Racial/ethnic and income disparities in neighborhood-level broadband access in 905 US cities, 2017-2021.

OBJECTIVES: Broadband access is an essential social determinant of health, the importance of which was made apparent during the COVID-19 pandemic. We sought to understand disparities in broadband access within cities and identify potential solutions to increase urban access. STUDY DESIGN: This was a descriptive secondary analysis using multi-year cross-sectional survey data. METHODS: Data were obtained from the City Health Dashboard and American Community Survey. We studied broadband access in 905 large US cities, stratifying neighborhood broadband access by neighborhood median household income and racial/ethnic composition. RESULTS: In 2017, 30% of urban households across 905 large US cities did not have access to high-speed broadband internet. After controlling for median household income, broadband access in majority Black and Hispanic neighborhoods was 10-15% lower than in majority White or Asian neighborhoods. Over time, lack of broadband access in urban households decreased from 30% in 2017 to 24% in 2021, but racial and income disparities persisted. CONCLUSIONS: As an emerging social determinant, broadband access impacts health across the life course, affecting students' ability to learn and adults' ability to find and retain jobs. Resolving lack of broadband access remains an urban priority. City policymakers can harness recent infrastructure funding opportunities to reduce broadband access disparities.

The Effects of a Walking Intervention on Gait Parameters in Older Adults Residing in Long-Term Care: A Randomized Controlled Trial.

OBJECTIVES: We examined the effects of a walking intervention in older adults residing in long-term care (LTC) homes on gait velocity (primary outcome), and stride length, cadence and heel-to-heel base of support (secondary outcomes) compared to those in an interpersonal interaction control group and a care-as-usual control group at 16-weeks post-intervention. METHODS: These previously unpublished gait data were collected as part of a larger prospective, randomized, three group study. One hundred and sixty-eight participants residing in 12 LTC homes were randomized into: a) a walking group (n=57) - 1:1 supervised, individualized, progressive, 30 minutes, five times a week walking program for 16 weeks; b) an interpersonal interaction group (n=55) - stationary 1:1 conversation time with research personnel; and, c) a care-as-usual control group (n=56). Gait was assessed at baseline and 16-weeks post-intervention using the GAITRite® computerized system. One-way Analysis of Covariance (ANCOVA), controlling for age, sex, cognitive status and baseline gait parameter (velocity, stride length, cadence, heel-to-heel base of support) was used to examine differences among groups for velocity, stride length, cadence, and heel-to-heel base of support at 16-weeks post-intervention. RESULTS: Ninety-one participants with available data were included in this analysis: walking group (n=31/57, mean age=82.77±6.75 years); interpersonal interaction group (n=31/55, mean age=82.74±9.27 years); care-as-usual control group (n=29/56, mean age=85.40±8.78 years). ANCOVA showed a significant difference in the mean gait velocity at 16-weeks post-intervention [F(2, 84) =6.99, p=0.0006); η2 (95%CI)=0.16 (0.02, 0.27)]. Post hoc comparisons using Sidak test showed that the estimated marginal mean (EMM) for velocity for the walking group [EMM (SE), 0.51m/s (0.03)] was significantly higher compared to the interpersonal interaction group [EMM (SE), 0.38m/s (0.03); t(83)=3.15, p=0.007] and the care-as-usual control group [EMM (SE), 0.38m/s (0.03)]; t(83)=3.32, p=0.004]. No significant difference was observed between groups for stride length, cadence or heel-to-heel base of support. CONCLUSION: LTC residents with limited physical functioning showed significant improvement in gait velocity but not in stride length, cadence or heel-to-heel base of support after a 16-week walking intervention.

Upscaling e-mental health in Europe: a six-country qualitative analysis and policy recommendations from the eMEN project.

E-mental health (eMH) encompasses the use of digital technologies to deliver, support, or enhance mental health services. Despite the growing evidence for the effectiveness of eMH interventions, the process of implementation of eMH solutions in healthcare remains slow throughout Europe. To address this issue, the e-Mental Health Innovation and Transnational Implementation Platform North-West Europe (eMEN) project was initiated to increase the dissemination and quality of eMH services in Europe. In this project, status analyses regarding eMH in the six participating countries (i.e., Belgium, France, Germany, Ireland, The Netherlands, and the UK) were conducted and eight recommendations for eMH were developed. Expert teams from the six participating countries conducted status analyses regarding the uptake of eMH based on a narrative literature review and stakeholder interviews. Based on these status analyses, the eMEN consortium developed eight policy recommendations to further support the implementation of eMH in Europe. The status analyses showed that the participating countries are in different stages of implementing eMH into mental healthcare. Some barriers to implementing eMH were common among countries (e.g., a limited legal and regulatory framework), while others were country-specific (e.g., fragmented, federal policies). The policy recommendations included fostering awareness, creating strong political commitment, and setting reliable standards related to ethics and data security. The eMEN project has provided the initial recommendations to guide political and regulatory processes regarding eMH. Further research is needed to establish well-tailored implementation strategies and to assess the generalizability of the recommendations beyond the countries involved in the eMEN project.

