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Berg CJ, Haardörfer R, Torosyan A, Dekanosidze A, Grigoryan L, Sargsyan Z, Hayrumyan V, Sturua L, Topuridze M, Petrosyan V, Bazarchyan A, Kegler MC. Examining local smoke-free coalitions in Armenia and Georgia: context and outcomes of a matched-pairs community-randomised controlled trial. BMJ Glob Health 2024; 9:e013282. [PMID: 38325896 PMCID: PMC10859987 DOI: 10.1136/bmjgh-2023-013282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 01/10/2024] [Indexed: 02/09/2024] Open
Abstract
INTRODUCTION Local coalitions can advance public health initiatives such as smoke-free air but have not been widely used or well-studied in low-income and middle-income countries. METHODS We conducted a matched-pairs community-randomised controlled trial in 28 communities in Armenia and Georgia (N=14/country) in which we helped establish local coalitions in 2019 and provided training and technical assistance for coalition activity promoting smoke-free policy development and enforcement (2019-2021). Surveys of ~1450 households (Fall 2018, May-June 2022) were conducted to evaluate coalition impact on smoke-free policy support, smoke-free home adoption, secondhand smoke exposure (SHSe), and coalition awareness and activity exposure, using multivariable mixed modelling. RESULTS Bivariate analyses indicated that, at follow-up versus baseline, both conditions reported greater smoke-free home rates (53.6% vs 38.5%) and fewer days of SHSe on average (~11 vs ~12 days), and that intervention versus control condition communities reported greater coalition awareness (24.3% vs 12.2%) and activity exposure (71.2% vs 64.5%). Multivariable modelling indicated that intervention (vs control) communities reported greater rates of complete smoke-free homes (adjusted Odds Ratio [aOR] 1.55, 95% confiedence interval [CI] 1.11 to 2.18, p=0.011) and coalition awareness (aOR 2.89, 95% CI 1.44 to 8.05, p=0.043) at follow-up. However, there were no intervention effects on policy support, SHSe or community-based activity exposure. CONCLUSIONS Findings must be considered alongside several sociopolitical factors during the study, including national smoke-free policies implementation (Georgia, 2018; Armenia, 2022), these countries' participation in an international tobacco legislation initiative, the COVID-19 pandemic and regional/local war). The intervention effect on smoke-free homes is critical, as smoke-free policy implementation provides opportunities to accelerate smoke-free home adoption via local coalitions. TRIAL REGISTRATION NUMBER NCT03447912.
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Affiliation(s)
- Carla J Berg
- Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, USA
| | - Regine Haardörfer
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Arevik Torosyan
- National Institute of Health Named After Academician Suren Avdalbekyan, Yerevan, Armenia
| | - Ana Dekanosidze
- National Center for Disease Control and Public Health, Tbilisi, Georgia
- Tbilisi State Medical University, Tbilisi, Georgia
| | - Lilit Grigoryan
- National Institute of Health Named After Academician Suren Avdalbekyan, Yerevan, Armenia
| | - Zhanna Sargsyan
- Turpanjian College of Health Sciences, American University of Armenia, Yerevan, Armenia
| | - Varduhi Hayrumyan
- Turpanjian College of Health Sciences, American University of Armenia, Yerevan, Armenia
| | - Lela Sturua
- National Center for Disease Control and Public Health, Tbilisi, Georgia
- Petre Shotadze Tbilisi Medical Academy, Tbilisi, Georgia
| | - Marina Topuridze
- National Center for Disease Control and Public Health, Tbilisi, Georgia
- Petre Shotadze Tbilisi Medical Academy, Tbilisi, Georgia
| | - Varduhi Petrosyan
- Turpanjian College of Health Sciences, American University of Armenia, Yerevan, Armenia
| | - Alexander Bazarchyan
- National Institute of Health Named After Academician Suren Avdalbekyan, Yerevan, Armenia
| | - Michelle C Kegler
