Enterococcus contamination of infant foods and implications for exposure to foodborne pathogens in peri-urban neighbourhoods of Kisumu, Kenya.

We collected infant food samples from 714 households in Kisumu, Kenya, and estimated the prevalence and concentration of Enterococcus, an indicator of food hygiene conditions. In a subset of 212 households, we quantified the change in concentration in stored food between a morning and afternoon feeding time. In addition, household socioeconomic characteristics and hygiene practices of the caregivers were documented. The prevalence of Enterococcus in infant foods was 50% (95% confidence interval: 46.1 - 53.4), and the mean log10 colony-forming units (CFUs) was 1.1 (SD + 1.4). No risk factors were significantly associated with the prevalence and concentration of Enterococcus in infant foods. The mean log10 CFU of Enterococcus concentration was 0.47 in the morning and 0.73 in the afternoon foods with a 0.64 log10 mean increase in matched samples during storage. Although no factors were statistically associated with the prevalence and the concentration of Enterococcus in infant foods, household flooring type was significantly associated with an increase in concentration during storage, with finished floors leading to 1.5 times higher odds of concentration increase compared to unfinished floors. Our study revealed high prevalence but low concentration of Enterococcus in infant food in low-income Kisumu households, although concentrations increased during storage implying potential increases in risk of exposure to foodborne pathogens over a day. Further studies aiming at investigating contamination of infant foods with pathogenic organisms and identifying effective mitigation measures are required to ensure infant food safety.

Effectiveness of implementing evidence-based approaches to promote physical activity in a Midwestern micropolitan area using a quasi-experimental hybrid type I study design.

BACKGROUND: Much evidence-based physical activity (PA) interventions have been tested and implemented in urban contexts. However, studies that adapt, implement, and evaluate the effectiveness of these interventions in micropolitan rural contexts are needed. The study aimed to evaluate the effectiveness of the Active Ottumwa intervention to promote PA in a micropolitan community. METHODS: Between 2013 - 2019, we implemented Active Ottumwa in a micropolitan setting, and subsequently implemented and evaluated its effectiveness using a Hybrid Type I design. In this paper, we describe the intervention's effectiveness in promoting PA. We collected PA data over 24 months from a cohort of community residents using accelerometers and PA data from two cross-sectional community surveys administered in 2013 and 2018, using the Global Physical Activity Questionnaire. RESULTS: From the cohort, we found significant change in PA over 24 months (P = 0.03) corresponding to a 45-min daily decrease in sedentary activity, a daily increase of 35-min in light PA and 9 min in moderate-to-vigorous PA. There was a statistically significant (P = 0.01) increasing trend at the population-level in the moderate-to-vigorous composition of 7 min between the two cross-sectional assessments (95% CI: 0.1%-1.34%). CONCLUSIONS: The study demonstrates that the adapted evidence-based PA interventions in a micropolitan context is effective.

The Association Between State Characteristics and Latinx People's Treated Hypertension in Established and New Latinx Destination States: A Multilevel Analysis.

This study sought to quantify the contributions of state-level factors including income inequality, state's legislature political control, and Medicaid expansion in new and established Latinx destination states on Latinx individuals' treated hypertension. Mixed-effects logistic regression analyses were conducted to analyze 2017 Behavioral Risk Factor Surveillance System data from 7524 Latinx adults nested within 39 states. Overall, 70% reported being pharmacologically treated for hypertension, and 66% resided in established destination states. Compared with Latinx people in established destination states, Latinx people in new destinations had lower odds of having treated hypertension (odds ratio [OR] = 0.72, 95% CI = 0.54-0.95). Within established Latinx destinations, the odds of treated hypertension were lower in states where legislatures expanded Medicaid than in states that did not expand Medicaid (OR = 0.84, 95% CI = 0.79-0.89). However, after controlling for the effects of individual-level factors, this association was no longer statistically significant. In new Latinx destination states, Medicaid expansion, legislatures' political control, and income inequality were not associated with treated hypertension. The study results highlight the importance of considering both individual- and state-level factors, as the interplay of such factors could hinder the successful implementation of cardiovascular risk reduction interventions.

The "dirty work" of last responders: Occupational stigma risk and protective factors.

