INTRODUCTION: An error grid compares measured versus reference glucose concentrations to assign clinical risk values to observed errors. Widely used error grids for blood glucose monitors (BGMs) have limited value because they do not also reflect clinical accuracy of continuous glucose monitors (CGMs). METHODS: Diabetes Technology Society (DTS) convened 89 international experts in glucose monitoring to (1) smooth the borders of the Surveillance Error Grid (SEG) zones and create a user-friendly tool-the DTS Error Grid; (2) define five risk zones of clinical point accuracy (A-E) to be identical for BGMs and CGMs; (3) determine a relationship between DTS Error Grid percent in Zone A and mean absolute relative difference (MARD) from analyzing 22 BGM and nine CGM accuracy studies; and (4) create trend risk categories (1-5) for CGM trend accuracy. RESULTS: The DTS Error Grid for point accuracy contains five risk zones (A-E) with straight-line borders that can be applied to both BGM and CGM accuracy data. In a data set combining point accuracy data from 18 BGMs, 2.6% of total data pairs equally moved from Zones A to B and vice versa (SEG compared with DTS Error Grid). For every 1% increase in percent data in Zone A, the MARD decreased by approximately 0.33%. We also created a DTS Trend Accuracy Matrix with five trend risk categories (1-5) for CGM-reported trend indicators compared with reference trends calculated from reference glucose. CONCLUSION: The DTS Error Grid combines contemporary clinician input regarding clinical point accuracy for BGMs and CGMs. The DTS Trend Accuracy Matrix assesses accuracy of CGM trend indicators.

This qualitative study takes place in an urban community that has high rates of HIV among Black youth. Six faith leaders were interviewed (five identified as Christian and one identified as Muslim). Three major themes arose from the interviews, including (1) the role of sex and HIV; (2) hindrances to sexual health conversations with youth; and (3) considering religious principles to prevent HIV in Black youth. Findings from this study can be used to inform an HIV-prevention curriculum for Black youth who identify strongly with their religion and spirituality and live in high HIV-risk communities. © 2024 by the authors.

OBJECTIVES: Higher prevalence of several chronic diseases occurs in men in the United States, including diabetes and prediabetes. Of the 34 million adults with diabetes and 88 million with prediabetes there is a higher prevalence of both conditions in men compared to women. Black, Hispanic, and American Indian men have some of the highest rates of diabetes and diabetes complications. Adopting a healthy lifestyle including healthy eating and physical activity, is important in preventing type 2 diabetes and diabetes complications. DESIGN: This study included six focus groups that explored facilitators and barriers to adopting a healthy lifestyle in Black, Hispanic, and American Indian men with diabetes or at risk for type 2 diabetes. Thematic analysis was used to identify facilitators and barriers to adopting a healthy lifestyle. RESULTS: Participants included males 18 years of age and older identifying as Black, Hispanic, or American Indian and diagnosed with prediabetes, diabetes, hypertension, or otherwise at risk for type 2 diabetes. Thirty-seven men participated, 19 diagnosed with diabetes and 18 at risk for type 2 diabetes. Fourteen Black, 14 Hispanic, and 9 American Indian men participated. The themes of facilitators to a healthy lifestyle included: family and the social network; psychosocial factors; health status, health priorities and beliefs about aging; knowledge about health and healthy behavior; and healthy community resources. Themes of barriers to a healthy lifestyle also included: mistrust of the health care system, cost, and low socioeconomic status. CONCLUSIONS: This study underscores the complexity of factors involved in adopting a healthy lifestyle for some racial and ethnic minority men with diabetes or at risk for type 2 diabetes.