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Berg CJ, Dekanosidze A, Hayrumyan V, LoParco CR, Torosyan A, Grigoryan L, Bazarchyan A, Haardörfer R, Kegler MC. Smoke-free home restrictions in Armenia and Georgia: motives, barriers and secondhand smoke reduction behaviors. Eur J Public Health 2023; 33:864-871. [PMID: 37500602 PMCID: PMC10567255 DOI: 10.1093/eurpub/ckad129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Promoting smoke-free homes (SFHs) in Armenia and Georgia is timely given high smoking and secondhand smoke exposure (SHSe) rates and recent national smoke-free policy implementation. This study examined theoretical predictors (e.g. motives, barriers) of SFH status, and among those without SFHs, past 3-month SFH attempts and intent to establish SFHs in the next 3 months. METHODS Multilevel logistic regression analyzed these outcomes using 2022 survey data from 1467 adults (31.6% past-month smokers) in Armenia (n = 762) and Georgia (n = 705). Correlates of interest included SHSe reduction behaviors and SFH motives and barriers; models controlled for country, community, age, sex, smoking status and other smokers in the home. RESULTS In this sample, 53.6% had SFHs (Armenia: 39.2%; Georgia: 69.2%). Among those without SFHs, one-fourth had partial restrictions, no smokers in the home and/or recent SFH attempts; 35.5% intended to establish SFHs; and ∼70% of multiunit housing residents supported smoke-free buildings. We documented common SHSe reduction behaviors (opening windows, limiting smoking areas), SFH motives (prevent smell, protect children/nonsmokers) and barriers (smokers' resistance). Correlates of SFHs were being from Georgia, other smokers in the home, fewer SHSe reduction behaviors, greater motives and fewer barriers. Among participants without SFHs, correlates of recent SFH attempts were other smokers in the home, greater SHSe reduction behaviors and SFH motives, and fewer barriers; correlates of SFH intentions were being female, greater SHSe reduction behaviors, greater motives, and fewer barriers. CONCLUSIONS SFH interventions should address motives, barriers and misperceptions regarding SHSe reduction behaviors. Moreover, smoke-free multiunit housing could have a great population impact.
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Affiliation(s)
- Carla J Berg
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington Cancer Center, George Washington University, Washington, DC, USA
| | - Ana Dekanosidze
- Georgia National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - Varduhi Hayrumyan
- Turpanjian College of Health Sciences, American University of Armenia, Yerevan, Armenia
| | - Cassidy R LoParco
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington Cancer Center, George Washington University, Washington, DC, USA
| | - Arevik Torosyan
- National Institute of Health named after academician S. Avdalbekyan, MOH, Yerevan, Armenia
| | - Lilit Grigoryan
- National Institute of Health named after academician S. Avdalbekyan, MOH, Yerevan, Armenia
| | - Alexander Bazarchyan
- National Institute of Health named after academician S. Avdalbekyan, MOH, Yerevan, Armenia
| | - Regine Haardörfer
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Michelle C Kegler
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Crawford K, Jakub K, Lockhart JS, Wold JL. Knowledge, attitudes, and beliefs of cardiovascular disease prevention in young adults in the country of Georgia. J Nurs Scholarsh 2023; 55:903-913. [PMID: 36660906 DOI: 10.1111/jnu.12875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 12/08/2022] [Accepted: 12/19/2022] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Cardiovascular disease (CVD) accounts for 46% of all mortality in the country of Georgia (former Soviet Union). Young adults in that country have not been studied regarding CVD and a need exists to understand lifestyle modifications to promote cardiovascular health. DESIGN An interpretive description qualitative design was used to explore Georgian young adults' knowledge, attitudes, and beliefs of CVD preventative practices and life experiences. METHODS A convenience sample of 19 ethnic Georgian participants (18-40 years old) who were fluent in either English, Georgian, or Russian from a local private university was used. Semi-structured interviews were conducted via video conferencing utilizing an interpreter. RESULTS Four themes were identified: (1) CVD and risk factor knowledge, (2) prevention attitudes, beliefs, and gender differences, (3) health literacy influences, and (4) culture and societal impacts. CVD knowledge was limited and influenced by health literacy and the current healthcare system in Georgia. CONCLUSION Cultural and societal gender norms influence cardiovascular health behaviors. CLINICAL IMPLICATIONS Georgian nurses can play a key role in CVD education and screening for young adults in Georgia.
