The effect of interpersonal communication in tobacco control campaigns: A longitudinal mediation analysis of a Ghanaian adolescent population.

This study examined the effectiveness of anti-smoking messages in positively shifting perceptions of risks related to smoking among adolescents in urban Ghana, both directly through exposure to messaging and indirectly through catalyzing discussions among peers and adults. We used data from two waves of a population-based survey of 3775 adolescent girls and 3279 adolescent boys aged 13-16 years in the urban areas of Accra, Teshie, Kumasi and Sunyani in Ghana. Using an interviewer-directed questionnaire, information was collected on sociodemographic characteristics, tobacco knowledge, exposure to messages about tobacco, frequency of conversations with peers and adults about the health risks associated with smoking, as well as beliefs and attitudes towards smoking. The outcome measure is smoking risk perception in relation to shisha and cigarettes. Using causal mediation analysis, we examine the direct and indirect effects of social media relative to mass media as they work to spur discussions among peers, as well as between peers and adults, about smoking risks and about aligning risk perceptions with objective risk. We find that media exposure - both social and mass media - can impact risk perceptions. We find in particular an 8.6 percentage point increase in shisha smoking risk perceptions due to social media campaign exposure (95% CI: 3.71-13.50) and a 2.3 percentage point increase in cigarette smoking risk perception due to mass media campaign exposure (95% CI: 0.26-4.27). We further find that the indirect effect of conversations with peers mediated 16.3% of the total effect of mass media campaign exposure on cigarette smoking risk perception and 4.8% of the total effect of social media campaigns on shisha smoking risk perception. Social media campaigns increased shisha smoking risk perception among girls by 11.6 percentage points (95% CI: 5.59-17.61), of which 6.8% was mediated by conversations with peers, while conversations with peers did not significantly mediate campaign effect among boys. Conversations with adults were never found to significantly mediate smoking prevention campaigns effects in this sample of Ghanaian adolescents. Behavior change communication programs that rely solely on traditional mass media can miss important opportunities for shifting smoking risk perceptions and sharing information on the harms of smoking. Evaluations that ignore the indirect effects of conversations among peers mediating campaign effects may fail to identify important channels that can be targeted and triggered by mass and social media tobacco control campaigns.

Impact of Medicaid Expansion on PrEP Utilization in the US: 2012-2018.

We investigated the impact of Medicaid expansions made possible by the 2010 Affordable Care Act on HIV Pre-Exposure Prophylaxis (PrEP) utilization in the US over the period 2012-2018. We used data on PrEP utilization from Symphony Health in a difference-in-differences regression analysis with bootstrapped standard errors. We found that Medicaid Expansion resulted on average in 7.78 additional estimated PrEP users per 100,000 population on a yearly basis (z = 2.72; p = 0.007). When restricting the sample to males, Medicaid Expansion resulted in 14.67 additional PrEP users per 100,000 population each year (z = 2.5; p = 0.012). People in the age group 25-34 were those who benefitted the most from Medicaid Expansion with 16.95 additional PrEP users per 100,000 population per year attributable to Medicaid Expansion (z = 3.2; p < 0.001). States that are considering expanding Medicaid may recognize the benefits in PrEP utilization we document here.

Is Covid-19 community level testing effective in reaching at-risk populations? Evidence from spatial analysis of New Orleans patient data at walk-up sites.

BACKGROUND: This paper evaluates the increase in coverage and use of Covid-19 testing services for vulnerable and hard-to-reach populations through the introduction of community-based walk-up sites in New Orleans, LA. While most GIS work on Covid-19 testing coverage and access has used census tract or ZIP code aggregated data, this manuscript is unique in that it uses individual level demographics and exact addresses to calculate distances actually traveled by patients. METHODS: We used testing data recorded for 9721 patients at 20 sites operating in May-June 2020. The dataset includes detailed age, race and ethnicity, and testing results as well as the exact address of each individual. Using GIS, we estimated changes in testing coverage for minority neighborhoods and calculated the actual distance covered by individuals. Logistic regression and multivariate linear regression were used to identify socio-demographic variables associated with distance travelled to and used of nearest testing site. We used a secondary dataset from drive-through sites to evaluate change in coverage at the census tract level for the metropolitan area. RESULTS: Walk-up sites significantly increased testing availability in New Orleans, and specifically in minority neighborhoods. Both African Americans and Asians were more likely (14.7 and 53.0%) to be tested at the nearest walk-up site. They also covered shorter distances to get tested. Being elderly was also significantly and positively associated with testing at the nearest site. Hispanics, however, were not associated with increased proximity to and use of nearest sites, and they traveled an additional 0.745 km to get tested. Individuals who tested positive also travelled significantly longer distances to obtain a test. CONCLUSIONS: Walk-up sites increased testing availability for some vulnerable populations who took advantage of the sites' proximity, although inequalities appear at the metropolitan scale. As cities are planning community vaccination campaigns, mobile, walk-up sites appear to improve both coverage and accessibility for hard-to-reach populations. With adequate technical (vaccine dose refrigeration) and messaging (addressing reticence to immunization) adaptations, they could constitute a key complementary approach to health facility points of delivery.

