Among sites serving pregnant WWH, 54% were fully and 21% partially integrated, with the highest proportions of fully integrated sites in Southern Africa (80%) and East Africa (76%) compared to 14%–40% in other regions . Among sites serving postpartum WWH, 51% were fully and 10% partially integrated, with a similar regional integration pattern to sites serving pregnant WWH. Among sites serving ICEH, 56% were fully and 9% were partially integrated, with the highest proportions of fully integrated sites in East Africa (76%), West Africa (58%) and Southern Africa (54%) compared to ≤33% in the other regions. Integration was heterogenous across IeDEA regions and most prevalent in East and Southern Africa. More research is needed to understand this heterogeneity and the impacts of integration on MCH outcomes globally.The WHO recommends the integration of routine HIV services within maternal and child health (MCH) services to reduce the fragmentation of and to promote retention in care for pregnant and postpartum women living with HIV (WWH) and their infants and children exposed to HIV (ICEH). During 2020–2021, we surveyed 202 HIV treatment sites across 40 low- and middle-income countries within the global International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. We determined the proportion of sites providing HIV services integrated within MCH clinics, defined as full [HIV care  The World Health Organization (WHO) defines HIV integration as “the co-location and sharing of services and resources across different health areas and includes offering HIV testing, prevention, treatment and care services alongside other relevant health services” . In 2006Despite this uncertainty, there is a growing body of literature indicating that integrated HIV and MCH services are increasingly being adopted in LMICs, particularly in sub-Saharan Africa where the burden of HIV is highest . Yet whiwww.iedea.org). IeDEA has conducted periodic consortium-wide site assessment surveys describing the available resources and implementation of HIV care and treatment for people living with HIV at affiliated sites since 2009  is a research consortium established by the U.S. National Institutes of Health which pools and harmonizes HIV data from over two million people with and at risk of HIV at clinical sites in 44 countries around the world , randomly sampled (n = 18), and those in IeDEA's database that are not part of a large programmatic cohort (n = 9) , North America , and four sub-Saharan Africa regions . As the Southern Africa region included >200 small clinics contributing data to IeDEA as part of larger programmatic cohorts, it was not considered feasible to survey 100% of active sites in this region. Therefore, a systematic, hybrid sampling strategy was used to (i) purposefully sample sites that had completed prior IeDEA site surveys to facilitate future longitudinal analyses, and (ii) ensure that selected sites were representative of the larger programmatic cohort by randomly sampling sites stratified by location  in line with the clinic distribution within each programmatic cohort. Thus, 32 representative sites from the Southern Africa region (15% of active sites) were included in the site assessment, which included sites that were purposively sampled ( (n = 9) .Sites in IeDEA regions were eligible for this analysis if they reported providing HIV services to pregnant WWH, postpartum WWH, or ICEH <24 months of age. NA-ACCORD was not included in the analysis as it comprises high-income countries with low HIV burdens, where factors influencing the integration of HIV and MCH services may differ markedly from those in LMICs. Sites and coordinating centers for all regions had institutional review board approvals in place permitting the collection of site-level data for this survey. Specifically, this study was approved by the Vanderbilt University Institutional Review Board where the survey data are housed.Survey development and data collection methods have been previously described . BrieflyThough originally intended to assess service delivery at the time the survey was administered in 2020–2021, the year 2019 was selected as the reference period for all survey questions due to the potential for disruptions in service delivery related to the COVID-19 pandemic. The survey was programmed in REDCap and distributed using a web-based link to a designated clinical staff member for each IeDEA clinic or cohort of clinics. Some sites completed paper-based surveys, which were entered into REDCap. The accuracy of data input was verified by the regional data team. REDCap servers were housed in a local data center hosted at Vanderbilt University Medical Center. Data from English and French surveys were merged in REDCap and exported for analysis.To inform our interpretation of the data, we also conducted a non-systematic search of the literature  and ministry of health websites for policies recommending the integration of HIV and MCH services on or before 2019 in each country included in the IeDEA survey. For this search, the presence of integration policy was defined as any statement recommending the delivery of HIV care or ART initiation in MCH clinic from a ministry of health or other government entity. The search was facilitated and verified by the study coauthors representing each IeDEA region. Countries for which integration policy was not identified in our search were designated as having “unconfirmed” integration policy to acknowledge the potential limitations of our non-systematic search. The results of the search were descriptively summarized and presented in the Supplementary Material .and ART initiation), partial (integration of HIV care or ART initiation), and no integration. These definitions were based on WHO guidance . The primary outcome was the proportion of sites providing HIV services integrated within MCH clinics for pregnant WWH, postpartum WWH, and ICEH, respectively. For pregnant WWH, this included integration of HIV services within antenatal care (ANC) clinics; for postpartum WWH, this included integration of HIV services within postnatal care (PNC) clinics  or MCH clinics ; and, for ICEH, this included integration of HIV services within well-baby clinics  or MCH clinics. Integration was defined as full , CCASAnet (n = 8), Central Africa (n = 21), East Africa (n = 74), Southern Africa (n = 28) and West Africa (n = 14).Between September 2020 and March 2021, clinical staff at 202 sites in 40 LMICs completed the survey, and of these sites, 193 (96%) reported providing services to pregnant WWH, postpartum WWH, or ICEH and were included in the analysis . The numOverall, 58 (30%) sites served an urban population, 43 (22%) served a rural population, and the remainder served a mixed urban/rural population . Most siFor pregnant WWH, HIV care was most frequently delivered in the ANC clinic in 80% of sites in East and Southern Africa . HoweverFor postpartum WWH, HIV care was delivered in the MCH clinic in 51% of sites overall and was highest in East Africa (76%). In contrast, approximately 80% of sites in the Asia-Pacific, CCASAnet, and Central and West Africa delivered HIV care in the HIV clinic. In Southern Africa, the location of HIV care for postpartum WWH was approximately 50% in each of the HIV, PNC, and MCH clinics. The locations of ART initiation for postpartum WWH  generally mirrored the locations of HIV care for postpartum WWH in each region. Full and partial integration of services for postpartum WWH occurred in 51% and 9% of sites, respectively, with the highest proportions of fully integrated sites in East Africa (76%) and Southern Africa (64%).For ICEH, HIV care was delivered in the MCH clinic at 55% of sites overall and was highest in East Africa (78%) followed by Southern Africa (63%). Compared to the MCH clinic, the well-baby clinic accounted for a higher proportion of HIV care in the Asia-Pacific (40% vs. 24%) and West Africa (58% vs. 8%). The locations of ART initiation for ICEH diagnosed with HIV were generally the same as the locations of HIV care in each region. Full and partial integration of services for ICEH occurred in 56% and 10% of sites, respectively, with the highest proportions of fully integrated sites in East Africa (76%), West Africa (58%) and Southern Africa (54%).Stratifying the integration outcome by population setting, full integration for pregnant WWH (74%), postpartum WWH (78%), and ICEH (80%) was more prevalent in rural settings compared to 30%–53% of urban and mixed urban/rural settings .We found policies recommending integration for 31 of 40 (78%) countries, including at least one country in each IeDEA region . The proIntegration of HIV and MCH services was reported in all IeDEA regions, with East and Southern Africa reporting the highest proportions of fully integrated services. In addition, we identified country-level policies recommending HIV and MCH integration for all countries in the East and Southern Africa IeDEA regions. East and Southern Africa have the highest burdens of HIV in the world, and account for half of all people with HIV, including two-thirds of all children with HIV . It is pNot all sites in East and Southern Africa offered integrated services, however, and there was heterogeneity in the prevalence and characteristics of integration both within and between IeDEA regions in our study. Similar heterogeneity in the uptake of integration was identified in a systematic review conducted in 2010 . We alsoSeveral factors could explain the lower proportions of integrated HIV and MCH services outside of East and Southern Africa. In the Asia-Pacific, the lower levels of HIV and MCH integration may relate to this region's higher overall economic status compared to other regions. The IeDEA Asia-Pacific region includes countries from upper-middle  and high  income strata according to World Bank classifications . These cIt is also possible that integration is linked in part to a site's geographic setting. In our study, integration was most prevalent at sites serving rural and mixed urban/rural populations compared to urban populations for pregnant and postpartum WWH, and ICEH. Rural clinics may have been better positioned and incentivized to implement integrated HIV and MCH services given more available clinic space or the need to optimize staffing and resource allocation. Patients desiring access to more specialized services and advanced care at urban clinics may also act as a counter force to integration in these settings, compared to rural clinics with less access to these services. Furthermore, the potential association between integration and rural settings was mostly driven by East Africa, which accounted for 37 of 43 (86%) rural sites included in the analysis, whereas sites in other IeDEA regions had relatively higher proportions of urban and mixed urban/rural population settings. The international and national integration policies we reviewed do not distinguish between rural and urban settings. These findings highlight the significant need for further research to understand what is enabling MCH integration in rural areas which may be transportable to other settings.A strength of our study is its use of the well-established IeDEA-wide site assessment platform to survey global HIV care and treatment sites. This platform enabled us to gather unique global data that have not been previously reported. A potential limitation of our study is that the IeDEA sites included in the analysis may not be generalizable to the broader array of HIV care and treatment sites in the countries represented. For example, sites were initially selected to participate in IeDEA based on their data collection infrastructures, which may imply that they have higher levels of resources, funding and available services compared to non-IeDEA sites. This potential limitation is the reason we elected not to segment the data at the country level. Our data may also be subject to social desirability and reporting biases by clinical staff who completed the surveys, as well as biases arising from the ways the questions were interpreted, for which there was limited ability for investigators to verify responses. Recall bias is also a potential limitation, as respondents were asked to consider practices prior to, rather than during, the COVID-19 pandemic.Our non-systematic search may have failed to identify relevant ministry of health integration policies for some countries. Country-level guidance on MCH integration can be disseminated through local policy circulars, notices and press releases published years ago that are no longer searchable electronically, so we did not consider it feasible to systematically assess all potentially related policy documents for all countries. Rather, our search was enhanced by direct communications with IeDEA regional and country-level representatives who were able to provide expertise on integration policy for each country. Donor policies and priorities, such as the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), may also have important influences on integration which were not accounted for in our search . Still, The integration of HIV and MCH services was most prevalent in East and Southern Africa, regions with the highest burdens of HIV disease and prevalence among women globally. However, there was heterogeneity in the prevalence of integration both within and between regions. More research is needed to understand the factors driving integration of HIV and MCH services, and the impacts of integration on vertical transmission and other maternal and infant outcomes, to inform how best to address the gaps in integration implementation. The findings of our study will be useful to policymakers interested in the impact of integration policy and its global implementation, as well as program stakeholders and researchers concerned with health system structures and improving service delivery to pregnant and postpartum WWH and their infants.


