Differences in Cancer Screening Responses to State Medicaid Expansions by Race and Ethnicity, 2011‒2019.

Objectives. To estimate whether state Medicaid expansions' relationships to breast, cervical, and colorectal cancer screening differ by race/ethnicity. Methods. Analyses conducted in 2021 used 2011-2016 and 2018-2019 Behavioral Risk Factor Surveillance System data on adults aged 40 to 64 years with household incomes below 400% of the federal poverty guideline (FPG; n = 537 250). Triple-difference analyses compared cancer screening in Medicaid expansion versus nonexpansion states, before versus after expansion, among people with incomes above versus below the eligibility cutoff (138% FPG). Race/ethnicity and ethnicity-by-language interaction terms tested for effect modification. Results. Associations between Medicaid expansions and cancer screening were significant for past-2-year mammograms and past-5-year colorectal screening. Effect modification analyses showed elevated mammography among non-Hispanic Asian women (+9.0 percentage points; 95% confidence interval [CI] = 3.2, 14.8) and Hispanic women (+6.0 percentage points; 95% CI = 2.0, 10.1), and Papanicolaou tests among Hispanic women (+4.2 percentage points; 95% CI = 0.1, 8.2). Findings were not limited to English- or Spanish-speaking respondents and were robust to insurance status controls. Conclusions. Medicaid expansions yielded statistically significant increases in income-eligible Asian and Hispanic women's mammography and Hispanic women's Pap testing relative to non-Hispanic White women. Neither language proficiency nor insurance status explained these findings. (Am J Public Health. 2022;112(11):1630-1639. https://doi.org/10.2105/AJPH.2022.307027).

Para athletes' perceptions of abuse: a qualitative study across three lower resourced countries.

OBJECTIVES: Interpersonal violence is an increasingly recognised risk of sport participation and causally linked to negative physical and mental health outcomes. Para athletes from low- and middle-income countries may be at highest risk of physical, psychological, sexual and neglect-related violence due to various factors; however, their perceptions of these abusive behaviours are unknown. This study examined the perceptions and experiences of abuse in para athletes from three lower resourced countries: Ghana, India and Brazil. METHODS: Qualitative data from semistructured focus group interviews conducted with 26 individuals were collected to explore characteristics of abuse observed, navigated and experienced by para athletes. The framework method for multidisciplinary qualitative research guided data analysis. RESULTS: Athletes identified a wide range of abusive behaviours they experienced within and outside of sport, including psychological, emotional, physical, sexual and neglect-related violence, which operated on both interpersonal and systemic levels. Most athletes described three less easily recognised forms of abuse in greater detail and more frequently than others: financial abuse, neglect and disability stigma. CONCLUSION: It is important to hear directly from athletes with diverse experiences and backgrounds and to integrate their insights and priorities into sport safeguarding policies, programmes and interventions. Understanding the requirements and challenges of para athletes and para sport is needed to achieve safe, equitable and inclusive sport. As new insights from diverse sport settings are added to the evidence base, globally balanced, athlete-generated and locally relevant preventative strategies can better protect all athletes.

Cost considerations for adoption of diabetes technology are pervasive: A qualitative study of persons living with type 1 diabetes and their families.

BACKGROUND: Cost is a major consideration in the uptake and continued use of diabetes technology. With increasing use of automated insulin delivery systems, it is important to understand the specific cost-related barriers to technology adoption. In this qualitative analysis, we were interested in understanding and examining the decision-making process around cost and diabetes technology use. MATERIALS AND METHODS: Four raters coded transcripts of four stakeholder groups using inductive coding for each stakeholder group to establish relevant themes/nodes. We applied the Social Ecological Model in the interpretation of five thematic levels of cost. RESULTS: We identified five thematic levels of cost: policy, organizational, insurance, interpersonal and individual. Equitable diabetes technology access was an important policy-level theme. The insurance-level theme had multiple subthemes which predominantly carried a negative valence. Participants also emphasized the psychosocial burden of cost specifically identifying diabetes costs to their families, the guilt of diabetes related costs, and frustration in the time and involvement required to ensure insurance coverage. CONCLUSION: We found broad consensus in how cost is experienced by stakeholder groups. Cost considerations for diabetes technology uptake extended beyond finances to include time, cost to society, morality and interpersonal relationships. Cost also reflected an important moral principle tied to the shared desire for equitable access to diabetes technology. Knowledge of these considerations can help clinicians and researchers promote equitable device uptake while anticipating barriers for all persons living with type 1 diabetes and their families.

