR = 0.57, CI = 0.46–0.71), and Uganda (OR = 0.79, CI = 0.67–0.94). Across all countries, household wealth was a strong determinant of healthy housing, with middle and rich households having higher odds of residing in healthy homes compared to poor households. Odds ratios ranged from 3.63 (CI = 2.96–4.44) for households in the middle wealth group in the DRC to 2812.2 (CI = 1634.8–4837.7) in Namibia’s wealthiest households. For other factors, the analysis also showed variation across countries. Our findings provide timely insights for the implementation of housing policies across SSA countries, drawing attention to aspects of housing that would promote occupant health and wellbeing. Beyond the contribution to the measurement of healthy housing in SSA, our paper highlights key policy and program issues that need further interrogation in the search for pathways to addressing the healthy housing deficit across most SSA countries. This has become critical amid the COVID-19 pandemic, where access to healthy housing is pivotal in its control.     

Effect of economic recession on psychosocial working conditions by workers' nationality

Background: Several publications have documented the effects of economic recessions on health. However, little is known about how economic recessions influence working conditions, especially among vulnerable workers.Objective: To explore the effects of 2008 economic crisis on the prevalence of adverse psychosocial working conditions among Spanish and foreign national workers.Methods: Data come from the 2007 and 2011 Spanish Working Conditions Surveys. Survey year, sociodemographic, and occupational information were independent variables and psychosocial factors exposures were dependent variables. Analyses were stratified by nationality (Spanish versus foreign). Prevalence and adjusted prevalence ratios (aPRs) of psychological job demands, job control, job social support, physical demands and perceived job insecurity were estimated using Poisson regression.Results: The Spanish population had higher risk of psychological and physical job demand (aPR = 1.07, 95% CI = [1.04–1.10] and aPR = 1.05, 95% CI = [1.01–1.09], respectively) in 2011 compared to 2007. Among both Spanish and foreign national workers, greater aPR were found for job loss in 2011 compared to 2007 (aPR = 2.47, 95% CI = [2.34–2.60]; aPR = 2.44, 95% CI = [2.15–2.77], respectively).Conclusion: The 2008 economic crisis was associated with a significant increase in physical demands in Spanish workers and increased job insecurity for both Spanish and foreign workers.     

Response to the COVID-19 Outbreak in Urban Settings in China

The COVID-19 outbreak in China was devastating and spread throughout the country before being contained. Stringent physical distancing recommendations and shelter-in-place were first introduced in the hardest-hit provinces, and by March, these recommendations were uniform throughout the country. In the presence of an evolving and deadly pandemic, we sought to investigate the impact of this pandemic on individual well-being and prevention practices among Chinese urban residents. From March 2–11, 2020, 4607 individuals were recruited from 11 provinces with varying numbers of COVID-19 cases using the social networking app WeChat to complete a brief, anonymous, online survey. The analytical sample was restricted to 2551 urban residents. Standardized scales measured generalized anxiety disorder (GAD), the primary outcome. Multiple logistic regression was conducted to identify correlates of GAD alongside assessment of community practices in response to the COVID-19 pandemic. We found that during the COVID-19 pandemic, the recommended public health practices significantly (p < 0.001) increased, including wearing facial mask, practicing physical distancing, handwashing, decreased public spitting, and going outside in urban communities. Overall, 40.3% of participants met screening criteria for GAD and 49.3%, 62.6%, and 55.4% reported that their work, social life, and family life were interrupted by anxious feelings, respectively. Independent correlates of having anxiety symptoms included being a healthcare provider (aOR = 1.58, p < 0.01), living in regions with a higher density of COVID-19 cases (aOR = 2.13, p < 0.01), having completed college (aOR = 1.38, p = 0.03), meeting screening criteria for depression (aOR = 6.03, p < 0.01), and poorer perceived health status (aOR = 1.54, p < 0.01). COVID-19 had a profound impact on the health of urban dwellers throughout China. Not only did they markedly increase their self- and community-protective behaviors, but they also experienced high levels of anxiety associated with a heightened vulnerability like depression, having poor perceived health, and the potential of increased exposure to COVID-19 such as living closer to the epicenter of the pandemic.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11524-020-00498-8.     

The COVID-19 Pandemic as a Threat Multiplier for Childhood Health Disparities: Evidence from St. Louis,MO

The COVID-19 pandemic has highlighted socioeconomic and racial health disparities in the USA. In this study, we examined the COVID-19 pandemic as a threat multiplier for childhood health disparities by evaluating health behavior changes among urban St. Louis, MO, children (ages 6–14) during the COVID-19 pandemic. From 27 October to 10 December 2020, 122 parents/guardians reported on their children’s health behaviors (Eating, Sleeping, Physical activity, Time outside, Time with friends in-person, Time with friends remotely, Time using media for educational proposes, Time using media for non-educational proposes, and Social connectedness) prior to and during the COVID-19 pandemic. We ran K-means cluster analyses to identify distinct health behavior cluster profiles. Relative risks were determined to evaluate behavioral differences between the two clusters. Two distinct cluster profiles were identified: a High Impact profile (n = 49) and a Moderate Impact profile (n = 73). Children in the High Impact cluster had a greater risk of being diagnosed with COVID-19, developed worsened eating habits (RR = 2.10; 95% CI = 1.50–2.93), spent less time sleeping, and spent less time outdoors (RR = 1.55; 95% CI = 1.03–2.43) than the Moderate Impact cluster. The High Impact cluster was more likely to include Black children and children from single-adult households than the Moderate Impact cluster (both p < 0.05). Our findings suggest that the COVID-19 pandemic may be a threat multiplier for childhood health disparities. Further research is needed to better understand the long-term effects of the COVID-19 pandemic on children’s health.     