Last responders constitute an occupational category that includes all those who are involved in the postmortem care of deceased persons and their families. The work of last responders is often considered "dirty work" and, as a result, stigmatized. Last responders are aware of this stigma, and stigma consciousness has been associated with negative health outcomes. Despite the wide acknowledgment of stigma among last responders, specific risk, or protective factors for experiencing stigma have not been investigated. This paper aims to identify determinants of stigma among last responders in the United States. The data for this study were obtained from a national cross-sectional survey of last responders. The survey included a measure of stigma and multiple sociodemographic characteristics. A hurdle model was used to assess the association between the characteristics of last responders and their perceived stigma. Respondents were predominantly male (55.1%), White non-Hispanic (90.2%), and employed full-time (96%). Seventy-seven percent reported having experienced at least one form of occupation-related stigma. There was no significant association between the experience of stigma and any socio-demographic variables. The experience of stigma is nearly ubiquitous among last responders->75% of last responders in the sample experienced at least one form of stigma. Another aspect of its ubiquitous nature is the lack of evidence that stigma was experienced differentially across sex, race/ethnicity, employment type, and length of years as a last responder. Interventions are needed to decrease stigma among last responders and to support last responders in managing the consequences of the stigma they experience.

Ignored and distressed: a cross-sectional study of the impact of COVID-19 on last responders.

BACKGROUND: Last responders constitute an occupational category that includes all those that are involved in the postmortem care of deceased persons and their families. Last responders are exposed to several categories of work-related stressors that affect their health and well-being. COVID-19 exacerbated these stressors. Research to understand the consequences of COVID-19 on the health and wellbeing of last responders is nascent. This study aimed to assess COVID-19 related stress, coping and wellbeing among last responders in the United States. METHODS: We conducted a national cross-sectional survey of last responders in July through September of 2020. The survey measured wellbeing, stress, coping, and stigma; COVID-19 experiences, and socio-demographics. A ridge regression model was fit for the outcome variables. RESULTS: Analysis was conducted on 366 respondents from 43 states. Respondents were male (55.4%), age 50 + (57.4%), and White non-Hispanic (90.3%); 54% reported moderate-high stress and 41% endorsed mild-severe anxiety. Seventy-seven percent had experienced at least one form of stigma related to their occupation. Variables associated with higher perceived stress and anxiety included gender (female), shorter length of employment, perceiving a higher impact from COVID-19 on everyday life, and increased perceived stigma. CONCLUSIONS: Last responders are a critical part of the health care system. Throughout this pandemic, last responders have been frequently ignored and not prioritized for protection and support. Interventions to support last responders cope with stress, and to decrease anxiety are urgently needed. There is also a critical need to challenge community stigma towards last responders.

Risk for Asymptomatic Household Transmission of Clostridioides difficile Infection Associated with Recently Hospitalized Family Members.

We evaluated whether hospitalized patients without diagnosed Clostridioides difficile infection (CDI) increased the risk for CDI among their family members after discharge. We used 2001-2017 US insurance claims data to compare monthly CDI incidence between persons in households with and without a family member hospitalized in the previous 60 days. CDI incidence among insurance enrollees exposed to a recently hospitalized family member was 73% greater than enrollees not exposed, and incidence increased with length of hospitalization among family members. We identified a dose-response relationship between total days of within-household hospitalization and CDI incidence rate ratio. Compared with persons whose family members were hospitalized <1 day, the incidence rate ratio increased from 1.30 (95% CI 1.19-1.41) for 1-3 days of hospitalization to 2.45 (95% CI 1.66-3.60) for >30 days of hospitalization. Asymptomatic C. difficile carriers discharged from hospitals could be a major source of community-associated CDI cases.

Evidence of within-facility patient-patient Clostridiodes difficile infection spread across diverse settings.

Previous studies have suggested that a hospital patient's risk of developing healthcare facility-onset (HCFO) Clostridioides difficile infections (CDIs) increases with the number of concurrent spatially proximate patients with CDI, termed CDI pressure. However, these studies were performed either in a single institution or in a single state with a very coarse measure of concurrence. We conducted a retrospective case-control study involving over 17.5 million inpatient visits across 700 hospitals in eight US states. We built a weighted, directed network connecting overlapping inpatient visits to measure facility-level CDI pressure. We then matched HCFO-CDIs with non-CDI controls on facility, comorbidities and demographics and performed a conditional logistic regression to determine the odds of developing HCFO-CDI given the number of coincident patient visits with CDI. On average, cases' visits coincided with 9.2 CDI cases, which for an individual with an average length of stay corresponded to an estimated 17.7% (95% CI 12.9-22.7%) increase in the odds of acquiring HCFO-CDI compared to an inpatient visit without concurrent CDI cases or fully isolated from both direct and indirect risks from concurrent CDI cases. These results suggest that, either directly or indirectly, hospital patients with CDI lead to CDIs in non-infected patients with temporally overlapping visits.

