Neighborhood Inequities in Tobacco Product Descriptors, Washington, DC, 2018-2019.

BACKGROUND: The tobacco industry uses product descriptors to communicate reduced harm and increase appeal. This cross-sectional study assessed store-level racial, ethnic, and socioeconomic inequities in the distribution of retail tobacco product descriptors in a convenience sample of retailers in Washington, DC. METHODS: Young adults (n = 146) who did not currently use tobacco reported real-time store visits over 14 days. Trained data collectors took high-resolution photographs of all tobacco (including e-cigarette) marketing in each store (n = 96) participants visited. We coded text descriptors on tobacco product advertisements and displays into descriptor categories (eg, fruit, sweet, concept). We fit multilevel models to examine relationships between store neighborhood census tract-level racial, ethnic, and socioeconomic characteristics and tobacco product descriptors in stores. As a supplementary analysis, we used geospatial methods to model predicted patterns of descriptors at the census tract level. RESULTS: Stores located in census tracts with the highest versus lowest percentage of Black residents had a greater count of fruit, sweet or dessert, alcohol, and concept descriptors (p < .05), similar to findings from the geospatial approach. Adjusted models also indicated some inequities in stores in census tracts with higher percentages of Hispanic or Latino residents for fruit, alcohol, and concept descriptors; however, tract-level models showed opposite results for concept flavors. CONCLUSIONS: In this convenience sample, fruit, alcohol, sweet/dessert, and concept FTP descriptors were prevalent in stores in neighborhoods with more Black residents demonstrated through two analytic approaches. Surveillance using representative samples of tobacco retailers could improve the ability to track the extent of this inequity. IMPLICATIONS: We document inequities in the amount of fruit, sweet or dessert, alcohol, and concept flavor descriptors in stores across neighborhoods in Washington, DC. Federal, state, and local regulatory action is needed to reduce inequities in flavored tobacco product availability and marketing, including for concept flavors.

Adult asthma associated with roadway density and housing in rural Appalachia: the Mountain Air Project (MAP).

BACKGROUND: Appalachian Kentucky is a rural area with a high prevalence of asthma among adults. The relative contribution of environmental exposures in the etiology of adult asthma in these populations has been understudied. OBJECTIVE: This manuscript describes the aims, study design, methods, and characteristics of participants for the Mountain Air Project (MAP), and focuses on associations between small area environmental exposures, including roadways and mining operations, and lifetime and current asthma in adults. METHODS: A cohort of residents, aged 21 and older, in two Kentucky counties, was enrolled in a community-based, cross-sectional study. Stratified cluster sampling was used to select small geographic areas denoted as 14-digit USGS hydrologic units (HUCs). Households were enumerated within selected HUCs. Community health workers collected in-person interviews. The proximity of nearby active and inactive coal mining operations, density of oil and gas operations, and density of roadways were characterized for all HUCs. Poisson regression analyses were used to estimate adjusted prevalence ratios. RESULTS: From 1,459 eligible households contacted, 1,190 individuals were recruited, and 972 persons completed the interviews. The prevalence of lifetime asthma was 22.8%; current asthma was 16.3%. Adjusting for covariates, roadway density was positively associated with current asthma in the second (aPR = 1.61; 95% CI 1.04-2.48) and third tertiles (aPR = 2.00; 95% CI 1.32-3.03). Increased risk of current asthma was associated with residence in public, multi-unit housing (aPR = 2.01; 95% CI 1.27-3.18) compared to a residence in a single-family home. There were no notable associations between proximity to coal mining and oil and gas operations and asthma prevalence. CONCLUSIONS: This study suggests that residents in rural areas with higher roadway density and those residing in public housing units may be at increased risk for current asthma after accounting for other known risk factors. Confirming the role of traffic-related particulates in producing high asthma risk among adults in this study contributes to the understanding of the multiple environmental exposures that influence respiratory health in the Appalachia region.

A New Look at Barriers to Clinical Care Among Appalachian Residents Living With Diabetes.

