Initiation and continued use of oral pre-exposure prophylaxis among pregnant and postpartum women in South Africa (PrEP-PP): a demonstration cohort study.

Emerging adulthood has been defined as the period from the late teens to the mid-late 20s [, ]. This developmental period is marked by numerous transitions into new roles, including those related to college and/or employment, development of new social networks, and need for increased independence from the family of origin []. Emerging adults (EAs) with type 1 diabetes (T1D) also face additional challenges related to their chronic condition, such as transitioning their medical care to adult health care providers (HCPs) [] and maintaining adequate health care insurance [] in order to avoid disruptions in care as well as access to medications and supplies. Therefore, it is not surprising to find that EAs have been shown to be at elevated risk for difficulties with diabetes management (DM) [], including lower use of diabetes management technologies such as continuous blood glucose monitors and insulin pumps [, ]. EAs with T1D also have suboptimal glycemic control in comparison to children and older adults [, ]. For example, one recent longitudinal study showed a statistically and clinically significant 1.0% increase in hemoglobin A1c (HbA1c) in the two years after high school graduation in a sample of 236 EAs []. Studies to investigate the factors that influence DM and glycemic control in this high-risk age group are therefore needed. The Diabetes Resilience Model [] is a theoretical model which has been widely used to predict behavioral resilience (e.g. higher levels of DM) and health resilience (e.g., optimized glucose control) among youth with T1D. It proposes that risks and assets at the level of the individual, family and broader social context interact with one another, and therefore these various domains should be assessed when identifying processes that contribute to diabetes health outcomes.. Most studies of EAs have assessed such factors at either the level of the individual, their family or the health care system. At the level of the individual, diabetes distress (DD) [] ), or negative affect and emotional burden that results from the challenges of living with diabetes, has been found to be common among EAs [, ]. DD can interfere with the completion of DM as well as result in higher blood glucose levels. []. However, given some studies with EAs have shown that DD affects DM, while others have shown only effects on glycemic control, the pathway by while DD exerts its effects on diabetes health is unclear []. Consistent with the developmental tasks of this age group, which include the successful transition to independence, EA’s self-efficacy and perceived competence for DM have also been shown to be an important predictor of both DM and glycemic control [, ]. At the level of the health-care system, quality of communication between EAs and their HCP has also been found to predict diabetes health; both “patient-centered communication” [] and “autonomy-supportive communication” on the part of HCPs [] are associated with better diabetes health outcomes. While there are numerous studies on the effects of risk and protective factors on diabetes health outcomes among EAs with T1D, studies of the effects of neighborhood influences such as neighborhood-level SES/ adversity, availability of neighborhood resources such as healthy foods or greenspace, and residential segregation are lacking. One of the few studies investigating the influence of neighborhoods on the health of EAs found an association between higher levels of neighborhood disadvantage and higher HbA1c , although this relationship was not significant once family-level socio-economic status was included in the model []. No associations between neighborhood disadvantage and DM were found. In a two-year longitudinal study using the same sample of EAs, Mello and colleagues [] found that higher levels of neighborhood disadvantage were predictive of lower family relationship quality, which in turn was associated with poorer DM and glycemic control. In light of the limited studies to date, it is unclear whether the effects of adverse neighborhood conditions on the diabetes health of EAs with T1D are conveyed through disruptions to DM (e.g., access to healthy food, opportunities for exercise) or reflect the effects of stressful environments in dysregulating the HPA axis, which in turn affects glycemic control. Stress-inducing aspects of neighborhoods, such as high rates of crime and violence, have been shown to be associated with glycemic control in adults with type 2 diabetes [] and with BMI in adults with obesity through their effects on inflammatory pathways []. However, to date, the effects of neighborhood crime on health have not been explored among EAs with T1D. Recent calls for more focus on health equity in T1D research and clinical care also highlight the need to better understand the effects of neighborhood and community-level factors [] on minoritized emerging adults with T1D. This group is at heightened risk for suboptimal diabetes outcomes []; i