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While road safety in the United States (U.S.) has been continually improving since the 1970's, there are indications that these improvements are becoming increasingly difficult to sustain. Strategic Highway Safety Plans (SHSPs) are prepared by States to guide road safety management, however assessing the appropriateness of these plans remains a significant challenge, especially for the future in which they are to be applied. This study developed a new methodology to assess SHSPs from the perspectives of comprehensive system-based safety management and relevant future issues that can be applied before SHSPs are implemented, thereby avoiding long periods after implementation before assessing the appropriateness of the plans. A rating scale was developed and applied to assess 48 U.S. SHSPs against two key criteria: 1. a comprehensive framework for road safety, and 2. the anticipated changing, difficult and unpredictable nature of future transport and its context. The analysis concluded that current SHSPs have good national oversight with several strengths but were weak in some areas of content and did not address future challenges. Improvements are suggested to strengthen the plans’ thoroughness by being consistent with systems theory and practice, as well as ways that these SHSPs can be more resilient to future circumstances. Implementing the recommendations in this paper provides the opportunity to adopt a system-based safety management practice that has been successful in other hazardous industries. Doing so is expected to most efficiently and effectively continue the recent improvements to road safety, which is likely to be increasingly difficult otherwise. [ABSTRACT FROM AUTHOR]

Background: There have been growing recommendations to include education in multi-disciplinary interventions targeting chronic pain management. However, effects of this strategy on short- and long-term self-management of chronic pain, remain largely unexplored. Objectives: 1. To provide an updated overview of studies that report on the impact of patient education in multi-disciplinary interventions, on self-management of chronic pain; 2. To explore associations between education and chronic pain self-management techniques; and 3. To identify the format and duration of suitable chronic pain interventions targeted at patient self-management. Methods: Design: Narrative systematic literature review of randomised or controlled study designs. Data Sources: PubMed, CINAHL, EMBASE, PsycINFO. Participants: Adult patients with chronic pain of any aetiology participating in multi-disciplinary programs that included education. Main outcome measures: Assessments of level of pain, function, quality of life, self-efficacy, self-management, and any other relevant assessments. Study Appraisal and Synthesis Methods: PRISMA guidelines, Cochrane Risk of Bias tool, and TIDieR model. Results: Database searching identified 485 potential papers. After removal of duplicates, and irrelevant articles by title and abstract, 120 full-text articles were reviewed and 27 studies were included in this systematic review. Studies were predominantly from the United States (n = 8; 29.6%). Over one hundred outcome measures were identified across all studies, with significant variation also observed in terms of how chronic pain duration was defined, and how education was delivered to participants. Overall, positive benefits of education were reported. Conclusions: Education, as part of multi-disciplinary programs, is likely to improve self-management and self-efficacy in people with chronic pain of any aetiology. Heterogeneity in terms of: chronic pain duration; educational resources; healthcare professionals; and outcome measures, were identified as limitations. Further research, in the form of Randomised Controlled Trials addressing these limitations, is recommended. [ABSTRACT FROM AUTHOR]

Objective: Lung cancer is the most common type of cancer around the world, and it represents the main cause of death in the USA. Surgical treatment is the optimal therapeutic strategy for resectable non-small cell lung cancer. The principal factor for long-term survival after complete resection is the anatomic extension of the neoplasm. However, other factors also have adverse effects on operative mortality, and influence long-term outcome. In this paper we propose an algorithmic solution for the estimation of 5-years survival rate in lung cancer patients undertaking pulmonary resection. Materials and methods: We address the issue of survival analysis through decision-making techniques based on fuzzy and soft set theories. We develop an expert system based on clinical and functional data of lung cancer resections in patients with cancer that can be used to predict the survival of patients. Results: The evaluation of surgical risk in patients undertaking pulmonary resection is a primary target for thoracic surgeons. Lung cancer survival is influenced by many factors. The computational performance of our algorithm is critically analyzed by an experimental study. The correct survival classification is achieved with an accuracy of 79.0%. Our novel soft-set based criterion is an effective and precise diagnosis application for the determination of the survival rate. [ABSTRACT FROM AUTHOR]

After decades-old efforts to nudge consumers towards healthier lifestyles through dietary guidelines, diet-related diseases are on the rise. In addition, a growing share of U.S. consumers proactively chooses nutritional supplements as an alternative preventative way of maintaining good health, a $25.5 billion industry in the United States. This paper investigates possible linkages between the economics of consumer supplement choices and the relationship to important dietary and health outcomes. We use National Health and Nutrition Examination Survey (NHANES) data to estimate the impact of nutritional supplements intake on respondent’s body weight outcomes, controlling for diet quality.: The focus of this article is to determine whether nutritional supplements takers differ from non-takers with regard to their health outcomes when controlling for differences in diet quality, based on individual Healthy Eating Index (HEI-2010) score. The analysis applies treatment effects estimators that account for the selection bias and endogeneity of self-reported behavior and diet-health outcomes. The analysis demonstrates a negative association between supplement intake and BMI but no significant effect on an individual’s diet quality. Our findings suggest that individuals proactively invest into their health by taking nutritional supplements instead of improving diet quality through more nutritious food choices. Our results provide important contributions to the literature on a key food policy issue. Knowledge of the determinants of supplement demand in the context of strong diet-health trends should also be helpful to stakeholders in the U.S. produce sector in their competition over consumer market share. [ABSTRACT FROM AUTHOR]

Objective: Heroin use in the United States has reached epidemic proportions. The objective of this paper is to estimate the annual societal cost of heroin use disorder in the United States in 2015 US dollars. Methods: An analytic model was created that included incarceration and crime; treatment for heroin use disorder; chronic infectious diseases (HIV, Hepatitis B, Hepatitis C, and Tuberculosis) and their treatments; treatment of neonatal abstinence syndrome; lost productivity; and death by heroin overdose. Results: Using literature-based estimates to populate the model, the cost of heroin use disorder was estimated to be $51.2 billion in 2015 US dollars ($50,799 per heroin user). One-way sensitivity analyses showed that overall cost estimates were sensitive to the number of heroin users, cost of HCV treatment, and cost of incarcerating heroin users. Conclusion: The annual cost of heroin use disorder to society in the United States emphasizes the need for sustained investment in healthcare and non-healthcare related strategies that reduce the likelihood of abuse and provide care and support for users to overcome the disorder. [ABSTRACT FROM AUTHOR]

Background: Policies designed to restrict marketing, access to, and public use of electronic cigarettes (e-cigarettes) are increasingly under debate in various jurisdictions in the US. Little is known about public perceptions of these policies and factors that predict their support or opposition. Methods: Using a sample of US adults from Amazon Mechanical Turk in May 2015, this paper identifies beliefs about the benefits and costs of regulating e-cigarettes and identifies which of these beliefs predict support for e-cigarette restricting policies. Results: A higher proportion of respondents agreed with 8 different reasons to regulate e-cigarettes (48.5% to 83.3% agreement) versus 7 reasons not to regulate e-cigarettes (11.5% to 18.9%). The majority of participants agreed with 7 out of 8 reasons for regulation. When all reasons to regulate or not were included in a final multivariable model, beliefs about protecting people from secondhand vapor and protecting youth from trying e-cigarettes significantly predicted stronger support for e-cigarette restricting policies, whereas concern about government intrusion into individual choices was associated with reduced support. Discussion: This research identifies key beliefs that may underlie public support or opposition to policies designed to regulate the marketing and use of e-cigarettes. Advocates on both sides of the issue may find this research valuable in developing strategic campaigns related to the issue. Implications: Specific beliefs of potential benefits and costs of e-cigarette regulation (protecting youth, preventing exposure to secondhand vapor, and government intrusion into individual choices) may be effectively deployed by policy makers or health advocates in communicating with the public. [ABSTRACT FROM AUTHOR]

This paper presents data from the Program for the International Assessment of Adult Competencies with a focus on the interrelationships among health information seeking behavior (HISB), and health status or use of preventive health measures for U.S. adults both with and without a high school diploma. Key results of ordinal and binary logistic regression analyses indicated that, after controlling for demographic factors, (1) adults with a high school diploma use more text-based health information sources while adults without a high school diploma use more oral sources, (2) using the Internet as a source of health information is more strongly related to reporting excellent/very good health status than having a high school diploma, (3) those without a high school diploma who use the Internet report the largest increase in health status over any other health information source, and (4) for those with learning disability or vision problem, a high facility in reading English is an important predictor of whether the Internet is used as a health information source. The Internet appears to play a key role in both enhancing health status and enabling use of preventive measures for those with and without a high school diploma; although, individuals without a high school diploma who use the Internet for health information derive substantial benefit in health status. [ABSTRACT FROM AUTHOR]

