Bias and Accuracy of Glomerular Filtration Rate Estimating Equations in the US: A Systematic Review and Meta-Analysis.

Importance: There is increasing concern that continued use of a glomerular filtration rate (GFR) estimating equation adjusted for a single racial group could exacerbate chronic kidney disease-related disparities and inequalities. Objective: To assess the performance of GFR estimating equations across varied patient populations. Data Sources: PubMed, Embase, Web of Science, ClinicalTrials.gov, and Scopus databases were systematically searched from January 2012 to February 2023. Study Selection: Inclusion criteria were studies that compared measured GFR with estimated GFR in adults using established reference standards and methods. A total of 6663 studies were initially identified for screening and review. Data Extraction and Synthesis: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 2 authors independently extracted data on studies that examined the bias and accuracy of GFR estimating equations. For each outcome, a random-effects model was used to calculate pooled estimates. Data analysis was conducted from March to December 2023. Main Outcomes and Measures: The primary outcomes were bias and accuracy of estimated GFRs in Black vs non-Black patients, as well as in individuals with chronic conditions. Bias was defined as the median difference between the measured GFR and the estimated GFR. Accuracy was assessed with P30 (the proportion of persons in a data set whose estimated GFR values were within 30% of measured GFR values) and measures of heterogeneity. Results: A total of 12 studies with a combined 44 721 patients were included. Significant heterogeneity was found in the bias of various GFR estimation equations. Race-corrected equations and creatinine-based equations tended to overestimate GFR in Black populations and showed mixed results in non-Black populations. For creatinine-based equations, the mean bias in subgroup analysis was 2.1 mL/min/1.73 m2 (95% CI, -0.2 mL/min/1.73 m2 to 4.4 mL/min/1.73 m2) in Black persons and 1.3 mL/min/1.73 m2 (95% CI, 0.0 mL/min/1.73 m2 to 2.5 mL/min/1.73 m2) in non-Black persons. Equations using only cystatin C had small biases. Regarding accuracy, heterogeneity was high in both groups. The overall P30 was 84.5% in Black persons and 87.8% in non-Black persons. Creatinine-based equations were more accurate in non-Black persons than in Black persons. For creatinine-cystatin C equations, the P30 was higher in non-Black persons. There was no significant P30 difference in cystatin C-only equations between the 2 groups. In patients with chronic conditions, P30 values were generally less than 85%, and the biases varied widely. Conclusions and Relevance: This systematic review and meta-analysis of GFR estimating equations suggests that there is bias in race-based GFR estimating equations, which exacerbates kidney disease disparities. Development of a GFR equation independent of race is a crucial starting point, but not the sole solution. Addressing the disproportionate burden of kidney failure on Black individuals in the US requires an enduring, multifaceted approach that should include improving diagnostics, tackling social determinants of health, confronting systemic racism, and using effective disease prevention and management strategies.

Intersectionality Impacts Survivorship: Identity-Informed Recommendations to Improve the Quality of Life of African American Breast Cancer Survivors in Health Promotion Programming.

(1) Background: African American women breast cancer survivors face unique experiences that impact their quality of life as they transition beyond treatments. Experiences may be complicated by living at the intersection of systemically oppressed identities, including gender, race, social class, and cancer-related disability. Using the Black Feminist Thought (BFT) framework and the PEN-3 cultural model, this qualitative study sought to: (a) understand African American women breast cancer survivors' lived experiences; (b) examine how the multiple intersecting factors of race, gender, social class/socioeconomic status, and cancer-related disability impact their quality of life; and (c) inform future health promotion programming that is culturally relevant to AAWBCS to improve their quality of life. (2) Methods: Seven focus groups were conducted with 30 African American breast cancer survivors in a Midwestern metropolitan region. Focus groups were audiotaped and transcribed verbatim. Framework analyses were conducted to identify themes with NVivo qualitative analysis software. (3) Results: Four themes emerged: (a) caregiving roles provide both support and challenges for survivors, (b) the "strong Black woman" is inherent in survivor experiences, (c) intersectionality impacts survivorship, and (d) African American women resist oppression through culturally specific supports and advocacy. (4) Conclusions: The intervention point of entry should be at the peer support group level and centered on family and provide community-based support and services. Future research should move upstream to address social determinants of health, including racism, sexism, and ableism; there is a critical need to discuss how structural racism affects health care and develop interventions to address racial discrimination and racial bias in health care.

