Association of Medicaid expansion with health insurance, unmet need for medical care and substance use disorder treatment among people who inject drugs in 13 US states.

BACKGROUND AND AIMS: Impoverished people who inject drugs (PWID) are at the epicenter of US drug-related epidemics. Medicaid expansion is designed to reduce cost-related barriers to care by expanding Medicaid coverage to all US adults living at or below 138% of the federal poverty line. This study aimed to measure whether Medicaid expansion is (1) positively associated with the probability that participants are currently insured; (2) inversely related to the probability of reporting unmet need for medical care due to cost in the past year; and (3) positively associated with the probability that they report receiving substance use disorder (SUD) treatment in the past year, among PWID subsisting at ≤ 138% of the federal poverty line. DESIGN: A two-way fixed-effects model was used to analyze serial cross-sectional observational data. SETTING: Seventeen metro areas in 13 US states took part in the study. PARTICIPANTS: Participants were PWID who took part in any of the three waves (2012, 2015, 2018) of data gathered in the Center for Disease Control and Prevention's National HIV Behavioral Surveillance (NHBS), were aged ≤ 64 years and had incomes ≤ 138% of the federal poverty line. For SUD treatment analyses, the sample was further limited to PWID who used drugs daily, a proxy for SUD. MEASUREMENTS: State-level Medicaid expansion was measured using Kaiser Family Foundation data. Individual-level self-report measures were drawn from the NHBS surveys (e.g. health insurance coverage, unmet need for medical care because of its cost, SUD treatment program participation). FINDINGS: The sample for the insurance and unmet need analyses consisted of 19 946 impoverished PWID across 13 US states and 3 years. Approximately two-thirds were unhoused in the past year; 41.6% reported annual household incomes < $5000. In multivariable models, expansion was associated with a 19.0 [95% confidence interval (CI) = 9.0, 30.0] percentage-point increase in the probability of insurance coverage, and a 9.0 (95% CI = -15.0, -0.2) percentage-point reduction in the probability of unmet need. Expansion was unrelated to SUD treatment among PWID who used daily (n = 17 584). CONCLUSIONS: US Medicaid expansion may curb drug-related epidemics among impoverished people who inject drugs by increasing health insurance coverage and reducing unmet need for care. Persisting non-financial barriers may undermine expansion's impact upon substance use disorder treatment in this sample.

Differences in Health Care Access and Use by Gender, Race, Income, Age and Employment among Residents of the Rural South.

Understanding how disparities are experienced by subpopulations within rural areas may inform efforts to mitigate persistent inequities in access to health care. Among 2,545 randomly sampled adults who completed a mailed survey in ten rural counties in Georgia as part of a health equity initiative, 50.8% of respondents were aged 35-64, 65.9% were women, 16.6% identified as Black, 36.0% worked full-time, and 39% had a high school degree or less. Significant disparities were observed in health care access, use and financial burden by age, employment status, race, and annual household income. In an examination of intersectionality of race and income, all sub-groups except for higher income Black respondents were more likely to report no health insurance and not seeing a doctor in the past 12 months due to cost relative to higher income White respondents. The findings shed insight into inequities in health care access within rural communities.

Exploring dimensions of social capital in relation to healthy eating behaviours in the US rural south.

