@Article{Guilkey2020,
  author          = {Guilkey, David K. and Escamilla, Veronica and Calhoun, Lisa M. and Speizer, Ilene S.},
  journal         = {Demography},
  title           = {The Examination of Diffusion Effects on Modern Contraceptive Use in Nigeria.},
  year            = {2020},
  issn            = {1533-7790},
  month           = may,
  abstract        = {This study uses data gathered for an evaluation of a Bill & Melinda Gates Foundation-funded initiative designed to increase modern contraceptive use in select urban areas of Nigeria. When the initiative was conceived, the hope was that any positive momentum in the cities would diffuse to surrounding areas. Using a variety of statistical methods, we study three aspects of diffusion and their effects on modern contraceptive use: spread through mass communications, social learning, and social influence. Using a dynamic causal model, we find strong evidence of social multiplier effects through social learning. The results for social influence and spread through mass communications are promising, but we are unable to identify definitive causal impacts.},
  citation-subset = {IM},
  country         = {United States},
  doi             = {10.1007/s13524-020-00884-6},
  issn-linking    = {0070-3370},
  keywords        = {Diffusion; Dynamic model estimation; Modern contraceptive use; Nigeria},
  nlm-id          = {0226703},
  owner           = {NLM},
  pii             = {10.1007/s13524-020-00884-6},
  pmid            = {32430893},
  pubmodel        = {Print-Electronic},
  pubstate        = {aheadofprint},
  revised         = {2020-05-20},
}

This study uses data gathered for an evaluation of a Bill & Melinda Gates Foundation-funded initiative designed to increase modern contraceptive use in select urban areas of Nigeria. When the initiative was conceived, the hope was that any positive momentum in the cities would diffuse to surrounding areas. Using a variety of statistical methods, we study three aspects of diffusion and their effects on modern contraceptive use: spread through mass communications, social learning, and social influence. Using a dynamic causal model, we find strong evidence of social multiplier effects through social learning. The results for social influence and spread through mass communications are promising, but we are unable to identify definitive causal impacts.

@Article{Speizer2020,
  author          = {Speizer, Ilene S. and Escamilla, Veronica and Lance, Peter M. and Guilkey, David K.},
  journal         = {Reproductive health},
  title           = {Longitudinal examination of changing fertility intentions and behaviors over a four-year period in urban Senegal.},
  year            = {2020},
  issn            = {1742-4755},
  month           = mar,
  pages           = {38},
  volume          = {17},
  abstract        = {Fertility intentions and contraceptive use are often used to demonstrate gaps in programs and policies to meet the contraceptive needs of women and couples. Prior work demonstrated that fertility intentions are fluid and change over a woman's (or couple's) life course with changing marital status, childbearing, and education/employment opportunities. This study uses longitudinal data to better examine the fluidity of women's fertility intentions and disentangle the complex interrelationships between fertility and contraceptive use. Using survey data from three time points and three urban sites in Senegal, this study examines how women's fertility intentions and contraceptive use in an earlier period affect pregnancy experience and the intentionality of experienced pregnancies among a sample of 1050 women who were in union at all three time points. We apply correlated random effect longitudinal regression methods to predict a subsequent birth by fertility intentions and modern contraceptive use at an earlier period addressing endogeneity concerns of earlier analyses that only include two time periods. Descriptive results demonstrate some change in fertility desires over time such that 6-8% of women who reported their pregnancy as intended (i.e., wanted to get pregnant at time of pregnancy) reported earlier that they did not want any(more) children. Multivariate analyses demonstrate that women who want to delay or avoid a pregnancy and are using modern contraception are the least likely to get pregnant. Among women who became pregnant, the only factor differentiating whether the pregnancy is reported as intended or unintended (mistimed or unwanted) was prior fertility intention. Women who wanted to delay a pregnancy previously were more likely to report the pregnancy as unintended compared to women who wanted to get pregnant soon. These results suggest some post-hoc rationalization among women who are getting pregnant. Women who say they do not want to get pregnant may be choosing not to use a contraceptive method in this urban Senegal context of high fertility. Programs seeking to reach these women need to consider their complex situations including their fertility intentions, family planning use, and the community norms within which they are reporting these intentions and behaviors.},
  citation-subset = {IM},
  country         = {England},
  doi             = {10.1186/s12978-020-0893-4},
  issn-linking    = {1742-4755},
  issue           = {1},
  keywords        = {Family planning; Fertility; Longitudinal; Pregnancy intentions; Senegal},
  nlm-id          = {101224380},
  owner           = {NLM},
  pii             = {10.1186/s12978-020-0893-4},
  pmc             = {PMC7077111},
  pmid            = {32183890},
  pubmodel        = {Electronic},
  pubstate        = {epublish},
  revised         = {2020-03-20},
}

Fertility intentions and contraceptive use are often used to demonstrate gaps in programs and policies to meet the contraceptive needs of women and couples. Prior work demonstrated that fertility intentions are fluid and change over a woman's (or couple's) life course with changing marital status, childbearing, and education/employment opportunities. This study uses longitudinal data to better examine the fluidity of women's fertility intentions and disentangle the complex interrelationships between fertility and contraceptive use. Using survey data from three time points and three urban sites in Senegal, this study examines how women's fertility intentions and contraceptive use in an earlier period affect pregnancy experience and the intentionality of experienced pregnancies among a sample of 1050 women who were in union at all three time points. We apply correlated random effect longitudinal regression methods to predict a subsequent birth by fertility intentions and modern contraceptive use at an earlier period addressing endogeneity concerns of earlier analyses that only include two time periods. Descriptive results demonstrate some change in fertility desires over time such that 6-8% of women who reported their pregnancy as intended (i.e., wanted to get pregnant at time of pregnancy) reported earlier that they did not want any(more) children. Multivariate analyses demonstrate that women who want to delay or avoid a pregnancy and are using modern contraception are the least likely to get pregnant. Among women who became pregnant, the only factor differentiating whether the pregnancy is reported as intended or unintended (mistimed or unwanted) was prior fertility intention. Women who wanted to delay a pregnancy previously were more likely to report the pregnancy as unintended compared to women who wanted to get pregnant soon. These results suggest some post-hoc rationalization among women who are getting pregnant. Women who say they do not want to get pregnant may be choosing not to use a contraceptive method in this urban Senegal context of high fertility. Programs seeking to reach these women need to consider their complex situations including their fertility intentions, family planning use, and the community norms within which they are reporting these intentions and behaviors.

@Article{Amuquandoh2019,
  author          = {Amuquandoh, Amy and Escamilla, Veronica and Mofolo, Innocent and Rosenberg, Nora E.},
  journal         = {International journal of STD & AIDS},
  title           = {Exploring the spatial relationship between primary road distance to antenatal clinics and HIV prevalence in pregnant females of Lilongwe, Malawi.},
  year            = {2019},
  issn            = {1758-1052},
  month           = jun,
  pages           = {639--646},
  volume          = {30},
  abstract        = {While urbanization in a sub-Saharan African (SSA) context can lead to greater independence in women, various sociological, biological, and geographical factors in urban areas may keep women at a higher risk for HIV than men. Access to major roads during Malawi's transition into rapid urbanization may leave women disproportionately vulnerable to HIV infection. It is not well established whether women who report to health clinics closer to major roads have higher or lower levels of HIV. In this study we explored the spatial heterogeneity of HIV prevalence among pregnant females in Lilongwe District, Malawi. Using Geographic Information Systems, we visually represented patterns of HIV prevalence in relation to primary roads. HIV prevalence data for 2015 were obtained from 44 antenatal clinics (ANC) in Lilongwe District. ANC prevalence data were aggregated to the administrative area and mapped. Euclidean distance between clinics and two primary roads that run through Lilongwe District were measured. A correlation was run to assess the relationship between area-level ANC HIV prevalence and clinic distance to the nearest primary road. ANC HIV prevalence ranged from 0% to 10.3%. Clinic to major road distance ranged from 0.1 to 35 km. Correlation results ( r= -0.622, p = 0.002) revealed a significant negative relationship between clinic distance to primary road and HIV prevalence, indicating that the farther the clinics stood from primary roads, the lower the reported antenatal HIV prevalence. Overall, the clinic catchments through which the major roads run reported higher ANC HIV prevalence. Antenatal HIV prevalence decreases as ANC distance from primary roads increases in Lilongwe, Malawi. As urbanization continues to grow in this region, road distance may serve as a good indicator of HIV burden and help to guide targeted prevention and treatment efforts.},
  citation-subset = {IM, X},
  completed       = {2019-11-18},
  country         = {England},
  doi             = {10.1177/0956462419830232},
  issn-linking    = {0956-4624},
  issue           = {7},
  keywords        = {Adolescent; Adult; Demography; Female; HIV Infections, epidemiology; Health Services Accessibility; Humans; Malawi, epidemiology; Middle Aged; Pregnancy; Pregnancy Complications, Infectious, epidemiology; Prenatal Care; Prevalence; Urban Population; Young Adult; Antenatal clinic; HIV prevalence; Lilongwe; Malawi; access; distance; geographic information systems; pregnant women; primary roads; sub-Saharan Africa; urbanization},
  nlm-id          = {9007917},
  owner           = {NLM},
  pmid            = {30890119},
  pubmodel        = {Print-Electronic},
  pubstate        = {ppublish},
  revised         = {2019-11-18},
}

While urbanization in a sub-Saharan African (SSA) context can lead to greater independence in women, various sociological, biological, and geographical factors in urban areas may keep women at a higher risk for HIV than men. Access to major roads during Malawi's transition into rapid urbanization may leave women disproportionately vulnerable to HIV infection. It is not well established whether women who report to health clinics closer to major roads have higher or lower levels of HIV. In this study we explored the spatial heterogeneity of HIV prevalence among pregnant females in Lilongwe District, Malawi. Using Geographic Information Systems, we visually represented patterns of HIV prevalence in relation to primary roads. HIV prevalence data for 2015 were obtained from 44 antenatal clinics (ANC) in Lilongwe District. ANC prevalence data were aggregated to the administrative area and mapped. Euclidean distance between clinics and two primary roads that run through Lilongwe District were measured. A correlation was run to assess the relationship between area-level ANC HIV prevalence and clinic distance to the nearest primary road. ANC HIV prevalence ranged from 0% to 10.3%. Clinic to major road distance ranged from 0.1 to 35 km. Correlation results ( r= -0.622, p = 0.002) revealed a significant negative relationship between clinic distance to primary road and HIV prevalence, indicating that the farther the clinics stood from primary roads, the lower the reported antenatal HIV prevalence. Overall, the clinic catchments through which the major roads run reported higher ANC HIV prevalence. Antenatal HIV prevalence decreases as ANC distance from primary roads increases in Lilongwe, Malawi. As urbanization continues to grow in this region, road distance may serve as a good indicator of HIV burden and help to guide targeted prevention and treatment efforts.

@Article{Escamilla2019,
  author          = {Escamilla, Veronica and Calhoun, Lisa and Odero, Norbert and Speizer, Ilene S.},
  journal         = {Reproductive health},
  title           = {Access to public transportation and health facilities offering long-acting reversible contraceptives among residents of formal and informal settlements in two cities in Kenya.},
  year            = {2019},
  issn            = {1742-4755},
  month           = nov,
  pages           = {161},
  volume          = {16},
  abstract        = {Despite improved health facility access relative to rural areas, distance and transportation remain barriers in some urban areas. Using household and facility data linked to residential and transportation geographic information we describe availability of health facilities offering long-acting reversible contraceptive (LARC) methods and measure access via matatus (privately owned mid-size vehicles providing public transport) in urban Kenya. Study data were collected by the Measurement, Learning and Evaluation (MLE) Project. Location information for clusters (2010) representative of city-level population were used to identify formal and informal settlement residents. We measured straight-line distances between clusters and facilities that participated in facility audits (2014) and offered LARCs. In Kisumu, we created a geographic database of matatu routes using Google Earth. In Nairobi, matatu route data were publicly available via the Digital Matatus Project. We measured straight-line distance between clusters and matatu stops on 'direct' routes (matatu routes with stop(s) ≤1 km from health facility offering LARCs). Facility and matatu access were compared by settlement status using descriptive statistics. We then used client exit interview data from a subset of facilities in Nairobi (N = 56) and Kisumu (N = 37) Kenya (2014) to examine the frequency of matatu use for facility visits. There were 141 (Informal = 71; Formal = 70) study clusters in Nairoibi and 73 (Informal = 37; Formal = 36) in Kisumu. On average, residential clusters in both cities were located ≤1 km from a facility offering LARCs and ≤ 1 km from approximately three or more matatu stops on direct routes regardless of settlement status. Client exit interview data in Nairobi (N = 1602) and Kisumu (N = 1158) suggest that about 25% of women use matatus to visit health facilities. On average, women who utilized matatus travelled 30 min to the facility, with 5% travelling more than 1 hour. Matatu use increased with greater household wealth. Overall, formal and informal settlement clusters were within walking distance of a facility offering LARCs, and multiple matatu stops were accessible to get to further away facilities. This level of access will be beneficial as efforts to increase LARC use expand, but the role of wealth and transportation costs on access should be considered, especially among urban poor.},
  chemicals       = {Contraceptive Agents},
  citation-subset = {IM},
  completed       = {2020-04-23},
  country         = {England},
  doi             = {10.1186/s12978-019-0828-0},
  issn-linking    = {1742-4755},
  issue           = {1},
  keywords        = {Adolescent; Adult; Cities; Contraceptive Agents, supply & distribution; Family Planning Services, statistics & numerical data; Female; Health Facilities, statistics & numerical data; Health Services Accessibility; Humans; Kenya; Long-Acting Reversible Contraception, statistics & numerical data; Middle Aged; Rural Population; Young Adult; Health facility access; Long-acting reversible contraceptive methods (LARC); Matatus; Public transportation access; Reproductive health},
  nlm-id          = {101224380},
  owner           = {NLM},
  pii             = {10.1186/s12978-019-0828-0},
  pmc             = {PMC6839122},
  pmid            = {31703700},
  pubmodel        = {Electronic},
  pubstate        = {epublish},
  revised         = {2020-04-23},
}

Despite improved health facility access relative to rural areas, distance and transportation remain barriers in some urban areas. Using household and facility data linked to residential and transportation geographic information we describe availability of health facilities offering long-acting reversible contraceptive (LARC) methods and measure access via matatus (privately owned mid-size vehicles providing public transport) in urban Kenya. Study data were collected by the Measurement, Learning and Evaluation (MLE) Project. Location information for clusters (2010) representative of city-level population were used to identify formal and informal settlement residents. We measured straight-line distances between clusters and facilities that participated in facility audits (2014) and offered LARCs. In Kisumu, we created a geographic database of matatu routes using Google Earth. In Nairobi, matatu route data were publicly available via the Digital Matatus Project. We measured straight-line distance between clusters and matatu stops on 'direct' routes (matatu routes with stop(s) ≤1 km from health facility offering LARCs). Facility and matatu access were compared by settlement status using descriptive statistics. We then used client exit interview data from a subset of facilities in Nairobi (N = 56) and Kisumu (N = 37) Kenya (2014) to examine the frequency of matatu use for facility visits. There were 141 (Informal = 71; Formal = 70) study clusters in Nairoibi and 73 (Informal = 37; Formal = 36) in Kisumu. On average, residential clusters in both cities were located ≤1 km from a facility offering LARCs and ≤ 1 km from approximately three or more matatu stops on direct routes regardless of settlement status. Client exit interview data in Nairobi (N = 1602) and Kisumu (N = 1158) suggest that about 25% of women use matatus to visit health facilities. On average, women who utilized matatus travelled 30 min to the facility, with 5% travelling more than 1 hour. Matatu use increased with greater household wealth. Overall, formal and informal settlement clusters were within walking distance of a facility offering LARCs, and multiple matatu stops were accessible to get to further away facilities. This level of access will be beneficial as efforts to increase LARC use expand, but the role of wealth and transportation costs on access should be considered, especially among urban poor.

