Rural Appalachian Women Will Suffer Disproportionately if Attempts to Further Restrict Emergency Contraception are Successful.

The removal of federal abortion protection has incited fear that restrictions on contraception may be next. Many states now imposing abortion restrictions and bans are in the South and Appalachian Regions of the U.S., where rates of unplanned pregnancy and poor health outcomes are already disproportionately high. Numerous studies have documented variable access to levonorgestrel EC (LNG EC) in community pharmacies, with particularly low rates of access at independent pharmacies that are more likely to be located in rural communities than chain pharmacies. Since the overturn of Roe v. Wade, some large chain pharmacies and online retailers are restricting the purchase of LNG EC, limiting its availability. Some legislators and activists are calling for a ban on EC based on a misunderstanding about its mechanism of action, equating it with abortion. At a time when access to the full range of contraceptive options is more critical than ever, already limited access to LNG EC is worsening. Extensive data on LNG EC availability in 509 pharmacies and 400 health clinics across West Virginia, contextualized with socioeconomic demographics, illustrate existing disparities in LNG EC access.

Levonorgestrel Emergency Contraception Information Accuracy From West Virginia Community Pharmacies: A Mystery Caller Approach.

BACKGROUND: To ensure access to effective levonorgestrel (LNG) emergency contraception (EC), pharmacies must keep medication in stock or available for quick delivery, and pharmacists must be knowledgeable about sales restrictions and the therapeutic window for EC. We conducted a mystery caller study to assess LNG EC availability and information accuracy provided by staff in West Virginia community pharmacies. METHODS: A female research team member posed as a 16-year-old caller to ask pharmacy staff questions about whether LNG EC was in stock, the requirements for purchase, and when it should be taken for effectiveness. Data were analyzed with SPSS using the Pearson's χ2 test to determine if there was a relationship between pharmacy type and response accuracy to our questions about point-of-sale requirements and timing for effectiveness for LNG EC. RESULTS: Of the 506 pharmacies in the sample, 275 (54.3%) were chain pharmacies and 231 (45.7%) were independent. Overall, chain pharmacies provided significantly more accurate answers than independent pharmacies on all point-of-sale requirements. Regarding timing for effectiveness, 49.2% of all pharmacies provided an accurate response (62.9% for chain pharmacies vs. 32.9% for independent pharmacies). CONCLUSIONS: Overall, availability and accuracy regarding LNG EC were poor in West Virginia pharmacies. Pharmacists, particularly those at independent pharmacies serving rural communities, are in a critical and powerful position to influence community health by providing accurate and timely information and access to all contraceptive options, including LNG EC.

The impact of caller characteristics on levonorgestrel emergency contraception access in West Virginia community pharmacies.

OBJECTIVE: Access to levonorgestrel (LNG) emergency contraception (EC) has increased since the FDA removed age restrictions on over-the-counter (OTC) LNG EC in 2013, but availability is highly variable and numerous barriers to access remain. The purpose of this study was to assess availability and accessibility of LNG EC at community pharmacies in West Virginia (WV). METHODS: A mystery caller cross-sectional study was conducted to assess availability and accessibility of LNG EC. Inquiries were made by identified 'research' staff and by staff presenting as a 16 y/o. RESULTS: Nearly half of community pharmacies reported having LNG EC in stock. Pharmacy staff were significantly more likely to tell research callers LNG EC was in stock (53%) and more likely to report willingness to order it (50%) than 'teen' callers (45% and 34%, respectively). There was no significant difference between caller types on the five barriers assessed. CONCLUSION: Lack of availability may contribute to teen and unintended pregnancies.

Acceptability of Time-Limited Eating in Pediatric Weight Management.

