Characterizing the spectrum of bladder health and lower urinary tract symptoms among men: Results from the CARDIA study

OBJECTIVES

To operationalize a new definition for bladder health, we examined the distribution and impact of lower urinary tract symptoms (LUTS), along with risk factors, among men in the Coronary Artery Risk Development in Young Adults (CARDIA) study.

METHODS

LUTS were defined by American Urologic Association Symptom Index (AUASI) scores and impact on quality of life (QoL). Separate questions assessed urinary incontinence (UI) and postvoid dribbling. We performed cluster analyses using AUASI scores, with and without urine incontinence and postvoid dribbling, and impact collected in 2010-11. We performed analyses to evaluate sociodemographic and cardiovascular risk factors between clusters.

RESULTS

Among CARDIA men (mean age: 50.0, SD = 3.6; range: 42-56 years) with complete LUTS data (n = 929), we identified and compared four clusters: men who reported no or very mild symptoms and no impact on well-being (bladder health, n = 696, 75%), men with moderate symptoms and moderate impact on well-being (moderate symptoms/impact, n = 84, 9%), men with high symptoms and high impact on well-being (severe symptoms/impact, n = 117, 13%), and a separate group that reported moderate symptoms and UI with a high impact on well-being (UI + moderate symptoms/severe impact, n = 32, 3%). Exploration of the groupings showed a large percentage of postvoid dribbling across groups (overall 69%). Sociodemographic and cardiovascular risk factors were not associated with symptom/impact groups.

CONCLUSIONS

Bladder health clustered into four categories. A majority of middle-aged men in the community showed no or mild bladder symptoms without impact on QoL. Postvoid dribbling is pervasive but did not cluster with a specific LUTS or impact category.

Black women's perspectives on bladder health: Social-ecological and life course contexts

AIMS

This paper explores Black women's perspectives on bladder health using a social-ecological conceptual framework and life course perspective.

METHODS

We conducted a directed content analysis of data from the Study of Habits, Attitudes, Realities, and Experiences (SHARE), a focus group study by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium. Analysis was conducted on data from five focus groups and a member-checking session where all participants self-identified as Black or African American.

RESULTS

Forty-two participants aged 11-14 or 45+ years reported life course experiences with their bladder. The intersection of race and gender was the lens through which participants viewed bladder health. Participants' accounts of their perspectives on bladder health explicitly and implicitly revealed structural racism as an explanatory overarching theme. Participants described (a) historically-rooted and still pervasive practices of discrimination and segregation, engendering inequitable access to quality medical care and public facilities, (b) institutional barriers to toileting autonomy in educational and occupational settings, promoting unhealthy voiding habits, (c) internalized expectations of Black women's stereotyped role as family caregiver, compromising caregiver health, (d) lack of reliable information on bladder health, leading to unhealthy bladder behaviors, and (e) potentially stress-related comorbid chronic conditions and associated medication use, causing or exacerbating bladder problems.

CONCLUSIONS

Bladder health promotion interventions should address social-ecological and life course factors shaping Black women's bladder health, including social and structural barriers to accessing equitable health information and medical care.

Investing in family-centered early childhood education: A conceptual model for preventing firearm homicide among Black male youth in the United States

INTRODUCTION

Firearms are now the number one killer of children and adolescents in the United States. Firearm homicides among Black male youth are the driver of this increase. Prevention requires a multi-faceted life course approach. Academic achievement has been identified as a protective factor. Early childhood education, which is linked to later achievement, is thus an intervention area of interest. Conceptualizing the potential links between early childhood education and reduced risk for youth firearm homicide is important for guiding policy advocacy and informing future research.

METHODS

This paper presents a conceptual model linking early childhood education to reduced risk for firearm homicide. Each link in the model is discussed, and a corresponding review of the literature is presented. The need for anti-racist policies to strengthen the impact of early childhood education is highlighted.

RESULTS

Early education and firearm homicide research are each well-established but largely disconnected. There are clear immediate benefits of early childhood education; however, these effects wane with time, particularly for youth of color. At the same time, juvenile delinquency-a major risk factor for firearm homicide-is influenced by educational inequities.

CONCLUSIONS

Effective interventions to reduce firearm homicides among Black male youth in the United States are needed. Early childhood education shows promise as an intervention. However, to have an impact, this education needs to be accessible and affordable for all, particularly families of color and low income. Societal structures and policies must also better support the positive gains seen through early childhood education to avoid dissipation.

The brain, gut, and bladder health nexus: A conceptual model linking stress and mental health disorders to overactive bladder in women

OBJECTIVE

A small, but growing literature links stressors and mental health disorders (MHDs) across the life course to overactive bladder (OAB) and urinary incontinence symptoms. Mechanisms by which stressors and MHDs may impact bladder health are not fully understood, limiting novel prevention and treatment efforts. Moreover, potential biopsychosocial mechanisms involving the brain and gut have not been considered in an integrated, comprehensive fashion.

METHODS

Members of the prevention of lower urinary tract symptoms Research Consortium developed conceptual models to inform research on biopsychosocial mechanisms through which stress and MDHs may impact bladder health among girls and women, focusing on brain and gut physiology.

RESULTS

Two conceptual models were developed-one to explain central (brain-based) and peripheral (gut-based) mechanisms linking stressors and MHDs to OAB and bladder health, and one to highlight bidirectional communication between the brain, gut, and bladder. Traumatic events, chronic stressors, and MHDs may lead to a maladaptive stress response, including dysregulated communication and signaling between the brain, gut, and bladder. Gut bacteria produce molecules and metabolites that alter production of neurotransmitters, amino acids, short-chain fatty acids, and inflammatory immune response molecules that mediate communication between the gut and brain. Microbiota signal neurogenesis, microglia maturation, and synaptic pruning; they also calibrate brain-gut-bladder axis communication through neurotransmission and synaptogenesis, potentially influencing bladder symptom development. Life course trajectories of risk may be prevented or interrupted by central and peripheral resources for neuropsychological resilience.

CONCLUSIONS

Depicted pathways, including brain-gut-bladder communication, have implications for research and development of novel prevention and treatment approaches.

Job strain, occupation, and bladder health among women

OBJECTIVES

Lower urinary tract symptoms (LUTS) are common among employed women. An underexplored topic is whether characteristics of women's occupations may influence LUTS. The present study examined whether job strain and its individual components (psychological demands, decision latitude) were associated with greater LUTS and their impact and whether, compared to managerial and professional occupations, occupations characterized by manual labor, sales, service, nursing, and teaching were associated with greater LUTS and their impact.

METHODS

Coronary Artery Risk Development in Young Adults cohort study data were analyzed. Job strain and occupation were assessed in 1987-88 and 1995-96. In 2012-13, LUTS and their impact were assessed. LUTS/impact category (a composite variable ranging from bladder health to mild, moderate, and severe LUTS/impact) was regressed on job strain and occupation in separate analyses, adjusting for age, race, parity, education, and financial hardship (n = 1006).

RESULTS

Job strain and its individual components were not associated with LUTS/impact. In comparison to managerial and professional occupations, service occupations in 1987-88 and 1995-96 were both associated with greater odds of LUTS/impact in proportional odds logistic regression analyses. Employment as a nurse, health assistant, or health aide in 1995-96 was associated with greater odds of any LUTS/impact versus bladder health. Support positions in 1987-88 and sales positions in 1995-96 were associated with greater odds of moderate or severe LUTS/impact versus bladder health or mild LUTS/impact.

CONCLUSIONS

Future research should examine characteristics of workplaces that may promote or constrain bladder health (e.g., time and autonomy to void when desired, infrastructure to void).

Financial strain across 25 years and women's bladder health: a life course perspective

BACKGROUND

A small number of cross-sectional studies have found that financial insecurity-a social determinant of health-is associated with lower urinary tract symptoms.

OBJECTIVE

This study aimed to examine (1) whether women in the Coronary Artery Risk Development in Young Adult Study with higher levels of financial strain, assessed at 7 time points across 25 years beginning in 1985-1986, were more likely to report lower urinary tract symptoms and impact after the 2010-2011 financial strain assessment and (2) whether healthcare access and comorbidities mediated potential associations.