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Affiliation(s)
- Kimberley Crawford
- Epsilon Phi Chapter, Duquesne University, Pennsylvania, Pittsburgh, USA
- Pi Nu Chapter, University of West Georgia, Georgia, Carrollton, USA
| | - Karen Jakub
- Epsilon Phi Chapter, Duquesne University, Pennsylvania, Pittsburgh, USA
| | - Joan Such Lockhart
- Epsilon Phi Chapter and Eta Chapter, Duquesne University, Pennsylvania, Pittsburgh, USA
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Hayrumyan V, Harutyunyan A, Torosyan A, Grigoryan L, Sargsyan Z, Bazarchyan A, Petrosyan V, Dekanosidze A, Sturua L, Kegler MC, Berg CJ. Tobacco-related risk perceptions, social influences and public smoke-free policies in relation to smoke-free home restrictions: findings from a baseline cross-sectional survey of Armenian and Georgian adults in a community randomised trial. BMJ Open 2022; 12:e055396. [PMID: 35131832 PMCID: PMC8823221 DOI: 10.1136/bmjopen-2021-055396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 01/19/2022] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Given high prevalence of smoking and secondhand smoke exposure in Armenia and Georgia and quicker implementation of tobacco legislation in Georgia versus Armenia, we examined correlates of having no/partial versus complete smoke-free home (SFH) restrictions across countries, particularly smoking characteristics, risk perceptions, social influences and public smoking restrictions. DESIGN Cross-sectional survey study design. SETTING 28 communities in Armenia and Georgia surveyed in 2018. PARTICIPANTS 1456 adults ages 18-64 in Armenia (n=705) and Georgia (n=751). MEASUREMENTS We used binary logistic regression to examine aforementioned correlates of no/partial versus complete SFH among non-smokers and smokers in Armenia and Georgia, respectively. RESULTS Participants were an average age of 43.35, 60.5% women and 27.3% smokers. In Armenia, among non-smokers, having no/partial SFHs correlated with being men (OR=2.63, p=0.001) and having more friend smokers (OR=1.23, p=0.002); among smokers, having no/partial SFHs correlated with being unmarried (OR=10.00, p=0.001), lower quitting importance (OR=0.82, p=0.010) and less favourable smoking attitudes among friends/family/public (OR=0.48, p=0.034). In Georgia, among non-smokers, having no/partial SFHs correlated with older age (OR=1.04, p=0.002), being men (OR=5.56, p<0.001), lower SHS risk perception (OR=0.43, p<0.001), more friend smokers (OR=1.49, p=0.002) and fewer workplace (indoor) restrictions (OR=0.51, p=0.026); among smokers, having no/partial SFHs correlated with being men (OR=50.00, p<0.001), without children (OR=5.88, p<0.001), daily smoking (OR=4.30, p=0.050), lower quitting confidence (OR=0.81, p=0.004), more friend smokers (OR=1.62, p=0.038) and fewer community restrictions (OR=0.68, p=0.026). CONCLUSIONS Private settings continue to lack smoking restrictions in Armenia and Georgia. Findings highlight the importance of social influences and comprehensive tobacco legislation, particularly smoke-free policies, in changing household smoking restrictions and behaviours. TRIAL REGISTRATION NUMBER NCT03447912.
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Affiliation(s)
- Varduhi Hayrumyan
- Turpanjian College of Health Sciences, American University of Armenia, Yerevan, Armenia
| | - Arusyak Harutyunyan
- Turpanjian College of Health Sciences, American University of Armenia, Yerevan, Armenia
| | - Arevik Torosyan
- MOH National Institute of Health Named After Academician Suren Avdalbekyan, Yerevan, Armenia
| | - Lilit Grigoryan
- MOH National Institute of Health Named After Academician Suren Avdalbekyan, Yerevan, Armenia
| | - Zhanna Sargsyan
- Turpanjian College of Health Sciences, American University of Armenia, Yerevan, Armenia
| | - Alexander Bazarchyan
- MOH National Institute of Health Named After Academician Suren Avdalbekyan, Yerevan, Armenia
| | - Varduhi Petrosyan
- Turpanjian College of Health Sciences, American University of Armenia, Yerevan, Armenia
| | - Ana Dekanosidze
- Non-Communicable Disease Department, National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - Lela Sturua
- Non-Communicable Disease Department, National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - Michelle C Kegler
- Department of Behavioral, Social, and Health Education Sciences, Emory University, Atlanta, Georgia, USA
| | - Carla J Berg
