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    Trends in dietary and total magnesium intake of Hispanic Adults, National Health and Nutrition Examination Survey (NHANES) 1999 – 2014
    (2019-03-05) Chen, Shande; Fulda, Kimberly; Huang, Yuhan; Tao, Meng-Hua; Liu, Jialiang
    Purpose Magnesium is an essential mineral that plays important roles in hundreds of physiologic activities; however, intake of magnesium has been histologically low in Americans. The 2015-2020 Dietary Guideline for Americans particularly identified magnesium as one nutrient of concerns. The purpose of this study is to report trends in magnesium intake from foods and total magnesium intake (from foods and supplement) between 1999 and 2014 among US Hispanic adults, overall and stratified by gender, race, age, family income level, and education level. Methods Data on 9,690 Hispanic adults aged 20 years or older from eight National Health and Nutrition Examination Surveys (NHANES) cycles (1999 – 2014) were included in this study. The sample size per cycle ranged from 957 to 1,651. In NHANES, daily dietary magnesium intake was collected through 24-hour dietary recalls, and supplemental intake of magnesium was obtained from a dietary supplement questionnaire. For each survey cycle, survey-weight, energy-adjusted average dietary and total magnesium intakes were estimated, and the prevalence of dietary and total magnesium intake below the Estimated Average Requirement (EAR) were estimated using the National Cancer Institute (NCI) method. Linear regression was used to test trends in mean intake and prevalence of inadequacy over time. Results Among Hispanic adults, overall both dietary and total magnesium intake increased significantly between 1999 – 2000 and 2013 – 2014, from 269 mg/day to 285 mg/day for dietary intake and from 289 mg/day to 305 mg/day for total intake (p-quadratic trend p trend Conclusions Our results indicate mild improvements in magnesium consumption level among U.S. Hispanic adults between 1999 and 2014, while the prevalence of magnesium inadequacy remained high, which suggesting the necessary to improve magnesium intake in this population through appropriate public health educations on nutrition and supplementation.
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    Break a Sweat, Mend Your Mind: Exercise and Mood Among Adolescents
    (2019-03-05) Thompson, Erika; Harrison, Samantha
    Purpose: The prevalence of depression in adolescents is rising, and regular exercise has been reported to have a decreasing effect on incidence of depressed mood in meta-analyses of adult interventions. There is a need to explore this association among adolescents. The purpose of this study was to examine the association between exercise and mood among United States adolescents responding to the Youth Risk Behavior Survey (YRBS) 2017. Methods: YRBS is a nationally representative sample of 9th through 12th grade students (N=14,765), and was restricted to an analytic sample (N=10,789). The outcome of interest was depressed or low mood (yes/no to feeling sad or hopeless in the past 12 months), and the exposure was physical activity (yes/no to being physically active for at least 60 minutes on five or more days in the past week). Covariates included: age, sex, race/ethnicity, physical education class attendance, sports team participation, and hours of sleep. SAS version 9.4 was used to perform survey-weighted descriptive estimates and crude and adjusted logistic regression models. Results: Overall, 47.5% of participants reported being physically active, and 31.3% reported feeling sad or hopeless in the last year. Respondents who reported physical activity were less likely to have reported feeling sad or hopeless when compared to those who were not physically active (OR=0.68, 95%CI 0.59, 0.79). When adjusting for age, sex, race/ethnicity, physical education class attendance, sports team participation, and hours of sleep, the association was no longer statistically significant (aOR=0.93 95%CI 0.80, 1.10). Conclusions: While an association between exercise and depressed mood was not observed in this cross-sectional study, further research is needed into the risk and protective factors for depression in adolescents due to the rising prevalence of the disorder.