There is strong epidemiological evidence that poor diet is associated with depression. The reverse has also been shown, namely that eating a healthy diet rich in fruit, vegetables, fish and lean meat, is associated with reduced risk of depression. To date, only one randomised controlled trial (RCT) has been conducted with elevated depression symptoms being an inclusion criterion, with results showing that a diet intervention can reduce clinical levels of depression. No such RCTs have been performed in young adults. Young adults with elevated levels of depression symptoms and who habitually consume a poor diet were randomly allocated to a brief 3-week diet intervention (Diet Group) or a habitual diet control group (Control Group). The primary and secondary outcome measures assessed at baseline and after the intervention included symptoms of depression (Centre for Epidemiological Studies Depression Scale; CESD-R; and Depression Anxiety and Stress Scale– 21 depression subscale; DASS-21-D), current mood (Profile of Mood States), self-efficacy (New General Self-Efficacy Scale) and memory (Hopkins Verbal Learning Test). Diet compliance was measured via self-report questionnaires and spectrophotometry. One-hundred-and-one individuals were enrolled in the study and randomly assigned to the Diet Group or the Control Group. Upon completion of the study, there was complete data for 38 individuals in each group. There was good compliance with the diet intervention recommendations assessed using self-report and spectrophotometry. The Diet group had significantly lower self-reported depression symptoms than the Control Group on the CESD-R (p = 0.007, Cohen’s d = 0.65) and DASS-21 depression subscale (p = 0.002, Cohen’s d = 0.75) controlling for baseline scores on these scales. Reduced DASS-21 depression subscale scores were maintained on follow up phone call 3 months later (p = .009). These results are the first to show that young adults with elevated depression symptoms can engage in and adhere to a diet intervention, and that this can reduce symptoms of depression. The findings provide justification for future research into the duration of these benefits, the impacts of varying diet composition, and their biological basis. [ABSTRACT FROM AUTHOR]

We aim to determine whether a game-theoretic model between an insurer and a healthcare practice yields a predictive equilibrium that incentivizes either player to deviate from a fee-for-service to capitation payment system. Using United States data from various primary care surveys, we find that non-extreme equilibria (i.e., shares of patients, or shares of patient visits, seen under a fee-for-service payment system) can be derived from a Stackelberg game if insurers award a non-linear bonus to practices based on performance. Overall, both insurers and practices can be incentivized to embrace capitation payments somewhat, but potentially at the expense of practice performance. [ABSTRACT FROM AUTHOR]

The Model for End-Stage Liver Disease (MELD) score has been successfully used to prioritize patients on the United States liver transplant waiting list since its adoption in 2002. The United Network for Organ Sharing (UNOS)/Organ Procurement Transplantation Network (OPTN) allocation policy has evolved over the years, and notable recent changes include Share 35, inclusion of serum sodium in the MELD score, and a ‘delay and cap’ policy for hepatocellular carcinoma (HCC) patients. We explored the potential of a registrant’s change in 30-day MELD scores (ΔMELD30) to improve allocation both before and after these policy changes. Current MELD and ΔMELD30 were evaluated using cause-specific hazards models for waitlist dropout based on US liver transplant registrants added to the waitlist between 06/30/2003 and 6/30/2013. Two composite scores were constructed and then evaluated on UNOS data spanning the current policy era (01/02/2016 to 09/07/2018). Predictive accuracy was evaluated using the C-index for model discrimination and by comparing observed and predicted waitlist dropout probabilities for model calibration. After the change to MELD-Na, increased dropout associated with ΔMELD30 jumps is no longer evident at MELD scores below 30. However, the adoption of Share 35 has potentially resulted in discrepancies in waitlist dropout for patients with sharp MELD increases at higher MELD scores. Use of the ΔMELD30 to add additional points or serve as a potential tiebreaker for patients with rapid deterioration may extend the benefit of Share 35 to better include those in most critical need. [ABSTRACT FROM AUTHOR]

Context: An estimated 21% of non-U.S.-born persons in the United States have a reactive tuberculin skin test (TST) and are at risk of progressing to TB disease. The effectiveness of strategies by healthcare facilities to improve targeted TB infection testing and linkage to care among this population is unclear. Evidence acquisition: Following Cochrane guidelines, we searched several sources to identify studies that assessed strategies directed at healthcare providers and/or non-U.S.–born patients in U.S. healthcare facilities. Evidence synthesis: Seven studies were eligible. In a randomized controlled trial (RCT), patients with reactive TST who received reminders for follow-up appointments were more likely to attend appointments (risk ratio, RR = 1.05, 95% confidence interval 1.00–1.10), but rates of return in a quasi-RCT study using patient reminders did not significantly differ between study arms (P = 0.520). Patient-provider language concordance in a retrospective cohort study did not increase provider referrals for testing (P = 0.121) or patient testing uptake (P = 0.159). Of three studies evaluating pre and post multifaceted interventions, two increased TB infection testing (from 0% to 77%, p < .001 and RR 2.28, 1.08–4.80) and one increased provider referrals for TST (RR 24.6, 3.5–174). In another pre-post study, electronic reminders to providers increased reading of TSTs (RR 2.84, 1.53–5.25), but only to 25%. All seven studies were at high risk of bias. Conclusions: Multifaceted strategies targeting providers may improve targeted TB infection testing in non-U.S.-born populations visiting U.S. healthcare facilities; uncertainties exist due to low-quality evidence. Additional high-quality studies on this topic are needed. [ABSTRACT FROM AUTHOR]

Objective: The Centers for Disease Control and Prevention (CDC) coordinates a labor-intensive process to measure the prevalence of autism spectrum disorder (ASD) among children in the United States. Random forests methods have shown promise in speeding up this process, but they lag behind human classification accuracy by about 5%. We explore whether more recently available document classification algorithms can close this gap. Materials and methods: Using data gathered from a single surveillance site, we applied 8 supervised learning algorithms to predict whether children meet the case definition for ASD based solely on the words in their evaluations. We compared the algorithms’ performance across 10 random train-test splits of the data, using classification accuracy, F1 score, and number of positive calls to evaluate their potential use for surveillance. Results: Across the 10 train-test cycles, the random forest and support vector machine with Naive Bayes features (NB-SVM) each achieved slightly more than 87% mean accuracy. The NB-SVM produced significantly more false negatives than false positives (P = 0.027), but the random forest did not, making its prevalence estimates very close to the true prevalence in the data. The best-performing neural network performed similarly to the random forest on both measures. Discussion: The random forest performed as well as more recently available models like the NB-SVM and the neural network, and it also produced good prevalence estimates. NB-SVM may not be a good candidate for use in a fully-automated surveillance workflow due to increased false negatives. More sophisticated algorithms, like hierarchical convolutional neural networks, may not be feasible to train due to characteristics of the data. Current algorithms might perform better if the data are abstracted and processed differently and if they take into account information about the children in addition to their evaluations. Conclusion: Deep learning models performed similarly to traditional machine learning methods at predicting the clinician-assigned case status for CDC’s autism surveillance system. While deep learning methods had limited benefit in this task, they may have applications in other surveillance systems. [ABSTRACT FROM AUTHOR]

