How deregulation, drought and increasing fire impact Amazonian biodiversity.

Biodiversity contributes to the ecological and climatic stability of the Amazon Basin1,2, but is increasingly threatened by deforestation and fire3,4. Here we quantify these impacts over the past two decades using remote-sensing estimates of fire and deforestation and comprehensive range estimates of 11,514 plant species and 3,079 vertebrate species in the Amazon. Deforestation has led to large amounts of habitat loss, and fires further exacerbate this already substantial impact on Amazonian biodiversity. Since 2001, 103,079-189,755 km2 of Amazon rainforest has been impacted by fires, potentially impacting the ranges of 77.3-85.2% of species that are listed as threatened in this region5. The impacts of fire on the ranges of species in Amazonia could be as high as 64%, and greater impacts are typically associated with species that have restricted ranges. We find close associations between forest policy, fire-impacted forest area and their potential impacts on biodiversity. In Brazil, forest policies that were initiated in the mid-2000s corresponded to reduced rates of burning. However, relaxed enforcement of these policies in 2019 has seemingly begun to reverse this trend: approximately 4,253-10,343 km2 of forest has been impacted by fire, leading to some of the most severe potential impacts on biodiversity since 2009. These results highlight the critical role of policy enforcement in the preservation of biodiversity in the Amazon.

Pre-existing conditions associated with post-acute sequelae of COVID-19.

Post-acute sequelae of COVID-19 (PASC) are conditions that occur or remain at least 28 days after SARS-CoV-2 infection. While some risk factors for PASC have been identified, little is known about pre-existing conditions that render one susceptible to developing PASC. Data from participants (n = 1224) in a longitudinal COVID-19 cohort study in Arizona were used to investigate comorbid conditions associated with PASC. After adjustment of the models for age, BMI, gender, race, and smoking, the following pre-existing conditions were statistically significantly associated with the development of PASC: asthma (OR = 1.54; 95% CI = 1.10-2.15); chronic constipation (OR = 4.29; 95% CI = 1.15-16.00); reflux (OR = 1.54; 95% CI = 1.01-2.34); rheumatoid arthritis (OR = 3.69; 95%CI = 1.15-11.82); seasonal allergies (OR = 1.56; 95% CI = 1.22-1.98); and depression/anxiety (OR = 1.72; 95% CI = 1.17-2.52). When grouping conditions together, statistically significant associations with PASC were observed for respiratory (OR = 1.47; 95% CI = 1.06-2.14); gastrointestinal (OR = 1.62; 95% CI = 1.16-2.26), and autoimmune conditions (OR = 4.38; 95% CI = 1.59-12.06). After adjustment for severity of acute SARS-CoV-2 infection and depression/anxiety, seasonal allergies (OR = 1.48; 95% CI 1.15-1.91) and autoimmune disease (OR = 3.78; 95% CI - 1.31-10.91) remained significantly associated with risk for PASC. These findings indicate that numerous pre-existing conditions may be associated with an increased risk for the development of PASC. Patients with these conditions should consider taking extra steps to avoid infection.

Darwin's naturalization conundrum can be explained by spatial scale.

Darwin proposed two seemingly contradictory hypotheses regarding factors influencing the outcome of biological invasions. He initially posited that nonnative species closely related to native species would be more likely to successfully establish, because they might share adaptations to the local environment (preadaptation hypothesis). However, based on observations that the majority of naturalized plant species in the United States belonged to nonnative genera, he concluded that the lack of competitive exclusion would facilitate the establishment of alien invaders phylogenetically distinct from the native flora (competition-relatedness hypothesis). To date, no consensus has been reached regarding these opposing hypotheses. Here, following Darwin, we use the flora of the United States to examine patterns of taxonomic and phylogenetic relatedness between native and nonnative taxa across thousands of nested locations ranging in size and extent, from local to regional scales. We find that the probability of observing the signature of environmental filtering over that of competition increases with spatial scale. Further, native and nonnative species tended to be less related in warm, humid environments. Our work provides an empirical assessment of the role of observation scale and climate in biological invasions and demonstrates that Darwin's two opposing hypotheses need not be mutually exclusive.

The Effectiveness of Social Norm Appeals on Promoting COVID-19 Prevention Behaviors: A Multistudy Examination.