@Article{Speizer2019,
  author          = {Speizer, Ilene S. and Guilkey, David K. and Escamilla, Veronica and Lance, Peter M. and Calhoun, Lisa M. and Ojogun, Osifo T. and Fasiku, David},
  journal         = {PloS one},
  title           = {On the sustainability of a family planning program in Nigeria when funding ends.},
  year            = {2019},
  issn            = {1932-6203},
  pages           = {e0222790},
  volume          = {14},
  abstract        = {Few studies have examined the sustainability of family planning program outcomes in the post-program period. This article presents the results of a natural experiment where the Nigerian Urban Reproductive Health Initiative Phase I programming ended in early 2015 and Phase II activities continued in a subset of cities. Using data collected in 2015 and 2017, we compare contraceptive ideation and modern family planning use in two cities: Ilorin where program activities concluded in 2015 and Kaduna where program activities continued. The results demonstrate that exposure to program activities decreased in Ilorin but for those individuals reporting continuing exposure, the effect size of exposure on modern family planning use remained the same and was not significantly different from Kaduna. Modern family planning use continued to increase in both cites but at a lower rate than during Phase I. The results are useful for designing family planning programs that sustain beyond the life of the program.},
  citation-subset = {IM},
  completed       = {2020-04-02},
  country         = {United States},
  doi             = {10.1371/journal.pone.0222790},
  issn-linking    = {1932-6203},
  issue           = {9},
  keywords        = {Adolescent; Adult; Contraception Behavior, statistics & numerical data; Family Planning Services, organization & administration; Female; Health Plan Implementation; Humans; Longitudinal Studies; Middle Aged; Nigeria; Program Evaluation; Reproductive Health, statistics & numerical data; Sex Education, organization & administration, statistics & numerical data; Socioeconomic Factors; Urban Population, statistics & numerical data; Young Adult},
  nlm-id          = {101285081},
  owner           = {NLM},
  pii             = {PONE-D-19-12246},
  pmc             = {PMC6762171},
  pmid            = {31557217},
  pubmodel        = {Electronic-eCollection},
  pubstate        = {epublish},
  revised         = {2020-04-02},
}

Few studies have examined the sustainability of family planning program outcomes in the post-program period. This article presents the results of a natural experiment where the Nigerian Urban Reproductive Health Initiative Phase I programming ended in early 2015 and Phase II activities continued in a subset of cities. Using data collected in 2015 and 2017, we compare contraceptive ideation and modern family planning use in two cities: Ilorin where program activities concluded in 2015 and Kaduna where program activities continued. The results demonstrate that exposure to program activities decreased in Ilorin but for those individuals reporting continuing exposure, the effect size of exposure on modern family planning use remained the same and was not significantly different from Kaduna. Modern family planning use continued to increase in both cites but at a lower rate than during Phase I. The results are useful for designing family planning programs that sustain beyond the life of the program.

@Article{Dominguez2019,
  author          = {Dominguez, Ricardo L. and Cherry, Charlotte B. and Estevez-Ordonez, Dago and Mera, Robertino and Escamilla, Veronica and Pawlita, Michael and Waterboer, Tim and Wilson, Keith T. and Peek, Richard M. and Tavera, Gloria and Williams, Scott M. and Gulley, Margaret L. and Emch, Michael and Morgan, Douglas R.},
  journal         = {BMC cancer},
  title           = {Geospatial analyses identify regional hot spots of diffuse gastric cancer in rural Central America.},
  year            = {2019},
  issn            = {1471-2407},
  month           = jun,
  pages           = {545},
  volume          = {19},
  abstract        = {Geospatial technology has facilitated the discovery of disease distributions and etiology and helped target prevention programs. Globally, gastric cancer is the leading infection-associated cancer, and third leading cause of cancer mortality worldwide, with marked geographic variation. Central and South America have a significant burden, particularly in the mountainous regions. In the context of an ongoing population-based case-control study in Central America, our aim was to examine the spatial epidemiology of gastric cancer subtypes and H. pylori virulence factors. Patients diagnosed with gastric cancer from 2002 to 2013 in western Honduras were identified in the prospective gastric cancer registry at the principal district hospital. Diagnosis was based on endoscopy and confirmatory histopathology. Geospatial methods were applied using the ArcGIS v10.3.1 and SaTScan v9.4.2 platforms to examine regional distributions of the gastric cancer histologic subtypes (Lauren classification), and the H. pylori CagA virulence factor. Getis-Ord-Gi hot spot and Discrete Poisson SaTScan statistics, respectively, were used to explore spatial clustering at the village level (30-50 rural households), with standardization by each village's population. H. pylori and CagA serologic status was determined using the novel H. pylori multiplex assay (DKFZ, Germany). Three hundred seventy-eight incident cases met the inclusion criteria (mean age 63.7, male 66.3%). Areas of higher gastric cancer incidence were identified. Significant spatial clustering of diffuse histology adenocarcinoma was revealed both by the Getis-Ord-GI* hot spot analysis (P-value < 0.0015; range 0.00003-0.0014; 99%CI), and by the SaTScan statistic (P-value < 0.006; range 0.0026-0.0054). The intestinal subtype was randomly distributed. H. pylori CagA had significant spatial clustering only in association with the diffuse histology cancer hot spot (Getis-Ord-Gi* P value ≤0.001; range 0.0001-0.0010; SaTScan statistic P value 0.0085). In the diffuse gastric cancer hot spot, the lowest age quartile range was 21-46 years, significantly lower than the intestinal cancers (P = 0.024). Geospatial methods have identified a significant cluster of incident diffuse type adenocarcinoma cases in rural Central America, suggest of a germline genetic association. Further genomic and geospatial analyses to identify potential spatial patterns of genetic, bacterial, and environmental risk factors may be informative.},
  citation-subset = {IM},
  completed       = {2019-11-20},
  country         = {England},
  doi             = {10.1186/s12885-019-5726-x},
  issn-linking    = {1471-2407},
  issue           = {1},
  keywords        = {Aged; Case-Control Studies; Central America, epidemiology; Disease Susceptibility; Female; Geography; Helicobacter Infections, complications, microbiology; Helicobacter pylori; Humans; Male; Middle Aged; Risk Assessment; Risk Factors; Rural Health; Spatial Analysis; Stomach Neoplasms, epidemiology, etiology, pathology; CA-4; Central America; Diffuse gastric cancer; Gastric cancer; Germline mutations; H. pylori; Honduras},
  nlm-id          = {100967800},
  owner           = {NLM},
  pii             = {10.1186/s12885-019-5726-x},
  pmc             = {PMC6554991},
  pmid            = {31174492},
  pubmodel        = {Electronic},
  pubstate        = {epublish},
  revised         = {2020-03-25},
}

Geospatial technology has facilitated the discovery of disease distributions and etiology and helped target prevention programs. Globally, gastric cancer is the leading infection-associated cancer, and third leading cause of cancer mortality worldwide, with marked geographic variation. Central and South America have a significant burden, particularly in the mountainous regions. In the context of an ongoing population-based case-control study in Central America, our aim was to examine the spatial epidemiology of gastric cancer subtypes and H. pylori virulence factors. Patients diagnosed with gastric cancer from 2002 to 2013 in western Honduras were identified in the prospective gastric cancer registry at the principal district hospital. Diagnosis was based on endoscopy and confirmatory histopathology. Geospatial methods were applied using the ArcGIS v10.3.1 and SaTScan v9.4.2 platforms to examine regional distributions of the gastric cancer histologic subtypes (Lauren classification), and the H. pylori CagA virulence factor. Getis-Ord-Gi hot spot and Discrete Poisson SaTScan statistics, respectively, were used to explore spatial clustering at the village level (30-50 rural households), with standardization by each village's population. H. pylori and CagA serologic status was determined using the novel H. pylori multiplex assay (DKFZ, Germany). Three hundred seventy-eight incident cases met the inclusion criteria (mean age 63.7, male 66.3%). Areas of higher gastric cancer incidence were identified. Significant spatial clustering of diffuse histology adenocarcinoma was revealed both by the Getis-Ord-GI* hot spot analysis (P-value < 0.0015; range 0.00003-0.0014; 99%CI), and by the SaTScan statistic (P-value < 0.006; range 0.0026-0.0054). The intestinal subtype was randomly distributed. H. pylori CagA had significant spatial clustering only in association with the diffuse histology cancer hot spot (Getis-Ord-Gi* P value ≤0.001; range 0.0001-0.0010; SaTScan statistic P value 0.0085). In the diffuse gastric cancer hot spot, the lowest age quartile range was 21-46 years, significantly lower than the intestinal cancers (P = 0.024). Geospatial methods have identified a significant cluster of incident diffuse type adenocarcinoma cases in rural Central America, suggest of a germline genetic association. Further genomic and geospatial analyses to identify potential spatial patterns of genetic, bacterial, and environmental risk factors may be informative.

@Article{Ross2019,
  author          = {Ross, Jerlinda G. C. and Escamilla, Veronica and Lee, Nita Karnik and Diane Yamada, S. and Lindau, Stacy Tessler},
  journal         = {Gynecologic oncology},
  title           = {Geospatial patterns of access to self-care resources for obesity among endometrial cancer survivors in a high poverty urban community.},
  year            = {2019},
  issn            = {1095-6859},
  month           = feb,
  pages           = {322--327},
  volume          = {152},
  abstract        = {To examine endometrial cancer survivors' access to recommended obesity-related self-care resources. Participants included women treated 2010-2015 for endometrial cancer at an academic medical center who lived in the surrounding 16 ZIP code area on Chicago's South Side. Demographic and health data were abstracted from medical records. A socioeconomic status (SES) score (SES-1 = low, SES-5 = high) was generated for each patient using census block group-level data. Self-care resources for exercise, healthy weight, and diet were obtained from a community resource census. Geospatial techniques assessed "walkable access" (~½-mile radius around a patient's home) to obesity-related resources. Multivariable logistic regression investigated associations between access to obesity-related resources and patient characteristics. Of 195 endometrial cancer survivors, 81% identified as Black/African American and 34% lived in an SES-1 census block. Two thirds (68%) had Stage I or II endometrial cancer. Nearly two thirds (62%) were obese (BMI ≥ 30 kg/m ). Obesity was inversely associated with SES (p = 0.05). Two thirds of survivors had access to at least one of all three recommended resource types. Access was lower in low SES regions and among Black/African American women. Lower SES was associated with lower odds of walkable access to recommended resources (AOR for access to two of each resource type 0.75, 95%CI 0.59, 0.97; AOR for access to three or more of each 0.44, 95%CI 0.32, 0.61). Obesity rates were higher and access to recommended resources was lower for Black/African American endometrial cancer survivors living in high poverty areas in Chicago.},
  citation-subset = {IM},
  completed       = {2019-02-21},
  country         = {United States},
  doi             = {10.1016/j.ygyno.2018.12.005},
  issn-linking    = {0090-8258},
  issue           = {2},
  keywords        = {Adult; African Americans, statistics & numerical data; Aged; Aged, 80 and over; Cancer Survivors, statistics & numerical data; Chicago, epidemiology; Endometrial Neoplasms, epidemiology, mortality; Female; Health Resources, statistics & numerical data; Humans; Middle Aged; Obesity, epidemiology; Poverty, statistics & numerical data; Self Care, statistics & numerical data; Urban Population; Access; Endometrial cancer; Obesity; Socioeconomic status; Yost index},
  nlm-id          = {0365304},
  owner           = {NLM},
  pii             = {S0090-8258(18)31470-7},
  pmid            = {30581035},
  pubmodel        = {Print-Electronic},
  pubstate        = {ppublish},
  revised         = {2019-02-21},
}

To examine endometrial cancer survivors' access to recommended obesity-related self-care resources. Participants included women treated 2010-2015 for endometrial cancer at an academic medical center who lived in the surrounding 16 ZIP code area on Chicago's South Side. Demographic and health data were abstracted from medical records. A socioeconomic status (SES) score (SES-1 = low, SES-5 = high) was generated for each patient using census block group-level data. Self-care resources for exercise, healthy weight, and diet were obtained from a community resource census. Geospatial techniques assessed "walkable access" ( ½-mile radius around a patient's home) to obesity-related resources. Multivariable logistic regression investigated associations between access to obesity-related resources and patient characteristics. Of 195 endometrial cancer survivors, 81% identified as Black/African American and 34% lived in an SES-1 census block. Two thirds (68%) had Stage I or II endometrial cancer. Nearly two thirds (62%) were obese (BMI ≥ 30 kg/m ). Obesity was inversely associated with SES (p = 0.05). Two thirds of survivors had access to at least one of all three recommended resource types. Access was lower in low SES regions and among Black/African American women. Lower SES was associated with lower odds of walkable access to recommended resources (AOR for access to two of each resource type 0.75, 95%CI 0.59, 0.97; AOR for access to three or more of each 0.44, 95%CI 0.32, 0.61). Obesity rates were higher and access to recommended resources was lower for Black/African American endometrial cancer survivors living in high poverty areas in Chicago.

@Article{Wu2018,
  author          = {Wu, Jianyong and Yunus, Mohammad and Ali, Mohammad and Escamilla, Veronica and Emch, Michael},
  journal         = {Environment international},
  title           = {Influences of heatwave, rainfall, and tree cover on cholera in Bangladesh.},
  year            = {2018},
  issn            = {1873-6750},
  month           = nov,
  pages           = {304--311},
  volume          = {120},
  abstract        = {Cholera is a severe diarrheal disease and remains a global threat to public health. Climate change and variability have the potential to increase the distribution and magnitude of cholera outbreaks. However, the effect of heatwave on the occurrence of cholera at individual level is still unclear. It is also unknown whether the local vegetation could potentially mitigate the effects of extreme heat on cholera outbreaks. In this study, we designed a case-crossover study to examine the association between the risk of cholera and heatwaves as well as the modification effects of rainfall and tree cover. The study was conducted in Matlab, a cholera endemic area of rural Bangladesh, where cholera case data were collected between January 1983 and April 2009. The association between the risk of cholera and heatwaves was examined using conditional logistic regression models. The results showed that there was a higher risk of cholera two days after heatwaves (OR = 1.53, 95% CI: 1.07-2.19) during wet days (rainfall > 0 mm). For households with less medium-dense tree cover, the heatwave after a 2-day lag was positively associated (OR = 1.80, 95% CI: 1.01-3.22) with the risk of cholera during wet days. However, for households with more medium-dense tree cover, the association between the risk of cholera and heatwave in 2-day lag was not significant. These findings suggest that heatwaves might promote the occurrence of cholera, while this relationship was modified by rainfall and tree cover. Further investigations are needed to explore major mechanisms underlying the association between heatwaves and cholera as well as the beneficial effects of tree cover.},
  citation-subset = {IM},
  completed       = {2019-03-13},
  country         = {Netherlands},
  doi             = {10.1016/j.envint.2018.08.012},
  issn-linking    = {0160-4120},
  keywords        = {Adolescent; Adult; Bangladesh, epidemiology; Child; Child, Preschool; Cholera, epidemiology; Climate Change; Disease Outbreaks; Extreme Heat; Female; Humans; Infant; Infant, Newborn; Male; Middle Aged; Odds Ratio; Trees; Young Adult; Case-crossover; Climate extreme; Greenspace; Infectious disease; Temperature},
  mid             = {NIHMS993197},
  nlm-id          = {7807270},
  owner           = {NLM},
  pii             = {S0160-4120(18)30499-9},
  pmc             = {PMC6690386},
  pmid            = {30107291},
  pubmodel        = {Print-Electronic},
  pubstate        = {ppublish},
  revised         = {2020-02-25},
}

Cholera is a severe diarrheal disease and remains a global threat to public health. Climate change and variability have the potential to increase the distribution and magnitude of cholera outbreaks. However, the effect of heatwave on the occurrence of cholera at individual level is still unclear. It is also unknown whether the local vegetation could potentially mitigate the effects of extreme heat on cholera outbreaks. In this study, we designed a case-crossover study to examine the association between the risk of cholera and heatwaves as well as the modification effects of rainfall and tree cover. The study was conducted in Matlab, a cholera endemic area of rural Bangladesh, where cholera case data were collected between January 1983 and April 2009. The association between the risk of cholera and heatwaves was examined using conditional logistic regression models. The results showed that there was a higher risk of cholera two days after heatwaves (OR = 1.53, 95% CI: 1.07-2.19) during wet days (rainfall > 0 mm). For households with less medium-dense tree cover, the heatwave after a 2-day lag was positively associated (OR = 1.80, 95% CI: 1.01-3.22) with the risk of cholera during wet days. However, for households with more medium-dense tree cover, the association between the risk of cholera and heatwave in 2-day lag was not significant. These findings suggest that heatwaves might promote the occurrence of cholera, while this relationship was modified by rainfall and tree cover. Further investigations are needed to explore major mechanisms underlying the association between heatwaves and cholera as well as the beneficial effects of tree cover.