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    An Assessment of Obesity and Sleep Sufficiency Among Adolescents in the United States
    (2019-03-05) Thompson, Erika; Mayfield, Laura
    An Assessment of Obesity and Sleep Sufficiency Among Adolescents in the United States Laura Mayfield, MPH Candidate, CHES Erika Thompson, PhD, MPH, CPH Purpose: Obesity is increasing among adolescents in the US, and understanding co-factors is needed. Insufficient sleep may contribute to obesity among adolescents. The purpose of this study was to assess the association between sufficient sleep and obesity among 9th-12th grade students in the United States. Methods: This study used the 2017 Youth Risk Behavior Surveillance System data (N=14,765). The sample was further restricted as a complete case analysis (N=10,350). The outcome was obesity, which was categorized dichotomously (obese, not obese) based on participants’ Body Mass Index. The exposure was sleep: those who got 8 or more hours of sleep on the average school night (sufficient sleep) and those who did not (insufficient sleep). Covariates included physical activity, sex, age, and race/ethnicity. All analyses were completed using survey- weighted procedures in SAS 9.4. A survey logistic regression model was used to calculate adjusted odds ratios and 95% confidence intervals modeling odds of obesity. Results: Among participants, 14.7% were obese and 74.5% had insufficient sleep. The association between sleep and obesity was not statistically significant (OR=0.91, 95% CI 0.76, 1.08). However, participants who were physically active for 60 minutes, 5 or more days each week, were less likely to be obese compared to participants who were not physically active, while controlling for sleep, sex, age, and race/ethnicity (OR=0.65, 95% CI 0.55, 0.76) Conclusions: Multiple factors are associated with obesity among American adolescents. Further research on obesity trends and associated factors is needed to help inform public health efforts to prevent and reduce obesity among adolescents. Keywords: YRBSS, Sleep, Obesity
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    Factors Associated with Medication Adherence Among Persons in Permanent Supportive Housing
    (2019-03-05) Nandy, Karabi , PhD; Nandy, Rajesh , PhD; Walters, Scott , PhD; Khan, Mahbuba
    Purpose: Nonadherence to medication is associated with poor health outcomes, worsening of disease and frequent hospitalization. People living in permanent supportive housing (PSH) may be at greater risk of medication nonadherence because of a history of chronic homelessness, increased prevalence of mental disorders and other vulnerabilities. Understanding factors associated with medication nonadherence in this vulnerable population may help alleviate an important deficiency in their life and advance them towards stability. The objective of this study was to estimate the prevalence of medication adherence among PSH residents and to identify factors associated with low medication adherence. Methods: Adult PSH residents voluntarily participated in the mobile community health assistance for tenant (m.chat) project during 2014-2017 in Fort Worth, Texas. The Morisky medication adherence scale was used to classify participants as having low, medium or high adherence to medication. Self-reported data on demographic variables, alcohol consumption, quality of life, substance use, and depression were collected. Multinomial logistic regression was used to identify factors associated with participants’ levels of medication adherence. Results: A total of 598 participants were included in the sample. The prevalence of low, medium and high medication adherence were 54.5%, 29.9%, and 15.6%, respectively. In unadjusted analyses, binge drinking (p-value=0.001), quality of life (p-value Conclusion: A majority of PSH residents were in the low medication adherence category. To better address the issue of medication noncompliance, intervention programs may want to target PSH residents who have depression, binge drinking habit, and have a poor quality of life.
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    Late Night Social Networking Use and the Associations with Adolescent and Young Adult Sleep Quality, Substance Use, and Anxiety
    (2019-03-05) LoParco, Cassidy; Galvin, Annalynn; Leon, Marcela; Lewis, Melissa; Litt, Dana M.; Lowery, Ashley
    Purpose: Research has shown social networking site use to be associated with adolescent and young adult health and risk behavior generally, but less is known about whether late night use is related to health and well-being. The purpose of this study is to examine late night use (between the hours of 11pm and 5am) of specific social networking site platforms (Snapchat, Instagram, Facebook) in relation to sleep quality, substance use (alcohol, marijuana), and anxiety. Methods: Adolescents and young adults ages 15-20 (mean age of 18.39, (SD = 1.32), 47% male) completed a survey from which the current data are drawn as part of a larger experimental study (N=306). Linear regressions were carried out, controlling for age, sex, education status, race, alcohol and marijuana use, and anxiety in all models. Results: Findings indicated that past week late night use of Instagram was associated with fewer hours of sleep at night on average (t = -2.02, p t = 3.44, pt = 2.11, p t = 2.78, p t = -2.12, p all p-values [greater than] .05). Finally, linear regression results indicated that past week late night use of Snapchat was positively associated with past month anxiety (t = 2.102, p Conclusions: Together, these findings contribute to the growing literature supporting the association between social media use and various aspects of well-being in adolescents and young adults. The present findings suggest that late night social networking site use by platform is an important factor that warrants further investigation in the context of adolescent and young adult sleep, substance use, and anxiety. IRB #: 2018-009
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    Project INTEGRATE: A Comprehensive and Systematic Meta-analysis Study of Brief Alcohol Interventions for Young Adults
    (2019-03-05) Li, Xiaoyin; Zhou, Zhengyang; Walters, Scott; Mun, Eun-Young
    Purpose: Project INTEGRATE is a large synthesis study of alcohol intervention trials, which has been supported by the National Institute on Alcohol Abuse and Alcoholism since 2010. This multi-site, interdisciplinary project involves experts from a wide range of disciplinary fields (e.g., psychology, sociology, public health, statistics) who come together to help promote public health. Currently, we are conducting a comprehensive meta-analysis to examine the comparative effectiveness of brief alcohol interventions (BAI) for adolescents and young adults (aged 11-25). Through a previous systematic review and data request, we have compiled aggregate data (AD) from 189 studies and individual participant data (IPD) from 24 studies. We are currently reviewing full-text articles from 2013 through 2018 to update AD and IPD. Methods/Results: To examine the efficacy and mechanisms of BAIs on alcohol outcomes, our work has extended network meta-analysis models and multivariate random-effects meta-analysis models. Using a multilevel Bayesian hurdle model, we demonstrated how IPD from heterogeneous clinical trials with abundant structural and empirical zeros can be modeled in one step analysis. To validly compare individuals across time and studies, we have developed scoring approaches to harmonize and advance item response theory (IRT) models using Markov chain Monte Carlo studies. The goal of our methodological work is to develop tools to provide better clarity for the field by maximizing available data that are most granular and comprehensive. Thus far, we found that an in-person brief motivational intervention (BMI) is efficacious for reducing alcohol-related problems, and the benefit is sustained through 12 months post-intervention. We also found that the implementation and content of intervention makes a difference. When BMIs were highly personalized to participants, it was more beneficial to have a higher number of intervention components; conversely, when interventions have more general content, it was better to cover fewer components. Conclusions: Project INTEGRATE is developing innovative approaches to synthesizing information that will provide more robust, large-scale evidence of what works well, for whom, and how. The model-based inference derived from this complex synthesis of all available data will provide more contextualized and mechanism-based answers to major stakeholders.
