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Located within the seismically active Pacific Ring of Fire, California's transportation infrastructure, especially in the Bay Area, is susceptible to earthquakes. A review of current research and stakeholder interviews revealed a growing awareness of emergency preparedness among local jurisdictions and transit agencies in recent years. However, many have yet to formalize and publish their recovery plans. This study introduces an agent-based multimodal transportation simulation tool to enhance post-earthquake transportation resilience. Integrating a road network simulator with a metro system simulator, the tool employs an optimized Dijkstra-based algorithm to calculate optimal routes, travel times, and fares. A case study is conducted for the East Bay, using the simulator to gauge the impact of a compromised Bay Area Rapid Transit (BART) system. The results suggested that original BART passengers could face either longer commute times or higher costs during the recovery phase of a major earthquake without appropriate policies. Such outcomes could disproportionately burden low-income riders, affecting their mobility and overall travel time.

Located on the tectonic boundary with multiple active faults, the San Francisco Bay Area is highly vulnerable to earthquakes. The United States Geological Survey (USGS) has estimated a 72% probability of an earthquakewith a magnitude of 6.7 or greater striking the region within the next 30 years. Historical seismic events have demonstrated the profound impact earthquakes can have on transportation systems. During the 1989 Loma Prieta Earthquake, the closure of the San Francisco-Oakland Bay Bridge, a critical transit route for San Francisco commuters, left nearly 400,000 commutersand approximately 245,000 vehicles daily with limitedalternative routes.

Many small, resource-strapped communities located in areas vulnerable to wildfire don’t have resources to conduct dedicated evacuation studies and many do not consider the impact of background traffic (i.e., normal traffic rather than evacuating traffic) on evacuation. In response, we explored the performance of several generalizable evacuation strategies with background traffic for representative communities in Marin County, including the Ross Valley, Woodacre Bowl, Tamalpais Valley, and an area near Highway 101 and Ignacio Boulevard in Novato (hereafter referred to as ‘Novato Neighborhood’). The strategies we explored include vehicle reduction (i.e., evacuees share a vehicle), phased evacuation (i.e., evacuees in different zones have different departure times), and off-street parking (i.e., street parking is prohibited on a high-fire Red Flag Day to increase overall road capacity in the event of an evacuation). We then tested each strategy using a wildfire-traffic simulation framework.

In the event of a wildfire, government agencies need to make quick, well-informed decisions to safely evacuate people. Small communities, such as in Marin County, with a mix of residences and flammable vegetation in Wildland-Urban Interface zones tend to lack resources to conduct evacuation studies. Consequently, this study uses a framework of wildfire and traffic simulations to test the performance of potential evacuation strategies, including reducing the volume of evacuating vehicles through car-pooling, phasing evacuations by staggering evacuation times by zone, and prohibiting street parking in four representative areas of Marin County. Results show that reducing vehicle numbers lowers the average travel time by 20%-70% and average exposure time to wildfire by 27%-60% from the baseline. Phased evacuations with suitable time intervals lower the average travel time by 13.5%-70%, but may expose more vehicles to fire in some situations. Prohibiting street parking yields varying results due to different numbers of exits and evacuees. In some cases, prohibiting street parking reduces the average travel time by over 50%, while in other cases it only reduces the average travel time by 9%, contributing little to evacuation efficiency. Altogether, Marin County may want to consider developing a communication and parking plan to reduce the number of evacuating vehicles in wildfire situations. Phased evacuation is also highly recommended, but the suitable phasing interval depends on the speed of fire spread and number of evacuees. Further, whether to establish street parking prohibition policies for a certain area depends on the number of exits and the number of vehicles on the streets.

OBJECTIVES: Depot medroxyprogesterone acetate-subcutaneous (DMPA-SC) can be prescribed through telemedicine and self-administered, but data about availability, particularly during the COVID-19 pandemic, are limited. This study assessed changes in the availability of DMPA-SC for self-administration during the pandemic. STUDY DESIGN: This study used survey data from a convenience sample of US providers engaged in contraceptive care and participating in a Continuing Medical Education-accredited contraceptive training (April 2020-April 2022; n = 849). Providers were recruited from across 503 clinics, including primary care and family planning clinics, public health departments, college and school-based health centers, independent abortion care clinics, and outpatient clinics in hospital settings. Measures included the availability of DMPA-SC for self-administration before and during the pandemic and the use of telemedicine. We used Poisson regression models and cluster-robust errors by clinic, adjusting for region, time of survey, and clinic size, to assess clinic availability of DMPA-SC for self-administration by practice setting. RESULTS: Compared to the prepandemic period (4%), the availability of DMPA-SC for self-administration increased significantly during the pandemic (14%) (adjusted prevalence ratios [aPR] 3.43, 95% CI [2.43-4.85]). During the pandemic, independent abortion clinics were more likely to offer DMPA-SC for self-administration compared to primary care clinics (aPR 2.44, 95% CI [1.10-5.41]). Clinics receiving Title X funds were also more likely to provide DMPA-SC for self-administration during the pandemic compared to other clinics (aPR 2.32, 95% CI [1.57-3.43]), and more likely to offer DMPA-SC for self-administration through telemedicine (aPR 2.35, 95% CI [1.52-3.63]). Compared to the early pandemic period (April-September 2022), telemedicine access to DMPA-SC for self-administration was highest during the later pandemic time period (October 2021-April 2022) (aPR 2.10, 95% CI [1.06-4.17]). CONCLUSIONS: The availability of DMPA-SC for self-administration significantly increased during the pandemic with differences by practice setting and Title X funding. However, overall method availability remains persistently low. IMPLICATIONS: Despite increased availability of DMPA-SC for self-administration among US contraceptive providers during the COVID-19 pandemic, there remains a need to train providers, educate patients, and remove barriers to ensure broader availability of this method across different practice settings.

