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Pregnancy in women with sickle cell disease (SCD) is fraught with complications, some of which are life-threatening. Managing pregnancy in these women can be challenging, especially with poor resources, which is often the case in low-income countries. In Nigeria, for instance, up to 90% of patients pay out of pocket for medical care due to the poorly developed health insurance system, and this worsens the morbidity and mortality associated with this condition. We describe a pragmatic approach to routinely managing pregnant women with SCD in the antenatal period, showing the feasibility of effective management of these high-risk pregnancies in limited-resource settings. We also present the case of a pregnant Nigerian woman with SCD who has intrauterine growth restriction (IUGR) and acute chest syndrome (ACS), conditions that are life-threatening for the fetus and the mother, respectively, and require prompt intervention. We highlight how we successfully managed this woman in a cost-effective manner by employing relatively inexpensive tests for diagnosis and treating her effectively with oxygen, appropriate antibiotics and manual exchange blood transfusion for the ACS, and finger pulse oximeters to monitor oxygen saturation. We explore pathophysiological concepts to IUGR in women with SCD and briefly discuss the appropriate mode of delivery, including the options for pain relief in labor.

BackgroundHousehold food insecurity persists in the United States and has important implications for health and well-being. Food insecurity in female-identified caregivers is particularly concerning, given its association with their mental health and adverse health outcomes for their children. Food insecurity is associated with disordered eating but, to our knowledge, no prior studies have examined an association between food insecurity and food addiction.ObjectiveOur aim was to examine whether food insecurity is associated with higher food addiction symptom endorsement in low-income female adults.DesignSecondary analysis of baseline data from a quasi-experimental study of a mindfulness-based intervention on gestational weight gain among low-income pregnant individuals and an observational study of low-income families.Participants/settingParticipants in study 1 (n= 208) were English-speaking, low-income pregnant individuals with overweight or obesity, recruited in California from 2011 to 2013. Participants in study 2 (n= 181) were English-speaking, low-income female caregivers for children aged 8 through 10 years, recruited in Michigan from 2018 to 2019. Both studies recruited participants from community health clinics, social service agencies, and online advertisements.Main outcome measuresThe primary outcome measure was food addiction symptoms, assessed by the Yale Food Addiction Scale.Statistical analysisMultivariate Poisson regression was used to examine the association between household food insecurity and food addiction symptoms in each sample, adjusted for sociodemographic characteristics.ResultsIn study 1, pregnant individuals in food-insecure households reported 21% higher food addiction symptoms than pregnant individuals in food-secure households (incidence rate ratio 1.21; 95% CI 1.00 to 1.47; P= .047). In study 2, caregivers in food-insecure households had 56% higher food addiction symptoms than caregivers in food-secure households (incidence rate ratio 1.56; 95% CI 1.01 to 2.40; P= .045).ConclusionsThese findings provide preliminary support for a relationship between household food insecurity and food addiction. Future research should examine potential mechanisms and whether interventions to reduce food insecurity lower risk of food addiction.

Distinguishing profiles of trauma exposure among low-income adolescent females with depressive symptoms is important for understanding comorbidity, family relationships, and treatment. Specifically, child maltreatment is essential to examine in comparison to other traumas. Participants included 170 adolescent females (65.3% Black; 21.2% White; 13.5% other race; 14.1% Latina/x) with depressive symptoms and their primary caregiver from low-income families. Latent class analysis (LCA) identified three trauma classes. Probabilities of endorsing different subtypes of maltreatment (physical abuse, physical neglect, emotional abuse, emotional neglect, and sexual abuse), number of subtypes of maltreatment, and non-maltreatment traumas (accident, experiencing or witnessing physical assault, death or injury of loved one, medical trauma) varied among groups. Higher levels of family dysfunction and traumatic stress symptoms were reported in both classes with maltreatment exposure as compared to the class with only non-maltreatment trauma exposure. Findings have implications for family-focused interventions for maltreated adolescent females with depressive symptoms from low-income contexts.

BACKGROUND: Low-income and middle-income countries (LMICs) face a double burden of malnutrition (DBM), whereby overnutrition and undernutrition coexist within the same individual, household, or population. This analysis investigates global inequalities in household-level DBM, expressed as a stunted child with an overweight mother, and its association with economic, social, and political globalisation across country income and household wealth. METHODS: We pooled anthropometric and demographic data for 1 132 069 children (aged

Background: Parent mentors are a potential community-based mechanism for delivering behavioral interventions. For communities at a higher risk of obesity and challenges with access to care, such as migrant and seasonal farm workers, this may be an effective intervention for obesity. This study examined the effect of parent mentors on weight outcomes. Methods: This randomized clinical trial assigned parents of 2- to 5 year-old children enrolled in Head Start 1:1:1 to control, a parent mentor teaching We Can!, or a parent mentor teaching an intervention derived from positive deviance methods. The parent mentor arms were designed to have weekly interactions and monthly community meetings over 6 months. The primary outcome was change in adiposity, as measured by body mass indices. Results: We randomized 188 parents, and 155 completed the 6-month visit. Most parents, 107 (58%), had less than a high school education, and 170 (90%) reported Latino ethnicity. In the intention-to-treat analysis, no difference between the groups was observed for change in percent distance from the median or BMI z-score. The median number of interactions was 14 (IQR 10-20) over 6 months for those who did engage, though 24 of 118 (20%) had no interaction. Those with no interactions in We Can! had a mean increase in change from median of 6.7 [standard deviation (SD) = 8.2]; those with higher participation experienced a 0.4 (SD = 9.2) change, p = 0.04. Conclusions: Parent mentors were not effective in changing the adiposity indices in this study overall, with some evidence of efficacy after accounting for participation. Clinicaltrials.gov registration number: NCT03330743.

This study examined characteristics and planned expenses of U.S. adults who received the economic impact payment (EIP) during the COVID-19 pandemic.Using a nationally representative sample of 6,607 middle- and low-income U.S. adults, the authors examined the proportion and correlates of EIP receipt among eligible adults and the associations among planned EIP-financed expenses, challenges with paying expenses, and clinical characteristics.Of the sample, 78.8% reported that they received the EIP, and 82.3% of EIP recipients reported that it had a positive impact on their life. Being a veteran (odds ratio [OR]=2.59), being married (OR=1.82), having a history of schizophrenia spectrum disorder (OR=1.74) or posttraumatic stress disorder (OR=1.51), and screening negative for recent suicidal ideation (OR=0.49) were associated with EIP receipt. Planned expenses with the EIP were savings, paying debt, and rent and accounted for 63.4% of the total amount. Screening positive for mental health or drug use problems was positively associated with greater planned expenses for substances and gambling. EIP receipt also was associated with fewer problems paying daily expenses, but participants who screened positive for mental health or alcohol use problems were more likely to report problems paying past-month daily expenses.Unconditional cash transfers such as the EIP may be important for sustaining the living situation of middle- and low-income populations. The management of funds is important to consider, especially among adults experiencing mental health and substance abuse problems, and such cash transfers may represent opportunities for financial literacy and money management interventions.

This article summarizes findings from the literature on the emotional and birth outcomes of women with low income receiving different types of prenatal care. This literature review included studies published between 2015 and 2020. The results indicated that women with low income have challenging experiences in traditional models of prenatal care. Evidence of improved birth outcomes with nontraditional prenatal care is mixed, but qualitative findings indicate that it is associated with better emotional outcomes for women with low income when compared to traditional prenatal care. Future research should investigate ways to improve the negative interpersonal and structural dimensions that can characterize prenatal care for women with low income.

