A narrative review of the CEPH-accredited bachelor's public health programs' curricula in the United States.

Background: Undergraduate programs in public health are becoming increasingly popular in the United States (US). The recent pandemic, growing climate instability, and the aging baby boomers have led to higher demands for skilled public health professionals at various levels of the workforce. This study examines the nature of courses being delivered in undergraduate public health programs across the United States. The goal is to assess domains, themes, competencies, and other specialized skills that are currently covered in these academic programs. Methodology: A search was conducted in February 2023 using the online CEPH program database to identify undergraduate public health programs in the US. In total, 86 institutions and 90 CEPH-accredited undergraduate public health programs were identified. Lists of public health courses were retrieved from each program, and a total of 2,259 unduplicated courses were extracted and analyzed. A content analysis of the extracted topics was conducted to generate 38 common themes among the courses offered. Coded course themes were mapped to the public health domains and competencies listed by the ASPPH and CEPH to evaluate the distribution of themes across course offerings. Results: Analysis of course themes found that Foundations of Public Health, Epidemiology, Public Health Management, Policy, and Leadership, Climate and Environmental Health, and Global Health Issues were the most prevalent. When course themes were mapped onto the ASPPH and CEPH domains of critical public health learning, "overview of public health" and "determinants of health" were the most populated domains. Programs had different emphases according to their approach, but overall, about two-thirds of course themes were focused on foundational and theoretical concepts of public health, and one-third were directed toward practical applications of public health concepts. Conclusion: As the demand for skilled public health workers continues to rise, programs will need to watch the skills and competencies required in the current working environment, as well as the ASPPH and CEPH criteria, and adjust their approach accordingly. Given the rapid changes in the public health landscape, schools and programs of public health should evaluate their curricula to ensure that they are meeting the needs of the workforce and the world.

Disparities in Access to Mental Health Services Among Children Diagnosed with Anxiety and Depression in the United States.

Child and adolescent mental health are major public health concerns in the US. Overall, 20% of US children have a reported mental health condition, while an estimated 40% will be diagnosed with one by age 18. Despite these concerns, little is known about factors associated with access to mental health services among children and adolescents. We analyzed data from a sample of 6655 children (aged 6 to 17 years) with either anxiety and/or depression drawn from the 2020-2021 National Survey of Children's Health (NSCH). A multivariable logistic regression model was fit to investigate predisposing, enabling, and need factors associated with caregiver's (i.e., parent or other guardian) perceived access to mental health services for their children. Approximately 50.8% of caregivers perceived obtaining mental health services for their children to be somewhat difficult, very difficult, or impossible. Children meeting criteria for having a medical home had lower odds of experiencing such difficulties (adjusted [a]OR = 0.38; 95% CI: 0.30-0.49). Further, compared to children who sometimes or never had health insurance coverage for mental or behavioral health needs, children who were always insured (aOR: 0.19; 95% CI 0.14, 0.25) and those who usually had coverage (aOR: 0.38; 95% CI 0.28, 0.51) had lower odds of experiencing perceived difficulties in obtaining care. The results indicate several enabling and need predictors of perceived access to mental health services--highlighting potential structural barriers to care access. Efforts to address access challenges should adopt a multifaceted approach and be tailored to families living in poverty, those with limited health coverage, and minoritized children with less than optimal general health.

Impact of Residential Segregation on Healthcare Utilization and Perceived Quality of Care Among Informal Caregivers in the United States.

