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Objectives When examining vaccination coverage, researchers must make decisions about how to define outcome measures based on many factors, including the timing of doses. Different operationalizations of the same outcome can often lead to different findings and can affect the ability to make comparisons across studies. This methodological article aimed to illustrate the implications of two options for operationalizing human papillomavirus (HPV) vaccination based on timing: initiation of the first dose at any age vs before the 13th birthday (on time). Study design Cross-sectional observational design. Methods The 2014 National Immunization Survey for Teens (N = 16,439 adolescents aged 13–17 years) was analyzed using multivariate logistic regression for each outcome measure and effect modification by gender. Results Age was positively associated with initiation at any age but negatively associated with on-time initiation. Gender modified the effect of race/ethnicity for both measures of initiation, but the pattern across groups was different for the two outcomes. Gender modified the effect of provider recommendation for initiation at any age, while gender modified the effects of age and region for on-time initiation. Conclusion Decisions of how to operationalize outcomes of HPV vaccine initiation among adolescents can lead to different conclusions about the role of age and gender differences for several predictive variables. To inform the development of public health efforts that promote on-time HPV vaccination among male and female adolescents, researchers should consider the importance of dose timing when operationalizing outcome measures. We recommend including on-time receipt of the HPV vaccine as an outcome measure.

Africans endure a high burden of pain and suffering from HIV/AIDS and cancer, yet receive a meager amount of the world's pain medication. This tragedy occurs needlessly, given that inexpensive, effective and easily administered interventions are available. WHO has a 'three-step analgesic ladder' framework for managing cancer pain. This widely adopted clinical practice guideline is an integral part of palliative care programs and has also been applied to non-cancer pain. However, untreated pain is a major public health problem due to the discordance between scientific evidence and public policy. Historically, the International Narcotics Board has taken an unbalanced prohibitionist approach to international drug control that has emphasized suppressing controlled substances over making them available for medical and scientific purposes. The procurement process for controlled pain medications in most African countries is a morass of restrictions that make it exceedingly difficult for patients to obtain these drugs. Often, these restrictions arise in part from a misunderstanding of addiction and dependence on opiates. The result has been widespread 'opiophobia' among African policy makers and physicians. A host of factors have misaligned the analgesic pharmaceutical supply chain. Taken together, access to medically necessary controlled substance in sub-Saharan Africa is suboptimal.

Background Cardiopulmonary disease is a major cause of morbidity and mortality in persons with sickle cell disease (SCD). Tricuspid regurgitant jet velocity (TRJV) and predicted forced expiratory volume in 1 s (FEV1%) predicted are independently associated with death in SCD. The goal of this study was to determine the prevalence of elevated TRJV and the association, if any, between TRJV and FEV1% predicted among persons with sickle cell anaemia (SCA) in Nigeria. Methods Using a cross-sectional design, we enrolled 100 adult Nigerians (≥15 y) with SCA. We screened participants using Doppler echocardiogram to determine their TRJV and assessed their lung function with spirometry. Results The prevalence of elevated TRJV was 6%, with 74% of participants having low FEV1% predicted (

The Ebola Virus Disease (EVD) outbreak in West Africa in 2014 resulted in cases spreading to other parts of the world, such as the United States of America (USA). A survey was carried out among Meharry Medical College residents to ascertain their knowledge of Center of Disease Control and Prevention (CDC) guidelines on prevention and management of EVD. A structured questionnaire was administered to a cross-section of residents at Meharry Medical College between December 2014 and January 2015. A total of 60 residents participated in the survey. Of these, 11 (18.3%) were psychiatry residents, 5 (8.3%) each were preventive and occupational medicine residents, while 13 (21.7%) and 26 (43.4%) were family and internal medicine residents, respectively. Compared to other specialties, resident physicians in occupational medicine had higher knowledge of the first step in the management of Ebola virus (EBOV) (p=0.042). On whether use of personal protective equipment (PPE) was required for individuals driving or riding in a vehicle carrying human remains of EBOV patients, only 10 respondents (16.7%) answered correctly, with preventive medicine residents performing significantly better than other physicians (p

BACKGROUND: Exposure to violence may explain sleep inadequacies reported by homeless adults, with women being potentially more susceptible to violence and sleep disturbances than men. This study examined the association between violence and sleep inadequacies among homeless adults and explored differences by sex. METHODS: Adult participants were recruited from a shelter (N=194; 71.1% men, M(age) = 43.8±12.2). Participants self-reported victimization and/or witnessing violence (mugging, fight, and/or sexual assault) at the shelter, sleep duration (over an average 24 hours), insufficient sleep (days without sufficient rest/sleep), and unintentional daytime sleep (days with unintentional sleep) in the past month. Linear regressions were used to estimate associations between violence and sleep inadequacies, controlling for sex, age, race, months homeless, and depression. Moderation by sex was examined via an interaction term following mean-centering of variables. RESULTS: Overall, 20.6% of participants (n=40) reported victimization since moving to the shelter. In the last month, participants reported witnessing an average of 2.9±5.1 acts of violence. Over the same timeframe, participants reported 6.9±2.0 hours of sleep nightly, 11.2±10.7 days of insufficient sleep, and 6.2±8.8 days with unintentional daytime sleep. In adjusted analyses, witnessing violence was associated with insufficient sleep (p=.001). Men and women differed only in age and race in unadjusted analyses; sex was not a significant moderator of any association between violence and sleep in adjusted analyses. CONCLUSIONS: Links between witnessing violence and sleep inadequacies should be considered in shelter health promotion efforts. Successful efforts to minimize violence may reduce insufficient sleep amongst both sexes.

