An intersectionality framework for identifying relevant covariates in health equity research.

Introduction: Health equity research uses impact evaluations to estimate the effectiveness of new interventions that aim to mitigate health inequities. Health inequities are influenced by many experiential factors and failure of research to account for such experiential factors and their potential interactions may jeopardize findings and lead to promoted methods that may unintentionally sustain or even worsen the targeted health inequity. Thus, it is imperative that health equity impact evaluations identify and include variables related to the circumstances, conditions, and experiences of the sample being studied in analyses. In this review, we promote intersectionality as a conceptual framework for brainstorming important yet often overlooked covariates in health equity related impact evaluations. Methods: We briefly review and define concepts and terminology relevant to health equity, then detail four domains of experiential factors that often intersect in ways that may obscure findings: Biological, Social, Environmental, and Economic. Results: We provide examples of the framework's application to lupus-related research and examples of covariates used in our own health equity impact evaluations with minority patients who have lupus. Discussion: Applying an intersectionality framework during covariate selection is an important component to actualizing precision prevention. While we do not provide an exhaustive list, our aim is to provide a springboard for brainstorming meaningful covariates for health equity evaluation that may further help unveil sustainable solutions to persisting health inequities.

Feasibility and Utility of a Pilot Peer Education Program to Improve Patient Engagement in Lupus Clinical Trials: Implementation and Evaluation in a Multisite Model Within a Lupus Clinical Trials Network.

OBJECTIVE: To assess outcomes related to Lupus Therapeutics' Patient Advocates for Lupus Studies (LT-PALS), a peer-to-peer lupus clinical trial (LCT) education program designed to improve representation of diverse groups in LCTs. Patients with lupus and clinical trial participation experience were trained as peer educators (PALs) providing trial-agnostic education to trial-naive patients with lupus. METHODS: We used a two-arm, randomized pretest/posttest study design to evaluate outcomes related to LCT participation: knowledge, attitudes, self-efficacy, and intentions to participate in an LCT. Five academic medical centers piloted the program. The intervention group (IG) individually received peer-to-peer education sessions with trained PALs, primarily via telephone; the control group (CG) received a 3-week waiting period. We conducted within/between-group t-tests and multiple linear regressions with posttest scores as dependent variables and participation in LT-PALS as the exposure variable. RESULTS: The sample (n = 136) included 64 IG and 72 CG participants, with 67.7% identifying as Black. At posttest, IG participants had higher knowledge (P < 0.01) scores than the CG participants. Regression models controlling for participant characteristics showed higher IG posttest scores for knowledge (P < 0.001) and intentions (P < 0.05). From pretest to 3-month follow-up, IG self-efficacy scores increased (P < 0.01). About half (46.9%) of IG participants reported engagement with an LCT at 1-year follow-up. Black and Hispanic participants rated higher overall program satisfaction compared with White (P < 0.01) and non-Hispanic (P < 0.05) participants. CONCLUSION: Findings demonstrated feasibility of LT-PALS and showed promise in increasing engagement from groups underrepresented in LCTs.

Sleep troubles in adolescence relate to future initiation of ENDS USE: A longitudinal cohort design using the PATH study waves 4.5-5 (2017-2019).

In a recent study, we demonstrated a relationship between self-reported sleep deprivation and youth susceptibility to initiate electronic nicotine delivery systems (ENDS) use; however, we were hampered by cross-sectional data. This study builds on our previous work by performing secondary analysis using the nationally representative Population Assessment of Tobacco and Health study datasets from wave 4.5 (2017-2018) and wave 5 (2018-2019) among respondents aged 12-17. Using a longitudinal cohort design, we assessed the extent self-reported sleep troubles at wave 4.5 related to transition from never-to-ever ENDS use by wave 5. We assessed youth who reported never having used any type of tobacco previously and who reported not using alcohol or other illicit substances the previous year. We ran four Poisson regression models on the dependent variable never-to-ever ENDS users at wave 5 and self-reported sleep troubles in the past year at wave 4.5. We controlled for demographic and sociographic factors and, in our final model, tobacco availability in home, exposure to ENDS advertising on social media, past year anxiety, depression, body mass index, physical activity, close friends that use ENDS, perceived harm of ENDS, school performance, sensation seeking, and the susceptibility of youth to initiate ENDS. Even when controlling for these factors, sleep troubles at wave 4.5 significantly and positively related to ENDS initiation by wave 5 (Past year sleep trouble: RR = 1.48 95 % CI = [1.14-1.93]). This key and novel finding has important implications for preventing youth ENDS use via protective self-care and social-environmental approaches.

Sleep deprivation and adolescent susceptibility to vaping in the United States.

