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Since April 2019, CA Bridge has worked with emergency departments (EDs) in diverse geographic and emergency care settings across California to scale up low-threshold buprenorphine access, patient navigation programs, harm reduction services, and take-home naloxone. Between April 2019 and June 2023, 268 (81.0%) of 331 acute care hospitals in California received funding and technical assistance from CA Bridge and completed data reporting. These hospitals provided navigation services during 279 025 patient encounters and gave patients buprenorphine in 89 549 ED visits. (Am J Public Health. 2024;114(9):874–878. https://doi.org/10.2105/AJPH.2024.307710) [ABSTRACT FROM AUTHOR]

Objectives. To determine facility-level factors associated with COVID-19 outbreaks in US Immigration and Customs Enforcement (ICE) detention centers. Methods. We obtained COVID-19 case counts at 88 ICE detention facilities from May 6, 2020, through June 21, 2021, from the COVID Prison Project. We obtained information about facility population size, facility type (dedicated to immigrants or mixed with other incarcerated populations), and facility operator (public vs private contractor) from third-party sources. We defined the threshold for a COVID-19 outbreak as a cumulative 3-week incidence of 10% or more of the detained population. Results. Sixty-three facilities (72%) had at least 1 outbreak. Facilities with any outbreak were significantly more likely to be privately operated (P <.001), to have larger populations (113 vs 37; P =.002), and to have greater changes in their population size over the study period (‒56% vs −26%; P <.001). Conclusions. Several facility-level factors were associated with the occurrence of COVID-19 outbreaks in ICE facilities. Public Health Implications. Structural and organizational factors that promote respiratory infection spread in ICE facilities must be addressed to protect detainee health. (Am J Public Health. 2024;114(9):909–912. https://doi.org/10.2105/AJPH.2024.307704) [ABSTRACT FROM AUTHOR]

Objectives. To identify sociodemographic shifts among unsheltered Latino people experiencing homelessness (PEH) between 2020–2022. Methods. We examined differences in characteristics reported in demographic surveys for Latino PEH older than 25 years from 2020 (n = 1215) and 2022 (n = 1395) in Los Angeles County, California, using weighted bivariate χ2 tests. Results. From 2020 to 2022, there was a 25% increase in the number of unsheltered Latino individuals. The share of Latino PEH who were unemployed increased (57% to 67%). The increase in homelessness occurred largely among individuals living in vehicles (14% to 33%), rather than in tents or on sidewalks. Latino PEH were significantly less likely to report mental illness (24% vs 18%) and had higher rates of first entry into homelessness in the past 2 years than non-Latino respondents. Conclusions. Our results are consistent with the effects of increasing socioeconomic vulnerability, likely related to COVID-19, in driving the increase in Latino PEH. Policy Implications. The rise in homelessness among economically vulnerable yet healthy Latinos suggests a need to bolster social safety nets and increase homelessness prevention programs. (Am J Public Health. 2024;114(S6):S510–S514. https://doi.org/10.2105/AJPH.2024.307717) [ABSTRACT FROM AUTHOR]

Objectives. To evaluate symptomatology and clinical outcomes among treatment-seeking health care workers (HCWs). We examined engagement, presenting symptomatology, and treatment outcomes among a diverse group of HCWs in a large urban health system. Methods. Demographic and pretreatment–posttreatment outcome data were available for 69 HCWs who sought cognitive behavioral therapy (CBT), with or without medication management, at a specialized clinical center from July 1, 2020, to April 25, 2022. Results. Treatment-seeking HWCs predominantly identified as female (78.3%) and non-White (53.6%) and had a mean age of 36.33 ± 10.72 years. Wilcoxon signed-rank tests showed significant reductions in all symptoms and increased well-being (P <.001), with effect sizes ranging from 0.59 to 0.71. Conclusions. Our findings replicate those of existing research on the prevalence of psychiatric distress among HCWs, uniquely focusing on those seeking care. Our outcome data suggest that short-term CBT is effective in reducing clinical symptoms and increasing HCW well-being. Public Health Implications. Given the elevated rates of distress found in HCW surveys, evidence-based interventions such as ours are essential to ensure workforce well-being. Providing mental health care to HCWs has both individual benefits and potential implications for improved patient care and workforce retention. (Am J Public Health. 2024;114(S2):S167–S170. https://doi.org/10.2105/AJPH.2023.307435) [ABSTRACT FROM AUTHOR]

Objectives. To model the relationship of unstable housing and evictions with physical and sexual violence perpetrated against women sex workers in intimate and workplace settings. Methods. We used bivariate and multivariable logistic regression with generalized estimating equations to model the association of unstable housing exposure and evictions with intimate partner violence (IPV) and workplace violence among a community-based longitudinal cohort of cisgender and transgender women sex workers in Vancouver, Canada, from 2010 through 2019. Results. Of 946 women, 85.9% experienced unstable housing, 11.1% eviction, 26.2% IPV, and 31.8% workplace violence. In multivariable generalized estimating equation models, recent exposure to unstable housing (adjusted odds ratio [AOR] = 2.04; 95% confidence interval [CI] = 1.45, 2.87) and evictions (AOR = 2.45; 95% CI = 0.99, 6.07) were associated with IPV, and exposure to unstable housing was associated with workplace violence (AOR = 1.46; 95% CI = 1.06, 2.00). Conclusions. Women sex workers face a high burden of unstable housing and evictions, which are linked to increased odds of intimate partner and workplace violence. Increased access to safe, women-centered, and nondiscriminatory housing is urgently needed. (Am J Public Health. 2023;113(4):442–452. https://doi.org/10.2105/AJPH.2022.307207) [ABSTRACT FROM AUTHOR]

Objectives. To compare 4 COVID-19 surveillance metrics in a major metropolitan area. Methods. We analyzed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in wastewater influent and primary solids in Raleigh, North Carolina, from April 10 through December 13, 2020. We compared wastewater results with lab-confirmed COVID-19 cases and syndromic COVID-like illness (CLI) cases to answer 3 questions: (1) Did they correlate? (2) What was the temporal alignment of the different surveillance systems? (3) Did periods of significant change (i.e., trends) align? Results. In the Raleigh sewershed, wastewater influent, wastewater primary solids, lab-confirmed cases, and CLI were strongly or moderately correlated. Trends in lab-confirmed cases and wastewater influent were observed earlier, followed by CLI and, lastly, wastewater primary solids. All 4 metrics showed sustained increases in COVID-19 in June, July, and November 2020 and sustained decreases in August and September 2020. Conclusions. In a major metropolitan area in 2020, the timing of and trends in municipal wastewater, lab-confirmed case, and syndromic case surveillance of COVID-19 were in general agreement. Public Health Implications. Our results provide evidence for investment in SARS-CoV-2 wastewater and CLI surveillance to complement information provided through lab-confirmed cases. (Am J Public Health. 2023;113(1):79–88. https://doi.org/10.2105/AJPH.2022.307108) [ABSTRACT FROM AUTHOR]