Risk for Clostridioides difficile Infection Among Hospitalized Patients Associated With Multiple Healthcare Exposures Prior to Admission.

BACKGROUND: Clostridioides difficile infection (CDI) is a common healthcare-associated infection and is often used as an indicator of hospital safety or quality. However, healthcare exposures occurring prior to hospitalization may increase risk for CDI. We conducted a case-control study comparing hospitalized patients with and without CDI to determine if healthcare exposures prior to hospitalization (ie, clinic visits, antibiotics, family members with CDI) were associated with increased risk for hospital-onset CDI, and how risk varied with time between exposure and hospitalization. METHODS: Records were collected from a large insurance-claims database from 2001 to 2017 for hospitalized adult patients. Prior healthcare exposures were identified using inpatient, outpatient, emergency department, and prescription drug claims; results were compared between various CDI case definitions. RESULTS: Hospitalized patients with CDI had significantly more frequent healthcare exposures prior to admission. Healthcare visits, antibiotic use, and family exposures were associated with greater likelihood of CDI during hospitalization. The degree of association diminished with time between exposure and hospitalization. Results were consistent across CDI case definitions. CONCLUSIONS: Many different prior healthcare exposures appear to increase risk for CDI presenting during hospitalization. Moreover, patients with CDI typically have multiple exposures prior to admission, confounding the ability to attribute cases to a particular stay.

COVID-19 Associated Suicidal Ideation in Older Adults: Two Case Reports With a Review of the Literature.

The COVID-19 pandemic may profoundly harm the mental health and emotional well- being of many older adults. Public health interventions to minimize the spread of the virus have had the unintended consequences of worsening social isolation, financial stress, and unemployment. Results of early research efforts assessing the impact of these interventions on the mental health of older adults have been mixed. Available findings suggest that a subset of community-dwelling older adults have been less negatively impacted than younger adults, while people of color, the poor, residents of nursing homes and other communal living environments, and those living with dementia and their caregivers are more likely to suffer from COVID-related health problems. This manuscript describes two older adults for whom COVID-19 associated stresses caused significant worsening in their psychiatric illnesses, including the emergence of suicidal ideation, summarizes the literature on the impact of interactions between psychosocial stresses and biological factors on the mental health and well-being of older adults, and discusses interventions to help older adults whose mental health has worsened due to COVID-19. Timely and accurate diagnosis, prompt provision of individualized care using both pharmacologic and psychotherapeutic interventions, adoption of new technologies that permit care to be provided safely at a distance and which allow for virtual social interactions, coupled with ongoing advocacy for policy changes that address significant health care disparities and provide older adults continued access to health care and relief from financial hardship, will help older adults remaining as healthy as possible during the pandemic.

Central Nervous System Systemic Lupus Erythematosus (CNS-SLE) Vasculitis Mimicking Lewy Body Dementia: A Case Report Emphasizing the Role of Imaging With an Analysis of 33 Comparable Cases From the Scientific Literature.

INTRODUCTION: Neuropsychiatric symptoms occur in 30% to 40% of patients living with systemic lupus erythematosus (SLE). Brain imaging may play a pivotal role in determining the etiology as it did for the case presented here. METHODS: A new case of central nervous system (CNS) SLE is presented along with an analysis of 33 comparable cases from the scientific literature. RESULTS: A 70-year-old female with subacute cutaneous lupus presented to a university-based geropsychiatry program after 1 year of benign visual hallucinations and several months of shuffling gait, recurrent falls, and forgetfulness. These symptoms were highly suggestive of Lewy body dementia; however, the patient's history of basal ganglia infarct, cognitive testing demonstrating inattention and executive dysfunction, and follow-up brain imaging, which did not reveal acute findings, aligned with cerebral pathology previously attributed to vasculitis and supported the diagnosis of subcortical dementia due to SLE-CNS vasculitis. Oral prednisone 20 mg daily resolved her symptoms. Over the next 19 months, her prednisone was tapered completely and her symptoms did not return. A systematic literature search identified 33 comparable cases. CONCLUSION: An analysis of previously published cases suggests that extending the duration of the prednisone taper beyond 1 year may decrease the risk of later occurring neuropsychiatric symptoms in this patient population.

