Physician engagement in reproductive health advocacy: findings from a mixed methods evaluation of a leadership and advocacy program.

BACKGROUND: Medical curricula include advocacy competencies, but how much physicians engage in advocacy and what enables this engagement is not well characterized. The authors assessed facilitators and barriers to advocacy identified by physician alumni of a reproductive health advocacy training program. METHODS: The authors present secondary results from a mixed methods program evaluation from 2018 to 2020, using alumni data from a cross-sectional survey (n = 231) and in-depth interviews (IDIs, n = 36). The survey measured engagement in policy, media, professional organization, and medical education advocacy and the value placed on the community fostered by the program (eight questions, Cronbach's alpha = 0.81). The authors estimated the association of community value score with advocacy engagement using multivariable Poisson regression to estimate prevalence ratios and analyzed IDI data inductively. RESULTS: Over one third of alumni were highly engaged in legislative policy (n = 90, 39%), professional organizations (n = 98, 42%), or medical education (n = 89, 39%), with fewer highly active in media-based advocacy (n = 54, 23%) in the year prior to the survey. Survey and IDI data demonstrated that passion, sense of urgency, confidence in skills, and the program's emphasis on different forms of advocacy facilitated engagement in advocacy, while insufficient time, safety concerns, and sense of effort redundancies were barriers. The program community was also an important facilitator, especially for "out loud" efforts and for those working in environments perceived as hostile to abortion care (e.g., alumni in hostile environments with high community value scores were 1.8 times [95% CI 1.3, 2.6] as likely to report medium/high levels of media advocacy compared to those with low scores after adjusting for age, gender, and clinical specialty). CONCLUSION: Physician advocacy training curricula should include both skills- and community-building and identify a full range of forms of advocacy. Community-building is especially important for physician advocacy for reproductive health services such as abortion care.

Identifying determinants of under-five child mortality in northern Togo.

Background: Although global rates of under-five mortality have declined, many low- and middle-income countries (LMICs), including Togo, have not achieved sufficient progress. We aimed to identify the structural and intermediary determinants associated with under-five mortality in northern Togo. Methods: We collected population-representative cross-sectional household surveys adapted from the Demographic Household Survey (DHS) and Multiple Indicator Cluster Survey from women of reproductive age in northern Togo in 2018. The primary outcome was under-five mortality for children born to respondents in the 10-year period prior to the survey. We selected structural and intermediary determinants of health from the World Health Organization Conceptual Framework for Action on the Social Determinants of Health. We estimated associations between determinants and under-five mortality for births in the last 10 years (model 1 and 2) and two years (model 3) using Cox proportional hazards models. Results: Of the 20 121 live births in the last 10 years, 982 (4.80%) children died prior to five years of age. Prior death of a sibling (adjusted hazard ratio (aHR) = 5.02; 95% confidence interval (CI) = 4.23-5.97), maternal ethnicity (i.e. Konkomba, Temberma, Lamba, Losso, or Peul), multiple birth status (aHR = 2.27; 95% CI = 1.78-2.90), maternal age under 25 years (women <19 years: aHR = 2.05; 95% CI = 1.75-2.39; women 20-24 years: aHR = 1.48; 95% CI = 1.29-1.68), lower birth interval (aHR = 1.51; 95% CI = 1.31-1.74), and higher birth order (second or third born: aHR = 1.45; 95% CI = 1.32-1.60; third or later born: aHR = 2.14; 95% CI = 1.74-2.63) were associated with higher hazard of under-five mortality. Female children had lower hazards of under-five mortality (aHR = 0.80; 95% CI = 0.73-0.89). Under-five mortality was also lower for children born in the last two years (n = 4852) whose mothers received any (aHR = 0.48; 95% CI = 0.30-0.78) or high quality (aHR = 0.51; 95% CI = 0.29-0.88) prenatal care. Conclusion: Compared to previous DHS estimates, under-five mortality has decreased in Togo, but remains higher than other LMICs. Prior death of a sibling and several intermediary determinants were associated with a higher risk of mortality, while receipt of prenatal care reduced that risk. These findings have significant implications on reducing disparities related to mortality through strengthening maternal and child health care delivery.

