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The Zika Contraception Access Network (Z-CAN) was established during the 2016-2017 Zika virus outbreak in Puerto Rico as a short-term emergency response program providing client-centered contraceptive counseling and same-day access to the full range of reversible contraceptive methods at no cost to women wishing to delay pregnancy. An evidence-based communication campaign, Ante La Duda, Pregunta (ALDP), was launched to encourage utilization of Z-CAN services. We assessed the effectiveness of campaign tactics in increasing awareness of Z-CAN among women in Puerto Rico. Data on campaign exposure and awareness were obtained through a self-administered online survey approximately two weeks after an initial Z-CAN visit, while the number of searches for participating clinics were obtained from monitoring the campaign website. Findings demonstrated that the most common ways survey respondents learned about Z-CAN were through friends or family (38.3%), social media (23.9%), a clinical encounter (12.7%), and website (11.7%). Nearly two-thirds (61.1%) of respondents had heard of the ALDP campaign. Over the campaign's duration, there were 27,273 searches for Z-CAN clinics. Findings suggest that evidence-based communication campaigns may increase awareness of needed public health services during emergencies. Word of mouth, social media, and digital engagement may be appropriate communication tactics for emergency response mobilization.

In December 2021 and early 2022, four medications received emergency use authorization (EUA) by the Food and Drug Administration for outpatient treatment of mild-to-moderate COVID-19 in patients who are at high risk for progressing to severe disease; these included nirmatrelvir/ritonavir (Paxlovid) and molnupiravir (Lagevrio) (both oral antivirals), expanded use of remdesivir (Veklury; an intraveneous antiviral), and bebtelovimab (a monoclonal antibody [mAb]).* Reports have documented disparities in mAb treatment by race and ethnicity (1) and in oral antiviral treatment by zip code-level social vulnerability (2); however, limited data are available on racial and ethnic disparities in oral antiviral treatment. † Using electronic health record (EHR) data from 692,570 COVID-19 patients aged ≥20 years who sought medical care during January-July 2022, treatment with Paxlovid, Lagevrio, Veklury, and mAbs was assessed by race and ethnicity, overall and among high-risk patient groups. During 2022, the percentage of COVID-19 patients seeking medical care who were treated with Paxlovid increased from 0.6% in January to 20.2% in April and 34.3% in July; the other three medications were used less frequently (0.7%-5.0% in July). During April-July 2022, when Paxlovid use was highest, compared with White patients, Black or African American (Black) patients were prescribed Paxlovid 35.8% less often, multiple or other race patients 24.9% less often, American Indian or Alaska Native and Native Hawaiian or other Pacific Islander (AIAN/NHOPI) patients 23.1% less often, and Asian patients 19.4% less often; Hispanic patients were prescribed Paxlovid 29.9% less often than non-Hispanic patients. Racial and ethnic disparities in Paxlovid treatment were generally somewhat higher among patients at high risk for severe COVID-19, including those aged ≥50 years and those who were immunocompromised. The expansion of programs focused on equitable awareness of and access to outpatient COVID-19 treatments, as well as COVID-19 vaccination, including updated bivalent booster doses, can help protect persons most at risk for severe illness and facilitate equitable health outcomes., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. William E. Trick reports institutional support from PCORnet, the National Patient-Centered Clinical Research Network. Anuradha Paranjape reports serving as the uncompensated president of the Association of Chiefs & Leaders of General Internal Medicine. Michael D. Kappelman reports consulting fees from Abbvie, Takeda, Janssen, and Pfizer, and stock ownership in Johnson & Johnson. Joshua L. Denson reports research funding from the American Diabetes Association, the Society of Critical Care Medicine, and the National Institutes of Health (NIH) (Grant funding the Louisiana Clinical and Translational Science Center Roadmap Scholars Award). Thomas W. Carton and Jason P. Block report grant support from NIH, as part of the Researching COVID to Enhance Recovery (RECOVER) research program. No other potential conflicts of interest were disclosed.

During the 2016-2017 Zika virus outbreak, preventing unintended pregnancy was recognized as a primary strategy to reduce adverse Zika-related pregnancy and birth outcomes. To increase awareness and uptake of contraceptive services provided through the Zika Contraception Access Network (Z-CAN) in Puerto Rico, a multi-strategy campaign called Ante La Duda, Pregunta (ALDP) was developed. The principal aim was to increase awareness of Z-CAN services, which included same-day access to the full range of reversible contraceptives at no cost to women living in Puerto Rico who choose to delay or avoid pregnancy during the 2016-2017 Zika virus outbreak. Using diverse strategies, ALDP increased exposure to and engagement with the campaign in order to raise awareness of Z-CAN services in Puerto Rico. The ALDP social marketing campaign played an important role in the overall Z-CAN effort. Of all the strategies utilized, Facebook appears to have reached the most people. While the importance of a social marketing campaign communicating to raise awareness and create demand has long been known, through the ALDP campaign efforts, it was shown that an effective campaign, built on formative research, can be developed and implemented rapidly in an emergency response situation without compromising on content, quality, or reach.

The number of new HIV diagnoses is highest in the South. Many persons who might benefit from pre-exposure prophylaxis (PrEP) are not engaged in the HIV PrEP continuum of care. We analyzed National HIV Behavioral Surveillance data to assess engagement in the PrEP continuum of care among persons with increased HIV risk. We compared PrEP awareness, discussion with a clinical provider, and use among persons living in the South to those living elsewhere in the United States. PrEP awareness was lowest among heterosexual persons (7%), highest among men who have sex with men (85%), and 26% among persons who inject drugs. PrEP use was low among each population (≤ 35% for all cycles). There was limited evidence of differences in PrEP use between persons in southern and non-southern U.S. Efforts are needed to increase use of PrEP among each of the groups with increased HIV risk., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Few studies have assessed providers' intent of prescribing PrEP in the future. We analyzed cross-sectional web-based surveys to estimate trends from 2016 to 2020 in PrEP awareness and prescribing behaviors in the United States among primary care providers. Multivariable logistic regression was used to estimate prevalence of PrEP awareness, prescribing behaviors, and likelihood of prescribing PrEP in the next 12 months. The adjusted prevalence for PrEP awareness was significantly higher in 2019 (93.7%, 95% CI 91.9%, 95.2%) compared to 2018 (88.1%, 95% CI 85.5%, 90.3%). The adjusted prevalence for prescribing PrEP was significantly higher in 2019 (16.4%, 95% CI 13.6%, 19.6%) and 2020 (15.6%, 95% CI 13.0%, 18.7%) compared to 2018 (12.2%, 95% CI 10.0%, 14.7%). Practicing in the West and regularly screening for HIV were associated with higher PrEP awareness and provision. Studies should examine factors associated with PrEP provision for groups with increased risk for HIV.

