BACKGROUND: While evidence suggests Medicaid expansion can reduce overdose, some expressed concern expansion fueled the US opioid overdose crisis by increasing access to low-cost prescription opioids diverted for non-prescribed use. Ecologic studies find a protective relationship or no relationship between expansion and area-level opioid prescribing. Little is known about the relationship between expansion and opioid use among people experiencing poverty who inject drugs (PWID), a population at heightened risk of overdose likely to benefit from Medicaid expansion. We examined whether expansion was associated with prescription opioid and benzodiazepine misuse among PWID experiencing poverty and whether associations varied by race/ethnicity and HIV status. METHODS: This serial cross-sectional observational study used generalized difference-in-differences models to analyze data (2012, 2015, 2018) from 19,728 PWID aged 18-64 with income ≤138 % of federal poverty line from 13 states in the CDC's National HIV Behavioral Surveillance. Outcomes included past 12-month non-injection and injection prescription opioid misuse and benzodiazepine misuse. RESULTS: The sample (N = 19,728) was 40 % non-Latinx Black persons and 22 % Latinx persons. Past 12-month non-injection prescription opioid misuse was 33 %, injection prescription opioid misuse was 16 %, and benzodiazepine use was 40 %. Across all models, there was no association between expansion and prescription opioid misuse (confidence intervals included 0) or prescription benzodiazepine misuse (confidence intervals included 0). Associations did not vary by race/ethnicity or HIV status. CONCLUSIONS: We found no association between Medicaid expansion and opioid or benzodiazepine misuse overall, by race/ethnicity, or HIV status among a large, geographically diverse sample of PWID. These findings provide empirical evidence that expansion is not associated with prescription opioid or benzodiazepine misuse in a population likely to benefit from expansion.

BACKGROUND: People who inject drugs (PWID) are especially vulnerable to harms from opioid use disorder (OUD). Medications for OUD (MOUD) effectively reduce overdose and infectious disease transmission risks. OBJECTIVE: We investigate whether state Medicaid coverage for methadone and buprenorphine is related to past-year MOUD use among PWID using cross-sectional, multilevel analyses with individual-level data on PWID from the Centers for Disease Control and Prevention's 2018 National HIV Behavioral Surveillance. The sample included 8,142 PWID aged 18-64 who reported daily opioid use from 22 U.S. metropolitan areas. Our outcome was any self-reported MOUD use in the past 12 months. Exposures were state Medicaid coverage and prior authorization requirements for methadone and buprenorphine. We interacted these exposures with PWID race/ethnicity, insurance status, and spatial access to treatment and harm reduction resources. RESULTS: Compared with PWID in states without Medicaid methadone coverage, odds of past-year MOUD use were 73% (p<0.05) higher among PWID in states with methadone coverage requiring prior authorization and 80% (p<0.05) higher among PWID in states with coverage without prior authorization. Insured PWID were twice as likely to report MOUD use than uninsured PWID, with no statistically significant differences between Medicaid versus other insurance. Medicaid prior authorization requirements for buprenorphine were not significantly associated with MOUD use. Non-Hispanic Black PWID were significantly less likely to use MOUD than non-Hispanic White and Hispanic PWID. CONCLUSIONS: State Medicaid methadone coverage was strongly associated with higher odds that PWID utilized MOUD, suggesting that expanding methadone insurance coverage could improve MOUD treatment in a vulnerable population.

PURPOSE: To explore whether school poverty level and funding modified the effectiveness of an evidence-based Comprehensive School Physical Activity Program called Health Empowers You! implemented in elementary schools in Georgia. DESIGN: Secondary data analysis of a multi-level, cluster-randomized controlled trial. SETTING: 40 elementary schools in Georgia in 2018-2019. SUBJECTS: 4(th) grade students in Georgia. MEASURES: Intervention schools implemented the Health Empowers You! program to increase school-day physical activity. The outcome was average daily moderate-to-vigorous physical activity, school free-reduced price lunch (FRPL) percentage and per pupil expenditures were effect modifiers. ANALYSIS: Separate linear mixed regression models estimated the effect of the intervention on average daily moderate-to-vigorous physical activity, with interaction terms between intervention status and (1) school FRPL percentage or (2) per pupil expenditures. RESULTS: The effect of the intervention was significantly higher in schools with higher FRPL percentage (intervention*school % FRPL β (95% CI): .06 (.01, .12)), and was modestly, but not statistically significantly, higher in schools with lower per pupil expenditures. CONCLUSION: Findings support the use of the Health Empowers You! intervention, which was effective in lower income schools, and may potentially reduce disparities in students' physical activity levels.