Objectives. To investigate what transpires at opioid overdoses where police administer naloxone and to identify the frequency with which concerns about police-administered naloxone are observed. Methods. We reviewed body-worn camera (BWC) footage of all incidents where a Tempe, Arizona police officer administered naloxone or was present when the Tempe Fire Medical Rescue (TFMR) administered it, from February 3, 2020 to May 7, 2021 (n = 168). We devised a detailed coding instrument and employed univariate and bivariate analysis to examine the frequency of concerns regarding police-administered naloxone. Results. Police arrived on scene before the TFMR in 73.7% of cases. In 88.6% of calls the individual was unconscious when police arrived, but 94.6% survived the overdose. The primary concerns about police-administered naloxone were rarely observed. There were no cases of improper naloxone administration or accidental opioid exposure to an officer. Aggression toward police from an overdose survivor rarely occurred (3.6%), and arrests of survivors (3.6%) and others on scene (1.2%) were infrequent. Conclusions. BWC footage provides a unique window into opioid overdoses. In Tempe, the concerns over police-administered naloxone are overstated. If results are similar elsewhere, those concerns are barriers that must be removed. (Am J Public Health. 2022;112(9):1326–1332. https://doi.org/10.2105/AJPH.2022.306918) [ABSTRACT FROM AUTHOR]

Life expectancy figures for countries and population segments are increasingly being reported to more decimal places and used as indicators of the strengths or failings of countries' health and social systems. Reports seldom quantify their intrinsic statistical imprecision or the age-specific numbers of deaths that determine them. The SE formulas available to compute imprecision are all model based. This note adds a more intuitive data-based SE method and extends the jackknife to the analysis of event rates more generally. It also describes the relationships between the magnitude of the SE and the numbers of person-years and deaths on which it is based. These relationships can help quantify the statistical noise present in published year-to-year differences in life expectancies, as well as in same-year differences between or within countries. Agencies and investigators are encouraged to use one of these SEs to report the imprecision of life expectancy numbers and to tailor the number of decimal places accordingly. (Am J Public Health. 2022;112(8):1151–1160. https://doi.org/10.2105/AJPH.2022.306805) [ABSTRACT FROM AUTHOR]

Objectives. To investigate trends in the use and quality of telehealth for contraceptive care during the COVID-19 pandemic in the United States. Methods. The 2021 Guttmacher Survey of Reproductive Health Experiences is a national online survey of 6211 people assigned female at birth, aged 18 to 49 years, and that ever had penile‒vaginal sex. We used weighted bivariable and multivariable logistic regressions to analyze the use of telehealth for contraceptive care and the quality of this care. Results. Of the respondents, 34% received a contraceptive service in the 6 months before the survey; of this group, 17% utilized telehealth. Respondents who were uninsured at some point in the 6 months before the survey had greater odds of using telehealth for this care. Respondents had lower odds of rating the person-centeredness of their care as "excellent" if they received services via telehealth compared with in person (25% vs 39%). Conclusions. Telehealth has helped bridge gaps in contraceptive care deepened by COVID-19. More work is needed to improve the quality of care and reduce access barriers to ensure telehealth can meet its full potential as part of a spectrum of care options. (Am J Public Health. 2022;112(S5):S545–S554. https://doi.org/10.2105/AJPH.2022.306886) [ABSTRACT FROM AUTHOR]

The point-in-time (PIT) homeless count conducted annually in communities across the United States is a major metric reported to the federal government that has a number of limitations. With the PIT count in 2021 being optional because of the COVID-19 pandemic and potential increases in homeless-related needs in the aftermath of the pandemic, there are opportunities for renewed efforts to improve how the United States enumerates homelessness, determines needs of communities, and tracks progress in ending homelessness throughout the nation. This article describes 2 divergent solutions: (1) improve the PIT by standardizing methodologies across jurisdictions and supplementing counts with other data sources or (2) replace the PIT with a new system. There are strengths and limitations of both solutions. Advocates for either solution agree that there are important funding considerations to take into account and advancing technologies to utilize. As the nation continues to ramp up public health efforts, homelessness is a public health crisis that could benefit from improved epidemiological and data science methods. (Am J Public Health. 2022;112(4):633–637. https://doi.org/10.2105/AJPH.2021.306640) [ABSTRACT FROM AUTHOR]

The National Center for Health Statistics' (NCHS's) National Vital Statistics System (NVSS) collects, processes, codes, and reviews death certificate data and disseminates the data in annual data files and reports. With the global rise of COVID-19 in early 2020, the NCHS mobilized to rapidly respond to the growing need for reliable, accurate, and complete real-time data on COVID-19 deaths. Within weeks of the first reported US cases, NCHS developed certification guidance, adjusted internal data processing systems, and stood up a surveillance system to release daily updates of COVID-19 deaths to track the impact of the COVID-19 pandemic on US mortality. This report describes the processes that NCHS took to produce timely mortality data in response to the COVID-19 pandemic. (Am J Public Health. 2021;111(12):2133–2140. https://doi.org/10.2105/AJPH.2021.306519) [ABSTRACT FROM AUTHOR]

During the COVID-19 pandemic, the Virtual Training Academy (VTA) was established to rapidly develop a contact-tracing workforce for California. Through June 2021, more than 10 000 trainees enrolled in a contact-tracing or case investigation course at the VTA. To evaluate program effectiveness, we analyzed trainee pre- and postassessment results using the Wilcoxon signed-rank test. There was a statistically significant (P <.001) improvement in knowledge and self-perceived skills after course completion, indicating success in training a competent contact-tracing workforce. (Am J Public Health. 2021;111(11):1934–1938. https://doi.org/10.2105/AJPH.2021.306468) [ABSTRACT FROM AUTHOR]

Objectives. To evaluate changes in mortality in US counties along the US–Mexico border in which there was substantial new border wall construction after the Secure Fence Act of 2006 relative to border counties in which there was no such border wall construction. Methods. Using complete 1990 to 2017 mortality microdata and a quasi-experimental difference-in-differences design, we evaluated changes in overall (all-cause) mortality, mortality from drug overdose, and mortality from homicide in the 10 counties with substantial new border wall construction and 11 counties with no such construction. We fit a linear model, adjusting for population characteristics and county and year fixed effects, with Bonferroni adjustments for multiple comparisons. Sensitivity analyses included the addition of adjacent inland counties and modifications to the statistical model. Results. Relative to counties without substantial new border wall construction, counties in which a substantial amount of new border wall was constructed exhibited a nonsignificant 0.02-percentage-point increase (95% confidence interval [CI] = −0.06, 0.10; P >.99) in overall mortality after construction. Border wall construction was not associated with changes in either deaths from overdose or deaths from homicide. Conclusions. Wall construction along the US–Mexico border after the Secure Fence Act of 2006 was not associated with discernible changes in mortality. [ABSTRACT FROM AUTHOR]