INTRODUCTION: Reaching, enrolling, and retaining participants in lengthy lifestyle change interventions for weight loss is a major challenge. The objective of our meta-analysis was to investigate whether lifestyle interventions addressing nutrition and physical activity lasting 6 months or less are effective for weight loss. METHODS: We searched for peer-reviewed studies on lifestyle change interventions of 6 months or less published from 2012 through 2023. Studies were screened based on inclusion criteria, including randomized controlled trials (RCTs) for adults with overweight or obesity. We used a random-effects model to pool the mean difference in weight loss between intervention and control groups. We also performed subgroup analyses by intervention length and control type. RESULTS: Fourteen RCTs were identified and included in our review. Half had interventions lasting less than 13 weeks, and half lasted from 13 to 26 weeks. Seven were delivered remotely, 4 were delivered in person, and 3 used combined methods. The pooled mean difference in weight change was -2.59 kg (95% CI, -3.47 to -1.72). The pooled mean difference measured at the end of the intervention was -2.70 kg (95% CI, -3.69 to -1.71) among interventions lasting less than 13 weeks and -2.40 kg (95% CI, -4.44 to -0.37) among interventions of 13 to 26 weeks. CONCLUSION: Short-term multicomponent interventions involving physical activity and nutrition can achieve weight loss for adults with overweight or obesity. Offering short-term interventions as alternatives to long-term ones may reach people who otherwise would be unwilling or unable to enroll in or complete longer programs.

Diabetes is a significant population health threat. Evidence-based interventions, such as the Centers for Disease Control and Prevention's National Diabetes Prevention Program and diabetes self-management education and support programs, can help prevent, delay, or manage the disease. However, participation is suboptimal, especially among populations who are at an increased risk of developing diabetes. Evaluations of programs reaching populations who are medically underserved or people with lower incomes can help elucidate how best to tailor evidence-based interventions, but it is also important for evaluations to account for cultural and contextual factors. Culturally responsive evaluation (CRE) is a framework for centering an evaluation in the culture of the programs being evaluated. We integrated CRE with implementation and outcome constructs from the Adapted Consolidated Framework for Implementation Research (CFIR) to ensure that the evaluation produced useful evidence for putting evidence-based diabetes interventions to use in real-world settings, reaching populations who are at an increased risk of developing diabetes. The paper provides an overview of how we integrated CRE and CFIR approaches to conduct mixed-methods evaluations of evidence-based diabetes interventions.

People experiencing homelessness are at risk for coronavirus disease 2019 (COVID-19) and may experience barriers to hand hygiene, a primary recommendation for COVID-19 prevention. We conducted in-depth interviews with 51 people experiencing sheltered and unsheltered homelessness in Atlanta, Georgia during May 2020 to August 2020 to (1) describe challenges and opportunities related to hand hygiene and (2) assess hand hygiene communication preferences. The primary hand hygiene barrier reported was limited access to facilities and supplies, which has disproportionately impacted people experiencing unsheltered homelessness. This lack of access has reportedly been exacerbated during COVID-19 by the closure of public facilities and businesses. Increased access to housing and employment were identified as long-term solutions to improving hand hygiene. Overall, participants expressed a preference for access to facilities and supplies over hand hygiene communication materials.

INTRODUCTION: Diabetes imposes large health and financial burdens on Medicare beneficiaries. Type 2 diabetes can be prevented or delayed through lifestyle modification programs. In 2018, Medicare began to offer the Medicare Diabetes Prevention Program (MDPP), a lifestyle intervention, to eligible beneficiaries nationwide. The number of MDPP-eligible beneficiaries is not known, but this information is essential in efforts to expand the program and increase enrollment. This study aimed to estimate the number and spatial variation of MDPP-eligible Part B beneficiaries at the county level and by urban-rural classification. METHODS: Data from 2011-2016 National Health and Nutrition Examination Surveys and a survey-weighted logistic regression model were used to estimate proportions of prediabetes in the United States by sex, age, and race/ethnicity based on the MDPP eligibility criteria. The results from the predictive model were applied to 2015 Medicare Part B beneficiaries to estimate the number of MDPP-eligible beneficiaries. The National Center for Health Statistics' Urban-Rural Classification Scheme for Counties from 2013 were used to define urban and rural categories. RESULTS: An estimated 5.2 million (95% CI = 3.5-7.0 million) Part B beneficiaries were eligible for the MDPP. By state, estimates ranged from 13,000 (95% CI = 8,500-18,000) in Alaska to 469,000 (95% CI = 296,000-641,000) in California. There were 2,149 counties with ≤1,000 eligible beneficiaries and 11 with >25,000. Consistent with demographic patterns, urban counties had more eligible beneficiaries than rural counties. CONCLUSIONS: These estimates could be used to plan locations for new MDPPs and reach eligible Part B beneficiaries for enrollment.

