State-Level Point-of-Sale Tobacco News Coverage and Policy Progression Over a 2-Year Period.

BACKGROUND: Mass media content may play an important role in policy change. However, the empirical relationship between media advocacy efforts and tobacco control policy success has rarely been studied. We examined the extent to which newspaper content characteristics (volume, slant, frame, source, use of evidence, and degree of localization) that have been identified as important in past descriptive studies were associated with policy progression over a 2-year period in the context of point-of-sale (POS) tobacco control. METHOD: We used regression analyses to test the relationships between newspaper content and policy progression from 2012 to 2014. The dependent variable was the level of implementation of state-level POS tobacco control policies at Time 2. Independent variables were newspaper article characteristics (volume, slant, frame, source, use of evidence, and degree of localization) and were collected via content analysis of the articles. State-level policy environment contextual variables were examined as confounders. RESULTS: Positive, significant bivariate relationships exist between characteristics of news content (e.g., high overall volume, public health source present, local quote and local angle present, and pro-tobacco control slant present) and Time 2 POS score. However, in a multivariate model controlling for other factors, significant relationships did not hold. DISCUSSION: Newspaper coverage can be a marker of POS policy progression. Whether media can influence policy implementation remains an important question. Future work should continue to tease out and confirm the unique characteristics of media content that are most associated with subsequent policy progression, in order to inform media advocacy efforts.

Comparison of Sampling Strategies for Tobacco Retailer Inspections to Maximize Coverage in Vulnerable Areas and Minimize Cost.

Introduction: In the United States, tens of thousands of inspections of tobacco retailers are conducted each year. Various sampling choices can reduce travel costs, emphasize enforcement in areas with greater noncompliance, and allow for comparability between states and over time. We sought to develop a model sampling strategy for state tobacco retailer inspections. Methods: Using a 2014 list of 10,161 North Carolina tobacco retailers, we compared results from simple random sampling; stratified, clustered at the ZIP code sampling; and, stratified, clustered at the census tract sampling. We conducted a simulation of repeated sampling and compared approaches for their comparative level of precision, coverage, and retailer dispersion. Results: While maintaining an adequate design effect and statistical precision appropriate for a public health enforcement program, both stratified, clustered ZIP- and tract-based approaches were feasible. Both ZIP and tract strategies yielded improvements over simple random sampling, with relative improvements, respectively, of average distance between retailers (reduced 5.0% and 1.9%), percent Black residents in sampled neighborhoods (increased 17.2% and 32.6%), percent Hispanic residents in sampled neighborhoods (reduced 2.2% and increased 18.3%), percentage of sampled retailers located near schools (increased 61.3% and 37.5%), and poverty rate in sampled neighborhoods (increased 14.0% and 38.2%). Conclusions: States can make retailer inspections more efficient and targeted with stratified, clustered sampling. Use of statistically appropriate sampling strategies like these should be considered by states, researchers, and the Food and Drug Administration to improve program impact and allow for comparisons over time and across states. Implications: The authors present a model tobacco retailer sampling strategy for promoting compliance and reducing costs that could be used by US states and the Food and Drug Administration (FDA). The design is feasible to implement in North Carolina. Use of the sampling design would help document the impact of FDA's compliance and enforcement program, save money, and emphasize inspections in areas where they are needed most. FDA should consider requiring probability-based sampling in their inspections contracts with states and private contractors.

Theoretical and Behavioral Mediators of a Weight Loss Intervention for Men.