@Article{Escamilla2018,
  author          = {Escamilla, Veronica and Calhoun, Lisa and Winston, Jennifer and Speizer, Ilene S.},
  journal         = {Journal of urban health : bulletin of the New York Academy of Medicine},
  title           = {The Role of Distance and Quality on Facility Selection for Maternal and Child Health Services in Urban Kenya.},
  year            = {2018},
  issn            = {1468-2869},
  month           = feb,
  pages           = {1--12},
  volume          = {95},
  abstract        = {Universal access to health care requires service availability and accessibility for those most in need of maternal and child health services. Women often bypass facilities closest to home due to poor quality. Few studies have directly linked individuals to facilities where they sought maternal and child health services and examined the role of distance and quality on this facility choice. Using endline data from a longitudinal survey from a sample of women in five cities in Kenya, we examine the role of distance and quality on facility selection for women using delivery, facility-based contraceptives, and child health services. A survey of public and private facilities offering reproductive health services was also conducted. Distances were measured between household cluster location and both the nearest facility and facility where women sought care. A quality index score representing facility infrastructure, staff, and supply characteristics was assigned to each facility. We use descriptive statistics to compare distance and quality between the nearest available facility and visited facility among women who bypassed the nearest facility. Facility distance and quality comparisons were also stratified by poverty status. Logistic regression models were used to measure associations between the quality and distance to the nearest facility and bypassing for each outcome. The majority of women bypassed the nearest facility regardless of service sought. Women bypassing for delivery traveled the furthest and had the fewest facility options near their residential cluster. Poor women bypassing for delivery traveled 4.5 km further than non-poor women. Among women who bypassed, two thirds seeking delivery and approximately 46% seeking facility-based contraception or child health services bypassed to a public hospital. Both poor and non-poor women bypassed to higher quality facilities. Our findings suggest that women in five cities in Kenya prefer public hospitals and are willing to travel further to obtain services at public hospitals, possibly related to free service availability. Over time, it will be important to examine service quality and availability in public sector facilities with reduced or eliminated user fees, and whether it lends itself to a continuum of care where women can visit one facility for multiple services reducing travel burden.},
  citation-subset = {IM},
  completed       = {2019-10-10},
  country         = {United States},
  doi             = {10.1007/s11524-017-0212-8},
  issn-linking    = {1099-3460},
  issue           = {1},
  keywords        = {Adolescent; Adult; Child; Child Health Services, organization & administration, statistics & numerical data; Female; Geography; Health Services Accessibility, organization & administration, statistics & numerical data; Humans; Kenya; Maternal Health Services, organization & administration, statistics & numerical data; Middle Aged; Pregnancy; Surveys and Questionnaires; Urban Health Services, organization & administration; Young Adult; Health service access; Kenya; Urban reproductive health},
  nlm-id          = {9809909},
  owner           = {NLM},
  pii             = {10.1007/s11524-017-0212-8},
  pmc             = {PMC5862698},
  pmid            = {29270709},
  pubmodel        = {Print},
  pubstate        = {ppublish},
  revised         = {2019-10-10},
}

Universal access to health care requires service availability and accessibility for those most in need of maternal and child health services. Women often bypass facilities closest to home due to poor quality. Few studies have directly linked individuals to facilities where they sought maternal and child health services and examined the role of distance and quality on this facility choice. Using endline data from a longitudinal survey from a sample of women in five cities in Kenya, we examine the role of distance and quality on facility selection for women using delivery, facility-based contraceptives, and child health services. A survey of public and private facilities offering reproductive health services was also conducted. Distances were measured between household cluster location and both the nearest facility and facility where women sought care. A quality index score representing facility infrastructure, staff, and supply characteristics was assigned to each facility. We use descriptive statistics to compare distance and quality between the nearest available facility and visited facility among women who bypassed the nearest facility. Facility distance and quality comparisons were also stratified by poverty status. Logistic regression models were used to measure associations between the quality and distance to the nearest facility and bypassing for each outcome. The majority of women bypassed the nearest facility regardless of service sought. Women bypassing for delivery traveled the furthest and had the fewest facility options near their residential cluster. Poor women bypassing for delivery traveled 4.5 km further than non-poor women. Among women who bypassed, two thirds seeking delivery and approximately 46% seeking facility-based contraception or child health services bypassed to a public hospital. Both poor and non-poor women bypassed to higher quality facilities. Our findings suggest that women in five cities in Kenya prefer public hospitals and are willing to travel further to obtain services at public hospitals, possibly related to free service availability. Over time, it will be important to examine service quality and availability in public sector facilities with reduced or eliminated user fees, and whether it lends itself to a continuum of care where women can visit one facility for multiple services reducing travel burden.

@Article{Drakeley2017,
  author          = {Drakeley, Chris and Abdulla, Salim and Agnandji, Selidji Todagbe and Fernandes, José Francisco and Kremsner, Peter and Lell, Bertrand and Mewono, Ludovic and Bache, Bache Emmanuel and Mihayo, Michael Gabriel and Juma, Omar and Tanner, Marcel and Tahita, Marc Christian and Tinto, Halidou and Diallo, Salou and Lompo, Palpouguini and D'Alessandro, Umberto and Ogutu, Bernhards and Otieno, Lucas and Otieno, Solomon and Otieno, Walter and Oyieko, Janet and Asante, Kwaku Poku and Dery, Dominic Bon-Ereme and Adjei, George and Adeniji, Elisha and Atibilla, Dorcas and Owusu-Agyei, Seth and Greenwood, Brian and Gesase, Samwel and Lusingu, John and Mahende, Coline and Mongi, Robert and Segeja, Method and Adjei, Samuel and Agbenyega, Tsiri and Agyekum, Alex and Ansong, Daniel and Bawa, John Tanko and Boateng, Harry Owusu and Dandalo, Léonard and Escamilla, Veronica and Hoffman, Irving and Maenje, Peter and Martinson, Francis and Carter, Terrell and Leboulleux, Didier and Kaslow, David C. and Usuf, Effua and Pirçon, Jean-Yves and Bahmanyar, Edith Roset},
  journal         = {Malaria journal},
  title           = {Longitudinal estimation of Plasmodium falciparum prevalence in relation to malaria prevention measures in six sub-Saharan African countries.},
  year            = {2017},
  issn            = {1475-2875},
  month           = oct,
  pages           = {433},
  volume          = {16},
  abstract        = {Plasmodium falciparum prevalence (PfPR) is a widely used metric for assessing malaria transmission intensity. This study was carried out concurrently with the RTS,S/AS01 candidate malaria vaccine Phase III trial and estimated PfPR over ≤ 4 standardized cross-sectional surveys. This epidemiology study (NCT01190202) was conducted in 8 sites from 6 countries (Burkina Faso, Gabon, Ghana, Kenya, Malawi, and Tanzania), between March 2011 and December 2013. Participants were enrolled in a 2:1:1 ratio according to age category: 6 months-4 years, 5-19 years, and ≥ 20 years, respectively, per year and per centre. All sites carried out surveys 1-3 while survey 4 was conducted only in 3 sites. Surveys were usually performed during the peak malaria parasite transmission season, in one home visit, when medical history and malaria risk factors/prevention measures were collected, and a blood sample taken for rapid diagnostic test, microscopy, and haemoglobin measurement. PfPR was estimated by site and age category. Overall, 6401 (survey 1), 6411 (survey 2), 6400 (survey 3), and 2399 (survey 4) individuals were included in the analyses. In the 6 months-4 years age group, the lowest prevalence (assessed using microscopy) was observed in 2 Tanzanian centres (4.6% for Korogwe and 9.95% for Bagamoyo) and Lambaréné, Gabon (6.0%), while the highest PfPR was recorded for Nanoro, Burkina Faso (52.5%). PfPR significantly decreased over the 3 years in Agogo (Ghana), Kombewa (Kenya), Lilongwe (Malawi), and Bagamoyo (Tanzania), and a trend for increased PfPR was observed over the 4 surveys for Kintampo, Ghana. Over the 4 surveys, for all sites, PfPR was predominantly higher in the 5-19 years group than in the other age categories. Occurrence of fever and anaemia was associated with high P. falciparum parasitaemia. Univariate analyses showed a significant association of anti-malarial treatment in 4 surveys (odds ratios [ORs]: 0.52, 0.52, 0.68, 0.41) and bed net use in 2 surveys (ORs: 0.63, 0.68, 1.03, 1.78) with lower risk of malaria infection. Local PfPR differed substantially between sites and age groups. In children 6 months-4 years old, a significant decrease in prevalence over the 3 years was observed in 4 out of the 8 study sites. Trial registration Clinical Trials.gov identifier: NCT01190202:NCT. GSK Study ID numbers: 114001.},
  citation-subset = {IM},
  completed       = {2018-05-14},
  country         = {England},
  doi             = {10.1186/s12936-017-2078-3},
  issn-linking    = {1475-2875},
  issue           = {1},
  keywords        = {Adolescent; Adult; Africa South of the Sahara, epidemiology; Aged; Child; Child, Preschool; Cross-Sectional Studies; Female; Humans; Infant; Malaria, Falciparum, epidemiology, prevention & control; Male; Middle Aged; Plasmodium falciparum, isolation & purification; Prevalence; Young Adult; Anaemia; Epidemiology; Malaria; Plasmodium falciparum; Prevalence; Transmission},
  nlm-id          = {101139802},
  owner           = {NLM},
  pii             = {10.1186/s12936-017-2078-3},
  pmc             = {PMC5658967},
  pmid            = {29078773},
  pubmodel        = {Electronic},
  pubstate        = {epublish},
  revised         = {2018-11-13},
}

Plasmodium falciparum prevalence (PfPR) is a widely used metric for assessing malaria transmission intensity. This study was carried out concurrently with the RTS,S/AS01 candidate malaria vaccine Phase III trial and estimated PfPR over ≤ 4 standardized cross-sectional surveys. This epidemiology study (NCT01190202) was conducted in 8 sites from 6 countries (Burkina Faso, Gabon, Ghana, Kenya, Malawi, and Tanzania), between March 2011 and December 2013. Participants were enrolled in a 2:1:1 ratio according to age category: 6 months-4 years, 5-19 years, and ≥ 20 years, respectively, per year and per centre. All sites carried out surveys 1-3 while survey 4 was conducted only in 3 sites. Surveys were usually performed during the peak malaria parasite transmission season, in one home visit, when medical history and malaria risk factors/prevention measures were collected, and a blood sample taken for rapid diagnostic test, microscopy, and haemoglobin measurement. PfPR was estimated by site and age category. Overall, 6401 (survey 1), 6411 (survey 2), 6400 (survey 3), and 2399 (survey 4) individuals were included in the analyses. In the 6 months-4 years age group, the lowest prevalence (assessed using microscopy) was observed in 2 Tanzanian centres (4.6% for Korogwe and 9.95% for Bagamoyo) and Lambaréné, Gabon (6.0%), while the highest PfPR was recorded for Nanoro, Burkina Faso (52.5%). PfPR significantly decreased over the 3 years in Agogo (Ghana), Kombewa (Kenya), Lilongwe (Malawi), and Bagamoyo (Tanzania), and a trend for increased PfPR was observed over the 4 surveys for Kintampo, Ghana. Over the 4 surveys, for all sites, PfPR was predominantly higher in the 5-19 years group than in the other age categories. Occurrence of fever and anaemia was associated with high P. falciparum parasitaemia. Univariate analyses showed a significant association of anti-malarial treatment in 4 surveys (odds ratios [ORs]: 0.52, 0.52, 0.68, 0.41) and bed net use in 2 surveys (ORs: 0.63, 0.68, 1.03, 1.78) with lower risk of malaria infection. Local PfPR differed substantially between sites and age groups. In children 6 months-4 years old, a significant decrease in prevalence over the 3 years was observed in 4 out of the 8 study sites. Trial registration Clinical Trials.gov identifier: NCT01190202:NCT. GSK Study ID numbers: 114001.

@Article{Escamilla2017,
  author          = {Escamilla, Veronica and Alker, Alisa and Dandalo, Leonard and Juliano, Jonathan J. and Miller, William C. and Kamthuza, Portia and Tembo, Tapiwa and Tegha, Gerald and Martinson, Francis and Emch, Michael and Hoffman, Irving F.},
  journal         = {Malaria journal},
  title           = {Effects of community-level bed net coverage on malaria morbidity in Lilongwe, Malawi.},
  year            = {2017},
  issn            = {1475-2875},
  month           = apr,
  pages           = {142},
  volume          = {16},
  abstract        = {The protective effect of insecticide-treated bed nets against individual-level malaria transmission is well known, however community-level effects are less understood. Protective effects from community-level bed net use against malaria transmission have been observed in clinical trials, however, the relationship is less clear outside of a controlled research setting. The objective of this research was to investigate the effect of community-level bed net use against malaria transmission outside of a bed net clinical trial setting in Lilongwe, Malawi following national efforts to scale-up ownership of long-lasting, insecticide-treated bed nets. An annual, cross-sectional, household-randomized, malaria transmission intensity survey was conducted in Lilongwe, Malawi (2011-2013). Health, demographic, and geographic-location data were collected. Participant blood samples were tested for Plasmodium falciparum presence. The percentage of people sleeping under a bed net within 400-m and 1-km radii of all participants was measured. Mixed effects logistic regression models were used to measure the relationship between malaria prevalence and surrounding bed net coverage. Each year, 800 people were enrolled (400 <5 years; 200 5-19 years; 200 ≥20 years; total n = 2400). From 2011 to 2013, malaria prevalence declined from 12.9 to 5.6%, while bed net use increased from 53.8 to 78.6%. For every 1% increase in community bed net coverage, malaria prevalence decreased among children under 5 years old [adjusted odds ratio: 0.98 (0.96, 1.00)]. Similar effects were observed in participants 5-19 years [unadjusted odds ratio: 0.98 (0.97, 1.00)]; the effect was attenuated after adjusting for individual-level bed net use. Community coverage was not associated with malaria prevalence among adults ≥20 years. Supplemental analyses identified more pronounced indirect protective effects from community-level bed net use against malaria transmission among children under 5 years who were sleeping under a bed net [adjusted odds ratio: 0.97 (0.94, 0.99)], compared to children who were not sleeping under a bed net [adjusted odds ratio: 0.99 (0.97, 1.01)]. Malawi's efforts to scale up ownership of long-lasting, insecticide-treated bed nets are effective in increasing reported use. Increased community-level bed net coverage appears to provide additional protection against malaria transmission beyond individual use in a real-world context.},
  citation-subset = {IM},
  completed       = {2017-06-08},
  country         = {England},
  doi             = {10.1186/s12936-017-1767-2},
  issn-linking    = {1475-2875},
  issue           = {1},
  keywords        = {Adolescent; Adult; Aged; Aged, 80 and over; Child; Child, Preschool; Cross-Sectional Studies; Disease Transmission, Infectious, prevention & control; Family Characteristics; Female; Humans; Infant; Infant, Newborn; Insecticide-Treated Bednets, statistics & numerical data; Malaria, Falciparum, epidemiology, prevention & control; Malawi, epidemiology; Male; Middle Aged; Mosquito Control, methods; Plasmodium falciparum; Prevalence; Random Allocation; Young Adult},
  nlm-id          = {101139802},
  owner           = {NLM},
  pii             = {10.1186/s12936-017-1767-2},
  pmc             = {PMC5383956},
  pmid            = {28388914},
  pubmodel        = {Electronic},
  pubstate        = {epublish},
  revised         = {2018-12-02},
}