Recent research shows social norm perceptions predict people's adherence to COVID-19 preventative health practices. Nonetheless, additional empirical studies are necessary to evaluate the effectiveness of different types of social norm messages on behavioral outcomes with experimental designs. Guided by the social norm literature and frameworks, the current research addresses this need by examining the effects of descriptive and injunctive norm appeals promoting the practice of social distancing and mask-wearing with both a controlled experiment and social media campaigns. Results from this multistudy investigation showed the effectiveness of descriptive and injunctive norm messages (v. no message exposure) in promoting focal behaviors and highlighted the superiority of injunctive norm appeals in promoting behavioral intentions and increasing social media engagement. Theoretical implications and recommendations for practice are discussed.

Development of a Definition of Postacute Sequelae of SARS-CoV-2 Infection.

Importance: SARS-CoV-2 infection is associated with persistent, relapsing, or new symptoms or other health effects occurring after acute infection, termed postacute sequelae of SARS-CoV-2 infection (PASC), also known as long COVID. Characterizing PASC requires analysis of prospectively and uniformly collected data from diverse uninfected and infected individuals. Objective: To develop a definition of PASC using self-reported symptoms and describe PASC frequencies across cohorts, vaccination status, and number of infections. Design, Setting, and Participants: Prospective observational cohort study of adults with and without SARS-CoV-2 infection at 85 enrolling sites (hospitals, health centers, community organizations) located in 33 states plus Washington, DC, and Puerto Rico. Participants who were enrolled in the RECOVER adult cohort before April 10, 2023, completed a symptom survey 6 months or more after acute symptom onset or test date. Selection included population-based, volunteer, and convenience sampling. Exposure: SARS-CoV-2 infection. Main Outcomes and Measures: PASC and 44 participant-reported symptoms (with severity thresholds). Results: A total of 9764 participants (89% SARS-CoV-2 infected; 71% female; 16% Hispanic/Latino; 15% non-Hispanic Black; median age, 47 years [IQR, 35-60]) met selection criteria. Adjusted odds ratios were 1.5 or greater (infected vs uninfected participants) for 37 symptoms. Symptoms contributing to PASC score included postexertional malaise, fatigue, brain fog, dizziness, gastrointestinal symptoms, palpitations, changes in sexual desire or capacity, loss of or change in smell or taste, thirst, chronic cough, chest pain, and abnormal movements. Among 2231 participants first infected on or after December 1, 2021, and enrolled within 30 days of infection, 224 (10% [95% CI, 8.8%-11%]) were PASC positive at 6 months. Conclusions and Relevance: A definition of PASC was developed based on symptoms in a prospective cohort study. As a first step to providing a framework for other investigations, iterative refinement that further incorporates other clinical features is needed to support actionable definitions of PASC.

Quantifying SARS-CoV-2 Infection Risk Within the Google/Apple Exposure Notification Framework to Inform Quarantine Recommendations.

Most early Bluetooth-based exposure notification apps use three binary classifications to recommend quarantine following SARS-CoV-2 exposure: a window of infectiousness in the transmitter, ≥15 minutes duration, and Bluetooth attenuation below a threshold. However, Bluetooth attenuation is not a reliable measure of distance, and infection risk is not a binary function of distance, nor duration, nor timing. We model uncertainty in the shape and orientation of an exhaled virus-containing plume and in inhalation parameters, and measure uncertainty in distance as a function of Bluetooth attenuation. We calculate expected dose by combining this with estimated infectiousness based on timing relative to symptom onset. We calibrate an exponential dose-response curve based on infection probabilities of household contacts. The probability of current or future infectiousness, conditioned on how long postexposure an exposed individual has been symptom-free, decreases during quarantine, with shape determined by incubation periods, proportion of asymptomatic cases, and asymptomatic shedding durations. It can be adjusted for negative test results using Bayes' theorem. We capture a 10-fold range of risk using six infectiousness values, 11-fold range using three Bluetooth attenuation bins, ∼sixfold range from exposure duration given the 30 minute duration cap imposed by the Google/Apple v1.1, and ∼11-fold between the beginning and end of 14 day quarantine. Public health authorities can either set a threshold on initial infection risk to determine 14-day quarantine onset, or on the conditional probability of current and future infectiousness conditions to determine both quarantine and duration.

"After those nets are torn, most people use them for other purposes": an examination of alternative bed net use in western Kenya.

