General Public Health

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    Not So Easy Sleeping: A Canary in The Coal Mine for Adolescent Asthma?
    (2022) Kade, Laura; Thompson, Erika
    Purpose: Sleep is an important biologic process and deficits in sleep can lead to poor physical and mental health outcomes. Proper sleep is important for all ages; however, younger individuals need more sleep to maintain a healthy lifestyle. Currently, U.S. adolescents do not sleep enough, which is a concerning warning sign for negative downstream health effects. In adolescents, a lack of sleep has been linked to poor performance in school, drug and alcohol use, sports injuries, car crashes, and even suicide. A recent study has also found that adolescents who have disrupted sleep timing (i.e., going to bed late and waking up late) are more likely to have asthma and allergies - about three times higher - than other adolescents who went to bed earlier. Asthma usually gets worse at night and poor sleep can lead to worse asthma symptoms, but the impact of sleep as a risk factor on the development of asthma is not well known. Given the increasing prevalence of asthma and poor sleep among adolescents, more research is needed in order to isolate appropriate interventions. The purpose of this study was to assess the proportion of high school students who were sleep deficient and if sleep was associated with the health outcome, asthma. Methods: The 2019 Youth Risk Behavior Surveillance System (YRBSS) was used to conduct an independent analysis of all Fort Worth high school student's (n=1,992) sleep and asthma status, stratified by demographic variables. A linear trend analysis from 2015 to 2019 of sleep and asthma, respectively, at the national and high school level was done using logistic regression models controlling for sex, race, and ethnicity. Additionally, a bivariate analysis was conducted using the YRBSS Analysis tool to assess for any associations between poor sleep and asthma. Results: A predominant portion of Fort Worth high school students do not get enough sleep (74.5%, CI [72.1, 76.8]), with 11th (76.9%, CI [72.6, 80.8], p value= 0.01) and 12th graders (82.4%, CI [78.1,86.0], p value=0.00) getting the least sleep in comparison with 9th graders (68.8%, CI [64.7,72.7]). While sleep has been on the decline (p value< 0.05) since 2015, asthma has been increasing (p value< 0.05) since 2015; however, individuals who identified as Hispanic were less likely to have asthma than individuals who identified as White (p value=0.01). The bivariate analysis found that adolescents who get less sleep have a 1.62 times higher likelihood of having asthma (p value< 0.00). Conclusion: Poor sleep is a persistent and significant issue among adolescents that can lead to increased anxiety, depression, and difficulty concentrating in the short-term, and a higher risk for health issues later in life, such as excess weight gain, dyslipidemia, and metabolic and cardiovascular diseases. Sleep must be reprioritized to reduce the propensity for long-term consequences, with a particular focus on 11th and 12th graders. Further research is warranted in regard to the association between sleep status and asthma but better sleep will lead to improved adolescent and lifelong health outcomes.
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    A Country-level Comparative Study on Knowledge, Perception and Readiness towards Drone-based Dengue Surveillance System
    (2022) Annan, Esther; Guo, Jinghui; Haque, Ubydul
    Drone use in the health sector may serve the purpose of surveillance and monitoring of Aedes mosquitoes. However community concerns about drone use around homes may potentially affect the effectiveness of a drone surveillance program. This study aimed to address the gap in knowledge, readiness and perception about how individuals may respond to drone use for rapid alert systems. A cross-sectional study was conducted in three countries; Mexico, Turkey, and Malaysia and data were analyzed using SAS, Python, and R. Comparisons were made within and across countries and tested for statistical significance.The survey comprised of 1,826 participants, in Malaysia (619), Mexico (605), and Turkey (602). Of the three countries, Turkey had the lowest knowledge scores about mosquito-borne diseases. Compared to individuals living in Turkey, people living in Mexico had 14.3 (p< 0.0001) times higher odds and Malaysians had 4.0 (p = 0.7030) times the odds of being willing to download a mosquito surveillance app. About 75%, 78% and 32% of residents in rural Mexico, Turkey and Malaysia respectively, expressed no concern for the use of drones around homes for surveillance purposes. An individual's willingness to be trained and acceptance of drone use in mosquito-endemic countries may help to further discussions and application of mosquito surveillance using drones. Privacy concerns may be addressed through the enforcement of drone regulatory standards.
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    Effectively recruiting for Family-central "E-health" research: Lessons from the Lifestyle Medicine Health Education and Intervention Program Study at a Pediatric Mobile Clinic
    (2022) Trammell, Benjamin Lewis III; Robinson, Christina; Kade, Laura
    Abstract: Background: Childhood obesity is a growing global epidemic with significant racial, ethnic, and socioeconomic disparities. While current efforts to stem the tide of the obesity epidemic have focused on public policy and individual level behaviors, little research has been done on community and family-based health interventions. In this study, a novel design of personalized text messages allowed flexible participation while relaying key lifestyle information on six major contributing factors to obesity. The patient population served by the Pediatric Mobile Clinic has been known to be difficult to reach in part because of their diverse range of cultures and languages, lack of access to affordable healthcare, housing instability, phone service capabilities, and access to individualized health related information. The purpose of this sub-analysis was to identify the most efficient and effective recruitment methods to reach a broader subset of underserved patient populations. Methods: Literature review and research study personnel experience informed the design and implementation of 6 recruitment styles to help increase participant engagement. These styles included a tracking sheet, in-person discussions, phone call tree, text messages, email prompts and an Electronic Medical Record review, all of which led to a pre-screen questionnaire that determined eligibility for enrollment. Results: 377 potential patients were pre-screened resulting in 19 participants being enrolled into the study, which is a 5% enrollment rate. 39 of them were screened in person whereas the remaining 338 were screened via phone call tree. Telephone calls produced more people enrolled per month; however, telephone call recruitment required a greater volume of participants screened to produce one enrolled subject in comparison to in-person screening. In person recruitment was most effective overall with 11 of the enrolled having been recruited in person vs 8 enrolled via telephone calls. Phone calling results in greater volume but may not be as efficient. The largest prescreen failure group was due to the inability of being able to contact potential participants followed by English not being a patient's primary language. Conclusions: Enrolling people in-person may be beneficial because you are able to make a human connection which could result in a greater conversion of prospective patients to consented participants. Contacting patients multiple times via different forms of communication (Text message; email; voicemail) helped increase recruitment numbers. Recruiting patients via multiple and diverse methods may be beneficial for enrollment, particularly with underserved patients who live busy lives and may not be as accessible during clinic or traditional 9-5 hours. Future studies should consider expanding their recruitment base by applying for IRB approval of materials in multiple languages. The recruitment methodology and findings from this unique and underserved patient population could potentially inform and shape future community and family-based e-health studies.
