Building Statewide Quality Improvement Capacity to Improve Cardiovascular Care and Health Equity: Lessons from the Tennessee Heart Health Network

DRIVING FORCES

Many states with high rates of cardiovascular disease (CVD) lack statewide quality improvement (QI) infrastructure (for example, resources, leadership, community) to address relevant health needs of the population. Academic health centers are well positioned to play a central role in addressing this deficiency. This article describes early experience and lessons learned in building statewide QI infrastructure through the Tennessee Heart Health Network (Network).

APPROACH

A statewide, multistakeholder network composed of primary care practices (PCPs), health systems, health plans, QI organizations, patients, and academic institutions was led by the University of Tennessee Health Science Center (UTHSC), an academic health center, to improve cardiovascular health by supporting dissemination and implementation of patient-centered outcomes research (PCOR) evidence-based interventions in primary care. PCPs were required to select and implement at least one of three interventions (health coaching, tailored health-related text messaging, and pharmacist-physician collaboration).

OUTCOMES AND KEY INSIGHTS

Thirty statewide organizational partners joined the Network in year one, including 18 health systems representing 77 PCPs (30.0% of 257 potentially eligible PCPs identified) with approximately 300,000 patients. The organizational partners share EHRs for the ongoing tracking and reporting of key health metrics, including hypertension control and delivery of tobacco cessation counseling. Of the 77 PCPs, 62 continue participation after year two (80.5% retention). Main barriers to participation and reasons for discontinuing participation included reluctance to share data and changes in leadership at the health system level. These 62 PCPs selected the following interventions to implement: health coaching (41.9%), tailored health-related text messages (48.4%), and pharmacist-physician collaboration (40.3%).

CONCLUSION AND WHAT'S NEXT

Academic health centers have broad reach and high acceptability by diverse stakeholders. Tennessee's experience illustrates how academic health centers can serve as platforms for building a statewide infrastructure for disseminating, implementing, and sustaining QI interventions at the practice level. Assessment of Network impact is ongoing.

Factors Associated With Myocardial Infarction in a Rural Population With Peripheral Arterial Diseases

Peripheral arterial disease (PAD) studies in rural populations are limited. The incidence of myocardial infarction (MI) is higher in patients with PAD. This study examined the association between sociodemographic and clinical risk factors and MI in patients with PAD in Central Appalachia, comprising of 230 counties across six states in the United States. Data from electronic medical records of 13,455 patients with PAD were extracted from a large health system in Central Appalachia. Bivariate and logistic regression analyses were conducted. The final sample consisted of 5574 patients with PAD, of whom 24.85% were also diagnosed with MI. The mean age was 71 ± 11.23 years, and the majority were male (56.40%). After adjusting for confounders, patients with hypertension had three times higher odds of MI (adjusted Odds Ratio [aOR] = 3.21; 95% CI: 2.50-4.14) compared with those without hypertension. The likelihood of MI increased by 51% among patients with diabetes (aOR = 1.51; 95% CI: 1.33-1.71), 34% among ever-smokers (aOR = 1.34; 95% CI: 1.18-1.52), and 45% in males (aOR = 1.45; 95% CI: 1.27-1.65). Hypertension, diabetes, smoking, and male sex were identified as significant risk factors for MI. Screening and effective management of these risk factors in rural areas could potentially prevent MI incidence among patients with PAD.

Factors Associated with COVID-19 Vaccine Hesitancy in South Central Appalachia

Introduction

The newly emergent COVID-19 virus reached pandemic levels in March 2020. By the middle of August 2020, there were over 1 million deaths attributed to COVID-19 in the U.S., with those in rural areas outpacing urban counterparts. Prior to emergency approval of the Pfizer, Moderna and Johnson & Johnson vaccine formulations, mitigation efforts addressing individual behavior were challenging. However, even with the entrance of these three new vaccines, herd immunity was not achieved in rural areas, as vaccine uptake remained low there. Although there has since been an abundance of COVID-19-related research addressing health literacy, vaccine hesitancy and overall medical mistrust, few of these studies focus on Appalachia.

Purpose

This study identifies barriers and facilitators to adherence with COVID-19 mitigation, focusing specifically on vaccine hesitancy in South Central Appalachia.

Methods

A secondary data study was conducted with a subset of Appalachian residents from the COVID-19 Public Health survey. Participants were grouped by county using ARC economic county designations for analysis. The dependent variable, vaccine hesitancy, was explored in relation to five categories of independent variable: (1) demographics (with four conceptual areas); (2) belief; (3) action; (4) medical mistrust; and (5) health literacy.

Results

Findings indicate vaccine hesitancy attributes include beliefs addressing COVID-19 threat, overstatement of severity of illness, risk of vaccines, vaccine safety information not present from manufacturer, and independent decision to vaccinate. Findings from this study are comparable to HPV vaccine studies in Appalachia.

Implications

As interventions are developed for Appalachia, it is paramount to focus vaccine administration at the individual and population level.

COVID-19 vaccine hesitancy and health literacy in US Southern states

OBJECTIVES

COVID-19 vaccination in the United States has stalled, with some of the lowest rates in the South. Vaccine hesitancy is a primary contributor and may be influenced by health literacy (HL). This study assessed the association between HL and COVID-19 vaccine hesitancy in a population residing in 14 Southern states.

STUDY DESIGN

Cross-sectional study using a web-based survey conducted between February and June 2021.

METHODS

The outcome was vaccine hesitancy, and the main independent variable was HL, assessed as an index score. Descriptive statistical tests were performed, and multivariable logistic regression analysis was conducted, controlling for sociodemographic and other variables.

RESULTS

Of the total analytic sample (n = 221), the overall rate of vaccine hesitancy was 23.5%. Vaccine hesitancy was more prevalent in those with low/moderate HL (33.3%) vs those with high HL (22.7%). The association between HL and vaccine hesitancy, however, was not significant. Personal perception of COVID-19 threat was significantly associated with lower odds of vaccine hesitancy compared with those without perception of threat (adjusted odds ratio, 0.15; 95% CI, 0.03-0.73; P = .0189). The association between race/ethnicity and vaccine hesitancy was not statistically significant (P = .1571).

CONCLUSIONS

HL was not a significant indicator of vaccine hesitancy in the study population, suggesting that general low rates of vaccination in the Southern region may not be due to knowledge about COVID-19. This indicates a critical need for place-based or contextual research on why vaccine hesitancy in the region transcends most sociodemographic differences.

Intervention to Increase Cervical Cancer Screening Behavior among Medically Underserved Women: Effectiveness of 3R Communication Model

Human Papillomavirus (HPV) self-sampling has the potential to increase Cervical Cancer Screening (CCS) and reduce the cervical cancer burden in Medically Underserved Women (MUW). However, interventions promoting self-sampling are limited. We examined the effectiveness of an intervention study in increasing CCS among MUW. We conducted a quasi-experimental intervention study. A face-to-face verbal approach was used to recruit MUW (n = 83, mean age 48.57 ± 11.02) living in a small city in the US. Behavioral intervention based on reframing, reprioritizing, and reforming (3R model) was used to educate the women about CCS in a group format. The women (n = 83) completed pre-and post-intervention assessments, and 10 of them were invited for follow-up interviews. The primary outcome was CCS uptake. Mixed methods analyses were conducted using a t-test for the primary outcome, PROCESS for mediation analysis, and NVivo for interview data. The majority of women (75%) completed self-testing. High-risk HPV among women was 11%, and of those, 57% followed up with physicians for care. We found that the significant increase in the women's post-intervention screening behaviors was mediated by the increase in knowledge (Indirect Effect [IE] = 0.1314; 95% CI, 0.0104, 0.4079) and attitude (IE = 0.2167; 95% CI, 0.0291, 0.6050) scores, (p < 0.001). Interview analyses offered further explanations why MUW found the intervention messages acceptable (encourages proactive behavior), feasible (simple and easy to understand), and appropriate (helpful and informative). Barriers, including lack of trust and fear of results, were identified. The findings suggest that an intervention that combines the 3R model and self-sampling may increase CCS among MUW.