In the United States, diabetes is the seventh leading cause of death and continues to rise in prevalence, with type 2 diabetes accounting for 90-95% of all cases. Rates of diabetes in Kentucky, and, in particular, the Appalachian region, are among the highest in the nation and are increasing faster than the national average. Despite this disproportionate burden, barriers to clinical appointment attendance have not been fully explored in this population. This article examines the association among perceived barriers to clinical attendance, glycemic control, and diabetes self-care as part of an ongoing study. We used a 25-item checklist developed using the Chronic Care Model to assess participants' barriers to clinic attendance. Glycemic control was assessed via A1C measurement. Diabetes self-care was assessed using the Summary of Diabetes Self-Care Activities measure. At the time of analysis, 123 of the 356 participants (34.6%) did not report any barriers to clinic attendance. For the remainder, the major reported barriers included forgetting appointments, inability to afford medicines or other treatment, and placing faith above medical care. The average A1C was 7.7%, and the average diabetes self-care summary score was 17.1 out of 35 points (with higher values indicating better self-care). Missing clinic appointments is associated with lower health outcomes, especially in vulnerable populations. This study can help educate clinic staff on perceived barriers to type 2 diabetes management among people with diabetes in Appalachia.

Real-Time Context of Tobacco Marketing Exposure and Community Vulnerability-An Ecological Momentary Assessment Among Young Adults.

BACKGROUND: Exposure to tobacco product marketing increases tobacco use among young adults, especially those from vulnerable communities (VCs). PURPOSE: This study examined real-time tobacco marketing exposure among young adults from vulnerable and non-vulnerable communities using Ecological Momentary Assessment (EMA). METHODS: This study used EMA data to assess context (e.g., location and activity) of tobacco marketing exposure using four text-messaging surveys per day over 2 weeks. Young adult non-current tobacco users living in Washington, D.C. (n = 146; ages 18-24) recorded 5,285 surveys, including 20 participants (13.2%) from VCs with high proportions of lower income and racial/ethnic minorities, and high smoking rates. Unadjusted and adjusted multilevel logistic regressions were used to assess the associations between exposure to any and flavored tobacco marketing, VC residence, and real-time context. RESULTS: Fifty-nine participants (40.4%) reported at least one tobacco marketing exposure and recorded 94 exposure moments. In adjusted models, odds of exposure were higher among VC residents (AOR = 2.6, 95% CI = 1.2-5.4), in the presence of anyone using tobacco versus no use (AOR = 4.0, 95% CI = 2.4-6.7), at store/retail (AOR = 17.0, 95% CI = 6.4-44.8), or outside/in transit (AOR = 4.1, 95% CI = 2.1-7.8) versus at home. VC residence (AOR = 7.2, 95% CI = 2.3-22.2) was the strongest predictor of flavored tobacco marketing exposure among all covariates examined. CONCLUSIONS: Young adults are predominantly exposed to tobacco marketing in their daily lives through retail advertisements. Young adults from VCs are at increased risks of seeing any tobacco and especially flavored tobacco marketing. Policies that curtail tobacco retailer density and advertisement displays may reduce overall and differential tobacco marketing exposure.

Inequitable Distribution of FTP Marketing by Neighborhood Characteristics: Further Evidence for Targeted Marketing.

