Ruaa Al Juboori

Background/Purpose: Diabetes prevalence in the Deep South remains among the highest in the United States. Yet few studies have examined the role of community level determinants, such as poverty, food insecurity, healthcare shortages, and unsafe environments in the geographic clustering of high diabetes burden in counties with higher proportions of racial/ethnic minoritized populations. Methods: We conducted an ecological, county-level study of 418 Deep South counties using publicly available data. The outcome was percentage of adults diagnosed with diabetes (2022). Exposures included food insecurity, access to exercise opportunities and parks, firearm mortality, healthcare workforce and insurance indicators, education, broadband access, and racial/ethnic composition (percent non-Hispanic Black, non-Hispanic White, Hispanic). We used descriptive statistics, Pearson correlations, and LISA mapping to identify hotspots and cold spots. Results: Average county level diabetes burden was 15.6%. Strong positive correlations were found with physical inactivity ( r = 0.82), obesity ( r = 0.78), poverty ( r = 0.74), firearm fatalities ( r = 0.67), and food insecurity ( r = 0.59). Inverse correlations were observed for broadband access ( r = -0.69), education ( r = -0.59), access to exercise opportunities ( r = -0.42), and primary care physician availability ( r = -0.28). LISA maps showed hotspots concentrated in the Mississippi Delta and parts of Alabama and Louisiana, co-occurring with higher poverty, higher firearm mortality, and higher proportions of non-Hispanic Black residents, while cold spots aligned with counties with stronger infrastructure and healthcare resources. Implications for Public Health: Diabetes in the Deep South reflects structural and environmental conditions beyond individual behaviors. Policies that expand health-promoting infrastructure, strengthen healthcare access, reduce food insecurity, and improve community safety are warranted, particularly in hotspot counties with higher proportions of racial/ethnic minoritized populations.

Context: Child nutrition (CN) professionals must meet ongoing United States Department of Agriculture (USDA) nutrition standards and professional training requirements, yet national evidence on priority training topics and preferred delivery formats across roles is limited. Objective: To identify high priority training needs and preferred delivery modes among School Nutrition (SN) and Child and Adult Care Food Program (CACFP) professionals nationwide. Design: Cross sectional, web-based survey. Setting: United States; survey distributed through the Institute of Child Nutrition national contact database (emails sent November 7 to December 5, 2023). Participants: A total of 777 CN professionals including SN management/other staff, SN frontline staff/workers, and CACFP professionals. Intervention (if applicable): Not applicable. Main Outcome Measure(s): Respondents selected high-need training topics to complete within the next 2 years and indicated preferred delivery mode (in-person live, live virtual, or self-paced online) for each selected topic. Results: Training priorities and delivery preferences differed by role and topic. SN management/other respondents most often preferred in-person live training for operational and complex topics such as food production (17.8%) and program management (17.6%), while live virtual training was most frequently preferred for special diets (19.0%). Self-paced online formats were most frequently preferred for compliance-oriented topics including civil rights (23.1%) and food safety/Hazard Analysis and Critical Control Point (22.2%). SN frontline staff/workers most often preferred self-paced online training for USDA meal pattern requirements (26.6%) and civil rights (22.9%), and live virtual training for special diets (17.4%). CACFP professionals most often preferred self-paced online training for USDA meal pattern requirements (30.7%) and health and safety (29.1%), with live virtual training commonly preferred for administration/paperwork (24.4%) and special diets (24.4%). Conclusions: CN professionals report role and topic-specific training needs and distinct delivery preferences, supporting flexible, differentiated training pathways (eg, in-person for hands on operations; self-paced online for standardized compliance content) to strengthen implementation of USDA standards.