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    Does Alcohol Use Differ by Metropolitan Status in Females Ages 25-44?
    (2019-03-05) Dainty, PA-S, Mackenzie; Weise, PA-S, Lauren; Dempsey, PA-S, Bethany; Hartos, Jessica; Thompson, MSPAS, PA-C, Feroza; Story, PA-S, Sarah
    Purpose: Alcohol use can lead to serious health concerns and even death, but findings are inconsistent regarding whether risk differs by where people live. The purpose of this study was to determine whether alcohol use differs by metropolitan status in female adults ages 25-44. Methods: This cross-sectional analysis used data from the 2016 Behavioral Risk Factor Surveillance System (BRFSS) for females ages 25-44 in California (N=271), Colorado (N=428), Florida (N=1109), New York (N=1456), and Texas (N=482). Ordered logistic regression analysis was used with combined state data to assess the relationship between alcohol use and metropolitan status while controlling for demographic and health-related factors. Results: Across states, almost half of participants reported alcohol use (49-65%), about one-fifth reported excessive alcohol use (14-26%), few were smokers (8-20%) and about half reported mental health issues in the past 30 days (38-52%). Metropolitan status varied among urban (12-54%), suburban (24-51%), and rural (5-42%) residents. Adjusted results indicated that metropolitan status, current smoking, and mental health status were significantly related to alcohol use. Conclusion: Overall, alcohol use differed by metropolitan status in female adults ages 25-44, with urban women reporting drinking more than their rural counterparts. In a primary care setting, providers may expect half of young adult females to drink alcohol, half to have mental health issues, and few to be smokers. Providers need to be aware that current smokers and those with mental health issues are more likely to report alcohol use. Because alcohol use is related to metropolitan status, providers should screen for alcohol use in every woman aged 25-44, and especially those from urban areas. They should also include screening for smoking and mental health status when any of these factors are present, and provide education and referrals to substance abuse programs and mental health counseling as necessary.
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    The Association Between Human Papillomavirus Vaccination and State Medicaid Expansion
    (2019-03-05) Al-Nahi, Ali; Certeza, Justinne; Fernandez, Jazmin; Hoffman, Katherine; Thompson, Erika; Hoff, Brandon
    Purpose: The human papillomavirus (HPV) vaccine is recommended for US adolescents 11-12 years of age. The HPV vaccine is currently covered for children enrolled in Medicaid through age 20. After the passage the Affordable Care Act in 2010, states were given the option to expand Medicaid eligibility to 138% of the federal poverty level, yet as of December 2017, only 36 states have elected to expand their Medicaid program. This study examines the association between Medicaid expansion and HPV vaccination among US adolescents. Methods: This cross-sectional study was conducted using data from the National Immunization Survey – Teen, 2017 (N=20,949). Logistic regression was used to model provider-reported HPV vaccination up-to-date status predicted by state Medicaid expansion while adjusting for the effects of sex, race/ethnicity, maternal education level, household income, and type of health insurance. All analyses were conducted using SAS Studio 3.7 Enterprise Edition with survey weighting procedures. Results: 52% of adolescents in this study were up-to-date on the HPV vaccine. Adolescents who lived in states that expanded Medicaid [OR = 1.51, (95% CI: 1.36, 1.68)] were more likely to be up-to-date on the HPV vaccine than adolescents who lived in states that did not expand Medicaid. Females [OR = 1.50, (95% CI: 1.35, 1.66)], Non-Hispanic Blacks [OR = 1.23, [95% CI: 1.09, 1.54)], and Hispanics [OR = 1.67, (95% CI: 1.42, 1.96)] were more likely than to be up-to-date on the HPV vaccine than males and Non-Hispanic Whites, respectively. Individuals who were enrolled in Medicaid [OR = 1.19, (95% CI: 1.02, 1.39)] were more likely to be up-to-date than those with private insurance. Conclusion: The results of this study indicate a positive association between Medicaid expansion and HPV vaccination. However, Medicaid expansion is only one of many health policy initiatives that can affect HPV vaccination. Recent research has suggested that state-level policies (e.g., school-entry requirements, policies permitting vaccination in pharmacies, classroom sex education policies, and parental education mandates) are significantly associated with uptake of the HPV vaccine in adolescents. Further research should be conducted to analyze the combinatorial effects of multiple health policies on HPV vaccination.