BackgroundThe molecular effects of intermediate and long-term exposure to air pollution and temperature, such as those on extracellular microRNA (ex-miRNA) are not well understood but may have clinical consequences.ObjectivesTo assess the association between exposure to ambient air pollution and temperature and ex-miRNA profiles.MethodsOur study population consisted of 734 participants in the Normative Aging Study (NAS) between 1999 and 2015. We used high-resolution models to estimate four-week, eight-week, twelve-week, six-month, and one-year moving averages of PM2.5, O3, NO2, and ambient temperature based on geo-coded residential addresses. The outcome of interest was the extracellular microRNA (ex-miRNA) profile of each participant over time. We used a longitudinal quantile regression approach to estimate the association between the exposures and each ex-miRNA. Results were corrected for multiple comparisons and ex-miRNAs that were still significantly associated with the exposures were further analyzed using KEGG pathway analysis and Ingenuity Pathway Analysis.ResultsWe found 151 significant associations between levels of PM2.5, O3, NO2, and ambient temperature and 82 unique ex-miRNAs across multiple quantiles. Most of the significant results were associations with intermediate-term exposure to O3, long-term exposure to PM2.5, and both intermediate and long-term exposure to ambient temperature. The exposures were most often associated with the 75th and 90th percentile of the outcomes. Pathway analyses of significant ex-miRNAs revealed their involvement in biological pathways involving cell function and communication as well as clinical diseases such as cardiovascular disease, respiratory disease, and neurological disease.ConclusionOur results show that intermediate and long-term exposure to all our exposures of interest were associated with changes in the ex-miRNA profile of study participants. Further studies on environmental risk factors and ex-miRNAs are warranted.

IntroductionAgency in contraceptive decision-making is an essential aspect of reproductive autonomy. We conducted qualitative research to investigate what agency means to patients seeking contraceptive care to inform the development of a validated measure of this construct.MethodologyWe held four focus group discussions and seven interviews with sexually-active individuals assigned female at birth, ages 16-29 years, recruited from reproductive health clinics in Northern California. We explored experiences in contraceptive decision-making during the clinic visit. We coded data in ATLAS.ti and by hand, compared codes across three coders, and used thematic analysis to identify salient themes.ResultsThe sample mean age was 21 years, with 17% of participants identifying as Asian, 23% as Black, 27% as Latinx, 17% as Multiracial/other, and 27% as white. Overall, participants reported active and engaged decision-making in their recent contraceptive visit but noted experiences that had undermined their agency in the past. They described how non-judgmental care allowed them to communicate openly, affirming their ability to make their own decisions. However, several mentioned how unexpected contraceptive side effects after the visit had reduced their sense of agency over their decision in retrospect. Several participants, including those who identified as Black, Latinx, and/or Asian, described prior experiences where pressure to use a contraceptive method had undermined their agency and where they had switched providers to regain agency over their contraceptive decisions.DiscussionMost participants were aware of their agency during contraceptive visits and how it varied in different experiences with providers and the healthcare system. Patient perspectives can help to inform measurement development and ultimately the delivery of care that supports contraceptive agency.

BackgroundWhile the health effects of air pollution and temperature are widely studied, the molecular effects are poorly understood. Extracellular microRNAs (ex-miRNAs) have the potential to serve as diagnostic or prognostic biomarkers and/or to act as intercellular signaling molecules that mediate the effects of environmental exposures on health outcomes.MethodsWe examined the relationship between short-term exposure to air pollution and ambient temperature and the ex-miRNA profiles of participants in the Normative Aging Study (NAS) from 1999 to 2015. Our exposures were defined as same-day, two-day, three-day, one-week, two-week, and three-week moving averages of PM2.5, NO2, O3, and temperature which were derived from high-resolution spatio-temporal models. The ex-miRNA profiles of the subjects were obtained during follow-up visits. We analyzed the data using a longitudinal quantile regression model adjusted for individual covariates, batch effects, and time trends. We adjusted for multiple comparisons using a false discovery rate (FDR) correction. Ex-miRNAs that were significantly associated with exposures were further investigated using pathway analyses.ResultsWe found that all the examined exposures were associated with changes in ex-miRNA profiles in our study, particularly PM2.5 which was responsible for most of the statistically significant results. We found 110 statistically significant exposure-outcome relationships that revealed associations with the levels of 52 unique ex-miRNAs. Pathway analyses showed these ex-miRNAs have been linked to target mRNAs, genes, and biological mechanisms that could affect virtually every organ system, and as such may be linked to multiple clinical disease presentations such as cardiovascular disease, respiratory disease, and neurological disease.ConclusionsAir pollution and temperature exposures were significantly associated with alterations in the ex-miRNA profiles of NAS subjects with possible biological consequences.

BackgroundAging-related cognitive decline is an early symptom of Alzheimer's disease and other dementias, and on its own can have substantial consequences on an individual's ability to perform important everyday functions. Despite increasing interest in the potential roles of extracellular microRNAs (miRNAs) in central nervous system (CNS) pathologies, there has been little research on extracellular miRNAs in early stages of cognitive decline. We leverage the longitudinal Normative Aging Study (NAS) cohort to investigate associations between plasma miRNAs and cognitive function among cognitively normal men.MethodsThis study includes data from up to 530 NAS participants (median age: 71.0 years) collected from 1996 to 2013, with a total of 1,331 person-visits (equal to 2,471 years of follow up). Global cognitive function was assessed using the Mini-Mental State Examination (MMSE). Plasma miRNAs were profiled using small RNA sequencing. Associations of expression of 381 miRNAs with current cognitive function and rate of change in cognitive function were assessed using linear regression (N = 457) and linear mixed models (N = 530), respectively.ResultsIn adjusted models, levels of 2 plasma miRNAs were associated with higher MMSE scores (p < 0.05). Expression of 33 plasma miRNAs was associated with rate of change in MMSE scores over time (p < 0.05). Enriched KEGG pathways for miRNAs associated with concurrent MMSE and MMSE trajectory included Hippo signaling and extracellular matrix-receptor interactions. Gene targets of miRNAs associated with MMSE trajectory were additionally associated with prion diseases and fatty acid biosynthesis.ConclusionsCirculating miRNAs were associated with both cross-sectional cognitive function and rate of change in cognitive function among cognitively normal men. Further research is needed to elucidate the potential functions of these miRNAs in the CNS and investigate relationships with other neurological outcomes.

