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OBJECTIVES The adverse effects of physician stress on health system performance are well documented. Financial stress is a notable cause of anxiety in medical residents; however, most residency programs lack formal, comprehensive financial education programs. Early single-center studies link financial education interventions to improved immediate fiscal well-being, but programs evaluating its long-term effects are lacking. METHODS Fifty (50) Emergency Medicine and Internal Medicine resident physicians from CommonSpirit Health's St. Joseph's Medical Center in Stockton, CA and Mercy One Medical Center in Des Moines, IA participated in a virtual 8-hour financial education course in April 2022. Participants completed pre-, post-, and 18-month follow-up course surveys to measure financial confidence in seven financial domains and six markers of stress of financial origin (SOFO). RESULTS Forty (40) of 50 residents (80%) completed the pre-and post-course surveys and 19 (38%) completed pre-, post-, and 18-month follow-up surveys. Immediately after the course, there was a statistically significant increase in financial confidence in all seven course domains (p

IntroductionThe Maternal and Infant Environmental Health Riskscape (MIEHR) Center was established to address the interplay among chemical and non-chemical stressors in the biological, physical, social, and built environments that disproportionately impact perinatal health among Black pregnant people in a large and diverse urban area with documented disparities in the U.S.MethodsThe MIEHR cohort is recruiting non-Hispanic Black and non-Hispanic white pregnant people who deliver their infants at major obstetric hospitals in Houston, Texas. At enrollment, all participants are asked to provide urine samples for chemical [metals, cotinine, and polycyclic aromatic hydrocarbons (PAHs)] analyses and blood samples. A subset of the cohort is asked to provide oral and vaginal swabs, and fecal samples. Questionnaire and electronic health record data gather information about residential address history during pregnancy, pregnancy history and prenatal care, sociodemographic and lifestyle factors, experiences of discrimination and stress, and sources of social support. Using information on where a participant lived during their pregnancy, features of their neighborhood environment are characterized. We provide summaries of key individual- and neighborhood-level features of the entire cohort, as well as for Black and white participants separately.ResultsBetween April 2021 and February 2023, 1,244 pregnant people were recruited. Nearly all participants provided urine samples and slightly less than half provided blood samples. PAH exposure patterns as assessed on 47% of participants thus far showed varying levels depending on metabolite as compared to previous studies. Additionally, analyses suggest differences between Black and white pregnant people in experiences of discrimination, stress, and levels of social support, as well as in neighborhood characteristics.DiscussionOur findings to date highlight racial differences in experiences of discrimination, stress, and levels of support, as well as neighborhood characteristics. Recruitment of the cohort is ongoing and additional neighborhood metrics are being constructed. Biospecimens will be analyzed for metals and PAH metabolites (urine samples), miRNAs (plasma samples) and the microbiome (oral swabs). Once enrollment ends, formal assessments are planned to elucidate individual- and neighborhood-level features in the environmental riskscape that contribute to Black-White disparities in perinatal health.

HIV self-testing (HIVST) holds promise for accessing hard-to-reach populations by overcoming sociocultural and structural barriers to awareness of HIV status. This phenomenological qualitative study explored the experiences and perspectives of married men in Kano, northern Nigeria, regarding HIV testing and counseling (HTC) and HIVST. Twenty married men from diverse socioeconomic backgrounds participated in in-depth interviews conducted in the local language. Thematic analysis was employed to analyze the data, yielding key themes related to prior test experiences, knowledge of self-testing, and perceived ease of use, in addition to motivation for self-testing and concerns about reliability and counseling support. The findings shed light on the impact of facility-based HIV testing experiences on the perspectives of participants. Concerns related to delays, overcrowding, discomfort, fear, and unsupportive attitudes from healthcare providers influenced their perceptions. Among persons with previous self-testing experience, initial uneasiness was overcome with repeated use, highlighting the ease of use associated with HIVST. Motivations for self-testing included privacy, convenience, personal empowerment, improved infection detection, and efficiency. Concerns were raised regarding the reliability of self-testing results compared to hospital-based testing, and the absence of counseling support during self-testing. Our findings underscore the need to address infrastructural limitations, enhance counseling support, and promote awareness and knowledge of HIVST.

Abstract Racial and socioeconomic disparities have become apparent in acute myeloid leukemia (AML) outcomes. We conducted a retrospective cohort study of hospitalizations for adults with a diagnosis of AML from 2009 to 2018 in the Nationwide Inpatient Sample (NIS). We categorized patients' ages in groups of

Objective: We conducted a systematic review to investigate electroencephalography (EEG) changes during periods of acute respiratory events such as apnoea and the effect of respiratory stimulants on EEG features in infants. Methods: Studies examining respiration and EEG-recorded brain activity in human neonates between 28 and 42 weeks postmenstrual age were included. Two reviewers independently screened all records and included studies were assessed using the Joanna Briggs Institute Critical Appraisal Tool. The protocol was registered in PROSPERO (CRD42022339873). Results: We identified 14 studies with a total of 534 infants. Nine articles assessed EEG changes in relation to apnoea, one assessed hiccups, and four investigated the effect of respiratory stimulants. The relationship between neonatal apnoea and EEG changes was inconsistent; EEG suppression and decreased amplitude and frequency were observed during some, but not all, apnoeas. Respiratory stimulants increased EEG continuity compared with before use. Conclusions: Current studies in this area are constrained by small sample sizes. Diverse exposure definitions and outcome measures impact inference. Significance: This review highlights the need for further work; understanding the relationship between respiration and the developing brain is key to mitigating the long-term effects of apnoea.

Objective: We sought to determine whether narcolepsy in pregnancy is associated with adverse maternal-fetal outcomes. Material and Methods: A retrospective, cross-sectional analysis was performed using the nationwide inpatient sample (NIS) for the period 2008-2017. The primary exposure was narcolepsy with cataplexy, narcolepsy type 1 (NT1), and without cataplexy, narcolepsy type 2 (NT2), and the endpoints were a composite of maternal-fetal outcomes or risk factors. Results: A total of 7,742 hospitalizations among pregnant women with narcolepsy were identified (prevalence = 17.6 per 100,000), of which 6,769 (88%) were diagnosed with NT2. Statistically significant positive associations were found between narcolepsy and the following conditions: obesity (odds ratio (OR): 2.99, confidence interval (CI): 2.4-3.74), anemia (OR=1.41, CI: 1.13-1.77), pre-pregnancy hypertension (OR=1.93, CI: 1.37-2.7), pre-pregnancy diabetes (OR=1.7, CI: 1.08-2.84), and gestational hypertension (OR=1.58, CI: 1.13-2.20) in the ICD-9 group. Similar findings were noted in the ICD-10 group with the exception of gestational hypertension, gestational diabetes, and anemia. Conclusion: Given these important findings, we propose a global approach of screening for narcolepsy among women of reproductive age with pre-existing risk factors prior to conception to minimize pregnancy complications.