This study aimed to investigate the impact of racial residential segregation on healthcare utilization and perceived quality of care among informal caregivers in the US. It further assessed potential variations in the estimated impact across caregivers' race and socioeconomic status. We used data from the Health Information National Trends Survey Data Linkage Project (fielded in 2020) for a sample of 583 self-identified informal caregivers in the US. Fitting a series of regression models with the maximum likelihood estimation, we computed the beta coefficients (ß) of interest and their associated Wald 95% confidence limits (CI). Caregivers who resided in areas with higher segregation, compared to those living in lower segregated areas, were less likely to visit a healthcare professional [ß = - 2.08; Wald 95%CI - 2.093, - 2.067] (moderate); [ß = - 2.53; Wald 95%CI - 2.549, - 2.523] (high)]. Further, caregivers residing in moderate [ß = - 0.766; Wald 95%CI - 0.770, - 0.761] and high [ß = - 0.936; Wald 95%CI - 0.941, - 0.932] segregation regions were less likely to perceive a better quality of care compared to those located in low segregation areas. Moreover, as segregation level increased, Black caregivers were less likely to see a health professional, less frequently used healthcare services, and had poorer perceived healthcare quality when compared to Whites. Our findings indicate that higher residential segregation is associated with lower healthcare utilization, such as visiting a healthcare professional, and poorer perceived healthcare quality among informal caregivers. Given the essential role of informal caregivers in the current healthcare system, it is vital to investigate and address challenges associated with access to and quality of essential healthcare services to improve caregivers' health and well-being, specifically for caregivers of minority backgrounds.

Predictors of U.S. Adults' Opinion Toward an R-Rating Policy for Movies With Cigarette Smoking.

Recently, multiple health organizations and advocacy groups have pushed for giving an R-rating for movies depicting tobacco imagery. This study examined several predictors of U.S. adults' opinion toward an R-rating policy for movies depicting cigarette smoking. We used data from the Health Information National Trends Survey (2020 cycle), for a nationally representative sample of 3,865 US adults (aged ≥ 18). The outcome variable was opinion toward an R-rating policy (support, neutral, and oppose) for movies depicting cigarette smoking. A weighted adjusted multinomial logistic regression analysis with comparisons of support versus oppose, support versus neutral, and neutral versus oppose was performed. About 48.2% of respondents were supportive of, 31.1% were neutral toward, and 20.7% were opposed to an R-rating policy. Adults aged 50 to 64 years (adjusted odds ratio [aOR] = 2.28, p = .008) and ≥65 years (aOR = 4.54, p <.001) (vs. 18-34 years) were more likely to support the R-rating policy than oppose it. Non-Hispanic Black respondents (vs. non-Hispanic Whites) were 1.74 times more likely to support than oppose the policy (aOR = 1.74, p = .04), whereas adults with a household annual income of US$75,000 or more (vs. <$20,000) and those with moderate (vs. liberal) political viewpoints were more likely to be neutral than oppose the policy. Former and current e-cigarette users (vs. never users) were less likely to support than oppose the policy. Tailored messaging addressing the rationale behind R-rating policy should be directed towards communities based on age, race/ethnicity, household income, e-cigarette usage, and political ideologies.

Burden of Chronic and Heavy Opioid Use Among Elderly Community Dwellers in the U.S.

Introduction: Opioid overprescribing may fuel the opioid epidemic and increase the risk of complications of opioid misuse. This study examined trends and determinants of chronic and heavy opioid use among elderly community dwellers in the U.S. Methods: Medicare Current Beneficiary Surveys data from 2006 to 2019 were used. Common opioid medications were identified in the prescription medication files (n=47,264). Patients with Chronic users were defined as those receiving 6 or more opioid prescriptions within a year or on medication for 3 or more months, and heavy users were those having an average daily dose of 90 or more morphine milligram equivalents or 3,780 morphine milligram equivalents or more per continuous treatment episode. Results: One in 6 elderly community dwellers ever used opioids during the study period. Chronic users were more likely to be women than men (68.9% vs 31.1%, p<0.001). Of all survey participants, 4.3% were chronic users, and 2.8% were heavy users. Among ever users, 27.7% were chronic users, and 18.1% were heavy users. The rate of opioid use rose from 12.1% in 2006, peaked at 22.8% in 2013, and decreased to 11.7% in 2019. Chronic use was 5.1%, 10.7%, and 7.6%, respectively. Heavy use was 5.5%, 10.7%, and 7.6%, respectively. However, for chronic and heavy users, there was no significant difference in the median opioid dosage and opioid duration between males and females. Conclusions: Among elderly Medicare beneficiaries, opioid prescriptions have been decreasing since 2013. However, a substantial number of elderly people were chronic and heavy users, calling for better opioid management among them.