BackgroundTelehealth use rapidly increased during the COVID-19 pandemic, including for contraceptive care (e.g., counseling and method provision). This study explored providers' experiences with contraceptive care via telehealth.MethodsWe conducted a survey with open-ended responses among contraceptive providers across the United States. The study population included physicians, nurse practitioners, health educators, and other health professionals (n = 546). Data were collected from April 10, 2020, to January 29, 2021. We conducted qualitative content analysis of the open-ended responses.ResultsProviders highlighted the benefits of telehealth, including continuing access to contraceptive services and accommodating patients who faced challenges attending in-person contraceptive visits. Providers at school-based health centers reported telehealth allowed them to reach young people while schools were closed. However, many providers noted a lack of patient awareness about the availability of telehealth services and disparities in access to technology. Providers felt there was less personal connection in virtual contraceptive counseling, noted challenges with confidentiality, and expressed concern about the inability to provide the full range of contraceptive methods through telehealth alone.ConclusionsThe pandemic significantly impacted contraceptive health care delivery. Telehealth has sustained access to contraception in important ways, but has been accompanied by various challenges, including technological access and confidentiality. As hybrid models of care evolve, it is important to assess how telehealth can play a role in providing contraceptive care while addressing its barriers.

Early and appropriate use of antenatal care services is critical for reducing maternal and neonatal mortality and morbidity. Yet most women in sub-Saharan Africa, including Uganda, do not seek antenatal care until later during pregnancy. This qualitative study explored pregnant women's reliance on social ties for information about initiation of antenatal care. We conducted semi-structured, in-depth interviews with 30 pregnant women seeking their first antenatal care visit at Kawempe Referral Hospital in Kampala, Uganda. Recruitment was done purposively to obtain variation by parity and whether women currently had a male partner. Study recruitment occurred from August 25th 2020 - October 26th, 2020. We used thematic analysis following a two-stage coding process, with both deductive and inductive codes. Deductive codes followed the key domains of social network and social support theory. We found that the most important source of information about antenatal care initiation was these women's mothers. Other sources included their mothers-in-law, female elders including grandmothers, and male partners. Sisters and female friends were less influential information sources about antenatal initiation. One of the primary reasons for relying on their own mothers, mothers-in-law, and elder women was due to these women's lived experience with pregnancy and childbirth. Trust in the relationship was also an important factor. Some pregnant women were less likely to rely on their sisters or female friends, either due to lack of trust or these women's lack of experience with pregnancy and childbirth. The advice that pregnant women received from their mothers and others on the ideal timing for antenatal care initiation varied significantly, including examples of misinformation about when to initiate antenatal care. Pregnant women seemed less likely to delay care when more than one social tie encouraged early antenatal care. Educating women's social networks, especially their mothers, mothers-in-law, and community elders, about the importance of early antenatal care initiation is a promising avenue for encouraging pregnant women to seek care earlier in pregnancy.

IntroductionBoth inpatient and outpatient providers may be at increased risk of stress, anxiety and depression from their roles as health providers during the COVID-19 epidemic. This study explores how the US COVID-19 epidemic has increased feelings of stress, anxiety and depression among outpatient reproductive health providers.MethodsWe conducted a survey with open-ended responses among outpatient reproductive health providers across the U.S. engaged in contraceptive care to collect data on their experiences with stress, anxiety and depression during the COVID-19 epidemic. The study population included physicians, nurses, social workers, and other health professions [n = 288]. Data were collected from April 21st-June 24th 2020. We used content analysis of free text responses among providers reporting increased stress, anxiety or depression.ResultsTwo-thirds (184) of providers reported increased stress and one-third (96) reported increased anxiety or depression related to care provision during the COVID-19 epidemic. The major sources of stress, anxiety and depression were due to patient care, worry about becoming infected or infecting family members, work- and home-related concerns, experiencing provider burnout, and fear of the unknown. Concerns about quality of patient care, providers' changing responsibilities, lack of personal protective equipment, and difficulty coping with co-worker illness and absence all contributed to provider stress and anxiety. Worries about unemployment and childcare responsibilities were also highlighted. Providers attributed their stress, anxiety or depression to feeling overwhelmed, being unable to focus, lacking sleep, and worrying about the unknown.ConclusionsUS outpatient providers are experiencing significant stress, anxiety, and depression during the US COVID-19 epidemic. Policy and programmatic responses are urgently needed to address the widespread adverse mental health consequences of this epidemic on outpatient providers, including reproductive health providers, across the US. Both inpatient and outpatient providers may be at increased risk of stress, anxiety and depression from their roles as health providers during the COVID-19 epidemic. This study explores how the US COVID-19 epidemic has increased feelings of stress, anxiety and depression among outpatient reproductive health providers across the US. We conducted a survey from April 21st to June 24th, 2020 among outpatient reproductive health providers, including physicians, nurses, social workers and other health professions. We asked open-ended questions to understand why providers reported increased stress, anxiety and/or depression. Two-thirds (184) of providers reported increased stress and one-third (96) reported increased anxiety or depression from care provision during the COVID-19 epidemic. Major sources of stress, anxiety and depression were due to patient care, worry about becoming infected or infecting family members, work- and home-related concerns, experiencing provider burnout, and fear of the unknown. Concerns about quality of patient care, providers' changing responsibilities, lack of personal protective equipment, and difficulty coping with co-worker illness and absence all contributed to provider stress and anxiety. Worries about unemployment and childcare responsibilities were also highlighted. Providers attributed their stress, anxiety or depression to feeling overwhelmed, being unable to focus, lacking sleep, and worrying about the unknown. This study highlights that US outpatient reproductive health providers are experiencing significant stress, anxiety, and depression during the US COVID-19 epidemic. Policy and programmatic responses are urgently needed to address the widespread adverse mental health consequences of this epidemic on outpatient providers, including reproductive health providers, across the US.

