Characterizing 1991 Gulf War women veterans from the Boston Biorepository and Integrative Network for Gulf War Illness: demographics, exposures, neuroimaging and cognitive outcomes.

Objective: Gulf War Illness (GWI) is a debilitating multisymptom condition that affects nearly a third of 1990-91 Gulf War (GW) veterans. Symptoms include pain, fatigue, gastrointestinal issues, and cognitive decrements. Our work has shown that GWI rates and potential causes for symptoms vary between men and women veterans. Studies have documented neuropsychological and neuroimaging findings mostly in men or combined sex datasets. Data are lacking for women veterans due to lack of power and repositories of women veteran samples. Methods: We characterized GW women veterans in terms of demographics, exposures, neuropsychological and neuroimaging outcomes from the newly collated Boston, Biorepository and Integrative Network (BBRAIN) for GWI. Results: BBRAIN women veterans are highly educated with an average age of 54 years. 81% met GWI criteria, 25% met criteria for current PTSD, 78% were white, and 81% served in the Army. Exposure to combined acetylcholinesterase inhibitors (AChEi) including skin pesticides, fogs/sprays and/or pyridostigmine bromide (PB) anti-nerve gas pill exposure resulted in slower processing speed on attentional tasks and a trend for executive impairment compared with non-exposed women. Brain imaging outcomes showed lower gray matter volumes and smaller caudate in exposed women. Conclusions: Although subtle and limited findings were present in this group of women veterans, it suggests that continued follow-up of GW women veterans is warranted. Future research should continue to evaluate differences between men and women in GW veteran samples. The BBRAIN women sub-repository is recruiting and these data are available to the research community for studies of women veterans.

The importance of community resources for breastfeeding.

BACKGROUND: Breastfeeding has long-lasting effects on children's cognition, behavioral, mental and physical health. Previous research shows parental characteristics (e.g., education, race/ethnicity, income level) are associated with breastfeeding initiation and duration. Further, research shows significant variation in access to community resources by race/ethnicity. It is unclear how community resources may impact breastfeeding practices and how this might intersect with maternal race/ethnicity. METHODS: This study combined nationally-representative data from the Study of Attitudes and Factors Effecting Infant Care (SAFE), which surveyed US mothers immediately after the infant's birth and at two to six months of infant age, with the Child Opportunity Index (COI) 2.0, a census tract measure of community resources associated with child development, to explore the association between community resources and breastfeeding initiation and whether this varies based on maternal race/ethnicity and country of birth. The SAFE Study used a stratified, two-stage, clustered design to obtain a nationally representative sample of mothers of infants, while oversampling Hispanic and non-Hispanic (NH) Black mothers. The SAFE study enrolled mothers who spoke English or Spanish across 32 US birth hospitals between January 2011 and March 2014. RESULTS: After accounting for individual characteristics, mothers residing in the highest-resourced communities (compared to the lowest) had significantly greater likelihood of breastfeeding. Representation in higher-resourced communities differed by race/ethnicity. Race/ethnicity did not significantly moderate the association between community resources and breastfeeding. In examining within race/ethnic groups, however, community resources were not associated with non-US born Black and Hispanic mothers' rates of breastfeeding, while they were with US born Black and Hispanic mothers. CONCLUSIONS: Findings suggest that even health behaviors like breastfeeding, which we often associate with individual choice, are connected to the community resources within which they are made. Study implications point to the importance of considering the impact of the contextual factors that shape health and as a potential contributor to understanding the observed race/ethnicity gap.

Heavy Alcohol Use and HIV Outcomes: The Moderating Role of Pain.

Pain and heavy alcohol consumption are prevalent among people living with HIV/AIDS (PLWH), each contributing to impaired functioning and diminished quality of life. Each of these conditions may have negative effects on the HIV care continuum, but less is known about their combined influences. The current study examined how heavy drinking and pain were associated with HIV viral suppression and CD4 cell count among participants receiving antiretroviral therapy (ART). The study sample consisted of 220 PLWH with past 12-month substance dependence or ever injection drug use enrolled in a large HIV cohort study. Logistic regression analyses showed an interaction between pain level (no/mild pain vs moderate/severe) and heavy drinking on viral suppression such that heavy drinking was a significant predictor of poorer viral suppression only for those who experienced moderate/severe pain. We also examined whether ART adherence differentially mediated the association between heavy drinking and HIV viral suppression by level of pain. Although there was a significant indirect effect of heavy drinking on viral suppression among those with moderate/severe pain, moderated mediational analyses did not indicate that the indirect effect of heavy drinking on viral suppression through ART adherence differed significantly by level of pain. Pain level did not significantly moderate the association between heavy drinking and CD4 cell count. We conclude that heavy drinking may be particularly likely to be associated with poorer HIV viral suppression among PLWH with moderate or severe pain. Providers should routinely address comorbid heavy drinking and pain to improve HIV outcomes.