Predictors of Adolescents' Transition Through the Stages of Change for Quitting E-Cigarettes: Findings From the Population Assessment of Tobacco and Health Study.

PURPOSE: To identify predictive factors associated with US adolescents' transition through the stages of change for potentially quitting e-cigarettes using the Trans-theoretical model of behavior change. DESIGN: Prospective cohort study. SETTING: United States. SUBJECTS: We utilized data from adolescents (12-17 years) in Wave 3 of the Population Assessment of Tobacco and Health study who used e-cigarettes exclusively over the past 30 days (n = 177) and were followed up with in Wave 4. MEASURES: Outcome variables were 3 transition categories: those who remained stagnant, those who progressed, and those who regressed in their stage of quitting e-cigarettes. Predictor variables were socio-demographics, e-cigarette harm perception, e-cigarette use at home or by important people, social norms, e-cigarette and anti-tobacco advertisements, and e-cigarette health warnings. ANALYSIS: Weighted-adjusted multinomial regression analysis was performed to determine the association between predictor and outcome variables. RESULTS: From Wave 3 to Wave 4, 19% of adolescents remained stagnant; 73.3% progressed; and 7.7% regressed. Adolescents were less likely to progress in their stage of change if they perceived nicotine in e-cigarettes to be "not at all/slightly harmful" (AOR = .26 [95% CI: .25, .27], P < .001); reported important people's use of e-cigarettes (AOR = .18 [95% CI: .05, .65, P = .009); and "rarely" noticed e-cigarette health warnings (AOR = .28 [95% CI: .08, .98, P = .054). CONCLUSION: Intervention efforts must target specific predictive factors that may help adolescents quit e-cigarettes.

Bidirectional associations between alcohol drinking and depressive symptom scores among US older adults.

BACKGROUND: This study examines the bidirectional associations between alcohol drinking and depression in which low to moderate alcohol drinking may reduce the risk of depression, while the occurrence of depression may increase the amount of alcohol drinking as a coping strategy. METHOD: Data for the community-dwelling older adults from the Medicare Current Beneficiary Survey (MCBS) 2016 to 2019 were analyzed using random intercept cross-lagged panel models to explore the within-individual causal associations for males and females separately. Socioeconomic status (SES), smoking and comorbidities were adjusted in the models. RESULTS: Among 3388 older adults with three measures for the number of alcohol drinks and Patient Health Questionnaire (PHQ) depression scores, a prior increase in the number of drinks was related to a moderate non-significant decrease in PHQ scores in the follow-up, but a previous increase in the PHQ scores was significantly associated with a decrease in the number of drinks at the follow-up visit in the adjusted models (regression coefficient = -0.144, p = 0.017 for males; and coefficient = -0.11, p < 0.001 for females). CONCLUSION: Prior depression may lead to reduced drinking in the follow up visits, but no bidirectional association was found among US older adults.

mHealth Apps Use and Their Associations With Healthcare Decision-Making and Health Communication Among Informal Caregivers: Evidence From the National Cancer Institute's Health Information National Trends Survey.