BackgroundEnsuring women have information, support and access to family planning (FP) services will allow women to exercise their reproductive autonomy and reduce maternal mortality, which remains high in countries such as Madagascar. Research shows that women's social networks - their ties with partners, family members, friends, and providers - affect their contraceptive use. Few studies have considered the role of men's social networks on women's contraceptive use. Insofar as women's contraceptive use may be influenced by their male partners, women's contraceptive use may also be affected by their partner's social networks. Men may differ by the types of ties they rely on for information and advice about FP. It is unknown whether differences in the composition of men's FP networks matter for couples' contraceptive use. This study assessed the association between men's FP networks and couples' contraceptive use.MethodsThis egocentric network study was conducted among married/partnered men (n = 178) in rural Madagascar. Study participants listed who they relied on for FP information and advice, including health providers and social ties. They provided ties' gender, age, relationship, and perceived support of contraceptive use. The primary outcome was couples' contraceptive use, and explanatory variables included FP networks and their composition (no FP network, social-only network, provider-only network, and mixed network of social and provider ties). Analyses used generalized linear models specifying a Poisson distribution, with covariate adjustment and cluster robust standard errors.ResultsMen who had FP networks were 1.9 times more likely to use modern contraception as a couple compared to men with no FP network (95% confidence interval [CI] 1.64-2.52; p ≤ 0.001). Compared to men with no FP network, men were more likely to use modern contraception if they had a social-only network, relative risk (RR) = 2.10 (95% CI, 1.65-2.68; p ≤ 0.001); a provider-only network, RR = 1.80 (95% CI, 1.54-2.11; p ≤ 0.001); or a mixed network, RR = 2.35 (95% CI, 1.97-2.80; p ≤ 0.001).ConclusionsWhether men have a FP network, be it provider or social ties, distinguishes if couples are using contraception. Interventions should focus on reaching men not only through providers but also through their social ties to foster communication and support for contraceptive use.

Wildfires have become a perpetual crisis for communities across California. For life-threatening wildfires, mass evacuation often becomes the only viable option to protect lives. Yet, looking back at recent events, including the devastating 2018 Camp Fire in Northern California, there are significant challenges associated with the evacuation process, such as multi-agency coordination, agency-resident communication, and management of extraordinarily high amounts of traffic within a short period of time. Currently, emergency planners use evacuation models that are typically based on existing traffic simulation models; however, it is increasingly clear that other factors need to be considered, such as fire progression and communication systems. To address this gap, UC Berkeley researchers constructed a framework and set of models that include the combined impacts of three dynamic processes on evacuations – fire progression, communication systems, and traffic flow. The framework and models were applied to two case studies in California: the town of Paradise and the unincorporated community of Bolinas. In the Paradise case, the scenarios were based on the 2018 Camp Fire event. For the Bolinas case, the scenarios were based on hypothetical wildfire events.

ObjectivesWomen may differ by whether they rely on health providers and/or social ties for seeking information and advice about family planning. It is unknown whether these differences matter for contraceptive outcomes. This study assessed the association between women's family planning (FP) network (social and/or provider ties) and contraceptive use.Study designThis cross-sectional, egocentric network study was conducted among reproductive-age women (n = 193) in rural Madagascar. Data included socio-demographics and contraceptive use. Respondents listed who they relied on for contraceptive information, advice or guidance and provided ties' gender, age, relationship, and perceived support of contraceptive use. The primary outcome was current contraceptive use. Predictors included having a FP network (0/1) and FP network composition (no network, social ties only, provider ties only, both provider and social ties), respectively. Analyses were conducted using a generalized linear model specifying a Poisson distribution, with covariate adjustment and cluster robust standard errors.ResultsHaving a network of individuals to turn to for contraceptive information compared to having no FP network was positively associated with contraceptive use (adjusted relative risk [aRR] 4.4, 95% confidence interval [CI] 2.00-9.87). Having a social network, a provider network, or a combination of social and provider network were all positively associated with contraceptive use (aRR 4.30 [CI 1.92-9.66], aRR 4.46 [CI 2.04-9.75], aRR 4.72 [CI 1.93-11.50], respectively), compared to having no FP network.ConclusionsContraceptive use was higher among women who relied on social ties, provider ties or both for contraceptive information and advice, compared to women with no FP network. These findings suggest that FP interventions should use a multicomponent approach taking into account both social and provider networks.ImplicationsIt is unknown whether differences in whether women rely on social ties (friends, partner, family members) vs. providers for contraceptive information and advice affect contraceptive outcomes. Women are just as likely to use contraception whether they rely on social ties, provider ties, or both for contraceptive information and advice.

As demonstrated by the Camp Fire evacuation, communications (city-to-city, city-to-residents) play important roles in coordinating traffic operations and safeguarding region-wide evacuation processes in wildfire events. This collaborative report across multiple domains (fire, communication and traffic), documents a series of simulations and findings of the wildfire evacuation process for resource-strapped towns in Northern California. It consists of: (1) meteorological and vegetation-status dependent fire spread simulation (cellular automata model); (2) agency-level and agency-to-residents communication simulation (system dynamics model); and (3) dynamic traffic assignment (spatial-queue model). Two case studies are conducted: one for the town of Paradise (and the surrounding areas) and another for the community of Bolinas. The data and models are based on site visits and interviews with local agencies and residents. The integrated simulation framework is used to assess the interdependencies among the natural environment, the evacuation traffic and the communication networks from an interdisciplinary point of view, to determine the performance requirements to ensure viable evacuation strategies under urgent, dynamic wildfire conditions. The case study simulations identify both potential traffic and communication bottlenecks. This research supports integrating fire, communication and traffic simulation into evacuation performance assessments.

The rare decay K_{L}→π^{0}νν[over ¯] was studied with the dataset taken at the J-PARC KOTO experiment in 2016, 2017, and 2018. With a single event sensitivity of (7.20±0.05_{stat}±0.66_{syst})×10^{-10}, three candidate events were observed in the signal region. After unveiling them, contaminations from K^{±} and scattered K_{L} decays were studied, and the total number of background events was estimated to be 1.22±0.26. We conclude that the number of observed events is statistically consistent with the background expectation. For this dataset, we set an upper limit of 4.9×10^{-9} on the branching fraction of K_{L}→π^{0}νν[over ¯] at the 90% confidence level.