Setting Patient-Centered Priorities for Cardiovascular Disease in Central Appalachia: Engaging Stakeholder Experts to Develop a Research Agenda

The disproportionate burden of cardiovascular diseases (CVD) and associated risk factors continues to exist in the Central Appalachian Region (CAR) of the United States. Previous studies to gather data about patient-centered care for CVD in the region were conducted through focus group discussions. There have not been any studies that used a collaborative framework where patients, providers, and community stakeholders were engaged as panelists. The objective of this study was to identify patient-centered research priorities for CVD in the CAR. We used a modified Delphi approach to administer questionnaires to forty-two stakeholder experts in six states representing the CAR between the fall of 2018 and the summer of 2019. Their responses were analyzed for rankings and derived priorities by research gaps. Six of the fifteen research priorities identified were patient-centered. These patient-centered priorities included shorter wait times for appointments; educating patients at their level; empowering patients to take responsibility for their health; access to quality providers; heart disease specialists for rural areas; and lifestyle changes. The participants' commitments to identify patient-centered research priorities indicate the potential to engage in community-based collaboration to address the burden of CVD in the CAR.

Examining Disparities in Current E-Cigarette Use among U.S. Adults before and after the WHO Declaration of the COVID-19 Pandemic in March 2020

This paper aims to estimate the prevalence of e-cigarette use before and after the COVID-19 pandemic declaration and to delineate disparities in use across subpopulations. Data were derived from the 2020 Health Information National Trends Survey (N = 3865) to conduct weighted multivariable logistic regression and marginal analyses. The overall prevalence of current e-cigarette use increased from 4.79% to 8.63% after the COVID-19 pandemic declaration. Furthermore, non-Hispanic Black people and Hispanic people had lower odds of current e-cigarette use than non-Hispanic White people, but no significant differences were observed between groups before the pandemic. Compared to heterosexual participants, sexual minority (SM) participants had higher odds of current e-cigarette use after the declaration, with insignificant differences before. People who had cardiovascular disease conditions, relative to those without, had higher odds of current e-cigarette use after the declaration, but no group differences were found before the declaration. The marginal analyses showed that before and after the pandemic declaration, SM individuals had a significantly higher probability of using e-cigarettes compared to heterosexual individuals. These findings suggest the importance of adopting a subpopulation approach to understand and develop initiatives to address substance use, such as e-cigarettes, during pandemics and other public health emergencies.

Secondhand Smoke Exposure Inside the Home Among Adults in Eight Countries in Sub-Saharan Africa: Global Adult Tobacco Survey, 2012-2018

INTRODUCTION

Secondhand tobacco smoke (SHS) exposure causes diseases and death in adults and children. Evidence indicates that most SHS exposures occur at home and in the workplace. Therefore, home is a major place where adults and children can be effectively protected from SHS. This study examined the magnitude of SHS exposure at home and associated factors in eight sub-Saharan African countries.

AIMS AND METHODS

We analyzed 2012-2018 Global Adult Tobacco Survey data for Botswana, Cameroon, Ethiopia, Kenya, Nigeria, Senegal, Tanzania, and Uganda. We computed prevalence estimates of self-reported monthly SHS exposure at home reported as anyone smoking inside their home daily, weekly, or monthly. We calculated SHS exposure at home prevalence and applied multivariable logistic regression models to identify related factors.

RESULTS

Overall median prevalence of SHS exposure at home was 13.8% in the eight countries; ranging from 6.6% (95% CI: 5.7%, 7.6%) in Nigeria to 21.6% (95% CI: 19.4%, 24.0%) in Senegal. In multivariable analysis across the countries, SHS exposure at home was associated with living with a smoker, ranging from an adjusted odds ratio (AOR) of 4.6 (95% CI: 3.6, 5.8) in Botswana to 27.6 (95% CI: 20.1, 37.8) in Nigeria. SHS exposure at home was significantly associated with lower education attainment (Kenya and Ethiopia), and lower wealth index (Uganda, Senegal, and Botswana).

CONCLUSIONS

SHS exposure in homes was associated with the presence of a smoker in the home and lower socioeconomic status.

Type 2 diabetes: an exploratory genetic association analysis of selected metabolizing enzymes and transporters and effects on cardiovascular and renal biomarkers

OBJECTIVES

This study sought to identify potential pharmacogenetic associations of selected enzymes and transporters with type 2 diabetes (T2D). In addition, pharmacogenomic profiles, concentrations of asymmetric dimethylarginine (ADMA) or kidney injury molecule-1 (KIM-1), and several covariates were investigated.

METHODS

Whole blood was collected from 63 patients, with 32 individuals with T2D. A pharmacogenomic panel was used to assay genetic profiles, and biomarker ELISAs were run to determine subject concentrations of ADMA and KIM-1. Additive genetic modeling with multiple linear and logistic regressions were performed to discover potential SNPs-outcome associations using PLINK.

RESULTS

Ten SNPs were found to be significant (p<0.05) depending on the inclusion or exclusion of covariates. Of these, four were found in association with the presence of T2D, rs2231142, rs1801280, rs1799929, and rs1801265 depending on covariate inclusion or exclusion. Regarding ADMA, one SNP was found to be significant without covariates, rs1048943. Five SNPs were identified in association with KIM-1 and T2D in the presence of covariates, rs12208357, rs34059508, rs1058930, rs1902023, and rs3745274. Biomarker concentrations were not significantly different in the presence of T2D.

CONCLUSIONS

This exploratory study found several SNPs related to T2D; further research is required to validate and understand these relationships.

Disparities in localized malignant lung cancer surgical treatment: A population‐based cancer registry analysis

BACKGROUND

Lung cancer (LC) continues to be the leading cause of cancer deaths in the United States. Surgical treatment has proven to offer a favorable prognosis and a better 5-year relative survival for patients with early or localized tumors. This novel study investigates the factors associated with the odds of receiving surgical treatment for localized malignant LC in Tennessee.

METHODS

Population-based data of 9679 localized malignant LC patients from the Tennessee Cancer Registry (2005-2015) were utilized to examine the factors associated with receiving surgical treatment for localized malignant LC. Bivariate and multivariate logistic regression analyses, cross-tabulation, and Chi-Square ( χ ² ) tests were conducted to assess these factors.

RESULTS

Patients with localized malignant LC who initiated treatment after 2.7 weeks were 46% less likely to receive surgery (adjusted odds ratio [AOR] = 0.54; 95% confidence interval [CI] = 0.50-0.59; p < 0.0001). Females had a greater likelihood (AOR = 1.14; CI = 1.03-1.24) of receiving surgical treatment compared to men. Blacks had lower odds (AOR = 0.76; CI = 0.65-0.98) of receiving surgical treatment compared to Whites. All marital groups had higher odds of receiving surgical treatment compared to those who were single/never married. Patients living in Appalachian county had lower odds of receiving surgical treatment (AOR = 0.65; CI = 0.59-0.71) compared with those in the non-Appalachian county. Patients with private (AOR = 2.09; CI = 1.55-2.820) or public (AOR = 1.42; CI = 1.06-1.91) insurance coverage were more likely to receive surgical treatment compared to self-pay/uninsured patients. Overall, the likelihood of patients receiving surgical treatment for localized malignant LC decreases with age.

CONCLUSION

Disparities exist in the receipt of surgical treatment among patients with localized malignant LC in Tennessee. Health policies should target reducing these disparities to improve the survival of these patients.

Social media and use of electronic nicotine delivery systems among school-going adolescents in a rural distressed Appalachian community

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Social media use to discuss ENDS among youth in distressed areas is understudied.

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Nearly 1 in 3 and 1 in 8 of youth were ever and current ENDS users, respectively.

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Nearly 1 in 5 of the youth reported using social media to talk about ENDS.

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Social media increased current and ever ENDS use by 4 and 3 times, respectively.

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Social media engagement may lead to ENDS uptake among youth in distressed areas.