Background: Drug abuse and sexually transmitted infections (STIs), including the human immunodeficiency virus (HIV), remain significant public health concerns in the United States. Youth are at disproportionate risk of drug use and STIs/HIV, yet interventions aimed at improving STI and HIV testing and reducing STI/HIV risk behaviors through technology-based engagement in clinic settings are limited. The purpose of this study was to examine the feasibility and acceptability of Storytelling 4 Empowerment (S4E), a multilevel mobile-health drug abuse and STI/HIV preventive application (app) for clinic settings. We also explored uptake of STI/HIV testing among youth immediately post-intervention. Method: Employing community-based participatory research principles and a multi-method research design, we developed a clinician-facing app, and examined the feasibility and acceptability of S4E among clinicians (n = 6) and youth (n = 20) in an urban youth-centered community health clinic. S4E aimed to improve clinician–youth risk communication and youths’ drug use and STI/HIV knowledge, self-efficacy, and refusal skills. We also explored youths’ uptake of STI and HIV testing. Quantitative data were analyzed by computing mean scores and proportions, and qualitative analyses followed the tenets of content analysis. Results: Among eligible participants, 86.9% of youth and 85.7% of clinicians enrolled in the study, suggesting the feasibility of recruiting participants from the targeted clinic. Most clinicians identified as non-Hispanic white (83%) and female (66.7%). Among the youth, 70% identified as non-Hispanic white, followed by 30% African American, and 50% identified as female with a mean age of 19.6 (SD = 1.5, Range = 16–21). The quantitative findings suggest that the acceptability of S4E is high, as indicated by the Client Satisfaction Questionnaire (mean score = 25.2, SD: 4.8). Immediately post-intervention, all youth who reported past 90-day condomless sex or having never been tested for STIs or HIV in their lifetime, were tested for both STIs and HIV. Qualitative themes revealed four overarching themes, including S4E: (1) faciliated timely, targeted, and tailored prevention and risk reduction strategies; (2) shaped clinician and youth communication and interaction during the clinic visit; (3) may have improved uptake of STI/HIV testing and increased STI/HIV knowledge and self-efficacy; and (4) had high feasibiliy and acceptability among youth and clninicans. Conclusions: Findings suggest the feasibility and acceptability of S4E in an urban community-based health clinic setting. A next important step is to examine the efficacy of S4E in a randomized controlled trial design. [ABSTRACT FROM AUTHOR]

Introduction: Compositional data analysis is one appropriate method for co-dependent data, even when data are collected for a subdivision of the 24-hour period, such as the waking day. Objectives were to use compositional analyses to examine the combined and relative associations of sedentary time (ST), light-intensity physical activity (LPA), moderate-intensity physical activity (MPA), and vigorous-intensity physical activity (VPA) with cardiometabolic biomarkers in a representative sample of children and youth. Methods: This cross-sectional study included 2544 participants aged 6–17 years from the 2003–2006 United States National Health and Nutrition Examination Survey. ST (<100 counts per minute), LPA (100 counts per minute to <4 METs; Freedson age-specific equation), MPA (4 to <7 METs), and VPA (≥7 METs) were accelerometer-derived. Cardiometabolic biomarkers included waist circumference, body mass index (BMI) z-score, HDL-cholesterol, C-reactive protein, and blood pressure. Triglycerides, glucose, insulin, and LDL-cholesterol were measured in a fasting sub-sample of adolescents (n = 670). Compositional linear regression models were conducted. Results: The composition of ST, LPA, MPA, and VPA was significantly associated with BMI z-score, log waist circumference, systolic and diastolic blood pressure, HDL-cholesterol, and log plasma glucose (variance explained: 1–29%). Relative to the other three behaviors, VPA was negatively associated with BMI z-score (γVPA = -0.206, p = 0.005) and waist circumference (γVPA = -0.03, p = 0.001). Conversely, ST was positively associated with waist circumference (γST = 0.029, p = 0.013). ST and VPA were also positively associated with diastolic blood pressure (γST = 2.700, p = 0.018; γVPA = 1.246, p = 0.038), relative to the other behaviors, whereas negative associations were observed for LPA (γLPA = -2.892, p = 0.026). Finally, VPA was positively associated with HDL-cholesterol, relative to other behaviors (γVPA = 0.058, p<0.001). Conclusions: The ST and physical activity composition appears important for many aspects of cardiometabolic health in children and youth. Compositions with more time in higher-intensity activities may be better for some aspects of cardiometabolic health. [ABSTRACT FROM AUTHOR]

Background: College affirmative action programs seek to expand socioeconomic opportunities for underrepresented minorities. Between 1996 and 2013, 9 US states-including California, Texas, and Michigan-banned race-based affirmative action in college admissions. Because economic opportunity is known to motivate health behavior, banning affirmative action policies may have important adverse spillover effects on health risk behaviors. We used a quasi-experimental research design to evaluate the association between college affirmative action bans and health risk behaviors among underrepresented minority (Black, Hispanic, and Native American) adolescents.Methods and Findings: We conducted a difference-in-differences analysis using data from the 1991-2015 US national Youth Risk Behavior Survey (YRBS). We compared changes in self-reported cigarette smoking and alcohol use in the 30 days prior to survey among underrepresented minority 11th and 12th graders in states implementing college affirmative action bans (Arizona, California, Florida, Michigan, Nebraska, New Hampshire, Oklahoma, Texas, and Washington) versus outcomes among those residing in states not implementing bans (n = 35 control states). We also assessed whether underrepresented minority adults surveyed in the 1992-2015 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) who were exposed to affirmative action bans during their late high school years continued to smoke cigarettes between the ages of 19 and 30 years. Models adjusted for individual demographic characteristics, state and year fixed effects, and state-specific secular trends. In the YRBS (n = 34,988 to 36,268, depending on the outcome), cigarette smoking in the past 30 days among underrepresented minority 11th-12th graders increased by 3.8 percentage points after exposure to an affirmative action ban (95% CI: 2.0, 5.7; p < 0.001). In addition, there were also apparent increases in past-30-day alcohol use, by 5.9 percentage points (95% CI: 0.3, 12.2; p = 0.041), and past-30-day binge drinking, by 3.5 percentage points (95% CI: -0.1, 7.2, p = 0.058), among underrepresented minority 11th-12th graders, though in both cases adjustment for multiple comparisons resulted in failure to reject the null hypothesis (adjusted p = 0.083 for both outcomes). Underrepresented minority adults in the TUS-CPS (n = 71,575) exposed to bans during their late high school years were also 1.8 percentage points more likely to report current smoking (95% CI: 0.1, 3.6; p = 0.037). Event study analyses revealed a discrete break for all health behaviors timed with policy discussion and implementation. No substantive or statistically significant effects were found for non-Hispanic White adolescents, and the findings were robust to a number of additional specification checks. The limitations of the study include the continued potential for residual confounding from unmeasured time-varying factors and the potential for recall bias due to the self-reported nature of the health risk behavior outcomes.Conclusions: In this study, we found evidence that some health risk behaviors increased among underrepresented minority adolescents after exposure to state-level college affirmative action bans. These findings suggest that social policies that shift socioeconomic opportunities could have meaningful population health consequences. [ABSTRACT FROM AUTHOR]

Objectives: Reviews of violence against children in disaster settings focus on armed conflict. Little is understood about natural disasters which has implications in planning humanitarian response. We examined the magnitude and direction of the association between exposure to natural disasters and physical, emotional, and sexual violence against children, and assessed the quality of the evidence. Methods: We searched 15 health and social science databases from first record until May 16, 2018. Publications describing all types of quantitative study design were eligible for inclusion. We presented study characteristics and quality in a narrative form and generated pooled estimates using a three-level random effects model. We evaluated Cochrane’s Q with p-values below 0.10 and radial plots to assess heterogeneity. Planned subgroup analyses explored differential results by violence form, study design, and analysis method. Results: 11 publications met inclusion criteria. The majority were cross-sectional studies examining physical or sexual violence in the United States. We found no evidence of a consistent association or directional influence between natural disasters and violence against children. Combined categorical violence outcomes had substantial heterogeneity [Q (df = 66) = 252.83, p < 0.001]. Subgroups without evidence of heterogeneity had confidence intervals that included a possible null effect. Our findings were mainly limited by inconsistencies in operational definitions of violence, a lack of representative sampling, and unclear establishment of temporal order between natural disaster exposure and violence outcomes. Conclusions: Based on the available evidence, we cannot confidently conclude that natural disasters increase the level or severity of violence against children above non-disaster settings, however heterogeneity and study quality hamper our ability to draw firm conclusions. More nuanced and rigorous research is needed to inform practice and policy as natural disasters increasingly affect human populations. [ABSTRACT FROM AUTHOR]

Commercial captive breeding and trade in body parts of threatened wild carnivores is an issue of significant concern to conservation scientists and policy-makers. Following a 2016 decision by Parties to the Convention on International Trade in Endangered Species of Wild Fauna and Flora, South Africa must establish an annual export quota for lion skeletons from captive sources, such that threats to wild lions are mitigated. As input to the quota-setting process, South Africa’s Scientific Authority initiated interdisciplinary collaborative research on the captive lion industry and its potential links to wild lion conservation. A National Captive Lion Survey was conducted as one of the inputs to this research; the survey was launched in August 2017 and completed in May 2018. The structured semi-quantitative questionnaire elicited 117 usable responses, representing a substantial proportion of the industry. The survey results clearly illustrate the impact of a USA suspension on trophy imports from captive-bred South African lions, which affected 82% of respondents and economically destabilised the industry. Respondents are adapting in various ways, with many euthanizing lions and becoming increasingly reliant on income from skeleton export sales. With rising consumer demand for lion body parts, notably skulls, the export quota presents a further challenge to the industry, regulators and conservationists alike, with 52% of respondents indicating they would adapt by seeking ‘alternative markets’ for lion bones if the export quota allocation restricted their business. Recognizing that trade policy toward large carnivores represents a ‘wicked problem’, we anticipate that these results will inform future deliberations, which must nonetheless also be informed by challenging inclusive engagements with all relevant stakeholders. [ABSTRACT FROM AUTHOR]