Access to HIV care and treatment for migrants between Lesotho and South Africa: a mixed methods study.

BACKGROUND: HIV treatment and care for migrants is affected by their mobility and interaction with HIV treatment programs and health care systems in different countries. To assess healthcare needs, preferences and accessibility barriers of HIV-infected migrant populations in high HIV burden, borderland districts of Lesotho. METHODS: We selected 15 health facilities accessed by high patient volumes in three districts of Maseru, Leribe and Mafeteng. We used a mixed methods approach by administering a survey questionnaire to consenting HIV infected individuals on anti-retroviral therapy (ART) and utilizing a purposive sampling procedure to recruit health care providers for qualitative in-depth interviews across facilities. RESULTS: Out of 524 HIV-infected migrants enrolled in the study, 315 (60.1%) were from urban and 209 (39.9%) from rural sites. Of these, 344 (65.6%) were women, 375 (71.6%) were aged between 26 and 45 years and 240 (45.8%) were domestic workers. A total of 486 (92.7%) preferred to collect their medications primarily in Lesotho compared to South Africa. From 506 who responded to the question on preferred dispensing intervals, 63.1% (n = 319) preferred 5-6 month ARV refills, 30.2% (n = 153) chose 3-4 month refills and only 6.7% (n = 34) opted for the standard-of-care 1-2 month refills. A total of 126 (24.4%) defaulted on their treatment and the primary reason for defaulting was failure to get to Lesotho to collect medication (59.5%, 75/126). Treatment default rates were higher in urban than rural areas (28.3% versus 18.4%, p = 0.011). Service providers indicated a lack of transfer letters as the major drawback in facilitating care and treatment for migrants, followed by discrimination based on nationality or language. Service providers indicated that most patients preferred all treatment services to be rendered in Lesotho, as they perceive the treatment provided in South Africa to be different often less strong or with more serious side effects. CONCLUSION: Existing healthcare systems in both South Africa and Lesotho experience challenges in providing proper care and treatment for HIV infected migrants. A need for a differentiated model of ART delivery to HIV infected migrants that allows for multi-month scripting and dispensing is warranted.

Louisiana Medicaid Expansion Associated With Reduced Travel For Care Among Minority Groups And Rural Residents.

Distance traveled to a provider has been associated with access to and timely use of health care services. Medicaid expansion has been previously linked to an increase in the number of providers accepting Medicaid patients. We hypothesized that by increasing the density of providers accepting Medicaid in any area, Louisiana's Medicaid expansion in July 2016 may have increased access to health care services for Medicaid patients already eligible for Medicaid in Louisiana by decreasing distances traveled to reach health care providers. We tested our hypothesis using a regression discontinuity model on all continuously enrolled Louisiana Medicaid beneficiaries' transactions from the period 2015-17 across eight different service lines. Distance traveled to appointments declined across all service lines, with declines ranging from -3.46 miles for general practices to -0.70 miles for specialty care. The most robust declines in distance traveled were among Black enrollees living in nonmetropolitan areas, with the largest being a decline of 9.25 fewer miles traveled for general practice care. Medicaid expansion has the potential to address racial and geographic disparities in health care access through decreased travel distances.

Opioid prescribing restrictions and opioid use among the Louisiana Medicaid population.

