This study examines property damage resulting from Superstorm Sandy (2012) using a household survey conducted in affected areas across ten states in the Northeastern United States. We employ spatial econometric tools to investigate the impact of hurricane intensity and home structural characteristics on damages, as well as associated spatial dependencies. To control for hurricane severity and assess hazard exposure, we generate multiple hurricane intensity measures at the census-tract level, which provides exogenous variation for the survey data. Our analysis provides empirical evidence demonstrating that both hurricane exposure and structural vulnerabilities significantly contribute to property damage. Additionally, we find that insurance coverage plays a crucial role in mitigating losses for affected households. Our analysis also uncovers several insurance challenges, including inadequate coverage, socioeconomic disparities, and underinsurance in high-risk areas. These findings highlight the need for improved insurance policies and disaster risk reduction strategies to better protect vulnerable communities from future hurricane risks.

Objectives To examine systemic challenges to health system resilience in Puerto Rico following Hurricane Maria, focusing on resource, management, and policy domains.Methods Semi-structured interviews (n = 62) were conducted from January to April 2023 with health care professionals, patients, community leaders, nonprofits, and government stakeholders using purposive sampling. Interviews were conducted in Spanish, transcribed, translated, and thematically analyzed.Results Resource failures centered on prolonged power outages (mean 62.7 days; up to 300 days), which cascaded into water, transport, and communication breakdowns. These disruptions endangered patients through interrupted surgeries, inoperable imaging, oxygen shortages, and infection control failures. Management challenges included depleted stockpiles, staff burnout, and workforce migration, which extended wait times to 6-8 months. Coordination was inconsistent, with duplication of aid in some areas and neglect in others, while top-down governance slowed response. Policy constraints compounded vulnerabilities: health insurance pre-authorizations delayed urgent care, capped Medicaid funds, and lack of federal parity, limited preparedness, and centralized aid distribution left rural communities underserved.Conclusions Puerto Rico's health system resilience was undermined by interdependent failures across infrastructure, management, and policy. Building resilience will require investment in decentralized power, reforms to emergency insurance protocols, stronger inter-agency coordination, and equitable federal financing to ensure preparedness for future climate-related disasters.

BACKGROUND: More than 80% of the global premature mortality from noncommunicable diseases (NCDs) occurs in low- and middle-income countries (LMICs). Nigeria, like most LMICs, has limited capacity to respond to diabetes and hypertension. As the Lagos State government accelerates the rollout of its mandatory health insurance, Lagos State Health Scheme (LSHS), the number of individuals with diabetes and hypertension seeking care will increase. This study aimed to determine service availability and service readiness for diabetes and hypertension among health facilities providing primary care for these conditions in Lagos State, and to explore the facility characteristics associated with service readiness. METHODS: We conducted a cross-sectional survey of 84 facilities enrolled in the baseline study of an impact evaluation of the Lagos State Health Scheme. We collected data using relevant modules of the World Health Organization’s Harmonized Health Facility Assessment tool. Service availability was defined as providing diagnosis or treatment for either condition, and service readiness scores were calculated as the proportion of tracer items available and functional at the facility on the survey day. Further, we used a multiple linear regression model to estimate associations between facility characteristics and service readiness. RESULTS: Service availability for both conditions was high. The mean diabetes and hypertension service readiness scores were 69% and 66%, respectively. The percentage of fully ready healthcare facilities was very low (2.6% for diabetes and 2.5% for hypertension). The staff and guidelines domain received the lowest score for both conditions. There was no association between service readiness and LSHS empanelment status. Providing only outpatient services had a negative association with service readiness for both conditions. Participation in a quality improvement program had a positive association with hypertension service readiness score. CONCLUSION: While the mean service readiness scores for diabetes and hypertension were moderately high among sampled health facilities, only a very small percentage were fully service ready. There were critical deficits in service readiness domains that must be addressed to ensure the required inputs for high-quality diabetes and hypertension care is available in the State.