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    E-cigarette Use Trend and Pattern among Texas High School Students: Considering the Inverse Relationship with Cigarette Smoking
    (2022) Odeyemi, Joseph; Thompson, Erika
    Purpose: Over the last decade, e-cigarettes have grown in popularity, surpassing cigarettes as the most widely used tobacco product among adolescents in the United States. Current evidence suggests that using e-cigarettes (vaping) may be less harmful than smoking cigarettes; however, while the long-term effects of vaping are still being studied, it has been linked to chronic lung and cardiovascular diseases and an increased likelihood of transitioning to cigarettes. Despite the association between smoking and vaping, the upward trend of vaping among young people is infrequently studied in concert with the prevalence of cigarette smoking. The objectives of this study are to explore the prevalence of e-cigarette use and socio-demographic factors that influence this behavior, and to examine the trend of e-cigarette use and potential associations with cigarette smoking among Texas high school students. Methods: This study analyzed and presented data on the prevalence of current and frequent use of e-cigarette products and cigarette smoking among high school students from the 2019 Texas Youth Risk Behavior Survey (YRBS), a biennial cross-sectional survey with a sample size of 2032. Previous Texas YRBS data were referenced to report relevant trends. Analysis was conducted using the YRBS online interactive data tool which utilized SAS (version 9.4) and SUDAAN (version 11.0.1). The pairwise t-test and Wald chi-square tests were used to determine significant differences and associations between estimates. Results: Nearly one in five respondents (18.7%) reported e-cigarette use during the 30 days before the survey and a quarter of e-cigarette users reported vaping almost every day. Non-Hispanic White students were significantly more likely to report current use of e-cigarettes than Hispanic and non-Hispanic Black adolescents (P< 0.001). Students who identified as bisexual were also more likely to report vaping than students who identified as heterosexual (P=0.03). The likelihood of reporting electronic vapor product use also appeared to increase with high school grades. Overall, the prevalence of cigarette smoking appeared to be on the decline from a reported 17.4% in 2011 to 4.9% in 2019. On the contrary, e-cigarette use has been on the increase, achieving a peak prevalence of 18.7% in 2019. Conclusions: Current public health anti-tobacco strategies appear to be effective in reducing cigarette smoking but not vaping among adolescents. The popularity of e-cigarettes among high school students has increased steadily over the last 10 years; however, a remarkable decline was observed between 2015 and 2017. It is important to further investigate the causes of this reported decline as this may inform future public health strategies. Halting the upward trend of e-cigarette use is a priority as these products put adolescents at risk of significant morbidity.
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    Associations between drinking context and simultaneous marijuana use among underage drinkers
    (2022) Webb, Nathanial; Rossheim, Matthew
    Purpose: Drinking context (e.g., the source of alcohol, where alcohol was consumed, the number of people an individual drank with) is associated with quantity of alcohol consumed and the level of risk, particularly among underage drinkers. However, it is unclear how contextual factors may be associated with simultaneous use of marijuana while drinking. Simultaneous alcohol and marijuana use is associated with more negative consequences experienced compared to consuming either substance alone. This study extends previous literature by examining associations between contextual factors of underage drinkers' most recent drinking episode and whether they simultaneously used marijuana, using a nationally representative sample. Methods: National Survey of Drug Use and Health data from 2010 - 2019 were used. The sample consisted of past-month drinkers under 21 years old (n = 40,128 unweighted; N = 7,707,382 weighted for nationally representative estimates). Multivariable logistic regression models were used. Results: Compared to those getting alcohol from their parents, those who were given it for free (OR = 2.659, 95% CI = 2.312, 3.059), paid someone else to buy it (OR = 3.268, 95% CI = 2.762, 3.861), purchased it themselves from a store (OR = 4.284, 95% CI = 3.435, 5.349), or got it some other way (OR = 2.115, 95% CI = 1.822, 2.689) had higher odds of engaging in simultaneous alcohol and marijuana use. The number of people the participant drank with was not statistically significantly associated with simultaneous alcohol and marijuana use. Compared to those drinking in their own home, those who drank in a bar (OR = 0.664, 95% CI=0.495, 0.890) or in an 'other' location (OR = 0.802, 95% CI=0.691, 0.931) had significantly lower odds of engaging in simultaneous alcohol and marijuana use, whereas those who drank in someone else's home (OR=1.373, 95% CI = 1.168, 1.614) or in more than one location (OR = 1.914, 95% CI = 1.458, 2.512) had significantly higher odds of simultaneously using marijuana. Conclusions: Given the associations between alcohol access and drinking locations with simultaneous alcohol and marijuana use, policy-level interventions should be considered. Specifically, enforcement of age verification laws in places where alcohol or marijuana is purchased or consumed should be strengthened. This may be accomplished by increasing the frequency of compliance checks for age verification at these retail locations. Furthermore, limiting the alcohol and marijuana outlet density, particularly in areas with a high population of underage drinkers (e.g., near colleges), may decrease the prevalence of underage use. Increasing prices and taxation of alcohol and cannabis products may also decrease prevalence of use, particularly among young adults with limited income. Lastly, increasing enforcement of social host liability and sales to minors laws to hold adults providing substances to young people legally accountable may decrease sale to underage individuals. These strengthened legal and enforcement efforts may increase barriers related to purchasing or using alcohol and marijuana among those under 21.