Healthy diet and exercise can improve quality of life and prognosis among men with prostate cancer. Understanding the perceived barriers to lifestyle change and patient preferences in a diverse cohort of men with prostate cancer is necessary to inform mobile health  lifestyle interventions and increase health equity.We conducted a multisite study to understand the preferences, attitudes, and health behaviors related to diet and lifestyle in this patient population. This report focuses on the qualitative findings from 4 web-based focus groups comprising a racially and ethnically diverse group of patients with advanced prostate cancer who are on androgen deprivation therapy.We used grounded theory analyses including open, axial, and selective coding to generate codes. Qualitative data were analyzed as a whole rather than by focus group to optimize data saturation and the transferability of results. We present codes and themes that emerged for lifestyle intervention design and provide recommendations and considerations for future mHealth intervention studies.Overall, 14 men participated in 4 racially and ethnically concordant focus groups . Analyses converged on 7 interwoven categories: context , motivation , preparedness , data-driven design , program mechanics , habits , and intervention impressions. These results suggest actionable pathways to increase program intuitiveness. Recommendations for future mHealth intervention design and implementation include but are not limited to assessment at the individual, household, and neighborhood levels to support a tailored intervention; prioritization of information to disseminate based on individuals’ major concerns and the delivery of information based on health and technological literacy and communication preferences; prescribing a personalized intervention based on individuals’ baseline responses, home and neighborhood environment, and support network; and incorporating strategies to foster engagement  to aid participant decision-making and behavior change.Assessing a patient’s social context, motivation, and preparedness is necessary when tailoring a program to each patient’s needs in all racial and ethnic groups. Addressing the patients’ contexts and motivation and preparedness related to diet and exercise including the household, access (to food and exercise), competing priorities, health and technological literacy, readiness to change, and clinical characteristics will help to customize the intervention to the participant. These data support a tailored approach leveraging the identified components and their interrelationships to ensure that mHealth lifestyle interventions will engage and be effective in racially and ethnically diverse patients with cancer.ClinicalTrials.gov NCT05324098; https://clinicaltrials.gov/ct2/show/NCT05324098 Healthy diet and exercise have been shown in numerous observational studies and randomized controlled trials to improve quality of life, treatment-related adverse effects, and prognosis among men with prostate cancer -7. HowevMobile health  interventions, defined by the World Health Organization as “Medical and public health practices supported by a mobile device, such as mobile phone, patient monitoring devices, personal digital assistants and other wireless devices” , are becGiven the importance of healthy lifestyle habits, well-documented disparities in prostate cancer care, and need for remote mHealth interventions, we conducted a qualitative study exploring diet and lifestyle behaviors among a racially and ethnically diverse cohort of men with advanced prostate cancer, to guide the development of an educational intervention focused on men treated with ADT. Findings from this qualitative study may also inform the design and delivery of future mHealth interventions in diverse populations.There was a cross-sectional mixed methods study designed to examine preferences, attitudes, and health (PATH) behaviors in men with advanced prostate cancer via a web-based exercise and food habit survey and focus groups. Sampling was purposive to ensure that men from diverse racial and ethnic groups were included. English-speaking and Spanish-speaking participants (n=104) were recruited between July 6, 2019, and November 11, 2020, at the University of California, San Francisco (UCSF); Zuckerberg San Francisco General; and San Francisco Veterans Affairs hospitals. The study was introduced by the study clinician , clinician (TF), or clinical research coordinator (SZ or ET). The clinical research coordinator screened potential participants for eligibility by reviewing oncology clinic schedules and electronic health records and then approached these patients in the clinic, by phone, or by email to participate in the study. Clinicians also introduced patients to the clinical research coordinator in the clinic, who then introduced them to the study. Participants were aged ≥18 years, diagnosed with hormone-sensitive prostate cancer, on hormone therapy, able to read English or Spanish, and able to understand written informed consent. Participants had metastatic hormone-sensitive prostate cancer if recruited from UCSF; we allowed participants in the community to have metastatic or nonmetastatic hormone-sensitive prostate cancer and did not verify metastasis status for these participants. Any man with any self-reported cognitive or neurologic condition that, in the opinion of the study team, would prohibit the ability to read and navigate the internet or follow a diet or exercise prescription independently were excluded. Recruitment in the community setting occurred through Facebook and Google advertisements; through oncologists at Kaiser Oakland hospital; and at community-based events including church events, support groups, and so on, by a community health educator and outreach or engagement coordinator to increase sample size and include a wide range of perspectives.Overall, 36 PATH study participants consented to be further contacted by the research team regarding optional study procedures . These participants were invited to a focus group via phone or email. All patients provided informed consent. Focus groups were stratified according to self-identified race and ethnicity. Overall, 14 participants—3 ( 21%) Asian American participants, 3 (21%) African American or Black participants, 3 (21%) Hispanic or Latino participants, and 5 (36%) White participants—attended focus groups between April and November 2020. Each participant received a gift card worth US $50 for participation in the PATH study, and focus group participants received an additional gift card worth US $50.Focus groups were conducted by researchers with expertise in urologic cancers, lifestyle, and associated disparities . SZ was the primary contact for study participants. Focus groups were conducted in English and recorded via Zoom (Zoom Video Communications) video software. Participants were asked about their experience with and perceptions regarding various lifestyle tools . For the interview guide, refer to We used a grounded theory approach ,15. The The number of focus group participants required to reach data saturation is debated and largely dependent on the scope of the topic of interest . We desiThe study was conducted in accordance with the Declaration of Helsinki and approved by the institutional review board (or ethics committee) of UCSF .Self-reported characteristics of focus group participants are presented in Analyses yielded 67 open codes, 25 axial codes, and 7 selective codes (categories), which are presented in Codes only represented in a subset of focus groups are presented in The relationships among these codes  represenThe purpose of this paper was to elucidate the perspectives and attitudes surrounding lifestyle change in racially or ethnically diverse men with advanced prostate cancer, as this has not previously been studied. Our results suggest that lifestyle-related preferences, needs, and limitations of men with prostate cancer from diverse racial and ethnic backgrounds are affected by multiple inherent, learned, and contextual dimensions, precluding a one-size-fits-all approach to intervention design for men of any given race and ethnicity. Lifestyle interventions may be improved and tailored to the individual by leveraging these components and their interrelationships. The findings from this study are informing a digital platform that provides lifestyle resources and support for men receiving ADT .So far, few studies have qualitatively explored the experiences of diverse groups of survivors of prostate cancer. The recent COVID-19 pandemic has presented novel challenges, especially among minoritized racial or ethnic populations ,22 and aMany codes under “context” (home environment and access) and “preparedness”  represent the downstream effects of social determinants of health ,25 or “fAs a first step, the codes generated in this study may serve as a preliminary guide for designing a comprehensive intake form. The breadth and interrelatedness of codes generated by participants signaled the need for a holistic and integrated mHealth intervention design; for example, our recommendations include providing education about normal adverse effects of prostate cancer treatments and the evidence surrounding diet and exercise recommendations as they relate to energy, strength, and motivation and gaining an understanding of participants’ current habits to identify realistic and priority areas for change . Future Every category was constructed with input from all focus groups, but certain codes were not represented in every focus group . These vLimitations of the study include the small subgroup sample size. Overall, 13.5% (14/104) of the eligible participants were both interested and available to participate in the focus groups at scheduled times. Although our sample size is acceptable because our objectives were to explore themes using a grounded theory approach, the absence of theoretical sampling precluded certainty of data saturation. However, open coding minimized researcher assumptions. Our focus groups of 3 to 5 participants provided a more intimate environment for people to share their experience with cancer, their treatments, side effects, and so on and thus was effective for eliciting responses to potentially sensitive research questions such as ours . The corThe discussions with focus groups of racially and ethnically diverse patients with prostate cancer about mHealth lifestyle interventions support a tailored approach that leverages the identified components and their interrelationships to ensure that the final intervention will engage and be effective in diverse patients with a cancer diagnosis. Addressing the home environment and patients’ roles related to diet and exercise in the household, access (to food and exercise), competing priorities, health and technological literacy, readiness to change, and clinical characteristics will help to customize the intervention to the participant. This study provides preliminary evidence that multiple dimensions should be considered in behavior change interventions and that each contributes to the totality of an individual’s social identities and contexts that influence dietary and exercise behaviors. Thus, an intersectional approach to tailoring interventions for all men that accounts for their needs based on an assessment of their context, motivation, preparedness, habits, and impressions, while incorporating design and program mechanics preferences of the participant, would most likely enhance prostate cancer survivorship.