STUDY DESIGN

This prospective cohort study recruited Black and White participants aged 18 to 30 years at baseline (1985-1986) from the populations of 4 US cities. The analytical sample was composed of women with complete data for analyses involving financial strain trajectories across 7 assessments (n=841) and mediation tests of data collected at 4 assessments (n=886). The outcome variable was previously developed through a cluster analysis of urinary incontinence severity, urinary incontinence impact, other lower urinary tract symptoms severity, and their impact in 2012-2013, which yielded 4 lower urinary tract symptoms and impact cluster categories: women with no symptom or very mild symptoms and no impact vs women with mild, moderate, or severe symptoms and impact. Financial strain was defined as finding it "very hard," "hard," or "somewhat hard" (vs "not very hard") to pay for the very basics, such as food, heating, and medical care. Using proportional odds logistic regression, cluster categories were regressed on the financial strain trajectory group, adjusting for age, race, education, and parity. For mediation analyses, separate financial strain variables (difficulty paying for the very basics, such as food and heating, and difficulty paying for medical care) were created by combining 1995-1996 and 2000-2001 values. Two healthcare access variables (difficulty receiving care and underutilization of care) and a single comorbidity index (smoking, physical inactivity, body mass index, hypertension, diabetes mellitus, and depressive symptoms) were created by combining 2005-2006 and 2010-2011 values. Regression analyses and structural equation modeling were used to test whether healthcare access and comorbidities mediated associations between financial strain and lower urinary tract symptoms and impact cluster categories.

RESULTS

In comparison to women who were consistently not financially strained, women who were consistently strained (odds ratio, 2.10; 95% confidence interval, 1.13-3.91), shifted into being strained (odds ratio, 2.00; 95% confidence interval, 1.29-3.10), or experienced >1 shift in strain (odds ratio, 1.99; 95% confidence interval, 1.46-2.71) had roughly twice the odds of reporting greater lower urinary tract symptoms and impact. Underutilization of healthcare and comorbidities mediated the association between difficulty paying for medical care and lower urinary tract symptoms and impact. In the structural equation model, difficulty paying for medical care and underutilization of care were associated (β=.31; P<.01), as was underutilization of care and greater lower urinary tract symptoms and impact (β=.09; P<.01). Moreover, difficulty paying for medical care and the comorbidity index were associated (β=.34; P<.01), as was the comorbidity index and greater lower urinary tract symptoms and impact (β=.24; P<.01). Collectively, these mediation pathways eliminated a direct association between difficulty paying for medical care and lower urinary tract symptoms and impact.

CONCLUSION

Underutilization of healthcare and comorbidities explained an association between financial strain (difficulty paying for medical care) and lower urinary tract symptoms and impact. Research is needed to confirm the findings and examine other mechanisms that may further explain the association. Accumulated evidence may inform future policies and practices.

Discrimination and bladder health among women in the CARDIA cohort study: Life course and intersectionality perspectives

OBJECTIVE

This study examines whether discriminatory experiences are associated with lower urinary tract symptoms (LUTS) and their impact among 972 women in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort study, which recruited participants from 4 cities in the United States.

METHOD

Exposure to discrimination was assessed 3 times (1992-93, 2000-01, 2010-11) and averaged across assessments. Participants separately reported whether they experienced discrimination on the basis of their gender, race or color, and socioeconomic position or social class. For each social identity, discrimination was assessed in 6-7 settings (e.g., when getting a job, medical care, or housing). At different time points, women who reported discriminatory experiences for a given social identity were asked how frequently the discrimination occurred and how stressful experience(s) were. Following the 2010-11 assessment, data on LUTS and their impact were collected. Women were classified into bladder health versus mild, moderate, or severe symptoms/impact clusters.

RESULTS

More Black than White women reported discriminatory experiences across all social identities and most settings. Perceived stress of discriminatory experiences did not differ between Black and White women. In analyses stratified by race and social identity, White women reported LUTS/impact with discriminatory experiences in more settings, more frequent discriminatory experiences across settings, and each additional social identity for which discrimination was experienced. Black women reported LUTS/impact with more frequent discriminatory experiences across settings. For Black women, greater perceived stress of both gender and race discrimination were associated with LUTS/impact. For White women, only greater perceived stress of race discrimination was associated with LUTS/impact.

CONCLUSIONS

This is one of the first studies to examine discrimination in relation to LUTS/impact. Additional research is needed to better understand differences in how discriminatory experiences based on potentially intersecting identities may be related to bladder health among women.

A review of HPV and HBV vaccine hesitancy, intention, and uptake in the era of social media and COVID-19

Prior to the COVID-19 pandemic, the World Health Organization named vaccine hesitancy as one of the top 10 threats to global health. The impact of hesitancy on the uptake of human papillomavirus (HPV) vaccines was of particular concern, given the markedly lower uptake compared to other adolescent vaccines in some countries, notably the United States. With the recent approval of COVID-19 vaccines, coupled with the widespread use of social media, concerns regarding vaccine hesitancy have grown. However, the association between COVID-related vaccine hesitancy and cancer vaccines such as HPV is unclear. To examine the potential association, we performed two reviews using Ovid Medline and APA PsychInfo. Our aim was to answer two questions: (1) Is COVID-19 vaccine hesitancy, intention, or uptake associated with HPV or hepatitis B (HBV) vaccine hesitancy, intention, or uptake? and (2) Is exposure to COVID-19 vaccine misinformation on social media associated with HPV or HBV vaccine hesitancy, intention, or uptake? Our review identified few published empirical studies that addressed these questions. Our results highlight the urgent need for studies that can shift through the vast quantities of social media data to better understand the link between COVID-19 vaccine misinformation and disinformation and its impact on uptake of cancer vaccines.

Trajectories of depressive symptoms over 20 years and subsequent lower urinary tract symptoms and impact among women

OBJECTIVE

The aim of the study is to examine the association between depressive symptoms and subsequent lower urinary tract symptoms (LUTS) and impact (a composite outcome) among women (N = 1,119) from the Coronary Artery Risk Development in Young Adults study.

METHODS

The Center for Epidemiologic Studies-Depression Scale (CES-D) was administered in 1990-1991 and every 5 years through 2010-2011. In 2012-2013, LUTS and impact data were collected for the first time. Accumulation of risk was examined in the following three ways: (1) mean CES-D score across 20 years (5 observations); (2) depressive symptom trajectory group, determined by group-based trajectory modeling; and (3) intercepts and slopes obtained from women's individual CES-D score trajectories through two-stage mixed effects modeling. For each approach, ordinal logistic regression analyses examined odds of having "greater LUTS/impact" for each unit change in a depressive symptom variable.

RESULTS

(1) With each one-unit increase in mean CES-D score over the 20-year period, women were 9% more likely to report greater LUTS/impact (odds ratio [OR] = 1.09, 95% CI = 1.07-1.11). (2) In comparison with women with consistently low depressive symptoms, women with consistently threshold depression or consistently high depressive symptoms were twice (OR = 2.07, 95% CI = 1.59-2.69) and over five times (OR = 5.55, 95% CI = 3.07-10.06) as likely, respectively, to report greater LUTS/impact. (3) Women's individual symptom intercept and slope interacted. Increases in depressive symptoms across 20 years (greater slopes) were associated with greater LUTS/impact when women's initial CES-D score (intercept) was in the moderate-to-high range relative to the sample.

CONCLUSIONS

Depressive symptoms over 20 years, examined with different degrees of nuance, were consistently associated with subsequently measured LUTS and impact.

But He Loves Me: Teens' Comments about Healthy and Unhealthy Romantic Relationships

Romantic relationships can positively affect adolescent development. However, adolescents may not always have a clear understanding of what healthy dating looks like, which may place some adolescents at risk for dating violence. The present study examined the following research questions: (1) What are adolescents' perceptions of healthy and unhealthy attributes of romantic relationships? (2) How do adolescents perceive jealousy and potentially controlling behaviors? (3) What is the relationship between adolescents' attitudes towards jealousy and controlling behaviors and their willingness to intervene in a peer's unhealthy romantic relationship? The study included a predominantly female, ethnically diverse sample of 72 adolescents (M = 17.5 years) who participated in an internet-based health promotion intervention that allowed peers and health educators to interact. Adolescents commented on message boards and completed a survey. Findings showed that adolescents can articulate both healthy and unhealthy romantic relationship attributes. Some adolescents struggled to understand relationship attributes including jealousy and possessiveness, as these behaviors can be perceived as expressions of strong romantic interest. Adolescents may benefit from programs that strengthen healthy dating behaviors, teach youth to distinguish healthy from unhealthy behaviors, address conflict in respectful ways, and tactfully intervene when they witness abusive behaviors in the relationships of others.

Development of a tool to assess bladder health knowledge, attitudes, and beliefs (BH-KAB)

INTRODUCTION

Few instruments measure knowledge, attitudes, and beliefs (KAB) related to bladder health. Existing questionnaires have predominantly focused on KAB related to specific conditions such as urinary incontinence, overactive bladder, and other pelvic floor disorders. To address this literature gap, the Prevention of Lower Urinary Tract Symptoms (PLUS) research consortium developed an instrument that is being administered in the baseline assessment of the PLUS RISE FOR HEALTH longitudinal study.

