Use of ultrasound and MRI to stage the axilla for breast cancer before and after neoadjuvant chemotherapy prior to targeted sentinel lymphadenectomy.

PURPOSE: Prior data from this Center demonstrated that for patients who had biopsy-proven axillary metastases, were ycN0 after neoadjuvant chemotherapy (NAC), and had a wire-directed (targeted) sentinel lymphadenectomy (WD-SLND), 60% were node negative. The hypothesis of this study was that results of axillary imaging either before or after NAC would be predictive of final pathologic status after WD-SLND. METHODS: For patients treated with NAC between 2015 and 2023, ultrasound and MRI images of the axilla were retrospectively reviewed by radiologists specializing in breast imaging, who were blinded to the surgical and pathology results. RESULTS: Of 113 patients who fit the clinical criteria, 66 (58%) were ypN0 at WD-SLND and 34 (30%) had a pathologic complete response to NAC. There was no correlation between the number of abnormal lymph nodes on pre-NAC ultrasound or MRI imaging and the final pathologic status of the lymph nodes. The positive predictive value (PPV) of abnormal post-NAC axillary imaging was 48% for ultrasound and 53% for MRI. The negative predictive value (NPV) for normal post-NAC axillary imaging was 67% for ultrasound and 68% for MRI. CONCLUSION: The results of axillary imaging were not adequate to identify lymph nodes after NAC that were persistently pathologically node positive or those which had become pathologically node negative.

Latent Class Analysis of Online Platforms for Partner-Seeking and Sexual Behaviors Among Men Who Have Sex with Men from Central Kentucky.

Little is known whether engagement in sexual behaviors associated with potential HIV risks differs by subgroups of men who have sex with men (MSM), who are distinct regarding patterns of use of online tools for partner-seeking. Using latent class analysis, we revealed four classes of app-using MSM (n = 181, 18-34 y.o., 82.4% identified as White and non-Hispanic) residing in Central Kentucky: the Grindr/Tinder class; the Poly App Use class of MSM-oriented apps; the General Social Media class, and the Bumble class. Unadjusted penalized logistic regressions showed associations of the Poly App Use class with increased numbers of receptive anal sex partners and reporting condomless receptive anal sex. Adjusting for other covariates, poly app users versus others were more likely to be older (25-34 vs. 18-24, AOR = 3.81, 95%CI = 1.70-9.03), to report past six-month illicit drug use (AOR = 2.93, 95%CI = 1.25-7.43) and to have ever used pre-exposure prophylaxis (AOR = 2.79, 95%CI = 1.10-7.12). Poly app users had behavior profiles associated with an elevated HIV risk and also reported HIV-related protective behaviors likely indicating increased risk awareness among this class. Our findings warrant differentiation of behavior profiles by patterns of app use and suggest not to generalize sexual behaviors associated with potential HIV risks to all app-using MSM.

RESUMEN: Poco se sabe si la participación en comportamientos sexuales asociados con riesgos potenciales de VIH difiere según distintos subgrupos de hombres que tienen sexo con hombres (HSH) en base a patrones en el uso de herramientas online para la búsqueda de pareja. Mediante el análisis de clases latentes, identificamos cuatro clases de HSH que usan aplicaciones (n = 181, 18­34 años, 82.4% identificados como Blancos y no-Hispanos) y residen en Kentucky Central: la clase Grindr/Tinder, la clase Poly App Use de aplicaciones orientadas a HSH, la clase General Social Media y la clase Bumble. Las regresiones logísticas penalizadas no ajustadas mostraron asociaciones de la clase Poly App Use con un alza en el número de parejas receptivas en relaciones sexuales anales y con reportes de sexo anal receptivo sin condón. Al ajustar por otras covariables, los miembros de la clase Poly App Use, con respecto a las otras clases, tuvieron más probabilidades de ser mayores (25­34 vs. 18­24, ORA = 3,81; IC95%=1,70 − 9,03), de informar el uso de drogas ilícitas en los últimos 6 meses (ORA = 2,93; IC95%=1,25 − 7,43) y haber utilizado alguna vez profilaxis-preexposición (ORA = 2,79; IC95%=1,10 − 7,12). Así mismo, los miembros de esta clase tuvieron perfiles de comportamiento asociado con el riesgo elevado de VIH y también informaron comportamientos de protección relacionados con el VIH que probablemente indican una mayor conciencia del riesgo entre ellos. Nuestros hallazgos justifican la diferenciación de perfiles de comportamiento en base a patrones de uso de aplicaciones y sugieren no generalizar los comportamientos sexuales asociados con riesgos potenciales de VIH a todos los HSH que las usan.