How can reporting of racial and ethnic representativeness in pediatric research studies be optimized for specificity and replication to address methodological gaps and reduce health disparities?In this cross-sectional study with a pooled sample of 104 schools located in 5 US states, the Bland-Altman method was adapted to quantify school-level racial and ethnic representativeness using measures of spread. Overall representativeness was observed, yet group means obscured the substantial within-group disparities observed with residuals on Bland-Altman plots.These results suggest that replication of the proposed Bland-Altman method may improve race and ethnicity reporting, representative recruitment, and external validity of the health evidence base. This cross-sectional study examines the utility of Bland-Altman analysis in quantifying the racial and ethnic representativeness of community-based populations in pediatric health research. Children from marginalized racial and ethnic groups are underrepresented in health research. To improve external validity and routinize race and ethnicity reporting, a specific and standardized methodology for quantifying representativeness of participant populations is needed.To develop a standardized method for quantifying the racial and ethnic representativeness of study samples.In this cross-sectional study, data from 7 US community-based health studies (conducted between 2003 and 2017) were retrospectively pooled to assess the school-level representativeness of enrolled samples by race and ethnicity. The sampling frame for the study was constructed using the National Center of Education Statistics Common Core of Data, which provides year-specific racial and ethnic counts by grade. Representativeness was quantified by aggregating children’s data at the school level, reported individually for Asian, Black, Hispanic or Latino, Native Hawaiian or other Pacific Islander, White, or multiple races. In this analysis, the Asian and Native Hawaiian or other Pacific Islander subgroups were combined. Data were analyzed from April 1 to June 15, 2022.Community-based nutritional health studies conducted with children in grades 1 to 8.Visual comparisons of percentage expected and percentage observed of the pooled sample by race and ethnicity were performed using scatterplots and Bland-Altman plots. Spearman rank-order correlation was used to assess associations.This study included 104 study schools (N = 5807 children) located in California, Kentucky, Massachusetts, Mississippi, and South Carolina. Bland-Altman analysis revealed notable patterns and variability in the representativeness of racial and ethnic groups. Differences in the overall representativeness of Asian or Native Hawaiian or other Pacific Islander children , Black children , and White children  were negligible, but measures of spread suggested that target population demographics affected representativeness differently across groups.The results of this cross-sectional study suggest that replicating, testing, and scaling the proposed method for quantifying racial and ethnic representativeness, which uses measures of spread, could improve the transparency of race and ethnicity reporting during publication and lead to a more externally valid health evidence base. During implementation, investigators should adopt community-based research methods and allocate appropriate resources during recruitment, including a priori assessment of population demographics, as these conditions may affect racial and ethnic study enrollment differently. Prioritizing these methodological decisions could alleviate rising inequities. At a minimum, addressing the causes of preventable racial and ethnic health disparities begins by ensuring that study samples reflect the demographics of the US.7Ensuring that marginalized racial and ethnic populations are well represented in research is essential to prevent growing health inequities. In the US, the health evidence base fails to reflect the true diversity of the population.12 examined 612 pediatric clinical trials published in top medical journals between 2011 and 2020, and found that 27.7% did not report participant race or ethnicity. Based on studies that provided data on the race of participants, the authors concluded that Black participants were enrolled in a greater proportion than their share of the US population aged younger than 19 years and were therefore overrepresented.12 Flores et al13 assessed reporting of race and ethnicity in 230 US vaccine trials, and they found that all studies reported participant age and sex but only 58.3% reported race and only 34.3% reported ethnicity.13 These reporting discrepancies may affect our understanding of racial and ethnic study representativeness, as findings rely on investigator transparency.14The longstanding consensus rightfully acknowledges the overrepresentation of White individuals in study populations and the underrepresentation of marginalized racial and ethnic groups. Yet specific representation patterns may be biased by the endogeneity of race and ethnicity reporting, since public disclosure of study demographics is not mandated by journals or funders; thus, investigators often forego this reporting. For example, Rees et al16 This approach could obscure disparities and provides little insight into recruitment procedures and the association between factors in the environment and enrollment within and across racial and ethnic groups. Overall, the health research community could benefit from a specific and consistent approach for assessing and reporting the racial and ethnic representativeness of study populations.When study demographics are reported in peer-reviewed literature, representativeness is traditionally quantified by comparing the overall share of each racial and ethnic group enrolled in the study against their mean share of the population without accounting for age groups or locations.Here, we describe a methodology for quantifying the racial and ethnic representativeness of study populations and demonstrate its utility by compiling a convenience sample of data from 7 US community-based pediatric health studies. All studies, conducted by members of our team, collected parent- and guardian-reported child race and ethnicity and recruited at public schools. Investigators allocated extensive resources a priori to identify, partner with, and recruit from schools in communities serving predominantly marginalized populations to ensure that they were well represented . InvestiSTROBE) reporting guideline.The Tufts University Institutional Review Board exempted this cross-sectional study from review because it did not constitute human participant research. For the 7 pediatric research studies described herein, informed consent was obtained from the parents or caregivers of participants. The current study followed the Strengthening the Reporting of Observational Studies in Epidemiology .18The Bland-Altman approach is widely accepted and applied in clinical settings to analyze the agreement between 2 quantitative measures.19 compared racial and ethnic discrepancies in pulse oximetry and arterial oxygen saturation measures. In the current study, we visualized differences between the percentage expected for representativeness and the percentage enrolled for the following racial and ethnic subgroups: Asian, Black, Hispanic or Latino, Native Hawaiian or other Pacific Islander, White, and multiple races , we used the National Center for Education Statistics (NCES) Public Elementary/Secondary School Universe Survey.20 These data are compiled into the Common Core of Data, which provides the total race and ethnicity enrollment counts by sex and grade for all US public schools. It is an authoritative sampling frame for pediatric research and widely relied on by investigators and in population surveillance surveys.21 We calculated percentage expected by dividing the total number of enrolled students in each racial and ethnic group in the target grades by the number of all enrolled in those grades. By deriving percentage expected from the schools’ true and precise population parameters, it can be conceptualized as the gold standard for proportionate representativeness.22To compute the share of each group expected for representativeness (herein referred to as percentage observed), we pooled data from 7 community-based health studies led by members of our research team across 104 schools in 5 states, including California, Kentucky, Massachusetts, Mississippi, and South Carolina. Individual measures from children in grades 1 to 8 who enrolled in nutritional health studies were aggregated by the school where they were recruited  is the overall percentage-point amount that the racial or ethnic group was represented across studies. The longer-dashed lines indicate the SDs (2) for this range; thus, wider intervals indicate greater variability in overall representativeness. Points along Y,0 are schools that were representative. Points above Y,0 are schools where each group was overrepresented, while schools below Y,0 were underrepresented. The distance between a point and Y,0 denotes the percentage-point distance from proportionate representation.Schools were the primary unit of analyses. We visually inspected scatterplots and Bland-Altman plots to quantify representation patterns. To assess the association between percentage expected and percentage observed for each racial and ethnic group, we used Spearman rank-order correlation coefficients and a 2-sided α level of .01 to establish statistical significance. All analyses were conducted from April 1 to June 15, 2022, using Stata SE software, version 17 (StataCorp LLC).Informed consent was obtained for 6325 participants but 518 (8.2%) were excluded from this cross-sectional analysis because the child’s race and/or ethnicity was either missing (n = 152), reported as multiracial in studies before 2009 (n = 211), or identified with the “other” race checkbox (n = 155). In total, 104 schools (N = 5807 children) were included in this analysis. Exclusion criteria with counts are provided in eTable 2 in P < .001; Asian or Native Hawaiian or other Pacific Islander children were overrepresented by 0.45 percentage points , but most schools had small population shares. The association between percentage expected and percentage observed was significant . The positive correlation between percentage expected and percentage observed for Black children was statistically significant . The positive correlation between percentage expected and percentage observed among Hispanic children was statistically significant . The positive correlation between percentage expected and percentage observed for White children was statistically significant , specific outlier sites were identified easily. Moreover, by examining the location of points along the x-axis of Bland-Altman plots, an association was observed between a racial and ethnic group’s share of the overall target population and their representativeness at the site. Illustrating this approach in our pooled data set underscored the importance of moving beyond reporting representativeness with group means alone. We observed that overall representativeness did not appreciably vary across racial and ethnic groups, but mean values obscured substantial within-group variation. We urge investigators to begin incorporating measures of spread into their research (1) to provide a more complete estimate of representativeness and (2) to pinpoint potential barriers and facilitators to study enrollment by race and ethnicity. Future research replicating our approach could maximize the transparency of racial and ethnic reporting, investigate whether our results in a nonrandom sample of community-based studies hold across other community-based studies in the US, and elucidate the degree to which