Association of Nightly Fasting, Meal Frequency, and Skipping Meals with Metabolic Syndrome among Kuwaiti Adults.

Mounting evidence suggests that meal timing and frequency are associated with cardiometabolic health by influencing circadian rhythms. However, the evidence is inconsistent and limited, especially in non-Western cultures. This cross-sectional study aims to investigate the association between temporal habits of dietary intake, such as nightly fasting duration and meal frequency, and metabolic syndrome among Kuwaiti adults. A 24-hour recall was used to assess temporal habits of dietary intake. Meal frequency was defined as the number of daily eating episodes. The study included a total of 757 adults aged 20 years and older. The participants' mean age was 37.8 ± 12.3 years. After adjusting for all confounders, higher meal frequency was found to be associated with a lower prevalence of metabolic syndrome in adults (OR, 0.43; 95%CI, 0.19-0.96) and a lower prevalence of elevated triglycerides in men only (OR, 0.23; 95%CI, 0.09-0.60). No association was found between nightly fasting and metabolic syndrome, but a longer fasting duration was associated with a lower prevalence of elevated triglycerides (OR, 0.19; 95%CI, 0.06-0.63). The findings suggest that having frequent meals and longer durations of nightly fasting may help decrease the risk of metabolic syndrome and elevated triglycerides.

Dietary Habits, Meal Timing, and Meal Frequency in Kuwaiti Adults: Analysis of the Kuwait National Nutrition Surveillance Data.

Dietary habits, including meal frequency, meal timing, and skipping meals, have been extensively studied due to their association with the development of noncommunicable diseases (NCDs). This study describes dietary habits, meal timing, frequency, skipping meals, and late-night eating in Kuwaiti adults. Kuwait National Nutrition Surveillance System data were utilized to reach the objectives of this study. The findings reveal that approximately 54% of the adults in Kuwait eat after 10 p.m., 29% skip breakfast, and 9.8% skip dinner. Furthermore, adults in Kuwait consume 4.4 meals per day on average. Women skip breakfast more often and have more extended night fasting than men (p < 0.001). Married adults skip breakfast and dinner less than unmarried adults (p < 0.001). In conclusion, this descriptive study provides valuable insights into the dietary habits of Kuwaiti adults, emphasizing the importance of further investigating the association between meal timing, meal frequency, and the prevalence of NCDs in Kuwait.

Population-based assessment of the burden of COVID-19 infection in African countries: a first-year report card and public health implications.

Background: The COVID-19 pandemic constitutes a global health threat and poses a major burden on the African continent. We assessed the real-world burden of COVID-19 infection in African Union (AU) member states to determine the distributional patterns of epidemiological measures during the first 1 year of the pandemic. Methods: This retrospective cross-sectional study utilized COVID-19 data from publicly available data repositories of the African Center for Disease Control and Prevention and Our World in Data for the period February 2020 to January 2021. AU member states were classified into low, medium, and high burdens based on COVID-19 morbidity. We conducted descriptive and inferential analyses of COVID-19-reported cases, deaths, recoveries, active cases, COVID-19 tests, and epidemiological measures that included morbidity and mortality rates, case fatality rate (CFR), and case ratios. Results: A total of 3.21 million cases were reported during the 1-year period, with 2.6 million recoveries, 536,784 cases remaining active, and 77,486 deaths. Most countries (49.1%, n = 26) in AU experienced a low burden of COVID-19 infection compared to 28.3% (n = 15) with medium burden and 22.6% (n = 12) with high burden. AU nations with a high burden of the disease were mainly in the northern and southern regions. South Africa recorded the highest number of cases (1.31 million), followed by Morocco with 457,625 and Tunisia with 175,065 cases. Correspondently, death tolls for these countries were 36,467, 7888, and 5528 deaths, respectively. Of the total COVID-19 tests performed (83.8 million) during the first 1 year, 62.43% were from high-burden countries. The least testing occurred in the medium-burden (18.42%) countries. The overall CFR of AU was 2.21%. A morbidity rate of 327.52/105 population and mortality rate of 5.96/105 population were recorded during the first 1-year period with significant variations (p < 0.0001) across burden levels. Continental morbidity and mortality rates of 17,359/105 and 315.933/105 populations were recorded with significant correlation (r = 0.863, p < 0.0001) between them and variations across selected epidemiological measures by COVID-19 burden levels. Conclusion: Understanding the true burden of the disease in AU countries is important for establishing the impact of the pandemic in the African continent and for intervention planning, preparedness, and deployment of resources during COVID-19 surges and future pandemics.