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    Factors Associated with Healthcare Provider Recommendations for Screening: Results from the 2017-2019 National Survey of Family Growth
    (2022) Mendez, Armando Dante; Griner, Stacey
    Early detection by screening for Human Immunodeficiency Virus (HIV) and sexually transmitted infections (STIs), such as chlamydia, gonorrhea, and syphilis, can prevent negative health outcomes such as delay and disruption of the HIV care continuum and infertility among men. STI screening recommendations typically focus on women and often overlook men, therefore healthcare provider recommendation and discussion have a strong influence on rates of HIV and STI screening. Research has also suggested provider-initiated conversations about HIV and STI screening may differ by patient's sociodemographic factors such as race and ethnicity and patient sexual behaviors. However, little is known on the specific interactions providers have with patients, including the risk factors and content discussed during sexual health visits and how that affects screening rates. The purpose of this study was to assess interactions with a healthcare provider regarding STIs and related risk factors and HIV/STI screening, adjusting (and testing interaction effects) for sexual orientation, race/ethnicity, and number of sexual partners. Using the 2017-2019 National Survey of Family Growth data, seven survey-weighted multivariable multinomial/binary logistic regression were analyzed in a complex, multistage probability-based sample designed to be representative of U.S. household members aged 15-49 years old. There were 5,206 men in the NSFG dataset; however, based on the inclusion and exclusion criteria, the final analysis sample consisted of 4,263 men. This study was approved by the North Texas Regional Institutional Review Board. Compared to White men, being Hispanic, Black, and Other race was associated with higher odds of a healthcare provider discussing: number of partners, condom usage, and type of sexual intercourse. Being a Black man was associated with higher odds of a healthcare provider discussing sexual orientation (aOR: 2.522 (95%CI: 1.711-3.592) and HIV/AIDS (aOR: 2.235), compared to White men. Identity as a Hispanic man was associated with higher odds of a healthcare provider discussing HIV/AIDS (aOR: 1.313) compared to White men. Identity as a sexual minority were associated with higher odds of a healthcare provider discussing all risk factors and HIV/AIDS compared to heterosexual men. A general trend was observed for number of sexual partners: every additional opposite/same-sex partner was associated with higher odds of HIV/AIDS screening (aOR: 1.080; 1.393), STI screening (aOR: 1.028; 1.201), respectively. Lastly, every additional same-sex partner was associated with higher odds of a healthcare provider discussing HIV/AIDS with the patient (aOR: 1.241). Results may provide insight on how healthcare providers facilitate HIV/AIDS and STI screening among men and which patient groups are more likely to receive a discussion of risks factors with from their healthcare provider. Additionally, these results may further support the need for more healthcare providers to utilize standardized guidelines for interactions with patients regarding sexual health (i.e., Sexual Health and Your Patients: A Provider's Guide by the National Coalition for Sexual Health). Future studies can use results from this study to design targeted interventions to promote equity in provider behavior and ultimately reduce the negative health outcomes associated with HIV and STIs.
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    Increasing Mental Health Literacy and Decreasing Stigma with the Lay Mental Health Advocates (LMHA) Program
    (2022) Ponce, Aiyana; Kenou, Bruny
    Purpose: Historically, mental health stigma, access to care, and discrimination all contribute to worsened health outcomes, especially for minority populations. To help address this, the Lay Mental Health Advocates (LMHA) program was created. This free, virtual training program is designed to teach laypersons the fundamentals needed to advocate for someone who is dealing with mental illness and their family members. LMHA focuses on teaching mental health advocacy by understanding how social determinants of health and racism play a key role in worsening mental health outcomes for marginalized communities. Workshops are led by psychiatry resident/attending physicians from Duke University Hospital and local community leaders. They include interactive role-playing advocacy practice, case study reviews, and other informative components. Those who complete at least 80% of the 8-week course material receive a certificate of completion and are eligible to apply to become an advocate through the LMHA volunteer network. Methods: LMHA began as a volunteer project of the National Institutes of Health Academy Fellows, a program that gives trainee scientists the opportunity to implement a volunteer health program that addresses health disparities in their local community. The pilot LMHA program took place in Spring 2021. Pre and post program surveys were distributed to all active participants. The 2021 program had 100 participants (ages 18-58). 77 of these earned certificates of completion. The revamped 2022 program is on track to have double the number of participants from across the country. The curriculum was created by modeling the Johns Hopkin's Medicine Lay Health Advocate Program and the Mental Health Allyship Program. Needs assessment surveys were analyzed for the DC, Baltimore, and Durham regions to model the program on the community's needs. 3 sets of focus groups were conducted throughout the pilot program to further the curriculum and gain the participant's insight. Results: Comparing pre and post program survey data, there were increases in participant's: 1. Level of comfort using skills learned with LMHA to serve as an advocate for someone, 2. Understanding of how racism can impact a person's mental health and access to mental healthcare, 3. Understanding of how social determinants of health can affect someone's mental health and access to mental health resources, and 4. Desire to become a mental health professional. Conclusions: There is a need for interventional programs to fill the mental health gap that is particularly prevalent among marginalized communities. Through LMHA, advocates can identify several different mental disorders, gain a greater understanding of the factors that exacerbate health disparities, understand how to provide effective emotional support, and gain confidence in the role they can play in affecting people in their community by being a mental health advocate.
