Shifts in Social Determinants of Vitamin A Supplementation Among Children Under Five in Kenya, 2003-2014.

OBJECTIVES: In Africa and Asia, 190 million preschoolers are vitamin A deficient. This study examined the social determinants of intake of vitamin A supplementation (VAS) among children aged 6-59 months during three different time periods in Kenya to identify those most vulnerable to vitamin A deficiency and highlight the varied targeting and outreach efforts; before the onset of a national restructuring and targeted distribution of VAS in children below 5 years through a twice-yearly door-to-door campaign called Child Health Weeks, during the implementation period, and several years later. METHODS: The cross-sectional, national Demographic and Health Surveys were administered in Kenya in 2003, 2008-09, and 2014. Bivariate and multivariable logistic regression analyses were used to assess variables associated with VAS among children (n = 28,239). RESULTS: An overall two-fold increase in VAS was recorded between 2003 (31.8%) and 2014 (67.5%). In 2008-09, children aged 6-11 months were the most likely to receive VAS. In 2003 and 2014, geographical regions and settings, birth order of the child, educational level of the mother, religion, wealth index, number of antenatal visits, and access to a radio were identified as being significantly associated with VAS, in at least one of the years. These determinants were not significant in 2008-09 during the initial Child Health Weeks promotion campaign. The determinants of VAS varied during the three study periods, particularly in 2008-09 when the Child Health Weeks was first implemented. CONCLUSION: As efforts to increase VAS continue, addressing child-specific determinants will be essential to reduce health disparities.

Creation of a Global Vaccine Risk Index.

The World Health Organization has identified vaccine hesitancy as one of its top ten global health threats for 2019. Efforts are underway to define the factors responsible for reductions in vaccine confidence. However, as global measles cases accelerated beginning in 2018, it became evident that additional factors were promoting measles re-emergence, including war, political and socio-economic collapse, shifting poverty, and vulnerability to weather events and climate change. Accordingly, we propose a Global Vaccine Risk Index (VRI) to consider these variables as a more comprehensive means to identify vulnerable nations where we might expect measles and other vaccine-preventable diseases to emerge or re-emerge. In Sub-Saharan African and Middle Eastern nations, conflict and political instability predominated as the basis for high vaccine risk scores, whereas in Southeast Asian countries, the major reasons included climate variability, current levels of measles vaccination coverage, and economic and educational disparities. In Europe, low vaccine confidence and refugee movements predominated, while in the Americas, economic disparities and vaccine confidence were important. The VRI may serve as a useful indicator and predictor for international agencies committed to childhood immunizations and might find relevance for accelerating future COVID19 vaccination programs.

Determinants of HIV Testing Uptake among Women (aged 15-49 years) in the Philippines, Myanmar, and Cambodia.

BACKGROUND: Many countries have been trying to eliminate Mother-to-Child transmission of the Human Immunodeficiency Virus (HIV) and achieve the 90-90-90 target goals. The targets mean that 90% of People Living with HIV (PLWHIV) know their HIV status, 90% of those who are infected receive Antiretroviral treatment (ART), and 90% of those achieve viral suppression. Despite some progress, the goals have not been met in the Philippines, Myanmar, and Cambodia, countries with relatively high or growing HIV prevalence. This study identifies the sociodemographic determinants of testing among women in these countries so that better health education and stigma reduction strategies can be developed. METHODS: Descriptive and multivariable analyses were conducted using Demographic and Health Survey data conducted in the Philippines (2017), Myanmar (2015/2016), and Cambodia (2014). The outcome variable was having ever been tested for HIV. Independent variables included knowledge and attitudes about HIV and social determinants of health. RESULTS: A significant difference in testing rates among women was observed (the Philippines: 5%, Myanmar: 19%, Cambodia: 42%). In Myanmar and Cambodia, women who had more HIV knowledge and less stigma towards PLWHIV were more likely to get tested for HIV than those who did not. Marital status, education, wealth were strong predictors for HIV testing among women. Younger women aged 15-19 and those who live in the rural areas were less likely to get HIV tested than older and those living in urban areas. Employed women were less likely to seek an HIV test than the unemployed in Myanmar and Cambodia, whereas, in the Philippines, the opposite relationship was found. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: Women with less education and those less familiar with HIV should be targeted for HIV testing interventions. Stigma reduction and different testing strategies could facilitate early screening leading to improved HIV testing among women.

