Racial/Ethnic Disparities in Health Care Receipt Among Male Cancer Survivors

Objectives. We examined racial/ethnic disparities in health care receipt among a nationally representative sample of male cancer survivors.Methods. We identified men aged 18 years and older from the 2006–2010 National Health Interview Survey who reported a history of cancer. We assessed health care receipt in 4 self-reported measures: primary care visit, specialist visit, flu vaccination, and pneumococcal vaccination. We used hierarchical logistic regression modeling, stratified by age (< 65 years vs ≥ 65 years).Results. In adjusted models, older African American and Hispanic survivors were approximately twice as likely as were non-Hispanic Whites to not see a specialist (odds ratio [OR] = 1.78; 95% confidence interval [CI] = 1.19, 2.68 and OR = 2.09; 95% CI = 1.18, 3.70, respectively), not receive the flu vaccine (OR = 2.21; 95% CI = 1.45, 3.37 and OR = 2.20; 95% CI = 1.21, 4.01, respectively), and not receive the pneumococcal vaccine (OR = 2.24; 95% CI = 1.54, 3.24 and OR = 3.10; 95% CI = 1.75, 5.51, respectively).Conclusions. Racial/ethnic disparities in health care receipt are evident among older, but not younger, cancer survivors, despite access to Medicare. These survivors may be less likely to see specialists, including oncologists, and receive basic preventive care.Gender and racial/ethnic disparities in health care utilization are prevalent. Men are less likely than are women to use health care services, including physician office visits and preventive care visits.1,2 Minorities are also less likely to use health care services than are non-Hispanic Whites.3–6 Contributors to these disparities include low socioeconomic status7–10 and lack of health insurance.7,8,11,12 Even after controlling for socioeconomic status and health insurance coverage, racial/ethnic disparities in health care utilization persist.4 These disparities are associated with poorer health and higher mortality rates among minorities and have important implications for survival and well-being for men with serious and chronic health conditions such as cancer.5Although numerous studies have documented racial/ethnic disparities in cancer screening, diagnosis, treatment, and mortality,10,13–18 little is known about how racial/ethnic disparities in health care among posttreatment cancer survivors influence follow-up care. Such care includes monitoring and managing late and long-term effects and follow-up tests to monitor for recurrence and detect second cancers. Management of noncancer comorbidities (e.g., diabetes) and preventive health care19 (e.g., vaccinations) are also recommended for cancer survivors.20–22 Follow-up care may include visits to both primary care and specialist providers.13,23–25 It is strongly recommended that cancer survivors receive lifelong follow-up care because of increased risk of recurrence, morbidity, and mortality.19Prior studies have used administrative data to explore this issue,13,24,26,27 but few of these studies have focused on male cancer survivors and none included younger survivors who are not covered by Medicare. Additionally, it is not known how patterns of health care receipt might differ among men with and without a history of cancer.We assessed racial/ethnic disparities in health care receipt among adult male cancer survivors and men without cancer using the National Health Interview Survey (NHIS).28 We first wanted to compare cancer survivors to a noncancer group to shed light on whether the disparities are specific to cancer or reflect underlying disparities. We explored (1) racial/ethnic disparities in health care receipt among cancer survivors compared with men with no cancer history, (2) racial/ethnic disparities in cancer survivors, and (3) the extent to which predisposing, enabling, and need factors explain racial/ethnic disparities in health care receipt among male cancer survivors.     

Intimate Partner Violence and Socioeconomic Deprivation in England: Findings From a National Cross-Sectional Survey

Objectives. We examined the prevalence of intimate partner violence (IPV) and its association with social deprivation in England.Methods. We used multivariable logistic regression to investigate IPV correlates among 21 226 men and women aged 16 to 59 years in the 2008 nationally representative cross-sectional British Crime Survey.Results. Lifetime IPV was reported by 23.8% of women and 11.5% of men. Physical IPV was reported by 16.8% and 7.0%, respectively; emotional-only IPV was reported by 5.8% and 4.2%, respectively. After adjustment for demographic confounders, lifetime physical IPV experienced by women was associated with social housing tenure (odds ratio [OR] = 2.3; 95% confidence interval [CI] = 2.0, 2.7), low household income (OR = 2.2; 95% CI = 1.8, 2.7), poor educational attainment (OR = 1.2; 95% CI = 1.0, 1.5), low social class (OR = 1.5; 95% CI = 0.3, 1.7), and living in a multiply deprived area (OR = 1.4; 95% CI = 1.1, 1.7). Physical IPV experienced by men and emotional IPV experienced by either gender were generally not associated with deprivation factors.Conclusions. Physical and emotional IPV are very common among adults in England. Emotional IPV prevention policies may be appropriate across the social spectrum; those for physical IPV should be particularly accessible to disadvantaged women.The World Health Organization highlights intimate partner violence (IPV) as a pressing public health and human rights issue.1 The World Health Organization defines IPV as physical or sexual violence, emotional abuse, or controlling behavior by a current or former intimate partner.2 In nearly 50 populationwide surveys globally some 10% to 69% of women report having ever experienced physical abuse by an intimate partner.2 In the United Kingdom, a 2009 review found that the prevalence of lifetime IPV against women was 13% to 31% in community studies, and 13% to 41% in clinical populations.3 The health impact of IPV extends beyond mortality and direct injury4 to poor overall self-rated health, mental health problems, and gynecological and sexual health problems.5,6 The annual UK domestic violence cost was estimated at £ 16 billion in 2008.7Often, IPV is seen in terms of physical or sexual violence perpetrated by men against women.1 As a consequence, most UK and international IPV prevention policies are targeted at women.1,8 However, some recent national surveys found a near-equal prevalence of physical IPV reported by men and women, mainly in North America and New Zealand, and there are calls for more services for male victims.9,10 Many have argued that this finding reflects measurement artifact, ignoring important differences in the nature and context of abuse.11 Further detailed examination of IPV as reported by both genders in national studies is needed to inform this debate.Policies for prevention of IPV also tend to emphasize that all women are at risk, regardless of their socioeconomic background.1,12 This is perhaps in an effort to decrease stigma associated with IPV. However, many studies show that both male perpetrators and female victims of physical IPV are more likely to come from disadvantaged backgrounds.13–15 The association with social deprivation depends on the broader social context, with more empowered women being at higher risk in some settings.16 There is little evidence on the socioeconomic profile of male victims. Finally, although central to the World Health Organization’s definition of IPV, emotional abuse is not well-described in the current literature among either gender. This is an important knowledge gap, as emotional abuse has a significant public health impact that can be as great as that of physical abuse.17,18 Understanding how social deprivation is associated with different types of abuse in both sexes will inform the need for targeted versus universal interventions.The British Crime Survey (BCS), a large national victimization survey in England and Wales, provides a detailed assessment of IPV. Home Office BCS reports examined associations between social deprivation and IPV victimization during the past year,19–21 but did not examine associations with lifetime IPV or IPV subtypes. To our knowledge there are no IPV studies using BCS data in the peer-reviewed scientific or public health literature, and only 1 UK national study using data other than the BCS, focusing on physical IPV.3,22 We used BCS data to describe the prevalence of both recent and lifetime IPV among men and women in England, and to explore whether different types of lifetime IPV were associated with social deprivation among either gender.To facilitate interpretation of our empirical findings we generated hypotheses in advance, following our review of theoretical and empirical literature. We expected to find that (1) women would report a higher prevalence of all types of IPV than men, particularly severe, prolonged, and controlling types of abuse11,23; (2) social deprivation would be associated with being a victim of lifetime IPV in both men and women13,15; and (3) social deprivation would be more strongly associated with being a victim of physical than of emotional lifetime IPV.17,24     