OBJECTIVE: Men are currently underrepresented in weight loss trials despite similar obesity rates, which limit our understanding about the most effective elements of treatment for men. The purpose of this study was to test the theoretical (autonomous motivation, self-efficacy, outcome expectancies, and self-regulation) and behavioral (calorie intake, physical activity, self-weighing) mediators of a men-only, Internet-delivered weight loss intervention focused on innovative and tailored treatment elements specifically for men. METHOD: Data comes from a 6-month randomized trial (N = 107) testing the intervention compared to a waitlist control group. Changes in the theoretical mediators between baseline and 3 months were tested as mediators of the intervention effect on weight change at 6 months in both single and multiple mediator models. Changes in behaviors between baseline and 6 months were tested in the same manner. RESULTS: The intervention produced greater weight losses compared to the control group (-5.57 kg ± 6.6 vs. -0.65 kg ± 3.3, p < 0.001) and significant changes (p's < 0.05) in most of the theoretical and behavior mediators. In multiple mediator models, changes in diet-related autonomous motivation, self-efficacy, and self-regulation all significantly mediated the relationship between the intervention and weight loss. The intervention effect was also mediated by changes in dietary intake and self-weighing frequency. CONCLUSIONS: By testing the theoretical mediators of this intervention in a multiple mediator context, this study contributes to current knowledge related to the development of weight loss interventions for men and suggests that interventions should target diet-focused constructs.

Understanding how perceptions of tobacco constituents and the FDA relate to effective and credible tobacco risk messaging: A national phone survey of U.S. adults, 2014-2015.

BACKGROUND: The passage of the 2009 Family Smoking Prevention and Tobacco Control Act has necessitated the execution of timely, innovative, and policy-relevant tobacco control research to inform Food and Drug Administration (FDA) regulatory and messaging efforts. With recent dramatic changes to tobacco product availability and patterns of use, nationally representative data on tobacco-related perceptions and behaviors are vital, especially for vulnerable populations. METHODS: The UNC Center for Regulatory Research on Tobacco Communication conducted a telephone survey with a national sample of adults ages 18 and older living in the United States (U.S.). The survey assessed regulatory relevant factors such as tobacco product use, tobacco constituent perceptions, and tobacco regulatory agency credibility. The study oversampled high smoking/low income areas as well as cell phone numbers to ensure adequate representation among smokers and young adults, respectively. Coverage extended to approximately 98 % of U.S. households. RESULTS: The final dataset (N = 5,014) generated weighted estimates that were largely comparable to other national demographic and tobacco use estimates. Results revealed that over one quarter of U.S. adults, and over one third of smokers, reported having looked for information about tobacco constituents in cigarette smoke; however, the vast majority was unaware of what constituents might actually be present. Although only a minority of people reported trust in the federal government, two thirds felt that the FDA can effectively regulate tobacco products. CONCLUSIONS: As the FDA continues their regulatory and messaging activities, they should expand both the breadth and availability of constituent-related information, targeting these efforts to reach all segments of the U.S. population, especially those disproportionately vulnerable to tobacco product use and its associated negative health outcomes.

The Effects of the Moms and Teens for Safe Dates Program on Dating Abuse: a Conditional Process Analysis.

Moms and Teens for Safe Dates (MTSD) is a dating abuse (DA) prevention program for teens exposed to domestic violence. In a randomized controlled trial (RCT), MTSD prevented certain types of DA victimization (psychological and physical) and perpetration (psychological and cyber) among teens with higher, but not lower, exposure to domestic violence. We built on these findings by using moderated mediation analysis to examine whether level of teen exposure to domestic violence conditioned the indirect effects of MTSD on these types of DA through targeted mediators. MTSD consisted of six mailed activity booklets. Mothers who had been former victims of domestic violence delivered the program to their teens. Mother and teen pairs were recruited into the RCT through community advertising and completed baseline and 6-month follow-up interviews (N = 277 pairs). As expected, MTSD had significant favorable effects for teens with higher but not lower exposure to domestic violence on several mediators that guided program content, including teen conflict management skills and mother-perceived severity of DA, self-efficacy for enacting DA prevention efforts, and comfort in communicating with her teen. MTSD had significant main effects on other mediators including teen feeling of family closeness and cohesion and mother-perceived susceptibility of her teen to DA. As expected, all significant indirect effects of MTSD on DA outcomes through mediators were for teens with higher exposure to domestic violence. Findings have implications for developing DA victimization and perpetration prevention programs for teens with high exposure to domestic violence.

Reducing Children's Susceptibility to Alcohol Use: Effects of a Home-Based Parenting Program.