The protective effect of insecticide-treated bed nets against individual-level malaria transmission is well known, however community-level effects are less understood. Protective effects from community-level bed net use against malaria transmission have been observed in clinical trials, however, the relationship is less clear outside of a controlled research setting. The objective of this research was to investigate the effect of community-level bed net use against malaria transmission outside of a bed net clinical trial setting in Lilongwe, Malawi following national efforts to scale-up ownership of long-lasting, insecticide-treated bed nets. An annual, cross-sectional, household-randomized, malaria transmission intensity survey was conducted in Lilongwe, Malawi (2011-2013). Health, demographic, and geographic-location data were collected. Participant blood samples were tested for Plasmodium falciparum presence. The percentage of people sleeping under a bed net within 400-m and 1-km radii of all participants was measured. Mixed effects logistic regression models were used to measure the relationship between malaria prevalence and surrounding bed net coverage. Each year, 800 people were enrolled (400 <5 years; 200 5-19 years; 200 ≥20 years; total n = 2400). From 2011 to 2013, malaria prevalence declined from 12.9 to 5.6%, while bed net use increased from 53.8 to 78.6%. For every 1% increase in community bed net coverage, malaria prevalence decreased among children under 5 years old [adjusted odds ratio: 0.98 (0.96, 1.00)]. Similar effects were observed in participants 5-19 years [unadjusted odds ratio: 0.98 (0.97, 1.00)]; the effect was attenuated after adjusting for individual-level bed net use. Community coverage was not associated with malaria prevalence among adults ≥20 years. Supplemental analyses identified more pronounced indirect protective effects from community-level bed net use against malaria transmission among children under 5 years who were sleeping under a bed net [adjusted odds ratio: 0.97 (0.94, 0.99)], compared to children who were not sleeping under a bed net [adjusted odds ratio: 0.99 (0.97, 1.01)]. Malawi's efforts to scale up ownership of long-lasting, insecticide-treated bed nets are effective in increasing reported use. Increased community-level bed net coverage appears to provide additional protection against malaria transmission beyond individual use in a real-world context.

@Article{Lindau2016,
  author          = {Lindau, Stacy T. and Makelarski, Jennifer and Abramsohn, Emily and Beiser, David G. and Escamilla, Veronica and Jerome, Jessica and Johnson, Daniel and Kho, Abel N. and Lee, Karen K. and Long, Timothy and Miller, Doriane C.},
  journal         = {Health affairs (Project Hope)},
  title           = {CommunityRx: A Population Health Improvement Innovation That Connects Clinics To Communities.},
  year            = {2016},
  issn            = {1544-5208},
  month           = nov,
  pages           = {2020--2029},
  volume          = {35},
  abstract        = {The CommunityRx system, a population health innovation, combined an e-prescribing model and community engagement to strengthen links between clinics and community resources for basic, wellness, and disease self-management needs in Chicago. The components of CommunityRx were a youth workforce, whose members identified 19,589 public-serving entities in the 106-square-mile implementation region between 2012 and 2014; community health information specialists, who used the workforce's findings to generate an inventory of 14,914 health-promoting resources; and a health information technology (IT) platform that was integrated with three electronic health record systems at thirty-three clinical sites. By mapping thirty-seven prevalent social and medical conditions to community resources, CommunityRx generated 253,479 personalized HealtheRx prescriptions for more than 113,000 participants. Eighty-three percent of the recipients found the HealtheRx very useful, and 19 percent went to a place they learned about from the HealtheRx. All but one organization continued using the CommunityRx system after the study period ended. This study demonstrates the feasibility of using health IT and workforce innovation to bridge the gap between clinical and other health-promoting sectors.},
  citation-subset = {IM},
  completed       = {2018-03-12},
  country         = {United States},
  doi             = {10.1377/hlthaff.2016.0694},
  issn-linking    = {0278-2715},
  issue           = {11},
  keywords        = {Chicago; Community Health Centers, organization & administration; Electronic Prescribing; Health Promotion, methods; Humans; Medical Informatics, methods; Population Health; Cross-Sector; Determinants Of Health; Health Promotion/Disease Prevention; Information Technology; Population Health},
  mid             = {NIHMS868186},
  nlm-id          = {8303128},
  owner           = {NLM},
  pii             = {35/11/2020},
  pmc             = {PMC5573228},
  pmid            = {27834242},
  pubmodel        = {Print},
  pubstate        = {ppublish},
  revised         = {2018-11-13},
}

The CommunityRx system, a population health innovation, combined an e-prescribing model and community engagement to strengthen links between clinics and community resources for basic, wellness, and disease self-management needs in Chicago. The components of CommunityRx were a youth workforce, whose members identified 19,589 public-serving entities in the 106-square-mile implementation region between 2012 and 2014; community health information specialists, who used the workforce's findings to generate an inventory of 14,914 health-promoting resources; and a health information technology (IT) platform that was integrated with three electronic health record systems at thirty-three clinical sites. By mapping thirty-seven prevalent social and medical conditions to community resources, CommunityRx generated 253,479 personalized HealtheRx prescriptions for more than 113,000 participants. Eighty-three percent of the recipients found the HealtheRx very useful, and 19 percent went to a place they learned about from the HealtheRx. All but one organization continued using the CommunityRx system after the study period ended. This study demonstrates the feasibility of using health IT and workforce innovation to bridge the gap between clinical and other health-promoting sectors.

@Article{Gopalan2016,
  author          = {Gopalan, Anjali and Makelarski, Jennifer A. and Garibay, Lori B. and Escamilla, Veronica and Merchant, Raina M. and Wolfe, Marcus B. and Holbrook, Rebecca and Lindau, Stacy Tessler},
  journal         = {Journal of medical Internet research},
  title           = {Health-Specific Information and Communication Technology Use and Its Relationship to Obesity in High-Poverty, Urban Communities: Analysis of a Population-Based Biosocial Survey.},
  year            = {2016},
  issn            = {1438-8871},
  month           = jun,
  pages           = {e182},
  volume          = {18},
  abstract        = {More than 35% of American adults are obese. For African American and Hispanic adults, as well as individuals residing in poorer or more racially segregated urban neighborhoods, the likelihood of obesity is even higher. Information and communication technologies (ICTs) may substitute for or complement community-based resources for weight management. However, little is currently known about health-specific ICT use among urban-dwelling people with obesity. We describe health-specific ICT use and its relationship to measured obesity among adults in high-poverty urban communities. Using data collected between November 2012 and July 2013 from a population-based probability sample of urban-dwelling African American and Hispanic adults residing on the South Side of Chicago, we described patterns of ICT use in relation to measured obesity defined by a body mass index (BMI) of ≥30 kg/m(2). Among those with BMI≥30 kg/m(2), we also assessed the association between health-specific ICT use and diagnosed versus undiagnosed obesity as well as differences in health-specific ICT use by self-reported comorbidities, including diabetes and hypertension. The survey response rate was 44.6% (267 completed surveys/598.4 eligible or likely eligible individuals); 53.2% were African American and 34.6% were Hispanic. More than 35% of the population reported an annual income of less than US $25,000. The population prevalence of measured obesity was 50.2%. People with measured obesity (BMI≥30 kg/m(2)) were more likely to report both general (81.5% vs 67.0%, P=.04) and health-specific (61.1% vs 41.2%, P=.01) ICT use. In contrast, among those with measured obesity, being told of this diagnosis by a physician was not associated with increased health-specific ICT use. People with measured obesity alone had higher rates of health-specific use than those with comorbid hypertension and/or diabetes diagnoses (77.1% vs 60.7% vs 47.4%, P=.04). In conclusion, ICT-based health resources may be particularly useful for people in high-poverty urban communities with isolated measured obesity, a population that is at high risk for poor health outcomes.},
  citation-subset = {IM},
  completed       = {2017-09-13},
  country         = {Canada},
  doi             = {10.2196/jmir.5741},
  issn-linking    = {1438-8871},
  issue           = {6},
  keywords        = {Adult; African Americans, statistics & numerical data; Aged; Chicago, epidemiology; Communication; Comorbidity; Diabetes Mellitus, epidemiology; Female; Health Resources, statistics & numerical data; Hispanic Americans, statistics & numerical data; Humans; Hypertension, epidemiology; Male; Medical Informatics, statistics & numerical data; Middle Aged; Obesity, epidemiology; Poverty, statistics & numerical data; Prevalence; Residence Characteristics; Surveys and Questionnaires; Urban Population, statistics & numerical data; Internet; obesity; technology; urban health},
  nlm-id          = {100959882},
  owner           = {NLM},
  pii             = {v18i6e182},
  pmc             = {PMC4942684},
  pmid            = {27352770},
  pubmodel        = {Electronic},
  pubstate        = {epublish},
  revised         = {2018-12-02},
}

More than 35% of American adults are obese. For African American and Hispanic adults, as well as individuals residing in poorer or more racially segregated urban neighborhoods, the likelihood of obesity is even higher. Information and communication technologies (ICTs) may substitute for or complement community-based resources for weight management. However, little is currently known about health-specific ICT use among urban-dwelling people with obesity. We describe health-specific ICT use and its relationship to measured obesity among adults in high-poverty urban communities. Using data collected between November 2012 and July 2013 from a population-based probability sample of urban-dwelling African American and Hispanic adults residing on the South Side of Chicago, we described patterns of ICT use in relation to measured obesity defined by a body mass index (BMI) of ≥30 kg/m(2). Among those with BMI≥30 kg/m(2), we also assessed the association between health-specific ICT use and diagnosed versus undiagnosed obesity as well as differences in health-specific ICT use by self-reported comorbidities, including diabetes and hypertension. The survey response rate was 44.6% (267 completed surveys/598.4 eligible or likely eligible individuals); 53.2% were African American and 34.6% were Hispanic. More than 35% of the population reported an annual income of less than US $25,000. The population prevalence of measured obesity was 50.2%. People with measured obesity (BMI≥30 kg/m(2)) were more likely to report both general (81.5% vs 67.0%, P=.04) and health-specific (61.1% vs 41.2%, P=.01) ICT use. In contrast, among those with measured obesity, being told of this diagnosis by a physician was not associated with increased health-specific ICT use. People with measured obesity alone had higher rates of health-specific use than those with comorbid hypertension and/or diabetes diagnoses (77.1% vs 60.7% vs 47.4%, P=.04). In conclusion, ICT-based health resources may be particularly useful for people in high-poverty urban communities with isolated measured obesity, a population that is at high risk for poor health outcomes.

@Article{Escamilla2016,
  author          = {Escamilla, Veronica and Hampton, Kristen H. and Gesink, Dionne C. and Serre, Marc L. and Emch, Michael and Leone, Peter A. and Samoff, Erika and Miller, William C.},
  journal         = {Sexually transmitted diseases},
  title           = {Influence of Detection Method and Study Area Scale on Syphilis Cluster Identification in North Carolina.},
  year            = {2016},
  issn            = {1537-4521},
  month           = apr,
  pages           = {216--221},
  volume          = {43},
  abstract        = {Identifying geographical clusters of sexually transmitted infections can aid in targeting prevention and control efforts. However, detectable clusters can vary between detection methods because of different underlying assumptions. Furthermore, because disease burden is not geographically homogenous, the reference population is sensitive to the study area scale, affecting cluster outcomes. We investigated the influence of cluster detection method and geographical scale on syphilis cluster detection in Mecklenburg County, North Carolina. We analyzed primary and secondary syphilis cases reported in North Carolina (2003-2010). Primary and secondary syphilis incidence rates were estimated using census tract-level population estimates. We used 2 cluster detection methods: local Moran's I using an areal adjacency matrix and Kulldorff's spatial scan statistic using a variable size moving circular window. We evaluated 3 study area scales: North Carolina, Piedmont region, and Mecklenburg County. We focused our investigation on Mecklenburg, an urban county with historically high syphilis rates. Syphilis clusters detected using local Moran's I and Kulldorff's scan statistic overlapped but varied in size and composition. Because we reduced the scale to a high-incidence urban area, the reference syphilis rate increased, leading to the identification of smaller clusters with higher incidence. Cluster demographic characteristics differed when the study area was reduced to a high-incidence urban county. Our results underscore the importance of selecting the correct scale for analysis to more precisely identify areas with high disease burden. A more complete understanding of high-burden cluster location can inform resource allocation for geographically targeted sexually transmitted infection interventions.},
  citation-subset = {IM},
  completed       = {2016-12-13},
  country         = {United States},
  doi             = {10.1097/OLQ.0000000000000421},
  issn-linking    = {0148-5717},
  issue           = {4},
  keywords        = {Adult; Cluster Analysis; Demography; Female; Humans; Incidence; Male; North Carolina, epidemiology; Sexually Transmitted Diseases, epidemiology; Syphilis, epidemiology},
  mid             = {NIHMS862108},
  nlm-id          = {7705941},
  owner           = {NLM},
  pii             = {00007435-201604000-00002},
  pmc             = {PMC5464419},
  pmid            = {26967297},
  pubmodel        = {Print},
  pubstate        = {ppublish},
  revised         = {2018-11-13},
}

Identifying geographical clusters of sexually transmitted infections can aid in targeting prevention and control efforts. However, detectable clusters can vary between detection methods because of different underlying assumptions. Furthermore, because disease burden is not geographically homogenous, the reference population is sensitive to the study area scale, affecting cluster outcomes. We investigated the influence of cluster detection method and geographical scale on syphilis cluster detection in Mecklenburg County, North Carolina. We analyzed primary and secondary syphilis cases reported in North Carolina (2003-2010). Primary and secondary syphilis incidence rates were estimated using census tract-level population estimates. We used 2 cluster detection methods: local Moran's I using an areal adjacency matrix and Kulldorff's spatial scan statistic using a variable size moving circular window. We evaluated 3 study area scales: North Carolina, Piedmont region, and Mecklenburg County. We focused our investigation on Mecklenburg, an urban county with historically high syphilis rates. Syphilis clusters detected using local Moran's I and Kulldorff's scan statistic overlapped but varied in size and composition. Because we reduced the scale to a high-incidence urban area, the reference syphilis rate increased, leading to the identification of smaller clusters with higher incidence. Cluster demographic characteristics differed when the study area was reduced to a high-incidence urban county. Our results underscore the importance of selecting the correct scale for analysis to more precisely identify areas with high disease burden. A more complete understanding of high-burden cluster location can inform resource allocation for geographically targeted sexually transmitted infection interventions.