Harnessing policy to promote inclusive medical product evidence: development of a reference standard and structured audit of clinical trial diversity policies.

Objective: To develop a reference standard based on US Food and Drug Administration and stakeholder guidance for pharmaceutical companies' policies on diversity in clinical trials and to assess these policies. Design: Development of a reference standard and structured audit for clinical trial diversity policies. Setting: 50 pharmaceutical companies selected from the top 500 by their market capitalizations in 2021 (the 25 largest companies and 25 non-large companies, randomly selected from the remaining 475 companies). Population: Data from pharmaceutical company websites and annual reports. Policy guidance from the Pharmaceutical Research and Manufacturers of America, International Federation of Pharmaceutical Manufacturers and Associations, Biotechnology Industry Organization, International Committee of Medical Journal Editors, the US Food and Drug Administration, European Medicines Agency, and World Health Organization, up to 15 May 2023. Main outcome measures: Multicomponent measure based on distinct themes derived from FDA and stakeholder guidance. Results: Reviewing FDA and stakeholder guidance identified 14 distinct themes recommended for improving diversity in clinical trials, which were built into a reference standard: (1) enrollment targets that reflect the prevalence of targeted conditions in populations, (2) broad eligibility criteria for trials, (3) diversity in the workforce, (4) identification and remedy of barriers to trial recruitment and retention, (5) incorporation of patient input into trial design, (6) health literacy, (7) multidimensional approaches to diversity, (8) sites with diverse providers and patient populations, (9) data collection after product approval, (10) diverse enrollment in every country where trials are conducted, (11) diverse enrollment should be a focus for all phases of clinical trials, not just later stage or pivotal trials, (12) varied trial design, (13) expanded access, and (14) public reporting of the personal characteristics of participants in trials. Applying this reference standard, 48% (24/50) of companies had no public policy on diversity in clinical trials; among those with policies, content varied widely. Large companies were more likely to have a public policy than non-large companies (21/25, 84% v 5/25, 20%, P<0.001). Large companies most frequently committed to using epidemiological based trial enrollment targets representing the prevalence of indicated conditions in various populations (n=15, 71%), dealing with barriers to trial recruitment (n=15, 71%), and improving patient awareness of trial opportunities (n=14, 67%). The location of the company was not associated with having a public diversity policy (P=0.17). The average company policy had five of the 14 commitments (36%, range 0-8) recommended in FDA and stakeholder guidance. Conclusions: The findings of the study showed that many pharmaceutical companies did not have public policies on diversity in clinical trials, although policies were more common in large than non-large companies. Policies that were publicly available varied widely and lacked important commitments recommended by stakeholder guidance. The results of the study suggest that corporate policies can be better leveraged to promote representation and fair inclusion in research, and implementation of FDA and stakeholder guidance.

Qualitative exploration of longer versus shorter quit attempts among adults using E-Cigarettes for combustible cigarette cessation.

Empirical evidence about the effectiveness of using e-cigarettes to quit smoking cigarettes remains inconclusive, yet e-cigarettes are commonly used for smoking cessation. Moreover, people who have longer duration quit attempts are likely to have even longer quit attempts in the future. Researchers analyzed 40 qualitative interviews to assess adults' experiences using e-cigarettes during their longest duration quit attempt. Interviewees quit smoking for ≥ one month (n = 20) or for shorter durations (n = 20). Thematic and comparative content analyses were used to analyze interview transcripts for factors facilitating or impeding the duration of quit attempts when using e-cigarettes. Participant narratives were mostly similar irrespective of their quit attempt duration. Six themes common across groups as well as themes more often discussed by people with shorter quit attempts are described. Most participants discussed using e-cigarette devices and flavors to either replace sensations similar to smoking combustible cigarettes (e.g., inhaling from a cylindrical object) or to distract themselves from cravings to smoke. E-cigarettes also were described by the majority of participants as useful for smoking cessation because they approximate combustible cigarette use, potentially reduce health-related harms, save money, and lead to reduced social stigma compared to smoking cigarettes. Those who reported shorter duration quit attempts shared e-cigarette product challenges, health concerns, needs for support. Study findings demonstrate the need for additional research on the factors that may increase the likelihood that using e-cigarettes will result in longer and sustained e-cigarette-based quit attempts among adults.