Pediatric diarrhea patients living in urban areas have a higher incidence of Clostridioides difficile infection.

Clostridioides difficile infection (CDI) is a major cause of antibiotic-associated diarrhea and an unappreciated contributor to child mortality in low- and middle-income countries where the diagnosis may be difficult. There is little information about the prevalence of CDI among infants, children, and adolescents in Africa. Using a cross-sectional design, seventy-six samples were collected from pediatric patients presenting with diarrhea, including infants (≤ 2 years old), children (2-12 years), and adolescents (13 ≤17 years) from three hospitals between January and December 2019. Demographic data, medical history, and prior antibiotic use were recorded. Toxigenic culture and PCR were used to detect and validate the presence of C. difficile in the samples. Data obtained were analyzed using descriptive and inferential statistics. A total of 29 (38.7%), 39 (52.0%) and 7 (9.3%) samples were from infants, children, and adolescents, respectively. The average age of the patients was 4.4 years. Of these samples, 31 (41%) were positive for C. difficile by culture and were verified by PCR amplification of C. difficile-specific genes (tcdA and tcdB). The most positive cases were children (53.3%) and infants (40.0%) with the majority of them residing in urban areas. Forty-nine (66.2%) of the patients had no known antibiotics exposure, whereas 29.0% and 29.7% reported the use of over-the-counter antibiotics at 14 and 90 days, prior to the hospital visit, respectively. CDI is relatively common among children with diarrhea in Northern Nigeria. Therefore, for effective management and treatment, more attention should be given to testing for C. difficile as one of the causative agents of diarrhea.

Healthcare Provider's Perceived Self-Efficacy in HPV Vaccination Hesitancy Counseling and HPV Vaccination Acceptance.

BACKGROUND: HPV vaccine hesitancy is a key contributor to the sub-optimal HPV vaccination uptake in the United States. We aimed to determine the association between healthcare providers' self-efficacy in HPV vaccination hesitancy counseling and HPV vaccination acceptance after initial and follow-up counseling sessions. METHODS: Population-based cross-sectional study of healthcare providers (HCPs) practicing in Texas. Logistic regression analyses were used to determine the odds of HPV vaccination acceptance by vaccine-hesitant patients. Additionally, generalized estimating equations were used to compare HPV vaccination acceptance by hesitant patients after follow-up versus initial counseling sessions. RESULTS: 1283 HCPs completed the survey with a mean (SD) age of 47.1 (11.3) years. HCPs who believed that they were very/completely confident in counseling HPV-vaccine-hesitant parents had higher odds of observing HPV vaccination acceptance very often/always after an initial counseling session (adjusted odds ratio (AOR): 3.50; 95% CI: 2.25-5.44) and after follow-up counseling sessions (AOR: 2.58; 95% CI: 1.66-4.00) compared to HCPs that perceived they were not at all/somewhat/moderately confident. The odds of HPV vaccination being accepted very often/always by vaccine-hesitant parents was 61% (AOR: 1.61; 95% CI: 1.32-1.95) higher after follow-up counseling sessions compared to an initial counseling session. The results were similar for the counseling of HPV-vaccine-hesitant adult patients. CONCLUSIONS: The confidence level of HCPs in counseling hesitant parents and adult patients impacts HPV vaccination acceptance. Importantly, acceptance was higher after follow-up counseling sessions than initial counseling sessions. HCPs should receive training in HPV vaccination counseling to enhance their confidence in counseling hesitant patients and should utilize every visit to counsel hesitant patients.

Sexual Behaviors and Human Papillomavirus Vaccination in a Heterosexually Active Adult Population at Increased Risk for HIV Infection.