@Article{Tung2016,
  author          = {Tung, Elizabeth L. and Peek, Monica E. and Makelarski, Jennifer A. and Escamilla, Veronica and Lindau, Stacy T.},
  journal         = {American journal of preventive medicine},
  title           = {Adult BMI and Access to Built Environment Resources in a High-Poverty, Urban Geography.},
  year            = {2016},
  issn            = {1873-2607},
  month           = nov,
  pages           = {e119--e127},
  volume          = {51},
  abstract        = {The purpose of this study is to examine the relationship between BMI and access to built environment resources in a high-poverty, urban geography. Participants (aged ≥35 years) were surveyed between November 2012 and July 2013 to examine access to common health-enabling resources (grocers, outpatient providers, pharmacies, places of worship, and physical activity resources). Survey data were linked to a contemporaneous census of built resources. Associations between BMI and access to resources (potential and realized) were examined using independent t-tests and multiple linear regression. Data analysis was conducted in 2014-2015. Median age was 53.8 years (N=267, 62% cooperation rate). Obesity (BMI ≥30) prevalence was 54.9%. BMI was not associated with potential access to resources located nearest to home. Nearly all participants (98.1%) bypassed at least one nearby resource type; half bypassed nearby grocers (realized access >1 mile from home). Bypassing grocers was associated with a higher BMI (p=0.03). Each additional mile traveled from home to a grocer was associated with a 0.9-higher BMI (95% CI=0.4, 1.3). Quality and affordability were common reasons for bypassing resources. Despite potential access to grocers in a high-poverty, urban region, half of participants bypassed nearby grocers to access food. Bypassing grocers was associated with a higher BMI.},
  citation-subset = {IM},
  completed       = {2018-01-16},
  country         = {Netherlands},
  doi             = {10.1016/j.amepre.2016.04.019},
  issn-linking    = {0749-3797},
  issue           = {5},
  keywords        = {Adult; Body Mass Index; Cities, statistics & numerical data; Female; Humans; Male; Middle Aged; Poverty; Residence Characteristics; Urban Population, statistics & numerical data},
  mid             = {NIHMS785085},
  nlm-id          = {8704773},
  owner           = {NLM},
  pii             = {S0749-3797(16)30128-3},
  pmc             = {PMC5067168},
  pmid            = {27288290},
  pubmodel        = {Print-Electronic},
  pubstate        = {ppublish},
  revised         = {2018-12-02},
}

The purpose of this study is to examine the relationship between BMI and access to built environment resources in a high-poverty, urban geography. Participants (aged ≥35 years) were surveyed between November 2012 and July 2013 to examine access to common health-enabling resources (grocers, outpatient providers, pharmacies, places of worship, and physical activity resources). Survey data were linked to a contemporaneous census of built resources. Associations between BMI and access to resources (potential and realized) were examined using independent t-tests and multiple linear regression. Data analysis was conducted in 2014-2015. Median age was 53.8 years (N=267, 62% cooperation rate). Obesity (BMI ≥30) prevalence was 54.9%. BMI was not associated with potential access to resources located nearest to home. Nearly all participants (98.1%) bypassed at least one nearby resource type; half bypassed nearby grocers (realized access >1 mile from home). Bypassing grocers was associated with a higher BMI (p=0.03). Each additional mile traveled from home to a grocer was associated with a 0.9-higher BMI (95% CI=0.4, 1.3). Quality and affordability were common reasons for bypassing resources. Despite potential access to grocers in a high-poverty, urban region, half of participants bypassed nearby grocers to access food. Bypassing grocers was associated with a higher BMI.

@Article{Cope2016,
  author          = {Cope, Anna B. and Powers, Kimberly A. and Serre, Marc L. and Escamilla, Veronica and Emch, Michael E. and Leone, Peter A. and Mobley, Victoria L. and Miller, William C.},
  journal         = {AIDS care},
  title           = {Distance to testing sites and its association with timing of HIV diagnosis.},
  year            = {2016},
  issn            = {1360-0451},
  month           = nov,
  pages           = {1423--1427},
  volume          = {28},
  abstract        = {Early HIV diagnosis enables prompt treatment initiation, thereby contributing to decreased morbidity, mortality, and transmission. We aimed to describe the association between distance from residence to testing sites and HIV disease stage at diagnosis. Using HIV surveillance data, we identified all new HIV diagnoses made at publicly funded testing sites in central North Carolina during 2005-2013. Early-stage HIV was defined as acute HIV (antibody-negative test with a positive HIV RNA) or recent HIV (normalized optical density <0.8 on the BED assay for non-AIDS cases); remaining diagnoses were considered post-early-stage HIV. Street distance between residence at diagnosis and (1) the closest testing site and (2) the diagnosis site was dichotomized at 5 miles. We fit log-binomial models using generalized estimating equations to estimate prevalence ratios (PR) and robust 95% confidence intervals (CI) for post-early-stage diagnoses by distance. Models were adjusted for race/ethnicity and testing period. Most of the 3028 new diagnoses were black (N = 2144; 70.8%), men who have sex with men (N = 1685; 55.7%), and post-early-stage HIV diagnoses (N = 2010; 66.4%). Overall, 1145 (37.8%) cases traveled <5 miles for a diagnosis. Among cases traveling ≥5 miles for a diagnosis, 1273 (67.6%) lived <5 miles from a different site. Residing ≥5 miles from a testing site was not associated with post-early-stage HIV (adjusted PR, 95% CI: 0.98, 0.92-1.04), but traveling ≥5 miles for a diagnosis was associated with higher post-early HIV prevalence (1.07, 1.02-1.13). Most of the elevated prevalence observed in cases traveling ≥5 miles for a diagnosis occurred among those living <5 miles from a different site (1.09, 1.03-1.16). Modest increases in post-early-stage HIV diagnosis were apparent among persons living near a site, but choosing to travel longer distances to test. Understanding reasons for increased travel distances could improve accessibility and acceptability of HIV services and increase early diagnosis rates.},
  chemicals       = {RNA, Viral},
  citation-subset = {IM, X},
  completed       = {2017-06-20},
  country         = {England},
  doi             = {10.1080/09540121.2016.1191599},
  issn-linking    = {0954-0121},
  issue           = {11},
  keywords        = {Adult; African Americans, statistics & numerical data; Delayed Diagnosis; Early Diagnosis; Female; HIV, isolation & purification; HIV Infections, diagnosis, virology; Health Services Accessibility; Homosexuality, Male, statistics & numerical data; Humans; Male; North Carolina; Patient Acceptance of Health Care, statistics & numerical data; RNA, Viral, blood; Time Factors; Young Adult; HIV testing; Recent HIV infection; barriers to testing; geographic distance; late diagnosis; surveillance},
  mid             = {NIHMS824591},
  nlm-id          = {8915313},
  owner           = {NLM},
  pmc             = {PMC5138063},
  pmid            = {27256764},
  pubmodel        = {Print-Electronic},
  pubstate        = {ppublish},
  revised         = {2018-12-02},
}

Early HIV diagnosis enables prompt treatment initiation, thereby contributing to decreased morbidity, mortality, and transmission. We aimed to describe the association between distance from residence to testing sites and HIV disease stage at diagnosis. Using HIV surveillance data, we identified all new HIV diagnoses made at publicly funded testing sites in central North Carolina during 2005-2013. Early-stage HIV was defined as acute HIV (antibody-negative test with a positive HIV RNA) or recent HIV (normalized optical density <0.8 on the BED assay for non-AIDS cases); remaining diagnoses were considered post-early-stage HIV. Street distance between residence at diagnosis and (1) the closest testing site and (2) the diagnosis site was dichotomized at 5 miles. We fit log-binomial models using generalized estimating equations to estimate prevalence ratios (PR) and robust 95% confidence intervals (CI) for post-early-stage diagnoses by distance. Models were adjusted for race/ethnicity and testing period. Most of the 3028 new diagnoses were black (N = 2144; 70.8%), men who have sex with men (N = 1685; 55.7%), and post-early-stage HIV diagnoses (N = 2010; 66.4%). Overall, 1145 (37.8%) cases traveled <5 miles for a diagnosis. Among cases traveling ≥5 miles for a diagnosis, 1273 (67.6%) lived <5 miles from a different site. Residing ≥5 miles from a testing site was not associated with post-early-stage HIV (adjusted PR, 95% CI: 0.98, 0.92-1.04), but traveling ≥5 miles for a diagnosis was associated with higher post-early HIV prevalence (1.07, 1.02-1.13). Most of the elevated prevalence observed in cases traveling ≥5 miles for a diagnosis occurred among those living <5 miles from a different site (1.09, 1.03-1.16). Modest increases in post-early-stage HIV diagnosis were apparent among persons living near a site, but choosing to travel longer distances to test. Understanding reasons for increased travel distances could improve accessibility and acceptability of HIV services and increase early diagnosis rates.

@Article{Escamilla2015,
  author          = {Escamilla, Veronica and Chibwesha, Carla J. and Gartland, Matthew and Chintu, Namwinga and Mubiana-Mbewe, Mwangelwa and Musokotwane, Kebby and Musonda, Patrick and Miller, William C. and Stringer, Jeffrey S. A. and Chi, Benjamin H.},
  journal         = {Journal of acquired immune deficiency syndromes (1999)},
  title           = {Implementation and Operational Research: Distance From Household to Clinic and Its Association With the Uptake of Prevention of Mother-to-Child HIV Transmission Regimens in Rural Zambia.},
  year            = {2015},
  issn            = {1944-7884},
  month           = nov,
  pages           = {e94--e101},
  volume          = {70},
  abstract        = {In rural settings, HIV-infected pregnant women often live significant distances from facilities that provide prevention of mother-to-child transmission (PMTCT) services. We offered universal maternal combination antiretroviral regimens in 4 pilot sites in rural Zambia. To evaluate the impact of services, we conducted a household survey in communities surrounding each facility. We collected information about HIV status and antenatal service utilization from women who delivered in the past 2 years. Using household Global Positioning System coordinates collected in the survey, we measured Euclidean (i.e., straight line) distance between individual households and clinics. Multivariable logistic regression and predicted probabilities were used to determine associations between distance and uptake of PMTCT regimens. From March to December 2011, 390 HIV-infected mothers were surveyed across four communities. Of these, 254 (65%) had household geographical coordinates documented. One hundred sixty-eight women reported use of a PMTCT regimen during pregnancy including 102 who initiated a combination antiretroviral regimen. The probability of PMTCT regimen initiation was the highest within 1.9 km of the facility and gradually declined. Overall, 103 of 145 (71%) who lived within 1.9 km of the facility initiated PMTCT versus 65 of 109 (60%) who lived farther away. For every kilometer increase, the association with PMTCT regimen uptake (adjusted odds ratio: 0.90, 95% confidence interval: 0.82 to 0.99) and combination antiretroviral regimen uptake (adjusted odds ratio: 0.88, 95% confidence interval: 0.80 to 0.97) decreased. In this rural African setting, uptake of PMTCT regimens was influenced by distance to health facility. Program models that further decentralize care into remote communities are urgently needed.},
  chemicals       = {Anti-HIV Agents},
  citation-subset = {IM, X},
  completed       = {2016-01-28},
  country         = {United States},
  doi             = {10.1097/QAI.0000000000000739},
  issn-linking    = {1525-4135},
  issue           = {3},
  keywords        = {Adolescent; Adult; Anti-HIV Agents, administration & dosage, therapeutic use; Cross-Sectional Studies; Female; HIV Infections, epidemiology, prevention & control, transmission; Humans; Infant, Newborn; Infectious Disease Transmission, Vertical, prevention & control; Maternal-Child Health Centers, organization & administration; Odds Ratio; Pilot Projects; Pregnancy; Pregnancy Complications, Infectious, drug therapy; Prenatal Care, organization & administration; Risk Factors; Rural Population; Transportation; Young Adult; Zambia, epidemiology},
  mid             = {NIHMS781023},
  nlm-id          = {100892005},
  owner           = {NLM},
  pii             = {00126334-201511010-00019},
  pmc             = {PMC4885744},
  pmid            = {26470035},
  pubmodel        = {Print},
  pubstate        = {ppublish},
  revised         = {2018-11-13},
}

In rural settings, HIV-infected pregnant women often live significant distances from facilities that provide prevention of mother-to-child transmission (PMTCT) services. We offered universal maternal combination antiretroviral regimens in 4 pilot sites in rural Zambia. To evaluate the impact of services, we conducted a household survey in communities surrounding each facility. We collected information about HIV status and antenatal service utilization from women who delivered in the past 2 years. Using household Global Positioning System coordinates collected in the survey, we measured Euclidean (i.e., straight line) distance between individual households and clinics. Multivariable logistic regression and predicted probabilities were used to determine associations between distance and uptake of PMTCT regimens. From March to December 2011, 390 HIV-infected mothers were surveyed across four communities. Of these, 254 (65%) had household geographical coordinates documented. One hundred sixty-eight women reported use of a PMTCT regimen during pregnancy including 102 who initiated a combination antiretroviral regimen. The probability of PMTCT regimen initiation was the highest within 1.9 km of the facility and gradually declined. Overall, 103 of 145 (71%) who lived within 1.9 km of the facility initiated PMTCT versus 65 of 109 (60%) who lived farther away. For every kilometer increase, the association with PMTCT regimen uptake (adjusted odds ratio: 0.90, 95% confidence interval: 0.82 to 0.99) and combination antiretroviral regimen uptake (adjusted odds ratio: 0.88, 95% confidence interval: 0.80 to 0.97) decreased. In this rural African setting, uptake of PMTCT regimens was influenced by distance to health facility. Program models that further decentralize care into remote communities are urgently needed.

@Article{Escamilla2014,
  author          = {Escamilla, Veronica and Emch, Michael and Dandalo, Leonard and Miller, William C. and Martinson, Francis and Hoffman, Irving},
  journal         = {Bulletin of the World Health Organization},
  title           = {Sampling at community level by using satellite imagery and geographical analysis.},
  year            = {2014},
  issn            = {1564-0604},
  month           = sep,
  pages           = {690--694},
  volume          = {92},
  abstract        = {Traditional random sampling at community level requires a list of every individual household that can be randomly selected in the study community. The longitudinal demographic surveillance systems often used as sampling frames are difficult to create in many resource-poor settings. We used Google Earth imagery and geographical analysis software to develop a sampling frame. Every household structure within the catchment area was digitized and assigned coordinates. A random sample was then generated from the list of households. The sampling took place in Lilongwe, Malawi and formed a part of an investigation of the intensity of Plasmodium falciparum transmission in a multi-site Phase III trial of a candidate malaria vaccine. Creation of a complete list of household coordinates within the catchment area allowed us to generate a random sample representative of the population. Once the coordinates of the households in that sample had been entered into the hand-held receivers of a global positioning system device, the households could be accurately identified on the ground and approached. In the development of a geographical sampling frame, the use of Google Earth satellite imagery and geographical software appeared to be an efficient alternative to the use of a demographic surveillance system. The use of a complete list of household coordinates reduced the time needed to locate households in the random sample. Our approach to generate a sampling frame is accurate, has utility beyond morbidity studies and appears to be a cost-effective option in resource-poor settings.},
  chemicals       = {Malaria Vaccines},
  citation-subset = {IM},
  completed       = {2016-09-22},
  country         = {Switzerland},
  doi             = {10.2471/BLT.14.140756},
  issn-linking    = {0042-9686},
  issue           = {9},
  keywords        = {Catchment Area, Health; Humans; Malaria Vaccines; Malaria, Falciparum, epidemiology, prevention & control; Malawi, epidemiology; Prevalence; Sampling Studies; Satellite Imagery; Software},
  nlm-id          = {7507052},
  owner           = {NLM},
  pii             = {BLT.14.140756},
  pmc             = {PMC4208578},
  pmid            = {25378761},
  pubmodel        = {Print-Electronic},
  pubstate        = {ppublish},
  revised         = {2019-12-10},
}

Traditional random sampling at community level requires a list of every individual household that can be randomly selected in the study community. The longitudinal demographic surveillance systems often used as sampling frames are difficult to create in many resource-poor settings. We used Google Earth imagery and geographical analysis software to develop a sampling frame. Every household structure within the catchment area was digitized and assigned coordinates. A random sample was then generated from the list of households. The sampling took place in Lilongwe, Malawi and formed a part of an investigation of the intensity of Plasmodium falciparum transmission in a multi-site Phase III trial of a candidate malaria vaccine. Creation of a complete list of household coordinates within the catchment area allowed us to generate a random sample representative of the population. Once the coordinates of the households in that sample had been entered into the hand-held receivers of a global positioning system device, the households could be accurately identified on the ground and approached. In the development of a geographical sampling frame, the use of Google Earth satellite imagery and geographical software appeared to be an efficient alternative to the use of a demographic surveillance system. The use of a complete list of household coordinates reduced the time needed to locate households in the random sample. Our approach to generate a sampling frame is accurate, has utility beyond morbidity studies and appears to be a cost-effective option in resource-poor settings.