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    School-based factors associated with attempted suicide among united states adolescents, 2015-2019
    (2022) Forschner, Caylee; Yockey, Robert; Griner, Stacey
    Purpose: Suicide is the second leading cause of death among adolescents in the United States, ages 15 to 19 years old. Previous research has identified an extensive list of risk factors associated with adolescent suicide and indicates sexual minority youth, who identify as lesbian, gay, bisexual, or unsure, are at increased risk for suicidal behaviors, but limited research examines the contextual factors that may be associated with suicide attempts among these youth. Additional research is warranted into school-based factors and their relationship with suicide among sexual minority youth. The purpose of the present study is to investigate school-based factors associated with suicide and explore differences by sexual minority status among a large, nationally representative sample of U.S. youth over multiple years. Methods: Pooled data from the 2015-2019 Youth Risk Behavior Survey (YRBS) were analyzed. The YRBS is a bi-annual survey conducted in the United States to examine health behaviors among youth in middle and high school. Weighted logistic regression models were conducted to determine conditional associations to past-year suicide attempt ("yes or no"). The conditional associations considered were, sexual orientation ("heterosexual, gay/lesbian, bisexual and not sure"), did not go to school because they felt unsafe ("yes and no"), and grades over the last year ("mostly A's/B's, mostly C's/D's/F's and none of these grades/not sure"). Interactions between sexual orientation and not going to school because they felt unsafe, were built and were mean centered to reduce multi-collinearity and interpretability of findings. Missing data were handled with multiple imputation methods and combined in multivariate analyses using Rubin's rules. The level of significance was set at p < .05 and were two-tailed. Analyses were conducted in Stata. Results: The total sample comprised of 44,066 students in 9th-12th grades, with nearly equal percentages of boys and girls (50.0% vs. 49.2%, respectively). An estimated 3.4% (95% confidence interval (CI): 3.15-3.62) of youth reported past year suicide attempt. Compared to heterosexual youth, bisexual youth (aOR: 1.38, 95%CI 1.24-1.53) were more likely to report attempting suicide. Students who reported feeling unsafe at school (aOR: 1.49, 95%CI 1.34-1.64) were more likely to attempt suicide compared to those who reported feeling safe at school. Sexual orientations and feeling safe at school interactions were not significant- the students who did not feel safe were not those that identified as sexual minorities. Students who reported their grades as C's/D's/F's (aOR: 0.75, 95%CI 0.64-0.86) were less likely than students who reported A's/B's to attempt suicide. Conclusions: These findings indicate that students who do not feel safe in school have an increased risk of suicide attempts, underscoring the importance of programs that promote a safe and supportive school environment. Students who reported lower grades have a decreased risk of suicide attempts, necessitating further research to identify the influence of academic pressures. Understanding school-based factors affecting adolescent suicide risk is important to identify students at greatest risk and develop targeted and effective programs to reduce suicide in this age group.
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    Evaluating the effects of the COVID-19 pandemic on patient management of Type 2 Diabetes Mellitus
    (2022) Wildish, Shelby
    Background: On March 11, 2020, the WHO declared Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), as a global pandemic. As a consequence of the COVID-19 pandemic, many countries implemented "lockdown" or quarantining regulations, to help maintain the virus spread. These declarations resulted in extended periods at home for patients, which is known to have undesirable consequences of physical inactivity, weight gain and increased risks of many pathologies such as Type 2 Diabetes Mellitus (T2DM). Type 2 Diabetes Mellitus is the seventh leading cause of death in the United States, and is a known risk factor for severe outcomes in COVID-19 patients. Texas has an increased prevalence of T2DM as compared to the US, with racial minorities, elderly and undereducated patients being disproportionately impacted by the condition. Purpose: This paper aims to explore the effects of the COVID-19 pandemic on the management of T2DM in patients in underserved communities who utilize free clinics for longitudinal primary care. Focus: Specifically, we intend to compare patient's Hemoglobin A1C (HbA1c), Weight and Body Mass Index (BMI) pre- vs. post-COVID-19 pandemic to investigate whether the COVID-19 pandemic affected the patient's management of T2DM.