Background: Adherence to dietary interventions is a significant barrier in the treatment of childhood obesity. Time-limited eating (TLE) is a simple dietary approach that limits food intake to a given number of consecutive hours per day, but parental and youth acceptability of TLE in youth with obesity is unknown. This study explored the feasibility of utilizing TLE among parents and youth attending pediatric weight management (PWM). Methods: Members of COMPASS (Childhood Obesity Multi-Program Analysis and Study System) developed a survey to assess the acceptability of TLE in families attending PWM, which included patient characteristics, current diet and sleep schedules, and interests in trying TLE. The survey was administered electronically via REDCap or manually to parents of patients between the ages of 8-17 years old and to patients 11-17 years old attending one of five PWM practices in the COMPASS network. Results: Patients (n=213) were 13.0 ± 2.5 years old, 58% female, 52% White, 22% Black, 17% Hispanic/Latino, and 47% reported a diagnosed psychological disorder. On average, parents reported their child's daily eating spanned 12.5 ± 1.9 hours (7:35am - 8:05pm) and included 5.6 ± 1.6 eating bouts (meals + snacks). Most parents reported being likely to try TLE ≤12 hours/d (TLE12: 66%), which was similar to the likelihood of following a nutrient-balanced diet (59%). Likelihood was lower for TLE ≤10 hours/d (TLE10: 39%) or ≤8 hours/d (TLE8: 26%) (p<0.001 for both). Interest in TLE was not consistently related to patient age, sex, or ethnicity, but was lower in patients with a psychiatric diagnosis vs. no diagnosis (TLE8: 19% vs. 32%; p=0.034). Patients of parents who reported being likely to try TLE, compared to those unlikely to try TLE, had shorter eating windows (p<0.001) and ate fewer snacks (p=0.006). Conclusions: Two-thirds of parents with children attending PWM programs report interest in TLE ≤12 hours/d regardless of demographic characteristics, but interest wanes when limiting eating to ≤10 or ≤8 hours per day. Time-limited eating appears to be a feasible option in PWM settings provided treatment options are individualized based on the interests and barriers of patients and their families.

Predicting Adolescent Electronic Cigarette Use: Differences by Never, Ever, and Current Users.

OBJECTIVE: Rising rates of adolescent electronic cigarette (ECIG) use is concerning because it can lead to adverse health outcomes and increased risk behavior. There are known predictors of ever versus never ECIG use, but less are known about risk factors for ever versus current use of ECIGs. Problem behavior theory (PBT) was used to evaluate possible risk factors for different ECIG use status. METHODS: Participants were 573 high school students who completed questionnaires measuring ECIG use, as well as constructs within the Social Environment, Perceived Environment, Personality, and Behavior domains of PBT. Multinomial logistic regression was used to evaluate how predictor variables differentiated between participants who reported (a) never use, (b) ever ECIG use, or (c) current ECIG use. RESULTS: Adolescents were more likely to endorse ever ECIG use than never use if they reported peer ECIG use, perceived more benefits and fewer costs (e.g., health) of ECIG use, higher extraversion, alcohol and cigarette use (never vs. ever vs. past 30 days), or attended a school with a higher percentage of socioeconomically disadvantaged students. Adolescents were more likely to report current ECIG use than ever ECIG use if they perceived fewer costs of ECIG use or used cannabis in their lifetime (yes/no). CONCLUSIONS: PBT variables differentiated between ever ECIG use and never ECIG use. However, these variables did not differentiate between ever and current ECIG use. Identifying unique risk factors for current versus ever ECIG use is important to understanding persistent ECIG use and subsequent targeted prevention and intervention programs.

The [underutilized] power of independent pharmacies to promote public health in rural communities: A call to action.

Independent community pharmacies are in a unique and powerful position to promote public and individual health in their communities. Independent pharmacies are particularly important in rural communities where there are few chain pharmacies and accessible health clinics. West Virginia received national attention recently when they opted out of the Federal Pharmacy Program collaborating with CVS and Walgreens and developed their own plan for COVID-19 vaccine distribution and administration, heavily relying on independent pharmacies and the infrastructure they already have in local communities. However, in other areas of public health with urgent, unmet need, such as pregnancy prevention, there is considerable room for independent pharmacies to improve. The pandemic has allowed independent pharmacies to shine during the vaccination effort and has demonstrated what can be accomplished when policymakers, providers, and pharmacists work together for the benefit of community health. Expanding such collaboration to include contraceptive provision and counseling in a timely, nonjudgmental manner could play a pivotal role in preventing unintended and unwanted pregnancies.

Associations Between Peer Use, Costs and Benefits, Self-Efficacy, and Adolescent E-cigarette Use.

