Enbal Shacham

• Saint Louis University

Background Pediatric asthma remains one of the most prominent chronic health conditions among US youth. Geographic determinants such as air pollutants have been identified as playing a role in asthma development and exacerbation. The purpose of this study was to determine geospatial predictors of pediatric asthma exacerbation events and to prioriti...

Climate and agricultural land-use change has increased the likelihood of infectious disease emergence and transmissions, but these drivers are often examined separately as combined effects are ignored. Further, seldom are the influence of climate and agricultural land use on emerging infectious diseases examined in a spatially explicit way at regio...

Climate and agricultural land-use change have increased the likelihood of infectious disease emergence and transmissions, but these drivers are often examined separately as synergistic effects are ignored. Further, seldom are the influence of climate and agricultural land use on emerging infectious diseases examined in a spatially explicit way at r...

Introduction As emerging infectious diseases (EIDs) increase, examining the underlying social and environmental conditions that drive EIDs is urgently needed. Ecological niche modeling (ENM) is increasingly employed to predict disease emergence based on the spatial distribution of biotic conditions and interactions, abiotic conditions, and the mobi...

Background As the COVID-19 pandemic progressed across the United States, older adults living in nursing home (NH) facilities were disproportionately affected because of living in communal spaces with close proximity to others, age-related medical conditions, and constant contact with staff who may support multiple clients and facilities. While thes...

Productive global agriculture is under a convergence of pressures, and particularly climate change and population growth. The impact is especially stark in East Africa where crop production is mostly rain-fed and population growth rates are among the highest in the world. Our objective for this study was to understand how climate change and populat...

Purpose of review: Tremendous advancements have been made in HIV treatment and prevention during the last 40 years that zero new HIV cases has become an attainable goal declared by international agencies. However, new cases of HIV infection persist. Recent findings: The emerging field of geospatial science is positioned to play key role in the r...

Objectives: Personal health information (PHI), including health status and behaviors, are often associated with personal locations. Smart devices and other technologies routinely collect personal location. Therefore, technologies collecting personal location do not just create generic questions of privacy, but specific concerns related to PHI. Me...

Human-induced climate change significantly alters the spatiotemporal characteristics of climate zones, which drives agricultural land use and ecosystem change. However, the detectability of shifting climate zones and the rate and time of the changes has yet to be adequately addressed at the regional-to-local scale. We mapped and analyzed changes to...

Introduction: Health disparities arise from biological-environmental interactions. Neuroimaging cohorts are reaching sufficiently large sample sizes such that analyses could evaluate how the environment affects the brain. We present a practical guide for applying geospatial methods to a neuroimaging cohort. Methods: We estimated brain age gap (BAG...

Early distribution of COVID-19 vaccines was largely driven by population size and did not account for COVID-19 prevalence nor location characteristics. In this study, we applied an optimization framework to identify distribution strategies that would have lowered COVID-19 related morbidity and mortality. During the first half of 2021 in the state o...

Early distribution of COVID-19 vaccines was largely driven by population size and did not account for COVID-19 prevalence nor location characteristics. In this study, we applied an optimization framework to identify distribution strategies that would have lowered COVID-19 related morbidity and mortality. Optimized vaccine allocation would have decr...

https://apha.confex.com/apha/2022/meetingapp.cgi/Paper/518299

Background: As the COVID-19 pandemic spread, school district administrators in the United States were faced with difficult decisions regarding the implementation of virtual or in-person learning to reduce risk of infection throughout student and staff populations. While a coordinated effort with surrounding districts would be most beneficial when...

In the United States (US), an estimated 35,900 human papillomavirus (HPV)-related cancers are diagnosed annually. HPV vaccines are projected to eliminate ∼90% of these cancers. Routine vaccination is recommended at age 11-12 with “catch-up” vaccination through age 26 and shared clinical decision making for ages 27-45. However, vaccine uptake has be...

Purpose Maternal depression and neighborhood characteristics are known to be associated both with each other and with adolescent mental health outcomes. These exposures are also subject to change throughout the life of a child. This study sought to identify multi-trajectories of maternal depression (MD) and self-reported neighborhood collective eff...

https://apha.confex.com/apha/2021/meetingapp.cgi/Paper/508991

Nursing homes (NH) continue to struggle with COVID-19 morbidity and mortality with older adult residents at greater risk of infection due to proximity to other residents, advanced aging-related chronic illnesses, and contact with staff. While many states have prioritized COVID-19 vaccinations among older adults, vaccinations among NH staff vary. Th...