community-based methods affected our findings.3In this cross-sectional study, we provided a practical approach for quantifying the representativeness of study populations by adapting the Bland-AltmanOur method of quantifying study population representativeness can be applied to a broad range of health research and policy contexts. We assessed the representativeness of enrolled children relative to their respective schools. Additionally, the method discussed supports comparisons at many other levels  or site-based locales . Our study focused on racial and ethnic representativeness, but the outcome could encompass a wide range of equity indicators . For example, data from national cohort studies could be aggregated by state to examine whether the income of enrolled participants matched the mean income of their state. Future replication studies could also determine whether representativeness varies based on the study outcome or disease type. For instance, by pooling data from cancer clinical trials, the racial representativeness of study populations could be examined based on the cancer type, using the hospital as the unit of analysis. Finally, the graphical component of Bland-Altman analysis can be used to obtain additional layers of information by coding points on the graphs to convey characteristics, such as the year of study enrollment, to detect patterns in representativeness over time.23 Our proposed method could quantify overall and racial and ethnic differences in WIC participation by state. Each point would indicate the zip code with individual plots for each race and ethnicity. Quantifying representativeness with this approach may provide substantial new knowledge for other federally funded programs, such as Medicare, Medicaid, Head Start, and the Supplemental Nutrition Assistance Program. However, such methodological advancement requires the cooperation of government agencies and relies on accurate and accessible sampling-frame data sets for comparison.Our adapted Bland-Altman method also holds promise for the more inclusive reach of federal health, nutrition, and education programs. For instance, the US government estimated that 11 million individuals were eligible to receive Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) benefits in 2019, but only 57% did.24 However, even the most rigorous and thoughtfully planned community-based studies, such as those in our sample, may face difficulty overcoming barriers to successfully enrolling individuals disproportionately facing adversity. For example, Asian, Black, and Hispanic children may be exposed to more discrimination at schools than their White peers, which directly impedes their health and may affect study enrollment.27 Our findings suggest that Black children, in particular, may be less likely to enroll in community-based studies when they do not belong to their school’s racial majority. Thus, efforts to include context-specific minoritized children are crucial to address rising health inequities effectively. Relatedly, we observed that the racial and ethnic composition of study settings may also incur beneficial effects. Specifically, Black children appeared more likely to be overrepresented at majority Black schools. Future qualitative research assessing inter- and intragroup social cohesion could examine how school and family racial and ethnic relations affect recruitment outcomes, which investigators should incorporate into individualized recruitment plans.28 Finally, each study worked in low-income and resource-limited communities. Identifying the contributing factors associated with site-level underrepresentation across racial and ethnic groups is crucial since children from low-income backgrounds remain underrepresented in the pediatric health literature. Overall, the mechanisms that limit the effectiveness of enrolling representative samples in community-based studies are not well understood but were partially revealed by our finding of school-level differences in representation based on the school majority.Community-based research methods are associated with more representative enrollment outcomes than traditional clinical and population-based approaches.A main limitation of this cross-sectional study was the exclusion of enrolled children from the analysis because their race and ethnicity data could not be compared with the NCES Common Core data sets . Moreover, the magnitude of representativeness should be interpreted cautiously, particularly since some schools had small numbers of individuals of each race and ethnicity; thus, deviations from representation could indicate differences of just a few children. Race and ethnicity are fluid social constructs. Discrepancies between school and study demographic response options could have affected our findings if parents reported the child’s race and ethnicity differently on each survey.15 Therefore, our representativeness findings may lack generalizability, but that extent should be confirmed with wider application of our technique. Future research could assess how additional factors, such as study design, community engagement, potential study risks, and indicators of social status , are associated with racial representativeness in pediatric health studies. Notably, such data must be collected on study surveys to overcome limitations of data availability during similar retrospective assessments.The included studies were led by investigators with expertise in community-based research. The goal of these community-based studies was to enroll eligible children from schools with certain socioeconomic compositions . These cIn this cross-sectional study, we confronted a critical barrier to health equity: the systematic underrepresentation of Asian, Black, and Hispanic populations in pediatric health research. Our approach for quantifying representativeness in health research is both feasible and replicable. Prevention of the racial and ethnic health disparities that manifest during childhood and persist over the life span requires a paradigm shift during recruitment and when describing study samples and results. Replication and testing of our application of Bland-Altman analysis could help improve the representation of minoritized racial and ethnic populations in the pediatric health evidence base and in health policies and programs. The proposed method may enable investigators to pinpoint the multilevel determinants of enrollment affecting racial and ethnic groups differently, and it could help alleviate preventable chronic disease disparities that are disproportionately endured by US youth from racially minoritized backgrounds.


Eating disorder treatment approaches and outcome studies have historically centered almost exclusively on cisgender populations. Transgender and nonbinary (TGNB) adults are underrepresented in general and intervention research despite being at increased risk for eating and body image-related problems.This scoping review was designed to gather and examine the research with TGNB adults who experience eating and body image related problems, as well as clinical studies on the effectiveness of treatment approaches.Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used for reporting this review. MEDLINE and PsychInfo were used as electronic databases for searching subject terms. Inclusion criteria for studies required the quantitative measurement or qualitative exploration of body image or eating for TGNB adults. The relevant data were extracted and summarized based on quantitative findings and qualitative themes.After review of over 1258 articles, 59 studies met criteria and data were extracted and summarized. Factors associated with eating disorders and body image problems across studies suggests gender-affirming medical interventions are effective and emphasized treatment for an eating disorder is warranted alongside gender affirming medical care. Body image was associated with eating patterns aimed at meeting gendered ideals of body shape and size. There was variation in guiding theories and absence of consensus in the definition of transgender in the review studies. This likely demonstrates the changing language, social acceptance of TGNB people and identities, diagnostic criteria, and clinical conceptualizations of eating and body image.Future research should consider the use of theory for guiding inclusion of salient social factors influencing eating patterns, body image, and treatment outcomes. In addition, future research is needed that centers on nonbinary and genderqueer populations, as well as those from minoritized racial and ethnic groups to inform culturally appropriate concerns, needs, and treatment modalities. Fifty-nine published research studies with transgender adults on eating patterns, body image, and associated risks and comorbidities were collected and summarized. Across studies, gender affirming medical interventions like hormone therapy and surgery were associated with decreases in eating disorder symptoms and improved body image. Studies from interviews with transgender adults found social causes for disordered eating and poor body image including rejection and discrimination. Future studies should use guiding theories for testing the causality and consider rejection and discrimination experienced by transgender adults. Eating disorder treatment approaches and outcome studies have centered almost exclusively on cisgender  participants . TransgeA guiding theory for this review is Minority Stress Theory (MST) as it has been applied and expanded for TGNB people. MST, first theorized in the context of gay, lesbian, and bisexual people , posits MST also proposes key protective factors for TGNB adults, including social acceptance in family, work, social, and healthcare settings , social changes , and access to medical services  . AcceptaMST for TGNB research and in this scoping review considers psychological and social factors as significant contributors to outcomes of marginalized subgroups within the TGNB population. Thus, MST aids in identifying missing factors and subgroups  not included in the current literature body. It also provides a critical lens to the review analysis about the types of methods employed for studying TGNB experiences, the language used about TGNB patients, and the treatment approach and outcomes of TGNB people in healthcare. External stressors are experienced across social settings for TGNB people, including in healthcare and research participation, impacting their health and safety , thus MSMST posits that TGNB health outcomes will vary based on external and internal stressors, which are further influenced by mental health comorbidities, age, social acceptance, race/ethnic group, and access to gender affirming healthcare and treatment. MST offers a lens for examining the literature with TGNB adults with eating and body image related problems. As a result, this scoping review aimed to answer four research questions: 1) What methodologies are being used to study eating and body image related problems with TGNB people? 2) What are the risks and protective factors for eating and body image related problems? 3) Who is being included and excluded in the TGNB samples of studies on eating and body image related problems? 