Nursing homes are high-risk settings for outbreaks of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1,2). During the COVID-19 pandemic, U.S. health departments worked to improve infection prevention and control (IPC) practices in nursing homes to prevent outbreaks and limit the spread of COVID-19 in affected facilities; however, limited resources have hampered health departments' ability to rapidly provide IPC support to all nursing homes within their jurisdictions. Since 2008, the Centers for Medicare & Medicaid Services (CMS) has published health inspection results and quality ratings based on their Five-Star Quality Rating System for all CMS-certified nursing homes (3); these ratings might be associated with facility-level risk factors for COVID-19 outbreaks. On April 17, 2020, West Virginia became the first state to mandate and conduct COVID-19 testing for all nursing home residents and staff members to identify and reduce transmission of SARS-CoV-2 in these settings (4). West Virginia's census of nursing home outbreaks was used to examine associations between CMS star ratings and COVID-19 outbreaks. Outbreaks, defined as two or more cases within 14 days (with at least one resident case), were identified in 14 (11%) of 123 nursing homes. Compared with 1-star-rated (lowest rated) nursing homes, the odds of a COVID-19 outbreak were 87% lower among 2- to 3-star-rated facilities (adjusted odds ratio [aOR] = 0.13, 95% confidence interval [CI] = 0.03-0.54) and 94% lower among 4- to 5-star-rated facilities (aOR = 0.06, 95% CI = 0.006-0.39). Health departments could use star ratings to help identify priority nursing homes in their jurisdictions to inform the allocation of IPC resources. Efforts to mitigate outbreaks in high-risk nursing homes are necessary to reduce overall COVID-19 mortality and associated disparities. Moreover, such efforts should incorporate activities to improve the overall quality of life and care of nursing home residents and staff members and address the social and health inequities that have been recognized as a prominent feature of the COVID-19 pandemic in the United States (5)., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Objective: To evaluate changes in Ebola-related knowledge, attitudes and prevention practices during the Sierra Leone outbreak between 2014 and 2015., Methods: Four cluster surveys were conducted: two before the outbreak peak (3499 participants) and two after (7104 participants). We assessed the effect of temporal and geographical factors on 16 knowledge, attitude and practice outcomes., Findings: Fourteen of 16 knowledge, attitude and prevention practice outcomes improved across all regions from before to after the outbreak peak. The proportion of respondents willing to: (i) welcome Ebola survivors back into the community increased from 60.0% to 89.4% (adjusted odds ratio, aOR: 6.0; 95% confidence interval, CI: 3.9-9.1); and (ii) wait for a burial team following a relative's death increased from 86.0% to 95.9% (aOR: 4.4; 95% CI: 3.2-6.0). The proportion avoiding unsafe traditional burials increased from 27.3% to 48.2% (aOR: 3.1; 95% CI: 2.4-4.2) and the proportion believing spiritual healers can treat Ebola decreased from 15.9% to 5.0% (aOR: 0.2; 95% CI: 0.1-0.3). The likelihood respondents would wait for burial teams increased more in high-transmission (aOR: 6.2; 95% CI: 4.2-9.1) than low-transmission (aOR: 2.3; 95% CI: 1.4-3.8) regions. Self-reported avoidance of physical contact with corpses increased in high but not low-transmission regions, aOR: 1.9 (95% CI: 1.4-2.5) and aOR: 0.8 (95% CI: 0.6-1.2), respectively., Conclusion: Ebola knowledge, attitudes and prevention practices improved during the Sierra Leone outbreak, especially in high-transmission regions. Behaviourally-targeted community engagement should be prioritized early during outbreaks., ((c) 2020 The authors; licensee World Health Organization.)

In response to the Zika virus outbreak in Puerto Rico (2015-2016), the Zika Contraception Access Network (Z-CAN) was established to provide same-day access to the full range of reversible contraception at no cost to women. Formative research was conducted to inform the development of a communication campaign about Z-CAN. Ten focus groups with women and men, aged 18 to 49 years, in Puerto Rico were conducted to collect data on contraception awareness, use, and decision making during the Zika outbreak, as well as culturally appropriate messaging and outreach strategies. Thematic analysis was conducted using the constant comparative method. Data showed that there was community awareness regarding Zika in Puerto Rico. However, it was not a motivating factor in contraception decision making; instead, economic factors were the major drivers. Most participants preferred to receive information on contraception, potential side effects, and where to access contraceptive services via Internet-based channels and health care providers. Based on these findings, the Ante La Duda, Pregunta [When in Doubt, Ask] campaign was launched to promote awareness of Z-CAN services among those who chose to prevent pregnancy during the Zika outbreak. Our results underscore the importance of conducting formative research to develop communication initiatives, while also demonstrating that it is feasible to perform these activities as part of an emergency response.

Background: Between January and October 2016, 575 symptomatic confirmed cases of Zika virus infection were reported in the U.S. Virgin Islands (USVI). Zika virus infection during pregnancy can cause serious birth defects. Preventing unintended pregnancy among women who choose to delay or avoid pregnancy is a primary strategy to reduce these adverse outcomes., Methods: A rapid assessment, using one men's and five women's focus groups (N = 43), was conducted to inform communication efforts to increase awareness of contraception as a means for preventing unintended pregnancy in the context of a Zika outbreak in the USVI., Results: Findings showed that people of reproductive age were aware of the relationship between Zika virus infection during pregnancy and adverse birth outcomes. However, when discussing methods for prevention, participants did not include preventing unintended pregnancy as a strategy to reduce these adverse outcomes. When asked about family planning in the USVI, participants discussed that, for some, planning pregnancies is not common. Participants wanted communications about contraception to include available methods, side effects, costs, and safety. Optimal communication channels included social media and local spokespersons. Participants identified health care providers as a trusted information source., Conclusions: Findings from this assessment informed the design of a culturally appropriate communication strategy to raise awareness of the prevention of unintended pregnancy as a primary strategy to reduce Zika-related adverse birth outcomes in the USVI., (Published by Elsevier Inc.)