METHODS

The bladder health knowledge, attitudes, and beliefs (BH-KAB) instrument development process consisted of two phases, item development and evaluation. Item development was guided by a conceptual framework, review of existing KAB instruments, and a review of qualitative data from the PLUS consortium Study of Habits, Attitudes, Realities, and Experiences (SHARE). Evaluation comprised three methods to assess content validity and reduce and refine items: q-sort, e-panel survey, and cognitive interviews.

RESULTS

The final 18-item BH-KAB instrument assesses self-reported bladder knowledge; perceptions of bladder function, anatomy, and related medical conditions; attitudes toward different patterns of fluid intake, voiding, and nocturia; the potential to prevent or treat urinary tract infections and incontinence; and the impact of pregnancy and pelvic muscle exercises on bladder health.

CONCLUSION

The PLUS BH-KAB instrument may be used independently or in conjunction with other KAB instruments for a more comprehensive assessment of women's KAB related to bladder health. The BH-KAB instrument can inform clinical conversations, health education programming, and research examining potential determinants of bladder health, LUTS, and related behavioral habits (e.g., toileting, fluid intake, pelvic muscle exercises).

RISE FOR HEALTH: Rationale and protocol for a prospective cohort study of bladder health in women

INTRODUCTION

The spectrum of bladder health and the factors that promote bladder health and prevent lower urinary tract symptoms (LUTS) among women are not well understood. This manuscript describes the rationale, aims, study design, sampling strategy, and data collection for the RISE FOR HEALTH (RISE) study, a novel study of bladder health in women conducted by the Prevention of Lower Urinary Tract Symptom (PLUS) Research Consortium.

METHODS AND RESULTS

RISE is a population-based, multicenter, prospective longitudinal cohort study of community-dwelling, English- and Spanish-speaking adult women based in the United States. Its goal is to inform the distribution of bladder health and the individual factors (biologic, behavioral, and psychosocial) and multilevel factors (interpersonal, institutional, community, and societal) that promote bladder health and/or prevent LUTS in women across the life course. Key study development activities included the: (1) development of a conceptual framework and philosophy to guide subsequent activities, (2) creation of a study design and sampling strategy, prioritizing diversity, equity, and inclusion, and (3) selection and development of data collection components. Community members and cross-cultural experts shaped and ensured the appropriateness of all study procedures and materials. RISE participants will be selected by simple random sampling of individuals identified by a marketing database who reside in the 50 counties surrounding nine PLUS clinical research centers. Participants will complete self-administered surveys at baseline (mailed paper or electronic) to capture bladder health and LUTS, knowledge about bladder health, and factors hypothesized to promote bladder health and prevent LUTS. A subset of participants will complete an in-person assessment to augment data with objective measures including urogenital microbiome specimens. Initial longitudinal follow-up is planned at 1 year.

DISCUSSION

Findings from RISE will begin to build the necessary evidence base to support much-needed, new bladder health promotion and LUTS prevention interventions in women.

Interpersonal Stressors and Resources for Support: Associations with Lower Urinary Tract Symptoms and Impact Among Women

Background: This study utilizes Coronary Artery Risk Development in Young Adults (CARDIA) data to examine whether women's perceived emotional support and interpersonal stressors are associated with lower urinary tract symptoms (LUTS) and their impact on quality of life. Materials and Methods: Emotional support was assessed at baseline/year 0 (1985-86), year 2 (1987-88), year 15 (2000-01), and year 20 (2005-06); interpersonal stressors were assessed at years 15 and 20. In 2012-13, LUTS and impact were assessed. LUTS/impact category (a composite variable ranging from bladder health to mild, moderate, and severe LUTS/impact) was regressed on trajectory groups of emotional support from years 0 to 20. Separately, LUTS/impact was regressed on mean emotional support and interpersonal stressors across years 15-20. Analyses were adjusted for age, race, education, and parity (n = 1104). Results: In comparison to women whose support trajectory from years 0 to 20 was consistently high, women whose support decreased from high to low had over twice the odds (odds ratio [OR] = 2.72; 95% confidence interval [CI] = 1.76-4.20) of being classified into a more burdensome LUTS/impact category. Mean support and interpersonal stressors across years 15-20 were independently associated with lower odds (OR = 0.59; 95% CI = 0.44-0.77) and greater odds (OR = 1.52; 95% CI = 1.19-1.94), respectively, of being classified into a more burdensome LUTS/impact category. Conclusions: In the CARDIA cohort, quality of women's interpersonal relationships, assessed between 1985-86 and 2005-06, was associated with LUTS/impact assessed in 2012-13. Additional research collecting LUTS/impact data at multiple time points is needed to test potential bidirectional associations of emotional support and interpersonal stressors with LUTS/impact, as well as potential mechanisms of association.

Sexual Health Behaviors by Age 17 and Lower Urinary Tract Symptoms at Age 19: PLUS Research Consortium Analysis of ALSPAC Data

PURPOSE

We examined how antecedent sexual health factors affect lower urinary tract symptoms (LUTS) in adolescent women.

METHODS

We analyzed 1,941 adolescent women from the Avon Longitudinal Study of Parents and Children at age 19. At ages 15 and 17, participants reported use of oral contraceptives (OCs), history of sexual intercourse, number of sexual partners, and condom use. At age 19, The Bristol Female Lower Urinary Tract Symptoms questionnaire quantified the frequency over the past month: stress incontinence, any incontinence, urgency, sensation of incomplete emptying, bladder pain, and urinary tract infection. Multivariable regression models examined associations between sexual health behaviors reported at ages 15 and 17 and six LUTS reported at age 19, after controlling for covariates.

RESULTS

Commonly reported LUTS at age 19 were past-month stress incontinence (26.8%), bladder pain (26.3%), any urine leakage (22.1%), and urinary tract infection (15.4%). OC use by age 17 was associated with urgency (odds ratio [OR] = 1.62, 95% confidence interval [CI] 1.19-2.20), incomplete emptying (OR = 1.62, 95% CI = 1.17-2.26), bladder pain (OR = 1.45, 95% CI = 1.15-1.83), and urinary tract infections (OR = 1.68, 95% CI = 1.28-2.21) at age 19 after adjustment for covariates. However, associations were attenuated after adjustment for condom use and number of sexual partners. Sexual intercourse by age 17 was associated with 1.53-2.65 increased odds of LUTs categories except incontinence, with lower confidence interval boundaries > 1.0. Associations were stronger among women with ≥ 3 sexual partners (vs. 0) by age 17.

DISCUSSION

We found longitudinally assessed associations between OC use, sexual intercourse, and number of sexual partners during adolescence and LUTS at age 19.

Contextual and Behavioral Correlates of Coping Strategies Among an Ethnically Diverse Sample of Urban Adolescents in the Midwestern United States

Coping is recognized as an important life skill. In the present cross-sectional analysis, early adolescents' relationships with their caregivers (support, conflict) and exposure to stressors (uncontrollable life events, violence) were examined as contextual correlates of both positive and negative coping strategies. Coping strategies were examined as mediators of associations between adolescents' family and community contexts and adjustment outcomes (externalizing symptoms, internalizing symptoms, academic investment). Participants were recruited from an urban Pre-K-8 school and Boys and Girls Club. Adolescents who reported greater support from caregivers reported greater engagement in all forms of positive coping (behavioral/problem-focused coping, cognitive/emotion-focused coping, and coping through seeking support); they also reported less engagement in coping through anger and helplessness. Adolescents who reported greater conflict with caregivers or violence exposure reported greater engagement in coping through avoidance, anger, and helplessness. Problem-focused coping, coping through anger, and coping through helplessness mediated associations between different contextual factors and outcomes.

Sexual and reproductive health during international travel: Expectations and experiences among female university students

ObjectiveTo evaluate female students' expectations and experiences related to their sexual and reproductive health (SRH) during international travel. Participants: Female students from a US university with a history of sex with men completed a cross-sectional survey about their upcoming (Pre-travelers; n = 170) or recent (Travelers; n = 340) international travel. Methods: Descriptive statistics were used to characterize pre-travel SRH expectations (for Pre-travelers) and to determine the prevalence of 15 SRH experiences during both recent and lifetime travel (for Travelers). Results: Pre-travelers overwhelmingly expected to be abstinent and many were unsure of whether SRH supplies would be accessible in their destination. During Travelers' recent trip, SRH experiences included getting off schedule with contraception (30%), unwanted sexual touching (18%), new male sex partners (17%), and unexpected sex (15%); lifetime prevalence estimates were higher. Conclusions: International travel poses risks to female students' SRH that can be addressed by pre-travel counseling from study-abroad programs and clinicians.