PURPOSE: The current study investigates associations between mHealth apps and healthcare decision-making and health communication among informal caregivers in the US. DESIGN: Cross-sectional study employing secondary data. SETTING: The Health Information National Trends Survey (HINTS5, Cycles 2 through 4, 2018 - 2020). SAMPLE: Self-identified informal caregivers (n = 1386; had mHealth apps = 61.3%, female = 63.2%, some college or more in education = 80.3%) who reported owning at least a smartphone or a tablet computer (i.e., ownership of a "smart device"). MEASURES: Sociodemographic characteristics, reports of having mHealth apps, smart device utilization in healthcare decision-making and health communication. ANALYSIS: Accounting for the complex design features of the HINTS data, we constructed multiple hierarchical logistic regressions to compute adjusted odds ratios (aOR) and their 95% confidence intervals (CI). RESULTS: Compared to caregivers without mHealth apps, those with the apps had higher odds of utilizing their smart devices to make a health-related decision, such as how to treat a disease or a medical condition (aOR = 1.65; 95% CI: 1.13-2.39, P < .01), or engage in health-related discussions with a healthcare provider (aOR = 2.36; 95% CI: 1.54-3.61, P < .001). CONCLUSION: Having mHealth apps was associated with a higher likelihood of using smart devices in healthcare decision-making and health communication by informal caregivers. Empowering caregivers to make informed health-related decisions and communicate effectively with healthcare providers are both crucial to health promotion and well-being. Future studies should investigate facilitators as well as barriers to using mHealth apps and smart devices in health-promoting strategies involving informal caregivers.

Disparities in E-Cigarette Harm and Addiction Perceptions Among Adolescents in the United States: a Systematic Review of the Literature.

BACKGROUND: Health disparities associated with e-cigarette use are increasingly apparent among US adolescents. Perceptions of e-cigarette harm and addiction play an important role in understanding adolescents' e-cigarette use behavior. The objective of this systematic review is to examine racial/ethnic and socio-economic disparities in e-cigarette harm and addiction perceptions among US adolescents. METHODS: We searched five databases to identify cross-sectional or longitudinal studies that focused on adolescents (≤ 18 years of age) who were ever, current, or never e-cigarettes users; we then examined how race/ethnicity and/or socio-economic status (SES) impacted e-cigarette harm and/or addiction perceptions. Two co-authors independently identified relevant studies, extracted data, and assessed the risk of bias. RESULTS: Adhering to PRISMA guidelines, eight of 226 identified studies met the inclusion criteria. These eight studies examined either perceptions regarding absolute e-cigarette harm and/or addiction (i.e., assessing perception of only e-cigarette) or relative e-cigarette harm and/or addiction (i.e., comparative perceptions to traditional cigarettes) by race and ethnicity. Two of the eight studies assessed absolute harm and/or addiction perceptions of e-cigarettes by SES. Our results indicate that, compared to all other racial/ethnic groups, relative e-cigarette harm and addiction perceptions were lower among Non-Hispanic White adolescents; however, absolute e-cigarette harm perception was higher among these groups. No clear patterns of racial/ethnic differences in absolute e-cigarette addiction perceptions and SES differences in absolute e-cigarette harm perceptions were reported. CONCLUSION: More research is needed to explicitly assess perceptions of e-cigarette harm and addiction among US adolescents by race/ethnicity and SES to develop subgroup appropriate public health messaging.

Association Between Adverse Childhood Experiences and Opioid Use-Related Behaviors: A Systematic Review.

As opioid use-related behaviors continue at epidemic proportions, identifying the root causes of these behaviors is critical. Adverse childhood experiences (ACEs) are shown to be an important predictor of opioid initiation, opioid dependence, and lifetime opioid overdose. The purpose of this systematic review is to examine the association between ACEs and opioid use-related behaviors later in life and to discuss implications for policy, practice, and research regarding ACEs and opioids. Five databases (PubMed, PsycINFO, CINAHL, Medline, and Scopus) were used to identify studies investigating the association between ACEs and opioid use-related behaviors. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 20 studies out of the initial 428 met the inclusion criteria for this review. Among the included 20 studies, 15 focused on the relationship between ACEs and lifetime opioid use-related behaviors, and five focused on current opioid use-related behaviors. All studies found statistical associations between ACEs and lifetime or current opioid use-related behaviors. Five studies found a significant gradient effect; that is, as the number of ACEs increased, the risk of opioid use-related behaviors also increased. A significant dose-response relationship exists between ACEs and opioid use-related behaviors. Hence, it is essential for clinicians to screen for ACEs before prescribing opioid medications, for opioid treatment to incorporate trauma-informed methods, and for messaging around opioid use interventions to include information about ACEs. The current review points to a critical need to implement standardized ACE screening instruments in clinical and research settings.