Prevalence, Management, and Associated Factors of Obesity, Hypertension, and Diabetes in Tibetan Population Compared with China Overall.

Tibetans' life expectancy lags behind China's average. Obesity and noncommunicable diseases (NCDs) contribute to health disparity, but NCD patterns among Tibetans are unknown. To examine the prevalence, management, and associated factors for obesity, hypertension, and diabetes among Tibetans, compared with China's average, we systematically searched PubMed and China National Knowledge Infrastructure databases for studies between January 2010 and April 2021. Thirty-nine studies were included for systematic review, among thirty-seven that qualified for meta-analysis, with 115,403 participants. Pooled prevalence was 47.9% (95% CI 38.0-57.8) for overweight/obesity among adults (BMI ≥ 24 kg/m2) and 15.4% (13.7-17.2) among children using Chinese criteria, which are lower than the national rates of 51.2% and 19.0%, respectively. The estimate for hypertension (31.4% [27.1-35.7]) exceeded China's average (27.5%), while diabetes (7.5% [5.2-9.8]) was lower than average (11.9%). Men had a higher prevalence of the three conditions than women. Residents in urban areas, rural areas, and Buddhist institutes had monotonically decreased prevalence in hypertension and diabetes. Awareness, treatment, and control rates for hypertension and diabetes were lower than China's average. Urban residence and high altitude were consistent risk factors for hypertension. Limited studies investigated factors for diabetes, yet none exist for obesity. Tibetans have high burdens of obesity and hypertension. Representative and longitudinal studies are needed for tailored interventions. There are considerable variations in study design, study sample selection, and data-analysis methods, as well as estimates of reviewed studies.

Effectiveness of Social Needs Screening and Interventions in Clinical Settings on Utilization, Cost, and Clinical Outcomes: A Systematic Review.

Objective: This systematic review examined and synthesized peer-reviewed research studies that reported the process of integrating social determinants of health (SDOH) or social needs screening into electronic health records (EHRs) and the intervention effects in the United States. Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines, a systematic search of Scopus, Web of Science Core Collection, MEDLINE, and Cochrane Central Register of Clinical Trials was performed. English language peer-reviewed studies that reported the process of integrating SDOH or social needs screening into EHRs within the U.S. health systems and published between January 2015 and December 2021 were included. The review focused on process measures, social needs changes, health outcomes, and health care cost and utilization. Results: In total, 28 studies were included, and half were randomized controlled trials. The majority of the studies targeted multiple SDOH domains. The interventions vary by the levels of intensity of their approaches and heterogeneities in outcome measures. Most studies (82%, n=23) reported the findings related to the process measures, and nearly half (43%, n=12) reported outcomes related to social needs. By contrast, only 39% (n=11) and 32% (n=9) of the studies reported health outcomes and impact on health care cost and utilization, respectively. Findings on patients' social needs change demonstrated improved access to resources. However, findings were mixed on intervention effects on health and health care cost and utilization. We also identified gaps in implementation challenges to be overcome. Conclusion: Our review supports the current policy efforts to increase U.S. health systems' investment toward directly addressing SDOH. While effective interventions can be more complex or resource intensive than an online referral, health care organizations hoping to achieve health equity and improve population health must commit the effort and investment required to achieve this goal.

Exposure to Chinese Famine during Early Life Increases the Risk of Fracture during Adulthood.