BACKGROUND. The objective of this study is to understand the effect of Medicaid expansion under the Affordable Care Act (ACA) on patterns of surgical care among low-income breast cancer patients. Emerging literature suggests cancer patients in Medicaid expansion states are presenting with earlier stages of disease. However, less is known regarding the implications of Medicaid expansion on patterns of surgical care in low-income women. PATIENTS AND METHODS. We compared nonmetastatic 30–64-year-old uninsured or Medicaid-insured Ohio breast cancer patients diagnosed 4 years before and 4 years after the state’s 2014 Medicaid expansion (study group); the control group was the privately insured. Time-to-surgery (TTS) was defined as days from diagnosis to surgery. Demographic and treatment variables before and after expansion were examined in multivariate analysis. RESULTS. There was a 10.4% point increase in breast conservation therapy (BCT) in the study group (pre-ACA 26.3%, post-ACA 36.7%; p < 0.01) compared with a 5.8% point increase in the control group (pre-ACA 36.0%, post-ACA 41.8%; p < 0.01). Disparities in reconstruction narrowed between the study (pre-ACA 21.4%, post-ACA 34.5%; p < 0.01) and the control (37.0% pre-ACA, 44.1% post-ACA group p < 0.01) groups. There was no statistically significant change in mean TTS in the study group (pre-ACA 42.1 days, post-ACA 43.1 days p = 0.18) but there was an increase in TTS in the control group (pre-ACA 35.0 days, post ACA 37.0 days; p < 0.01). CONCLUSIONS. Medicaid expansion appears to have narrowed disparities in the utilization of BCT and reconstruction in low-income women. However, there was no improvement in surgical delay.

Purpose We compared the Risk subtest of the Diagnostic Evaluation of Language Variation–Screening Test (DELV–Screening Test Risk) with two other screeners when administered to low-income prekindergartners (pre-K) who spoke African American English (AAE) in the urban South. Method Participants were 73 children (six with a communication disorder and 67 without) enrolled in Head Start or a publicly funded pre-K in an urban Southern city. All children completed the DELV–Screening Test Risk, the Fluharty Preschool Speech and Language Screening Test–Second Edition (FLUHARTY-2), and the Washington and Craig Language Screener (WCLS). Test order was counterbalanced across participants. Results DELV–Screening Test Risk error scores were higher than those reported for its standardization sample, and scores on the other screeners were lower than their respective standardization/testing samples. The 52% fail rate of the DELV–Screening Test Risk did not differ significantly from the 48% rate of the WCLS. Fail rates of the FLUHARTY-2 ranged from 34% to 75%, depending on the quotient considered and whether scoring was modified for dialect. Although items and subtests assumed to measure similar constructs were correlated to each other, the three screeners led to inconsistent pass/fail outcomes for 44% of the children. Conclusions Like other screeners, the DELV–Screening Test Risk subtest may lead to high fail rates for low-income pre-K children who speak AAE in the urban South. Inconsistent outcomes across screeners underscore the critical need for more study and development of screeners within the field.

Summary Background Childhood immunisation is one of the most cost-effective health interventions. However, despite its known value, global access to vaccines remains far from complete. Although supply-side constraints lead to inadequate vaccine coverage in many health systems, there is no comprehensive analysis of the funding for immunisation. We aimed to fill this gap by generating estimates of funding for immunisation disaggregated by the source of funding and the type of activities in order to highlight the funding landscape for immunisation and inform policy making. Methods For this financial modelling study, we estimated annual spending on immunisations for 135 low-income and middle-income countries (as determined by the World Bank) from 2000 to 2017, with a focus on government, donor, and out-of-pocket spending, and disaggregated spending for vaccines and delivery costs, and routine schedules and supplementary campaigns. To generate these estimates, we extracted data from National Health Accounts, the WHO–UNICEF Joint Reporting Forms, comprehensive multi-year plans, databases from Gavi, the Vaccine Alliance, and the Institute for Health Metrics and Evaluation's 2019 development assistance for health database. We estimated total spending on immunisation by aggregating the government, donor, prepaid private, and household spending estimates. Findings Between 2000 and 2017, funding for immunisation totalled US$112·4 billion (95% uncertainty interval 108·5–118·5). Aggregated across all low-income and middle-income countries, government spending consistently remained the largest source of funding, providing between 60·0% (57·7–61·9) and 79·3% (73·8–81·4) of total immunisation spending each year (corresponding to between $2·5 billion [2·3–2·8] and $6·4 billion [6·0–7·0] each year). Across income groups, immunisation spending per surviving infant was similar in low-income and lower-middle-income countries and territories, with average spending of $40 (38–42) in low-income countries and $42 (39–46) in lower-middle-income countries, in 2017. In low-income countries and territories, development assistance made up the largest share of total immunisation spending (69·4% [64·6–72·0]; $630·2 million) in 2017. Across the 135 countries, we observed higher vaccine coverage and increased government spending on immunisation over time, although in some countries, predominantly in Latin America and the Caribbean and in sub-Saharan Africa, vaccine coverage decreased over time, while spending increased. Interpretation These estimates highlight the progress over the past two decades in increasing spending on immunisation. However, many challenges still remain and will require dedication and commitment to ensure that the progress made in the previous decade is sustained and advanced in the next decade for the Immunization Agenda 2030. Funding Bill & Melinda Gates Foundation.

PURPOSE Children in low-income, urban areas are at a greater risk of poor physical activity (PA) and academic outcomes. The purpose of this study was to examine feasibility, acceptability, and engagement of a pilot implementation of the Active Science (AS) exer-learning program in 3rd grade physical education (PE) classes to inform potential upscaling after efficacy evaluation. METHODS AS was implemented within PE at five public schools serving low-income, urban neighborhoods, using a phased implementation approach. A mixed methods approach was utilized; feasibility and engagement were measured using quantitative dose and fidelity measures, students were surveyed regarding acceptability, and PE teachers were interviewed pre/post-intervention regarding perceptions of the program. RESULTS N = 638 students in k = 25 PE classes across five schools averaged 8.8 weeks of AS implementation with nearly universal inclusivity. Students averaged 1468 steps/session; an average of 15% of available PE class time was spent in MVPA. Semi-structured interviews revealed high staff perceptions of feasibility, as well as specific improvements that should be implemented before upscaling. CONCLUSIONS Process and PA measures indicate high feasibility, with excellent engagement across all five schools. Together with high acceptability reported by students and staff, these results show that AS can feasibly integrate into PE classes low-income, urban schools to improve student engagement in both PA and science learning.