@Article{Winston2013,
  author          = {Winston, Jennifer Jane and Escamilla, Veronica and Perez-Heydrich, Carolina and Carrel, Margaret and Yunus, Mohammad and Streatfield, Peter Kim and Emch, Michael},
  journal         = {American journal of public health},
  title           = {Protective benefits of deep tube wells against childhood diarrhea in Matlab, Bangladesh.},
  year            = {2013},
  issn            = {1541-0048},
  month           = jul,
  pages           = {1287--1291},
  volume          = {103},
  abstract        = {We investigated whether deep tube wells installed to provide arsenic-free groundwater in rural Bangladesh have the added benefit of reducing childhood diarrheal disease incidence. We recorded cases of diarrhea in children younger than 5 years in 142 villages of Matlab, Bangladesh, during monthly community health surveys in 2005 and 2006. We surveyed the location and depth of 12,018 tube wells and integrated these data with diarrhea data and other data in a geographic information system. We fit a longitudinal logistic regression model to measure the relationship between childhood diarrhea and deep tube well use. We controlled for maternal education, family wealth, year, and distance to a deep tube well. Household clusters assumed to be using deep tube wells were 48.7% (95% confidence interval = 27.8%, 63.5%) less likely to have a case of childhood diarrhea than were other household clusters. Increased access to deep tube wells may provide dual benefits to vulnerable populations in Matlab, Bangladesh, by reducing the risk of childhood diarrheal disease and decreasing exposure to naturally occurring arsenic in groundwater.},
  citation-subset = {AIM, IM},
  completed       = {2013-08-13},
  country         = {United States},
  doi             = {10.2105/AJPH.2012.300975},
  issn-linking    = {0090-0036},
  issue           = {7},
  keywords        = {Bangladesh, epidemiology; Child, Preschool; Diarrhea, epidemiology, prevention & control; Educational Status; Health Surveys; Humans; Incidence; Income; Infant; Infant, Newborn; Logistic Models; Risk Factors; Rural Population; Time Factors; Water Wells, standards},
  mid             = {NIHMS443619},
  nlm-id          = {1254074},
  owner           = {NLM},
  pmc             = {PMC3676444},
  pmid            = {23409905},
  pubmodel        = {Print-Electronic},
  pubstate        = {ppublish},
  revised         = {2018-11-13},
}

We investigated whether deep tube wells installed to provide arsenic-free groundwater in rural Bangladesh have the added benefit of reducing childhood diarrheal disease incidence. We recorded cases of diarrhea in children younger than 5 years in 142 villages of Matlab, Bangladesh, during monthly community health surveys in 2005 and 2006. We surveyed the location and depth of 12,018 tube wells and integrated these data with diarrhea data and other data in a geographic information system. We fit a longitudinal logistic regression model to measure the relationship between childhood diarrhea and deep tube well use. We controlled for maternal education, family wealth, year, and distance to a deep tube well. Household clusters assumed to be using deep tube wells were 48.7% (95% confidence interval = 27.8%, 63.5%) less likely to have a case of childhood diarrhea than were other household clusters. Increased access to deep tube wells may provide dual benefits to vulnerable populations in Matlab, Bangladesh, by reducing the risk of childhood diarrheal disease and decreasing exposure to naturally occurring arsenic in groundwater.

@Article{Kiser2013,
  author          = {Kiser, Michelle and Escamilla, Veronica and Samuel, Jonathan and Eichelberger, Kacey and Mkwaila, Judith and Cairns, Bruce and Charles, Anthony},
  journal         = {World journal of surgery},
  title           = {Sex differences in interpersonal violence in Malawi: analysis of a hospital-based trauma registry.},
  year            = {2013},
  issn            = {1432-2323},
  month           = dec,
  pages           = {2972--2978},
  volume          = {37},
  abstract        = {Although interpersonal violence ("assault") exists in every society, the World Health Organization (WHO) estimated that 90 % of the exposure burden occurs in low- and middle-income countries. The objectives of this study were to define the incidence of assault-related injuries among subjects presenting for emergency room care secondary to sustained trauma in Lilongwe, Malawi; to measure the impact of sex on incidence, injury type, and care received; and to measure the effect of both sex and geographic location of the injury on time to presentation for medical care. This is a retrospective cohort analysis of data prospectively collected in the Kamuzu Central Hospital Trauma Surveillance Registry from July 2008 to December 2010 (n = 23,625). We used univariate, bivariate, and logistic regression analyses to measure association of sex with variables of interest, and geospatial mapping to evaluate the association of location of assault on time to presentation for care. The mean age of our trauma cohort was 27.7 years. Assaults accounted for 26.8 % of all injuries. Of those assaulted, 21.0 % (1299) were female, who were younger (26.2 vs. 28.1 years, p < 0.001), more likely to arrive to the hospital by minibus (p < 0.001), and less likely to arrive by police (p < 0.001). Altogether 62 % of the females were assaulted in their homes-much more often than their male counterparts (p < 0.001). Females were more likely to sustain contusions (p < 0.001) and males more likely to have lacerations and penetrating stab wounds (p < 0.001) or head injury (p < 0.001). Females had delayed hospital presentation following assault (p = 0.001) and were more likely to be treated as outpatients after adjusting for age, injury type, and injury location (adjusted odds ratio 1.74, 95 % CI 1.3-2.3, p < 0.001). Assaults clustered geographically in the Lilongwe district. Delayed presentation of females occurred irrespective of proximity to the hospital. This study brings attention to sex differences in assault victims. A prevention strategy focusing on sex roles and domestic abuse of women is paramount. Efforts are needed to stop dischargin female assault victims back into a potentially unsafe, abusive environment.},
  citation-subset = {IM},
  completed       = {2015-04-13},
  country         = {United States},
  doi             = {10.1007/s00268-013-2204-5},
  issn-linking    = {0364-2313},
  issue           = {12},
  keywords        = {Adult; Cohort Studies; Developing Countries; Emergency Service, Hospital; Female; Humans; Incidence; Logistic Models; Malawi, epidemiology; Male; Multivariate Analysis; Registries; Retrospective Studies; Risk Factors; Sex Factors; Violence, statistics & numerical data; Wounds and Injuries, epidemiology, etiology},
  mid             = {NIHMS565461},
  nlm-id          = {7704052},
  owner           = {NLM},
  pmc             = {PMC4017199},
  pmid            = {24048582},
  pubmodel        = {Print},
  pubstate        = {ppublish},
  revised         = {2018-11-13},
}

Although interpersonal violence ("assault") exists in every society, the World Health Organization (WHO) estimated that 90 % of the exposure burden occurs in low- and middle-income countries. The objectives of this study were to define the incidence of assault-related injuries among subjects presenting for emergency room care secondary to sustained trauma in Lilongwe, Malawi; to measure the impact of sex on incidence, injury type, and care received; and to measure the effect of both sex and geographic location of the injury on time to presentation for medical care. This is a retrospective cohort analysis of data prospectively collected in the Kamuzu Central Hospital Trauma Surveillance Registry from July 2008 to December 2010 (n = 23,625). We used univariate, bivariate, and logistic regression analyses to measure association of sex with variables of interest, and geospatial mapping to evaluate the association of location of assault on time to presentation for care. The mean age of our trauma cohort was 27.7 years. Assaults accounted for 26.8 % of all injuries. Of those assaulted, 21.0 % (1299) were female, who were younger (26.2 vs. 28.1 years, p < 0.001), more likely to arrive to the hospital by minibus (p < 0.001), and less likely to arrive by police (p < 0.001). Altogether 62 % of the females were assaulted in their homes-much more often than their male counterparts (p < 0.001). Females were more likely to sustain contusions (p < 0.001) and males more likely to have lacerations and penetrating stab wounds (p < 0.001) or head injury (p < 0.001). Females had delayed hospital presentation following assault (p = 0.001) and were more likely to be treated as outpatients after adjusting for age, injury type, and injury location (adjusted odds ratio 1.74, 95 % CI 1.3-2.3, p < 0.001). Assaults clustered geographically in the Lilongwe district. Delayed presentation of females occurred irrespective of proximity to the hospital. This study brings attention to sex differences in assault victims. A prevention strategy focusing on sex roles and domestic abuse of women is paramount. Efforts are needed to stop dischargin female assault victims back into a potentially unsafe, abusive environment.

@Article{Bowman2013,
  author          = {Bowman, Natalie M. and Congdon, Seth and Mvalo, Tisungane and Patel, Jaymin C. and Escamilla, Veronica and Emch, Michael and Martinson, Francis and Hoffman, Irving and Meshnick, Steven R. and Juliano, Jonathan J.},
  journal         = {Scientific reports},
  title           = {Comparative population structure of Plasmodium falciparum circumsporozoite protein NANP repeat lengths in Lilongwe, Malawi.},
  year            = {2013},
  issn            = {2045-2322},
  pages           = {1990},
  volume          = {3},
  abstract        = {Humoral immunity to Plasmodium falciparum circumsporozoite protein is partly mediated by a polymorphic NANP tetra-amino acid repeat. Antibody response to these repeats is the best correlate of protective immunity to the RTS,S malaria vaccine, but few descriptions of the natural variation of these repeats exist. Using capillary electrophoresis to determine the distribution of NANP repeat size polymorphisms among 98 isolates from Lilongwe, Malawi, we characterised the diversity of P. falciparum infection by several ecological indices. Infection by multiple distinct variants was common, and 20 distinct repeat sizes were identified. Diversity of P. falciparum appeared greater in children (18 variants) than adults (12 variants). There was evidence of genetic distance between different geographic regions by Nei's Standard Genetic Distance, suggesting parasite populations vary locally. We show that P. falciparum is very diverse with respect to NANP repeat length even on a local level and that diversity appears higher in children.},
  chemicals       = {Protozoan Proteins, circumsporozoite protein, Protozoan},
  citation-subset = {IM},
  completed       = {2013-10-17},
  country         = {England},
  doi             = {10.1038/srep01990},
  issn-linking    = {2045-2322},
  keywords        = {Adult; Animals; Child; Child, Preschool; Electrophoresis, Capillary; Female; Humans; Malawi; Male; Plasmodium falciparum, metabolism; Protozoan Proteins, chemistry, metabolism},
  nlm-id          = {101563288},
  owner           = {NLM},
  pii             = {srep01990},
  pmc             = {PMC3683670},
  pmid            = {23771124},
  pubmodel        = {Print},
  pubstate        = {ppublish},
  revised         = {2018-11-13},
}

Humoral immunity to Plasmodium falciparum circumsporozoite protein is partly mediated by a polymorphic NANP tetra-amino acid repeat. Antibody response to these repeats is the best correlate of protective immunity to the RTS,S malaria vaccine, but few descriptions of the natural variation of these repeats exist. Using capillary electrophoresis to determine the distribution of NANP repeat size polymorphisms among 98 isolates from Lilongwe, Malawi, we characterised the diversity of P. falciparum infection by several ecological indices. Infection by multiple distinct variants was common, and 20 distinct repeat sizes were identified. Diversity of P. falciparum appeared greater in children (18 variants) than adults (12 variants). There was evidence of genetic distance between different geographic regions by Nei's Standard Genetic Distance, suggesting parasite populations vary locally. We show that P. falciparum is very diverse with respect to NANP repeat length even on a local level and that diversity appears higher in children.

@Article{Knappett2012,
  author          = {Knappett, Peter S. K. and McKay, Larry D. and Layton, Alice and Williams, Daniel E. and Alam, Md J. and Huq, Md R. and Mey, Jacob and Feighery, John E. and Culligan, Patricia J. and Mailloux, Brian J. and Zhuang, Jie and Escamilla, Veronica and Emch, Michael and Perfect, Edmund and Sayler, Gary S. and Ahmed, Kazi M. and van Geen, Alexander},
  journal         = {Environmental science & technology},
  title           = {Implications of fecal bacteria input from latrine-polluted ponds for wells in sandy aquifers.},
  year            = {2012},
  issn            = {1520-5851},
  month           = feb,
  pages           = {1361--1370},
  volume          = {46},
  abstract        = {Ponds receiving latrine effluents may serve as sources of fecal contamination to shallow aquifers tapped by millions of tube-wells in Bangladesh. To test this hypothesis, transects of monitoring wells radiating away from four ponds were installed in a shallow sandy aquifer underlying a densely populated village and monitored for 14 months. Two of the ponds extended to medium sand. Another pond was sited within silty sand and the last in silt. The fecal indicator bacterium E. coli was rarely detected along the transects during the dry season and was only detected near the ponds extending to medium sand up to 7 m away during the monsoon. A log-linear decline in E. coli and Bacteroidales concentrations with distance along the transects in the early monsoon indicates that ponds excavated in medium sand were the likely source of contamination. Spatial removal rates ranged from 0.5 to 1.3 log(10)/m. After the ponds were artificially filled with groundwater to simulate the impact of a rain storm, E. coli levels increased near a pond recently excavated in medium sand, but no others. These observations show that adjacent sediment grain-size and how recently a pond was excavated influence the how much fecal contamination ponds receiving latrine effluents contribute to neighboring groundwater.},
  chemicals       = {Sewage},
  citation-subset = {IM},
  completed       = {2012-06-04},
  country         = {United States},
  doi             = {10.1021/es202773w},
  issn-linking    = {0013-936X},
  issue           = {3},
  keywords        = {Bangladesh; Environmental Monitoring, methods, statistics & numerical data; Escherichia coli, isolation & purification; Geologic Sediments; Particle Size; Sewage, microbiology; Toilet Facilities; Water Supply; Water Wells, microbiology},
  mid             = {NIHMS349773},
  nlm-id          = {0213155},
  owner           = {NLM},
  pmc             = {PMC3602418},
  pmid            = {22191430},
  pubmodel        = {Print-Electronic},
  pubstate        = {ppublish},
  revised         = {2018-11-13},
}

Ponds receiving latrine effluents may serve as sources of fecal contamination to shallow aquifers tapped by millions of tube-wells in Bangladesh. To test this hypothesis, transects of monitoring wells radiating away from four ponds were installed in a shallow sandy aquifer underlying a densely populated village and monitored for 14 months. Two of the ponds extended to medium sand. Another pond was sited within silty sand and the last in silt. The fecal indicator bacterium E. coli was rarely detected along the transects during the dry season and was only detected near the ponds extending to medium sand up to 7 m away during the monsoon. A log-linear decline in E. coli and Bacteroidales concentrations with distance along the transects in the early monsoon indicates that ponds excavated in medium sand were the likely source of contamination. Spatial removal rates ranged from 0.5 to 1.3 log(10)/m. After the ponds were artificially filled with groundwater to simulate the impact of a rain storm, E. coli levels increased near a pond recently excavated in medium sand, but no others. These observations show that adjacent sediment grain-size and how recently a pond was excavated influence the how much fecal contamination ponds receiving latrine effluents contribute to neighboring groundwater.