This study focused on identifying whether exposure to the Chinese Great Famine (1959-1961) in early life amplified the potential for fractures in adulthood. The survey was conducted using data from the 1997-2015 China Health and Nutrition Survey (CHNS)-5235 adults born between 1954 and 1964 were selected as the sample size. Fracture was defined based on self-report. Those born from 1962-1964 were treated as non-exposure group. Those with exposure to famine were divided into four subgroups: Fetal, early childhood, mid-childhood, and late childhood cohorts. The association between the groups and fracture was determined using Cox regression. In follow-up data (mean of 11 years), fractures were identified in 418 of the participants. The incidence of fracture was 8.7 in late childhood, 8.1 in mid-childhood, 8.3 in early childhood, 7.0 in fetal, and 5.4 in non-exposed cohorts per 1000 person-year. Compared with the non-exposed group, the famine-exposed groups had an increased risk of developing fracture in adulthood with hazard ratio (HR) and 95% CI of 1.29 (0.90-1.85), 1.48 (1.08-2.03), 1.45 (1.02-2.06), and 1.54 (1.08-2.20), respectively. The positive link of famine exposure to risk of fracture occurred primarily in those participants with a modern diet who lived in urban areas. In conclusion, the risk of fracture in Chinese adults is associated with famine exposure.

Higher Serum Testosterone Level Was Associated with a Lower Risk of Prediabetes in US Adults: Findings from Nationally Representative Data.

Low testosterone may be a novel risk factor for prediabetes. We assessed the associations between prediabetes and total serum testosterone (TT), and whether the associations were modified by population characteristics. The data from 5330 adults aged ≥ 20 years, who participated in the 2011−2016 National Health and Nutrition Examination Survey in the United States, were used. Prediabetes was based on fasting plasma glucose, HbA1c, or OGTT. Sociodemographic, obesity, co-morbidities, and lifestyle factors were included in logistic regression models. A dose-response relationship was found between prediabetes and the testosterone quartiles. The odds ratio (OR and 95% CI) for prediabetes across the quartiles of TT were: 1.00, 0.68 (0.50−0.92), 0.51 (0.36−0.72), and 0.48 (0.34−0.70) in men; and 1.00, 1.06 (0.81−1.40), 0.81 (0.61−1.06), and 0.68 (0.49−0.93) in women. The results changed marginally if the models were adjusted for additional variables such as BMI. The subgroup analyses showed differences in the association, which was stronger in some groups (for men: age < 50, white and black, overweight/obese, adequate physical activity, never-smoking; and for women: age ≥ 50, black). A higher testosterone level was associated with a lower risk of prediabetes among US adults. The strength of the association varied by population characteristics, weight status, gender, and lifestyle factors.

The Association between Methionine Intake and Diabetes in Chinese Adults-Results from the China Health and Nutrition Survey.

This study aimed to evaluate the association between methionine intake and diabetes prevalence in Chinese adults and explore whether the association was source-specific. Data from 12,849 adults aged ≥20 years old were used from the China Health and Nutrition Survey during 1997-2011. Diabetes was diagnosed as self-reported and/or when blood tests results met the diagnostic criteria. A 3-day, 24-h recall was used to assess different sources of methionine. Multivariable mixed linear regression was used to examine the associations. Across the quartiles of total methionine intake, the odds ratio (ORs, 95% CI) of diabetes were 1.00, 1.49 (1.21 to 1.82), 1.72 (1.37 to 2.15), and 2.53 (1.97 to 3.23). In the subgroup analysis, similar trends were observed in both animal and plant methionine. There was a significant interaction between urbanization and diabetes. The positive association was only significant in those who lived in low or medium urbanization areas. The ORs (95% CI) were 1.00, 1.27 (0.85 to 1.88), 1.56 (1.01 to 2.39), and 1.79 (1.09 to 2.95) for medium urbanization, respectively. No interaction was identified when stratified by different methionine sources. In conclusion, methionine intake was positively associated with diabetes independent of food source, and it was modified by urbanization levels.

Dietary Patterns and Changes in Weight Status Among Chinese Men and Women During the COVID-19 Pandemic.

