Identifying heterogeneity among injection drug users: a cluster analysis approach

Objectives. We used cluster analysis to subdivide a population of injection drug users and identify previously unknown behavioral heterogeneity within that population.Methods. We applied cluster analysis techniques to data collected in a cross-sectional survey of injection drug users in Winnipeg, Manitoba. The clustering variables we used were based on receptive syringe sharing, ethnicity, and types of drugs injected.Results. Seven clusters were identified for both male and female injection drug users. Some relationships previously revealed in our study setting, such as the known relationship between Talwin (pentazocine) and Ritalin (methylphenidate) use, injection in hotels, and hepatitis C virus prevalence, were confirmed through our cluster analysis approach. Also, relationships between drug use and infection risk not previously observed in our study setting were identified, an example being a cluster of female crystal methamphetamine users who exhibited high-risk behaviors but an absence or low prevalence of blood-borne pathogens.Conclusions. Cluster analysis was useful in both confirming relationships previously identified and identifying new ones relevant to public health research and interventions.Syringe sharing is a well-established mechanism for the spread of HIV and HCV.1^–3 The introduction of syringe exchange programs (SEPs) has had a substantial impact with respect to decreasing the attributable risk of infectious blood-borne pathogens such as HIV and HCV among injection drug users.4^–11 However, studies have shown variations in the effectiveness of SEPs,11^–18 in that syringe sharing behavior persists among some injection drug users.12^,18^–21Epidemiological studies in which contextual factors are used to explain syringe sharing (i.e., social network analyses22) have demonstrated that sharing behavior is not based exclusively on individual choice7^,23^–26; that is, factors other than syringe access may drive sharing among certain injection drug users.20^,26^–28 For example, syringe sharing has been demonstrated to be associated with dyadic relationships involving close friends or sexual partners12^,26^,29^,30 and partnerships in which injection drug users pool resources to obtain drugs or injection equipment.21^,24^,26^,31^,32 Thus, variation in sharing behaviors is explained by differences between high-risk groups.Some researchers suggest that designing interventions around variances seen between groups, and the context in which these variances reside, may be both efficient and efficacious,33^–38 especially in terms of public health practice. Understanding the heterogeneity in high-risk groups may be particularly relevant for those behaviors that persist despite the establishment of structural interventions such as SEPs.15^,18^–20^,28^,39^–44 Consequently, the use of nontraditional statistical methodologies (such as social network analysis) has been encouraged to capture this variance.33^,35 Cluster analysis,45^,46 “an exploratory technique that can be used to reveal unknown heterogeneity,”35^(p196) focuses on the inherent differences between cases rather than variables. It has been used in the HIV literature to develop typologies of behavior33^,37; however, its use is more widespread in the psychiatric and psychological literatures.38^,47^–50We used cluster analysis as an exploratory tool to investigate whether empirically derived clusters could help to explain heterogeneity in a sample of injection drug users. The broader applicability of this technique to public health investigations in general was also addressed.     

Burden of HIV infection among aboriginal injection drug users in Vancouver, British Columbia

Objectives. We sought to examine whether there were differential rates of HIV incidence among Aboriginal and non-Aboriginal injection drug users in a Canadian setting.Methods. Data were derived from 2 prospective cohort studies of injection drug users in Vancouver, British Columbia. Using the Kaplan–Meier method and Cox proportional hazards regression, we compared HIV incidence among Aboriginal and non-Aboriginal participants.Results. Overall, 2496 individuals were recruited between May 1996 and December 2005. Compared with that of non-Aboriginal persons, the baseline HIV prevalence was higher among Aboriginal persons (16.0% vs 25.1%; P<.001). Among participants who were HIV negative at baseline, the cumulative HIV incidence at 48 months was higher among Aboriginal persons (18.5% vs 9.5%; P<.001). In multivariate analyses, Aboriginal ethnicity was independently associated with elevated HIV incidence (relative hazard=1.59; 95% confidence interval=1.12, 2.26; P=.009).Conclusions. Aboriginal persons in Vancouver had a significantly elevated burden of HIV infection, which calls for a culturally sensitive and evidence-based response. Policymakers in other settings with at-risk Aboriginal populations should seek to avert similar public health emergencies by being proactive with evidence-based HIV-prevention programs.During the past 2 decades, the HIV epidemic has transitioned from primarily a sexually driven epidemic to one in which syringe sharing among illicit injection drug users contributes to a significant proportion of new infections.1 The United Nations Program on HIV/AIDS estimates that one third of new HIV infections outside sub-Saharan Africa is attributable to injection drug use.2 In North America, injection drug use accounts for approximately 1 in 4 cases of HIV,1 and in some areas where HIV is spreading most rapidly, such as Eastern Europe and Central Asia, more than 80% of all HIV cases occur among injection drug users.2 Among populations of injection drug users, recent surveillance reports have suggested that ethnic minorities may be particularly vulnerable to HIV infection.1At the same time, there are growing concerns about the health of Aboriginal and Indigenous populations.3 The health status of Aboriginal populations varies across settings around the globe, as has recently been well articulated.3^–6 However, Aboriginal persons have been shown to commonly have lower life expectancy as a result of higher rates of chronic diseases, such as heart disease and diabetes, and lower access to healthcare and prevention services. Access not only means physical access but also culturally appropriate and meaningful access to health services.3^–6 High rates of poverty and illicit drug use, including injection drug use, have also been documented among Aboriginal populations.7 These conditions may make Aboriginal populations particularly vulnerable to the spread of HIV, although few studies have examined this issue.8^,9 Therefore, we sought to examine rates of HIV infection among Aboriginal and non-Aboriginal injection drug users in a Canadian setting.     

Childhood socioeconomic position, gender, adult body mass index, and incidence of type 2 diabetes mellitus over 34 years in the Alameda County Study

Objectives. We examined the association between childhood socioeconomic position and incidence of type 2 diabetes and the effects of gender and adult body mass index (BMI).Methods. We studied 5913 participants in the Alameda County Study from 1965 to 1999 who were diabetes free at baseline (1965). Cox proportional hazards models estimated diabetes risk associated with childhood socioeconomic position and combined childhood socioeconomic position–adult BMI categories in pooled and gender-stratified samples. Demographic confounders and potential pathway components (physical inactivity, smoking, alcohol consumption, hypertension, depression, health care access) were included as covariates.Results. Low childhood socioeconomic position was associated with excess diabetes risk, especially among women. Race and body composition accounted for some of this excess risk. The association between childhood socioeconomic position and diabetes incidence differed by adult BMI category in the pooled and women-only groups. Adjustment for race and behaviors attenuated the risk attributable to low childhood socioeconomic position among the obese group only.Conclusions. Childhood socioeconomic position was a robust predictor of incident diabetes, especially among women. A cumulative risk effect was observed for both childhood socioeconomic position and adult BMI, especially among women.In recent years, much effort has gone into characterizing biological and social exposures during gestation and childhood that may lead to adult chronic diseases. Childhood socioeconomic disadvantage has been associated with mortality1^–4 and several adult physical5^–7 and mental health5^,7^–9 outcomes.Studies investigating the relationship between childhood socioeconomic disadvantage and diabetes have shown inconsistent results. Childhood socioeconomic position (SEP) was linked to prevalent type 2 diabetes,10^–14 insulin resistance,15 higher glucose levels,16^,17 and metabolic syndrome18^,19 in some studies, yet showed no association with impaired glucose tolerance20^,21 or metabolic syndrome22 in others. Three studies investigated the association between childhood SEP and incident diabetes in adulthood and reported either modest11^,23 or no effects.12Although the evidence thus far is insufficient to establish a causal link between childhood SEP and incident type 2 diabetes, the hypothesis is plausible. Childhood disadvantage has been linked to illnesses, such as cardiovascular diseases,24 that have overlapping pathologies with diabetes. Persons exposed to socioeconomic disadvantage in childhood are more likely to be of lower socioeconomic means as adults.25^,26 Several studies have shown inverse, graded associations between different measures of adult SEP and the prevalence11^,13^,22^,27^,28 and incidence11^,12^,23^,29^–34 of type 2 diabetes. Childhood SEP also influences adult body composition35^–41 and several behaviors20^,42^–45 that are risk factors for type 2 diabetes.Obesity is a strong predictor of type 2 diabetes.46^–48 Therefore, the effect of childhood SEP on diabetes incidence may differ by body mass index (BMI; weight in kilograms divided my height in meters squared) in adulthood. For example, low childhood SEP and adult obesity together may impart a greater risk of type 2 diabetes than the risk imparted by low childhood SEP alone. Such exposure patterns may represent an accumulation of risk over time or a risk pathway. In addition, several studies have shown that the effects of childhood circumstances on adult health and risk behaviors differ by gender.37^,38^,40^,49^–52 The question remains whether childhood SEP differentially influences diabetes risk for women and men.Previous studies of childhood SEP and incident diabetes had short follow-up periods,11^,12^,23 and one was limited to women.23 Our approach complemented these studies by using 5 waves of data collected in a population-based sample from 1965 to 1999 to examine the association between childhood SEP and the incidence of type 2 diabetes and how this association may differ by gender or adult BMI.     