Impact of the Affordable Health Care Act (ACA) on Racial/Ethnic Inequities in Access to and Utilization of Healthcare in New York City.

The Affordable Care Act (ACA) expanded health insurance coverage in the USA, but whether it increased healthcare utilization or reduced racial/ethnic inequities in access to and utilization of care is unclear. We evaluated the ACA impact on health insurance coverage, unmet medical need, and having a personal doctor and whether this impact was modified by racial/ethnic identity among New York City (NYC) residents. We used data from multiple years of the Community Health Survey (2009-2017) and used logistic regression to assess whether having health insurance, unmet medical need, or a personal doctor varied pre- (2009-2012) versus post-ACA (2013-2017), adjusting for age, sex, nativity status, and general health. We assessed effect measure modification by race/ethnicity and stratified if we found significant interaction. We found that health insurance coverage and having a personal doctor increased post-ACA (aOR = 1.44, p < 0.001 and aOR = 1.09, p = 0.024, respectively) while having unmet medical need decreased (aOR = 0.90, p = 0.004). There was little indication of interaction between ACA and race/ethnicity; in stratified models, the ACA had a stronger impact on health insurance coverage for those of other race than all other groups (aOR = 2.16, p = 0.002 versus aOR 1.22-1.54 for white, Black, and Hispanic adults) and a stronger impact on having a personal doctor for Hispanic adults (aOR 1.27, p < 0.001 versus weaker non-significant associations for other groups), with no effect modification for unmet medical need. Thus, it appears that ACA improved healthcare access and utilization but did not have a major impact on reducing racial/ethnic inequities in these outcomes in NYC.

Patient perspectives of using reproductive autonomy to measure quality of care: a qualitative study.

BACKGROUND: Current measures of reproductive health care quality, such as rates of "unintended" pregnancies, neglect to incorporate patients' desires and center their reproductive autonomy. This study explores patients' perspectives on and receptivity to alternative metrics for measuring quality of such care. METHODS: An online research recruitment firm identified eligible participants living in New York, ages 18-45, self-identifying as women, and having visited a primary care provider in the last year. We conducted five virtual focus groups and eight in-depth interviews with participants (N = 30) in 2021. Semi-structured guides queried on ideal clinic interactions when preventing or attempting pregnancy and their perspectives on how to measure the quality of such encounters, including receptivity to using our definition of reproductive autonomy to develop one such metric: "whether the patient got the reproductive health service or counseling that they wanted to get, while having all the information about and access to their options, and not feeling forced into anything." We employed an inductive thematic analysis. RESULTS: Participants wanted care that was non-judgmental, respectful, and responsive to their needs and preferences. For pregnancy prevention, many preferred unbiased information about contraceptive options to help make their own decisions. For pregnancy, many desired comprehensive information and more provider support. There was considerable support for using reproductive autonomy to measure quality of care. CONCLUSIONS: Patients had distinct desires in their preferred approach to discussions about preventing versus attempting pregnancy. Quality of reproductive health care should be measured from the patient's perspective. Given participants' demonstrated support, future research is needed to develop and test a new metric that assesses patients' perceptions of reproductive autonomy during clinical encounters.

Approaches to Research Ethics in Health Research on YouTube: Systematic Review.