BACKGROUND: Alternative long-lasting insecticidal net (LLIN) use for purposes other than sleeping protection from mosquitoes is widely debated as a limitation to successful malaria control efforts, yet rarely rigorously studied. METHODS: A cross-sectional survey of 1217 households in an epidemic highland site and an endemic lowland site in western Kenya collected information on alternative use in three ways: direct observations, participant self-report, and participant reporting of community-level practices. LLIN misuse was defined as use of an intact net for alternative purposes and repurposing as alternatively using an old or damaged net. Associations between households with observed repurposed nets and universal access and household net use were examined. RESULTS: Households describe repurposing nets when they are torn and/or old. Repurposed nets were observed in 8.1% (52/643) highlands households and 33.0% (184/574) lowlands households. Repurposed nets served as chicken coops (33% highlands, 20% lowlands), fences (37% highlands, 25% lowlands), tree covers (22% lowlands), curtains (3% highlands), covering bathrooms (1.5% highlands, 9% lowlands), and washing sponges (13% lowlands). No association was found between repurposing and universal access or household net use. Misuse was rare. Of 379 repurposed nets, 4 (1.06%) were in good condition with no holes. Of 1,758 active nets, 13 (0.74%) were misused. CONCLUSIONS: Alternative net use in this study involved repurposing rather than misuse. Repurposing was not detrimental to malaria prevention efforts in these communities. Standardized measurement of alternative net use should be used to better understand the practice and its potential impact on the success of malaria interventions.

Bed net care practices and associated factors in western Kenya.

BACKGROUND: Insecticide-treated nets (ITNs) and long-lasting insecticidal nets (LLINs) are effective for malaria prevention and are designed to provide nearly 5 years of mosquito protection. However, many ITNs and LLINs become damaged and ineffective for mosquito bite prevention within 1 to 2 years in field conditions. Non-adherence to recommended bed net care and repair practices may partially explain this shortened net longevity. METHODS: Using data from a cross-sectional study, a net care adherence score was developed and adherence to net care practices described from two regions of western Kenya. Relationships between attitudes and environmental factors that influence net longevity were measured with adherence to bed net care practices. RESULTS: While overall care practices are highly adherent particularly in the highlands, practices related to daily storage, washing frequency, and drying location need improvement in the lowlands. Seventy-seven percent of nets in the lowlands were washed < 3 months prior to the survey compared to 23% of nets in the highlands. More nets were dried in the sun in the lowlands (32% of nets) compared to the highlands (4% of nets). Different elements of care are influenced by various malaria attitudes and environmental factors, highlighting the complexity of factors associated with net care. For example, households that learned about net care from community events, that share a sleeping structure with animals, and that have nets used by adult males tend to adhere to washing frequency recommendations. CONCLUSIONS: In western Kenya, many nets are cared for in accordance to recommended practices, particularly in the highlands sites. In the lowlands, demonstrating methods at community events to tie nets up during the day coupled with messaging to emphasize infrequent washing and drying nets in the shade may be an appropriate intervention. As illustrated by differences between the highlands and lowlands sites in the present study, should interventions to improve adherence to bed net care practices be necessary, they should be context-specific.

Increasing women's engagement in vector control: a report from Accelerate To Equal project workshops.

Workshops with academic, national and local government, and community stakeholders were held in Kenya (2017) and Indonesia (2018) to understand the role and perceptions of women in vector control and to identify strategies for accelerating involvement of women in sustained support for vector control interventions at multiple levels/sectors.

Reported bed net ownership and use in social contacts is associated with uptake of bed nets for malaria prevention in pregnant women in Ghana.

BACKGROUND: Despite progress made in the last decades, malaria persists as a pressing health issue in sub-Saharan Africa. Pregnant women are particularly vulnerable to infection and serious health outcomes for themselves and their unborn child. Risk can be mitigated through appropriate use of control measures such as insecticide-treated bed nets. Although social networks can influence uptake of preventive strategies, the role of social influence on bed net ownership has not been explored. During an evaluation of a bed net distribution programme, the influence of non-health care advisors on ownership and use of bed nets by pregnant women in Kumasi, Ghana was examined. METHODS: Data were collected through in-person interviews with 300 pregnant women seeking antenatal care in an urban hospital in Kumasi, Ghana. Participants were asked about their bed net ownership, bed net use, and information about three personal contacts that they go to for pregnancy advice. Information about these advisors was combined into an influence score. Logistic regression models were used to determine the association between the score and bed net ownership. Those who owned a bed net were further assessed to determine if interpersonal influence was associated with self-reported sleeping under the bed net the previous night. RESULTS: Of the 294 women in the analysis, 229 (78%) reported owning bed nets. Of these bed net owners, 139 (61%) reported using a bed net the previous night. A dose response relationship was observed between the interpersonal influence score and bed net ownership and use. Compared to the lowest influence score, those with the highest influence score (>1 SD above the mean) were marginally more likely to own a bed net [OR = 2.37, 95% CI (0.87, 6.39)] and much more likely to use their bed net [5.38, 95% CI (1.89, 15.25)] after adjusting for other factors. CONCLUSIONS: Interpersonal influence appears to have modest impact on ownership and use of bed nets by pregnant women in an urban area of Ghana. Further investigations would need to be conducted to determine if the relationship is causal or if individuals who associate are simply more likely to have similar practices.