Hypertension Prevalence Jointly Influenced by Acculturation and Gender in US Immigrant Groups.

BACKGROUND: Latinos and Asians in the United States are disproportionately burdened by hypertension, a leading risk factor for cardiovascular disease. Few studies have used multicomponent measures of acculturation to compare cardiovascular risk factors across immigrant-origin groups. Additionally, little is known about how acculturation and gender shape hypertension risk among immigrants. METHODS: We created an acculturation score composed of language use, nativity, and years in the United States and fit separate race/ethnicity log-binomial models examining associations with hypertension prevalence (≥130/80 mm Hg) among Latino (n = 4,267) and Asian (n = 2,142) National Health and Nutrition Examination Survey 2011-2016 participants aged 18+. Joint effect models tested the concept of "intersectionality" between acculturation and gender. RESULTS: Adjusting for age, gender, and socioeconomic position, Latinos and Asians with high acculturation were 25% and 27% more likely to have hypertension, respectively, compared with low acculturation groups. Latino and Asian American men with high levels of acculturation were 74-79% more likely to have hypertension compared with women with low acculturation (adjusted prevalence ratios (aPR) for Latinos = 1.74, 95% confidence interval (CI): 1.49-2.03; aPR for Asians = 1.79, 95% CI: 1.42-2.25). The gradient of increasing hypertension with increasing acculturation was most apparent among Latino men (adjusted risk differences (aRD) = 12.0%, P < 0.001) and Asian women (aRD = 14.0%, P = 0.003) and nonsignificant among Latino women and Asian men when comparing high vs. low acculturation categories. CONCLUSIONS: Our results correspond with prior literature demonstrating increased morbidity among immigrants with increasing acculturation but also suggest differing patterns by race/ethnicity and gender. Future research should explore how migration processes differentially influence hypertension among men and women.

Prevalence and Correlates of Smoking among Low-Income Adults Residing in New York City Public Housing Developments-2015.

To guide targeted cessation and prevention programming, this study assessed smoking prevalence and described sociodemographic, health, and healthcare use characteristics of adult smokers in public housing. Self-reported data were analyzed from a random sample of 1664 residents aged 35 and older in ten New York City public housing developments in East/Central Harlem. Smoking prevalence was 20.8%. Weighted log-binomial models identified to be having Medicaid, not having a personal doctor, and using health clinics for routine care were positively associated with smoking. Smokers without a personal doctor were less likely to receive provider quit advice. While most smokers in these public housing developments had health insurance, a personal doctor, and received provider cessation advice in the last year (72.4%), persistently high smoking rates suggest that such cessation advice may be insufficient. Efforts to eliminate differences in tobacco use should consider place-based smoking cessation interventions that extend cessation support beyond clinical settings.

Longitudinal trends in mental health among ethnic groups in Canada.

INTRODUCTION: Immigration continues to transform the ethnic composition of the Canadian population. We investigated whether longitudinal trends in mental distress vary between seven cultural and ethnic groups and whether mental distress within the same ethnic group varies by demographic (immigrant status, sex, age, marital status, place and length of residence), socio-economic (education, income), social support and lifestyle factors. METHOD: The study population consisted of 14 713 respondents 15 years and older from the first six cycles of the National Population Health Survey (NPHS); 20% reported themselves to be immigrant at Cycle 1, in 1994/1995. The logistic regression model was fitted by modifying a multivariate quasi-likelihood approach, and robust variance estimates were obtained by using balanced repeated replication techniques. RESULTS: Based on the multivariable model and self-reported data, we observed that female respondents were more likely to report moderate/high mental distress than male respondents; younger respondents more than older respondents; single respondents more than those in a relationship; urban-dwellers more than rural-dwellers; less educated respondents more than more educated respondents; current and former smokers more than non-smokers; and those living in a smoking household more than those living in non-smoking households. The relationship between ethnicity and mental distress was modified by immigrant status, sex, social involvement score and education. Confirming other research, we found an inverted U-shaped relationship between length of stay and mental distress: those who had lived in Canada for less than 2 years were less likely to report moderate/high mental distress, while those who had lived in Canada for 2 to 20 years were significantly more likely to report moderate/high mental distress than those who had lived in Canada for more than 20 years. CONCLUSION: There is a need to develop ethnicity-specific mental health programs targeting those with low education attainment and low social involvement. Policies and programs should also target women, the younger age group (15-24 years) and low-income adequacy groups.