BACKGROUND: YouTube has become a popular source of health care information, reaching an estimated 81% of adults in 2021; approximately 35% of adults in the United States have used the internet to self-diagnose a condition. Public health researchers are therefore incorporating YouTube data into their research, but guidelines for best practices around research ethics using social media data, such as YouTube, are unclear. OBJECTIVE: This study aims to describe approaches to research ethics for public health research implemented using YouTube data. METHODS: We implemented a systematic review of articles found in PubMed, SocINDEX, Web of Science, and PsycINFO following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. To be eligible to be included, studies needed to be published in peer-reviewed journals in English between January 1, 2006, and October 31, 2019, and include analyses on publicly available YouTube data on health or public health topics; studies using primary data collection, such as using YouTube for study recruitment, interventions, or dissemination evaluations, were not included. We extracted data on the presence of user identifying information, institutional review board (IRB) review, and informed consent processes, as well as research topic and methodology. RESULTS: This review includes 119 articles from 88 journals. The most common health and public health topics studied were in the categories of chronic diseases (44/119, 37%), mental health and substance use (26/119, 21.8%), and infectious diseases (20/119, 16.8%). The majority (82/119, 68.9%) of articles made no mention of ethical considerations or stated that the study did not meet the definition of human participant research (16/119, 13.4%). Of those that sought IRB review (15/119, 12.6%), 12 out of 15 (80%) were determined to not meet the definition of human participant research and were therefore exempt from IRB review, and 3 out of 15 (20%) received IRB approval. None of the 3 IRB-approved studies contained identifying information; one was explicitly told not to include identifying information by their ethics committee. Only 1 study sought informed consent from YouTube users. Of 119 articles, 33 (27.7%) contained identifying information about content creators or video commenters, one of which attempted to anonymize direct quotes by not including user information. CONCLUSIONS: Given the variation in practice, concrete guidelines on research ethics for social media research are needed, especially around anonymizing and seeking consent when using identifying information. TRIAL REGISTRATION: PROSPERO CRD42020148170; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=148170.

BugSigDB captures patterns of differential abundance across a broad range of host-associated microbial signatures.

The literature of human and other host-associated microbiome studies is expanding rapidly, but systematic comparisons among published results of host-associated microbiome signatures of differential abundance remain difficult. We present BugSigDB, a community-editable database of manually curated microbial signatures from published differential abundance studies accompanied by information on study geography, health outcomes, host body site and experimental, epidemiological and statistical methods using controlled vocabulary. The initial release of the database contains >2,500 manually curated signatures from >600 published studies on three host species, enabling high-throughput analysis of signature similarity, taxon enrichment, co-occurrence and coexclusion and consensus signatures. These data allow assessment of microbiome differential abundance within and across experimental conditions, environments or body sites. Database-wide analysis reveals experimental conditions with the highest level of consistency in signatures reported by independent studies and identifies commonalities among disease-associated signatures, including frequent introgression of oral pathobionts into the gut.

The prevalence of SARS-CoV-2 infection and other public health outcomes during the BA.2/BA.2.12.1 surge, New York City, April-May 2022.

BACKGROUND: Routine case surveillance data for SARS-CoV-2 are incomplete, unrepresentative, missing key variables of interest, and may be increasingly unreliable for timely surge detection and understanding the true burden of infection. METHODS: We conducted a cross-sectional survey of a representative sample of 1030 New York City (NYC) adult residents ≥18 years on May 7-8, 2022. We estimated the prevalence of SARS-CoV-2 infection during the preceding 14-day period. Respondents were asked about SARS-CoV-2 testing, testing outcomes, COVID-like symptoms, and contact with SARS-CoV-2 cases. SARS-CoV-2 prevalence estimates were age- and sex-adjusted to the 2020 U.S. POPULATION: We triangulated survey-based prevalence estimates with contemporaneous official SARS-CoV-2 counts of cases, hospitalizations, and deaths, as well as SARS-CoV-2 wastewater concentrations. RESULTS: We show that 22.1% (95% CI 17.9-26.2%) of respondents had SARS-CoV-2 infection during the two-week study period, corresponding to ~1.5 million adults (95% CI 1.3-1.8 million). The official SARS-CoV-2 case count during the study period is 51,218. Prevalence is estimated at 36.6% (95% CI 28.3-45.8%) among individuals with co-morbidities, 13.7% (95% CI 10.4-17.9%) among those 65+ years, and 15.3% (95% CI 9.6-23.5%) among unvaccinated persons. Among individuals with a SARS-CoV-2 infection, hybrid immunity (history of both vaccination and infection) is 66.2% (95% CI 55.7-76.7%), 44.1% (95% CI 33.0-55.1%) were aware of the antiviral nirmatrelvir/ritonavir, and 15.1% (95% CI 7.1-23.1%) reported receiving it. Hospitalizations, deaths and SARS-CoV-2 virus concentrations in wastewater remained well below that during the BA.1 surge. CONCLUSIONS: Our findings suggest that the true magnitude of NYC's BA.2/BA.2.12.1 surge may have been vastly underestimated by routine case counts and wastewater surveillance. Hybrid immunity, bolstered by the recent BA.1 surge, likely limited the severity of the BA.2/BA.2.12.1 surge.