Study objectivesMany pediatric providers serving adolescents are not trained to offer comprehensive contraceptive services, including intrauterine devices (IUDs) and implants, despite high safety and satisfaction among adolescents. This study assessed an initiative to train providers at school-based health centers (SBHCs) to offer students the full range of contraceptive methods.DesignSurveys were administered at baseline pre-training and at follow-up 3 months post-training. Data were analyzed using generalized estimating equations for clustered data to examine clinical practice changes.SettingEleven contraceptive trainings at SBHCs across the United States from 2016-2019.ParticipantsA total of 260 providers from 158 SBHCs serving 135,800 students.InterventionsOn-site training to strengthen patient-centered counseling and to equip practitioners to integrate IUDs and implants into contraceptive services.Main outcome measuresThe outcomes included counseling experience on IUDs and implants, knowledge of patient eligibility, and clinician method skills.ResultsAt follow-up, providers were significantly more likely to report having enough experience to counsel on IUDs (adjusted odds ratio [aOR], 4.08; 95% confidence interval [CI], 2.62-6.36]) and implants (aOR, 3.06; 95% CI, 2.05-4.57). Provider knowledge about patient eligibility for IUDs, including for adolescents, increased (P

Building capacity for contraceptive services in primary care settings, including for intrauterine devices (IUDs) and implants, can help to broaden contraceptive access across the US. Following a randomized trial in family planning clinics, we brought a provider training intervention to other clinical settings including primary care in all regions. This implementation science study evaluates a national scale-up of a contraceptive training intervention to varied practice settings from 2013 to 2019 among 3216 clinic staff serving an estimated 1.6 million annual contraceptive patients. We measured providers' knowledge and clinical practice changes regarding IUDs and implants using survey data. We estimated the overall intervention effect, and its relative effectiveness in primary care settings, with generalized estimating equations for clustered data. Patient-centered counseling improved, along with comfort with method provision and removal. Provider knowledge increased (p

Arrested girls in the United States (US) are often diverted from detention through referrals to juvenile specialty courts (e.g., juvenile drug court), community-based diversion programs, or pre-adjudicated probation services. Limited research suggests that sexual and reproductive health needs for diverted, or court-involved, non-incarcerated (CINI) girls are similar to that of their detained counterparts. Despite the US justice system's emphasis on diverting youth from detention, research and programmatic efforts to improve sexual and reproductive health outcomes has primarily focused on detained girls. Policy and programming for CINI girls is scant and thus warrants further attention. This report details the immediate sexual and reproductive health needs of CINI girls. We discuss implications of current health care policies and practices for this population and conclude with recommendations for research focused on improving access to sexual and reproductive health care.

What percentage of Americans have ever had a family member incarcerated? To answer this question, we designed the Family History of Incarceration Survey (FamHIS). The survey was administered in the summer of 2018 by NORC at the University of Chicago using their AmeriSpeak Panel. It was funded by FWD.us, which released a separate report using the data. The data show that 45 percent of Americans have ever had an immediate family member incarcerated. The incarceration of an immediate family member was most prevalent for blacks (63 percent) but common for whites (42 percent) and Hispanics (48 percent) as well. College graduates had a lower risk of having a family member incarcerated, but the risk for black college graduates was comparatively high. The most common form of family member incarceration was the incarceration of a sibling.

What percentage of Americans have ever had a family member incarcerated? To answer this question, we designed the Family History of Incarceration Survey (FamHIS). The survey was administered in the summer of 2018 by NORC at the University of Chicago using their AmeriSpeak Panel. It was funded by FWD.us, which released a separate report using the data. The data show that 45 percent of Americans have ever had an immediate family member incarcerated. The incarceration of an immediate family member was most prevalent for blacks (63 percent) but common for whites (42 percent) and Hispanics (48 percent) as well. College graduates had a lower risk of having a family member incarcerated, but the risk for black college graduates was comparatively high. The most common form of family member incarceration was the incarceration of a sibling.

RationaleDespite the importance of primary partners for health, little is known about factors that constrain the ability of couples to work collaboratively towards HIV care and treatment (dyadic coordination). This study examined the interplay of marital infidelity, food insecurity, and couple instability on dyadic coordination and adherence to antiretroviral therapy (ART) in Malawi.MethodsIn 2016, we conducted 80 in-depth interviews with 25 couples with at least one partner on ART. Couples were recruited at two HIV clinics in the Zomba district when attending clinic appointments. Participants were asked about their relationship history, relationship dynamics (love, trust, conflict), experiences with HIV care and treatment, and how partners were involved. Using an innovative analysis approach, we analyzed the data at the couple-level by examining patterns within and between couples.ResultsThree patterns emerged. For some couples, ART led to positive changes in their relationships after men terminated their extramarital partnerships in exchange for love and support. For other couples with power imbalances and ongoing conflict, men's infidelity continued after ART and negatively affected dyadic coordination. Finally, some couples agreed to remain "faithful", but could not overcome stressors related to food insecurity, which directly impacted their adherence.ConclusionsCouples-based interventions targeting ART adherence should improve relationship quality, while also addressing interpersonal stressors such as marital infidelity and food insecurity. Multi-level interventions that address both dyadic and structural levels may be necessary for couples with severe food insecurity.

OBJECTIVE:To examine whether an empirically derived taxonomy of Accountable Care Organizations (ACOs) is associated with quality and spending performance among patients of ACOs in the Medicare Shared Savings Program (MSSP). DATA SOURCES:Three waves of the National Survey of ACOs and corresponding publicly available Centers for Medicare & Medicaid Services performance data for NSACO respondents participating in the MSSP (N = 204); SK&A Office Based Physicians Database from QuintilesIMS. STUDY DESIGN:We compare the performance of three ACO types (physician-led, integrated, and hybrid) for three domains: quality, spending, and likelihood of achieving savings. Sources of performance variation within and between ACO types are compared for each performance measure. PRINCIPAL FINDINGS:There is greater heterogeneity within ACO types than between ACO types. There were no consistent differences in quality by ACO type, nor were there differences in likelihood of achieving savings or overall spending per-person-year. There was evidence for higher spending on physician services for physician-led ACOs. CONCLUSIONS:ACOs of diverse structures perform comparably on core MSSP quality and spending measures. CMS should maintain its flexibility and continue to support participation of diverse ACOs. Future research to identify modifiable organizational factors that account for performance variation within ACO types may provide insight as to how best to improve ACO performance based on organizational structure and ownership.

The health of adolescents, perhaps more than in any other period of their life, is shaped by the social determinants of health (SDH). The constellation of SDH that disadvantages a specific group's health may also make members of that population unable or unwilling to engage in health research. To build a comprehensive body of knowledge about how SDH operate within a specific social context, researchers must design studies that take into account how various vulnerabilities and oppressions may affect people's experiences of being recruited, interviewed and retained in a study. In 2014, we initiated a prospective cohort study with Latino youth living in the agricultural area of Salinas, California. We began this study with the understanding that it was imperative to develop methodological strategies that actively addressed potential challenges in ways that were culturally responsive, community engaged and inclusive. In this article, we describe our approach to developing best practices in four key areas: 1) building community partnerships and engagement; 2) consideration of staffing and staff support; 3) engaging youth's perspectives; and 4) developing culturally appropriate research protocols. In our sample of 599 participants, nearly all youth identify as Latinx (94 per cent), half (49 per cent) have at least one parent employed as a farmworker, 60 per cent reside in crowded housing conditions, and 42 per cent have mothers who did not complete high school. Given these multiple vulnerabilities, we view a robust number of youth expressing interest in study participation, the willingness of their parents to permit their children to be enrolled, and the achievement of an ambitious sample target as evidence that our efforts to undertake best practices in community-engaged and inclusive research were well received.