Human papillomavirus (HPV) is the most common sexually acquired infection in the US. Vaccination is effective against infection with high-risk HPV strains, yet HPV vaccine coverage is lower in the US than the national target. This study aimed to determine the relationship between sexual behaviors and HPV vaccination in a heterosexually active population at increased risk for HIV infection. Data from 380 participants aged 18-45 years obtained from the National HIV Behavioral Surveillance system increased risk heterosexuals cycle 5 (2019) in Houston, Texas, was analyzed. RDS-Analyst was used to generate population-based descriptive statistics. Modified Poisson regression models clustered on recruitment chain were conducted in SAS 9.4 to assess the relationship between sexual behaviors and HPV vaccination. Only 11.5% of participants had received at least one dose of the HPV vaccine. Regarding behaviors within the past 12 months, 44.8% reported having condomless casual sex, 51.3% reported having concurrent sexual partnerships while in their most recent relationship, 14.5% reported exchanging sex, and participants had an average of 4-5 sex partners. Further, those who exchanged sex had a significantly lower prevalence of HPV vaccine uptake when compared to those who did not exchange sex (adjusted prevalence ratio 0.23; confidence interval 0.10-0.52), while all other measures of sexual behavior were not significantly associated with HPV vaccination. More research is needed to understand the relationship between exchange sex and low prevalence of vaccination, specifically in women who bear the highest burden of poor HPV-related morbidity and mortality.

Regional outbreak of multidrug-resistant Klebsiella pneumoniae carbapenemase-producing Pseudomonas Aeruginosa.

Klebsiella pneumoniae carbapenemase-producing P. aeruginosa (KPC-CRPA) are rare in the United States. An outbreak of KPC-CRPA was investigated in Texas using molecular and epidemiologic methods and 17 cases of KPC-CRPA were identified. The isolates were genetically related and harbored the emerging P. aeruginosa multilocus sequence type 235, the first in the United States.

Regional transmission patterns of carbapenemase-producing Enterobacterales: A healthcare network analysis.

OBJECTIVE: Carbapenem-resistant Enterobacterales (CRE) pose a serious public health threat and spread rapidly between healthcare facilities (HCFs) during interfacility patient movement. We examined patterns of transmission of CRE associated with network clustering and positions during patient interfacility transfer. METHODS: A retrospective cohort study was conducted in the Greater Houston region ofTexas, , and social network analysis was performed by constructing facility-to-facility patient transfer network using CRE surveillance data. The network method (community detection algorithm) was used to detect clustering patterns of CRE in the network. In addition, network measures of centrality and local connectivity (clustering coefficient) were computed for each healthcare facility. Zero-inflated negative binomial regression analysis was applied to test the association between network measures and facility-specific incidence rate of CRE. RESULTS: A network of 268 healthcare facilities was identified, in which 10 acute-care hospitals (ACHs) alone accounted for 63% of identified CRE cases. Transmission of New Delhi metallo-ß-lactamase-producing CRE occurred in 3 clusters, yet all cases were traced to patients who had had medical care abroad. The incidence rate of CRE attributed to ACHs was >4-fold (adjusted rate ratio, 4.5; 95% confidence interval [CI], 3.02-6.72) higher than that of long-term care facilities. Each additional patient shared with another HCF conferred a 3% (95% CI, 2%-4%) increase in the incidence rate of CRE at that HCF. CONCLUSIONS: The incidence rates of CRE at a given HCF was predicted by the healthcare network metrics. Increased surveillance and selective targeting of high-risk facilities are warranted.

HPV Vaccination Training of Healthcare Providers and Perceived Self-Efficacy in HPV Vaccine-Hesitancy Counseling.

HPV vaccine hesitancy is a key barrier to HPV vaccination. Using a population-based survey of HCPs practicing in Texas we determined the association between formal training of HCPs and perceived self-efficacy in counseling HPV vaccine-hesitant parents and adult patients. A total of 1283 HCPs completed the survey, with 879 providing vaccination services to pediatric patients and 1018 providing vaccination services to adult patients. Among HCPs included in this study, 405 of 577 (70%) and 315 of 505 (62%) perceived they were very/completely confident in counseling HPV vaccine-hesitant parents and adult patients, respectively. Compared to HCPs who received no training, those who received formal training in HPV vaccination promotion or counseling had 2.56 (AOR: 2.56; 95% CI:1.69-3.86) and 2.84 times higher odds (AOR: 2.84; 95% CI:1.87-4.33) of perceiving that they were very/completely confident in counseling HPV vaccine-hesitant parents and adult patients, respectively. Additionally, increasing years of practice and volume of patients seen were positively associated with being very/completely confident in counseling HPV vaccine-hesitant parents and adult patients. On the other hand, nurses were less likely than physicians to be very/completely confident in counseling HPV vaccine-hesitant parents. To increase HPV vaccination uptake, HCPs should receive tailored training to improve their self-efficacy in addressing HPV vaccine-hesitancy.