It is difficult to assess the true prevalence of SARS-CoV-2, the virus that causes COVID-19, due to changes in testing practices and behaviors, including increasing at-home testing and decreasing healthcare provider-based testing. We conducted a population-representative survey in New York City to estimate the prevalence of SARS-CoV-2 during the second Omicron surge in spring 2022. We compared survey-based SARS-CoV-2 prevalence estimates with data on diagnosed cases, hospitalizations, deaths, and SARS-CoV-2 concentration in wastewater. Our survey-based estimates were nearly 30 times higher than official case counts and estimates of immunity among those with active infection were high. Taken together, our results suggest that the magnitude of the second Omicron surge was likely significantly underestimated, and high levels of immunity likely prevented a major surge in hospitalizations/deaths. Our findings might inform future work on COVID-19 surveillance and how to mitigate its spread.

Intrauterine contraceptive discontinuation reasons among female trial participants living with HIV in Cape Town, South Africa: A qualitative analysis.

Introduction: While young women in South Africa may navigate both HIV infection and pregnancy risks, intrauterine contraceptive (IUC) use is low. Though IUCs have low failure rates, concerns exist about whether the IUC is an appropriate method choice for women living with HIV (WLHIV). In this qualitative study, we explore WLHIVs' experiences of using IUC and reasons for discontinuation. Methods: This qualitative study included in-depth interviews (IDIs) with 17 WLHIV who electively discontinued their allocated IUC while participating in a randomized controlled trial comparing the safety of the levonorgestrel intrauterine system (LNG-IUS) and the copper intrauterine device (C-IUD) in Cape Town, South Africa. The transcripts were coded and emergent themes were grouped to examine women's experiences with IUC use and reasons for discontinuation, highlighting experiential differences between the two methods. Results: Women's experience with the allocated IUC related most commonly to bleeding and/or abdominal pain just after insertion. Most C-IUD discontinuers, but only one LNG-IUS discontinuer, complained of pain and/or increased bleeding as the main reason for removal. Three women (two LNG-IUS, one C-IUD) requested removal because they desired pregnancy, while two others discontinued due to fears the IUC was exacerbating non-gynecologic conditions (hypertension, diabetes). Generally, women acknowledged advantages of IUC use and many expressed their desire to continue use if not for the side effects. Conclusions: In the South African context, IUC use for WLHIV should be promoted with specific counseling considerations. Both providers and potential users should receive specific information about potential menstrual-related side effects and countering common misperceptions to enable informed contraceptive decision-making.

The application of intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) to examine birthweight inequities in New York City.

Exploring the intersection of dimensions of social identity is critical for understanding drivers of health inequities. We used multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) to examine the intersection of age, race/ethnicity, education, and nativity status on infant birthweight among singleton births in New York City from 2012 to 2018 (N = 725,875). We found evidence of intersectional effects of various systems of oppression on birthweight inequities and identified U.S.-born Black women as having infants of lower-than-expected birthweights. The MAIHDA approach should be used to identify intersectional causes of health inequities and individuals affected most to develop policies and interventions redressing inequities.

Ethical considerations and methodological uses of Facebook data in public health research: A systematic review.