This 4-year efficacy trial tested whether a home-based, self-administered parenting program could have a long-term effect on children's cognitive susceptibility to alcohol use, and it tested hypothesized moderators and mediators of any such program effect. Using a two-group randomized controlled design, 1076 children (540 treatment; 536 control; mean age of 9.2 years at baseline) completed telephone interviews prior to randomization and follow-up interviews 12, 24, 36, and 48 months post-baseline. Mothers of children randomized to treatment received a 5-month-long parenting program during year 1, followed by two 1-month-long boosters in years 2 and 3. Exposure to the program was significantly inversely associated with susceptibility to alcohol use 48 months post-baseline (b = -0.03, p = .04), with no variation in program effects by parental alcohol use or mother's race/ethnicity or education, suggesting broad public health relevance of the parenting program. Path analyses of simple indirect effects through each hypothesized mediator showed that program exposure positively influenced parental communication to counter pro-drinking influences in the family and media domains and parental rule setting 36 months post-baseline; these variables, in turn, predicted reduced susceptibility to alcohol use 48 months post-baseline. Parallel (multiple) mediation analysis showed that the program had a significant indirect effect on susceptibility through parental rule setting. Together, the findings indicate that internalization of protective alcohol-related expectancies and intentions is possible among children whose mothers provide early exposure to alcohol-specific socialization. Additional research is needed to link alcohol-specific socialization during childhood with adolescent drinking outcomes.

Shared Risk Factors for the Perpetration of Physical Dating Violence, Bullying, and Sexual Harassment Among Adolescents Exposed to Domestic Violence.

The high risk of perpetrating physical dating violence, bullying, and sexual harassment by adolescents exposed to domestic violence points to the need for programs to prevent these types of aggression among this group. This study of adolescents exposed to domestic violence examined whether these forms of aggression share risk factors that could be targeted for change in single programs designed to prevent all three types of aggression. Analyses were conducted on 399 mother victims of domestic violence and their adolescents, recruited through community advertising. The adolescents ranged in age from 12 to 16 years; 64 % were female. Generalized estimating equations was used to control for the covariation among the aggression types when testing for shared risk factors. Approximately 70 % of the adolescents reported perpetrating at least one of the three forms of aggression. In models examining one risk factor at a time, but controlling for demographics, adolescent acceptance of sexual violence, mother-adolescent discord, family conflict, low maternal monitoring, low mother-adolescent closeness, low family cohesion, depressed affect, feelings of anger, and anger reactivity were shared across all three aggression types. In multivariable models, which included all of the risk factors examined and the demographic variables, low maternal monitoring, depressed affect and anger reactivity remained significant shared risk factors. Our findings suggest that programs targeting these risk factors for change have the potential to prevent all three forms of aggression. In multivariable models, poor conflict management skills was a risk for bullying and sexual harassment, but not dating violence; acceptance of dating violence was a risk for dating violence and bullying, but not sexual harassment; and none of the examined risk factors were unique to aggression type. The study's implications for the development of interventions and future research are discussed.

Opt-out HIV testing in prison: informed and voluntary?

HIV testing in prison settings has been identified as an important mechanism to detect cases among high-risk, underserved populations. Several public health organizations recommend that testing across health-care settings, including prisons, be delivered in an opt-out manner. However, implementation of opt-out testing within prisons may pose challenges in delivering testing that is informed and understood to be voluntary. In a large state prison system with a policy of voluntary opt-out HIV testing, we randomly sampled adult prisoners in each of seven intake prisons within two weeks after their opportunity to be HIV tested. We surveyed prisoners' perception of HIV testing as voluntary or mandatory and used multivariable statistical models to identify factors associated with their perception. We also linked survey responses to lab records to determine if prisoners' test status (tested or not) matched their desired and perceived test status. Thirty-eight percent (359/936) perceived testing as voluntary. The perception that testing was mandatory was positively associated with age less than 25 years (adjusted relative risk [aRR]: 1.45, 95% confidence interval [CI]: 1.24, 1.71) and preference that testing be mandatory (aRR: 1.81, 95% CI: 1.41, 2.31) but negatively associated with entry into one of the intake prisons (aRR: 0.41 95% CI: 0.27, 0.63). Eighty-nine percent of prisoners wanted to be tested, 85% were tested according to their wishes, and 82% correctly understood whether or not they were tested. Most prisoners wanted to be HIV tested and were aware that they had been tested, but less than 40% understood testing to be voluntary. Prisoners' understanding of the voluntary nature of testing varied by intake prison and by a few individual-level factors. Testing procedures should ensure that opt-out testing is informed and understood to be voluntary by prisoners and other vulnerable populations.