Objectives: This study sought to: 1) under­stand how the perceived food environment (availability, accessibility, and affordability) is associated with cardiometabolic health outcomes in predominately low-income Black residents in urban neighborhoods with limited healthy food access; and 2) examine the association of shopping at specific store types with cardiometabolic health outcomes. Methods: We report on cross-sectional data from 459 individuals participating in the Pittsburgh, PA Hill/Homewood Research on Neighborhoods and Health (PHRESH) study. Mean participant age was 60.7 (SD=13.9); 81.7% were female. We used logistic regression to examine associations between three factors (perceived fruit and vegetable availability, quality, and price; primary food shopping store characteristics; and frequency of shopping at stores with low or high access to healthy foods) and cardiometabolic and self-rated health. Results: Adjusting for sociodemographic characteristics, participants with higher perceived fruit and vegetable accessibility (AOR:.47, 95%CI: .28-.79, P=.004) and affordability (AOR:.59, 95%CI: .36-.96, P=.034) had lower odds of high blood pres­sure. Shopping often (vs rarely) at stores with low access to healthy foods was associated with higher odds of high total cholesterol (AOR:3.52, 95%CI: 1.09-11.40, P=.035). Finally, primary food shopping at a discount grocery (vs full-service supermarket) was as­sociated with lower odds of overweight/obe­sity (AOR:.51, 95%CI: .26-.99, P=.049). Conclusions: These results suggest that both perceived accessibility and affordability of healthy foods are associated with reduced cardiometabolic risk factors in this urban, low-income predominantly Black population. Additionally, discount grocery stores may be particularly valuable by providing access and affordability of healthy foods in this population. Ethn Dis. 2021;31(4):537-546; doi:10.18865/ed.31.4.537

Web-based relationship programs are effective in improving low-income couples' relationship functioning. However, little is known about: (a) whether parenting couples presenting for relationship help also have difficulties in coparenting and parenting, (b) whether relationship-focused programs can improve these two domains, and (c) whether program effects differ across baseline levels of those domains. We examined these questions in a parenting subsample (Nindividuals = 934) and a coparenting subsample (Ndyads = 342) of low-income couples participating in a randomized controlled trial of two web-based relationship education programs-the OurRelationship (OR) program and the ePREP program. Although the majority of participants were relationally distressed at baseline, most coparents (83%) reported parenting well together. Parents "often" engaged in nurturing behaviors and "hardly ever" or "sometimes" felt overwhelmed by their parenting responsibilities. Among parents who had engaged in the harsh verbal discipline (59%) and physical discipline (28%) in the past month, the average frequency was 4.08 and 5.50 times per month, respectively. Moreover, compared to waitlist control parents, parents in OR but not ePREP reported significantly greater improvements in parental nurturance and harsh verbal discipline during the program. There was no evidence of program effects on coparenting, physical discipline, or parenting stress for OR or ePREP, nor was there any evidence of baseline functioning moderating program effects. Findings suggested that most low-income parents seeking relationship help did not have severe problems in coparenting or parenting and that effective relationship programs without a focus on coparenting and/or parenting had somewhat limited effects on these domains. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Sharing of sanitation is common in low-income settlements in Sub-Saharan Africa. However, shared (limited) sanitation facilities have been thought to pose health risks due to poor hygiene levels. Interventions to improve user behavior and cleanliness of shared sanitation are few, both in literature and in practice. This study details the codesign and testing of strategies to improve the cleanliness of shared sanitation facilities in low-income areas of Kisumu City in Kenya. The strategies included a cleaning plan, monitoring system, and discussions among users, and were codesigned through workshops with stakeholders and group discussions with landlords and tenants. These strategies were tested in 38 compound houses through the Trials of Improved Practices approach over a 5-month period. Field staff visited the compounds, observed the cleanliness of the shared toilets, and through discussions, encouraged users to develop a formal cleaning system and a monitoring plan. The discussions built social capital and collective action and facilitated uptake of the cleaning plan with notable improvements in cleanliness of shared toilets. The results support the acceptability of shared sanitation in low-income settlements, the importance of codesigning and coproducing solutions with users, and the need to evaluate the effects of these strategies on cleanliness of shared sanitation.

STUDY OBJECTIVES: Black individuals and individuals of low socioeconomic status are at increased risk for obstructive sleep apnea (OSA). The Berlin Questionnaire is one of the most widely used screening tools for OSA; however, there is limited research on its diagnostic accuracy in low-income Black populations. METHODS: This study analyzed data from an ongoing study taking place among a cohort from 2 predominantly Black neighborhoods in Pittsburgh, Pennsylvania (96.3% Black, 79.6% female). The sample included 269 individuals without a prior diagnosis of OSA who completed the Berlin Questionnaire and also participated in a home sleep apnea test. An apnea-hypopnea index ≥ 15 events/h was used to identify individuals with moderate or severe OSA. RESULTS: 19.3% of individuals met criteria for moderate to severe OSA based on home sleep apnea test, while 31.2% of participants screened as high risk for OSA based on the overall Berlin index. Using apnea-hypopnea index ≥ 15 events/h as the reference standard, the Berlin Questionnaire had a sensitivity of 46.2%, specificity of 72.4%, positive predictive value of 28.6%, and negative predictive value of 84.9% among this sample. Analyses stratified by sex suggested that the Berlin Questionnaire had better diagnostic validity in women than men. CONCLUSIONS: The Berlin Questionnaire has lower sensitivity and positive predictive value in our sample than those observed in general population samples. The measure performed better among women, though a higher proportion of men fell into the moderate or severe OSA range based on the home sleep apnea test. Given the significant downstream consequences of OSA, utilizing screening tools that better detect OSA in Black communities is key. CITATION: Holliday SB, Haas A, Dong L, et al. Examining the diagnostic validity of the Berlin Questionnaire in a low-income Black American sample. J Clin Sleep Med. 2021;17(10):1987–1994.

Background Exposure to chronic stressors may contribute to the development of psychoneurological symptoms (i.e., fatigue, cognitive dysfunction, sleep disturbance, depressed mood, and pain) that can compromise maternal function. Objectives In two studies of low-income mothers, we investigated the presence of psychoneurological symptoms and explored associations between mothers' stressors and psychoneurological symptoms as well as between symptoms and function. We also considered the possible mediating role of the symptoms between stressors and function. Methods We conducted secondary analyses of psychoneurological symptoms in two studies of low-income mothers of infants and toddlers in the United States. Study 1 sampled Latina women with limited English proficiency, while Study 2 was conducted with English-speaking women from diverse backgrounds. In both studies, symptoms were measured using items from the Center for Epidemiological Studies Depression Scale and the Medical Outcomes Study Short-Form Health Survey. Maternal function was measured through self-report and researcher observation. In Study 2, stressors were measured using the Everyday Stressors Index. Multiple linear regressions were used to investigate associations while controlling for relevant covariates. Results In both studies, mothers endorsed a wide range of psychoneurological symptoms. In Study 1, psychoneurological symptoms had significant negative associations with role function, social function, and developmental stimulation. In Study 2, psychoneurological symptoms had significant negative associations with role function, social function, and physical function. Using Aroian test for mediation, we found that psychoneurological symptoms mediated all significant relationships between stressors and maternal functions in Study 2. Discussion In two samples of low-income mothers, psychoneurological symptoms were prevalent and associated with chronic stressors and with maternal function and may mediate the association between those two factors. These findings extend prior research on depressive symptoms in mothers by investigating pain as an additional key symptom. The studies advance symptom science by highlighting psychoneurological symptoms in a heterogeneous sample without known health conditions.