Expectations of employers in the United States for entry-level public health job skills with a bachelor's degree: an analysis of the positions advertised in an online job portal.

Objectives: To analyze the current public health labor market for bachelor's-level graduates. Methods: Public health-related job postings (N = 365) from across the United States were collected from an online job portal, Indeed.com, from November 7-14, 2022. Job titles, organization type, degree requirements, work experience, job location, and preferred skills for bachelor's-level public health positions were analyzed. Results: Thirty-one job titles were identified. Approximately one-third (32.33%) of postings were from the Northeastern US; 23.56% were from the Southeastern region. Thirty-five job skill categories were identified. Most jobs (92.33%) required oral and written communication skills, and 85.21% specified educational skills for public health promotion. Cultural competency, project management, and case management abilities were also highly sought. Conclusion: This study revealed the needs of the public health workforce and bolstered the case that public health degree-seekers should be equipped with a set of strategic skills applicable to a range of multisectoral and multidisciplinary public health jobs. Policy implications: Given the rapid changes in the field of public health, ongoing analysis of the labor market benefits educators, employers, and policymakers alike.

Methamphetamine-Induced Wakefulness and Sleep Management: A Qualitative Analysis of Online Narratives.

While much attention has been given to methamphetamine's wake-promoting properties and the concept of using methamphetamine to increase energy, little is known about the ways people who use methamphetamine manage their use to pursue their functional goals or the challenges they encounter doing so. This qualitative study explores the experiences of people who used methamphetamine to manage wakefulness and reduce sleep as a means to achieve functional goals. We conducted a grounded theory analysis of 202 anonymous letters submitted to an online forum. Five themes emerged from this process: (1) Using methamphetamine to extend wakefulness and reduce the need for sleep; (2) Losing control over wakefulness and the need for sleep; (3) Managing wakefulness and the need for sleep while on methamphetamine; (4) Getting caught in a cycle of wakefulness and sleep; and (5) Sleep disruptions even after ceasing methamphetamine use. Participants believed methamphetamine was critical to meeting their functional goals, and they went to great lengths to try to manage the substance's ill effects. Thus, clients in treatment for methamphetamine use disorder may benefit from interventions addressing their underlying motivations and perceived associations between methamphetamine and meeting functional goals.

Driving under the influence of substances and motor vehicle fatalities among older adults in the United States.

OBJECTIVE: This study examines contribution of substance use (including alcohol, cannabinoids, stimulants, narcotics, depressants, and hallucinogens) on the probability of drivers being at-fault for a crash on U.S. public roads, with specific emphasis on older adult drivers. METHODS: Data from the National Highway Traffic Safety Administration's Fatality Analysis Reporting System (FARS) for the years 2010-2018 were employed for 87,060 drivers (43,530 two-vehicle crash pairs) involved in two moving vehicle crashes. The quasi-induced exposure (QIE) method was used to compute the relative crash involvement ratios (CIRs) for each relevant substance and illicit drug. Mixed-effect generalized linear regression models were fit to examine the effect of substance use on the probability of a driver being at-fault for a crash. RESULTS: There were 75.51% males and 73.88% Non-Hispanic Whites in our sample. The CIR for those aged 70-79 years was 1.17, and more than double (2.56) for the ≥80 years old drivers, while being relatively low among drivers of ages 20 to 69. Substance use, in general, disproportionately increased the probability of being at-fault during a crash, regardless of driver's age. Though older drivers are less likely than other age groups to report substance use, presence of substances among older drivers increased the probability of their being at-fault two to four times during a crash across almost all substances. The regression models, after adjusting for driver's sex, road grade, weather, light conditions, distraction, and speeding at time of crash, revealed that older drug-impaired drivers were twice as likely to be at fault in a fatal crash (aOR = 1.947; 95% CI = 1.821, 2.082; <0.0001) compared to their middle-aged counterparts. Similarly, most substance use categories were responsible for the probabilities of higher CIRs among the drivers. CONCLUSION: These findings necessitate continued efforts to bring awareness to the deadly consequences of "drugged driving," especially among older adult drivers.