The study of Autism Spectrum Disorder (ASD) in the United States has identified a growing prevalence of the disorder across the country, a high economic burden for necessary treatment, and important gaps in insurance for individuals with autism. Confronting these facts, states have moved quickly in recent years to introduce mandates that insurers provide coverage for autism care. This study analyzes these autism insurance mandates and demonstrates that while states have moved swiftly to introduce them, the generosity of the benefits they mandate insurers provide varies dramatically across states. Furthermore, our research finds that controlling for policy need, interest group activity, economic circumstances, the insurance environment, and other factors, the passage of these mandates and differences in their generosity are driven by the ideology of state residents and politicians–with more generous benefits in states with more liberal citizens and increased Democratic control of state government. We conclude by discussing the implications of these findings for the study of health policy, politics, and autism in America. [ABSTRACT FROM AUTHOR]

Both academic and popular literatures have repeatedly contended that emerging adults are the most narcissistic and entitled age-group in modern times. Although this contention is fiercely debated, the message that emerging adults are narcissistic and entitled has saturated popular culture. Despite this saturation, relatively little empirical work has examined how emerging adults might react to such labels. Across three studies in five samples in the U.S., the present work sought to address this deficit in research. Results from cross-sectional samples of university students at two universities, as well as an online convenience sample of web-using adults (Study 1), indicated that emerging adults believe their age-group and the one following them (e.g., adolescents) to be the most narcissistic and entitled age-groups, that they have generally negative opinions of narcissism and entitlement, and that they respond negatively to being labeled as narcissistic and entitled. Additionally, results from adult web-users revealed that, while all age groups tend to view adolescents and emerging adults as more narcissistic and entitled than older age-groups, these opinions are more exaggerated among members of older age-groups. Finally, across two experimental studies (Studies 2 & 3), results indicated that emerging adults react negatively to labeling of their age-group as narcissistic and entitled, but no more negatively than they do to potentially related undesirable labels (e.g., oversensitive). Collectively, these results indicate that emerging adults are aware of and somewhat distressed by messaging that casts their age-group as the most narcissistic and entitled age-group ever. [ABSTRACT FROM AUTHOR]

Evidence suggests that suicide rates can increase following the suicide of a prominent celebrity or peer, sometimes known as ‘suicide contagion’. The risk of contagion is especially high when media coverage is detailed and sensational. A recent study reported a 10% increase in U.S. suicides in the months following the suicide of comedian Robin Williams, who died in August 2014. The authors tentatively linked this increase to sensational media coverage; however, no content analysis of U.S. media was performed. As such, the aim of the present study is to formally examine the tone and content of U.S. newspaper coverage of Williams’ suicide. The primary objective is to assess adherence to suicide reporting guidelines in U.S. newspapers after his suicide. The secondary objective is to identify common emerging themes discussed in these articles. The tertiary objective is to compare patterns of results in the U.S media with those in the Canadian media. Articles about Williams’ suicide were collected from 10 U.S. newspapers in the 30-day period following his death using systematic retrieval software, which were then examined for adherence to suicide reporting recommendations. An inductive thematic analysis was also undertaken. A total of 63 articles were included in the study. We found that 100% of articles did not call it a ‘successful’ suicide, 96.8% did not use pejorative phrases and 71% did not say ‘commit’ suicide. However, only 11% included information about help-seeking, 27% tended to romanticize his suicide and 46% went into detail about the method. The most prominent emerging theme was Williams’ struggles with mental illness and addiction. These findings suggest that U.S. newspapers moderately adhered to best practice recommendations when reporting Williams’ suicide. Key recommendations were underapplied, which may have contributed to suicide contagion. New interventions targeting U.S. journalists and media may be needed to improve suicide reporting. [ABSTRACT FROM AUTHOR]

Background: Treatment decision-making regarding immunosuppressive therapy is challenging for individuals with lupus. We assessed the effectiveness of a decision aid for immunosuppressive therapy in lupus nephritis.Methods and Findings: In a United States multicenter, open-label, randomized controlled trial (RCT), adult women with lupus nephritis, mostly from racial/ethnic minority backgrounds with low socioeconomic status (SES), seen in in- or outpatient settings, were randomized to an individualized, culturally tailored, computerized decision aid versus American College of Rheumatology (ACR) lupus pamphlet (1:1 ratio), using computer-generated randomization. We hypothesized that the co-primary outcomes of decisional conflict and informed choice regarding immunosuppressive medications would improve more in the decision aid group. Of 301 randomized women, 298 were analyzed; 47% were African-American, 26% Hispanic, and 15% white. Mean age (standard deviation [SD]) was 37 (12) years, 57% had annual income of <$40,000, and 36% had a high school education or less. Compared with the provision of the ACR lupus pamphlet (n = 147), participants randomized to the decision aid (n = 151) had (1) a clinically meaningful and statistically significant reduction in decisional conflict, 21.8 (standard error [SE], 2.5) versus 12.7 (SE, 2.0; p = 0.005) and (2) no difference in informed choice in the main analysis, 41% versus 31% (p = 0.08), but clinically meaningful and statistically significant difference in sensitivity analysis (net values for immunosuppressives positive [in favor] versus negative [against]), 50% versus 35% (p = 0.006). Unresolved decisional conflict was lower in the decision aid versus pamphlet groups, 22% versus 44% (p < 0.001). Significantly more patients in the decision aid versus pamphlet group rated information to be excellent for understanding lupus nephritis (49% versus 33%), risk factors (43% versus 27%), medication options (50% versus 33%; p ≤ 0.003 for all); and the ease of use of materials was higher in the decision aid versus pamphlet groups (51% versus 38%; p = 0.006). Key study limitations were the exclusion of men, short follow-up, and the lack of clinical outcomes, including medication adherence.Conclusions: An individualized decision aid was more effective than usual care in reducing decisional conflict for choice of immunosuppressive medications in women with lupus nephritis.Trial Registration: Clinicaltrials.gov, NCT02319525. [ABSTRACT FROM AUTHOR]

A growing body of literature suggests that post-secondary students experience food insecurity (FI) at greater rates than the general population. However, these rates vary dramatically across institutions and studies. FI assessment methods commonly used in studies with college students have not been scrutinized for psychometric properties, and varying protocols may influence resulting FI prevalence estimates. The objective of this study was to assess the performance of standard food security assessment protocols and to evaluate their agreement as well as the relative accuracy of these protocols in identifying student FI. A randomized sample of 4,000 undergraduate students were invited to participate in an online survey (Qualtrics, LLC, Provo, Utah, USA) that evaluated sociodemographic characteristics and FI with the 2-item food sufficiency screener and the 10-item USDA Adult Food Security Survey Module (FSSM; containing the abbreviated 6-item module). Four hundred sixty-two eligible responses were included in the final sample. The psychometric analysis revealed inconsistencies in college student response patterns on the FSSM when compared to national evaluations. Agreement between FI protocols was generally high (>90%) but was lessened when compared with a protocol that incorporated the 2-item screener. The 10-item FSSM with the 2-item screener had the best model fit (McFadden's R2 = 0.15 and Bayesian Information Criterion = -2049.72) and emerged as the tool providing the greatest relative accuracy for identifying students with FI. Though the 10-item FSSM and 2-item screener yields the most accuracy in this sample, it is unknown why students respond to FSSM items differently than the general population. Further qualitative and quantitative evaluations are needed to determine which assessment protocol is the most valid and reliable for use in accurately identifying FI in post-secondary students across the U.S. [ABSTRACT FROM AUTHOR]