Being poor and coping with stress: health behaviors and the risk of death

Objectives. Individuals may cope with perceived stress through unhealthy but often pleasurable behaviors. We examined whether smoking, alcohol use, and physical inactivity moderate the relationship between perceived stress and the risk of death in the US population as a whole and across socioeconomic strata.Methods. Data were derived from the 1990 National Health Interview Survey’s Health Promotion and Disease Prevention Supplement, which involved a representative sample of the adult US population (n=40335) and was linked to prospective National Death Index mortality data through 1997. Gompertz hazard models were used to estimate the risk of death.Results. High baseline levels of former smoking and physical inactivity increased the impact of stress on mortality in the general population as well as among those of low socioeconomic status (SES), but not middle or high SES.Conclusions. The combination of high stress levels and high levels of former smoking or physical inactivity is especially harmful among low-SES individuals. Stress, unhealthy behaviors, and low SES independently increase risk of death, and they combine to create a truly disadvantaged segment of the population.Perceived stress is a negative affective state that individuals may attempt to relieve or cope with through unhealthy but often pleasurable behaviors.1^–9 High levels of perceived stress are associated with smoking initiation, increased smoking levels, less successful smoking cessation attempts, drinking alcohol more often and in heavier quantities, increased problem drinking, and reports of positive attitudes toward drinking.4^,10^–23 Some people exercise to control their stress,24 but most individuals respond to stress by exercising less frequently and at lower levels because sedentary behavior is more rewarding in the short term.4^,10^,23^,25Stress and unhealthy behaviors each increase the risk of death.15^,26^–36 Numerous social stressors and high levels of perceived stress have been shown to be positively associated with mortality.15^,26 Current and former smoking and physical inactivity are also positively associated with mortality.27^–32 Alcohol consumption has a J-shaped relationship with mortality; abstainers and heavy drinkers are at increased risk of death relative to moderate drinkers.29^,33^–36 To our knowledge, no research has examined whether unhealthy behaviors moderate the relationship between stress and mortality.Our first aim in this study was to examine whether unhealthy behaviors moderate the stress–mortality relationship in a nationally representative sample of US adults. There are 3 possible relationships between stress, health behaviors, and the risk of death. First, the “double jeopardy” perspective suggests that multiple risk factors combine to increase the risk of death more than a single risk factor alone would indicate.37^,38 Smoking, alcohol use, and physical inactivity may be pleasurable but deleterious strategies for coping with perceived stress, and they may inadvertently increase the effects of stress on mortality.39^,40 Second, unhealthy behaviors may allow individuals to cope effectively with stress.3^,5^,7^,8^,41 Unhealthy behaviors and high stress levels are each associated with increased mortality, but unhealthy behaviors may nevertheless reduce the effects of stress on mortality. Finally, the null hypothesis implies that unhealthy behaviors will not moderate the stress–mortality relationship.Our second aim was to examine whether unhealthy behaviors moderate the impact of stress on mortality differently across different socioeconomic strata. The social vulnerability hypothesis suggests that the combination of unhealthy behaviors and high stress levels may be particularly risky among individuals of low socioeconomic status (SES), who might be more vulnerable, or less resilient, to accumulating health risks.42^,43 Those who are less advantaged “experience multiple threats to their health, with each threat making the other more serious.”43^(p302)By contrast, the “Blaxter hypothesis” posits that unhealthy behaviors may be less harmful among those in low-SES groups, precisely because members of these groups already face numerous insults resulting from unsafe housing, work, and neighborhood environments.44 Improving unhealthy behaviors without ameliorating underlying socioeconomic disadvantages may yield few health benefits.3^,45^–47 Thus, if unhealthy behaviors increase the relationship between stress and mortality, their influence may be attenuated among low-SES individuals.     

Neighborhood psychosocial hazards and cardiovascular disease: the Baltimore Memory Study

Objectives. We examined associations between cardiovascular disease and neighborhood psychosocial hazards, such as violent crime, abandoned buildings, and signs of incivility, to evaluate whether features of place are associated with older adult health.Methods. We analyzed first-visit data from the Baltimore Memory Study of randomly selected residents aged 50 to 70 years (n=1140) of 65 contiguous neighborhoods in Baltimore, Maryland. We looked for associations between self-reports of history of selected cardiovascular diseases and scores on the 12-item neighborhood psychosocial hazards scale.Results. After adjustment for established individual risk factors for cardiovascular disease, residents in neighborhoods with scores in the highest quartile of the psychosocial hazards scale had more than 4 times higher odds of a history of myocardial infarction and more than 3 times higher odds of myocardial infarction, stroke, transient ischemic attack, or intermittent claudication compared with residents living in neighborhoods scoring in the lowest quartile.Conclusions. Neighborhood psychosocial hazards were significantly associated with self-reported cardiovascular disease after adjustment for individual-level risk factors. This is consistent with the hypothesis that environmental stress plays a role in the etiology of cardiovascular disease.The effect on health of the places in which people live—apart from individual, genetic, or lifestyle characteristics—is of increasing interest to researchers.1 A new wave of research is examining the health consequences of various aspects of residential neighborhoods. Moving beyond the study of individual risk factors to the study of neighborhoods may be a key to understanding widening health disparities across racial/ethnic and sociodemographic groups.2^,3Many aspects of neighborhoods are hypothesized to influence cardiovascular disease (CVD) risk through several different and potentially interrelated mechanisms.4^–6 Health behavior has received significant attention. Some data suggest that residents of socioeconomically deprived neighborhoods are more likely to engage in high-risk health behaviors, including inactivity,7^,8 poor diet,9 illicit drug use,10^,11 and smoking.12 However, studies that found an association between neighborhood of residence and CVD after adjustment for many of these health behaviors raised doubts that behavior was the sole mechanism.13^,14Several studies have examined the relationship between neighborhood socioeconomic characteristics (such as percentage of residents living in poverty) and CVD. Living in disadvantaged neighborhoods was found to be independently associated with increased risk of subclinical CVD,15 coronary heart disease,13^,16 and stroke,17 as well as poorer prognosis and decreased survival after myocardial infarction.18 Several explanations have been suggested for this association.4Psychosocial hazards in the neighborhood may be an important link between neighborhood socioeconomic disadvantage and adverse health outcomes.5^,19 Psychosocial hazards are visible characteristics of neighborhoods—such as violent crime, abandoned buildings, and signs of incivility—that give rise to a heightened state of vigilance, alarm, or threat.6^,20 Daily exposure to psychosocial hazards in the neighborhood is known to activate a physiological stress response.21^,22 Chronic stress may in turn lead to dysregulation of either the autonomic nervous system23 or the hypothalamic–pituitary–adrenal axis, or both. Dysregulation of the latter has been linked to key CVD risk factors, including the deposition of abdominal fat,24^,25 acute and chronic elevations in blood pressure,26 and various inflammatory processes.27We tested the hypothesis that a higher level of neighborhood psychosocial hazards is associated with increased odds of self-reported myocardial infarction, stroke, transient ischemic attack, and intermittent claudication, independent of individual-level risk factors.     