Initial Stage of Disease Similar for White and Black Patients With Early-Onset Colorectal Cancer at a Safety-Net Hospital.

BACKGROUND: Non-Hispanic Black (NHB) patients with early-onset colorectal cancer (EOCRC) are more likely to present with advanced-stage disease than their Non-Hispanic White (NHW) counterparts. To further elucidate whether differences in tumor biology or disparities in access to care may be responsible, we examined the association between race/ethnicity and initial stage of disease, time to diagnosis, and tumor characteristics among NHW and NHB patients with EOCRC cared for in a safety-net health care setting. METHODS: We performed a retrospective cohort study of NHW and NHB patients diagnosed with primary EOCRC who received care at Boston Medical Center between January 2000 and May 2020. We compared demographics, risk factors, presenting signs/symptoms, time to diagnosis, health care utilization, and tumor characteristics (stage, grade, location, and mutational status). RESULTS: We identified 103 patients (mean age 41.5±7.2 y, 53.4% men), including 40 NHWs and 63 NHBs, with EOCRC. NHB and NHW patients were similar with respect to demographics, presenting signs/symptoms, and risk factor distribution. There were also no significant differences between NHWs and NHBs with respect to the advanced stage of disease at presentation (45.0% vs. 42.9%, P =0.83), the median time to diagnosis [152 d (IQR, 40 to 341) vs. 160 d (IQR, 61 to 312), P =0.79] or tumor characteristics, except for a predilection for proximal disease among NHBs (30.2% vs. 15.0%). CONCLUSIONS: NHB patients were no more likely than NHW patients to present with advanced-stage disease, aggressive tumor histology, or experience delays in diagnosis within a safety-net health care system.

Self-medication of pain and discomfort with alcohol and other substances by people with HIV infection and substance use disorder: preliminary findings from a secondary analysis.

There is a limited literature regarding factors associated with self-medication of pain and discomfort using alcohol, non-prescription substances or overuse of prescription medications among people living with Human Immunodeficiency Virus (HIV). This cross-sectional analysis used data from the Boston ARCH Cohort among participants with HIV infection and a history of alcohol or other substance use. Among 248 participants, 37% were female, 50% Black, 25% Latinx; 36% reported fair to poor health and 89% had CD4 cell counts >200/mm3. Half reported self-medication and of those, 8.8% reported doing so only with alcohol, 48.8% only with other substances and 42.4% with both alcohol and other substances. Those reporting self-medication were significantly (p < .05) younger (mean 47 vs 50 years), less employed (11% vs 21%), and less likely to have HIV viral suppression (60% vs. 80%). Depression, anxiety, and HIV symptoms were associated with significantly greater odds of self-medicating, as were substance dependence, recent injection substance use, heavy alcohol use, cocaine use, opioid use, sedative use, and cannabis use. Self-medication, highly prevalent and associated with worse mental health symptoms, greater substance use, and lesser HIV disease control, should be explored by HIV clinicians caring for people who use substances.

Alcohol Consumption and Illicit Drug Use: Associations With Fall, Fracture, and Acute Health Care Utilization Among People With HIV Infection.