4) What are the empirically supported treatments for eating and body image problems for TGNB patients? The focus of this paper is on adults only. Adolescent and young adult literature is detailed in another scoping review .Current analyses that center TGNB people are narrative in nature , 15, spaMEDLINE, PsychINFO, CINAHL: Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systemic Reviews, Social work Abstracts, Social Services Abstracts, and Sociological Abstracts to identify potential articles about transgender adults and eating, body, and weight related problems. The second author (WL) was consulted based on her expertise to review initial searches for relevant articles. The preliminary searches demonstrated two databases—MEDLINE and PsychINFO– were superior for identifying relevant articles. To search the databases, the OVID interface was used, and official subject terms were identified for each database to ensure the use of consistent vocabulary. In MEDLINE, the search terms—transgender persons, gender identity, transsexualism, gender dysphoria, body image, body dissatisfaction, self-concept, feeding behavior, anorexia nervosa, binge eating, and bulimia nervosa—were used. The trans/gender terms and body/eating terms were then searched together for identifying articles where both subjects were categorized. A similar process was used for PsychINFO with the following subject terms—transgender, gender dysphoria, gender identity, gender nonconforming, transsexualism, body image, body esteem, body satisfaction, body dissatisfaction, body awareness, and eating behavior or attitudes or disorders. Eating behavior or attitudes or disorders subject terms included anorexia, bulimia nervosa, and binge eating disorders. No limits were set by date of publication in order to capture the changing theories and findings in the field up to literature published online or in print in December 2022.This literature review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines in the search, review, and reporting processes , 21. TheArticles included in this review met the following criteria: 1) published in peer review journals (including online advance publications); 2) published in English language by December 2022; 3) described qualitative or quantitative empirical research (including case reports and case studies); 4) addressed review questions about eating behavior and body image including those addressing treatment and intervention; and 5) sample of transgender participants  over the age of 18 years old. The following types of studies were excluded from the review: book chapters; review articles; editorial commentaries; clinical opinion articles without case or research data; non-English language studies; dissertations; studies where outcomes from transgender participant data were not reported separately from larger sample; and studies that did not include at least one of the following—eating behavior or disorder measurement, body image measurement, or interview data on eating or body image. Finally, we removed studies examining only young adults samples (ages 18 to 25) as a unique part of adolescent development [The identified articles were uploaded to Covidence©, an online software, for managing duplicate removal and then the processes of abstract review, full text review, and, finally, data extraction. Duplications were removed initially by the software. This was reviewed by the first author to ensure accuracy of the removal. Reviews were completed by three research team members  and four graduate research assistants. Pairs of authors and graduate research assistants reviewed abstracts based on the inclusion/exclusion criteria. Discrepancies in the reviews were resolved by the first and second authors. Then full text reviews were completed by the second and third authors and the graduate research assistants. Again, discrepancies were resolved by the first and second authors. Data extraction was completed by the second, third and fourth authors. Finally, one case control study article was removed at data extraction as two reviewers  agreed that the study did not meet our inclusion criteria as transgender people were the subject of the work, but not the participants in the study . The PRIData were finally downloaded from Covidence© to a spreadsheet developed by the first author where the sample characteristics, guiding theories, definitions of ‘transgender’ and/or language about gender, measurements, funding sources, limitations, bias, and other commentary were noted. The third and fourth authors led the data movement to the spreadsheet. Then analysis of the data followed three modalities. First, studies were separated by age to create youth  and adult  tables for separate analysis. Again, this manuscript will only report on the adult samples and the youth and young adult articles are summarized in a separate scoping review manuscript .Then, study methodology  was analyzed by the first and third authors. The method of articles was analyzed for identifying and quantifying types of methodology, sample size and demographics, measurement use, and geographic location. We sought to summarize and critique the current body of literature based on method and the limitations this may create for drawing conclusions and implications from the studies. Finally, variable outcomes  were analyzed by the second and fourth authors. Variable outcomes were reported based on divergent and consistent findings across studies. In addition, unique findings were noted for subsamples, if appropriate. The outcome results were then narratively summarized.To assess rigor and potential bias in studies, the authors used four items from the STrengthening the Reporting of OBservational Studies in Epidemiology (STROBE) checklist  and the The review identified 59 articles for inclusion (see Table n = 47) did not include a guiding theory. Of the studies that did include theory, MST  [n = 4; 6.8%) [Review of bias and limitations across studies showed five studies lacked limitations sections and 10 studies were missing acknowledgments of potential biases in the study. Many of the studies lacked a full description of the methodology and demographics of the sample. Over 78% of studies   and obje4; 6.8%)  were then = 22). Three studies defined, and some diagnosed, transsexualism  now seen as outdated and offensive language. These studies seemed to be grounded in the diagnostic criteria and current language and clinical thinking about transgender identities. While other studies used less clinical terms, like transgender, gender minority, or gender nonconformity or incongruence and, in some cases, allowed for self-identification as part of the inclusion criteria. Some of the clinical samples lacking explicit definition of transgender denoted “male-to-female” or “female-to-male” gender transitions (n = 10) were in progress, complete, or the person was seeking gender affirming clinical medical care. Given the dated and potentially offensive language used in some of the studies, the results, discussion, and tables . Several different measures were used to assess the variables of interest, with the most common being the Eating Attitudes Test, Body Uneasiness Test, Symptoms Checklist-90, and Eating Disorders Inventory. The sample sizes of the quantitative studies were well-distributed from less than 50 to over 5000. Demographically, most quantitative studies did not report racial data as part of the sample characteristics, and of the studies that did report racial information, 14 included primarily racially White samples. Most of the quantitative studies originated from outside of the United States, including from Italy (n = 8), Sweden (n = 5), UK/England (n = 2), multicenter data from four European countries (n = 5), Germany (n = 4), Netherlands (n = 2), Belgium (n = 1), Turkey (n = 1), Iran (n = 1), Spain (n = 1), Canada (n = 1), Finland (n = 1), multicenter data from the United States, Canada, and Europe (n = 1). The remaining 15 quantitative studies included data collected only in the United States.A total of 48 studies relied on quantitative measurements, scales, and analyses. Most of the articles retained for this study employed a cross-sectional study design  detailing one to five individual cases of gender dysphoria, eating disorders, body image and dissatisfaction, and obesity with quantitative and qualitative data presented. The findings from these case reports focused on psychiatric care [Within the articles retained for this scoping literature review of TGNB adults, 12 utilized a qualitative or case study approach. The case studies  examined a body image construct either as a primary finding or alongside eating disorders. Body image, as it applies to TGNB populations, utilized varied construct definitions leading to a variety of measures for body image including assessing body satisfaction, shame, and surveillance. Body shame referred to the perception of one’s body failing to meet cultural expectations of attractiveness that become internalized through objectification experiences [Most studies  may alleviate eating disorder symptomology and negative body image , 85, 89.The existing research is primarily observational in nature. Little is known about how TGNB patients may respond to eating disorder prevention or treatment approaches traditionally designed for cisgender populations. Riddle and colleagues responded that TGNB patients may show improved symptomology in higher levels of eating disorder treatment yet may experience more severe depression and show less improvement during treatment compared to cisgender patients . In contThe review found variations and absences in definitions of transgender, body image or shame, and guiding theories. This demonstrates the changing language, diagnostic criteria, emergence of MST over the past 40 years, and clinical conceptualizations of eating and body image as uniquely intertwined among TGNB populations. The studies rarely addressed social and interpersonal factors; either through theory or inquiry  despite the significance of social supports and resources on the health of TGNB people demonstrated in MST. These social needs are lifelong for TGNB adults . Future Many of the studies, especially qualitative studies, lacked racial and ethnic diversity in the samples and none looked at non-binary or gender queer individuals exclusively. This may reflect high concealment and the associated risk of violence experienced by TGNB people from minoritized racial groups  and obseIn addition, the purpose of the study, even in large sample sizes, may begin with a bias where individual academic medical professionals who are not utilizing MST as a framework for understanding the social determinants of health of TGNB people, could further pathologize TGNB patients in their care based on weight and eating patterns . TherefoThis review has several limitations. The team carefully planned and utilized software to accurately answer the study questions and conduct the review. However, research studies may have been missed. The current studies still lack nuance by variations in gender identity, expression, and social factors. Limiting the search by English means other international studies were missed. Some of the studies included transgender and non-transgender samples, requiring reliance on portions of the data or only descriptive analysis. Many of the studies were cross-sectional in nature, limiting causal associations between risk factors, treatments, and outcomes documented in the studies. Finally, the rigor could have been enhanced by pre-registering our search protocol with the International Prospective Register of Systemic Reviews.The scoping review offers an overview and examination of research with TGNB adults who experience eating and body image related problems as well as clinical studies on treatment approaches and effectiveness. The 59 studies identified demonstrated the significance of gender-affirming medical interventions for alleviating eating and body image issues though with limitations given the social stigma and discrimination experienced by TGNB people. Future research should consider the use of theory for guiding inclusion of salient social factors influencing eating patterns, body image, and treatment outcomes. In addition, more studies are needed with those from minoritized racial and ethnic groups and varied gender identities  for identifying differences in needs and treatment modalities.