Objectives.: To assess the quality of population-level US mortality data in the US Census Bureau Numerical Identification file (Numident) and describe the details of the mortality information as well as the novel person-level linkages available when using the Census Numident. Methods.: We compared all-cause mortality in the Census Numident to published vital statistics from the Centers for Disease Control and Prevention. We provide detailed information on the linkage of the Census Numident to other Census Bureau survey, administrative, and economic data. Results.: Death counts in the Census Numident are similar to those from published mortality vital statistics. Yearly comparisons show that the Census Numident captures more deaths since 1997, and coverage is slightly lower going back in time. Weekly estimates show similar trends from both data sets. Conclusions.: The Census Numident is a high-quality and timely source of data to study all-cause mortality. The Census Bureau makes available a vast and rich set of restricted-use, individual-level data linked to the Census Numident for researchers to use. Public Health Implications.: The Census Numident linked to data available from the Census Bureau provides infrastructure for doing evidence-based public health policy research on mortality. [ABSTRACT FROM AUTHOR]

Objectives. To evaluate the sensitivity of health care facility documentation of suicide deaths among US veterans with recent Veterans Health Administration (VHA) care and assess variation in identification by veteran, clinical, and suicide death characteristics. Methods. Cross-sectional analyses included 11 148 veterans who died by suicide in 2013 to 2017, per National Death Index death certificate information, with VHA encounters in the year of death or the previous year. Facility suicide ascertainment was assessed per site reports in the VHA Suicide Prevention Applications Network. Bivariate and multivariable analyses assessed ascertainment by decedent demographic, clinical, utilization, and method of suicide characteristics. Results. Site reports identified 3667 suicide decedents (32.9%). Veteran suicide decedents identified by facilities were more likely to be younger and with clinical risk factors and more recent VHA encounters. Suicide deaths involving poisoning were less likely to be identified than deaths involving other methods. Conclusions. VHA facility ascertainment of suicide deaths among recent patients was neither comprehensive nor representative. Findings will inform efforts to enhance facility suicide surveillance and veteran suicide prevention. [ABSTRACT FROM AUTHOR]

Objectives. To investigate changes from 1993 to 2019 in the percentage of US citizens suffering extreme distress. Methods. Using data on 8.1 million randomly sampled US citizens, we created a new proxy measure for exceptional distress (the percentage who reported major mental and emotional problems in all 30 of the last 30 days). We examined time trends for different groups and predictors of distress. Results. The proportion of the US population in extreme distress rose from 3.6% in 1993 to 6.4% in 2019. Among low-education midlife White persons, the percentage more than doubled, from 4.8% to 11.5%. Regression analysis revealed that (1) at the personal level, the strongest statistical predictor of extreme distress was "I am unable to work," and (2) at the state level, a decline in the share of manufacturing jobs was a predictor of greater distress. Conclusions. Increasing numbers of US citizens report extreme levels of mental distress. This links to poor labor-market prospects. Inequality of distress has also widened. Public Health Implications. Policymakers need to recognize the crisis of an ever-growing group of US citizens in extreme distress. [ABSTRACT FROM AUTHOR]

Objectives. To assess the role of health-related factors, health care, nutrition, and socioeconomic factors in food insecurity prevalence in a sample of previously homeless adults living in permanent supportive housing. Methods. In 2016 to 2017, we recruited and completed survey interviews with permanent supportive housing residents aged 45 years and older in Los Angeles, California (n = 237). We conducted univariable and multivariable analyses to determine the odds and covariates of low or very low food security, according to the US Department of Agriculture's definition and measure. Results. Two thirds of residents (67%) reported low or very low food security. In the multivariable analyses, several variables were positively associated with this outcome, including accessing food aid or being late in paying bills. The odds of low or very low food security decreased by 8% for every $100 increase in monthly income. Conclusions. The prevalence of food insecurity in our sample exceeded rates among similarly aged low-income adults in the general population and adults who are currently homeless. This suggests that food insecurity, along with other indicators of socioeconomic disadvantage, remains a threat to health equity for formerly homeless individuals even after they transition to stable housing. [ABSTRACT FROM AUTHOR]

Objectives. To assess the environmental justice implications of flooding from Hurricane Harvey in Greater Houston, Texas, we analyzed whether the areal extent of flooding was distributed inequitably with respect to race, ethnicity, and socioeconomic status, after controlling for relevant explanatory factors. Methods. Our study integrated cartographic information from Harvey's Inundation Footprint, developed by the US Federal Emergency Management Agency, with sociodemographic data from the 2012–2016 American Community Survey. Statistical analyses were based on bivariate correlations and multivariate generalized estimating equations. Results. The areal extent of Harvey-induced flooding was significantly greater in neighborhoods with a higher proportion of non-Hispanic Black and socioeconomically deprived residents after we controlled for contextual factors and clustering. Conclusions. Results provide evidence of racial/ethnic and socioeconomic injustices in the distribution of flooding and represent an important starting point for more detailed investigation of disproportionate impacts associated with Hurricane Harvey. Public Health Implications. Our findings highlight the need to prepare for and address the unequal social consequences of climate change-related disasters, which are expected to increase in frequency and severity. [ABSTRACT FROM AUTHOR]

Objectives. To characterize interactions that female sex workers (FSWs) have with the police and explore associations with client-perpetrated violence. Methods. Baseline data were collected April 2016 to January 2017 from 250 FSWs from the Sex Workers and Police Promoting Health in Risky Environments (SAPPHIRE) study based in Baltimore, Maryland. Interviewer-administered questionnaires captured different patrol or enforcement and abusive police encounters, experiences of client-perpetrated violence, and other risk factors, including drug use. We conducted bivariate and multivariable analysis in Stata/SE version 14.2 (StataCorp LP, College Station, TX). Results. Of participants, 78% reported lifetime abusive police encounters, 41% reported daily or weekly encounters of any type. In the previous 3 months, 22% experienced client-perpetrated violence. Heroin users (70% of participants) reported more abusive encounters (2.5 vs 1.6; P <.001) and more client-perpetrated violence (26% vs 12%; P =.02) than others. In multivariable analysis, each additional type of abusive interaction was associated with 1.3 times (95% confidence interval [CI] = 1.1, 1.5) increased odds of client-perpetrated violence. For patrol or enforcement encounters, this value was 1.3 (95% CI = 1.0, 1.7). Conclusions. Frequent exposures to abusive police practices appear to contribute to an environment where client-perpetrated violence is regularly experienced. For FSWs who inject drugs, police exposure and client-perpetrated violence appear amplified. Public Health Implications. Structural interventions that address police–FSW interactions will help alleviate police's negative impact on FSWs' work environment. [ABSTRACT FROM AUTHOR]