Houselessness and syringe service program utilization among people who inject drugs in eight rural areas across the USA: a cross-sectional analysis.

BACKGROUND: Research conducted in urban areas has highlighted the impact of housing instability on people who inject drugs (PWID), revealing that it exacerbates vulnerability to drug-related harms and impedes syringe service program (SSP) use. However, few studies have explored the effects of houselessness on SSP use among rural PWID. This study examines the relationship between houselessness and SSP utilization among PWID in eight rural areas across 10 states. METHODS: PWID were recruited using respondent-driven sampling for a cross-sectional survey that queried self-reported drug use and SSP utilization in the prior 30 days, houselessness in the prior 6 months and sociodemographic characteristics. Using binomial logistic regression, we examined the relationship between experiencing houselessness and any SSP use. To assess the relationship between houselessness and the frequency of SSP use, we conducted multinomial logistic regression analyses among participants reporting any past 30-day SSP use. RESULTS: Among 2394 rural PWID, 56.5% had experienced houselessness in the prior 6 months, and 43.5% reported past 30-day SSP use. PWID who had experienced houselessness were more likely to report using an SSP compared to their housed counterparts (adjusted odds ratio [aOR] = 1.24 [95% confidence intervals [CI] 1.01, 1.52]). Among those who had used an SSP at least once (n = 972), those who experienced houselessness were just as likely to report SSP use two (aOR = 0.90 [95% CI 0.60, 1.36]) and three times (aOR = 1.18 [95% CI 0.77, 1.98]) compared to once. However, they were less likely to visit an SSP four or more times compared to once in the prior 30 days (aOR = 0.59 [95% CI 0.40, 0.85]). CONCLUSION: This study provides evidence that rural PWID who experience houselessness utilize SSPs at similar or higher rates as their housed counterparts. However, housing instability may pose barriers to more frequent SSP use. These findings are significant as people who experience houselessness are at increased risk for drug-related harms and encounter additional challenges when attempting to access SSPs.

Measurement in the study of human exposure to animal feces: A systematic review and audit.

BACKGROUND: Human exposure to animal feces is increasingly recognized as an important transmission route of enteric pathogens. Yet, there are no consistent or standardized approaches to measurement of this exposure, limiting assessment of the human health effects and scope of the issue. OBJECTIVE: To inform and improve approaches to the measurement of human exposure to animal feces, we audited existing measurement in low- and middle-income countries. METHODS: We systematically searched peer-reviewed and gray literature databases for studies with quantitative measures of human exposure to animal feces and we classified measures in two ways. First, using a novel conceptual model, we categorized measures into three 'Exposure Components' identified a priori (i.e., Animal, Environmental, Human Behavioral); one additional Component (Evidence of Exposure) inductively emerged. Second, using the exposure science conceptual framework, we determined where measures fell along the source-to-outcome continuum. RESULTS: We identified 1,428 measures across 184 included studies. Although studies overwhelmingly included more than one single-item measure, the majority only captured one Exposure Component. For example, many studies used several single-item measures to capture the same attribute for different animals, all of which were classified as the same Component. Most measures captured information about the source (e.g. animal presence) and contaminant (e.g. animal-sourced pathogens), which are most distal from exposure on the source-to-outcome continuum. DISCUSSION: We found that measurement of human exposure to animal feces is diverse and largely distal from exposure. To facilitate better assessment of the human health effects of exposure and scope of the issue, rigorous and consistent measures are needed. We recommend a list of key factors from the Animal, Environmental, and Human Behavioral Exposure Components to measure. We also propose using the exposure science conceptual framework to identify proximal measurement approaches.