OBJECTIVE: Prior research identified peer use as a salient risk factor of adolescent electronic cigarette (e-cigarette) use, but has not expanded on the mechanisms of this association. METHODS: Participants were 562 adolescents recruited from rural and suburban public high schools and an adolescent medicine clinic in the mid-Atlantic United States. Participants completed a packet of questionnaires that assessed demographics, substance use, expectations about the consequences of e-cigarette use, and perceptions of their own self-efficacy to resist using e-cigarettes. We estimated a series of mediation models using the MODEL INDIRECT command in MPLUS statistical software. In all models, significance of indirect effects from peer e-cigarette use to self-reported e-cigarette use were tested via two variables: (a) expected costs, (b) benefits of e-cigarette use, and (c) the perceived self-efficacy of the individual to refrain from e-cigarette use. RESULTS: Adolescents with more peers using e-cigarettes were more likely to have ever used an e-cigarette and perceived greater benefits and fewer costs, which was associated with a reduced self-efficacy to refrain from e-cigarette smoking (Model 1). Those with more peers using e-cigarettes were more likely to be currently using e-cigarettes themselves because they perceived greater benefits and fewer costs, which was associated with a reduced self-efficacy to refrain from e-cigarette smoking (Model 2). CONCLUSION: Peer use, self-efficacy to resist use, and expectations of cost and benefits of e-cigarette use should be considered as possible targets when devising tailored interventions and policies to prevent or reduce negative health consequences of long-term e-cigarette use.

Harder to get than you think: Levonorgestrel emergency contraception access in West Virginia community pharmacies.

OBJECTIVES: Emergency contraception (EC) is the only noninvasive form of contraception available after risk exposure and is an important tool for preventing unintended pregnancy resulting from unprotected sex, sexual assault, or contraceptive failure. The U.S. Food and Drug Administration (FDA) removed age restrictions on levonorgestrel EC and made it available over-the-counter to everyone in 2013. Despite improved availability and accessibility since the change in FDA regulations, community pharmacies have not uniformly embraced the policy. West Virginia is a rural state with high rates of poverty and teen pregnancy. DESIGN: The investigators called community pharmacies in West Virginia to assess the availability and accessibility of levonorgestrel EC in addition to the pharmacy staff's knowledge of effectiveness for this cross-sectional study. SETTING AND PARTICIPANTS: The study sample consisted of 509 community pharmacies throughout the state. OUTCOME MEASURES: A structured script was employed to conduct phone calls to community pharmacies with items assessing availability, accessibility, and knowledge of effectiveness. RESULTS: At the time of the phone calls, levonorgestrel EC was reported to be available in 48.9% of the community pharmacies in West Virginia. Chain pharmacies were more likely to report EC as being in stock (0.76) than independent pharmacies (0.15.). Other measures of accessibility also favored chain pharmacies versus independent pharmacies. The overall accessibility of EC at West Virginia community pharmacies was derived from a binary composite variable of "completely accessible" or "not completely accessible" by combining 5 predetermined items. Overall, EC was completely accessible to callers in 0.27 of all pharmacies with significant differences by pharmacy type (0.47 of chain pharmacies as compared with 0.03 of independent pharmacies). CONCLUSION: Accessible EC could reduce unintended pregnancy and help break the state's generational cycle of poverty and poor educational, social, and health outcomes. Pharmacists will be instrumental in expanding access to EC.

Providing Care for Transgender and Gender Diverse Youth.

Transgender and gender diverse youth (TGDY) experience modifiable health disparities and difficulty accessing the physical and mental health care systems. Providers and staff should understand the unique needs of this population and provide affirming spaces where these resilient young people can thrive. In addition to addressing social, setting, and system level barriers to access, providers should consider offering comprehensive gender care because this reduces barriers to medical services and can improve health outcomes. This article educates providers about TGDY, reviews the role of mental health care, and provides an overview of medical interventions for gender affirmation.

Improving Discharge Outcomes by Using a Standardized Risk Assessment and Intervention Tool Facilitated by Advanced Pediatric Providers.