Vaccination is a critical tool in the global response to the COVID-19 pandemic. Yet, COVID-19 vaccine hesitancy has not been well explored in parts of Nigeria. We assessed the predictors of acceptability of the COVID-19 vaccine and identified reasons for vaccine hesitancy among adults in urban Kano, northern Nigeria. Using a mixed-methods design, we administered structured questionnaires to a cross-section of adults (n = 446), complemented with 20 in-depth interviews. Binary logistic regression and the framework approach were used to analyze the data. About one-half (51.1%, n = 228) of the respondents were willing to take the COVID-19 vaccine. Vaccine acceptance was higher among older respondents (≥30 years) (adjusted Odds Ratio (aOR) = 1.76, 95% Confidence Interval (CI): 1.14–2.99 (≥30 vs.

Objective This study aimed to examine the association between maternal pre-pregnancy underweight and the risk of small-for-gestational-age (SGA) birth among Asian Americans compared with non-Hispanic (NH) whites. Methods Using 2014–2018 birth data, we categorized maternal underweight and SGA according to severity. Bivariate analyses were performed to examine the demographics and maternal body mass index (BMI). Adjusted logistic regression models were used to analyze the association between maternal BMI and SGA among Asian Americans compared with NH-Whites. Results In Asian Americans, the likelihood of SGA birth was higher among underweight mothers than among mothers with a normal BMI (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.30-1.46). We observed that as the severity of maternal underweight increased, the adjusted odds of SGA increased. Underweight Asian American mothers were more likely to give birth to SGA infants than underweight NH-White mothers (OR, 1.36; 95% CI, 1.28-1.44). Conclusion This study shows the association between maternal underweight and SGA birth among Asian Americans, supporting the development of culture-sensitive interventions addressing the impact of weight on pregnancy.

Background and Objective: Therapeutic options for pediatric inflammatory bowel disease (PIBD) have dramatically changed over the last 20 years. However, the impact of modern medical management on PIBD outcomes remains unclear. We aimed to fill this gap in the literature by using a large, validated, national database, to study the change in hospitalization rates, surgical rates, and postoperative complications in PIBD over the last decade. Methods: The National Inpatient Sample (NIS) Database and ICD-9-CM codes were utilized to identify inpatient admissions with a primary or secondary diagnosis of pediatric Crohn’s disease (CD) or ulcerative colitis (UC) from 2002-2015. Trends in hospitalizations, comorbidities (including malnutrition and weight loss), surgical procedures, and postoperative complications were examined using joinpoint regression analysis, a statistical modeling approach to evaluate the extent to which the rate of a condition changes over time. Results: There were 119,282 admissions for PIBD during the study period. The annual incidence of hospitalization increased significantly over time for both CD (average annual percent change [AAPC] 6.0%) and UC (AAPC 7.2%). The rate of intestinal resection decreased in CD patients (AAPC -6.4%) while postoperative complications remained unchanged. However, comorbidities increased significantly in CD patients (AAPC 6.8%). For pediatric UC patients, postoperative complications (AAPC 6.7%), and comorbidities (AAPC 10.2%) increased significantly over time while intestinal resection rates remained stable. Intestinal resection rate in pediatric CD has decreased over time, but not in pediatric UC. Conclusion and Global Health Implications: Annual incidence of hospitalization and comorbidities continue to increase in PIBD. Intestinal resection rate in pediatric CD has decreased over time, but not in pediatric UC. Our findings emphasize the critical need for prevention and novel therapeutic options for this vulnerable patient population. Copyright © 2021 Ihekweazu et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License CC BY 4.0.

Introduction: Social determinants of health (SDOH) have significant impacts on patients who seek care in the emergency department (ED). We administered a social needs screening tool and needs assessment survey to assess SDOH and evaluate for trends in the population of patients visiting our ED. Methods: A survey was distributed via convenience sampling to adult ED patients to capture self-reported demographic information and data about social needs. We categorized the questions related to SDOH based on the International Classification of Diseases, Tenth Revision, Clinical Modification coding format and created a composite variable called “SDOH Strata” based on the SDOH Index scores (0–5-low, 6–10-middle, or ≥11-high). We conducted bivariate analyses using the sociodemographic characteristics of the patients and their SDOH Strata using Fisher’s exact test. We then conducted multinomial logistic regression to examine the association between the patients’ sociodemographic characteristics and the SDOH Strata. Results: A total of 269 surveys were collected. We observed that Hispanic/Latino patients were more than two times as likely (odds ratio: 2.04, 95% confidence interval [CI], 1.12,−6.51) to be in the higher impact stratum than in the lower impact stratum. Those who were undocumented had 3.43 times increased adjusted odds (95% CI, 1.98, 9.53) of being in the higher than the lower impact stratum compared to US citizens. Additionally, people speaking Spanish as their primary language were 5.16 times as likely to be in the higher impact stratum compared to the reference (English-speaking and lower impact stratum). Conclusion: In our patient population, patients noted to have the highest impact burden of the SDOH were those who identified as Hispanic/Latino, Spanish-speaking, and undocumented immigrant status.

Background: Against a background of security challenges, Nigeria conducted recently the largest population-based HIV survey in the world to ascertain the burden of the HIV disease in the country. Objective: We evaluated the main outcomes of the survey and the level of success using participation/response indicators. Methods: The survey was conducted from July–December 2018 by over 6,000 field staff across Nigeria in six consecutive webs, using two-stage cluster sampling. We estimated the prevalence of HIV, hepatitis B and hepatitis C in the entire country and by conflict zone status. Adjusted odds ratios (OR) and 95% confidence intervals (CI) from survey logistic regression models were used to compare the likelihood of test positivity for the three infections between zones. Findings: A total of 186,405 adults were interviewed from 97,250 households in 3,848 census enumeration areas. The overall HIV, hepatitis B and hepatitis C positivity rates were 1.55%, 7.63% and 1.73%, respectively. The prevalence of HIV, hepatitis B and C infection was significantly greater in conflict than non-conflict zones (HIV: 1.75% versus 1.0%; hepatitis B: 9.9% versus 7.3%; and hepatitis C: 3.2% versus 0.3%; p < 0.01 in all cases). Individuals living in conflict zones were about three times as likely to test positive for HIV (OR = 2.80, 95% CI = 2.08, 3.60) and nearly six times as likely to test positive for hepatitis C (OR = 5.90, 95% CI = 2.17, 16.67). Conclusion: Large population-based surveys are feasible, even in armed conflict settings. The burden of HIV, hepatitis B and hepatitis C was significantly higher in areas of conflict in Nigeria, highlighting the need for reinforced public health control measures in these settings in order to attain UNAIDS’ 95-95-95 targets of controlling the HIV epidemic in sub-Saharan Africa by 2030.

