Neurological Manifestations in COVID-19: An Unrecognized Crisis in Our Elderly?

As of December 2020, there were more than 900,000 COVID-19 hospitalizations in the US with about 414,000 among individuals aged 65 years and older. Recent evidence suggests a growing number of older patients continue to suffer serious neurological comorbidities including polyneuropathy, cerebrovascular disease, central nervous system infection, cognitive deficits, and fatigue following discharge. Studies suggest that complaints manifest late in disease and persist beyond resolution of acute COVID-19 symptoms. Recent research reports that neurocognitive symptoms are correlated with severe disease, older age, male gender, and comorbidities including hypertension, renal failure, and neoplastic disease. The underlying causes are unclear, but current hypotheses include hypoxic-ischemic brain injury, immunopathological mechanisms, and neurotropism of SARS-CoV-2 infection. There is a pressing need for more research into the underlying mechanisms of post-COVID-19 neurological sequela, particularly in the elderly, a population already burdened with neurocognitive disorders.

Health workers' perspectives on barriers and facilitators to implementing a new national cervical cancer screening program in Ethiopia.

BACKGROUND: Cervical cancer disproportionately affects women in sub-Saharan Africa, compared with other world regions. In Ethiopia, a National Cancer Control Plan published in 2015, outlines an ambitious strategy to reduce the incidence and mortality of cervical cancer. This strategy includes widespread screening using visual inspection with acetic acid (VIA). As the national screening program has rolled out, there has been limited inquiry of provider experiences. This study aims to describe cancer control experts' perspectives regarding the cancer control strategy and implementation of VIA. METHODS: Semi-structured interviews with 18 participants elicited provider perspectives on cervical cancer prevention and screening. Open-ended interview questions queried barriers and facilitators to implementation of a new national screening program. Responses were analyzed using thematic analysis and mapped to the Integrated Behavioral Model. Participants were health providers and administrators with positionality as cancer control experts including screening program professionals, oncologists, and cancer focal persons at town, zone, and federal health offices at eleven government facilities in the Arsi, Bale, and Shoa zones of the Oromia region, and in the capital Addis Ababa. RESULTS: The cancer control plan and screening method, VIA, were described by participants as contextually appropriate and responsive to the unique service delivery challenges in Ethiopia. Screening implementation barriers included low community- and provider-awareness of cervical cancer and screening, lack of space and infrastructure to establish the screening center, lack of materials including cryotherapy machines for the "screen-and-treat" approach, and human resource issues such as high-turnover of staff and administration. Participant-generated solutions included additional training for providers, demand creation to increase patient flow through mass media campaigns, decentralization of screening from large regional hospitals to local health centers, improved monitoring and evaluation, and incentivization of screening services to motivate health providers. CONCLUSIONS: As the Ethiopian government refines its Cancer Control Plan and scales up screening service implementation throughout the country, the findings from this study can inform the policies and practices of cervical cancer screening. Provider perspectives of barriers and facilitators to effective cancer control and screening implementation reveal areas for continued improvement such as provider training and coordination and collaboration in the health system.

Socioenvironmental Risk Factors for Adolescent Marijuana Use in a United States-Mexico Border Community.

PURPOSE: We examined how socioenvironmental risk factors unique to the United States-Mexico border, defined as border community and immigration stress, normalization of drug trafficking, and perceived disordered neighborhood stress, contribute to tobacco, alcohol, and marijuana use among adolescents residing there. DESIGN: Cross-sectional design. SETTING: The study was conducted at a high school on the United States-Mexico border. SUBJECTS: A sample of 445 primarily Hispanic students (ages 14-18). MEASURE: Perceived Disordered Neighborhood Stress Scale, Border Community and Immigration Stress Scale, and Normalization of Drug Trafficking Scale. ANALYSIS: Logistic regression assessed the association between the socioenvironmental risk factors and past 30-day tobacco, alcohol, and marijuana use. RESULTS: Participants with higher border community and immigration stress scores were significantly more likely to have used tobacco (adjusted odds ratio [aOR] = 1.41, P < .01) and alcohol (aOR = 1.31, P < .01) in the past 30 days. Perceived disordered neighborhood stress also was associated with past 30-day alcohol use (aOR = 1.46, P < .00). The normalization of drug trafficking was associated with past 30-day marijuana use (aOR = 1.45, P < .05). CONCLUSIONS: Public health practitioners, educational institutions, and policy makers should consider the economic and normative environment of the United States-Mexico border for future substance use prevention and risk reduction efforts targeting border adolescents.