OBJECTIVE: This study examined relationships between dimensions of social capital (SC) (social trust, network diversity, social reciprocity and civic engagement) and fruit, vegetable, and sugar-sweetened beverage (SSB) consumption among rural adults. Potential moderators (neighbourhood rurality, food security, gender and race/ethnicity) were explored to develop a more nuanced understanding of the SC-healthy eating relationship. DESIGN: Data were from a 2019 mailed population-based survey evaluating an eleven-county initiative to address health equity. Participants self-reported health behaviours, access to health-promoting resources and demographics. Logistic regression models were used to analyse relationships between predictors, outcomes and moderators. SETTING: Five rural counties, Georgia, USA. PARTICIPANTS: 1120 participants. RESULTS: Among participants who lived in the country (as opposed to in town), greater network diversity was associated with consuming ≥ 3 servings of fruit (OR = 1·08; 95 % CI 1·01, 1·17, P = 0·029), yet among participants who lived in town, greater civic engagement was associated with consuming ≥ three servings of fruit (OR = 1·36; 95 % CI 1·11, 1·65, P = 0·003). Both food-secure and food-insecure participants with greater social reciprocity had lower odds of consuming 0 SSB (OR = 0·92; 95 % CI 0·86, 0·98, P = 0·014, OR = 0·92; 95 % CI 0·86, 0·99, P = 0·037, respectively). Men with greater social trust were more likely to consume 0 SSB (OR = 1·09; 95 % CI 1·01, 1·18, P = 0·038), and Whites with greater network diversity were more likely to meet daily vegetable recommendations (OR = 1·10; 95 % CI 1·01, 1·19, P = 0·028). CONCLUSIONS: Findings provide a basis for future qualitative research on potential mechanisms through which SC and related social factors influence healthy eating in rural communities.

Evaluation Design for The Two Georgias Initiative: Assessing Progress Toward Health Equity in the Rural South.

As persistent inequities in health gained increased attention nationally due to COVID-19 and racial justice protests in 2020, it has become increasingly important to evaluate both the process and outcomes associated with coalition-based efforts to address health inequities. The Two Georgias Initiative supports coalitions in 11 rural counties to (1) achieve greater health equity, (2) improve health and health care, (3) build healthier rural communities and improve social conditions that impact the health of rural populations, and (4) build community, organizational, and individual leadership capacity for health equity. Rural communities suffer significant health disparities relative to urban areas, and also experience internal inequities by race and poverty level. The evaluation framework for The Two Georgias Initiative provides a comprehensive mixed methods approach to evaluating both processes and outcomes. Early results related to community readiness and capacity to address health inequities, measured through a coalition member survey (n = 236) conducted at the end of the planning phase, suggest coalitions were in the preparation stage, with higher levels of readiness among coalition members and organizations/groups similar to the coalition members' own, lower levels among public officials and other leaders, and the lowest levels among county residents. In addition, coalition members reported more experience with downstream drivers (e.g., access to care) of health than upstream drivers (e.g., affordable housing, environmental or racial justice). By providing a logic model, evaluation questions and associated indicators, as well as a range of data collection methods, this evaluation approach may prove practical to others aiming to evaluate their efforts to address health equity.

Neighborhood and Household Environment as Contributors to Racial Disparities in Sleep Duration among U.S. Adolescents.

Objective: Racial disparities in adolescent sleep duration have been documented, but pathways driving these disparities are not well understood. This study examined whether neighborhood and household environments explained racial disparities in adolescent sleep duration. Methods: Participants came from Waves I and II of Add Health (n=13,019). Self-reported short sleep duration was defined as less than the recommended amount for age (<9 hours for 6-12 years, <8 hours for 13-18 years, and <7 hours for 18-64 years). Neighborhood factors included neighborhood socioeconomic disadvantage, perceived safety and social cohesion. Household factors included living in a single parent household and household socioeconomic status (HSES). Structural equation modeling was used to assess mediation of the neighborhood and household environment in the association between race/ethnicity and short sleep duration. Results: Only HSES mediated racial disparities, explaining non-Hispanic (NH) African American-NH White (11.6%), NH American Indian-NH White (9.9%), and Latinx-NH White (42.4%) differences. Unexpectedly, higher HSES was positively associated with short sleep duration. Conclusion: Household SES may be an important pathway explaining racial disparities in adolescent sleep duration. Future studies should examine mechanisms linking household SES to sleep and identify buffers for racial/ethnic minority adolescents against the detrimental impacts that living in a higher household SES may have on sleep.

Inequities in Physical Activity Environments and Leisure-Time Physical Activity in Rural Communities.