Background: Human Immunodeficiency Virus (HIV)-exposed and HIV-infected infants are at increased risk of vaccine-preventable diseases. However, little is known about health care workers’ knowledge and immunization counseling practices in this population. We determined the predictors of health care workers’ knowledge of vertical transmission risks, HIV exposed/infected infant immunization, and counseling practices in a tertiary center in Northern Nigeria. Methods: A cross-section of 297 health workers were interviewed using a structured, validated questionnaire. Knowledge and HIV-exposed infant immunization counseling practices were analyzed, and adjusted odds ratios for predictors were derived from logistic regression models. Results: Of the 297 participating health care workers, (32.3%, n=96) had adequate knowledge of HIVexposed/infected infant immunization. Two-thirds (67%, n=199) of the participants appropriately identified the timing of infant diagnosis, while (73%, n=217) and (56.2%, n=167) correctly categorized infants as HIV-exposed and HIV-infected, respectively. Only (19.5%, n=58) participants had ever counselled a HIVpositive mother on infant immunization. Knowledge was predicted by work unit (HIV clinic vs. Obstetrics & Gynecology clinic), (Adjusted Odds Ratio (AOR) =3.78, 95% CI: 1.27-5.54), age (30-39 vs.

Currently, there is an insufficient representation of racial/ethnic minority groups in the maternal and child health (MCH) workforce. A student-run outreach organization, the Global Alliance for Maternal and Child Health (GLAM), seeks to address this disparity by increasing the representation of racial/ethnic minority groups in MCH workforce. Founded by students at Texas Southern University in Houston, Texas, United States, GLAM, seeks to establish productive alliances and create programs that would help improve the well-being of mothers, infants, and children locally, nationally, and internationally by engaging an active cadre of students passionate about MCH. Through community outreach and global engagement using evidence-based strategies, GLAM is committed to the elimination of health disparities plaguing the MCH population. Key words: • Maternal and Child Health • Pipeline program • Students-driven • Community outreach • Global engagement Copyright © 2021 Harris et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in this journal, is properly cited.

Background: American trypanosomiasis, commonly referred to as Chagas disease, is caused by a single cell protozoan known as Trypanosoma cruzi (T. cruzi). Although those affected are mainly in Latin America, Chagas has been detected in the United States (US), Canada and in many European countries due to migration. Few studies have explored the epidemiology of Chagas within the US or changes in disease burden over the past decade. The objective of this study was to explore the trends and associated characteristics for Chagas disease among hospitalized women of reproductive age in the US. Methods: We analyzed admissions data including socio-demographic and hospital characteristics for inpatient hospitalization for women of reproductive age (15–49 years) in the US from 2002 through 2017. We employed Joinpoint regression analysis to determine trends in the prevalence of Chagas disease over this period. Results: A total of 487 hospitalizations of Chagas disease were identified, corresponding to 3.7 per million hospitalizations over the study period. The rate statistically increased from 1.6 per million in 2002 to 7.6 per million hospitalizations in 2017. Chagas was most prevalent among older women, Hispanics and those in the highest zip income bracket. The in-hospital mortality rate was about 10 times greater among women with Chagas compared to those without the condition (3.1% versus 0.3%), and the condition tended to be clustered in women treated at large, urban teaching hospitals in the Northeastern region of the US. Conclusion: Chagas disease diagnosis appears to be increasing among hospitalized women of reproductive age in the US with a 10-fold elevated risk of mortality.

Background: Although regarded as rare in the United States (US), increased global traffic and importation of malaria from endemic countries may lead to a rise in gestational malaria in the US. Methods: This multi-year retrospective study analyzed trends in diagnosed cases of gestational malaria from 2002 to 2017 using joinpoint regression models. We also assessed the association between gestational malaria and selected maternal-fetal adverse outcomes. Results: Mothers diagnosed with gestational malaria tended to be older, and the majority of diagnosed cases (52.9%) were among Non-Hispanic (NH) Blacks. Diagnosed cases of gestational malaria are on the rise in the US. Mothers diagnosed with gestational malaria were 5 times as likely (OR = 5.05, 95% CI: 4.05–6.29) to be anemic as compared to those without malaria. Compared to NH-Whites, NH-Black mothers were twice as likely to experience stillbirth, had nearly 50% greater adjusted odds of severe preeclampsia, and had about 30% elevated likelihood for preterm labor. Conclusions: There is a need to dedicate appropriate resources to identify women that are at risk for gestational malaria in order to prevent related pregnancy complications.

This year’s summit was unique given the COVID-19 pandemic: a major global outbreak that has imposed severe restrictions in all aspects of our life. At the outset, we were faced with three mutually exclusive options. First option was to cancel the summit in its entirety: this was the easiest and most obvious choice once the COVID-19 pandemic forced a near total lockdown all over the country with unprecedented disruptions of normal daily activities as the disease announced its thunderous touchdown on United States (US) soil. It was also the most-logical response faced with uncertainty regarding summit logistics and expected poor attendance due to the raging pandemic. Second option was to conduct a digital summit restricted to local audiences at Baylor College of Medicine: this option entailed implementing a virtual summit with attendance restricted to participants from our institution only. It sounded like a reasonable choice but that would impede the presence of diversity of topics, perspectives, insights and experiential learning opportunities, which are what render the summit exciting and worth attending. And finally, the last option was to conduct a digital unrestricted summit open to all interested audiences throughout the US. The conduct of a virtual summit open to all participants from around the country was initially considered daunting given the likelihood of amplified technical problems associated with an array of internet access differentials around the country, which would require a strong Information Technology (IT) presence throughout the sessions. Nonetheless, the attractiveness of going national with a virtual summit, despite the pandemic and logistical challenges, slowly gained converts and became the dominant choice. The response and level of participation in this first virtual summit showed an unanticipated surge despite the increase in registration fees to cover IT costs. This year, we had attendees from all regions of the US as well as from the United Kingdom. The range of topics was quite diverse encompassing health disparities in relation to cancers, nutrition, musculo-skeletal disorders, amputation rates, vaccination uptakes and COVID-19 infections. Various solutions were passionately presented to address these disparities including novel health technologies, community engagement and partnerships, improvement in health literacy and alternative therapeutics. There were no hitches despite the complex breakout sessions, and above all, attendees were satisfied and offered outstanding evaluation scores. This was definitely a summit that metamorphosed from pessimism to a triumphant success! Copyright © 2020 Salihu et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0)which permits unre-stricted use, distribution, and reproduction in any medium, provided the original work, first published in this journal, is properly cited.

Prior to the COVID-19 pandemic, African-American mothers were three times as likely to die from pregnancy-related causes compared to white mothers. The impact of the pandemic among African- Americans could further worsen the racial disparities in maternal mortality (MM) and severe maternal morbidity (SMM). This study aimed to create a theoretical framework delineating the contributors to an expected rise in maternal mortality (MM) and severe maternal morbidity (SMM) among African-Americans in the era of the COVID-19 pandemic due to preliminary studies suggesting heightened vulnerability of African-Americans to the virus as well as its adverse health effects. Rapid searches were conducted in PubMed and Google to identify published articles on the health determinants of MM and SMM that have been or likely to be disproportionately affected by the pandemic in African-Americans. We identified socioeconomic and health trends determinants that may contribute to future adverse maternal health outcomes. There is a need to intensify advocacy, implement culturally acceptable programs, and formulate policies to address social determinants of health. Keywords: • COVID-19 • Maternal mortality • Severe maternal morbidity • African-Americans Copyright © 2020 Yusuf et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in this journal, is properly cited.