Objectives: To examine whether self-reported exposure to Testing Makes Us Stronger™ (TMUS), an HIV testing health communication campaign for black gay, bisexual, and other men who have sex with men (BMSM), was associated with key intermediate outcomes targeted by the campaign's messages., Methods: Data from sexually active, HIV-negative or unknown status BMSM aged 18-44 (N = 590) were collected through an anonymous Web-based survey that measured sociodemographics, campaign exposure, attitudinal beliefs, normative beliefs, self-efficacy, and HIV testing intentions, among other variables. The association between exposure to TMUS and intermediate outcomes was evaluated using propensity-score weight adjusted correlations., Results: Exposure to TMUS was high (43%) among the priority audience. Exposure to the campaign was correlated with 8 of 11 intermediate outcomes measured, including key attitudinal beliefs about the accessibility of the test and benefits to the individual, injunctive norms, self-efficacy, and HIV testing intention., Conclusion: Adhering to principles of effective campaign design, such as using theory as a conceptual foundation for message design, can increase a campaign's chances for successfully meeting its goals and objectives., Practice Implications: Findings from this study can be used to inform message design for other communication efforts to promote HIV testing among BMSM., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Stigmatizing attitudes toward people living with HIV (PLWH) cause psychological distress for PLWH and hinder HIV prevention efforts. We estimated the prevalence of stigmatizing attitudes among 6809 adults and 885 adolescents who responded to online surveys in 2015. Fear of casual contact with PLWH was reported by 17.5% [95% confidence interval (CI) 16.3-18.6%] of adults and 31.6% (CI 27.8-35.4%) of adolescents. Among adults, 12.5% (CI 11.6-13.5%) endorsed a measure of moral judgment toward PLWH. Stigmatizing attitudes toward PLWH persist in the United States. Continued monitoring of these attitudes and efforts to reduce associated stigma are warranted.

Identifying patients at-risk for HIV infection, such as men who have sex with men (MSM), is an important step in providing HIV testing and prevention interventions. It is unknown how primary care providers (PCPs) assess MSM status and related HIV-risk factors. We analyzed data from a panel-derived web-based survey for healthcare providers conducted in 2014 to describe how PCPs in the U.S. determined their patients' MSM status. We calculated adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) to describe PCP characteristics associated with systematically determining MSM status (i.e., PCP used "a patient-completed questionnaire" or "routine verbal review of sex history"). Among the 1008 PCPs, 56% determined MSM status by routine verbal review of sexual history; 41% by patient disclosure; 39% by questions driven by symptoms/history; 23% by using a patient-completed questionnaire, and 9% didn't determine MSM status. PCPs who systematically determined MSM status (n=665; 66%) were more likely to be female (aPR=1.16, CI=1.06-1.26), to be affiliated with a teaching hospital (aPR=1.15, CI=1.06-1.25), to routinely screen all patients aged 13-64 for HIV (aPR=1.29, CI=1.18-1.41), and to estimate that 6% or more of their male patients are MSM (aPR=1.14, CI=1.01-1.30). The majority of PCPs assessed MSM status and HIV risk factors through routine verbal reviews of sexual history. Implementing a systematic approach to identify MSM status and assess risk may allow PCPs to identify more patients needing frequent HIV testing and other preventive services, while mitigating socio-cultural barriers to obtaining such information., (Published by Elsevier Inc.)

Partnership for Health (PfH) is an evidence-based, clinician-delivered HIV prevention program conducted in the United States for HIV-positive patients. This intervention strives to reduce risky sexual behaviors through provider-patient discussions on safer sex and HIV status disclosure. A cross-sectional, mixed-methods design was used to evaluate the dissemination and implementation of PfH, including training evaluations, an online trainee survey, and interviews with national trainers for PfH. Descriptive statistics were calculated with the categorical data, whereas thematic analysis was completed with the qualitative data. Between 2007 and 2013, PfH was disseminated to 776 individuals from 104 different organizations in 21 states/territories. The smallest proportion of trainees was physicians (6.9%). More than three-fourths of survey respondents (78.6%) reported using PfH, but less than one-third (31.8%) used the intervention with every patient. The PfH training supports the implementation of the intervention; however, challenges were experienced in clinician engagement. Tailored strategies to recruit and train clinicians providing care to HIV-positive patients are required.

Objectives: We estimated the number of women of reproductive age in need who would gain coverage for contraceptive services after implementation of the Affordable Care Act, the extent to which there would remain a need for publicly funded programs that provide contraceptive services, and how that need would vary on the basis of state Medicaid expansion decisions., Methods: We used nationally representative American Community Survey data (2009), to estimate the insurance status for women in Massachusetts and derived the numbers of adult women at or below 250% of the federal poverty level and adolescents in need of confidential services. We extrapolated findings to simulate the impact of the Affordable Care Act nationally and by state, adjusting for current Medicaid expansion and state Medicaid Family Planning Expansion Programs., Results: The number of low-income women at risk for unintended pregnancy is expected to decrease from 5.2 million in 2009 to 2.5 million in 2016, based on states' current Medicaid expansion plans., Conclusions: The Affordable Care Act increases women's insurance coverage and improves access to contraceptive services. However, for women who remain uninsured, publicly funded family planning programs may still be needed.

We assessed the impact of Central Hillsborough Healthy Start (CHHS), a federally-funded program dedicated to improving maternal and infant outcomes in a population of high-risk obese mothers in the socio-economically challenged community of East Tampa in Florida on preterm birth and very preterm birth (VPTB). We utilized hospital discharge records linked to vital statistics data in Florida (2004-2007) to study obese women with a singleton birth, matching mothers in the CHHS catchment area with those from the rest of Florida. We conducted conditional logistic regression with the matched data. Obese mothers in the CHHS service area had a 61% lower likelihood of having a VPTB infant than obese mothers in the rest of the state (AOR = 0.39, 95% CI 0.21-0.70). Obese women of reproductive age may benefit from services from federal Healthy Start programs. Study findings underscore the need for further research to explore the impact of such programs.