INTRODUCTION: Flavored tobacco products (FTPs) are disproportionately used among young people and racial/ethnic minority populations. However, few studies have examined the retail distribution of such product marketing beyond menthol cigarettes. This study created geographic-based predictions about marketing of FTPs (overall, cigarettes, cigars, e-cigarettes, and smokeless) in stores across Washington, DC neighborhoods. We examined neighborhood-level demographic correlates of the amount of FTP and non-FTP marketing. METHODS: We conducted photographic audits of interior and exterior tobacco marketing in 96 Washington, DC tobacco retailers visited by 149 young adult respondents between 2018-2019. We created a geographic predictive surface of overall and product-specific tobacco marketing and then estimated the average predicted amount of marketing at the census-tract level using zonal statistics. Using linear regression, we examined neighborhood demographic correlates (race/ethnicity, family poverty, and youth population under 18) of FTP and non-FTP marketing. RESULTS: The predicted amount of non-FTP ads/displays were evenly distributed with no neighborhood variability (Range 8.46-8.46). FTP marketing overall was geographically concentrated with greater range across neighborhoods (Range 6.27-16.77). Greater FTP marketing overall and flavored cigar marketing was available in neighborhoods with higher percentages of Black residents. Flavored cigar marketing was less available in neighborhoods with more Hispanic residents, but there was greater flavored smokeless tobacco marketing. Nonflavored marketing overall and by product did not vary across neighborhoods. CONCLUSIONS: This study provides evidence of disproportionate distribution of FTP marketing in Black neighborhoods, especially for flavored cigars, at the point-of-sale. Policies that restrict the sale of FTPs may enhance health equity. IMPLICATIONS: Tobacco marketing has frequently been shown to be more prevalent in neighborhoods with lower household income and more Black residents. Using geographic-based predictions, we find that greater flavored tobacco marketing in these neighborhoods, not decreased marketing for nonflavored tobacco, is driving this disparity. Targeting Black neighborhoods with increased marketing of flavored tobacco products, which has been found to be more appealing, easier to use, and harder to quit is a social justice issue.

An evaluation of injurious falls and Fall-Risk-Increasing-Drug (FRID) prescribing in ambulatory care in older adults.

BACKGROUND: Falls are a major public health problem affecting millions of older adults each year. Little is known about FRID prescribing behaviors after injurious falls occur. The primary objective of this study was to investigate whether an injurious fall is associated with being prescribed a new FRID. METHODS: We conducted a cross-sectional analysis using data from the National Ambulatory Medical Care Survey (2016). We included visits from patients age ≥ 65 years and classified visits based on presence of an injurious fall. The outcome of interest was prescription of new FRID between those with and without an injurious fall. Multivariable logistic regression weighted for sampling and adjusted for demographics, health history and other medications was used. Age and Alzheimer's disease were examined as potential effect measure modifiers. Odds ratios and 95% confidence intervals were reported. Bayes factor upper bounds were also reported to quantify whether the data were better predicted by the null hypothesis or the alternative hypothesis. RESULTS: The sample included 239,016,482 ambulatory care visits. 5,095,734 (2.1%) of the visits were related to an injurious fall. An injurious fall was associated with a non-statistically significant increase in odds of at least one new FRID prescription: adjusted OR = 1.6 (95% CI 0.6, 4.0). However, there was non-statistically significant evidence that the association depended on patient age, with OR = 2.6 (95% CI 0.9, 7.4) for ages 65-74 versus OR = 0.4 (95% CI 0.1, 1.6) for ages ≥ 75. In addition to age, Alzheimer's disease was also identified as a statistically significant effect measure modifier, but stratum specific estimates were not determined due to small sample sizes. CONCLUSIONS: Ambulatory care visits involving an injurious fall showed a non-statistically significant increase in odds of generating a new FRID prescription, but this association may depend on age.

Persistent disparities in smoking among rural Appalachians: evidence from the Mountain Air Project.

BACKGROUND: Adult smoking prevalence in Central Appalachia is the highest in the United States, yet few epidemiologic studies describe the smoking behaviors of this population. Using a community-based approach, the Mountain Air Project (MAP) recruited the largest adult cohort from Central Appalachia, allowing us to examine prevalence and patterns of smoking behavior. METHODS: A cross-sectional epidemiologic study of 972 participants aged 21 years and older was undertaken 2015-2017, with a response rate of 82%. Prevalence ratios and 95% confidence intervals for current smoking (compared to nonsmokers) were computed for the entire cohort then stratified by multiple characteristics, including respiratory health. Adjusted prevalence ratios for current smoking versus not smoking were also computed. RESULTS: MAP participants reported current smoking prevalence (33%) more than double the national adult smoking prevalence. Current smoking among participants with a reported diagnosis of chronic obstructive pulmonary disease and emphysema was 51.5 and 53.3%, respectively. Compared to participants age 65 years and older, those age 45 years or younger reported double the prevalence of smoking (PR: 2.04, 95% CI: 1.51-2.74). Adjusted analyses identified younger age, lower education, unmet financial need, and depression to be significantly associated with current smoking. CONCLUSIONS: Despite declining rates of smoking across the United States, smoking remains a persistent challenge in Central Appalachia, which continues to face marked disparities in education funding and tobacco control policies that have benefitted much of the rest of the nation. Compared with national data, our cohort demonstrated higher rates of smoking among younger populations and reported a greater intensity of cigarette use.