BACKGROUND: Most states in the U.S. have enacted prescription opioid quantity limits to curb long-term opioid dependency. While several studies of these policies find reductions in subsequent prescriptions, others find mixed results in reducing overall opioid prescriptions and prescription length. Our objective was to examine three opioid restriction policies implemented in Louisiana Medicaid: (1) a 15-day quantity limit for opioid-naïve acute pain patients, (2) a subsequent further reduction to a 7-day quantity limit and a Morphine Milligram Equivalent Dosing (MME) limit of 120mg per day, and (3) a final reduction in daily MMEs to 90mg per day. METHODS: Using interrupted time series (ITS) models with Medicaid pharmacy claims data, we estimated changes in trends of opioid prescription fills associated with opioid restriction policies in Louisiana Medicaid. Outcomes of interest included average opioid prescription length, average MMEs per day, and the likelihood that an opioid-naïve beneficiary who received their first opioid prescription filled a second prescription within 30 or 60 days of their initial fill. RESULTS: 15-day and 7-day opioid prescription quantity limits were associated with a 0.720 and a 0.401 day reduction in average opioid prescription lengths. 7-day limits were associated with a 2.7 and a 3.0 percentage point reduction in the likelihood of a second opioid prescription fill within 30 or 60 days of the initial fill. The 120mg per day MME limit was associated with a 0.80 MMEs per day reduction in average daily MMEs. Further restricting daily MMEs to 90mg per day had no statistically significant association with average daily MMEs. CONCLUSION: These findings suggest that efforts to limit opioid exposure through the implementation of prescription quantity limits and MME restrictions in Louisiana's Medicaid program were successful and are likely to be associated with a reduction in future opioid dependency among the state's Medicaid population.

Association of State Gestational Age Limit Abortion Laws With Infant Mortality.

INTRODUCTION: A growing number of state legislatures have passed laws that restrict access to abortion care after a specified gestational age (gestational age limit laws). The impact of these laws on maternal and child population health outcomes and inequities is unknown. The objective of this study is to determine whether states that implement gestational age limit laws experience subsequent changes in rates of infant mortality. METHODS: Using U.S. population‒based data from the National Center for Health Statistics Linked Infant Birth-Death Files (2005-2017), difference-in-differences models were estimated using multivariable linear regressions to compare the trends in infant mortality (all-cause and cause-specific rates) in states with gestational age limit laws with the trends in states without such laws. Models stratified by maternal racial/ethnic group explored racial heterogeneity in the law's impact. Data were analyzed in 2020. RESULTS: This study included 16,232,133 births in states that enacted a gestation age limit abortion law and 36,472,309 births in states that did not from 2005 to 2017. In difference-in-difference analyses, gestational age limit laws were associated with 0.23 excess infant deaths per 1,000 live births (95% CI=0.09, 0.37, p<0.01). In cause-specific analyses, gestational age limit laws were associated with 0.10 additional infant deaths owing to congenital anomalies per 1,000 live births (95% CI=0.03, 0.17, p=0.01). Associations between gestational age limit laws and infant mortality in models stratified by maternal racial/ethnic group were not statistically significant. CONCLUSIONS: On the basis of data from 2005 to 2017, states that enacted gestational age limit abortion laws subsequently experienced increased infant mortality rates.

Willingness to use PrEP among female university students in Lesotho.

Oral pre-exposure prophylaxis (PrEP) for HIV-negative individuals at high risk was introduced in Lesotho in April 2016. To assess the feasibility and acceptability of PrEP in Lesotho and to study the attitudes and beliefs around HIV risk and prevention measures among young women, between September and December 2016 we asked 302 female university students at fourteen higher education institutions in Lesotho about their sexual behavior, experiences of sexual coercion and abuse, HIV risk perception, willingness to use PrEP, as well as their attitudes toward condom use and self-administration of daily medications. Overall, 57.3% of the sample reported perceiving themselves at risk of acquiring HIV and 32.1% reported being strongly willing to use PrEP if it were available in their community. In a multivariate mediation analysis, perceived HIV risk was associated with 11.5 percentage points increase in likelihood of using PrEP (p = 0.041). Multiple concurrent sexual partnership was associated with 16.1 percentage points increase in likelihood of self-perceived HIV risk (p = 0.007), while having sexual partners in polygamous relationships was associated with 17.8 percentage points increase in likelihood of self-perceived HIV risk (p = 0.002) and the mediated indirect effect accounted for 18.2% of its total effect. Those who reported strong adherence to antibiotics were 23.1 percentage points more likely to express willingness to use PrEP than those who did not (p = 0.004), and those who reported to dislike condoms were 19.1 percentage points more likely to be willing to use PrEP than those who did not report aversion to condom use: these effect were direct and not mediated by HIV risk perception. Intimate partner violence (IPV) in the network of peers was also directly associated with willingness to use PrEP and its effect was not significantly mediated by HIV risk perception: those who had friends who experienced intimate partner violence were 14.9 percentage points more likely to be willing to use PrEP than those who did not report IPV in their network of peers (p = 0.009). These findings support the inclusion of individuals with multiple concurrent sexual partners among the key populations for PrEP provision and confirm that willingness to use PrEP is not solely driven by HIV risk perception. They also indicate that the presence of IPV in peer networks is related to one's willingness to use PrEP. PrEP service provision may generate synergies with IPV prevention programs when offered within this framework.