Challenges to Help-Seeking Among Women of Color Exposed to Intimate Partner Violence.

Women exposed to intimate partner violence (IPV) often rely on support from their informal support networks to obtain resources that may mitigate IPV. This study explored the challenges women of color encounter in seeking advice and information from their informal support networks (i.e., family, friends, neighbors, community members) regarding IPV support services. In-depth interviews were conducted with 29 IPV survivors who self-identified as Black or Hispanic. Data were analyzed using grounded theory methodology. Results showed that participants lacked informational support, both in their communities and in their interpersonal relationships with family and friends. Communities treated IPV as normal and propagated the belief that women's responsibilities were to men and family. Family and friends discouraged IPV information seeking and advised that IPV should be kept private to avoid community shaming. The community environments also lacked information about resources for women experiencing IPV. The lack of information from their informal support networks appeared to delay participants' help-seeking. As the frequency and severity of violence escalated, some participants engaged in independent information searching, using social media and online information sources as well as conventional media like radio and newspapers. Others received information from first responders in the wake of a violent emergency. Participants described the information they received online or from first responders as empowering, encouraging them to engage in support services. Similarly, they felt empowered by the information they received from social workers, counselors, and victims' advocates, and they wished to use what they learned to help other women in similar circumstances. Women experiencing IPV and their communities need more information regarding IPV support services. Successful interventions for IPV survivors and their support networks may necessitate community-level education and altering biased perceptions of gender-appropriate behaviors.

Food security status and breast cancer screening among women in the United States: Evidence from the Health and Retirement Study and Health Care and Nutrition Study.

PURPOSE: To assess the impact of food insecurity on biennial breast cancer screenings (i.e., mammography or breast X-ray) among older women in the United States (US). METHODS: Data from the 2014 and 2016 waves of the Health and Retirement Study and the 2013 Health Care and Nutrition Study were used. The analyses were limited to a nationally representative sample of 2,861 women between 50 and 74 years of age, residing in the US. We employed a propensity score weighting method to balance observed confounders between food-secure and food-insecure women and fit a binary logistic regression to investigate population-level estimates for the association between food security and breast cancer screening. RESULTS: Food insecurity was significantly associated with failure to obtain a mammogram or breast X-ray within the past two years. Food-insecure women had 54% lower odds of reporting breast cancer screening in the past 2 years (adjusted OR = 0.46; 95% CI 0.30-0.70, p-value < 0.001) as compared to food-secure women. Additional factors associated with a higher likelihood of receiving breast cancer screenings included greater educational attainment, higher household income, regular access to health care/advice, not smoking, and not being physically disabled or experiencing depressive symptoms. CONCLUSION: Results demonstrate a socioeconomic gradient existing in regard to the utilization of regular breast cancer screenings among women. Those who tend to have lower education, lower income, and lack of reliable healthcare access are more likely to be food insecure. Thus, more likely to face the financial, logistical, or environmental barriers in obtaining screening services that accompany food insecurity.

Efficacy of Extended-Release Injectable Naltrexone on Alcohol Use Disorder Treatment: A Systematic Review.

Alcohol use disorder (AUD) is a serious public health problem. Over 3.3 million people worldwide die each year due to alcohol-related causes, which is almost 5.3% of all deaths. This systematic review examines the effectiveness of injectable naltrexone treatment for people with AUD based on randomized clinical trial studies conducted between January 2004 and December 2019. Following PRISMA-P, this review searched PubMed, PsycINFO, CINAHL, Cochrane Library, and Web of Science for relevant studies. The inclusion criteria were AUD treatment, injectable naltrexone, and randomized clinical trials. Only articles written in English, involving human participants, and published in peer-reviewed journals were considered for this review. A total of 11 studies met the inclusion criteria. Ten out of the 11 studies assessed the impact of injectable naltrexone in a 3- to 6-month follow-up period, with one study having a year follow-up. This systematic review indicates that overall, injectable naltrexone therapy produced positive AUD treatment outcomes, including reduced mean time to first drinking day and/or heavy drinking day, decreased number of drinking and/or heavy drinking days, and increased abstinence, frequently at a statistically significant level in the larger studies. However, in all studies, less than half of the participants were completely abstinent after receiving injectable naltrexone. Injectable naltrexone treatment along with psychosocial therapy holds promise for addressing AUD.