Project VIVA: a multilevel community-based intervention to increase influenza vaccination rates among hard-to-reach populations in New York City

Objectives. We sought to determine whether the work of a community-based participatory research partnership increased interest in influenza vaccination among hard-to-reach individuals in urban settings.Methods. A partnership of researchers and community members carried out interventions for increasing acceptance of influenza vaccination in disadvantaged urban neighborhoods, focusing on hard-to-reach populations (e.g., substance abusers, immigrants, elderly, sex workers, and homeless persons) in East Harlem and the Bronx in New York City. Activities targeted the individual, community organization, and neighborhood levels and included dissemination of information, presentations at meetings, and provision of street-based and door-to-door vaccination during 2 influenza vaccine seasons. Participants were recruited via multiple modalities. Multivariable analyses were performed to compare interest in receiving vaccination pre- and postintervention.Results. There was increased interest in receiving the influenza vaccine postintervention (P<.01). Being a member of a hard-to-reach population (P=.03), having ever received an influenza vaccine (P<.01), and being in a priority group for vaccination (P<.01) were also associated with greater interest in receiving the vaccine.Conclusions. Targeting underserved neighborhoods through a multilevel community-based participatory research intervention significantly increased interest in influenza vaccination, particularly among hard-to-reach populations. Such interventions hold promise for increasing vaccination rates annually and in pandemic situations.National guidelines recommend annual influenza vaccination for high-risk groups—specifically, persons 50 years and older and persons of any age with chronic medical conditions and their household contacts.1 Despite these guidelines and the patent benefits of influenza vaccination—including reductions in influenza-related morbidity and mortality, attendant health care costs, and productivity losses2—vaccination rates among adults in the United States remain lower than recommended levels, especially among elderly with high-risk conditions and racial/ ethnic minorities.1^,3^–5Although data are sparse, influenza vaccination rates are particularly low among marginalized hard-to-reach urban populations such as substance abusers, undocumented immigrants, and homebound elderly.6 During the 2004–2005 influenza vaccine shortage, the vaccination rate was 21% among hard-to-reach populations in designated priority groups for vaccination, compared with estimates of 42% among designated priority groups in the general population during this same period.7 Members of these hard-to-reach groups are less likely to access routine health care or have a health care provider.8^–10 Low vaccination rates combined with risk factors and barriers to accessing health care place hard-to-reach populations at particularly high risk for influenza and attendant morbidity.Additionally, the need for improvements in annual influenza coverage is coupled with recent concern for the potential of a human influenza pandemic.11^,12 Unvaccinated persons within the larger population may propagate disease, particularly in the event of a pandemic.2^,13 Consequently, public health officials face mounting pressure to vaccinate persons in all risk groups and to do so in a brief period of time.14^–16 Members of disadvantaged, urban, multiethnic communities may face additional challenges during a pandemic, including increased vulnerability and transmissibility from overcrowded living conditions, reliance on mass transportation, and limited access to health care.17Although there have been some previous efforts to vaccinate high-risk populations, few were community-based.18 Community-based programs that contributed to increased vaccination coverage have included vaccination at syringe exchange sites,19 an immunization “blitz” in a neighborhood with widespread injection drug use,20 interventions in religion-based neighborhood health centers, and public service announcements and mailings targeted to racial/ethnic minority Medicaid populations.21^,22 Interventions in medical settings have included components such as standing orders,23^,24 mailings,25^–27 education,28^–30 targeted advertising,31 and visiting nurse programs.32 Unfortunately, these efforts may have had little impact on hard-to-reach populations, because members of these groups are less likely to access routine health care.In December 2003, members of the Harlem Community and Academic Partnership,33 comprised of representatives from community and academic organizations committed to implementing interventions by using a community-based participatory research (CBPR) approach, formed an intervention working group to address challenges in vaccinating local hard-to-reach populations. Community-based participatory research is a collaborative process among researchers and community members that emphasizes building trust, equitable power sharing, capacity building, and long-term commitment from all involved in the research process.34^–36 The intervention working group, which was comprised of members representing community residents, community-based organizations (CBOs), academic institutions, and the local health department, met regularly throughout the project to develop the research agenda and study design and to guide project implementation and evaluation. Guided by the Harlem Community and Academic Partnership principles of collaboration, the working group adopted a participatory approach to decisionmaking processes. A multilevel study design was chosen to address individual, social, and contextual factors related to access to, and acceptance of, the influenza vaccine among hard-to-reach populations.37^,38 The working group developed methods to target intervention activities to 3 levels: neighborhood, CBO, and individual.The overall goal of the Project VIVA (Venue-Intensive Vaccines for Adults) intervention was to develop, implement, and assess a rapid-vaccination protocol for hard-to-reach populations that would increase interest in vaccination, provide free vaccination during 2 influenza seasons, and establish a model for the rapid vaccination of individuals that could be generalizable to other urban areas. We report the results of Project VIVA, including pre–post surveys in the 8 target areas within East Harlem and the Bronx, New York City, that evaluated whether interest in receiving influenza vaccination changed after intervention.     

Chronic conditions and mortality among the oldest old

Objectives. We sought to determine whether chronic conditions and functional limitations are equally predictive of mortality among older adults.Methods. Participants in the 1998 wave of the Health and Retirement Study (N=19430) were divided into groups by decades of age, and their vital status in 2004 was determined. We used multivariate Cox regression to determine the ability of chronic conditions and functional limitations to predict mortality.Results. As age increased, the ability of chronic conditions to predict mortality declined rapidly, whereas the ability of functional limitations to predict mortality declined more slowly. In younger participants (aged 50–59 years), chronic conditions were stronger predictors of death than were functional limitations (Harrell C statistic 0.78 vs. 0.73; P=.001). In older participants (aged 90–99 years), functional limitations were stronger predictors of death than were chronic conditions (Harrell C statistic 0.67 vs. 0.61; P=.004).Conclusions. The importance of chronic conditions as a predictor of death declined rapidly with increasing age. Therefore, risk-adjustment models that only consider comorbidities when comparing mortality rates across providers may be inadequate for adults older than 80 years.Numerous studies have shown that both chronic conditions and functional limitations are powerful independent predictors of mortality.1^–4 However, a growing body of research suggests that some risk factors behave differently in people at different ages.5^–10 Some researchers have found that well-established mortality risk factors among younger persons, such as hypertension,7^,8^,11 hypercholesterolemia,7^,8^,12 increased body mass index,7^,9^,13^,14 heart disease,5^,8^,9 and cancer,5^,9 may not continue to pose a risk to the oldest old, suggesting that the association between chronic conditions and mortality may be weaker in the elderly. Autopsy series have also supported this notion, showing that a definitive cause of death attributable to a single disease process is often not found among older people.15 These observations have spurred a growing recognition within the geriatrics community that our methods of measuring and accounting for the burden of disease may be inappropriate for our oldest patients.16^–18Despite these concerns, chronic disease diagnoses remain at the center of clinical care and risk adjustment for older patients.17 However, if the association between chronic conditions and mortality is weaker in the elderly, risk adjustment tools that rely solely on chronic disease diagnoses (such as the Charlson Comorbidity Index19 and the Elixhauser method20) may be suboptimal for our oldest old. Therefore, the use of these methods to compare risk-adjusted outcomes as a proxy for the quality of care21^,22 may lead to erroneous conclusions. Improved risk-adjustment methods may lead to improvements in targeting health care quality interventions, ultimately resulting in better population health outcomes.To address these issues, we examined the ability of specific types of risk factors—chronic conditions, functional limitations, and demographic variables—to differentiate between people at high and low risk of death across a range of age groups. Based on previous research, we hypothesized that chronic conditions would be less predictive of death among older people. Because functional limitations often represent a final common pathway of decline regardless of underlying etiology,23^–25 we further hypothesized that functional limitations would be a stronger predictor of mortality than chronic conditions among our oldest participants.     