The COVID-19 pandemic threatens to set back major successes that have been achieved in global vaccine initiatives. We conducted a rapid review and synthesis of the literature on immunization provision and Utilization since the onset of the COVID-19 pandemic. A total of 11 papers comprising peer-reviewed articles and key policies and guidelines, published between January 1 and June 15, 2020, were analyzed. Widespread disruptions of routine immunization and vaccination campaigns were reported leaving millions of children worldwide at risk of measles outbreaks. We present an expanded model of the World Health Organization’s Global Routine Immunization Strategic Plan (GRISP) action areas as a tool to help countries quickly adapt to immunization challenges in the presence of COVID-19 and close the emerging immunization coverage gaps. Key words: • Immunization • Child health • Vaccination • COVID-19 • Essential health services • Corona virus Copyright © 2020 Olorunsaiye et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in this journal, is properly cited.

Long-term home confinement during the ongoing COVID-19 can have negative mental and physical health consequences, which in turn can reduce productivity among those working remotely. We sought to delineate factors related to neuro-behavioral economics that employers should consider for their employees who are teleworking during the current Covid-19 pandemic. Physical and mental well-being are intertwined and are strongly correlated to high productivity at workplace. By integrating the factors of neuro-behavioral economics into the work culture, companies will alleviate work-related stress leading to improved mental and physical functioning; thus leading to increased productivity. Key words: • Neuro-behavioral economics • COVID-19 • Teleworking • Mental health Copyright © 2020 Dongarwar et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in this journal, is properly cited.

As the global impact of the COVID-19 pandemic continues to evolve, robust data describing its effect on maternal and child health (MCH) remains limited. The aim of this study was to elucidate an agenda for COVID-19 research with particular focus on its impact within MCH populations. This was achieved using the Nominal Group Technique through which researchers identified and ranked 12 research topics across various disciplines relating to MCH in the setting of COVID-19. Proposed research topics included vaccine development, genomics, and artificial intelligence among others. The proposed research priorities could serve as a template for a vigorous COVID-19 research agenda by the NIH and other national funding agencies in the US. Key words: • COVID-19 • Coronavirus • Pandemics • Maternal and child health • MCH • Big data • Artificial intelligence Copyright © 2020 Ikedionwu et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in this journal, is properly cited.

African Americans are bearing a disproportionate burden of morbidity and mortality due to COVID-19 pandemic. To our knowledge, no previous study has delineated inequities potentially incentivized by systemic racism, and whether synergistic effects impose an abnormally high burden of social determinants of mental health on African American families in the era of COVID-19 pandemic. We applied the social ecological model (SEM) to portray inequities induced by systemic racism that impact the mental health of African American families. In our model, we identified systemic racism to be the primary operator of mental health disparity, which disproportionately affects African American families at all levels of the SEM. Programs tailored towards reducing the disproportionate detrimental effects of COVID-19 on the mental health of African Americans need to be culturally appropriate and consider the nuances of systemic racism, discrimination, and other institutionalized biases. Key words: • African American • COVID-19 • Mental health • Systemic racism • Social determinants of mental health Copyright © 2020 Ibrahimi et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in this journal, is properly cited.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the causative agent for coronavirus disease 2019 (COVID-19), and its ensuing mitigation measures have negatively affected the Maternal and Child Health (MCH) population. There is currently no surveillance system established to enhance our understanding of SARS-CoV-2 transmission to guide policy decision making to protect the MCH population in this pandemic. Based on reports of community and household spread of this novel infection, we present an approach to a robust family-centered surveillance system for the MCH population. The surveillance system encapsulates data at the individual and community levels to inform stakeholders, policy makers, health officials and the general public about SARS-CoV-2 transmission dynamics within the MCH population. Key words: • COVID-19 • Coronavirus • Maternal and child health • Family-centered • Surveillance system • Individual level data elements • Community level data elements • Community transmission of SARS-CoV-2 Copyright © 2020 Ajewole et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in this journal, is properly cited.

We analysed Natality data obtained from the National Vital Statistics System from 1971 through 2018. Overall, the rates of singletons declined among all racial groups over the five decades of the study. However, the rates of twins and higher-order multiples increased over the same period although for the past two decades, the rates of higher-order multiples had substantially plummeted. The global health implication of these findings is that policy changes in the US in the form of professional practice guidelines have succeeded in reducing the birth of vulnerable populations (i.e., higher-order multiples) who are predominantly created using assisted reproductive technology. Key words: • Trends in Multiple Gestations • US • Black • White • Singletons • Twins • Higher-order multiples Copyright © 2020 Wang et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in this journal, is properly cited.

We present a conceptual model that describes the social determinants of health (SDOH) pathways contributing to worse outcomes in minority maternal and child health (MCH) populations due to the current COVID-19 pandemic. We used International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) codes in the categories Z55-Z65 to identify SDOH that potentially modulate MCH disparities. These SDOH pathways, coupled with pre-existing comorbidities, exert higher-than-expected burden of maternal-fetal morbidity and mortality in minority communities. There is an urgent need for an increased infusion of resources to mitigate the effects of these SDOH and avert permanent truncation in quality and quantity of life among minorities following the COVID-19 pandemic. Key words: • COVID-19 • Maternal and child health disparity • Social determinants of health • Minority women Copyright © 2020 Dongarwar et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in this journal, is properly cited.

Since its outbreak, COVID-19 pandemic has been the biggest global concern with exponentially increasing number of cases and associated deaths across all habitable continents. Various countries around the world with their diverse health care systems, have responded to the pandemic in very distinctive ways. In this paper, we: compared COVID-19 mortality rates across global geographic regions; and assessed differences in COVID-19-related case fatality rate (CFR) based on presence or absence of Universal Health Coverage (UHC). We found that as of May 6, 2020, Europe had experienced the highest CFR globally of 9.6%, followed by 5.9% in North America. Although the pandemic originated in Asia, the continent ranked second to the last in terms of CFR (3.5%). Countries with UHC had lower number of cases of 37.6%, but the CFR of countries with UHC was twice that of countries without UHC (10.5% versus 4.9%). In conclusion, UHC does not appear to protect against mortality in a pandemic environment such as with COVID-19. Key words: • COVID-19 • Global disparity • Universal Health Coverage • Case fatality rate