Conceptualizations of Mental Disorder at a US Academic Medical Center.

How health care professionals conceptualize mental illness has received relatively little attention in existing literature. This survey explored how health care professionals, academic faculty, and trainees at a US academic medical center (departments of psychiatry, neurology, family medicine, and geriatric medicine, as well as medical students, nurses, and social workers) conceptualize the notion of mental disorder. Respondents (N = 209) were asked to rate their agreement or disagreement with a variety of conceptual statements. Overall, distress and impairment were seen as essential features of mental disorder, and the presence of a biological abnormality was not considered necessary. There was significant correlation between disease status and biological etiology attribution for all conditions except homosexuality. Psychology trainees and psychologists were significantly less likely to call a condition a disease compared with other groups. There was a general lack of consensus regarding conceptual issues fundamental to psychiatry. Conceptualizations of mental disorder held by respondents were complex and did not fit easily within the "biological psychiatry" paradigm.

Geriatric Mental Healthcare Training: A Mini-Fellowship Approach to Interprofessional Assessment and Management of Geriatric Mental Health Issues.

INTRODUCTION: The population in United States aged 65 and older has rapidly grown and is projected to grow faster than any other segment of the population. Despite this demographic shift, the nation's geriatric workforce is shrinking. AIM: The primary goal of the fellowship was to form a learning collaborative that would help trainees in medicine, nursing, social work, pharmacy and occupational/physical therapy understand the roles of each discipline involved in the provision of geriatric mental healthcare and to enhance basic knowledge of common geriatric syndromes. METHODS: Faculty from the University of Pittsburgh developed a format for the mini-fellowship. Trainees from five disciplines were recruited for participation in the mini-fellowship. This was offered annually over four-year period, hosted by the John A. Hartford Foundation Centers of Excellence in Geriatric Psychiatry at the University of Pittsburgh and University of California at San Diego. RESULTS: Eighty-one participants across five schools of the health sciences completed the mini-fellowship. Feedback was positive: most participants appreciated learning from other team members, endorsed appreciation of the contributions of other disciplines to patient care, and reported improved understanding of three major geriatric syndromes. CONCLUSION: Conducting an interdisciplinary mini-fellowship in geriatric mental health was feasible and well received by trainees. The fellowship enabled better appreciation for the provision of geriatric mental health care within the context of an interprofessional team. However, decanal and faculty leadership across the schools needs to place greater emphasis on the importance of interprofessional team-based learning and to free up time for such activity.

Analysis of network interventions with an application to hospital-acquired infections.

Regional interventions to prevent the spread of hospital-acquired infections, vaccination campaigns, and information dissemination strategies are examples of treatment interventions applied to members of a network with the intent of effecting a network-wide change. In designing clinical trials or determining policy changes, it may not be cost effective or otherwise possible to treat all actors of a network. There is a notable lack of study designs and statistical frameworks with which to plan a network-wide intervention in this context and analyze the resulting data. This paper builds off of the network autocorrelation model in order to provide such a framework for a pre-post study design. We derive key quantitative measures of the network-wide treatment effect, exact formulas for power analyses of these measures, and extensions for the context in which the network is unknown. As the treatment assignation is part of the network-wide treatment, we provide methods for determining the assignation which optimizes the overall treatment effect over all members of the network subject to any arbitrary set of implementation costs and cost constraint. We implement these methods on Clostridioides difficile data for the state of California, where the hospitals are linked through patient sharing.

Sexuality and the Older Adult.