African American men who have sex with men (MSM) have high rates of HIV, but interventions are needed to address their low rates of engagement in the HIV care continuum. To identify modifiable factors potentially affecting such engagement, we conducted qualitative interviews guided by the Theory of Planned Behavior with 27 African American MSM who had participated in an HIV risk-reduction intervention trial. Qualitative analyses resulted in four overarching themes: stigma, concerns with health care providers (HCPs), social support, and logistical issues. Facilitators of care continuum engagement included reassurance about health, feeling and looking better, receiving treatment, avoiding infecting others, good relations with HCP, and social support. Barriers included HIV stigma, concerns about confidentiality, negative perceptions of HCP, convenience and availability of testing/treatment facilities, cost, and lack of social support. Efforts to improve African American MSM HIV care continuum engagement should focus on individual and health care system changes.

African American men are disproportionately affected by, not only HIV/AIDS, but also chronic non-communicable diseases. Despite the known benefits of physical activity for reducing chronic non-communicable diseases, scant research has identified factors that may influence physical activity in this population. A growing literature centers on the syndemic theory, the notion that multiple adverse conditions interact synergistically, contributing to excess morbidity. This secondary data analysis examined two primary questions: whether syndemic conditions prospectively predicted physical activity, and whether, consistent with the syndemic theory, syndemic conditions interacted to predict physical activity. Participants were 595 African American men who have sex with men (MSM), a population underrepresented in health research, enrolled in a health-promotion intervention trial from 2008-2011. We used generalized-estimating-equations models to test the associations of syndemic conditions and resilience factors measured pre-intervention to self-reported physical activity 6 and 12 months post-intervention. As hypothesized, reporting more syndemic conditions pre-intervention predicted reporting less physical activity 6 and 12 months post-intervention, adjusting for the intervention. However, contrary to the syndemic theory, we did not find evidence for the interaction effects of syndemic conditions in predicting physical activity. Receiving high school education and having greater social network diversity predicted more physical activity whereas older age predicted less physical activity. To our knowledge, this is the first study to examine the syndemic theory in relation to physical activity. Although reporting a greater number of syndemic conditions was related to reduced physical activity, there was no evidence for synergy among syndemic conditions.

Although progress has been made toward the objective of increased employment for people with disabilities, the 17.2% employment rate of people with disabilities stands in distressing contrast to the 65% rate of those without disabilities. This article summarizes the results of a comparative survey of representative academic literature and industry publications related to employer policies and practices that can affect workforce participation of individuals with disabilities. Emergent themes include variance in employer perspectives on hiring of individuals with disabilities, impact of perceived versus actual cost as a hiring barrier, and the perceived mismatch of education and/or skills to job qualifications among applicants with disabilities. These themes represent key areas to probe in subsequent research. The research objective is to identify focal points in the industry literature, representative of employer and industry (demand side) points of view that differ from those generally portrayed in the academic literature (more generally, supply side). Findings from a thematic analysis of industry publications can provide (1) evidenced based background to assist in crafting targeted policy to address employer awareness, (2) informed development of industry guidance on topics that may assist employers to achieve a more inclusive workplace, and (3) insights applicable to addressing barriers to broadening participation by technical, scientific, and engineering trained individuals with disabilities.