Objectives. To examine 23-year trends in both physically and cognitively healthy life expectancy from age 65 years in the Netherlands. Methods. We used 8 waves between 1993 and 2016 from the nationally representative Longitudinal Aging Study Amsterdam (12 948 observations). We calculated physically and cognitively healthy life expectancies by using the Sullivan life table method and tested prevalence trends over time by using generalized estimating equations. Results. Total life expectancy at age 65 years rose from 14.7 to 18.7 years (men) and from 19.2 to 21.4 years (women). Life expectancy in poor physical health increased nonlinearly from 1.8 to 2.9 years for men; for women it fluctuated around 5.7 years. Meanwhile, life expectancy in good cognitive health increased linearly from 11.0 to 15.7 years (men) and from 13.4 to 18.0 years (women). The proportion of people with poor physical and poor cognitive health combined did not increase, averaging 5.9% (men) and 8.7% (women). Conclusions. This multiwave study shows that a negative trend in physically healthy life expectancy is accompanied by a positive trend in cognitively healthy life expectancy. [ABSTRACT FROM AUTHOR]

An editorial about the importance of accurate data when reporting COVID-19 cases is presented. Topics of discussion include the number versus the rate when comparing COVID-19 cases in different countries, selective testing for the novel coronavirus SARS-CoV-2, and Great Britain's changing approach to COVID-19. The need for accurate immunologic tests and disease surveillance is emphasized.

Objectives. To examine postgraduation employment trends among graduates of doctoral programs in public health from 2003 to 2015. Methods. We analyzed pooled cross-sectional data from a census of graduates receiving a research doctorate from US accredited institutions. The outcome of interest was employment status. Covariates included public health discipline, sociodemographic characteristics, and institutional attributes. Results. Of 11 771 graduates, nearly two thirds secured employment in either academic (34.8%) or nonacademic (31.4%) settings at the time of graduation. The proportion of those still seeking employment increased over time. Individuals who were White, younger, trained in either biostatistics or epidemiology, or from an institution with the highest level of research intensity were significantly more likely to secure employment. Academic employment was the most common setting for all 5 public health disciplines, but we observed differences in employment patterns (e.g., government, nonprofit, for-profit) across disciplines. Conclusions. Certain characteristics among public health doctoral recipients are correlated with postgraduation employment. More research is needed, but the observed increase in individuals still seeking employment may be attributable to increases in general public health graduates from for-profit institutions. [ABSTRACT FROM AUTHOR]

Objectives. To determine whether food bank provision of self-management support and diabetes-appropriate food improves glycemic control among clients with diabetes. Methods. We screened 5329 adults for diabetes at food pantries (n = 27) affiliated with food banks in Oakland, California; Detroit, Michigan; and Houston, Texas, between October 2015 and September 2016. We individually randomized 568 participants with hemoglobin A1c (HbA1c) 7.5% or greater to waitlist control or 6-month intervention including food, diabetes education, health care referral, and glucose monitoring. The primary outcome was HbA1c at 6 months. Results. Food security (relative risk [RR] = 0.85; 95% confidence interval [CI] = 0.73, 0.98), food stability (RR = 0.77; 95% CI = 0.64, 0.93), and fruit and vegetable intake (risk difference [RD] = 0.34; 95% CI = 0.34, 0.34) significantly improved among intervention participants. There were no differences in self-management (depressive symptoms, diabetes distress, self-care, hypoglycemia, self-efficacy) or HbA1c (RD= 0.24; 95% CI = -0.09, 0.58). Conclusions. Food banks are ideally situated to provide diabetes-appropriate food to food-insecure households. Effective strategies for food banks to support improvements in diabetes clinical outcomes require additional study. Public Health Implications. Moving chronic disease support from clinics into communities expands reach into vulnerable populations. However, it is unclear how community interventions should be integrated with clinical care to improve disease outcomes. Trial Registration Number. NCT02569060 [ABSTRACT FROM AUTHOR]

Life expectancy (LE) based on a period life table (PLT) traditionally serves as a general population summary metric. It is, however, becoming more frequently reported for chronically afflicted subpopulations. In general populations, there is always an obvious real cohort sharing the hypothetical PLT cohort characteristics, and the LE estimate is intuitively understood as that real cohort mean survival time, assuming constancy of death risks. In diseased subpopulations, the correspondence between the hypothetical cohort and a real cohort is not straightforward. Furthermore, the excess mortality of chronic diseases usually changes according to age at onset and time since onset. The standard PLT method does not allow for proper control of these issues, so the LE estimate can only be deemed valid under specific assumptions. Without clear statements about the real cohort to whom the estimate is intended and the assumptions allowing disregard of the effect of age at onset and time since onset, LEs of afflicted subpopulations computed with the PLT are only abstract numbers summarizing mortality rates. If called "life expectancy," they can be seriously misleading. The same applies to health-adjusted LE. [ABSTRACT FROM AUTHOR]

Objectives. To assess how health department contextual factors influence perceptions of the 15 Public Health Preparedness Capabilities, developed by the Centers for Disease Control and Prevention (CDC) to provide guidance on organizing preparedness activities. Methods. We conducted an online survey and focus group between September 2015 and May 2016 with directors of preparedness programs in state, metropolitan, and territorial jurisdictions funded by CDC’s Public Health Emergency Preparedness (PHEP) cooperative agreement. The survey collected demographic information and data on contextual factors including leadership, partnerships, organizational structure, resources and structural capacity, and data and evaluation. Results. Seventy-seven percent (48 of 62) of PHEP directors completed the survey and 8 participated in the focus group. Respondents were experienced directors (mean = 10.6 years), and 58% led 7 or more emergency responses. Leadership, partnerships, and access to fiscal and human resources were associated with perception and use of the capabilities. Conclusions. Despite some deficiencies, PHEP awardees believe the capabilities provide useful guidance and a flexible framework for organizing their work. Contextual factors affect perceptions of the capabilities and possibly the effectiveness of their use. Public Health Implications. The capabilities can be used to address challenges in preparedness, including identifying evidence-based practices, developing performance measures, and improving responses. [ABSTRACT FROM AUTHOR]