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    The epidemiology of obesity among U.S. adolescents and the association with adequate sleep
    (2022) Shah, Jil; Thompson, Erika
    Purpose: Childhood obesity, a leading risk factor for chronic illnesses and deaths, is a major public health concern. Increasing evidence suggests that sleep deprivation has a negative impact on metabolism and results in increased fatigue and hunger. Short sleep duration is considered a potential risk for overweight/obesity in childhood and adolescence. This study aims to understand the descriptive epidemiology of childhood obesity in the U.S. and explore the association between sleep and obesity. Methods: The national Youth Risk Behavior Survey (YRBS), 2019 (n=13,677), which is a cross-sectional survey among high school students grades 9 through 12 in the U.S., was used to assess the prevalence of obesity and correlates. Obesity was measured from self-reported height and weight, considering the participants' age and sex. Additional stratification by demographic variables (sex, race/ethnicity, grade, sexual orientation), and sleep duration was conducted, and these associations were analyzed using t-test results from the YRBS Analysis Tool with a 0.05 level of significance. Results: Sixteen percent of high-school students in the U.S. (2019) reported being obese and the trend is continually increasing from 2009 to 2019. Some populations were significantly more likely to be obese than others, namely, males as compared to females (p-value< 0.01), American Indian/Alaskan Native as compared to Asians (p-value=0.01), bisexuals as compared to heterosexuals (p-value< 0.01), and those who did not get 8 hours or more of sleep as compared to those who did get 8 hours or more of sleep (p-value=0.02). Conclusion: There is a health disparity in childhood obesity prevalence by sex, race/ethnicity, and sexual orientation. Inadequate sleep is a significant factor associated with obesity. Further research is warranted to establish causality between sleep and obesity. Understanding contributors to obesity among subpopulations of adolescents could contribute to targeted interventions focusing on vulnerable populations, which could help lower the prevalence of childhood obesity, its persistence into adulthood, and comorbidities.
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    Are Retail Sales of Delta-8 THC and Four Loko Associated? Findings from Fort Worth, Texas
    (2022) Agwuncha, Theresa; McDonald, Kayla; Walker, Drew; Shah, Mauli Vidyutbhai; Boezinger, Matt; Trangenstein, Pamela; Livingston, Melvin D.; Yockey, Robert; Thombs, Dennis; Rossheim, Matthew
    Objectives: Four Loko is an inexpensive and high-alcohol content product. Across the U.S., Four Loko retailers concentrate in impoverished areas; however, it is unclear whether this geographic patterning exists at a micro level, such as within a city. Delta-8 THC, an isomer of the more common form of the Cannabis plant Delta-9, is an unregulated psychoactive substance that was legalized by the Farm Bill in 2018. It is unknown if retailers that sell risky products like Delta-8 THC may be more likely to sell Four Loko, creating niche stores that sell unregulated or intoxicating substances. Methods: The study sample included 168 retailers in Fort Worth, Texas that had licenses to sell beer off-premise. Stores were contacted in September and October 2021 and asked whether they sold Delta-8 THC. Data regarding Four Loko's availability at each retail site was obtained from the manufacturer's website. Area deprivation index (ADI) scores, a marker of socioeconomic disadvantage (a continuous variable with range 1-10, with higher scores indicating more disadvantage), were linked to each store's zip code. A multivariable logistic regression model was used to examine associations between retail of Delta-8 THC, having a retail tobacco license, ADI scores, and retail of Four Loko. Results: In the overall sample, 55% of stores sold Four Loko and 17% sold Delta-8 THC. Specifically, 41% of stores only sold Four Loko (mean ADI = 6.46, SE = 0.36), 4% only sold Delta-8 THC (mean ADI = 1.67, SE = 0.33), 14% sold both Four Loko and Delta-8 THC (mean ADI = 5.8, SE = 0.71), and 42% did not sell either (mean ADI = 5.18, SE = 0.42). Logistic regression results indicate higher ADI scores (OR = 1.15, 95% CI = 1.03, 1.28) and selling Delta-8 THC products (OR = 8.50, 95% CI = 2.32, 31.17) were associated with increased odds of selling Four Loko. Having a tobacco license was also associated with increased odds of selling Four Loko products, although not statistically significant (OR = 3.41, 95% CI = 0.99, 11.76, p = 0.052). Discussion: Stores that sold Delta-8 THC were 8 times as likely to sell Four Loko. These results suggest that some retail locations may specialize in the sale of high-risk products, including unregulated products. This is important, especially in the context of retail locations, given the rapid development of novel psychoactive substances which future research should focus on. Given associations between type of product sold at each location and ADI scores, residents of socioeconomically deprived neighborhoods may have higher exposures to these dangerous products. Future research should assess the geographic distribution and density of Four Loko and Delta-8 THC sales to determine specific geographic areas that may be at high risk. Additionally, future research should investigate the etiology of health disparities and crimes near these establishments. Implications may suggest supporting the development and implementation of public nuisance laws and/or policies that restrict the sale of unregulated/high-risk substances.