Prior research indicates that infants with absent fathers are vulnerable to unfavorable fetal birth outcomes. HIV is a recognized risk factor for adverse birth outcomes. However, the influence of paternal involvement on fetal morbidity outcomes in women with HIV remains poorly understood. Using linked hospital discharge data and vital statistics records for the state of Florida (1998-2007), the authors assessed the association between paternal involvement and fetal growth outcomes (i.e., low birth weight [LBW], very low birth weight [VLBW], preterm birth [PTB], very preterm birth [VPTB], and small for gestational age [SGA]) among HIV-positive mothers (N=4,719). Propensity score matching was used to match cases (absent fathers) to controls (fathers involved). Conditional logistic regression was employed to generate adjusted odds ratios (OR). Mothers of infants with absent fathers were more likely to be Black, younger (<35 years old), and unmarried with at least a high school education (p<.01). They were also more likely to have a history of drug (p<.01) and alcohol (p=.02) abuse. These differences disappeared after propensity score matching. Infants of HIV-positive mothers with absent paternal involvement during pregnancy had elevated risks for adverse fetal outcomes (LBW: OR=1.30, 95% confidence interval [CI]=1.05-1.60; VLBW: OR=1.72, 95% CI=1.05-2.82; PTB: OR=1.38, 95% CI=1.13-1.69; VPTB: OR=1.81, 95% CI=1.13-2.90). Absence of fathers increases the likelihood of adverse fetal morbidity outcomes in women with HIV infection. These findings underscore the importance of paternal involvement during pregnancy, especially as an important component of programs for prevention of mother-to-child transmission of HIV., (© The Author(s) 2013.)

The study purpose was to assess the relationship between various grades of preterm birth (moderate preterm: 33-36 weeks; severe preterm: 27-32 weeks; extreme preterm: ≤ 26 weeks) in the first pregnancy and neonatal mortality (death within 28 days of birth; early: 0-7 days; late: 8-28 days) in the second pregnancy. Using the Missouri maternally-linked dataset (1989-2005), a population-based, retrospective cohort analysis with propensity score-weighted matching was conducted on mothers with two consecutive singleton live births (n = 310,653 women). Women with a prior preterm birth were more likely to subsequently experience neonatal death. The odds increased in a dose-dependent pattern with ascending severity of the preterm event in the first pregnancy (moderate preterm: AOR = 1.32; 95% CI: 1.10-1.60; severe preterm: AOR = 2.62; 95% CI: 2.01-3.41; extreme preterm: AOR = 5.84; 95% CI: 4.28-7.97; p value for trend < 0.001). However, the pathway for the relationship between prior preterm birth and subsequent neonatal mortality may be the recurrence of preterm birth.

To examine the associations between maternal hepatitis B (HBV) and hepatitis C (HCV) infection status and selected infant neurological outcomes diagnosed at birth, we conducted a population-based, retrospective cohort study on singleton live births in Florida from 1998 to 2009. Primary exposures included maternal HBV and HCV monoinfection. The neurological outcomes included brachial plexus injury, cephalhematoma, foetal distress, feeding difficulties, intraventricular h aemorrhage and neonatal seizures. Multivariable logistic regression models were used to generate odds ratios (OR) and 95% confidence intervals (CI) that were adjusted for socio-demographic characteristics, risky behaviours, pregnancy complications and pre-existing medical conditions, and timing of delivery. The risk of an adverse neurological outcome was higher in infants born to mothers with hepatitis viral infection (7.2% for HCV, 5.0% for HBV), compared with infants of hepatitis virus-free mothers (4.2%). After adjusting for potential confounders, women with HBV were twice as likely to have infants who suffered from brachial plexus injury (OR = 2.04, 95% CI = 1.15-3.60), while those with HCV had an elevated odds of having an infant with feeding difficulties (OR: 1.32, 95% CI = 1.06-1.64) and a borderline increased likelihood for neonatal seizures (OR = 1.74, 95% CI = 0.98-3.10). Additionally, HCV+ mothers had a 22% increased odds of having an infant with some type of adverse neurological outcome (OR: 1.22, 95% CI = 1.03-1.44). Our findings add to current understanding of the association between maternal HBV/HCV infections and infant neurological outcomes. Further research evaluating the role of maternal HBV and HCV infections (including viraemia, treatment) on pregnancy outcomes is warranted., (© 2014 John Wiley & Sons Ltd.)

The absence of fathers during pregnancy increases the risk of feto-infant morbidities, including low birth weight (LBW), preterm birth (PTB), and small-for-gestational age. Previous research has shown that the Central Hillsborough Healthy Start project (CHHS)-a federally funded initiative in Tampa, Florida-has improved birth outcomes. This study explores the effectiveness of the CHHS project in ameliorating the adverse effects of fathers' absence during pregnancy. This retrospective cohort study used CHHS records linked to vital statistics and hospital discharge data (1998-2007). The study population consisted of women who had a singleton birth with an absent father during pregnancy. Women were categorized based on residence in the CHHS service area. Propensity score matching was used to match cases (CHHS) to controls (rest of Florida). Conditional logistic regression was employed to generate odds ratios (OR) and 95 % confidence intervals (CI) for matched observations. Women residing in the CHHS service area were more likely to be high school graduates, black, younger (<35 years), and to have adequate prenatal care compared to controls (p < 0.01). These differences disappeared after propensity score matching. Mothers with absent fathers in the CHHS service area had a reduced likelihood of LBW (OR 0.76, 95 % CI 0.65-0.89), PTB (OR 0.72, 95 % CI 0.62-0.84), very low birth weight (OR 0.50, 95 % CI 0.35-0.72) and very preterm birth (OR 0.48, 95 % CI 0.34-0.69) compared to their counterparts in the rest of the state. This study demonstrates that a Federal Healthy Start project contributed to a significant reduction in adverse fetal birth outcomes in families with absent fathers.