Electronic nicotine delivery systems (ENDS) are the most used tobacco products among middle and high schoolers in the United States (U.S.). Familial relations and access play a major role in uptake among adolescents; yet the role of social media in this phenomenon in the context of communities impacted by tobacco-related health disparities is understudied. In Spring 2019, data were collected from adolescents in 8th and 9th grades in a school located in a rural distressed county in Tennessee to assess social media’s role in ENDS uptake. Descriptive and multivariable statistical analyses were performed to delineate factors associated with ENDS use. Of a total of 399 respondents, 12.5 % reported current ENDS use and 22.1 % indicated having ever discussed ENDS on social media. Closed messaging platforms (Snapchat) and video platforms (Facebook/Instagram/You Tube) were the most reported form of social media used (8.31 % and 8.31 % respectively). Social media use was positively associated with both ever ENDS use (odds ratio [OR] = 2.9) and current ENDS use (OR = 3.98). Parental advice against ENDS use was positively associated with ever ENDS use. In conclusion, social media use was positively associated with both ever and current ENDS use, and Snapchat was the most popular platform among this population of students. The results indicate that youth social media engagement may lead to exposure that can influence ENDS uptake. Future studies are needed to further examine these associations among distressed communities.

Between and Within Sexual Identity-Group Differences in Asthma Prevalence in the United States

BACKGROUND

Although prior studies have established the association of asthma with smoking and obesity, literature on difference-in-differences analyses involving sexual identity is sparse. Therefore, this study aimed to examine the between and within sexual identity-group differences in asthma prevalence among individuals who smoke and are obese.

METHODS

We aggregated the 2017-2019 National Survey on Drug Use and Health data on adults (N = 128,319) to perform weighted multivariable logistic regression analysis and marginal estimates and marginsplot to determine asthma prevalence by sexual identity and the status of smoking and obesity.

RESULTS

About 66% of the study population reported having asthma. Among the individuals with asthma, 42% were obese, 10% were daily cigarette smokers, and 6% identified as bisexual persons. Lesbian/gay daily smokers (86%) or former smokers (75%) had a higher probability of having asthma than bisexual (daily smokers = 78% vs former smokers = 72%) and heterosexual (daily smokers = 68% vs former smokers = 65%) persons. Within each sexual identity subgroup, daily smokers (68-86%) had the highest probability of asthma. Obese bisexual (73%) or lesbian/gay (72%) persons had higher probabilities of having asthma than heterosexual persons (69%). Obese (73%) or overweight (72%) bisexual (compared to normal weight = 70% or underweight = 51%) and obese (69%) or overweight (65%) heterosexual (compared to normal weight = 62% or underweight = 57%) persons had the highest probabilities of having asthma within their groups, whereas overweight persons (overweight = 81% vs underweight = 79%, normal weight = 78%, and obese = 72%) had the highest probabilities within lesbian/gay persons.

CONCLUSIONS

Smoking and obesity show heightened odds for asthma, with significant odds for sexual minorities in asthma diagnosis relative to heterosexuals. These findings provide formative information for future longitudinal and experimental studies to explore these mechanisms of asthma risks among sexual and gender minorities.

Exploring Patterns of the Use of Electronic Nicotine Delivery Systems among Adolescents in High-Risk Appalachian (U.S.A) Communities

Background: Electronic nicotine delivery systems (ENDS) use among adolescents in the United States (U.S.) has surpassed conventional tobacco products (CTPs), including cigarettes. Increasingly, ENDS are used concurrently with CTPs and substances such as cannabis. However, few studies involve Central Appalachia, a region with historically high rates of tobacco and other substance use. Objective:  To examine prevalence of concurrent use of ENDS and cannabis among school-going adolescents in Appalachian Tennessee and delineate associations between ENDS use and substance-related risk behavior (cannabis use), social relations (peer use), and school-related risk behavior (academic performance). Methods: Data were obtained from a survey conducted with youth aged 13-17 years in 2018 in a county in Appalachian Tennessee (n = 280). A multivariable logistic regression model was fit to evaluate associations between ENDS and cannabis use, and other factors. Results: Overall, lifetime ENDS and cannabis prevalence estimates were 31.1% and 18.6%, respectively. Lifetime ENDS users had increased odds of also being lifetime cannabis users [OR = 9.22, 95% confidence interval (CI): 3.44-24.75]. Lifetime ENDS users had increased odds of reporting ENDS use among peers [OR = 12.11; 95% CI: 5.40-27.12] and lower academic performance (OR associated with mostly C or D vs. A grades was 4.28, 95% CI: 1.68-10.90). Conclusion: This study found an association between ENDS and cannabis use among adolescents in Appalachian Tennessee exists. Additionally, peer use and academic performance were associated with ENDS use. The findings have implications for public health intervention planning to address not only ENDS but also substance use among Appalachian youth.

Correction: Perceptions of risk for COVID-19 among individuals with chronic diseases and stakeholders in Central Appalachia

[This corrects the article DOI: 10.1057/s41599-021-00906-7.].

Health workers' perceptions on where and how to integrate tobacco use cessation services into tuberculosis treatment; a qualitative exploratory study in Uganda

Background

Tobacco use is associated with exacerbation of tuberculosis (TB) and poor TB treatment outcomes. Integrating tobacco use cessation within TB treatment could improve healing among TB patients. The aim was to explore perceptions of health workers on where and how to integrate tobacco use cessation services into TB treatment programs in Uganda.

Methods

Between March and April 2019, nine focus group discussions (FGDs) and eight key informant interviews were conducted among health workers attending to patients with tuberculosis on a routine basis in nine facilities from the central, eastern, northern and western parts of Uganda. These facilities were high volume health centres, general hospitals and referral hospitals. The FGD sessions and interviews were tape recorded, transcribed verbatim and analysed using content analysis and the Chronic Care Model as a framework.

Results

Respondents highlighted that just like TB prevention starts in the community and TB treatment goes beyond health facility stay, integration of tobacco cessation should be started when people are still healthy and extended to those who have been healed as they go back to communities. There was need to coordinate with different organizations like peers, the media and TB treatment supporters. TB patients needed regular follow up and self-management support for both TB and tobacco cessation. Patients needed to be empowered to know their condition and their caretakers needed to be involved. Effective referral between primary health facilities and specialist facilities was needed. Clinical information systems should identify relevant people for proactive care and follow up. In order to achieve effective integration, the health system needed to be strengthened especially health worker training and provision of more space in some of the facilities.

Conclusions

Tobacco cessation activities should be provided in a continuum starting in the community before the TB patients get to hospital, during the patients’ interface with hospital treatment and be given in the community after TB patients have been discharged. This requires collaboration between those who carry out health education in communities, the TB treatment supporters and the health workers who treat patients in health facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11502-4.

Association between per and polyfluoroalkyl substances and markers of inflammation and oxidative stress

OBJECTIVES

This study aimed to examine the association of Per and Polyfluoroalkyl substances (PFAS) and markers of chronic inflammation and oxidative stress.

METHODS

Using data (n = 6652) from the National Health and Nutrition Examination Survey (NHANES) 2005-2012, generalized linear models were used to examine the association between PFAS and inflammatory (ferritin, alkaline phosphatase, C-reactive protein, absolute neutrophil count and lymphocyte count) and oxidative stress (serum bilirubin, albumin and iron) per unit exposure to PFAS while adjusting for covariates. Study participants were those ≥20 years of age. Outcome variables were markers of chronic inflammation and oxidative stress and exposure variables were PFAS.

RESULLTS

Percentage change in Perfluorohexane sulfonic acid (PFHxS), Perfluorononanoic acid (PFNA), Perfluorooctanoic acid (PFOA), Perfluorooctane sulfonic acid (PFOS), and Perfluorodecanoic acid (PFDA) were all significantly associated with percentage increases in lymphocyte counts, beta (95% confidence interval); 0.04(0.02,0.05), 0.04(0.02,0.05), 0.05(0.03, 0.07), 0.04(0.03,0.05), 0.03(0.13,1.23) and with percentage increases in serum iron 0.07(0.05,0.09), 0.04(0.02,0.07), 0.10(0.07,0.12), 0.05(0.03,0.07), 0.04(0.02,0.06) and increased serum albumin 0.02(0.02,0.02), 0.02(0.02,0.03), 0.03(0.03,0.04), 0.02(0.017, 0.025), 0.01 (0.01, 0.05). Only PFHxS, PFNA, PFOA and PFOS were associated with percentage increases in serum total bilirubin 0.04(0.03,0.05), 0.02(0.00,0.03), 0.06(0.04,0.08), 0.03(0.02,0.05). Similar results were obtained for categorical quintile analysis with PFOA showing a significant trend (P < 0.001) with lymphocyte count, serum iron, serum total bilirubin and serum albumin. Trend for neutrophil count was not significant (p = 0.183).