Disparities in COVID-19 vaccine hesitancy among a diverse community-based sample in Connecticut, United States.

Though vaccination is among our strongest tools to prevent COVID-19 infections, its delivery has proven challenging. At a time when COVID-19 cases were rapidly increasing in the Northeast, we examined the role of sociodemographic factors, social determinants of health (SDOH), and health-related beliefs, including conspiracy theories, in influencing COVID-19 vaccine hesitancy among a diverse sample of Connecticut (United States) residents. Between August and December 2020, utilizing community partners and advertisements via social media, we surveyed communities known to be most impacted by COVID-19. We used descriptive analysis and multivariable logistic regression to examine vaccine hesitancy. Among 252 participants, most were female (69.8%) and under the age of 55 (62.7%). Approximately one-third reported household incomes less than $30,000 per year and 23.5% were non-Hispanic Black and 17.5% were Hispanic/Latinx. While 38.9% of participants were vaccine hesitant, non-Hispanic Black and Hispanic/Latinx participants were more vaccine hesitant (adjusted odds ratio [AOR] = 3.62; 95% CI 1.77, 7.40) compared to non-Hispanic Whites/Others. Additional factors associated with vaccine hesitancy after adjustment for socioeconomic status and barriers related to SDOH included low perceived risk of COVID-19 and not receiving COVID-19 information from medical institutions and community health workers (p < 0.05). Race/ethnicity, perceived risk, sources of health information, and conspiracy beliefs played a significant role in vaccine hesitancy among this diverse sample. Interventions to promote vaccination should include trusted messengers and sources of information, while long term efforts should focus on addressing the social conditions that deter confidence in scientific data, vaccine efficacy, and the healthcare system.

Association of racial discrimination in health care settings and use of electronic cigarettes to quit smoking among Black adults.

INTRODUCTION: Black people are disproportionately burdened by tobacco-related diseases and are less successful at cigarette cessation with current treatments. We know little about the effectiveness of e-cigarettes as a smoking cessation method compared to currently approved methods in Black adults who smoke. Many Black adults report experiencing racial discrimination in health care, but if discrimination is related to utilization of smoking cessation aids including e-cigarettes and success with smoking cessation in this population is unclear. Therefore, this exploratory study aimed to understand how negative experiences and racial discrimination in health care influence use of e-cigarettes for cigarette cessation and success with cigarette cessation among Black adults. METHODS: The study interviewed 201 Black adults who used cigarettes and tried to quit in their lifetime from the Family and Community Health Study in 2016. The study asked if they had tried and successfully quit cigarettes with e-cigarettes vs. other methods (support groups, medications, nicotine replacement therapies, call-in help lines, cold turkey [quit on their own], counseling) and asked about their negative experiences and racial discrimination in health care. We performed separate logistic regressions that evaluated the association of negative experiences and racial discrimination in health care with 1) use of e-cigarettes for cigarette cessation vs. other quitting methods and 2) success with cigarette cessation using any method among Black adults while controlling for age, sex, socioeconomic status, health insurance status, and age of onset of cigarette use. RESULTS: More reported negative experiences and racial discrimination in health care were associated with ever trying to quit with e-cigarettes compared to other methods (OR:1.75, 95 % CI [1.05-2.91]), but negative experiences and racial discrimination in health care were not associated with cigarette quitting success. Interestingly, trying e-cigarettes was associated with being less successful at quitting compared to using other methods to quit smoking (OR: 0.40, 95 % CI [0.20, 0.81]). CONCLUSIONS: These results suggest that educating health care professionals that anticipated discrimination in health care settings may be driving Black adults who smoke to engage in non-evidence-based smoking cessation practices, such as e-cigarettes instead of those that are evidence-based, and may be more effective in this population.