Poor health literacy reduces the efficacy of behavior change interventions, hampers management of health conditions, and attenuates understanding of the prevention and treatment of diseases. Poor health literacy has also been linked to fair/poor self-rated health in domiciled samples; however, there is a paucity of studies on the relation amongst homeless adults, who bear a disproportionate burden of disease and disability and require a high level of care and access to health services. Here, we examined the association between health literacy and self-rated health among a convenience sample of homeless adults. Participants were recruited from six homeless-serving agencies in Oklahoma City (N = 575; 63% men, Mage = 43.6+12.3). We used logistic regression to assess the association between health literacy (confidence completing medical forms: extremely/quite a bit versus somewhat/little bit/not at all) and self-rated health (poor/fair versus good/very good/excellent), controlling for age, subjective social status, education, race, sex, income, health insurance, employment, social security recipient status, diabetes diagnosis, high blood pressure diagnosis, and high cholesterol diagnosis. In the adjusted model, health literate homeless individuals had greater odds of endorsing good/very good/excellent self-rated health compared to those somewhat/a little bit/not at all confident completing medical forms (AOR = 2.02, [CI95% = 1.35-3.02]). Interventions targeted at adjusting reading level and comprehensibility of health information are needed for homeless individuals with poor/limited health literacy, which may ultimately impact their self-rated health. Shelters and homeless-serving agencies could host classes focused on practical skills for enhancing health literacy and/or provide navigation services.

Throughout the world, coal is responsible for generating approximately 38% of power. Coal ash, a waste product, generated from the combustion of coal, consists of fly ash, bottom ash, boiler slag, and flue gas desulfurization material. Fly ash, which is the main component of coal ash, is composed of spherical particulate matter with diameters that range from 0.1 μm to >100 μm. Fly ash is predominately composed of silica, aluminum, iron, calcium, and oxygen, but the particles may also contain heavy metals such as arsenic and lead at trace levels. Most nations throughout the world do not consider fly ash a hazardous waste and therefore regulations on its disposal and storage are lacking. Fly ash that is not beneficially reused in products such as concrete is stored in landfills and surface impoundments. Fugitive dust emissions and leaching of metals into groundwater from landfills and surface impoundments may put people at risk for exposure. There are limited epidemiological studies regarding the health effects of fly ash exposure. In this article, the authors provide an overview of fly ash, its chemical composition, the regulations from nations generating the greatest amount of fly ash, and epidemiological evidence regarding the health impacts associated with exposure to fly ash.

The purpose of this paper is to describe the approaches and recruitment strategies of a study focused on the impact of coal fly ash on neurobehavioral performance among children living in proximity to coal-burning power plants. Challenges encountered with each recruitment approach are highlighted as well as solutions used to overcome those challenges and ultimately enroll children and one of their parents or guardians. To ensure participants were distributed throughout the study area, geographical information systems were used to guide recruitment and achieve the target sample size (N = 300). Several approaches were employed to recruit the number of needed participants, including "shoe leather" or door-to-door recruitment, placement of flyers and brochures in public spaces, mailings to targeted addresses, media announcements, and local government outreach. Since September 2015, 265 participants have been enrolled in the study using a combination of the described recruitment approaches. Even with a well-designed plan, it is important to re-examine strategies at every step to maximize recruitment efforts. Researcher flexibility in adapting to new strategies is vital in facilitating recruitment efforts, and the recruitment of participants in the study remains a dynamic and evolving process.