BACKGROUND: Given alcohol and/or other drug (AOD) use occurs among people with HIV (PWH), we examined its association with falls and fall-related outcomes and whether frailty moderates the association. SETTING: Northeastern US city. METHODS: We analyzed an observational cohort of PWH with current or past AOD use. Alcohol measures were any past 14-day heavy use, average alcohol/day, and days with heavy use. Drug use measures were past 30-day illicit use of cocaine, opioids, and sedatives. Repeated cross-sectional associations were estimated with separate multivariable generalized estimating equation regression models for each fall-related outcome. RESULTS: Among PWH (n = 251; mean age 52 [SD = 10]), 35% reported heavy alcohol use, 24% cocaine, 16% illicit opioids, 13% illicit sedatives, and 35% any fall; 27% were frail. Heavy alcohol use was associated with a fall (AOR = 1.49, 95% CI: 1.08 to 2.07), multiple falls (AOR = 1.55 95% CI: 1.10 to 2.19), and fall/fracture-related emergency department visit or hospitalization (AOR = 1.81, 95% CI: 1.10 to 2.97). Higher average alcohol/day and more heavy drinking days were associated with multiple falls. Illicit sedative use was associated with a fall, multiple falls, and emergency department visit/hospitalization and opioid use with fracture. Frailty moderated the association of heavy alcohol use and a fall (AOR = 2.26, 95% CI: 1.28 to 4.01 in those frail) but not in those not frail. CONCLUSION: The effect of AOD use on falls and fall-related outcomes was most pronounced with alcohol, particularly among frail PWH. Heavy alcohol, illicit sedative, and illicit opioid use are high-priority targets for preventing falls and fall-related consequences for PWH.

Development and Validation of an Abbreviated Child and Adult Food Security Scale for Use in Clinical and Research Settings in the United States.

BACKGROUND: Food insecurity (FI) prevalence was consistently >10% over the past 20 years, indicating chronic economic hardship. Recession periods exacerbate already high prevalence of FI, reflecting acute economic hardship. To monitor FI and respond quickly to changes in prevalence, an abbreviated food security scale measuring presence and severity of household FI in adults and children is needed. OBJECTIVE: Our aim was to develop an abbreviated, sensitive, specific, and valid food security scale to identify severity levels of FI in households with children. DESIGN: Cross-sectional and longitudinal survey data were analyzed for years 1998 to 2022. PARTICIPANTS/SETTING: Participants were racially diverse primary caregivers of 69,040 index children younger than 4 years accessing health care in 5 US cities. STATISTICAL ANALYSES PERFORMED: Sensitivity, specificity, positive and negative predictive values, accuracy, and area under the receiver operator curve were used to test combinations of questions for the most effective abbreviated scale to assess levels of severity of adult and child FI compared with the Household Food Security Survey Module. Adjusted logistic regression models assessed convergent validity between the Abbreviated Child and Adult Food Security Scale (ACAFSS) and health measures. McNemar tests examined the ACAFSS performance in times of acute economic hardship. RESULTS: The ACAFSS exhibited 91.2% sensitivity; 99.6% specificity; 98.3% and 97.6% positive and negative predictive values, respectively; 97.7% accuracy; and a 99.6% area under the receiver operator curve, while showing high convergent validity. CONCLUSIONS: The ACAFSS is highly sensitive, specific, and valid for detecting severity levels of FI among racially diverse households with children. The ACAFSS is recommended as a stand-alone scale or a follow-up scale after households with children screen positive for FI risk. The ACAFSS is also recommended for planning interventions and evaluating their effects not only on the binary categories of food security and FI, but also on changes in levels of severity, especially when rapid decision making is crucial.

The differential predictive utility of two caregiver-targeted self-efficacy measures to promote oral health of underserved children.

OBJECTIVE: Oral health self-efficacy is a modifiable determinant of early childhood caries, which is one of the most prevalent childhood diseases. Yet, two common measures of self-efficacy (i.e., context-specific and behavior-specific) lack validation and clarity in the prediction of children's oral health behaviors. This study examined the psychometric properties of two caregiver oral health self-efficacy measures and investigated the predictive ability and age-varying effects of caregiver oral health self-efficacy on child oral health behaviors. METHOD: In this secondary data analysis of caregiver-child dyads (n = 754, Mchild age = 2.4, 56.2% Black or African American, 68.3% below poverty level), caregivers reported their oral health self-efficacy and their child's tooth brushing frequency, diet, and sugar-sweetened beverage (SSB) consumption at baseline and 4, 12, and 24 months. Psychometrics were examined with confirmatory factor analyses (CFAs) and the predictive ability and age-varying effects of caregiver self-efficacy on child oral health behaviors were examined with time-varying effect models (TVEMs). RESULTS: The context- and behavior-specific oral health self-efficacy CFA models indicated mixed model fit. In the predictive TVEM models, greater behavior-specific, but not context-, oral health self-efficacy predicted greater child tooth brushing across all ages. Greater context-specific oral health self-efficacy predicted healthier child diet throughout childhood, but greater behavior-specific self-efficacy only predicted healthier child diet in older children. Greater behavior-specific self-efficacy predicted lower SSB consumption throughout childhood while greater context-specific self-efficacy only predicted lower SSB consumption in younger children. CONCLUSIONS: Both caregiver oral health self-efficacy measures were psychometrically comparable and differentially predicted oral health behaviors across varying childhood ages. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Association Between Material Hardship in Families With Young Children and Federal Relief Program Participation by Race and Ethnicity and Maternal Nativity.