Racial/ethnic differences in the development of disability among older adults

Objectives. We investigated differences in the development of disability in activities of daily living among non-Hispanic Whites, African Americans, Hispanics interviewed in Spanish, and Hispanics interviewed in English.Methods. We estimated 6-year risk for disability development among 8161 participants 65 years or older and free of baseline disability. We evaluated mediating factors amenable to clinical and public health intervention on racial/ethnic difference.Results. The risk for developing disability among Hispanics interviewed in English was similar to that among Whites (hazard ratio [HR]=0.99; 95% confidence interval [CI] = 0.6, 1.4) but was substantially higher among African Americans (HR=1.6; 95% CI=1.3, 1.9) and Hispanics interviewed in Spanish (HR=1.8; 95% CI=1.4, 2.1). Adjustment for demographics, health, and socioeconomic status reduced a large portion of those disparities (African American adjusted HR=1.1, Spanish-interviewed Hispanic adjusted HR=1.2).Conclusions. Higher risks for developing disability among older African Americans, and Hispanics interviewed in Spanish compared with Whites were largely attenuated by health and socioeconomic differences. Language- and culture-specific programs to increase physical activity and promote weight maintenance may reduce rates of disability in activities of daily living and reduce racial/ethnic disparities in disability.Disability among older adults (those 65 years or older) is a major health issue involving high personal and economic costs. The number of Americans 65 years or older with chronic disability exceeds 7 million.1 Maintaining the quality of life for older adults by delaying disability may be as important as prolonging life.2^,3 Disability is more strongly associated with medical spending than with life expectancy.4^,5 Long-term care expenditures for older people are projected to reach $161 billion per year by 2010, of which two thirds will be paid by government programs.6The composition of the US population is changing. In 2000, 18% of people in the United States spoke a language at home other than English, up from 11% in 1980.7 The fastest-growing part of the older US population comprises minority groups, particularly African Americans and Hispanics.8 As the number of older people belonging to minority groups increases, there are growing public health concerns about racial/ethnic disparities in health outcomes.9 Although overall rates of disability among older Americans have declined over time, racial/ethnic disparities persist.1^,10^–13 The literature on racial/ethnic disparities in disability mostly focuses on African Americans; national studies investigating disability among Hispanics are limited.1^,12^,14^,15Despite the common practice of conducting interviews in languages other than English to allow respondents to participate in their primary language, few national studies have considered the influence of language differences on health outcomes.16 There are known differences in health and mortality related to immigration and acculturation.16^–19 Use of an interview language other than that of the host culture may be a proxy for acculturation and a predictor of future poor health.20^–23 Insight from a broader investigation of risk factors that includes language differences in relation to disparities in the development of disability is essential to the development of population-based public health programs to help maintain independence among older adults.We investigated racial/ethnic differences in disability among people 65 years and older using 6 years of data from the Health and Retirement Study (HRS),24 Finally, we investigated whether factors amenable to public health and policy intervention mediate minority differences in the development of disability among these Medicare-aged adults.     

Health status, health care use, medication use, and medication adherence among homeless and housed people living with HIV/AIDS

Objectives. We sought to compare health status, health care use, HIV anti-retroviral medication use, and HIV medication adherence among homeless and housed people with HIV/AIDS.Methods. Data were obtained from a cross-sectional, multisite behavioral survey of adults (N=7925) recently reported to be HIV positive.Results. At the time interviews were conducted, 304 respondents (4%) were homeless. Self-ratings of mental, physical, and overall health revealed that the health status of homeless respondents was poorer than that of housed respondents. Also, homeless respondents were more likely to be uninsured, to have visited an emergency department, and to have been admitted to a hospital. Homeless respondents had lower CD4 counts, were less likely to have taken HIV anti-retroviral medications, and were less adherent to their medication regimen. Homeless respondents needed more HIV social and medical services, but nearly all respondents in both groups had received needed services. Housing status remained a significant predictor of health and medication outcomes after we controlled for potential confounding variables.Conclusions. Homeless people with HIV/AIDS are at increased risk of negative health outcomes, and housing is a potentially important mechanism for improving the health of this vulnerable group.Homeless people are at a disproportionate risk for negative health consequences. For instance, they typically have more chronic diseases and more physical and mental health problems than do the general population, and they are at greater risk for infectious diseases.1^–13 Homelessness is often coincident with poverty, mental illness, and alcohol and drug use, compounding the other health problems experienced by these individuals.14^–17Homeless people are also more likely than other groups to engage in behaviors that place them at risk for HIV infection, including risky sexual practices, injection drug use and needle sharing, and performing sexual acts in exchange for money, drugs, or a place to stay.18^–25 Perhaps not surprisingly, previous research has shown that HIV is 3 to 9 times more prevalent among homeless individuals than among individuals in stable housing situations.18^,20^,21^,26^–29It may be difficult for homeless people, who are often faced with immediate subsistence needs (e.g., finding adequate food and shelter), to obtain medical care and adhere to treatment regimens.30^,31 As a result, homeless individuals are less likely than are the general population to have stable sources of care, and they often rely on emergency departments or ambulatory care settings for their health care needs.32^,33 Delayed medical care or lack of care has negative effects such as delayed HIV diagnoses and higher rates of serious opportunistic infections.7^,31^,34People who are living with HIV/AIDS and are homeless face additional burdens not faced by homeless people without HIV/AIDS. For instance, individuals with HIV/AIDS need greater access to comprehensive health care, and barriers to care—including lack of financial resources, lack of transportation, and insufficient (or nonexistent) health insurance coverage—may be compounded among homeless people living with the disease.30^,34People with HIV/AIDS also may have difficulty adhering to prescribed HIV antiretroviral medication regimens.35^,36 These regimens can be complex and often involve restrictions on when and how the medications should be taken and stored.31^,34 In addition, these medications can have side effects, such as recurring diarrhea, that are especially problematic for homeless individuals. Medical providers may believe that homeless individuals will not be adherent, and thus they may be reluctant to prescribe antiretroviral medications for these individuals37 given that inadequate adherence can lead to drug resistance.34 Despite its importance, few studies have investigated the issue of adherence to antiretroviral medication regimens in this population.35^,36^,38^–42Overall, minimal research has been conducted on the health of homeless people living with HIV/AIDS.15^,43^,44 We used data from a large, multisite investigation to (1) assess differences between homeless and housed persons living with HIV/AIDS regarding sociodemographic, health care, and medication adherence variables and (2) examine associations between housing status and health, and medication adherence outcomes after controlling for potential confounding factors.     