Background: Intraspecific variation in foraging niche can drive food web dynamics and ecosystem processes. In particular, male and female animals can exhibit different, often cascading, impacts on their interaction partners. Despite this, studies of plant-pollinator interaction networks have focused on the partitioning of the floral community between pollinator species, with little attention paid to intraspecific variation in plant preference between male and female bees. We designed a field study to evaluate the strength and prevalence of sexually dimorphic foraging, and particularly resource preferences, in bees. Study design: We observed bees visiting flowers in semi-natural meadows in New Jersey, USA. To detect differences in flower use against a shared background of resource (flower) availability, we maximized the number of interactions observed within narrow spatio-temporal windows. To distinguish observed differences in bee use of flower species, which can reflect abundance patterns and sampling effects, from underlying differences in bee preferences, we analyzed our data with both a permutation-based null model and random effects models. Findings: We found that the diets of male and female bees of the same species were often dissimilar as the diets of different species of bees. Furthermore, we demonstrate differences in preference between male and female bees. We show that intraspecific differences in preference can be robustly identified among hundreds of unique species-species interactions, without precisely quantifying resource availability, and despite high phenological turnover of both bees and plant bloom. Given the large differences in both flower use and preferences between male and female bees, ecological sex differences should be integrated into studies of bee demography, plant pollination, and coevolutionary relationships between flowers and insects. [ABSTRACT FROM AUTHOR]

Brazilians are a rapidly increasing Latino immigrant group in the United States (US), yet little research has examined factors influencing physical activity (PA) levels and behaviors of children growing up in Brazilian immigrant families. This information is needed to develop culturally sensitive interventions tailored to this population. Therefore, this qualitative study explored PA parenting practices used by Brazilian immigrant mothers living in the US. Thirty-seven Brazilian immigrant mothers with at least one child between the ages of 2 and 5 years participated in 1of 7 focus group discussions. Thematic analysis identified seven parenting practices that mothers employ that may encourage or facilitate physical activity their preschool-aged children's PA including: 1) modeling PA; 2) engaging and being physically active with child; 3) providing logistic support; 4) encouraging, praising, and offering motivational support; 5) watching, supervising, and teaching children how to engage in PA; 6) monitoring and setting limits to child's screen time; and 7) prompting child to be physically active. In addition, analysis identified four parenting practices that may discourage or inhibit children's PA including: 1) modeling of sedentary behaviors; 2) having rules and restrictions due to safety- and weather-related concerns; 3) limiting child's outdoor time due to parental time constraints; and 4) restricting child's outdoor and play time as punishment. Furthermore, analyses demonstrated that social contextual factors (e.g., income, housing, neighborhood safety, etc.) influence mothers' PA parenting practices and consequently, their children's PA. This is the first qualitative study, to our knowledge, to explore PA parenting practices of Brazilian-born immigrant mothers living in the US. Future research should further explore PA parenting practices of Brazilian immigrant parents including quantifying PA parenting practices that encourage and discourage PA, as well as examining the influence of fathers' PA parenting practices on young children's PA. [ABSTRACT FROM AUTHOR]

This study examines the potential for point-of-decision prompts (PDPs) to promote healthier food choices among shoppers in a rural, low-income, minority community. We hypothesized that a narrowly defined PDP (focused on fresh produce) would be easier for shoppers to remember than a broadly defined PDP (focused on any healthy items), resulting in a higher proportion of healthy items purchased. PDPs were placed at the entrance to a supermarket in Mission, South Dakota, United States of America, on the Rosebud Sioux Reservation for alternating time periods, July 9–10, 2017. Sales records from 653 transactions were retrieved from the supermarket, comprising periods in which PDPs were in place and control periods. We examined the proportion of selected items and proportion of total expenditures that were a) any healthy foods and b) fresh fruits and vegetables. Data were analyzed in 2018. The narrowly defined prompt consistently resulted in a higher proportion of items and expenditures on healthy foods than either the broad prompt or the control condition. Shoppers in the narrow prompt condition purchased and spent significantly more on any healthy foods and fresh produce than shoppers in the control condition. While shoppers in the narrow prompt condition purchased more healthy foods and fresh produce than shoppers in the broad prompt condition, the differences were not statistically significant. Shoppers exposed to the narrow PDP consistently purchased more healthy foods than shoppers in a control group, while shoppers in the broad PDP did not, highlighting the importance of considering cognitive processes when designing health promotion messages. [ABSTRACT FROM AUTHOR]

Breweries across the country are investing in energy efficient and low-carbon brewing practices. Drawing insights from the sustainable consumption and ecological economics literature, this analysis evaluates whether consumers are willing to pay more for sustainable beer and what predicts the value of the premium. Based on a survey of beer consumers from across the U.S. that contained one of two willingness-to-pay exercises, we evaluate what respondent attributes are associated with a higher willingness-to-pay for sustainably brewed beer. We find that the majority of beer consumers are willing to pay more for sustainable beer. Consumers who are prepared to pay a premium tend to already pay more per unit of beer, are more aware of their purchasing behavior and the manner in which their consumption patterns may affect the environment, and pursue lifestyles based on professional advancement, helping the environment, and helping other causes. [ABSTRACT FROM AUTHOR]

Introduction: Flavored e-cigarettes are enticing to new users and established cigarette smokers using e-cigarettes to quit smoking due to the wide variety of flavor options. However, specific flavor combinations that are popular among e-cigarette users are understudied. Recently, the Deeming rule extended the US Food and Drug Administration’s authority over all tobacco products, including e-cigarettes. Methods: The Population Assessment of Tobacco and Health Study Wave 2 data were analyzed to assess the prevalence of self-reported flavor categories that are used individually and in combination with other flavor categories among past 30-day youth and adult e-cigarette users in the US. Results: Most youth and adult participants reported using a flavored e-cigarette. Reporting an individual flavor category was more common than reporting a combination of flavor categories. Fruit flavor was the most common flavor category reported among youth, and ‘menthol/mint’ was most common among adults. Fruit and candy/other sweets were the most common flavor categories reported together among both youth and adult past 30-day e-cigarette users. Conclusions: The use of flavored e-cigarettes is very popular among youth and adults. Most consumers reported using a single flavor category, although some consumers did use a combination of flavor categories. Preference for menthol/mint among adults may represent a carryover from associations with tobacco cigarettes. Typically, sweeter flavors, such as fruit, were among the most popular flavor categories reported, both individually and in combination with other flavors, while more bitter flavors (i.e.: clove/spice) were less common. Implications: This study identified predominant flavor categories among past 30-day youth and adult e-cigarette users. Findings indicate that the wide variety of flavors available and the freedom to “mix-and-match” flavors may maintain use of e-cigarettes among youth and adults, and future research should focus on the composition of the ENDS liquid/vapor to disentangle the contributions of sweeteners and flavorants. [ABSTRACT FROM AUTHOR]

E-cigarettes are promoted as healthier alternatives to conventional cigarettes. Many cigarette smokers use both products. It is unknown whether the additional use of e-cigarettes among cigarette smokers (dual users) is associated with reduced exposure to tobacco-related health risks. Cross-sectional analysis was performed using baseline data from the Health eHeart Study, among English-speaking adults, mostly from the United States. Cigarette use (# cigarettes/day) and/or e-cigarette use (# days, # cartridges, and # puffs) were compared between cigarette only users vs. dual users. Additionally, we examined cardiopulmonary symptoms/ conditions across product use: no product (neither), e-cigarettes only, cigarettes only, and dual use. Among 39,747 participants, 573 (1.4%) reported e-cigarette only use, 1,693 (4.3%) reported cigarette only use, and 514 (1.3%) dual use. Dual users, compared to cigarette only users, reported a greater median (IQR) number of cigarettes per day, 10.0 (4.0–20.0) vs. 9.0 (3.0–15.0) (p < .0001), a lower (worse) median (IQR) SF-12 general health score, 3.3 (2.8–3.8) vs. 3.5 (2.8–3.9) (p = .0014), and a higher (worse) median (IQR) breathing difficulty score in the past month, 2.0 (1.0–2.0) vs. 1.0 (1.0–2.0) (p = .001). Of the 19 cardiopulmonary symptoms/ conditions, having a history of arrhythmia was significantly different between cigarette only users (14.2%) and dual users (17.8%) (p = .02). In this sample, dual use was not associated with reduced exposure to either (i) cigarettes, compared to cigarette only users or (ii) e-cigarettes, compared to e-cigarette only users. E-cigarette only use, compared to no product use, was associated with lower general health scores, higher breathing difficulty scores (typically and past month), and greater proportions of those who responded ‘yes’ to having chest pain, palpitations, coronary heart disease, arrhythmia, COPD, and asthma. These data suggest the added use of e-cigarettes alone may have contributed to cardiopulmonary health risks particularly respiratory health risks. [ABSTRACT FROM AUTHOR]