PURPOSE OF REVIEW: This paper provides an overview of biopsychosocial components of sexuality in older adults, sexual expression in older LGBTQ and cognitively impaired adults, and inappropriate sexual behaviors (ISBs) in dementia. RECENT FINDINGS: Sexual expression of older adults is influenced by diverse psychosocial and biologic determinants including ageist beliefs. Although the prevalence of sexual dysfunction increases with age, studies of sexual satisfaction reveal that only a minority experience significant distress. Stigma against sexual expression in LGBTQ older adults may cause concealment of sexual orientation from family or care providers due to fears of rejection. Cognitive impairment affects frequency of and satisfaction with sexual activity, as well as capacity to consent. Staff biases about sexuality can negatively impact sexual expression in healthcare settings. Dementia-related inappropriate sexual behaviors (ISBs) are common and distressing. Recent research has focused on early identification and prevention of ISB, in addition to management through non-pharmacologic and pharmacologic approaches. Sexuality remains integral to quality of life for many older adults and informed consideration of their needs is critical to healthcare delivery and institutional service planning. A comprehensive understanding of older adults' sexuality can enhance education, research, policy, and clinical care for this growing population.

Gay and Gray Session: An Interdisciplinary Approach to Transgender Aging.

With the overarching goals of improving the healthcare of older transgender individuals and of inspiring pertinent clinical research, a session at the 2017 American Association for Geriatric Psychiatry Annual Meeting focused on an interdisciplinary approach to transgender aging. The older the transgender adult, the more likely the individual grew up in a historical context when there was greater social stigma towards their gender identity, even among mental health professionals. In order to provide optimal healthcare to transgender adults, mental health care providers should become familiar with the basic terminology presented in this article. Transgender older adults face greater risks of poor physical health, disability, anxiety and depressive symptoms, victimization, and stigma, and higher rates of smoking, excessive alcohol use, and risky sexual behavior compared with non-transgender older adults. In spite of notable health disparities, some evidence points to resilience among transgender older adults. The mental health professional often serves as the first contact for a patient who is struggling with gender identity. The role of a mental health professional can be divided into five categories: 1) assessment of gender dysphoria; 2) psychoeducation of patients and family members about the diversity of gender identities and various options for alleviating gender dysphoria; 3) referral to and collaboration with other healthcare professionals; 4) treatment of coexisting mental health concerns; 5) advocating for transgender patients and for the transgender community. Recently, the criteria for medical and surgical transition have been simplified. End-of-life preparations are especially important for transgender individuals.

Fecal Fingerprints of Enteric Pathogen Contamination in Public Environments of Kisumu, Kenya, Associated with Human Sanitation Conditions and Domestic Animals.

Young children are infected by a diverse range of enteric pathogens in high disease burden settings, suggesting pathogen contamination of the environment is equally diverse. This study aimed to characterize across- and within-neighborhood diversity in enteric pathogen contamination of public domains in urban informal settlements of Kisumu, Kenya, and to assess the relationship between pathogen detection patterns and human and domestic animal sanitation conditions. Microbial contamination of soil and surface water from 166 public sites in three Kisumu neighborhoods was measured by enterococcal assays and quantitative reverse transcription polymerase chain reaction (qRT-PCR) for 19 enteric pathogens. Regression was used to assess the association between observed sanitary indicators of contamination with enterococci and pathogen presence and concentration, and pathogen diversity. Seventeen types of pathogens were detected in Kisumu public domains. Enteric pathogens were codetected in 33% of soil and 65% of surface water samples. Greater pathogen diversity was associated with the presence of domestic animal feces but not with human open defecation, deteriorating latrines, flies, or disposal of human feces. Sanitary conditions were not associated with enterococcal bacteria, specific pathogen concentrations, or "any pathogen". Young children played at 40% of observed sites. Managing domestic animal feces may be required to reduce enteric pathogen environmental contamination in high-burden settings.

A qualitative assessment of the smoking policies and cessation activities at smaller workplaces.

BACKGROUND: To reduce the negative consequences of smoking, workplaces have adopted and implemented anti-smoking initiatives. Compared to large workplaces, less research exists about these initiatives at smaller workplaces, which are more likely to hire low-wage workers with higher rates of smoking. The purpose of this study was to describe and compare the smoking policies and smoking cessation activities at small (20-99 employees) and very small (< 20 employees) workplaces. METHODS: Thirty-two key informants coming from small and very small workplaces in Iowa completed qualitative telephone interviews. Data collection occurred between October 2016 and February 2017. Participants gave descriptions of the anti-smoking initiatives at their workplace. Additional interview topics included questions on enforcement, reasons for adoption, and barriers and facilitators to adoption and implementation. The data were analyzed using counts and content and thematic analysis. RESULTS: Workplace smoking policies were nearly universal (n = 31, 97%), and most workplaces (n = 21, 66%) offered activities to help employees quit smoking. Reasons for adoption included the Iowa Smokefree Air Act, to improve employee health, and organizational benefits (e.g., reduced insurance costs). Few challenges existed to adoption and implementation. Commonly cited facilitators included the Iowa Smokefree Air Act, no issues with compliance, and support from others. Compared to small workplaces, very small workplaces offered cessation activities less often and had fewer tobacco policy restrictions. CONCLUSIONS: This study showed well-established tobacco control efforts in small workplaces, but very small workplaces lagged behind. To reduce potential health disparities in smoking, future research and intervention efforts in tobacco control should focus on very small workplaces.