Chronic diseases, including heart disease, stroke, cancer, diabetes, and obesity, are the leading causes of death in the United States and account for most of the nation’s health care costs (1). Heart disease is the leading cause of death among men and women in the United States, accounting for 1 of every 4 deaths (1). Approximately 140,000 Americans die each year from stroke, and it is a leading cause of long-term disability (2,3). It is estimated that more than 9% of the US population has diabetes, which is the leading cause of kidney failure, lower-limb amputations other than those caused by injury, and new cases of blindness among adults (4). Additionally, more than one-third of US adults have obesity, which is associated with several chronic conditions (5,6).

Diabetes, a serious and costly condition, is characterized by illness and death from long-term microvascular and macrovascular complications (1). Additionally, numerous and well-known comorbidities can accompany diabetes, including cardiovascular disease, retinopathy, amputations, and nephropathy (1). Often these complications and comorbidities interfere with a person’s ability to self-manage their diabetes (2). The Centers for Disease Control and Prevention (CDC) projects that as many as 1 in 3 adults could have diabetes by 2050 (3). In 2012, the United States spent an estimated $245 billion on diabetes care, including $176 billion in direct medical costs and $69 billion in indirect costs from lost workdays, restricted activity, disability, and early death (4). Many costly complications among people with diabetes can be prevented or delayed with appropriate preventive care and self-management (5).

The Centers for Disease Control and Prevention (CDC) developed a cooperative agreement with health departments in all 50 states and the District of Columbia to strengthen chronic disease prevention and management efforts through the implementation of evidence-based strategies, such as CDC's National Diabetes Prevention Program. The National Diabetes Prevention Program supports organizations to deliver the year-long lifestyle change program that has been proven to prevent or delay the onset of type 2 diabetes among those at high risk. This article describes activities, barriers, and facilitators reported by funded states during the first 3 years (2013-2015) of a 5-year funding cycle.

We provide an overview of the comprehensive evaluation of State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health (State Public Health Actions). State Public Health Actions is a program funded by the Centers for Disease Control and Prevention to support the statewide implementation of cross-cutting approaches to promote health and prevent and control chronic diseases. The evaluation addresses the relevance, quality, and impact of the program by using 4 components: a national evaluation, performance measures, state evaluations, and evaluation technical assistance to states. Challenges of the evaluation included assessing the extent to which the program contributed to changes in the outcomes of interest and the variability in the states' capacity to conduct evaluations and track performance measures. Given the investment in implementing collaborative approaches at both the state and national level, achieving meaningful findings from the evaluation is critical.

There is a clear, persistent association between poverty and HIV risk and HIV infection. Low educational attainment, neighborhood disadvantage, and residential instability are ways in which poverty is instrumentally experienced in urban America. We investigated the role of lived poverty at both the individual and neighborhood levels in transactional sex behavior among African American men who have sex with men (MSM) residing in urban neighborhoods. Using population-averaged models estimated by generalized estimating equation (GEE) models, we identified individual-level and neighborhood-level factors that are associated with exchanging sex for drugs and/or money. We tested the association between neighborhood and individual-level socioeconomic status and HIV risk behavior by combining area-based measures of neighborhood quality from the US Census with individual survey data from 542 low-income African American MSM. The primary outcome measure was self-reported transactional sex defined as exchanging sex for drugs or money. Individual-level covariates included high school non-completion, income, and problem drug use. Neighborhood-level covariates were high school non-completion and poverty rates. The findings suggested that educational attainment is associated with both the individual level and neighborhood level. Participants were more likely to engage in transactional sex if they did not complete high school (OR = 1.78), and similarly if their neighbors did not complete high school (OR = 7.70). These findings suggest potential leverage points for both community-level interventions and advocacy for this population, particularly related to transactional sex and education, and will aid HIV prevention efforts that seek to address the contextual constraints on individual risk behavior.