Aims: To identify dietary patterns during the coronavirus disease-2019 (COVID-19) pandemic and to examine their association with changes in weight status in the Chinese population. Methods: The 2020 China COVID-19 cross-sectional survey is an anonymous 74-item survey administered via social media across 31 provinces in mainland China between April and May 2020. Dietary data were assessed by a Food Frequency Questionnaire and the changes in weight status were self-reported. Exploratory factor analysis using the principal component analysis method was applied to identify dietary patterns. The multinomial regression models were conducted, and forest plots were used to present the associations between dietary patterns and changes in weight status. Results: Of a total of 10,545 adults (aged ≥18 years), more than half of participants reported to have weight gain, with 18.6% of men and 16.3% of women having weight gain >2.5 kg. Approximately 8% of participants reported to have weight loss, with 2.1% of men and 2.5% women having weight loss >2.5 kg. Two dietary patterns, namely, the modern and prudent dietary patterns, were identified during the COVID-19 pandemic. The modern dietary pattern was loaded heavily with soft drinks, fried foods, pickles, and inversely with fresh vegetables. The prudent dietary pattern was characterized by high intake of fresh fruits, vegetables, and inversely with soft drinks and fried food. The modern dietary pattern was positively associated with weight gain in men and women, while the prudent dietary pattern was negatively associated with both weight gain and loss in men and women during the COVID-19 pandemic. Conclusion: Dietary patterns during COVID-19 are significantly associated with the changes in weight status, which may subsequently increase the risk of diet-related non-communicable disease among the Chinese population.

Navigator Role for Promoting Adaptive Sports and Recreation Participation in Individuals With Disabilities.

OBJECTIVE: The aims of the study were to gain a better understanding of the resources, barriers, and facilitators of participation in adaptive sport and recreational activities as a means of achieving physical activity recommendations in individuals with disability and to understand preferences for a patient navigator service to help mitigate the barriers. DESIGN: Clinical, academic, and community stakeholders applied a community-engaged research approach to develop online surveys and focus group questions for adults with a disability or parents of a child with a disability to meet study objectives. RESULTS: One hundred ninety-eight adults and 146 parents completed the online surveys. Sixteen adults and 18 parents took part in focus groups. Many participants lacked knowledge of available adaptive sport and recreational resources; other barriers were expense, limited number of trained volunteers, and need for instruction. Conversely, persons were facilitated by community, socialization, and words of encouragement/motivation. Participants strongly preferred a patient navigator to be a person active in adaptive sport and recreational or an informative resource-filled website. CONCLUSIONS: Our findings suggest that physical activity programs including adaptive sport and recreational should be designed to offer people with disabilities opportunities to build social networks and strengthen social support. A patient navigator service could help increase participation in adaptive sport and recreational and physical activity within a community context.

Perceived risk, behavior changes and Health-related outcomes during COVID-19 pandemic: Findingsamong adults with and without diabetesin China.

AIMS: To examine perceived infection risk of COVID-19 and the health and related behavior changes among people with diabetes, compared with people without diabetes, and to examine factors associated with self-reported health during the national quarantine period in China. METHODS: The 2020 China COVID-19 Survey is an anonymous 74-item survey administered via social media across China. A national sample of 10,545 adults in all 31 provinces in mainland China provided data on sociodemographic characteristics, awareness, attitudes towards COVID-19, lifestyle factors, and health outcomes during the quarantine. Regression models tested associations among study variables adjusting for covariates. RESULTS: Among the 9,016 total participants (42.6% men and 57.4% women), 585 reported having diagnosed diabetes and 8,431 had no diabetes. Participants with diabetes perceived themselves to be at higher risk and were more worried about being infected with COVID-19 when compared to non-diabetic individuals (p < 0.001). During the COVID-19 pandemic, participants with diabetes were more likely to experience food and drug shortages and to increase their physical activity, compared to their counterparts. Among diabetic respondents, a high proportion of current smokers (74.1%) and drinkers (68.5%) reported increased amounts of smoking and drinking. People with diabetes were 11% less likely to report excellent or very good health. Having 150 min/week physical activity was positively associated with excellent or very good health (prevalence ratio, PR = 1.14, 95%CI 1.11-1.16). CONCLUSIONS: A high proportion of people with diabetes perceived risk of COVID-19 infection and increased their smoking and drinking during the pandemic.

Functional Corticomuscular Signal Coupling Is Weakened during Voluntary Motor Action in Cancer-Related Fatigue.