Calibration of the global physical activity questionnaire to Accelerometry measured physical activity and sedentary behavior.

BACKGROUND: Self-report questionnaires are a valuable method of physical activity measurement in public health research; however, accuracy is often lacking. The purpose of this study is to improve the validity of the Global Physical Activity Questionnaire by calibrating it to 7 days of accelerometer measured physical activity and sedentary behavior. METHODS: Participants (n = 108) wore an ActiGraph GT9X Link on their non-dominant wrist for 7 days. Following the accelerometer wear period, participants completed a telephone Global Physical Activity Questionnaire with a research assistant. Data were split into training and testing samples, and multivariable linear regression models built using functions of the GPAQ self-report data to predict ActiGraph measured physical activity and sedentary behavior. Models were evaluated with the testing sample and an independent validation sample (n = 120) using Mean Squared Prediction Errors. RESULTS: The prediction models utilized sedentary behavior, and moderate- and vigorous-intensity physical activity self-reported scores from the questionnaire, and participant age. Transformations of each variable, as well as break point analysis were considered. Prediction errors were reduced by 77.7-80.6% for sedentary behavior and 61.3-98.6% for physical activity by using the multivariable linear regression models over raw questionnaire scores. CONCLUSIONS: This research demonstrates the utility of calibrating self-report questionnaire data to objective measures to improve estimates of physical activity and sedentary behavior. It provides an understanding of the divide between objective and subjective measures, and provides a means to utilize the two methods as a unified measure.

The Seasonal Variability of Surgical Site Infections in Knee and Hip Arthroplasty.

BACKGROUND: Surgical site infections (SSIs) after total knee (TKA) and total hip (THA) arthroplasty are devastating to patients and costly to healthcare systems. The purpose of this study is to investigate the seasonality of TKA and THA SSIs at a national level. METHODS: All data were extracted from the National Readmission Database for 2013 and 2014. Patients were included if they had undergone TKA or THA. We modeled the odds of having a primary diagnosis of SSI as a function of discharge date by month, payer status, hospital size, and various patient co-morbidities. SSI status was defined as patients who were readmitted to the hospital with a primary diagnosis of SSI within 30 days of their arthroplasty procedure. RESULTS: There were 760,283 procedures (TKA 424,104, THA 336,179) in our sample. Our models indicate that SSI risk was highest for patients discharged from their surgery in June and lowest for December discharges. For TKA, the odds of a 30-day readmission for SSI were 30.5% higher at the peak compared to the nadir time (95% confidence interval [CI] 20-42). For THA, the seasonal increase in SSI was 19% (95% CI 9-30). Compared to Medicare, patients with Medicaid as the primary payer had a 49% higher odds of 30-day SSI after TKA (95% CI 32-68). CONCLUSION: SSIs following TKA and THA are seasonal peaking in summer months. Payer status was also a significant risk factor for SSIs. Future studies should investigate potential factors that could relate to the associations demonstrated in this study.

Effect of short-term research training programs on medical students' attitudes toward aging.

Strategies to build a larger workforce of physicians dedicated to research on aging are needed. One method to address this shortage of physician scientists in geriatrics is short-term training in aging research for early-stage medical students. The authors examined the effects of two summer research training programs, funded by the National Institutes of Health, on medical students' attitudes toward aging, using the Carolina Opinions on Care of Older Adults (COCOA). The programs combined mentored research, didactics, and some clinical exposure. In a sample of 134 participants, COCOA scores improved significantly after completion of the research training program. There was a significant interaction of gender, such that female students had higher baseline scores than males, but this gender difference in COCOA scores was attenuated following the program. Four of the six COCOA subscales showed significant improvement from baseline: early interest in geriatrics, empathy/compassion, attitudes toward geriatrics careers, and ageism.