The gut microbiome in konzo.

Konzo, a distinct upper motor neuron disease associated with a cyanogenic diet and chronic malnutrition, predominately affects children and women of childbearing age in sub-Saharan Africa. While the exact biological mechanisms that cause this disease have largely remained elusive, host-genetics and environmental components such as the gut microbiome have been implicated. Using a large study population of 180 individuals from the Democratic Republic of the Congo, where konzo is most frequent, we investigate how the structure of the gut microbiome varied across geographical contexts, as well as provide the first insight into the gut flora of children affected with this debilitating disease using shotgun metagenomic sequencing. Our findings indicate that the gut microbiome structure is highly variable depending on region of sampling, but most interestingly, we identify unique enrichments of bacterial species and functional pathways that potentially modulate the susceptibility of konzo in prone regions of the Congo.

Childhood immunization during the COVID-19 pandemic in Texas.

In 2020, the state of Texas implemented coronavirus disease 2019 (COVID-19) social distancing guidelines in order to prevent surges at Texas hospital emergency rooms and in intensive care units. As noted in other states, an unintended consequence of these activities was significant declines in childhood immunizations. After analyzing state-wide immunization register data for Texas, we observed a 47% relative decline in immunization rates between 2019 and 2020 among 5-month-olds and a 58% decline among 16-month-olds. We observed a small decline (5%) among 24-month-olds, and no decline in vaccines received at birth (Hepatitis B). Declines were larger in rural counties compared to urban. These declines are superimposed on increases in state vaccine exemptions over the last five years due to an aggressive anti-vaccine movement in Texas. There are concerns that continued declines in childhood immunization coverage due to COVID-19 could lead to co-endemics of measles and other vaccine preventable diseases.

Examining social determinants of undiagnosed diabetes in Namibia and South Africa using a behavioral model of health services use.

AIMS: To examine factors associated with undiagnosed diabetes in Namibia and South Africa. METHODS: This study used the most recent Demographic and Health Surveys (DHS) from Namibia (2013) and South Africa (2016). This study focused on adults at 35-64 years old. Using Andersen's Behavioral Model, potential contributing factors were categorized into predisposing factors (sex and education), enabling factors (wealth, health insurance, and residence), and a need factor (age, BMI, and high blood pressure). Separate multivariable logistic regression models were used to examine factors associated with undiagnosed diabetes in Namibia (N = 242) and South Africa (N = 525). RESULTS: In Namibia, higher odds of having undiagnosed diabetes were associated with rural residence (adjusted odds ratio (aOR) = 2.21) and age younger than 45 years old (aOR = 3.20). In South Africa, odds of having undiagnosed diabetes were higher among the poorest-to-poorer group than it was in the richer-to-richest group (aOR = 2.33). In both countries, having high blood pressure was associated with lower odds of having undiagnosed diabetes (aOR = 0.31 in Namibia; aOR = 0.21 in South Africa). DISCUSSION: Different enabling and need factors were associated with undiagnosed diabetes in these two countries, which implies potentially-different mechanisms driving the high prevalence of undiagnosed diabetes, as well as the needs for different solutions.

COVID-19 vaccine decisions: considering the choices and opportunities.

In the coming months, most American adults will have the opportunity to receive at least one of up to five different COVID-19 vaccines produced by Operation Warp Speed and released through emergency use authorization by the U.S. Food and Drug Administration (FDA). A similar group of vaccines will also be released in Europe by the European Medicines Agency (EMA) and in the United Kingdom by the Medicines & Healthcare products Regulatory Agency (MHRA). Those living outside of North America and Europe may not have access to those particular vaccines, but they will benefit from receiving vaccines produced in Brazil, China, India, or Russia. These vaccines and some of their major features based on clinical trials and testing are listed in Table 1 [1-25]. As vaccine scientists and policy experts working in the area of coronavirus disease 2019 (COVID-19), we are frequently asked about potential choices regarding the available vaccines, both in the U.S. and globally. Provided here is a summary and informal decision-making tool kit for considering the different vaccine options at this time.