Is the Association between Neighborhood Drug Prevalence and Marijuana use Independent of Peer Drug and Alcohol Norms? Results from a Household Survey of Urban Youth

To inform policy debates surrounding marijuana decriminalization and add to our understanding of social and structural influences on youth drug use, we sought to determine whether there was an independent association between neighborhood drug prevalence and individual-level marijuana use after controlling for peer drug and alcohol norms. We analyzed cross-sectional data from a household survey of 563 youth aged 15–24 in Baltimore, Maryland. The study population was 88 % African-American. Using gender-stratified, weighted, multilevel logistic regression, we tested whether neighborhood drug prevalence was associated with individual-level marijuana use after controlling for peer drug and alcohol norms. Bivariate analyses identified a significant association between high neighborhood drug prevalence and marijuana use among female youth (AOR = 1.76, 95 % CI = 1.26, 2.47); the association was in a similar direction but not significant among male youth (AOR = 1.26, 95 % CI = 0.85, 1.87). In multivariable regression controlling for peer drug and alcohol norms, high neighborhood drug prevalence remained significantly associated among female youth (AOR = 1.59, 95 % CI = 1.12, 2.27). Among male youth, the association was attenuated toward the null (AOR = 0.95, 95 % CI = 0.63, 1.45). In the multivariable model, peer drug and alcohol norms were significantly associated with individual-level marijuana use among female youth (AOR = 1.54, 95 % CI = 1.17, 2.04) and male youth (AOR = 2.59, 95 % CI = 1.65, 4.07). This work suggests that individual-level marijuana use among female youth is associated with neighborhood drug prevalence independent of peer norms. This finding may have important implications as the policy landscape around marijuana use changes.     

Social Distancing,Mask Use,and Transmission of Severe Acute Respiratory Syndrome Coronavirus 2, Brazil,April–June 2020

We assessed the associations of social distancing and mask use with symptomatic, laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection in Porto Alegre, Brazil. We conducted a population-based case-control study during April–June 2020. Municipal authorities furnished case-patients, and controls were taken from representative household surveys. In adjusted logistic regression analyses of 271 case-patients and 1,396 controls, those reporting moderate to greatest adherence to social distancing had 59% (odds ratio [OR] 0.41, 95% CI 0.24–0.70) to 75% (OR 0.25, 95% CI 0.15–0.42) lower odds of infection. Lesser out-of-household exposure (vs. going out every day all day) reduced odds from 52% (OR 0.48, 95% CI 0.29–0.77) to 75% (OR 0.25, 95% CI 0.18–0.36). Mask use reduced odds of infection by 87% (OR 0.13, 95% CI 0.04–0.36). In conclusion, social distancing and mask use while outside the house provided major protection against symptomatic infection.     

Free Bus Travel and Physical Activity,Gait Speed,and Adiposity in the English Longitudinal Study of Ageing