Racial Differences in Breast Cancer Stage at Diagnosis in the Mammography Era

Objectives. We assessed racial differences in breast cancer mortality by stage at diagnosis, since mammography became available.Methods. We calculated adjusted odds of distant (versus local or regional) tumors for 143 249 White and 13 571 Black women aged 50 to 69 years, diagnosed with breast cancer between 1982 and 2007 and living in a Surveillance, Epidemiology, and End Results region. We compared linear trends in stage at diagnosis before and after 1998.Results. Distant-stage cancer was diagnosed in 5.8% of White and 10.2% of Black participants. The Black–White disparity in distant tumors narrowed until 1998 (1998 adjusted difference = 0.65%), before increasing. Between 1982 and 1997, the proportion of distant tumors decreased for Blacks (adjusted odds ratio [AOR]/y = 0.973; 95% confidence interval [CI] = 0.960, 0.987) and Whites (AOR/y = 0.978; 95% CI = 0.973, 0.983), with no racial differences (P = .47). From 1998 to 2007, the odds of distant versus local or regional tumors increased for Blacks (AOR/y = 1.036; 95% CI = 1.013, 1.060) and Whites (AOR/y = 1.011; 95% CI = 1.002, 1.021); the rate of increase was greater for Blacks than Whites (P = .04).Conclusions. In the mammography era, racial disparities remain in stage at diagnosis.Despite a lower incidence of invasive breast cancer, Black women in the United States are more likely than are White women to die of the disease.1,2 Since 1992, although breast cancer deaths have declined in both White and Black women, the overall disparity in mortality has increased.3 Stage at diagnosis is the strongest predictor of survival in breast cancer,4–6 and Black women are more often diagnosed with advanced-stage disease than are White women.7–10Mammography is an important tool in the early detection of breast cancer.11–13 First introduced in the United States in the early 1980s,14 mammography was initially most prevalent among White women. Racial disparities in mammography rates narrowed by the mid-1990s,12,15 and Black women had rates equivalent to or greater than those of White women between 1996 and 2000.10,15,16 From 2000 to 2005, mammography use declined nationally in women aged 50 to 64 years (78.6% to 71.8%), with a slightly larger decrement for White (−4.0%) than Black (−3.3%) women.13The survival benefit of any screening program, including mammography, is related to its ability to detect tumors at earlier stages. Meta-analyses continue to find mortality benefit for mammography, although uncertainty remains regarding both the appropriate target population and the optimal screening interval.11,17,18 Consistent with the expected effect of screening, an observational cohort analysis found that improvements in screening rates for both Black and White women during the 1990s contributed to diagnosis at an earlier stage in both groups.10Nevertheless, despite generally equivalent rates of mammography for the past 15 years, the racial disparity in breast cancer mortality between Black and White women persists. Although previous meta-analyses suggested a mortality benefit for mammography, randomized controlled data regarding the efficacy of screening programs in minority populations are limited.18,19 Because stage at diagnosis is an important predictor of survival in breast cancer, we assessed temporal changes in the distribution of stage at diagnosis between 1982 and 2007, in both Black and White women, adjusting for covariates known to affect stage at diagnosis.     

Impaired-Driving Prevalence Among US High School Students: Associations With Substance Use and Risky Driving Behaviors

Objectives. We examined the prevalence of impaired driving among US high school students and associations with substance use and risky driving behavior.Methods. We assessed driving while alcohol or drug impaired (DWI) and riding with alcohol- or drug-impaired drivers (RWI) in a nationally representative sample of 11th-grade US high school students (n = 2431). We examined associations with drinking and binge drinking, illicit drug use, risky driving, and demographic factors using multivariate sequential logistic regression analysis.Results. Thirteen percent of 11th-grade students reported DWI at least 1 of the past 30 days, and 24% reported RWI at least once in the past year. Risky driving was positively associated with DWI (odds ratio [OR] = 1.25; P < .001) and RWI (OR = 1.09; P < .05), controlling for binge drinking (DWI: OR = 3.17; P < .01; RWI: OR = 6.12; P < .001) and illicit drug use (DWI: OR = 5.91; P < .001; RWI: OR = 2.29; P = .05). DWI was higher for adolescents who drove after midnight (OR = 15.7), drove while sleepy or drowsy (OR = 8.6), read text messages (OR = 11.8), sent text messages (OR = 5.0), and made cell phone calls (OR = 3.2) while driving.Conclusions. Our findings suggest the need for comprehensive approaches to the prevention of DWI, RWI, and other risky driving behavior.Motor vehicle crashes are the leading cause of mortality for US adolescents.1 In general, alcohol and drug use impairs driving performance in proportion to the amount consumed and contributes significantly to motor vehicle crashes,2,3 particularly among younger drivers.4 In 2008, 31% of young drivers who were killed in motor vehicle crashes had been drinking5; in 2009, half of the child passengers who died in crashes involving alcohol were riding with an alcohol-impaired driver.6 Illicit drug use also contributes to a large portion of fatal motor vehicle crashes involving adolescents and adults.7–10 Despite downward trends among adolescents in rates of drinking and driving (from 17% in 1991 to 10% in 2009) and riding with drinking drivers (from 40% in 1991 to 28% in 2009), rates remain alarmingly high.11 Therefore, better understanding of the current prevalence, variability, and determinants of adolescent driving while intoxicated (DWI) and riding with alcohol- or drug-impaired drivers (RWI) is needed to guide the development of prevention strategies.Adolescence, the transition period from childhood to emerging adulthood, is a time of increased sensation seeking and risk behavior.12,13 During this transition, learning to drive and obtaining a license are major rites of passage for entering adulthood. However, adolescent drivers have high crash rates and tend to drive in a deliberately risky manner, typified by speeding, close following, sharp cornering, and hard stops.14–18 At the same time, drinking and drug use increase during adolescence, and vehicles become a primary means of transportation and provide a somewhat private place for adolescents to drink and use illicit drugs.19,20Previous research indicates that the prevalence of DWI and RWI among adolescents is higher for male than female adolescents and for Latinos than Whites.21–24 Concurrent and longitudinal research has shown that drinking, binge drinking, cigarette use, and marijuana use are associated with adolescent DWI and RWI.20,25–28 Similarly, drinking, drug use, and traffic violations are associated with adolescent risky driving.17,26 It has been shown in a few regional studies that risky driving covaries with other problem behaviors,17,26,29 but no national studies have reported associations between risky driving and DWI and RWI among adolescents.Using a national probability sample, we examined the following: (1) the variability in the prevalence of DWI and RWI among adolescents by demographic factors; (2) the association between risky driving and DWI and RWI; and (3) the independent contribution of binge drinking, illicit drug use, and risky driving to DWI and RWI.     