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    Characteristics of Delta-8 THC retailers in a large metropolitan city
    (2022) LoParco, Cassidy; Walker, Drew; McDonald, Kayla; Pathak, Sunidhi Santosh; Eggleston, Jensen; Olsson, Sofia; Yockey, Robert; Luningham, Justin M.; Kong, Amanda; Henry, Doug; Rossheim, Matthew
    Background: Retail sales of Delta-8 THC, an isomer of the more common form of cannabis (Delta-9 THC), have increased in the U.S. market since the passing of the 2018 Farm Bill. Specifically, the Farm Bill allowed for the sale of hemp products, which are classified as products having less than 0.3% Delta-9 THC by dry weight. Importantly, sales of Delta-8 THC are unregulated and may introduce possible risk arising from either psychoactive effects or unregulated solvents left behind from the synthesis of Delta-8 THC from CBD. The current study describes the Delta-8 THC retail sales environment in a large metropolitan city. Methods: Potential Delta-8 THC retailers were identified by identifying lists of current retail locations with alcohol, CBD, and tobacco licenses in Fort Worth, Texas (n = 1,961). Research assistants called retailers between September 8 and October 14, 2021, to query about sales of products containing Delta-8 THC; 69% (n = 1,223) of retailers answered and provided data on Delta-8 THC. Outlets' 9-digit ZIP codes were merged with area socioeconomic deprivation index scores. Chi-squared tests compared socioeconomic deprivation index scores between outlets that sold Delta-8 THC versus those that did not sell Delta-8 THC. Among a subsample of those who did sell Delta-8 THC, t-tests examined associations between prices and the type of Delta-8 THC products. Results: Approximately one in ten retail outlets (11%, n = 133) reported selling products containing Delta-8 THC. Most (96%) sold Delta-8 THC in the form of flower/vapes, and three-fourths (76%) sold edibles. Among the least expensive Delta-8 THC products available at these retail outlets were edibles (mean price = $15.39), which cost $8.58 less than flowers/vapes (mean price: $23.97; p < 0.001) on average. Retail outlets that sold Delta-8 THC, compared to those that did not, were in zip codes with greater deprivation (p = 0.02). Most outlets reported having a minimum age for sales of Delta-8 THC as 21 years; however, 4% reported 18 years or no minimum age for sale of Delta-8 THC products. Discussion: Delta-8 THC retail outlets were disproportionately located in ZIP codes with higher levels of socioeconomic deprivation. Legal intervention, such as zoning laws, may be warranted to prevent potential health disparities from overexposing a subset of communities to these products. Policies, such as increasing Delta-8 THC product prices and restricting the types of products sold may help reduce access and appeal to people under 21 years old.
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    Trends in short sleep duration and trouble sleeping among US adults, 2005-2018
    (2022) Wang, Shanshan; Rossheim, Matthew; Nandy, Rajesh
    Background: Better understanding current trends in prevalence of short sleep duration and trouble sleeping is critical for prevention and management of sleep problems. The objective of the study was to determine trends in prevalence of short sleep duration and trouble sleeping among US adults from 2005 to 2018, and assess how sleep trends vary by sex and race/ethnicity. Methods: Seven cycles of the National Health and Nutrition Examination Survey (NHANES) data between 2005-2006 and 2017-2018 were analyzed. Participants who were 18 years or older and provided completed data regarding sleep duration were included. The final analytic sample size was 41416. Trouble sleeping and sleep duration were self-reported. Short sleep duration was defined as sleep duration ≤ 6 hours. Age-standardized prevalence of trouble sleeping and short sleep duration were estimated among the overall US adult population, and by sex and race/ethnicity. Results: From the 2005-2006 cycle through the 2013-2014 cycle, the age-adjusted prevalence of short sleep duration remained similar in the overall population (p for trend>0.05). Non-Hispanic Black people had the highest prevalence of short sleep duration among all the race/ethnicity groups in all seven cycles. Prevalence of short sleep duration appears lower in 2015-2018 than in 2005-2014 due to different measurement methods applied. However, from 2005-2006 to 2017-2018, there were increasing trends in age-adjusted prevalence of trouble sleeping in the overall population, among both men and women, and all race/ethnicity groups (p for trend< 0.05). Compared to men, women had a higher prevalence of trouble sleeping. Among all the race/ethnicity groups, non-Hispanic White people had the highest prevalence of trouble sleeping. Conclusions: The prevalence of trouble sleeping increased significantly between 2005 and 2018, while no trends were detected in the prevalence of short sleep duration. Meanwhile, non-Hispanic Black people had the highest prevalence of short sleep duration, whereas non-Hispanic White people had the highest prevalence of trouble sleeping. These findings suggested that the sources contributing to the increasing trends in trouble sleeping were different from those contributing to the trends in short sleep duration. Also, targeted management and prevention efforts should be made for different race/ethnicity groups to address the race/ethnic disparities in sleep health. Keywords: Trends, Prevalence, Short sleep duration, Trouble sleeping
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    Parent and Teen Feedback on a Prototype of a Novel Parent-Based Intervention for Adolescent Alcohol Use and Social Networking Site Use
    (2022) Seamster, Morgan; Kannard, Emma; Resendiz, Raul; Walker, Travis; Lewis, Melissa; Litt, Dana M.
    Purpose: Social networking site (SNS) use has been associated with increased alcohol use and risky health behaviors in adolescents. Previous research has demonstrated the role of parents in mitigating the adverse effects of SNS on alcohol use. As an emerging area of research, digital parent-based interventions (PBIs) may be used to prevent adolescent risk behaviors related to alcohol and SNS. To ensure the efficacy of these interventions, parent and adolescent feedback is essential to optimize user engagement and acceptability. The current investigation aimed to gather parent and teen perspectives on usability and acceptability of a prototype digital PBI, developed in part based on previous focus group findings, for adolescent alcohol use and SNS use. Methods: A total of 29 parents (female = 86.2%, avg. age = 44) and 27 teens (female = 55.6%, avg. age = 16) dyads were recruited from across Texas. Parents and teens attended groups separately and were presented with prototype intervention content, including website modules and video content. Groups were asked to discuss initial reactions to and thoughts about usability (i.e., ease of navigation, layout and design, etc.) and acceptability (i.e., favorability of overall PBI, likelihood of using different features, etc.). Transcripts were reviewed to generate themes and trends in participant feedback across groups. Conclusions and Implications: Both parents and teens reported that dynamic module navigation features, which allow for tailoring of educational content to user interests, appeared highly usable. Participants generally agreed that a feature allowing parents to send video content directly to their teens from the PBI was an important aspect of the program, as it would provide an opportunity for both parents and teens to independently prepare for joint conversations and learning. Both parents and teens emphasized the importance of video narrator relatability including delivery tone, age, gender, and diversity. Participants expressed desire for visually stimulating content based on user learning styles. Lastly, parents reported preferences toward fact-based and research-oriented content, whereas teens preferred intervention content with humor or shock value. Overall, feedback yielded important guidance for optimizing features to improve engagement and user learning. Findings are currently being integrated into the final digital PBI to be tested in an upcoming pilot study.