The 2015/16 Zika virus epidemic in South and Central America left the scientific community urgently trying to understand the factors that contribute to Zika virus pathogenesis. Because multiple other flaviviruses are endemic in areas where Zika virus emerged, it is hypothesized that a key to understanding Zika virus disease severity, is to study Zi...

As COVID-19 has caused significant morbidity and mortality throughout the world, the development and distribution of an effective vaccine have been swift but not without challenges. Earlier demand and access barriers have seemingly been addressed with more free and accessible vaccines now available for a wide variety of ages. While rates of COVID-1...

The purpose of this study was to explore potential differences in health behaviors and outcomes of sexual minority women (SMW) of color compared to White SMW, heterosexual women of color, and White heterosexual women. Data from 4878 women were extracted from the 2011 to 2016 National Health and Nutritional Examination Survey. The four-category inde...

The 2015/16 Zika virus epidemic in South and Central America left the scientific community urgently trying to understand the disease and the factors which modulate Zika virus pathogenesis. Multiple other flaviviruses are endemic in areas where Zika virus emerged in 2015/16. Therefore, it is hypothesized that a key to understanding how Zika virus in...

Purpose Identifying geographic-level prevalence of occupations associated with mobility during local stay-at-home pandemic mandate. Methods A spatio-temporal ecological framework was applied to determine census-tracts that had significantly higher rates of occupations likely to be deemed essential: food-service, business and finance, healthcare su...

The purpose of this study was to examine adherence to COVID-19 nonpharmaceutical interventions within the context of same-sex households. Same-sex households within City of Saint Louis census-tracts were identified using U.S. Census Bureau data. Secondary smart-device GPS data was used to ascertain community-mobility during shelter-in-place orders....

Importance This study assessed the longitudinal impact of new COVID-19 cases when a mask ordinance was implemented in 2 of a 5-county Midwestern U.S. metropolitan region over a 3-month period of time. Reduction in case growth was significant and reduced infection inequities by race and population density. Objective The objective of this study was...

This study aimed to identify differences in condom use among adolescents by alcohol consumption patterns using the 2017 Youth Risk Behavior Survey. Results suggest significant increased risk of condomless sex among binge drinking youth. Surprisingly, no significant difference in condom utilization was identified between non-drinkers and only modera...

Objectives: HIV prevention strategies prioritize medication adherence among people living with HIV (PLWH). Of the 1.1 million PLWH in the United States, more than two-fifths are not virally suppressed and thus experience increased morbidity and mortality as well as transmission risk. Integrated care models are meant to address these gaps and often...

Professional conferences and networking events are under-utilized resources for workforce development in the geospatial intelligence (GEOINT) field, present opportunities and advantages, and, if used properly, can help address the field's generational shift. Many organizations tend to focus on their mid-to senior-level workforce when participating...

Clinic appointment attendance is a significant determinant of improved HIV health outcomes. A retrospective longitudinal analysis from 2009 to 2015 examined the relationship of clinic policy attendance with and without medical case management (MCM) on HIV clinical outcomes. Clinical parameters were abstracted across the study years and latent growt...

Background: The city of St. Louis, Missouri is considered one of the most dangerous cities in the US. Rates of violent crime in St. Louis remain higher than the national average. Violent crimes are associated with many adverse outcomes, poor mental health is one of these outcomes. This study was conducted to elucidate the relationship between viole...

Purpose: We assess the effectiveness of multilevel regression with poststratification (MRP) as a tool to mitigate selection bias from online surveys of small geographical regions. Methods: We collected self-reported health information from an Internet-based sample of adults residing within the St. Louis, MO, metropolitan area in 2017. We created...

Identifying distinct patterns of behavior and mood in natural environments that interrupt medication adherence among individuals with HIV will be useful in informing intervention development. This pilot study assessed the initial efficacy of using ecologic momentary assessment to define patterns of alcohol use, mood, and medication adherence. Parti...

BACKGROUND Individuals with HIV have high rates of mood disorders that have been noted to interrupt adherence care practices. Yet, intraday fluctuations in mood among these individuals are mostly unknown. OBJECTIVE This study examined mood and alcohol use among a sample of individuals with HIV in their natural environments. METHODS This prospecti...