Online Partner Seeking and Sexual Behaviors Among Men Who Have Sex With Men From Small and Midsized Towns: Cross-sectional Study.

BACKGROUND: Men who have sex with men (MSM) residing outside of large urban areas are underrepresented in research on online partner seeking and sexual behaviors related to transmission of HIV. OBJECTIVE: We aimed to determine associations between the use of the internet or social networking apps (online tools) to meet partners for sex, dating, or for both purposes (online partner seeking) and sexual behaviors among MSM residing in small and midsized towns in Kentucky, United States. METHODS: Using peer-referral sampling and online self-administered questionnaires, data were collected from 252 men, aged 18 to 34 years, who had recently (past 6 months) engaged in anal sex with another man and resided in Central Kentucky. Using multivariable logistic regression models, we assessed associations of online partner seeking and HIV-related sexual behaviors. RESULTS: Most (181/252, 71.8%) of the participants reported using online tools for partner seeking. Of these 181 respondents, 166 (91.7%) had used online tools to meet partners for sex (n=45, 27.1% for sex only; and n=121, 72.9% for sex and dating) and 136 (75.1%) had used online tools to meet partners for dating (n=15, 11% for dating only; and n=121, 89% for sex and dating). Adjusted analyses revealed that MSM who had engaged in condomless insertive and receptive anal intercourse were less likely to report online partner seeking (adjusted odds ratio [aOR] 0.22, 95% CI 0.07-0.68; P=.009 and aOR 0.25, 95% CI 0.10-0.66; P=.005, respectively). Increased number of insertive and receptive anal sex partners and substance use before or during sex were associated with higher odds of online partner seeking (aOR 1.31, 95% CI 1.11-1.55; P=.001; aOR 1.20, 95% CI 1.05-1.39; P=.008; and aOR 2.50, 95% CI 1.41-4.44; P=.002, respectively). CONCLUSIONS: Among MSM who reside outside of large urban areas and practice online partner seeking, HIV risk-reduction interventions should address safer sex practices, including the risks for HIV transmission associated with alcohol or drug use before or during sex. MSM who do not practice online partner seeking are in need of continued outreach to reduce condomless anal sex.

Capacity for sustainment of recently established syringe service programs in Appalachian Kentucky: The central role of staff champions.

INTRODUCTION: Ensuring adequate harm reduction infrastructure in rural areas is imperative, as drug-related epidemics expand into them. Here, we explore the capacity for sustainment of syringe service programs (SSP) in Appalachian Kentucky. METHODS: We interviewed all staff (n = 16) of all SSPs (n = 7) in two Kentucky health districts in 2018-2019 using semi-structured one-on-one qualitative interviews; local departments of health (DOH) operated the SSPs. Interview domains encompassed: (i) SSP establishment; (ii) day-to-day operations, participation and health impacts; (iii) perceived prospects for sustainment; and (iv) perceived influences on #i-#iii. We analysed verbatim transcripts using thematic analytic methods; Schell's 'capacity for sustainment' constructs were treated as sensitising concepts during the analysis. RESULTS: Most community members, law enforcement and DOH staff opposed SSPs before they opened, because of stigma and concerns about enabling and needlestick injuries; DOH staff also opposed SSPs because they believed they lacked the capacity to operate them. Training, technical assistance, visible evidence of the programs' public health impact and contact with SSP participants transformed DOH staff into program champions. As champions, SSP staff developed programs that had strong capacity for sustainment, as defined by Schell (e.g. visible public health impact, stable funding, political support). Staff reported that the SSPs had high prospects for sustainment. DISCUSSION AND CONCLUSION: As in SSPs that opened in cities decades ago, staff in emerging SSPs in these rural areas appear to have become crucial champions for these controversial programs, and may serve as vital resources for expanding harm reduction programming more broadly in these underserved areas.