OBJECTIVE: Since 2016, around seven in 10 adults in the United States (U.S.) actively use Facebook. While much Facebook data is publicly available for research, many users may not understand how their data are being used. We sought to examine to what extent research ethical practices were employed and the research methods being used with Facebook data in public health research. METHODS: We conducted a systematic review (PROSPERO registration CRD42020148170) of social media-based public health research focused on Facebook published in peer-reviewed journals in English between January 1, 2006 and October 31, 2019. We extracted data on ethical practices, methodology, and data analytic approaches. For studies that included verbatim user content, we attempted to locate users/posts within a timed 10-min period. RESULTS: Sixty-one studies met eligibility criteria. Just under half (48%, n = 29) sought IRB approval and six (10%) sought and obtained informed consent from Facebook users. Users' written content appeared in 39 (64%) papers, of which 36 presented verbatim quotes. We were able to locate users/posts within 10 min for half (50%, n = 18) of the 36 studies containing verbatim content. Identifiable posts included content about sensitive health topics. We identified six categories of analytic approaches to using these data: network analysis, utility (i.e., usefulness of Facebook as a tool for surveillance, public health dissemination, or attitudes), associational studies of users' behavior and health outcomes, predictive model development, and two types of content analysis (thematic analysis and sentiment analysis). Associational studies were the most likely to seek IRB review (5/6, 83%), while those of utility (0/4, 0%) and prediction (1/4, 25%) were the least likely to do so. CONCLUSIONS: Stronger guidance on research ethics for using Facebook data, especially the use of personal identifiers, is needed.

The prevalence of SARS-CoV-2 infection and long COVID in U.S. adults during the BA.4/BA.5 surge, June-July 2022.

Due to changes in SARS-CoV-2 testing practices, passive case-based surveillance may be an increasingly unreliable indicator for monitoring the burden of SARS-CoV-2, especially during surges. We conducted a cross-sectional survey of a population-representative sample of 3042 U.S. adults between June 30 and July 2, 2022, during the Omicron BA.4/BA.5 surge. Respondents were asked about SARS-CoV-2 testing and outcomes, COVID-like symptoms, contact with cases, and experience with prolonged COVID-19 symptoms following prior infection. We estimated the weighted age and sex-standardized SARS-CoV-2 prevalence, during the 14-day period preceding the interview. We estimated age and gender adjusted prevalence ratios (aPR) for current SARS-CoV-2 infection using a log-binomial regression model. An estimated 17.3% (95% CI 14.9, 19.8) of respondents had SARS-CoV-2 infection during the two-week study period-equating to 44 million cases as compared to 1.8 million per the CDC during the same time period. SARS-CoV-2 prevalence was higher among those 18-24 years old (aPR 2.2, 95% CI 1.8, 2.7) and among non-Hispanic Black (aPR 1.7, 95% CI 1.4,2.2) and Hispanic adults (aPR 2.4, 95% CI 2.0, 2.9). SARS-CoV-2 prevalence was also higher among those with lower income (aPR 1.9, 95% CI 1.5, 2.3), lower education (aPR 3.7 95% CI 3.0,4.7), and those with comorbidities (aPR 1.6, 95% CI 1.4, 2.0). An estimated 21.5% (95% CI 18.2, 24.7) of respondents with a SARS-CoV-2 infection >4 weeks prior reported long COVID symptoms. The inequitable distribution of SARS-CoV-2 prevalence during the BA.4/BA.5 surge will likely drive inequities in the future burden of long COVID.

First-trimester surgical abortion practice in Canada in 2012.

OBJECTIVE: To evaluate practices among first-trimester surgical abortion facilities and providers in Canada in 2012 and examine the characteristics of the surgical abortion work force. DESIGN: Self-administered paper or electronic survey adapted from a survey previously fielded in the United States. SETTING: Canada. PARTICIPANTS: Facility administrators and physicians. MAIN OUTCOMES MEASURES: Descriptive statistics on reported first-trimester surgical abortion practice and provider demographic characteristics. RESULTS: Eighty-three percent of identified facilities (78 of 94) and 178 physicians responded. Of the respondents, 99% of facilities and 96% of physicians provided first-trimester surgical abortions. Responding facilities provided 68,154 first-trimester surgical abortions in 2012. This represented 96% of their reported total (combined medical and surgical) first-trimester abortions. More than half (55%) of responding facilities were community based, while 45% were hospital affiliated. Most physician providers were female (68%) and were family doctors (59%). Preoperatively, 96% of physicians routinely used ultrasound and 89% gave perioperative antibiotics. Almost half (48%) used manual vacuum aspiration, but less than 35% did so beyond 9 weeks after the last menstrual period. At most facilities, most procedures were performed under combined local anesthesia and intravenous sedation (73%); only 7% indicated deep sedation or general anesthesia were used exclusively. Postoperatively, 81% of physicians performed immediate tissue examination and 96% offered postabortion contraception on the same day as the abortion. Other assessed outcomes included medication regimens and cervical preparation, with a high degree of consistency among facilities and physicians. CONCLUSION: First-trimester surgical abortion providers are mostly family physicians and most are female. Practices across Canada were mostly uniform and followed evidence-based guidelines. Uptake of the most recent Canadian practice guidelines may help further standardize patient care and improve routine perioperative antibiotic use and immediate tissue examination.