Introduction We used the Theory of Planned Behavior (TPB) to guide the development and evaluation of a comprehensive tobacco prevention program (Dentists Fighting Nicotine Dependence [DFND]) to prevent tobacco use among seventh grade female students in Jeddah, Saudi Arabia. Methods We used a quasi-experimental controlled design. Two middle schools served as intervention (n=203) and two as control (n=168). Intervention schools received the new tobacco prevention program (DFND), whereas the control schools received only a tobacco informational booklet. The program was administered by trained instructors over five weeks, two sessions/week. Pre- and post-test surveys were collected. Study outcomes were current tobacco use, tobacco knowledge, attitude towards not using tobacco, and perceived behavioral control of tobacco use. Covariates included sex, parent education, academic performance, absenteeism, student allowance, and religiosity. Data were analyzed using two-level hierarchical mixed models. Results At one week post-intervention, 349 surveys were analyzed: intervention = 195; control = 154. Intervention group participants had higher mean scores for knowledge and attitude toward not using tobacco compared to controls. Tobacco use prevalence decreased from 8.9% to 5.6% among intervention participants but remained the same for controls (3.0%). At two years post-intervention, 278 surveys were analyzed: intervention = 163; control = 115. Tobacco use prevalence increased threefold compared to baseline among control participants (from 3% to 10%), whereas it only doubled among intervention participants (9% to 20%). This difference was not significant after adjustment for covariates. Conclusions Our study contributes to the existing knowledge about tobacco use and documents a steady increase in tobacco use among adolescent females in Saudi Arabia. Findings suggest that designing developmental school-based tobacco programs for adolescent females is feasible and when carefully implemented can be effective in increasing knowledge about the adverse health effects of tobacco use, promoting attitudes towards not using tobacco, and reducing intentions and initiation of tobacco use.

The world is currently witnessing a dramatic disruption of everyday life owing to the rapid progression of the coronavirus disease 2019 (COVID-19) pandemic. As the pandemic evolves, there is an urgent need to better understand its epidemiology, characterize its potential impact, and identify mitigatory strategies to avert pandemic-related mortality. There is a need for a tool or algorithm to evaluate the extent to which public health policy and/or economic preparedness measures are effectively averting COVID-19 related mortality. We present a simple and yet practical epidemiological tool, the Pandemic Efficiency Index (PEI), that can be utilized globally to test the relative efficiency of measures put in place to avert death resulting from COVID-19 infection. Using the PEI and current COVID-19-related mortality, we determined that so far Germany demonstrates the highest PEI (5.1) among countries with more than 5,000 recorded cases of the infection, indicating high quality measures instituted by the country to avert death during the pandemic. Italy and France currently have the lowest COVID-19-related PEIs. Epidemics and pandemics come and go, but local, national, and global abilities to determine the efficiency of their efforts in averting deaths is critical. Key words: • COVID-19 • Pandemic Efficiency Index • PEI • Coronavirus • Mortality • Pandemic • Epidemic • Global health Copyright © 2020 Salihu et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background or Objectives: Despite the global decline in maternal mortality within the last decade, women continue to die excessively from pregnancy-related complicationsin developing countries. We assessed the trends in maternal mortality, fetal mortality and cesarean section (C-Section) rates within 25 selected Nigerian hospitals over the last decade. Methods: Basic obstetric data on all deliveries were routinely collected by midwives using the maternity record book developed for the project in all the participating hospitals. Trends of C-Section Rates (CSR), Maternal Mortality Rates (MMR), Fetal Mortality Rates (FMR) and Spontaneous Vaginal Delivery rates (SVD) were calculated using joinpoint regression models. Results: The annual average percent change in CSR was 12.2%, which was statistically significant, indicating a rise in CSR over the decade of the study. There was a noticeable fall in MMR from a zenith of about 1,868 per 100,000 at baseline down to 1,315/100,000 by the end of the study period, representing a relative drop in MMR of about 30%. An average annual drop of 3.8% in FMR and 1.5% drop in SVD over time were noted over the course of the study period. Conclusion and Global Health Implications: We observed an overall CSR of 10.4% and a significant rise in CSR over the 9-year period (2008-2016) of about 108% across hospital facilities in Nigeria. Despite the decrease in MMR, it was still high compared to the global average of 546 maternal deaths per 100 000 livebirths. The FMR was also high compared with the global average. The MMR found in this study clearly indicates that Nigeria is far behind in making progress toward achieving the Sustainable Development Goal 3 (SGD 3) which aims to reduce the global MMR to less than 70 per 100 000 live births by 2030. Key words: • Cesarean section • Maternal mortality • Fetal mortality • Spontaneous vaginal delivery • Trends in MMR • Nigeria Copyright © 2020 Galadanci et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Copyright © 2020 Harris. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Artificial Intelligence (AI) applications in medicine have grown considerably in recent years. AI in the forms of Machine Learning, Natural Language Processing, Expert Systems, Planning and Logistics methods, and Image Processing networks provide great analytical aptitude. While AI methods were first conceptualized for radiology, investigations today are established across all medical specialties. The necessity for proper infrastructure, skilled labor, and access to large, well-organized data sets has kept the majority of medical AI applications in higher-income countries. However, critical technological improvements, such as cloud computing and the near-ubiquity of smartphones, have paved the way for use of medical AI applications in resource-poor areas. Global health initiatives (GHI) have already begun to explore ways to leverage medical AI technologies to detect and mitigate public health inequities. For example, AI tools can help optimize vaccine delivery and community healthcare worker routes, thus enabling limited resources to have a maximal impact. Other promising AI tools have demonstrated an ability to: predict burn healing time from smartphone photos; track regions of socioeconomic disparity combined with environmental trends to predict communicable disease outbreaks; and accurately predict pregnancy complications such as birth asphyxia in low resource settings with limited patient clinical data. In this commentary, we discuss the current state of AI-driven GHI and explore relevant lessons from past technology-centered GHI. Additionally, we propose a conceptual framework to guide the development of sustainable strategies for AI-driven GHI, and we outline areas for future research. Keywords: • Artificial Intelligence • AI Framework • Global Health • Implementation • Sustainability • AI Strategy Copyright © 2020 Hadley et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background and Objectives: While the impact of maternal factors on birth outcomes are widely reported, the extent to which paternal involvement and varying cultural family dynamics influence birth outcomes particularly in an international context, remain understudied. The purpose of this study was to assess the relationship between paternal involvement and adverse birth outcomes in South Gujarat, India. Methods: An in-person questionnaire was administered to adult women at delivery or during the one-month postpartum visit at New Civil Hospital, in South Gujarat, India between May and June 2016 to assess level of paternal support and attendance at prenatal appointments and household structure. Pregnancy variables including birthweight and gestational age at delivery were collected from maternal and newborn record/chart review. Chi-square and t-test were used to assess demographics, as appropriate. Logistic regression was used to examine the association between paternal involvement and pregnancy birth outcomes. Results: Of the 404 infants born during the study period, 26.7% were premature (

Children with neurodevelopmental disabilities (NDD) suffer poor oral health problems (OHP) leading to adverse health outcomes. We examined the association between NDD and OHP among children in the United States (US) ages 3-17 years using data from the National Survey of Children’s Health (NSCH) 2016-17. The prevalence of OHP was 19.1%. Children with NDD had about 40% greater likelihood of poor oral health compared to their non-NDD counterparts (p