INTRODUCTION: Differential access to environments supportive of physical activity (PA) may help explain racial and socioeconomic disparities in leisure-time physical activity (LTPA) in rural communities. METHODS: We used baseline data from a mailed survey (N = 728) conducted in 2019 as part of an evaluation of The Two Georgias Initiative to examine the relationships among LTPA, sociodemographic characteristics, and perceived access to supportive PA environments (eg, areas around the home/neighborhood, indoor and outdoor exercise areas, town center connectivity) in 3 rural Georgia counties. RESULTS: More than half of respondents (53.5%) engaged in LTPA in the previous month. Perceptions of PA environments were generally neutral to somewhat negative. In multivariable models, overall PA environment was associated with LTPA (OR, 1.58; 95% CI, 1.06-2.35), as was annual household income >$50,000 relative to ≤$20,000 (OR, 2.72; 95% CI, 1.53-4.83) and race, with Black respondents less likely to engage in LTPA than White respondents (OR, 0.49; 95% CI, 0.29-0.85). Of the 5 PA environment domains examined, town center connectivity was significantly associated with LTPA (OR, 1.68, 95% CI, 1.20-2.36). Both the overall PA score (ß = -0.014; 95% CI, -0.029 to -0.002) and town center connectivity (ß = -0.020; 95% CI, -0.038 to -0.005) partially mediated associations between annual household income and LTPA. Areas supportive of PA around the home/neighborhood partially mediated the association by race (ß = 0.016; 95% CI, 0.001-0.034). CONCLUSION: Findings lend support for investing in town centers and racially diverse neighborhoods to increase walkability and PA infrastructure as potential strategies to reduce inequities in LTPA.

Medicaid expansion and opioid overdose mortality among socioeconomically disadvantaged populations in the US: A difference in differences analysis.

BACKGROUND: Opioid-related overdoses are a major cause of mortality in the US. Medicaid Expansion is posited to reduce opioid overdose-related mortality (OORM), and may have a particularly strong effect among people of lower socioeconomic status. This study assessed the association between state Medicaid Expansion and county-level OORM rates among individuals with low educational attainment. METHODS: This quasi-experimental study used lagged multilevel difference-in-difference models to test the relationship of state Medicaid Expansion to county-level OORM rates among people with a high-school diploma or less. Longitudinal (2008-2018) OORM data on 2978 counties nested in 48 states and the District of Columbia (DC) were drawn from the National Center for Health Statistics. The state-level exposure was a time-varying binary-coded variable capturing pre- and post-Medicaid Expansion under the Affordable Care Act (an "on switch"-type variable). The main outcome was annual county-level OORM rates among low-education adults adjusted for potential underreporting of OORM. FINDINGS: The adjusted county-level OORM rates per 100,000 among the study population rose on average from 10.26 (SD = 13.56) in 2008-14.51 (SD = 18.20) in 2018. In the 1-year lagged multivariable model that controlled for policy and sociodemographic covariates, the association between state Medicaid Expansion and county-level OORM rates was statistically insignificant. CONCLUSIONS: We found no evidence that expanding Medicaid eligibility reduced OORM rates among adults with lower educational attainment. Future work should seek to corroborate our findings and also identify - and repair - breakdowns in mechanisms that should link Medicaid Expansion to reduced overdoses.

Are Training and Experience Adapting Evidence-Based Interventions Associated With Self-Efficacy and Attitudes? A Cross-Sectional Survey of Students and Practitioners With Varying Levels of Adaptation Experience.