The fact that people with HIV (PWH) who have an undetectable viral load cannot sexually transmit HIV has been disseminated under the messaging "Undetectable = Untransmittable" (U = U). U = U messaging intends to destigmatize HIV by demonstrating that PWH can have healthy sexual lives. Among a sample of low-income heterosexually active Black and Latino adults, we aimed to (1) measure the prevalence of U = U awareness and (2) determine its association with anticipated HIV stigma. Low-income heterosexually active adults were recruited through respondent-driven sampling in New York City. Among Black and Latino participants who self-reported not having HIV, multiple linear regression was used to determine the association between U = U awareness with the following types of anticipated HIV stigma, as determined by principal component analyses: (1) general; (2) dating related; and (3) sex related. Of 485 participants, 35% were aware of U = U. Those who were aware reported less dating-related [adjusted B: -0.20; 95% confidence interval (CI): -0.37 to -0.03] and sex-related (adjusted B: -0.15; 95% CI: -0.29 to -0.002) anticipated HIV stigma. Although the prevalence of U = U awareness was much lower than reported in other populations (e.g., gender and sexual minorities and PWH), prevalence was moderate in our sample, given that awareness efforts have generally not focused on heterosexually active adults. Our findings provide preliminary evidence that U = U awareness may have an impact on anticipated HIV stigma related to dating and sex. Additional methods to disseminate U = U messaging and dismantle HIV stigma in this population should be explored.

To efficiently target capacity-building efforts for child mental health services in low- and middle-income countries (LMICs), it is critical to define how care is structured across sectors and individual-level factors.In a community-based sample of 1,408 children and adolescents (ages 6-15 years) from Itaboraí, Brazil, the authors assessed need and service use across four care systems (mental health specialty, health, welfare, and informal). Individual-level factors included child gender and age, maternal perception of child mental health need, paternal absence, maternal education, and maternal anxiety and depression.The mental health treatment gap was 88%, with only 12% of children with psychiatric problems using mental health services. Children with mental health problems were more likely than those without these problems to use health and other sectors of care and to use services in more than one sector of care. Overall, 46% of the children with any clinical mental health problems and 31% of those with only internalizing problems were identified by their mothers as having a mental health need. Among those with clinical mental health problems, factors associated with mental health service use were being a boy and paternal absence but not mental health problem type or maternal awareness.Closing the child mental health treatment gap in urban settings in LMICs where resources are scarce will likely require system-level changes, such as engagement of diverse service sectors of care. Interventions need to target increased maternal awareness about mental health problems and encourage provision of mental health services to girls.

Objective:In 2016, a Whole Foods Market© opened in the Englewood community of Chicago, IL – a predominately low-income African American community. This study aimed to examine changes to food and beverage availability and marketing in Englewood’s existing food stores after the opening of this supermarket.Design:Quasi-experimental study.Setting:Two low-income African American communities in Chicago, IL.Participants:Fieldworkers audited all small grocery and limited service stores (e.g. convenience stores, liquor stores and dollar/discount stores) located within one-square mile of the new supermarket and a one-square mile area of a demographically comparable community that also lacked a supermarket. Stores were audited before (2016) and after (2017 and 2018) the supermarket opened.Results:Of the 78 stores audited at baseline, 71·8 % were limited service stores and 85·9 % accepted Supplemental Nutrition Assistance Program (SNAP) benefits. Overall, the availability of healthy food and beverage options in nearby small stores was low at baseline and both follow-up periods. Difference-in-difference regression models revealed a significant increase in: (1) the percentage of stores in the intervention community (i.e. Englewood) offering regular cheese and promoting salty snacks at check-out from 2016 to 2017; and (2) the percentage of stores in the comparison community with interior store promotions for other sweetened beverages from 2016 to 2018.Conclusions:Minimal changes in food and beverage availability and marketing occurred 1 and 2 years after the opening of a new supermarket. However, the wide range of staple food items offered by the supermarket expanded healthy food retail in Chicago’s Englewood community.

This cross-sectional study examined the relationships of financial literacy (FL) and financial behaviour (FB) with health-related quality of life (HRQOL) during the COVID-19 pandemic among low-income working population (20–60 years old) in Malaysia. A self-administered questionnaire survey was used with HRQOL data were gathered using the EuroQol 5-Dimension 5-Level (EQ-5D-5L) tool. A generalised linear model was employed to examine the hypothesised relationships between the constructs. From 1186 respondents, the majority were employed (73.9%), had a monthly household income of less than RM 2500 (74.5%), and did not have any chronic medical conditions (74.5%). The mean (SD) values of FL, FB, and EQ-5D-5L were 5.95 (1.48), 22.08 (4.79), and 0.96 (0.10), respectively. The results of the adjusted model revealed lower age group, Malay ethnicity, Indian ethnicity, and increased FB score as significant determinants of higher EQ-5D-5L scores. With the addition of the chronic medical condition factor into the saturated model, the lower age group, ethnicity, and no chronic medical condition were significant determinants of higher HRQOL. The effects of FB on QOL were confounded by chronic diseases, implying that interventions that focus on improving FB for those with chronic medical condition may help to improve the QOL among the low-income working population.

The link between socioeconomic status and posttraumatic stress disorder (PTSD) symptoms is well established. Given that Black women are disproportionately burdened by both poverty and PTSD symptoms, research focusing on these constructs among this population is needed. The current study assessed the association between material hardship (i.e., difficulty meeting basic needs) and PTSD symptoms among 227 low-income Black women in the United States. We explored several potential explanations for the association between poverty and PTSD symptoms (e.g., individuals living in poverty may experience higher levels of trauma exposure; individuals living in poverty may have less access to relevant protective resources, like social support; poverty itself may represent a traumatic stressor). Using robust negative binomial regression, a positive association between material hardship and PTSD symptoms emerged, B = 0.10, p = .009, SMD = 0.08. When trauma exposure was added to the model, it was positively associated with PTSD symptoms, B = 0.18, p < .001, SMD = 0.16, and material hardship remained positively associated with PTSD symptoms, B = 0.10, p = .019, SMD = 0.08. When social support indicators were added to the model, they were not associated with PTSD symptoms; however, material hardship remained significantly associated, B = 0.10, p = .021, SMD = 0.08. In the model with material hardship and trauma exposure, a significant interaction between material hardship and trauma exposure on PTSD symptoms emerged, B = −0.04, p = .027. These results demonstrate the importance of including material hardship in trauma research, assessment, and treatment.

BACKGROUND: Adverse childhood experiences (ACEs) are stressors that can have lifelong detrimental health effects. ACEs are a concern for children of immigrant parents. METHODS: The low-income mothers of 75 rural farmworker and 63 urban non-farmworker 8-year old Latinx children in immigrant families completed a standardized ACEs inventory. RESULTS: 47.1% of mothers reported no ACEs, 33.3% reported 1, 8.7% reported 2, and 10.9% reported 3 or more. A logistic regression model indicated that urban versus rural children had a higher odds (OR=2.35, 95% CI=1.01,5.48) of at least one ACE. Children living in families with 2 versus 1 adults (OR=0.10, 95% CI=0.02,0.49) and 3 versus 1 adults (OR=0.12, 95% CI=0.02,0.78) had a lower odds of at least one ACE. DISCUSSION: ACEs prevalence was similar to other children in immigrant families, with children living in urban communities having twice the likelihood of experiencing an ACE. Detailed research is needed on locality-based ACEs prevalence.