Importance: Even brief periods of hardship during early childhood may have lifelong consequences. Prior cross-sectional research limited to respondents with English proficiency and internet access during the COVID-19 crisis documented families with young children that struggled to afford basic needs like food and rent. Few studies have examined experiences of families with young children by race and ethnicity and maternal nativity. Objective: To examine the association of COVID-19 relief programs with the mitigation of household food insecurity among families with young children, as well as being behind on rent and disparities in program receipt. Design, Setting, and Participants: This cohort study used data from the ongoing repeat cross-sectional Children's HealthWatch study comprising families surveyed at baseline (January 1, 2018, to March 20, 2020) and during the COVID-19 crisis (September 1, 2020, to June 30, 2021). Baseline questionnaires were administered face to face to caregivers of children aged 48 months or younger in English or Spanish in emergency departments or primary care clinics in 5 US cities. The follow-up questionnaires were administered via telephone. Exposures: Supplemental Nutrition Assistance Program (SNAP) participation or receipt of at least 1 Economic Impact Payment (EIP; ie, stimulus check) during the COVID-19 crisis. Main Outcomes and Measures: The primary outcomes were household food insecurity (assessed via the US Household Food Security Survey Module: Six-Item Short Form) and being behind on rent. Logistic and binomial regression models were used to calculate adjusted odds ratios (aORs) and unadjusted and adjusted prevalence ratios (PRs). Results: Of 1396 caregiver-child dyads (20.3% response rate), race and ethnicity data were available for 1357 caregivers: 514 (37.9%) were Black, non-Latino; 558 (41.1%) were Latino; 230 (16.9%) were White, non-Latino; and 55 (4.1%) were of other non-Latino race or ethnicity. Among 1390 responses with nonmissing data, 417 children (30.0%) had an immigrant mother, and among 1388 responses, 1238 (33.5%) were publicly insured. During the crisis, 467 of 1395 respondents (33.5%) reported household food insecurity, and 567 of 1391 respondents (40.8%) reported being behind on rent. Families with immigrant mothers had lower odds of EIP and SNAP participation than families with US-born mothers (eg, aOR, 0.07 [95% CI, 0.05-0.12] for both EIP and SNAP vs neither), despite being more likely to report household food insecurity (adjusted PR [aPR], 1.48 [95% CI, 1.28-1.71]) and being behind on rent (aPR, 1.14 [95% CI, 1.00-1.30]). Families with Black (unadjusted PR [uPR], 1.40 [95% CI, 1.08-1.82]) or Latino (uPR, 1.54 [95% CI, 1.19-1.98]) caregivers or caregivers of other race and ethnicity (uPR, 1.67 [1.12-2.49]) were also more likely than families with White, non-Latino caregivers to experience household food insecurity or being behind on rent (families with Black caregivers: uPR, 2.02 [95% CI, 1.58-2.58]; families with Latino caregivers: 1.68 [95% CI, 1.30-2.16]; families with caregivers of other race or ethnicity: uPR, 1.94 [95% CI, 1.34-2.80]). Adjustment for covariates and differential participation in relief programs did not entirely account for these disparities. Conclusions and Relevance: The results of this cohort study suggest that the COVID-19 crisis exacerbated preexisting inequities in food insecurity and difficulty paying rent according to race and ethnicity and maternal nativity and that equity-focused policy changes are needed to ensure that all children and their families in the US can afford basic needs for optimal health.

Associations of household unmet basic needs and health outcomes among very low birth weight children.