The year 2017 marked one of the most catastrophic U.S. hurricane seasons, encompassing three devastating hurricanes—Harvey, Irma, and Maria. Even three years after Hurricane Maria, 40% of Puerto Rican households still reported high or extreme impacts, reflecting a significant reduction in household well-being. This study evaluated the prolonged impacts of the hurricane by analyzing survey data from 502 Puerto Rican households, combined with GIS-based spatial factors. Findings reveal that extended utility disruptions, severe property damage, prolonged displacement, and income loss increased household impacts, while insufficient disaster aid further exacerbated them. However, proactive preparedness measures, e.g., alternative electricity sources to counter service interruptions, structural modifications to prevent damage, and insurance to mitigate financial burdens, significantly reduced the likelihood of severe impacts and promoted household resilience. While larger households displayed greater resilience, those with elderly members endured more adverse effects. These critical insights highlight the need for stronger and collaborative disaster management strategies and resilient infrastructure development to protect vulnerable regions against household impacts in future disasters.

In advance of an approaching hurricane, residents must prepare and make decisions. Families might need windows boarded up before the storm and fallen trees removed afterward. Those sheltering in place may need additional resources, such as generators, food, potable water, and access to healthcare. Local governments may provide information at a municipality level, but sharing awareness about more proximate hazards may be beyond their capabilities. We developed a web application, StormShare, to assist with these and other needs, contributing to capacity building for social resiliency. Developed with guidance from domain experts, three Florida municipalities, and a focus group, with further refinements recommended by two additional focus groups, StormShare depends on crowdsourcing, whereby users provide information to facilitate cooperation through community involvement. Users can post about where goods can be found, services they are willing to provide, and localized alerts, while other users rely on these posts to make informed decisions. In this paper, we describe StormShare, explore some of the considerations of developing a crowdsourcing application for hurricane preparedness, and offer recommendations for future improvements.

Intimate partner violence (IPV) negatively impacts pregnant women and their unborn children. Globally, an estimated 19%, 9%, and 6% of women experience psychological, physical, and sexual IPV, respectively, during pregnancy. These rates are higher among pregnant women living with a stigmatizing disease. In this study, we examined the effect of antenatal screening for sickle cell disease (SCD) using the sickle cell solubility test on the risk of IPV among pregnant women in the city of Nagpur in Maharashtra state of India. We hypothesized that a positive solubility test increases the risk of IPV via partner disclosure. We conducted a cohort study comparing IPV in 182 pregnant women, before (baseline) and after (endline) having a solubility test. Of the 182 participants, 91 were pregnant women with a positive solubility test and 91 with a negative solubility test. We used the 49-item Indian Family Violence and Control Scale (α = 0.88) to measure IPV and estimated associations using binomial logistic regressions with robust standard errors. Pregnant women with a positive solubility test were at least twice as likely to experience physical, sexual, or psychological IPV as pregnant women with a negative solubility test, even after adjusting for baseline differences between these two groups on common IPV risk factors including the lower level of education and scheduled-caste membership. Pregnant women who have a positive solubility test are at risk of IPV after following routine instructions to disclose their test results to their male partners, so that they can undergo further testing to determine the baby's risk of SCD, sickle cell trait, or no risk. In resource-poor settings with high SCD prevalence, antenatal clinics are increasingly screening pregnant women to prevent mother-to-child transmission of SCD. There is a need to integrate strategies for women to disclose sickle cell screening test results and prevention of IPV caused by male partners.