Comparisons of social and demographic determinants of tobacco use in the Democratic Republic of the Congo.

BACKGROUND: Worldwide, tobacco use has caused over 100 million deaths in the twentieth century and is projected to cause death in up to one billion people in the twenty-first century. It is a leading cause of early death and disability in over 100 countries and accounts for over 11% of global deaths, disproportionately affecting low- and middle-income countries. The purpose of the study was to examine a variety of social determinants of tobacco use in the Democratic Republic of the Congo, including region, sex, ethnicity, education, literacy, wealth index and place of residence, to gain insights with regard to tobacco use among sub-national groups. METHODS: This project was a secondary data analysis of the 2013-2014 Demographics and Health Survey (DHS) for the Democratic Republic of the Congo. Logistic regressions predicting smoking, use of snuff and smoking cigars or natural tobacco as dichotomous variables were conducted. Independent variables included age, educational level, religion, rurality, literacy, wealth index, occupation and ethnicity. RESULTS: Tobacco use is highest among those with less education and low literacy. It was also highest among the working poor. Older age and living in larger cities were predictive of smoking, although the relationship between age and smoking was not linear. There was a strong linear effect for wealth. Being in a professional, technical or managerial position was highly protective against smoking while being engaged in services, skilled and unskilled manual labor, and the army had significantly greater odds of smoking. CONCLUSIONS: Data indicate that tobacco use in the DRC, as is common in the developing world, is heavily concentrated in the working poor with lower educational status. Higher educational status is consistently predictive of avoiding tobacco use. Additionally, examining only national-level data to ascertain tobacco use levels and patterns may lead to mistaken conclusions that can lead to inefficient and ineffective allocation of resources aimed at controlling tobacco use.

Combating vaccine hesitancy and other 21st century social determinants in the global fight against measles.

The year 2019 marked the return of measles after almost two decades of unprecedented successes in global vaccination programs. Measles transmission due to sharp declines in measles-mumps-rubella (MMR) vaccination coverage is now widespread among nations that previously saw impressive public health gains including Philippines, DR Congo, Madagascar, Samoa, many in Europe, and the United States and Venezuela in the Americas. Key determinants include the interruption of vaccine health systems due to war, conflict, and political instability; food insecurity and urbanization; and an increasingly globalized vaccine hesitancy or antivaccine movement. Vaccine hesitancy is partly responsible for over 100000 measles cases in Europe in 2019, and the re-emergence of measles to the United States almost twenty years after it was eliminated. Three major elements currently comprise the American antivaccine movement, including a media empire, a political arm, and deliberate predatory behavior. New strategies will be required to counter these activities.

Heat-not-burn tobacco product use in Japan: its prevalence, predictors and perceived symptoms from exposure to secondhand heat-not-burn tobacco aerosol.

OBJECTIVES: A heat-not-burn (HNB) tobacco product, IQOS, was first launched in Japan and Italy as test markets and is currently in commerce in 30 countries. Using two data sources, we examined interest in HNB tobacco (IQOS, Ploom and glo), its prevalence, predictors of its use and symptoms from exposure to secondhand HNB tobacco aerosol in Japan, where HNB tobacco has been sold since 2014. METHODS: Population interest in HNB tobacco was explored using Google search query data. Prevalence of HNB tobacco current use (ie, use in the previous 30 days) was calculated using a longitudinal internet survey of 8240 individuals (15-69 years old in 2015) followed up to 2017. Rates of perceived symptoms from exposure to exhaled aerosol of others' HNB tobacco were also calculated. RESULTS: The largest internet search volume for IQOS occurred in April 2016 in the week after a popular national entertainment TV show introduced IQOS. For Ploom and glo, search volumes have remained limited since their launch. Prevalence of IQOS users increased from 0.3% in January-February 2015 to 0.6% in January-February 2016 and up to 3.6% in January-February 2017, while estimated rates of use of other HNB tobacco products remained low in 2017. Respondents who had seen the TV programme in 2016 were more likely to have used IQOS than those who had not seen it (10.3% vs 2.7%). Among never-smokers who had been exposed to secondhand HNB tobacco aerosol, nearly half reported at least one acute symptom, although these symptoms were not serious. CONCLUSIONS: A popular TV programme triggered IQOS diffusion in Japan. Extrapolating from survey results to the general population, around 3.1 million people currently use IQOS in Japan. Tobacco control organisations and governments should closely monitor HNB tobacco and consider how to regulate it.