Do mammographic technologists affect radiologists' diagnostic mammography interpretative performance?

OBJECTIVE: The purpose of this study was to determine whether the technologist has an effect on the radiologists' interpretative performance of diagnostic mammography. MATERIALS AND METHODS: Using data from a community-based mammography registry from 1994 to 2009, we identified 162,755 diagnostic mammograms interpreted by 286 radiologists and performed by 303 mammographic technologists. We calculated sensitivity, false-positive rate, and positive predictive value (PPV) of the recommendation for biopsy from mammography for examinations performed (i.e., images acquired) by each mammographic technologist, separately for conventional (film-screen) and digital modalities. We assessed the variability of these performance measures among mammographic technologists, using mixed effects logistic regression and taking into account the clustering of examinations within women, radiologists, and radiology practices. RESULTS: Among the 291 technologists performing conventional examinations, mean sensitivity of the examinations performed was 83.0% (95% CI, 80.8-85.2%), mean false-positive rate was 8.5% (95% CI, 8.0-9.0%), and mean PPV of the recommendation for biopsy from mammography was 27.1% (95% CI, 24.8-29.4%). For the 45 technologists performing digital examinations, mean sensitivity of the examinations they performed was 79.6% (95% CI, 73.1-86.2%), mean false-positive rate was 8.8% (95% CI, 7.5-10.0%), and mean PPV of the recommendation for biopsy from mammography was 23.6% (95% CI, 18.8-28.4%). We found significant variation by technologist in the sensitivity, false-positive rate, and PPV of the recommendation for biopsy from mammography for conventional but not digital mammography (p < 0.0001 for all three interpretive performance measures). CONCLUSION: Our results suggest that the technologist has an influence on radiologists' interpretive performance for diagnostic conventional but not digital mammography. Future studies should examine why this difference between modalities exists and determine if similar patterns are observed for screening mammography.

Predictors of smoke-free policies in affordable multiunit housing, North Carolina, 2013.

INTRODUCTION: Smoke-free policies can effectively protect nonsmokers from secondhand smoke (SHS) exposure in multiunit housing. We surveyed all affordable multiunit housing properties in North Carolina to determine the statewide prevalence of smoke-free policies and to identify predictors of smoke-free policies. METHODS: Representatives of affordable housing properties in North Carolina completed a mailed or online survey during June through October 2013. The primary outcome measure was presence of a smoke-free policy, defined as prohibiting smoking in all residential units. We used χ(2) analysis and multivariate logistic regression to identify correlates of smoke-free policies. RESULTS: Of 1,865 eligible properties, responses were received for 1,063 (57%). A total of 16.5% of properties had policies that prohibited smoking in all residential units, while 69.6% prohibited smoking in indoor common areas. In multivariate analysis, an increase in the number of children per unit was associated with a decrease in the odds of having a smoke-free policy at most properties. Newer properties across all company sizes were more likely to have smoke-free policies. Accessing units from interior hallways predicted smoke-free policies among medium-sized companies. CONCLUSION: More smoke-free policies in affordable multiunit housing are needed to protect vulnerable populations, particularly children, from SHS exposure. Public health professionals should continue to educate housing operators about SHS and the benefits of smoke-free policies at all properties, including older ones and ones where units are accessed from outside rather than from an interior hallway.

Brief report: A randomized controlled trial examining peer support and behavioral weight loss treatment.