Objectives: The aims were to (1) identify the frequency of consumption of top food trends in schools participating in the National School Lunch Program (NSLP) and School Breakfast Program (SBP), (2) examine the average nutrient content of recipes for the top menu trends, and (3) quantify the current added-sugar and sodium levels in core recipes to establish baseline data for subsequent modifications. Background: The US Department of Agriculture (USDA) Food and Nutrition Service has issued a final rule regarding the school meal standards, aligning with the 2020–2025 Dietary Guidelines for Americans. Key updates include a gradual reduction in sodium and new product-based limits on added sugars. Identifying modifiable school menu items is essential to ensuring the NSLP and SBP can meet the needs of the student population. Methods: This research used a multiphase approach investigating menu trends in K–12 and modifiable school menu options. Popular menu trends were identified using data from a 2024 survey of 1691 school nutrition professionals. A follow-up survey assessed the frequency of consumption of these trends. Recipes for top menu items were sourced from common online repositories, ensuring flexibility for modification to meet nutritional guidelines. Nutritional analysis of selected recipes was conducted using USDA-approved Health-e Pro software (Health-e Pro; Anacortes, WA, USA). Descriptive statistics were used to analyze nutrient content and the frequency of menu trends. Results: Popular breakfast items, such as muffins, yogurt parfaits, and breakfast smoothies, were major contributors to added-sugar content, while sausage biscuits and breakfast pizza were highest in sodium. Lunch items, including flavored wings and walking tacos, demonstrated high sodium levels, with flavored wings averaging over 2100 mg per serving. Condiments such as BBQ sauce and honey mustard also contributed added sugars and sodium. Conclusion: While many top food trends are widely served in schools, some exceed recommended thresholds for sodium and added sugars. This study highlights the potential to modify existing recipes using herbs, spices, and ingredient substitutions to meet the USDA’s updated school meal standards by 2027, without compromising student acceptability.

Background: The US Deep South bears a disproportionate human immunodeficiency virus (HIV) burden. Mismatch between HIV burden and measurable proxies of biomedical prevention and care performance, pre-exposure prophylaxis (PrEP) utilization, viral suppression (treatment as prevention), and density of listed HIV testing locations may contribute to geographic variation in outcomes, but regional patterns are poorly described. Methods: We conducted an ecological county-level analysis across the US Deep South states (Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas). Using public datasets, we constructed a Prevention Gap Index (PGI), defined as standardized HIV prevalence minus the mean of three standardized prevention/care proxies aligned with Ending the HIV Epidemic (EHE) domains: pre-exposure prophylaxis (PrEP) (Prevent), viral suppression (Treat), and testing site listing density (Diagnose/access). Indicators were z-standardized, and counties were classified into PGI quartiles to flag potential gaps for planning and resource allocation. Spatial weights used queen contiguity. Multivariable ordinary least squares (OLS) and spatial regression models examined associations between PGI and structural determinants (ethnicity, income, education, and social association measures). Convergent validity was assessed by comparing high PGI counties with EHE Phase I priority counties. Results: The dataset included 877 counties. Testing site density averaged 7.40 per 100,000 [standard deviation (SD), 8.71]; PGI mean was 0.01 (SD, 1.12). Notably, 65% (13/20) of regional EHE Phase I counties were high PGI (top quartile), and PGI moderately differentiated EHE designation [area under the curve (AUC), 0.761; p < 0.001]. Among counties with available new diagnosis rates ( n = 512), PGI correlated with diagnoses (Spearman coefficient, ρ = 0.51; p < 0.05) and classified high-diagnosis counties (AUC, 0.819; p < 0.001). In bivariate analyses, PGI correlated positively with the percentage of non-Hispanic Black ( r = 0.362; p < 0.001) and negatively with log income ( r = −0.171; p < 0.001), social associations ( r = −0.095; p = 0.005), and some college education ( r = −0.085; p = 0.012). In adjusted OLS models, the percentage of non-Hispanic Black remained positively associated with PGI ( β = 0.024; 95% confidence interval [CI], 0.020–0.027). Residual clustering supported spatial modeling; spatial lag and error models improved fit, with the spatial error model best capturing remaining dependence. Conclusion: HIV burden and prevention/care proxies vary spatially across the Deep South. PGI may support geographically targeted planning and monitoring toward national HIV goals and evaluation locally over time, but should be complemented with local program data that capture additional prevention domains.