Increasing use of evidence-based interventions (EBIs) in local settings will help reduce the research-practice gap and improve health equity. Because adaptation to new settings and populations is essential to effective EBI use, frameworks to guide practice are receiving more attention; most, however, only provide broad guidelines without instructions for making adaptations in practice. Therefore, practitioners may need additional training or technical assistance (TA) to implement and adapt EBIs. This study explores whether practitioners' and students' general EBI training or TA and level of adaptation experience are associated with self-efficacy in adapting EBIs and with attitudes toward EBI use. We analyzed baseline survey data of participants in an evaluation of IM-Adapt Online, a newly developed decision support tool. We asked about previous training on EBIs, general and specific adaptation behaviors, and attitudes toward EBIs and found an association between previous training or TA in using EBIs with higher self-efficacy for using and adapting EBIs. Respondents with prior EBI training were significantly more likely to have higher self-efficacy in EBI behaviors across subdomains and in total than those without training. Respondents reported lowest self-efficacy for planning adaptations (M = 3.35) and assessing fit of EBIs to their local context (M = 3.41). This study suggests the importance of EBI adaptation training and TA to increase adoption and adaptation of EBIs, subsequently. More adaptation-specific training is warranted to assist students, practitioners, and researchers undertaking the adaptation process and implement EBIs. Future training on EBI adaptation can help practitioners tailor EBIs to meet the specific needs of their populations.

Intrinsic and instrumental agency associated with nutritional status of East African women.

The 2030 Agenda for Sustainable Development prioritizes women's empowerment in Sustainable Development Goal (SDG) #5: to achieve gender equality and empowerment among all women and girls. Research on the relationships of women's empowerment and nutrition has focused on the child's nutrition. Less is known about how women's empowerment influences their own nutritional status. We examined the pathways by which three domains of women's empowerment (WE)-assets, intrinsic agency, and instrumental agency-may influence women's nutritional status (WNS) in East Africa. We used data from 42,721 married non-pregnant women, 15-49 years old interviewed in Demographic and Health Surveys (DHS) from five east Africa countries (2011-2016). WNS was operationalized through body mass index (BMI) and altitude-adjusted blood-hemoglobin level (Hb). A latent factor for women's human/social assets (assets) measured women's enabling resources. Two additional latent factors measured women's intrinsic agency (power within; women's non-justification of intimate partner violence (IPV) against wives) and instrumental agency (power to; influence in household decision-making). We used structural equation models with latent variables to estimate the strength of the hypothesized pathways from women's assets to WNS through measures of intrinsic and instrumental agency. All three domains of WE had direct, positive associations with women's BMI [(estimate (95% CI) (Assets: [0.17 (0.14,0.20)]; Intrinsic Agency: [0.25 (0.22,0.27)]; Instrumental Agency [0.08 (0.03,0.10)])]. Women's instrumental agency was positively associated with women's Hb [0.12 (0.09,0.14)]. Total associations, including direct and indirect effects, with women's BMI were positive through intrinsic agency & instrumental agency. Total associations with women's Hb were positive through instrumental agency. Direct and indirect effects from assets through both components of agency to BMI were higher in magnitude by household wealth category. Domains of WE were positively associated with WNS. Findings indicate that the process of women's empowerment may be an important driver of their nutritional status.

Disparities in Retention in Care Among Adults Living with HIV/AIDS: A Systematic Review.

As national HIV prevention goals aim to increase the proportion of persons living with HIV, determining existing disparities in retention in care will allow for targeted intervention. The purpose of this systematic review was to identify existing disparities in retention in care. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) 2015 guided this systematic review. Electronic databases, including PubMed/MEDLINE, CINAHL, Sociological Collection, PsychInfo, and Cab Direct/Global Health, were systematically searched and twenty studies were included. This review identified disparities in retention in care that have been documented by race, gender, age, HIV exposure, incarceration history, place of birth, and U.S. geographic location. Research is necessary to further identify existing disparities in retention in care and to better understand determinants of health disparities. Additionally, interventions must be tailored to meet the needs of health disparate populations and should be assessed to determine their effectiveness in reducing health disparities.

Disseminating a Smoke-free Homes Program to Low Socioeconomic Status Households in the United States Through 2-1-1: Results of a National Impact Evaluation.