The health of adolescents, perhaps more than in any other period of their life, is shaped by the social determinants of health (SDH). The constellation of SDH that disadvantages a specific group's health may also make members of that population unable or unwilling to engage in health research. To build a comprehensive body of knowledge about how SDH operate within a specific social context, researchers must design studies that take into account how various vulnerabilities and oppressions may affect people's experiences of being recruited, interviewed and retained in a study. In 2014, we initiated a prospective cohort study with Latino youth living in the agricultural area of Salinas, California. We began this study with the understanding that it was imperative to develop methodological strategies that actively addressed potential challenges in ways that were culturally responsive, community engaged and inclusive. In this article, we describe our approach to developing best practices in four key areas: 1) building community partnerships and engagement; 2) consideration of staffing and staff support; 3) engaging youth's perspectives; and 4) developing culturally appropriate research protocols. In our sample of 599 participants, nearly all youth identify as Latinx (94 per cent), half (49 per cent) have at least one parent employed as a farmworker, 60 per cent reside in crowded housing conditions, and 42 per cent have mothers who did not complete high school. Given these multiple vulnerabilities, we view a robust number of youth expressing interest in study participation, the willingness of their parents to permit their children to be enrolled, and the achievement of an ambitious sample target as evidence that our efforts to undertake best practices in community-engaged and inclusive research were well received.

BackgroundLatino youth, particularly in rural settings, experience significant disparities in rates of teen pregnancy and violence. Few data are available regarding social and structural influences on Latino youth's developmental trajectories, specifically on factors that promote wellbeing and protect them from engagement in high-risk sexual and violence-related behaviors.MethodsForty-two youth aged 13 to 19 years old were recruited from middle schools and youth leadership programs to participate in one of eight community-based focus groups in Salinas, a predominantly Latino, urban center in California's rural central coast. Focus groups covered youths' experiences with the risk and protective factors associated with exposure to violence and romantic relationships. Four researchers completed coding with a Grounded Theory approach, informed by the theoretical frameworks of the social ecological model and social capital. The study's design and participant recruitment were informed by a community advisory board of local youth-serving organizations and health care providers.ResultsParticipants described family lives rich in bonding social capital, with strong ties to parents and near-peer family members. They reported that while parents had a strong desire to promote healthful behaviors and social mobility, they often lacked the bridging or linking social capital required to help youth navigate structural systems, such as college applications and access to confidential health care. Youth also reported that some families link their children to negative social capital, such as exposure to gang affiliation.ConclusionAdolescents in this agricultural community identified robust sources of bonding social capital within their families. However, they identified limitations in their families' capacities to link them to structural resources in education, employment, and health care that could support healthful behaviors and upward social mobility.

BackgroundLatino youth, particularly in rural settings, experience significant disparities in rates of teen pregnancy and violence. Few data are available regarding social and structural influences on Latino youth's developmental trajectories, specifically on factors that promote wellbeing and protect them from engagement in high-risk sexual and violence-related behaviors.MethodsForty-two youth aged 13 to 19 years old were recruited from middle schools and youth leadership programs to participate in one of eight community-based focus groups in Salinas, a predominantly Latino, urban center in California's rural central coast. Focus groups covered youths' experiences with the risk and protective factors associated with exposure to violence and romantic relationships. Four researchers completed coding with a Grounded Theory approach, informed by the theoretical frameworks of the social ecological model and social capital. The study's design and participant recruitment were informed by a community advisory board of local youth-serving organizations and health care providers.ResultsParticipants described family lives rich in bonding social capital, with strong ties to parents and near-peer family members. They reported that while parents had a strong desire to promote healthful behaviors and social mobility, they often lacked the bridging or linking social capital required to help youth navigate structural systems, such as college applications and access to confidential health care. Youth also reported that some families link their children to negative social capital, such as exposure to gang affiliation.ConclusionAdolescents in this agricultural community identified robust sources of bonding social capital within their families. However, they identified limitations in their families' capacities to link them to structural resources in education, employment, and health care that could support healthful behaviors and upward social mobility.

Research suggests that optimal couple functioning depends on adopting a "we" orientation to health. Using qualitative data from 20 male couples in which at least one partner was HIV-positive, we examined how couples viewed their health involvement and its relation to social support. One group described their health as highly interconnected; in a second group, at least one partner viewed health as a personal responsibility. Results revealed that there was not a uniform "we" approach toward health; rather, sero-concordance, sero-discordance, and coping with other chronic illnesses strongly contributed to orientations toward health. Orientations toward health were not found to determine social support.

In the growing field of research on the consequences of criminal justice contact for family life, a heavy emphasis has been placed on how imprisonment influences the emotional, physical, and socioeconomic wellbeing of prisoners' loved ones. In this article, I elaborate on and analyze the experiences of family members of people with frequent, low-level criminal justice involvement. I draw on ethnographic data collected in partnership with a clinical social worker over the course of a three-year study of an intensive case management intervention for HIV-positive individuals. Findings indicate that loved ones' brief jail stays and community supervision through probation and parole pose hardships for family members that are distinct from those hardships that arise during imprisonment. These experiences are uniquely destabilizing, may confer specific risks to family members' wellbeing, and merit further study to inform programs, social services, and public policy.