Substance use and high-risk sexual behaviors remain pressing public health challenges among U.S. adolescents, with tobacco, alcohol, and marijuana being the most used substances. While previous research has shown an association between substance use and risky sexual behavior, there is limited data on how these associations vary based on demographic modifiers such as race, sex, and sexual identity among sexually active adolescents. This study explores the association between current substance use (cigarettes, e-cigarettes, alcohol, and marijuana) and high-risk sexual behaviors (having multiple sexual partners and lack of condom use), examining how these associations vary by race, sex, and sexual identity. The 2023 Youth Risk Behavior Survey (YRBS) data was analyzed for 5420 adolescents attending U.S. public and private high schools. Multiple Logistic regression was used to examine associations, and interaction effects for race, sex, and sexual identity were introduced to the model to determine variations in associations. Overall adjusted analyses revealed current use of cigarette, e-cigarette, and alcohol was associated with higher likelihood of having multiple (2 or more) sexual partners in the past 3 months. Additionally, current marijuana use was associated with a higher likelihood of not using a condom during last sexual intercourse. A statistically significant interaction was observed only for the association between current marijuana use and condomless sex during last sexual intercourse ( p = 0.010). Stratified analyses indicated that this association varied by sexual identity and was stronger among heterosexual students compared to Lesbian, Gay, Bisexual, Queer, and other (LGBQ+) students. Results confirm the link between substance use and high-risk sexual behavior among youth, reinforcing our need for increased programming around substance use prevention and sexual health education. Heterosexual youth may be at increased risk for high-risk sexual behavior associated with their marijuana use, calling for tailored interventions that target the unique needs of this demographic subgroup.

Background: Cardiovascular disease remains a leading cause of preventable mortality in the United States, with rural counties in the Deep South experiencing disproportionately high burdens. Grounded in the Andersen healthcare utilization model, this study examined how enabling resources, predisposing characteristics, and access-related barriers relate to coronary heart disease (CHD) prevalence and mortality. Methods: This ecological analysis included 418 counties across Alabama, Georgia, Louisiana, Mississippi, and South Carolina. Using Local Indicators of Spatial Association (LISA) and multivariable linear regression, we tested three theory-based hypotheses and assessed the spatial clustering of CHD outcomes, while identifying key structural and sociodemographic predictors. Results: Counties with greater rurality and fewer healthcare providers exhibited significantly higher rates of CHD prevalence and mortality. Primary care provider availability and higher household income were protective factors. Digital exclusion, measured by lack of access to computers or mobile devices, was significantly associated with higher CHD prevalence and mortality. Spatial analysis identified the counties with better-than-expected cardiovascular outcomes despite structural disadvantages, suggesting the potential role of localized resilience factors and unmeasured community-level interventions. Conclusions: The findings affirm the relevance of the Andersen model for understanding rural health disparities and highlight the importance of investing in both digital infrastructure and healthcare capacity. Expanding telehealth without addressing provider shortages and social determinants may be insufficient. Local policy innovations and community resilience mechanisms may offer scalable models for improving cardiovascular health in disadvantaged areas.

HIV testing is an entry point for both HIV prevention and treatment, and the CDC recommends that all adults of reproductive age undergo HIV testing at least once in their lifetime. However, HIV testing rates remain suboptimal. This study analyzed trends in HIV testing using Behavioral Risk Factor Surveillance System data from 2017 to 2023 across nine Deep South states—Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas. Descriptive statistics and Joinpoint linear regression were employed to assess lifetime HIV testing and testing within the past 12 months. Findings showed that the overall trend in having ever tested for HIV rose from 43% in 2017 to 47% in 2019 but declined to 40% in 2022, with a slight increase to 41% in 2023. Significant declines in ever testing were observed in North Carolina and among adults aged 25–44, non-Hispanic Black, non-Hispanic multiracial, and those identifying as lesbian or gay. Furthermore, the overall trend in HIV testing in the past 12 months declined significantly from 48% in 2017 to 42% in 2022, with a slight increase to 43% in 2023. Significant declines were found in Florida, Georgia, Louisiana, North Carolina, and South Carolina, and among adults aged 18–34, non-Hispanic White, non-Hispanic Black, male, female, and heterosexual individuals. These trends, observed largely during the COVID-19 pandemic, underscore the need to scale up HIV prevention and care initiatives, particularly in populations and regions experiencing significant declines. Trends should continue to be monitored and examined post-COVID pandemic.