A multisite focus group study of US adult women's beliefs and assumptions about bladder health and function

AIMS

This analysis explored and characterized the ideas adult women have about how the bladder works, the assumptions guiding their bladder-related behaviors, and the beliefs they hold about how their behaviors affect bladder health.

METHODS

This was a directed content analysis of qualitative data from the Study of Habits, Attitudes, Realities, and Experiences, a focus group study conducted at seven United States research centers (July 2017 to April 2018). Participants were 316 adult women organized by four age categories (age range: 18-93 years). Analysis and interpretation focused on the "bladder assumptions and beliefs" code using a transdisciplinary lens and inductive approach.

RESULTS

During their focus group discourse, participants exhibited a speculative mode of thinking about bladder health and function characterized by uncertainty about how the bladder works. They described the bladder as a mechanism for cleansing the body of impurities, viewing it as part of a larger interconnected bodily system to enable the body to stay healthy. They saw it as susceptible to anatomical changes, such as those related to pregnancy and aging. The women also postulated perceived relationships between bladder function and several health behaviors, including eating healthy foods, staying hydrated, engaging in physical activity and exercise, and adopting specific toileting and hygiene practices.

CONCLUSIONS

The findings underscore the importance of guidance from healthcare professionals and systematic community based educational programs for promoting women's understanding about bladder health and empowering them to exert agency to engage in healthy bladder behaviors.

Noncancerous Genitourinary Conditions as a Public Health Priority: Conceptualizing the Hidden Burden

OBJECTIVE

To provide a conceptual framework to guide investigations into burdens of noncancerous genitourinary conditions (NCGUCs), which are extensive and poorly understood.

METHODS

The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop of diverse, interdisciplinary researchers and health professionals to identify known and hidden burdens of NCGUCs that must be measured to estimate the comprehensive burden. Following the meeting, a subgroup of attendees (authors of this article) continued to meet to conceptualize burden.

RESULTS

The Hidden Burden of Noncancerous Genitourinary Conditions Framework includes impacts across multiple levels of well-being and social ecology, including individual (ie, biologic factors, lived experience, behaviors), interpersonal (eg, romantic partners, family members), organizational/institutional (eg, schools, workplaces), community (eg, public restroom infrastructure), societal (eg, health care and insurance systems, national workforce/economic output), and ecosystem (eg, landfill waste) effects. The framework acknowledges that NCGUCs can be a manifestation of underlying biological dysfunction, while also leading to biological impacts (generation and exacerbation of health conditions, treatment side effects).

CONCLUSION

NCGUCs confer a large, poorly understood burden to individuals and society. An evidence-base to describe the comprehensive burden is needed. Measurement of NCGUC burdens should incorporate multiple levels of well-being and social ecology, a life course perspective, and potential interactions between NCGUCs and genetics, sex, race, and gender. This approach would elucidate accumulated impacts and potential health inequities in experienced burdens. Uncovering the hidden burden of NCGUCs may draw attention and resources (eg, new research and improved treatments) to this important domain of health.

Sex in the Context of Substance Use: A Study of Perceived Benefits and Risks, Boundaries, and Behaviors among Adolescents Participating in an Internet-Based Intervention

Little research has examined adolescents' perspectives of sex with substance use. This study examined (1) adolescents' perceived benefits and risks of sex with substance use, as well as boundaries; (2) the potential for positive and negative social influences among adolescents when they discuss these topics; and (3) whether exposure to health-promoting content is associated with trajectories of sex with substance use over a 6-month period. To address the first two objectives, 176 comments were analyzed from 71 adolescents (90% female) aged 14-18 years who participated in an Internet-based sexual health promotion intervention and posted to at least one message board addressing sex with substance use. Adolescents' perceived benefits and risks of sex with substance use primarily reflected concern for the experience of sex in the moment; perceived risks and boundaries primarily reflected concern for the ability to develop and maintain meaningful relationships. Comments of 63% and 22% of adolescents, respectively, were evaluated to have potential for health-promoting and risk-promoting social influence. To address the third objective, trajectories of self-reported sex with substance use were compared between 89 intervention and 54 control participants. No significant differences were observed. However, a dose-response effect was observed; intervention participants who completed less than one third of assigned tasks reported increases in sex with alcohol or marijuana use over time, while no marked changes or much smaller changes in sex with substance use were observed among intervention participants who completed one third or more tasks. Implications for prevention and intervention programs are discussed.

Race-related Stressors and Resources for Resilience: Associations With Emotional Health, Conduct Problems, and Academic Investment Among African American Early Adolescents

OBJECTIVE

African American youths in the United States grow up in a society with a long, pervasive, and living history of interpersonal and institutional racism. This study examined whether race-related stressors (awareness and experiences of racism) and resources for resilience (racial-ethnic connectedness and perceptions of embedded achievement) were associated with emotional health, conduct problems, and academic investment among African American early adolescents. Embedded achievement is the belief that achievement is a part of one's racial or ethnic group identity.

METHOD

Participants were recruited from an urban school and youth club (N = 75, mean age = 11.6 years, 71% male participants). Structured interviews were administered to youths.

RESULTS

Adjusting for age and sex, racial-ethnic connectedness and embedded achievement were associated with fewer emotional problems and conduct problems. In addition, embedded achievement was associated with greater academic investment. Racial-ethnic connectedness modified associations between awareness and experiences of racism and emotional problems; racism was associated with more emotional problems, but only among youths with lower levels of racial-ethnic connectedness. Youths' perceptions of embedded achievement modified an association between experiences of racism and conduct problems; experiences of racism were associated with more conduct problems, but only among youths with lower perceptions of embedded achievement.

CONCLUSION

Race-related resources for resilience appear to promote emotional, behavioral, and academic well-being among African American youths and to confer protection when youths are confronted with the stress and adversity of racism. Health professionals can advocate for policies and practices to combat racism and to foster racial pride and connectedness among youths of color.

Communication about Sexual Consent and Refusal: A Learning Tool and Qualitative Study of Adolescents' Comments on a Sexual Health Website

Sexual communication skills are needed to create healthy romantic relationships. Arguably, these skills also can be used to prevent some instances of unwanted sex. This study presents a qualitative analysis of adolescents' comments after reading a teen-friendly article on sexual consent as part of a web-based sexual health promotion intervention. The sample was comprised predominantly of female adolescents recruited from a Midwest urban region in the United States. Adolescents varied with respect to self-efficacy to request, provide, and deny consent, as well as the perceived need to ask for consent in the context of established relationships. Many adolescents perceived that nonverbal methods of communication were sufficient to request, provide, or deny sexual consent. Factors that make it difficult to discuss sexual boundaries and say "no" to unwanted sex included low self-efficacy and an underlying desire to nurture or preserve a relationship. Cultural norms must be changed to support verbal, affirmative sexual consent. In addition, adolescents must be aided in the development of skills to request sexual consent, say "yes" to specific activities, and say "no" to others. Without supportive norms and skills to enhance self-efficacy, adolescents may be unwilling to engage in verbal communication about sexual consent and boundaries.

Characterizing the Spectrum of Bladder Health and Lower Urinary Tract Symptoms (LUTS) Among Women: Results From the CARDIA Study

OBJECTIVES

To operationalize a new definition for bladder health, we examined the distribution of lower urinary tract symptoms (LUTS) and impact, along with associated factors, among women in the Coronary Artery Risk Development in Young Adults (CARDIA) study.

METHODS

We performed cluster analyses using validated LUTS symptom burden and impact scales collected between 2005-2006 and 2010-2011. We performed multinomial logistic regression analyses to evaluate cardiovascular factors (metabolic syndrome, cardiovascular health behaviors, and inflammation) between clusters after adjusting for covariates (demographic, obstetric/gynecologic, co-morbidities).

RESULTS

Among CARDIA women (median age 51, range 42-59) with complete LUTS data (n = 1302), we identified and compared 4 cluster groups: women who reported no or very mild symptoms and no impact on well-being (bladder health, 44%, n = 569), versus women with LUTS and negative impact on well-being ranging from mild (31%, n = 407), moderate (20%, n = 259), to severe (5%, n = 67). With each 1-point lower BMI (kg/m2), odds of membership in mild (OR 0.97, CI 0.95-0.99), moderate (OR 0.95, CI 0.93-0.98), and severe (OR 0.90, CI 0.88-0.94) LUTS cluster groups versus the bladder health group were lower. Compared to women with metabolic syndrome, women without metabolic syndrome had lower odds of membership in mild (OR 0.67, CI 0.45-0.99), moderate (OR 0.51, CI 0.33-0.79), and severe (OR 0.48, CI 0.24-0.94) LUTS cluster groups versus the bladder health group.