CONCLUSION

Per and Polyfluoroalkyl substances are associated with markers of chronic inflammation and oxidative stress. Increased exposure leads to increase in serum concentration of these markers meaning these chemicals are associated with both chronic inflammation and oxidative stress.

A cross-sectional study of the association between perfluorinated chemical exposure and cancers related to deregulation of estrogen receptors

BACKGROUND

Environmental exposures acting through different mechanisms have been linked with a number of cancers. Perfluoroalkyl chemicals (PFCs) are endocrine disrupting chemicals affecting estrogen homeostasis.

OBJECTIVES

We examined the association between PFCs and a group of estrogen related cancers and explored if increased non-occupational exposure was associated with increased odds of developing these cancers. We also explored which of these chemical exposures was more correlated with each cancer.

METHODS

Using data from the National Health and Nutrition Examination Survey (NHANES), we selected participants ≥ 20 years of age. Our outcome variable was presence or absence of breast, prostate, ovarian and uterine cancer (yes/no); our exposure variables were serum PFCs. Logistic regression models were used in investigating the association between PFCs and cancer types and between quartiles of PFCs exposure concentrations and presence or absence of cancer while adjusting for covariates. Discriminant analysis was used to assess the correlation between individual PFCs compounds and individual cancer types.

RESULTS

PFCs were associated with increased odds of ovarian cancer; PFOA: 1.02(1.01, 1.02), PFOS: 1.01 (1.012, 1.013), PFHS 1.031 (1.030, 1.033), PFDE: 1.29(1.27, 1.30) and increased odds of breast cancer; PFOA: 1.089(1.089, 1.09), PFOS: 1.011(1.011, 1.011), PFNA: 1.031(1.030, 1.033), PFHS: 1.02 (1.02, 1.02), PFDE: 1.19(1.18, 1.19). PFCs were not associated with increased odds of prostate or uterine cancers. Comparing the odds in quartile 4 to quartile 1 for ovarian cancer, PFOA: 1.77(1.75,1.79), PFOS: 2.25(2.22, 2.28), PFHS: 1.86(1.84, 1.88), PFDE: 2.11(2.09, 2.14). For breast cancer, PFOA: 2.30(2.28, 2.31), PFOS: 1.47(1.46, 1.48), PFNA: 1.04(1.03, 1.05), PFHS:7.07(6.97,7.17), PFDE: 1.38(1.37, 1.39). PFOA was more correlated with breast cancer (0.7) and PFHS was more correlated with ovarian cancer (0.9).

DISCUSSION

PFCs were associated with increased odds of ovarian and breast cancers with a positive dose-response relationship. PFOA was more correlated with breast cancer and PFHS more with ovarian cancer.

The co-existence of diabetes and subclinical atherosclerosis in rural central Appalachia: Do residential characteristics matter?

Aim Disparities exist in cardiovascular diseases (CVD) and diabetes in the United States (U.S.) with Central Appalachia having disproportionate burden. This study examined prevalence and correlates of CVD risk-factors among patients with diabetes/subclinical atherosclerosis in Central Appalachia.

METHODS

During 2012-2016, 3000 patients from Central Appalachia were screened for subclinical atherosclerosis, using coronary artery calcium (CAC) scores; 419 participants had diabetes. Patients were categorized into four groups, with emphasis on those having subclinical atherosclerosis, CAC score ≥ 1. Descriptive statistics and multilevel multinomial logistic regression were conducted to identify CVD risk and spatial factors associated with co-existence of diabetes and subclinical atherosclerosis.

RESULTS

Among participants, prevalence of CVD risk-factors ranged from 11.7% for current smokers to 69.2% for those with CVD family history. Average BMI was 29.8. Compared to patients with diabetes only, age [RR = 1.07; p ≤ 0.0001], being male [RR = 5.33; p ≤ 0.0001], having hypertension [RR = 2.37; p ≤ 0.05] and being a former smoker were associated with increased likelihood of having diabetes/subclinical atherosclerosis. At the zip-code level, unemployment rate [RR = 1.37; p ≤ 0.05] was significantly associated with having diabetes/subclinical atherosclerosis.

CONCLUSION

Consistent with clinical guidelines, study results suggest the need to integrate CAC screening into primary care diabetes programs while addressing spatial issues that predispose patients to have diabetes/subclinical atherosclerosis.

The Cardiovascular Effects of Electronic Cigarettes

PURPOSE OF REVIEW

Electronic cigarettes (e-cigarettes) are gaining rapid popularity among all age groups, especially among youth. They have evolved into technologically advanced devices capable of delivering nicotine concentration and other substances. In addition to nicotine, e-cigarettes' constituents possess variety of toxic chemicals that have adverse effects on human body.

RECENT FINDINGS

In recent years, steady downward trend in tobacco usage has been observed; however, e-cigarette use is on upward trend. E-cigarettes are advertised as "safer" alternatives to conventional smoking and as an aid to smoking cessation. Emerging studies have, however, shown that e-cigarettes have harmful effects on the cardiovascular system and that most of the e-cigarette users are dual users, concurrently using e-cigarettes and smoking conventional cigarettes. Despite a gap in clinical studies and randomized trials analyzing adverse cardiovascular effects of e-cigarette use, the existing literature supports that different constituents of e-cigarettes such as nicotine, carbonyls, and particulate matters carry potential risk for cardiovascular diseases (CVD) on its users.

The association between experiencing police arrest and suicide ideation among emerging young adults: Does race matter?

The objective of the study was to examine the association between lifetime arrest and marijuana-related first arrest with past-year suicide ideation among Black and White people. We used data from Wave-IV (2008-2009; N = 5114) of the publicly available National Adolescent Health Study (Add Health) data. A total of 4313 Non-Hispanic Black and White participants were selected for this study. Logistic regression was used to assess whether lifetime arrest and marijuana-related arrests were associated with past year suicide. Overall, 28.8% of the sample reported lifetime arrest, 6.3% reported lifetime suicide ideation, and 3.7% reported marijuana-related arrest. A significantly higher percentage of Black people (32.3%) in comparison to White people (27.4%) reported lifetime arrest (χ2 = 9.91; p < 0.001; df = 1). Among Black people, lifetime arrest (AOR = 2.98; 95% CI, 1.66-5.35; p < 0.001) and marijuana-related arrest (AOR = 4.09; 95% CI, 1.47-11.35; p < 0.001) were both associated with lifetime suicide ideation. Given the rate of death by suicide among Black people has been rising for two decades, further efforts are needed to educate and inform key stakeholders including law enforcement and policymakers regarding racial disparities in arrests, which may contribute to reducing risk for death by suicide among Black people.

Support for smoke-free public places among adults in four countries in sub-Saharan Africa

INTRODUCTION

There is no known safe level of secondhand smoke exposure; yet, less than 30% of the global population is covered by comprehensive smoke-free policies as of 2016 and there are few smoke-free policies in sub-Saharan Africa (SSA). This study examines the support for smoke-free public places in SSA and delineates their correlates.

METHODS

Data collected through the Global Adult Tobacco Survey (2012-2017) were analyzed using SAS for descriptive and multivariable analyses, with a significance level set at p < .05.

RESULTS

No SSA country had comprehensive smoke-free policies, defined as a prohibition of smoking in eight public places. In the four countries whose Global Adult Tobacco Survey data were analyzed (Nigeria, Cameroon, Kenya, and Uganda), support for the prohibition of smoking in public places was over 90% in all eight public places except bars. Support for smoking prohibition in bars was 65.8%, 81.1%, 81.4%, and 91.0% in Nigeria, Cameroon, Kenya, and Uganda, respectively. Factors associated with support for smoke-free bars differed across the four countries, but in all countries, current smokers had decreased odds of support for smoke-free bars. Knowledge of secondhand smoke harm and living in smoke-free homes were associated with increased odds of support for smoke-free bars in all countries except Kenya.

CONCLUSION

The high support for smoke-free public places should inform the efforts of the public health community and policymakers in these four SSA countries toward meeting their obligations of Article 8 of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC).