Clinical Outcomes Associated with Co-infection of Carbapenem-Resistant Enterobacterales and other Multidrug-Resistant Organisms.

Background: Infections with carbapenem-resistant Enterobacterales (CRE) are associated with increased risk of death. Polymicrobial infections with antimicrobial-resistance may add to the burden of clinical care and patients' clinical prognosis. Aim: To examine the impact of CRE co-infection with other multi-drug resistant organisms (MDRO) on patient clinical outcomes. Study Design: A retrospective observational study was conducted to compare the clinical outcomes of CRE patients who were co-infected with carbapenem-resistant Pseudomonas aeruginosa (CRPA), multidrug-resistant Acinetobacter baumannii (MDRA) and Methicillin-resistant Staphylococcus aureus (MRSA). Results: A total of 224 CRPA and 209 MDRA co-infections with CRE were identified from 4,236 cases from 2015-2020. The overall 90-day all-cause mortality was 21.6% but increased to 35.0% and 33.5% among patients who were co-infected with CRPA and MDRA, respectively. The odds of all-cause mortality among CRE patients who were co-infected with CRPA was twice that of patients identified with CRE alone [adjusted odds ratio (AOR) = 2.02, 95% confidence interval (CI): 1.18-3.46]. Further, the odds of all-cause mortality among CRE patients who were concomitantly identified with MRSA was more than twice that of patients who were not identified with MRSA [AOR = 2.16, 95%CI:1.31-3.56]. The clinical outcome of patients with CRE did not differ significantly depending on the presence of carbapenemase genes. Conclusion: The results show that CRPA and CRE co-infections have synergistic effects on clinical outcomes. Further investigation is necessary to understand the mechanism. Screening high risk patients for concomitant antimicrobial-resistant infections may have a significant clinical impact, including effective therapies, antibiotic stewardship, and infection control policies.

Association of provider HPV vaccination training with provider assessment of HPV vaccination status and recommendation of HPV vaccination.

The delivery of strong HPV vaccine recommendations hinges on the expertise of healthcare providers (HCPs) in assessing patients' status and recommending HPV vaccination. We conducted a population-based cross-sectional study of HCPs practicing in Texas to examine the relationship between HPV vaccination training of HCPs and HPV vaccination status assessment and recommendation. Logistic regression analyses were used to assess the association between HCPs' formal training and recency of training in HPV vaccination promotion or counseling with HPV vaccination status assessment and recommendation. Of the 1,283 HCPs who completed the online survey, 43% had received training in HPV vaccination promotion or counseling, 47% often/always assess HPV vaccination status, and 59% often/always recommend HPV vaccination. Compared with HCPs who received no training, those who received training had over four times higher odds (adjusted odds ratio [AOR]: 4.32; 95% CI: 3.06-6.10) of often/always assessing HPV vaccination status and over three and half times higher odds (AOR: 3.66; 95% CI: 2.73-4.90) of often/always recommending HPV vaccination. Furthermore, HCPs who recently received HPV vaccination training had higher odds of HPV vaccination status assessment and recommendations than those without training. Hispanic HCPs had higher odds of often/always assessing HPV vaccination status and recommending vaccination than did non-Hispanic White HCPs. Also, nurses and physician assistants had lower odds of often/always assessing HPV vaccination status and recommending HPV vaccination than did physicians. Targeted and continuous training of HCPs in HPV vaccination promotion or counseling is needed to increase HPV vaccination status assessment, recommendation, and uptake rates.

Evaluation of the kitchen microbiome and food safety behaviors of predominantly low-income families.