Gay, bisexual, and other men who have sex with men (MSM) are disproportionately affected by HIV. MSM comprise roughly 2% of the US population, yet approximately two-thirds of new HIV infections are among MSM (Centers for Disease Control and Prevention, 2016). Additionally, significant racial and ethnic disparities exist with respect to HIV transmission among MSM. Based on the current HIV diagnoses rates in the US, about 1 in 2 African American men who have sex with men (AAMSM), 1 in 4 Latino MSM (LMSM) and 1 in 11 white MSM will be diagnosed with HIV during their lifetime (Center for Disease Control and Prevention (CDC), 2016a). In general, substance-using MSM are among the groups with the greatest risk for HIV infection (Centers for Disease Control and Prevention, 2011; Margolis, Joseph, Hirshfield, et al., 2014; Pines, Gorbach, Weiss, et al., 2014; Plankey, Ostrow, Stall, et al., 2007); nearly a third of incident HIV infections among MSM may be associated with non-injection drug use (Mansergh et al., 2008; Van Tieu & Koblin, 2009). Substance-using sexual minorities are more likely to underutilize substance use treatment (McCabe, Bostwick, Hughes, West, & Boyd, 2010) and may be an HIV transmission bridge to non-drug-using populations (Lambert et al., 2011). | With respect to alcohol use, high rates of both alcohol consumption and binge drinking have been documented among MSM populations (Finlayson et al., 2011). Additionally, previous studies have found associations between heavy drinking, as define as having 6 or more drinks on one occasion or 4 or more drinks daily, and HIV risk behaviors among MSM, such as condomless anal intercourse and greater number of sexual patterns (Colfax et al., 2004; Greenwood et al., 2001; Koblin et al., 2003a; Woolf & Maisto, 2009). Previous studies also suggest that many substance-using MSM populations engage in use of multiple substances, often concomitantly (Santos et al., 2013). There also may be a dose response with number and frequency of substances used with respect to condomless anal sex among HIV negative MSM (Santos et al., 2013). However, patterns of substance-use vary across racial and ethnic MSM populations, e.g. African American substance-using MSM being more likely to use crack/cocaine relative to other substance-using MSM populations (Goldstein, Burstyn, LeVasseur, & Welles, 2016; Halkitis & Jerome, 2008; Hatfield, Horvath, Jacoby, & Simon Rosser, 2009; Mimiaga, Reisner, Fontaine, et al., 2010; Paul, Boylan, Gregorich, Ayala, & Choi, 2014). Thus, it is important to better understand patterns of concomitant substance-use, e.g. methamphetamine, crack/cocaine and alcohol, across specific sociodemographic categories among MSM populations (Santos et al., 2013). Sociodemographic characteristics which may be particularly relevant for specific MSM populations include poverty and history of incarceration. For example, pronounced racial disparities have been found between AAMSM and other MSM populations with respect to structural barriers, such as low income, unemployment and incarceration, associated with HIV infection (Millet, Peterson, Flores, Hart, et al., 2012). Additionally, a recent study conducted by Rutledge et al, found a high proportion of MSM reporting both a history of incarceration and substance use. This study found rates of incarceration highest among men who classified themselves as “down-low”, e.g. endorsing secrecy about same-sex sexual behavior, promting the authors to posit that this population may engage in trading sex for money more often and thus increase their risk for incarceration (Rutledge, Jemmott, O'Leary, & Icard, 2016).