IMPLICATIONS

Much of the population in SSA is not protected by comprehensive smoke-free policies. It was found that the overwhelming majority of adults in four large countries in SSA support the prohibition of smoking in public places and that knowledge of the health dangers of smoking and exposure to secondhand smoke and home smoking rules increased support for the prohibition. High support for the prohibition of smoking in these four SSA countries suggests tobacco control proponents should advocate for comprehensive smoke-free policies.

Human papillomavirus vaccination practices and perceptions among Ghanaian Healthcare Providers: A qualitative study based on multi-theory model

BACKGROUND

Healthcare providers' (HCPs) recommendations for the Human Papillomavirus (HPV) vaccine are likely to increase the vaccination uptake. However, little is known about Ghanaian HCPs' general practices regarding HPV vaccination. We used Multi-Theory Model (MTM) constructs (i.e. participatory dialogue, behavioral confidence, environment, social and emotional transformation) to examine Ghanaian HCPs' attitudes towards HPV vaccination and their vaccination recommendation practices.

METHODS

We conducted three, 60-minute focus group discussions (FGDs) with HCP in the second-largest government hospital in Ghana. Sixteen semi-structured open-ended questions based on MTM constructs were used to guide the FGDs. We explored HCPs' general knowledge about HPV, vaccination recommendation behavior, physical environment, and socio-cultural factors associated with the HPV vaccination. Data from the FGDs were transcribed and thematically coded using NVivo software.

RESULTS

The sample of (n = 29) HCPs consisting of males (n = 15) and females (n = 14) between the ages of 29 and 42 years participated in the FGDs. Our analyses showed that HCPs (a) rarely offered HPV vaccination recommendations, (b) showed varied understanding about who should be vaccinated regarding age eligibility, gender, and infection status. Perceived barriers to HPV vaccination include (a) low urgency for vaccination education due to competing priorities such as malaria and HIV/AIDS; (b) lack of data on HPV vaccination; (c) lack of awareness about the vaccine safety and efficacy; (c) lack of HPV vaccine accessibility and (d) stigma, misconceptions and religious objections. HCPs expressed that their motivation for counseling their clients about HPV vaccination would be increased by having more knowledge about the vaccine's efficacy and safety, and the involvement of the parents, chiefs, churches, and opinion leaders in the vaccination programs.

CONCLUSION

The study's findings underscore the need for a comprehensive HPV vaccination education for HCPs in Ghana. Future HPV vaccination education programs should include information about the efficacy of the vaccine and effective vaccination messages to help mitigate HPV vaccine-related stigma.

Cardiovascular Diseases Health Literacy among Patients, Health Professionals, and Community-Based Stakeholders in a Predominantly Medically Underserved Rural Environment

OBJECTIVE

The central Appalachian region of the United States is disproportionately burdened with cardiovascular disease (CVD); however, the level of literacy about CVD among residents has not been well studied. This study aimed to examine the prevalence and factors of CVD health literacy (HL) among a sample of patients/caregivers, providers/professionals, and community stakeholders.

METHODS

In 2018, data were collected from central Appalachian residents in six states: Kentucky, North Carolina, Ohio, Tennessee, Virginia, and West Virginia. CVD HL status was determined by assessing correct responses to five interrelated questions about basic knowledge of CVD. Multiple logistic regression analyses were used to examine the associations between potential factors and CVD HL status.

RESULTS

Of the total respondents (N = 82), <50% correctly answered all 5 CVD HL questions. Multiple logistic regression analyses showed that compared with respondents with advanced college degrees, those with a college degree or less were more likely to have low HL for "typical symptom of CVD," "physical exercise and CVD," "blood pressure and CVD," and "stress and CVD." In addition, compared with respondents younger than 50 years, those 50 years and older were 3.79 times more likely to have low HL for "physical exercise and CVD."

CONCLUSIONS

These results suggest the incorporation of CVD HL into CVD care and that educational attainments should be part of CVD policies and programs in the region.

Is the positive association between middle-income and rich household wealth and adult sub-Saharan African women's overweight status modified by the level of education attainment? A cross-sectional study of 22 countries

Background

Previous studies show a positive association between household wealth and overweight in sub-Saharan African (SSA) countries; however, the manner in which this relationship differs in the presence of educational attainment has not been well-established. This study examined the multiplicative effect modification of educational attainment on the association between middle-income and rich household wealth and overweight status among adult females in 22 SSA countries. We hypothesized that household wealth was associated with a greater likelihood of being overweight among middle income and rich women with lower levels of educational attainment compared to those with higher levels of educational attainment.

Methods

Demographic and Health Survey (DHS) data from 2006 to 2016 for women aged 18–49 years in SSA countries were used for the study. Overweight was defined as a body mass index (BMI) ≥ 25 kg/m². Household wealth index tertile was the exposure and educational attainment, the effect modifier. Potential confounders included age, ethnicity, place of residence, and parity. Descriptive analysis was conducted, and separate logistic regression models were fitted for each of the 22 SSA countries to compute measures of effect modification and 95% confidence intervals. Analysis of credibility (AnCred) methods were applied to assess the intrinsic credibility of the study findings and guide statistical inference.

Results

The prevalence of overweight ranged from 12.6% in Chad to 56.6% in Swaziland. Eighteen of the 22 SSA countries had measures of effect modification below one in at least one wealth tertile. This included eight of the 12 low-income countries and all 10 middle income countries. This implied that the odds of overweight were greater among middle-income and rich women with lower levels of educational attainment than those with higher educational attainment. On the basis of the AnCred analysis, it was found that the majority of the study findings across the region provided some support for the study hypothesis.

Conclusions

Women in higher wealth strata and with lower levels of educational attainment appear to be more vulnerable to overweight compared to those in the same wealth strata but with higher levels of educational attainment in most low- and middle- income SSA countries.

Governing Noncommunicable Diseases Through Political Rationality and Technologies of Government: A Discourse Analysis

In the last two decades, global action to address noncommunicable diseases (NCDs) has accelerated, but policy adoption and implementation at the national level has been inadequate. This analysis examines the role of rationalities of governing, or governmentality, in national-level adoption of global recommendations. Critical discourse analysis was conducted using 49 formal institutional and organizational documents obtained through snowball sampling methodology. Text were coded using a framework of five forms of governmentality and analyzed to describe the order of discourse which has emerged within the global NCD policy domain. The dominant political rationality used to frame NCDs is rooted in risk governmentality. Recommendations for tobacco control and prevention of harmful alcohol use rely on a governmentality of police mixed with discipline. The promotion of physical activity relies heavily on disciplinary governmentality, and the prevention of unhealthy diet mixed disciplinary measures, discipline, and neoliberal governmentalities. To translate global NCD prevention and control strategies to national action, acceptability for the political rationalities embodied in policy options must be nurtured as new norms, procedures, and institutions appropriate to the political rationalities of specific interventions are developed.

A Qualitative Study to Explore Perception of Impacts of Preemption of Tobacco Regulation on Counties in Appalachian Tennessee

Bottom-up processes, starting at the local government level, are valuable for more-stringent tobacco control measures. The existence of industry-backed state-level tobacco control preemption in states has impeded policy progress within the state and localities/communities. A national public health goal under Healthy People 2020 is to eliminate state-level preemption across the United States. This study explored individual-level perceptions of the impact of state-level preemption in Appalachian Tennessee-a high-smoking, low-income region. During 2015-2016, a community-engagement project to develop a Population Health Improvement Plan (PHIP) involving over 200 stakeholders and 90 organizations was conducted in Appalachian Tennessee to identify policies/programs to address tobacco use. Using a multifaceted framework approach that focused on prevention, protection, and cessation, interviews and meeting discussions were audio-recorded and transcribed. Content analysis using NVivo 11 was conducted to generate themes. Although the central focus of the PHIP was not preemption, the issue emerged naturally in the discussions as a major concern among participants. Cultural and normative factors in Appalachian Tennessee were identified as key rationales for participants' aversion to state preemption. Thus, repealing preemption would facilitate culturally tailored and region-specific policies/programs to the high tobacco use among Appalachian Tennessee communities where statewide/nationwide policies/programs have not had the intended impacts.

Young adults' human papillomavirus-related knowledge: source of medical information matters

OBJECTIVES

Few studies examine the influence that different sources of medical information has on human papillomavirus (HPV)-related knowledge. We examined the relationship between the primary source of medical information and knowledge about HPV in young adults aged 18-26 years.