Self-Reported Health Among Recently Incarcerated Mothers

Objectives. We examined self-reported health among formerly incarcerated mothers.Methods. We used data from the Fragile Families and Child Wellbeing Study (n = 4096), a longitudinal survey of mostly unmarried parents in urban areas, to estimate the association between recent incarceration (measured as any incarceration in the past 4 years) and 5 self-reported health conditions (depression, illicit drug use, heavy drinking, fair or poor health, and health limitations), net of covariates including health before incarceration.Results. In adjusted logistic regression models, recently incarcerated mothers, compared with their counterparts, have an increased likelihood of depression (odds ratio [OR] = 1.60; 95% confidence interval [CI] = 1.18, 2.17), heavy drinking (OR = 1.79; 95% CI = 1.19, 2.68), fair or poor health (OR = 1.49; 95% CI = 1.08, 2.06), and health limitations (OR = 1.78; 95% CI = 1.27, 2.50). This association is similar across racial/ethnic subgroups and is larger among mothers who share children with fathers who have not been recently incarcerated.Conclusions. Recently incarcerated mothers struggle with even more health conditions than expected given the disadvantages they experience before incarceration. Furthermore, because incarceration is concentrated among those who are most disadvantaged, incarceration may increase inequalities in population health.The US incarceration rate, though recently stabilized, has increased rapidly over the past 4 decades. Accordingly, researchers have become acutely aware of the sheer number of individuals who experience incarceration and the vulnerabilities these individuals face before, during, and after incarceration.1 In particular, a growing literature has documented the consequences of mass incarceration, defined as the historically and comparatively extreme rates of incarceration in the United States, for population health.2–5 Formerly incarcerated individuals, compared with their counterparts, have elevated rates of mortality,6 infectious diseases,7 cardiovascular diseases,8 and disability,9 as well as an array of mental health problems including depression,10 anxiety,9 and life dissatisfaction.11Despite the fact that, since the early 1980s, women’s incarceration rates have increased faster than men’s incarceration rates,12,13 very little research has explicitly considered the health of formerly incarcerated women. Instead, research on incarcerated women often focuses on the consequences of incarceration for their families and children.14–19 The dearth of research on formerly incarcerated women’s health is an important oversight because these women are an extremely vulnerable population and present a pressing public health concern. Formerly incarcerated mothers are an especially important group because poor physical and mental health among mothers may have deleterious consequences for their children.20–23We used data from the Fragile Families and Child Wellbeing Study, a longitudinal study of mostly unmarried parents living in urban areas, to provide the first examination of the relationship between recent incarceration, measured as any incarceration experience in the past 4 years, and 5 self-reported health conditions among mothers: depression, illicit drug use, heavy drinking, fair or poor health, and health limitations. First, we estimated the association between recent incarceration and self-reported health. We then estimated this association by race/ethnicity and by romantic partner’s incarceration history. Our analyses adjusted for a large number of individual characteristics that may render the association between recent incarceration and health conditions spurious (including health before incarceration). Adjusting for these characteristics is especially important because incarcerated mothers are at risk for poor physical and mental health before incarceration.5,24–26     

Flavored Alcoholic Beverage Use,Risky Drinking Behaviors,and Adverse Outcomes Among Underage Drinkers: Results From the ABRAND Study

Objectives. We examined associations between consumption of different types of flavored alcoholic beverages (FABs) and risky drinking and drinking-related harms among underage drinkers.Methods. For the Alcohol Brand Research among Underage Youth study, we applied multivariable logistic regression analyses to data from underage drinkers (n = 1031, aged 13–20 years), recruited from a national Internet panel in 2011 to 2012, to estimate associations between consumption of malt-based drinks; spirits-based, premixed- or ready-to-drink cocktails; and supersized alcopops, alone or in combination, and alcohol-related outcomes.Results. After adjustment for confounding variables, the exclusive consumption of alcopops was associated with episodic heavy drinking (odds ratio [OR] = 4.35; 95% confidence interval [CI] = 1.24, 15.31; P < .05) and alcohol-related injuries (OR = 6.25; 95% CI = 1.34, 29.10; P < .05). Exclusive consumption of cocktails was associated with episodic heavy drinking (odds ratio [OR] = 2.61; 95% CI = 1.26, 5.41; P < .05) and injuries requiring medical attention (OR = 6.50; 95% CI = 2.09, 20.17; P < .001. Exclusive consumption of 2 or more FABs was associated with episodic heavy drinking (OR = 2.78; 95% CI = 1.25, 6.16; P < .05), fighting (OR = 3.30; 95% CI = 1.46, 7.47; P < .001), and alcohol-related injuries (OR = 2.83; 95% CI = 1.43, 5.58; P < .001).Conclusions. FABs present an emerging public health problem among youths.Alcohol continues to be the most commonly used drug among youths in the United States and is responsible for more than 4300 annual deaths among underage drinkers.1 Approximately 33% of eighth graders and 70% of 12th graders have consumed alcohol, and 13% of eighth graders and 40% of 12th graders drank during the past month.2 Close to 200 000 emergency department visits by persons younger than 21 years are reported annually for injuries and other conditions linked to alcohol.3 An important trend in underage drinking is the popularity of flavored alcoholic beverages (FABs).4–12 Despite their popularity, little is known about associations between FAB consumption, risky drinking behaviors, and related harms among underage drinkers.FAB brands can be classified into 3 categories: malt-based beverages; spirits-based, premixed- or ready-to-drink cocktails; and supersized alcopops.4 Although these products are widely classified as FABs, distinctions between them are important because these beverages differ in serving size (e.g., the supersized alcopops can contain 2 to 3 times the alcohol volume of other brands) and average alcohol content by volume (malt beverages, 7.8%; premixed- or ready-to-drink cocktails, 14.2%; supersized alcopops, 10.8%).4We used ABRAND (Alcohol Brand Research among Underage Youth) data collected by GfK Knowledge Networks13 to analyze the brands of alcoholic beverages a national sample of youth drinkers aged 13 to 20 years reported consuming and found that nearly half of young drinkers (n = 515) had consumed FABs in the past 30 days.4 These results roughly matched those of the 2012 Monitoring the Future report, which found that more than half (57.5%) of students in grades 8, 10, and 12 who reported past 30-day alcohol use had consumed at least 1 FAB during that time.2 The ABRAND data also showed that 43% of drinkers aged 13 to 15 years, 48.9% of those aged 16 to 18 years, and 52% of those aged 19 to 20 years consumed FABs.4 Consumption prevalence was greatest for malt beverages (33.8%), followed by premixed- or ready-to-drink cocktails (23.9%) and supersized alcopops (8.6%). Almost one quarter of respondents (24.5%) had consumed at least 1 FAB during a heavy-drinking episode (defined as consuming ≥ 5 drinks in a row).4FABs'' high alcohol content, low price, sweet flavoring, attractive packaging, and targeted marketing strategies have caused concern that FAB consumption might disproportionately contribute to alcohol-related emergency department visits by underage drinkers.5 One case study found that consumption of supersized alcopops such as Four Loko contributed to alcohol-related emergencies involving drinkers as young as 13 years.14We used the ABRAND sample of underage drinkers to examine the relationship between consumption of different types and combinations of FABs and risky drinking behaviors and adverse outcomes among youths aged 13 to 20 years.     