PurposeIntimate partner violence (IPV) is challenging to measure due to underreporting by both men and women. The reasons why men fail to disclose their IPV perpetration in societies where such behavior is more socially accepted remain an open question. Men’s lack of awareness of how their behaviors can harm women is a contributing factor. We evaluated the impact of an intervention designed to increase men’s understanding of IPV on their ability to report it accurately, as indicated by men reporting IPV consistently with their female partners (whose reports are valid indicators of IPV).MethodsWe analyzed data from a cluster-randomized controlled trial conducted in Tanzania. A total of 450 couples from nine villages were randomly assigned to one of three arms, with each arm comprising 150 couples. In Intervention Arm 1, men participated in peer groups that explored gender relations and IPV. In Intervention Arm 2, men participated in peer groups, and communities additionally engaged in dialogues on similar topics. The Control Arm had no such activities. IPV data were collected from both partners, following ethical guidelines to ensure women’s safety. Our primary outcome includes couples reporting concordantly whether IPV occurred (couples’ concordant reporting).ResultsFrom baseline to endline, concordant reporting among couples increased for physical (31%, p = 0.002), sexual (24%, p = 0.01), and economic (22%, p = 0.05) IPV in Intervention Arm 1, accompanied by fewer men disagreeing with their female partners’ IPV reports. Similarly, in Intervention Arm 2, concordant reporting increased for physical (24%, p = 0.02) and sexual (22%, p = 0.04) IPV. There was no improvement in the concordant reporting of emotional IPV across the arms. Compared to couples in the Control Arm, those in Intervention Arm 1 had higher odds of reporting concordantly on physical (OR: 1.85, 95% CI: 0.97, 3.51, p = 0.09) and economic (OR: 1.83, 95% CI: 0.96, 3.46, p = 0.09) IPV at endline compared to baseline.ConclusionIn communities that do not link IPV to fault, men may not report IPV because they do not recognize their behaviors as abuse. Including a preamble that defines IPV in a survey questionnaire can improve men’s reporting of IPV.

People living with HIV and beginning antiretroviral therapy (ART) often struggle with medication adherence and attending appointments due to multi-level challenges such as depression symptoms, substance use, stigma and disclosure, food insecurity, health system challenges, transportation challenges, and gender inequity. The SUSTAIN trial seeks to improve initiation adherence through multiple monitoring and support interventions in three clinics in Mitchells Plain township, Cape Town, South Africa. We qualitatively explored the multi-level challenges impacting adherence at the individual, interpersonal, and structural levels among 60 study participants within the first six months after initiation on ART. The in-depth interview sample was selected purposively based on participant experiences with at least one of these factors reported through a baseline survey, gender, and age. We conducted a content analysis and utilized syndemic theory to understand the synergistic effects of multiple adherence challenges. To manage their HIV diagnosis, participants described positive and negative coping mechanisms, including how substance use affected adherence particularly on big event days (e.g., birthdays, holidays, or funerals). Participants described fears of stigma motivat decisions on disclosure of their HIV status and decreased potential social support, possibly reducing motivation to adhere to ART. Gender inequity reinforced experiences with and perceptions of stigma and disclosure. Participants indicated that food insecurity resulted in feelings of shame when associated with perceived larger appetites due to ART use and with lack of employment. Participants described both positive and negative ways the health system impacted their adherence and retention in care, citing information provided by clinic staff, clinician attitudes, and clinic operations. Misunderstandings regarding the strict timing of ART dose-taking (often from lack of clear information or counselling by clinicians) meant participants often had limited competence to make decisions about their dosing schedule and how to best integrate treatment into their daily lives. Participants described a notable fear of commuting to and from clinics due to dangerous and difficult paths on which muggings occurred frequently; women were at particular risk of violence. Often, participants mentioned multiple factors simultaneously affecting adherence, with additive or synergistic effects. Syndemic factors affecting ART adherence exist across multiple levels. Enhanced adherence counseling, designed as a behavior change intervention, might help PLWH cope with individual adherence barriers and support strategizing about ways to mitigate or overcome structural barriers. Continued efforts by government and implementers to address health system, gender inequity, and security challenges could further support ART adherence.

Using multiple hurricane surveys collected from different areas in the U.S., this study estimates how much distance and how much time were traveled by evacuees to reach safer destinations during a hurricane event. Regression results indicate that flood risk, respondents’ age, income, and education levels are correlated with both the distance and travel time of hurricane evacuation trips. Moreover, to gain deeper insights, we estimated the price and income elasticities of hurricane evacuation trip characteristics. The estimated elasticities of travel distance reveal that travel distance is a necessary and ordinary good, implying that safety is essential and less responsive to price changes. In addition, the estimated elasticities of travel time suggest that travel time is an inferior good, indicating that as income goes up, people tend to spend less time traveling for evacuation. This finding provides logistic implications for emergency management agencies to analyze the evacuation travel demand and ensure safety in vulnerable communities.