STUDY DESIGN

This study used cross-sectional data from the Health Information National Trends Survey.

METHODS

Respondents (n = 404) self-reported their knowledge about HPV-related diseases and vaccinations and their sources of medical information. Sources of medical information included electronic/print media, family/friends, or a healthcare provider. Bivariate and multivariate analyses were used to examine the association between the source of information and HPV knowledge.

RESULTS

Fifty-six percent of respondents used electronic or print media as their primary source of medical information. A greater proportion of Hispanic (40.0%) and black (36.0%) respondents received medical information from their family/friends than white respondents (20.0%). Respondents who received medical information from family/friends had 4.34 (95% confidence interval [CI]: 2.14, 8.79), 4.06 (95% CI: 2.05, 8.04), and 2.35 (95% CI: 1.10, 5.04) times higher odds than those who received information from healthcare providers of not knowing that HPV causes cervical cancer, knowing HPV is a sexually transmitted infection, and hearing about the HPV vaccine, respectively.

CONCLUSION

Source of medical information was significantly associated with knowledge of HPV. Receiving medical information from family/friends negatively influenced young adults' HPV knowledge. These findings may guide future interventions to target peer and familial influence on medical decisions.

Mortgage possessions, spatial inequality, and obesity in large US metropolitan areas

OBJECTIVES

As social determinants of health, mortgage possessions (primarily foreclosures in the US context) and housing instability have been associated with certain mental and physical health outcomes at the individual level. However, individual risks of foreclosure and of poor health are spatially patterned. The objective of this study is to examine the extent to which area-specific social and economic characteristics help explain the relationship between mortgage possessions and obesity prevalence in 75 of the 100 most populous US metropolitan areas.

STUDY DESIGN

This is a cross-sectional study.

METHODS

The study relies on three sources of data: the Selected Metropolitan/Micropolitan Area Risk Trends (SMART) project, RealtyTrac foreclosure data, and the American Community Survey. Focal social and economic characteristics include foreclosure rates, levels of racial residential segregation, and poverty. Obesity prevalence and several control measures for each metropolitan area are also used. Ordinary least squares regression, weighted using the SMART project data, is used, and statistical significance is set at 0.05.

RESULTS

The results suggest that mortgage possessions are independently associated with higher obesity prevalence and that foreclosures operate through the specific channel of racial residential segregation and its tie to the racial composition of a metropolitan area. Socio-economic status of an area, and not poverty, is related to foreclosures and obesity prevalence.

CONCLUSION

Mortgage possessions not only are socio-economic but also have negative health consequences, such as obesity. The findings provide an empirical base for other researchers to uncover the relationships between segregation, mortgage possessions, and obesity at the individual level of analysis. The public health community should be engaged in addressing the issue of foreclosures in the US because the failure to engage may have broad financial and health consequences across large cities.

Association between smoking status and homocysteine levels and possible effect modification by cholesterol and oestradiol

Introduction: This study aimed to examine the association of smoking status with homocysteine levels and to determine whether the association is modified by oestradiol or cholesterol.Methods: Data (N = 4580) were obtained from National Health and Nutrition Examination Survey 2003-2004 with analysis done in 2018 on adults aged ≥20 years. The outcome was homocysteine; smoking status was the exposure variable and categorized as current, former or never smoker. Generalized linear models were used to examine the associations between smoking status and homocysteine levels, while assessing the impact of oestradiol and cholesterol.Results: After adjusting for age, sex, ethnicity, education and income level, homocysteine levels did differ by smoking status ((current smokers versus never smokers: β: 0.18 CI: 0.00, 0.36), (former smokers: β: 0.10 CI: -0.09, 0.28)). The addition of oestradiol as an interaction term in adjusted models was associated with a 16.6% increase in homocysteine levels when compared to models without the interaction term. Oestradiol but not cholesterol did moderate the association between smoking status and homocysteine levels.Discussion and conclusions: Homocysteine levels did differ across smoking status after adjusting for confounders. Oestradiol did moderate the relationship between homocysteine and smoking status.

Country-Level Analysis of the Association between Maternal Obesity and Neonatal Mortality in 34 Sub-Saharan African Countries

Background

Prior work examining the association of maternal obesity and neonatal mortality indicate the presence of a positive relationship. However, regional evidence to provide insight on country-level heterogeneities within sub-Saharan Africa (SSA) with nationally representative datasets are non-existent.

Objective

We aimed to determine the relationship between maternal obesity and neonatal mortality at the country level in SSA countries. Moreover, we also estimate regional measures of association to complement previous findings.

Methods

Demographic and Health Survey (DHS) data from 34 SSA countries conducted from 2006-2016 were used for this study. After missing data (36.9% of cases) were addressed with multiple imputations, we identified a total of 175,860 women for the analysis. Complete case and multiply imputed datasets were analyzed individually with multilevel logistic regression models. Potential confounders adjusted for in the regression model included maternal age, level of educational attainment, area of residence, access to prenatal care, birth order and multiple birth (singleton vs twin birth). Regional and country-specific associations were computed, and unadjusted and adjusted odds ratios (ORs), along with the confidence intervals (CIs) were reported.

Findings

Of the total study population, 8,451 (7.6%) were obese. In the regional level analyses, maternal obesity was associated with 40% increased odds of neonatal deaths. This finding was consistent in subgroup analyses by urban and rural residence, and geographic region of residence in SSA. Additionally, obese women were more likely to report neonatal death in the first week of life (OR, days 0-1: 1.39, 95% CI 1.15-1.69; OR, days 2-6: 1.35, 95% CI 1.02-1.79). In the individual country analyses, majority of the countries studied had central estimates supporting elevated odds of neonatal mortality, but the confidence intervals were imprecise.

Conclusion

This study highlights the potential burden of neonatal mortality borne by obese women in SSA. There is, however, a need for longitudinal studies to confirm the results.

The Usage and Associated Factors of Alternative Tobacco Products among School-going Youth in Central Appalachia

OBJECTIVE

To examine alternative tobacco product (ATP) use and associated factors among middle school students in Appalachian Tennessee.

METHOD

Data (2015-2016; N=573) from school-based tobacco surveys in 11 middle schools in Appalachian Tennessee were analyzed. Multiple logistic regression model described factors associated with ATP use.

RESULTS

More than one-tenth (13.2%) of participants have ever used ATPs. Approximately 9%, 7%, 6%, and 2% of participants have ever used e-cigarettes, cigarettes, smokeless tobacco, and little cigars or cigarillos, respectively. The following were significantly associated with ever use of ATPs: believing tobacco users have more friends, owning tobacco-branded item(s), living with a tobacco user, having ever smoked cigarettes, and living in homes where smoking is allowed.

CONCLUSION

More than one in 10 of participants have ever used at least one ATP, and association with desirable objects and situations may promote ATP use. Interventions should seek to reduce these positive images and make all tobacco products unappealing.

Association between cardiovascular risk factors and the diameter of the main pulmonary artery in asymptomatic population in the Appalachian region

Background

Pulmonary artery (PA) diameter may be altered in association with cardiovascular (CV) risk factors as noted in aorta in systemic hypertension. The flow of blood from the right ventricle to the PA and all the way to the capillary level depends on the pulmonary vascular resistance and to a lesser extent compliance and impedance of the PA, which are the fundamental conduit for maintenance of the right heart hemodynamics. Our objective is to determine the association between CV risk factors and the main pulmonary artery (MPA) diameter.

Methods

The study population are asymptomatic individuals with no known diagnosis of CV diseases in central Appalachia (n=1,282). Adults aged 18 years or older were eligible for the screening if they were referred by a physician. For self-referral, only males aged ≥45 years and females aged ≥55 years were eligible. Unadjusted and adjusted linear regression analyses were performed.

Results

The mean MPA diameter was significantly higher among males compared to females (27.19±4.20 vs. 24.99±3.91 mm, P<0.0001). Participants with diabetes also had wider MPA diameter (26.79±4.56 mm) compared to those without diabetes (25.93±4.11 mm) (P=0.015). Further, hypertensive (26.42±4.15 vs. 25.71±4.21 mm, P=0.002) and obese (27.25±4.11 vs. 25.28±4.07 mm, P<0.0001) participants had significantly wider MPA diameter compared to non-hypertensive and non-obese participants, respectively. Multivariable model showed that age, sex and body mass index (BMI) were significantly associated with MPA diameter. A 1-year increase in age increased MPA diameter by 0.046 mm (P<0.0001). The diameter of MPA was wider among males by 2.16 mm compared to females (P<0.0001). Finally, with one unit increase in BMI, the MPA diameter increased by 0.16 mm (P<0.0001).