Background: Mississippi has one of the highest rates of food insecurity in the United States, with many counties experiencing significant disparities in access to healthy food. Therefore, understanding the spatial distribution of these disparities is essential for developing targeted interventions. Purpose: This study aims to investigate the spatial distribution of food insecurity and its associated social and health factors across Mississippi counties to identify areas in need of intervention. Methods: Cross sectional study was conducted using publicly available datasets to examine food insecurity and its associated factors at the county level. Pearson correlations and bivariate Moran’s I were used to explore relationships between food insecurity, food banks, health outcomes, and social determinants of health. Results: Food insecurity was highest in counties bordering Louisiana, with significant correlations between food insecurity and poverty, poor health outcomes, and limited broadband access. Conversely, food banks were concentrated in Northeast Mississippi, where food insecurity rates were lower. Conclusions: The findings highlight the need for more equitable distribution of resources across Mississippi counties, particularly in areas with higher food insecurity rates. This study provides valuable insights for public health officials to address food insecurity through targeted, region-specific interventions.

Academic adaptation is crucial for the success and well-being of international students, especially in rural areas where cultural and social support resources may be limited. This study aimed to identify predictors of academic adaptation among international students in the rural southern United States, focusing on social support, cultural integration, alcohol use, and acculturative stress. A cross-sectional study was conducted with 141 international students from two universities: the University of Mississippi/Oxford campus and the University of Alabama. Data were collected through a web-based survey using validated scales to measure cultural integration, acculturative stress, social support, alcohol use, and academic adaptation. Pearson correlation and multiple linear regression analyses were performed to identify significant predictors of academic adaptation. The sample consisted of 54.6% male and 45.4% female students, with a mean age of 29.4 years. The majority were graduate students (89.4%), with the majority being funded by graduate teaching or research assistantships (78.7%). Correlation analyses showed that social support was positively correlated with academic adaptation (r = 0.62, p < 0.01). Also, cultural integration was positively corelated with academic adaptation (r = 0.33, p < 0.001). However, acculturative stress was negatively correlated with academic adaptation (r = −0.20, p < 0.05). The fully adjusted regression analyses identified social support as a positive predictor of academic adaptation among international students in rural U.S. universities. The model demonstrated that each unit increase in the social support score was associated with a 0.61 increase in the academic adaptation score (95% CI [0.44, 0.79], p < 0.001). These findings highlight the need for tailored support programs addressing the unique challenges faced by this population to enhance their academic success and overall well-being.

Acceptance of domestic violence against women refers to the belief that violence can be justified. Women’s attitudes towards domestic violence shape societal acceptance, victimization, disclosure, and help-seeking behaviors. This study explored the role of gender, socio-economic status, regional disparities, and empowerment in domestic violence acceptance among Iraqi women. Using data from the 2018 Iraq Multiple Indicator Cluster Survey (MICS 6) with 19,443 married Iraqi women, this cross-sectional study employed logistic regression analyses to investigate individual, interpersonal, community, and societal determinants of domestic violence acceptance. 48.4% of married Iraqi women accepted domestic violence, with higher acceptance in South/Central regions (62–73%). Factors associated with higher acceptance included lower education (aOR = 0.39, 95% CI: 0.35–0.45 for upper secondary education compared to preprimary or non), functional difficulties (aOR = 1.60, 95% CI: 1.40–1.83), marriage to blood-related spouses (aOR = 1.45, 95% CI: 1.36–1.54), and rural residence (aOR = 1.20, 95% CI: 1.15–1.33). Conversely, owning a mobile phone (aOR = 0.47, 95% CI: 0.44–0.50) and using a computer/tablet (aOR = 0.34, 95% CI: 0.30–0.38) were associated with lower acceptance. These findings, given the lack of research on domestic violence among Iraqi women, highlight the urgent need for policy discussions supporting Sustainable Development Goals on gender equity and well-being. Enhanced access to technology could help women have better access to resources, support systems, and information, which would lower acceptance for domestic violence.