Drawing the Curtain Back on Injured Commercial Bicyclists

Objectives. We determined the demographic characteristics, behaviors, injuries, and outcomes of commercial bicyclists who were injured while navigating New York City’s (NYC’s) central business district.Methods. Our study involved a secondary analysis of prospectively collected data from a level 1 regional trauma center in 2008 to 2014 of bicyclists struck by motor vehicles. We performed univariable and multivariable logistic regression analyses.Results. Of 819 injured bicyclists, 284 (34.7%) were working. Commercial bicyclists included 24.4% to 45.1% of injured bicyclists annually. Injured commercial bicyclists were more likely Latino (56.7%; 95% confidence interval [CI] = 50.7, 62.8 vs 22.7%; 95% CI = 19.2, 26.5). Commercial bicyclists were less likely to be distracted by electronic devices (5.0%; 95% CI = 2.7, 8.2 vs 12.7%; 95% CI = 9.9, 15.9) or to have consumed alcohol (0.7%; 95% CI = 0.9, 2.5 vs 9.5%; 95% CI = 7.2, 12.3). Commercial and noncommercial bicyclists did not differ in helmet use (38.4%; 95% CI = 32.7, 44.4 vs 30.8%; 95% CI = 26.9, 34.9). Injury severity scores were less severe in commercial bicyclists (odds ratio = 0.412; 95% CI = 0.235, 0.723).Conclusions. Commercial bicyclists represent a unique cohort of vulnerable roadway users. In NYC, minorities, especially Latinos, should be targeted for safety education programs.In the United States in 2012, 726 bicyclists were killed and 49 000 were injured in motor vehicle collisions1–3; these fatalities accounted for 2.2% of motor vehicle–related deaths, but represented a 6.5% increase from 2011.1,2 In New York City (NYC), there were 4207 bicycle collisions in 2012 that resulted in injury, including 20 fatalities.4An estimated 185 000 people bike in NYC daily; of these, 5000 are commercial bicyclists making deliveries.5 Although commercial bicyclists include only 2.7% of bicyclists in NYC, they account for 16% of daily bicycle trips, at an average of 22 trips per day per commercial bicyclist.5 There are an estimated 109 375 food delivery trips made daily across NYC, covering 100 000 miles.5 NYC businesses have been required to provide employee bicyclists with helmets and safety gear, including reflectors, since 2007 and identification cards and reflective vests since 2013.6–9 Following a 10-month safety education initiative for business owners, the NYC Department of Transportation (DOT) increased enforcement of existing commercial bicycling safety laws in April 2013 by deploying inspectors to businesses to issue violations for missing or improper safety equipment and nonadherence to mandatory safety courses.10–12Commercial bicyclists represent a unique population whose characteristics, behaviors, and injuries have not been previously documented. A comprehensive literature search yielded only 3 articles13–15 relevant to the subject matter, emphasizing the need for more data on this population. Furthermore, current New York State and City databases do not identify injured bicyclists as commercial or noncommercial.1,4 Previous work from our trauma center revealed that 43% of injured bicyclists involved in motor vehicle collisions were commercial.16,17 Although commercial bicyclists provide a convenient service in many urban centers, essential information regarding their safety practices, behaviors, and outcomes in the event of injury is lacking. Our hypothesis was that commercial bicyclists represent a distinct cohort of vulnerable roadway users with a high minority representation. The objective of this study was to describe the demographic characteristics, behaviors, injuries, and outcomes of commercial bicyclists who were injured while navigating NYC’s central business district.     

Posttraumatic Stress Disorder and Incident Heart Failure Among a Community-Based Sample of US Veterans

Objectives. We investigated the association between posttraumatic stress disorder (PTSD) and incident heart failure in a community-based sample of veterans.Methods. We examined Veterans Affairs Pacific Islands Health Care System outpatient medical records for 8248 veterans between 2005 and 2012. We used multivariable Cox regression to estimate hazard ratios and 95% confidence intervals for the development of heart failure by PTSD status.Results. Over a mean follow-up of 7.2 years, veterans with PTSD were at increased risk for developing heart failure (hazard ratio [HR] = 1.47; 95% confidence interval [CI] = 1.13, 1.92) compared with veterans without PTSD after adjustment for age, gender, diabetes, hyperlipidemia, hypertension, body mass index, combat service, and military service period. Additional predictors for heart failure included age (HR = 1.05; 95% CI = 1.03, 1.07), diabetes (HR = 2.54; 95% CI = 2.02, 3.20), hypertension (HR = 1.87; 95% CI = 1.42, 2.46), overweight (HR = 1.72; 95% CI = 1.25, 2.36), obesity (HR = 3.43; 95% CI = 2.50, 4.70), and combat service (HR = 4.99; 95% CI = 1.29, 19.38).Conclusions. Ours is the first large-scale longitudinal study to report an association between PTSD and incident heart failure in an outpatient sample of US veterans. Prevention and treatment efforts for heart failure and its associated risk factors should be expanded among US veterans with PTSD.Posttraumatic stress disorder (PTSD) is a psychiatric illness that affects approximately 7.7 million Americans aged older than 18 years.1 PTSD typically results after the experience of severe trauma, and veterans are at elevated risk for the disorder. The National Vietnam Veterans Readjustment Study reported the prevalence of PTSD among veterans who served in Vietnam as 15.2% among men and 8.1% among women.2 In fiscal year 2009, nearly 446 045 Veterans Administration (VA) patients had a primary diagnosis of PTSD, a threefold increase since 1999.3 PTSD is of growing clinical concern as evidence continues to link psychiatric illnesses to conditions such as arthritis,4 liver disease,5 digestive disease,6 and cancer.6 When the postwar health status of Vietnam veterans was examined, those with PTSD had higher rates of diseases of the circulatory, nervous, digestive, musculoskeletal, and respiratory systems.7The evidence linking PTSD to coronary heart disease (CHD) is substantial.8–10 Veterans with PTSD are significantly more likely to have abnormal electrocardiograph results, myocardial infarctions, and atrioventricular conduction deficits than are veterans without PTSD.11 In a study of 605 male veterans of World War II and the Korean War, CHD was more common among veterans with PTSD than among those without PTSD.12 Worldwide, adults exposed to the disaster at Chernobyl experienced increased rates of CHD up to 10 years after the event,13 and studies of stressors resulting from the civil war in Lebanon found elevated CHD mortality.14,15Although the exact biological mechanism by which PTSD contributes to CHD remains unclear, several hypotheses have been suggested, including autonomic nervous system dysfunction,16 inflammation,17 hypercoagulability,18 cardiac hyperreactivity,19 altered neurochemistry,20 and co-occurring metabolic syndrome.16 One of the hallmark symptoms of PTSD is hyperarousal,21 and the neurobiological changes brought on from sustained sympathetic nervous system activation affect the release of neurotransmitters and endocrine function.22 These changes have negative effects on the cardiovascular system, including increased blood pressure, heart rate, and cardiac output.22,23Most extant literature to date examining cardiovascular sequelae has shown a positive association between PTSD and coronary artery disease.8–10 Coronary artery disease is well documented as one of the most significant risk factors for future development of heart failure.24 Despite burgeoning evidence for the role of PTSD in the development of coronary artery disease, there are few studies specifically exploring the relationship between PTSD and heart failure. Limited data suggest that PTSD imparts roughly a threefold increase in the odds of developing heart failure in both the general population5 and in a sample of the elderly.25 These investigations, however, have been limited by cross-sectional study design, a small proportion of participants with PTSD, and reliance on self-reported measures for both PTSD and heart failure.5,25 Heart failure is a uniquely large public health issue, as nearly 5 million patients in the United States are affected and there are approximately 500 000 new cases each year.26 Identifying predictors of heart failure can aid in early detection efforts while simultaneously increasing understanding of the mechanism behind development of heart failure.To mitigate the limitations of previous investigations, we undertook a large-scale prospective study to further elucidate the role of prevalent PTSD and development of incident heart failure among veterans, while controlling for service-related and clinical covariates. Many studies investigating heart failure have relied on inpatient records; we leveraged outpatient records to more accurately reflect the community burden of disease.     