Bacterial pathogens in the domestic environment present a risk to residents, particularly among susceptible populations. However, the impact of consumer demographic characteristics and food handling methods on kitchen microbiomes is not fully understood. The domestic kitchen bacterial communities of ten predominantly low-income families in Houston, TX, were assessed in conjunction with a cross-sectional food safety survey to evaluate differences in household and surface-specific microbiomes and bacterial foodborne pathogen presence. Three kitchen surfaces within each household, including the sink drain, the refrigerator handle, and the counter, were environmentally sampled and metataxonomically evaluated via targeted 16S rRNA sequencing. Disposable dish sponges were also acquired and examined. Results indicated that alpha diversity did not vary by the households, sampling locations, or demographic characteristics evaluated. Significant differences in beta diversity were observed among the bacterial communities of five pairs of households and between refrigerator handle and disposable dish sponge microbiomes. A total of 89 unique bacterial foodborne pathogens were identified across surface types. Each household contained at least one contaminated surface, and the most common bacterial foodborne pathogens identified were Escherichia coli, Staphylococcus aureus, and Klebsiella pneumoniae. All parents reported washing their hands before meal preparation, washing fresh fruits and vegetables, and washing cutting boards with soap after use to prepare raw animal proteins. Gaps in food safety behaviors identified included a lack of serious concern for food contamination with germs and inappropriate handwashing, food handling, and cleaning behaviors. The number of unique bacterial foodborne pathogens identified within households was significantly higher among households whose respondent parent reported that they did not consider food contamination with germs to be a serious food safety problem (median: 41.0 species) compared to households whose respondent parent did consider food contamination to be a serious food safety problem (median: 3.0 species; p value = 0.0218). These results demonstrate that domestic kitchen taxonomic abundance profiles vary according to household and surface type. Data suggest that low-income consumers may be at risk of foodborne pathogen exposure from contaminated home kitchen surfaces, and that food safety attitudes may directly contribute to this hazard.

Food Safety Attitudes, Behaviors, and Hygiene Measures among Predominantly Low-Income Parents in Houston, Texas.

ABSTRACT: Foodborne infections in the United States affect racial-ethnic minority and low-income populations at higher rates than the general population. To identify the prevalence of food safety behaviors and demographic characteristics associated with food handling practices among a susceptible, high-risk population, a cross-sectional survey was administered to 106 parents with children enrolled at two elementary schools serving predominantly low-income families in Houston, Texas. Relationships between demographic characteristics and food safety behavioral outcomes were examined using cross-tabulations and Fisher's exact test. Most respondents were female (93.4%), Hispanic, Latino, or Mexican American (94.9%), and had no previous food handling employment experience (75.0%). The primary source of food safety information reported was the Internet (32.7%), and nearly half of parents (42.7%) reported that they did not consider contamination of food with germs a serious food safety problem. Hand washing before food preparation was more common (98.0%) than before touching the refrigerator handle (66.3%), after electronic device use (55.6%), or after handling raw animal proteins (77.6%). The prevalence of fresh fruit (98.0%) and vegetable (97.9%) washing and appropriate contaminated cutting board handling (89.0%) was high among parents. Self-reported gaps in food handling behaviors identified included lack of food thermometer ownership (80.4%), use of reusable cleaning tools (71.0%), inappropriate defrosting methods (67.4%), and washing of raw poultry (86.3%), seafood (84.9%), and meat (74.7%). Hand washing after electronic device use and defrosting methods were observed to vary significantly according to demographic characteristics. Food safety education with messages targeted to specific demographic groups may be necessary to reduce the risk of foodborne disease among low-income parents and young children.

Secondary plant metabolites as potent drug candidates against antimicrobial-resistant pathogens.

Antibiotic resistance is a major public health threat of the twenty-first century and represents an important risk to the global economy. Healthcare-associated infections mainly caused by drug-resistant bacteria are wreaking havoc in patient care worldwide. The spread of such pathogens limits the utility of available drugs and complicates the treatment of bacterial diseases. As a result, there is an urgent need for new drugs with mechanisms of action capable of curbing resistance. Plants synthesize and utilize various metabolic compounds to deter pathogens and predators. Utilizing these plant-based metabolites is a promising option in identifying novel bioactive compounds that could be harnessed to develop new potent antimicrobial drugs to treat multidrug-resistant pathogens. The purpose of this review is to highlight medicinal plants as important sources of novel antimicrobial agents that could be developed to help combat antimicrobial resistance.

Awareness of human papillomavirus and reported human papillomavirus vaccine uptake in a high-risk population.