Late-Stage Melanoma: Be Sure to Screen Uninsured, Unmarried Men.

OBJECTIVE: The purpose of this study was to assess for any associations between individual and social factors and late-stage melanoma in Kentucky from 1995 to 2013. METHODS: The study combines three datasets: individual-level data from the Kentucky Cancer Registry, census tract-level data from the US Census, and county-level physician licensure data from the Kentucky Department for Public Health. The study population is described by all cases, early stage, and late stage. Logistic regression was used to evaluate the unadjusted associations between each covariate and early-stage and late-stage disease groups. All of the significant variables were assessed for interaction effect, and the significant interaction terms were used in the final model. Multiple logistic regression provided the final model of late-stage disease. RESULTS: In this study population, a dramatic increase in melanoma incidence is seen from 1995 to 2013 with a threefold increase in the number of cases per year. Of the 10,109 cases reported, 13.6% have late-stage disease, with a mean age for all cases at 56.9 years and the majority being men. Late-stage cases are more commonly uninsured or insured with Medicaid or Medicare compared with cases with early-stage lesions. Having a spouse or partner is clearly protective from being diagnosed as having late-stage melanoma, whereas being uninsured or having Medicaid increases the odds of late-stage melanoma. CONCLUSIONS: The incidence of melanoma is increasing dramatically. With no screening recommendation for the general population from the US Preventive Task Force, clinicians should focus on those at increased risk of late-stage melanoma: unmarried men who are uninsured or receiving Medicaid.

Achieving 80% BSN by 2020: Lessons Learned From Kentucky's Registered Nurses.

OBJECTIVE: The aim of this study was to understand the educational status and plans of Kentucky's RN workforce in advancing nursing educational levels. BACKGROUND: The Institute of Medicine called for 80% of nurses to hold a minimum of a BSN by 2020. Nurse leaders from practice, academe, and the community need evidence to guide the development of effective strategies. METHODS: An electronic survey was administered to Kentucky's RNs. This descriptive analysis was based on 1363 usable responses. RESULTS: Only 40% of Kentucky's RNs held at least a BSN. Another 17% were enrolled in a nursing degree program; half of those enrolled were pursuing a BSN. Of those not enrolled in a degree program, 61.5% reported no plans to return to school. The top barriers were lack of perceived benefit, financial concerns, family obligations, and planned retirement. The top motivating factor was career advancement. CONCLUSION: The gap between the current reality and the goal is wide. Nurse leaders will need to develop creative strategies that strengthen motivating factors and reduce barriers to accelerate movement toward increasing BSN rates.

Limited association between perceived control and health-related quality of life in patients with heart failure.

BACKGROUND: Perceived control has been suggested as a modifiable factor associated with health-related quality of life (HRQOL). However, the relationship between perceived control and HRQOL has not been evaluated in patients with heart failure (HF). The purpose of this study was to determine whether perceived control independently predicts HRQOL in HF patients. METHODS: A total of 423 HF patients were included. Hierarchical linear regression was performed to determine the independent association of perceived control to HRQOL after controlling for covariates. RESULTS: Higher levels of perceived control were associated with better HRQOL in univariate analysis. However, this relationship was strongly attenuated after controlling for relevant demographic, clinical, and psychological factors; the variance in HRQOL explained by the addition of perceived control to this model was small (1.4%). CONCLUSIONS: We found only a weak relationship between perceived control and HRQOL when considered in the presence of demographic, clinical, and psychological factors.