Objectives. We investigated associations between having a bus pass, enabling free local bus travel across the United Kingdom for state pension–aged people, and physical activity, gait speed, and adiposity.Methods. We used data on 4650 bus pass–eligible people (aged ≥ 62 years) at wave 6 (2012–2013) of the English Longitudinal Study of Ageing in regression analyses.Results. Bus pass holders were more likely to be female (odds ratio [OR] = 1.67; 95% confidence interval [CI] = 1.38, 2.02; P < .001), retired (OR = 2.65; 95% CI = 2.10, 3.35; P < .001), without access to a car (OR = 2.78; 95% CI = 1.83, 4.21; P < .001), to use public transportation (OR = 10.26; 95% CI = 8.33, 12.64; P < .001), and to be physically active (OR = 1.43; 95% CI = 1.12, 1.84; P = .004). Female pass holders had faster gait speed (b = 0.06 meters per second; 95% CI = 0.02, 0.09; P = .001), a body mass index 1 kilogram per meter squared lower (b = –1.20; 95% CI = –1.93, –0.46; P = .001), and waist circumference 3 centimeters smaller (b = –3.32; 95% CI = –5.02, –1.62; P < .001) than women without a pass.Conclusions. Free bus travel for older people helps make transportation universally accessible, including for those at risk for social isolation. Those with a bus pass are more physically active. Among women in particular, the bus pass is associated with healthier aging.Maintaining physical activity is key to good physical functioning in older age,1 aging healthily,2 and reducing obesity risk,3 but only 49% of men and 36% of women aged 65 years and older in England met physical activity guidelines in 2012.4 Active modes of transportation, including public transportation, can contribute substantially to total physical activity.5 Among working-age adults, commuting by public transportation increases physical activity levels6 and can improve health,7–9 but evidence about older people is sparse.The UK older people’s bus pass (“bus pass” herein) enables people of the state retirement age for women (previously 60 years) and older to travel free of charge on local buses, anywhere in the country.10 To our knowledge, this nationwide policy of free bus transportation for older people, irrespective of financial circumstances, is unique. The bus pass was introduced in Scotland in 2002, England and Wales in 2006, and Northern Ireland in 2008, with concessionary policies operating previously. There remain various additional local benefits; for instance, older people living in London are eligible for a Freedom Pass, which provides free travel on all public transportation.Of the forms of public transportation available in the United Kingdom, buses serve the widest range of communities; even the majority of very rural areas have some bus services. Buses operate over relatively short distances, transporting people between residential areas and urban centers, shopping areas, and hospitals. The bus pass is a widely recognized state benefit for older people often discussed in the media. Advice on obtaining a pass is offered by many organizations including older people’s charities and local authorities. The application form is short and simple, and can either be completed online or acquired locally—for example, from a Post Office or government offices.The aim of the bus pass is to “tackle social exclusion” among older people.11 Evidence suggests that it has been successful, providing opportunities for social interaction, giving a feeling of visibility and belonging, improving quality of life, reducing feelings of social exclusion, and improving access to services.12–14 The bus pass has been estimated to cost the UK government approximately £1 billion a year15 and the recent climate of austerity has led to suggestions that eligibility for the bus pass should be means tested, whereby only older people with income and wealth below a certain level would be eligible. However, many of the benefits derive, at least in part, from the universality of free bus travel for older people and the lack of stigma therefore associated with the pass.12,13In addition to the benefits to older people’s social inclusion, there may be unanticipated benefits of the bus pass—for instance, to physical health. We have previously shown that the bus pass is linked to increased walking frequency16 and reduced obesity17; however, it has not been possible to investigate these relationships directly or in detail. We hypothesized that older people who hold bus passes will be more physically active and will have better physical functioning and lower adiposity. We contend that, if these hypothesized relationships are observed, this would indicate that the bus pass helps enable healthier aging, which leads to health care expenditure savings that may mitigate the cost of providing the bus pass to older people.We used data from the English Longitudinal Study of Ageing (ELSA) to determine (1) among those eligible, who takes up the bus pass; (2) what factors are associated with frequency of bus use among those who have a bus pass; (3) whether having a bus pass is associated with how often people use any public transportation; and (4) whether having a bus pass is associated with physical activity levels, gait speed, and adiposity.     

Influenza vaccination in the time of COVID-19: A national U.S. survey of adults

IntroductionDecisions about influenza vaccination for fall-winter 2020 were made against the backdrop of the COVID-19 pandemic. During May 2020, the authors examined intended vaccination in the next 12 months in relationship to demographic variables, healthcare attitudes, and personal COVID-19 experiences for two samples of adults--those who did not receive influenza vaccine during the prior 12 months, and those who did.MethodsIn May 2020, a cross-sectional online survey was conducted with a national US sample. Participants reported prior influenza vaccination (yes/no during prior 12 months) and anticipated vaccination (yes/no during next 12 months). Covariates included demographic characteristics (e.g., gender, race-ethnicity, political ideology), general beliefs (e.g., benefits of vaccines, altruistic attitudes), and COVID-19 health beliefs and experiences (COVID-19 worry and severity, perception of COVID-19 as a community threat, knowing someone with COVID-19). For each group, hierarchical multivariable logistic regression was conducted with intent to vaccinate as the outcome.ResultsAmong participants (n = 3502), 47% did not receive influenza vaccine in the prior 12 months and 53% had; 25.5% of non-vaccinators and 91.9% of vaccinators intended future vaccination. For non-vaccinators, odds of intending vaccination was associated with race/ethnicity (Hispanics were more likely to intend than white-NH; AOR = 1.74; 95% CI = 1.23–2.4), greater perceived benefits of vaccination (AOR = 2.19; 95% CI = 1.88–2.54), and perception of COVID-19 as a community threat (AOR = 1.91; 95% CI = 1.49–2.45). For vaccinators, odds of intending vaccination was associated with age (AOR = 1.04; 95% CI = 1.03–1.05), race/ethnicity (Black-NH and Other-NH were less likely to intend than white-NH, AOR = 0.60; 95% CI = 0.36–0.999; and AOR = 0.45; 95% CI = 0.24–0.84, respectively), greater perceived benefits of vaccination (AOR = 1.88; 95% CI = 1.45–2.45) and greater perception of collective benefits of vaccines (AOR = 1.48; 95% CI = 1.15–1.90).ConclusionsThe COVID-19 pandemic may have served as a cue to action for influenza vaccination intention among some prior non-vaccinators whereas intention among prior vaccinators is more related to positive attitudes toward vaccination.     