Background and Purpose: Cancer-related fatigue (CRF) is widely recognized as one of the most common symptoms and side effects of cancer and/or its treatment. However, neuropathological mechanisms contributing to CRF are largely unknown, and the lack of knowledge makes CRF difficult to treat. Recent research has shown dissociation between changes in the brain and muscle signals during voluntary motor performance in cancer survivors with CRF, and this dissociation may be caused by an interruption in functional coupling (FC) of the two signals. The goal of this study was to assess the FC between EEG (cortical signal) and EMG (muscular signal) in individuals with CRF and compare the FC with that of healthy controls during a motor task that led to progressive muscle fatigue. Method: Eight cancer survivors with CRF and nine healthy participants sustained an isometric elbow flexion contraction (at 30% maximal level) until self-perceived exhaustion. The entire duration of the EEG and EMG recordings was divided into the first-half (less-fatigue stage) and second-half (more-fatigue stage) artifact-free epochs without overlapping. The EEG-EMG coupling (measured by coherence of the two signals) in each group and stage was computed. Coherence values at different frequencies were statistically analyzed using a repeated-measure general linear model. Results: The results demonstrated that compared to healthy controls, CRF participants sustained the contraction for a significantly shorter time and exhibited robust and significantly lower EEG-EMG coherence at the alpha (8~14 Hz) and beta (15~35 Hz) frequency bands. Both the CRF and healthy control groups exhibited significantly decreased EEG-EMG coherence from the less-fatigue to more-fatigue stages at the alpha and beta frequency bands, indicating fatigue-induced weakening of functional corticomuscular coupling. Conclusion: Impaired functional coupling between the brain and muscle signals could be a consequence of cancer and/or its treatment, and it may be one of the contributing factors to the abnormal feeling of fatigue that caused the early failure of sustaining a prolonged motor task.

Culture, identity, strength and spirituality: A qualitative study to understand experiences of African American women breast cancer survivors and recommendations for intervention development.

OBJECTIVE: Despite advancements in cancer treatment, racial disparities in breast cancer survival persist, with African American women experiencing lower survival rates and poorer quality of life than non-Hispanic White women. Using a social cognitive model of restorative well-being as a framework, this qualitative study sought: (a) to examine strength- and culture-related factors associated with African American female breast cancer survivors' cancer coping and post-treatment experiences and (b) to make recommendations for culturally sensitive intervention. METHODS: Eight focus groups occurred with a total of 40 local African American breast cancer survivors. Focus groups were audiotaped and transcribed verbatim. Framework analyses were used to identify themes. NVivo qualitative analysis software-managed data. RESULTS: Two major themes emerged from the focus group discussions: (a) God enables breast cancer survivorship and works every day in our lives and (b) the healthiest thing about us is that we are strong African American women. Recommendations for intervention planning and implementation were made towards intervention structure, content development and language framing in a local context. CONCLUSION: Findings suggest a need for community-based participatory survivorship interventions that are culturally and spiritually consonant and peer-based. Such interventions may respond to the cancer-related and personal needs of the target population.

Researcher Requests for Inappropriate Analysis and Reporting: A U.S. Survey of Consulting Biostatisticians.

Background: Inappropriate analysis and reporting of biomedical research remain a problem despite advances in statistical methods and efforts to educate researchers. Objective: To determine the frequency and severity of requests biostatisticians receive from researchers for inappropriate analysis and reporting of data during statistical consultations. Design: Online survey. Setting: United States. Participants: A randomly drawn sample of 522 American Statistical Association members self-identifying as consulting biostatisticians. Measurements: The Bioethical Issues in Biostatistical Consulting Questionnaire soliciting reports about the frequency and perceived severity of specific requests for inappropriate analysis and reporting. Results: Of 522 consulting biostatisticians contacted, 390 provided sufficient responses: a completion rate of 74.7%. The 4 most frequently reported inappropriate requests rated as "most severe" by at least 20% of the respondents were, in order of frequency, removing or altering some data records to better support the research hypothesis; interpreting the statistical findings on the basis of expectation, not actual results; not reporting the presence of key missing data that might bias the results; and ignoring violations of assumptions that would change results from positive to negative. These requests were reported most often by younger biostatisticians. Limitations: The survey provides information on the reported frequency of inappropriate requests but not on how such requests were handled or whether the requests reflected researchers' maleficence or inadequate knowledge about statistical and research methods. In addition, other inappropriate requests may have been made that were not prespecified in the survey. Conclusion: This survey suggests that researchers frequently make inappropriate requests of their biostatistical consultants regarding the analysis and reporting of their data. Understanding the reasons for these requests and how they are handled requires further study. Primary Funding Source: U.S. Department of Health and Human Services.