Sleep deprivation may be a contributing factor to adolescents' willingness to experiment with substance use, including electronic nicotine devices (ENDS). While it is generally accepted that nicotine has a negative overall effect on sleep, no studies have yet explored whether sleep deprivation may contribute to adolescents' initiation of ENDS use. The purpose of this study is to explore whether sleep deprivation is associated with adolescents' self-reported susceptibility to initiating ENDS use in the next month. Respondents were 1,100 adolescents aged 13-17 across the United States who participated in the Vaping Attitudes Youth Perspectives Survey (VAYPS). We used logistic regression to examine cross-sectional associations between self-reported average sleep duration and self-reported likelihood of trying ENDS in the future. Results of the three logistic regression models show that adolescents who reported getting less than six hours of sleep per night were associated with greater odds of reporting any likelihood to try a vape in the next 30 days even when controlling for demographics and potential confounders (<6hrs sleep: OR = 2.63, 95% CI 1.30-5.31). Future research on the association between sleep deprivation and ENDS use among adolescents will benefit from using longitudinal approaches to better understand causality.

Reactions to electronic nicotine delivery system (ENDS) prevention messages: results from qualitative research used to inform FDA's first youth ENDS prevention campaign.

BACKGROUND: Youth e-cigarette use is a major public health concern. Large-scale tobacco prevention campaigns are a proven strategy to prevent tobacco use. There is a gap in understanding what types of e-cigarette prevention messages might be most effective. This study addresses this gap by reporting youth reactions to health messages aimed at preventing e-cigarette use. METHODS: In 2018, twenty-four focus groups, with 159 teens (12-17) at risk for or experimenting with e-cigarettes were conducted in four cities across the USA. During focus groups, youth responded to creative concepts dealing with (1) the addictive nature of e-cigarettes, (2) the fact that e-cigarettes come in flavours, which may encourage youth initiation, and nicotine which may lead to addiction, or (3) that youth who use e-cigarettes are more likely to use cigarettes. Youth also gave feedback to specific facts about harmful and potentially harmful chemicals in e-cigarettes. Transcripts were analysed using thematic analysis. RESULTS: Messages focusing on addiction alone did not resonate with participants. While youth found the idea that e-cigarettes may contain nicotine and can be addictive believable, with many describing personal experiences of addiction, they questioned how bad this really was, comparing addiction to e-cigarettes to things like being addicted to food. Participants wanted more information about negative consequences of vaping. Concepts paired with strong health effects messages resonated with participants. CONCLUSION: These focus groups clarified which e-cigarette prevention messages might be most persuasive to teens. Youth in this study responded favourably to messages stating specific health consequences of e-cigarette use.

The State of Lupus Clinical Trials: Minority Participation Needed.

In the United States, the reported prevalence of lupus is 100,000 to 500,000 patients. Lupus disproportionately affects minority populations, including African Americans and Latinos, and the associated health disparities are substantial. Women are at a higher risk of lupus than men and lupus prevalence is the highest in African Americans and Latinos compared to non-Hispanic whites. African Americans and Latinos also have increased disease symptom severity, experience more lupus-related complications, and have a two- to three-fold mortality rate compared to non-Hispanic Whites. Lupus clinical trials offer opportunities for quality care and can result in new treatment options, but African Americans and Latinos are underrepresented in clinical trials because of substantial patient- and provider-side barriers. In conjunction with the limited knowledge of clinical trials that potential participants may have, the healthcare staff approaching participants have limited time to adequately educate and explain the aspects of clinical trials. Indeed, ninety percent of clinical trials fail to meet their recruitment goals on time, so a multi-faceted approach is necessary to address the issue of low minority participation in clinical trials.

Effects of the above the influence brand on adolescent drug use prevention normative beliefs.

Health brands are based on the relations between individuals and health behaviors and lifestyles. Brands can be measured by the brand equity construct validated in previous studies. The National Youth Anti-Drug Media Campaign brands alternative, non-drug use behaviors as a behavior change strategy. This study goes beyond previous campaign evaluations, which did not include specific brand equity measurements. Using data from a nationally representative media tracking, this study examined the relation between antidrug campaign brand equity and adoption of targeted attitudes, beliefs, and behaviors. Data were gathered before the relaunch of the campaign, and follow-up data collected 3 months later. On the basis of factor analysis, the authors developed a higher order antidrug brand equity factor and regressed campaign outcomes on that factor in multivariable models. The authors observed significant effects of higher brand equity on higher levels of targeted antidrug attitudes and normative beliefs at follow-up. The authors also observed some counterintuitive relations (i.e., less positive attitudes at follow-up). They interpreted these results in light of the changing messages and campaign strategy. The authors conclude that antidrug brand equity is an important construct for understanding campaign effectiveness. The present campaign shows signs of changing targeted antidrug attitudes and beliefs among youth with brand equity.

Gender differences in preschool children's commentary on self and other.

To examine gender differences in commentary about self and others in same- and mixed-gender contexts, the authors analyzed dyadic conversations involving 78 children in 5 preschool facilities. Compared to girls talking to girls, boy talking to boys made more statements with negative connotations for others and less often pointed out self-other similarities. No gender differences were observed in mixed-gender contexts. Compared to boys talking with boys, boys talking with girls spoke more frequently of similarities and abilities. Compared to girls with girls, girls with boys less often spoke descriptively or talked of activities and possessions and more often spoke of conduct, possibly in an effort to manage boys' behavior. Overall, the findings support a social-constructivist or contextual rather than a biological perspective on early gender differences.