OBJECTIVE: We examined associations of past year household hardships (housing, energy, food, and healthcare hardships) with postnatal growth, developmental risk, health status, and hospitalization among children 0-36 months born with very low birth weight (VLBW) and the extent that these relationships differed by receipt of child supplemental security income (SSI). STUDY DESIGN: We examined cross-sectional data from 695 families. Growth was measured as weight-for-age z-score change. Developmental risk was defined as ≥1 concerns on the "Parents' Evaluation of Developmental Status" screening tool. Child health status was categorized as excellent/good vs. fair/poor. Hospitalizations excluded birth hospitalizations. RESULTS: Compared to children with no household hardships, odds of developmental risk were greater with 1 hardship (aOR 2.0 [1.26, 3.17]) and ≥2 hardships (aOR) 1.85 [1.18, 2.91], and odds of fair/poor child health (aOR) 1.59 [1.02, 2.49] and hospitalizations (aOR) 1.49 [1.00, 2.20] were greater among children with ≥2 hardships. In stratified analysis, associations of hardships and developmental risk were present for households with no child SSI and absent for households with child SSI. CONCLUSION: Household hardships were associated with developmental risk, fair/poor health status, and hospitalizations among VLBW children. Child SSI may be protective against developmental risk among children living in households with hardships.

Impact of alcohol use disorder severity on human immunodeficiency virus (HIV) viral suppression and CD4 count in three international cohorts of people with HIV.

BACKGROUND: Alcohol use has been linked to worse human immunodeficiency virus (HIV) immunologic/virologic outcomes, yet few studies have explored the effects of alcohol use disorder (AUD). This study assessed whether AUD severity is associated with HIV viral suppression and CD4 count in the three cohorts of the Uganda Russia Boston Alcohol Network for Alcohol Research Collaboration on HIV/AIDS (URBAN ARCH) Consortium. METHODS: People with HIV (PWH) in Uganda (n = 301), Russia (n = 400), and Boston (n = 251), selected in-part based on their alcohol use, were included in analyses. Logistic and linear regressions were used to assess the cross-sectional associations between AUD severity (number of DSM-5 diagnostic criteria) and (1) HIV viral suppression, and (2) CD4 count (cells/mm3 ) adjusting for covariates. Analyses were conducted separately by site. RESULTS: The proportion of females was 51% (Uganda), 34% (Russia), and 33% (Boston); mean age (SD) was 40.7 (9.6), 38.6 (6.3), and 52.1 (10.5), respectively. All participants in Uganda and all but 27% in Russia and 5% in Boston were on antiretroviral therapy. In Uganda, 32% met criteria for AUD, 92% in Russia, and 43% in Boston. The mean (SD) number of AUD criteria was 1.6 (2.4) in Uganda, 5.6 (3.3) in Russia, and 2.4 (3.1) in Boston. Most participants had HIV viral suppression (Uganda 92%, Russia 57%, Boston 87%); median (IQR) CD4 count was 673 (506, 866), 351 (201, 542), and 591 (387, 881), respectively. In adjusted models, there were no associations between AUD severity and HIV viral suppression: adjusted odds ratios (AOR) (95%CI) per 1 additional AUD criterion in Uganda was 1.08 (0.87, 1.33); Russia 0.98 (0.92, 1.04); and Boston 0.95 (0.84, 1.08) or CD4 count: mean difference (95%CI) per 1 additional criterion: 5.78 (-7.47, 19.03), -3.23 (-10.91, 4.44), and -8.18 (-24.72, 8.35), respectively. CONCLUSIONS: In three cohorts of PWH, AUD severity was not associated with HIV viral suppression or CD4 count. PWH with AUD in the current era of antiretroviral therapy can achieve virologic control.

Polysubstance Use Patterns Associated With HIV Disease Severity Among Those With Substance Use Disorders: A Latent Class Analysis.

OBJECTIVE: Polysubstance use is common among people with HIV infection (PWH) and with substance use disorder (SUD), but its effects are understudied. We aimed to identify polysubstance use patterns over time and assess their associations with HIV disease severity. METHOD: In 233 PWH with current or past SUD, latent class analysis identified polysubstance use patterns based on the Alcohol Use Disorders Identification Test-Consumption and past-30-day use of cannabis, cocaine, opioids, and tranquilizers at baseline. We categorized changes in use patterns and tested associations between those changes and CD4 count and HIV viral suppression at 12 months in linear and logistic regressions. RESULTS: Three patterns were identified at baseline: 18% did not use any substance (NONE--a priori defined); 63% used mostly cannabis and alcohol (CA); and 19% used opioids along with other drugs, including cocaine, tranquilizers, cannabis, and alcohol (MULTI). At 12 months, 40% moved from a high to a lower substance use class (MULTI to CA, either to NONE) or remained as NONE, 43% were in CA both times and 17% increased (NONE to CA, either to MULTI) or remained as MULTI. The adjusted mean CD4 count (for baseline covariates and baseline CD4 count) was significantly lower among participants increasing or remaining in MULTI (523, 95% CI [448, 598], cells/mm3) compared with those who decreased/abstained throughout (607, 95% CI [552, 663], p = .02). No significant difference was observed for HIV viral suppression. CONCLUSIONS: We identified distinct polysubstance use patterns among PWH with SUD: cannabis/alcohol and opioids with alcohol and other drugs. Changes over time toward fewer substances/no use were associated with lower HIV disease severity based on CD4 count but not based on HIV viral suppression.