Objective: To compare the prevalence of demographic characteristics and sexual behaviours across age groups and to estimate their significance in predicting sexual risk factors by age cohort., Methods: This cohort study examined sexually transmitted infection (STI) prevalence among heterosexual men in Brazil, Mexico and the USA (N=3047). Participants completed a sexual risk factor questionnaire and were tested for chlamydia, gonorrhoea, syphilis and genital herpes. We examined sexual risk in the study population through a composite measure of STI positivity by age cohort (young: 18-30 years; middle-aged: 31-44 years; older: 45-70 years). Multivariable logistic regression models were used to generate adjusted odds ratios (AORs) and 95% confidence intervals (CIs)., Results: We found that STI positivity varied significantly by age group among heterosexual men by a number of covariates. In younger men, having more advanced education had a protective effect (16 years: AOR=0.37, 95% CI 0.15- 0.92), whereas higher numbers of sexual partners elevated the risk for STIs (20-49 partners: AOR=2.06, 95% CI 1.04-4.06; ≥ 50 partners: AOR=4.33, 95% CI 1.74-10.76). Middle-aged men who were black (AOR=1.64, 95% CI 1.10-2.42) and divorced/separated/widowed (AOR=1.91, 95% CI 1.21-3.02) had an increased risk for a positive STI test. Among older men, a younger age at first vaginal sexual encounter (AOR=3.75, 95% CI 1.45-9.74) and a history of exchanging sex for money or drugs heightened STI risk (AOR=2.30, 95% CI 1.0-5.04)., Conclusions: These findings demonstrate that age-related life experiences among heterosexual men influence sexual risk and STI transmission. This topic warrants further investigation to support the development and implementation of targeted interventions that may potentially reduce adverse sexual health outcomes., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

In Tampa, Florida, researchers have partnered with community- and faith-based organizations to create the Comparative Effectiveness Research for Eliminating Disparities (CERED) infrastructure. Grounded in community-based participatory research, CERED acts on multiple levels of society to enhance informed decision making (IDM) of prostate cancer screening among Black men. CERED investigators combined both comparative effectiveness research and community-based participatory research to design a trial examining the effectiveness of community health workers and a digitally enhanced patient decision aid to support IDM in community settings as compared with "usual care" for prostate cancer screening. In addition, CERED researchers synthesized evidence through the development of systematic literature reviews analyzing the effectiveness of community health workers in changing knowledge, attitudes and behaviors of African American adults toward cancer prevention and education. An additional systematic review analyzed chemoprevention agents for prostate cancer as an emerging technique. Both of these reviews, and the comparative effectiveness trial supporting the IDM process, add to CERED's goal of providing evidence to eliminate cancer health disparities.

Aim: The aim of this paper was to assess the association between all-cause infant mortality (death<365 days) in the first pregnancy and the risk of preterm birth (<37 weeks of gestation) in the second pregnancy., Methods: Using the Missouri maternally linked dataset from 1989 to 2005 (N.=639134 singleton live births), we conducted a population-based retrospective cohort analysis with women who had two singleton births between 1989 and 2005. We employed Cox Proportional Hazards Regression to generate adjusted hazard ratios (AHR) and 95% confidence intervals (CI) to approximate relative risks., Results: Prior infant mortality was associated with an increased risk for preterm birth in the second pregnancy (AHR=1.96, 95% CI=1.80-2.13). For black women, the risk of preterm birth following infant mortality was more than three-fold (AHR=3.37, 95% CI=2.92-3.89), while the risk for white women was twice as high (AHR=2.04, 95% CI=1.86-2.26) (referent=white women without infant death in the first pregnancy)., Conclusion: Women with a history of infant mortality are at risk for preterm birth in subsequent pregnancies. This risk was significantly elevated for black women. These findings provide further evidence that previous childbearing experiences play a critical role in the occurrence of adverse feto-infant outcomes.

To evaluate the relationship between pregnancy weight gain and placental abruption, Missouri's population-based, maternally linked, longitudinal dataset (1989-2005, n = 1,146,935) was assessed. Regardless of baseline body mass index, women who gained less than the optimal amount recommended by the Institute of Medicine had a 67% increased likelihood of placental abruption (adjusted odds ratio [AOR] for placental abruption = 1.673; 95%CI = 1.588-1.762) compared with those who gained an optimal amount of weight, while those who gained more than the recommended optimal amount of weight had a 30% reduced AOR for placental abruption (AOR = 0.695, 95%CI = 0.660-0.731). These findings underscore the importance of maternal weight management as part of preconception care to improve pregnancy outcomes., (© 2013 International Life Sciences Institute.)

Objective: The contribution of sickle cell disease (SCD) and other common thalassemias in infants to adverse birth outcomes is under-studied. We therefore sought to compare adverse birth outcomes in infants with and without hemoglobinopathy., Study Design: Retrospective cohort study utilizing a population-based dataset from Florida (1998-2007, n=1,564,038). The primary outcomes were low birthweight (LBW), very low birthweight (VLBW), preterm birth (PTB), very preterm birth (VPTB) and small for gestational age (SGA). We used propensity scores to match infants with hemoglobinopathy to those without hemoglobinopathy on selected variables. To approximate relative risks, we generated adjusted odds ratios (AOR) and 95% confidence intervals (CI) from logistic regression models and accounted for the matched design using generalized estimating equations framework., Results: Infants with SCD or thalassemia had a heightened risk for LBW (AOR=1.58, 95% CI: 1.29-1.93), VLBW (AOR=3.01, 95% CI: 2.12-4.25), PTB (AOR=1.36, 95% CI: 1.12-1.65), VPTB (AOR=2.70, 95% CI: 1.93-3.78), and neurological conditions (AOR=2.04, 95% CI: 1.48-2.81) compared to infants without hemoglobinopathy., Conclusion: Infants with SCD or thalassemia experience considerably higher risks for multiple infant morbidities. Our findings are potentially important in prenatal counseling, as well as for targeted care of affected pregnancies in the prenatal period., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

To examine the association between prior infant mortality and subsequent risk for small for gestational age (SGA). This population-based, retrospective cohort study used the Missouri maternally linked, longitudinal dataset (1989-2005). Analyses were restricted to women who had two singleton pregnancies during the study period. Logistic regression was conducted to obtain adjusted odds ratios (AOR) and 95 % confidence intervals (CI) for the association between infant mortality in the first pregnancy and SGA in the second pregnancy. Women with a prior occurrence of infant death were more likely to be black and obese and had lower educational levels and had higher rates of pregnancy-related complications (p < 0.01). White women with previous infant mortality were at 1.46 times greater risk for SGA in the subsequent pregnancy (AOR = 1.46, 95 % CI = 1.24-1.71). For black women with prior infant death, the risk for SGA increased to 2.77 times (AOR = 2.77, 95 % CI = 2.19-3.51). White mothers who experienced infant mortality coupled with SGA in the first pregnancy had a nearly threefold heightened risk for SGA in the second pregnancy (AOR = 2.89, 95 % CI = 2.21-3.78), whereas black women with this history were more than four times as likely to have an infant with SGA (AOR = 4.60 95 % CI = 3.05-6.96). Prior occurrence of infant mortality is associated with increased risk for subsequent SGA. This finding has important implications for health professionals, as targeted inter-conception strategies for women who have experienced infant death, as well as SGA, may be warranted.