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    Factors Associated with Electronic Cigarette Use in a Population-Based Sample in the US.
    (2019-03-05) Garg, Ashvita; Wan, Bingchun; Nandy, Ph.D., Karabi; Peeri, Noah
    Factors Associated with Electronic Cigarette Use in a Population-Based Sample in the US. Noah C. Peeri1 Ashvita Garg1 Bingchun Wan1 Karabi Nandy1 1University of North Texas Health Science Center, School of Public Health, Department of Biostatistics and Epidemiology, Ft. Worth, TX Purpose Electronic cigarettes (e-cigarettes) are lithium-ion battery powered devices that deliver nicotine vapor by heating a coil immersed in a solution of nicotine, propylene glycol, or some other humectant, delivering nicotine and flavor to the users’ lungs. They are often marketed as devices for cessation of traditional cigarette smoking. However, they are not considered an entirely safe option because they contain nicotine, lead, volatile organic compounds, and known carcinogenic agents. This work examined the prevalence and patterns of electronic cigarette use in a recent population-based sample of the US. Methods Utilizing data from the 2017 Behavioral Risk Factor Surveillance Survey (BRFSS), 529,714 participants aged 18 and older were included in the analysis. E-cigarette user status was defined as current, former and never. Weighted multinomial logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Results Prevalence of current, former and never users of e-cigarette were 3.2%, 12.3% and 84.5%, respectively. Females had higher odds of being current e-cigarette users, compared to being former (OR: 1.17; 95% CI: 1.06,1.30) and never users (OR:1.52; 95% CI:1.38,1.67). Older age was associated with higher odds of current use, with a significantly increasing trend with age (ptrend Conclusions Utilizing data from a cross sectional nationally representative sample of the united states, we identified factors associated with current, former and never users of e-cigarette. This information could inform intervention strategies for groups at highest risk of e-cigarette use.
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    Number of interventions identified in the initial comprehensive medical review for HIV patients and its association to patient complexity
    (2019-03-05) Suzuki, Sumihiro; Clay, Patrick; Adams, Ann
    Background: Over the past decades, there has been a marked decrease in HIV infection and morbidity rates, which has resulted in a growing and aging population of people living with HIV (PLWH) worldwide. In comparison to the general population, PLWH experience an increased risk of age-related morbidity. Among these, hypertension, hyperlipidemia, and endocrine disease (including diabetes) have been identified as the three most common comorbidities for this population, not including HIV. Furthermore, previous projections have indicated that the growth of the workforce providing HIV care is not enough to meet the needs of the growing PLWH population. To address the concerns associated with the care of this population, the patient-centered HIV care model designed to enhance medication therapy management (MTM) services provided by community-based pharmacists through partnerships with medical providers, has been suggested as a possible effective strategy. MTM are pharmacist-driven interventions (action plans) that aim to resolve medication-related issues. First, a systematic review of the patient’s entire medication regimen is conducted. After the review, the pharmacist will compile a medical action plan that consists of recommended actions for the patient, his/her care provider(s), or the pharmacist themselves to resolve the issues identified in the medication review process. Previous studies have noted the benefits of MTM for both HIV and certain chronic conditions. Despite this, there appear to be barriers to implementing these services on a regular basis. Surveyed pharmacists often cite lack of time as their top barrier to integrating MTM services within their practices and carrying out the actions plans identified. A few published studies have documented the amount of time that is allocated to providing MTM services, but no study has investigated the amount of time necessary to provide MTM to PLWH, a subpopulation whose needs are unique and complex. As most pharmacies have established industry standards for the time it takes for each intervention, a crucial first step for the regular adaptation of MTM services for PLWH is to quantify the number of interventions that they require to determine the time that would be required to care for these patients. Purpose: The purpose of this research is to determine the relationship between the three most common comorbidities for PLWH (i.e., hypertension, hyperlipidemia, and diabetes) and the number of interventions (as a proxy for time) identified on the comprehensive medication review at the baseline of a patient-centered HIV care model study. Methods: Data for this project were obtained from a patient-centered HIV care model study which was built as a part of a collaboration project between the CDC, Walgreens, and UNTHSC. Patients were recruited into the study across 10 different sites across 8 different states. Regression analysis was conducted for the analysis. Results and Conclusions: The analyses are still being conducted. We expect to find that there is an association between the complexity of the patient, i.e., more comorbidities, and the number of interventions. Such findings will help practitioners determine the amount of time that should be allocated for PLWH.