Peer support among adolescents has been positively associated with heath behaviors; however, enhancing peer support for weight loss has rarely been studied among adolescents. This study examined whether a peer support training component delivered to enhance a standard weight loss program led to improved outcomes. Forty-one overweight adolescent females were randomly assigned to a Standard or Enhanced Peer Support intervention. The Enhanced group received in person peer support skills training and practiced skills using social networking. At 16 weeks, participants in the Enhanced condition reported significantly increased perceptions of friend support. Both groups demonstrated significant weight loss (6.4 lbs, ± 8.3). Attendance and self-monitoring were associated with weight loss. Perceptions of peer support can be increased with a peer training component, but did not increase weight loss during the short term.

Redefining racial residential segregation and its association with physical activity among African Americans 50 years and older: a mixed methods approach.

Physical inactivity is one of the factors contributing to disproportionate disease rates among older African Americans. Previous literature indicates that older African Americans are more likely to live in racially segregated neighborhoods and that racial residential segregation is associated with limited opportunities for physical activity. A cross-sectional mixed methods study was conducted guided by the concept of therapeutic landscapes. Multilevel regression analyses demonstrated that racial residential segregation was associated with more minutes of physical activity and greater odds of meeting physical activity recommendations. Qualitative interviews revealed the following physical activity related themes: aging of the neighborhood, knowing your neighbors, feeling of safety, and neighborhood racial identity. Perceptions of social cohesion enhanced participants' physical activity, offering a plausible explanation to the higher rates of physical activity found in this population. Understanding how social cohesion operates within racially segregated neighborhoods can help to inform the design of effective interventions for this population.

Risk factors for suicide among older adults with cancer.

OBJECTIVE: To determine whether the increased risk of suicide for individuals with cancer may be explained by functional limitations, lack of social support, or other factors. METHOD: In this population-based case-control study, interviews of primary informants for suicides in the state of North Carolina were compared to interviews with participants in the Piedmont Health Study of the Elderly to estimate adjusted odds ratios for suicide and self-reported, physician diagnosed cancer, heart attack, stroke, and hip fracture. RESULTS: Adjusting for all other factors, there was a statistically significant association of suicide and cancer (odds ratio [OR] 2.62, 95% confidence interval [CI] CI 1.84-3.73), but not heart attack, hip fracture, or stroke. The risk of suicide was also elevated for men vs. women (OR 17.15, CI 10.88-27.02), whites vs. blacks (OR 9.70, CI 6.07-15.50), and individuals with stressful life events (OR 2.75, CI 1.97-3.86) or limitations of instrumental (OR 2.93, CI 2.03-4.22) but not physical activities of daily living. Suicide cases were not more likely to be short of breath or poor sleep quality. Suicide was statistically significantly less likely for study participants who were married with spouse living vs. other (OR 0.61, CI 0.43-0.88) or who had one or more indicators of social support (OR 0.27, CI 0.19-0.39). CONCLUSION: After adjustment for other risk factors, suicide was strongly associated with cancer but not with other disabling, potentially fatal conditions.

The influence of stigma and discrimination on female sex workers' access to HIV services in St. Petersburg, Russia.

Stigma associated with HIV and risk behaviors is known to be a barrier to health care access for many populations. Less is known about female sex workers (FSW) in Russia, a population that is especially vulnerable to HIV-infection, and yet hard-to-reach for service providers. We administered a questionnaire to 139 FSW to better understand how stigma and discrimination influence HIV service utilization. Logistic regression analysis indicated that HIV-related stigma is negatively associated with uptake of HIV testing, while sex work-related stigma is positively associated with HIV testing. HIV-positive FSW are more likely than HIV-negative FSW to experience discrimination in health care settings. While decreasing societal stigma should be a long-term goal, programs that foster inclusion of marginalized populations in Russian health care settings are urgently needed.

Attributes that differentiate children who sip alcohol from abstinent peers.