Physical activity and annual medical outlay in U.S. colorectal, breast and prostate cancer survivors.

Multiple chronic conditions in cancer survivors are highly prevalent and may increase health care costs for both patients and the health care system. Studies of cancer survivors reveal positive effects of physical activity (PA) on reducing risk of cancer recurrence, other chronic conditions, and secondary cancer. Few nationally representative studies have examined how physical activity levels have affected survivors' annual economic burden in the United States. Leisure-time physical activity data from the National Health Interview Survey was linked to health care expenditure data from the Medical Expenditure Panel Survey data (2008-2012). We calculated per-person annual total medical expenditures for identified colorectal, breast, and prostate cancer survivors. We conducted multivariable analyses controlled for survival years and other sociodemographic variables. Generalized linear models were performed to measure correlation between medical expenditure and PA level using STATA 14. All analyses considered the complex survey design and were conducted in 2017. Of 1015 cancer survivors sampled, 30% (n = 305) adhered to physical activity recommendation, while the other 70% (n = 710) did not. Multivariable-adjusted expenditure in adherence group was $9108.8 (95% CI 7410.9-10,806.7) versus 12,899.1 (95% CI 11,450.2-14,348) in non-adherence group. Stratified analyses revealed cancer survivors who adhered to their PA recommendation saved $4686.1 (1-5 years' survival time) and $2874.5 (11 or more years' survival time) on average for total health care expenditure, respectively. Analyses of the national representative sample revealed that the economic burden of survivors from the three most prevalent cancers is substantial. Increasing survivor's PA to guidelines may reduce U.S. health care expenditure.

Identifying bioethical issues in biostatistical consulting: findings from a US national pilot survey of biostatisticians.

OBJECTIVES: The overall purposes of this first US national pilot study were to (1) test the feasibility of online administration of the Bioethical Issues in Biostatistical Consulting (BIBC) Questionnaire to a random sample of American Statistical Association (ASA) members; (2) determine the prevalence and relative severity of a broad array of bioethical violations requests that are presented to biostatisticians by investigators seeking biostatistical consultations; and (3) establish the sample size needed for a full-size phase II study. DESIGN: A descriptive survey as approved and endorsed by the ASA. PARTICIPANTS: Administered to a randomly drawn sample of 112 professional biostatisticians who were ASA members. PRIMARY AND SECONDARY OUTCOME MEASURES: The 18 bioethical violations were first ranked by perceived severity scores, then categorised into three perceived severity subcategories in order to identify seven 'top tier concern violations' and seven 'second tier concern violations'. RESULTS: Methodologically, this phase I pilot study demonstrated that the BIBC Questionnaire, as administered online to a random sample of ASA members, served to identify bioethical violations that occurred during biostatistical consultations, and provided data needed to establish the sample size needed for a full-scale phase II study. The No. 1 top tier concern was 'remove or alter some data records in order to better support the research hypothesis'. The No. 2 top tier concern was 'interpret the statistical findings based on expectation, not based on actual results'. In total, 14 of the 18 BIBC Questionnaire items, as judged by a combination of 'severity of violation' and 'frequency of occurrence over past 5 years', were rated by biostatisticians as 'top tier' or 'second tier' bioethical concerns. CONCLUSION: This pilot study gives clear evidence that researchers make requests of their biostatistical consultants that are not only rated as severe violations, but further that these requests occur quite frequently.

Mixed-Method Quasi-Experimental Study of Outcomes of a Large-Scale Multilevel Economic and Food Security Intervention on HIV Vulnerability in Rural Malawi.