Objective: This systematic review was conducted to synthesize the existing evidence regarding key considerations influencing African Americans' participation in cancer clinical trials (CCTs)., Methods: The PubMed and PsycINFO databases were searched to identify peer-reviewed publications during the last decade (2002-2011) that met our inclusionary criteria. Our search utilized Boolean combinations of the following terms: "clinical trial"; "cancer"; "neoplasm"; "African American"; "Black"; "caregiver"; "decision making"; "recruitment"; "companion"; "family"; "significant other"; and "social support"., Results: A total of 267 articles were identified in the database searches. Of these articles, a total of 31 were determined to meet the inclusion criteria and were retained for review. Key issues that emerged as impediments to a successful recruitment of African Americans to CCTs included negative attitudes towards clinical trials, low levels of knowledge and awareness regarding CCTs, religious beliefs, and structural barriers, such as transportation, childcare, and access to health care. Recommendations from physicians, family members, and friends may promote CCT participation. Multimedia, and culturally-appropriate recruitment approaches may also be effective in soliciting participation among African Americans., Conclusion: Existing research underscores the importance of social support from family and friends, cultural appropriateness and sensitivity from physicians and in the design of the CCT, and enhanced education among African Americans in decision-making processes. As African Americans are underrepresented in CCTs, targeted strategies to enhance recruitment efforts and improve cancer treatment outcomes are essential., (Published by Elsevier Inc.)

Quality of life has emerged as an essential health component that broadens the traditionally narrow concerns focused on only morbidity and life expectancy. Although a growing number of tools to measure quality of life are in circulation, there is a lack of guidelines as well as rigorous assessment for their use with pregnant and postpartum populations. It is also unclear whether these instruments could validly be employed to measure patient-reported outcomes in comparative effectiveness research of maternal care interventions. This paper reviews articles cited in CINAHL, COCHRANE, EMBASE, PSYCINFO, and PUBMED that addressed quality of life in pregnant and postpartum populations. Instruments used to measure quality of life in selected articles were assessed for their adherence to international guidelines for health outcomes instrument development and validation. The authors identified 129 articles that addressed quality of life in pregnant and/or postpartum women. Out of these, only 64 quality (generic and specific) scales were judged relevant to be included in this study. Analysis of measurement scales used in the pregnant and/or postpartum populations revealed important validity, reliability and psychometric inadequacies that negate their use in comparative effectiveness analysis in pregnant and post-partum populations. Valid, reliable, and responsive instruments to measure patient-reported outcomes in pregnant and postpartum populations are lacking. To demonstrate the effectiveness of various treatment and prevention programs, future research to develop and validate a robust and responsive quality of life measurement scale in pregnant and postpartum populations is needed.

Objective: To assess the current state of knowledge regarding sleep disorders and their relationship to obstetric outcomes., Study Design: A systematic literature review of the previous two decades (1991 to 2010) was conducted. The exposure was sleep disorders during pregnancy, and the outcomes of interest were feto-infant morbidity and maternal complications., Results: Sleep apnea, snoring, and sleep quantity/duration were identified as the most frequently examined sleep disorders among pregnant women. Although our review found that studies examining the impact of sleep disorders on feto-infant outcomes were lacking, previous research indicates that such disorders may enhance the risk of preterm birth. Additionally, the current body of evidence suggests that sleep disorders adversely impact maternal health, increasing the likelihood of preeclampsia, and gestational diabetes., Conclusion: Existing research points to the potentially harmful effects of sleep disorders on obstetric outcomes. The limited research in this arena highlights the need for further studies regarding the nature and strength of this relationship. Given the multiple dimensions of sleep and pregnancy, multivariate research approaches that incorporate biological and psychosocial factors are warranted., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

The objective of this study is to evaluate the levels of emergency obstetrics care (EOC) signal functions in health facilities in a developing setting with high maternal morbidity and mortality indices and to determine if there are differences between public and private health facilities in terms of availability of these signal functions. A survey of health facilities was carried out in six of the 16 Local Government Areas (LGAs) of Kwara State Nigeria. All health facilities in these LGAs including public and private health facilities offering some services to pregnant women were surveyed using an interviewer- administered, facility-assessment questionnaire adapted from the WHO/UNFPA/UNICEF international guidelines for monitoring the availability and use of obstetric services. Frequency tables, percentages and charts were used for presenting the data. Comparing public and private facilities was done using chi-square tests. A total of 258 health facilities that provide maternal health services were surveyed in this study, out of which 76 (29.5%) were private facilities and 182 (70.5%) were public sector facilities. Most of the UN indicators were not met by the health facilities in Kwara state. The availability of EOC facilities was more among the private sector and this was statistically significant. This study shows that all stakeholders involved in reducing maternal mortality have a big challenge in the areas of availability, inequity in geographical distribution of EOC facilities and poor utilisation of these EOC services by women.