Medical case management (MCM) is a core medical service in The Ryan White HIV/AIDS Program and aims to provide treatment and care for people living with HIV/AIDS by engaging, identifying and eliminating barriers to HIV care. Little research has examined the impact of this intervention; therefore, the purpose of this study was to examine how MCM aff...

DS_10.1177_2381468318781093 – Supplemental material for A Comparison Between Subjective and Objective Methods of Predicting Health Care Expenses to Support Consumers’ Health Insurance Plan Choice

States that did not expand Medicaid under the Affordable Care Act (ACA) in the United States have seen a growth in the number of individuals who fall in the assistance gap, defined as having incomes above the Medicaid eligibility limit (≥44% of the federal poverty level) but below the lower limit (<100%) to be eligible for tax credits for premium s...

Interventions are needed to address each phase of the HIV care continuum in order to improve health outcomes and reduce likelihood of HIV transmission. The purpose of this study was to assess the impact of a community- and clinic-based intervention designed and implemented to reengage individuals who were lost to HIV care. Eligible participants had...

Social support has been noted to improve health outcomes for individuals with HIV. Understanding how neighborhoods contribute to feelings of social support is beneficial to create environments where populations with HIV can be supported. This study assessed the relationship between neighborhood perceptions and social support with HIV management. A...

The role of sexual function and its impact on HIV management have been inadequately evaluated. A cross-sectional study in 2009 of 202 patients with HIV were recruited to examine sexual function and psychosocial/HIV management factors. Analyses assessed the relationship between sexual function, sociodemographic factors, biomedical markers, and depre...

Objectives: To understand where transmission of Zika virus has the highest likelihood to occur in the contiguous United States with regard to its transmission both sexually and via Aedes aegypti mosquito bites. Methods: We evaluated the 2 routes of transmission risk with predictors of sexually transmitted infections (percentage women of childbea...

Identifying predictors that contribute to geographic disparities in sexually transmitted infections (STIs) is necessary in order to reduce disparities. This study assesses the spatial relationship condom availability and accessibility in order to better identify determinants of geographic disparities in STIs. We conducted a telephone-based audit am...

Introduction Since the Affordable Care Act was passed, more than 12 million individuals have enrolled in the health insurance marketplace. Without support, many struggle to make an informed plan choice that meets their health and financial needs. Methods We designed and evaluated a decision aid, Show Me My Health Plans (SMHP), that provides educat...

Regardless of medical advancements, new HIV infections persist. Young adults are most often newly infected, thus research is needed to assess medication adherence barriers specific to young adults with HIV. The data were abstracted from medical charts to include both self-reported behavioral and psychological distress data and HIV parameters in 201...

Adverse neighborhood conditions play an important role beyond individual characteristics. There is increasing interest in identifying specific characteristics of the social and built environments adversely affecting health outcomes. Most research has assessed aspects of such exposures via self-reported instruments or census data. Potential threats...

As individuals with HIV infection are living longer, the management of psychiatric disorders has increasingly been incorporated into comprehensive care. Individuals were recruited from an outpatient HIV clinic to assess the prevalence and related associations of current psychiatric disorders and biomarkers. Of the 201 participants who completed the...

Background The implementation of the ACA has improved access to quality health insurance, a necessary first step to improving health outcomes. However, access must be supplemented by education to help individuals make informed choices for plans that meet their individual financial and health needs. Methods/Design Drawing on a model of information...

Background: Identifying predictors that contribute to geographical disparities in sexually transmitted infections (STIs) is necessary. This study assesses the spatial relationship between condom availability to locations of STIs in order to better understand these geographical disparities. Objectives: We conducted a condom availability audit amo...

African American (AA) men remain one of the most disconnected groups from health care. This study examines the association between AA men's rating of health care and rating of their personal physician. The sample included 12,074 AA men aged 18 years or older from the 2003 to 2006 waves of the Consumer Assessment of Healthcare Providers and Systems...

The Affordable Care Act allows uninsured individuals to select health insurance from numerous private plans, a challenging decision-making process. This study examined the effectiveness of strategies to support health insurance decisions among the uninsured. Participants (N = 343) from urban, suburban, and rural areas were randomized to 1 of 3 cond...