Burden of Chronic Obstructive Pulmonary Disease Attributable to Tuberculosis: A Microsimulation Study.

Tuberculosis (TB) is a risk factor for chronic obstructive pulmonary disease (COPD), but COPD is also a predictor of TB. The excess life-years lost to COPD caused by TB can potentially be saved by screening for and treating TB infection. We examined the number of life-years that could be saved by preventing TB and TB-attributable COPD. We compared the observed (no intervention) and counterfactual microsimulation models constructed from observed rates in the Danish National Patient Registry (covering all Danish hospitals between 1995 and 2014). In the Danish population of TB and COPD-naive individuals (n = 5,206,922), 27,783 persons (0.5%) developed TB. Among those who developed TB, 14,438 (52.0%) developed TB with COPD. Preventing TB saved 186,469 life-years overall. The excess number of life-years lost to TB alone was 7.07 years per person, and the additional number of life-years lost among persons who developed COPD after TB was 4.86 years per person. The life-years lost to TB-associated COPD are substantial, even in regions where TB can be expected to be identified and treated promptly. Prevention of TB could prevent a substantial amount of COPD-related morbidity; the benefit of screening and treatment for TB infection is underestimated by considering morbidity from TB alone.

Adverse effects of COVID-19 pandemic on a multicenter randomized controlled trial.

OBJECTIVE: Describe the effects of the COVID-19 pandemic on subject enrollment in a multicenter randomized controlled trial. STUDY DESIGN: We assessed the number of eligible infants approached and consented for enrollment over five separate epochs including baseline, peak pandemic, and gradual but incomplete recovery. RESULT: The pandemic had a major effect on ability to approach parents for consent. Parents approached dropped from 95.4% baseline to 13.1% in the peak pandemic epoch and has not recovered to baseline even in the just-completed post-pandemic epoch (84.9%). Despite the decrease in subjects approached, there was no significant change in the overall consent rate for the study CONCLUSION: The pandemic has significantly limited ability to approach parents of eligible infants for consent, with only partial recovery. Opportunities for interactions of investigators and study coordinators with parents continue to present challenges limiting full recovery.

Racial and Ethnic Disparities in Breastfeeding Continuation Among U.S. Hispanic Mothers: Identification of Mechanisms.

Objective: We examined the extent to which social, maternal, and infant factors and Theory of Planned Behavior (TPB) domains-attitudes, perceived control, and subjective norms-mediate the relationship between maternal race and ethnicity and birth country, and breastfeeding continuation. Materials and Methods: A nationally representative cohort of 2,810 mothers with self-reported race, ethnicity, and birth country was used. Main outcomes included any and exclusive breastfeeding at 2-6 months of infant age. A conceptual framework with the aforementioned mediators of interest was developed. Logistic regression was used to examine main associations, and structural equation modeling was used to identify the extent to which proposed mediators explained the relationship between independent and dependent variables. Results: One thousand two hundred twenty-one mothers were U.S.-born non-Hispanic white (NHW), 432 U.S.-born Hispanic, 329 Mexico-born Hispanic, 107 Central- or South America-born Hispanic, 33 Caribbean-born Hispanic, and 688 U.S.-born non-Hispanic black (NHB). No differences in breastfeeding continuation among U.S.-born NHW and U.S.-born Hispanic mothers were found. In contrast, compared with U.S.-born NHW mothers, Mexico-born (odds ratio [OR] 1.99, 95% confidence interval [CI] 1.46-2.72) and Central- or South America-born (OR 3.42, 95% CI 1.89-6.17) Hispanic mothers had higher odds, and Caribbean-born Hispanic mothers had lower odds (OR 0.45, 95% CI 0.26-0.76) of any breastfeeding. These relationships were mediated by attitudes and subjective norms. Conclusions: Breastfeeding continuation among U.S. Hispanic mothers varied by birth country, highlighting the heterogeneity of breastfeeding populations of Hispanic mothers in the United States. Tailored interventions should strengthen policies supportive of positive attitudes toward and subjective norms around breastfeeding.