Human Papillomavirus Vaccination Among Young Adult Gay and Bisexual Men in the United States

Objectives. We examined human papillomavirus (HPV) vaccination among gay and bisexual men, a population with high rates of HPV infection and HPV-related disease.Methods. A national sample of gay and bisexual men aged 18 to 26 years (n = 428) completed online surveys in fall 2013. We identified correlates of HPV vaccination using multivariate logistic regression.Results. Overall, 13% of participants had received any doses of the HPV vaccine. About 83% who had received a health care provider recommendation for vaccination were vaccinated, compared with only 5% without a recommendation (P < .001). Vaccination was lower among participants who perceived greater barriers to getting vaccinated (odds ratio [OR] = 0.46; 95% confidence interval [CI] = 0.27, 0.78). Vaccination was higher among participants with higher levels of worry about getting HPV-related disease (OR = 1.54; 95% CI =  1.05, 2.27) or perceived positive social norms of HPV vaccination (OR = 1.57; 95% CI =  1.02, 2.43).Conclusions. HPV vaccine coverage is low among gay and bisexual men in the United States. Future efforts should focus on increasing provider recommendation for vaccination and should target other modifiable factors.Oncogenic human papillomavirus (HPV) types (mainly types 16 and 18) cause an estimated 93% of anal cancers, 63% of oropharyngeal cancers, and 36% of penile cancers among men in the United States.1 Nononcogenic HPV types 6 and 11 cause almost all anogenital warts.2 Gay and bisexual men have high rates of HPV infection and HPV-related disease. A recent review suggests that more than 50% of HIV-negative gay and bisexual men have an anogenital HPV infection.3 About 7% of gay and bisexual men report a history of genital warts.4 Anal cancer is also of great concern, with incidence among HIV-negative gay and bisexual men estimated to be 35 cases per 100 000 population.5 The anal cancer incidence rate among all men in the United States is just 1.6 cases per 100 000 population.6US guidelines began including the quadrivalent HPV vaccine (against HPV types 6, 11, 16, and 18) for males in October 2009.7 The Advisory Committee on Immunization Practices (ACIP) first provided a permissive recommendation that allowed the HPV vaccine to be given to males aged 9 to 26 years but did not include the vaccine in their routine vaccination schedule.7 In October 2011, the ACIP began recommending routine vaccination for boys aged 11 to 12 years with catch-up vaccination for males aged 13 to 21 years.8 Importantly, the ACIP recommends HPV vaccination for men who have sex with men through age 26 years.8The HPV vaccine series consists of 3 doses, with the second dose administered 1 to 2 months after the first dose, and the third dose is administered 6 months after the first dose.7 The quadrivalent HPV vaccine is currently approved to protect males against genital warts and anal cancer.9 Despite recommendations, recent data suggest that fewer than 21% of males in the United States have received any doses of the HPV vaccine.10–14Although several HPV-related disparities exist among gay and bisexual men, little research has addressed HPV vaccination among this population. Past studies have shown that knowledge about HPV and the HPV vaccine tends to be modest among gay and bisexual men.15–19 Many gay and bisexual men have indicated their willingness to get the HPV vaccine, with estimates ranging from 36% to 86%.16,18–20 Data on actual HPV vaccine coverage are sparse; a past study found only 7% of 68 young adult gay and bisexual men had received any doses of the HPV vaccine.11 This study was, however, conducted before the ACIP recommendation for routine vaccination of males.We built on this past research by examining HPV vaccination among a national sample of young adult gay and bisexual men in the recommended age range for HPV vaccination (18–26 years). We identified correlates of vaccination and why young adult gay and bisexual men are not getting the HPV vaccine. These data will help inform future programs for increasing HPV vaccination among this high-risk population.     

The Collateral Damage of Mass Incarceration: Risk of Psychiatric Morbidity Among Nonincarcerated Residents of High-Incarceration Neighborhoods

Objectives. We examined whether residence in neighborhoods with high levels of incarceration is associated with psychiatric morbidity among nonincarcerated community members.Methods. We linked zip code–linked information on neighborhood prison admissions rates to individual-level data on mental health from the Detroit Neighborhood Health Study (2008–2012), a prospective probability sample of predominantly Black individuals.Results. Controlling for individual- and neighborhood-level risk factors, individuals living in neighborhoods with high prison admission rates were more likely to meet criteria for a current (odds ratio [OR] = 2.9; 95% confidence interval [CI] = 1.7, 5.5) and lifetime (OR = 2.5; 95% CI = 1.4, 4.6) major depressive disorder across the 3 waves of follow-up as well as current (OR = 2.1; 95% CI = 1.0, 4.2) and lifetime (OR = 2.3; 95% CI = 1.2, 4.5) generalized anxiety disorder than were individuals living in neighborhoods with low prison admission rates. These relationships between neighborhood-level incarceration and mental health were comparable for individuals with and without a personal history of incarceration.Conclusions. Incarceration may exert collateral damage on the mental health of individuals living in high-incarceration neighborhoods, suggesting that the public mental health impact of mass incarceration extends beyond those who are incarcerated.The United States leads the world in the percentage of its population that serves time in prison or jail.1,2 As of 2012, nearly 7 million men and women are on probation, parole, or under some other form of community supervision, which means that nearly 3% of the American adult population is currently involved in correctional supervision.3 The burden of incarceration in the United States is not equally distributed in the population. Current estimates from the Bureau of Justice Statistics indicate that 1 of every 3 Black men will serve time in prison in their lifetimes.4 In some communities, these figures are even starker. In Washington, DC, for example, more than 95% of Black men have been in prison in their lifetimes.1 Because of the scope of incarceration within particular subgroups, the current state of the US criminal justice system has been described in such terms as mass imprisonment5 and hyperincarceration.6Research on the health consequences of incarceration falls largely into 2 broad categories. The first, which has received the most empirical attention, has focused on individuals directly involved in the criminal justice system. Individual incarceration exposure is associated with adverse mental7–9 and physical10 health outcomes. A second line of inquiry has evaluated the broader health consequences of incarceration—what has been variously called the “long arm” of corrections,11 the collateral consequences of mass incarceration,5 and “spillover” effects related to incarceration.12 For example, female partners of recently released male prisoners experience depression and anxiety symptoms,13,14 and the children of incarcerated parents are at increased risk for behavioral and mental health problems.15,16 The deleterious health effects of incarceration are not merely confined to the family members of incarcerated individuals, however. Nonincarcerated individuals living in the communities from which inmates are drawn also appear to be at heightened risk for a variety of adverse outcomes, including increased crime rates17 and infectious diseases.18Although this research provides important initial insights into some of the negative consequences of incarceration at the community level, it remains largely unknown whether incarceration influences the mental health of community members who reside in neighborhoods with high-incarceration rates. How might incarceration affect community mental health? High levels of incarceration in neighborhoods can alter the social ecology of communities by eroding social capital and disrupting the kinds of social and family networks and relationships that are necessary for sustaining individuals’ mental health as well as the well-being of communities.1,19–22We examined whether high levels of incarceration in neighborhoods affect the mental health of individuals living in these neighborhoods. We treated incarceration as an ecological or contextual effect, rather than as an individual-level risk factor, which has characterized the majority of research on incarceration and mental health.7,23 That is, rather than examining the mental health consequences of incarceration among those who have themselves been incarcerated or among their family members, we examined the mental health of individuals living in communities that have been exposed to elevated levels of incarceration.     