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    Adolescent Health Data: Feelings of Depression and Marijuana Use
    (2019-03-05) Thompson, Erika; Davis, Ambriale
    Adolescent Health Data: Feelings of Depression and Marijuana Use Objective The purpose of this study is to examine an association between feelings of depression and marijuana use amongst high school students in the United States. Methods Data were analyzed based on the Youth Risk Behavior Surveillance System (YRBS), 2017. SAS 9.4 was used to apply survey weighting procedures to the bivariate and logistic regression models as well as to calculate univariate and bivariate descriptive statistics, and crude and adjusted odds ratios for the outcome, exposure, and covariates (n=13,916). Outcome was measured as “During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities” and operationalized by yes/no. Exposure was measured by ““during your life, how many times have you used marijuana” and operationalized as no if zero and yes if any other number. Results Students who had feelings of depression were more likely to have ever used marijuana (49.1%) than those who did not have feelings of depression (29.4%). Also, females were more likely to have experienced feelings of depression when compared to males, 67.2% and 32.8% respectively. High school students who ever tried marijuana had 2.46(95% CI:2.15-2.82) times the odds of feeling depressed compared to those who had never tried marijuana. Female students had 2.73(95% CI:2.37-3.13) times the odds of feeling depressed compared to male students. Black or African American, 0.83(95% CI:0.69-0.99), and 15 year old, 0.78(95% CI:0.64-0.96), students had less odds than whites and those 17 years and older respectively. Conclusions This study revealed that students who had feelings of depression were more likely to have ever used marijuana compared to students that did not. Race and age were protective factors for depression. Female students had almost three times the odds of feeling depressed than males. Results can inform future research surrounding attitudes of marijuana use among high school students with feelings of depression in order to prevent or delay marijuana use in this population.
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    Relationship Between Sexual Dating Violence and Feeling Sad or Hopeless Among High School Students
    (2019-03-05) Thompson, Erika PhD, MPH, CPH; Edochie, Chinelo MPH Candidate, CPH
    Purpose: Sexual dating violence among high school students is estimated to be on the rise. Effects of sexual dating violence in teenage years can carry on to adulthood and result in depression and suicidality, but there is a need to examine both conditions during adolescence. The purpose of the study was to assess the relationship between sexual dating violence and feeling sad or hopeless among 9th-12th graders in the U.S. Methods: The Youth Risk Behavior Survey (YRBS) 2017 is a nationally representative survey of 9-12th graders in the US (N=14,765). The analytic sample size for this study was limited to a complete case analysis (N=8,244). The outcome variable was feeling sad or hopeless in the past 12 months (yes/no). The exposure variable was experience of sexual dating violence in the last 12 months (yes/no). A survey-weighted adjusted logistic regression model estimated the association of sexual dating violence with feeling sad or hopeless while controlling for covariates (age, sex, race/ethnicity and binge drinking), using SAS 9.4. Results: In the sample, 18% reported feeling sad or hopeless and 4% experienced sexual dating violence. Students who experienced sexual dating violence were significantly more likely to feel sad or hopeless while controlling for age, sex, race and binge drinking (OR=4.58, 95% CI 3.63, 5.80). Additionally, females were nearly three times more likely to feel sad or depressed compared to the males (OR=2.98, 95% CI 2.61, 3.41). Conclusions: The findings indicate that there may be an association between sexual dating violence and feeling sad or hopeless when controlling for gender, binge drinking and race among adolescents. Promoting safe, healthy relationships through social-emotional programs for high-schoolers may also promote positive mental health. Next steps would be to examine the association using a longitudinal study design among adolescents.
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    A Bigger View: US public TB prevention initiatives with a broader health systems perspective
    (2019-03-05) Miller, Thaddeus; Grebennikov, Sarah; Stockbridge, Erica L.; Hussain, Anusha
    Background: Tuberculosis (TB) is a complex disease and persists as a greater threat than most understand. Responsibility for TB treatment and control has generally fallen to public health agencies. Unfortunately, important limitations to the public health sector’s of TB control are beginning to show. UNTHSC recently hosted a “systems thinking symposium” with the goal of helping public health authorities view their work in broader context. This project presents an analysis of industry perspectives on public TB control initiatives drawn from symposium discussions. Purpose: We analyzed 36 hours of discussions to better understand how CDC’s messaging around TB prevention and managing latent TB infection (LTBI) in particular is heard, accepted, and potentially acted on in various health care sectors. Methods: Approximately 30 participants from across the US healthcare system discussed how incentives and disincentives within their industry might affect TB-related public health initiatives. Discussion sessions focused on how at-risk patients self-identify and seek care; how providers identify potentially at-risk patients; how clinical evaluation is initiated and conducted; treatment initiation; and treatment completion. We analyzed discussion transcripts to identify industry perspectives, opportunities and barriers, and potential gaps in TB control initiatives. The unit of study was the program or industry represented by responses, not individual respondents, and the North Texas Regional IRB determined the project not to be human subjects research. Results: We identified the 15 most commonly used context appropriate words from a 78,604 word transcript. These were mapped to broad themes such as improving screening target populations, continuity of care, and potential roles of the non-public health sector. Notable barriers were identified within the clinical and managed care sectors, including consistent questioning of TB prevention as a priority activity, including potential risks, benefits, and the value proposition. Conclusions: CDC’s promotion of targeted LTBI screening and treatment, and TB prevention in general, is not well reflected in the attitudes of the non-public healthcare sector in our sample. Most health care professionals would choose not to prioritize LTBI due to the logistics of insurance and more urgent and emergent diseases. It may be important for CDC to consider who and how they target TB elimination messaging in order to enhance impact.