OBJECTIVES: Pediatric discharge from the inpatient setting is a complex, error-prone process. In this study, we evaluated the outcomes of using a standardized process for hospital discharge of pediatric patients. METHODS: A 1-year pre- and postintervention pilot study was designed to improve discharge transition of care. The bundle intervention, facilitated by advanced practice providers, included risk identification and intervention. Process and outcome metrics included patient satisfaction measures on the discharge domain (overall discharge, speed of discharge process, whether they felt ready for discharge), use of handouts, scheduling of follow-up appointments, and postdischarge phone call. RESULTS: Significant improvements were found in all aspects of patient satisfaction, including speed of the discharge process and instructions for discharge, discharge readiness, and the overall discharge process. Length of stay decreased significantly after intervention. The checklist identified ∼4% of discharges without a correct primary care physician. Significant differences were found for scheduled primary care appointment before discharge and patients receiving handouts. The bundle identified risks that may complicate transition of care in approximately half of the patients. Phone communication occurred with almost half of the patients after discharge. CONCLUSIONS: Integration of an evidence-based discharge checklist can improve processes, increase delivery of patient education, and improve patient and family perceptions of the discharge process. Involvement of key stakeholders, use of evidence-based interventions with local adaptation, and use of a consistent provider responsible for implementation can improve transitions of care.

Crisis Pregnancy Centers in the United States: Lack of Adherence to Medical and Ethical Practice Standards; A Joint Position Statement of the Society for Adolescent Health and Medicine and the North American Society for Pediatric and Adolescent Gynecology.

Crisis pregnancy centers (CPCs) attempt to dissuade pregnant people from considering abortion, often using misinformation and unethical practices. While mimicking health care clinics, CPCs provide biased, limited, and inaccurate health information, including incomplete pregnancy options counseling and unscientific sexual and reproductive health information. The centers do not provide or refer for abortion or contraception but often advertise in ways that give the appearance that they do provide these services without disclosing the biased nature and marked limitations of their services. Although individuals working in CPCs in the United States have First Amendment rights to free speech, their provision of misinformation might be harmful to young people and adults. The Society for Adolescent Health and Medicine and North American Society for Pediatric and Adolescent Gynecology support the following positions: (1) CPCs pose risk by failing to adhere to medical and ethical practice standards; (2) governments should only support health programs that provide accurate, comprehensive information; (3) CPCs and individuals who provide CPC services should be held to established standards of ethics and medical care; (4) schools should not outsource sexual education to CPCs or other entities that do not provide accurate and complete health information; (5) search engines and digital platforms should enforce policies against misleading advertising by CPCs; and (6) health professionals should educate themselves, and young people about CPCs and help young people identify safe, quality sources of sexual and reproductive health information and care.

Monetary Cost of the MyPlate Diet in Young Adults: Higher Expenses Associated with Increased Fruit and Vegetable Consumption.

BACKGROUND: Cost is a commonly reported barrier to healthy eating. This is a secondary research analysis designed to examine the food expenditures of young adults on a university campus following the United States Department of Agriculture (USDA) MyPlate guidelines for fruits and vegetables. METHODS: Meal receipts and dietary intake were recorded weekly. Anthropometrics and clinical assessments were recorded before intervention. Researchers rated compliance based on the participant's dietary food log, receipt matching, food pictures, and reports during weekly 1-hour consultations. RESULTS: Fifty-three young adults (18-30 years old) at-risk of, or diagnosed with, metabolic syndrome (MetS) were enrolled in the study, with 10 excluded (n = 43) from analyses due to enrollment in a fixed cost university campus dining meal plan. A two sample t-test assessed differences in food costs and regression analysis determined associations between food cost and diet compliance while controlling for confounding factors of age, sex, and body mass index (BMI). Diet compliant subjects (n = 38) had higher weekly food cost at $95.73 compared to noncompliant subjects (n = 5) who spent $66.24 (p=0.01). A regression analysis controlling for age, sex, BMI, and geographical region also indicated cost differences based on diet compliance (p < 0.0001). CONCLUSION: Results indicate an ∼$29.00 per week increase in food cost when eating the recommended amount of fruit and vegetables. These findings can contribute to research incentive design, program planning cost, and determining effective interventions to improve diet in this population.

Early testing of insulin resistance: a tale of two lipid ratios in a group of 5th graders screened by the Coronary Artery Risk Detection in Appalachian Communities Project (CARDIAC Project).