Background or Objectives: Father involvement is a key component in maintaining healthy families and communities. This study presents quantitative results of the first five years of a comprehensive fatherhood training program offered by REACHUP, Inc. in Florida, United States. Methods: The program utilized the 24/7 Dad® curriculum for the fatherhood training program. Key program outcome was differences in pre and post-test scores on self-awareness, fathering skills, parenting skills, relationship skills, and self-care. Demographic and pretest-posttest data collected between 2013 and 2017 were analyzed using chi-square test for categorical variables, McNemar’s test for differences in proportions pre- and post-intervention, paired sample t-test to compare means in pretest and posttest scores and analysis of variance (ANOVA) to test the difference between means across years and demographic characteristics. Results: Attendance in the program increased yearly, nearly doubling from 55 participants in 2013 to 97 in 2017. The mean pretest score was 8.90 (±4.04) and the mean posttest score was 16.42 (±4.54) out of 22 total points, representing a highly significant positive effect of the program on self-awareness, fathering skills, parenting skills, relationship skills and self-care which will enable men to establish long-lasting positive relationships with their children. There were significant differences by demographic characteristics. Younger participants tended to score lower on the pretest but made the most knowledge gains following the training as indicated by the difference in pre- and posttest scores (

Background and Objectives: The identification of risk factors for shorter telomere length, especially during fetal development, would be important towards caffeine consumption recommendations for pregnant women on a global scale. The purpose of this study was to evaluate the association between caffeine intake and fetal telomere length as well as racial/ethnic differences in telomere length regardless of maternal caffeine consumption status. Methods: Caffeine intake was measured using a food frequency questionnaire (FFQ). Three generalized linear models (GLM) were compared based on binary categorical variables of caffeine levels using data mean value of 117.3 mg as cut-off; the World Health Organization (WHO) recommendations of 300 mg; and the American College of Obstetricians and Gynecologists (ACOG) recommendations of 200 mg. The association between caffeine consumption and telomere length (telomere to single-copy [T/S] ratio) was then assessed. Results: Among 57 maternal-fetal dyads, 77.2% reported less than 200 mg of caffeine (ACOG) and 89.5% less than 300 mg (WHO). Both WHO and ACOG models found that caffeine intake was significantly and positively associated with longer telomere length (p

Background And Objectives: Studies on male involvement and pregnancy outcomes have often not incorporated the providers’ perspectives, which are potentially critical to understanding program context, evolution, perceived impact, and sustainability. We sought to evaluate the 24/7 Dad® program from the viewpoint of the program providers. Methods: We conducted purposive sampling of 24/7 Dad program facilitators and administrators who were involved in recruitment, training, and follow up of program participants within a federal Healthy Start program (REACHUP) in Tampa, Florida, USA. Using a snowballing approach, we recruited six key informants who had administered the program for at least four years. We elicited and evaluated factors impacting the performance of the father involvement program using content analysis. Results: Under program participation and perceived impact, most providers thought that the program had created a safe space previously unavailable for men in the community. The most useful recruitment strategy was building partnerships with other organizations. The key informants noted an important evolutionary trend in the father involvement program over time as well as the nature of linkages to partner organizations within the area. Threats to program sustainability included the continued reluctance and scepticism to invest funds to address male issues, sub-optimal retention of participants who were living transient lives as well as geographical/transportation barriers. Conclusion and Global Health Implications: The involvement of fathers during pregnancy has significant implications for healthy babies. Our study results provide a clarion call to augment capacity and infuse more resources to improve paternal involvement in order to attain the United Nations Sustainable Goal (2015-2030) of ensuring healthy lives and the promotion of well-being for all at all ages. Key words: • Fatherhood involvement • Fatherhood training • REACHUP • Childhood development • 24/7 Dad program Copyright © 2020 Obure et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

We are thrilled to present this special collection of articles entitled “Current and Emerging Issues in Global Health.” This special collection pursued three main goals. First, the collection presents an opportunity for innovation. Second, it presents an opportunity to engage the field and community around a common theme. Finally, the collection provides a reality-check for the journal editors to support the field in evaluating the extent to which we have collectively attempted to confront the global maternal and child health (MCH) issues of our time regardless of where in the world we live. Unique to this special collection is the geographical spread of the article submissions. We have articles and contributions from researchers and research groups from three continents in a single edition: Africa, Asia and North America, making the articles opportunities for crossfertilization of ideas across the global North and South. Public health is passing through a seismic transformation. Whether at the global, national, state, and local levels, disease outbreaks, patient demographics, and health technology have changed the global health landscape in a way never imagined. Our hope is that papers in this special collection will spark new ideas for invention, improved patient care, and transform population health. Key words: • Global health • Maternal and child health • Father’s health • Mother’s health • Pediatrics • HIV/AIDS • MCH Copyright © 2020 Salihu and Azuine. This is an open-access article distributed under the terms of the Creative Com - mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objectives: To determine the association between access to health care among pregnant women in Malawi and occurrence of obstetric vesicovaginal fistula (VVF). Methods: This was a case-control study using data obtained from patients’ records documented by the ‘Fistula Care Center-Bwaila Hospital’ in Malawi. Socio-demographic characteristics of women with VVF (study arm, n=1046) and perineal tear (control arm, n=37) were examined. A composite variable called “Malawi Healthcare Access Index” (MHAI) was created through summation of scores related to three factors of access to care: (1) walking distance to closest health center; (2) presence of trained provider at delivery; and (3) receipt of antenatal care. Binomial logistic regression models were built to determine the association between the MHAI and presence of VVF. Results: Obstetric VVF was more common in women from rural areas, mothers delivering at extremes of age, those with less education, and patients with long labor (>12 hours). In adjusted models, women with “insufficient” health access based on the MHAI were at greater risk (OR = 2.64, 95%CI = 1.07 – 6.03) of obstetric VVF than women with “sufficient” score on the MHAI. Conclusion and Global Health Implications: Inadequate access to essential obstetric care increases the risk of VVF. Key words: • Health care index • Obstetric complications • Vesicovaginal fistula • Poverty • Malawi • Malawi Healthcare Access Index Copyright © 2020 Rupley et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Childhood obesity is one of the foremost threats to population health in the United States (U.S.) leading to the emergence of co-morbidities and increased healthcare cost. We explore the influence of selected social determinants of health (SDOH) on overweight and obesity among U.S. children. Methods: We utilized the National Survey of Children’s Health (NSCH) 2016-17 dataset for this analysis. Overweight was defined as Body Mass Index (BMI) ? 85th to