CONCLUSION

Two out of 5 midlife women met our definition of bladder health. Bladder health and cardiovascular health among women may share common factors, including lower BMI and the absence of metabolic syndrome.

Female Genital Cutting and Deinfibulation: Applying the Theory of Planned Behavior to Research and Practice

At least 200 million girls and women across the world have experienced female genital cutting (FGC). International migration has grown substantially in recent decades, leading to a need for health care providers in regions of the world that do not practice FGC to become knowledgeable and skilled in their care of women who have undergone the procedure. There are four commonly recognized types of FGC (Types I, II, III, and IV). To adhere to recommendations advanced by the World Health Organization (WHO) and numerous professional organizations, providers should discuss and offer deinfibulation to female patients who have undergone infibulation (Type III FGC), particularly before intercourse and childbirth. Infibulation involves narrowing the vaginal orifice through cutting and appositioning the labia minora and/or labia majora, and creating a covering seal over the vagina with appositioned tissue. The WHO has published a handbook for health care providers that includes guidance in counseling patients about deinfibulation and performing the procedure. Providers may benefit from additional guidance in how to discuss FGC and deinfibulation in a manner that is sensitive to each patient's culture, community, and values. Little research is available to describe decision-making about deinfibulation among women. This article introduces a theoretically informed conceptual model to guide future research and clinical conversations about FGC and deinfibulation with women who have undergone FGC, as well as their partners and families. This conceptual model, based on the Theory of Planned Behavior, may facilitate conversations that lead to shared decision-making between providers and patients.

Understanding Women's Responses to Sexual Pain After Female Genital Cutting: An Integrative Psychological Pain Response Model

The World Health Organization estimates that over 200 million women and girls have experienced female genital cutting (FGC). Many women and girls who have undergone FGC have migrated to areas of the world where providers are unfamiliar with the health needs associated with FGC. Both providers in Western healthcare systems and female immigrant and refugee patients report communication difficulties leading to distrust of providers by women who have experienced FGC. Sexual pain is one common problem requiring discussion with healthcare providers and possible intervention. Yet, existing clinical and research literature provides little guidance for assessment and intervention when sexual pain is a result of FGC. Several conceptual frameworks have been developed to conceptualize and guide treatments for other types of pain, such as back pain and headaches. In this article, we integrate four prominent models-the fear avoidance model, eustress endurance model, distress endurance model, and pain resilience model-to conceptualize sexual pain in women who have experienced FGC. The resulting integrative psychological pain response model will aid in providing culturally responsive clinical management of sexual pain to women who have experienced FGC. This integrative model also provides a theoretical foundation for future research in this population.

School Toileting Environment, Bullying, and Lower Urinary Tract Symptoms in a Population of Adolescent and Young Adult Girls: Preventing Lower Urinary Tract Symptoms Consortium Analysis of Avon Longitudinal Study of Parents and Children

OBJECTIVES

To examine whether the school toilet environment at age 13, including bullying at toilets, is associated with female lower urinary tract symptoms (LUTS) at ages 13 and 19, as little is known about the association among school toilet environment, voiding behaviors, and LUTS in adolescent girls.

METHODS

The sample comprised 3962 female participants from the Avon Longitudinal Study of Parents and Children. At age 13, participants reported on 7 school toilet environment characteristics and a range of LUTS items. At age 19, participants completed the Bristol Female Lower Urinary Tract Symptoms questionnaire.

RESULTS

All toilet environmental factors were associated with at least 1 LUTS outcome at age 13. Holding behavior was associated with all school toilet environmental factors, with odds ratios ranging from 1.36 (95% confidence interval [CI]: 1.05, 1.76) for dirty toilets to 2.38 (95% CI: 1.60, 3.52) for feeling bullied at toilets. Bullying was associated with all daytime LUTS symptoms and nocturia; odds ratios ranged from 1.60 (95% CI: 1.04, 2.07) for nocturia to 2.90 (95% CI: 1.77, 4.75) for urgency. Associations between age 13 school toilets and age 19 LUTS were in the same direction as age 13 LUTS.

CONCLUSION

This is the first examination of associations between school toilets and LUTS. Toileting environments were cross-sectionally associated with LUTS in adolescent girls. While further work is needed to determine whether these associations are causal, school toilet environments are modifiable and thus a promising target for LUTS prevention.

Social Processes Informing Toileting Behavior Among Adolescent and Adult Women: Social Cognitive Theory as an Interpretative Lens

Little is known about social processes shaping adolescent and adult women's toileting behaviors. The "Study of Habits, Attitudes, Realities, and Experiences" (SHARE) examines adolescent and adult women's experiences related to bladder health across the life course. Forty-four focus groups with 360 participants organized by six age groups were conducted across seven sites. A transdisciplinary team used social cognitive theory as an interpretive lens across a five-stage analysis. The act of observing was identified as the overarching social process informing women's toileting behaviors in three ways: (a) observing others' toileting behavior, (b) being aware that one's own toileting behaviors are monitored by others, and (c) observing oneself relative to others. We found that underlying processes of toileting behaviors, seemingly private are, in fact, highly social. We suggest, given this social embeddedness that health promotion efforts should leverage interpersonal networks for "social norming" interventions and policies to promote healthy toileting behaviors.

Development of Conceptual Models to Guide Public Health Research, Practice, and Policy: Synthesizing Traditional and Contemporary Paradigms

This applied paper is intended to serve as a "how to" guide for public health researchers, practitioners, and policy makers who are interested in building conceptual models to convey their ideas to diverse audiences. Conceptual models can provide a visual representation of specific research questions. They also can show key components of programs, practices, and policies designed to promote health. Conceptual models may provide improved guidance for prevention and intervention efforts if they are based on frameworks that integrate social ecological and biological influences on health and incorporate health equity and social justice principles. To enhance understanding and utilization of this guide, we provide examples of conceptual models developed by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium. PLUS is a transdisciplinary U.S. scientific network established by the National Institutes of Health in 2015 to promote bladder health and prevent lower urinary tract symptoms, an emerging public health and prevention priority. The PLUS Research Consortium is developing conceptual models to guide its prevention research agenda. Research findings may in turn influence future public health practices and policies. This guide can assist others in framing diverse public health and prevention science issues in innovative, potentially transformative ways.

Psychosocial Factors Influence Sexual Satisfaction among Women with Vulvodynia

Vulvodynia affects about 8% of women, many of whom report a negative impact on their ability to have sexually satisfying relationships. In this study, we examined predictors of sexual satisfaction in 207 women with clinically confirmed vulvodynia. We adapted a model examining resilience in chronic pain patients originally developed by Sturgeon and Zautra to include resilience factors (communication with partner about sexual health and coping strategies) and vulnerable factors (abuse history, pain intensity, rumination). These variables were regressed onto sexual satisfaction. In the full model, only emotion-based rumination was predictive of sexual satisfaction. Thus, focusing on emotion-based rumination in clinical intervention may improve sexual satisfaction.

Adolescent Women's Sexual Self-Efficacy: Associations with Personal and Perceived Partner Beliefs that Condoms Interfere with Pleasure

Sexual self-efficacy, an individual's confidence in the domain of sexual health behaviors, was studied among an ethnically diverse sample of 128 sexually active adolescent women between the ages of 14 and 18 years. A hypothesized interaction between women's belief that condoms interfere with sexual pleasure and her perception of a partner's belief that condoms interfere with sexual pleasure was not supported. Both adolescent women's belief that condoms interfere with pleasure and their perception that their partner believed condoms interfere with pleasure were separately associated with lower self-efficacy to refuse sex without condoms and use condoms. Both a partner's and one's own sexual pleasure may be important determinants of adolescent women's confidence to engage in health protective sexual behaviors. Adolescents' self-efficacy to experience pleasure when using condoms should be enhanced.

Is the juice worth the squeeze? Transdisciplinary team science in bladder health

AIMS

Prior research on lower urinary tract symptoms (LUTS) has focused on the treatment and management of these conditions with scant attention to prevention. The Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium was formed to address the complexities of preventing LUTS and promoting bladder health.

METHODS

Herein, we describe challenges faced and strategies used to develop the PLUS Research Consortium into an engaged and productive transdisciplinary scientific team. We apply four previously defined team science phases (development, conceptualization, implementation, and translation) to frame our progress.