PROBLEM/CONDITION: Diabetes self-management education (DSME) is a clinical practice intended to improve preventive practices and behaviors with a focus on decision-making, problem-solving, and self-care. The distribution and correlates of established DSME programs in nonmetropolitan counties across the United States have not been previously described, nor have the characteristics of the nonmetropolitan counties with DSME programs. REPORTING PERIOD: July 2016. DESCRIPTION OF SYSTEMS: DSME programs recognized by the American Diabetes Association or accredited by the American Association of Diabetes Educators (i.e., active programs) as of July 2016 were shared with CDC by both organizations. The U.S. Census Bureau's census geocoder was used to identify the county of each DSME program site using documented addresses. County characteristic data originated from the U.S. Census Bureau, compiled by the U.S. Department of Agriculture's Economic Research Service into the 2013 Atlas of Rural and Small-Town America data set. County levels of diagnosed diabetes prevalence and incidence, as well as the number of persons with diagnosed diabetes, were previously estimated by CDC. This report defined nonmetropolitan counties using the rural-urban continuum code from the 2013 Atlas of Rural and Small-Town America data set. This code included six nonmetropolitan categories of 1,976 urban and rural counties (62% of counties) adjacent to and nonadjacent to metropolitan counties. RESULTS: In 2016, a total of 1,065 DSME programs were located in 38% of the 1,976 nonmetropolitan counties; 62% of nonmetropolitan counties did not have a DSME program. The total number of DSME programs for nonmetropolitan counties with at least one DSME program ranged from 1 to 8, with an average of 1.4 programs. After adjusting for county-level characteristics, the odds of a nonmetropolitan county having at least one DSME program increased as the percentage insured increased (adjusted odds ratio [AOR] = 1.10, 95% confidence interval [CI] = 1.08-1.13), the percentage with a high school education or less decreased (AOR = 1.06, 95% CI = 1.04-1.07), the unemployment rate decreased (AOR = 1.19, 95% CI = 1.11-1.23), and the natural logarithm of the number of persons with diabetes increased (AOR = 3.63, 95% CI = 3.15-4.19). INTERPRETATION: In 2016, there were few DMSE programs in nonmetropolitan, socially disadvantaged counties in the United States. The number of persons with diabetes, percentage insured, percentage with a high school education or less, and the percentage unemployed were significantly associated with whether a DSME program was located in a nonmetropolitan county. PUBLIC HEALTH ACTION: Monitoring the distribution of DSME programs at the county level provides insight needed to strategically address rural disparities in diabetes care and outcomes. These findings provide information needed to assess lack of availability of DSME programs and to explore evidence-based strategies and innovative technologies to deliver DSME programs in underserved rural communities.

Elucidation of the evolutionary history and interrelatedness of Plasmodium species that infect humans has been hampered by a lack of genetic information for three human-infective species: P. malariae and two P. ovale species (P. o. curtisi and P. o. wallikeri). These species are prevalent across most regions in which malaria is endemic and are often undetectable by light microscopy, rendering their study in human populations difficult. The exact evolutionary relationship of these species to the other human-infective species has been contested. Using a new reference genome for P. malariae and a manually curated draft P. o. curtisi genome, we are now able to accurately place these species within the Plasmodium phylogeny. Sequencing of a P. malariae relative that infects chimpanzees reveals similar signatures of selection in the P. malariae lineage to another Plasmodium lineage shown to be capable of colonization of both human and chimpanzee hosts. Molecular dating suggests that these host adaptations occurred over similar evolutionary timescales. In addition to the core genome that is conserved between species, differences in gene content can be linked to their specific biology. The genome suggests that P. malariae expresses a family of heterodimeric proteins on its surface that have structural similarities to a protein crucial for invasion of red blood cells. The data presented here provide insight into the evolution of the Plasmodium genus as a whole.

BACKGROUND: Few trials have tested physical-activity interventions among sexual minorities, including African American men who have sex with men (MSM). PURPOSE: We examined the efficacy and mediation of the Being Responsible for Ourselves (BRO) physical-activity intervention among African American MSM. METHOD: African American MSM were randomized to the physical-activity intervention consisting of three 90-min one-on-one sessions or an attention-matched control intervention and completed pre-intervention, immediately post-intervention, and 6- and 12-month post-intervention audio computer-based surveys. RESULTS: Of the 595 participants, 503 completed the 12-month follow-up. Generalized estimating equation models revealed that the intervention increased self-reported physical activity compared with the control intervention, adjusted for pre-intervention physical activity. Mediation analyses suggested that the intervention increased reasoned action approach variables, subjective norm and self-efficacy, increasing intention immediately post-intervention, which increased physical activity during the follow-up period. CONCLUSIONS: Interventions targeting reasoned action approach variables may contribute to efforts to increase African American MSM's physical activity. CLINICAL TRIAL REGISTRATION: The trial was registered with the ClinicalTrials.gov Identifier NCT02561286 .