Examining the potential role of e-cigarettes to reduce health disparities associated with menthol cigarette use: Characterizing e-cigarette use, flavors, and reasons for use among US adults smoking menthol cigarettes.

INTRODUCTION: Menthol cigarette use contributes to disproportionate tobacco-related health disparities amongst minoritized race/ethnic groups. E-cigarettes are available in flavors such as menthol and may be a less harmful substitute among adults who smoke. Yet little is known about e-cigarette flavor preference and reasons for use by race/ethnicity among adults who smoke menthol cigarettes. METHODS: Nationally representative PATH wave 4 adult data (Dec. 2016-Jan. 2018) were used to examine how menthol cigarette status and race/ethnicity were associated with past 30-day e-cigarette use, flavors used, and reasons for use with adjusted logistic regression models. RESULTS: Menthol (vs. non-menthol) cigarette use was associated with higher odds of e-cigarette use (AOR=1.33, 95%CI=1.16-1.52). However, non-Hispanic (NH) Black and Hispanic individuals (vs. NH White) had lower odds of e-cigarette use (p's ≤ 0.004). In terms of flavor used, adults smoking menthol cigarettes and NH Black and Hispanic individuals had greater odds of using menthol/mint-flavored e-cigarettes (p's ≤ 0.02), and older adults (vs. 18-24-year-olds) had lower odds of using sweet-flavored e-cigarettes (p's < 0.0001). Regarding reasons for use, adults smoking menthol cigarettes had higher odds of reporting using e-cigarettes due to liking flavors (AOR=1.63, 95%CI=1.30-2.04), while NH Black adults had lower odds of liking flavors (AOR=0.64, 95%CI=0.43-0.96), and Hispanic adults had lower odds of using e-cigarettes to cut down on cigarette smoking (AOR=0.59, 95%CI=0.42-0.83). CONCLUSIONS: Findings suggest menthol flavored e-cigarettes may be important for adults who smoke menthol cigarettes, although racial disparities in current e-cigarette use and reasons for use may exacerbate tobacco-related health disparities.

Qualitative Study of User Experiences with Loop, an Open-Source Automated Insulin Delivery System.

Background: Loop is an open-source automated insulin delivery (AID) system, used by more than 9,000 people with type 1 diabetes. Understanding the pros and cons of Loop use may help improve disease management and support population level innovation. Methods: Focus groups revealed 72 new and existing users' perspectives on Loop uptake, use, and persistence. A subsample of participants from a mixed-methods, observational cohort study shared first-hand accounts of their experiences using Loop. Participants were predominately white (95%), male (50%), privately insured (94%), and reported annual household income ≥$100K (73%) and education exceeding a bachelor's degree (87%) with a mean HbA1c of 6.6% ± 0.8%. Data were analyzed and synthesized by a multidisciplinary team. Results: Participants detailed their experiences with (1) Loop technical support and troubleshooting, (2) decreased mental/behavioral burden, (3) technical issues with parts of the system, (4) glycemic control, (5) personalizing settings, and (6) providers while using Loop. Decreased burden was the most endorsed benefit defined by less worry, stress, and cognitive effort and less time spent on diabetes management tasks. Participants highlighted the benefits of Loop overnight and their introduction to "Loop communities" during use. The most discussed challenges involved technical issues. A range of provider attitudes and knowledge about Loop complicated users' clinical experiences and disclosure. Conclusions: This sample of new and experienced Loop users reported benefits to quality of life and glycemic control that outweighed challenges of setting up system components, customizing the system to suit one's lifestyle and habits, and adjusting system settings. Challenges related to system setup and calibrating settings are remediable and, if addressed, may better serve Loop users. Users reported feeling empowered by the customizability of and the educational effects facilitated by the open-source AID system. Loop helped users learn more about their chronic illness and physiology in an acceptable format. Clinical Trial Registration number: NCT03838900.