Disentangling Race and Social Context in Understanding Disparities in Chronic Conditions among Men

Disparities in men’s health research may inaccurately attribute differences in chronic conditions to race rather than the different health risk exposures in which men live. This study sought to determine whether living in the same social environment attenuates race disparities in chronic conditions among men. This study compared survey data collected in 2003 from black and white men with similar incomes living in a racially integrated neighborhood of Baltimore to data from the 2003 National Health Interview Survey. Multivariable logistic regression models estimated to determine whether race disparities in chronic conditions were attenuated among men living in the same social environment. In the national sample, black men exhibited greater odds of having hypertension (odds ratio [OR] = 1.58, 95 % confidence interval [CI] 1.34, 1.86) and diabetes (OR = 1.62, 95 % CI 1.27–2.08) than white men. In the sample of men living in the same social context, black and white respondents had similar odds of having hypertension (OR = 1.05, 95 % CI 0.70, 1.59) and diabetes (OR = 1.12, 95 % CI 0.57–2.22). There are no race disparities in chronic conditions among low-income, urban men living in the same social environment. Policies and interventions aiming to reduce disparities in chronic conditions should focus on modifying social aspects of the environment.     

Consumption of ultra-processed foods is associated with obesity,diabetes and hypertension in Canadian adults

ObjectiveTo assess the association between consumption of ultra-processed foods and obesity, diabetes, hypertension and heart disease in a nationally representative sample of Canadian adults.MethodsThis study used cross-sectional data from 13,608 adults (aged 19+ years) from the 2015 Canadian Community Health Survey–Nutrition. The survey provided data on food consumption (from 24-h recall) and prevalent obesity (BMI ≥ 30 kg/m²) and self-reported diabetes, hypertension and heart disease. All foods and drinks consumed were classified according to the extent and purpose of industrial processing using the NOVA classification. Ultra-processed food consumption was estimated as proportion of total daily energy intake. Multivariable logistic regression models assessed the association between ultra-processed food consumption and obesity, diabetes, hypertension and heart disease, adjusting for a range of socio-demographic and lifestyle factors.ResultsIn 2015, ultra-processed food contributed, on average, to 24% of total daily energy intake in the lowest tertile of ultra-processed food consumption and 73% in the highest tertile. Compared with those in the lowest tertile, adults in the highest tertile of ultra-processed food consumption had 31% higher odds of obesity (OR = 1.31, 95% CI: 1.06–1.60), 37% higher odds of diabetes (OR = 1.37, 95% CI: 1.01–1.85) and 60% higher odds of hypertension (OR = 1.60, 95% CI: 1.26–2.03), adjusting for a range of covariates.ConclusionHigher consumption of ultra-processed foods is associated with higher prevalence of obesity, diabetes and hypertension among Canadian adults. A comprehensive set of strategies and policies is needed to discourage consumption of ultra-processed foods in Canada and to make unprocessed or minimally processed foods more affordable, available and appealing.Electronic supplementary materialThe online version of this article (10.17269/s41997-020-00429-9) contains supplementary material, which is available to authorized users.     

Route Infrastructure and the Risk of Injuries to Bicyclists: A Case-Crossover Study

Objectives. We compared cycling injury risks of 14 route types and other route infrastructure features.Methods. We recruited 690 city residents injured while cycling in Toronto or Vancouver, Canada. A case-crossover design compared route infrastructure at each injury site to that of a randomly selected control site from the same trip.Results. Of 14 route types, cycle tracks had the lowest risk (adjusted odds ratio [OR] = 0.11; 95% confidence interval [CI] = 0.02, 0.54), about one ninth the risk of the reference: major streets with parked cars and no bike infrastructure. Risks on major streets were lower without parked cars (adjusted OR = 0.63; 95% CI = 0.41, 0.96) and with bike lanes (adjusted OR = 0.54; 95% CI = 0.29, 1.01). Local streets also had lower risks (adjusted OR = 0.51; 95% CI = 0.31, 0.84). Other infrastructure characteristics were associated with increased risks: streetcar or train tracks (adjusted OR = 3.0; 95% CI = 1.8, 5.1), downhill grades (adjusted OR = 2.3; 95% CI = 1.7, 3.1), and construction (adjusted OR = 1.9; 95% CI = 1.3, 2.9).Conclusions. The lower risks on quiet streets and with bike-specific infrastructure along busy streets support the route-design approach used in many northern European countries. Transportation infrastructure with lower bicycling injury risks merits public health support to reduce injuries and promote cycling.Bicycling is an active mode of transportation with a range of individual and public health benefits.1–5 However, bicycling is underused for transportation in Australia, Canada, Ireland, the United States, and the United Kingdom, constituting an estimated 1% to 3% of trips, compared with 10% to 27% of trips in Denmark, Germany, Finland, the Netherlands, and Sweden.6–8 The reasons for low bicycle share of trips are multifaceted, but safety is one of the most frequently cited deterrents.9–11 These concerns are well founded: bicycling injury rates are higher in countries where cycling for transportation is less common.8,12,13To reduce bicycling injuries, the first step is to understand the determinants of risk. Studies in many English-speaking countries have focused on head injury reductions afforded by helmets.14–17 However, helmet use cannot explain the risk difference because helmets are rarely used in the European countries with lower injury rates.8,18,19 Typical route infrastructure (physical transportation structures and facilities) in countries with low bicycle share of trips differs from that in countries with high trip shares. In Germany, Denmark, and the Netherlands, bicycle-specific infrastructure is frequently available,20 so this is a promising avenue for investigating injury risks. In a review of route infrastructure and injury risk,21 we found some evidence that bicycle-specific infrastructure was associated with reduced risk. However, the studies reviewed had problems that have compromised confidence in the results: grouping of route categories that may have different risks, unclear definitions of route infrastructure, and difficulty controlling for characteristics of cyclists and for exposure to various route types. Debates continue about the contribution of route design to safety and about the safety of various route types.12,13,20,21Here we present a study designed to overcome these limitations.22 We examined injury risk of 14 route types using a case-crossover design in which injured participants served as their own controls. The design compared route characteristics at the location where the injury event occurred to those at a randomly selected point on the same trip route where no injury occurred. By randomly selecting the control site in this way, the probability that a specific infrastructure type would be chosen was proportional to its relative length on the trip (e.g., on a 4-km trip, there would be a 25% chance of selecting a control site on a 1-km section that was on a bike path). Because comparisons were within-trip, personal characteristics such as age, gender, and propensity for risk-taking behavior were matched, as were trip conditions such as bicycle type, clothing visibility, helmet use, weather, and time of day. This allowed the comparisons to focus on between-site infrastructure differences.     