A qualitative study on pharmacy policies toward over-the-counter syringe sales in a rural epicenter of US drug-related epidemics.

BACKGROUND: Expanding access to sterile syringes in rural areas is vital, as injection-related epidemics expand beyond metropolitan areas globally. While pharmacies have potential to be an easily accessible source of sterile syringes, research in cities has identified moral, legal and ethical barriers that preclude over-the-counter (OTC) sales to people who inject drugs (PWID). The current study builds on prior urban-based research by elucidating (1) pharmacy OTC policies and (2) pharmacists' rationale for, and barriers and facilitators to, OTC syringe sales in a US rural area hard hit by drug-related epidemics. METHODS: We conducted 14 semi-structured interviews with pharmacists recruited from two Eastern Kentucky health districts. Interview domains included experiences with, and attitudes toward, selling OTC syringes to PWID. Constructivist grounded theory methods were used to analyze verbatim transcripts. RESULTS: Most pharmacists operated "restrictive OTC" pharmacies (n = 8), where patients were required to have a prescription or proof of medical need to purchase a syringe. The remainder (n = 6) operated "open OTC" pharmacies, which allowed OTC syringe sales to most patients. Both groups believed their pharmacy policies protected their community and pharmacy from further drug-related harm, but diverging policies emerged because of stigma toward PWID, perceptions of Kentucky law, and belief OTC syringe sales were harmful rather than protective to the community. CONCLUSION: Our results suggest that restrictive OTC pharmacy policies are rooted in stigmatizing views of PWID. Anti-stigma education about substance use disorder (SUD), human immunodeficiency virus (HIV), and Hepatitis C (HCV) is likely needed to truly shift restrictive pharmacy policy.

Factors that influence enrollment in syringe services programs in rural areas: a qualitative study among program clients in Appalachian Kentucky.

BACKGROUND: Enrolling sufficient number of people who inject drugs (PWID) into syringe services programs (SSP) is important to curtail outbreaks of drug-related harms. Still, little is known about barriers and facilitators to SSP enrollment in rural areas with no history of such programs. This study's purpose was to develop a grounded theory of the role of the risk environment and individual characteristics of PWID in shaping SSP enrollment in rural Kentucky. METHODS: We conducted one-on-one semi-structured interviews with 41 clients of 5 SSPs that were established in rural counties in Appalachian Kentucky in 2017-2018. Interviews covered PWID needs, the process of becoming aware of SSPs, and barriers and facilitators to SSP enrollment. Applying constructivist grounded theory methods and guided by the Intersectional Risk Environment Framework (IREF), we applied open, axial and selective coding to develop the grounded theory. RESULTS: Stigma, a feature of IREF's meso-level social domain, is the main factor hampering SSP enrollment. PWID hesitated to visit SSPs because of internalized stigma and because of anticipated stigma from police, friends, family and healthcare providers. Fear of stigma was often mitigated or amplified by a constellation of meso-level environmental factors related to healthcare (e.g., SSPs) and social (PWID networks) domains and by PWID's individual characteristics. SSPs mitigated stigma as a barrier to enrollment by providing low threshold services in a friendly atmosphere, and by offering their clients program IDs to protect them from paraphernalia charges. SSP clients spread positive information about the program within PWID networks and helped their hesitant peers to enroll by accompanying them to SSPs. Individual characteristics, including child custody, employment or high social status, made certain PWID more susceptible to drug-related stigma and hence more likely to delay SSP enrollment. CONCLUSIONS: Features of the social and healthcare environments operating at the meso-level, as well as PWID's individual characteristics, appear to enhance or mitigate the effect of stigma as a barrier to SSP enrollment. SSPs opening in locations with high stigma against PWID need to ensure low threshold and friendly services, protect their clients from police and mobilize PWID networks to promote enrollment.