Background and Objectives: India, the second most populous country in the world, has two-thirds of its population living in rural areas. Rural women in developing countries like India have worse access to healthcare compared to their urban counterparts. We examined the association between place of residence and various pregnancy and birth outcomes among Indian women. Methods: We analyzed data from the 2015-2016 India Demographic and Health Survey (DHS). Sociodemographic and reproductive health-related information were obtained from Indian women of reproductive age. We calculated the prevalence of selected pregnancy and birth outcomes among the study participants. We conducted adjusted survey log binomial regression to determine the level of association between place of residence and various pregnancy and birth outcomes. Results: About 66.4% of the survey responders resided in villages. When adjusted for covariates, rural women had increased likelihood of experiencing miscarriage, stillbirth, early neonatal, late neonatal and infant mortality as compared to urban women. Urban women had 22% higher likelihood (PR = 1.22, 95% CI=1.10-1.35) of having an abortion as compared to rural dwellers. Conclusion and Global Health Implications: Despite India’s extensive efforts to improve maternal and reproductive health, wide geographical disparities exist between its urban and rural population. Interventions at various socio-ecologic and cultural levels, along with improved health literacy, access to improved health care and sanitation need attention when formulating and implementing policies and programs for equitable progress towards improved maternal and reproductive health. Key words: • India • Maternal and reproductive health • Pregnancy outcomes • Birth outcomes • Miscarriage • Stillbirth • Neonatal mortality • Infant mortality • Abortion • Health equity Copyright © 2020 Dongarwar and Salihu. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background Or Objectives: Intimate partner violence (IPV) against women is common globally, and is associated with several adverse consequences. This study provides a comparative analysis of potential regional differences in the association between IPV and knowledge and use of contraceptives within Africa. Methods: A multi-country cross-sectional study was conducted using data on women of reproductive age 15-49 years from the Demographic and Health Surveys covering five African regions. Exposure and outcome variables were IPV and reproductive literacy (comprising modern contraception knowledge and contraception usage) respectively. We used survey log-binomial regression models to generate prevalence ratios that estimated the association between IPV versus knowledge and usage of modern contraception. Results: Overall IPV prevalence in Africa was 30.8% with notable regional differences. Demographic, socioeconomic, and reproductive history markers of IPV were more pronounced in younger women, rural residents, women of low socioeconomic status and those with copious knowledge but poor usage of modern contraception. The level of knowledge of contraception was 84% greater among African women who were victims of IPV compared to their counterparts who were not victims of IPV (p < 0.0001). IPV was not associated with actual usage of modern contraception (p = 0.21). Conclusion And Global Health Implications: IPV against women in Africa may incentivize knowledge seeking of modern contraception as protective mechanisms. Regional variations notwithstanding, understanding the existing and new characteristics predictive of IPV may inform policy development, resource allocation and prevention of IPV globally. Key words: • Violence • Women • Contraception; • Knowledge • Usage • Africa • Intimate partner violence • Demographic and health surveys • Benin • Burundi • Egypt • Kenya • South Africa Copyright © 2020 Yusuf et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Risk perception and recognition of danger signs are important cues for accessing obstetric care. These measures are not well documented in many resource-limited settings, including northern Nigeria, a region with poor maternal health indices. Objective: To assess community level obstetric risk perception, danger sign recognition and their predictors in Kano, northern Nigeria. Method: This is a community-based cross-sectional study. Participants were surveyed using structured, pretested questionnaires. Knowledge of obstetric risk factors and danger sign recognition were analyzed, and their predictors modeled using logistic regression to generate adjusted odds ratios (AORs). Results: The obstetric risk factors identified by the 400 respondents included: maternal age (64.3%), history of abortion (37.0%), postpartum haemorrhage (36.0%), previous operative delivery (31.8%), and high parity (31.3%). The most frequently recognised danger signs during pregnancy were: vaginal bleeding (76.8%), seizures (44.5%), and severe abdominal pain (34.8%). Common intrapartum danger signs recognised included: severe bleeding (77.8%), seizures (55.5%), and loss of consciousness (38.3%). Severe bleeding (80.5%), seizures (42.0%), and high fever (28.5%) were the top three danger signs identified in the postpartum period. At multivariate level, respondent sex (female vs. male) (aOR = 3.10, 95% CI = 1.67–5.74), ethnicity (Yoruba vs. Hausa) (aOR = 7.53, 95% CI = 2.51–22.6), occupation (employed vs. unemployed) (aOR = 4.07, 95% CI = 1.87–8.84) and parity (≥5 versus 0) (aOR = 0.23, 95% CI = 0.06–0.92) predicted good obstetric risk perception. Participants’ ethnicity (Yoruba vs. Hausa) (aOR = 4.40, 95% CI = 1.10–19.2) and obstetric risk perception (good vs. poor) (aOR = 12.0, 95% CI = 6.8–21.2) predicted danger sign recognition. Conclusion: The perception of obstetric risk and recognition of danger signs were influenced by participant sex, parity, employment status, and ethnicity. Targeted communication strategies and community-based education are essential to enhance effective utilisation of emergency obstetric services.

Objective: The main objective of this initiative was to present evaluation results from an innovative adaptation of the Advanced Life Support in Obstetrics (ALSO) training course. We modified the traditional ALSO curriculum in our institution by adding hands-on training in laceration repairs and simulation scenarios on acute maternity care. Methods: The modified ALSO provider course was designed to enhance cognitive and procedural skills of health care professionals in managing obstetric emergencies. Forty-nine participants attended this course and completed a posttraining survey. Descriptive statistics were used to describe the participant-reported assessment scores for the ALSO course on three domains (subject knowledge, organization and clarity, and teaching effectiveness) for each of 12 course topics. Results: Evaluation of the results showed a high rate of trainee satisfaction as evidenced by the mean assessment scores across all topics ranging from 4.80 to 4.98 (out of 5.00). All trainees said they would refer others to the course. Our modified ALSO course effectively addressed the important needs of primary care physicians involved in maternity care, especially in underserved communities where specialized obstetric care is not readily available. Both simulation scenarios and workshops using simulated human tissue provide a better foundation before formal training. Conclusion: Given the changing legal and regulatory climate, we expect that learning to treat complex obstetric situations on the job will become increasingly risky. With this in mind, both simulation scenarios and workshops using simulated human tissue will provide a better foundation before formal training.

Background: Globally, female sex workers (FSWs) constitute one of the most vulnerable populations for HIV/STI acquisition. However, very little is known about these infections and their risk factors among FSWs in Ecuador and Latin America. Objectives: To assess the level of knowledge, risk behaviors and factors associated with the prevalence of HIV, syphilis and self-reported STI among FSWs in a high HIV prevalence province in Ecuador. Methods: Data from 270 FSWs in Ecuador recruited by snowball sampling were analyzed. Structured questionnaires were administered through face-to-face interviews and blood samples were obtained and tested for HIV and syphilis. Results: The prevalence were 0.7% for HIV infection, 3.3% for syphilis and 26.4% for other self-reported STIs. Age of onset of sex work, knowledge of HIV transmission and condom use were significant risk factors for HIV/syphilis co-infection. The factors associated with self-reported STI were the age of onset of sex work, knowledge of any STI, marital status, and sex with other person(s) other than clients. Conclusions: In a high HIV prevalent region of Ecuador, among FSWs the prevalence of HIV and syphilis was low but self-reported STIs was high, and this study identified several risk factors that provide scientific evidences for health policy decisions like the strength of health promotion and education programs for FSWs, especially the among the youngest.