Fear of infectious disease can create a variety of problems not the least of which is fear itself. An important question is how individuals attempt to manage their fear. The appearance of Zika in the U.S. presented an opportunity to examine this issue in a consequential natural context. Beginning nine days after the W.H.O. declared Zika a world health crisis, two-waves of survey data were collected from women ages 18–35 who were living in the Southern U.S. (N = 561). Most respondents (71%) used one or more emotion regulation strategies and a plurality (41%) utilized multiple strategies. Fear of Zika showed no demonstrable effect on avoidance, reappraisal, or contesting and none of these three strategies were effective at down-regulating fear. Fear and suppression, however, showed a self-reinforcing cycle in which fear increased use of suppression and suppression increased intensity of the fear response. Although the observed associations were small, even modest effects can be consequential when cumulated over time or across large numbers of individuals. [ABSTRACT FROM AUTHOR]

Background: Tobacco addiction is a complex, multicomponent phenomenon stemming from nicotine's pharmacology and the user's biology, psychology, sociology, and environment. After decades of public denial, the tobacco industry now agrees with public health authorities that nicotine is addictive. In 2000, Philip Morris became the first major tobacco company to admit nicotine's addictiveness. Evolving definitions of addiction have historically affected subsequent policymaking. This article examines how Philip Morris internally conceptualized addiction immediately before and after this announcement.Methods and Findings: We analyzed previously secret, internal Philip Morris documents made available as a result of litigation against the tobacco industry. We compared these documents to public company statements and found that Philip Morris's move from public denial to public affirmation of nicotine's addictiveness coincided with pressure on the industry from poor public approval ratings, the Master Settlement Agreement (MSA), the United States government's filing of the Racketeer Influenced and Corrupt Organizations (RICO) suit, and the Institute of Medicine's (IoM's) endorsement of potentially reduced risk products. Philip Morris continued to research the causes of addiction through the 2000s in order to create successful potentially reduced exposure products (PREPs). While Philip Morris's public statements reinforce the idea that nicotine's pharmacology principally drives smoking addiction, company scientists framed addiction as the result of interconnected biological, social, psychological, and environmental determinants, with nicotine as but one component. Due to the fragmentary nature of the industry document database, we may have missed relevant information that could have affected our analysis.Conclusions: Philip Morris's research suggests that tobacco industry activity influences addiction treatment outcomes. Beyond nicotine's pharmacology, the industry's continued aggressive advertising, lobbying, and litigation against effective tobacco control policies promotes various nonpharmacological determinants of addiction. To help tobacco users quit, policy makers should increase attention on the social and environmental dimensions of addiction alongside traditional cessation efforts. [ABSTRACT FROM AUTHOR]

Population wellbeing, an aggregate measure of positive mental, physical, and emotional health, has previously been used as a marker of community thriving. We examined whether several community measures of wellbeing, and their change since 2012, could be used to understand electoral changes that led to the outcome of the 2016 United States presidential election. We found that areas of the US which had the largest shifts away from the incumbent party had both lower wellbeing and greater drops in wellbeing when compared with areas that did not shift. In comparison, changes in income were not related to voting shifts. Well-being may be more useful in predicting and understanding electoral outcomes than some more conventional voting determinants. [ABSTRACT FROM AUTHOR]

The HPTN 065 (TLC-Plus) study tested the feasibility and effectiveness of using financial incentives (FIs) to increase linkage to care (L2C) among individuals with newly diagnosed HIV and those out of care in the Bronx, NY and Washington, DC. Qualitative data collection with a subset of participating patients and staff focused on experiences with and attitudes about the FI intervention. Semi-structured interviews were conducted with 15 patients and 14 site investigators. Four focus group discussions were conducted with a total of 15 staff members. The use of FIs for L2C was generally viewed favorably. Patients were grateful and benefited financially, but sites had some challenges implementing the program. Challenges included the timing and sensitive introduction of the intervention immediately after an HIV diagnosis, negative attitudes towards paying people for health behaviors, and the existence and strength of existing linkage programs. Future programs should consider optimal timing and presentation of FIs. [ABSTRACT FROM AUTHOR]

Using the Truth Tobacco Industry Documents Library and Congressional records, we examined the tobacco industry’s involvement with the 1990 Americans with Disabilities Act (ADA). During legislative drafting of the ADA (1989–1990), the Tobacco Institute, the tobacco industry’s lobbying and public relations arm at the time, worked with industry lawyers and civil rights groups to include smoking in the ADA’s definition of “disability.” Focus was on smoking as a perceived rather than actual disability so that tobacco companies could maintain that smoking is not addictive. Language that would have explicitly excluded smoking from ADA coverage was weakened or omitted. Tobacco Institute lawyers did not think the argument that smokers are “disabled” would convince the courts, so in the two years after the ADA was signed into law, the Tobacco Institute paid a lawyer to conduct media tours, seminars, and write articles to convince employers that hiring only non-smokers would violate the ADA. The ultimate goal of these activities was to deter employers from promoting a healthy, tobacco-free workforce and, more broadly, to promote the social acceptability of smoking. Employers and policy makers need to be aware that tobacco use is not protected by the ADA and should not be misled by tobacco industry efforts to insinuate otherwise. [ABSTRACT FROM AUTHOR]

Background & aims: The impact of marijuana on nonalcoholic fatty liver disease (NAFLD) is largely unknown. We studied the association between marijuana and NAFLD utilizing cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) from 2005–2014 and NHANES III (1988–1994). Methods: Suspected NAFLD was diagnosed if serum alanine aminotransferase (ALT) was > 30 IU/L for men and > 19 IU/L for women in the absence of other liver diseases (NHANES 2005–2014). In NHANES III cohort, NAFLD was defined based on ultrasonography. Results: Of the 14,080 (NHANES 2005–2014) and 8,286 (NHANES III) participants, prevalence of suspected NAFLD and ultrasonographically-diagnosed NAFLD were inversely associated with marijuana use (p < 0.001). Compared to marijuana-naïve participants, marijuana users were less likely to have suspected NAFLD (odds ratio [OR]: 0.90, 95% confidence interval [CI]: 0.82–0.99 for past user; OR: 0.68, 95% CI: 0.58–0.80 for current user) and ultrasonographically-diagnosed NAFLD (OR: 0.75, 95% CI: 0.57–0.98 for current user) in the age, gender, ethnicity-adjusted model. On multivariate analysis, the ORs for suspected NAFLD comparing current light or heavy users to non-users were 0.76 (95% CI 0.58–0.98) and 0.70 (95% CI 0.56–0.89), respectively (P for trend = 0.001) with similar trends in ultrasonographically-diagnosed NAFLD (OR: 0.77, 95% CI: 0.59–1.00 for current user; OR: 0.71, 95% CI: 0.51–0.97 for current light user). In insulin resistance-adjusted model, marijuana use remained an independent predictor of lower risk of suspected NAFLD. Conclusions: In this nationally representative sample, active marijuana use provided a protective effect against NAFLD independent of known metabolic risk factors. The pathophysiology is unclear and warrants further investigation. [ABSTRACT FROM AUTHOR]

In 2015, we conducted a cross-sectional, Internet-based, U.S. nationally representative probability survey of 2,021 adults (975 men, 1,046 women) focused on a broad range of sexual behaviors. Individuals invited to participate were from the GfK KnowledgePanel®. The survey was titled the 2015 Sexual Exploration in America Study and survey completion took about 12 to 15 minutes. The survey was confidential and the researchers never had access to respondents’ identifiers. Respondents reported on demographic items, lifetime and recent sexual behaviors, and the appeal of 50+ sexual behaviors. Most (>80%) reported lifetime masturbation, vaginal sex, and oral sex. Lifetime anal sex was reported by 43% of men (insertive) and 37% of women (receptive). Common lifetime sexual behaviors included wearing sexy lingerie/underwear (75% women, 26% men), sending/receiving digital nude/semi-nude photos (54% women, 65% men), reading erotic stories (57% of participants), public sex (≥43%), role-playing (≥22%), tying/being tied up (≥20%), spanking (≥30%), and watching sexually explicit videos/DVDs (60% women, 82% men). Having engaged in threesomes (10% women, 18% men) and playful whipping (≥13%) were less common. Lifetime group sex, sex parties, taking a sexuality class/workshop, and going to BDSM parties were uncommon (each <8%). More Americans identified behaviors as “appealing” than had engaged in them. Romantic/affectionate behaviors were among those most commonly identified as appealing for both men and women. The appeal of particular behaviors was associated with greater odds that the individual had ever engaged in the behavior. This study contributes to our understanding of more diverse adult sexual behaviors than has previously been captured in U.S. nationally representative probability surveys. Implications for sexuality educators, clinicians, and individuals in the general population are discussed. [ABSTRACT FROM AUTHOR]