Introduction  In-utero experience of violence through maternal experience of intimate partner violence (IPV) is a risk factor for adverse pregnancy outcomes via 'biological programming,' whose effect can be mediated by sleep. We conducted a scoping review to synthesize the current evidence of the association between experiences of violence and sleep in women. Methods  Between August and October 2023, we conducted a search in four databases (PubMed, APA PsycInfo, Embase, and Web of Science) for peer-reviewed articles, using 11 inclusion and exclusion criteria. Any study published in English in peer-reviewed journals that conducted original research on the association between exposure to violence (lifetime IPV, IPV during the previous year, during and 1 year after pregnancy, as well as adverse childhood experiences) and poor sleep outcomes (sleep disturbances, insomnia, poor sleep quality, and longer time to fall asleep) in the perinatal population were included. Results  The synthesis of the 12 included studies revealed a positive association between exposure to violence and poor sleep, and between adverse childhood experiences and sleep disturbances or poor sleep during pregnancy. Moreover, IPV in the postpartum period was associated with poor sleep. Conclusion  Most of the evidence synthesized comprises data from high-income countries, resulting in lack of cultural context. However, it is evident that the experience of violence throughout life is a risk for poor perinatal sleep quality. Thus, there is a growing need to study this association, especially in resource-limited settings, where data on sleep health is largely absent, inform pregnancy care and maternal and child health policies.

Due to its unique location, Bangladesh often faces devastating hydroclimatic shocks such as floods and cyclones. In the recent past, three major cyclones (Sidr in 2007, Aila in 2009, and Komen in 2015) claimed 3800 lives and damaged hundreds of thousands of houses with billions of dollars in property damages. In this paper, we focus on understanding people's evacuation behaviors in the face of approaching cyclones using survey data collected through face-to-face interviews with residents living in the coastal areas of Bangladesh. Through various statistical models, including probit, panel probit, bivariate probit, and multinomial logit models, we have explored the determinants of both past and future evacuation decisions, as well as the choice of evacuation destinations. Our findings reveal consistent patterns across different cyclone events, highlighting the significant roles played by warning time, proximity to the coast, property loss, shelter accessibility, housing structure, literacy, past evacuation experiences, and demographic factors such as age, gender, and employment status. Additionally, the analysis of evacuation destinations uncovers nuanced insights into the preferences and challenges faced by evacuees, including the need for improving shelter accessibility. With rising vulnerabilities in coastal areas in Bangladesh and worldwide, identifying what drives households' evacuation decisions and their destination choices can provide useful inputs for evacuation planning and effective disaster management.

Master of Public Health (MPH) “core courses” are essential preparation for advanced study and professional practice. As a multidisciplinary, core course teaching team, we aim to balance collaboration, the need to update content, and consistency across sections with faculty autonomy, while also attending to time constraints and Council on Education for Public Health (CEPH) accreditation requirements. In this paper, we describe and discuss advantages and disadvantages of the four strategies we used to illuminate how we spend class time, prioritize content, and balance institutional consistency with instructor individuality. The strategies are: create common course materials; hold regular instructional team meetings; capture teacher impressions after each weekly class; and conduct individual syllabus and semester review interviews with the teaching team. Analysis led to seven recommendations for both teaching teams and administrators of schools and programs of public health that have the potential to improve the teaching of core subjects. Core courses present instructors with opportunities to feature our specific departments and potentially inspire students to work in our specialty areas. These findings are relevant to colleagues who are striving to respect the autonomy to which many in academia are accustomed and help ensure students enjoy consistent, high-quality experiences in team-taught courses.