BACKGROUND The prevalence of landscape fires has increased, particularly in low-income and middle-income countries (LMICs). We aimed to assess the impact of exposure to landscape fire smoke (LFS) on the health of children. METHODS We conducted a sibling-matched case-control study and selected 552 155 children (aged

To assess breastfeeding exclusivity and rate of breastfeeding, breastfeeding self-efficacy, and satisfaction with breastfeeding after hospital discharge among low-income women with late-preterm and early-term infants compared with women with full-term infants.Prospective, comparative, with repeated measures.Four Midwestern U.S. Special Supplemental Nutrition Program for Women, Infants, and Children offices.Participants included 270 mother-infant dyads.We assessed breastfeeding exclusivity, rate of breastfeeding, and breastfeeding self-efficacy at 2 weeks, 2 months, and 5 months and satisfaction with breastfeeding at 5 months after birth or when participants stopped breastfeeding.More than 50% of women in each subgroup were non-Hispanic White. Late-preterm and early-term infants had lower breastfeeding exclusivity rates than full-term infants across the three time points (40%, 51%, and 65% at 2 weeks, p = .029; 22.5%, 34%, and 58% at 2 months, p .001; and 7%, 15%, and 28.46% at 5 months, p .001, respectively). The overall exclusive breastfeeding rate for all groups was 55.93% at 2 weeks, 44.07% at 2 months, and 20.37% at 5 months; 55.56% continued any breastfeeding at 5 months. Breastfeeding self-efficacy during the first 5 months after birth, satisfaction with breastfeeding, level of education, and attending breastfeeding classes were positively correlated with breastfeeding exclusivity. We found significantly less exclusive breastfeeding, lower breastfeeding self-efficacy, and lower satisfaction with breastfeeding among participants with late-preterm and early-term infants compared to those with full-term infants.Ongoing professional breastfeeding support for women is needed to improve and promote breastfeeding exclusivity and continuation among their late-preterm and early-term infants.

Background: Anthracycline therapy-related cardiac dysfunction (ATRCD) is the most notorious adverse side-effect of chemotherapy. It has become a significant cardiovascular health concern for long-term cancer survivors. With the emerging concept of subclinical ATRCD and newer diagnostictools (Speckle Tracking Echocardiography (STE) and biomarkers), detecting anthracycline cardiac toxicity at an early stage has become an important step to prevent severe cardiac dysfunction and improve the cardiovascular outcome in cancer survivors. Despite the increasing population at risk in sub-Saharan Africa (SSA), there is no contemporary data in Uganda to address the burden, pathogenesis and risk factors of subclinical ATRCD. This big gap in knowledge has led to a lack of local guidelines for monitoring and management of ATRCD. Methods: SATRACD (Detecting Subclinical Anthracycline Therapy Related Cardiac Dysfunction In Low Income Country) study is an observational prospective cohort study. Three hundred and fifty-three anthracycline naïve cancer patients will be recruited at baseline. Patients are followed up on completion of anthracycline-based chemotherapy and at 6 months after completion of anthracycline therapy. Data on demographics, cancer profile and clinical presentation will be collected at baseline. Comprehensive cardiac assessment will be performed at each visit, including electrocardiogram, conventional echo- cardiography, STE, cardiac and oxidative stress markers. We will be able to determine the incidence of subclinical and clinical ATRCD at 6 months after completion of anthracycline therapy, determine whether hypertension is a major risk factor for ATRCD, evaluate the role of conventional echocardiography parameters, and biomarkers for detecting subclinical ATRCD. Conclusion: This SATRACD study will provide contemporary data on Ugandan cancer patients who have subclinical and clinical ATRCD, help in the development of local strategies to prevent and manage ATRCD, and improve cardiovascular outcome for Ugandan cancer survivors. Keywords: SATRACD study; subclinical anthracycline therapy; cardiac dysfunction; low income country.

This study examined differences in the associations between food insecurity and serious psychological distress (SPD) by key sociodemographic factors in a population-based sample of low-income adults from the 2017 California Health Interview Survey ( n = 6266). After adjusting for sociodemographic characteristics, low food security, and very low food security were both positively associated with SPD among all low-income adults. Upon stratification, these associations were most pronounced among adults under age 50, males, and in adults with children. Understanding disparities in the associations between food insecurity and psychological distress is critical in developing effective programs or policies to target the most vulnerable sub-groups.

To examine the influence of habit and theory of planned behavior (TPB) variables in predicting low-income older adults' fruit and vegetable (FV) consumption.Cross-sectional study.A city in the southeast United States.A total of 372 low-income older adults participated in this study.Participants completed a validated survey measuring TPB variables (attitude, subjective norm, perceived behavioral control, and intention), FV intake using the Block Dietary Fruit-Vegetable Screener, and self-reported habit index to measure FV consumption. Perceived behavioral control was the largest factor influencing intention to consume FV, followed by attitude and subjective norm. In addition, there was a significant interaction between habit strength and intention, such that intention influenced FV consumption only among individuals with average or higher habit strength.Findings from this study suggest health promotion programs aimed at increasing FV intake among low-income older adults should focus on establishing FV intake as a habit so that an individual's intentions to consume FV can be transformed into actual FV intake. Also, emphasizing how to overcome potential barriers would improve low-income older adults' actual FV intake by increasing their sense of control over consuming FV.

Background Effective pain management is closely related to nurses' knowledge and attitudes toward pain. Limited studies have been performed related to nurses’ knowledge and attitudes toward pain in hospitals in low-income areas. Aims This study surveyed the knowledge and attitudes of nurses toward pain management in county hospitals from low-income areas in Hunan Province, China. Setting and participants The study included 4,668 registered nurses working in 48 county hospitals in low-income areas in China. Methods A cross-sectional study examined the knowledge and attitudes of nurses with regard to pain using the Chinese version of the Knowledge and Attitude Survey Regarding Pain (KASRP) via the WeChat application. Results The 4,668 registered nurses completed the survey; of these, 43.6% indicated they had never received continuing education for pain. The mean percentage score for KASRP was (40.3 ± 7.95), and none of the respondents achieved a percentage score of >80%. Further, of the 40 items, only two had a correct rate of >80%. Continuing pain education did not significantly affect KASRP. Multiple stepwise linear regression showed that education level, ethnicity, professional title, position, and department were independent influencing factors for KASRP scores. Conclusion Almost all nurses in county hospitals of low-income areas had deficiencies in various aspects of pain management knowledge. Better educated nurses with higher professional title or management position, those from the Han ethnicity, and those from the oncology department had higher mean KASRP scores. Current continuing education programs for pain did not improve the pain management capability of the nurse. High-quality and standardized pain educational programs should be implemented to improve pain management.

Background To achieve elimination of hepatitis C virus (HCV) infection, limited resources can be best allocated through estimation of “care cascades” among groups disproportionately affected. In San Francisco and elsewhere, these groups include young (age ≤ 30 years) people who inject drugs (YPWID), men who have sex with men who inject drugs (MSM-IDU), and low-income trans women. Methods We developed cross-sectional HCV care cascades for YPWID, MSM-IDU, and trans women using diverse data sources. Population sizes were estimated using an inverse variance-weighted average of estimates from the peer-reviewed literature between 2013 and 2019. Proportions of past/current HCV infection, diagnosed infection, treatment initiation, and evidence of cure (sustained virologic response at 12 weeks posttreatment) were estimated from the literature using data from 7 programs and studies in San Francisco between 2015 and 2020. Results The estimated number of YPWID in San Francisco was 3748; 58.4% had past/current HCV infection, of whom 66.4% were diagnosed with current infection, 9.1% had initiated treatment, and 50% had confirmed cure. The corresponding figures for the 8135 estimated MSM-IDU were: 29.4% with past/current HCV infection, 70.3% diagnosed with current infection, 28.4% initiated treatment, and 38.9% with confirmed cure. For the estimated 951 low-income trans women, 24.8% had past/current HCV infection, 68.9% were diagnosed with current infection, 56.5% initiated treatment, and 75.5% had confirmed cure. Conclusions In all 3 populations, diagnosis rates were relatively high; however, attention is needed to urgently increase treatment initiation in all groups, with a particular unmet need among YPWID.