Evolution of a Disease Surveillance System: An Increase in Reporting of Human Monkeypox Disease in the Democratic Republic of the Congo, 2001-2013.

OBJECTIVE: Evaluating the effectiveness of a surveillance system, and how it improves over time has significant implications for disease control and prevention. In the Democratic Republic of Congo (DRC), the Integrated Disease Surveillance and Response (IDSR) was implemented to estimate the burden of disease, monitor changes in disease occurrence, and inform resource allocation. For this effort we utilized national passive surveillance data from DRC's IDSR to explore reporting trends of human monkeypox (MPX) from 2001 to 2013. METHODS: We obtained surveillance data on MPX cases occurring between January 2001 and December 2013 from the DRC Ministry of Health (MoH). Phases of the surveillance system, yearly trends in reporting and estimated incidence for MPX were analyzed using SAS v9.2 and Health Mapper. RESULTS: Between 2001 and 2013, three discrete surveillance phases were identified that described the evolution of the surveillance system. Overall, an increase in suspected MPX cases was reported, beyond what would be expected from simply an improved reporting system. When restricting the analysis to the "stable phase," national estimated incidence increased from 2.13 per 100,000 in 2008 to 2.84 per 100,000 in 2013. CONCLUSIONS: The reported increase in MPX, based on an evolving surveillance system, is likely to be a true increase in disease occurrence rather than simply improvements to the surveillance system. Further analyses should provide critical information for improved prevention and control strategies and highlight areas of improvement for future data collection efforts.

Disparity and Trends in Secondhand Smoke Exposure among Japanese Employees, Particularly Smokers vs. Non-Smokers.

BACKGROUND: Monitoring disparities in secondhand smoke (SHS) exposure is important for tailoring smoke-free policies to the needs of different groups. We examined disparity and trends in SHS exposure among both nonsmokers and smokers at Japanese workplaces between 2002 and 2012. METHODS: A total of 32,940 employees in nationally representative, population-based, repeated cross-sectional surveys in 2002, 2007 and 2012 in Japan was analyzed. Adjusted rate ratios for workplace SHS exposure from other people ("everyday" and "everyday or sometimes") were calculated according to covariates, using log-binomial regression models with survey weights. In this survey, employees who do not smoke at workplace are defined as workplace-nonsmokers; and those smoke at workplace are used as workplace-smokers. SHS exposure for smokers does not involve their own SHS. RESULTS: While everyday SHS exposure prevalence in workplace-nonsmokers decreased markedly (33.2% to 11.4%), that in workplace-smokers decreased only slightly (63.3% to 55.6%). Workplace-smokers were significantly more likely to report everyday SHS exposure than workplace-nonsmokers, and the degree of association increased over time: compared with the nonsmokers (reference), covariates-adjusted rate ratio (95% confidence interval) for the smokers increased from 1.70 (1.62-1.77) in 2002 to 4.16 (3.79-4.56) in 2012. Similar results were observed for everyday or sometimes SHS exposure. Compared with complete workplace smoking bans, partial and no bans were consistently and significantly associated with high SHS exposure among both nonsmokers and smokers. We also observed disparities in SHS exposure by employee characteristics, such as age group and worksite scale. CONCLUSIONS: Although overall SHS exposure decreased among Japanese employees between 2002 and 2012, the SHS exposure disparity between nonsmokers and smokers widened. Because smokers reported more frequent SHS exposure than nonsmokers, subsequent mortality due to SHS exposure may be higher in smokers than in nonsmokers. This information may be useful for advocating workplace smoke-free policies.

Psychosocial correlates of smokeless tobacco use among Indiana adolescents.