Advanced maternal age (AMA) and HIV status have been investigated separately for their influence on infant outcomes. Both are associated with adverse fetal growth outcomes, including low birth weight (LBW) and preterm birth (PTB). However, the impact of the cooccurrence of these factors in relation to birth outcomes remains relatively understudied. We analyzed Florida hospital discharge data linked to vital records. The study population consisted of women who had a singleton live birth between 1998 and 2007 (N=1,687,176). The exposure variables were HIV infection and maternal age, while the outcomes of interest were LBW, PTB, and small for gestational age (SGA). We matched HIV-positive women to HIV-negative women on selected variables using propensity scores. To approximate relative risks, we computed adjusted odds ratios (AOR) and 95% confidence intervals (CI) generated from logistic regression models and accounted for the matched design using the generalized estimating equations framework. After adjusting for demographic variables, clinical conditions, and route of birth, the risks of LBW, PTB, and SGA remained significant for HIV-positive women, regardless of age. HIV-positive women of AMA (≥35 years) were more likely to have infants of LBW (AOR=1.73, 95% CI=1.37-2.18), PTB (AOR=1.35, 95% CI: 1.06-1.71), and SGA (AOR=1.52, 95% CI=1.22-1.89), compared to uninfected mothers of younger age (<35 years). For women of advanced age, HIV positivity elevates their risk for LBW and PTB. The interplay of HIV status and age should be considered by healthcare providers when determining appropriate interconception strategies for women and their families.

Objective: To determine whether female genital mutilation (FGM) is a risk factor for intimate partner violence (IPV) and its subtypes (physical, sexual and emotional)., Design: Population-based cross-sectional study., Setting: The study used the 2006 Demographic and Health Survey (DHS) conducted in Mali., Population: A total of 7875 women aged 15-49 years who responded to the domestic violence and female circumcision modules in the 2006 administration of the DHS in Mali., Methods: Multivariable logistic regression was used to compute adjusted odds ratios (aOR) and 95% confidence intervals (CI) to measure risk for IPV., Main Outcome Measures: The outcomes of interest were IPV and its subtypes., Results: Women with FGM were at heightened odds of IPV (aOR 2.71, 95% CI 2.17-3.38) and IPV subtypes: physical (aOR 2.85, 95% CI 2.22-3.66), sexual (aOR 3.24, 95% CI 1.80-5.82), and emotional (aOR 2.28, 95% CI 1.68-3.11). The odds of IPV increased with ascending FGM severity (P for trend <0.0001). The most elevated odds were observed among women with severe FGM, who were nearly nine times as likely to experience more than one IPV subtype (aOR 8.81, 95% CI 5.87-13.24)., Conclusions: Study findings underscore the need for multi-tiered strategies, incorporating policy and education, to reduce FGM and IPV, potentially improving the holistic health and wellbeing of Malian women., (© 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.)

We sought to assess (1) the relationship between air particulate pollutants and feto-infant morbidity outcomes and (2) the impact of a Federal Healthy Start program on this relationship. This is a retrospective cohort study using de-identified hospital discharge information linked to vital records, and air pollution data from 2000 through 2007 for the zip codes served by the Central Hillsborough Federal Healthy Start Project in Tampa, Florida. Mathematical modeling was employed to compute minimal Euclidean distances to capture exposure to ambient air particulate matter. The outcomes of interest were low birth weight (LBW), very low birth weight (VLBW), small for gestational age, preterm (PTB), and very preterm birth. We used odds ratios to approximate relative risks. A total of 12,356 live births were analyzed. Overall, women exposed to air particulate pollutants were at elevated risk for LBW (AOR = 1.24; 95% CI = 1.07-1.43), VLBW (AOR = 1.58; 95% CI = 1.09-2.29) and PTB (AOR = 1.18; 95% CI = 1.03-1.34). Analysis by race/ethnicity revealed that the adverse effects of air particulate pollutants were most profound among black infants. Infants of women who received services provided by the Central Hillsborough Federal Healthy Start Project experienced improved feto-infant morbidity outcomes despite exposure to air particulate pollutants. Environmental air pollutants represent important risk factors for adverse birth outcomes, particularly among black women. Multi-level interventional approaches implemented by the Central Hillsborough Federal Healthy Start were found to be associated with reduced likelihood for feto-infant morbidities triggered by exposure to ambient air particulate pollutants.

Purpose: To examine the association between small for gestational age (SGA) in the first pregnancy and risk for infant mortality in the second pregnancy., Methods: This is a population-based, retrospective cohort study in which we used the Missouri maternally linked cohort dataset for 1978-2005. Analyses were restricted to women who had two singleton pregnancies during the study period. The exposure was SGA in the first pregnancy, whereas the primary outcome was infant mortality in the second pregnancy. Kaplan-Meier Estimate and Cox proportional hazard regression were conducted., Results: Infant mortality was significantly greater among mothers with previous SGA (P < .01). A persistent association of previous SGA with subsequent infant mortality was observed (adjusted hazard ratio [AHR] 1.35, 95% confidence interval [95% CI] 1.24-1.48). Race-specific data illustrated that black women with a previous SGA birth were 40% more likely to experience infant mortality (AHR 1.40, 95% CI 1.21-1.63) than their counterparts without a history of SGA, but white women with a previous SGA had an increased risk of 31% (AHR 1.31, 95% CI 1.17-1.46)., Conclusions: Women with previous SGA bear increased risks for subsequent infant mortality, which was greater among black mothers. Hence, SGA plays an important role in the black-white disparity in infant mortality. Women's previous childbearing experiences could serve as important criterion in determining appropriate interconception strategies to improve infant health and survival., (Copyright © 2012 Elsevier Inc. All rights reserved.)

We sought to assess the association between air particulate pollutants and feto-infant morbidity outcomes across racial/ethnic subgroups. This is a retrospective cohort study from 2000 through 2007 based on three linked databases: (1) The Florida Hospital Discharge database; (2) The vital statistics records of singleton live births in Florida; (3) Air pollution and meteorological data from the Environmental Protection Agency. Using computerized mathematical modeling, we assigned exposure values of the air pollutants of interest (PM(2.5), PM(10) and the PM coarse fraction [PM(10) - PM(2.5)]) to mothers over the period of pregnancy based on Euclidean minimum distance from the air pollution monitoring sites. The primary outcomes of interest were: low birth weight, very low birth weight, preterm birth, very preterm birth, and small for gestational age (SGA). We used adjusted odds ratios to approximate relative risks. We observed increased risk for overall feto-infant morbidity outcome in women exposed to any of the three particulate pollutants (values above the median). Exposed women had increased odds for low birth weight, very low birth weight and preterm birth with the greatest risk being that for very low birth weight (AOR = 1.27, 95% CI = 1.08-1.49). Black women exposed to any particulate pollutant had the greatest odds for all the morbidity outcomes, most pronounced for very low birth weight (AOR = 3.32, 95% CI = 2.56-4.30). Environmental particulate pollutants are associated with adverse feto-infant outcomes among exposed women, especially blacks. Black-white disparity in adverse fetal outcomes is widened in the presence of these pollutants, which provide a target for intervention.