African American men who have sex with men (AAMSM) are vastly overrepresented among people with HIV/AIDS. Using data from 595 AAMSM in Philadelphia, we explored differences in sociodemographics, psychosocial characteristics related to beliefs about ethnicity, sexuality and masculinity, and sexual behavior with men and women by self-reported sexual identity (gay, bisexual, down low, straight). Roughly equivalent numbers identified as gay (40.6 %) and bisexual (41.3 %), while fewer identified as straight (7.6 %) or down low (10.5 %), with significant differences in age, income, history of incarceration, HIV status, alcohol and drug problems, childhood sexual abuse, and connection to the gay community evident among these groups. Analysis of psychosocial characteristics theorized to be related to identity and sexual behavior indicated significant differences in masculinity, homophobia, and outness as MSM. Gay and straight men appeared to be poles on a continuum of frequency of sexual behavior, with bisexual and down low men being sometimes more similar to gay men and sometimes more similar to straight men. The percentage of men having total intercourse of any kind was highest among down low and lowest among gay men. Gay men had less intercourse with women, but more receptive anal intercourse with men than the other identities. There were no significant differences by identity in frequency of condomless insertive anal intercourse with men, but gay men had significantly more condomless receptive anal intercourse. There were significant differences by identity for condomless vaginal and anal intercourse with women. This study demonstrates the importance of exploring differences in types of sex behavior for AAMSM by considering sexual identity.

Although breastfeeding is on the rise in the United States (US), rates of breastfeeding still fall short of national objectives.1,2 Whereas 79% of infants born in 2011 initiated breastfeeding, only 49% were breastfeeding at 6 months and 27% at 12 months, compared to the national objectives of 81.9%, 60.6%, and 34.1%, respectively.1,2 Within this context, the United States has seen an increase in the number of Baby-Friendly hospitals.3 In 2013, 7.15% of US live births occurred in Baby-Friendly designated facilities, compared to 1.79% of live births in 2007.1 Hospitals and birthing facilities must implement the Ten Steps to Successful Breastfeeding and abide by the provisions of the International Code of Marketing of Breast-Milk Substitutes to receive and retain Baby-Friendly designation.3 A number of studies have been conducted to evaluate the implementation and effectiveness of the Baby-Friendly Initiatives in the United States, and they found that full implementation of Baby-Friendly policies was associated with increased breastfeeding rates.4-6 Although there have been increases in the total number of Baby-Friendly designated hospitals in the United States, evaluation studies also indicate challenges with implementing Step 10—foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center.7-9 The challenges most frequently reported with implementing this step included hospitals not facilitating peer counseling for breastfeeding mothers, lack of referral systems to other agencies that provide postpartum breastfeeding support, and hospitals not having control of the services outside of the hospital.7-9 | Community-based support strategies that have demonstrated effective results in initiation of breastfeeding include breastfeeding-friendly maternity care practices in clinical settings,10 breastfeeding education and professional support for health care professionals,11-13 support for breastfeeding in the workplace,14 peer support programs,11 and access to breastfeeding information for new mothers.15 Evidence from international Breastfeeding-Friendly Community Initiatives indicates that maximizing existing resources in the government and working through nongovernmental organizations already implementing community-level activities can achieve significant increases in breastfeeding initiation and exclusivity over large populations.16,17

The Michigan Department of Community Health (MDCH) funded 9 local breastfeeding coalitions to implement breastfeeding support groups and to develop breastfeeding resources for mothers and health professionals. The authors conducted qualitative analyses of reports, success stories, and MDCH grantees' interview responses (via follow-up call with 3 coalitions) to assess key barriers, facilitators, and lessons learned for coalitions implementing breastfeeding support groups. Coalitions noted implementation barriers related to their organizational structure and to recruiting mothers and finding meeting locations. Facilitators to implementing breastfeeding support groups included referrals, expertise, resources, and incentives. The following themes emerged from the reports analysis regarding how to implement breastfeeding support groups: "meet moms where they are," build community partnerships, and leverage in-kind and financial resources to sustain breastfeeding support groups.