Sipping alcohol during childhood may be a marker of differentiation as regards children's future risk of underage drinking; yet very little is known about alcohol use when it occurs among elementary school-aged children. The purpose of the present study is to examine alcohol sipping behavior in a sample of third-grade school children to learn whether sipping is associated with attributes that could increase children's likelihood of further underage drinking. We collected telephone interview data from 1,050 mothers and their third grade children (mean age 9.2 years; 48.2% male) residing in the Southeastern United States. The majority of mothers were White non-Hispanic (69.02%) or Black non-Hispanic (21.3%); most (85%) lived in households shared with fathers or other adult caretakers. We hypothesized that children who sip alcohol would score lower than abstinent peers on indicators of competence and score higher on indicators of exposure to alcohol-specific socialization by parents and peers. A multivariate model controlling for frequency of parent alcohol use and demographic covariates showed that children who had sipped alcohol were significantly less likely than abstinent peers to affirm indicators of competence and significantly more likely to affirm indicators of exposure to alcohol specific socialization by parents and by same age peers. These preliminary findings suggest that developmental attributes associated with risk of underage drinking begin to differentiate at least as young as middle childhood. Research is needed to test prospectively for continuity between alcohol risk attributes present in middle childhood and future alcohol use.

Improving participant understanding of informed consent in an HIV-prevention clinical trial: a comparison of methods.

Empirical research on informed consent has shown that study participants often do not fully understand consent information. This study assessed participant understanding of three mock consent approaches describing an HIV-prevention clinical trial in Lilongwe, Malawi prior to trial implementation. Pregnant women (n = 297) were systematically selected from antenatal-care waiting lines and sequentially allocated to receive an enhanced standard consent form (group 1), a context-specific consent form (group 2), or context-specific counseling cards (group 3). Understanding of research concepts and study procedures was assessed immediately postintervention and at 1-week follow-up. At postintervention, participants in groups 2 and 3 understood more about research concepts and study procedures compared with group 1. Group 3 participants also understood more about study procedures compared with group 2. At follow-up, participants in groups 2 and 3 continued to understand more about research concepts and study procedures. Context-specific approaches improved understanding of consent information in this study.

Effect of observing change from comparison mammograms on performance of screening mammography in a large community-based population.

PURPOSE: To evaluate the effect of comparison mammograms on accuracy, sensitivity, specificity, positive predictive value (PPV(1)), and cancer detection rate (CDR) of screening mammography to determine the role played by identification of change on comparison mammograms. MATERIALS AND METHODS: This HIPAA-compliant and institutional review board-approved prospective study was performed with waiver of patient informed consent. A total of 1,157,980 screening mammograms obtained between 1994 and 2008 in 435,183 women aged at least 40 years were included. Radiologists recorded presence of comparison mammograms and change, if seen. Women were followed for 1 year to monitor cancer occurrence. Performance measurements were calculated for screening with comparison mammograms versus screening without comparison mammograms and for screening with comparison mammograms that showed a change versus screening with comparison mammograms that did not show a change while controlling for age, breast density, and data clustering. RESULTS: Comparison mammograms were available in 93% of examinations. For screening with comparison mammograms versus screening without comparison mammograms, CDR per 1000 women was 3.7 versus 7.1; recall rate, 6.9% versus 14.9%; sensitivity, 78.9% versus 87.4%; specificity, 93.5% versus 85.7%; and PPV(1), 5.4% versus 4.8%. For screening with comparison mammograms that showed a change versus screening with comparison mammograms that did not show a change, CDR per 1000 women was 25.4 versus 0.8; recall rate, 41.4% versus 2.0%; sensitivity, 96.6% versus 43.5%; specificity, 60.4% versus 98.1%; and PPV(1), 6.0% versus 3.9%. Detected cancers with change were 21.1% ductal carcinoma in situ and 78.9% invasive carcinoma. Detected cancers with no change were 19.3% ductal carcinoma in situ and 80.7% invasive carcinoma. CONCLUSION: Performance is affected when change from comparison mammograms is noted. Without change, sensitivity is low and specificity is high. With change, sensitivity is high, with a high false-positive rate (low specificity). Further work is needed to appreciate changes that might indicate cancer and to identify changes that are likely not indicative of cancer.

The prevalence of evidence-based drug use prevention curricula in U.S. middle schools in 2008.