Payer Status,Race/Ethnicity,and Acceptance of Free Routine Opt-Out Rapid HIV Screening Among Emergency Department Patients

Objectives. We estimated associations between payer status, race/ethnicity, and acceptance of nontargeted opt-out rapid HIV screening in the emergency department (ED).Methods. We analyzed data from a prospective clinical trial between 2007 and 2009 at Denver Health. Patients in the ED were offered free HIV testing. Patient demographics and payer status were collected, and we used multivariable logistic regression to estimate associations with HIV testing acceptance.Results. A total of 31 525 patients made 44 765 unique visits: 40% were White, 37% Hispanic, 14% Black, 1% Asian, and 7% unknown race/ethnicity. Of all visits, 10 237 (23%) agreed to HIV testing; 27% were self-pay, 23% state-sponsored, 18% Medicaid, 13% commercial insurance, 12% Medicare, and 8% another payer source. Compared with commercial insurance patients, self-pay patients (odds ratio [OR] = 1.63; 95% confidence interval [CI] = 1.51, 1.75), state-sponsored patients (OR = 1.64; 95% CI = 1.52, 1.77), and Medicaid patients (OR = 1.24; 95% CI = 1.14, 1.34) had increased odds of accepting testing. Compared with White patients, Black (OR = 1.29; 95% CI = 1.21, 1.38) and Hispanic (OR = 1.17; 95% CI = 1.11, 1.23) patients had increased odds of accepting testing.Conclusions. Many ED patients are uninsured or subsidized through government programs and are more likely to consent to free rapid HIV testing.Despite substantial public health efforts, infection with HIV remains an important cause of preventable death in the United States.1 It is estimated that 230 000 people remain unaware of their infections in the United States and 56 300 new infections occur each year, most of which are attributable to contact with those who remain unaware of their HIV status.2–5In an effort to have a further impact on the epidemiology of HIV infection in the United States, the Centers for Disease Control and Prevention (CDC) published revised recommendations for HIV testing in health care settings in 2006.6 These recommendations attempted to reduce exceptionalism associated with HIV testing by, in part, advocating the performance of routine (nontargeted) screening with an opt-out consent approach. Unfortunately, at that time, little was known about the effectiveness of this approach in most clinical settings, including emergency departments (EDs).Although our understanding of the impact of performing nontargeted HIV screening in EDs has been improved over the past several years, we still have little understanding of specific individual-level characteristics that may influence the performance of this important preventive intervention. In fact, several studies have reported varying proportions of testing when the testing is performed in an ED environment and have highlighted differences in the proportions of patients who accept HIV testing and those who actually complete testing.7–10 Perceived risk by the patient and the patient''s medical acuity likely contribute to the relatively small proportion of patients who accept HIV testing, and several operational considerations likely prevent many of those who accept testing to actually complete testing. Other considerations that may importantly contribute to patient acceptance of nontargeted HIV screening include the ability to pay, specific demographic characteristics, and socioeconomic status.11The primary goal of this study was to estimate associations between payer status, race/ethnicity, and acceptance of nontargeted opt-out rapid HIV screening when performed in the ED. The secondary goal was to estimate associations between payer status, race/ethnicity, and completion of nontargeted opt-out rapid HIV screening in the ED.     