BACKGROUND: In West Virginia (WV), 47% of fifth-grade children are either overweight or obese. There is no clear consensus regarding the definition of insulin resistance in children, and directly measuring insulin on the population level is costly. Two proposed measures examined further in this study include triglyceride (TRIG)/high-density lipoprotein cholesterol (HDL-C) ratio and TRIG/low-density lipoprotein (LDL-C) ratio. The purpose of this study is to examine the relationship between TRIG/HDL-C ratio, TRIG/LDL-C ratio and insulin resistance in fifth-graders with acanthosis nigricans (AN). METHODS: Between 2007 and 2016, 52,545 fifth-grade students in WV were assessed for AN. Fasting glucose and insulin levels were collected only for a sub-group of students who were AN-positive and was used to determine insulin resistance using the Homeostatic Model for Insulin Resistance (HOMA-IR) equation. Statistical analysis included t tests and logistic regression with receiver operating characteristic curves. RESULTS: Of the students assessed for AN, 4.5% (n = 2360) tested positive. The prevalence of insulin resistance was 79% (n = 814) among 1030 with AN and complete HOMA-IR. TRIG/HDL-C ratio and TRIG/LDL-C ratio were significantly associated with insulin resistance (TRIG/HDL-C:Est. = 0.36, P < 0.0001, AUC = 0.68; TRIG/LDL-C: Est. = 0.87, P < 0.0001, AUC = 0.69). Multivariate analysis showed that increased body mass index (Est. = 0.05, P < 0.0001), gender (Est. = 0.49, p < 0.0001) and TRIG/HDL-C ratio (Est. = 0.21, P < 0.0001) were significantly associated with insulin resistance. CONCLUSIONS: TRIG/HDL-C is a better surrogate marker of insulin resistance in AN-positive children compared to TRIG/LDL-C ratio; so, on a population-level, cholesterol rather than insulin may be obtained for preliminary testing of early insulin resistance in children.

Consumption of Health-Related Content on Social Media Among Adolescent Girls: Mixed-Methods Pilot Study.

BACKGROUND: Consumption of health- and fitness-related social media content is a predominant behavior among teenage girls, which puts them at risk for consuming unreliable health-related information. OBJECTIVE: This mixed-methods study (qualitative and quantitative) assessed health behavior attitudes and practices as well as social media use among adolescent girls. Additionally, similar practices and behaviors of adults who regularly interact with this population were studied. METHODS: Girls aged 12-18 years were recruited to complete a 28-item survey and participate in a 45- to 60-minute focus group. Adults who regularly interact with adolescent girls, including parents, teachers, and healthcare professionals, were recruited from the local community and given a link to provide online consent and complete a survey. RESULTS: A total of 27 adolescent girls participated in one of nine focus groups. Participants included 18 high school (age: mean 16.1 years; SD 1.3 years) and 9 middle school (age: mean 12.4 years; SD 0.7 years) girls. Eleven adults completed the online survey. Adolescents used social media to communicate and connect with friends, rather than as a source of health information. Although adolescents may see health-related content, most do not follow health-related pages or share such pages themselves, and fewer are actively searching for this information. Adolescents tend to trust information from familiar sources, and the participants reported that they do not follow official news accounts. Adults considered modeling and discussing healthy behaviors important and reportedly expected adolescents to see some level of health-related, especially fitness-related, content on social media. CONCLUSIONS: Education interventions are warranted for both adolescents and adults with whom adolescent girls regularly interact, in the areas of sedentary behavior to guide them to access reliable online health-related information and be judicious consumers of online health information.

Educational intervention improves fruit and vegetable intake in young adults with metabolic syndrome components.

The FRUVEDomics study investigates the effect of a diet intervention focused on increasing fruit and vegetable intake on the gut microbiome and cardiovascular health of young adults with/at risk for metabolic syndrome (MetS). It was hypothesized that the recommended diet would result in metabolic and gut microbiome changes. The 9-week dietary intervention adhered to the US Department of Agriculture Dietary Guidelines for Americans and focused on increasing fruit and vegetable intake to equal half of the diet. Seventeen eligible young adults with/or at high risk of MetS consented and completed preintervention and postintervention measurements, including anthropometric, body composition, cardiovascular, complete blood lipid panel, and collection of stool sample for microbial analysis. Participants attended weekly consultations to assess food logs, food receipts, and adherence to the diet. Following intention-to-treat guidelines, all 17 individuals were included in the dietary, clinical, and anthropometric analysis. Fruit and vegetable intake increased from 1.6 to 3.4 cups of fruits and vegetables (P < .001) daily. Total fiber (P = .02) and insoluble fiber (P < .0001) also increased. Clinical laboratory changes included an increase in sodium (P = .0006) and low-density lipoprotein cholesterol (P = .04). In the fecal microbiome, Erysipelotrichaceae (phylum Firmicutes) decreased (log2 fold change: -1.78, P = .01) and Caulobacteraceae (phylum Proteobacteria) increased (log2 fold change = 1.07, P = .01). Implementing a free-living 9-week diet, with intensive education and accountability, gave young adults at high risk for/or diagnosed with MetS the knowledge, skills, and feedback to improve diet. To yield greater impact, a longer diet intervention may be needed in this population.