Using Promotores Programs to Improve Latino Health Outcomes: Implementation Challenges for Community-based Nonprofit Organizations.

Promotores are community lay health workers, who provide outreach and services to Latinos. Little research on the promotores programs exists and the focus of this article is to identify the challenges faced by community-based nonprofits when implementing promotores programs. To explore this type of program telephone interviews were conducted with ten promotores academic experts and nonprofit executives. The results suggest that implementation challenges fall into three major categories: the lack of standardized information on promotores programs, labor issues, and organizational costs. Future recommendations are made which highlight promotores recruitment and retention strategies, and the development of a clearinghouse of programmatic implementation information for community-based nonprofits.

An empirical assessment of the Above the Influence advertising campaign.

This study evaluated the efficacy of Above the Influence (ATI), a national media-based health persuasion campaign to deter youth drug use. The campaign uses public service anti-drug prevention messages and targets youth between the ages of 14 and 16, a period of heightened susceptibility to peer influences. The evaluation utilized mall intercepts from geographically dispersed regions of the country. Theoretical impetus for the campaign combines elements of the theory of reasoned action (TRA), persuasion theory, and the health belief model. A series of structural equation models were tested with four randomly drawn cross-validation samples (N = 3,000). Findings suggest that awareness of ATI is associated with greater anti-drug beliefs, fewer drug use intentions, and less marijuana use. Congruent with the TRA, changes in beliefs and intentions are intermediate steps linking campaign awareness with behavior. This study provides further evidence of positive campaign effects and may strengthen reliance on mass media health persuasion campaigns as a useful adjunct to other programs targeting youth.

Teens and the misuse of prescription drugs: evidence-based recommendations to curb a growing societal problem.

The misuse of prescription drugs by teens in the United States is a growing public health problem. This article provides a systematic synthesis of multiple strands of literature to recommend effective prevention methods. Using a social-ecological framework, we review the scope of the problem of prescription drug use among teens. Then, we analyze the multiple factors that may influence teen knowledge and attitudes toward prescription drugs and discuss the important challenges related to the construction of effective prevention programs. Finally, we provide recommendations for practice that attempt to overcome these challenges.

A preliminary evaluation of the effects of a science education curriculum on changes in knowledge of drugs in youth.

Drug and alcohol use among youth remains at pervasively high levels, but students are receiving less school-based prevention. Infusing health information into core curricula may be a valuable prevention approach. Therefore, behavior change theory was used to develop a science education curriculum on drugs for fourth- and fifth-grade students, which was then evaluated using a pretest/posttest quasi-experimental design. Exposure to the curriculum was associated with a change in knowledge; other characteristics like grade level also played a role. More positive attitudes toward science at pretest predicted greater knowledge change, and students who knew less at the start showed a greater change in knowledge. Results of this evaluation may support the efficacy of the curriculum and the utility of combining behavior change theory with educational approaches.

Computerized screening of substance abuse problems in a primary care setting: older vs. younger adults.

The purpose of the current study was to examine differences in responses of older adults (age 55 and above) and younger adults (ages 18 to 54) to the Drug Abuse Problem Assessment for Primary Care (DAPA-PC), a computerized drug and alcohol abuse screening instrument developed for primary care settings. Data were collected from a diverse population of 327 adults presenting for care at The George Washington University Medical Faculty Associates clinic in downtown Washington, DC. Results indicated that rates of drug and alcohol abuse were similar in both groups. However, older adults were less likely than younger adults to perceive their drug use as problematic. This finding has serious implications for older adults, who tend to be underrepresented in treatment programs. There is a need for screening seniors and identifying those who may be at risk for substance abuse problems. Differences in responses to alcohol and drug assessments by age should be taken into consideration when designing screening instruments. The results of this study suggest that the DAPA-PC would provide a useful instrument for screening older adults in a primary care setting.

Responses to a drug and alcohol problem assessment for primary care by ethnicity.

Differences in responses by ethnic group to The Drug Abuse Problem Assessment for Primary Care (DAPA-PC) were examined. The DAPA-PC is a self-administered (via computer), internet-based screening instrument with automatic scoring, patient profile for medical reference, and unique motivational messages. Results indicate differences between blacks and whites on responses to several items in these instruments. Differences in drug use were also found between the two ethnic groups in hair/urine results. The screening criteria for the DAPA-PC instrument appear to work for both the groups in this study. Differences in responses to alcohol and drug screening instruments by ethnic group should be taken into consideration when designing screening instruments for alcohol and/or other drug use and these instruments should be adapted for different ethnic groups, when necessary. The results of this study suggest that the DAPA-PC instrument is a useful alcohol and drug abuse screening instrument for both the blacks and whites in a primary care population.