In this population-based retrospective study, we sought to investigate the association between HIV/AIDS during pregnancy and adverse birth outcomes, including low birth weight (LBW), very low birth weight (VLBW), preterm birth (PTB), very preterm birth (VPTB), and small for gestational age (SGA), among women in Florida by sociodemographic variables. Using data from Florida's maternally linked birth cohort files, we examined singleton live births in the state during 1998 to 2007 (N = 1,698,107). The study population was categorized based on the maternal HIV/AIDS status. Poisson regression models were used to generate adjusted rate ratios (ARR) to estimate the association between HIV/AIDS status and fetal growth parameters. The main outcome measures were fetal growth parameters, including LBW, VLBW, PTB, VPTB, and SGA. As compared to HIV/AIDS-negative women, mothers with HIV/AIDS had elevated risks for LBW (ARR = 1.40; 95% CI = 1.30-1.50), VLBW (ARR = 1.25; 95% CI = 1.04-1.51), SGA (ARR = 1.26; 95% CI = 1.17-1.35), PTB (ARR = 1.23; 95% CI = 1.03-1.47), and VPTB (ARR = 1.27; 95% CI = 1.20-1.36). Risk estimates for LBW and SGA were highest among Hispanics mothers with HIV/AIDS, while white mothers with HIV/AIDS had the highest risk levels for VLBW and PTB, compared to their HIV/AIDS negative counterparts. Our findings show that women with HIV/AIDS have elevated risks for inhibited fetal growth and shortened gestation with important racial/ethnic variation. This is the first known population-based study that reveals racial/ethnic differences in HIV/AIDS-related fetal growth morbidity outcomes.

Research investigating the role of paternal age in adverse birth outcomes is limited. This population-based retrospective cohort study used the Missouri maternally linked data set from 1989 to 2005 to assess whether paternal age affects fetal birth outcomes: low birth weight (LBW), preterm birth (PTB), stillbirth, and small size for gestational age (SGA). We examined these outcomes among infants across seven paternal age-groups (<20, 20-24, 25-29, 30-34, 35-39, 40-45, and >45 years) using the generalized estimating equation framework. Compared with infants born to younger fathers (25-29 years), infants born to fathers aged 40 to 45 years had a 24% increased risk of stillbirth but a reduced risk of SGA. A 48% increased risk of late stillbirth was observed in infants born to advanced paternal age (>45 years). Moreover, advanced paternal age (>45 years) was observed to result in a 19%, 13%, and 29% greater risk for LBW, PTB, and VPTB (very preterm birth) infants, respectively. Infants born to fathers aged 30 to 39 years had a lower risk of LBW, PTB, and SGA, whereas those born to fathers aged 24 years or younger had an elevated likelihood of experiencing these same adverse outcomes. These findings demonstrate that paternal age influences birth outcomes and warrants further investigation.

Aim: The aim of this paper was to assess whether maternal obesity causes preeclampsia., Methods: A systematic literature review of the previous two decades (1992-2011) was conducted. The exposure was maternal obesity while the outcome of interest was preeclampsia., Results: Our review revealed consistent findings showing strong association between obesity and preeclampsia. Multiple biomarkers that potentially explain the mechanistic pathway in this relationship were identified, including leptin and adiponectin, matrix metalloproteinase (MMP), C-reactive protein (CRP), and sex hormone-binding globulin (SHBG). A causative biologic linkage remains, however, elusive., Conclusion: Epidemiologic evidence exists linking maternal obesity and preeclampsia. However, the exact causal pathway remains poorly defined. Given the minimal understanding of the nature of this relationship, research studies that utilize prospective designs and expand on the previous examination of biomarkers are recommended to determine potential causative pathways.

Aim: To examine the association between infant mortality, the day of birth and sociodemographic factors., Methods: This population-based retrospective study analyzed all singleton live births in the state of Missouri during the period 1989 to 1997. The main outcome of interest was infant survival after birth. Hazard ratios (HR) and 95% confidence intervals (CI) for the association between infant mortality and the day of birth were obtained through parametric time to event models., Results: The neonatal mortality rate was higher on weekends (3.25/1000) compared to weekdays (2.87/1000) (P = 0.042). Cesarean section delivery increased the risk of neonatal death by a magnitude of 31.5 compared to vaginal births (HR = 31.47, 95% CI: 15.79, 62.74). Adolescent females (age <18) were more likely to experience neonatal (HR = 2.20, 95% CI: 1.47, 3.31), post-neonatal (HR = 2.20, 95% CI: 1.47, 3.30) and infant mortality (HR = 4.06, CI: 2.02, 8.14)., Conclusions: Cesarean section delivery heightens the risk of all infant death, including neonatal and post-neonatal death, regardless of the day of birth, underscoring the need for multi-tiered strategies to reduce the occurrence of medically unnecessary cesarean sections. Furthermore, the elevated risk of infant mortality among adolescent mothers highlights the importance of enhanced preconception care and age-appropriate pregnancy prevention interventions., (© 2012 The Authors. Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology.)

African Americans are disproportionately affected by prostate cancer, yet less is known about the most salient psychosocial dimensions of quality of life. The purpose of this study was to explore the perceptions of African American prostate cancer survivors and their spouses of psychosocial issues related to quality of life. Twelve African American couples were recruited from a National Cancer Institute Comprehensive Cancer Center registry and a state-based non-profit organization to participate in individual interviews. The study was theoretically based on Ferrell's Quality of Life Conceptual Model. Common themes emerged regarding the psychosocial needs of African American couples. These themes were categorized into behavioral, social, psychological, and spiritual domains. Divergent perspectives were identified between male prostate cancer survivors and their female spouses. This study delineated unmet needs and areas for future in-depth investigations into psychosocial issues. The differing perspectives between patients and their spouses highlight the need for couple-centered interventions.