Household- and employment-related risk factors for depressive symptoms during the COVID-19 pandemic

ObjectivesThe COVID-19 pandemic has generated multiple psychological stressors, which may increase the prevalence of depressive symptoms. Utilizing Canadian survey data, this study assessed household- and employment-related risk factors for depressive symptoms during the pandemic.MethodsA sample of 1005 English-speaking Canadian adults aged 18+ years completed a web-based survey after physical distancing measures were implemented across Canada. Hierarchical binary logistic regression analyses were conducted to examine the associations of depressive symptoms with household- (household size, presence of children, residence locale) and employment-related (job with high risk of COVID-19 exposure, working from home, laid off/not working, financial worry) risk factors, controlling for demographic factors (gender, age, education, income).ResultsAbout 20.4% of the sample reported depressive symptoms at least 3 days per week. The odds of experiencing depressive symptoms 3+ days in the past week were higher among women (AOR = 1.67, p = 0.002) and younger adults (18–29 years AOR = 2.62, p < 0.001). After adjusting for demographic variables, the odds of experiencing depressive symptoms were higher in households with 4+ persons (AOR = 1.88, p = 0.01), in households with children aged 6 to 12 years (AOR = 1.98, p = 0.02), among those with a job at high risk for exposure to COVID-19 (AOR = 1.82, p = 0.01), and those experiencing financial worry due to COVID-19 (‘very worried’ AOR = 8.00, p < 0.001).ConclusionPandemic responses must include resources for mental health interventions. Additionally, further research is needed to track mental health trajectories and inform the development, targeting, and implementation of appropriate mental health prevention and treatment interventions.     

Are school-based measures of walkability and greenness associated with modes of commuting to school? Findings from a student survey in Ontario,Canada

ObjectivesIn Canada, students are increasingly reliant on motorized vehicles to commute to school, and few meet the recommended overall physical activity guidelines. Infrastructure and built environments around schools may promote active commuting to and from school, thereby increasing physical activity. To date, few Canadian studies have examined this research question.MethodsThis study is a cross-sectional analysis of 11,006 students, aged 11–20, who participated in the 2016/2017 Ontario Student Drug Use and Health Survey. The remote sensing-derived Normalized Difference Vegetation Index (NDVI), at a buffer of 500 m from the schools’ locations, was used to characterize greenness, while the 2016 Canadian Active Living Environments (Can-ALE) measure was used for walkability. Students were asked about their mode of regular commuting to school, and to provide information on several socio-demographic variables. Multivariable logistic regression models were used to quantify associations between active commuting and greenness and the Can-ALE. The resulting odds ratios, and their 95% confidence intervals, were adjusted for a series of risk factors that were collected from the survey.ResultsOverall, 21% of students reported active commuting (biking or walking) to school, and this prevalence decreased with increasing age. Students whose schools had higher Can-ALE scores were more likely to be active commuters. Specifically, the adjusted odds ratio (OR) of being an active commuter for schools in the highest quartile of the Can-ALE was 2.11 (95% CI = 1.64, 2.72) when compared with those in the lowest. For children, aged 11–14 years, who attended schools in high dwelling density areas, a higher odds of active commuting was observed among those in the upper quartile of greenness relative to the lowest (OR = 1.41; 95% CI = 0.92, 2.15). In contrast, for lower dwelling density areas, greenness was inversely associated with active commuting across all ages.ConclusionOur findings suggest that students attending schools with higher Can-ALE scores are more likely to actively commute to school, and that positive impacts of greenness on active commuting are evident only in younger children in more densely populated areas. Future studies should collect more detailed data on residential measures of the built environment, safety, distance between home and school, and mixed modes of commuting behaviours.Electronic supplementary materialThe online version contains supplementary material available at 10.17269/s41997-020-00440-0.     

Access to Care and Chronic Disease Outcomes Among Medicaid-Insured Persons Versus the Uninsured

Objectives. We sought to determine the association between Medicaid coverage and the receipt of appropriate clinical care.Methods. Using the 1999 to 2012 National Health and Nutritional Examination Surveys, we identified adults aged 18 to 64 years with incomes below the federal poverty level, and compared outpatient visit frequency, awareness, and control of chronic diseases between the uninsured (n = 2975) and those who had Medicaid (n = 1485).Results. Respondents with Medicaid were more likely than the uninsured to have at least 1 outpatient physician visit annually, after we controlled for patient characteristics (odds ratio [OR] = 5.0; 95% confidence interval [CI] = 3.8, 6.6). Among poor persons with evidence of hypertension, Medicaid coverage was associated with greater awareness (OR = 1.83; 95% CI = 1.26, 2.66) and control (OR = 1.69; 95% CI = 1.32, 2.27) of their condition. Medicaid coverage was also associated with awareness of being overweight (OR = 1.30; 95% CI = 1.02, 1.67), but not with awareness or control of diabetes or hypercholesterolemia.Conclusions. Among poor adults nationally, Medicaid coverage appears to facilitate outpatient physician care and to improve blood pressure control.Lack of health insurance is associated with lower rates of preventive care, delays in necessary care, forgone care, medical bankruptcy, and increased mortality.1–5 The Affordable Care Act (ACA; Pub L No. 111–148) expanded Medicaid insurance for people with low incomes (< 138% of the federal poverty level [FPL]) in 31 states. However, whether Medicaid coverage improves health outcomes remains controversial. Several studies described differences in chronic disease prevalence and control between uninsured persons and those with Medicaid, but have not been designed or powered to explore whether Medicaid coverage might cause these differences.6–8Some have suggested that Medicaid’s low reimbursement rates discourage physician acceptance of Medicaid patients, limiting access to care and resulting in poor health outcomes.9,10 Recently, the Oregon Health Insurance Experiment (OHIE), a randomized, controlled trial, found that Medicaid coverage increased health care use, improved patients’ financial security and self-reported health, lowered depression rates, and raised diabetes diagnosis rates.11–13 However, the OHIE did not find improvements in other important health outcomes such as control of other chronic diseases, fueling Medicaid’s critics.14,15The rigorous design of the OHIE provides strong evidence on the impact of Medicaid in the Portland, Oregon, metropolitan area where it was conducted. However, Portland’s relatively robust medical safety net for the uninsured16,17 may have attenuated the potential for health improvements from Medicaid expansion compared with other locales, or the United States as a whole.We used the nationally representative National Health and Nutrition Examination Survey (NHANES) to compare outpatient physician visit frequency among the uninsured and comparable persons with Medicaid coverage. We also assessed whether individuals with major chronic conditions had been previously diagnosed with the condition, and whether it was under control.     