Adolescent tobacco use is influenced by intrapersonal (e.g., impulse control) and external factors, such as behaviors of friends and peers. The relationships of these factors to smokeless tobacco (ST) use are not yet fully understood. This is especially true as it pertains to the simultaneous examination of psychological and normative perceptions. Using constructs of the Biopsychosocial Model, this study investigates factors associated with lifetime ST use among middle and high school students. Data were analyzed from 938 Indiana middle and high school students. Binary sequential logistic regression was performed to examine the relationship of personal characteristics and psychosocial measures to adolescent lifetime ST use. Approximately 9 % reported having ever used ST, among which 78.6 % were male. Females and younger students were less likely to have used ST in their lifetime, whereas participants with a sibling smoker and those who compared their life to the lives of others were more likely to report lifetime ST usage. In the presence of psychological and normative variables, sex, age, and comparing one's life to others remained significant. Additionally, participants who perceived higher friend approval of substance use were significantly more likely to report lifetime ST use. Understanding the normative perceptions of adolescents may lend insight into the drivers of ST use adolescent subgroups and, which may enable community and school officials to tailor interventions to prevent ST initiation and promote cessation.

An exploration of transactional states and cessation-related social variables within adolescent smokers.

BACKGROUND: Given the high rate of adolescent smoking, cessation remains a vital public health priority. This study explored archival data using a structured phenomenological framework known as Reversal Theory (RT). In order to better understand aspects of adolescent tobacco use we compared the transactional, psychological states described by RT to the factor structure of adolescents' self-reported social environment influencing tobacco use. METHODS: In a two step analysis of questions about self-reported tobacco use cognitions, attitudes, and behaviors from youth enrolled during the 2003-2004 period in a Texas, state-wide, mandated tobacco cessation program (N=1807), four factors and 11 items were identified as significantly related to the influence of social context and adolescents' tobacco use. These first step results guided the items to be selected for further analysis. In step two the variables were subjected to a factor analysis using principal components extraction and varimax rotation. The resulting factor structure was compared and interpreted within the context of descriptions of RT transactional states. RESULTS: The analysis indicated that four factors were closely aligned to descriptions of the Reversal Theory transactional states and could be reinterpreted from within the framework of RT. The first factor included feelings of self-efficacy for quitting (autic mastery). The second and third transactional factors diverged between one factor to quit, and an opposing transactional factor to continue to smoke. Both of these transactional states are variants of the autocentric state where one wants to experience feelings of gain with the help of others. The fourth factor could be interpreted as 'confidence' or 'optimism'. CONCLUSIONS: This intra-individual conflict revealed by the opposition of factors two and three clarifies a paradoxical issue where an adolescent wants to quit smoking with social support in one setting yet in another social environment chooses to smoke to gain or retain peer acceptance. These data illustrate that adolescent' self-identified quit skills and social support structures are important to the quitting process. This exploratory investigation has important implications for addressing RT state reversals in youth cessation programming activities.

A Smoke-Free Paso del Norte: impact over 10 years on smoking prevalence using the Behavioral Risk Factor Surveillance System.

OBJECTIVES: We assessed the impact of a tobacco control initiative over 10 years on cessation and prevention. METHODS: We examined 2000-2009 Behavioral Risk Factor Surveillance System cases of a metropolitan statistical area (MSA) with systematic tobacco control efforts throughout the decade (El Paso, TX) and 2 comparison MSAs similar in size and population with less coordinated tobacco control efforts (Austin-Round Rock, TX and San Antonio, TX). RESULTS: Yearly, El Paso exhibited a 6% increase in the prevalence of former smokers, a 6% decrease in prevalence of daily smokers, and a 7% decrease in the prevalence of established smoking (≥ 100 cigarettes per lifetime and currently smoking); we did not observe similar trends in the comparison MSAs. There was no change in the prevalence of nondaily smokers in any of the MSAs. CONCLUSIONS: The coordinated tobacco control activities in El Paso are related to cessation among daily smokers and prevention of established smoking at the population level but have not stimulated cessation among nondaily smokers. Comprehensive tobacco control should focus more on not only daily smokers but also nondaily smokers.

Factors associated with tobacco smoking practices among middle-aged and older women in Texas.

This study examines middle-aged and older women's smoking practices and identifies factors associated with tobacco use and cessation in this population. Data of 593 women were analyzed from a seven-county random household sample in Texas. Sequential multinomial logistic regression compared associations with having never smoked, having quit smoking, and currently smoking. Compared to smokers, never smokers and past smokers were significantly more likely to be older, more educated, of better general health, and report past-year physician visits and fewer depressive symptoms. Mental health and smoking are interrelated, indicating the need for addressing depression in smoking-cessation efforts for aging women.