Comparing ownership and use of bed nets at two sites with differential malaria transmission in western Kenya.

BACKGROUND: Challenges persist in ensuring access to and optimal use of long-lasting, insecticidal bed nets (LLINs). Factors associated with ownership and use may differ depending on the history of malaria and prevention control efforts in a specific region. Understanding how the cultural and social-environmental context of bed net use may differ between high- and low-risk regions is important when identifying solutions to improve uptake and appropriate use. METHODS: Community forums and a household, cross-sectional survey were used to collect information on factors related to bed net ownership and use in western Kenya. Sites with disparate levels of transmission were selected, including an endemic lowland area, Miwani, and a highland epidemic-prone area, Kapkangani. Analysis of ownership was stratified by site. A combined site analysis was conducted to examine factors associated with use of all available bed nets. Logistic regression modelling was used to determine factors associated with ownership and use of owned bed nets. RESULTS: Access to bed nets as the leading barrier to their use was identified in community forums and cross-sectional surveys. While disuse of available bed nets was discussed in the forums, it was a relatively rare occurrence in both sites. Factors associated with ownership varied by site. Education, perceived risk of malaria and knowledge of individuals who had died of malaria were associated with higher bed net ownership in the highlands, while in the lowlands individuals reporting it was easy to get a bed net were more likely to own one. A combined site analysis indicated that not using an available bed net was associated with the attitudes that taking malaria drugs is easier than using a bed net and that use of a bed net will not prevent malaria. In addition, individuals with an unused bed net in the household were more likely to indicate that bed nets are difficult to use, that purchased bed nets are better than freely distributed ones, and that bed nets should only be used during the rainy season. CONCLUSION: Variations in factors associated with ownership should be acknowledged when constructing messaging and distribution campaigns. Despite reports of bed nets being used for other purposes, those in the home were rarely unused in these communities. Disuse seemed to be related to beliefs that can be addressed through education programmes. As mass distributions continue to take place, additional research is needed to determine if factors associated with LLIN ownership and use change with increasing availability of LLIN.

Awareness and support of release of genetically modified "sterile" mosquitoes, Key West, Florida, USA.

After a dengue outbreak in Key West, Florida, during 2009-2010, authorities, considered conducting the first US release of male Aedes aegypti mosquitoes genetically modified to prevent reproduction. Despite outreach and media attention, only half of the community was aware of the proposal; half of those were supportive. Novel public health strategies require community engagement.

Risk of Mortality According to Body Mass Index and Body Composition Among Postmenopausal Women.

Obesity, often defined as a body mass index (BMI; weight (kg)/height (m)(2)) of 30 or higher, has been associated with mortality, but age-related body composition changes can be masked by stable BMI. A subset of Women's Health Initiative participants (postmenopausal women aged 50-79 years) enrolled between 1993 and 1998 who had received dual-energy x-ray absorptiometry scans for estimation of total body fat (TBF) and lean body mass (LBM) (n = 10,525) were followed for 13.6 (standard deviation, 4.6) years to test associations between BMI, body composition, and incident mortality. Overall, BMI ≥35 was associated with increased mortality (adjusted hazard ratio (HR) = 1.45, 95% confidence interval (CI): 1.16, 1.82), while TBF and LBM were not. However, an interaction between age and body composition (P < 0.001) necessitated age stratification. Among women aged 50-59 years, higher %TBF increased risk of death (HR = 2.44, 95% CI: 1.38, 4.34) and higher %LBM decreased risk of death (HR = 0.41, 95% CI: 0.23, 0.74), despite broad-ranging BMIs (16.4-69.1). However, the relationships were reversed among women aged 70-79 years (P < 0.05). BMI did not adequately capture mortality risk in this sample of postmenopausal women. Our data suggest the clinical utility of evaluating body composition by age group to more robustly assess mortality risk among postmenopausal women.