The Epidemiology of Long Coronavirus Disease in US Adults.

BACKGROUND: We estimated the prevalence of long COVID and impact on daily living among a representative sample of adults in the United States. METHODS: We conducted a population-representative survey, 30 June-2 July 2022, of a random sample of 3042 US adults aged 18 years or older and weighted to the 2020 US population. Using questions developed by the UK's Office of National Statistics, we estimated the prevalence of long COVID, by sociodemographics, adjusting for gender and age. RESULTS: An estimated 7.3% (95% confidence interval: 6.1-8.5%) of all respondents reported long COVID, corresponding to approximately 18 828 696 adults. One-quarter (25.3% [18.2-32.4%]) of respondents with long COVID reported their day-to-day activities were impacted "a lot" and 28.9% had severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection more than 12 months ago. The prevalence of long COVID was higher among respondents who were female (adjusted prevalence ratio [aPR]: 1.84 [1.40-2.42]), had comorbidities (aPR: 1.55 [1.19-2.00]), or were not (vs were) boosted (aPR: 1.67 [1.19-2.34]) or not vaccinated (vs boosted) (aPR: 1.41 [1.05-1.91]). CONCLUSIONS: We observed a high burden of long COVID, substantial variability in prevalence of SARS-CoV-2, and risk factors unique from SARS-CoV-2 risk, suggesting areas for future research. Population-based surveys are an important surveillance tool and supplement to ongoing efforts to monitor long COVID.

"I totally didn't need to be there in person": New York women's preferences for telehealth consultations for sexual and reproductive healthcare in primary care.

BACKGROUND: Expanding telehealth in the United States during the COVID-19 pandemic supported patients with needed sexual and reproductive healthcare (SRH) for continuity of care and reproductive autonomy. While telehealth for SRH is feasible and acceptable, studies have not explored patient preferences towards telehealth SRH from primary care settings. OBJECTIVE: We explore New York women's preferences for telehealth SRH in primary care. METHODS: In 2021, we conducted 5 focus groups and 8 interviews with New York women of reproductive age who had a consultation with a primary care provider in the last year as part of a larger study on assessing SRH quality in primary care. We queried on experiences with telehealth for SRH and perceptions of measuring SRH quality in primary care telehealth consultations. We employed reflexive thematic analysis. RESULTS: We recruited 30 participants. They preferred telehealth for "basic" SRH conversations, such as contraceptive counselling, and desired in-person consultations for "complex" topics, like pregnancy and preconception, especially if nulliparous. Telehealth benefits included convenience, simplicity of some SRH needs, and alleviating power dynamics in patient-provider relationships. Challenges included lack of one-on-one connection, seriousness of pregnancy discussions, privacy, and internet access. Measuring quality of telehealth SRH should include fostering positive and engaging environments. CONCLUSION: Participants find telehealth SRH in primary care preferable, underscoring the importance of offering and expanding this care. As telehealth SRH expands, providers should strengthen quality by building rapport to facilitate conversations on "serious" topics and their ability to help patients remotely.