BACKGROUND AND AIMS: Impoverished people who inject drugs (PWID) are at the epicenter of US drug-related epidemics. Medicaid expansion is designed to reduce cost-related barriers to care by expanding Medicaid coverage to all US adults living at or below 138% of the federal poverty line. This study aimed to measure whether Medicaid expansion is (1) positively associated with the probability that participants are currently insured; (2) inversely related to the probability of reporting unmet need for medical care due to cost in the past year; and (3) positively associated with the probability that they report receiving substance use disorder (SUD) treatment in the past year, among PWID subsisting at ≤ 138% of the federal poverty line. DESIGN: A two-way fixed-effects model was used to analyze serial cross-sectional observational data. SETTING: Seventeen metro areas in 13 US states took part in the study. PARTICIPANTS: Participants were PWID who took part in any of the three waves (2012, 2015, 2018) of data gathered in the Center for Disease Control and Prevention's National HIV Behavioral Surveillance (NHBS), were aged ≤ 64 years and had incomes ≤ 138% of the federal poverty line. For SUD treatment analyses, the sample was further limited to PWID who used drugs daily, a proxy for SUD. MEASUREMENTS: State-level Medicaid expansion was measured using Kaiser Family Foundation data. Individual-level self-report measures were drawn from the NHBS surveys (e.g. health insurance coverage, unmet need for medical care because of its cost, SUD treatment program participation). FINDINGS: The sample for the insurance and unmet need analyses consisted of 19 946 impoverished PWID across 13 US states and 3 years. Approximately two-thirds were unhoused in the past year; 41.6% reported annual household incomes < $5000. In multivariable models, expansion was associated with a 19.0 [95% confidence interval (CI) = 9.0, 30.0] percentage-point increase in the probability of insurance coverage, and a 9.0 (95% CI = -15.0, -0.2) percentage-point reduction in the probability of unmet need. Expansion was unrelated to SUD treatment among PWID who used daily (n = 17 584). CONCLUSIONS: US Medicaid expansion may curb drug-related epidemics among impoverished people who inject drugs by increasing health insurance coverage and reducing unmet need for care. Persisting non-financial barriers may undermine expansion's impact upon substance use disorder treatment in this sample.

Background: Alternative tobacco product (ATP) use as well as co-use of various tobacco products has increased in recent years, particularly among young adults. However, little is known about the differential role of motives for ATP or polytobacco use. Methods: We examined (1) motives for tobacco use in relation to polytobacco versus cigarette only use and (2) motives for tobacco use in relation to levels of tobacco use across products. We analyzed data from past 30-day tobacco users at Wave 2 (Spring 2015) of a six-wave longitudinal study of 3418 students aged 18-25 years from seven U.S. colleges/universities. Variables included sociodemographics, tobacco use (cigarettes, little cigars/cigarillos [LCCs], smokeless tobacco [SLT], hookah, and e-cigarettes), and tobacco use motives (social, self-enhancement, boredom relief, and affect regulation). Results: Multivariate analyses found that boredom relief motives were associated with polytobacco use versus cigarette only use (p = .007). Higher consumption levels demonstrated the following associations: cigarettes-positively with boredom relief (p = .025) and affect regulation motives (p < .001); LCCs-positively with affect regulation motives (p = .035); SLT-negatively with social (p = .003) and positively with self-enhancement (p = .017) and boredom relief motives (p = .007); and hookah-positively with social (p = .002) and boredom relief motives (p = .033) and negatively with self-enhancement (p = .004) and affect regulation motives (p = .001). Conclusions: Distinct motives for use were associated with polytobacco use among smokers. Moreover, higher levels of use among single product users also demonstrated distinct associations across use motives. These data should inform targeted cessation interventions addressing motives for use in ATP and polytobacco users. Implications: Interventionists, public health practitioners, and health care providers must address the increasing issue of ATP and polytobacco use and tailor interventions to reduce ATP and polytobacco use in light of the distinct motives for use.