An audit of condom availability conducted in urban Malawi identified limited access to this HIV prevention method. Barriers included cost, location in store, and few stores selling or distributing condoms. Prevalence of HIV in sub-Saharan African countries persists at alarming rates. There are currently four promoted methods to prevent HIV infectio...

Access to parks improves overall health outcomes in the general population. Given that HIV infection has become a chronic disease to manage, among populations engaged in medical care, parks may be promoted as physical activity opportunities in order to manage chronic comorbid conditions. We conducted a cross-sectional examination of the relationshi...

Introduction: New HIV infections persist, regardless of medical advancements. With young adults being those that are most often newly infected, research needs to be conducted to assess adherence barriers, specific to young adults with HIV. Methods: As standard of care, patients presenting for care completed behavioral and psychological distress a...

Voluntary medical male circumcision (VMMC) is being suggested as an essential HIV prevention strategy in high-prevalence areas. These analyses reflect data collected from 360 married couples, 50% of which included a circumcised husband and the other 50% uncircumcised, in rural Malawi. Regardless of their circumcision status, men were more likely to...

Introduction: Epidemiologic data suggest that geographic clustering of new HIV infections is a common phenomenon, particularly in urban areas among populations of low socioeconomic status. As HIV management has been identified as an integral component of secondary prevention, better understanding of multi-level factors that influence medication adh...

Summary Despite advancements in the public's understanding of HIV infection, felt stigma towards individuals living with HIV persists. Stigma has been associated with adverse health outcomes, including poor adherence to care, and increased participation in HIV transmission risk behaviours. We evaluated the level of felt stigma and its relationship...

To examine beliefs, prior use, and interest in using pharmacotherapy among people living with HIV/AIDS (PLWHA). Cross-sectional survey of smokers in a midwestern HIV clinic. The sample (N = 146) included 69% men, 82% African Americans, 45% were in precontemplation for quitting, and 46% were interested in using pharmacotherapy. Primary reasons for n...

Depression is a common comorbidity among HIV-infected individuals. We studied the relationship between depressive symptoms, risk behaviors (risky-sexual behavior, tobacco, alcohol, and illicit drug use) and HIV outcomes. This cross-sectional study conducted in 2009 at the Washington University HIV Clinic included screening for depression with patie...

In addition to their contribution to long-term sexual health complications, infection with sexually transmitted infections (STIs) increases the biological risk of HIV infection. Understanding the distribution of sexual health resources in a community can inform interventions aimed at preventing STIs. We developed an audit to assess condom availabil...

HIV infection has become a manageable chronic disease due to treatment advances. Secondary prevention efforts have proven inadequate to reduce the estimated incidence of new HIV infections. Epidemiologic data suggests that geographic clustering of new HIV infections is a common phenomenon, particularly in urban areas among populations of low socioe...

By 2014, uninsured adults will be eligible for health insurance through exchanges with multiple plan options. Choosing health insurance is challenging even for those who have engaged in the process previously. We examined 51 uninsured adults' health insurance knowledge and preferences through semistructured qualitative interviews. Our sample was pr...

Purpose: As a result of the passage of the Affordable Care Act (ACA), by 2014, 52 million Americans without health insurance will be eligible for insurance through an exchange system that allows them to choose from multiple plans. Understanding information, making comparisons across plans, and choosing a plan that best suits one’s financial and hea...

Abstract Psychometric properties of an 18-item HIV felt stigma questionnaire were evaluated utilizing data collected from a diverse ethnic and socioeconomic group of 370 people living with HIV/AIDS and receiving HIV/AIDS-related health services at an HIV clinic in Kenya. Factor analyses revealed a four factor solution (public attitudes, ostracize,...

HIV infection has become a manageable chronic disease as a result of treatment advances. Secondary prevention efforts have proved inadequate to reduce the estimated incidence of new HIV infections. Epidemiological data suggest that geographical clustering of new HIV infections is a common phenomenon, particularly in urban areas among populations of...

Background: Effectiveness of antiretroviral therapy (ART) in a routine clinical care may result different from the clinical trials. We assessed the virologic outcomes in treatment-naive persons who received either efavirenz (EFV) or atazanavir/ritonavir (ATV/r) with a backbone of tenofovir/emtricitabine (TDF/FTC) as their combination ART (cART)....