Interventions to increase uptake of cervical screening in sub-Saharan Africa: a scoping review using the integrated behavioral model.

BACKGROUND: Sub-Saharan Africa (SSA) experiences disproportionate burden of cervical cancer incidence and mortality due in part to low uptake of cervical screening, a strategy for prevention and down-staging of cervical cancer. This scoping review identifies studies of interventions to increase uptake of cervical screening among women in the region and uses the Integrated Behavioral Model (IBM) to describe how interventions might work. METHODS: A systematic search of literature was conducted in PubMed, Web of Science, Embase, and CINAHL databases through May 2019. Screening and data charting were performed by two independent reviewers. Intervention studies measuring changes to uptake in screening among women in SSA were included, with no restriction to intervention type, study setting or date, or participant characteristics. Intervention type and implementation strategies were described using behavioral constructs from the IBM. RESULTS: Of the 3704 citations the search produced, 19 studies were selected for inclusion. Most studies were published between 2014 and 2019 (78.9%) and were set in Nigeria (47.4%) and South Africa (26.3%). Studies most often assessed screening with Pap smears (31.6%) and measured uptake as ever screened (42.1%) or screened during the study period (36.8%). Education-based interventions were most common (57.9%) and the IBM construct of knowledge/skills to perform screening was targeted most frequently (68.4%). Willingness to screen was high, before and after intervention. Screening coverage ranged from 1.7 to 99.2% post-intervention, with six studies (31.6%) reporting a significant improvement in screening that achieved ≥60% coverage. CONCLUSIONS: Educational interventions were largely ineffective, except those that utilized peer or community health educators and mHealth implementation strategies. Two economic incentivization interventions were moderately effective, by acting on participants' instrumental attitudes, but resulted in screening coverage less than 20%. Innovative service delivery, including community-based self-sampling, acted on environmental constraints, striving to make services more available, accessible, and appropriate to women, and were the most effective. This review demonstrates that intent to perform screening may not be the major determinant of screening behavior, suggesting other theoretical frameworks may be needed to more fully understand uptake of cervical screening in sub-Saharan Africa, particularly for health systems change interventions.

The role of social and behavioral risk factors in explaining racial disparities in age-related cognitive impairment: a structured narrative review.

Alzheimer's disease (AD) is a growing public health concern with large disparities in incidence and prevalence between African Americans (AAs) and non-Hispanic whites (NHWs). The aim of this review was to examine the evidence of association between six modifiable risk factors (education, smoking, physical inactivity, obesity, social isolation, and psychosocial stress) and Alzheimer's disease risk in AAs and NHWs. We identified 3,437 studies; 45 met inclusion criteria and were included in this review. Of the examined risks, education provided the strongest evidence of association with cognitive outcomes in AAs and NHWs. This factor may operate directly on Alzheimer's disease risk through the neurocognitive benefits of cognitive stimulation or indirectly through social status.

Youth Participatory Action Research for Youth Substance Use Prevention: A Systematic Review.