Child and Adolescent Manganese Biomarkers and Adolescent Postural Balance in Marietta CARES Cohort Participants.

BACKGROUND: Manganese (Mn) plays a significant role in both human health and global industries. Epidemiological studies of exposed populations demonstrate a dose-dependent association between Mn and neuromotor effects ranging from subclinical effects to a clinically defined syndrome. However, little is known about the relationship between early life Mn biomarkers and adolescent postural balance. OBJECTIVES: This study investigated the associations between childhood and adolescent Mn biomarkers and adolescent postural balance in participants from the longitudinal Marietta Communities Actively Researching Exposures Study (CARES) cohort. METHODS: Participants were recruited into CARES when they were 7-9 y old, and reenrolled at 13-18 years of age. At both time points, participants provided samples of blood, hair, and toenails that were analyzed for blood Mn and lead (Pb), serum cotinine, hair Mn, and toenail Mn. In adolescence, participants completed a postural balance assessment. Greater sway indicates postural instability (harmful effect), whereas lesser sway indicates postural stability (beneficial effect). Multivariable linear regression models were conducted to investigate the associations between childhood and adolescent Mn biomarkers and adolescent postural balance adjusted for age, sex, height-weight ratio, parent/caregiver intelligence quotient, socioeconomic status, blood Pb, and serum cotinine. RESULTS: CARES participants who completed the adolescent postural balance assessment (n=123) were 98% White and 54% female and had a mean age of 16 y (range: 13-18 y). In both childhood and adolescence, higher Mn biomarker concentrations were significantly associated with greater adolescent sway measures. Supplemental analyses revealed sex-specific associations; higher childhood Mn biomarker concentrations were significantly associated with greater sway in females compared with males. DISCUSSION: This study found childhood and adolescent Mn biomarkers were associated with subclinical neuromotor effects in adolescence. This study demonstrates postural balance as a sensitive measure to assess the association between Mn biomarkers and neuromotor function. https://doi.org/10.1289/EHP13381.

Active coping, personal satisfaction, and attachment to land in older African-American farmers.

Elevated suicide mortality rates have been reported for farmers and for the elderly. Very little literature exists that looks at the health of older minority farmers. This mixed-method study describes older African-American farmers (N = 156) in the contexts of active coping, personal satisfaction from farm work, and attachment to their farmland to provide insight into the psychosocial dimensions of their mental health. Findings show that the farmers have positive perspectives on work and farm future, and strong attachment to the land. Differences were noted by gender. Nurses can use these findings to frame culturally appropriate strategies for aging farmers to maximize positive outcomes.

The relationship between psychosocial factors, self-care, and blood sugar in an Appalachian population.

Introduction: Appalachian residents are more likely than other populations to have Type 2 Diabetes Mellitus (T2DM) and to experience more severe complications from the disease, including excess and premature mortality. Methods: This study examines health alongside sociodemographic factors, psychosocial factors (including knowledge, empowerment, social support/function, religiosity, distress), and perceived problems in diabetes management that may influence self-care and HbA1c among vulnerable rural residents. A survey of a community-based sample of 356 adults with diagnosed diabetes or HbA1c > 6.5 was conducted in six counties in Appalachian Kentucky. Results: Findings suggest that neither religiosity nor social support/function mediate/moderate the relationship between psychosocial factors and dependent variables (problem areas in diabetes, T2DM self-care or HbA1c). Results also suggest that distress is a predictor of problem areas in diabetes, and both distress and empowerment are predictors of T2DM self-care. Implications: This study addresses the gap in the literature concerning the influence of psychosocial factors on problem areas in diabetes, T2DM self-care and HbA1c among vulnerable rural residents, as well as the potential mediating/modifying effects of religiosity and social function/support. Future research is needed to inform strategies for identifying and addressing distress among vulnerable populations burdened by T2DM, including Appalachian adults.

Work organization and occupational health: perspectives from Latinos employed on crop and horse breeding farms.