Conclusions

MPA diameter was significantly associated with age, sex, and BMI. Further prospective studies are needed to correlate computed tomography (CT) measurement of MPA diameter with pulmonary pressure as assessed by echocardiogram to diagnose pulmonary hypertension (PH).

Prospective study of dual use of e-cigarettes and other tobacco products among school-going youth in rural Appalachian Tennessee

INTRODUCTION:

E-cigarettes have emerged as the most commonly used tobacco or nicotine products among youth in the United States (US), and usage with other products (dual use) is not well understood. This study assessed dual use and identified associated factors of usage in school-going youth in the high tobacco burdened region of rural Appalachian Tennessee.

METHODS:

Two waves of data for the same cohort of students were collected in 2014 (Wave 1) and 2016 (Wave 2). Dual use of e-cigarettes with any other tobacco product was the dependent variable. The independent variables consisted of exposure to tobacco use at home, home smoking rules, smoking inside the vehicle, attitudes toward smoking, exposure to tobacco industry marketing/promotion, and peer/family pressure. Descriptive statistics and multivariate logistic regression analyses were conducted to determine the prevalence of dual use and delineate factors associated with usage.

RESULTS:

Dual use increased from 13.3% in Wave 1 to 18.6% in Wave 2. Results of logistic regression show that exposure to tobacco industry marketing/promotion was significantly associated with dual use in the two waves, odds ratio (OR) = 4.18 (confidence interval [CI] = 1.69–10.38) and OR = 4.43 (CI = 2.03–9.67), respectively. While allowing smoking inside the vehicles, sometimes, significantly increased dual use in Wave 1 (OR = 3.18 [CI = 1.19–8.48]), exposure to tobacco use at home (OR = 2.94 [1.24–6.97]), and peer/family pressure (OR = 2.92 [1.87–7.19]) increased usage in Wave 2.

CONCLUSION:

The increasing trend in dual use of e-cigarettes and other tobacco products among youth in Appalachia Tennessee suggests a critical need for comprehensive tobacco control programs to avert exacerbating disparities in tobacco use and tobacco-related diseases in the US.

Intention to Try Tobacco Among Middle School Students in a Predominantly Rural Environment of Central Appalachia

BACKGROUND

Disparities in tobacco use exist across regions in the United States. The Central Appalachian region carries some of the very high rates of tobacco use prevalence but research on tobacco use initiation is sparse.

OBJECTIVE

To investigate the intention to try tobacco and its associated factors among nonsmoking youth.

METHOD

Data were obtained from school-based tobacco surveys (n = 539) conducted in 11 middle schools (6th-8th grades; aged 10-15 years) in Northeast Tennessee in 2015-2016. Nonsmoking participants without firm commitment to abstain from trying tobacco in the next year were considered to have an intention to try tobacco. The Full Information Maximum Likelihood estimation (FIML) method in Mplus was employed to conduct a multivariable logistic regression analysis to delineate correlates of intention to try tobacco.

RESULTS

Overall, 20.0% of participants had intention to try tobacco. Among participants with intention to try tobacco, 53.7% owned tobacco-branded item(s), 86.1% believed that tobacco users have more friends, and 88.9% lived with tobacco users. In the adjusted logistic model, ever use of tobacco products, home smoking rules, owning tobacco-branded item(s), living with tobacco users, believing that tobacco users have more friends, and perception of easy access to tobacco products were significantly associated with intention to try tobacco (p < .02).

CONCLUSION

This study suggests that individual, interpersonal, and community level factors influence intention to try tobacco in this environment where tobacco pre-emption laws impede development of local tobacco control policies and regulations. Thus, efforts should focus on tobacco use initiation preventive programs, including school-based tobacco control programs.

Health Care Provider Intervention and Utilization of Cessation Assistance in 12 Low- and Middle-Income Countries

Background and Aim

There is a need to improve utilization of cessation assistance in low- and middle-income countries (LMICs), and tobacco cessation research has been identified as priority in LMICs. This study evaluates the relationship between health care provider intervention and cessation assistance utilization in LMICs.

Methods

Data from 13 967 participants (aged ≥15 years, 90.3% males) of the Global Adults Tobacco Survey conducted in 12 LMICs (74.3%-97.3% response rates) were analyzed with utilization of counseling/cessation clinic, WHO-recommended medications, and quitline as outcome variables. Health care provider intervention ("no intervention," only "tobacco screening," "quit advice") was the exposure variable. Weighted multiple logistic regression models were used to examine the relationship between each outcome variable and the exposure variable, adjusting for other covariates. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) are reported.

Results

Approximately 52%, 8%, and 40% of participants received no intervention, only tobacco screening, and advice to quit, respectively. Overall, 0.4%, 1.9%, 3.0%, and 4.5% used quitline, WHO-recommended medications, counseling/cessation clinic, and any cessation assistance, respectively. Compared with no intervention, quit advice was associated with increased utilization of quitline (OR = 2.24, 95% CI = 1.2 to 4.4), WHO-recommended medications (OR = 1.67, 95% CI = 1.2 to 2.3), counseling/cessation clinic (OR = 4.41, 95% CI = 3.2 to 6.1), and any assistance (any of the three types) (OR = 2.80, 95% CI = 2.2 to 3.6).

Conclusion

The findings of this study suggest that the incorporation of quit advice by health care providers in tobacco control programs and health care systems in LMICs could potentially improve utilization of cessation assistance to improve smoking cessation in LMICs.

Implications

This first study of association between health care provider intervention and the utilization of cessation assistance in LMICs reports that there was a missed opportunity to provide quit advice to about 60% of smokers who visited a health care provider in the past year. The odds of utilization of counseling/cessation clinic, WHO-recommended medications, and quitline were significantly increased in participants who were advised to quit smoking. The results suggest that effective integration and implementation of advice to quit in tobacco control programs and the national health care systems may increase the use of cessation assistance to quit smoking.

The Progress of Tobacco Control Research in Sub-Saharan Africa in the Past 50 Years: A Systematic Review of the Design and Methods of the Studies

Over one billion of the world's population are smokers, with increasing tobacco use in low- and middle-income countries. However, information about the methodology of studies on tobacco control is limited. We conducted a literature search to examine and evaluate the methodological designs of published tobacco research in Sub-Saharan Africa (SSA) over the past 50 years. The first phase was completed in 2015 using PubMed, Embase, CINAHL, and Cochrane Central Register of Controlled Trials. An additional search was completed in February 2017 using PubMed. Only tobacco/smoking research in SSA countries with human subjects and published in English was selected. Out of 1796 articles, 447 met the inclusion criteria and were from 26 countries, 11 of which had one study each. Over half of the publications were from South Africa and Nigeria. The earliest publication was in 1968 and the highest number of publications was in 2014 (n = 46). The majority of publications used quantitative methods (91.28%) and were cross-sectional (80.98%). The commonest data collection methods were self-administered questionnaires (38.53%), interviews (32.57%), and observation (20.41%). Around half of the studies were among adults and in urban settings. We conclud that SSA remains a "research desert" and needs more investment in tobacco control research and training.

Diabetes, subclinical atherosclerosis and multiple cardiovascular risk factors in hard-to-reach asymptomatic patients

AIM

To examine the association of cardiovascular disease risk factors with and their cumulative effect on coronary artery calcium in hard-to-reach asymptomatic patients with diabetes.

METHODS

A total of 2563 community-dwelling asymptomatic subjects from Central Appalachia participated in coronary artery calcium screening at a heart centre. Binary variable was used to indicate that coronary artery calcium was either present or absent. Independent variables consisted of demographic and modifiable risk factors and medical conditions. Descriptive statistics and multinomial logistic regression analyses were conducted.