Changes in Economic Hardships Arising During the COVID-19 Pandemic: Differences by Nativity and Race.

Hardships in early childhood impact health. Few longitudinal studies have examined pandemic-related hardships among families with young children by race/ethnicity or nativity. We used prospective longitudinal data from 1,165 caregivers of children < 4 years surveyed in English and Spanish face-to-face in 5 urban hospitals 1/2018 to 3/2020 (pre-pandemic) and again by telephone 9/2020 to 3/2021 (during pandemic). Caregivers reported hardships (household food insecurity [HFI], child food insecurity [CFI]), behind on rent [BOR]) and maternal race/ethnicity and nativity. During the pandemic vs pre-pandemic, families with immigrant mothers had greater increases in HFI [aOR = 2.15 (CI 1.49-3.09)] than families with US-born mothers [aOR = 1.44 (CI 1.09-1.90)] and greater increases in BOR [families with immigrant mothers aOR = 4.09 (CI 2.78-6.01) vs. families with US-born mothers aOR = 2.19 (CI 1.68-2.85)]. CFI increases for all groups did not vary by nativity nor race/ethnicity. HFI and BOR increases during COVID were significantly greater in families with Latina mothers and those with immigrant mothers than other groups.

Study Protocol for a Pilot Randomized Trial of a Virtual Occupational Therapy Fall Prevention Intervention for People With HIV and Alcohol Use.

Background: People living with HIV (PLWH) are at risk for falls due to polypharmacy, unhealthy substance (risky alcohol and/or illicit drug) use, low physical activity, and frailty combined with typical age-related physical changes. Fall prevention is needed to reduce the morbidity related to falls and fractures, however, there is a paucity of data on the design of a fall prevention intervention and whether it can be delivered virtually. We describe the protocol of a pilot randomized trial of a virtual occupational therapy fall prevention intervention for people with HIV at high risk for falls and recent alcohol and/or drug use. Method: PLWH will be recruited from the Boston ARCH 4F Cohort study, an observational study of PLWH to examine the impact of alcohol on falls. Trial participants will be randomized to either an occupational therapy-led fall prevention intervention or provided with written education about fall prevention and alcohol use (control). The 10-week fall prevention intervention was based upon results from qualitative interviews with PLWH about falls and will consist of weekly virtual group sessions, home exercises and phone-check-ins, delivered by occupational therapists. The primary outcome measures will be number of groups attended and a participant-completed satisfaction survey. Change in number of falls, alcohol and other drug use, and physical functioning will be examined. Discussion: A virtual occupational therapy fall prevention intervention addresses the emerging concern of fall risk in PLWH and alcohol use. This pilot study will provide preliminary estimates of fall-related outcomes as well as feasibility of study procedures for a larger trial. ClinicalTrialsgov Identifier: NCT04804579. Boston University Protocol Record H-41041.

National Prevalence of Social Determinants of Health Screening Among US Neonatal Care Units.

OBJECTIVES: The extent that universal social determinants of health (SDH) screening in clinical encounters, as recommended by the American Academy of Pediatrics, has been implemented in inpatient pediatric settings is unknown. We aimed to determine the national prevalence and predictors of standardized SDH screening in US level 2 to 4 neonatal care units (NICUs), describe characteristics of SDH screening programs, and ascertain beliefs of clinical leaders about this practice in the NICU setting. METHODS: We randomly selected 100 hospitals with level 2 to 4 NICUs among each of 5 US regions (n = 500) and surveyed clinical leaders from January to November 2021 regarding standardized SDH screening. Responses were weighted for number of level 2 to 4 NICUs in each region and nonresponse. RESULTS: Overall response rate was 34% (28%-40% by region). Twenty-three percent of US level 2 to 4 NICUs reported standardized SDH screening. We found no associations of hospital characteristics, such as region, size, or safety-net status, with implementation of this practice. Existing programs conducted systematic screening early in the hospitalization (84%), primarily led by social workers (92%). We identified practice variation regarding the type of screening tool, but there was substantial overlap among domains incorporated in the screening. Reported barriers to implementation included perceived lack of resources, inadequate referrals, and lack of an inpatient screening tool. CONCLUSIONS: The prolonged neonatal hospitalization provides opportunities to systematically address SDH. Yet, only 23% of US level 2 to 4 NICUs have implemented this practice. To scale-up implementation, quality improvement may support adaptation of screening and referral processes to the NICU context.