Wearable Activity Tracker Use and Physical Activity Among Informal Caregivers in the United States: Quantitative Study.

BACKGROUND: With an increase in aging population and chronic medical conditions in the United States, the role of informal caregivers has become paramount as they engage in the care of their loved ones. Mounting evidence suggests that such responsibilities place substantial burden on informal caregivers and can negatively impact their health. New wearable health and activity trackers (wearables) are increasingly being used to facilitate and monitor healthy behaviors and to improve health outcomes. Although prior studies have examined the efficacy of wearables in improving health and well-being in the general population, little is known about their benefits among informal caregivers. OBJECTIVE: This study aimed to examine the association between use of wearables and levels of physical activity (PA) among informal caregivers in the United States. METHODS: We used data from the National Cancer Institute's Health Information National Trends Survey 5 (cycle 3, 2019 and cycle 4, 2020) for a nationally representative sample of 1273 community-dwelling informal caregivers-aged ≥18 years, 60% (757/1273) female, 75.7% (990/1273) had some college or more in education, and 67.3% (885/1273) had ≥1 chronic medical condition-in the United States. Using jackknife replicate weights, a multivariable logistic regression was fit to assess an independent association between the use of wearables and a binary outcome: meeting or not meeting the current World Health Organization's recommendation of PA for adults (≥150 minutes of at least moderate-intensity PA per week). RESULTS: More than one-third (466/1273, 37.8%) of the informal caregivers met the recommendations for adult PA. However, those who reported using wearables (390/1273, 31.7%) had slightly higher odds of meeting PA recommendations (adjusted odds ratios 1.1, 95% CI 1.04-1.77; P=.04) compared with those who did not use wearables. CONCLUSIONS: The results demonstrated a positive association between the use of wearables and levels of PA among informal caregivers in the United States. Therefore, efforts to incorporate wearable technology into the development of health-promoting programs or interventions for informal caregivers could potentially improve their health and well-being. However, any such effort should address the disparities in access to innovative digital technologies, including wearables, to promote health equity. Future longitudinal studies are required to further support the current findings of this study.

Factors Associated with E-Cigarette Quit Intention Among Adolescents in the United States.

Background: Given increasing use of e-cigarettes among adolescents in the United States and its potential for nicotine addiction, encouraging adolescents to quit using these products has become a public health priority. This study examined factors at various socio-ecological levels associated with e-cigarette quit intention (pre-contemplation, contemplation, or preparation) using the Stages of Change of the Trans-theoretical Model among the U.S. adolescents. Methods: We used cross-sectional data from the past 30-day adolescent exclusive e-cigarette users participating in Wave 4 of the Population Assessment of Tobacco and Health study (n = 349). Weighted adjusted multinomial logistic regression models were used to analyze the data. Results: Compared to pre-contemplators and contemplators, preparators were more likely to believe that nicotine in e-cigarettes was "very/extremely harmful" (vs. "not at all harmful") to health (p < 0.001) and people cause a "lot of harm" (vs. "no harm") to themselves when they use e-cigarettes (p < 0.001). In comparison to pre-contemplators, contemplators and preparators were more likely to report that their parents/guardians talked with them about not using e-cigarettes than those whose parents/guardians did not talk with them (p < 0.001). Additionally, contemplators and preparators were also more likely to report that they "often/very often" (vs. never) noticed health warnings on e-cigarette packages (p < 0.001). Conclusion: Our findings suggest that harm perception, influence of family, and e-cigarette health warnings are some of the important factors associated with the stages of change for intention to quit among adolescent e-cigarette users. This study will help public health practitioners and researchers design multi-level e-cigarette cessation interventions for adolescents.