The expansion of phone- and video-based consultations in the United States for sexual and reproductive healthcare (SRH) during the COVID-19 pandemic supported patients with needed continuity of care, while minimizing virus exposure. As COVID-19 becomes endemic, medical organizations and providers recommend sustaining and expanding telehealth for SRH and other primary care needs. No studies to date have explored patient acceptability of telehealth for SRH services broadly in primary care settings. This brief report explores preferences for telehealth for SRH in primary care among New York women of reproductive age through focus groups and interviews. Overall, participants preferred telehealth for "basic" SRH conversations, such as contraceptive options, and in-person consultations for more "complex" topics, like pregnancy and preconception. Benefits of telehealth services included convenience, simplicity of some SRH needs, and being able to minimize uncomfortable power dynamics in the patient­provider relationship. Challenges included the lack of one-on-one connection with a provider, the perceived seriousness of pregnancy-related conversations, privacy, and internet access concerns. Patients find telehealth for SRH in primary care preferable, especially for simple SRH conversations, which suggests the importance of continuing to offer services in this manner.

Ethical and Methodological Considerations of Twitter Data for Public Health Research: Systematic Review.

BACKGROUND: Much research is being carried out using publicly available Twitter data in the field of public health, but the types of research questions that these data are being used to answer and the extent to which these projects require ethical oversight are not clear. OBJECTIVE: This review describes the current state of public health research using Twitter data in terms of methods and research questions, geographic focus, and ethical considerations including obtaining informed consent from Twitter handlers. METHODS: We implemented a systematic review, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, of articles published between January 2006 and October 31, 2019, using Twitter data in secondary analyses for public health research, which were found using standardized search criteria on SocINDEX, PsycINFO, and PubMed. Studies were excluded when using Twitter for primary data collection, such as for study recruitment or as part of a dissemination intervention. RESULTS: We identified 367 articles that met eligibility criteria. Infectious disease (n=80, 22%) and substance use (n=66, 18%) were the most common topics for these studies, and sentiment mining (n=227, 62%), surveillance (n=224, 61%), and thematic exploration (n=217, 59%) were the most common methodologies employed. Approximately one-third of articles had a global or worldwide geographic focus; another one-third focused on the United States. The majority (n=222, 60%) of articles used a native Twitter application programming interface, and a significant amount of the remainder (n=102, 28%) used a third-party application programming interface. Only one-third (n=119, 32%) of studies sought ethical approval from an institutional review board, while 17% of them (n=62) included identifying information on Twitter users or tweets and 36% of them (n=131) attempted to anonymize identifiers. Most studies (n=272, 79%) included a discussion on the validity of the measures and reliability of coding (70% for interreliability of human coding and 70% for computer algorithm checks), but less attention was paid to the sampling frame, and what underlying population the sample represented. CONCLUSIONS: Twitter data may be useful in public health research, given its access to publicly available information. However, studies should exercise greater caution in considering the data sources, accession method, and external validity of the sampling frame. Further, an ethical framework is necessary to help guide future research in this area, especially when individual, identifiable Twitter users and tweets are shared and discussed. TRIAL REGISTRATION: PROSPERO CRD42020148170; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=148170.

Knowledge, Attitudes, and Practices towards PrEP from Cisgender Men and Transgender Women Who Have Sex with Men in the Largest Suburban HIV Epidemic.

We conducted a cross-sectional web-based study to assess attitudes and experiences with HIV pre-exposure prophylaxis (PrEP) amongst a multiracial cohort of gay, bisexual, and other men who have sex with men (MSM) and transgender women in Long Island, New York. Participants were recruited through clinical providers and community-based organizations. The survey assessed knowledge and attitudes toward PrEP and factors that facilitate willingness to take it. Of the 189 respondents, most participants were Latinx/Hispanic (57.1%; n = 105), gay-identifying (81.2%; n = 151), and cisgender men (88.7%; n = 165). One in five participants completed high school or lower (19.4%; n = 36). Among those who had never used PrEP (53.4%; n = 101), nearly all participants were willing to use it if it were free or covered as part of their insurance (89.4%; n = 84). The most common barriers to not using PrEP was not knowing where to obtain it (68.3%; n = 69), concerns about side effects (42.1%; n = 35), and concerns about affordability (38.5%; n = 25). This study discusses specific nuances to the suburbs, including cultural norms and structural barriers that should be incorporated in health promotion initiatives in addressing these factors.