Objectives. To evaluate and describe outcomes of state and local medical countermeasure preparedness planning, which is critical to ensure rapid distribution and dispensing of a broad spectrum of life-saving medical assets during a public health emergency. Methods. We used 2007 to 2014 state and local data collected from the Centers for Disease Control and Prevention’s Technical Assistance Review. We calculated descriptive statistics from 50 states and 72 local Cities Readiness Initiative jurisdictions that participated in the Technical Assistance Review annually. Results. From 2007 to 2014, the average overall Technical Assistance Review score increased by 13% for states and 41% for Cities Readiness Initiative jurisdictions. In 2014, nearly half of states achieved the maximum possible overall score (100), and 94% of local Cities Readiness Initiative jurisdictions achieved a score of 90 or more. Conclusions. Despite challenges, effective and timely medical countermeasure distribution and dispensing is possible with appropriate planning, staff, and resources.However, vigilance in training, exercising,and improving plans from lessons learned in a sustained, coordinated way is critical to ensure continued public health preparedness success. [ABSTRACT FROM AUTHOR]

Objectives. To assess whether Primary Care Emergency Preparedness Network member sites reported indicators of preparedness for public health emergencies compared with nonmember sites.The network—a collaboration between government and NewYork City primary care associations—offers technical assistance to primary care sites to improve disaster preparedness and response. Methods. In 2015, we administered an online questionnaire to sites regarding facility characteristics and preparedness indicators. We estimated differences between members and nonmembers with natural logarithm–linked binomial models. Open-ended assessments identified preparedness gaps. Results. One hundred seven sites completed the survey (23.3% response rate); 47 (43.9%) were nonmembers and 60 (56.1%) were members. Members were more likely to have completed hazard vulnerability analysis (risk ratio [RR] = 1.94; 95% confidence interval [CI] = 1.28, 2.93), to have identified essential services for continuity of operations (RR = 1.39; 95% CI = 1.03, 1.86), to have memoranda of understanding with external partners (RR = 2.49; 95% CI = 1.42, 4.36), and to have completed point-of-dispensing training (RR = 4.23; 95% CI = 1.76, 10.14). Identified preparedness gaps were improved communication, resource availability, and train-the-trainer programs. Public Health Implications. Primary Care Emergency Preparedness Network membership is associated with improved public health emergency preparedness among primary care sites. [ABSTRACT FROM AUTHOR]

Objectives. To assess the feasibility of chronic disease surveillance using distributed analysis of electronic health records and to compare results with Behavioral Risk Factor Surveillance System (BRFSS) state and small-area estimates. Methods. We queried the electronic health records of 3 independent Massachusettsbased practice groups using a distributed analysis tool called MDPHnet to measure the prevalence of diabetes, asthma, smoking, hypertension, and obesity in adults for the state and 13 cities. We adjusted observed rates for age, gender, and race/ethnicity relative to census data and compared them with BRFSS state and small-area estimates. Results. The MDPHnet population under surveillance included 1 073 545 adults (21.8% of the state adult population). MDPHnet and BRFSS state-level estimates were similar: 9.4% versus 9.7% for diabetes, 10.0% versus 12.0% for asthma, 13.5% versus 14.7% for smoking, 26.3% versus 29.6% for hypertension, and 22.8% versus 23.8% for obesity. Correlation coefficients for MDPHnet versus BRFSS small-area estimates ranged from 0.890 for diabetes to 0.646 for obesity. Conclusions. Chronic disease surveillance using electronic health record data is feasible and generates estimates comparable with BRFSS state and small-area estimates. [ABSTRACT FROM AUTHOR]

In 2004, Murray et al. reviewed methodological developments in the design and analysis of group-randomized trials (GRTs). We have highlighted the developments of the past 13 years in design with a companion article to focus on developments in analysis. As a pair, these articles update the 2004 review. We have discussed developments in the topics of the earlier review (e.g., clustering, matching, and individually randomized group-treatment trials) and in new topics, including constrained randomization and a range of randomized designs that are alternatives to the standard parallel-arm GRT. These include the stepped- wedge GRT, the pseudo-cluster randomized trial, and the network-randomized GRT, which, like the parallel-arm GRT, require clustering to be accounted for in both their design and analysis. [ABSTRACT FROM AUTHOR]

Objectives. To describe the health status of the transgender population in the United States. Methods. We used 2014 Behavioral Risk Factor Surveillance System data that comprised a probability sample from 19 US states and Guam (n = 151 456). Results. Bivariate analyses showed that, in comparison with cisgender individuals, transgender individuals had a higher prevalence of poor general health (odds ratio [OR] = 1.7; 95% confidence interval [CI] = 1.2, 2.4), more days per month of poor physical (b = 2.43; 95% CI = 0.61, 4.24; P < .01) and mental (b = 1.74; 95% CI = 0.28, 3.19; P = .02) health, and a higher prevalence of myocardial infarction (OR = 1.7; 95% CI = 1.1, 2.5). In addition, more transgender than cisgender people lacked health care coverage (OR = 1.8; 95% CI = 1.2, 2.7) and a health care provider (OR = 1.5; 95% CI = 1.0, 2.1), and they were less likely to have visited a dentist in the preceding year (OR = 0.7; 95% CI = 0.5, 1.0). However, transgender individuals did not differ from cisgender individuals with respect to prevalence of chronic diseases, cancers, or depressive disorders or in terms of health behaviors such as smoking, binge drinking, and always wearing a seatbelt. Conclusions. Our findings highlight areas of unmet needs in the transgender population. [ABSTRACT FROM AUTHOR]

Objectives. To investigate the relationship between vision and disability in the elderly. Methods. We used a baseline visual indicator (combining near acuity with Snellen equivalent < 20/30 and self-reported distance visual loss) to explore the association between visual loss and subsequent disability (mobility, instrumental activities of daily living [IADLs], ADLs, and participation restriction) from 1999 to 2007 in 8491 elderly participants of the French Three-City Cohort (Bordeaux, Dijon, and Montpellier). Results. In multiadjusted analyses, near visual impairment, alone or associated with distance visual function loss, was associated with greater risk of developing ADL limitations (P = .027), IADL limitations (P = .002), and participation restriction (P < .001), but not mobility (P = .848). The disabling impact of visual loss was significant for 11 of the 15 activities, when analyzed one by one. Conclusions. Both near and distance visual loss was associated with greater functional decline over time, and the combination of the two could be even worse. Public Health Implications. In the context of rapid aging of the population, maintaining good vision in the elderly represents a promising prevention track, visual impairment being common in the elderly, largely undermanaged, and mostly reversible. Further research, especially trials, is necessary to estimate the public health impact of such interventions. [ABSTRACT FROM AUTHOR]