RESULTS

In total, 55.8% and 13.7% of study participants had subclinical atherosclerosis (coronary artery calcium ⩾1) and diabetes, respectively. The presence of coronary artery calcium was higher in subjects with diabetes (68.5%) than those without (53.8%). Compared to subjects without diabetes with coronary artery calcium = 0, obesity, hypertension, hypercholesterolaemia and smoking increased the odds of the presence of coronary artery calcium (coronary artery calcium score ⩾1) regardless of diabetes status; however, with larger odds ratios in subjects with diabetes. Compared to subjects without diabetes with coronary artery calcium score = 0, having 3, 4 and ⩾5 risk factors increased the odds of presence of coronary artery calcium in subjects with diabetes by 14.06 (confidence interval = 3.26-62.69), 32.30 (confidence interval = 7.41-140.82) and 47.12 (confidence interval = 10.35-214.66) times, respectively.

CONCLUSION

There is a need for awareness about subclinical atherosclerosis in patients with diabetes and more research about coronary artery calcium in subpopulations of patients.

The associated risk factors for coronary artery calcium in asymptomatic individuals with and without diabetes in rural Central Appalachia

AIM

To examine the risk factor of coronary artery calcium (CAC) in individuals with diabetes and those without diabetes in Central Appalachia.

METHODS

Study population included 2479 asymptomatic participants who underwent CAC screening between August 2012 and November 2016. CAC score was classified into four categories [0 (no plaque), 1-99 (mild plaque), 100-399 (moderate plaque), and ≥400 (severe plaque)]. Multinomial logistic regression analyses were conducted to test the association between CAC and cardiovascular disease (CVD) risk factors among participants with diabetes, age and gender matched controls, and randomly selected controls.

RESULTS

13.6% of total participants had diabetes. Around 69%, 59.8%, and 57.7% of the participants with diabetes, matched controls, and randomly selected controls had CAC score ≥1, respectively. Participants with diabetes had higher prevalence of all CVD risk factors than controls. Among participants with diabetes, hypertension and physical inactivity increased the odds of CAC = 100-399, while among those without diabetes, hypertension and hypercholesteremia increased the odds of having CAC = 1-99 and CAC ≥ 400.

CONCLUSION

Half of study participants had subclinical atherosclerosis (i.e., CAC), and individuals with diabetes had higher CAC scores. This study suggests that individuals with diabetes in Central Appalachia might benefit from screening for CAC.

Incorporating a structural approach to reducing the burden of non-communicable diseases

BACKGROUND

Non-communicable diseases (NCDs) account for over two-thirds of deaths worldwide, and global efforts to address NCDs have accelerated. Current prevention and control efforts rely primarily on individual behavior/lifestyle approaches that place the onus of responsibility for health on the individual. These approaches, however, have not stopped the increasing trend of NCDs worldwide. Thus, there is urgent need for exploring alternative approaches in order to attain the aim of reducing global premature NCDs mortality by 25% by 2025, and meeting the NCD reduction objective in the Sustainable Development Goals.

DISCUSSION

We suggest the need for a structural approach to addressing the NCDs epidemic that integrates social science and public health theories. We evaluate two overarching principles (empowerment and human rights) and three social determinants of health (labor and employment, trade and industry, and macroeconomics) addressed in the 2013 Global Action Plan for the Prevention and Control of NCDs to demonstrate how a structural approach to NCDs can be incorporated into existing NCD interventions. For each area considered, theoretical considerations for structural thinking are provided and conclude with recommended actions.

CONCLUSION

Achieving the global health agenda goals of reducing NCDs mortality will require a shift to a paradigm that embraces concerted efforts to address both behavioral/lifestyle factors and structural dimensions of NCDs.

The Use of E-cigarettes Among School-Going Adolescents in a Predominantly Rural Environment of Central Appalachia

E-cigarette use among youth in the United States (U.S.) continues to increase. In the rural Northeast Tennessee, where prevalence of tobacco use is higher than national and state averages, there is no literature on e-cigarette use to inform policies and programs. This study aimed to estimate the prevalence of e-cigarette use and examine association of e-cigarette use with two tobacco products among school-going adolescents. Data from 894 participants of a school-based survey conducted in 2016 in Northeast Tennessee were analyzed. Descriptive statistics and logistic regression analyses were conducted to estimate the prevalence and delineate the associations between e-cigarette use and other tobacco products. Approximately 11% of the participants currently used e-cigarettes, and 35% had ever used e-cigarettes. About 6% of the participants were current users of both e-cigarettes and cigarettes; 4% were current users of e-cigarettes and smokeless tobacco; 3% were current users of all three products, and 15% had ever tried all three products. More than one-half of current e-cigarette users (52%) also smoked cigarettes. Adjusting for covariates, current e-cigarette use was positively associated with cigarette smoking [Odds Ratio (OR) 27.32, 95% confidence interval (CI) 14.4-51.7] and smokeless tobacco use [OR 7.92, 95% CI 3.8-16.5]. E-cigarette use was more common among the high school students than cigarette and smokeless tobacco use, and a significant proportion of users either smoked cigarettes, used smokeless tobacco, or both. Thus, there is a critical need for preventive policies and programs to address dual and poly-use of these products.

Intentions to quit tobacco smoking in 14 low- and middle-income countries based on the transtheoretical model

INTRODUCTION

Over 80% of the world's one billion tobacco smokers reside in low- and middle-income countries (LMICs); therefore, it is important to understand factors that promote intention to quit smoking in these countries. This study evaluated factors associated with three stages of intention to quit tobacco smoking among adults in LMICs.

METHODS

Data from 43,540 participants of the Global Adult Tobacco Survey in 14 LMICs were analyzed. Intentions to quit smoking were categorized into precontemplation (referent category), contemplation, and preparation stages based on the transtheoretical model. A multinomial logit model was used to estimate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Approximately 82%, 14%, and 4% of the smokers were in precontemplation, contemplation, and preparation stages, respectively. Rural residents had increased odds of being in contemplation stage (OR=1.41, 95% CI=1.09-1.83) compared to urban residents. Compared to homes where smoking was allowed, smoke-free homes were associated with increased odds of contemplation (OR=1.77, 95% CI=1.41-2.23) and preparation (OR=2.18, 95% CI=1.78-2.66). Exposure to anti-smoking messages in more than one media channel was associated with increased odds of contemplation (OR=1.60, 95% CI=1.33-1.92) and preparation (OR=1.73, 95% CI=1.28-2.33) compared to no exposure to anti-smoking messages.

CONCLUSION

The results suggest that anti-smoking media campaigns and smoke-free policies may promote intention to quit smoking in LMICs. While these suggest the need for implementation of comprehensive anti-smoking campaigns and smoke-free policies, longitudinal studies are required to confirm these findings and to evaluate how intention to quit translates into quit attempts in LMICs.

Never-Smoking Adolescents' Exposure to Secondhand Smoke in Africa

INTRODUCTION

Though Africa is in Stage 1 of the tobacco epidemic, lack of effective public smoking laws or political will implies that secondhand smoke (SHS) exposure may be high in youth. The study objective is to estimate prevalence and identify determinants of SHS exposure among never-smoker adolescents in Africa and make cross-country comparisons.

METHODS

Pooled data from the Global Youth Tobacco Surveys conducted in 25 African countries during 2006-2011 were used. Based on the venue of exposure in past 7 days, SHS was categorized into exposure inside, outside, and overall exposure (either inside or outside of the home), respectively. Data were analyzed in 2015 using logistic regression models to identify factors related to SHS exposure in three venues.

RESULTS

About 21% and 39% of adolescents were exposed to SHS inside or outside of the home, with overall exposure of 45%. In all 25 African countries, parental smoking was significantly associated with SHS exposure inside the home (ORs ranging from 3.02 [95% CI=2.0, 4.5] to 14.65 [95% CI=10.0, 21.5]). Peer smoking was associated with SHS exposure outside the home in 18 countries (ORs ranging from 1.45 [95% CI=1.0, 2.1] to 3.00 [95% CI=1.8, 5.1]). Parental smoking, peer smoking, and anti-smoking messages in media were identified as three major factors associated with SHS exposure.

CONCLUSIONS

A significant proportion of never-smoking adolescents in Africa are exposed to SHS, suggesting the need for countries to adopt policies to protect never smokers through the implementation of the WHO Framework Convention on Tobacco Control.