OBJECTIVE: To investigate the potential dietary impact of the opening of new retailers of healthy foods. DESIGN: Systematic review of the peer-reviewed research literature. SETTING: References published before November 2015 were retrieved from MEDLINE, EMBASE and Web of Science databases using keyword searches. SUBJECTS: The outcome of the review was change in fruit and vegetable consumption among adults. RESULTS: Of 3514 references retrieved, ninety-two articles were reviewed in full text, and twenty-three articles representing fifteen studies were included. Studies used post-test only (n 4), repeated cross-sectional (n 4) and repeated measures designs (n 7) to evaluate the dietary impact of supermarket (n 7), farmers' market (n 4), produce stand (n 2) or mobile market (n 2) openings. Evidence of increased fruit and vegetable consumption was most consistent among adults who began shopping at the new retailer. Three of four repeated measures studies found modest, albeit not always statistically significant, increases in fruit and vegetable consumption (range 0.23-0.54 servings/d) at 6-12 months after baseline. Dietary change among residents of the broader community where the new retailer opened was less consistent. CONCLUSIONS: The methodological quality of studies, including research designs, sampling methods, follow-up intervals and outcome measures, ranged widely. Future research should align methodologically with previous work to facilitate meta-analytic synthesis of results. Opening a new retailer may result in modest short-term increases in fruit and vegetable consumption among adults who choose to shop there, but the potential longer-term dietary impact on customers and its impact on the broader community remain unclear.

Special events such as health fairs, cultural festivals and charity runs are commonly employed in the community to increase cancer screening; however, little is known about their effectiveness. The purpose of this study is to assess the activities, screening outcomes, barriers and recommendations of special events to increase breast, cervical and colorectal cancer screening. In-depth interviews were conducted nationally with 51 coordinators of events in June to September 2012. Health fairs and screening days were the most common events conducted, primarily for breast cancer education. Goals were to increase awareness of cancer screening and reach special populations. Evidence-based Community Guide strategies to increase cancer screening employed were: small media, reducing structural barriers, one-on-one education or group education. For each event that provided screening on-site or through referral, a mean of 35 breast, 28 cervical and 19 colorectal cancer screenings were reported. Coordinators made recommendations for further evaluation of special events, and most plan to conduct another special event. These data are novel and provide baseline documentation of activities and recommendations for a commonly used community-based cancer screening intervention that lacks evidence of effectiveness. Additional research to better understand the use of special events for increasing cancer screening is warranted.

BACKGROUND: Special events are common community-based strategies for health promotion. This paper presents findings from a systematic literature review on the impact of special events to promote breast, cervical or colorectal cancer education and screening. METHODS: Articles in English that focused on special events involving breast, cervical, and/or colorectal cancer conducted in the U.S. and published between January 1990 and December 2011 were identified from seven databases: Ovid, Web of Science, CINAHL, PsycINFO, Sociological Abstract, Cochrane Libraries, and EconLit. Study inclusion and data extraction were independently validated by two researchers. RESULTS: Of the 20 articles selected for screening out of 1,409, ten articles on special events reported outcome data. Five types of special events were found: health fairs, parties, cultural events, special days, and plays. Many focused on breast cancer only, or in combination with other cancers. Reach ranged from 50-1732 participants. All special events used at least one evidence-based strategy suggested by the Community Guide to Preventive Services, such as small media, one-on-one education, and reducing structural barriers. For cancer screening as an outcome of the events, mammography screening rates ranged from 4.8% to 88%, Pap testing was 3.9%, and clinical breast exams ranged from 9.1% to 100%. For colorectal screening, FOBT ranged from 29.4% to 76%, and sigmoidoscopy was 100% at one event. Outcome measures included intentions to get screened, scheduled appointments, uptake of clinical exams, and participation in cancer screening. CONCLUSIONS: Special events found in the review varied and used evidence-based strategies. Screening data suggest that some special events can lead to increases in cancer screening, especially if they provide onsite screening services. However, there is insufficient evidence to demonstrate that special events are effective in increasing cancer screening. The heterogeneity of populations served, event activities, outcome variables assessed, and the reliance on self-report to measure screening limit conclusions. This study highlights the need for further research to determine the effectiveness of special events to increase cancer screening.