INTRODUCTION: Given homes are now a primary source of secondhand smoke (SHS) exposure in the United States, research-tested interventions that promote smoke-free homes should be evaluated in real-world settings to build the evidence base for dissemination. This study describes outcome evaluation results from a dissemination and implementation study of a research-tested program to increase smoke-free home rules through US 2-1-1 helplines. METHODS: Five 2-1-1 organizations, chosen through a competitive application process, were awarded grants of up to $70 000. 2-1-1 staff recruited participants, delivered the intervention, and evaluated the program. 2-1-1 clients who were recruited into the program allowed smoking in the home, lived in households with both a smoker and a nonsmoker or child, spoke English, and were at least 18 years old. Self-reported outcomes were assessed using a pre-post design, with follow-up at 2 months post baseline. RESULTS: A total of 2345 households (335-605 per 2-1-1 center) were enrolled by 2-1-1 staff. Most participants were female (82%) and smokers (76%), and half were African American (54%). Overall, 40.1% (n = 940) reported creating a full household smoking ban. Among the nonsmoking adults reached at follow-up (n = 389), days of SHS exposure in the past week decreased from 4.9 (SD = 2.52) to 1.2 (SD = 2.20). Among the 1148 smokers reached for follow-up, 211 people quit, an absolute reduction in smoking of 18.4% (p < .0001), with no differences by gender. CONCLUSIONS: Among those reached for 2-month follow-up, the proportion who reported establishing a smoke-free home was comparable to or higher than smoke-free home rates in the prior controlled research studies. IMPLICATIONS: Dissemination of this brief research-tested intervention via a national grants program with support from university staff to five 2-1-1 centers increased home smoking bans, decreased SHS exposure, and increased cessation rates. Although the program delivery capacity demonstrated by these competitively selected 2-1-1s may not generalize to the broader 2-1-1 network in the United States, or social service agencies outside of the United States, partnering with 2-1-1s may be a promising avenue for large-scale dissemination of this smoke-free homes program and other public health programs to low socioeconomic status populations in the United States.

A qualitative study of the process of adoption, implementation and enforcement of smoke-free policies in privately-owned affordable housing.

BACKGROUND: Household smoke-free home rules cannot fully protect nonsmokers from secondhand smoke (SHS) if they live in multi-unit housing (MUH). Instead, property-level smoke-free policies are needed to prevent SHS incursion into apartment units and to keep common areas smoke-free. Smoke-free policies are usually at the discretion of property management companies and owners within the context of market-rate and privately-owned affordable housing in the U.S. METHODS: Semi-structured interviews on the policy development, implementation and enforcement experiences of 21 different privately-owned affordable housing management companies were conducted with representatives from properties in North Carolina and Georgia who had established smoke-free policies before 2016. RESULTS: The decision to adopt was typically made by corporate leadership, board members, owners or property managers, with relatively little resident input. Policy details were influenced by property layout, perceptions of how best to facilitate compliance and enforcement, and cost of creating a designated smoking area. Policies were implemented through inclusion in leases, lease addenda or house rules with 6 months' notice most common. Participants thought having a written policy, the norms and culture of the housing community, public norms for smoke-free environments, and resident awareness of the rules and their consequences, aided with compliance. Violations were identified through routine inspections of units and resident reporting. Resident denial and efforts to hide smoking were shared as challenges to enforcement, along with a perception that concrete evidence would be needed in eviction court and that simply the smell of SHS was insufficient evidence of violation. Over half had terminated leases or evicted residents due to violations of the smoke-free policy. The most common benefits cited were reduced turnover cost and time, and lower vacancy rates. CONCLUSIONS: Understanding the smoke-free policy process in privately-owned affordable housing can help practitioners encourage policies within subsidized housing contexts. The study identified salient benefits (e.g., reduced cost, time, and vacancies) that can be highlighted when encouraging MUH partners to adopt policies. Additionally, study findings provide guidance on what to consider when designing smoke-free policies (e.g., layout, costs), and provide insights into how to enhance compliance (e.g., resident awareness) and manage enforcement (e.g., routine inspections).