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    Patient Reported Outcomes: Why are we still using percentage change from baseline as an outcome?
    (2022) Sule, Olagoke
    Patient-reported outcome (PRO) measures are generally used to examine the effect of medical interventions on how patients feel or functional status. When analyzing PRO endpoints, interpreting the change in scores between two-time points or the difference in change scores between treatment groups can be challenging. There is a lack of consensus in the research community regarding a frequently used endpoint 'change from baseline percentage.' This research discusses the advantages and disadvantages of using the anchor-based method in PRO studies. A case example is provided to illustrate concepts. Appropriate search parameters were identified to examine the topic, and PubMed was selected as the most relevant database. Published studies were retrieved between January 2000 and December 2021. Search terms included keywords: "anchor-based," "patient-reported outcome", "SF-36" and "change from baseline,". Articles were excluded if they did not include 'anchor-based' as a method. The information from the resulting articles was grouped into four categories: advantages, disadvantages, validity of the PRO method, and the PRO method's ability to detect change. The mismatch between the PRO instrument and the intended outcome is an important consideration in using percentage change from baseline as an outcome. This study provides an overview of key issues in assessing and documenting how patients feel or function.
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    Honey, I'm Home: A Social Media Campaign for House Bill 331 Pertaining to Evidence-Based and Universal Home Visitation Programs in Texas
    (2022) Molina, Jillian; Griner, Stacey
    Background Universal and evidence-based home visitation programs can help address preterm birth, maternal death, domestic violence, and sudden infant death syndrome in Texas. Programs utilize trained health professionals to promote health and wellness by visiting homes of families before, during, and after pregnancy. Programs that were implemented have been shown to reduce domestic violence, prevent maternal death, promote economic stability, and connect families to helpful community resources. House Bill 331 (HB 331) pertaining to universal home visitation programs in Texas can provide families with education, resources, and advocates to be healthy. Objective The goal of the social media strategy and campaign was to educate the public on how home visitation programs can assist families and engage voters in a call to action so HB 331 could gain support and be passed in the upcoming 2023 legislative session. Methods To promote HB 331, a social media strategy was developed using Twitter as the platform for dissemination. One tweet was serious by mentioning public health issues while the other tweets were light-hearted and informative. In every tweet, HB 331 was mentioned. Two of the hashtags were used as a call to action while the others were meant to evoke emotion. The "memes" were used to target young voters. Tweets will be launched in 2022, so people have time to reach out to their representatives for the 2023 legislative session. Results The social media posts were developed to inform young voters and gain support. The tweets communicate that home visitation programs promote healthy families, benefit everyone, and need the public's support to become reality in Texas. In the first tweet, a meme is used to ask the audience to change the author's mind about how helpful home visiting programs are. The content of the tweet then goes on to describe the benefits of the program and insinuate that their mind cannot be changed. The second tweet contains a photo of a home visitation occurring and contains information about what public health issues are being addressed by implementing these programs. This tweet is meant to be serious. Finally, the third tweet is a meme of the rapper Drake smiling at the notion of passing HB 331. In the content of the tweet, the need for home visiting programs is explained in addition to how they can lower healthcare costs. Conclusions This campaign calls people to action and may increase HB 331 awareness. Social media is an appropriate avenue because it is cost-effective and can reach many. Other ways to advocate for the bill include writing a letter to the editor for your local newspaper, a letter to your representative, and sharing the tweets above. Home visitation programs are vital to the health of families in Texas and this campaign ensures that the state prioritizes the health of women and children. Further research on health information dissemination via social media is needed to ensure voters are effectively being reached and influenced by future social media campaigns and improve maternal and child health.
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    Impact of Education on Influenza Immunization Rates and Care Planning
    (2022) Hua, Vincent
    Influenza vaccination is the most effective way to prevent the flu and associated complications. Similarly, acute care planning in rural areas is more limited than in urban areas as clinics face significant barriers. By increasing education, clinics in rural populations can increase advance care planning and decrease complications of the flu. On a random day, patients will be asked if they have any future care plan and if they have gotten their flu shot. If they answered "no" to either question, a pamphlet will be given educating the patient on the importance of the flu shot or future care planning. The subject will then be asked if they have changed their mind regarding their previous answer. Number of patients sampled was 21 (8 M, 13 F) with an age range of 30-92. Intervention resulted in 23.81% increase in patients who had a future care plan and a 19.05% increase in patients who got the flu shot. The short length of time as well as the small sample size make it difficult to measure exactly how big of an impact the intervention would make over a larger period or with a larger sample size. In addition, this study has a wide age range which could skew the data, as younger patients might not be as willing as older patients to think about future care planning. However, though flawed, the study shows the potential a small intervention could have on patient' health and well-being.
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    Qualitative Descriptions of "What is Delta-8 THC"?