Learning from lives together: medical and social work students' experiences of learning from people with disabilities in the community.

The study aims to evaluate an interprofessional community-based learning event, focussing on disability. The learning opportunity was based on the Leicester Model of Interprofessional Education, organised around the experiences and perceptions of service users and their carers. Programme participants were drawn from medicine and social work education in Leicester, UK, bringing together diverse traditions in the care of people with disabilities. Small student groups (3-4 students) worked from one of the eight community rehabilitation hospitals through a programme of contact with people with disabilities in hospital, at home or in other community settings. The evaluation, in March 2005, used a mixed methods approach, incorporating questionnaire surveys, focus group interviews with students and feedback from service users. Responses were collated and analysed using quantitative and qualitative measures. Fifty social work and 100 medical students completed the first combined delivery of the module. The findings indicated that the merging of social work and medical perspectives appear to create some tensions, although overall the student experience was found to be beneficial. Service users (16 responses) valued the process. They were not concerned at the prospect of meeting a number of students at home or elsewhere and were pleased to think of themselves as educators. Problems and obstacles still anticipated include changing the mindset of clinicians and practising social workers to enable them to support students from each other's disciplines in practice learning. The generally positive outcomes highlight that disability focussed joint learning offers a meaningful platform for interprofessional education in a practice environment.

Preparation of educators involved in interprofessional education.

To achieve effective interprofessional learning there must be effective teaching. In this study we analyse the impact of a Masters level two day course designed to prepare teachers for their role(s) in the design development and facilitation of interprofessional student groups. Since its inception the course has run periodically each year attracting over 70 health and social care teachers from academic and practice settings. The evaluation has confirmed the original hypothesis of the course design, that in order to properly facilitate interprofessional education, teachers need tailored professional developmental opportunities. They need to consider both the underpinnings and implications of interprofessionality and the ways in which appropriate pedagogical practice can illuminate and embed truly interprofessional learning.

Early interprofessional interactions: does student age matter?

In this mixed-method evaluation we report on student responses to an introductory interprofessional learning event, accessed by ten professions within six months of commencing their chosen professional curricula. Of 898 students, 754 (84%) completed pre and post course questionnaires, and 81 took part in uni-professional focus groups. Student responses were compared with those of 14 facilitators. Younger students entering straight from school achieved more learning outcomes and were more positive about the learning than older students (e.g., undergraduate medics, range p = 0.001-0.011; graduate medics, range p = 0.001-0.819). Mature entrants valued interprofessional education, but preferred to interact with students of a similar age demanding a more challenging and relevant set of learning resources, sensitive to their prior life experience. Positive and negative stereotyping was differently constructed between younger and older students. The views of facilitators endorsed the lack of engagement of mature learners compared to their younger counterparts. The study highlights the need to consider age when bringing together large numbers of different professions for their first taste of interprofessional education.

Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain.

OBJECTIVE: To determine whether a short course of traditional acupuncture improves longer term outcomes for patients with persistent non-specific low back pain in primary care. DESIGN: Pragmatic, open, randomised controlled trial. SETTING: Three private acupuncture clinics and 18 general practices in York, England. PARTICIPANTS: 241 adults aged 18-65 with non-specific low back pain of 4-52 weeks' duration. INTERVENTIONS: 10 individualised acupuncture treatments from one of six qualified acupuncturists (160 patients) or usual care only (81 patients). MAIN OUTCOME MEASURES: The primary outcome was SF-36 bodily pain, measured at 12 and 24 months. Other outcomes included reported use of analgesics, scores on the Oswestry pain disability index, safety, and patient satisfaction. RESULTS: 39 general practitioners referred 289 patients of whom 241 were randomised. At 12 months average SF-36 pain scores increased by 33.2 to 64.0 in the acupuncture group and by 27.9 to 58.3 in the control group. Adjusting for baseline score and for any clustering by acupuncturist, the estimated intervention effect was 5.6 points (95% confidence interval -0.2 to 11.4) at 12 months (n = 213) and 8.0 points (2.8 to 13.2) at 24 months (n = 182). The magnitude of the difference between the groups was about 10%-15% of the final pain score in the control group. Functional disability was not improved. No serious or life threatening events were reported. CONCLUSIONS: Weak evidence was found of an effect of acupuncture on persistent non-specific low back pain at 12 months, but stronger evidence of a small benefit at 24 months. Referral to a qualified traditional acupuncturist for a short course of treatment seems safe and acceptable to patients with low back pain. TRIAL REGISTRATION: ISRCTN80764175 [controlled-trials.com].