Objectives. To compare the predictive power of synthetic absolute income measures with that of asset-based wealth quintiles in low- and middle-income countries (LMICs) using child stunting as an outcome. Methods. We pooled data from 239 nationally representative household surveys from LMICs and computed absolute incomes in US dollars based on households' asset rank as well as data on national consumption and inequality levels. We used multivariable regression models to compare the predictive power of the created income measure with the predictive power of existing asset indicator measures. Results. In cross-country analysis, log absolute income predicted 54.5% of stunting variation observed, compared with 20% of variation explained by wealth quintiles. For within-survey analysis, we also found absolute income gaps to be predictive of the gaps between stunting in the wealthiest and poorest households (P < .001). Conclusions. Our results suggest that absolute income levels can greatly improve the prediction of stunting levels across and within countries over time, compared with models that rely solely on relative wealth quintiles. [ABSTRACT FROM AUTHOR]

Numerous examples exist in population health of work that erroneously forces the causes of health to sumto 100%.This is surprising. Clear refutations of this error extend back 80 years. Because public health analysis, action, and allocation of resources are ill served by faulty methods, I consider why this error persists. I first review several highprofile examples, including Doll and Peto's 1981 opus on the causes of cancer and its current interpretations; a 2015 highpublicity article in Science claiming that two thirds of cancer is attributable to chance; and the influential Web site "County Health Rankings & Roadmaps: Building a Culture of Health, County by County," whosemodel sums causes of health to equal 100%: physical environment (10%), social and economic factors (40%), clinical care (20%), and health behaviors (30%). Critical analysis of these works and earlier historical debates reveals that underlying the error of forcing causes of health to sum to 100% is the still dominant but deeplyflawed view that causation can be parsed as nature versus nurture. Better approaches exist for tallying risk and monitoring efforts to reach health equity. [ABSTRACT FROM AUTHOR]

Objectives. To examine food insecurity and cardiovascular disease-related health outcomes among American Indians (AIs) in rural Oklahoma. Methods. We surveyed a cross-sectional sample of 513 AI adults to assess food insecurity domains (i.e., food quality and quantity) and obesity, diabetes, and hypertension. Results. Among AIs surveyed, 56% reported inadequate food quantity and 62% reported inadequate food quality. The unadjusted prevalence of diabetes (28.4% vs 18.4%), obesity (60.0% vs 48.3%), and hypertension (54.1% vs 41.6%) was higher among participants with inadequate food quantity than among those with adequate food quantity. These associations did not reach statistical significance after adjustment for age, gender, study site, education, and income. The unadjusted prevalence of obesity (60.7% vs 45.8%), diabetes (27.3% vs 18.8%), and hypertension (52.5% vs 42.5%)was higher among those with inadequate food quality than among those with adequate food quality, even after adjustment for age, gender, study site, education, and income. Conclusions. Tribal, federal, and state policymakers, as well as businesses and nonprofit organizations, must collaboratively take aggressive action to address food insecurity and its underlying causes, including improving tribal food environments, reducing barriers to healthy foods, and increasing living wages. [ABSTRACT FROM AUTHOR]

Objectives. To determine the number and type of US workers taking maternity or paternity leave. Methods. We created a publicly available ecological long-term series for measuring parental leave from 1994 to 2015 by using the Current Population Survey, which interviews about 60 000 randomly selected households monthly. Results. The average month from 1994 to 2015 saw 273 000 women and 13 000 men on maternity or paternity leave. Maternity leave rates per 10 000 births showed no trend over 22 years (mean = 677.6). Paternity figures increased by a factor of 3, but started from a small base (14.7-54.6).We observed no national impact on maternity or paternity leave after implementation of state laws that provided paid leave. About half (51.1%) of employees on maternity or paternity leave during 2015 received paid time off. The typical woman on maternity leave was older, more likely married, more likely non-Hispanic White, and more educated than the typical woman who gave birth. Conclusions. Although the US economy has expanded dramatically since 1994, this improvement does not appear to have translated into more women taking maternity leave. [ABSTRACT FROM AUTHOR]

Objectives. To describe trends in suicides with opioid poisoning noted as a contributing cause of death. Methods. Using National Vital Statistics data (1999-2014), we calculated age-adjusted rates of suicide with opioid poisoning (International Classification of Diseases, Tenth Revision codes T40.0-T40.4) per 100 000 population per year and annual percentage change (APC) in rates. We used Joinpoint regression to examine trends in suicide rates and proportion of suicides involving opioids. Results. The annual age-adjusted death rate from suicide with opioid poisoning as a contributing cause of death increased from 0.3 per 100 000 in 1999 to 0.7 per 100 000 in 2009 (APC = 8.1%; P < .001), and remained at 0.6 to 0.7 per 100 000 through 2014. The percentage of all suicides with opioid poisoning listed as a contributing cause of death increased from 2.2% in 1999 to 4.4% in 2010 (P < .001). Rates were similar for men and women, higher among Whites than non-Whites, higher in the West, and highest for individuals aged 45 to 64 years. Conclusions. Opioid involvement in suicides has doubled since 1999. These analyses underscore the need for health care providers to assess suicidal risk in patients receiving opioids. [ABSTRACT FROM AUTHOR]

Objectives. To examine civil legal needs among people experiencing homelessness and the extent to which medical-legal partnerships exist in homeless service sites, which promote the integration of civil legal aid professionals into health care settings. Methods. We surveyed a national sample of 48 homeless service sites across 26 states in November 2015. The survey asked about needs, attitudes, and practices related to civil legal issues, including medical-legal partnerships. Results. More than 90% of the homeless service sites reported that their patients experienced at least 1 civil legal issue, particularly around housing, employment, health insurance, and disability benefits. However, only half of all sites reported screening patients for civil legal issues, and only 10% had a medical-legal partnership. The large majority of sites reported interest in receiving training on screening for civil legal issues and developing medical-legal partnerships. Conclusions. There is great need and potential to deploy civil legal services in health settings to serve unstably housed populations. Training homeless service providers how to screen for civil legal issues and how to develop medical-legal partnerships would better equip them to provide comprehensive care. [ABSTRACT FROM AUTHOR]