Trust in government agencies plays a key role in advancing these organizations' agendas, influencing behaviors, and effectively implementing policies. However, few studies have examined the extent to which individuals are aware of and trust the leading United States agencies devoted to protecting the public’s health. Using two national samples of adolescents (N = 1,125) and adults (N = 5,014), we examined demographic factors, with a focus on vulnerable groups, as correlates of awareness of and trust in the Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), and the federal government. From nine different weighted and adjusted logistic regression models, we found high levels of awareness of the existence of the FDA and CDC (ranging from 55.7% for adolescents’ awareness of the CDC to 94.3% for adults’ awareness of the FDA) and moderate levels of trust (ranging from a low of 41.8% for adults’ trust in the federal government and a high of 78.8% for adolescents’ trust of the FDA). In the adolescent and adult samples, awareness was higher among non-Hispanic Blacks and respondents with low numeracy. With respect to trust, few consistent demographic differences emerged. Our findings provide novel insights regarding awareness and trust in the federal government and specific United States public health agencies. Our findings suggest groups to whom these agencies may want to selectively communicate to enhance trust and thus facilitate their communication and regulatory agendas. [ABSTRACT FROM AUTHOR]

Background: There is continuing public debate about treatment preferences at the end of life, and the acceptability and legal status of treatments that sustain or end life. However, most surveys use binary yes/no measures, and little is known about preferences in neurological disease when decision-making capacity is lost, as most studies focus on cancer. This study investigates changes in public preferences for care towards the end of life, with a focus on measures to sustain or end life. Methods: Large-scale international public opinion surveys using a six-stage patient vignette, respondents chose a level of intervention for each stage as health and decision-making capacity deteriorated. Cross-sectional representative samples of the general public in Great Britain and the USA (N = 2016). Primary outcome measure: changes in respondents’ preferences for care, measured on a four-point scale designed before data collection. The scale ranged from: maintaining life at all costs; to intervention with agreement; to no intervention; to measures for ending life. Results: There were no significant differences between GB and USA. Preference for measures to sustain life at all costs peaked at short-term memory loss (30.2%, n = 610). Respondents selecting ‘measures to help me die peacefully’ increased from 3.9% to 37.0% as the condition deteriorated, with the largest increase occurring when decision-making capacity was lost (10.3% to 23.0%). Predictors of choosing ‘measures to help me die peacefully’ at any stage were: previous personal experience (OR = 1.34, p<0.010), and older age (OR = 1.09 per decade, p<0.010). Negative predictors: living with children (OR = 0.72, p<0.010) and being of “black” race/ethnicity (OR = 0.45, p<0.001). Conclusions: Public opinion was uniform between GB and USA, but markedly heterogeneous. Despite contemporaneous capacitous consent providing an essential legal safeguard in most jurisdictions, there was a high prevalence of preference for “measures to end my life peacefully” when decision-making capacity was compromised, which increased as dementia progressed. In contrast, a significant number chose preservation of life at all costs, even in end stage dementia. It is challenging to respect the longstanding values of people with dementia concerning either the inviolability of life or personal autonomy, whilst protecting those without decision-making capacity. [ABSTRACT FROM AUTHOR]

Background: Alcohol and marijuana are the two most abused substances in US colleges. However, research on the combined influence (cross sectional or longitudinal) of these substances on academic performance is currently scant. Methods: Data were derived from the longitudinal 2-year Brain and Alcohol Research in College Students (BARCS) study including 1142 freshman students who completed monthly marijuana use and alcohol consumption surveys. Subjects were classified into data-driven groups based on their alcohol and marijuana consumption. A linear mixed-model (LMM) was employed using this grouping factor to predict grade point average (GPA), adjusted for a variety of socio-demographic and clinical factors. Results: Three data-driven clusters emerged: 1) No/low users of both, 2) medium-high alcohol/no-low marijuana, and 3) medium-high users of both substances. Individual cluster derivations between consecutive semesters remained stable. No significant interaction between clusters and semester (time) was noted. Post-hoc analysis suggest that at the outset, compared to sober peers, students using moderate to high levels of alcohol and low marijuana demonstrate lower GPAs, but this difference becomes non-significant over time. In contrast, students consuming both substances at moderate-to-high levels score significantly lower at both the outset and across the 2-year investigation period. Our follow-up analysis also indicate that when students curtailed their substance use over time they had significantly higher academic GPA compared to those who remained stable in their substance use patterns over the two year period. Conclusions: Overall, our study validates and extends the current literature by providing important implications of concurrent alcohol and marijuana use on academic achievement in college. [ABSTRACT FROM AUTHOR]

In a resource-limited world, organisations attempting to reduce the impact of health or behaviour issues need to choose carefully how to allocate resources for the highest overall impact. However, such choices may not always be obvious. Which has the biggest impact? A large change to a small number of individuals, or a small change to a large number of individuals? The challenge is identifying the issues that have the greatest impact on the population so potential interventions can be prioritised. We addressed this by developing a score to quantify the impact of health conditions and behaviour problems in a population of working guide dogs using data from Guide Dogs, UK. The cumulative incidence of different issues was combined with information about their impact, in terms of reduction in working life, to create a work score. The work score was created at population-level to illustrate issues with the greatest impact on the population and to understand contributions of breeds or crossbreeds to the workforce. An individual work deficit score was also created and means of this score used to illustrate the impact on working life within a subgroup of the population such as a breed, or crossbreed generation. The work deficit scores showed that those removed for behavioural issues had a greater impact on the overall workforce than those removed for health reasons. Additionally trends over time illustrated the positive influence of interventions Guide Dogs have made to improve their workforce. Information highlighted by these scores is pertinent to the effort of Guide Dogs to ensure partnerships are lasting. Recognising that the scores developed here could be transferable to a wide variety of contexts and species, most notably human work force decisions; we discuss possible uses and adaptations such as reduction in lifespan, quality of life and yield in production animals. [ABSTRACT FROM AUTHOR]

Background: Physician associates, known internationally as physician assistants, are a mid-level practitioner, well established in the United States of America but new to the United Kingdom. A small number work in primary care under the supervision of general practitioners, where they most commonly see patients requesting same day appointments for new problems. As an adjunct to larger study, we investigated the quality of the patient consultation of physician associates in comparison to that of general practitioners. Method: We conducted a comparative observational study using video recordings of consultations by volunteer physician associates and general practitioners with consenting patients in single surgery sessions. Recordings were assessed by experienced general practitioners, blinded to the type of the consulting practitioner, using the Leicester Assessment Package. Assessors were asked to comment on the safety of the recorded consultations and to attempt to identify the type of practitioner. Ratings were compared across practitioner type, alongside the number of presenting complaints discussed in each consultation and the number of these which were acute, minor, or regarding a chronic condition. Results: We assessed 62 consultations (41 general practitioner and 21 physician associates) from five general practitioners and four physician associates. All consultations were assessed as safe; but general practitioners were rated higher than PAs in all elements of consultation. The general practitioners were more likely than physician associates to see people with multiple presenting complaints (p<0.0001) and with chronic disease related complaints (p = 0.008). Assessors correctly identified general practitioner consultations but not physician associates. The Leicester Assessment Package had limited inter-rater and intra-rater reliability. Conclusions: The physician associate consultations were with a less complex patient group. They were judged as competent and safe, although general practitioner consultations, unsurprisingly, were rated as more competent. Physician associates offer a complementary addition to the medical workforce in general practice. [ABSTRACT FROM AUTHOR]