- Department of Prevention and Community Health, George Washington University, Washington, District of Columbia, USA
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Wysota CN, Topuridze M, Sargsyan Z, Dekanosidze A, Sturua L, Kegler MC, Petrosyan V, Harutyunyan A, Hayrumyan V, Berg CJ. Psychosocial Factors, Smoke-Free Restrictions, and Media Exposure in Relation to Smoking-Related Attitudes and Behaviors among Adults in Armenia and Georgia. Int J Environ Res Public Health 2021; 18:4013. [PMID: 33920451 DOI: 10.3390/ijerph18084013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/02/2021] [Accepted: 04/07/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Perceived harm, social influences, smoke-free policies, and media exposure have been understudied in relation to tobacco-related attitudes/behaviors in aggregate or in low and middle-income countries; thus, this study examined these factors collectively in relation to smoking-related outcomes among Armenian and Georgian adults. METHODS Using 2018 cross-sectional survey data (n = 1456), multivariable regression analyses examined these factors in relation to smoking status, perceived harm among nonsmokers, and readiness to quit and past-year quit attempts among smokers. RESULTS Significant predictors (p < 0.05) of current smoking (27.3%) included lower perceived harm, more smoking friends, and fewer home and vehicle restrictions. Among nonsmokers, more home and restaurant/bar restrictions, fewer vehicle restrictions, greater anti-tobacco media exposure, and less pro-tobacco media exposure predicted greater perceived harm. Among smokers, greater perceived social acceptability of smoking, less anti-tobacco media exposure, and greater pro-tobacco media exposure predicted readiness to quit (12.7% of smokers). More smoking friends, more home restrictions, less anti-tobacco media exposure, and greater pro-tobacco media exposure predicted past-year quit attempts (19.2%). CONCLUSIONS Findings support the importance of smoke-free policies but were counterintuitive regarding the roles of social and media influences, underscoring the need to better understand how to address these influences, particularly in countries with high smoking rates.
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Harutyunyan A, Hayrumyan V, Sargsyan Z, Torosyan A, Dekanosidze A, Kegler M, Sturua L, Berg CJ. Smokers' and non-smokers' secondhand smoke experiences and interactions to reduce exposure in Armenia and Georgia. Tob Prev Cessat 2021; 7:6. [PMID: 33537511 PMCID: PMC7845734 DOI: 10.18332/tpc/131059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/17/2020] [Accepted: 11/30/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Armenia and Georgia have high rates of smoking and secondhand smoke exposure (SHSe). Greater progress in recent smoke-free legislation in Georgia and Armenia provides a pivotal time for examining the impact on smokers' and non-smokers' experiences and interactions regarding SHSe. METHODS Surveys were conducted in 28 communities in Armenia (n=705) and Georgia (n=751) in 2018 and assessed past 30-day SHSe and smoking in different contexts, as well as attitudes toward and interactions regarding SHSe. RESULTS In this sample (mean age 43.4 years, SD=13.5; 60.5% female; 27.3% smokers), SHSe among non-smokers was usually in homes (42.7%), cars (42.4%), and outdoor public places (38.2%); smokers also reported smoking usually in these places (70.0%, 62.1%, and 60.0%, respectively). Smokers indicated greater likelihood of putting out cigarettes and non-smokers indicated greater likelihood of asking smokers to put them out in places where smoking was prohibited versus allowed (76.5% vs 57.3%, and 46.6% vs 30.7%, respectively). Moreover, 89.9% of smokers indicated being very likely to put out cigarettes around small children if asked and 75.8% indicated trying to minimize SHSe. While 39.7% of participants reported seeing requests to smokers to put out cigarettes in the past 6 months, only 23.3% of smokers reported being asked to do so. Non-smokers in Georgia versus Armenia reported greater likelihood of engaging in behaviors to lower SHSe (p<0.001). CONCLUSIONS Smoke-free legislation may catalyze more behaviors to lower SHSe, particularly among non-smokers; however, private settings (e.g. homes) remain prominent SHSe sources. Public health efforts must consider implications of such policies on SHSe in private settings.