Background. Transgender individuals have a gender identity that differs from the sex they were assigned at birth. The population size of transgender individuals in the United States is not well-known, in part because official records, including the US Census, do not include data on gender identity. Population surveys today more often collect transgenderinclusive gender-identity data, and secular trends in culture and the media have created a somewhat more favorable environment for transgender people. Objectives. To estimate the current population size of transgender individuals in the United States and evaluate any trend over time. Search methods. In June and July 2016, we searched PubMed, Cumulative Index to Nursing and Allied Health Literature, andWebof Science for national surveys, as well as "gray" literature, through an Internet search. We limited the search to 2006 through 2016. Selection criteria. We selected population-based surveys that used probability sampling and included self-reported transgender-identity data. Data collection and analysis. We used random-effects meta-analysis to pool eligible surveys and used meta-regression to address our hypothesis that the transgender population size estimate would increase over time. We used subsample and leave-one-out analysis to assess for bias. Main results. Our meta-regression model, based on 12 surveys covering 2007 to 2015, explained 62.5% of model heterogeneity, with a significant effect for each unit increase in survey year (F = 17.122; df = 1,10; b = 0.026%; P = .002). Extrapolating these results to 2016 suggested a current US population size of 390 adults per 100 000, or almost 1 million adults nationally. This estimate may be more indicative for younger adults, who represented more than 50% of the respondents in our analysis. Authors' conclusions. Future national surveys are likely to observe higher numbers of transgender people. The large variety in questions used to ask about transgender identity may account for residual heterogeneity in our models. Public health implications. Under- or nonrepresentation of transgender individuals in population surveys is a barrier to understanding social determinants and health disparities faced by this population. Were commend using standardized questions to identify respondents with transgender and nonbinary gender identities, which will allow a more accurate population size estimate. [ABSTRACT FROM AUTHOR]

Counterfactual frameworks and statistical methods for supporting causal inference are powerful tools to clarify scientific questions and guide analyses in public health research. Counterfactual accounts of causation contrast what would happen to a population’s health under alternative exposure scenarios. A long-standing debate in counterfactual theory relates to whether sex, race, and biological characteristics, including obesity, should be evaluated as causes, given that these variables do not directly correspond to clearly defined interventions. We argue that sex, race, and biological characteristics are important health determinants. Quantifying the overall health effects of these variables is often a natural starting point for disparities research. Subsequent assessments of biological or social pathways mediating those effects can facilitate the development of interventions designed to reduce disparities. [ABSTRACT FROM AUTHOR]

Objectives. To test a community health worker (CHW)-led health literacy intervention on mammogram and Papanicolaou test screening among Korean American women. Methods. We conducted a cluster-randomized trial at 23 ethnic churches in the Baltimore, Maryland–Washington, DC, metropolitan area between 2010 and 2014. Trained CHWs enrolled 560 women. The intervention group received an individually tailored cancer-screening brochure followed by CHW-led health literacy training and monthly telephone counseling with navigation assistance. Study outcomes included receipt of an age-appropriate cancer screening test, health literacy, cancer knowledge, and perceptions about cancer screening at 6 months. Results. The odds of having received a mammogram were 18.5 (95% confidence interval [CI] = 9.2, 37.4) times higher in the intervention than in the control group, adjusting for covariates. The odds of receiving a Papanicolaou test were 13.3 (95% CI = 7.9, 22.3) times higher; the odds of receiving both tests were 17.4 (95% CI = 7.5, 40.3) times higher. Intervention effects also included increases in health literacy and positive perceptions about cancer screening. Conclusions. A health literacy–focused CHW intervention successfully promoted cancer-screening behaviors and related cognitive and attitudinal outcomes in Korean American women. [ABSTRACT FROM AUTHOR]

Objectives. To examine associations of maternal age at childbirth and parity with survival to age 90 years (longevity). Methods. We performed a prospective study among a multiethnic cohort of postmenopausal US women in the Women’s Health Initiative recruited from 1993 to 1998 and followed through August 29, 2014. We adjusted associations with longevity for demographic, lifestyle, reproductive, and health-related characteristics. Results. Among 20 248 women (mean age at baseline, 74.6 years), 10 909 (54%) survived to age 90 years. The odds of longevity were significantly higher in women with later age at first childbirth (adjusted odds ratio = 1.11; 95% confidence interval = 1.02, 1.21 for age 25 years or older vs younger than 25 years; P for trend = .04). Among parous women, the relationship between parity and longevity was significant among White but not Black women. White women with 2 to 4 term pregnancies compared with 1 term pregnancy had higher odds of longevity. Conclusions. Reproductive events were associated with longevity among women. Future studies are needed to determine whether factors such as socioeconomic status explain associations between reproductive events and longevity. [ABSTRACT FROM AUTHOR]

Objectives. To compare health care use and spending of Medicaid enrollees seen at federally qualified health centers versus non-health center settings in a context of significant growth. Methods. Using fee-for-service Medicaid claims from 13 states in 2009, we compared patients receiving the majority of their primary care in federally qualified health centers with propensity score-matched comparison groups receiving primary care in other settings. Results. We found that health center patients had lower use and spending than did non-health center patients across all services, with 22% fewer visits and 33% lower spending on specialty care and 25% fewer admissions and 27% lower spending on inpatient care. Total spending was 24% lower for health center patients. Conclusions. Our analysis of 2009 Medicaid claims, which includes the largest sample of states and more recent data than do previous multistate claims studies, demonstrates that the health center program has provided a cost-efficient setting for primary care for Medicaid enrollees. [ABSTRACT FROM AUTHOR]

Objectives. To test whether ¡Cuídate!, a program culturally adapted for Hispanic youths, affects sexual risk behavior. Methods. We evaluated 3 replications of ¡Cuídate! in California, Arizona, and Massachusetts in a randomized controlled trial (registry no. NCT02540304) in which 2169 primarily Hispanic participants were randomly assigned to an intervention (n = 1326) or a control (n = 870) group. Youths were surveyed at baseline (September 2012-April 2014) and 6 months postbaseline (March 2013-October 2014). We estimated pooled and subgroup impacts using a regression framework with baseline covariates to increase statistical precision (1216 youths analyzed in the treatment group, 806 analyzed in the control group). Results. We found no impacts on the study's primary outcomes of recent sexual activity or recent unprotected sexual activity. However, ¡Cuídate! improved knowledge (10%-20% increase; P < .001), attitudes (effect size = .24; P < .001), and skills (effect size = .14; P = .002). Exploratory subgroup analyses suggest potentially problematic effects for some groups. Conclusions. Findings suggest that ¡Cuídate! was effective in improving youths' knowledge and attitudes. However, after 6 months, these changes did not translate to improvements in reported sexual risk behaviors. [ABSTRACT FROM AUTHOR]

