Frederick S. Pardee RAND Graduate School

Alcohol use disorder (AUD) is a major public health concern; medications for AUD (MAUD) are an effective form of treatment but remain underused. Identifying MAUD access trends and the characteristics of counties with limited availability can inform targeted efforts to expand treatment capacity. To examine trends in geographic availability of MAUD at US substance use disorder treatment facilities (SUDTFs) from 2017 to 2023 and assess county characteristics associated with SUDTFs offering MAUD. This nationwide cross-sectional study used data from the Mental Health and Addiction Treatment Tracking Repository, which includes longitudinal data on licensed SUDTFs and whether they offer MAUD (acamprosate, disulfiram, or naltrexone), to quantify trends in MAUD availability at SUDTFs from January 2017 to December 2023. The primary outcome was a county-year indicator for whether at least 1 SUDTF in the county offered MAUD. Explanatory county variables included rurality, percentage of traffic fatalities involving alcohol, percentage of the population that drank excessively, percentage of uninsured individuals, poverty rate, percentage of individuals over age 65 years, and percentage of non-Hispanic White individuals. Univariate logistic regressions with state and year fixed effects were used to explore associations between county characteristics and the probability that a county had any SUDTFs offering MAUD. Across 22 000 county-years in a total of 3153 counties, the mean (SD) percentage of counties with at least 1 SUDTF offering MAUD increased from 34.12% (47.42%) in 2017 to 43.88% (49.63%) in 2021, but growth plateaued after 2021. Lower MAUD presence in a county was associated with rural-adjacent (difference, -22.40 percentage points [pp]; 95% CI, -24.43 to -20.38 pp) and rural-remote (-23.64 pp; 95% CI, -25.72 to -21.56 pp) relative to metropolitan county status as well as with a higher poverty rate (-0.66 pp; 95% CI, -0.93 to -0.38 pp), greater percentage of individuals aged 65 years or older (-2.33 pp; 95% CI, -3.02 to -1.65 pp), and higher proportion of non-Hispanic White individuals (-0.58 pp; 95% CI, -0.71 to -0.46 pp), whereas greater prevalence of binge drinking (difference, 1.90 pp; 95% CI, 1.26-2.54 pp) and a higher percentage of college-educated individuals (1.28 pp; 95% CI, 1.13-1.43) were associated with higher MAUD presence. In this cross-sectional study, the proportion of SUDTFs offering MAUD increased from 2017 to 2021, but growth then plateaued. Policies supporting the expansion of MAUD-providing facilities, particularly in underserved counties, may be needed to address persistent gaps in access.

Background/Objectives: Legal access to cannabinoids is increasing, and patients with chronic pelvic pain from endometriosis were hypothesized to explore and find benefit from the use of marijuana for symptom management. A survey of women with endometriosis was conducted with the objective of characterizing their experience with marijuana for management of pelvic pain: exploring symptom benefit, characteristics of use, and factors contributing to use and discontinuation. Methods: A descriptive cross-sectional survey was undertaken using an anonymous online questionnaire. Participants were recruited from an outpatient gynecology clinic using endometriosis ICD-10 diagnostic codes, and from the Endometriosis Association mailing list. Results: Marijuana use for symptom relief was reported by 78 (32.2%) Endometriosis Association participants, and 58 (46.8%) clinic participants. Within both populations, marijuana was considered very or moderately effective by most users (68.0 to 75.9%). Legality of recreational and medicinal marijuana in the state of residence was strongly associated with use (OR 7.13 [95% CI: 2.57–19.8]). Among users specifying current or past use, discontinuation was reported by 45% (54 of 121), and most frequently attributed to non-clinical factors of legal/employment risk and obstacles to marijuana access; 64.8% of former users attributed discontinuation to non-clinical factors only. Lack of symptom relief from other clinical management was the most cited motivation for initiation (55.1% clinic, 39.7% EA users). Conclusions: Marijuana use is common among women with endometriosis and chronic, refractory pelvic pain. Legality and access appear to impact use and discontinuation. While legal access to marijuana is associated with increased use, marijuana obtained outside of legal routes is also commonly being used for symptom relief.

Caregivers of African American hospice patients report unsatisfactory spiritual support in hospice. Hospice professionals, chaplains, clergy, and policymakers need to understand factors influencing spiritual care of African American hospice patients to advance equitable end-of-life and hospice care. We partnered with large community hospice in Georgia, USA, and interviewed caregivers of African American hospice decedents, their clergy, and chaplains. We heard caregivers of African American hospice patients desired chaplains to pray, visit frequently and be present. Caregivers’ lack of knowledge about hospice, general medical mistrust, and clergy’s minimal understanding of the breadth of spiritual care were barriers to adequate spiritual care.