Disentangling the effects of racial and weight discrimination on body mass index and obesity among Asian Americans

Objectives. We examined whether racial discrimination is associated with increased body mass index (BMI) and obesity among Asian Americans. Further, we explored whether this association strengthens with increasing time in the United States.Methods. We analyzed data from the 2002 to 2003 National Latino and Asian American Study (n=1956). Regression models tested whether reports of racial discrimination were associated with BMI and obesity, after accounting for weight discrimination, age, gender, marital status, ethnicity, generation, employment, health status, and social desirability bias (the tendency to seek approval by providing the most socially desirable response to a question).Results. We found that (1) racial discrimination was associated with increased BMI and obesity after we controlled for weight discrimination, social desirability bias, and other factors and (2) the association between racial discrimination and BMI strengthened with increasing time in the United States.Conclusions. Racial discrimination may be an important factor related to weight gain among ethnic minorities.Stress caused by disadvantaged social status may be related to obesity. Two elements provide the foundation for this observation. First, stress may have adverse physiological consequences, including increased risk for obesity and allostatic load, the “wear and tear” on organ systems that contributes to health problems.1 Stressors activate the hypothalamic–pituitary–adrenal axis system, releasing cortisol and other glucocorticoids. Glucocorticoids may stimulate appetite and blunt the satiety system.2 Cortisol increases fat retention, particularly in the abdominal region.3 Moreover, stressors may selectively increase the intake of “comfort foods” over other foods among humans and other animals.4^,5Stress may also be related to abdominal and general obesity. Daily stress,6 anxiety,7 and depressed mood8^,9 are related to visceral obesity. Among monozygotic twins, stress-induced hormonal changes result in greater intra-abdominal fat deposits in the twin with higher stress.10 Further, obesity, indicated by a high body mass index (BMI), has been associated with work stress11^,12 and early childhood trauma.13 In a prospective study of British civil servants, job stress was associated with metabolic syndrome (a group of risk factors that includes abdominal obesity, elevated blood pressure, and atherogenic dyslipidemia)8 and general and visceral obesity.12Second, social disadvantage, such as experiences with racial discrimination, may produce stress.14 Self-reported discrimination appears to be related to several stress-related and obesity-related outcomes, including high blood pressure,15 depression and anxiety,16 sleep problems,17 and coronary calcification.18 Individuals may also use alcohol to cope with discrimination,19^–21 and alcohol can contribute to obesity.22 Hence, discrimination may directly produce weight gain by activating the stress system and by influencing behavior change. Discrimination also may act indirectly by hindering socioeconomic advancement23^,24 and by segregating individuals into communities with fewer healthy food options25^,26 and fewer safe places for physical activity.27^,28Consistent with these observations, several studies have suggested that discrimination is associated with weight gain and metabolic problems. Tull et al. found that reports of internalized racism were associated with greater obesity among women in Barbados.29 Similarly, Chambers et al. found associations between internalized racism and insulin resistance among girls in Barbados.30 Butler et al. found associations between internalized racism and greater waist circumference and higher fasting glucose among Dominica women.31We tested the first hypothesis that reports of discrimination are associated with higher BMI and the risk of obesity and build on previous research in 3 primary ways. First, overweight people may encounter weight discrimination,32 and associations between racial discrimination and weight might therefore be confounded by weight discrimination. To reduce the chance of spurious findings, we controlled for weight discrimination and other factors.Second, we examined whether findings from Black populations generalize to Asian Americans. Among Asian Americans, discrimination is associated with outcomes related to obesity, including cardiovascular conditions,33^,34 depression,35^–37 and substance use,19 but no study has directly examined whether discrimination is associated with BMI and obesity in this population.Third, we tested the main effects of discrimination and investigated whether discrimination is moderated by time spent in the United States. US-born Asians appear to have higher rates of obesity than their foreign-born counterparts, but the rates of obesity among the foreign born increase with years in the United States.38^–40 Additionally, immigrants often report less racial discrimination than do nonimmigrants, but reports of discrimination increase with years spent in the United States, perhaps because immigrants are more likely to encounter and recognize discrimination over time.41^–43 A recent study found that among African and Latino immigrants, the association between racial discrimination and mental health strengthened with increasing time in the United States.44 These observations motivate the second hypothesis that time spent in the United States will interact with the association between racial discrimination, such that the association between racial discrimination and BMI among immigrant Asians will strengthen with increasing time spent in the United States.     

Relationships between skin color, income, and blood pressure among African Americans in the CARDIA Study

Objectives. We explored how income and skin color interact to influence the blood pressure of African American adults enrolled in the longitudinal Coronary Artery Risk Development in Young Adults (CARDIA) Study.Methods. Data were derived from 1893 African American CARDIA year-15 participants who had undergone skin reflectance assessments at year 7. We adjusted for age, gender, body mass index, smoking status, and use of antihypertensive medication to examine whether year-15 self-reported family incomes, in interaction with skin reflectance, predicted blood pressure levels.Results. Mean systolic and diastolic blood pressure levels were 117.1 (±16.07) and 76.9 (±12.5) mm Hg, respectively. After adjustment, the interaction between skin reflectance and income was significantly associated with systolic blood pressure (P< .01). Among lighter-skinned African Americans, systolic pressure decreased as income increased (b= −1.15, P<.001); among those with darker skin, systolic blood pressure increased with increasing income (b=0.10, P=.75).Conclusions. The protective gradient of income on systolic blood pressure seen among African Americans with lighter skin is not observed to the same degree among those with darker skin. Psychosocial stressors, including racial discrimination, may play a role in this relationship.In the United States, marked racial disparities in morbidity and mortality exist across a wide range of health indicators.1^,2 Gaps in health between African Americans and White Americans are particularly pronounced for cardiovascular diseases and their related risk factors3^,4 and persist despite considerable advances in clinical treatment and care.5 Rates of hypertension (blood pressure above 140/90 mm Hg) are nearly twice as high among African Americans as among Whites, and the condition tends to be more severe and to have an earlier onset among African Americans.6 This racial disparity in hypertension is also the largest contributor to broader all-cause mortality differentials between African and White Americans.7Racial disparities in health are complex in terms of their underlying causes and are not completely understood, with a range of social–environmental factors implicated in the poorer cardiovascular health of African Americans. One such factor is socioeconomic status (SES), which is associated with cardiovascular disease risk in a gradient fashion in the United States and other developed nations and is lower on average among African Americans than among Whites.8^,9 However, evidence has increasingly suggested that race and class interact in complex ways to influence health, and the magnitude of association between SES and health varies according to race.10^–15Although the relationship has been less consistent, skin color is another socially significant factor that has shown a graded association with cardiovascular health, particularly blood pressure, among African Americans.16^–18 Given the social significance of skin color in United States society,19^–21 it may constitute an additional factor along which SES effects on health vary.The well-documented SES gradient in health, wherein incremental increases in economic standing are associated with improved health across the entire SES range, suggests that psychosocial stress may be an important contributor to health disparities.9^,22 Because African Americans are overrepresented at the bottom of the SES ladder, some social–environmental models of health disparities have posited that economic factors are largely responsible for race gaps in health status.12 However, it is now well demonstrated that SES alone does not account for racial health disparities, and the effects of SES on health are not uniform across race groups.10^,11^,13^,23For example, Farmer and Ferraro13 recently demonstrated that although the SES gradient is strong for White Americans, economic success does not carry the same health benefits for African Americans. They observed a pattern of “diminishing returns”13^(p192) in general health status among African Americans of higher economic standing. A similar pattern was recently observed with respect to body mass index (BMI; weight in kilograms divided by height in meters squared), an important cardiovascular risk factor. Lewis et al.14 found that, among women, racial differences in BMI were most pronounced at higher levels of education, with White women having lower BMIs than African American women.These findings highlight the complexity of interactions among race and class and suggest that additional social–environmental factors should be considered in attempts to explain racial health disparities. An example of such a social–environmental factor is skin color.19^,24 A skin color gradient in blood pressure, such that darker skin color is associated with higher average blood pressure levels, has long been observed among African Americans and other African diaspora populations.16^,19^,25 In the first observations of this gradient, during the 1970s, the relationship was largely attributed to genetic or unknown physiological causes.16^,25However, skin color has been shown to be an imperfect marker of proportional genetic ancestry in multiracial societies.26^,27 In addition, genetic components seem to explain relatively little population-level prevalence rates of common, complex diseases such as hypertension.28 Thus, skin color is not likely to be a significant marker of differences in gene-based disease susceptibility.27Skin color has long been recognized to carry considerable social significance in United States society, however, and many studies have noted the potential confounding effects of psychosocial factors on the skin color gradient in blood pressure.17^–19^,29^,30 Relative to African Americans with lighter skin, it has been shown that, on average, African Americans with darker skin are employed in occupations with lower incomes and less prestige.31^–33Studies examining the potential confounding effects of economic status on the skin color gradient in blood pressure have produced mixed findings.16^–18 Harburg et al. found that the relationship between skin color and blood pressure is independent of SES,16 whereas Keil et al. suggested that skin color differences in blood pressure are contingent on SES.17 Klag et al.18 found a moderating effect of SES on the association between skin color and blood pressure, with only individuals in lower socioeconomic tiers exhibiting the skin color gradient. The findings of these studies indicate that more research is needed regarding the interactive effects of skin color and SES on blood pressure among African Americans.Recently, Gravlee et al.24^,34 reported that, among adults in Puerto Rico, socially ascribed “color,” of which skin tone is a dimension, moderates the SES gradient in blood pressure. They found higher SES to be associated with lower blood pressure only among those of lighter ascribed color. A similar pattern may exist for skin pigmentation in the United States; whereas skin color is associated with SES, it is also a marker of other social realities and experiences that may affect health status, including discrimination and low social standing.19^,35^,36Thus, skin color may represent an additional dimension of social variation along which health varies in the United States and, as such, may complicate the effects of SES on the health of African Americans. Similar to recent findings showing that the health benefits of higher SES are more limited for African Americans than they are for Whites,13 these benefits may also be more limited depending on one’s skin color.We explored whether skin color is a significant moderator of the effects of SES on blood pressure among African Americans taking part in the Coronary Artery Risk Development in Young Adults (CARDIA) Study. We sought to answer the following question: does the SES gradient in blood pressure vary among African Americans of darker skin color and those of lighter skin color?     