Flavored Alcoholic Beverage Use,Risky Drinking Behaviors,and Adverse Outcomes Among Underage Drinkers: Results From the ABRAND Study

Objectives. We examined associations between consumption of different types of flavored alcoholic beverages (FABs) and risky drinking and drinking-related harms among underage drinkers.Methods. For the Alcohol Brand Research among Underage Youth study, we applied multivariable logistic regression analyses to data from underage drinkers (n = 1031, aged 13–20 years), recruited from a national Internet panel in 2011 to 2012, to estimate associations between consumption of malt-based drinks; spirits-based, premixed- or ready-to-drink cocktails; and supersized alcopops, alone or in combination, and alcohol-related outcomes.Results. After adjustment for confounding variables, the exclusive consumption of alcopops was associated with episodic heavy drinking (odds ratio [OR] = 4.35; 95% confidence interval [CI] = 1.24, 15.31; P < .05) and alcohol-related injuries (OR = 6.25; 95% CI = 1.34, 29.10; P < .05). Exclusive consumption of cocktails was associated with episodic heavy drinking (odds ratio [OR] = 2.61; 95% CI = 1.26, 5.41; P < .05) and injuries requiring medical attention (OR = 6.50; 95% CI = 2.09, 20.17; P < .001. Exclusive consumption of 2 or more FABs was associated with episodic heavy drinking (OR = 2.78; 95% CI = 1.25, 6.16; P < .05), fighting (OR = 3.30; 95% CI = 1.46, 7.47; P < .001), and alcohol-related injuries (OR = 2.83; 95% CI = 1.43, 5.58; P < .001).Conclusions. FABs present an emerging public health problem among youths.Alcohol continues to be the most commonly used drug among youths in the United States and is responsible for more than 4300 annual deaths among underage drinkers.1 Approximately 33% of eighth graders and 70% of 12th graders have consumed alcohol, and 13% of eighth graders and 40% of 12th graders drank during the past month.2 Close to 200 000 emergency department visits by persons younger than 21 years are reported annually for injuries and other conditions linked to alcohol.3 An important trend in underage drinking is the popularity of flavored alcoholic beverages (FABs).4–12 Despite their popularity, little is known about associations between FAB consumption, risky drinking behaviors, and related harms among underage drinkers.FAB brands can be classified into 3 categories: malt-based beverages; spirits-based, premixed- or ready-to-drink cocktails; and supersized alcopops.4 Although these products are widely classified as FABs, distinctions between them are important because these beverages differ in serving size (e.g., the supersized alcopops can contain 2 to 3 times the alcohol volume of other brands) and average alcohol content by volume (malt beverages, 7.8%; premixed- or ready-to-drink cocktails, 14.2%; supersized alcopops, 10.8%).4We used ABRAND (Alcohol Brand Research among Underage Youth) data collected by GfK Knowledge Networks13 to analyze the brands of alcoholic beverages a national sample of youth drinkers aged 13 to 20 years reported consuming and found that nearly half of young drinkers (n = 515) had consumed FABs in the past 30 days.4 These results roughly matched those of the 2012 Monitoring the Future report, which found that more than half (57.5%) of students in grades 8, 10, and 12 who reported past 30-day alcohol use had consumed at least 1 FAB during that time.2 The ABRAND data also showed that 43% of drinkers aged 13 to 15 years, 48.9% of those aged 16 to 18 years, and 52% of those aged 19 to 20 years consumed FABs.4 Consumption prevalence was greatest for malt beverages (33.8%), followed by premixed- or ready-to-drink cocktails (23.9%) and supersized alcopops (8.6%). Almost one quarter of respondents (24.5%) had consumed at least 1 FAB during a heavy-drinking episode (defined as consuming ≥ 5 drinks in a row).4FABs'' high alcohol content, low price, sweet flavoring, attractive packaging, and targeted marketing strategies have caused concern that FAB consumption might disproportionately contribute to alcohol-related emergency department visits by underage drinkers.5 One case study found that consumption of supersized alcopops such as Four Loko contributed to alcohol-related emergencies involving drinkers as young as 13 years.14We used the ABRAND sample of underage drinkers to examine the relationship between consumption of different types and combinations of FABs and risky drinking behaviors and adverse outcomes among youths aged 13 to 20 years.     