Abstract In general, an initial diagnosis of HIV is likely to be correlated with the onset of HIV stigma. HIV-positive individuals are likely to internalize stigma, may suffer from psychosocial issues, or engage in maladaptive behaviors to cope with the diagnosis. Internalized stigma stems from fear of stigmatization also known as felt stigma. The...

Background: Initial diagnosis of HIV is reportedly correlated with stigma which is associated with shame, rejection or blame, towards people living with HIV/AIDS (PLWHA). Limited studies have examined HIV related felt stigma in a Kenyan context. To necessitate valid and reliable measurement of HIV felt stigma in Kenya, it is critical to cross-cultu...

RESEARCH OBJECTIVE: Health information seeking outside of the medical encounter has increased significantly. Patients seek health information to learn more about health conditions, assess symptoms, and to improve communication with health care providers. Men's health is a relatively new area of study. Consequently, the literature is sparse related...

RESEARCH OBJECTIVE: Health information seeking and use are associated with positive health outcomes. An empowered patient is associated with better health status and medical adherence. Men's health continues to lag behind women's health, however men's health remains understudied. The aim of this study is to assess the differences by race in confide...

Individuals with HIV experience fluctuating levels of distress throughout the course of their infection. This cross-sectional study was conducted to examine the prevalence of and associations between anxiety symptoms, sociodemographic, and biomedical markers among individuals presenting for care. A total of 635 individuals were screened, the majori...

We examined the association between perceived discrimination and smoking status and whether psychological distress mediated this relationship in a large, multiethnic sample. We used 2004 through 2008 data from the Behavioral Risk Factor Surveillance System Reactions to Race module to conduct multivariate logistic regression analyses and tests of me...

Socially disadvantaged individuals with HIV experience unacceptably high rates of AIDS and death. The authors developed an adversity index to quantify the impact of demographic and psychosocial factors on HIV care. This retrospective cohort study included 431 participants with HIV on combined antiretroviral therapy between 2000 and 2005. Poor outco...

Among persons in current HIV outpatient care, data on opioid prescribing are lacking. This study aims to evaluate predictors of repeat opioid prescribing and to characterize outpatient opioid prescribing practices. Retrospective cross-sectional study of persons ≥18 years in HIV outpatient care who completed an annual behavioral assessment between J...

Serostatus disclosure is an important component of secondary HIV prevention with potential benefits for both the individual by experiencing increased social support and society by reducing HIV transmission risk behaviors. This cross-sectional study assessed disclosure patterns to sex partners, family members, and friends by sociodemographic and HIV...

Individuals with HIV experience fluctuating levels of distress throughout the course of HIV infection. This cross-sectional study was conducted to examine the prevalence of and associations between anxiety symptoms and sociodemographic and clinical markers that were measured using the General Anxiety Disorder 7 (GAD-7) among individuals presenting...

As individuals with HIV are living longer with less morbidity, developing interventions that address co-morbidities are essential. Psychological distress symptoms fluctuate throughout HIV infection and interrupt self-care practices. This pilot study was conducted to test the implementation of a clinic-recruited sample to participate in a community-...

Trends in transmitted drug resistance-associated mutations (TDRM) in HIV-1infection vary depending on geographic and cohort characteristics. The impact of TDRM among patients receiving fully active combination antiretroviral therapy (cART) is poorly characterized. This was a retrospective study of 801 HIV-1-infected treatment-naive patients from 20...

Risk behavior surveys often target sexually transmitted disease (STD) clinic populations, but few studies address risk behaviors in primary care settings. This cross-sectional study performed at a university adult primary care clinic evaluated risk behaviors using an anonymous, self-administered survey. The following data were collected: demographi...

The documented prevalence of alcohol use among individuals with HIV is higher than reported among the general public. Little is known about how populations with HIV perceive the risks of alcohol use and what they consider to be safe levels of consumption. This qualitative study was conducted to increase understanding of the situations and environme...

Previous research has examined sexual behavior in the context of HIV transmission risk. The role of sexual function and its role in HIV prevention have been inadequately evaluated. Methods: This cross sectional study of 203 individuals with HIV followed in a publicly funded urban US HIV clinic was conducted to increase the understanding of sexual f...