Emphasizing Choice and Autonomy in Personal Hygiene, Menstrual Health, and Sexual Health Product Distribution to People Experiencing Homelessness in Atlanta, Georgia During COVID-19.

The Dignity Pack Project is a small-scale, crisis-oriented supply chain in Atlanta, Georgia, designed to meet the acute personal hygiene,menstrual health, and sexual health needs of people experiencing homelessness (PEH). It was organized in response to conditions during the COVID-19 pandemic that continue to illuminate and exacerbate the distinct and complex challenges PEH face when trying to meet their basic needs and maintain their health. In addition to being particularly vulnerable to COVID-19 due to underlying conditions, crowding, and shared living spaces, the pandemic makes it harder for PEH to access already scant resources. Specifically, shelters across the United States have experienced outbreaks and, as a result, have reduced capacity or closed completely. Social support organizations have paused or restricted services. Donations and volunteering have decreased due to economic conditions and social distancing requirements. This practice note describes how we integrated feedback from PEH at the outset of the Dignity Pack project-and continue to do so-enabling the development of a pragmatic, humanistic outreach model that responds to the evolving needs of PEH as pandemic conditions and the seasons change. We detail how we established complementary partnerships with local organizations and respond to critical insights provided by PEH. We offer lessons and recommendations driven by the needs and preferences of PEH.

Willingness to Participate in At-Home HIV Testing Among Young Adults Who Use Opioids in Rural Appalachia.

New HIV infections associated with injection drug use are of major concern in rural US communities. This study explores acceptability of, consent for, and uptake of free at-home HIV testing among people who use drugs (PWUD) in one of the nation's epicenters for drug-related harms and HIV vulnerability: Rural Central Appalachia. Eligible participants were 18-35 years old, lived in Appalachian Kentucky, and reported using opioids to get high in the previous 30 days. A majority reported being likely (63.6%, 96/151) to take a free at-home HIV tests and 66.9% (101/151) consented to receive one. Among those who were randomly selected to receive a Home Access HIV-1 test kit (n = 37), 37.8% mailed in blood spots and 21.6% called to receive results. This study provides evidence that PWUD may be willing to take an at-home test, but other barriers may inhibit actual completion.

Novel Recruitment Methods for Research Among Young Adults in Rural Areas Who Use Opioids: Cookouts, Coupons, and Community-Based Staff.

OBJECTIVES: Rural communities in the United States are increasingly becoming epicenters of substance use and related harms. However, best practices for recruiting rural people who use drugs (PWUD) for epidemiologic research are unknown, because such strategies were developed in cities. This study explores the feasibility of web- and community-based strategies to recruit rural, young adult PWUD into epidemiologic research. MATERIALS AND METHODS: We recruited PWUD from rural Kentucky to participate in a web-based survey about opioid use using web-based peer referral and community-based strategies, including cookouts, flyers, street outreach, and invitations to PWUD enrolled in a concurrent substance use study. Staff members labeled recruitment materials with unique codes to enable tracking. We assessed eligibility and fraud through online eligibility screening and a fraud detection algorithm, respectively. Eligibility criteria included being aged 18-35, recently using opioids to get high, and residing in the study area. RESULTS: Recruitment yielded 410 complete screening entries, of which 234 were eligible and 151 provided complete, nonfraudulent surveys (ie, surveys that passed a fraud-detection algorithm designed to identify duplicate, nonlocal, and/or bot-generated entries). Cookouts and subsequent web-based peer referrals accounted for the highest proportion of screening entries (37.1%, n = 152), but only 29.6% (n = 45) of entries from cookouts and subsequent web-based peer referrals resulted in eligible, nonfraudulent surveys. Recruitment and subsequent web-based peer referral from the concurrent study yielded the second most screening entries (27.8%, n = 114), 77.2% (n = 88) of which resulted in valid surveys. Other recruitment strategies combined to yield 35.1% (n = 144) of screening entries and 11.9% (n = 18) of valid surveys. CONCLUSIONS: Web-based methods need to be complemented by context-tailored, street-outreach activities to recruit rural PWUD.