Risk factors associated with default from multidrug-resistant tuberculosis treatment, South Africa, 1999-2001.

SETTING: Multidrug-resistant tuberculosis (MDR-TB) treatment centers in five provinces, South Africa. OBJECTIVES: To estimate the mortality and evaluate risk factors associated with default from MDR-TB treatment. DESIGN: Using registries and a standardized questionnaire, we conducted a case-control study among patients diagnosed and treated for MDR-TB. Cases were defined as patients who began MDR-TB treatment between 1 October 1999 and 30 September 2001 and defaulted from treatment for more than 2 months; controls were defined as patients who began MDR-TB treatment during the same time and were cured, completed or failed. RESULTS: After initial identification and reclassification, 269 cases and 401 controls were confirmed eligible for interview. Further investigation revealed that 74 (27%) cases and 44 (10%) controls had died. Among 96 cases located who consented and were interviewed, 70% had defaulted after receiving at least 6 months of treatment. In a multivariate model, the strongest individual risk factors for default included reporting smoking marijuana or mandrax during treatment, and having an unsatisfactory opinion about the attitude of health care workers. CONCLUSION: Mortality among MDR-TB defaulters was high. Interventions to reduce default from MDR-TB treatment should center on substance abuse treatment, patient education and support and improving provider-patient relationships.

Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain.

OBJECTIVES: To test whether patients with persistent non-specific low back pain, when offered access to traditional acupuncture care alongside conventional primary care, gained more long-term relief from pain than those offered conventional care only, for equal or less cost. Safety and acceptability of acupuncture care to patients, and the heterogeneity of outcomes were also tested. DESIGN: A pragmatic, two parallel group, randomised controlled trial. Patients in the experimental arm were offered the option of referral to the acupuncture service comprising six acupuncturists. The control group received usual care from their general practitioner (GP). Eligible patients were randomised in a ratio of 2:1 to the offer of acupuncture to allow between-acupuncturist effects to be tested. SETTING: Three non-NHS acupuncture clinics, with referrals from 39 GPs working in 16 practices in York, UK. PARTICIPANTS: Patients aged 18-65 years with non-specific low back pain of 4-52 weeks' duration, assessed as suitable for primary care management by their general practitioner. INTERVENTIONS: The trial protocol allowed up to ten individualised acupuncture treatments per patient. The acupuncturist determined the content and the number of treatments according to patient need. MAIN OUTCOME MEASURES: The Short Form 36 (SF-36) Bodily Pain dimension (range 0-100 points), assessed at baseline, and 3, 12 and 24 months. The study was powered to detect a 10-point difference between groups at 12 months post-randomisation. Cost--utility analysis was conducted at 24 months using the EuroQoL 5 Dimensions (EQ-5D) and a preference-based single index measure derived from the SF-36 (SF-6D). Secondary outcomes included the McGill Present Pain Index (PPI), Oswestry Pain Disability Index (ODI), all other SF-36 dimensions, medication use, pain-free months in the past year, worry about back pain, satisfaction with care received, and safety and acceptability of acupuncture care. RESULTS: A total of 159 patients were in the 'acupuncture offer' arm and 80 in the 'usual care' arm. All 159 patients randomised to the offer of acupuncture care chose to receive acupuncture treatment, and received an average of eight acupuncture treatments within the trial. Analysis of covariance, adjusting for baseline score, found an intervention effect of 5.6 points on the SF-36 Pain dimension [95% confidence interval (CI) -1.3 to 12.5] in favour of the acupuncture group at 12 months, and 8 points (95% CI 0.7 to 15.3) at 24 months. No evidence of heterogeneity of effect was found for the different acupuncturists. Patients receiving acupuncture care did not report any serious or life-threatening events. No significant treatment effect was found for any of the SF-36 dimensions other than Pain, or for the PPI or the ODI. Patients receiving acupuncture care reported a significantly greater reduction in worry about their back pain at 12 and 24 months compared with the usual care group. At 24 months, the acupuncture care group was significantly more likely to report 12 months pain free and less likely to report the use of medication for pain relief. The acupuncture service was found to be cost-effective at 24 months; the estimated cost per quality-adjusted (QALY) was 4241 pounds sterling (95% CI 191 pounds sterling to 28,026 pounds sterling) using the SF-6D scoring algorithm based on responses to the SF-36, and 3598 pounds sterling (95% CI 189 pounds sterling to 22,035 pounds sterling) using the EQ-5D health status instrument. The NHS costs were greater in the acupuncture care group than in the usual care group. However, the additional resource use was less than the costs of the acupuncture treatment itself, suggesting that some usual care resource use was offset. CONCLUSIONS: Traditional acupuncture care delivered in a primary care setting was safe and acceptable to patients with non-specific low back pain. Acupuncture care and usual care were both associated with clinically significant improvement at 12- and 24-month follow-up. Acupuncture care was significantly more effective in reducing bodily pain than usual care at 24-month follow-up. No benefits relating to function or disability were identified. GP referral to a service providing traditional acupuncture care offers a cost-effective intervention for reducing low back pain over a 2-year period. Further research is needed to examine many aspects of this treatment including its impact compared with other possible short-term packages of care (such as massage, chiropractic or physiotherapy), various aspects of cost-effectiveness, value to patients and implementation protocols.