BackgroundOver 1.5 million people are incarcerated in state and federal correctional facilities in the United States. Formerly incarcerated men have significantly higher rates of mortality and morbidity than the general population, disparities that have been partially attributed to higher rates of tobacco smoking-related illnesses such as cardiovascular disease, pulmonary disease and cancer.MethodsWe compared the prevalence of smoking tobacco in a sample of 172 men who were released from California state prisons to Oakland and San Francisco between 2009 and 2011 to sub-populations of respondents to the 2009 California Health Interview Survey (CHIS). Using logistic regression, we analyzed the association between lifetime history of incarceration and self-reported smoking status.ResultsSeventy-four percent of men recently released from prison reported being current tobacco smokers. The prevalence of smoking in a demographically similar group of men in the CHIS was 24%. We found in bivariate analysis that each additional five years of history of incarceration was associated with 1.32 times greater odds of smoking (95% CI 1.02 to 1.71). Illicit substance use was associated with a 2.47 higher adjusted odds of smoking (95% CI 1.29 to 5.39). In the multivariate model adjusting for age, income, substance use and mental health, every five years of incarceration was associated with 1.23 greater odds of smoking (95% CI 0.94 to 1.63) which was not statistically significant.ConclusionsGiven the high prevalence of smoking tobacco among former prisoners and the underlying high tobacco-related mortality rates, these findings suggest that a history of incarceration may be an important determinant of smoking. Prison and parole systems may be important potential settings for smoking-cessation interventions.

BackgroundOver 1.5 million people are incarcerated in state and federal correctional facilities in the United States. Formerly incarcerated men have significantly higher rates of mortality and morbidity than the general population, disparities that have been partially attributed to higher rates of tobacco smoking-related illnesses such as cardiovascular disease, pulmonary disease and cancer.MethodsWe compared the prevalence of smoking tobacco in a sample of 172 men who were released from California state prisons to Oakland and San Francisco between 2009 and 2011 to sub-populations of respondents to the 2009 California Health Interview Survey (CHIS). Using logistic regression, we analyzed the association between lifetime history of incarceration and self-reported smoking status.ResultsSeventy-four percent of men recently released from prison reported being current tobacco smokers. The prevalence of smoking in a demographically similar group of men in the CHIS was 24%. We found in bivariate analysis that each additional five years of history of incarceration was associated with 1.32 times greater odds of smoking (95% CI 1.02 to 1.71). Illicit substance use was associated with a 2.47 higher adjusted odds of smoking (95% CI 1.29 to 5.39). In the multivariate model adjusting for age, income, substance use and mental health, every five years of incarceration was associated with 1.23 greater odds of smoking (95% CI 0.94 to 1.63) which was not statistically significant.ConclusionsGiven the high prevalence of smoking tobacco among former prisoners and the underlying high tobacco-related mortality rates, these findings suggest that a history of incarceration may be an important determinant of smoking. Prison and parole systems may be important potential settings for smoking-cessation interventions.

BACKGROUND: Due to the significantly high levels of comorbid substance use and mental health diagnosis among urban poor populations, examining the intersection of drug policy and place requires a consideration of the role of housing in drug user mental health. In San Francisco, geographic boundedness and progressive health and housing polices have coalesced to make single room occupancy hotels (SROs) a key urban built environment used to house poor populations with co-occurring drug use and mental health issues. Unstably housed women who use illicit drugs have high rates of lifetime and current trauma, which manifests in disproportionately high rates of post-traumatic stress disorder (PTSD), anxiety, and depression when compared to stably housed women. METHODS: We report data from a qualitative interview study (n=30) and four years of ethnography conducted with housing policy makers and unstably housed women who use drugs and live in SROs. RESULTS: Women in the study lived in a range of SRO built environments, from publicly funded, newly built SROs to privately owned, dilapidated buildings, which presented a rich opportunity for ethnographic comparison. Applying Rhodes et al.s framework of socio-structural vulnerability, we explore how SROs can operate as mental health risk environments in which macro-structural factors (housing policies shaping the built environment) interact with meso-level factors (social relations within SROs) and micro-level, behavioral coping strategies to impact womens mental health. The degree to which SRO built environments were trauma-sensitive at the macro level significantly influenced womens mental health at meso- and micro-levels. Women who were living in SROs which exacerbated fear and anxiety attempted, with limited success, to deploy strategies on the meso- and micro-level to manage their mental health symptoms. CONCLUSION: Study findings underscore the importance of housing polices which consider substance use in the context of current and cumulative trauma experiences in order to improve quality of life and mental health for unstably housed women.

Due to the significantly high levels of comorbid substance use and mental health diagnosis among urban poor populations, examining the intersection of drug policy and place requires a consideration of the role of housing in drug user mental health. In San Francisco, geographic boundedness and progressive health and housing polices have coalesced to make single room occupancy hotels (SROs) a key urban built environment used to house poor populations with co-occurring drug use and mental health issues. Unstably housed women who use illicit drugs have high rates of lifetime and current trauma, which manifests in disproportionately high rates of post-traumatic stress disorder (PTSD), anxiety, and depression when compared to stably housed women. We report data from a qualitative interview study (n=30) and four years of ethnography conducted with housing policy makers and unstably housed women who use drugs and live in SROs. Women in the study lived in a range of SRO built environments, from publicly-funded, newly built SROs to privately-owned, dilapidated buildings, which presented a rich opportunity for ethnographic comparison. Applying Rhodes et al.’s framework of socio-structural vulnerability, we explore how SROs can operate as “mental health risk environments” in which macro-structural factors (housing policies shaping the built environment) interact with meso-level factors (social relations within SROs) and micro-level, behavioral coping strategies to impact women’s mental health. The degree to which SRO built environments were “trauma-sensitive” at the macro level significantly influenced women’s mental health at meso- and micro- levels. Women who were living in SROs which exacerbated fear and anxiety attempted, with limited success, to deploy strategies on the meso- and micro- level to manage their mental health symptoms. Study findings underscore the importance of housing polices which consider substance use in the context of current and cumulative trauma experiences in order to improve quality of life and mental health for unstably housed women.

BackgroundObservational studies suggest that HIV-focused pharmacies can improve antiretroviral therapy (ART) refill adherence, but there is a lack of clear documentation about the kind and variability of adherence interventions that are conducted.ObjectiveTo use qualitative research methods to obtain an in-depth understanding of how ART adherence support and counseling is provided in human immunodeficiency virus (HIV)-focused community pharmacies. To determine relevant facilitators and barriers around adherence support from both patient's and pharmacist's perspectives. MethodsA qualitative research study of patients who patronized and pharmacists who were employed at HIV-focused pharmacies in the San Francisco Bay Area was conducted. Participants were recruited using flyers at HIV clinics and community-based organizations and using blurbs in newsletters. Transcripts were analyzed using grounded theory methods to determine emergent themes in the data. Results19 eligible patients with a self-reported diagnosis of HIV, who were taking their current ART regimen for at least 3 months, and who obtained their ART from a community pharmacy in the San Francisco Bay Area were included; 9 pharmacists who were employed at 9 different pharmacy locations frequented by participants were interviewed. Emergent themes included descriptions of pharmacy adherence counseling and support, roles and responsibilities regarding medication adherence, barriers to providing adherence support, and feeling connected as a facilitator to adherence support relationships. ConclusionPharmacists provide diverse types of ART adherence support and are uniquely positioned to help clients manage their medications. Additional training on developing relationships with patients and advertising their adherence services may further the role of community pharmacists in supporting antiretroviral adherence.