Population-based prevalence of malaria among pregnant women in Enugu State, Nigeria: the Healthy Beginning Initiative.

BACKGROUND: Malaria adversely affects pregnant women and their fetuses or neonates. Estimates of the malaria burden in pregnant women based on health facilities often do not present a true picture of the problem due to the low proportion of women delivering at these facilities in malaria-endemic regions. METHODS: Data for this study were obtained from the Healthy Beginning Initiative using community-based sampling. Self-identified pregnant women between the ages of 17-45 years were recruited from churches in Enugu State, Nigeria. Malaria parasitaemia was classified as high and low based on the malaria plus system. RESULTS: Of the 2069 pregnant women for whom malaria parasitaemia levels were recorded, over 99 % tested positive for malaria parasitaemia, 62 % showed low parasitaemia and 38 % high parasitaemia. After controlling for confounding variables, odds for high parasitaemia were lower among those who had more people in the household (for every one person increase in a household, OR = 0.94, 95 % CI 0.89-0.99). CONCLUSION: Results of this study are consistent with hospital-based estimates of malaria during pregnancy in southeastern Nigeria. Based on the high prevalence of malaria parasitaemia in this sample, education on best practices to prevent malaria during pregnancy, and resources in support of these practices are urgently needed.

Contrasting Perceptions, Knowledge, and Actions around Lyme Disease in an Urban Area of Emerging Lyme Disease and an Area of Endemic Lyme Disease in the Northeastern United States.

Lyme disease transmission dynamics in the northeastern United States vary by context. Periurban regions, including Block Island, RI, have experienced decades of endemic transmission. In urban areas, including Staten Island, a borough in New York City, NY, Lyme disease is an emerging issue. Knowledge, attitudes, and practices around Lyme disease evolve as an area progresses from emergent to endemic. We conducted focus group discussions and household surveys within Staten Island, NY and Block Island, RI to compare knowledge, attitudes, and practices surrounding Lyme disease and other tick-borne diseases. Qualitative data were coded into themes, and survey data were used to provide more general context of the focus group discussions. Using item response theory, we developed an index of knowledge from relevant factors within the household survey. We identified a significant difference in knowledge scores between the two study areas. Additionally, we identified key differences across multiple domains. Participants from Block Island were more likely to report prior tick exposure and Lyme disease in themselves or household members and were more likely to express concerns about the environmental impact of mitigation strategies. Individuals on Staten Island were more likely to assign responsibility of prevention and control to local, state, and federal government than to take personal prevention measures. Prevention of Lyme disease and other tick-borne diseases must be tailored to the community context and monitored over time as perceptions and priorities may evolve as transmission dynamics transition from emergent to endemic.

Preferences and Demand for Mosquito Control among Dengue-Endemic Communities in Peñuelas, Puerto Rico: An Application of the Best-Worst Choice Model.

Aedes aegypti is the primary vector of dengue virus and threatens 3.9 billion people living in many tropical and subtropical countries. Prevention and reduction of dengue and other Aedes-borne viruses, including Zika and chikungunya, requires control of mosquito populations. Community mobilization and input are essential components of vector control efforts. Many vector control campaigns do not engage communities prior to implementation, leading to program failure. Those that do often conduct basic knowledge, attitude, and practice surveys that are not designed to explicitly elicit preferences. Here, we applied a novel stated preference elicitation tool, best-worst choice, to understand preferences, willingness to participate, and willingness to pay for mosquito control in dengue-endemic communities of Peñuelas, Puerto Rico. Findings revealed that the community preferred mosquito control programs that are 1) applied at the neighborhood level, 2) implemented by the local government, and 3) focused specifically on reducing disease transmission (e.g., dengue) instead of mosquito nuisance. Programs targeting the reduction of disease transmission and higher educational level of participants increased willingness to participate. Participants were willing to pay an average of $72 annually to have a program targeting the reduction of diseases such as dengue. This study serves as a model to engage communities in the design of mosquito control programs and improve stakeholders' decision-making.

A country bug in the city: urban infestation by the Chagas disease vector Triatoma infestans in Arequipa, Peru.