Introduction: Disparities in human papillomavirus (HPV) awareness and HPV vaccine uptake are likely exacerbated among racial/ethnic minority populations living in low-income areas. This study aims to determine the prevalence and correlates of HPV awareness and HPV vaccine uptake in an urban, low-income, racial/ethnic minority population. Methods: Secondary data analyses were performed in 2021 using 380 participants aged 18-45 years from the 2019 National HIV Behavioral Surveillance for high-risk heterosexuals, which monitors HIV risk behaviors among individuals living in high-poverty, high HIV prevalence neighborhoods. Prevalence estimates and modified Poisson regression models were used to assess the relationship between HPV awareness and HPV vaccine uptake, and sociodemographic characteristics. Results: Only 53% of participants had heard of HPV and 11.5% had received at least one dose of the HPV vaccine. Those who were female, non-Hispanic White or other, had public health insurance, lived above the federal poverty level, had experienced homelessness and incarceration, and had usual source of healthcare showed higher awareness of HPV while those who were younger, female, non-Hispanic White or other, recently incarcerated, had a usual source of healthcare, and had a healthcare encounter in the past year showed higher prevalence of HPV vaccine uptake. Conclusions: Prevalence of HPV vaccination in this high-risk population was low and there was a lack of preventive care utilization. Further research is needed on how to effectively target these populations to not only increase vaccine uptake, but to mitigate barriers that contribute to low awareness and suboptimal vaccination uptake in high-risk heterosexual populations.

Clinical epidemiology of carbapenem-resistant Enterobacterales in the Greater Houston region of Texas: a 6-year trend and surveillance analysis.

OBJECTIVES: Carbapenem-resistant Enterobacterales (CRE) remain an urgent public health priority in the United States. CRE poses a major threat to patients in healthcare and a potential risk to the community. This study examined the epidemiological trends, clinical, and microbiological data of CRE in the Greater Houston region of Texas. METHODS: A multi-institutional retrospective observational study was conducted using surveillance data collected from 2015 to 2020. Predictors of incidence rates of CRE were determined by a negative binomial regression fit using a generalized estimation equation. RESULTS: Over a 6-year period, 4236 CRE cases were reported, of which Klebsiella pneumoniae accounted for 84.8%. The results show a steady increase in CRE cases, with a sharp rise since 2018. The majority of carbapenemase-producing Enterobacterales were Klebsiella pneumoniae carbapenemase (KPC)-producing (77.2%), followed by other rare carbapenemases, which includes OXA-48, NDM, IMP, VIM, coproduction of KPC with OXA-48, KPC with NDM, and NDM with OXA-48. Acute care hospitals (ACH) accounted for 68.5% of the source of CRE cases. The incidence rate of CRE cases reported from ACH and long-term acute care (LTAC) facilities was 1.16 times that of long-term care facilities (adjusted rate ratio [ARR] = 1.16, 95% confidence interval [CI]:1.04-1.30). The incidence rate of CRE among patients with indwelling devices was 15% (ARR = 0.85, 95% CI: 0.79-0.92) lower than that of patients without indwelling devices. CONCLUSION: The rise in the rate of CRE cases despite aggressive infection prevention and control strategies in the region is alarming. Evaluating and improving the current infection control strategies may be warranted.

Meal Timing, Meal Frequency and Metabolic Syndrome.

Individuals with metabolic syndrome have increased risk for developing health conditions, including cardiovascular diseases and stroke. Modifiable risk factors, such as exercise and diet, are key components in the prevention and control of metabolic syndrome. Specifically, dietary patterns and habits are extremely successful in controlling more than one of the metabolic syndrome risk factors. Meal timing and frequency have been associated with type 2 diabetes, cardiovascular diseases, and other chronic conditions. However, there is limited evidence linking metabolic syndrome to meal timing and meal frequency. This review summarizes and discusses how meal timing and frequency impact metabolic outcomes in adults.

Exploring Preventive Healthcare in a High-Risk Vulnerable Population.

This study describes preventive care behaviors and explores opportunities to deliver preventive sexual healthcare to a high-risk vulnerable population. Data from the National HIV Behavioral Surveillance (NHBS) system high-risk heterosexuals (HET) cycle (2019) in Houston, Texas, was used to describe preventive care utilization and assess the relationship between healthcare utilization and sociodemographic characteristics. More than 47% reported having no usual source of healthcare, and 94.6% reported receiving no non-HIV STI testing in the past 12 months. Additionally, many sociodemographic factors were associated with healthcare utilization and having a usual source of healthcare. Future efforts should be targeted at increasing preventive healthcare utilization among high-risk vulnerable populations as well as implementing more preventive sexual healthcare services in the community health centers where these populations most frequently encounter healthcare.