Discontinued Use of the Loop Insulin Dosing System: A Mixed-Methods Investigation.

Background: Loop is an open-source automated insulin dosing system that allows users unrivaled control over system settings that affect future glucose prediction. Thousands use Loop, but little is known about those who discontinue. Methods: In a large observational study, 874 Loop participants completed surveys and provided glycemic data, 46 (5.3%) of those self-identified as discontinuing Loop use during the observation window, 45 completed a discontinued use survey, 22 provided system settings data, and 19 participated in semistructured interviews about their discontinuation. Qualitative data were transcribed, coded, and analyzed. Results: Older age and not trusting Loop were associated with discontinued use, although no other demographic or clinical characteristics were significant correlates. The most endorsed reasons were "I decided to try something else" (27.8%) followed by "It just didn't help as much as I thought it would" (22.2%). Qualitative analyses revealed prominent themes centered upon mental and emotional burden and adjusting settings. Other reasons for discontinued use included fear of disapproval of Loop use from diabetes provider, barriers to acquiring component devices, a desire to try new/different technologies, concerns that Loop could not accommodate specific exercise or low insulin dose regimens, and worry about Loop use during pregnancy. It was noted that burdens might be alleviated by enhanced technical assistance and expert guidance. Conclusions: Although the majority of individuals in the Loop observational study continued use, those who discontinued reported similar challenges. Technical support and education specific to setting calculations could expand Loop benefits, alleviate burden, and support sustained use among new Loop users. Clinical Trial Registration: clinicaltrials.gov (NCT03838900).

Demographic and substance use-related differences among high school adolescents who vape cannabis versus use other cannabis modalities.

BACKGROUND: Vaping is the second most common modality of using cannabis following smoking. We examined differences in demographics and substance use behaviors between adolescent cannabis vapers and those exclusively using other cannabis modalities. METHODS: In 2019, 4875 students from six Connecticut high schools completed school-wide, online surveys. Past-month cannabis users (n = 931; 52.8% female, 16.38(1.27) years old, 44.9% non-Hispanic White) reported on cannabis modalities used (e.g., combustible, vaporizable, edible) and were classified as cannabis vapers or non-vapers. Cannabis vapers reported on device type used to vape cannabis: a cannabis-specific device or modified/hacked e-cigarette. Unadjusted and adjusted relationships were examined to identify demographic and substance-related differences between cannabis vapers and non-vapers. RESULTS: 56.3% of past-month cannabis users reported vaping cannabis. Cannabis vapers reported using both cannabis-specific vaporizers (91.9%) and modifying/hacking e-cigarettes (23.7%). Cannabis vapers, relative to other cannabis users, were more likely to be male, White, initiate cannabis use at a younger age; endorse past-month use of all cannabis modalities, alcohol, and e-cigarettes; and report smoking and dabbing cannabis more frequently; consuming more drinks per drinking day; and using e-cigarettes at a younger age and more frequently. CONCLUSIONS: Relative to other cannabis modalities, vaping was associated with increased use of several cannabis products and other substances. Adolescent past-month cannabis users reported modifying e-cigarettes to vape cannabis. Findings suggest that regulations should be implemented to prevent e-cigarettes from being modifiable for use with cannabis and highlight the importance of assessing different cannabis use modalities, as vaping was associated with distinct substance-related risks.

Trust in hybrid closed loop among people with diabetes: Perspectives of experienced system users.

Automated closed loop systems will greatly change type 1 diabetes management; user trust will be essential for acceptance of this new technology. This qualitative study explored trust in 32 individuals following a hybrid closed loop trial. Participants described how context-, system-, and person-level factors influenced their trust in the system. Participants attempted to override the system when they lacked trust, while trusting the system decreased self-management burdens and decreased stress. Findings highlight considerations for fostering trust in closed loop systems. Systems may be able to engage users by offering varying levels of controls to match trust preferences.

Diabetes and cardiometabolic risk factors in Cambodia: Results from two screening studies.