Maternal depressive symptoms, parenting self-efficacy, and child growth

Objectives. We assessed whether maternal depressive symptoms and parenting self-efficacy were associated with child growth delay.Methods. We collected data from a random sample of 595 low-income mothers and their children aged 6 to 24 months in Teresina, Piauí, Brazil, including information on sociodemographic characteristics, mothers’ depressive symptoms and parenting self-efficacy, and children’s anthropometric characteristics. We used adjusted logistic regression models in our analyses.Results. Depressive symptoms among mothers were associated with 1.8 times higher odds (95% confidence interval [CI] = 1.1, 2.9) of short stature among children. Parenting self-efficacy was not associated with short stature, nor did it mediate or modify the relationship between depressive symptoms and short stature. Maternal depressive symptoms and self-efficacy were not related to child underweight.Conclusions. Our results showed that among low-income Brazilian families maternal depressive symptoms, but not self-efficacy, were associated with short stature in children aged 6 to 24 months after adjustment for known predictors of growth.Stunting caused by undernutrition disproportionately affects the poor,1 is indirectly responsible for more than half of deaths among young children worldwide,2 and is associated with inadequate physical and cognitive development and limited social mobility.3^–6 Research from industrialized countries shows that failure to thrive (growth delay) is more likely to occur in children of depressed care-givers,6^,7 but few studies have examined this relationship in developing countries.Previous studies in which both short stature and underweight have been used as indicators suggest an association between maternal depression and inadequate growth.8 One investigation involving a clinic-based sample in Jamaica showed that rates of depression were higher and parenting self-esteem was lower in a group of mothers with underweight children than in a group of mothers with well-nourished children.9 In another study, psychiatric disorders among mothers living in favelas (shanty towns) in São Paulo were associated with child underweight.10 A study comparing 4 developing countries showed a relationship between maternal depression and child underweight in India and Vietnam but not in Peru or Ethiopia.11 Reasons for such regional variations are not well understood.Psychosocial conditions have received increasing attention in efforts to explain children’s growth and development. The concept of collateral health effects (the transfer of health benefits from one individual to another through social rather than biological pathways12) may be pertinent because optimizing mothers’ mental health may foster positive caregiving behaviors that benefit their infants. Parenting self-efficacy (a parent’s level of confidence in performing in her or his role as a caregiver) and depression are closely related,13^–15 and high self-efficacy is related to a variety of positive parenting behaviors16^–19 (e.g., responsive feeding practices and breast-feeding duration) that may affect child growth.Maternal psychosocial care has been shown to be associated with child nutritional status,20 but it may play a more important role in lower- and middle-income countries than in affluent countries.8 For example, maternal depressive symptoms and parenting self-efficacy may be especially salient in low-income populations facing economic stressors. We examined relationships between low-income Brazilian mothers’ depressive symptoms and self-efficacy as exposures and short stature and underweight among their infants as outcomes.     

Perceived discrimination and mortality in a population-based study of older adults

Objectives. We examined the relation of individual-level perceived discrimination to mortality in a biracial, population-based sample.Methods. Participants were 4154 older adults from the Chicago Health and Aging Project who underwent up to 2 interviews over 4.5 years. Perceived discrimination was measured at baseline, and vital status was obtained at each follow-up and verified through the National Death Index.Results. During follow-up, 1166 deaths occurred. Participants reporting more perceived discrimination had a higher relative risk of death (hazard ratio [HR]= 1.05; 95% confidence interval [CI]=1.01, 1.09). This association was independent of differences in negative affect or chronic illness and appeared to be stronger among Whites than among Blacks (Whites: HR=1.12; 95% CI=1.04, 1.20; Blacks: HR=1.03; 95% CI=0.99, 1.07). Secondary analyses revealed that the relation to mortality was related to discriminatory experiences of a more demeaning nature and that racial differences were no longer significant when the sample was restricted to respondents interviewed by someone of the same race.Conclusions. Perceived discrimination was associated with increased mortality risk in a general population of older adults. The results suggest that subjective experience of interpersonal mistreatment is toxic in old age. This study adds to a growing literature documenting discrimination as an important social determinant of health.There is growing interest in the health effects of perceived discrimination.1^,2 Although evidence has been mixed, several studies have demonstrated that discrimination is related to poor physical and mental health, including blood pressure,3^,4 breast cancer,5 self-rated health,4^,6^–8 psychological distress,7^–10 well-being10^,11 and depressive symptoms.8^,12 Several studies have reported no or conditional associations as well.13^–18 Inconsistency in results may be because, at least in part, of the variation in the measurement of discrimination, differences in study methodologies and populations, and the variety of outcomes that have been considered.1^,2 Overall, however, it appears that the results have been stronger for mental health than for physical health outcomes. Although the mechanisms are not clear, hypotheses include restricted access to socioeconomic resources, poor health behaviors, and stress responses.6^,19^–22Few studies have focused on well-established clinical outcomes, such as hypertension. Although some studies have reported that discrimination increases the risk for hypertension,23^,24 others have not found an association.13^,14 Discrimination has also been linked with subclinical cardiovascular disease, including carotid intima-media thickness25 and coronary artery calcification.26We examined perceived discrimination in relation to all-cause mortality for 2 reasons. First, this end point has rarely been considered in relation to discrimination.27^,28 Second, mortality serves as the common end point of many disease processes that affect adult populations. Because the negative health effects of discrimination are thought to be nonspecific—that is, they are not restricted to a particular disease process—this end point may be particularly suitable to capture much of the spectrum of adverse outcomes associated with this risk factor.Racism, racial discrimination, and perceived discrimination have been used interchangeably in the research literature. We focused on perceived discrimination, defined as the subjective experience of common forms of unfair treatment,10 and its relation to mortality in a population-based study of older Blacks and Whites. Because the weight of the current evidence shows that discrimination is associated with poorer health among minorities, we hypothesize that perceived discrimination is related to an increased risk for mortality and that this risk is stronger among Blacks than among Whites.     