Aim: To assess the severity of persistent pulmonary hypertension (PPH) in congenital diaphragmatic hernia (CDH) neonates solely using oxygenation index (OI). Study Design: A prospective study was c...

Background Breast cancer is the most common cancer diagnosed in women. Screening mammography is the only imaging screening study for breast cancer with a proven. mortality benefit. This study aims to analyze the cost-effectiveness of screening mammography in Ethiopia. Methods Multistate Markov model was used for computer simulation to estimate cost and health benefits of screening mammography interventions for age-group of 40–49 years and 50–59 years. The cost-effectiveness analysis was made for 4 policies based on where the screening mammography procedures were conducted: government institution only, the private institution only, 50% ratio for each, and 10% private institution policy. Outputs were expressed in total cost, life-years gained (LYG) incremental cost-effectiveness ratio (ICER), and incremental net monetary benefit (INMB). Results All 4 policies of annual screening mammography failed to achieve acceptable ICER and lead to a net loss in INMB. The lowest ICER value was for government institution-only policy with 3510.3 USD/LYG and 3224.9 USD/LYG both above the cost-effectiveness threshold of 2808.5 USD. The cost per single death averted for each group was 110,206.7 USD and 77,088.2 USD for age-group 40–49 years and 50–59 years respectively. Conclusion Screening mammography could not be shown to be cost-effective in Ethiopia with the current low cost-effectiveness threshold. Alternative screening approach like annual clinical breast examination may need to be investigated.

Background: The treatment gap for bipolar disorder is aggravated by economic inequality. Around half of the world's population live in a low-or lower-middle-income country, where research on treatment is scarce. Hence, this review aims to determine the number and types of intervention studies conducted on adults with bipolar disorder in low-income and lower-middle-income countries and analyze the effect of these interventions on symptom severity, medical adherence, and quality of life. Methods: A systematic review was conducted in June and November 2021 using eight databases. Controlled intervention trials on adults with bipolar disorder on data from low-income and lower-middle-income countries at time of publication were included. The risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials or The Risk Of Bias In Non-randomized Studies of Interventions assessment tool. Results: Twenty-one studies met the inclusion criteria. These were divided into four subtypes based on the intervention; pharmacotherapy (=12), psychosocial (=7), electroconvulsive therapy (=1), and traditional medicine (=1). Three studies were from low-income countries. A high risk of bias characterized the studies; only four studies reported the procedures used for randomization. Most studies, however, identified a beneficial effect on symptom severity, and in addition, medical adherence could be improved with psychosocial interventions. Limitations: Heterogeneity across studies prevented any meaningful pooling of data to meta-analyses. Conclusion: Data for treatment interventions contextualized to the local setting for bipolar disorder remains sparse, particularly from low-resource settings. Further studies are urgently needed to target the treatment gap for bipolar disorder. Trial registration: PROSPERO: CRD42020170953.

Synanthropic rodents are ubiquitous in low-income communities and pose risks for human health, as they are generally resistant to control programs. However, few or no studies have evaluated the long-term effect of chemical and infrastructural interventions on rodent population dynamics, especially in urban low-income communities, or evaluated the potential recovery of their population following interventions. We conducted a longitudinal study in a low-income community in the city of Salvador (BA, Brazil) to characterize the effect of interventions (chemical and infrastructural) on the dynamics of rodent population, and documented the post-intervention recovery of their population. We evaluated the degree of rodent infestation in 117 households/sampling points over three years (2014 – 2017), using tracking plates, a proxy for rodent abundance/activity. We reported a significant lower rodent activity/abundance after the chemical and infrastructural interventions (Z=-4.691 (p

This study identified coping and sociodemographic correlates and predictors of depressive symptoms in mothers at risk for clinical depression. A descriptive, cross-sectional design was employed. A convenience sample of 88 low-income or ethnic-minority mothers aged 21 to 45 completed a depression scale, demographic data sheet, and responded to an open-ended question. Content analysis, descriptive, and inferential statistics was used for data analysis. Exactly 42.5% of mothers reported high depressive symptoms (>16). Lower income levels ( r = .342, p = .01) and head-of-household status ( r = .220, p = .04) were significantly associated with higher depressive symptoms. Those who used social support coping had lower depressive symptoms than those who did not ( t = 2.50, p = .014). Those using emotion-focused coping only had higher depressive symptoms than those using a mix of coping strategies ( t = 2.60, p = .011). Healthcare providers can employ vigilant depression screening and encourage utilization of a mix of problem and emotion-focused coping strategies to reduce depressive symptoms and prevent clinical depression.

OBJECTIVE: To access urban-rural disparities in vaccination service use among Medicaid-enrolled adolescents and examine its association with residence county characteristics. STUDY DESIGN: We used the 2016 Medicaid T-MSIS Analytic File to estimate adolescents’ use of vaccination services, defined as the proportion of adolescents aged 11–18 years with ≥ 1 vaccination visit in a county. We used linear regression and the Oaxaca-Blinder decomposition method to examine the association between county characteristics and urban-rural disparities in vaccination service use. RESULTS: The analysis included 2,473 counties located in 38 states. The mean proportion of adolescents making ≥ 1 vaccination visit at the county level was low (36.09%) and was lower in rural than in urban counties (31.99% vs. 36.85%, p < .01). The number of primary care physicians (PCPs) was positively associated with vaccination service use in rural counties; in urban counties, % of households without a vehicle was negatively associated with vaccination service use. The decomposition results showed that 66.78% (3.24 percentage points) of the urban-rural disparities in vaccination service use could be attributed to urban-rural differences in the county characteristics included in the study. Characteristics measuring access to care (number of PCPs), social and economic factors (% adults with at least a bachelor’s degree and % children in poverty), quality of care (influenza vaccination rates and preventable hospital stays), and demographics (% non-Hispanic black, % Hispanic, and % females) played a role in urban-rural disparities. CONCLUSIONS: Differences in county characteristics could partly explain the observed urban-rural disparities in vaccination service use among low-income adolescents.

Daily oral pre-exposure prophylaxis (PrEP) is a key tool in addressing high HIV incidence among young women, and breaking the cycle of transmission. From 2017 to 2020, Médecins Sans Frontières (MSF) offered PrEP, in conjunction with contraception and risk-reduction counselling, to women aged 18–25, in a government-run clinic in Khayelitsha, a low income high HIV prevalence area in South Africa. Drawing on clinical, quantitative, and qualitative interview data, we describe participants’ experiences and engagement with the PrEP program, participant adherence (measured by TFV-DP levels in dried blood spots) over time, and the indirect benefits of the PrEP program. Of 224 screened and eligible participants, 164 (73.2%) initiated PrEP, with no large differences between those who initiated and those who did not. Overall, 47 (29%) completed 18 months follow-up, with 15 (9.1%) attending all visits. 76 (46.9%) participants were lost to follow-up, 15 (9.1%) exited when leaving the area, and 28.7% of exits happened in the first month of the study. We identified two different trajectories of PrEP adherence: 67% of participants had, on average, consistently low TFV-DP levels, with the remaining 33% having sustained high adherence. Few baseline characteristics predicted good adherence. The main reported barrier to taking PrEP was forgetting to take or travel with the pills. Encouragement from others declined as a reported facilitator from month 6 to 18 (family: 93.1% vs 77.6%, p = 0.016, friends: 77.6% vs 41.4%, p ≤ 0.001, partners: 62.1% vs 46.6%, p = 0.096, other PrEP users: 89.7% vs 74.1%, p = 0.020). Disclosure to friends and family in some cases opened dialogue around sex, and helped to educate others about PrEP. Self-reported sex with more than one partner, and sex without a condom, decreased significantly after enrolment (p