RESULTS

Strategies to progress through the development phase included the generation of a shared mission, and valuing of other disciplinary perspectives. The conceptualization phase included generating a shared language and developing a team transdisciplinary orientation. During the implementation phase, the group developed roles and procedures and focused on conflict management. The translation phase includes continued refinement of the mission and goals, implementation of research protocols, and robust dissemination of the scientific work products related to bladder health.

CONCLUSION

A diverse group has matured into a productive transdisciplinary team science consortium. Achieving this outcome required dedicated effort for each member to engage in activities that often required more time than single discipline research activities. Provision of the necessary time and tools has fostered a transdisciplinary team science culture and rich research agenda that reflects the complexity of the health issue to be addressed. Our experience may be useful for others embarking on team science projects.

Applying concepts of life course theory and life course epidemiology to the study of bladder health and lower urinary tract symptoms among girls and women

AIMS

Although lower urinary tract symptoms (LUTS) may occur at different periods during the life course of women, a little research on LUTS has adopted a life course perspective. The purpose of this conceptual paper is to demonstrate how life course theory and life course epidemiology can be applied to study bladder health and LUTS trajectories. We highlight conceptual work from the Prevention of Lower Urinary Tract Symptoms Research Consortium to enhance the understanding of life course concepts.

METHODS

Consortium members worked in transdisciplinary teams to generate examples of how life course concepts may be applied to research on bladder health and LUTS in eight prioritized areas: (a) biopsychosocial ecology of stress and brain health; (b) toileting environment, access, habits, and techniques; (c) pregnancy and childbirth; (d) physical health and medical conditions; (e) musculoskeletal health; (f) lifestyle behaviors; (g) infections and microbiome; and (h) hormonal status across the life span.

RESULTS

Life course concepts guided consortium members' conceptualization of how potential risk and protective factors may influence women's health. For example, intrapartum interventions across multiple pregnancies may influence trajectories of bladder health and LUTS, illustrating the principle of life span development. Consortium members also identified and summarized methodologic and practical considerations in designing life course research.

CONCLUSIONS

This paper may assist researchers from a variety of disciplines to design and implement research identifying key risk and protective factors for LUTS and bladder health across the life course of women. Results from life course research may inform health promotion programs, policies, and practices.

International Travel as a Context for Sexual and Contraceptive Behaviors: A Qualitative Study of Young Women Traveling Outside the U.S

International travel is popular worldwide, yet its implications for sexual and reproductive health are not fully understood. Few studies have examined the contextual factors that shape women's sexual and contraceptive behaviors-and thus, their risk of unintended pregnancy and sexually transmitted infections (STIs)-while traveling outside their home country. In this qualitative study, female university students with recent (n = 25) or upcoming (n = 19) travel outside the U.S. completed semi-structured interviews from October 2015 to March 2017. Transcripts were analyzed for themes related to contraceptive and sexual behaviors: (1) participants' pre-travel expectations of sex; (2) the circumstances surrounding sexual encounters with men while traveling; (3) negotiation about condom and contraception use with partners; and (4) factors affecting contraceptive adherence. Participants generally expected to be abstinent during travel, citing myriad rationales that included personal values, no perceived opportunities for sex, and the nature of the trip. Some travelers had unexpected sexual encounters, involving health-protecting behaviors and risk-taking (e.g., unprotected sex, substance use). New sexual partnerships were fueled by increased attention from men, situational disinhibition, and perceived heightened intimacy. International travel brought many contraceptive considerations (adequacy of supplies, access to refrigeration, time zone differences, etc.) as well as obstacles that triggered contraceptive lapses and discontinuation. Pill users described the most challenges, while travelers using intrauterine devices expressed appreciation for their maintenance-free contraception. This study suggests complex associations between international travel and young women's sexual and reproductive health. Some travelers were more vulnerable to situational risk factors, while others may have been more insulated. We identify potential intervention opportunities via clinical services, education, and policy to reduce young women's risk of adverse sexual and reproductive health outcomes while traveling abroad. We urge greater recognition of and conversations about contraceptive lapse and unintended pregnancy as potential health risks for female travelers of reproductive age, just as clinical guidelines acknowledge travel-associated STI.

Laying the Foundation for Bladder Health Promotion in Women and Girls

Prevention strategies have been effective in many areas of human health, yet have not been utilized for lower urinary tract symptoms (LUTS) or bladder health (BH). This commentary outlines LUTS prevention research initiatives underway within the NIH-sponsored Prevention of Lower Urinary Tract Symptoms Research Consortium (PLUS). Prevention science involves the systematic study of factors associated with health and health problems, termed protective and risk factors, respectively. PLUS is enhancing traditional prevention science approaches through use of: (1) a transdisciplinary team science approach, (2) both qualitative and quantitative research methodology (mixed methodology), and (3) community engagement. Important foundational work of PLUS includes development of clear definitions of both BH and disease, as well as a BH measurement instrument that will be validated for use in the general population, adolescents, and Latinx and Spanish-speaking women.¹ The BH measurement instrument will be used in an upcoming nationally-representative cohort study that will measure BH and investigate risk and protective factors. PLUS investigators also developed a conceptual framework to guide their research agenda; this framework organizes a broad array of candidate risk and protective factors that can be studied across the life course of girls and women.¹ As PLUS begins to fill existing knowledge gaps with new information, its efforts will undoubtedly be complemented by outside investigators to further advance the science of LUTS prevention and BH across additional populations. Once the BH community has broadened its understanding of modifiable risk and protective factors, intervention studies will be necessary to test LUTS prevention strategies and support public health efforts. LUTS providers may be able to translate this evolving evidence for individual patients under their care and act as BH advocates in their local communities.

Designing a Mobile App to Enhance Parenting Skills of Latinx Parents: A Community-Based Participatory Approach

Background

Latinx families are among the highest users of smartphones, yet few health-focused Web programs have been developed for this audience. Parent-based smartphone apps designed for Latinx families may help increase access to evidence-informed parenting programming and ultimately reduce health disparities among children and adolescents. To maximize uptake of such apps, the Center for eHealth Research and Disease Management (CeHRes) Roadmap for electronic health (eHealth) development recommends 5 phases of development: (1) contextual inquiry, (2) value specification, (3) design, (4) operationalization, and (5) evaluation.

Objective

Guided by the CeHRes Roadmap, our objective was to apply a community-based participatory research (CBPR) approach to mobile app development. We present a formative evaluation to inform the design of an eHealth mobile app for Latinx parents of adolescents based on a face-to-face parenting program, Padres Informados/Jovenes Preparados (PIJP).

Methods

Community participants in the process included Latinx parents and stakeholders. We conducted a parent survey (N=115) and interviews (N=20) to understand the context and obtain feedback on a mockup and prototype of the app, facilitator workshops to streamline content, and stakeholder interviews (N=4) to discuss values and app requirements.

Results

We report results from the first 3 phases of the CeHRes Roadmap. In the survey, 96.5% (111/115) of parents reported they had access to a cell phone, 85.6% (89/104) reported they would use a parenting app in the next month if they had access, and 80.2% (89/111) reported intentions to use a stress reduction app. Parents reported that setting goals about parenting and tracking those goals were important potential features of an app. In logistic regression analyses, technology attitudes and barriers were not related to parent’s intentions to use a parenting mobile app (95% CI 0.51-1.17 and 95% CI 0.28-2.12, respectively). Qualitative interviews confirmed Latinx parents’ technology engagement and desire for education and child development information online. Stakeholder interviews identified 3 community values: familism, the promotion of adolescent health, and delivery of economic value. Community stakeholders participated in defining the mobile app requirements. On the basis of community and parent input, the mobile app prototype was designed with 3 sections: (1) 8 modules of video-based parenting skills instruction with content from the face-to-face PIJP program, (2) breath rate information from a wearable device to support awareness of stress levels that could affect parenting, and (3) goal setting and tracking capacities.

Conclusions

The findings of this study highlight the utility of an iterative, participatory design process. The CBPR approach and community collaboration enhanced the CeHRes Roadmap by promoting power sharing, facilitating recruitment, and building trust among community members. Experiences applying community research to the initial 3 phases of the CeHRes Roadmap in a Latinx community are discussed, along with plans for the 2 final phases.

I never knew anyone who peed on themselves on purpose: Exploring adolescent and adult women's lay language and discourse about bladder health and function

AIMS

This analysis explored and characterized adolescent and adult women's lay language and discourse related to bladder health/function.

METHODS

Forty-four focus groups were conducted across seven United States research centers with 360 adolescents and adult women, organized by six age categories. Multilevel content analyses classified emergent themes. A transdisciplinary lens and inductive approach guided data interpretation. Interpretive insights were validated by a community engagement panel.