Prenatal,Perinatal, Early Life,and Sociodemographic Factors Underlying Racial Differences in the Likelihood of High Body Mass Index in Early Childhood

Objectives. We investigated early childhood disparities in high body mass index (BMI) between Black and White US children.Methods. We compared differences in Black and White children’s prevalence of sociodemographic, prenatal, perinatal, and early life risk and protective factors; fit logistic regression models predicting high BMI (≥ 95th percentile) at age 4 to 5 years to 2 nationally representative samples followed from birth; and performed separate and pooled-survey estimations of these models.Results. After adjustment for sample design–related variables, models predicting high BMI in the 2 samples were statistically indistinguishable. In the pooled-survey models, Black children''s odds of high BMI were 59% higher than White children''s (odds ratio [OR] = 1.59; 95% confidence interval [CI]= 1.32, 1.92). Sociodemographic predictors reduced the racial disparity to 46% (OR = 1.46; 95% CI = 1.17, 1.81). Prenatal, perinatal, and early life predictors reduced the disparity to nonsignificance (OR = 1.18; 95% CI = 0.93, 1.49). Maternal prepregnancy obesity and short-duration or no breastfeeding were among predictors for which racial differences in children’s exposures most disadvantaged Black children.Conclusions. Racial disparities in early childhood high BMI were largely explained by potentially modifiable risk and protective factors.Over recent decades, as the prevalence of high body mass index (BMI; defined as at or above the Centers for Disease Control and Prevention 95th percentile1) has increased dramatically among all children,2,3 racial disparities have been documented in nationally representative samples of children at very young ages.4–7 Reviews and prevalence studies highlight the need for a better understanding of the predictors of these disparities in BMI and other indicators of childhood obesity,8,9 especially in early childhood.7Previous research on high BMI in early childhood with racially and ethnically diverse samples has identified risk and protective factors at multiple developmental stages. In the prenatal and perinatal period, risks include higher birth weight,10–13 maternal prepregnancy BMI,14 and maternal smoking during pregnancy.14,15 In infancy and early life, risks include maternal employment,11 especially among highly educated women,12,16 nonparent child care,13,17,18 and television viewing hours.12,19–21 Protective factors include breastfeeding10,12,14 and family meals.12,21,22Studies have shown that young racial/ethnic minority children are exposed to more of these risks and fewer of these protections.23,24 Nevertheless, in analyses of nationally representative samples, high BMI remains more common among Black than White children even after adjusting for sociodemographic characteristics and risk and protective factors.6,11,12,14,16 We suspect that the persistence of racial disparities in these studies might be attributable to omitted predictors or less detailed measurement of the age and duration of children’s exposures. This type of comprehensive assessment is methodologically challenging because of the number of variables and observations required to draw statistically valid inferences.We employed a novel 2-survey methodological design to overcome these challenges. We used data from 2 nationally representative samples of US children followed from birth to age 4 to 5 years in separate and pooled-survey analyses to identify prenatal, perinatal, early life, and sociodemographic factors that may explain Black–White disparities in early childhood high BMI. The separate analyses in 2 surveys that cover a historical period of more than 10 years increased the robustness of our findings to differences in sample design, measurement protocols, and period variability in unobserved confounders. The pooled-survey analyses enhanced the statistical power of our study and thereby strengthened our conclusions about which factors explain Black–White disparities in early childhood high BMI.     

Free Bus Travel and Physical Activity,Gait Speed,and Adiposity in the English Longitudinal Study of Ageing

Objectives. We investigated associations between having a bus pass, enabling free local bus travel across the United Kingdom for state pension–aged people, and physical activity, gait speed, and adiposity.Methods. We used data on 4650 bus pass–eligible people (aged ≥ 62 years) at wave 6 (2012–2013) of the English Longitudinal Study of Ageing in regression analyses.Results. Bus pass holders were more likely to be female (odds ratio [OR] = 1.67; 95% confidence interval [CI] = 1.38, 2.02; P < .001), retired (OR = 2.65; 95% CI = 2.10, 3.35; P < .001), without access to a car (OR = 2.78; 95% CI = 1.83, 4.21; P < .001), to use public transportation (OR = 10.26; 95% CI = 8.33, 12.64; P < .001), and to be physically active (OR = 1.43; 95% CI = 1.12, 1.84; P = .004). Female pass holders had faster gait speed (b = 0.06 meters per second; 95% CI = 0.02, 0.09; P = .001), a body mass index 1 kilogram per meter squared lower (b = –1.20; 95% CI = –1.93, –0.46; P = .001), and waist circumference 3 centimeters smaller (b = –3.32; 95% CI = –5.02, –1.62; P < .001) than women without a pass.Conclusions. Free bus travel for older people helps make transportation universally accessible, including for those at risk for social isolation. Those with a bus pass are more physically active. Among women in particular, the bus pass is associated with healthier aging.Maintaining physical activity is key to good physical functioning in older age,1 aging healthily,2 and reducing obesity risk,3 but only 49% of men and 36% of women aged 65 years and older in England met physical activity guidelines in 2012.4 Active modes of transportation, including public transportation, can contribute substantially to total physical activity.5 Among working-age adults, commuting by public transportation increases physical activity levels6 and can improve health,7–9 but evidence about older people is sparse.The UK older people’s bus pass (“bus pass” herein) enables people of the state retirement age for women (previously 60 years) and older to travel free of charge on local buses, anywhere in the country.10 To our knowledge, this nationwide policy of free bus transportation for older people, irrespective of financial circumstances, is unique. The bus pass was introduced in Scotland in 2002, England and Wales in 2006, and Northern Ireland in 2008, with concessionary policies operating previously. There remain various additional local benefits; for instance, older people living in London are eligible for a Freedom Pass, which provides free travel on all public transportation.Of the forms of public transportation available in the United Kingdom, buses serve the widest range of communities; even the majority of very rural areas have some bus services. Buses operate over relatively short distances, transporting people between residential areas and urban centers, shopping areas, and hospitals. The bus pass is a widely recognized state benefit for older people often discussed in the media. Advice on obtaining a pass is offered by many organizations including older people’s charities and local authorities. The application form is short and simple, and can either be completed online or acquired locally—for example, from a Post Office or government offices.The aim of the bus pass is to “tackle social exclusion” among older people.11 Evidence suggests that it has been successful, providing opportunities for social interaction, giving a feeling of visibility and belonging, improving quality of life, reducing feelings of social exclusion, and improving access to services.12–14 The bus pass has been estimated to cost the UK government approximately £1 billion a year15 and the recent climate of austerity has led to suggestions that eligibility for the bus pass should be means tested, whereby only older people with income and wealth below a certain level would be eligible. However, many of the benefits derive, at least in part, from the universality of free bus travel for older people and the lack of stigma therefore associated with the pass.12,13In addition to the benefits to older people’s social inclusion, there may be unanticipated benefits of the bus pass—for instance, to physical health. We have previously shown that the bus pass is linked to increased walking frequency16 and reduced obesity17; however, it has not been possible to investigate these relationships directly or in detail. We hypothesized that older people who hold bus passes will be more physically active and will have better physical functioning and lower adiposity. We contend that, if these hypothesized relationships are observed, this would indicate that the bus pass helps enable healthier aging, which leads to health care expenditure savings that may mitigate the cost of providing the bus pass to older people.We used data from the English Longitudinal Study of Ageing (ELSA) to determine (1) among those eligible, who takes up the bus pass; (2) what factors are associated with frequency of bus use among those who have a bus pass; (3) whether having a bus pass is associated with how often people use any public transportation; and (4) whether having a bus pass is associated with physical activity levels, gait speed, and adiposity.     