The impact of a communitywide smoke-free ordinance on smoking among older adults.

INTRODUCTION: Clean-air and smoke-free ordinances have been shown to reduce the prevalence of smoking among the overall population, but their effects on the smoking prevalence among older adults deserves further attention. We examined changes in self-reported cigarette smoking and in attitudes toward smoking after the implementation of such ordinances in Fort Collins, Colorado, in 2003. METHODS: Communitywide health status surveys were mailed out to northern Larimer County residents recruited via random-digit dialing in 2001 and 2004. Secondary data analysis was conducted for respondents living in Fort Collins, comparing the entire sample with a subsample of adults aged 50 years or older. Univariate analyses were used to determine differences in self-reported cigarette smoking between the groups across the 2 surveys. Multivariate logistic regression models estimated differences in smoking status and in attitudes toward acceptability of public smoking between the 2 survey administrations, controlling for demographic correlates. RESULTS: Smoking rates among older respondents failed to change, despite significant decreases in smoking rates in the entire adult population. Furthermore, attitudes toward smoking in public did not change between the 2 surveys for either of the groups. CONCLUSION: Different factors may influence the decision to stop smoking for older adults and younger adults. We recommend the use of multiple approaches on different ecological levels to ensure that communitywide antismoking intervention efforts reach all population segments.

Confirming the structure of the Why Do You Smoke? Questionnaire: a community resource for adolescent tobacco cessation.

In response to the problem of adolescent smoking and limited appropriate cessation resources, this study examined the pattern and structure of the American Lung Association, Why Do You Smoke? (WDS) to determine its appropriateness for use in youth smoking cessation programs. The WDS is used to help smokers identify primary motivations for using tobacco and is comprised of eight subscales, each with three items representing primary smoking motivations ("Stimulation," "Handling," "Pleasure," "Crutch," "Psychological," "Habit," "Peer," and "Independence"). Study participants were all minors enrolled in a tobacco cessation program (n = 251). The pattern and structure of this self-assessment was examined using a correlated multiple group component factor analysis as a confirmatory approach. Findings show that the level of endorsement (as evidenced by subscale means and standard deviations) was relatively large across the eight subscales. Alpha coefficients ranged from .54 to .85. Results also underlined that the pattern coefficient matrix provided support for the hypothesized subscales through an examination of simultaneously extracted confidence intervals. These subscales should be further examined as to their usefulness in cessation interventions, such as the validity of using this instrument by gender, ethnicity, and age. However, from a measurement perspective, the confirmatory analysis provides excellent credence for the continued use of the WDS in cognitive/behavioral intervention programs targeting adolescents.

Seasonal variations in the initiation of smoking among adolescents.

Numerous studies have identified a variety of reasons that youths give for starting smoking. Few efforts have been made, however, to identify seasonal variations in initiation. This study was an attempt to fill that void. We examined data from 342 youths participating in a mandated smoking education and cessation program in Texas. Data were collected based on responses to questions in participant workbooks, including an item asking participants about the month in which they started smoking. A total of 47% of the participants indicated that they started smoking in May through August (chi2 = 91.42, df = 3). Post-hoc analyses indicated that significantly more youths than expected began smoking in May and June, whereas significantly fewer youths than expected began smoking in September and November. Unsupervised time out of school during the first months of summer vacation is a period of increased danger for smoking initiation. The significantly lower rates during September seem to be related to the beginning of school.

A vision for doctoral research training in health behavior: a position paper from the American Academy of Health Behavior.

OBJECTIVE: To establish and disseminate the position of the American Academy of Health Behavior (The Academy) on doctoral research training. METHODS: A collaborative process involving the Work Group on Doctoral Research Training with input from The Academy membership led to the development of the guidelines described herein. RESULTS: A set of guidelines is provided that describe the process of learning to be a scholar/researcher and the outcomes of learning the practice of health behavior research. CONCLUSIONS: The doctoral students who are to become the stewards of our field should be prepared to engage in scholarship that creates new knowledge, uses research to transform practice, and effectively communicates research findings.