RESULTS

A repertoire of bladder function terms emerged, including explicit functional terms, formal and polite euphemistic terms, and informal familiar terms, as well as cultural and regional metaphors and idioms. Terminology usage was historically grounded, developmental, and cumulative across the life course. Lay discourse was contextual and affectively valent, suggesting unspoken, commonly understood, situation-based "rules" for talking about bladder function. Discourse appeared to be siloed within family and friendship circles. Adolescents and adult women often described, rather than named, bladder sensations or problems. Terminology for bladder issues tended to minimize severity and frequency, with medical language only relevant to extreme examples and not applicable to mild episodes.

CONCLUSIONS

A definitional discordance between medical and lay views of bladder problems was identified, signifying a need to clarify the meaning of medical terms for lay persons. Adolescents and adult women do not have or use standardized precise terminology for bladder health and function, relying instead on social convention and interpersonal context. Findings can be used to foster shared understandings between lay persons and health professionals, informing development of clinical, research, and public health initiatives to promote bladder health.

Homelessness experiences and gender identity in a population-based sample of adolescents

This paper examines the prevalence of homelessness among transgender/gender diverse (TGD) youth in a population-based sample of adolescents. We used data from a statewide sample of 9th and 11th grade adolescents in Minnesota who responded to a school-based survey during 2016 (N = 80,929). Survey questions assessed adolescents' gender identity and experiences of homelessness (either with adult family members or unaccompanied) in the past 12 months. We used chi-square analyses to compare the prevalence of homelessness between gender identity groups. Overall, 2.7% of the sample reported identifying as TGD. Significantly more TGD (vs. cisgender) youth reported experiencing homelessness either with adult family members (6.7% vs. 3.5%) or unaccompanied (3.6% vs. 1.1%; p < .0001). Findings from this population-based survey suggest that TGD youth are more likely to experience homelessness, either with a family member or unaccompanied, than cisgender peers. Ensuring housing stability among this population is critical, given health risks associated with homelessness during adolescence. Data on homelessness experiences of TGD youth are needed to inform practice and policies for this distinct population.

U.S. Adolescent and Adult Women's Experiences Accessing and Using Toilets in Schools, Workplaces, and Public Spaces: A Multi-Site Focus Group Study to Inform Future Research in Bladder Health

The World Health Organization recognizes access to clean and safe toilets as crucial for public health. This study explored U.S. adolescent and adult cisgender women's lived experiences accessing toilets in schools, workplaces, and public spaces. As part of the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium, we conducted 44 focus groups with female participants (n = 360; ages 11-93). Focus groups were stratified by age (11-14, 15-17, 18-25, 26-44, 45-64, 65+) and conducted across 7 geographically diverse U.S. sites from July 2017-April 2018. Using a transdisciplinary approach, we conducted conventional qualitative coding informed by our PLUS conceptual framework and used content analysis processes to identify salient themes. Across settings, toilet access was restricted by "gatekeepers" (i.e., individuals who control access to toilets). In contrast, self-restricting toilet use (deciding not to use the toilet despite biologic need to urinate) was based on internalized norms to prioritize school and job responsibilities over urination. In public spaces, self-restricting use was largely in response to lack of cleanliness. Across the life course, participants perceived gender disparities in the ability to easily access public toilets. Further research is needed to determine if and how these factors impact bladder health across the life course.

Prevention of Lower Urinary Tract Symptoms Research Consortium Focus Group Study of Habits, Attitudes, Realities, and Experiences of Bladder Health

AIM

The study purpose is to explore adolescent and adult women's experiences, perceptions, beliefs, knowledge and behaviors related to bladder health across the life course using a socioecological perspective. Lower urinary tract symptoms affect between 20-40% of young adult to middle-aged women, with symptoms increasing in incidence and severity with aging. There is limited evidence to address bladder health promotion and prevention of dysfunction. This first study of the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium is designed to address gaps in existing qualitative research in this area.

DESIGN

This focus group study will be implemented across seven geographically diverse United States research centers using a semi-structured focus group guide informed by a conceptual framework based on the socioecological model.

METHODS

The study was approved in July 2017. A total of 44 focus groups composed of 6-8 participants representing six different age categories (ranging from 11 to over 65 years) will be completed. We aim to recruit participants with diverse demographic and personal characteristics including race, ethnicity, education, socioeconomic status, urban/rural residence, physical/health conditions and urinary symptom experience. Up to 10 of these focus groups will be conducted in Spanish. Focus group transcripts will undergo content analysis and data interpretation to identify and classify themes and articulate emerging themes.

DISCUSSION

This foundational qualitative study seeks to develop an evidence base to inform future research on bladder health promotion in adolescent and adult women.

IMPACT

This study has the potential to provide new insights and understanding into adolescent and adult women's lived experience of bladder health, the experience of lower urinary symptoms and knowledge and beliefs across the life course. This article is protected by copyright. All rights reserved.

Relationships Between Adolescent Stress, Depressive Symptoms, and Sexual Risk Behavior in Young Adulthood: A Structural Equation Modeling Analysis

INTRODUCTION

This study examined longitudinal associations between stressful life events and depressive symptoms, assessed during two time points of adolescence, and sexual risk behavior, assessed during young adulthood.

METHODS

Structural equation modeling was conducted with three waves of data from the National Longitudinal Study of Adolescent to Adult Health.

RESULTS

Analyses revealed bidirectional relationships between stressful life events and depressive symptoms during the two time points of adolescence. Adolescent depressive symptoms indirectly affected young adult sexual risk behavior through adolescent stressful life events. Adolescent stressful life events during late adolescence were directly associated with young adult sexual risk behavior.

DISCUSSION

Findings highlight the need to screen for both depression and stressful life events during adolescence, to identify at-risk adolescents and deliver tailored interventions to prevent sexual risk behavior during young adulthood.

Pregnancy Prevention on the Fly: An Exploratory Study of Contraceptive Lapse Among Young Women Traveling Internationally

Background: International travel is increasingly popular, and women comprise half of all outbound travel from the United States (almost 46 million trips in 2017). The implications of international travel for women's reproductive health are not fully clear due to lack of data on travelers' contraceptive use. Methods: Women attending a U.S. university (n = 340) completed a cross-sectional survey in 2016-2017 about their sexual and reproductive health during recent international travel. Participants were 18-29 years old (mean: 21.1) and had a history of male sex partners. We calculated the prevalence of contraceptive lapse-nonadherence (e.g., missed pill) or having sex without contraception-by individual and travel-related characteristics and evaluated multivariable correlates of lapse using modified Poisson regression and prevalence ratios (PRs). Results: Prevalence of contraceptive lapse was 29% overall and especially high among pill users (50%). Multivariable correlates of lapse were the following: using the pill (PR 4.51, 95% confidence interval [CI] 2.57-7.94) compared to other or no contraception; trip duration of >30 days versus 1-7 days (PR 2.02, 95% CI 1.14-3.57); having trouble communicating with a male partner about contraception (PR 1.79, 95% CI 1.16-2.75); a high perceived impact of language barriers (PR 1.77, 95% CI 1.02-3.08); and perceiving local access to abortion as difficult (PR 1.67, 95% CI 1.22-2.27). There was a trend toward increased lapse prevalence among participants who had difficulty maintaining their contraceptive schedule while traveling across time zones (PR 1.38, 95% CI 1.00-1.91). Conclusions: During international travel, prevalence of contraceptive lapse varied by young women's chosen contraceptive method as well as travel-specific factors. Pretravel counseling by clinicians can help women anticipate contraceptive challenges and reduce the likelihood of unintended pregnancy.

Terminology for bladder health research in women and girls: Prevention of Lower Urinary Tract Symptoms transdisciplinary consortium definitions

AIM

To report research terminology and definitions for describing healthy bladder function among women and girls.

METHODS

The Prevention of Lower Urinary tract Symptoms (PLUS) Consortium developed research terminology and definitions for elements of healthy bladder function based on existing understanding of storage and emptying functions of the bladder and accepted definitions of lower urinary tract symptoms (LUTS). The novel concept of a bladder "bioregulatory" function was also proposed. Elements of bladder function corresponding to bladder health (BH) and LUTS were developed and refined using an iterative process. A comprehensive reference table structured by bladder function (Storage, Emptying, and Bioregulatory) and elements of each function was created to document proposed research terminology and definitions.

RESULTS

The BH research definitions for each bladder function are: (1) Storage: the ability to hold urine for a reasonable duration of time and sense bladder fullness without fear of or concern about urgency, discomfort or leakage; (2) Emptying: the ability to empty the bladder completely in a timely, efficient, effortless, comfortable manner; and (3) Bioregulatory: the bladder barrier protects the individual/host from pathogens, chemicals, and malignancy. Research definitions for seven Storage, seven Emptying, and three Bioregulatory elements of function are presented. Novel LUTS research definitions were developed when gaps in existing definitions were identified or nonclinical language was desired.