The No Child Left Behind Act mandates the implementation of evidence-based drug prevention curricula in the nation's schools. The purpose of this paper is to estimate changes in the prevalence of such curricula from 2005 to 2008. We surveyed school staff in a nationally representative sample of schools with middle school grades. Using a web-based approach to data collection that we supplemented by telephone calls, we secured data from 1892 schools for a response rate of 78.2%. We estimate that the prevalence of evidence-based drug prevention curricula rose from 42.6% in 2005 to 46.9% in 2008, and that the prevalence of schools that used these curricula most frequently increased from 22.7% to 25.9% over this period. In addition, the proportion of schools using locally developed curricula also rose, from 17.6% to 28.1%. This study suggests the success of efforts by the Office of Safe and Drug-Free Schools to increase the prevalence of evidence-based curricula, as well as the need to continue to track the prevalence of these curricula in response to any reductions in the Office's fiscal support for evidence-based drug prevention curricula in the nation's schools.

Attributes of drinking water, sanitation, and hygiene associated with microbiological water quality of stored drinking water in rural schools in Mozambique and Uganda.

Contaminated drinking water causes morbidity and mortality worldwide, especially in low- and middle-income countries. Drinking water quality has been studied extensively in household settings, but little research is available on drinking water quality in schools. School settings are of particular importance, because children are more susceptible than adults to a variety of diseases from contaminated drinking water. Many school water, sanitation and hygiene (WaSH) interventions have been studied for their efficacy to reduce diarrheal disease incidence, but few have evaluated drinking water quality, which reflects an important exposure pathway between WaSH services and health outcomes. Using school surveys developed from internationally established WaSH indicators and field microbiological water quality tests, we studied 374 rural schools in Mozambique and Uganda to understand the association between specific WaSH services and drinking water microbiological contamination, specifically testing most probable number (MPN) of Escherichia coli, an indicator of fecal contamination, per 100 mL. In Mozambique and Uganda, 71% and 83% respectively of rural schools had low risk drinking water quality (<1 E. coli/100 mL); thirteen percent and seven percent had very high-risk water quality (≥100 E. coli/100 mL). When accounting for all WaSH services studied, schools that used an improved-type water source had 0.22 times less E. coli in stored drinking water in Mozambique (95% CI: 0.07, 0.65) and 0.12 times less E. coli in Uganda (95% CI: 0.02, 0.80). In Mozambique, use of a water source within 30 minutes for travel and collection and the presence of water and soap/ash for handwashing were also significantly associated with less E. coli in drinking water. The findings of this study provide public health practitioners with implementable WaSH services to improve school drinking water quality, which has implications for the health, learning environment, and cognitive development of school children in rural Mozambique and Uganda.

Race moderates the relationship between obesity and colorectal cancer screening in women.

OBJECTIVE: To determine if the relationship between obesity and usage of colorectal cancer (CRC) screening in women varies when stratifying by race. METHODS: Using nationally representative data from the 2005 National Health Interview Survey, we examined the relationship between obesity and CRC screening for white and African-American women aged 50 and older. Screening usage variables indicated if a woman was up-to-date for any CRC screening test, colonoscopy, or FOBT. We used multivariable logistic regression models that included interaction terms to determine if race moderates the obesity-screening relationship. We also calculated adjusted up-to-date colonoscopy rates using direct standardization to model covariates. RESULTS: The relationship between obesity and screening differed by race for any CRC screening test (P = 0.04 for interaction) and for colonoscopy (P = 0.01 for interaction), but not for FOBT. Obese white women had a lower adjusted colonoscopy rate (30.2%, 95% CI 25.9-34.8) than non-obese white women (39.1%, 95% CI 36.1-42.2). Obese African-American women, on the other hand, had a higher adjusted colonoscopy rate (41.2%, 95% CI 31.6-51.4) than their non-obese counterparts (35.6%, 95% CI 28.3-43.6). Overall, adjusted colonoscopy rates were lowest among obese white women. CONCLUSIONS: Obesity is associated with lower CRC screening rates in white, but not African-American women.