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    Developing Tuberculosis Prevention Strategies via Interdisciplinary Systems-Thinking: Latent Tuberculosis Infection Risk Recognition and Care
    (2019-03-11) Chhetri, Shlesma; Dhakal, Eleena; Stockbridge, Erica L.; Miller, Thaddeus; Jose, Roslin
    Background: Tuberculosis (TB) remains a threat to public health, both globally and within the US. An estimated 80% of active TB cases in the US are from reactivation of latent TB infection (LTBI). Reactivation is preventable with proactive, targeted LTBI screening and treatment but public health agencies lack the capacity to mitigate this threat. Recent guidelines recommend that LTBI-related services be rendered by private sector healthcare providers. In order to identify systemic barriers to appropriate LTBI-related care in the private sector and brainstorm new strategies to facilitate this care, UNTHSC hosted an LTBI Systems Thinking Symposium. Aims: 1) To identify barriers and facilitating factors that influence patient and provider recognition of LTBI risk and subsequent care-seeking or care-recommending behavior, as articulated by symposium participants. 2) To determine whether the factors identified by attendees varied by attendee profession. Methods: Thirty healthcare and public health professionals were divided into 6 interdisciplinary groups. Participants identified barriers to care and opportunities to facilitate care by discussing each step in the LTBI care continuum. We used Grounded Theory approach to code participants’ distinct ideas. Each open code was systematically categorized into axial codes by two independent coders. A third coder calculated inter-coder reliability; the two coders agreed 80% of the time. Coders collaborated on the remaining 20% to create a final list of axial codes, which were further categorized into selective themes. Results: Barriers (78%) to targeted LTBI screening and treatment were mentioned more frequently than strategies to facilitate care (22%). The top three barriers were lack of awareness among patients, lack of ideal testing tools, and lack of health insurance among high-risk persons. Facilitators included increasing patient awareness, health insurance that covers LTBI services, community outreach, and population-level health communication. Variations in perceived barriers and facilitating factors based on the industries our participants represented were observed. Conclusion: Both patient and health systems-related factors present barriers to the initial identification of LTBI in the private sector healthcare setting, but there are opportunities to overcome these barriers. The facilitating factors identified by symposium participants can serve as beacons for prevention strategies and future health policies.
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    Association between Cyber-Bullying and Weapons Carrying at School: Analysis of the 2017 Youth Risk Behavior Survey
    (2019-03-05) Thompson, Erika; Morris, Kimberly
    Objective: Previous research has found that victims of bullying are more likely to carry a weapon and say that it is “not wrong” to take a gun to school. Moreover, studies have shown that cyberbullying and traditional bullying are highly correlated. With the rate of online harassment nearly doubling from 2000 to 2010 further research is needed to study the link between cyberbullying and weapons carrying. The objective of this study was to examine the association between cyberbullying and weapons carrying at school among adolescents participating in the 2017 Youth Risk Behavior Survey (YRBS). Methods: The YRBS 2017 is a representative dataset for 9th through 12th graders in both public and private schools in the United States (N = 14,765). The analytic sample was restricted to a complete case analysis for the variables of interest (N = 13,944). The outcome variable was weapon carrying on campus (yes/no). Predictor variables included: cyberbullying, sex, grade, race/ethnicity, and bullying. A survey-weighted adjusted logistic regression model was estimated for the association between cyberbullying and weapons carrying using SAS 9.4. Results: 14.84% of students surveyed reported experiencing cyberbullying and 3.51% reported ever carrying a weapon on school ground. Students reporting weapons carrying were 74.7% male, 32.8% 11th graders, and 56.0% white; 27.7% reported experience bullying, and 22.2% cyberbullying. In the multivariable model predicting the outcome of weapon carrying on school grounds, exposure to cyberbullying, (Adjusted Odds Ratio (AOR) = 1.70, 95% CI: 1.27, 2.29), being a male student (AOR = 3.60, 95% CI: 2.91, 4.44), being in 11th(AOR = 2.29, 95% CI: 1.64, 3.19) or 12th(AOR = 1.97, 95% CI: 1.27, 2.64) grade and being bullied on school grounds (AOR = 1.56, 95% CI:1.21, 2.00) were significantly associated. Conclusions: Although a statistically significant correlation between cyberbullying and carrying a weapon on school grounds was found, results should be interpreted with caution due to the temporality of the data, and correlation between bullying and carrying a weapon on school grounds. Regardless, the results show that additional research is needed to investigate the affect cyberbullying has on eventual weapons carrying to ensure schools remain safe in the modern era.
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    Dissemination and Implementation of School-Based Asthma Initiatives: The Asthma 411 Pilot
    (2019-03-05) Aryal, Subhash; Sterling, David; Spence-Almaguer, Emily; Allsopp, Leslie C.