BACKGROUND: Despite growing attention to diabetes throughout Asia, data from Southeast Asia are limited. This article reports rates of diabetes, hypertension, and obesity in Cambodia. METHODS: Two studies were conducted across different regions of Cambodia: (i) a 2012 screening study across urban, semi-urban, and rural areas that used point-of-care capillary glucose for determination of diabetes (n = 13 997); and (ii) a 2005 epidemiological study with random selection from two main urban areas that used oral glucose tolerance tests for determination of diabetes (n = 1863). Blood pressure and anthropometrics were also measured. RESULTS: In the screening study, rates of diabetes were significantly higher in urban than rural sites, with intermediate rates in semi-urban areas. There was a significant dose-response effect for urbanicity on overweight, obesity, and waist:hip ratio, with higher rates for urban versus semi-urban and for semi-urban versus rural locales. Rural sites had the lowest rates of hypertension, followed by urban and semi-urban sites. Among people who screened positive for diabetes, there was a dose-response effect for urbanicity on undiagnosed diabetes; rates of previously undiagnosed diabetes were lowest in urban (51%), followed by semi-urban (55%) and rural (67%) locales. Rural participants reported the highest rates of smoking and alcohol use. In the urban epidemiological study, prevalence rates of diabetes and impaired glucose tolerance were approximately 10%, indicating a prevalence of total glucose intolerance of approximately 20%. CONCLUSIONS: In Cambodia, diabetes rates are high among urban residents and undiagnosed diabetes is highest among rural residents. A country-wide public health response is urgently needed; as development continues, rates of diabetes are expected to rise.

What End Users and Stakeholders Want From Automated Insulin Delivery Systems.

OBJECTIVE: The purpose of this study was to rigorously explore psychosocial factors associated with automated insulin delivery systems among people living with type 1 diabetes. RESEARCH DESIGN AND METHODS: Across four sites in the U.S. and U.K., 284 participants completed structured interviews or focus groups on expectations, desired features, potential benefits, and perceived burdens of automated insulin delivery systems. Recorded audio files were transcribed and analyzed using NVivo. RESULTS: Three themes were identified as critical for uptake of automated insulin delivery: considerations of trust and control, system features, and concerns and barriers to adoption. Children and adolescents with type 1 diabetes primarily identified needs specific to their life stage and social contexts (e.g., school). Adults with type 1 diabetes, parents of youth with type 1 diabetes, and partners of adults with type 1 diabetes were most concerned about the accuracy, adaptability, and algorithm quality alongside expectations that systems stabilize glucose levels and reduce risk for long-term complications. CONCLUSIONS: Incorporating stakeholder perspectives on use of automated insulin delivery systems will improve the adoption of devices, quality of life, and likelihood of optimal health. Efforts to build trust in systems, optimize user-system interactions, and provide clear guidance about device capabilities and limitations may help potential users achieve optimal glycemic outcomes.

Expectations and Attitudes of Individuals With Type 1 Diabetes After Using a Hybrid Closed Loop System.

Purpose The first hybrid closed loop (HCL) system, which automates insulin delivery but requires user inputs, was approved for treatment of type 1 diabetes (T1D) by the US Food and Drug Administration in September 2016. The purpose of this study was to explore the benefits, expectations, and attitudes of individuals with T1D following a clinical trial of an HCL system. Methods Thirty-two individuals with T1D (17 adults, 15 adolescents) participated in focus groups after 4 to 5 days of system use. Content analysis generated themes regarding perceived benefits, hassles, and limitations. Results Some participants felt misled by terms such as "closed loop" and "artificial pancreas," which seemed to imply a more "hands-off" experience. Perceived benefits were improved glycemic control, anticipated reduction of long-term complications, better quality of life, and reduced mental burden of diabetes. Hassles and limitations included unexpected tasks for the user, difficulties wearing the system, concerns about controlling highs, and being reminded of diabetes. Conclusion Users are willing to accept some hassles and limitations if they also perceive health and quality-of-life benefits beyond current self-management. It is important for clinicians to provide a balanced view of positives and negatives to help manage expectations.