Factors Associated With E-Cigarette Quitting Behavior Among Adolescents in the United States: A Prospective Observational Study.

PURPOSE: This prospective observational study examined the association of socioecological factors with quitting behavior among US adolescents who exclusively use electronic cigarettes (e-cigarettes). METHODS: We used data from past 30-day adolescent exclusive e-cigarette users (n = 243) participating in Wave 3 of the Population Assessment of Tobacco and Health study, who were then followed-up with approximately 12 months later for Wave 4. Weighted unadjusted and adjusted multivariate logistic regression models and structural equation modeling were performed to analyze the data. RESULTS: Adolescents were significantly less likely to quit e-cigarettes if they perceived that nicotine in e-cigarettes was "slightly/somewhat harmful" to health (adjusted odds ratio [aOR] = 0.38; 95% confidence interval [CI]: 0.16-0.90, p = .02). Similarly, adolescents who reported that someone else in their home owned an e-cigarette (aOR = 0.43 [95% CI: 0.19-0.94], p = .03) or important people in their life used e-cigarettes (aOR = 0.45 [95% CI: 0.21-0.95], p = .03) were significantly less likely to quit e-cigarettes. The structural equation modeling showed a direct significant relationship of individual-level (b = 0.206, p = .02) and interpersonal-level factors (b = 0.170, p = .04) with e-cigarette quitting behavior. DISCUSSION: Our findings suggest that individual-level (harm perception) and interpersonal-level (e-cigarette use at home and by important people) factors may play a significant role in e-cigarette quitting behavior among US adolescents.

Longitudinal associations between time-varying insomnia symptoms and all-cause health care services utilization among middle-aged and older adults in the United States.

OBJECTIVE: To examine longitudinal associations between time-varying insomnia symptoms (difficulty initiating sleep, difficulty maintaining sleep, early-morning awakenings, and nonrestorative sleep) and all-cause health care services utilization (HSU), including overnight hospital stays, nursing home stays, and home health care services among middle-aged and older adults. DATA SOURCES: The Health and Retirement Study (HRS), a nationwide, population-representative survey of primarily middle-aged and older adults in the United States. STUDY DESIGN: This study is an analysis of prospective data from the HRS for a cohort of 13,168 adults (aged ≥50 years; females = 57.7%). Study participants were followed for 16 years. This study focuses on the associations between time-varying insomnia symptoms, both cumulatively and independently, and repeated HSUs. A marginal structural modeling approach was used to capture time-varying biological, psycho-cognitive, and behavioral health factors, and to adjust for selection bias such as differential loss to follow-up. Generalized estimating equations were employed to compute average marginal effects and their 95% confidence intervals. DATA COLLECTION/EXTRACTION METHODS: We extracted longitudinal data from 2002 through 2018 waves of the HRS. PRINCIPAL FINDINGS: Experiencing higher numbers of insomnia symptoms on a cumulative scale was associated with higher probabilities of HSU. For instance, the likelihood of overnight hospital stays for individuals reporting one symptom increased from 4.7 percentage points on average (95% CI: 3.7-5.6, p < 0.001), to 13.9 percentage points (95% CI: 10.3-17.5, p < 0.001) for those reporting four symptoms, relative to individuals experiencing no insomnia symptoms. Further, experiencing each of difficulty initiating and maintaining sleep, and nonrestorative sleep, as standalone symptoms, was associated with a higher likelihood of HSU when compared to those not experiencing the symptoms. CONCLUSIONS: The results demonstrate the potential consequences and adverse impacts of insomnia symptoms on HSU among middle-aged and older adults. Future investigations should focus on the underlying causes and health systems pathways linking insomnia symptoms to HSU.