    Purpose: The dissemination and implementation (D&I) of evidence based practices (EBIs) has been identified as one of the most critical barriers to improvement of the public’s health. The Asthma 411 EBI was developed, implemented and evaluated in St. Louis, MO from 2002-2008; Asthma 411 was disseminated, adapted, and piloted in Fort Worth, TX from 2013-2015. The evaluation of the pilot was designed to examine processes and outcomes of the program’s dissemination, inform ongoing expansion, and identify approaches that may support dissemination of other school health EBIs. Methods: In 2013, an engaged process was used to retain core components of Asthma 411 while adapting peripheral program elements. The pilot was implemented in one elementary (n=567) and 1 middle school (n=791). Three service categories were included: 1) access to rescue medication through standing orders; 2) support for enhanced school asthma services; and 3) support for communication with parents and health care providers to support comprehensive, prevention oriented care. Data collected included 1) school day EMS calls one year prior and both years of the program, 2) logs of aggregated nursing services, 3) individual level school absence and demographic data, 4) availability of medication provided through existing policies, and 5) informal interviews. Results: The pilot was positively received by schools and parents. During the pre-implementation year, there were 19 asthma-related EMS calls from the pilot schools. During the two years of the pilot, school day, asthma-related EMS calls were eliminated. Across the two year study, there was an increase in documented asthma self-management education, use of Asthma Control Tests, proportion of students with asthma that have authorization for rescue medication, and documented efforts to communicate with parents and health providers. Evaluation of absences was limited by the lack of pre-implementation data, small numbers, large variance, and short duration. Between year 1 and year 2, the gap between unadjusted, weighted absences among students with and without asthma was reduced 1.1 day. However, this difference was not seen in a fully adjusted negative, binomial regression analysis which provided a modeled mean difference of 1.28 absence days between children with and without asthma (95%CI 1.10, 1.50, p = .002) during year one, and 1.24 days (95% CI 1.07, 1.47, p = .006) in year two. Conclusions: The Asthma 411 case study identifies important characteristics of interventions, interventionists, contextual factors, and processes that may support effective dissemination of school based health initiatives. More research is needed to clarify impacts on absenteeism, and to determine if observed benefits are sustained.
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    Does Mental Health Differ by Obesity in Younger, Middle Aged, and Older Females?
    (2019-03-05) Torre, Jacob; Zeitz, Erica; Fuller, Aleksandra; Hartos, Jessica; Shropshire, Michelle
    Purpose: Although the relationship between mental health and obesity has been well studied, it has not been researched by age groups. The purpose of this study is to examine the relations between mental health and obesity among younger, middle aged, and older adult female age categories in the general population. Methods: The cross-sectional analysis used 2016 data from the Behavioral Risk Factor Surveillance System (BRFSS) for females from Arkansas, Louisiana, Mississippi, and Tennessee. Multiple logistic regression was used by state to assess the relationship between obesity and mental health in females of different age groups while controlling for race, education level, income level, employment status, marital status, general health, health conditions, tobacco use, alcohol use, and physical activity. Results: The majority of participants in all age groups reported good mental health (younger: 49-56%; middle aged: 57-59%, older: 71-82%), and less than half of participants across age groups were obese (younger: 29-41%; middle aged: 38-49%; older: 27-35%). In the adjusted analyses, mental health did not differ by weight status across states and age groups. However, a moderate inverse relationship was found between good mental health and number of health conditions across all age groups. Conclusion: The results of this study indicate that obesity is not related to mental health in females in different age groups in the general population, but is moderately to highly related to number of health conditions. For female patients in a primary care setting, it is recommended to screen for mental health when 2 or more health conditions are present, regardless of the patient’s age, and educate and treat as comorbid symptoms.
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    Application of an Interprofessional Team in Pediatric Nutritional Wellness
    (2019-03-05) Baker, Bryan; Farmer, David; Rew, Martha; Habiba, Nusrath; Muqueet, Sameera
    Purpose: Childhood obesity poses a significant health risk to children in the United States and has been increasing in recent years. Childhood obesity is associated with increased risk of hyperlipidemia, diabetes, and hypertension manifesting later in life. Early intervention is crucial in preventing these health problems. Therefore, it is important that parents receive early education on nutritional wellness as well as the most accurate information possible. A team-based application of health care delivery is one possible way of achieving this patient education. This study aims to evaluate patient satisfaction with the use of an interprofessional healthcare team in delivering nutritional wellness information to parents in an outpatient pediatric clinic. Methods: Patients were seen by a three member interprofessional team consisting of a Physician or Physician Assistant (PA), medical student or PA student, and dietetic intern. At the end of the visit, patients were given a survey to assess their satisfaction with the visit. The survey evaluated patient satisfaction with the interprofessional team with, how helpful and how likely they were to use the nutritional advice given to them during the visit, and their perception on whether the interprofessional team improved the quality of their visit. Patients were asked to rank these factors on a scale of 1-5 with 1 being unsatisfied and a 5 being highly satisfied. Results: Out of 95 patients, 96.8% rated their happiness with the interprofessional team as a 5/5; 95.7% rated the helpfulness of the nutritional advice 5/5; 94.7% rated their likelihood of utilizing the nutritional advice 5/5; 94.7% rated the improvement in the quality of their visit 5/5. Conclusions: Overall, patients were satisfied with the nutritional information they received from the interprofessional team and viewed being seen by a team as an improvement in the quality of their visit. Utilizing an interprofessional team has the potential to be an efficacious method of delivery of nutritional information to patients and improve wellness and prevention. In future studies, the likelihood of patients to implement this nutritional advice will be tracked via EMR and compared to groups that were not seen by an interprofessional team in order to assess the efficacy of team-based healthcare.