Knowledge of an HIV-infected individual's sexual behaviors and routine sexually transmitted diseases (STDs) testing greatly facilitates HIV prevention efforts, but current data in older individuals are lacking. This study was developed to compare sexual behaviors and STD prevalence between older HIV-infected individuals and their younger counterpar...

Elevated psychological distress during HIV infection has been consistently correlated with negative HIV-related health outcomes in studies conducted in various regions of the world. This study was conducted to compare the nature and range of psychological distress among HIV-infected individuals who had sought mental health care as part of their HIV...

Understanding challenges to virologic suppression is essential to optimizing health outcomes among individuals with HIV. This cross-sectional behavioral assessment was conducted among 514 individuals presenting at an urban U.S. HIV clinic between June and September 2007. The majority of the sample was African American and male, with a mean age of 4...

The impact of premature frailty in HIV-infected individuals on the prevalence of sexual behaviors and sexually transmitted infections (STIs) is unknown. We compared these factors among individuals aged ≥ 18 years, who had prior determination of a frailty phenotype at the Washington University HIV Clinic between June and December 2008. All P values...

Previous research reports that populations with HIV consume higher rates of alcohol than general population. This cross-sectional study (n = 391) was conducted to measure alcohol consumption, factors associated with consumption, and the relationship between alcohol and HIV viral loads among individuals receiving HIV care. Increased alcohol consumpt...

Over the past decade, the number of individuals who have been diagnosed with HIV in nonmetropolitan areas (population of less than 50,000 individuals) has increased; however, the majority of the research has been conducted in metropolitan areas. Even less research has examined the levels of psychological distress among rural individual living with...

Background: Little is known about whether differences in psychological distress exist between individuals living with HIV who identify as LGBT or heterosexual. Purpose: To examine the differences in psychological distress among self-identified heterosexual and LGBT individuals living with HIV/AIDS. Methods: Sociodemographic data and levels of psych...

Individuals with HIV experience fluctuating levels of distress throughout the course of HIV infection. This study was conducted to examine the associations of depressive symptomatology with HIV disease in a cohort of individuals who are engaged in routine medical care. This cross-sectional study examined the prevalence of depressive symptoms that w...

Objective: HIV infection is the most common preventable and treatable cause of neurocognitive impairment in individuals under the age of 50 years. Highly active antiretroviral therapy (HAART) has reduced the incidence of HIV dementia by 40-50%. We sought to describe the prevalence and identify risk factors associated with HIV neurocognitive impairm...

Frailty among HIV-infected persons is increasingly recognized but data are limited. We aimed to determine frailty prevalence, predictors and clinical significance in this population. This was a prospective cross-sectional study of HIV-infected persons > or =18 years attending Washington University HIV Clinics between June and December 2008. Frailty...

HIV prevention efforts require a focus on reducing high risk sexual behavior. Because these are self-reported, assessments that reduce memory bias and improve elicitation of data are needed. As part of a multi-site psychometric study of club drug use, abuse, and dependence, data were collected with a test-retest design that measured the reliability...

Recent studies support technology-based behavioral interventions for individuals with HIV. This study focused on the use of cell phone and internet technologies among a cohort of 515 HIV-infected individuals. Socio-demographic and clinic data were collected among individuals presenting at an urban Midwestern university HIV clinic in 2007. Regular i...

Background: As the HIV-related infrastructure continues to develop in sub-Saharan African countries, it will be important to consider appropriate mechanisms that will support attention to psychological distress among those seeking care and treatment. Aim: The purpose of this study was to assess the reliability and validity of the Brief Symptom Inve...

This study examined the prevalence of sexual behavior and its relationship with psychological distress among individuals with HIV who were seeking mental health care. Upon self-enrollment in HIV-related mental health care, 845 participants completed self-assessments of demographics, psychological distress, and sexual behaviors. Participants were ca...

Background-depression greatly burdens sub-Saharan Africa, especially populations living with HIV/AIDS, for whom few validated depression scales exist. Patient Health Questionnaire-9 (PHQ-9), a brief dual-purpose instrument yielding DSM-IV diagnoses and severity, and PHQ-2, an ultra-brief screening tool, offer advantages in resource-constrained sett...

In recent years there has been an increase in the number of individuals living with HIV who are 50 years of age and older. However, the majority of HIV and mental health research has focused on younger individuals. Therefore, the purpose of this study was explore differences in psychological distress among younger (under age 50) and older adults (5...