CONCLUSIONS

PLUS BH definitions reflect a transdisciplinary approach to standardizing research definitions for elements of bladder function from a perspective of health rather than dysfunction and provide a framework for studying BH in clinical practice, public health promotion, and LUTS prevention.

Early-life Chronic Stressors, Rumination, and the Onset of Vulvodynia

INTRODUCTION

Vulvodynia is a debilitating, chronic vulvar pain condition. Community-based case-control studies have consistently shown associations between early-life chronic stressors and vulvodynia onset.

AIM

We examined rumination as a specific stress response involved in the psychobiological mechanism of vulvodynia.

METHODS

A psychosocial survey with questions specific to early-life traumatic events and rumination were administered to 185 matched case-control pairs of women with and without vulvodynia. Conditional logistic regression was used to examine associations between rumination constructs (ie, total rumination, emotion-focused, instrumental, and searching for meaning) and vulvodynia onset. Conditional logistic regression was also used to determine whether these associations depended on early-life stressors (ie, severity of childhood abuse and of self-reported antecedent traumatic events). Age at interview, antecedent pain disorders, any childhood abuse, and antecedent psychiatric morbidity were included as covariates.

MAIN OUTCOME MEASURES

We estimated the odds of rumination in relation to the onset of vulvodynia within a community-based and clinically confirmed sample of women with and without vulvodynia.

RESULTS

Vulvodynia was associated with the highest tertile of emotion-focused (odds ratio [OR] = 2.1; 95% CI = 1.2, 3.2) and instrumental (OR = 2.1; 95% CI = 1.1, 4.0) rumination. These associations were attenuated after additional adjustment for antecedent psychiatric morbidity. Among women who reported rumination about early-life stressors before vulvar pain in cases or matched reference age in control subjects, those with vulvodynia were >2 times more likely to report the highest tertile of total rumination (OR = 2.3; 95% CI = 1.1, 5.0) compared with those without vulvodynia.

CLINICAL IMPLICATIONS

Healthcare providers may be able to identify subsets of women who could benefit from preventive measures before the development of vulvodynia.

STRENGTH & LIMITATIONS

This is the first study to use a community-based and clinically confirmed sample of women with and without vulvodynia to examine the associations between rumination about early-life trauma and the onset of vulvodynia. However, as with all retrospective studies, the reporting of information (eg, traumatic events) was subject to recall bias and misclassification.

CONCLUSION

Our findings indicate that a prolonged cognitive stress response (ie, rumination) may be 1 important mechanism by which early-life chronic stressors contribute to the onset vulvodynia. Prospective studies are recommended to examine whether and how cognitive, affective, and physiological components of prolonged stress responses interact to influence the development of vulvodynia. Understanding both the psychobiological and behavioral mechanisms may help in addressing and treating individuals to potentially reverse the development of vulvodynia. Khandker M, Brady SS, Rydell SA, et al. Early-life Chronic Stressors, Rumination, and the Onset of Vulvodynia. J Sex Med 2019;16:880-890.

Risk of Contraceptive Lapse and New Sexual Partnership Among Female University Students Traveling Internationally

CONTEXT

International travel is common and may influence women's sexual and reproductive health through myriad pathways. Existing studies focus on travelers' risk of acquiring STDs, but not their pregnancy prevention behaviors. Further, it is unclear whether sexual and reproductive health outcomes observed for female travelers are associated with travel itself, because few studies compare travelers with nontravelers.

METHODS

An online survey was conducted in 2016-2017 among females attending a U.S. university who reported a history of sex with men; the sample comprised 340 students who had traveled internationally in the past three months (travelers) and 170 who intended to travel in the next three months (pretravelers). Multivariable modified Poisson regression models assessed associations between travel status and two outcomes during travelers' recent trip or a period of similar duration for pretravelers: contraceptive lapse (incorrect or inconsistent use of any method) and new sexual partnership.

RESULTS

Travelers and pretravelers reported similar levels of contraceptive lapse (29% and 32%, respectively) and new sexual partnerships (17% and 12%). Multivariable analysis confirmed that travelers were no more likely than pretravelers to have contraceptive lapses, but indicated that they were more likely to report a new male partner (relative risk, 1.7). Most participants (80%) had a regular source of sexual and reproductive health care; 42% of travelers had seen a health care provider in preparation for their trip.

CONCLUSION

If the findings are corroborated by additional research, they may suggest a role for health care providers in students' pretravel period.

Implementing the Communities That Care Prevention System: Challenges, Solutions, and Opportunities in an Urban Setting

INTRODUCTION

Communities That Care, refined and tested for more than 25years, offers a step-by-step coalition-based approach to promote well-being and prevent risk behaviors among youth. Communities That Care guides coalitions to identify and prioritize underlying risk and protective factors; set specific, measurable community goals; adopt tested, effective prevention programs to target selected factors; and implement chosen programs with fidelity. Communities That Care has been implemented in a variety of communities, but has only recently begun to be systematically evaluated in diverse, urban communities.

METHODS

This paper presents a process evaluation of Communities That Care implementation within a Midwestern ethnically diverse, urban community. In-depth surveys of 25 black male youth aged 8-14years and their caregivers were conducted to determine the degree to which coalition-selected priorities aligned with the experience of black families. Implementation and survey data were collected in 2014-2017 and analyzed in 2017-2018.

RESULTS

Roughly 30% of youth reported ever being bullied or bullying someone else on school property; this aligned with the coalition's decision to focus on positive social skills and bullying prevention. Additional data aligned with the coalition's intent to expand its community action plan to encompass other priorities, including family transitions and mobility. For example, roughly one third of caregivers went on welfare and one third of families moved to a new home or apartment in the past year.

CONCLUSIONS

In communities whose residents have experienced historical and current inequities, an effective community prevention plan may need to address structural as well as social determinants of well-being among youth and their families.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Parents Speak: A Needs Assessment for Community Programming for Black Male Youth

INTRODUCTION

Although adolescence can be a difficult developmental period for all children, negative environmental forces make this period particularly risky for many inner-city black males. As part of the Center for Healthy African American Men through Partnerships, this project is utilizing community-based participatory concepts to design and implement programs to address risk-taking behaviors among middle school black males.

METHODS

In 2014, parents of black males between the ages of 11 and 14years were recruited from an urban middle school to participate in focus group discussions. Letters were provided to the school to be mailed to parents inviting them to participate in discussion groups. Four focus groups were conducted. Data analyses were conducted fall 2014.

RESULTS

Twenty-one parents participated. The major issue affecting the well-being and future success of young black males reported by parents was the lack of social support. Other areas of concern included negative peer pressure, bullying, violence, and lack of opportunities. Across groups, parents identified the lack of male parental presence in households and the subsequent perceived need by the young males to assume leadership roles, anger among the young males, and the lack of licensed counselors to address mental health issues as barriers to success and well-being. Parents emphasized the needs of the individual, family, and community for social support, positive role models, self-esteem, and respect.

CONCLUSIONS

The present data can inform prevention programs designed to reduce disparities, such as educational underachievement, exposure to violence, and premature mortality experienced by black males.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Preventing Violent Encounters Between Police and Young Black Men: A Comparative Case Study

INTRODUCTION

In the past several years, high profile events have drawn attention to the longstanding problem of violent encounters between police and young black men in the U.S. This paper highlights the results of a 1-year qualitative study to describe (1) perceptions of police-youth violence prevention policies, programs, and practices; and (2) existing infrastructures that can be leveraged to strengthen police-youth violence prevention efforts.

METHODS

Semi-structured interviews were conducted with 48 key stakeholders from four groups (young black men aged 14-24years, parents and educators, police officers, and staff in youth serving organizations) in 2017. Stakeholders were asked to (1) identify any policies, programs, or practices aimed at police-youth violence prevention; (2) evaluate the effectiveness of these efforts and how they might be improved; and (3) envision any new efforts to prevent future violent encounters between police and young black men. Data were collected and analyzed in 2017 using content analysis methods.

RESULTS

Key stakeholders demonstrated high awareness of efforts, particularly programs to deter youth violence. However, none of them were able to identify specific efforts to reduce violent encounters between local police and young black men. Responses differed across key stakeholder groups. Young people often stated that police needed to become more involved in the communities they serve; however, police believed they were building relationships with the community.

CONCLUSIONS

Future violence prevention efforts must incorporate policies, programs, and practices that explicitly address violent encounters between police and young black men.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.