Background: A growing body of research points to the efficacy of participatory methods in decreasing rates of alcohol, tobacco, and other drug use and other risky behaviors among youth. However, to date, no systematic review of the literature has been conducted on Youth Participatory Action Research (YPAR) for youth substance use prevention. This review draws on the peer-reviewed literature on YPAR in the context of youth substance use prevention published from January 1, 1998 through April 30, 2018. Methods: We summarize (1) the published evidence regarding YPAR for youth substance use prevention; (2) the level of youth engagement in the research process; (3) the methodologies used in YPAR studies for youth substance use prevention; and (4) where more research is needed. We used Reliability-Tested Guidelines for Assessing Participatory Research Projects to assess the level of youth engagement in the research process. Results: In all, we identified 15 unduplicated peer-reviewed, English-language articles that referenced YPAR, Community Based Participatory Research, youth, and substance use prevention. Conclusions: Our findings indicated that youth participation in research and social action resulted in increased community awareness of substance use and related solutions. This supports the premise of youth participation as an agent of community change by producing community-specific substance use data and prevention materials. Identified weaknesses include inconsistent levels of youth engagement throughout the research process, a lack of formalized agreements between youth and researchers with regard to project and data management, and a lack of outcome evaluation measures for assessing YPAR for youth substance use prevention.

Changes in health behaviors and self-rated health of participants in Meta Salud: a primary prevention intervention of NCD in Mexico.

BACKGROUND: Meta Salud was a community health worker-facilitated intervention for the prevention of noncommunicable diseases in Northern Mexico. OBJECTIVES: This analysis examined changes in perceived health, eating habits, and physical activity immediately and 3 months after the intervention. The impact on the resulting behavioral and psychological factors are reported. METHODS: This was a nonrandomized intervention study with 1 baseline and 2 post-intervention follow-ups. Outcome evaluation consisted of anthropometric measurements, laboratory tests, and a lifestyle questionnaire. RESULTS: The most consistent patterns were increases in metabolic equivalent of task values expended per day from baseline to post-intervention (difference = 996; 95% confidence interval [CI]: 81 to 1,912) and to 3-month follow-up (difference = 1,073; 95% CI: 119 to 2,028); greater likelihood of meeting Centers for Disease Control and Prevention daily exercise recommendations, with an increase from 49% to 60% at post-intervention (OR: 1.6, 95% CI: 1.0 to 2.4) and 63% at follow-up (OR: 1.7, 95% CI: 1.7 to 2.7); lesser likelihood for consuming whole milk, from 38% to 59% (OR: 2.9, 95% CI: 1.8 to 4.7); fewer daily servings of packaged foods, from 0.72 to 0.57 (difference = -0.16; 95% CI: -0.28 to -0.03); fewer days of poor mental health, from 9.3 to 5.8 (difference = -3.4; 95% CI: -5.1 to -1.7); and greater likelihood for reporting good self-rated health, from 41% to 54% post-intervention (OR: 2.1, 95% CI: 1.3 to 3.6) and 57% at follow-up (OR: 2.5, 95% CI: 1.5 to 4.4). Changes in other outcomes, although in the expected direction of association, were not statistically significant. CONCLUSIONS: The study identified important strategies for making feasible dietary changes in the consumption of whole milk, sugary drinks, and packaged foods, yet there is still a need to identify strategies for improving consumption of healthy foods. There was stronger evidence for ways of improving physical activity as opposed to other outcome measures. Overall, it highlights the importance of behavioral and psychosocial factors as key intervention targets in preventing noncommunicable diseases in low- and middle-income countries.

Development and Psychometric Assessment of the Measure of Globalization Influence on Health Risk (MGIHR) Among Mexican Women with Breast Cancer.

Lacking in the literature are data addressing the extent to which changes in reproductive and lifestyle factors predispose women in developing nations to higher breast cancer rates, and the degree to which these are due to globalization influences. This article describes the development and psychometric assessment of an instrument intended to measure global, predominantly U.S., influences on breast cancer risk profile among women residing in Mexico. Using investigator consensus and a focus group methodology, the Measure of Globalization Influence on Health Risk (MGIHR) was developed and completed by 341 women. Psychometric analysis support the use of an 11-item Consumerism and Modernity scale and 7-item Reproductive Control and Gender Role scale. The MGIHR is a valid and reliable instrument for understanding changing lifestyle and reproductive factors for breast cancer risk and may provide a more complete understanding of breast cancer development and needed interventions.