Smokers Who Try E-Cigarettes to Quit Smoking: Findings From a Multiethnic Study in Hawaii

Objectives. We characterized smokers who are likely to use electronic or “e-”cigarettes to quit smoking.Methods. We obtained cross-sectional data in 2010–2012 from 1567 adult daily smokers in Hawaii using a paper-and-pencil survey. Analyses were conducted using logistic regression.Results. Of the participants, 13% reported having ever used e-cigarettes to quit smoking. Smokers who had used them reported higher motivation to quit, higher quitting self-efficacy, and longer recent quit duration than did other smokers. Age (odds ratio [OR] = 0.98; 95% confidence interval [CI] = 0.97, 0.99) and Native Hawaiian ethnicity (OR = 0.68; 95% CI = 0.45, 0.99) were inversely associated with increased likelihood of ever using e-cigarettes for cessation. Other significant correlates were higher motivation to quit (OR = 1.14; 95% CI = 1.08, 1.21), quitting self-efficacy (OR = 1.18; 95% CI = 1.06, 1.36), and ever using US Food and Drug Administration (FDA)–approved cessation aids such as nicotine gum (OR = 3.72; 95% CI = 2.67, 5.19).Conclusions. Smokers who try e-cigarettes to quit smoking appear to be serious about wanting to quit. Despite lack of evidence regarding efficacy, smokers treat e-cigarettes as valid alternatives to FDA-approved cessation aids. Research is needed to test the safety and efficacy of e-cigarettes as cessation aids.Electronic cigarettes, or e-cigarettes, are battery-powered devices that generate vaporized nicotine or non-nicotine vapor that may be inhaled orally in the manner in which conventional cigarettes are smoked. E-cigarettes deliver the vapor when a cartridge containing nicotine solution is heated. Because e-cigarettes are likely to contain lower levels of toxins or carcinogens than combustible tobacco products,1 e-cigarettes are commonly promoted as safer alternatives to regular cigarettes and even as smoking cessation aids.2,3 Currently, the US Food and Drug Administration (FDA) lacks regulations for e-cigarettes as therapeutic drug delivery devices and intends to regulate them as tobacco products.3Whether e-cigarettes deserve consideration as possibly effective cessation aids is a subject of ongoing debate.1,4 Much of the debate has been fueled by the uncertainties regarding the public health risks and benefits of e-cigarette use.5,6 The FDA has maintained that most available e-cigarettes lack quality control, tend to deliver inconsistent levels of nicotine (which at higher doses can be lethal), and may not be entirely free of toxins or carcinogens.3 Moreover, the FDA is concerned that e-cigarette use may facilitate tobacco use initiation and increased nicotine addiction among youths and young adults.3 Recently, however, researchers have drawn attention to the promising aspects of e-cigarettes as cessation or harm reduction devices.4,7–10E-cigarettes appear promising as cessation aids because e-cigarettes not only deliver nicotine in the manner in which nicotine replacement therapy does but also closely simulate the experience of smoking combustible tobacco. Moreover, e-cigarettes may have a comparative advantage over current FDA-approved cessation aids in terms of user satisfaction because e-cigarettes seem better suited to address both the pharmacological and the sensorimotor aspects of smoking.7,11 However, at present the research examining the efficacy of e-cigarettes as cessation aids is in its early stages. In a study involving 40 non–treatment-seeking daily smokers who were assigned to use a particular brand of e-cigarette with the purpose of helping them quit or reduce smoking, 22.5% of participants showed sustained abstinence at 24-week follow-up and an additional 32.5% were found to have reduced their cigarette consumption by half.12 In another study, a group of first-time purchasers of a brand of e-cigarettes were contacted 6 months after the purchase date.13 Of the 4.5% of potential participants who responded, 31% reported point prevalence abstinence. Thus, the studies that have suggested that e-cigarettes are likely to be effective as cessation aids have been nonexperimental and based on convenience samples. In addition, although studies have tended to agree that e-cigarettes reduce craving and withdrawal symptoms in abstinent smokers,14–16 whether e-cigarettes are efficient as nicotine delivery devices is not clear.14,15,17,18 Hence, the usefulness of e-cigarettes as cessation aids is not certain.However, the popularity of e-cigarettes has continued to soar in the United States and elsewhere.19–22 According to a recent study, approximately 6% of all adults and 21% of adult current daily smokers in the United States report ever using e-cigarettes.19 Although the majority of current e-cigarette users seem to report smoking cessation or reduction as the primary motive for e-cigarette use,11,23–24 limited evidence currently exists regarding smokers’ use of e-cigarettes as cessation aids, especially in the United States.22 Moreover, limited or no data are available on how smokers’ sociodemographic characteristics, nicotine dependence, smoking behavior, motivation and self-efficacy to quit, quit attempts, and use of FDA-approved cessation aids are related to the likelihood of having ever used e-cigarettes as cessation aids. We addressed these gaps in the literature. Specifically, we examined the prevalence of use of e-cigarettes as cessation aids in a multiethnic sample of adult current daily smokers from Hawaii and examined the associations of sociodemographic factors and smoking- and cessation-related characteristics with ever having used e-cigarettes for smoking cessation. Thus, the results of this study will help guide future research by quantifying the nature of the relationships between e-cigarette use for cessation and smokers’ characteristics, including their cessation-related attitudes and behavior. For example, knowledge about the extent of statistically significant associations of e-cigarette use with demographic and cognitive correlates will help guide the design and analytic aspects of future studies on the etiology of e-cigarette use among current smokers. In addition, the results of this study will help guide future studies testing the efficacy of e-cigarettes as cessation aids. For example, cessation-related variables found to be significant correlates of e-cigarette use for cessation may be tested as potential moderators of the efficacy of e-cigarettes as cessation aids. Thus, this study is likely to advance the research on e-cigarette use, especially among smokers.     