The objective of the Savings, Agriculture, Governance, and Empowerment for Health (SAGE4Health) study was to evaluate the impact of a large-scale multi-level economic and food security intervention on health outcomes and HIV vulnerability in rural Malawi. The study employed a quasi-experimental non-equivalent control group design to compare intervention participants (n = 598) with people participating in unrelated programs in distinct but similar geographical areas (control, n = 301). We conducted participant interviews at baseline, 18-, and 36-months on HIV vulnerability and related health outcomes, food security, and economic vulnerability. Randomly selected households (n = 1002) were interviewed in the intervention and control areas at baseline and 36 months. Compared to the control group, the intervention led to increased HIV testing (OR 1.90; 95 % CI 1.29-2.78) and HIV case finding (OR = 2.13; 95 % CI 1.07-4.22); decreased food insecurity (OR = 0.74; 95 % CI 0.63-0.87), increased nutritional diversity, and improved economic resilience to shocks. Most effects were sustained over a 3-year period. Further, no significant differences in change were found over the 3-year study period on surveys of randomly selected households in the intervention and control areas. Although there were general trends toward improvement in the study area, only intervention participants' outcomes were significantly better. Results indicate the intervention can improve economic and food security and HIV vulnerability through increased testing and case finding. Leveraging the resources of economic development NGOs to deliver locally-developed programs with scientific funding to conduct controlled evaluations has the potential to accelerate the scientific evidence base for the effects of economic development programs on health.

mHealth text messaging for physical activity promotion in college students: a formative participatory approach.

OBJECTIVES: To develop mobile-based physical activity promotion text messages, understand users' preferences, and assess feasibility and acceptability in a college student sample. METHODS: Five focus groups (N = 33) were conducted using a participatory approach. An Audience Response System was adopted for data collection to ensure confidentiality and for directing the discussion foci. A framework analysis of transcribed focus group discussions was conducted. Atlas. ti qualitative analysis software was used to manage the data. RESULTS: Participants were uniformly enthusiastic about a text message-based intervention to encourage regular physical activity. They also preferred positive, supportive personally tailored messages. Participants placed a high value on messages related to establishing and monitoring realistic and achievable goals. CONCLUSIONS: mHealth text messaging was well received. The results support the feasibility and acceptance of such an intervention.

Methods and protocol of a mixed method quasi-experiment to evaluate the effects of a structural economic and food security intervention on HIV vulnerability in rural Malawi: The SAGE4Health Study.

BACKGROUND: Poverty and lack of a predictable, stable source of food are two fundamental determinants of ill health, including HIV/AIDS. Conversely, episodes of poor health and death from HIV can disrupt the ability to maintain economic stability in affected households, especially those that rely on subsistence farming. However, little empirical research has examined if, and how, improvements in people's economic status and food security translate into changes in HIV vulnerability. METHODS: In this paper, we describe in detail the methods and protocol of an academic-NGO collaboration on a quasi-experimental, longitudinal study of the mechanisms and magnitude of the impact of a multilevel economic and food security program (Support to Able-Bodied Vulnerable Groups to Achieve Food Security; SAFE), as implemented by CARE. Primary outcomes include HIV vulnerability (i.e., HIV risk behaviors, HIV infection), economic status (i.e., income, household assets) and food security (including anthropometric measures). We recruited participants from two types of areas of rural central Malawi: traditional authorities (TA) selected by CARE to receive the SAFE program (intervention group) and TAs receiving other unrelated CARE programming (controls). In the intervention TAs, we recruited 598 program participants (398 women, 200 men) and interviewed them at baseline and 18- and 36-month follow-ups; we interviewed 301 control households. In addition, we conducted random surveys (n = 1002) in the intervention and control areas with a 36-month assessment interval, prior to and after implementation of SAFE. Thus, we are examining intervention outcomes both in direct SAFE program participants and their larger communities. We are using multilevel modeling to examine mediators and moderators of the effects of SAFE on HIV outcomes at the individual and community levels and determine the ways in which changes in HIV outcomes feed back into economic outcomes and food security at later interviews. Finally, we are conducting a qualitative end-of-program evaluation consisting of in-depth interviews with 90 SAFE participants. DISCUSSION: In addition to examining pathways linking structural factors to HIV vulnerability, this research will yield important information for understanding the impact of a multilevel environmental/structural intervention on HIV, with the potential for other sustainable long-term public health benefits.