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    Retrospective Analysis of Unintentional Firearm Injuries Presenting to CCMC
    (2019-03-05) Guzman, Daniel; Hamby, Tyler; Reyes, Kristy; Kunkel, Claire
    Background: An estimated 110 children die each year in the US due to unintentional firearm accidents. Studies show that current educational strategies are ineffective long-term and have called for more research towards improving children’s safety. Purpose: The purpose of this study was to determine trends among victims of unintentional firearm injuries to identify potential risk factors. Methods: This was a retrospective chart review of Cook Children’s Medical Center (CCMC) electronic medical records. Patients ages 0-18 years presenting with unintentional gunshot injuries to the CCMC Emergency Department between January 1, 2011 and June 27, 2018 were included. We excluded injuries deemed to be intentional and patients over age 18. Data were stored in REDCap. Results: There were 140 patients who met inclusion criteria, and 30 of these were excluded (25 for intentional shooting, 2 for being over age 18, and 3 for intentional shooting in patients over age 18). Of the remaining 110 (84.5% male) patients, percentages by type of gun were as follows: BB gun, 50.0%; handgun, 20.0%; pellet gun, 13.7%; other, 16.3%. We also collected data on who pulled the trigger, which was by a friend in 34.7% of cases, a sibling in 26.9% of cases, and the patient in 24.0% of cases. Most injuries (73.8%) occurred at patient’s home, with the second most common location being a friend’s house (15.0%). Locations of injuries included 39.0% to the face, 35.0% to an extremity, and 11.0% to the abdomen. Only 50.0% of the patients were discharged home from the ED, while the other 50.0% were either admitted to CCMC or transferred for further care. Most injuries (60.9%) were considered minor, followed by moderate (23.6%) and serious or critical (15.5%). Conclusions: In the present study of unintentional gunshot injuries, most were considered to be minor or moderate, but almost half still needed a hospital admission. Most of the injuries occurred at the patients’ homes, so we suggest that many of these accidents could be prevented by proper gun storage when not in use and proper safety equipment when in use. Several other injuries also occurred at friends’ homes, and we suggest that many of these injuries could be avoided by encouraging parents to talk to other parents about guns in the home. The most common location for these injuries was the face, so we encourage wearing eye protection when using guns recreationally. Further research should be done to corroborate these possibilities.
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    Being Data Driven: Visualizing program data to aid stakeholder comprehension and decision-making in the TESSA project.
    (2019-03-05) Spence-Almaguer, Emily; Grace, Jessica; Chhetri, Shlesma; Prabhakar, Pushan
    Purpose: Programs within the community gather large volumes of raw data on their target populations. Representing these data to stakeholders in a presentable format and customized to suit their varying needs poses a challenge. Data visualization may help streamline complex datasets for audiences. The Technology Enhanced Screening and Supportive Assistance (TESSA) project serves primary care clinics and interpersonal violence agencies in Tarrant County with a tablet-based screening and health advocacy component. The objective of this project is to determine the effectiveness of data dashboards for stakeholder decision-making from clinics and agencies. Methods: Data obtained from the TESSA project were visualized into dashboards using the software Tableau. Two dashboards were created based on the sources from which they were obtained (Computerized Intervention Authoring Software [CIAS] and FileMakerPro). These dashboards were then presented to the respective stakeholders from seven organizations and/or health systems for iterative feedback and also to aid in decision-making (e.g., referral process, client needs). Results: The two dashboards started with a baseline of what the evaluation team deemed necessary at the onset. The FileMakerPro dashboard details the interpersonal violence agency data and the health advocate encounters. The FileMakerPro dashboard went through multiple iterations based on stakeholder feedback before culminating in the current version. The CIAS dashboard, which details the primary care clinic data, had to be modified with a password protected feature to allow clinics to have online accessibility. The CIAS dashboards are also customized according to the individual clinics. Conclusion: Data visualization in the form of dashboards have helped influence stakeholder decision-making in the TESSA project. These findings are evident from the multiple iterative processes and feedback received from the stakeholders regarding the respective dashboards. Data visualization serves as an essential tool in breaking down complex streams of data into more digestible formats for community collaborators.