Food insecurity associated with educational disruptions during the COVID-19 pandemic for college students and the role of anxiety and depression.

Objective: To test the association between food insecurity and educational disruptions from the COVID-19 pandemic and the role of anxiety or depression in mediating this association. Participants: Representative sample of 2,282 City University of New York students. Methods: Using an April 2020 online survey, we estimated adjusted prevalence ratios (aPR) for educational outcomes based on food insecurity status, adjusting for age, sex, race/ethnicity, and degree level with weighted Poisson regressions with robust standard errors. Results: Prevalence of decreased ability to do schoolwork was greater in those with moderate (aPR = 1.12, 95% CIs 1.02, 1.23) and high (aPR = 1.18, 95% CIs 1.08, 1.2) levels of food insecurity compared to food-secure students. Results were similar for dropping/withdrawing from classes and expecting delays or uncertainty around graduation. Anxiety and depression mediated the relationship between food insecurity and educational outcomes. Conclusion: Findings emphasize the urgency of expanded food assistance and mental health services for college students.

Stakeholder perspectives in New York State on reproductive health and pregnancy intention screening in primary care: A qualitative study.

OBJECTIVE: To assess New York State stakeholders' perspectives regarding providing reproductive health services in primary care settings, including asking patients about pregnancy intentions and providing long-acting reversible contraception (LARC). STUDY DESIGN: We conducted semistructured key-informant interviews (n = 22) with stakeholders representing diverse sectors, including primary care (family medicine) and specialty (obstetrician/gynecologist) physicians, health educators/promoters, advocates, and public health/health care professionals. Grounded theory methodology informed sampling and thematic analysis within and across sectors. RESULTS: Key informants across sectors supported integrating reproductive health services into primary care. Pregnancy intention screening was considered appropriate yet required improved measures. Such screening was viewed as fostering childbearing discussions and counseling for contraception/preconception health that could benefit patients while also requiring attention to concerns from the patient (e.g., potential for coercion, access barriers) and health care systems (e.g., buy-in, training) contexts. Three themes related to LARC included provider bias, knowledge and training, counseling and patient education, and logistics/financial situation, which were differentially emphasized by stakeholder sector; providers expressed greater concern regarding training, bias, and logistical considerations, whereas health educators and advocates focused on patient education and autonomous decision-making. Similarly, awareness of reproductive justice principles varied by sector. CONCLUSION: There is consensus among informants from the 5 sectors for expanding reproductive health services in primary care. This will require reproductive health-related training for providers, organizational buy-in, and system protocol changes, including unbiased contraceptive counseling of all methods, specifically balancing discussion of LARC effectiveness with information regarding side effects. Incorporating reproductive justice principles may increase informed patient decision-making and reproductive autonomy. IMPLICATIONS: Expanding reproductive health services in primary care requires provider training and protocols for patient-centered care, including unbiased provision of all contraceptive options. The reproductive justice framework offers the possibility of addressing diverse stakeholders' concerns for both preconception and contraceptive care with patient decision-making at the forefront.

The primacy of meeting public university students' essential needs in the wake of COVID-19: An overdue higher education priority.

OBJECTIVES: We investigated the holistic experiences of university students during the pandemic. PARTICIPANTS: Thirty-eight students in a public university system in New York City (NYC) purposively selected from neighborhoods highly affected by the pandemic based on level of self-reported impact. METHODS: We conducted virtual in-depth interviews from May to August 2021 and analyzed data using thematic coding and constant comparison techniques informed by grounded theory. RESULTS: Financial and social support systems, such as governmental and school resources, were critical to addressing essential needs and allowing students to persist. For those whose essential needs were met, faculty members' flexibility and students' experience with online learning were central to their academic success. CONCLUSIONS: Institutions of higher education should strengthen financial and social support systems to meet students' essential needs. Academic policies to bolster online pedagogy and faculty's flexibility can facilitate student retention and completion.