As part of a multi-institutional study of zoo elephant welfare, we evaluated female elephants managed by zoos accredited by the Association of Zoos and Aquariums and applied epidemiological methods to determine what factors in the zoo environment are associated with reproductive problems, including ovarian acyclicity and hyperprolactinemia. Bi-weekly blood samples were collected from 95 African (Loxodonta africana) and 75 Asian (Elephas maximus) (8–55 years of age) elephants over a 12-month period for analysis of serum progestogens and prolactin. Females were categorized as normal cycling (regular 13- to 17-week cycles), irregular cycling (cycles longer or shorter than normal) or acyclic (baseline progestogens, <0.1 ng/ml throughout), and having Low/Normal (<14 or 18 ng/ml) or High (≥14 or 18 ng/ml) prolactin for Asian and African elephants, respectively. Rates of normal cycling, acyclicity and irregular cycling were 73.2, 22.5 and 4.2% for Asian, and 48.4, 37.9 and 13.7% for African elephants, respectively, all of which differed between species (P < 0.05). For African elephants, univariate assessment found that social isolation decreased and higher enrichment diversity increased the chance a female would cycle normally. The strongest multi-variable models included Age (positive) and Enrichment Diversity (negative) as important factors of acyclicity among African elephants. The Asian elephant data set was not robust enough to support multi-variable analyses of cyclicity status. Additionally, only 3% of Asian elephants were found to be hyperprolactinemic as compared to 28% of Africans, so predictive analyses of prolactin status were conducted on African elephants only. The strongest multi-variable model included Age (positive), Enrichment Diversity (negative), Alternate Feeding Methods (negative) and Social Group Contact (positive) as predictors of hyperprolactinemia. In summary, the incidence of ovarian cycle problems and hyperprolactinemia predominantly affects African elephants, and increases in social stability and feeding and enrichment diversity may have positive influences on hormone status. [ABSTRACT FROM AUTHOR]

Compared to other population groups in the United States, caries (tooth decay) is a disproportionately prevalent disease among Latino populations, especially among low-income and rural sub-groups and children under five years of age. Fluoride is a primary preventive for caries. While water fluoridation is a major and effective public health means for delivering fluoride on a mass scale, it does not reach many rural areas or population groups such as Latinos who eschew drinking water from municipal sources. This study examines the acceptability to such groups of salt fluoridation, an alternate means of delivering fluoride long used on a global scale. An ethnographic study in California’s rural Central Valley was performed. Thirty individual interviews and 5 focus groups (N = 61) were conducted in Spanish to investigate low-income Latino migrant caregivers’ experiences, views and understandings of domestic salt, oral health, caries prevention and fluoride. Audio data were transcribed, translated, coded and thematically analyzed. Table salt was readily available and frequently consumed. Both adult and child daily sodium consumption was high. Despite a general feeling that it was good, and present in dentifrices or dietary supplements, most participants had little knowledge about fluoride. Concerns were raised about cardio-vascular and other possibly deleterious effects if an increase in salt consumption occurred because fluoridated salt was viewed as having ‘extra’ benefits. Once informed about fluoride’s safety and role in caries prevention, most participants expressed willingness to use fluoridated salt, especially if it benefitted children. Reassurance about its safety and benefits, and demonstration of its taste, were important aspects of acceptance. Taste was paramount. Participants would not consume more fluoridated salt than their current salt as that would result in unpleasant changes in food flavor and taste. While salt fluoridation is acceptable, the feasibility of producing and distributing fluoridated salt in the United States is, however, complex and challenging. [ABSTRACT FROM AUTHOR]

Sustainable development efforts in urban areas often focus on understanding and managing factors that influence all aspects of health and wellbeing. Research has shown that public parks and green space provide a variety of physical, psychological, and social benefits to urban residents, but few studies have examined the influence of parks on comprehensive measures of subjective wellbeing at the city level. Using 2014 data from 44 U.S. cities, we evaluated the relationship between urban park quantity, quality, and accessibility and aggregate self-reported scores on the Gallup-Healthways Wellbeing Index (WBI), which considers five different domains of wellbeing (e.g., physical, community, social, financial, and purpose). In addition to park-related variables, our best-fitting OLS regression models selected using an information theory approach controlled for a variety of other typical geographic and socio-demographic correlates of wellbeing. Park quantity (measured as the percentage of city area covered by public parks) was among the strongest predictors of overall wellbeing, and the strength of this relationship appeared to be driven by parks’ contributions to physical and community wellbeing. Park quality (measured as per capita spending on parks) and accessibility (measured as the overall percentage of a city’s population within ½ mile of parks) were also positively associated with wellbeing, though these relationships were not significant. Results suggest that expansive park networks are linked to multiple aspects of health and wellbeing in cities and positively impact urban quality of life. [ABSTRACT FROM AUTHOR]

Despite increased awareness and concern about children with developmental disabilities wandering away from adult supervision, there is a paucity of research about elopement. This is the first study to examine and report the prevalence and correlates of elopement in a nationally representative sample of school-age children in the United States with an autism spectrum disorder (ASD) and/or cognitive impairment. Data were obtained from the CDC's "Pathways" Survey, a follow-up telephone survey of the parents of 4,032 children with a developmental condition. 3,518 children that had ASD, intellectual disability (ID), and/or developmental delay (DD) at the time of survey administration were included for analysis. Children were divided into three condition groups: ASD-only; ID/DD-only; ASD+ID/DD. Logistic regression analyses were used to compare the prevalence of elopement and rates of preventive measure use (barriers and/or electronic devices) across condition groups, and to examine the clinical and demographic correlates of elopement. T-tests were also performed to compare scores on the Children's Social Behavior Questionnaire (CSBQ) between wanderers and non-wanderers. Overall, 26.7% of children had reportedly eloped within the previous year, most commonly from public places. Children with ASD-only and ASD+ID/DD were more likely to have eloped than those with ID/DD-only. Across all groups, wanderers scored higher than non-wanderers on five out of six CSBQ subscales; they were more likely not to realize when there is danger, to have difficulty distinguishing between strangers and familiar people, to show sudden mood changes, to over-react to everything/everyone, to get angry quickly, to get lost easily, and to panic in new situations or if change occurs. Even after controlling for elopement history, parents of children in the ASD+ID/DD group were more likely than those in the other condition groups to report using physical or electronic measures to prevent wandering. [ABSTRACT FROM AUTHOR]

Visual illusions and other perceptual phenomena can be used as tools to uncover the otherwise hidden constructive processes that give rise to perception. Although many perceptual processes are assumed to be universal, variable susceptibility to certain illusions and perceptual effects across populations suggests a role for factors that vary culturally. One striking phenomenon is seen with two-tone images—photos reduced to two tones: black and white. Deficient recognition is observed in young children under conditions that trigger automatic recognition in adults. Here we show a similar lack of cue-triggered perceptual reorganization in the Pirahã, a hunter-gatherer tribe with limited exposure to modern visual media, suggesting such recognition is experience- and culture-specific. [ABSTRACT FROM AUTHOR]

Diversity awareness has enormous benefits, and universities in the United States increasingly require students to complete diversity-related courses. Prior research has demonstrated that students' initial attitudes toward these courses affect their subsequent engagement, as well as the quality of their learning experience; however, very little research has examined how these initial attitudes are formed. We conducted an experiment to examine this issue in the context of a women's and gender studies course in psychology. Participants read one of two identical course descriptions that varied only the course title (i.e., Psychology of Gender versus Psychology of Women) and instructor gender. Participants perceived a women-titled course to be narrowly focused compared to an identical gender-titled course and were more interested in taking the gender-titled course. Instructor gender had no effects on any of the variables. Additionally, female participants had more positive attitudes toward the course than male participants, regardless of title. Exploratory mediation analyses indicated that the main effects of course title and participant gender were mediated by perceptions of course content. Implications for improving student experiences and interest in diversity-related courses are discussed. [ABSTRACT FROM AUTHOR]

Abstract: Autism is on the rise, with 1 in 88 children receiving a diagnosis in the United States, yet the process for diagnosis remains cumbersome and time consuming. Research has shown that home videos of children can help increase the accuracy of diagnosis. However the use of videos in the diagnostic process is uncommon. In the present study, we assessed the feasibility of applying a gold-standard diagnostic instrument to brief and unstructured home videos and tested whether video analysis can enable more rapid detection of the core features of autism outside of clinical environments. We collected 100 public videos from YouTube of children ages 1–15 with either a self-reported diagnosis of an ASD (N = 45) or not (N = 55). Four non-clinical raters independently scored all videos using one of the most widely adopted tools for behavioral diagnosis of autism, the Autism Diagnostic Observation Schedule-Generic (ADOS). The classification accuracy was 96.8%, with 94.1% sensitivity and 100% specificity, the inter-rater correlation for the behavioral domains on the ADOS was 0.88, and the diagnoses matched a trained clinician in all but 3 of 22 randomly selected video cases. Despite the diversity of videos and non-clinical raters, our results indicate that it is possible to achieve high classification accuracy, sensitivity, and specificity as well as clinically acceptable inter-rater reliability with nonclinical personnel. Our results also demonstrate the potential for video-based detection of autism in short, unstructured home videos and further suggests that at least a percentage of the effort associated with detection and monitoring of autism may be mobilized and moved outside of traditional clinical environments. [ABSTRACT FROM AUTHOR]