@Article{Ferguson2012,
  author          = {Ferguson, Andrew S. and Layton, Alice C. and Mailloux, Brian J. and Culligan, Patricia J. and Williams, Daniel E. and Smartt, Abby E. and Sayler, Gary S. and Feighery, John and McKay, Larry D. and Knappett, Peter S. K. and Alexandrova, Ekaterina and Arbit, Talia and Emch, Michael and Escamilla, Veronica and Ahmed, Kazi Matin and Alam, Md Jahangir and Streatfield, P. Kim and Yunus, Mohammad and van Geen, Alexander},
  journal         = {The Science of the total environment},
  title           = {Comparison of fecal indicators with pathogenic bacteria and rotavirus in groundwater.},
  year            = {2012},
  issn            = {1879-1026},
  month           = aug,
  pages           = {314--322},
  volume          = {431},
  abstract        = {Groundwater is routinely analyzed for fecal indicators but direct comparisons of fecal indicators to the presence of bacterial and viral pathogens are rare. This study was conducted in rural Bangladesh where the human population density is high, sanitation is poor, and groundwater pumped from shallow tubewells is often contaminated with fecal bacteria. Five indicator microorganisms (E. coli, total coliform, F+RNA coliphage, Bacteroides and human-associated Bacteroides) and various environmental parameters were compared to the direct detection of waterborne pathogens by quantitative PCR in groundwater pumped from 50 tubewells. Rotavirus was detected in groundwater filtrate from the largest proportion of tubewells (40%), followed by Shigella (10%), Vibrio (10%), and pathogenic E. coli (8%). Spearman rank correlations and sensitivity-specificity calculations indicate that some, but not all, combinations of indicators and environmental parameters can predict the presence of pathogens. Culture-dependent fecal indicator bacteria measured on a single date did not predict total bacterial pathogens, but annually averaged monthly measurements of culturable E. coli did improve prediction for total bacterial pathogens. A qPCR-based E. coli assay was the best indicator for the bacterial pathogens. F+RNA coliphage were neither correlated nor sufficiently sensitive towards rotavirus, but were predictive of bacterial pathogens. Since groundwater cannot be excluded as a significant source of diarrheal disease in Bangladesh and neighboring countries with similar characteristics, the need to develop more effective methods for screening tubewells with respect to microbial contamination is necessary.},
  chemicals       = {Drinking Water},
  citation-subset = {IM},
  completed       = {2012-11-30},
  country         = {Netherlands},
  doi             = {10.1016/j.scitotenv.2012.05.060},
  issn-linking    = {0048-9697},
  keywords        = {Bacteroides, pathogenicity; Bangladesh; Coliphages, pathogenicity; Drinking Water, microbiology; Enterobacteriaceae, pathogenicity; Escherichia coli, genetics, pathogenicity; Feces, microbiology, virology; Groundwater, microbiology, virology; Humans; Rotavirus, pathogenicity; Shigella, pathogenicity; Vibrio, pathogenicity; Water Microbiology},
  mid             = {NIHMS387725},
  nlm-id          = {0330500},
  owner           = {NLM},
  pii             = {S0048-9697(12)00742-5},
  pmc             = {PMC3587152},
  pmid            = {22705866},
  pubmodel        = {Print-Electronic},
  pubstate        = {ppublish},
  revised         = {2018-11-13},
}

Groundwater is routinely analyzed for fecal indicators but direct comparisons of fecal indicators to the presence of bacterial and viral pathogens are rare. This study was conducted in rural Bangladesh where the human population density is high, sanitation is poor, and groundwater pumped from shallow tubewells is often contaminated with fecal bacteria. Five indicator microorganisms (E. coli, total coliform, F+RNA coliphage, Bacteroides and human-associated Bacteroides) and various environmental parameters were compared to the direct detection of waterborne pathogens by quantitative PCR in groundwater pumped from 50 tubewells. Rotavirus was detected in groundwater filtrate from the largest proportion of tubewells (40%), followed by Shigella (10%), Vibrio (10%), and pathogenic E. coli (8%). Spearman rank correlations and sensitivity-specificity calculations indicate that some, but not all, combinations of indicators and environmental parameters can predict the presence of pathogens. Culture-dependent fecal indicator bacteria measured on a single date did not predict total bacterial pathogens, but annually averaged monthly measurements of culturable E. coli did improve prediction for total bacterial pathogens. A qPCR-based E. coli assay was the best indicator for the bacterial pathogens. F+RNA coliphage were neither correlated nor sufficiently sensitive towards rotavirus, but were predictive of bacterial pathogens. Since groundwater cannot be excluded as a significant source of diarrheal disease in Bangladesh and neighboring countries with similar characteristics, the need to develop more effective methods for screening tubewells with respect to microbial contamination is necessary.

@Article{Wu2011,
  author          = {Wu, Jianyong and Yunus, Mohammad and Streatfield, Peter Kim and van Geen, Alexander and Escamilla, Veronica and Akita, Yasuyuki and Serre, Marc and Emch, Michael},
  journal         = {Environmental health : a global access science source},
  title           = {Impact of tubewell access and tubewell depth on childhood diarrhea in Matlab, Bangladesh.},
  year            = {2011},
  issn            = {1476-069X},
  month           = dec,
  pages           = {109},
  volume          = {10},
  abstract        = {During the past three decades in Bangladesh, millions of tubewells have been installed to reduce the prevalence of diarrheal disease. This study evaluates the impacts of tubewell access and tubewell depth on childhood diarrhea in rural Bangladesh. A total of 59,796 cases of diarrhea in children under 5 were recorded in 142 villages of Matlab, Bangladesh during monthly community health surveys between 2000 and 2006. The location and depth of 12,018 tubewells were surveyed in 2002-04 and integrated with diarrhea and other data in a geographic information system. A proxy for tubewell access was developed by calculating the local density of tubewells around households. Logistic regression models were built to examine the relationship between childhood diarrhea, tubewell density and tubewell depth. Wealth, adult female education, flood control, population density and the child's age were considered as potential confounders. Baris (patrilineally-related clusters of households) with greater tubewell density were associated with significantly less diarrhea (OR (odds ratio) = 0.87, 95% confidence interval (CI): 0.85-0.89). Tubewell density had a greater influence on childhood diarrhea in areas that were not protected from flooding. Baris using intermediate depth tubewells (140-300 feet) were associated with more childhood diarrhea (OR = 1.24, 95% CI: 1.19-1.29) than those using shallow wells (10-140 feet). Baris using deep wells (300-990 feet) had less diarrheal disease than those using shallow wells, however, the difference was significant only when population density was low (< 1000 person/km(2)) or children were at the age of 13-24 months. Increased access to tubewells is associated with a lower risk of childhood diarrhea. Intermediate- depth wells are associated with more childhood diarrhea compared to shallower or deeper wells. These findings may have implications for on-going efforts to reduce exposure to elevated levels of arsenic contained in groundwater that is pumped in this study area primarily from shallow tubewells.},
  chemicals       = {Drinking Water},
  citation-subset = {IM},
  completed       = {2012-05-14},
  country         = {England},
  doi             = {10.1186/1476-069X-10-109},
  issn-linking    = {1476-069X},
  keywords        = {Arsenic Poisoning, prevention & control; Bangladesh, epidemiology; Child, Preschool; Diarrhea, epidemiology, prevention & control; Drinking Water, microbiology; Humans; Infant; Infant, Newborn; Logistic Models; Prevalence; Risk Factors; Rural Health; Seasons; Water Wells, standards},
  nlm-id          = {101147645},
  owner           = {NLM},
  pii             = {1476-069X-10-109},
  pmc             = {PMC3274461},
  pmid            = {22192445},
  pubmodel        = {Electronic},
  pubstate        = {epublish},
  revised         = {2018-11-13},
}

During the past three decades in Bangladesh, millions of tubewells have been installed to reduce the prevalence of diarrheal disease. This study evaluates the impacts of tubewell access and tubewell depth on childhood diarrhea in rural Bangladesh. A total of 59,796 cases of diarrhea in children under 5 were recorded in 142 villages of Matlab, Bangladesh during monthly community health surveys between 2000 and 2006. The location and depth of 12,018 tubewells were surveyed in 2002-04 and integrated with diarrhea and other data in a geographic information system. A proxy for tubewell access was developed by calculating the local density of tubewells around households. Logistic regression models were built to examine the relationship between childhood diarrhea, tubewell density and tubewell depth. Wealth, adult female education, flood control, population density and the child's age were considered as potential confounders. Baris (patrilineally-related clusters of households) with greater tubewell density were associated with significantly less diarrhea (OR (odds ratio) = 0.87, 95% confidence interval (CI): 0.85-0.89). Tubewell density had a greater influence on childhood diarrhea in areas that were not protected from flooding. Baris using intermediate depth tubewells (140-300 feet) were associated with more childhood diarrhea (OR = 1.24, 95% CI: 1.19-1.29) than those using shallow wells (10-140 feet). Baris using deep wells (300-990 feet) had less diarrheal disease than those using shallow wells, however, the difference was significant only when population density was low (< 1000 person/km(2)) or children were at the age of 13-24 months. Increased access to tubewells is associated with a lower risk of childhood diarrhea. Intermediate- depth wells are associated with more childhood diarrhea compared to shallower or deeper wells. These findings may have implications for on-going efforts to reduce exposure to elevated levels of arsenic contained in groundwater that is pumped in this study area primarily from shallow tubewells.

@Article{Carrel2011,
  author          = {Carrel, Margaret and Escamilla, Veronica and Messina, Jane and Giebultowicz, Sophia and Winston, Jennifer and Yunus, Mohammad and Streatfield, P. Kim and Emch, Michael},
  journal         = {International journal of health geographics},
  title           = {Diarrheal disease risk in rural Bangladesh decreases as tubewell density increases: a zero-inflated and geographically weighted analysis.},
  year            = {2011},
  issn            = {1476-072X},
  month           = jun,
  pages           = {41},
  volume          = {10},
  abstract        = {This study investigates the impact of tubewell user density on cholera and shigellosis events in Matlab, Bangladesh between 2002 and 2004. Household-level demographic, health, and water infrastructure data were incorporated into a local geographic information systems (GIS) database. Geographically-weighted regression (GWR) models were constructed to identify spatial variation of relationships across the study area. Zero-inflated negative binomial regression models were run to simultaneously measure the likelihood of increased magnitude of disease events and the likelihood of zero cholera or shigellosis events. The aim of this study was to examine the effect of tubewell density on both the occurrence of diarrheal disease and the magnitude of diarrheal disease incidence. In Matlab, households with greater tubewell density were more likely to report zero cholera or shigellosis events. Results for both cholera and shigellosis GWR models suggest that tubewell density effects are spatially stationary and the use of non-spatial statistical methods is appropriate. Increasing the amount of drinking water available to households through increased density of tubewells contributed to lower reports of cholera and shigellosis events in rural Bangladesh. Our findings demonstrate the importance of tubewell installation and access to groundwater in reducing diarrheal disease events in the developing world.},
  chemicals       = {Drinking Water},
  citation-subset = {IM},
  completed       = {2011-12-12},
  country         = {England},
  doi             = {10.1186/1476-072X-10-41},
  issn-linking    = {1476-072X},
  keywords        = {Bangladesh, epidemiology; Diarrhea, epidemiology; Drinking Water, microbiology; Geography; Humans; Population Surveillance; Regression Analysis; Rural Population; Water Wells},
  nlm-id          = {101152198},
  owner           = {NLM},
  pii             = {1476-072X-10-41},
  pmc             = {PMC3136404},
  pmid            = {21676249},
  pubmodel        = {Electronic},
  pubstate        = {epublish},
  revised         = {2018-11-13},
}

This study investigates the impact of tubewell user density on cholera and shigellosis events in Matlab, Bangladesh between 2002 and 2004. Household-level demographic, health, and water infrastructure data were incorporated into a local geographic information systems (GIS) database. Geographically-weighted regression (GWR) models were constructed to identify spatial variation of relationships across the study area. Zero-inflated negative binomial regression models were run to simultaneously measure the likelihood of increased magnitude of disease events and the likelihood of zero cholera or shigellosis events. The aim of this study was to examine the effect of tubewell density on both the occurrence of diarrheal disease and the magnitude of diarrheal disease incidence. In Matlab, households with greater tubewell density were more likely to report zero cholera or shigellosis events. Results for both cholera and shigellosis GWR models suggest that tubewell density effects are spatially stationary and the use of non-spatial statistical methods is appropriate. Increasing the amount of drinking water available to households through increased density of tubewells contributed to lower reports of cholera and shigellosis events in rural Bangladesh. Our findings demonstrate the importance of tubewell installation and access to groundwater in reducing diarrheal disease events in the developing world.

@Article{Wu2011a,
  author          = {Wu, Jianyong and van Geen, Alexander and Ahmed, Kazi Matin and Alam, Yasuyuki Akita Jahangir and Culligan, Patricia J. and Escamilla, Veronica and Feighery, John and Ferguson, Andrew S. and Knappett, Peter and Mailloux, Brian J. and McKay, Larry D. and Serre, Marc L. and Streatfield, P. Kim and Yunus, Mohammad and Emch, Michael},
  journal         = {PloS one},
  title           = {Increase in diarrheal disease associated with arsenic mitigation in Bangladesh.},
  year            = {2011},
  issn            = {1932-6203},
  pages           = {e29593},
  volume          = {6},
  abstract        = {Millions of households throughout Bangladesh have been exposed to high levels of arsenic (As) causing various deadly diseases by drinking groundwater from shallow tubewells for the past 30 years. Well testing has been the most effective form of mitigation because it has induced massive switching from tubewells that are high (>50 µg/L) in As to neighboring wells that are low in As. A recent study has shown, however, that shallow low-As wells are more likely to be contaminated with the fecal indicator E. coli than shallow high-As wells, suggesting that well switching might lead to an increase in diarrheal disease. Approximately 60,000 episodes of childhood diarrhea were collected monthly by community health workers between 2000 and 2006 in 142 villages of Matlab, Bangladesh. In this cross-sectional study, associations between childhood diarrhea and As levels in tubewell water were evaluated using logistic regression models. Adjusting for wealth, population density, and flood control by multivariate logistic regression, the model indicates an 11% (95% confidence intervals (CIs) of 4-19%) increase in the likelihood of diarrhea in children drinking from shallow wells with 10-50 µg/L As compared to shallow wells with >50 µg/L As. The same model indicates a 26% (95%CI: 9-42%) increase in diarrhea for children drinking from shallow wells with ≤10 µg/L As compared to shallow wells with >50 µg/L As. Children drinking water from shallow low As wells had a higher prevalence of diarrhea than children drinking water from high As wells. This suggests that the health benefits of reducing As exposure may to some extent be countered by an increase in childhood diarrhea.},
  chemicals       = {Water Pollutants, Chemical, Arsenic},
  citation-subset = {IM},
  completed       = {2012-05-21},
  country         = {United States},
  doi             = {10.1371/journal.pone.0029593},
  issn-linking    = {1932-6203},
  issue           = {12},
  keywords        = {Arsenic, isolation & purification; Bangladesh, epidemiology; Child; Diarrhea, epidemiology; Humans; Water Pollutants, Chemical, isolation & purification; Water Supply},
  nlm-id          = {101285081},
  owner           = {NLM},
  pii             = {PONE-D-11-08747},
  pmc             = {PMC3247276},
  pmid            = {22216326},
  pubmodel        = {Print-Electronic},
  pubstate        = {ppublish},
  revised         = {2018-11-13},
}

Millions of households throughout Bangladesh have been exposed to high levels of arsenic (As) causing various deadly diseases by drinking groundwater from shallow tubewells for the past 30 years. Well testing has been the most effective form of mitigation because it has induced massive switching from tubewells that are high (>50 µg/L) in As to neighboring wells that are low in As. A recent study has shown, however, that shallow low-As wells are more likely to be contaminated with the fecal indicator E. coli than shallow high-As wells, suggesting that well switching might lead to an increase in diarrheal disease. Approximately 60,000 episodes of childhood diarrhea were collected monthly by community health workers between 2000 and 2006 in 142 villages of Matlab, Bangladesh. In this cross-sectional study, associations between childhood diarrhea and As levels in tubewell water were evaluated using logistic regression models. Adjusting for wealth, population density, and flood control by multivariate logistic regression, the model indicates an 11% (95% confidence intervals (CIs) of 4-19%) increase in the likelihood of diarrhea in children drinking from shallow wells with 10-50 µg/L As compared to shallow wells with >50 µg/L As. The same model indicates a 26% (95%CI: 9-42%) increase in diarrhea for children drinking from shallow wells with ≤10 µg/L As compared to shallow wells with >50 µg/L As. Children drinking water from shallow low As wells had a higher prevalence of diarrhea than children drinking water from high As wells. This suggests that the health benefits of reducing As exposure may to some extent be countered by an increase in childhood diarrhea.