We conducted qualitative research among people with HIV (PWH) and care providers in Cape Town, South Africa to understand the impact of negative clinic experiences on adherence and support preferences. In-depth interviews were conducted with 41 patients with an unsuppressed viral load or a treatment gap, and focus group discussions with physicians, nurses, counselors, and community health workers. Questions addressed treatment history and adherence barriers, then participants evaluated evidence-based adherence interventions for potential scale up. Inductive analysis examined care experiences and corresponding preference for intervention options. More than half of PWH described negative experiences during clinic visits, including mistreatment by staff and clinic administration issues, and these statements were corroborated by providers. Those with negative experiences in care stated that fear of mistreatment led to nonadherence. Most patients with negative experiences preferred peer support groups or check-in texts to clinic-based interventions. We found that PWH's negative clinic experiences were a primary reason behind nonadherence and influenced preferences for support mechanisms. These findings emphasize the importance of HIV treatment adherence interventions at multiple levels both in and outside of the clinic, and providing more comprehensive training to providers to better serve PWH in adherence counseling, especially those who are most vulnerable..

The added threat from the COVID-19 pandemic created a complex dilemma for households that were also facing evacuation decisions during natural disasters. This paper characterized household concerns and evacuation preferences in the context of both hurricanes and pandemic risks. We conducted a survey of 504 households across 119 different zip code areas in Puerto Rico impacted by Hurricane Maria (2017). The households were asked to make a choice between staying isolated at home or evacuating with or without isolation in the event of a future hurricane threat during a pandemic. Our findings revealed that households, in the early stages of the COVID-19 pandemic, expressed greater concern about the risks associated with a pandemic compared to those related to hurricanes, and that there was a risk–risk trade-off when making the critical evacuation decision. In addition to hurricane-related concerns, past evacuation experiences, and the consideration of evacuation costs, we found that evacuation preferences were heterogeneous across age, gender, and ethnic groups, and were also driven by perceptions of infection risks and attitudes towards social distancing. Our research aimed to provide valuable insights to help develop effective responses and preparations for coastal hurricanes that consider the complexities of multiple hazards and health risks.

In the United States, many rural communities are confronted with the dual burden of intimate partner violence (IPV) and the opioid crisis. In the past decade, rural US communities have experienced extremely high rates of opioid use disorder and opioid-related fatalities. At the same time, rural communities continue to experience high rates of IPV and a lack of accessible services. This chapter presents the findings of an interdisciplinary, community-based participatory study of 33 rural Vermont residents who have experienced co-occurring opioid use and IPV and 18 service providers representing a county Coordinated Community Response team. Their experiences richly illustrate the reality of social and geographic isolation, inaccessible social services, and the amplified impact of stigma in small town settings. We demonstrate important challenges for delivering victim services for rural residents with complex, interrelated needs, especially when supporting communities via teleservices, as so many organisations have had to do during the COVID-19 pandemic. We conclude with recommendations for multidisciplinary, inter-agency approaches to reducing barriers to care.

This study evaluated the effect of revisions to existing peer-counselor services, called Mentor Mothers (MM), at maternal and child health clinics on medication adherence for women living with HIV (WLWH) in Kenya and on early infant HIV testing. The Enhanced Mentor Mother Program study was a 12-site, two-arm cluster-randomized trial enrolling pregnant WLWH from March 2017 to June 2018 (with data collection through September 2020). Six clinics were randomized to continued MM-supported standard care (SC). Six clinics were randomized to the intervention arm (INT = SC plus revised MM services to include more one-on-one interactions). Primary outcomes for mothers were defined as: (PO1) the proportion of days covered (PDC) with antiretroviral therapy (ART) ≥ 0.90 during the last 24-weeks of pregnancy; and (PO2) ≥ 0.90 PDC during the first 24-weeks postpartum. Secondary outcomes were infant HIV testing according to national guidelines (at 6, 24, and 48 weeks). Crude and adjusted risk differences between study arms are reported. We enrolled 363 pregnant WLHV. After excluding known transfers and subjects with incomplete data extraction, data were analyzed for 309 WLWH (151 SC, 158 INT). A small share achieved high PDC during the prenatal and postnatal periods (0.33 SC/0.24 INT achieved PO1; 0.30 SC/0.31 INT achieved PO2; crude or adjusted risk differences were not statistically significant). In addition, 75