Multiple Sclerosis (MS) is a progressive neurodegenerative disease that affects more than 2 million people worldwide. Increasing knowledge about MS in different populations has advanced our understanding of disease epidemiology and variation in the natural history of MS among White and minority populations. In addition to differences in incidence, African American (AA) and Hispanic patients have greater disease burden and disability in earlier stages of disease compared to White patients. To further characterize MS in AA and Hispanic populations, we conducted a retrospective chart analysis of 112 patients treated at an MS center in Houston, Texas. Here, we describe similarities and differences in clinical presentation, MRI findings, treatment regimens, disability progression, and relapse rate. While we found several similarities between the groups regarding mean age, disability severity, and degree of brain atrophy at diagnosis, we also describe a few divergences. Interestingly, we found that patients who were evaluated by a neurologist at symptom onset had significantly decreased odds of greater disability [defined as Expanded Disability Status Scale (EDSS) > 4.5] at last presentation compared to patients who were not evaluated by a neurologist (OR: 0.04, 95% CI: 0.16–0.9). We also found that active smokers had significantly increased odds of greater disability both at diagnosis and at last clinical encounter compared to nonsmokers (OR: 2.44, 95% CI: 1.10–7.10, OR= 2.44, 95% CI: 1.35–6.12, p = 0.01, respectively). Additionally, we observed significant differences in treatment adherence between groups. Assessment of the degree of brain atrophy and progression over time, along with an enumeration of T1, T2, and gadolinium-enhancing brain lesions, did not reveal differences across groups.

Abstract Background Despite the protective effect of male circumcision (MC) against HIV in men, the acceptance of voluntary MC in priority countries for MC scale–up such as Uganda remains limited. This study examined the role of women’s sociodemographic characteristics, knowledge of HIV and sexual bargaining power as determinants of women’s support of male circumcision (MC). Methods Data from the Uganda AIDS Indicator Survey, 2011 were analyzed (n = 4,874). Bivariate and multivariate logistic regression analyses with random intercept were conducted to identify factors that influence women’s support of MC. Results Overall, 67.0 % (n = 3,276) of the women in our sample were in support of MC but only 28.0 % had circumcised partners. Women who had the knowledge that circumcision reduces HIV risk were about 6 times as likely to support MC than women who lacked that knowledge [AOR (adjusted odds ratio) = 5.85, 95 % CI (confidence interval) = 4.83–7.10]. The two indicators of women’s sexual bargaining power (i.e., ability to negotiate condom use and ability to refuse sex) were also positively associated with support of MC. Several sociodemographic factors particularly wealth index were also positively associated with women’s support of MC. Conclusions The findings in this study will potentially inform intervention strategies to enhance uptake of male circumcision as a strategy to reduce HIV transmission in Uganda.

Objective. HIV and tuberculosis represent diseases of major public health importance worldwide. Very little is known about HIV-TB coinfection among pregnant women, especially from industrialized settings. In this study, we examined the association between TB, HIV, and HIV-TB coinfection among pregnant mothers and obstetric complications, alcohol use, drug abuse, and depression. Method. We examined inpatient hospital discharges in the United States from January 1, 2002, through December 31, 2014. We employed multivariable survey logistic regression to generate adjusted estimates for the association between infection status and study outcomes. Results. We analyzed approximately 57 million records of pregnant women and their delivery information. HIV-TB coinfection was associated with the highest risks for several obstetric complications, alcohol use, and drug abuse. The risk for alcohol abuse was more than twice as high among HIV-monoinfected as compared to TB-monoinfected mothers. That risk gap more than doubled with HIV-TB coinfection. Both HIV-monoinfected and HIV-TB coinfected mothers experienced similarly increased risks for depression. Conclusions. Mothers with HIV-TB coinfection experienced relatively heightened risks for obstetric complications, alcohol use, and drug abuse. The findings of this study underscore the importance of augmenting and enhancing social and structural support systems for HIV-TB coinfected pregnant women.

Objective: To assess whether conversion from twin to singleton pregnancy following the demise of a co-twin influences survival. Methods: This retrospective study compared the risk for neonatal, post-neonatal and infant death for converted co-twins versus unconverted co-twins using the US matched multiple file dataset for the period 1995–2000. We also examined the same risks for converted versus same-quantile co-twins, hazard ratios (HR) and 95% confidence intervals (CI) were computed using Cox Proportional Hazards models. Results: The risk for neonatal (HR = 0.18, 95% CI: 0.09–0.34 and HR = 0.69, 95% CI: 0.50–0.96) and infant death (HR = 0.22, 95% CI: 0.12–0.42 and HR = 0.57, 95% CI: 0.42–0.77) were significantly lower for converted twins than for unconverted twins and same-quantile twins, respectively. For black compared to white, the risk for post-neonatal death increased by 89% (HR = 1.89, 95% CI = 1.03, 3.48), and 79% (HR = 1.79, 95% CI = 1.53, 2.09) for converted vs. unconverted and converted vs. same-quantile, respectively. For converted black, the risk for neonatal death decreased by 17% (HR = 0.83, 95% CI = 0.73–0.93) as compared to unconverted. Conclusions: Risks for all mortality types were lower among converted co-twins than their unconverted or same-quantile counterparts. The lower neonatal and higher post-neonatal mortality among black require future research.

Background: Numerous barriers and challenges can hinder the successful enrollment and retention of study participants in clinical trials targeting minority populations. To conduct quality research, it is important to investigate these challenges, determine appropriate strategies that are evidence-based and continue seeking methods of improvement. Methods: In this paper, we report such experiences in a registered clinical trial in an underserved minority population in the Southern part of United States. This research study is a randomized doubleblind controlled clinical trial that tests the efficacy of higher-strength as compared to low-strength/standard of care folic acid to prevent fetal body and brain size reduction in pregnant women who smoke. A unique approach in this socio-behavioral, genetic-epigenetic clinical trial is that we have adopted the socio-ecological model as a functional platform to effectively achieve and maintain high participant recruitment and retention rates. Results: We highlight the barriers we have encountered in our trial and describe how we have successfully applied the socio-ecological model to overcome these obstacles. Conclusions and Global Health Implications: Our positive experience will be of utility to other researchers globally. Our findings have far-reaching implications as the socio-ecological model approach is adaptable to developed and developing regions and has the potential to increase recruitment and retention of hard-to-reach populations who are typically under-represented in clinical trials.

Dr. Holtz and colleagues present a synthesis of evidence from published studies over the previous decade on the collective impact of HIV-targeted interventions on maternal mortality. Amongst an assortment of interventions [that include antiretroviral therapy (ART), micronutrients (multivitamins, vitamin A and selenium), and antibiotics], only ART reduced maternal mortality among HIV-infected pregnant and post-partum mothers. These findings have fundamental and global strategic implications. They are also timely since they provide the evidence that ART reduces HIV-related maternal mortality, and by further enhancing access to ART in HIV-challenged and poor regions of the world, significant improvement in maternal morbidity and mortality indices could be attained. The paper bears good tidings and sound scientific proof that the financial investment made globally by government and non-governmental organizations and agencies to reduce the global burden of HIV/AIDS primarily by making ART more accessible to regions of the world most affected by the epidemic is beginning to show beneficial effects not only in terms of numerical reductions in the rates of new cases of HIV/AIDS among women, but also in maternal mortality levels.