@Article{Knappett2011,
  author          = {Knappett, Peter S. K. and Escamilla, Veronica and Layton, Alice and McKay, Larry D. and Emch, Michael and Williams, Daniel E. and Huq, R. and Alam, J. and Farhana, Labony and Mailloux, Brian J. and Ferguson, Andy and Sayler, Gary S. and Ahmed, Kazi M. and van Geen, Alexander},
  journal         = {The Science of the total environment},
  title           = {Impact of population and latrines on fecal contamination of ponds in rural Bangladesh.},
  year            = {2011},
  issn            = {1879-1026},
  month           = aug,
  pages           = {3174--3182},
  volume          = {409},
  abstract        = {A majority of households in Bangladesh rely on pond water for hygiene. Exposure to pond water fecal contamination could therefore still contribute to diarrheal disease despite the installation of numerous tubewells for drinking. The objectives of this study are to determine the predominant sources (human or livestock) of fecal pollution in ponds and examine the association between local population, latrine density, latrine quality and concentrations of fecal bacteria and pathogens in pond water. Forty-three ponds were analyzed for E. coli using culture-based methods and E. coli, Bacteroidales and adenovirus using quantitative PCR. Population and sanitation spatial data were collected and measured against pond fecal contamination. Humans were the dominant source of fecal contamination in 79% of the ponds according to Bacteroidales measurements. Ponds directly receiving latrine effluent had the highest concentrations of fecal indicator bacteria (up to 10⁶ Most Probable Number (MPN) of culturable E. coli per 100 mL). Concentrations of fecal indicator bacteria correlated with population surveyed within a distance of 30-70 m (p<0.05) and total latrines surveyed within 50-70 m (p<0.05). Unsanitary latrines (visible effluent or open pits) within the pond drainage basin were also significantly correlated to fecal indicator concentrations (p<0.05). Water in the vast majority of the surveyed ponds contained unsafe levels of fecal contamination attributable primarily to unsanitary latrines, and to lesser extent, to sanitary latrines and cattle. Since the majority of fecal pollution is derived from human waste, continued use of pond water could help explain the persistence of diarrheal disease in rural South Asia.},
  chemicals       = {Sewage, Water Pollutants},
  citation-subset = {IM},
  completed       = {2011-09-20},
  country         = {Netherlands},
  doi             = {10.1016/j.scitotenv.2011.04.043},
  issn-linking    = {0048-9697},
  issue           = {17},
  keywords        = {Adenoviridae, growth & development, isolation & purification; Bacteria, growth & development, isolation & purification; Bangladesh; Environmental Monitoring; Feces; Fresh Water, chemistry, microbiology, virology; Humans; Risk Assessment; Rural Population; Sewage, analysis, microbiology, virology; Water Microbiology; Water Pollutants, analysis; Water Supply, analysis},
  mid             = {NIHMS301437},
  nlm-id          = {0330500},
  owner           = {NLM},
  pii             = {S0048-9697(11)00431-1},
  pmc             = {PMC3150537},
  pmid            = {21632095},
  pubmodel        = {Print-Electronic},
  pubstate        = {ppublish},
  revised         = {2018-11-13},
}

A majority of households in Bangladesh rely on pond water for hygiene. Exposure to pond water fecal contamination could therefore still contribute to diarrheal disease despite the installation of numerous tubewells for drinking. The objectives of this study are to determine the predominant sources (human or livestock) of fecal pollution in ponds and examine the association between local population, latrine density, latrine quality and concentrations of fecal bacteria and pathogens in pond water. Forty-three ponds were analyzed for E. coli using culture-based methods and E. coli, Bacteroidales and adenovirus using quantitative PCR. Population and sanitation spatial data were collected and measured against pond fecal contamination. Humans were the dominant source of fecal contamination in 79% of the ponds according to Bacteroidales measurements. Ponds directly receiving latrine effluent had the highest concentrations of fecal indicator bacteria (up to 10⁶ Most Probable Number (MPN) of culturable E. coli per 100 mL). Concentrations of fecal indicator bacteria correlated with population surveyed within a distance of 30-70 m (p<0.05) and total latrines surveyed within 50-70 m (p<0.05). Unsanitary latrines (visible effluent or open pits) within the pond drainage basin were also significantly correlated to fecal indicator concentrations (p<0.05). Water in the vast majority of the surveyed ponds contained unsafe levels of fecal contamination attributable primarily to unsanitary latrines, and to lesser extent, to sanitary latrines and cattle. Since the majority of fecal pollution is derived from human waste, continued use of pond water could help explain the persistence of diarrheal disease in rural South Asia.

@Article{Geen2011,
  author          = {van Geen, Alexander and Ahmed, Kazi Matin and Akita, Yasuyuki and Alam, Md Jahangir and Culligan, Patricia J. and Emch, Michael and Escamilla, Veronica and Feighery, John and Ferguson, Andrew S. and Knappett, Peter and Layton, Alice C. and Mailloux, Brian J. and McKay, Larry D. and Mey, Jacob L. and Serre, Marc L. and Streatfield, P. Kim and Wu, Jianyong and Yunus, Mohammad},
  journal         = {Environmental science & technology},
  title           = {Fecal contamination of shallow tubewells in Bangladesh inversely related to arsenic.},
  year            = {2011},
  issn            = {1520-5851},
  month           = feb,
  pages           = {1199--1205},
  volume          = {45},
  abstract        = {The health risks of As exposure due to the installation of millions of shallow tubewells in the Bengal Basin are known, but fecal contamination of shallow aquifers has not systematically been examined. This could be a source of concern in densely populated areas with poor sanitation because the hydraulic travel time from surface water bodies to shallow wells that are low in As was previously shown to be considerably shorter than for shallow wells that are high in As. In this study, 125 tubewells 6-36 m deep were sampled in duplicate for 18 months to quantify the presence of the fecal indicator Escherichia coli. On any given month, E. coli was detected at levels exceeding 1 most probable number per 100 mL in 19-64% of all shallow tubewells, with a higher proportion typically following periods of heavy rainfall. The frequency of E. coli detection averaged over a year was found to increase with population surrounding a well and decrease with the As content of a well, most likely because of downward transport of E. coli associated with local recharge. The health implications of higher fecal contamination of shallow tubewells, to which millions of households in Bangladesh have switched in order to reduce their exposure to As, need to be evaluated.},
  chemicals       = {Arsenic},
  citation-subset = {IM},
  completed       = {2014-03-17},
  country         = {United States},
  doi             = {10.1021/es103192b},
  issn-linking    = {0013-936X},
  issue           = {4},
  keywords        = {Arsenic, analysis; Bangladesh; Environmental Monitoring; Escherichia coli, isolation & purification; Feces, microbiology; Groundwater; Humans; Water Pollution, analysis; Water Supply, standards},
  nlm-id          = {0213155},
  owner           = {NLM},
  pmc             = {PMC3037737},
  pmid            = {21226536},
  pubmodel        = {Print-Electronic},
  pubstate        = {ppublish},
  revised         = {2018-11-13},
}

The health risks of As exposure due to the installation of millions of shallow tubewells in the Bengal Basin are known, but fecal contamination of shallow aquifers has not systematically been examined. This could be a source of concern in densely populated areas with poor sanitation because the hydraulic travel time from surface water bodies to shallow wells that are low in As was previously shown to be considerably shorter than for shallow wells that are high in As. In this study, 125 tubewells 6-36 m deep were sampled in duplicate for 18 months to quantify the presence of the fecal indicator Escherichia coli. On any given month, E. coli was detected at levels exceeding 1 most probable number per 100 mL in 19-64% of all shallow tubewells, with a higher proportion typically following periods of heavy rainfall. The frequency of E. coli detection averaged over a year was found to increase with population surrounding a well and decrease with the As content of a well, most likely because of downward transport of E. coli associated with local recharge. The health implications of higher fecal contamination of shallow tubewells, to which millions of households in Bangladesh have switched in order to reduce their exposure to As, need to be evaluated.

@Article{Emch2010,
  author          = {Emch, Michael and Yunus, Mohammad and Escamilla, Veronica and Feldacker, Caryl and Ali, Mohammad},
  journal         = {Environmental health : a global access science source},
  title           = {Local population and regional environmental drivers of cholera in Bangladesh.},
  year            = {2010},
  issn            = {1476-069X},
  month           = jan,
  pages           = {2},
  volume          = {9},
  abstract        = {Regional environmental factors have been shown to be related to cholera. Previous work in Bangladesh found that temporal patterns of cholera are positively related to satellite-derived environmental variables including ocean chlorophyll concentration (OCC). This paper investigates whether local socio-economic status (SES) modifies the effect of regional environmental forces. The study area is Matlab, Bangladesh, an area of approximately 200,000 people with an active health and demographic surveillance system. Study data include (1) spatially-referenced demographic and socio-economic characteristics of the population; (2) satellite-derived variables for sea surface temperature (SST), sea surface height (SSH), and OCC; and (3) laboratory confirmed cholera case data for the entire population. Relationships between cholera, the environmental variables, and SES are measured using generalized estimating equations with a logit link function. Additionally two separate seasonal models are built because there are two annual cholera epidemics, one pre-monsoon, and one post-monsoon. SES has a significant impact on cholera occurrence: the higher the SES score, the lower the occurrence of cholera. There is a significant negative association between cholera incidence and SSH during the pre-monsoon period but not for the post-monsoon period. OCC is positively associated with cholera during the pre-monsoon period but not for the post-monsoon period. SST is not related to cholera incidence. Overall, it appears cholera is influenced by regional environmental variables during the pre-monsoon period and by local-level variables (e.g., water and sanitation) during the post-monsoon period. In both pre- and post-monsoon seasons, SES significantly influences these patterns, likely because it is a proxy for poor water quality and sanitation in poorer households.},
  citation-subset = {IM},
  completed       = {2010-04-27},
  country         = {England},
  doi             = {10.1186/1476-069X-9-2},
  issn-linking    = {1476-069X},
  keywords        = {Bangladesh, epidemiology; Cholera, epidemiology, etiology; Demography; Environmental Monitoring; Epidemiological Monitoring; Humans; Risk Factors; Sanitation; Seawater, chemistry; Socioeconomic Factors; Weather},
  nlm-id          = {101147645},
  owner           = {NLM},
  pii             = {1476-069X-9-2},
  pmc             = {PMC2819239},
  pmid            = {20074356},
  pubmodel        = {Electronic},
  pubstate        = {epublish},
  revised         = {2018-11-13},
}

Regional environmental factors have been shown to be related to cholera. Previous work in Bangladesh found that temporal patterns of cholera are positively related to satellite-derived environmental variables including ocean chlorophyll concentration (OCC). This paper investigates whether local socio-economic status (SES) modifies the effect of regional environmental forces. The study area is Matlab, Bangladesh, an area of approximately 200,000 people with an active health and demographic surveillance system. Study data include (1) spatially-referenced demographic and socio-economic characteristics of the population; (2) satellite-derived variables for sea surface temperature (SST), sea surface height (SSH), and OCC; and (3) laboratory confirmed cholera case data for the entire population. Relationships between cholera, the environmental variables, and SES are measured using generalized estimating equations with a logit link function. Additionally two separate seasonal models are built because there are two annual cholera epidemics, one pre-monsoon, and one post-monsoon. SES has a significant impact on cholera occurrence: the higher the SES score, the lower the occurrence of cholera. There is a significant negative association between cholera incidence and SSH during the pre-monsoon period but not for the post-monsoon period. OCC is positively associated with cholera during the pre-monsoon period but not for the post-monsoon period. SST is not related to cholera incidence. Overall, it appears cholera is influenced by regional environmental variables during the pre-monsoon period and by local-level variables (e.g., water and sanitation) during the post-monsoon period. In both pre- and post-monsoon seasons, SES significantly influences these patterns, likely because it is a proxy for poor water quality and sanitation in poorer households.

@Article{Wang2008,
  author       = {Wang, Fahui and McLafferty, Sara and Escamilla, Veronica and Luo, Lan},
  journal      = {The Professional geographer : the journal of the Association of American Geographers},
  title        = {Late-Stage Breast Cancer Diagnosis and Health Care Access in Illinois.},
  year         = {2008},
  issn         = {0033-0124},
  month        = feb,
  pages        = {54--69},
  volume       = {60},
  abstract     = {The variations of breast cancer mortality rates from place to place reflect both underlying differences in breast cancer prevalence and differences in diagnosis and treatment that affect the risk of death. This article examines the role of access to health care in explaining the variation of late-stage diagnosis of breast cancer. We use cancer registry data for the state of Illinois by zip code to investigate spatial variation in late diagnosis. Geographic information systems and spatial analysis methods are used to create detailed measures of spatial access to health care such as convenience of visiting primary care physicians and travel time from the nearest mammography facility. The effects of spatial access, in combination with the influences of socioeconomic factors, on late-stage breast cancer diagnosis are assessed using statistical methods. The results suggest that for breast cancer, poor geographical access to primary health care significantly increases the risk of late diagnosis for persons living outside the city of Chicago. Disadvantaged population groups including those with low income and racial and ethnic minorities tend to experience high rates of late diagnosis. In Illinois, poor spatial access to primary health care is more strongly associated with late diagnosis than is spatial access to mammography. This suggests the importance of primary care physicians as gatekeepers in early breast cancer detection.},
  country      = {United States},
  doi          = {10.1080/00330120701724087},
  issn-linking = {0033-0124},
  issue        = {1},
  mid          = {NIHMS43763},
  nlm-id       = {100969256},
  owner        = {NLM},
  pmc          = {PMC2367325},
  pmid         = {18458760},
  pubmodel     = {Print},
  pubstate     = {ppublish},
  revised      = {2019-11-20},
}

The variations of breast cancer mortality rates from place to place reflect both underlying differences in breast cancer prevalence and differences in diagnosis and treatment that affect the risk of death. This article examines the role of access to health care in explaining the variation of late-stage diagnosis of breast cancer. We use cancer registry data for the state of Illinois by zip code to investigate spatial variation in late diagnosis. Geographic information systems and spatial analysis methods are used to create detailed measures of spatial access to health care such as convenience of visiting primary care physicians and travel time from the nearest mammography facility. The effects of spatial access, in combination with the influences of socioeconomic factors, on late-stage breast cancer diagnosis are assessed using statistical methods. The results suggest that for breast cancer, poor geographical access to primary health care significantly increases the risk of late diagnosis for persons living outside the city of Chicago. Disadvantaged population groups including those with low income and racial and ethnic minorities tend to experience high rates of late diagnosis. In Illinois, poor spatial access to primary health care is more strongly associated with late diagnosis than is spatial access to mammography. This suggests the importance of primary care physicians as gatekeepers in early breast cancer detection.