Pharmacists' attitudes and practices about selling syringes to people who inject drugs in Tajikistan: Results of a syringe purchase audit and a survey.

BACKGROUND: In Tajikistan, governmental policies leave the decision whether or not to sell syringes to people who inject drugs (PWID) to pharmacists' discretion. This exploratory study tests a theory-driven model explaining Tajikistani pharmacists' actual syringe sale practices to inform future HIV advocacy activities. METHODS: Data were collected via attempts to purchase syringes without prescription and a subsequent survey among a sample of 232 pharmacists in two cities (Dushanbe and Kulob) in Tajikistan in 2015. The survey collected data on attitudes and beliefs related to selling syringes to PWID, stigma against PWID and background contextual factors such as social conservatism, HIV and drug use knowledge. Structural equation modelling was used to assess the relationships between syringe sale practice and pharmacists' attitudinal and background factors. RESULTS: The majority (87.9%, n = 204) of sampled pharmacists agreed to sell syringes to the study research assistants without a prescription. According to the final model, agreeing to sell syringes was moderately associated with the reported intent to provide syringes without prescription (ß = 0.36, p < 0.001), lower stigma against PWID (ß=-0.43, p = 0.01), and stronger social conservatism (ß = 0.35, p = 0.02). Intent to provide syringes correlated with positive attitudes towards provision of syringes (ß = 0.35, p = 0.008), which in turn were negatively associated with stigma (ß=-0.54, p < 0.001) and positively with age (ß = 0.20, p = 0.03). Stigma against PWID was directly associated with social conservatism (ß = 0.47, p < 0.001) and inversely with university-level education (ß=-0.28, p < 0.001). CONCLUSION: We demonstrated the accessibility of over-the-counter syringes in urban pharmacies of Tajikistan and emphasized the role of stigma in shaping pharmacists' syringe sale practices. Advocacy interventions should target pharmacists to reduce stigmatization of PWID and ensure access to clean syringes.

Steps Toward Scalability: Illustrations From a Smoke-Free Homes Program.

Scalable interventions remain effective across a range of real-world settings and can be modified to fit organizational and community context. "Smoke-Free Homes: Some Things are Better Outside" has been effective in promoting smoke-free home rules in low-income households in efficacy, effectiveness, generalizability, and dissemination studies. Using data from a dissemination study in collaboration with five 2-1-1 call centers in Ohio, Florida, Oklahoma, and Alabama (n = 2,345 households), this article examines key dimensions of scalability, including effectiveness by subpopulation, secondary outcomes, identification of core elements driving effectiveness, and cost-effectiveness. Evaluated by 2-1-1 staff using a pre-post design with self-reported outcomes at 2 months postbaseline, the program was equally effective for men and women, across education levels, with varying number of smokers in the home, and whether children were present in the home or not. It was more effective for nonsmokers, those who smoked fewer cigarettes per day, and African Americans. Creating a smoke-free home was associated with a new smoke-free vehicle rule (odds ratio [OR] = 3.38, confidence interval [CI 2.58, 4.42]), decreased exposure to secondhand smoke among nonsmokers (b = -2.33, p < .0001), and increased cessation among smokers (OR = 5.8, CI [3.81, 8.81]). Use of each program component was significantly associated with success in creating a smoke-free home. Using an intent-to-treat effect size of 40.1%, program benefits from 5 years of health care savings exceed program costs yielding a net savings of $9,633 for delivery to 100 households. Cost effectiveness, subpopulation analyses, and identification of core elements can help in assessing the scalability potential of research-tested interventions such as this smoke-free homes program.

How race, ethnicity, and income moderate the relationship between urban vegetation and physical activity in the United States.