Correction: Characterizing the Rural Opioid Use Environment in Kentucky Using Google Earth: Virtual Audit.

[This corrects the article DOI: 10.2196/14923.].

People, places, and stigma: A qualitative study exploring the overdose risk environment in rural Kentucky.

BACKGROUND: Though overdose rates have been increasing in US rural areas for two decades, little is known about the rural risk environment for overdoses. This qualitative study explored the risk environment for overdoses among young adults in Eastern Kentucky, a rural epicenter of the US opioid epidemic. METHODS: Participants were recruited via community-based outreach. Eligibility criteria included living in one of five rural Eastern Kentucky counties; being aged 18-35; and using opioids to get high in the past 30 days. Semi-structured interviews explored the rural risk environment, and strategies to prevent overdose and dying from an overdose. Interviews were transcribed verbatim and analyzed using constructivist grounded-theory methods. RESULTS: In this sample (N = 19), participants reported using in a range of locations, including homes and outdoor settings; concerns about community stigma and law enforcement shaped the settings where participants used opioids and the strategies they deployed in these settings to prevent an overdose, and to survive an overdose. Almost half of participants reported using opioids in a "trap house" or other dealing locations, often to evade police after buying drugs, and reported that others present pressed them to use more than usual. If an overdose occurred in this setting, however, these same people might refuse to call EMS to protect themselves from arrest. Outdoor settings presented particular vulnerabilities to overdose and dying from an overdose. Most participants reported using opioids outdoors, where they skipped overdose prevention steps to reduce their risk of arrest; they worried that no one would find them if they overdosed, and that cell phone coverage would be too weak to summon EMS. CONCLUSION: Findings suggest that initiatives to reduce overdoses in Eastern Kentucky would be strengthened by de-escalating the War on Drugs and engaging law enforcement in initiatives to protect the health of people who use opioids.

Characterizing the Rural Opioid Use Environment in Kentucky Using Google Earth: Virtual Audit.

BACKGROUND: The opioid epidemic has ravaged rural communities in the United States. Despite extensive literature relating the physical environment to substance use in urban areas, little is known about the role of physical environment on the opioid epidemic in rural areas. OBJECTIVE: This study aimed to examine the reliability of Google Earth to collect data on the physical environment related to substance use in rural areas. METHODS: Systematic virtual audits were performed in 5 rural Kentucky counties using Google Earth between 2017 and 2018 to capture land use, health care facilities, entertainment venues, and businesses. In-person audits were performed for a subset of the census blocks. RESULTS: We captured 533 features, most of which were images taken before 2015 (71.8%, 383/533). Reliability between the virtual audits and the gold standard was high for health care facilities (>83%), entertainment venues (>95%), and businesses (>61%) but was poor for land use features (>18%). Reliability between the virtual audit and in-person audit was high for health care facilities (83%) and entertainment venues (62%) but was poor for land use (0%) and businesses (12.5%). CONCLUSIONS: Poor reliability for land use features may reflect difficulty characterizing features that require judgment or natural changes in the environment that are not reflective of the Google Earth imagery because it was captured several years before the audit was performed. Virtual Google Earth audits were an efficient way to collect rich neighborhood data that are generally not available from other sources. However, these audits should use caution when the images in the observation area are dated.

Using Web-Based Pin-Drop Maps to Capture Activity Spaces Among Young Adults Who Use Drugs in Rural Areas: Cross-Sectional Survey.