Bionic artificial neural networks (BANNs) are a type of artificial neural network (ANN)  that draBANNs typically consist of multiple layers of interconnected artificial neurons , which pThere are two advantages of BANNs: (i) First, their ability to learn from experience and adjust their behavior accordingly. This is achieved through a process known as training, in which the network is exposed to a large amount of data and adjusts its weights and connections in response to the patterns it observes . Over tiBANNs have a wide range of potential applications, from computer vision and natural language processing to robotics and control systems. They are particularly well-suited to tasks that require real-time decision-making  and adapMIA uses computer algorithms and machine learning techniques to analyze and interpret medical images . MIP rouPreprocessing improves the quality and relevance of the images by removing noise, enhancing contrast , and segClassification  uses macBANNs can help MIA by providing a powerful machine-learning framework  that canAdditionally, BANNs can incorporate feedback mechanisms  and otheBionic artificial intelligence;Bionic artificial neural networks;Bionic engineering;Deep learning;Evolutionary machine learning;Global optimization;Image processing;Machine learning;Metaheuristic;Optimization;Supervised learning;Transfer learning;Transformer;Unsupervised learning.We propose this Special Issue (SI), ‘Bionic Artificial Neural Networks and Artificial Intelligence’, which focuses on the application of BANNs and artificial intelligence (AI)  in varioThis SI calls for papers that discuss the use of bionic neural networks and AI in areas such as image processing , speech


In this Policy Forum piece, Aditya Narayan and colleagues discuss the challenges and opportunities for tuberculosis preventive treatment in carceral settings. Persons deprived of liberty (PDLs) are disproportionately impacted by tuberculosis, with high incidence rates and often limited access to diagnostics, treatment, and preventive measures.The World Health Organization (WHO) expanded its recommendations for tuberculosis preventive treatment (TPT) to many high-risk populations, but their guidance does not include PDL, and most low- and middle-income countries do not routinely provide TPT in prisons.Recent studies demonstrate high acceptability and completion rates of short-course TPT regimens in jails and prisons; costs of these regimens have been markedly reduced through international agreements, making this an opportune for further expanding their use.We argue that PDL should be a priority group for TPT in national guidelines and discuss implementation considerations and resource needs for TPT programs in carceral facilities.Scaling access to TPT for PDL is important for reducing disease and transmission in this population; it is also critical to advancing an equitable response to tuberculosis.Tuberculosis continues to be a leading cause of illness and death globally, with greater than 10 million people becoming ill with tuberculosis and 1.6 million deaths estimated to occur each year . GloballIn response to the growing evidence reporting the disproportionate burden of tuberculosis faced by PDLs, the World Health Organization (WHO) updated its guidance in 2021 to strongly recommend systematic screening for tuberculosis disease in prisons . Such guRecently published global estimates, leveraging data from more 150 countries, estimated that 125,000 people develop tuberculosis disease in prisons each year, while only 53% are detected and notified . EstimatA key question for programs providing testing and treatment of tuberculosis infection is the timing of screening. In high tuberculosis–burden communities, and among previously incarcerated individuals, the prevalence of tuberculosis infection is often high, supporting an approach of screening at entry or reentry. By contrast, among individuals incarcerated for the first time in communities with low or moderate tuberculosis incidence, prevalence may be low at entry. For example, a study in Brazil found that <10% of individuals had positive tuberculin skin tests at the time of first incarceration but then incurred a >20% annual risk of infection during incarceration . Taken tTesting for tuberculosis infection may be performed by tuberculin skin tests (TSTs) or interferon gamma release assays (IGRAs); the latter are typically more expensive and require phlebotomy and laboratory equipment. Both approaches, however, confer different advantages with respect to specificity and sensitivity, as well as the need for follow-up. In some high tuberculosis–burden settings, including prisons, programs have elected to forego testing for tuberculosis infection and directly offer preventive treatment to all high-risk individuals . The ratWith respect to TPT regimens, 6 to 9 months of daily isoniazid (INH) was historically the most commonly used regimen in carceral settings. The effectiveness of this strategy in these settings has been limited, however, due to low treatment acceptance and completion rates. A systematic review of INH-based regimens delivered in carceral settings found a median completion rate of just 44% due to patient and system-level factors . EquallyThe cost of rifapentine remains one of the major obstacles to adoption and scale-up of short-course TPT regimens in LMICs. UNITAID and its partners brokered a 70% price reduction in 3HP in 2022, with the entire course now available for $14.25 . Such inOne of the principal challenges to effective delivery of TPT in carceral settings is treatment continuity among individuals leaving the setting, due to interinstitutional transfer or release to the community, which historically resulted in low linkage to care and completion rates . Short-cIn most countries, PDL have higher rates of psychiatric and substance use disorders and related comorbidities, including HIV and chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections . These cAlthough treatment of tuberculosis infection has been standard of care in the United States since the early 1960s and the scope of its recommended use was recently broadened by WHO, there continues to be concern about implementing TPT programs among PDL . One serIn many settings, the burden of rifampicin-resistant (RR) or multidrug-resistant (MDR) tuberculosis is higher in prisons than in the surrounding communities, with several studies identifying prisons as important drivers of MDR/RR tuberculosis in the broader population ,35. WhilPreventive treatment remains a crucial but underutilized intervention for reducing the high tuberculosis incidence in carceral settings, particularly in LMICs where the greatest burden occurs. Further, given the dynamic nature of incarceration and high incidence of disease among individuals following release, prevention of tuberculosis in prisons may have outsized benefits for their surrounding communities. Data demonstrating high treatment completion rates for short-course regimens in these settings, together with reductions in the price of rifapentine, make this an opportune moment for expanding access to preventive treatment for PDL. In the absence of international guidance, most countries will not incorporate TPT for PDL into national guidelines and financially prioritize its implementation. Updating and upgrading recommendations for TPT use among PDL, including provision of specific guidance around approaches to testing for infection, screening for disease, and management of medical comorbidities, could provide the foundation for national tuberculosis programs to increase focus on and resources for this population. Given the extraordinarily high incidence of tuberculosis in prisons, such efforts are likely to reduce disparities and advance health equity.


Advancements in biologics and personalized medicine and the implementation of national prescription drug policies have likely prompted payers to implement additional health technology assessment and cost-containment strategies. A payer’s decision to provide coverage for a drug and its associated benefit design draws on information from many sources. However, there is an incomplete understanding of the process employed and the criteria applied in formulary assessments of pharmaceuticals by public and private health plans.To explore the pharmaceutical technology assessment (PTA) process to determine (a) who is involved in the decision making, (b) the timing and process of assessment and decision making, (c) the information and data that are considered, and (d) the outcomes of the assessment.Methods: Using a convenience sample drawn for exploratory purposes, we targeted health plans, pharmacy benefit management (PBM) companies, stand-alone Medicare Part D prescription drug plans, Medicaid agencies, and drug compendia. We used multiple approaches to identify and recruit medical and pharmacy directors responsible for prescription drug benefit design and formulary management. We conducted 1-hour semistructured telephone interviews with pharmacy benefit decision makers between November 2009 and April 2010 to address the PTA process, and they rated the importance of different sources and types of evidence. Qualitative analysis and descriptive statistics were used to explore coverage, preferred choice, and utilization management.Thirty-two respondents representing 26 organizations participated in the interview. On a scale from 1 to 5 (not important to very important), interview respondents most valued published peer-reviewed studies, technology assessments, and internal data on drug utilization as sources of information . Randomized controlled trials (RCTs) and systematic reviews/meta-analyses were the most valued types of evidence ; economic and observational data studies received low ratings . There was substantial variation in the process of evidence review, who and how individuals participated in the process, and outcomes related to formulary tier placement and utilization management.U.S. health plan payers have established processes for PTA and prefer certain sources and types of evidence. Formulary decision makers value a broad range of information, and the specific factors influencing coverage and utilization management decisions vary across organizations and therapeutic areas.