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Affiliation(s)
- Arusyak Harutyunyan
- Turpanjian School of Public Health, American University of Armenia, Yerevan, Armenia
| | - Varduhi Hayrumyan
- Turpanjian School of Public Health, American University of Armenia, Yerevan, Armenia
| | - Zhanna Sargsyan
- Turpanjian School of Public Health, American University of Armenia, Yerevan, Armenia
| | - Arevik Torosyan
- National Institute of Health named after academician S. Avdalbekyan, Ministry of Health, Yerevan, Armenia
| | - Ana Dekanosidze
- Georgia National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - Michelle Kegler
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, United States.,Winship Cancer Institute, Emory University, Atlanta, United States
| | - Lela Sturua
- Georgia National Center for Disease Control and Public Health, Tbilisi, Georgia.,Petre Shotadze Tbilisi Medical Academy, Tbilisi, Georgia
| | - Carla J Berg
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, United States.,George Washington Cancer Center, George Washington University, Washington, United States
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Topuridze M, Berg CJ, Dekanosidze A, Torosyan A, Grigoryan L, Bazarchyan A, Sargsyan Z, Hayrumyan V, Maglakelidze N, Sturua L, Haardörfer R, Kegler MC. Smokers' and Nonsmokers' Receptivity to Smoke-Free Policies and Pro- and Anti-Policy Messaging in Armenia and Georgia. Int J Environ Res Public Health 2020; 17:ijerph17155527. [PMID: 32751714 PMCID: PMC7432748 DOI: 10.3390/ijerph17155527] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/24/2020] [Accepted: 07/27/2020] [Indexed: 12/02/2022]
Abstract
Garnering support for smoke-free policies is critical for their successful adoption, particularly in countries with high smoking prevalence, such as Armenia and Georgia. In 2018, we surveyed 1456 residents (ages 18–64) of 28 cities in Armenia (n = 705) and Georgia (n = 751). We examined support for cigarette and electronic nicotine delivery systems (ENDS)/heated tobacco product (HTP) smoke-free policies in various locations and persuasiveness of pro- and anti-policy messaging. Participants were an average age of 43.35, 60.5% female, and 27.3% current smokers. Nonsmokers versus smokers indicated greater policy support for cigarette and ENDS/HTP and greater persuasiveness of pro-policy messaging. Armenians versus Georgians generally perceived pro- and anti-policy messaging more persuasive. In multilevel linear regression, sociodemographics (e.g., female) and tobacco use characteristics (e.g., smoking less frequently, higher quitting importance) correlated with more policy support. Greatest policy support was for healthcare, religious, government, and workplace settings; public transport; schools; and vehicles carrying children. Least policy support was for bar/restaurant outdoor areas. The most compelling pro-policy message focused on the right to clean air; the most compelling anti-policy message focused on using nonsmoking sections. Specific settings may present challenges for advancing smoke-free policies. Messaging focusing on individual rights to clean air and health may garner support.
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Affiliation(s)
- Marina Topuridze
- Non-Communicable Diseases Department, National Center for Disease Control and Public Health, Tbilisi 0198, Georgia; (M.T.); (A.D.); (N.M.); (L.S.)
- School of Natural Sciences and Medicine, Ilia State University, Tbilisi 0162, Georgia
| | - Carla J. Berg
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington Cancer Center, George Washington University, Washington, DC 20052, USA
- Correspondence:
| | - Ana Dekanosidze
- Non-Communicable Diseases Department, National Center for Disease Control and Public Health, Tbilisi 0198, Georgia; (M.T.); (A.D.); (N.M.); (L.S.)
| | - Arevik Torosyan
- National Institute of Health Named after Academician S. Avdalbekyan, MoH, Yerevan 0051, Armenia; (A.T.); (L.G.); (A.B.)
| | - Lilit Grigoryan
- National Institute of Health Named after Academician S. Avdalbekyan, MoH, Yerevan 0051, Armenia; (A.T.); (L.G.); (A.B.)
| | - Alexander Bazarchyan
- National Institute of Health Named after Academician S. Avdalbekyan, MoH, Yerevan 0051, Armenia; (A.T.); (L.G.); (A.B.)
| | - Zhanna Sargsyan
- Turpanjian School of Public Health, American University of Armenia, Yerevan 0019, Armenia; (Z.S.); (V.H.)
| | - Varduhi Hayrumyan
- Turpanjian School of Public Health, American University of Armenia, Yerevan 0019, Armenia; (Z.S.); (V.H.)
| | - Nino Maglakelidze
- Non-Communicable Diseases Department, National Center for Disease Control and Public Health, Tbilisi 0198, Georgia; (M.T.); (A.D.); (N.M.); (L.S.)
| | - Lela Sturua
- Non-Communicable Diseases Department, National Center for Disease Control and Public Health, Tbilisi 0198, Georgia; (M.T.); (A.D.); (N.M.); (L.S.)
- Public Health Department Petre Shotadze Tbilisi Medical Academy, Tbilisi 0144, Georgia
| | - Regine Haardörfer
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA; (R.H.); (M.C.K.)
| | - Michelle C. Kegler
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA; (R.H.); (M.C.K.)
- Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
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