BACKGROUND: Epicenters of harmful drug use are expanding to US rural areas, with rural young adults bearing a disproportionate burden. A large body of work suggests that place characteristics (eg, spatial access to health services) shape vulnerability to drug-related harms among urban residents. Research on the role of place characteristics in shaping these harms among rural residents is nascent, as are methods of gathering place-based data. OBJECTIVE: We (1) analyzed whether young rural adults who used drugs answered self-administered Web-based mapping items about locations where they engaged in risk behaviors and (2) determined the precision of mapped locations. METHODS: Eligible individuals had to report recently using opioids to get high; be aged between 18 and 35 years; and live in the 5-county rural Appalachian Kentucky study area. We used targeted outreach and peer-referral methods to recruit participants. The survey asked participants to drop a pin in interactive maps to mark where they completed the survey, and where they had slept most; used drugs most; and had sex most in the past 6 months. Precision was assessed by (1) determining whether mapped locations were within 100 m of a structure and (2) calculating the Euclidean distance between the pin-drop home location and the street address where participants reported sleeping most often. Measures of central tendency and dispersion were calculated for all variables; distributions of missingness for mapping items and for the Euclidean distance variable were explored across participant characteristics. RESULTS: Of the 151 participants, 88.7% (134/151) completed all mapping items, and ≥92.1% (>139/151) dropped a pin at each of the 4 locations queried. Missingness did not vary across most participant characteristics, except that lower percentages of full-time workers and peer-recruited participants mapped some locations. Two-thirds of the pin-drop sex and drug use locations were less than 100 m from a structure, as were 92.1% (139/151) of pin-drop home locations. The median distance between the pin-drop and street-address home locations was 2.0 miles (25th percentile=0.8 miles; 75th percentile=5.5 miles); distances were shorter for high-school graduates, staff-recruited participants, and participants reporting no technical difficulties completing the survey. CONCLUSIONS: Missingness for mapping items was low and unlikely to introduce bias, given that it varied across few participant characteristics. Precision results were mixed. In a rural study area of 1378 square miles, most pin-drop home addresses were near a structure; it is unsurprising that fewer drug and sex locations were near structures because most participants reported engaging in these activities outside at times. The error in pin-drop home locations, however, might be too large for some purposes. We offer several recommendations to strengthen future research, including gathering metadata on the extent to which participants zoom in on each map and recruiting participants via trusted staff.

Web-Based Eligibility Quizzes to Verify Opioid Use and County Residence Among Rural Young Adults: Eligibility Screening Results from a Feasibility Study.

BACKGROUND: Web-based methods can be used to collect data from hidden populations, including people who use drugs (PWUD). These methods might be especially advantageous among PWUD in rural areas, where transportation barriers are prevalent, stigma may heighten concerns about confidentiality, and internet access is improving. However, Web-based research with PWUD can be challenging, especially in verifying eligibility. Administering quizzes to verify residential and substance use eligibility could prove valuable in online research among PWUD, yet the utility of this approach is currently unknown. OBJECTIVE: This study describes the implementation of online eligibility quizzes about the local community to verify residence in the target study area along with drug dose, appearance, and price to verify opioid misuse. METHODS: To be eligible, individuals had to live in 1 of 5 eastern Kentucky counties, report using opioids to get high in the past 30 days, and be 18 to 35 years old. Participants recruited from August 2017 to July 2018 were asked questions about their opioid use followed by a quiz about drug dose, appearance, and price to verify substance use eligibility. Residential eligibility was verified with 5-question quizzes assessing knowledge of the county where they reported living. Questions tested knowledge about towns, festivals, and landmarks; local school mascots and colors; and presence of certain retail stores, restaurants, and facilities (eg, jails). A subsample that reported using opioids in the past 24 hours was randomly selected to complete urine drug testing (UDT). Nonparametric tests were performed to explore differences across demographic subgroups. RESULTS: Of the 410 entries assessed for eligibility, 39.3% (161/410) were ineligible as they reported no substance use, being outside the age range, or living outside the study area. Of the remaining 249 who met the eligibility criteria based on age, residency, and opioid misuse, 94.0% (234/249) passed the eligibility quizzes. Among those who passed the heroin quiz, 99.4% (167/168) recognized the image of powdered heroin, 94.6% (159/168) answered the cap size (ie, the purchase unit) question correctly, and 97.0% (163/168) answered the street price question correctly. Among those who passed the drug quiz for prescription opioids, 95% (36/38) answered the dose question correctly, and 82% (31/38) selected the correct image. In a random sample of participants who completed UDT within 3 days of their online screening, 74% (25/34) tested positive for an opioid. CONCLUSIONS: This study demonstrated the utility of using online eligibility screening quizzes to verify opioid misuse and residence. Participants accurately recognized heroin and prescription opioid doses, prices, and images and correctly answered questions about features of their county. Online quizzes to screen and enroll PWUD hold promise for future research as an alternative to more time- and resource-intensive approaches that could offset the advantages of Web-based methods.