This mixed-methods study describes processes to actively engage underserved, immigrant, and refugee communities in COVID-19 vaccine efforts to cocreate culturally relevant resources and dissemination.A survey on healthcare characteristics and COVID-19 attitudes was deployed between March and November 2021 followed by listening sessions conducted in December 2021. All participants were recruited through the project's Community Advisory Board. The survey, completed by 77 adults, was available in English, Spanish, Burmese, Kizigua, and Karen. Listening sessions were led by trained, multilingual, and multicultural interviewers.Doctors/healthcare providers were rated as the most trusted messengers of COVID-19 information; however, trusted sources varied across communities. Data from 3 listening sessions  expanded survey findings with a focus on trusted sources of COVID-19 communication.This study confirmed the importance of healthcare professionals as trusted messengers for COVID-19 information among underserved communities. Qualitative data highlighted the importance of schools, ethnically based community organizations, and friends/family with health and English literacy skills for immigrant and refugee communities. Findings suggest opportunities for collaboration with specific trusted sources for future public health dissemination efforts. A quantitative survey regarding health and healthcare characteristics, COVID-19 attitudes, and experiences was first deployed, followed by a series of qualitative listening sessions designed to expand upon specific survey findings. The University of California San Diego IRB approved this study. All participants provided their verbal or written consent to share their data.Participants invited to complete the quantitative survey were recruited through the project's Community Advisory Board  agreed to be contacted about a follow-up listening session when they completed the survey and (2) identified as being a member of the Karen, Latina/o, or Somali Bantu community. These 3 community groups were selected to participate in a listening session because they are among the most prevalent immigrant and refugee communities in the local study area and because the study's Community Partner  has established relationships with ethnically based organizations serving these community groups. The sample goal for each listening session was 6 participants per community. A total of 3 listening sessions were conducted in each of the following languages: Karen, Spanish, and Kizigua. Listening sessions were conducted in December 2021 and January 2022 through Zoom or in person. Listening session participants received a $40 gift card.To facilitate culturally appropriate and authentic engagement, 3 community specialists were hired and trained as research staff to support quantitative and qualitative data collection for communities who spoke Burmese, Karen, and Kizigua. Community specialists were nominated by the project's Community Advisory Board for their leadership and engagement skills within their respective communities and their fluency in multiple languages spoken by local immigrant and refugee communities. The community specialists completed the University of Illinois Chicago Human Subjects Research CIRTification Online program along with an initial 1-hour training with University of California San Diego research staff regarding the conduct of in-person and remote listening sessions and data collection procedures. The specific activities that community specialists led included the administration of the quantitative survey, the conduct of listening sessions in specific languages, and the translation/transcription of data into English. These community specialists received a stipend ($400 for survey data collection activities and $400 for listening session data collection activities) for completing these activities.The quantitative survey included 27 items from the CEAL Common Survey (Version 1) developed by National Needs Assessment and Evaluation Working Group. The 27 items assessed domains of (1) COVID-19 preventive behaviors and trusted sources of pandemic information, (2) COVID-19 clinical trial participation, (3) COVID-19 vaccine attitudes and experiences, (4) sociodemographic characteristics, and (5) impacts of COVID-19 on daily activities. Two additional items were developed for this project related to motivations for COVID-19 vaccination, and 3 items related to vaccine status were also developed. In this article, we prioritized examining and reporting on the domain of trusted sources of pandemic information.Where did you get your information about the COVID-19 pandemic?, (2) Which sources did you trust and why?, (3) What did you do with the information you received?, (4) What can be done to ensure you have easy access to trusted information?, and (5) Would you like to share anything else about your experience receiving information related to the COVID-19 pandemic?The listening session guide was iteratively developed in partnership between the academic and community partners after reviewing findings from the survey data and was designed to expand upon the survey findings in service of the larger project goal to inform culturally relevant community resources and dissemination approaches. The final listening session guide focused on further understanding the trusted sources of COVID-19 information in San Diego immigrant and refugee communities and which sources should be used when communicating information about public health issues to improve reach and trust. A semistructured interview was led by 1 facilitator who posed the following questions: (1) Survey data were analyzed descriptively by community group . The listening session qualitative data were analyzed using a rapid analytic approachn=49) relative to the number who completed an online survey. A subset of 14 adults from the survey sample and who expressed interest in participating in a follow-up qualitative data collection participated in a listening session. A total of 77 adults consented to participate and shared their responses on the paper (58%) or online (42%) surveys. The approximate response rate is 65% on the basis of the number of individuals who started an online survey (From the survey data, results revealed that the most trusted sources for accurate information about COVID-19 reported by all community groups were doctors/healthcare providers, the U.S. Coronavirus Task Force, the U.S. Government, and closer friends or family. The least trusted sources were social media and news on the radio, on the TV, online, or in the newspaper. Faith leaders were the most trusted source among Somali Bantu participants and the least trusted source among English-speaking, African American participants.Qualitative data from 3 listening sessions conducted in Karen, Spanish, or Kizigua expanded survey findings by enriching the understanding of the breadth of trusted sources of COVID-19 communication and reasons why specific sources were trusted by unique communities. In addition to healthcare providers, the Karen, Latina/o, and Somali Bantu communities described the important and unique roles of their family, children, and friends in receiving up-to-date information and recommendations for protecting their health. For those with school-aged children, listening session participants reported the usefulness of receiving communication from their children's school about COVID-19 preparedness and response. Karen and Somali Bantu participants uniquely shared the essential role of local, ethnically based community organizations that disseminated COVID-19 health information and resources in their preferred language and easily accessible communication modes. This mixed-methods CEAL study offers important and understudied perspectives from underserved, immigrant, and refugee communities in Southern California about trusted messengers of COVID-19 information. Overall, findings confirmed the key role of healthcare professionals as trusted disseminators of COVID-19 public health information and guidance. An additional expansion of this information with qualitative data highlighted the importance of schools, ethnically based community organizations, and friends or family with health and English literacy skills for immigrant and refugee communities to access, understand, and act upon COVID-19 prevention and response recommendations. These findings are generally consistent with results from recent publications that examined differences in trusted messengers for subgroups of underserved communities.This study has several strengths and limitations. A noteworthy strength is the successful engagement of immigrant and refugee communities living in San Diego, one of the primary resettlement hubs in the U.S., in COVID research and service. To invite participation from these communities, the CEAL team relied on the expertise of Community Advisory Board members and community specialists who identified as members of local immigrant and refugee communities and had strong relationships with ethically based community organizations. Following the principles for community engagement,Balanced with these strengths are limitations in the design and potential generalizability of findings. The primary limitation is the small sample sizes within each of our diverse community groups. The efforts to engage these underserved, immigrant, and refugee communities in culturally competent and meaningful ways necessitated dedicated financial, personnel, and time resources that precluded a larger sample size for the survey or listening sessions. For example, the Somali Bantu community engaged in our study primarily uses oral language to communicate; therefore, our community specialist needed to complete the survey in an interview style for all participants. Because of the relatively small sample size for the quantitative and qualitative data and because we did not have the opportunity to conduct a listening session with English-speaking participants, caution is recommended in generalizing findings to other underserved, immigrant, and refugee communities and those outside of Southern California.Another limitation is that we were not able to report on a larger number of demographic characteristics. Although we included preferred language, age, gender, employment status, education, and household size, we aimed to minimize the response burden in our survey and listening sessions. As such, we identified, with our community partner, the minimal number of important demographic data to collect to maximize our opportunity to ask more substantive questions about trusted sources of health information.Taken together, our findings suggest several opportunities to actively engage specific trusted sources in future public health dissemination efforts. Healthcare providers are clearly central to trusted health dissemination for the immigrant and refugee communities in our study. To expand healthcare provider influence, it is recommended that health systems develop and nurture strategic partnerships with local elementary and high schools, ethnically based organizations, and community-based organizations for public health preparedness and response initiatives. Community health workers may be particularly helpful to reinforce and clarify health guidance initially relayed by healthcare professionals. Associated resources to support these partnerships are essential, including access to up-to-date public health surveillance, best practices, community resources, and staff who can translate this public health guidance into culturally and linguistically relevant materials.Understanding the priorities and preferences of underserved communities, a priori, is especially critical to address the health equity gap that exists for these groups. Specifically, providing information about critical public health concerns such as the COVID-19 pandemic using messengers who are most trusted by communities of color and immigrant communities has the potential to increase their acceptance and uptake of this information and leads to better public health outcomes.


Editorial on the Research TopicBronchopulmonary dysplasia: latest advancesBronchopulmonary dysplasia (BPD) is a complex and devastating condition related to prematurity. BPD is the most common chronic condition of infancy and is associated with significant morbidity and mortality and high financial burden on healthcare systems, families, and communities . InfantsHwang et al. describes the importance of using new evolving definition of BPD and its impact on predicting long term outcome and development of pulmonary hypertension. This retrospective study enrolled preterm infants born at <32-week GA B/W 2014–2018 at Guri Hospital, Korea. This is the first study that compares the different criteria of BPD regarding pulmonary hypertension in preterm infants and showed an association between recently described criteria for defining BPD as NICHD 2018 & NICHD 2019 criteria with severity of BPD and later outcome including pulmonary hypertension in preterm infants. This is an important concept to recognize as BPD is now described as a form of pulmonary vascular disease  are a diverse array of nano-sized membranous structures that are becoming recognized as intercellular and inter-organ communication mediators. Wang et al. describe that a combining clinical data, molecular biomarkers, and echocardiogram measurements can be valuable in predicting BPD. The tricuspid regurgitation jet, N-terminal-pro-B-brain natriuretic peptide (NT-pro BNP), ventilator associated pneumonia, days of FiO2 ≧40%, red blood cell volume, and proportion of infants who receive total enteral milk  ≧24 days after birth are the most practical factors for predicting the risk of BPD. Gaertner et al. use electrical impendence tomography (EIT) to measure regional ventilation distribution and overall lung aeration. They describe that EIT markers of aeration at 30 min after birth accurately predict the need of oxygen supplement at 28 days of age but not the need of intubation or BPD.Various biomarkers have been studied for early prediction of BPD , 16–18. The Research Topic “Bronchopulmonary dysplasia: Latest Advances” goal was to incorporate the most recent advances in basic science research, translational research, clinical data, and preventive measures towards the better understanding and management of patients with BPD. Even though there have been promising advancements in understanding and management of the BPD, this condition remains complex and without any definitive cure. Continued research and collaboration among healthcare professionals and researchers are crucial to further improve the understanding, prevention, and treatment of bronchopulmonary dysplasia.