BACKGROUND: We examined antiretroviral therapy (ART) initiation and retention by sex and pregnancy status in rural Nigeria. METHODS: We studied HIV-infected ART-naive patients aged >/=15 years entering care from June 2009 to September 2013. We calculated the probability of early ART initiation and cumulative incidence of loss to follow-up (LTFU) during the first year of ART and examined the association between LTFU and sex/pregnancy using Cox regression. RESULTS: The cohort included 3813 ART-naive HIV-infected adults (2594 women [68.0%] 273 [11.8%] of them pregnant). The proportion of pregnant clients initiating ART within 90 days of enrollment (78.0% 213/273) was higher than among non-pregnant women (54.3%1261/2321) or men (53.0% 650/1219) both p

Vanderbilt University affiliate Friends in Global Health was funded in 2008 to support comprehensive HIV/AIDS services in north-central Nigeria. We summarise programme characteristics and trends in enrolment and quality of data collection in this rural, resource-limited environment.We used routinely collected programme data in supported sites from June 1 2009 to September 30, 2013.Baseline characteristics were defined as those collected closest to a 90-day window period before and after enrolment. Summary characteristics were compared by site and enrolment year.We enrolled 3,960 HIV-infected patients into care (68% women), median age of 32 years [interquartile range (IQR): 27-40]. Most clients were married (79%) and unemployed (60%). At enrolment, median CD4+ cell count was 230 cells/μL (IQR: 114-390) and haemoglobin was 10.7 g/dL (IQR: 9.3-11.9). Advanced clinical disease [World Health Organization (WHO) clinical stage III/IV] at enrolment was documented in 29% of clients. Cumulative enrolment increased from 377 patients in 2009 to 3,960 patients by 2013.With each successive year, more clients were enrolled at earlier stages of disease; in 2009, 37% of patients were identified as WHO clinical stage I, while in 2013, 55% of patients were so classified. While documentation of clinical staging remained stable, the completeness of CD4+ cell count and haemoglobin data declined with time.Expanded testing in a comprehensive HIV programme in rural Nigeria brought persons to care at earlier stages of illness. Yet, as clinical services expanded, data collection quality declined. The paradox of successful scaling up HIV services but deteriorating quality of data underscores the importance of data management training and quality improvement efforts.

Women are by no means the exclusive victims of intimate partner violence (IPV). This study assessed the lifetime prevalence and predictors of female-perpetrated IPV among public servants in Kano, Nigeria. Using a descriptive cross-sectional design and systematic sampling, pre-tested structured self-administered questionnaires were used to assess prevalence, types, and predictors of IPV among 302 married men. The lifetime prevalence of IPV was 66.8% ( n = 177; 95% confidence interval [CI] = [60.7, 72.4]). Of surveyed men who have ever experienced violence, 78.0% ( n = 138), 81.4% ( n = 144), and 16.4% ( n = 29) encountered physical assault, psychological aggression, and sexual coercion, respectively. After controlling for confounders, having ≥5 children, adjusted odds ratio (aOR) [95% CI] = 3.93 [1.16, 13.29], p = .027, and childhood experience of violence, aOR [95% CI] = 0.14 [0.05, 0.39], p = .0001, remained significant predictors of female-perpetrated IPV. In conclusion, female-perpetrated IPV is prevalent in northern Nigeria. Addressing IPV will require comprehensive violence prevention measures, including counseling and support for victims and exposed children.

Objective To determine the prevalence of and risk factors for intimate partner violence (IPV) among women attending a large urban fertility clinic in Kano, Nigeria. Methods Interviewers administered questionnaires to a cross-section of women attending an infertility clinic in Northwest Nigeria, regarding their experience of IPV and associated factors. Results In total, 373 individuals were interviewed. Of the individuals interviewed, 134 (35.9%; 95% confidence Interval [CI] 31.1%–41.0%) had experienced at least one form of IPV in the preceding year. Of the 134 patients who had encountered violence, 126 (94.0%), 111 (82.8%), 47 (35.1%), and 25 (18.7%) had experienced psychological, sexual, verbal, and physical forms of violence, respectively. Of the affected individuals, 34 (25.4%) experienced multiple forms of violence, with spouses being the main perpetrators. A lack of formal education (adjusted odds ratio [OR] 2.21; 95%CI 1.21–7.43), employment in the informal sector (OR 2.01; 95%C: 1.02–4.52), and having an unemployed spouse (OR 1.56; 95%CI 1.02–3.15) or one with low level of education (OR 2.32; 95%CI 1.87–4.21) were independently associated with IPV. Conclusion In this setting, women who were infertile experienced a high incidence of IPV. Women presenting at fertility clinics should be screened for IPV and provided with links to appropriate support services.

Background Multidrug resistant tuberculosis (MDR-TB), is an emerging public health problem in sub-Saharan Africa (SSA). This study aims to determine the trends in prevalence of MDR-TB among new TB cases in sub-Saharan Africa over two decades. Methods We searched electronic data bases and accessed all prevalence studies of MDR-TB within SSA between 2007 and 2017. We determined pooled prevalence estimates using random effects models and determined trends using meta-regression. Results Results: We identified 915 studies satisfying inclusion criteria. Cumulatively, studies reported on MDR-TB culture of 34,652 persons. The pooled prevalence of MDR-TB in new cases was 2.1% (95% CI; 1.7-2.5%). There was a non-significant decline in prevalence by 0.12% per year. Conclusion We found a low prevalence estimate of MDR-TB, and a slight temporal decline over the study period. There is a need for continuous MDR-TB surveillance among patients with TB.