Performance of model-based vs. permutation tests in the HEALing (Helping to End Addiction Long-termSM) Communities Study, a covariate-constrained cluster randomized trial.

BACKGROUND: The HEALing (Helping to End Addiction Long-termSM) Communities Study (HCS) is a multi-site parallel group cluster randomized wait-list comparison trial designed to evaluate the effect of the Communities That Heal (CTH) intervention compared to usual care on opioid overdose deaths. Covariate-constrained randomization (CCR) was applied to balance the community-level baseline covariates in the HCS. The purpose of this paper is to evaluate the performance of model-based tests and permutation tests in the HCS setting. We conducted a simulation study to evaluate type I error rates and power for model-based and permutation tests for the multi-site HCS as well as for a subgroup analysis of a single state (Massachusetts). We also investigated whether the maximum degree of imbalance in the CCR design has an impact on the performance of the tests. METHODS: The primary outcome, the number of opioid overdose deaths, is count data assessed at the community level that will be analyzed using a negative binomial regression model. We conducted a simulation study to evaluate the type I error rates and power for 3 tests: (1) Wald-type t-test with small-sample corrected empirical standard error estimates, (2) Wald-type z-test with model-based standard error estimates, and (3) permutation test with test statistics calculated by the difference in average residuals for the two groups. RESULTS: Our simulation results demonstrated that Wald-type t-tests with small-sample corrected empirical standard error estimates from the negative binomial regression model maintained proper type I error. Wald-type z-tests with model-based standard error estimates were anti-conservative. Permutation tests preserved type I error rates if the constrained space was not too small. For all tests, the power was high to detect the hypothesized 40% reduction in opioid overdose deaths for the intervention vs. comparison group both for the overall HCS and the subgroup analysis of Massachusetts (MA). CONCLUSIONS: Based on the results of our simulation study, the Wald-type t-test with small-sample corrected empirical standard error estimates from a negative binomial regression model is a valid and appropriate approach for analyzing cluster-level count data from the HEALing Communities Study. TRIAL REGISTRATION: ClinicalTrials.gov http://www. CLINICALTRIALS: gov ; Identifier: NCT04111939.

Eviction and Household Health and Hardships in Families With Very Young Children.

BACKGROUND: Families with versus without children are at greater eviction risk. Eviction is a perinatal, pediatric, and adult health concern. Most studies evaluate only formal evictions. METHODS: Using cross-sectional surveys of 26 441 caregiver or young child (<48 months) dyads from 2011 to 2019 in emergency departments (EDs) and primary care clinics, we investigated relationships of 5 year history of formal (court-involved) and informal (not court-involved) evictions with caregiver and child health, history of hospitalizations, hospital admission from the ED on the day of the interview, and housing-related and other material hardships. RESULTS: 3.9% of 26 441 caregivers reported 5 year eviction history (eviction), of which 57.0% were formal evictions. After controlling for covariates, we found associations were minimally different between formal versus informal evictions and were, therefore, combined. Compared to no evictions, evictions were associated with 1.43 (95% CI: 1.17-1.73), 1.55 (95% confidence interval [CI]: 1.32-1.82), and 1.24 (95% CI: 1.01-1.53) times greater odds of child fair or poor health, developmental risk, and hospital admission from the ED, respectively, as well as adverse caregiver and hardship outcomes. Adjusting separately for household income and for housing-related hardships in sensitivity analyses did not significantly alter results, although odds ratios were attenuated. Hospital admission from the ED was no longer significant. CONCLUSIONS: Demonstrated associations between eviction and health and hardships support broad initiatives, such as housing-specific policies, income-focused benefits, and social determinants of health screening and community connections in health care settings. Such multifaceted efforts may decrease formal and informal eviction incidence and mitigate potential harmful associations for very young children and their families.