Factors that influence mammography use and breast cancer detection among Mexican-American and African-American women.

OBJECTIVE: This study examined factors that influence mammography use and breast cancer detection, including education, health insurance, and acculturation, among Mexican-American (MA) and African-American (AA) women. METHODS: The study included 670 breast cancer cases (388 MAs and 282 AAs), aged 40-86 years at diagnosis. Data on mammography use, detection, and delay in seeking care were collected via questionnaires and medical records. Using a language-based bidimensional acculturation measure, MAs were classified as English-dominant (n = 67), bilingual (n = 173), and Spanish-dominant (n = 148). Mammography prior to diagnosis was assessed by racial/ethnic acculturation subgroup using logistic regression. RESULTS: In age-adjusted models, mammography use was non-significantly lower among English-dominant (OR = 0.84; 95% CI: 0.45-1.59) and bilingual (OR = 0.86; 95% CI: 0.55-1.35) MAs and significantly lower among Spanish-dominant MAs (OR = 0.53; 95% CI: 0.34-0.83) than among AA women. After adjustment for education or insurance, there was no difference in mammography use by race/ethnicity and acculturation subgroup. Despite high self-reported mammography use (75%), a large proportion of cases reported self-detection (59%) and delay in seeking care >90 days (17%). CONCLUSIONS: These findings favor promoting culturally appropriate messaging about the benefits and limitations of mammography, education about breast awareness, and prompt reporting of findings to a health professional.

Global positive expectancies in adolescence and health-related behaviours: longitudinal models of latent growth and cross-lagged effects.

Constructs representative of global positive expectancies (GPE) such as dispositional optimism and hope have been theoretically and empirically linked to many positive mental and physical health outcomes. However such expectancies' health implications for adolescents, as well as their trajectory over time, are less well understood than for adult populations. This study tested whether GPE predict the key indicators of adolescents' future physical health status, their health-related behaviours. A prospective longitudinal study design was employed whereby a diverse population-based cohort (N = 744; mean age at baseline = 12) completed three surveys over approximately 18 months. Rigorous tests of causal predominance and reciprocal effects were conducted through latent growth and cross-panel structural equation models. Results showed GPE systematically decreased during the course of the study, yet higher initial levels of GPE predicted less alcohol drinking, healthier food choice and greater physical activity over time. GPE's protective relationships towards health protective behaviours (vs. health risk behaviours that also included tobacco smoking) appear more independent from depressive symptomatology, and the primary findings were robust across socio-demographic groups.

Using Rasch modeling to measure acculturation in youth.

Ethnic differences in health outcomes are assumed to reflect levels of acculturation, among other factors. Health surveys frequently include language and social interaction items taken from existing acculturation instruments. This study evaluated the dimensionality of responses to typical bilinear items in Latino youth using Rasch modeling. Two seven-item scales measuring Anglo-Hispanic orientation were adapted from Marin and Gamba (1996) and Cuellar, Arnold, and Maldonado (1995). Most of the items fit the Rasch model. However, there were gaps in both the Hispanic and Anglo scales. The Anglo items were not well targeted for the sample because most students reported they always spoke English. The lack of variability found in a heterogeneous sample of Latino youth has negative implications for the common practice of relying on language as a measure of acculturation. Acculturation instruments for youth probably need more sensitive items to discriminate linguistic differences, or to measure other factors.

Bicultural stress and adolescent risk behaviors in a community sample of Latinos and non-Latino European Americans.