Not all clots are created equal: a review of deficient thrombolysis with tissue plasminogen activator (tPA) in patients with metabolic syndrome.

Metabolic syndrome is a cluster of cardiovascular risk factors associated with a prothrombotic, proinflammatory and hypofibrinolysis state. Although resistance to tissue plasminogen activator (tPA) in metabolic syndrome patients has been associated with a defective fibrinolytic system, the factors and mechanisms underlining such resistance is unclear. While there is a great debate on proposed mechanisms, fundamental questions regarding resistance to tPA in metabolic syndrome patients with ischemic stroke remain unanswered. This article reviews articles and documents published between 2001 and 2017, and provides an overview of metabolic syndrome, factors associated with tPA resistance in metabolic syndrome, conflicting evidence of insufficient dosing of tPA in overweight/obese patients and future directions for research.

Future Implications of Using Registered Dietitians in Multidisciplinary Polycystic Ovary Syndrome Treatment.

Polycystic ovary syndrome (PCOS) is the most common reproductive endocrine disorder in females with insulin resistance playing a key role in pathogenesis. The objective of this study was to investigate current trends and future implications of multidisciplinary PCOS clinics with inclusion of dietitians. A two-phase, formative investigation on practitioners was conducted through an anonymous survey followed by focus groups. Survey respondents included 261 health care providers from around the world; the majority (59%) representing multidisciplinary teams. Focus group participants included four dietitians, three physicians, a health psychologist and a licensed nutritionist. Primary barriers for future multidisciplinary clinics included: money/resources, insurance reimbursement, and difference of opinions. Potential advantages included: more comprehensive and integrated care, greater convenience/efficiency, and better long-term outcomes. A majority of respondents (89%) stated that dietitians should be 'involved' or 'highly involved' in treatment. The greatest challenges for dietitians include insurance, limited disease knowledge, and lack of referrals. Most providers agreed that multidisciplinary clinics would lead to a better prognosis. A greater emphasis needs to be placed on educating professionals on the importance of nutrition counseling. Access to educated dietitians is likely the best way to ensure that PCOS patients have access to lifestyle interventions.

Illness Representations of Pertussis and Predictors of Child Vaccination Among Mothers in a Strict Vaccination Exemption State.

Background Vaccine preventable diseases are making a comeback in the US. However, research is lacking on illness representations of vaccine preventable diseases and their application in improving childhood immunization. Objective We utilized the common sense model of self-regulation to examine illness representations of pertussis and their associations with child's receipt of any vaccine, up-to-date vaccination status, and mothers' intentions to follow the recommended vaccination schedule in the future. Methods We developed vaccine worry and vaccine hassles scales to assess mothers' worries and hassles for child vaccination, and used an open ended question to assess mother's illness representations of pertussis. We surveyed mothers with children <3 years old (N = 160) in the Appalachian state of West Virginia, which only allows medical vaccine exemptions. Results Some children (5.0%) had received no vaccination, 15.0% were not up-to-date with the recommended vaccination schedule, and 13.8% mothers reported no intention to follow the recommended schedule in future (future intention). Illness representations included identity (17.8%), timeline (61.8%), consequences (58.6%), cause (35.0%), and cure/control (56.7%). Higher vaccine worry was associated with child receiving no vaccine. Not using daycare, higher vaccine worry, and difficulty breathing (identity) were associated with child not being up-to-date. Higher vaccine worry, cough (identity), and belief that vaccines are ineffective (cure/control) were associated with no future intention. Conclusions Vaccination interventions need to address mothers' worry regarding vaccine safety. 'Common Sense' beliefs regarding vaccines need to be reconciled with scientific data about vaccine safety and effectiveness, even among those with high socio-economic status in a strict vaccination state.