Suicide mortality among individuals receiving treatment for depression in the Veterans Affairs health system: associations with patient and treatment setting characteristics

Objectives. We sought to report clinical and demographic factors associated with suicide among depressed veterans in an attempt to determine what characteristics identified depressed veterans at high risk for suicide.Methods. We used longitudinal, nationally representative data (1999–2004) to determine suicide rates among depressed veterans, estimating time until suicide using Cox proportional hazards regression models.Results. Of 807694 veterans meeting study criteria, 1683 (0.21%) committed suicide during follow-up. Increased suicide risks were observed among male, younger, and non-Hispanic White patients. Veterans without service-connected disabilities, with inpatient psychiatric hospitalizations in the year prior to their qualifying depression diagnosis, with comorbid substance use, and living in the southern or western United States were also at higher risk. Posttraumatic stress disorder (PTSD) with comorbid depression was associated with lower suicide rates, and younger depressed veterans with PTSD had a higher suicide rate than did older depressed veterans with PTSD.Conclusions. Unlike the general population, older and younger veterans are more prone to suicide than are middle-aged veterans. Future research should examine the relationship between depression, PTSD, health service use, and suicide risks among veterans.Suicide is a complex, multidetermined phenomenon.1 There are individual-level biological and psychological contributors, in addition to social, environmental, and economic risk factors.2^–4 Rates of suicide also differ based on demographic and clinical characteristics. In the general population, the incidence of suicide is higher among older than among younger individuals5 and among males than among females.6 Whites are more likely to commit suicide than are African Americans, and older White men have the highest risk of suicide among all age and race groups.6 Suicide rates vary with rates of gun ownership, poverty, employment status, geographical location, and levels of social support,4^,7^,8 as well as other clinical and demographic characteristics. The US Surgeon General,9 the Institute of Medicine,4 and the Department of Veterans Affairs10 (VA) recognize suicide as a key public health problem in need of a national strategy for suicide prevention.Patients with psychiatric disorders, particularly depressive disorders, are at much greater risk for suicide than those in the general population.11^–16 Approximately 5% to 12% of men and 10% to 25% of women will have a major depressive episode during their lifetimes, and higher percentages will experience significant depressive symptoms, which increases their risk for suicide.17^,18 Of patients treated for depression in a variety of settings, approximately 2% to 7% die from suicide,19^,20 with higher rates of suicide occurring among patients who have been hospitalized for depression.3^,14^,19^,21 Patients with co-occurring disorders, such as depression and alcohol abuse or depression and posttraumatic stress disorder (PTSD), have been reported to be at much higher risk for suicide than patients with only 1 of these disorders.11^,12^,22^,23 Patients with prior hospitalizations for psychiatric disorders, such as depression or prior suicide attempts, are also at higher risk of suicide.24^–26The relationship between depression and other risk factors for suicide is likely complex. Qin et al. found that having a psychiatric disorder increased suicide risk more among women than among men.7 Major depression also may increase suicide risk more among older adults than among younger adults.14As a group, veterans may be at particularly high risk for suicide as a result of their high prevalence of depressive disorders and comorbid psychiatric conditions. According to the Veterans Health Study, the prevalence of significant depressive symptoms among veterans is 31%, 2- to 5-times higher than among the general US population.27 In 2002, 12% of veterans treated in VA health care facilities were diagnosed with depressive disorders by a health care provider during an encounter.28 Among veterans, as in the general population, completed suicide is usually associated with a mental disorder, most often depressive disorders and alcohol or substance use disorders; those with comorbid psychiatric disorders are at highest risk.29^,30Because of limited research examining completed suicide, little is known about the relative risks of suicide associated with demographic and clinical factors among depressed veterans. Among depressed patients, the relative risk of suicide among men compared with among women appears to be smaller than that seen for the same comparison among the general population.7^,31 Pokorny reported that, among former VA psychiatric inpatients, older patients did not have a greater suicide risk than did younger patients.32 Thompson et al. reported that the relative risk of suicide deaths in the VA was 2.3 for Whites compared with African Americans,26 which is the same as relative risk of suicide between Whites and African Americans in the general population.6 However, among former VA medical center psychiatric inpatients, Desai et al. reported relative risks for suicide of only 1.5 among men compared with those among women, but relative risks of 3.8 among Whites compared with those among African Americans33—a race disparity that is substantially higher than that observed in the general population.6Several investigators have noted the importance of determining risk profiles for the particular population being targeted.26 Clinicians use this information as “background knowledge” when completing suicide assessments. Administrators also need this information to be able to design, evaluate, and target interventions to decrease suicide risks.In this study, we examined associations between demographic and clinical characteristics and risk of suicide among veterans treated for depression in the VA health system. Based on previous studies of veterans, we hypothesized that the differential risks for suicide associated with being older, male, White, and having medical comorbidities would be smaller within the depressed VA patient population than has been reported for the general population. We also hypothesized that patients with depression and comorbid substance use, PTSD, or a recent psychiatric hospitalization would be at higher risk for suicide than would be patients who have depression without these psychiatric comorbidities.     

Physical education and academic achievement in elementary school: data from the early childhood longitudinal study

Objectives. We examined the association between time spent in physical education and academic achievement in a longitudinal study of students in kindergarten through fifth grade.Methods. We used data from the Early Childhood Longitudinal Study, Kindergarten Class of 1998 to 1999, which employed a multistage probability design to select a nationally representative sample of students in kindergarten (analytic sample = 5316). Time spent in physical education (minutes per week) was collected from classroom teachers, and academic achievement (mathematics and reading) was scored on an item response theory scale.Results. A small but significant benefit for academic achievement in mathematics and reading was observed for girls enrolled in higher amounts (70–300 minutes per week) of physical education (referent: 0–35 minutes per week). Higher amounts of physical education were not positively or negatively associated with academic achievement among boys.Conclusions. Among girls, higher amounts of physical education may be associated with an academic benefit. Physical education did not appear to negatively affect academic achievement in elementary school students. Concerns about adverse effects on achievement may not be legitimate reasons to limit physical education programs.Physically active youth may be less likely than physically inactive youth to experience chronic disease risk factors1 and to become obese,2 and they may be more likely to remain active throughout adolescence3 and possibly into adulthood.4 Physical activity also has beneficial influences on behavior and cognitive functioning that may result in improving students’ academic achievement.5^–7 Direct indicators of academic achievement include grade-point averages, scores on standardized tests, and grades in specific courses; measures of concentration, memory, and classroom behavior provide indirect estimates.1Several cross-sectional studies examined the association between physical activity and direct measures of academic achievement.8^–13 In addition, several intervention studies were conducted to examine the effect of introducing more physical activity and physical education programs during the school day on indirect estimates of behaviors related to academic achievement (e.g., concentration, memory, disruptive behavior) or on direct measures (e.g., standardized tests, academic record, teacher reports).6^,7^,14^–23 These studies had mixed results. Investigators observed either no association6^,8^,13^,14^,16^,18^,23 or a modest-to-moderate positive association6^,7^,9^–12^,15^,17^,19^–22 between physical activity and academic achievement.Physical education classes provide an opportunity for students to be physically active during the school day.1 School-based physical education has many benefits, including increasing physical activity and improving physical fitness and muscular endurance.24^–28 Increasing physical activity through physical education is also a proposed public health strategy to reduce childhood obesity.29 Although there has been no evidence to date to show that maintaining or increasing time in physical education class negatively affects academic achievement in other subjects, there is concern that physical education classes could take time away from those subjects.1^,28^,30 More information is needed to address this concern and support public health objectives to maintain or expand physical education programs.31We examined the influence of physical education in US elementary schools on direct measures of academic achievement in mathematics and reading from kindergarten through fifth grade. Our study was unique in at least 3 ways: first, the measurement of academic achievement was a standardized test administered at 5 time points. Second, we examined the association between physical education and academic achievement with a prospective cohort design. Finally, we examined participation in physical education as it existed in a representative sample of US students entering kindergarten in fall 1998 who were followed through spring 2004.     