Palestinian youth in the West Bank, occupied Palestinian territory (oPt) live in proximity to various forms of Israeli occupation infrastructure, such as checkpoints, road obstructions, a separation barrier, and Israeli settlements. We investigated the effect of proximity to such infrastructure on youth mental health and health risk behaviors by linking geospatial data on the locations of occupation infrastructure to geocoded survey data collected from a representative sample of Palestinian youth living in the West Bank. We estimated the relationship of youth mental health and proximity to each type of occupation infrastructure with controls for exposure to conflict-related violence and a range of demographic factors. We found that youth mental health is strongly negatively impacted by proximity to manned checkpoints (for males and females) and proximity to settlements (for females), and these impacts appear to be direct rather than mediated by conflict-related trauma exposure. The results indicate the importance of environmental aspects of the conflict for youth mental health, in addition to conflict-related violence itself.

Game theory in pandemics, social media rumors, and disasters, is reviewed. Evolutionary game theory is commonly used to account for the time dimension. Overarchingly, the game-theoretic precautionary principle accounts for threat, uncertainty, action, and command. Players pursue uncertainty thresholds repeatedly, with uncertainty about which game is played, which players participate, strategy sets, payoffs, incomplete information, risk attitudes, and bounded rationality. Pandemics involve games between multiple societal actors, i.e., companies and various sectors of the economy, countries, governments, individuals, etc. Individuals may choose whether to behave riskily or safely, whether to buy vaccines and drugs, mask-wearing, distancing, etc. Companies may produce vaccines and drugs. Policymakers and the international community may free ride on who shall bear the costs. Social media platforms play censorship games classifying the information as true or false. Organizations may identify ideologically in various ways, and may play games through time as updated evidence becomes available. Governments and companies play regulation games during disasters. Companies weigh profit against safety while the governments may subsidize, penalize, and tax. Games between nongovernmental organizations, donors, and individuals are considered.

There is much focus in the field of HIV prevention research on understanding the impact of social determinants of health (e.g., housing, employment, incarceration) on HIV transmission and developing interventions to address underlying structural drivers of HIV risk. However, such interventions are resource-intensive and logistically challenging, and their evaluation is often limited by small sample sizes and short duration of follow-up. Because they allow for both detailed and large-scale simulations of counterfactual experiments, agent-based models (ABMs) can demonstrate the potential impact of combinations of interventions that may otherwise be infeasible to evaluate in empirical settings and help plan for efficient use of public health resources. There is a need for computational models that are sufficiently realistic to allow for evaluation of interventions that address socio-structural drivers of HIV transmission, though most HIV models to date have focused on more proximal influences on transmission dynamics. Modeling the complex social causes of infectious diseases is particularly challenging due to the complexity of the relationships and limitations in the measurement and quantification of causal relationships linking social determinants of health to HIV risk. Uncertainty exists in the magnitude and direction of associations among the variables used to parameterize the models, the representation of sexual transmission networks, and the model structure (i.e. the causal pathways representing the system of HIV transmission) itself. This paper will review the state of the literature on incorporating social determinants of health into epidemiological models of HIV transmission. Using examples from our ongoing work, we will discuss Uncertainty Quantification and Robust Decision Making methods to address some of the above-mentioned challenges and suggest directions for future methodological work in this area.

While recent developments in artificial intelligence (AI) and robotics may reign in a new era in human-machine interaction (HMI), we can draw on a wealth of existing and evolving experiences and intellectual adventures rooted in philosophy and science, technology, and society (STS) studies to inform our theoretical and practical engagement with this new phase. In this paper, we propose widening the set of stakeholders and tools deployed to explore pathways to navigate the risks and opportunities these developments entail, how the narratives we use in describing and envisioning shape how we think about HMI, and how specific philosophical frameworks can be well suited in envisioning the complexities of human and AI/Robotics collaboration.

We study the working conditions of low-skilled workers in a developing country, Bangladesh, to shed light on the conditions workers value and employers may be willing to provide. Using a carefully designed choice experiment embedded in a unique survey of employers and employees, we elicit preferences for compensation, leave and termination policies, working hours, overtime pay, and accident compensation. Workers value termination notice and accident compensation, and employers are not averse to providing them. However, workers find long working hours without overtime compensation to be highly undesirable, whereas many employers are unwilling to provide shorter hours or overtime pay unless they face the threat of fines or are offered substantial incentives. Our findings suggest that encouraging the provision of termination notice and accident compensation may be relatively easy, but that increasing compliance with legal limits on working hours and overtime compensation is likely to require increased enforcement or substantial incentives.