Roof-harvested rainwater (RHRW) is considered relatively clean water, even though the possible presence of pathogens in the water may pose human health risks. In this study, we investigated the occurrence of enteric viruses in the first flush (10 mm) of RHRW from a densely populated and low-income urbanized region of Rio de Janeiro. One hundred samples (5 L) were collected from 10 rainfall events between April 2015 and March 2017. RNA and DNA viruses were concentrated using the skimmed milk flocculation method and analyzed using the TaqMan® quantitative RT-qPCR and qPCR. Human adenoviruses, noroviruses, rotaviruses A, and avian parvoviruses were detected in 54%, 31%, 12%, and 12% of the positive samples. JC polyomavirus, also targeted, was not detected. Virus concentrations ranged from 1.09 × 101 to 2.58 × 103 genome copies/Liter (GC/L). Partial nucleotide sequence confirmed the presence of HAdV type 41, norovirus genotype GII.4, and avian parvovirus 1. The results suggest that the first flush diversion devices may not adequately remove enteric virus from the rainwater. Additional treatment of RHRW is required to mitigate potential health risks from potable use of captured water.

Background: Tobacco-smoking in children is one of the most crucial public health concerns, which could be highly prevalent in underprivileged populations. Methods: A cross sectional, random sampling survey was conducted to determine the prevalence of current tobacco-smoking and related risk factors among adolescents living in a low-income area of Santiago de Chile. Results: Of the 2,747 adolescents participating in the study, 24.0% [95% confidence interval (CI) 22.3–25.5] were current smokers, with no significant difference between girls and boys. Factors associated with current smoking were as follows: positive attitude to smoking cigarettes offered by peers [odds ratio (OR) 8.0; 95% CI 5.7–11.3, P

The current study addresses the need to empirically develop effective mental health interventions for youth from ethnic/racial minority and low-income neighborhoods. Using Stage Model evaluation methods supported by the National Institutes of Health in the US to address underutilization of mental healthcare among racial/ethnic minority youth, this feasibility study demonstrates empirical adaptation of an innovative sport-specific psychological intervention for use in youth from ethnic/racial minority and low-income neighborhoods. An international group of professionals familiar with sport performance and mental health intervention serving the target population experientially examined the adapted intervention protocols in workshops and provided feedback. Survey results indicated the professionals found the intervention components were easy to administer and likely to be safe, enjoyable, engaging and efficacious for youth mental health and sport performance. The protocols were revised based on feedback from these professionals and the intervention was examined in a case trial involving an Asian American youth who evidenced Social Anxiety Disorder. Case study results indicated the intervention could be implemented with integrity, and severity of psychiatric symptoms and factors interfering with sport performance decreased after intervention implementation. The participant’s relationships with family, coaches and teammates were also improved.

OBJECTIVES: To describe reasons for refusal to be referred to or enroll in a depression treatment study and post-enrollment challenges to treatment engagement and technology-related problems among low-income homebound individuals aged 50+ years with depression. METHODS: Data came from a 3-arm randomized clinical trial that evaluated real-world effectiveness of lay counselor-delivered behavioral activation (BA) versus clinician-delivered problem-solving therapy (PST). Interventionists were embedded in a large home-delivered meals program and treatment sessions were videoconferenced; hence Tele-BA and Tele-PST. We described refusal reasons of those who refused initial case manager referrals (n = 279), telephone screening (n = 64), enrollment (n = 47), or post-enrollment baseline assessments (n = 18). We used inductive thematic analysis to explore challenges to effectual treatment engagement and tele-delivery-related problems among Tele-PST or Tele-BA participants (n = 183) from the interventionists’ tele-session process recordings. RESULTS: More than a third of potentially eligible older adults refused their case managers’ referral, and a quarter of those who accepted referral refused further screening or enrollment. Three quarters of those who refused reported no interest or need or declined to talk about depression. Others refused given their busy schedule with medical appointments and caregiving. Nearly 80% of Tele-BA or Tele-PST participants had some challenges to effectual engagement in treatment sessions due to environmental and health-related conditions and other life stressors including financial distress. Though many tele-sessions had connectivity and other technology-related problems, these did not affect depression outcomes. CONCLUSION: Mental health service providers for low-income older adults need to be aware of these challenges when adopting best practice strategies for them.

OBJECTIVE: This study examines the media use of children from low-income homes during school closings during the COVID-19 pandemic. METHODS: Caregivers of 151 kindergarteners from low-income homes completed questionnaires as part of a larger study. Caregivers reported how much time children spent watching television/videos and using apps on the most recent weekday and weekend days. Caregivers also reported how their child's current use of media for several different purposes compared with how much the child usually uses media for that purpose. RESULTS: Weekly average media use was 46.3 hours or 6.6 hours per day. Counter to previous research, weekday media use was higher than weekend media use, suggesting that media was likely used as a replacement for time usually spent in school. Caregivers reported increased child media use for positive purposes, such as education and maintaining relationships with family and friends outside of the home, and potentially useful but less socially valued purposes, such as occupying the child's time while caregivers were completing other tasks. Having more children in the household was related to higher media use, and girls used media for maintaining remote relationships more than boys. CONCLUSION: These findings provide reason for both concern and optimism for the impacts of pandemic closures on low-income children. High levels of media use seem to be prevalent in this population. However, the diverse purposes for media use suggest that caregivers relied on media to supplement children's academic and social growth at a time when school and socializing were not safe in their typical forms.

OBJECTIVE: Black children and children from low-income communities are disproportionately affected by asthma, attributed partly to pollution exposure. Air purifiers reduce indoor air pollution and improve asthma symptoms in children. In order to implement air purifier interventions, an understanding of patterns of use and potential barriers is necessary. METHODS: In a home intervention study, 127 children with asthma living in Baltimore were randomized to receive two active or two placebo air purifiers. The 16-week study period included: baseline clinic visit, home visit for air purifier installation (active or placebo) with instruction to use the high or turbo settings, and electronic adherence monitoring of air purifiers. Determinants of adherence were identified using linear regression models. RESULTS: Air purifiers were used 80% of the time, and participants demonstrated adherence to high or turbo settings for 60% of the time. In an adjusted model, season was the major determinant of air purifier adherence, with 21% lower use in the winter (p=0.025) attributed to the cold draft generated by the machine. CONCLUSION: In a clinical trial with electronic adherence monitoring, air purifier use was high and participants were adherent to use of high or turbo settings the majority of the time. Addressing practical barriers to consistent use, such as draft during the winter, in addition to financial barriers may improve air purifier adherence among children with asthma living in low-income, urban households.

The author aimed to assess changes in mental health service use, unmet need for mental health care, and barriers to obtaining care among low-income adults after the implementation of the Affordable Care Act in 2014.Data on 15,968 adults with psychological distress and family income100% of the federal poverty level were drawn from the National Survey on Drug Use and Health, 2009-2018. Health insurance coverage, contact with mental health services, unmet need for mental health care, and self-reported barriers to care were compared between 2009-2013 and 2014-2018.Health insurance coverage increased between 2009-2013 and 2014-2018. However, mental health service use did not change, and unmet need for care modestly decreased. Financial barriers were common and did not change significantly over time. Attitudinal and structural barriers increased.Further efforts are needed to address the enduring barriers to mental health care among low-income adults.