OBJECTIVES: The study examined the relation between adolescent risk behaviors and bicultural stress due to discrimination, immigration, and acculturation factors. We hypothesized bicultural stress would be related to increased risk behavior and depressive symptoms independent of socioeconomic status, ethnic self-identification, and acculturation. DESIGN: Middle school student participants (n=519; median age 14) completed a self-report questionnaire on their risk behaviors, psychosocial antecedents, and socio-demographic factors. Latino (304) and non-Latino European American (215) students were surveyed through a large, urban, West Coast US school district. RESULTS: More bicultural stress was significantly related to reports of all risk behaviors (i.e. smoking, drinking, drug use, and violence) and depressive symptoms. Further, bicultural stress was a robust explanatory variable across sub-groups, and appears largely independent from depressive symptoms. CONCLUSION: The hypotheses were supported. Bicultural stress appears to be an important underlying factor for health disparities among US adolescents. Future research may consider promoting well-being in majority, as well as minority adolescents, through targeting sources of bicultural stressors or examining ways to moderate their effects on adolescent risk behaviors.

A prospective test of distal and proximal determinants of smoking initiation in early adolescents.

This study tests a broad array of determinants of utility for developing smoking preventive interventions using a population-based cohort of early adolescents. Multivariable logistic regressions using never-smokers at baseline (N=1137; age 11-14) showed a model of distal determinants was more predictive of initiation within the approximate 10 month follow up period than one of proximal determinants. When all determinants were simultaneously considered, lesser academic achievement and fewer environmental impediments to smoking most strongly predicted initiation. The findings are consistent with some current smoking prevention programs, however such programs may be further potent by using theory-based social development approaches and through reducing tobacco availability or social contexts where youth can smoke without another adult knowing.

An intervention for parents to promote preschool children's sun protection: effects of Sun Protection is Fun!

BACKGROUND: Young children are an important focus of sun-protection efforts, but there has been relatively little study of sun-protection interventions developed for preschool-aged children and their parents. This paper reports on the evaluation of Sun Protection is Fun! (S.P.F.), designed to improve parents' practices and psychosocial outcomes related to protecting preschool children from sun exposure. METHODS: A group-randomized trial was conducted in 20 preschools to evaluate the S.P.F. parent intervention that included a video, newsletters, and handbooks. A separate, on-site intervention for preschool staff aimed to create a preschool climate that encouraged parents' sun protection for their children. Cross-sectional samples of parents completed surveys at baseline (n = 384), 12 months (n = 640), and 24 months (n = 694). RESULTS: S.P.F. demonstrated significant effects on parents' sun-avoidance strategies at 12 months (P < .05) and sunscreen use at 24 months (P < .05). There were significant intervention effects on parents' sun-protection knowledge (P < .001), perceived norms of teachers' sunscreen use (P < .001), sunscreen impediments (P < .05), and sunscreen expectancies (P < .05) at 12 months. Parents' perceived norms of teacher sunscreen use were significantly improved at 24 months (P < .001). CONCLUSIONS: More intense intervention strategies may need to complement take-home materials to result in greater effects on parents' sun protection for their children.

Validity and reliability of the parental sun protection scales.

Skin cancer is the most common cancer diagnosed in the US and its incidence continues to rise. Epidemiological studies have shown that excessive sun exposure received during childhood may increase the risk of developing skin cancer later in life. Yet, there are few published reports on the development of reliable and valid theory-based scales that assess the factors associated with parental sun-protection practices to reduce sun exposure in preschool children. To fill this gap, the Parental Sun Protection Scales were developed and validated. Two series of confirmatory factor analytic models were employed to test the factor structure of the scales and to examine the inter-relationships among the proposed psychosocial factors. Sunscreen-use and sun-avoidance behavioral models were tested in a sample of 384 parents. The results provided a basis for the reliable and valid measurement of psychosocial factors related to parental sun-protection practices. These scales may be useful in more fully understanding the determinants of sun-protection behaviors and in evaluating intervention programs designed to improve such behaviors.