Fraud Detection Protocol for Web-Based Research Among Men Who Have Sex With Men: Development and Descriptive Evaluation.

BACKGROUND: Internet is becoming an increasingly common tool for survey research, particularly among "hidden" or vulnerable populations, such as men who have sex with men (MSM). Web-based research has many advantages for participants and researchers, but fraud can present a significant threat to data integrity. OBJECTIVE: The purpose of this analysis was to evaluate fraud detection strategies in a Web-based survey of young MSM and describe new protocols to improve fraud detection in Web-based survey research. METHODS: This study involved a cross-sectional Web-based survey that examined individual- and network-level risk factors for HIV transmission and substance use among young MSM residing in 15 counties in Central Kentucky. Each survey entry, which was at least 50% complete, was evaluated by the study staff for fraud using an algorithm involving 8 criteria based on a combination of geolocation data, survey data, and personal information. Entries were classified as fraudulent, potentially fraudulent, or valid. Descriptive analyses were performed to describe each fraud detection criterion among entries. RESULTS: Of the 414 survey entries, the final categorization resulted in 119 (28.7%) entries identified as fraud, 42 (10.1%) as potential fraud, and 253 (61.1%) as valid. Geolocation outside of the study area (164/414, 39.6%) was the most frequently violated criterion. However, 33.3% (82/246) of the entries that had ineligible geolocations belonged to participants who were in eligible locations (as verified by their request to mail payment to an address within the study area or participation at a local event). The second most frequently violated criterion was an invalid phone number (94/414, 22.7%), followed by mismatching names within an entry (43/414, 10.4%) and unusual email addresses (37/414, 8.9%). Less than 5% (18/414) of the entries had some combination of personal information items matching that of a previous entry. CONCLUSIONS: This study suggests that researchers conducting Web-based surveys of MSM should be vigilant about the potential for fraud. Researchers should have a fraud detection algorithm in place prior to data collection and should not rely on the Internet Protocol (IP) address or geolocation alone, but should rather use a combination of indicators.

A trans-university center for global health.

Can the challenge of improving health engage university faculty and students across all disciplines to more deeply understand the world and its people in order to make it a better place? Faculty and staff at the University of Virginia's (UVa) Center for Global Health (CGH) think it can. The authors argue that by working to understand, teach, and improve the human condition, universities can engage multiple disciplines, help reverse the "brain drain," and even change perspectives.The transuniversity Center for Global Health (CGH) at UVa employs three components for addressing global health issues: (1) scholars: sending UVa students abroad to conduct international fieldwork focused on global health, (2) fellows: inviting international colleagues selected by collaborating institutions abroad to work and train at UVa and return to become leaders in their home institutions, and (3) curricula: supporting and developing global health-related curricula throughout the university.UVa's CGH is associated with sister CGHs in Fortaleza, Brazil; Hefei, China; Manila, Philippines; Accra, Ghana; and Thohoyandou, South Africa. Work with international colleagues in these centers provides opportunities for bilateral training of the next generations of leaders in global health around the world. Universities are uniquely positioned to enlist multiple disciplines to unravel the complex causes of health disparities, sustain international collaborations, and change students' outlook on the world through overseas experiences. A university that actively supports global health becomes increasingly internationalized, grounded in scientific excellence, and committed to addressing the most pressing issues humanity faces today.