BACKGROUND: Interruption of vector-borne transmission of Trypanosoma cruzi remains an unrealized objective in many Latin American countries. The task of vector control is complicated by the emergence of vector insects in urban areas. METHODS: Utilizing data from a large-scale vector control program in Arequipa, Peru, we explored the spatial patterns of infestation by Triatoma infestans in an urban and peri-urban landscape. Multilevel logistic regression was utilized to assess the associations between household infestation and household- and locality-level socio-environmental measures. RESULTS: Of 37,229 households inspected for infestation, 6,982 (18.8%; 95% CI: 18.4 - 19.2%) were infested by T. infestans. Eighty clusters of infestation were identified, ranging in area from 0.1 to 68.7 hectares and containing as few as one and as many as 1,139 infested households. Spatial dependence between infested households was significant at distances up to 2,000 meters. Household T. infestans infestation was associated with household- and locality-level factors, including housing density, elevation, land surface temperature, and locality type. CONCLUSIONS: High levels of T. infestans infestation, characterized by spatial heterogeneity, were found across extensive urban and peri-urban areas prior to vector control. Several environmental and social factors, which may directly or indirectly influence the biology and behavior of T. infestans, were associated with infestation. Spatial clustering of infestation in the urban context may both challenge and inform surveillance and control of vector reemergence after insecticide intervention.

Aedes aegypti abundance in urban neighborhoods of Maricopa County, Arizona, is linked to increasing socioeconomic status and tree cover.

BACKGROUND: Understanding coupled human-environment factors which promote Aedes aegypti abundance is critical to preventing the spread of Zika, chikungunya, yellow fever and dengue viruses. High temperatures and aridity theoretically make arid lands inhospitable for Ae. aegypti mosquitoes, yet their populations are well established in many desert cities. METHODS: We investigated associations between socioeconomic and built environment factors and Ae. aegypti abundance in Maricopa County, Arizona, home to Phoenix metropolitan area. Maricopa County Environmental Services conducts weekly mosquito surveillance with CO2-baited Encephalitis Vector Survey or BG-Sentinel traps at > 850 locations throughout the county. Counts of adult female Ae. aegypti from 2014 to 2017 were joined with US Census data, precipitation and temperature data, and 2015 land cover from high-resolution (1 m) aerial images from the National Agricultural Imagery Program. RESULTS: From 139,729 trap-nights, 107,116 Ae. aegypti females were captured. Counts were significantly positively associated with higher socioeconomic status. This association was partially explained by higher densities of non-native landscaping in wealthier neighborhoods; a 1% increase in the density of tree cover around the trap was associated with a ~ 7% higher count of Ae. aegypti (95% CI: 6-9%). CONCLUSIONS: Many models predict that climate change will drive aridification in some heavily populated regions, including those where Ae. aegypti are widespread. City climate change adaptation plans often include green spaces and vegetation cover to increase resilience to extreme heat, but these may unintentionally create hospitable microclimates for Ae. aegypti. This possible outcome should be addressed to reduce the potential for outbreaks of Aedes-borne diseases in desert cities.

Healthcare System Distrust and Non-Prescription Antibiotic Use: A Cross-Sectional Survey of Adult Antibiotic Users.

Antibiotic resistance is a major public health concern driven by antibiotic overuse. Antibiotic stewardship programs are often limited to clinical settings and do little to address non-prescription antibiotic use in community settings. This study investigates the association between non-prescription antibiotic use and healthcare system distrust in the United States and Mexico. An online survey was deployed in the United States and Mexico with enhanced sampling through in-person recruiting in the border region. Non-prescription antibiotic use was defined as having bought or borrowed non-prescription oral or injectable antibiotics within the last 3 years. The survey included a previously validated 10-item scale to measure healthcare system distrust. Logistic regression was used to model the use of non-prescription antibiotics by the level of healthcare system distrust, adjusted for demographic characteristics and antibiotic knowledge. In total, 568 survey participants were included in the analysis, 48.6% of whom had used non-prescription oral or injectable antibiotics in the last 3 years. In the fully adjusted regression model, the odds of using non-prescription antibiotics were 3.2 (95% CI: 1.8, 6.1) times higher for those in the highest distrust quartile versus the lowest. These findings underscore the importance of community-based antibiotic stewardship and suggest that these programs are particularly critical for communities with high levels of healthcare system distrust.