Speaking the same language: treatment outcome definitions for multidrug-resistant tuberculosis.

SETTING: Globally it is estimated that 273000 new cases of multidrug-resistant tuberculosis (MDR-TB, resistance to isoniazid and rifampicin) occurred in 2000. To address MDR-TB management in the context of the DOTS strategy, the World Health Organization and partners have been promoting an expanded treatment strategy called DOTS-Plus. However, standard definitions for MDR-TB patient registration and treatment outcomes do not exist. OBJECTIVE: To propose a standardized set of case registration groups and treatment outcome definitions for MDR-TB and procedures for conducting cohort analyses under the DOTS-Plus strategy. DESIGN: Using published definitions for drug-susceptible TB as a guide, a 2-year-long series of meetings, conferences, and correspondence was undertaken to review published literature and country-specific program experience, and to develop international agreement. RESULTS: Definitions were designed for MDR-TB patient categorization, smear and culture conversion, and treatment outcomes (cure, treatment completion, death, default, failure, transfer out). Standards for conducting outcome analyses were developed to ensure comparability between programs. CONCLUSION: Optimal management strategies for MDR-TB have not been evaluated in controlled clinical trials. Standardized definitions and cohort analyses will facilitate assessment and comparison of program performance. These data will contribute to the evidence base to inform decision makers on approaches to MDR-TB control.

Capacity building for international tuberculosis control through operations research training.

SETTING: In resource-poor countries, few tuberculosis (TB) program staff at the national, provincial, and even district levels have the basic analytical and epidemiological skills necessary for collecting and analyzing quality data pertaining to national TB control program (NTP) improvements. This includes setting program priorities, operations planning, and implementing and evaluating program activities. OBJECTIVES: To present a model course for building capacity in basic epidemiology and operations research (OR). DESIGN: A combination of didactic lectures and applied field exercises were used to achieve the main objectives of the 6-day OR course. These were to increase the understanding of quantitative and qualitative research concepts, study design, and analytic methods, and to increase awareness of how these methods apply to the epidemiology and control of TB; and to demonstrate the potential uses of OR in answering practical questions on NTP effectiveness. As a final outcome, course participants develop OR proposals that are funded and later implemented. RESULTS: Since 1997, this OR course has been conducted nine times in five countries; 149 key NTP and laboratory staff have been trained in OR methods, and 44 OR protocols have been completed or are underway. CONCLUSION: This low-cost model course can be adapted to a wide range of public health issues.

Genome sequence of the non-pathogenic strain 15 of pneumonia virus of mice and comparison with the genome of the pathogenic strain J3666.