Objective Examine the acceptability of an evidence-based, contextually tailored, virtual avatar coaching approach for nutrition education among adult-child dyads with low income. Design Structured observations and semistructured interviews. Setting Low-income communities in 2 midsized urban areas. Participants Fifteen African American adult and child (aged 5–10 years old) dyads recruited from community agencies. Phenomenon of Interest Structured observation during the use of the virtual avatar coaching program and qualitative feedback on program experience after using the program. Analysis Transcripts were independently coded by 2 trained coders. Content analysis was conducted to determine trends and patterns in responses, and salient quotes were extracted from the manuscripts. Results The program generated dialogue between the children and adults around preferences and dietary habits. Adults and children described the program as being helpful, informative, motivational, and fun. Adults and children liked that the avatar acknowledged them at a personal level, provided accountability, and was tailored to them and their environment. Children wanted the ability to customize the avatar, more gamification, and avatar demonstration of healthy behaviors. Children felt the program would improve their health behaviors and were interested in using it again. Conclusions and Implications This study highlights information that can be used to improve avatar-based programs for nutrition education with children and their adult caregivers who have low income. Future work should assess the impact of user customization experience, program impact on dietary behaviors, and resources required to scale and maintain the program with community agencies.

Low- and middle-income countries account for over 90% of burns worldwide. Though mission trips, public health interventions and educational strategies have been introduced in recent years, a disparity remains in treatment provided between high- and low -income countries. This analysis aims to review available literature pertaining to strategies for training in burns management, with a focus on those applicable to low-income countries.Mesh terms including "burns", "burns care", "burns management", "training", "teaching" and "education" were inputted into Medline and EMBase. Studies were included on the basis that they include an educational intervention to train doctors to provide surgical burns care in low-income countries. Included literature was analysed using scoring tools then a critical appraisal was performed.Fourteen studies were included in this analysis. These describe e-learning (n = 1), video-based teaching (n = 1), lecture-based teaching (n = 1), simulation training (n = 8) and hospital-based training achieved through collaborative efforts between high and low-income countries such as mission trips and fellowship programmes (n = 3). The strategies described have been summarised and presented.Burns care training should be accessible at a global scale and so, involve training methods including simulation, courses and fellowship programmes that are affordable and accessible to surgeons in low-income countries.

Shifting environmental conditions and poor or insufficient hygiene facilitates the transmission of bacteria and viruses between and within species of animals; between humans; and between humans and animals. Taking a One Health perspective, we used interviews to explore with 20 women living on low income in Kenya: their gendered hygiene practices and daily contact with animals; how and why they access water and sanitation facilities for themselves, their families, and any livestock; and their understandings of (zoonotic) health risks and disease transmission within their local environments. The women described how they worked every day to keep bodies and homes clean by washing bodies, surfaces and clothes. Women's hygiene practices focussed on removing visible dirt partly because of concerns for health but also to support their families' social standing in their community. While they were less aware of any 'invisible' risks to health through contact with animals or other hazards present in their daily living environments, most exercised care to source and manage water for drinking. Contaminated water was recognised as a risk to health suggesting that in this case, women accepted that there were 'invisible risks' to health, even in clear water, and took steps to mitigate them.

Background Substance use remains a public health problem worldwide, and it is particularly concerning among adolescents because of its harmful effects. There is a need to better understand the factors associated with adolescents’ substance use to inform policies for effective prevention. Methods We used data from the Global School-based Student Health Surveys. Data were collected by anonymous self-report questionnaires. This study is based on three questions assessing substance use and four questions assessing psychological distress. Logistic regression models were used to analyse associations between substance use and psychological distress. We calculated the pooled overall and regional estimates by random-effects meta-analysis. Results We included 126,763 adolescents (boys, 44.7%; girls, 55.3%). Substance users tended to be older, male, physically attacked, in physical fighting, bullied; to experience psychological distress; and to have a higher socio-economic status. Alcohol use was consistently associated with medium and high psychological distress. In terms of four aspects of psychological distress, only suicidal ideation was consistently associated with the substance use components and all specific combinations of substance use. Additionally, the prevalence of alcohol use was higher than that of cigarette use and drug use. Region-wise analysis showed that substance use was associated with psychological distress in the African region, American region, South-East region and Western Pacific region. Limitations The cross-sectional data could not infer causality. Conclusions This study indicated that high levels of substance use were significantly associated with an increased likelihood of psychological distress among adolescents. In addition, age also had an effect on substance use.

Purpose: To test for racial/ethnic differences in perceived argument strength in favor of structural interventions to curb childhood obesity among lower-income parents of young children. Design: Cross-sectional, self-report. Setting: Online research panel, national sample of 1485 US adults in Fall 2019. Participants: Parents of children (age 0-5 years) with an annual income Measures: SSB consumption, policy support, and strength of arguments in favor of marketing restrictions and a penny-per-ounce tax. Analysis: Descriptive statistics, multivariable OLS models. Results: Race/ethnicity was not a significant predictor of the perceived strength of a composite of marketing arguments (pBlack = 0.07; pLatinx = 0.10), however it was a significant predictor of the perceived strength of tax arguments (pBlack = 0.01; pLatinx = 0.01). Perceptions of strength of 12 of 35 discrete SSB tax arguments differed by race/ethnicity (p < .05). Arguments regarding industry targeting of Black children (marketing: pBlack < .001; pLatinx = .001; tax: pBlack < .001; pLatinx = .001), were particularly demonstrative of this difference. In contrast, arguments that these policies would provide support for parents (marketing: pBlack = 0.20; pLatinx = 0.84) and communities (tax: pBlack = 0.24; pLatinx = 0.58) were seen as strong arguments across groups. Conclusions: Black and Hispanic/Latinx parents may be more prepared to move toward SSB policy support than white parents. Emphasizing community benefits of policy may be effective in moving constituents toward policy support across groups.

Objectives The aim of this study was to evaluate the efficacy and safety of sofosbuvir/ledipasvir ± ribavirin in Malagasy patients with hepatitis C virus genotypes 1 and 2, in real conditions. Patients and methods This was a retrospective monocentric clinical study, carried out over a period of 3 years from March 1, 2017 to February 28, 2020, in a hospital hepato-gastroenterology department. Results In total, 26 patients (M/F: 11/15) with hepatitis C virus genotype 1 (n = 13) or genotype 2 (n = 13), were treated with sofosbuvir/ledipasvir without (n = 21) or with (n = 5) ribavirin for 12 weeks. The mean age was 61.38 ± 7.09 years. Seventeen patients (65.4%) had cirrhosis. The overall sustained virological response was 96.2% (95% CI = 80.4–99.9%). There was no significant difference between the sustained virological responses of genotypes 1 and 2 (92.3% vs 100%; p = 0.31) or those of cirrhotic or non-cirrhotic patients (94.1% vs 100%; p = 0.46). A relapse was observed in one patient (5.9%) — cirrhotic and genotype 1b — under sofosbuvir/ledipasvir with ribavirin. Seven patients (26.9%) experienced mild adverse reactions, including asthenia (57.1%) and insomnia (42.9%). Conclusion Treatment with sofosbuvir/ledipasvir ± ribavirin for infection with hepatitis C virus genotype 1 has been shown to be safe and effective, even in the presence of cirrhosis. The sofosbuvir/ledipasvir combination is a good option for genotype 2 non-cirrhotic patients.