Objectives. To investigate the impact of Be the Exception, a newly developed program to delay onset of sexual behaviors, in a White, rural population. Methods. A cluster randomized controlled trial in northwestern Indiana (14 schools, 1776 students, 2011-2015) compared an intervention (5 group sessions and multimedia assembly) with a no-intervention group; both continued usual standard health education. Multilevel mixed-effects logistic regressions with 1455 students measured long-term outcomes 12 months after baseline questionnaire. Results. Intervention group students reported ever having had sexual intercourse and sexual intercourse in past 3 months significantly less often than did the comparison group (1.91% vs 6.29% and 1.09% vs 4.26%, respectively). No statistical differences were observed for reported sexual intercourse in past 3 months with risky behavior (1.23% vs 2.24%), without condom use (1.04% vs 1.73%), or without birth control (1.00% vs 1.53%). Cumulatively, intervention group students significantly more often reported no activity, holding hands, hugging and kissing and less often reported touching above and below the waist, other sex, or sexual intercourse. Conclusions. Be the Exception is effective in delaying the onset of sexual behavior among rural middle school students. [ABSTRACT FROM AUTHOR]

Objectives. To evaluate the impacts of an enhanced version of the Family Life and Sexuality Module of the HealthTeacher middle school curriculum. Methods. We conducted a cluster randomized trial of Chicago, Illinois, middle schools. We randomly assigned schools to a treatment group that received the intervention during the 2010-2011 school year or a control group that did not. The primary analysis sample included 595 students (7 schools) in the treatment group and 594 students (7 schools) in the control group. Results. Students in the treatment schools reported greater exposure to information on reproductive health topics such as sexually transmitted infections (STIs; 78% vs 60%; P< .01), abstinence (64% vs 37%; P< .01), and birth control (45% vs 29%; P< .01). They also reported higher average scores on an index of knowledge of contraceptive methods and STI transmission (0.5 vs 0.3; P= .02). We found no statistically significant differences in rates of sexual intercourse (12%vs12%;P= .99),oral sex (12%vs9%;P= .18), or other intermediateoutcomes. Results. Students in the treatment schools reported greater exposure to information on reproductive health topics such as sexually transmitted infections (STIs; 78% vs 60%; P< .01), abstinence (64% vs 37%; P< .01), and birth control (45% vs 29%; P< .01). They also reported higher average scores on an index of knowledge of contraceptive methods and STI transmission (0.5 vs 0.3; P= .02). We found no statistically significant differences in rates of sexual intercourse (12%vs12%;P= .99),oral sex (12%vs9%;P= .18), or other intermediateoutcomes. [ABSTRACT FROM AUTHOR]

Objectives. To consider whether Youth All Engaged! (a text message intervention) intensified the effects of the adolescent pregnancy prevention Teen Outreach Program (control) for youths. Methods. In this trial performed inDenver, Colorado, from 2011 to 2014,we randomized 8 Boys& Girls Clubs each of 4 years into 32 clubs per year combinations to ensure each club would serve as a treatment site for 2 years and a control site for 2 years. Control intervention consisted of the Teen Outreach Program only. We enrolled 852 youths (aged 14-18 years), and 632were retained at follow-up, with analytic samples ranging from50 to 624 across outcomes. We examined program costs, and whether the intervention increased condom and contraceptive use, access to care, and pregnancy prevention. Results. Control program costs were $1184 per participant, and intervention costs were an additional $126 per participant (+10.6%). There were no statistically significant differences in primary outcomes for the full sample. Hispanic participants in the intervention condition had fewer pregnancies at follow-up (1.79%) than did those in the control group (6.72%; P = .02). Conclusions. Youth All Engaged is feasible, low cost, and could have potential benefits for Hispanic youths. [ABSTRACT FROM AUTHOR]

Objectives. We evaluated the impact of the 3-year Healthy Futures program on reducing sexual behaviors among middle school students. Methods. Fifteen public middle schools in Haverhill, Lowell, and Lynn, Massachusetts, participated in this longitudinal school-cluster randomized controlled trial (2011-2015), which included 1344 boys and girls. We collected student survey data at baseline, immediately after each Nu-CULTURE curriculum (classroom component of Healthy Futures) in the sixth, seventh, and eighth grades, and at a 1-year follow-up in the ninth grade (cohort 1 students only). Results. Healthy Futures did not reduce the overall prevalence of eighth-grade students who reported ever having vaginal sex. In the eighth-grade follow-up, fewer girls in the treatment group than in the control group reported ever having vaginal sex (P = .04), and fewer Hispanic treatment students than Hispanic control students reported ever having vaginal sex (P = .002). Conclusions. There was some evidence of delaying sexual initiation by the end of Nu-CULTURE, for girls and Hispanics, but not for boys. Future research should focus on improving implementation of the supplemental components intended to foster interpersonal and environmental protective factors associated with sustained delays in sexual activity. [ABSTRACT FROM AUTHOR]

Objectives. To assess whether a sexual health education intervention reduces pregnancy rates in high school students. Methods. We performed a secondary analysis of a 3-year quasi-experimental study performed in South Texas from 2011 to 2015 in which 1437 students without a history of pregnancy at baseline were surveyed each fall and spring. Potentially confounding risk factors considered included sexual behaviors, intentions, and demographics. The outcome measure was self-reported pregnancy status for male and female students. We performed analyses for male and female students using separate discrete time-toevent models. Results. We found no difference in pregnancy rates between intervention and comparison students within the first 3 years of high school. Female and male students in the intervention groups had pregnancy hazard ratios of, respectively, 1.62 (95% CI = 0.9, 2.61; P = .1) and 0.78 (95% CI = 0.44, 1.48; P = .4) relative to the comparison groups. Conclusions. The educational intervention had no impact on the pregnancy rate. Social media tools in pregnancy prevention programs should be adaptive to new technologies and rapidly changing adolescent preferences for these services. [ABSTRACT FROM AUTHOR]

Objectives. To test the efficacy of Reducing the Risk (RTR) and Love Notes (LN) on reducing risky sexual behavior among youths yet to experience or cause a pregnancy. Methods. The four dependent variables were ever had sex, condom use, birth control use, and number of sexual partners at 3- and 6-month follow-up in a 3-arm cluster randomized controlled trial of 1448 impoverished youths, aged 14 to 19 years, in 23 community-based organizations in Louisville, Kentucky, from September 2011 through March 2014. Results. At 3 and 6 months, compared with the control condition, youths in RTR reported fewer sexual partners and greater use of birth control. At 6 months, LN participants reported greater use of birth control and condoms, fewer sexual partners, and were less likely to have ever had sex compared with the control condition. Conclusions. We provided additional evidence for the continued efficacy of RTR and the first rigorous study of LN, which embeds sex education into a larger curriculum on healthy relationships and violence prevention. [ABSTRACT FROM AUTHOR]