BACKGROUND: Community-based organizations (CBOs) have an important role to play in promoting breastfeeding continuation among mothers. The Centers for Disease Control and Prevention's Nutrition, Physical Activity, and Obesity Program's Cooperative Agreement Breastfeeding Supplement funded 6 state health departments to support CBOs to implement community-based breastfeeding support activities. OBJECTIVES: Study objectives were to (1) describe the reach of the Cooperative Agreement, (2) describe breastfeeding support strategies implemented by state health departments and CBOs, and (3) understand the barriers and facilitators to implementing community-based breastfeeding support strategies. METHODS: Qualitative and quantitative data were abstracted from state health departments' final evaluation reports. Qualitative data were analyzed for common themes using deductive and inductive approaches. RESULTS: Within the 6 states funded by the Cooperative Agreement, 66 primary CBOs implemented breastfeeding support strategies and reported 59 256 contacts with mothers. Support strategies included incorporating lactation services into community-based programs, training staff, providing walk-in locations for lactation support, connecting breastfeeding mothers to resources, and providing services that reflect community-specific culture. Community partnerships, network building, stakeholders' commitment, and programmatic and policy environments were key facilitators of program success. CONCLUSION: Key lessons learned include the importance of time in creating lasting organizational change, use of data for program improvement, choosing the right partners, taking a collective approach, and leveraging resources.

The present study sought to replicate effects of the number of syndemic psychosocial health conditions on sexual risk behavior and HIV infection among a sample of high-risk African American men who have sex with men (MSM) and to identify resilience factors that may buffer these effects. We used baseline data from an HIV risk-reduction trial to examine whether a higher number of syndemic conditions was associated with higher rates of self-reported sexual risk behavior and HIV infection. Using logistic regression models, we tested for interactions between number of syndemic conditions and several potential resilience factors to identify buffering effects. Replicating previous studies, we found significant associations between numbers of syndemic conditions and higher rates of sexual risk behavior and HIV infection. Surprisingly, we also replicated a previous finding (Stall et al., Am J Public Health, 93(6):939-942, 2003) that the effects of syndemic burden on HIV status fell off at the highest levels of syndemic conditions. Among a variety of potential resilience factors, two-optimism and education-buffered the syndemic effect on HIV prevalence. This is, to our knowledge, the first paper to identify resilience factors buffering against syndemic effects among MSM. It also constitutes a significant contribution to the literature regarding prevention among black MSM. These results point to the need to identify HIV-positive black MSM and provide effective treatment for them and to develop interventions addressing both syndemic and resilience factors.

OBJECTIVE: To examine diabetic retinopathy, dilated eye examination, and eye care education among African Americans before and after a community-level public health intervention. METHODS: We analyzed data from Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together) participants with self-reported diabetes (617 in 1996-1997 and 672 in 2003-2004) in Raleigh (intervention community) and Greensboro (comparison community), North Carolina. All analyses were weighted to adjust for the complex sample design of pre and post cross-sectional surveys. Estimates were age standardized to the 2000 US Census population. We used multivariate logistic regression to calculate odds ratios and corresponding 95% confidence intervals. RESULTS: We found no significant difference in prevalence of diabetic retinopathy between the control and intervention communities (p > .05). However, after adjusting for other confounders, receipt of eye care education (OR, 1.59; 95% CI, 1.19-2.13) was independently associated with receipt of dilated eye examination among African Americans with diabetes. Compared with individuals without diabetic retinopathy, those with diabetic retinopathy were more likely to use eye care services (OR, 1.89; 95% CI, 1.41-2.54). CONCLUSIONS: Diabetic retinopathy is a considerable problem among African American communities. Community intervention efforts, such as comprehensive eye care education, that specifically target improvement in diabetic retinopathy and use of eye are services could help better serve this population.