Acquired brain injury (ABI) is a leading cause of ambulation deficits in the United States every year. ABI  results in ambulation deficits with residual gait and balance deviations persisting even after 1 year. Current research is focused on evaluating the effect of robotic exoskeleton devices (RD) for overground gait and balance training. In order to understand the device effectiveness on neuroplasticity, it is important to understand RD effectiveness in the context of both downstream  and upstream  metrics. The review identifies gaps in research areas and suggests recommendations for future research. We carefully delineate between the preliminary studies and randomized clinical trials in the interpretation of existing evidence. We present a comprehensive review of the clinical and pre-clinical research that evaluated therapeutic effects of RDs using various domains, diagnosis and stage of recovery. Acquired brain injury (ABI) is a leading cause of ambulation deficits affecting people in the United States every year  have mobility deficits; despite rehabilitation, over half of them present with functional ambulation deficits even after 1 year, limiting their community ambulation, independence, and activities of daily living (ADL)  for over-ground gait training in individuals with ABI  How does early RD therapy change the recovery curve?; (b) Who should use multi-joint RD vs. single joint RD?; (c) Does a person with low deficits benefit from multi-joint or single joint RD therapy during the acute stages of recovery?; (d) Would it be beneficial to use a single joint robot over multi-joint robot to target a deficit or reduce a compensatory mechanism?; and (e) How does providing assistance/resistance change the way we learn? In order to answer these questions, we need to understand: (1) the effect of RDs on functional recovery, as well as biomechanical, physiological, and cortical mechanisms, and (2) the effect of mechanical and software (control) characteristics of RDs on time since injury, as well as on the various deficits. To date, most published studies have analyzed functional recovery, but there is limited research on the effect of RD over-ground gait training on biomechanical, physiological, and cortical mechanisms in children and adults with ABI. Biomechanical and physiological outcomes quantitatively reflect the underlying impairment in joint mechanisms, inter-limb coordination or balance mechanisms, and their recovery. Understanding the changes in gait and balance mechanisms will help us understand the reasons for the observed functional changes and will help us to better understand recovery. Research on structural and functional changes in the cortical and subcortical levels will help us understand the underlying mechanisms of neuroplasticity. Therefore, comprehensive efficacy studies across parameters will help us understand the effects of RDs and how to improve rehabilitation strategies. Most of the available literature reviews on exoskeleton research have focused on design and development activities in terms of electromechanical design or software controllers to provide optimal and efficient device  with adults and children post acquired brain injury as an intervention for overground gait rehabilitation. Articles were included if they reported functional outcomes , clinical outcomes , biomechanical outcomes , physiological  and neurological .Lower extremity RDs are herein operationally defined as a wearable robotic device that actuates at least one of the three lower extremity joints  during overground gait either unilaterally or bilaterally in one or more movement planes'. Articles were excluded if they were on neurological conditions other than ABI; articles on industrial and military applications; reported only technology development; reported only orthotic effect of RD; reported only feasibility of usage; included only healthy participants; utilized a treadmill-based device; or if only an abstract was available. Titles and abstracts were screened for relevance by two authors according to the inclusion and exclusion criteria above. In the event of conflict, a third author was consulted for resolution. Full-texts were then screened, and reference lists of all selected articles were searched for additional studies. Included articles were then examined to extract data regarding study design, RD, participant characteristics, intervention, training period, outcome measures, adverse effects, and results. We examined the changes in functional, clinical, biomechanical, physiological, and neurological outcomes published in the qualifying literature.A total of 6,908 articles were retrieved using the search criteria. After removing the articles based on the inclusion and exclusion criteria , 57 artiThe review results have been divided based on the diagnosis . The review is further divided based on outcomes metrics . The soft RD's were reviewed separately from rigid exoskeletons. RD sessions across studies were quantified for the cerebral palsy (CP) population to demonstrate the dosing effect, and is shown in Utilization of RD (HAL) gait training in children and adults with CP was evaluated. The preliminary analysis demonstrated improvements in functional and biomechanical outcomes such as gait speed, step length, and cadence in children and adults with no change in GMFM  to restore ambulation. An improvement in biomechanical metrics including step length  RD showed that participants improved their walking speed and stride length with a corresponding increase in soleus (SO) and VL muscle activity, where SO activity was 39% similar to unimpaired individuals after RD training  training walked twice the distance compared to the standard of care/conventional gait training (SOC/CGT) group during their inpatient physical rehabilitation, though both groups received the same duration of training (time spent in inpatient rehabilitation training session) and similar dosing  has shown significant improvements in functional outcomes  gait training increased the walking speed and the distance walked during 2-minute walk test (2MWT), cadence, and stride length in subacute stroke  training , and BBS compared to SOC in chronic stroke patients  gait training in the three chronic stroke patients showed that the participants performed a more symmetric gait in RD training and there were slight improvements in 6MWT, TUG, and FMA-LE in all the participants after training , with a statistically significant change in walking time, standing time, and number of steps with the progression of gait training and MAS in sub-acute stroke patients  and SOC] showed a small and non-significant tendency to reduce the amount of uninvolved limb loading after therapy, which may indicate gradual improvement in limb loading symmetry  training in individuals with stroke resulted in improvements in gait speed, spatial symmetry, and step length  using EMG in acute stroke patients  using the manual muscle strength test of the tibialis anterior muscle in acute and subacute stroke patients were evaluated. No significant difference was observed between control and RD groups but both groups improved after training  training on EMG and functional gait in individuals with subacute stroke  compared to without RD  was effective in improving biomechanical and physiological outcomes in stroke patients  is an actuated RD that provided assistance for extension and flexion. Preliminary data showed improved clinical (BBS and LE-FMA) outcomes  training, in hemiplegic chronic stroke patients, resulted in greater improvement with medium to large effect size in 10MW, RMI, TUG, CSE and sensory-motor integration (SMI) using Transcranial Magnetic Stimulation (TMS), frontoparietal effective connectivity (FPEC) using EEG, than SOC  training in people with chronic stroke. Study findings showed a strong relation between lesion lateralization, dominance and connectivity modulations  using TMS after intervention with the RD compared to the control group  showed that individuals with stroke increased their walking speed with and without RD after 5 days of RD training  significantly improved gait speed and BBS. In addition, improvements were also observed in FIM and BI  was used to assess the changes in gait cortical control after using RD (Regent) for 10 sessions in individuals with chronic stroke . The selection of an RD would be dependent on the amount of support and control the user requires from the robot. A non-ambulatory participant with ABI would require maximal assistance with rigid supports to walk and balance. On the other hand, an ambulatory participant may require assistance to perform accurate symmetrical gait with limited supports (soft RD), allowing for multidimensional walking and balance. Further research is required to precisely determine the optimal use of rigid and soft RDs at different stages of recovery to allow for treatment progression.A healthy walking control mechanism involves supporting the body weight and providing stability in the forward and lateral directions during forward progression Winter, . In eachThe last decade has seen an enormous growth in the development of RDs for neuro-rehabilitation , heart rate, and measures of oxygen consumption. In people with sub-acute stroke, the perceived exertion was above fairly light exertion based on self-reported measures  was better after RD training than conventional gait training in the preliminary analysis  capabilities of each RD are widespread and still evolving with the technology. RDs can be classified as deficit-targeted or function-targeted devices. Deficit-targeted devices focus on a single joint, while function-targeted devices target gait and balance mechanisms. Both kinds of RDs have shown improvement in ambulation, but the comparative effectiveness of such devices needs to be more comprehensively evaluated. It is unclear whether it is more beneficial to use single joint targeted devices or to target gait and balance function, both overall and/or under which circumstances. In addition, the control strategies vary between RDs. Thus, the training could be altered to provide varying levels of assistance (complete to no assistance) or resistance or trajectory guidance. The effect of these varying control strategies on the different stages of recovery also need to be analyzed. In addition, more comprehensive analysis of the length of training, the amount of training , intensity, the effect of assistance, and how and when to reduce assistance and how this affects recovery is needed in order to guide the future trajectory of ABI rehabilitation. In order to answer such questions, comprehensive evaluations of various devices need to be compiled, and their effects on downstream and upstream metrics need to be evaluated.Research has not addressed the effect of age, time since injury, or patient level of injury on recovery after using RDs. Since recovery plateaus during the chronic stages of ABI, it is important to understand the effects of time since injury. Neurological recovery might be influenced by age, especially with younger individuals having different sequelae influenced by their development; resulting in different patterns of recovery. The severity and location of injury  might influence the trajectory of recovery. Injury characteristics might influence the functional connectivity related to gait and balance mechanisms, resulting in varying biomechanical and physiological deficits and recovery. All these factors warrant research in their own right and are a necessary prerequisite for a more comprehensive understanding of post-ABI recovery.RD research is still evolving. We have provided foundation of the preliminary evidence for over ground robotic devices in order to build more rigorously controlled research study as well as RCTs. The review also lays out the systematic framework to evaluate these devices based on diagnosis, domain  and based on stage of recovery. We need to first evaluate the RDs for each pathology in each domain separately throughout the different stages of recovery. This will help us determine responders and non-responders in various diseases, domain, and recovery phases. This will help us narrow the devices for translation into clinical practice.SP, CB, and EL assisted with sorting the manuscript based on the inclusion/exclusion criteria. KK validated the selected articles based on the inclusion/exclusion criteria and drafted the manuscript. KN and SS reviewed the manuscript. All authors contributed to the article and approved the submitted version.