Interruptions in Mental Health Care,Cannabis Use,Depression, and Anxiety during the COVID-19 Pandemic: Findings from a Cohort of HIV-Positive and HIV-Negative MSM in Los Angeles,California

The objective was to examine the impact of the COVID-19 pandemic on mental health care, cannabis use, and behaviors that increase the risk of STIs among men living with or at high risk for HIV. Data were from mSTUDY — a cohort of men who have sex with men in Los Angeles, California. Participants who were 18 to 45 years and a half were HIV-positive. mSTUDY started in 2014, and at baseline and semiannual visits, information was collected on substance use, mental health, and sexual behaviors. We analyzed data from 737 study visits from March 2020 through August 2021. Compared to visits prior to the COVID-19 pandemic, there were significant increases in depressive symptomatology (CES-D ≥ 16) and anxiety (GAD-7 ≥ 10). These increases were highest immediately following the start of the pandemic and reverted to pre-pandemic levels within 17 months. Interruptions in mental health care were associated with higher substance use (especially cannabis) for managing anxiety/depression related to the pandemic (50% vs. 31%; p-value < .01). Cannabis use for managing pandemic-related anxiety/depression was higher among those reporting changes in sexual activity (53% vs. 36%; p-value = 0.01) and was independently associated with having more than one sex partner in the prior 2 weeks (adjusted OR = 1.5; 95% CI 1.0–2.4). Our findings indicate increases in substance use, in particular cannabis, linked directly to experiences resulting from the COVID-19 pandemic and the associated interruptions in mental health care. Strategies that deliver services without direct client contact are essential for populations at high risk for negative sexual and mental health outcomes.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11524-022-00607-9.     

Disparities by Sexual Orientation in Frequent Engagement in Cancer-Related Risk Behaviors: A 12-Year Follow-Up

Objectives. We examined sexual-orientation disparities in frequent engagement in cancer-related risk indicators of tobacco, alcohol, diet and physical activity, ultraviolet radiation, and sexually transmitted infections (STIs).Methods. We used longitudinal data from the national Growing Up Today Study (1999–2010). Of the analytic sample (n = 9958), 1.8% were lesbian or gay (LG), 1.6% bisexual (BI), 12.1% mostly heterosexual (MH), and 84.5% completely heterosexual (CH).Results. More sexual minorities (LGs, BIs, and MHs) than CHs frequently engaged in multiple cancer-related risk behaviors (33%, 29%, 28%, and 19%, respectively). Sexual-minority young women, especially BI and MH, more frequently engaged over time in substance use and diet and physical activity risk than CH women. More young gay than CH men frequently engaged over time in vomiting for weight control (odds ratio [OR] = 3.2; 95% confidence interval [CI] = 1.1, 9.4), being physically inactive (OR = 1.7; 95% CI = 1.2, 2.4), and using tanning booths (OR = 4.7; 95% CI = 3.0, 7.4), and had a higher prevalence of ever having an STI (OR = 3.5; 95% CI = 2.0, 6.4). Individual analyses were generally comparable to the group-level analyses.Conclusions. Young sexual minorities are at risk for cancer through frequent exposure to cancer-related risk behaviors over time. Long-term, longitudinal studies and surveillance data are essential and warranted to track frequent engagement in the risk behaviors and cancer-related morbidity and mortality.A 2011 report by the Institute of Medicine highlighted the absence of national data on cancer incidence and prevalence for sexual minorities (lesbians, gays, and bisexuals) and transgender individuals.1 The lack of data is surprising because cancer remains the second-leading cause of mortality in the United States, responsible for approximately 1 in 4 deaths.2 Furthermore, behaviors that increase the risk of cancer are more prevalent among sexual minorities. Despite the fact that cancer-related risk behaviors may become habitual over time through behaviorally reinforcing contingencies and neurobiological reward circuits, little is known about the extent to which sexual minorities engage in the behaviors over time. Frequent engagement in the behaviors over time would increase risk for cancer, as would the potential additive or synergistic effects resulting from clustering of the behaviors.Although the prevalence of engaging (yes or no) in risk behaviors among sexual minorities has been studied in literatures that are relatively independent of each other, rarely has the risk of many such behaviors for cancer been noticed. Such awareness and documentation are necessary to argue for the surveillance of cancer morbidity and mortality that the Institute of Medicine1 found lacking. We used a large national cohort of young people to document sexual-orientation disparities in frequent engagement over time in cancer-related risk behaviors at the group and individual levels of analysis.