    (2022) Olsson, Sofia; LoParco, Cassidy; Rossheim, Matthew
    Background: Delta-8 THC is a chemical isomer of the more common form of THC found in the Cannabis plant, Delta-9. Delta-8 THC retail increased after the 2018 Farm Bill was passed. This bill defined hemp as anything having less than 0.3% Delta-9 THC by dry weight, thus implicitly defining Delta-8 THC as hemp rather than marijuana. The retail of Delta-8 THC is unregulated, and both consumers and retailers may lack an understanding of the substance. This study utilized qualitative responses of retailers selling Delta-8 THC products in Fort Worth, Texas to understand how retailers are explaining the product to consumers. Methods: Retail locations in Fort Worth, Texas with alcohol, CBD, or tobacco retail licenses was compiled (n = 1,777). Retail locations were contacted between September 8 and October 14, 2021, by research assistants to query the retail of Delta-8 THC products. This study utilized a subsample of retail locations (n = 125) that answered the question asking, "What is Delta-8?" Qualitative analysis was performed by authors SO and CRL. Results: Cohen's kappa was 0.92, indicating a good inter-rater reliability. Many retailers (20.8%, n = 26) reported that they were unsure of what Delta-8 is while 7 (5.6%) told surveyors to look it up themselves. Several retailers (8.8%, n = 11) withheld information, stating they would provide information over the phone. Nearly a quarter (23.2%, n = 29) of retailers made claims on the legal status of Delta-8 THC (e.g., that it was legal), seven (5.6%) of which specifically mentioned the 0.3% Delta-9 THC threshold. Delta-8 THC was often described as a form of marijuana (34.4%, n = 43). Importantly, Delta-8 THC was also frequently described as CBD (19.2%, n = 24) or hemp (7.2%, n = 9), substances without psychoactive effects. Several retailers described the potential effects of Delta-8 (e.g., "It relaxes you"; 26.4%, n = 33) or the potency (e.g., "Not high dose"; 13.6%, n = 17). Discussion: Comments on the legal status of Delta-8 products may be misleading to consumers as lack of regulation may result in illegal product composition. For example, recent research has found that 76% (n = 51) of Delta-8 products surveyed had Delta-9 THC levels above the legal limit (Johnson 2021). Several retailers verbally withheld information or said they were unsure of what the product is, which may be due to the lack of clarity surrounding Delta-8 THC product composition and/or legality. Retailers often described Delta-8 THC by focusing on psychoactive experiences or potency, rather than an explicit definition of the product, which may be a marketing strategy. Without proper laws regulating the marketing or packaging of Delta-8 THC products, individuals may be unaware of the contents. This may lead to increased consumption, particularly among adolescents and young adults or those not expecting psychoactive effects. Regulation, surveillance, and product definitions of Delta-8 are important to reduce the risk of adverse effects.
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    Drink prices, drink specials, and tobacco policies in a national sample of on-premise drinking establishments
    (2022) LoParco, Cassidy; Walker, Drew; Livingston, Melvin D.; Trangenstein, Pamela; Khoshhal, Bita; Gonzalez-Pons, Kwynn; Thombs, Dennis; Rossheim, Matthew
    Background: Bar and nightclub practices, such as offering inexpensive drinks, having pricing promotions (e.g., 2-for-1, happy hour), and permitting e-cigarette use indoors can increase the amount of alcohol that individuals consume and the number of negative consequences they experience. College students in particular may have a greater risk of increased consumption and related harms to themselves and others. Despite the implications, few studies have assessed the presence of low-cost alcohol and e-cigarette-friendly environments around colleges. The current study surveilled drink prices and specials and examined associated characteristics of on-premise drinking establishments near large universities. Methods: In 2018, telephone calls about prices, practices, and policies were made to 404 randomly selected bars and nightclubs within 2 miles of the largest residential universities in each U.S. state. The Alcohol Policy Information System provided data on state-level alcohol policies. Multivariable linear and logistic regression models examined associations between drinking establishment characteristics, drink prices, and drink specials. Results: The average price for a beer and a shot of vodka were $3.62 and $4.77, respectively. Most establishments (65%) had happy hour specials and 6% had 2-for-1 drink specials. Nearly all (91%) sold food, while 9% sold cigarettes on-premise and 8% allowed smoking inside. Almost 1 in 5 establishments (18%) allowed e-cigarette use inside. Allowing e-cigarette use indoors (b = -0.54) and selling cigarettes on-premise (b = -0.79) were associated with significantly lower vodka prices, whereas allowing cigarette smoking inside (b = -0.46) was associated with significantly lower beer prices. Several factors were significantly associated with higher odds of having a happy hour special, including lower beer prices (OR = 1.38), selling food (OR = 2.97), no state law banning happy hour specials with full day price reductions permitted (OR = 12.74), and no complete bans on happy hour specials (OR = 4.24). Allowing e-cigarette use indoors was significantly associated with higher odds of having a 2-for-1 drink special (OR = 6.38). Conclusions: The current study is one of the first to identify associations between business practices/policies of on-premise drinking establishments and drink prices. This study used a national sample of on-premise drinking locations near large universities to provide insight into how alcohol prices may be discounted to promote sales of other products. For example, locations selling cigarettes on-premise were associated with lower vodka prices. Importantly, previous research indicates positive associations between alcohol consumption and smoking. Coupled with the lowered drink prices, settings that are permissive of smoking and vaping may be associated with increased risk of both heavy drinking and tobacco use, as well as their related harms. Given the frequently offered drink specials and strong association between price and consumption, more research is needed regarding alcohol prices/specials at on-premise drinking sites.