BACKGROUND: Agriculture is hazardous and increasingly dependent on Latino workers, a vulnerable population. However, little research has studied how work organization influences Latino farmworker health. METHODS: Using a work organization framework, this cross-sectional study describes and compares the work organization and occupational health characteristics of a sample of Latino crop (n = 49) and horse production (n = 54) workers in Kentucky. RESULTS: Crop workers experienced more physical demands, work-related and environmental stressors, and musculoskeletal and ill-health symptoms. Significantly more crop workers indicated work-related illness or missed work due to work-related illness/injury, though one-fourth of both groups reported work-related injury in the past year. A majority of both groups cited exposure to toxic chemicals, a minority of whom received training on their use. CONCLUSION: Further surveillance is needed to understand the rate and precursors of illness/injury in these populations, as is research on the relationship between supervisory practices, psychosocial stressors, and occupational health.

Neighborhood distribution of availability of newer tobacco products: A US four-site study, 2021.

Audits of tobacco retailers can identify marketing patterns as newer tobacco products are introduced in the US. Our study examined store and neighborhood correlates of availability of nicotine pouches and disposable e-cigarettes in four US sites. We conducted standardized store audits of n = 242 tobacco retailers in 2021 in different states: New Jersey, Kentucky, North Carolina, and New York. We geocoded stores linking them with census tract demographics. We conducted unadjusted and adjusted Poisson regression of availability of each product with correlates of the proportion of Non-Hispanic White residents, households under poverty, proximity to schools, site, and store type. Nicotine pouches and disposable e-cigarettes were each available in around half the stores overall, but availability differed across sites (range: 76 %-32 %). In adjusted analyses, nicotine pouches were less likely to be available in each store type vs chain convenience (IRR range 0.2-0.6) and more likely in stores in census tracts with a greater percentage of non-Hispanic White residents (IRR range 1.8-2.3). In contrast, disposable e-cigarettes were more likely to be available in tobacco/vape shops (IRR 1.9 (1.4-2.5) than convenience stores and less likely in non-specialty store types like groceries (IRR 0.2 (0.1-0.4). Newer tobacco products like nicotine pouches and disposable e-cigarettes were widely available in stores across sites, but retail marketing patterns appear to differ. As these product types become subject to increased regulation as they go through the FDA pre-market authorization process, understanding patterns and changes in the retail environment is critical to inform potential policies regulating their sale and marketing.

Impact of the COVID-19 Shutdown on Mental Health in Appalachia by Working Status.

INTRODUCTION: To slow the spread of COVID-19 in the United States, businesses shutdown in Spring 2020. Research has indicated the impact on frontlines workers, yet little is known about the impact on those who were not working outside the home or switched to working remotely. PURPOSE: The purpose of this report is to identify the financial and healthcare issues and mental health impact of the COVID-19 shutdown on Appalachians by worker categories. METHODS: An online survey was administered from May 8 - June 6, 2020 to a convenience sample of previous research participants and shared through social media networks, i.e., snowball sampling. Questions investigated mental health, financial and healthcare issues, and employment status. Survey responses were summarized by percentages overall and by working categories. RESULTS: Of the 751 participants, 276 (42%) resided in Appalachia. After removing 17 who lost their job due to COVID-19, 59 (23%) indicated not working outside the home prior to COVID-19, whereas 111 (43%) and 89 (34%) switched to working remotely and continued working outside the home during the shutdown. Respondents were predominately Caucasian and female. Nearly a quarter of participants had lost or reduced income due to the shutdown. Approximately half missed or postponed healthcare appointments. Mental health impacts were similar across the groups, with half of the respondents reporting anxiety due to COVID-19. IMPLICATIONS: Further research is needed to explore health outcomes associated with missed healthcare appointments during the shutdown. Mental health support may be needed equally by those isolated at home and frontline workers.

Disinfectant use by K-12 school staff to combat SARS-CoV-2.

K-12 school staff from Indiana, Kentucky and Ohio were asked about their use of disinfectants to mitigate the spread of COVID-19 in schools. Survey participants (n = 1,555) reported frequent use of disinfectants, often using unknown products, and were provided little to no training on safe and effective use. Participant concerns included student involvement in disinfection, inadequate ventilation, surface contact time, and potential health effects.