To facilitate physical activity interventions, researchers identify which factors associate with physical activity, such as vegetation levels of the surrounding environment. While most studies examining vegetation and physical activity find a positive correlation, the literature does not investigate how vegetation may have a varied effect on physical activity based on demographic composition. This study examined how race, ethnicity, and income moderate the relationship between both non-tree vegetation and tree canopy on the percentage of individuals participating in leisure-time physical activity per census tract. Physical activity data from 2013 to 2014 for 7842 census tracts across 25 US cities originated from the CDC's 500 Cities project. Aerial images from the USDA's National Agriculture Imagery Program were used to classify vegetation levels per tract. Demographic variables originated from the American Community Survey 2011-2015 5-year estimates. Tracts were stratified into four types (Black + low income, Hispanic + low income, White + high income, and remaining) and assessed through multilevel modeling as to whether tract type moderated the relationship between vegetation and physical activity. Results showed that non-tree vegetation negatively associated with physical activity across all census tract types, while tree canopy exhibited a mixed association with physical activity, based on tract type. These findings can spur further research into how vegetation impacts physical activity of different demographic groups, and potentially inform greenspace and tree planting installments in those areas at greatest risk for physical inactivity-related diseases.

A multilevel analysis of factors influencing the inaccuracy of parental reports of adolescent HPV vaccination status.

BACKGROUND: Parental reports are commonly used for adolescent HPV vaccination status but may be subjected to bias. Guided by the Socioecological Framework, our study explores potential multilevel factors influencing the inaccuracy of parental reports of adolescent HPV vaccination status. METHODS: Data from parents of 19,683 adolescents with provider-verified data were analyzed using multilevel modeling. Correlates included adolescent characteristics, parent/household factors, number of providers seen, state-level median income, and state-level HPV vaccine policy. Outcomes included inaccuracy in reporting: vaccine initiation (≥1 dose), completion (3 doses), and number of doses. RESULTS: 24% and 25% of parents reported initiation and completion inaccurately; 28% under-reported and 11% over-reported number of doses. All adolescent characteristics, parent/household factors, and number of healthcare providers seen were associated with the outcomes. Of note, compared to parents of White adolescents, parents of racial/ethnic minority adolescents were more likely to inaccurately report all outcomes (aOR ranges from 1.43 to 1.76 for initiation, 1.45-1.75 for completion, 1.98-2.05 for under-reporting, and 1.17-1.41 for over-reporting). Households with higher maternal education (aOR = 0.70, 0.92, 0.79, and 0.80) and income (aOR = 0.54, 0.62, 0.50, and 0.70) were less likely to inaccurately report initiation, report completion, under-report, and over-report, respectively. Those having seen more providers were less likely to inaccurately report initiation and completion but more likely to over-report number of vaccine doses. DISCUSSION: Being parents of females, older adolescents, and racial/ethnic minority adolescents, having lower material education, and poverty status were associated with higher odds of inaccurately reporting HPV vaccination status. These results have implications for estimates drawn from self-reports. Future research can examine sources of inaccuracies (e.g., social desirability or health literacy); they could also explore solutions (e.g., access to vaccine records) that can help parents accurately report vaccination status. State policy does not appear to have an impact on report accuracy.

Ecological momentary assessment of various tobacco product use among young adults.