Pneumonia virus of mice (PVM) is a member of the subfamily Pneumovirinae and is the closest known relative of respiratory syncytial virus. Both viruses cause pneumonia in their respective hosts. Here, the genome sequences of two strains of PVM, non-pathogenic strain 15 and pathogenic strain J3666, are reported. Comparison of the genome sequences revealed 59 nucleotide differences between the two strains, 37 of which were coding. The nucleotide differences were spread throughout the genome, affecting cis-acting regulatory regions and seven of the ten genes. Development of a reverse-genetics system for PVM should allow further elucidation of the functional importance of the genetic differences between the two strains identified here.

Encouraging outcomes in the first year of a TB control demonstration program: Orel Oblast, Russia.

SETTING: Orel, Russia. OBJECTIVE: To evaluate outcomes of tuberculosis (TB) patients treated in the first year of a TB control demonstration project using a revised strategy of directly observed treatment, short-course (DOTS). Standard methods recommended by World Health Organization (WHO) were adapted to include mycobacterial cultures. DESIGN: Retrospective cohort analysis of TB patients diagnosed between October 1999 and September 2000. RESULTS: Among 749 TB patients, 65% had bacteriologic confirmation of pulmonary TB, 31% were diagnosed clinically, and 4% had extra-pulmonary TB. Most (92%) had no previous TB treatment, but 8% were identified as retreatment cases. Of all patients, 41% had new sputum smear-positive TB. No patients were HIV-infected. Multidrug-resistant (MDR) TB levels were 3% among new and 17% among retreatment patients. Among new smear-positive patients, treatment success was 79% (72% cure, 7% completion); remaining outcomes were 8% failure, 3% default, 8% death, and 1% transfer. Success rates for new culture-positive and clinically diagnosed patients were 81% and 91%, respectively. CONCLUSION: Despite historical differences, successful implementation of the revised TB strategy in Russia is possible. Treatment success rates were high, suggesting WHO targets of 85% cure for smear-positive patients is attainable. Obstacles include drug resistance and elevated death rates among smear-positive patients.

Clinical guidelines for the treatment of depressive disorders. VI. Special populations.

BACKGROUND: The Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments partnered to produce clinical guidelines for psychiatrists for the treatment of depressive disorders. METHODS: A standard guidelines development process was followed. Relevant literature was identified using a computerized Medline search supplemented by review of bibliographies. Operational criteria were used to rate the quality of scientific evidence, and the line of treatment recommendations included consensus clinical opinion. This section, "Special Populations," is 1 of 7 articles that were drafted and reviewed by clinicians. Revised drafts underwent national and international expert peer review. RESULTS: This section reports on the prevalence, course, and outcome of depression for specific populations. Psychological, pharmacologic, and other biological treatment options for these populations--children and adolescents, the elderly, women at times of increased risk within the reproductive cycle, and specific ethnocultural groups--are critically evaluated. CONCLUSIONS: Major depressive disorder (MDD) is prevalent across the lifespan. In general, clinical presentations are more similar than different across age, sex, and cultural divides. Although less evidence is available for the efficacy of treatments in these subpopulations than in mid-life patients, comparable rates of response for pharmacotherapies, electroconvulsive therapy (ECT), and, in some cases, evidence-based psychotherapies have been reported.

Injection-related risk behaviors in young urban and suburban injection drug users in Chicago (1997-1999).

We compared injection-related risk practices between urban and suburban injection drug users (IDUs) in a large cross-sectional sample of young IDUs. From 1997 to 1999, we recruited 700 active IDUs aged 18 to 30 years in Chicago and its suburbs. A suburban residence was reported by 38% of participants. Participants were interviewed at four urban locations and screened for HIV and hepatitis C virus antibodies. Receptive sharing of syringes and other paraphernalia by urban and suburban IDUs in the preceding 6 months was compared using univariable and multivariable models. Sharing injection paraphernalia in the total sample was high, with 50% of participants reporting receptive syringe sharing and 70% reporting sharing cotton, cookers, and/or rinse water. After adjusting for demographic characteristics, injection settings, frequency, and duration of injection as well as ease of acquiring new syringes, suburban IDUs were significantly more likely than urban IDUs to share syringes (adjusted odds ratio = 1.7; 95% confidence interval: 1.1-2.5); however, the likelihood of sharing cotton, cookers, or rinse water was roughly equal. Despite overall higher risk profiles among suburban IDUs, HIV and hepatitis C prevalence levels were significantly lower than among urban participants. Current high levels of injection risk behaviors in suburban groups represent a potential for rapid dissemination of infection.