Perceptions of opioid and other illicit drug exposure reported among first responders in the southeast, 2017 to 2018.

BACKGROUND: Opioid use has risen dramatically in recent years, and its illegal use puts first responders at risk when intervening in overdoses. Synthetic opioids, like fentanyl with a potency 50 to 100 times greater than morphine, pose a great risk and accidental exposure via ingestion, inhalation, mucosal, or percutaneous routes, can potentially lead to fatal outcomes. Anecdotal media accounts in early 2017 of accidental occupational opioid exposure among first responders generated a national concern. METHODS: To identify first responders' recollections, beliefs, and concerns about possible occupational exposure to opioids and other drugs, researchers in Kentucky, Virginia, Mississippi, and Georgia administered an emailed, anonymous convenience sample survey. RESULTS: A total of 5955 surveys were analyzed with 15% of respondents reporting they believed they had been exposed to opioids, and of those, less than 1% reported experiencing health effects from perceived exposure. Over half (51%) of respondents reported being "very or somewhat concerned" about developing health effects from exposure to opioids. Half of respondents reported being unaware of Centers for Disease Control and Prevention (CDC)/National Institutes for Occupational Safety and Health (NIOSH) guidelines for preventing occupational-related opioid exposures. CONCLUSIONS: Only a small fraction of first responders believed they had experienced symptoms related to opioid exposure in overdose response calls, but half were concerned about potential exposures and half were unaware of the educational guidance on prevention available. The high level of concern regarding potential exposure warrants the need for the development and or enhancement of targeted educational training interventions and further dissemination of pre-existing training interventions to ensure first responders have the knowledge and understanding of occupational opioid exposures and minimize stress associated with the potential rare exposures.

Exposure risks and tetanus immunization status in farmers ages 50 and over.

BACKGROUND: Despite an effective tetanus vaccine, tetanus continues to claim lives worldwide. The very young and the elderly are at highest risk for the disease. Farmers are at high risk for injury, the leading factor associated with tetanus. METHODS: As part of a larger study of older members of farm households in the southern United States, 595 participants provided data on health, injuries, work, socioeconomic status, and healthcare. RESULTS: 69% reported receiving a tetanus booster in the past ten years, 24% had not, and 7% did not know. Females were less likely to be currently immunized. There was no association between immunization status and age, income, or race. There were associations between farm tasks, farm work-related injury, and immunization. CONCLUSIONS: Older farmers are at risk for tetanus by virtue of their age and work environment. Health care providers should explore strategies to improve immunization status among this work group.

Physicians in Kentucky Perceive Physician Assistants to Be Competent Health Care Providers.

PURPOSE: The use of certified physician assistants (PA) has increased throughout the US health care system. The purpose of this study was to objectively evaluate physicians' perceptions of PAs' mastery of specific skills. It is important to understand stakeholders' perceptions of PAs' capabilities to support future changes in policies for better utilization of PAs in our health care system. METHODS: From 2014 to 2015, randomly chosen "active" physicians listed with the Kentucky Board of Medical Licensure were surveyed about their perceptions of competencies of certified PAs. Six competency domains (medical knowledge, interpersonal and communication skills, patient care, professionalism, practice-based learning, and improvement and systems-based practice) were rated using a Likert scale. Each competency-derived skill-based question was ranked by the number of physicians giving the highest scores on the Likert scale (a score of 4 or 5) and by effect size. Cronbach's alpha for the survey was calculated. RESULTS: An overwhelming majority of the physicians perceived certified PAs to be competent (n ≥ 161, ≥ 60%) for specific skills. The survey had internal consistency with Cronbach's alpha ranging from 0.75 to 0.87 for competency domains. Effect size ranged from 0.44 to 0.98 for scores given by physicians with, versus without, experience with PAs. CONCLUSIONS: For the first time, there is objective evidence of physicians' perceptions of PAs' mastery of specific competency-derived PA skill sets. This study will help guide effective utilization of PAs throughout the health care system and future PA education.