Correlates of the stages of change for physical activity in a population survey

Objectives. We sought to identify variables associated with being in a particular stage of change for physical activity—a measure of behavioral intention to engage in regular physical activity. Understanding behavioral intentions can be useful in explaining why individuals are physically inactive or active.Methods. Data from the Rhode Island 2000 Behavioral Risk Factor Surveillance System were used to evaluate predictors of stage of change for physical activity. There were 3454 observations in the data set, representing a weighted population of 742636 people. Estimates were obtained from polytomous multiple logistic models.Results. Being a woman, Hispanic, non-Hispanic Black, and older than 55 years of age were associated with being in precontemplation and contemplation stages of change rather than maintenance. Self-perceived health status and rarely feeling healthy or full of energy were strongly predictive of stage of change. Having a health limitation was a dichotomous predictor, predicting being in action and precontemplation stages.Conclusions. Several sociodemographic and health variables were associated with varying patterns of stages of change for physical activity. The complexity of individual intentions for physical activity provides evidence for the potential existence of mediating, effect-modifying, and confounding variables that differ depending on individual characteristics.The Transtheoretical Model combines key social–cognitive models of health behavior change with the core construct, stages of change, reflecting behavioral intention.1^,2 The Transtheoretical Model purports that people progress through 5 stages as they change health behaviors.1 First applied to physical activity behavior by Marcus et al.,3^–6 the model has been validated against measures of physical activity behavior, physical fitness, and health,7^–16 and has been successfully applied in an array of populations and settings.17^–24Despite public health efforts, the proportion of the population engaging in healthful levels of physical activity is low.25 Between 1990 and 1998, the prevalence of adults engaging in optimal levels of physical activity in the United States increased from 24.3% to 25.4%.26 At the same time, prevalence of walking remained stable, although select subgroups showed improvement.27 These data intimate that there is a need for improved understanding of this complex behavior.28^,29Epidemiological studies have described correlates of physical activity behavior and inactivity,30^–36 but few37^,38 have studied the intentions for physical activity. To gain a better understanding of physical activity, it is important to understand not only the behavior, but also the intentions for the behavior.15 Studying the stages of change for physical activity should improve the understanding of physical activity behavior, because of its focus on intentions for behavior.There are few studies describing the stages of change for physical activity in large populations, and only limited data on factors associated with stages of change.38^–43 We sought to identify variables associated with the probability of being in a stage of change for physical activity in a population sample.     

Physical health complaints among lesbians, gay men, and bisexual and homosexually experienced heterosexual individuals: results from the California Quality of Life Survey

Objectives. We examined evidence that minority sexual orientation is associated with more-frequent reports of physical health complaints. We also investigated the possible role of HIV infection among gay men and higher rates of psychological distress among lesbians, gay men, and bisexually and homosexually experienced heterosexual individuals in generating these health disparities.Methods. We used data from the California Quality of Life Survey (N=2272 adults) to examine associations between sexual orientation and self-reports about physical health status, common health conditions, disabilities, and psychological distress.Results. Prevalent HIV infection was reported by nearly 18% of gay, bisexual, and homosexually experienced heterosexual men. Gay men and bisexual and homosexually experienced heterosexual individuals had higher levels of psychological distress compared with exclusively heterosexual individuals. Self-reported physical health status varied by gender and by sexual orientation.Conclusions. Lesbians and bisexual and homosexually experienced heterosexual women reported a greater variety of health conditions and limitations compared with exclusively heterosexual women; however, these differences mostly disappeared when distress levels were taken into account. Among men, differences in health complaints appeared to reflect the ongoing burden of HIV and other sexually transmitted diseases in the gay male community.Although it is well-known that men who have sex with men are at a higher risk for contracting HIV1 and other sexual transmitted infections (STIs),2 accumulating evidence shows that minority sexual orientation may also be an underrecognized risk factor for psychiatric morbidity,3^–13 alcohol14^–18 and illicit drug use,19^–21 cigarette smoking,15^,22 and problems with health care use.22^–24 This has led to speculation that, compared with exclusively heterosexual individuals, lesbians, gay men, and bisexual and homosexually experienced heterosexual men and women may also experience unrecognized disparities in general physical health that go beyond the conditions specifically associated with STIs among homosexually active men.25 These disparities may include a higher risk for cardiovascular disease,22^,23^,26 lung cancer as a possible consequence of higher rates of smoking,15^,27^–30 and a higher risk for diabetes among lesbians and bisexual women.31^,32 Indeed, a recent survey of Dutch adults found that those adults who reported predominant or exclusive same-sex preferences were more likely to report a number of health conditions compared with other respondents.33One difficulty with estimating physical health disparities that are associated with sexual orientation lies in the dearth of population-based surveys that have measured both sexual orientation and markers of physical health, including HIV infection status. The Dutch study,33 for example, did not measure HIV status, which is a critical factor for understanding health complaints by gay men. A second concern is that lesbians, gay men, and bisexual and homosexually experienced heterosexuals have higher levels of psychological distress,6^,10^,34 which has been associated with more frequent reporting of some chronic conditions, health limitations, and poorer physical health status.35^–37 Generally, psychological distress is both a consequence of physical illness and a direct predictor of self-perceived physical health status38; however, the patterns of causal relationships among distress, chronic conditions, and self-perceived physical health are complex and may at times be recursive. For example, there is good evidence that psychiatric morbidity, including subthreshold mental disorders,39 inflates reports of somatic complaints and physical disability among individuals with similar levels of physical illness.38^,40Furthermore, prospective studies have identified psychological distress as a precursor for incident pain conditions41^,42 and preexisting depression as a risk factor for disability incidence.43 Thus, associations between sexual orientation and reports of chronic health conditions—particularly pain, disability, and poor overall physical health—may in fact reflect both direct effects of factors associated with sexual orientation and confounding from preexisting levels of psychological distress. This is relevant because previous studies have shown both higher levels of perceived social discrimination among lesbians, gay men, and bisexual individuals compared with heterosexual individuals44 and a strong positive association between perceptions of discrimination and psychological morbidity.44^,45To bring clarity to these issues, we examined the associations between sexual orientation, reports of common physical health complaints, and perceptions of physical health status with data from the California Quality of Life Survey, a population-based health survey of adult Californians that was conducted in late 2004 and early 2005. This survey oversampled individuals who were likely to be lesbian, gay, or bisexual, and it measured both sexual orientation identity and genders of sexual partners since age 18 years. We hypothesized that individuals with minority sexual orientation (defined both in terms of identity and sexual behavior) would have higher levels of psychological distress compared with exclusively heterosexual men and women. We also hypothesized that prevalent HIV infection would be more common among men who were likely to have had sex with men compared with exclusively heterosexual men. Furthermore, we anticipated that individuals with minority sexual orientation would show a greater burden of physical health complaints and a greater impairment in physical health, much like the Dutch study.33 However, we hypothesized that 2 factors—higher rates of psychological distress and, among gay and bisexual men, possible concurrent HIV infection—would account for any differences in the patterns of health problems we observed.