INTRODUCTION: Young adults are at high risk for using traditional and novel tobacco products. However, little is known about daily/weekly use patterns or psychosocial triggers for using various tobacco products. METHODS: This ecological momentary assessment (EMA) study examined timing, tobacco cravings, affect, social context, and other substance use (alcohol, marijuana) in relation to use of cigarettes, electronic nicotine delivery systems (ENDS), and any tobacco product (i.e., cigarettes, ENDS, cigars, hookah), respectively. We also examined interactions between these predictors, sex, and race/ethnicity. From a longitudinal study of 3418 18-25 year-olds from seven Georgia colleges/universities, we recruited 72 reporting current tobacco use to participate in the 21-day EMA study; 43 participated, of which 31 completed ≥66% assessments and were analyzed. Cravings, affect, social context, and substance use were assessed daily across four four-hour windows. RESULTS: Of the 31 participants, average age was 21.10 years (SD = 1.95), 45.2% were female, and 71.0% non-Hispanic White; 71.0% used cigarettes, 58.1% ENDS, 38.7% cigars, and 25.8% hookah (25.6% used one product, 46.5% two, 27.9% ≥ three). Predictors of cigarette use included higher anxiety, greater odds of marijuana and alcohol use, and higher boredom levels among women. Predictors of ENDS use included being non-White and greater odds of marijuana use, as well as higher tobacco cravings among women and higher boredom among men. Predictors of any tobacco product use included being non-White, higher boredom levels, and greater odds of marijuana and alcohol use. CONCLUSIONS: Distinct interventions may be needed to address use of differing tobacco products among young adults.

UNHEALTHY WEIGHT IN INDIAN FAMILIES: THE ROLE OF THE FAMILY ENVIRONMENT IN THE CONTEXT OF THE NUTRITION TRANSITION.

India faces a dual burden of increasing obesity and persistent underweight as it experiences the nutrition transition-the dietary and lifestyle changes that accompany globalization, economic development, and technological change. Yet, the nutrition transition is not solely a top-down process; rather, global forces converge with local practices at multiple levels of the social ecology. The family environment, a key site for the transmission of local customs and norms, remains largely unexplored in India. We examined the extent to which opposite-gender siblings and mother-child pairs were concordant or discordant in body weight, and whether domains of the family environment, specifically, food practices, food-related gender norms, and household resources, were associated with patterns of unhealthy weight within and between families. Multilevel dyadic analysis and logistic regression were conducted using survey data from a representative sample of 400 families in a Southern Indian city. We identified substantial clustering of weight among opposite-gender sibling pairs (ICC=0.43) and mother-child pairs, as well as important patterns of discordance, including 11% of families experiencing a dual burden of underweight and overweight. Household resources, including mother's education and income, were salient in explaining the distribution of body weight within and between families. Importantly, less examined domains of the family environment were also relevant, including food practices (e.g. grocery shopping frequency), and food-related gender norms (e.g. mother's control of food served at home). Continued exploration of how global and local practices converge in households will be necessary to develop programming that effectively addresses India's dual burden of unhealthy weight.

Psychosocial and cessation-related differences between tobacco-marijuana co-users and single product users in a college student population.

Limited research has examined psychosocial factors that differ among cigarette users, marijuana users, and co-users and influence their cessation efforts. We examined: 1) sociodemographic, mental health, and other substance use in relation to user category; and 2) associations among these factors in relation to recent quit attempts and readiness to quit among single product versus co-users. We used a cross-sectional design to study college students aged 18-25 from seven Georgia campuses, focusing on the 721 reporting cigarette and/or marijuana use in the past 4months (238 cigarette-only; 331 marijuana-only; 152 co-users). Multinomial logistic regression showed that correlates (p's<0.05) of cigarette-only versus co-use included attending public or technical colleges (vs. private) and not using little cigars/cigarillos (LCCs), e-cigarettes, and alcohol. Correlates of marijuana-only versus co-use included being Black or Hispanic (vs. White), not attending technical school, and not using LCCs and e-cigarettes. Importance was rated higher for quitting cigarettes versus marijuana, but confidence was rated lower for quitting cigarettes versus marijuana (p's<0.001). Co-users were more likely to report readiness to quit and quit attempts of cigarettes versus marijuana (p's<0.001). While 23.26% of marijuana-only and 15.13% of cigarette-only users reported readiness to quit, 41.18% of cigarette-only and 21.75% of marijuana-only users reported recent quit attempts (p's<0.001). Binary logistic regressions indicated distinct correlates of readiness to quit and quit attempts of cigarettes and marijuana. Cessation efforts of the respective products must attend to co-use with the other product to better understand relative perceptions of importance and confidence in quitting and actual cessation efforts.