Sleep disturbances have been reported to be higher in human immunodeficiency virus (HIV)-infected individuals compared to the general population. Despite the consequences of poor quality of sleep (QOS), research regarding sleep disturbances in HIV infection is lacking and many questions regarding correlates of poor QOS, especially in marginalized populations, remain unanswered. We conducted one-on-one qualitative interviews with 14 marginalized HIV-infected individuals who reported poor QOS to examine self-reported correlates of sleep quality and explore the relationship between QOS and antiretroviral adherence. Findings suggest a complex and multidimensional impact of mental health issues, structural factors, and physical conditions on QOS of these individuals. Those reporting poor QOS as a barrier to antiretroviral adherence reported lower adherence due to falling asleep or feeling too tired to take medications in comparison to those who did not express this adherence barrier. These interviews underscore the importance of inquiries into a patient's QOS as an opportunity to discuss topics such as adherence, depression, suicidal ideation, and substance use.

Sleep disturbances have been reported to be higher in human immunodeficiency virus (HIV)-infected individuals compared to the general population. Despite the consequences of poor quality of sleep (QOS), research regarding sleep disturbances in HIV infection is lacking and many questions regarding correlates of poor QOS, especially in marginalized populations, remain unanswered. We conducted one-on-one qualitative interviews with 14 marginalized HIV-infected individuals who reported poor QOS to examine self-reported correlates of sleep quality and explore the relationship between QOS and antiretroviral adherence. Findings suggest a complex and multidimensional impact of mental health issues, structural factors, and physical conditions on QOS of these individuals. Those reporting poor QOS as a barrier to antiretroviral adherence reported lower adherence due to falling asleep or feeling too tired to take medications in comparison to those who did not express this adherence barrier. These interviews underscore the importance of inquiries into a patient's QOS as an opportunity to discuss topics such as adherence, depression, suicidal ideation, and substance use.

Objective: We conducted a mixed-methods study to examine serodiscordant and seroconcordant (HIV-positive/HIV-positive) male couples' PrEP awareness, concerns regarding health care providers offering PrEP to the community, and correlates of PrEP uptake by t

In an effort to deepen our understanding of how circumstances of forced separation and the interdiction of physical contact affect women's sexual behavior, we investigated the development and maintenance of heterosexual couples' intimacy when the male partner is incarcerated. As HIV-prevention scientists who work with women visiting men at a California state prison, we recognize that correctional control extends to these women's bodies, both when they are within the facility's walls visiting their mates and when they are at home striving to remain connected to absent men. This paper analyzes the impact of a peculiar public "place", a penitentiary, on couples' romantic and sexual interactions, drawing out the implications of imprisonment for relationship decision making, sexual health, and HIV risk. Using qualitative interviews with 20 women who visit their incarcerated partners and 13 correctional officers who interact with prison visitors, we examined how institutional constraints such as the regulation of women's apparel, the prohibition of physical contact, and the lack of forums for privacy result in couples forging alternative "spaces" in which their relationships occur. We describe how romantic scripts, the build-up of sexual tension during the incarceration period, and conditions of parole promote unprotected sexual intercourse and other HIV/STD risk behavior following release from prison.

Assessing the changing dynamic between the demand that is placed upon a community by cumulative exposure to hazards and the capacity of the community to mitigate or respond to that risk represents a central problem in estimating the community's resilience to disaster. This paper presents an initial effort to simulate the dynamic between increasing demand and decreasing capacity in an actual disaster response system to determine the point at which the system fails, or the fragility of the system. Public organizations with legal responsibilities for the protection of human life and property, as well as private organizations responsible for managing utilities, communications, and transportation systems in metropolitan regions, are unable to monitor the interdependent effects of these critical infrastructure systems in real time. Further, they are not able to share information effectively about an emerging threat, nor can they communicate easily among different response organizations at different jurisdictions in a regional event. Modeling the fragility of sociotechnical response systems is critical to enabling metropolitan regions to manage their exposure to risk more efficiently and effectively. To construct a theoretical model of this process, we observe the changing relationship between the demand for assistance and the capacity of the community to provide assistance. We include in our model measures of the magnitude of the disaster, the number of jurisdictions, and a simple type of cooperation to observe how these factors influence the efficiency of disaster operations. Information spreads quickly through inter-organizational or human networks. Stress in organizational performance arises when the amount of information surpasses human capacity to absorb and comprehend it, leading to failure in action. In complex disaster environments, failure in one component of an interdependent system triggers failure in other components, decreasing performance throughout the system and threatening potential collapse. Based on the assessment of disaster operations as a dynamic process among interdependent organizations, we sought to build a computational model of the relationship between demand and capacity in an evolving disaster response system. We developed a simulation platform using Cellular Automata (Epstein et al., 1996; Wolfram, 1994) to describe the pattern of interaction between demand and capacity. To formalize the interaction between organizations and information flow, we used evolving network theory which has been studied in the field of mathematics (Erdos et al., 1960), computer science, and physics (Barabasi et al., 1999; Newman, 2003). We show that different phases of disaster response require different types of information and management skills. The efficiency of disaster response is affected by the initial magnitude of the disaster, the type and amount of resources available, the number of jurisdictions engaged, and the type of response strategies used. The results from the simulation confirm that efficiency has a negative correlation to initial disaster magnitude and a positive correlation to initial capacity. The number of jurisdictions involved in response operations is an independent variable influencing efficiency in disaster response, but the strength and direction of this influence requires further study. Also, sharing resources without specific information to improve coordination appears not to enhance efficiency in disaster response. Finally, we focus not on the amount of information that is available to practicing managers, but on strategies for access to core information that enhance the efficiency of information flow throughout the network of responding organizations. Network theory is used to identify the core information.

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