Racial/Ethnic Disparities in Hypertension Prevalence: Reconsidering the Role of Chronic Stress

Objectives. We investigated the association between anticipatory stress, also known as racism-related vigilance, and hypertension prevalence in Black, Hispanic, and White adults.Methods. We used data from the Chicago Community Adult Health Study, a population-representative sample of adults (n = 3105) surveyed in 2001 to 2003, to regress hypertension prevalence on the interaction between race/ethnicity and vigilance in logit models.Results. Blacks reported the highest vigilance levels. For Blacks, each unit increase in vigilance (range = 0–12) was associated with a 4% increase in the odds of hypertension (odds ratio [OR] = 1.04; 95% confidence interval [CI] = 1.00, 1.09). Hispanics showed a similar but nonsignificant association (OR = 1.05; 95% CI = 0.99, 1.12), and Whites showed no association (OR = 0.95; 95% CI = 0.87, 1.03).Conclusions. Vigilance may represent an important and unique source of chronic stress that contributes to the well-documented higher prevalence of hypertension among Blacks than Whites; it is a possible contributor to hypertension among Hispanics but not Whites.Racial and ethnic disparities in hypertension are some of the most widely studied and consequential sources of social disparities in health in the United States.1–3 For example, recent prevalence estimates show that roughly 40% of Black adults but only 30% of White adults have hypertension.4 In addition, the incidence of hypertension occurs at younger ages for Blacks than Whites.1 These disparities are reflected in the larger burden of hypertension-related health and economic costs carried by non-White than White Americans. For example, mortality rates attributable to hypertension are roughly 15 deaths per 100 000 people for White men and women; the mortality rate for Black women is 40 per 100 000 and more than 50 per 100 000 for Black men.5 Among all health conditions, hypertension accounts for the greatest portion of disparities in years of lost life.6 Economically speaking, if Black Americans had the hypertension prevalence of White Americans, about $400 million would be saved in out-of-pocket health care expenses, about $2 billion would be saved in private insurance costs, and $375 million would be saved from Medicare and Medicaid—per year.7Despite the tremendous amount of research devoted to clarifying the factors that generate these disparities, most studies find that they persist after adjustment for a wide range of socioeconomic, behavioral, and biomedical risk factors.8 In fact, although disparities exist for several of these risk factors (e.g., socioeconomic status), numerous studies have shown no disparities in many others (e.g., smoking, obesity for men, lipid profile).2 Despite substantial investment in interventions to eliminate hypertension disparities, evidence suggests that these disparities have actually grown over the past few decades,9 suggesting that numerous unknown factors drive disparities in hypertension.3     

A Syndemic of Psychosocial Health Disparities and Associations With Risk for Attempting Suicide Among Young Sexual Minority Men

Objectives. We examined a syndemic of psychosocial health issues among young men who have sex with men (MSM), with men and women (MSMW), and with women (MSW). We examined hypothesized drivers of syndemic production and effects on suicide attempts.Methods. Using a pooled data set of 2005 and 2007 Youth Risk Behavior Surveys from 11 jurisdictions, we used structural equation modeling to model a latent syndemic factor of depression symptoms, substance use, risky sex, and intimate partner violence. Multigroup models examined relations between victimization and bullying experiences, syndemic health issues, and serious suicide attempts.Results. We found experiences of victimization to increase syndemic burden among all male youths, especially MSMW and MSM compared with MSW (variance explained = 44%, 38%, and 10%, respectively). The syndemic factor was shown to increase the odds of reporting a serious suicide attempt, particularly for MSM (odds ratio [OR] = 5.75; 95% confidence interval [CI] = 1.36, 24.39; P < .001) and MSMW (OR = 5.08; 95% CI = 2.14, 12.28; P < .001) compared with MSW (OR = 3.47; 95% CI = 2.50, 4.83; P < .001).Conclusions. Interventions addressing multiple psychosocial health outcomes should be developed and tested to better meet the needs of young MSM and MSMW.Substantial evidence has been accumulating over the past several decades to suggest that men who have sex with men (MSM) experience substantial disparities in many facets of health.1 An important characteristic of these disparities is that they tend to arise early in the life course. For example, meta-analyses have shown that by adolescence and young adulthood MSM experience significantly higher rates of depression,2 substance use,3 HIV sexual risk behaviors,4 and suicidality2 than do their heterosexual peers. Little research has been conducted on the health of young men who have sex with men and women (MSMW). The few empirical studies separating adolescent MSM from adolescent MSMW have shown that adolescent MSMW report significantly higher rates of substance use, including tobacco use, than do their heterosexual3 and MSM5–9 counterparts. Additionally, MSMW have been found to be more likely to report HIV sexual risk behaviors than are their heterosexual peers.9One theoretical explanation for these disparities is syndemics.10–12 Syndemic theory posits that as individuals are confronted with adversity across the life course, particularly in the forms of social marginalization and victimization, they develop psychosocial health problems such as low self-image, depression, and substance use.13 These conditions tend to co-occur, which has a snowballing effect on overall health. In fact, several studies have demonstrated that as the number of psychosocial conditions within an individual increases, so does their risk of major negative health outcomes.10–12,14 It follows from this argument that young MSM, who experience far greater levels of adversity than do heterosexual youths,15–18 would also experience greater rates of syndemics and higher rates of the resulting negative health outcomes.We examined syndemic production in a population-based sample of young men and its association with serious suicide attempts. By looking at syndemics in a large enough sample that could be broken into MSM, MSMW, and men who have sex with women (MSW), we sought to determine whether syndemics are a general human phenomenon or whether they exist and are associated with negative health outcomes only for certain socially marginalized populations.10,11,19 We also examined the structure of the syndemic construct by testing for measurement invariance using multigroup confirmatory factor analysis (CFA),20 which, essentially, asks whether the meaning of the syndemic construct is the same across groups. Next we examined the relation between experienced adversity and syndemic production to see whether this association exists for all groups of young men, and if so, to what degree. Finally, we tested the relationship between syndemics and a serious adverse health outcome—making a life-threatening suicide attempt—and whether the negative effects were the same across groups.     

Nonoccupational and Occupational Injuries to US Workers With Disabilities

Objectives. We examined medically treated injuries among US workers with disability.Methods. Using 2006–2010 National Health Interview Survey data, we compared 3-month rates of nonoccupational and occupational injuries to workers with disability (n = 7729) and without disability (n = 175 947). We fitted multivariable logistic regression models to calculate odds ratios and 95% confidence intervals of injuries by disability status, controlling for sociodemographic variables. We also compared leading causes of injuries by disability status.Results. In the 3-month period prior to the survey, workers with disability were more likely than other workers to have nonoccupational injuries (odds ratio [OR] = 2.35; 95% confidence interval [CI] = 2.04, 2.71) and occupational injuries (OR = 2.39; 95% CI = 1.89, 3.01). For both groups, the leading cause was falls.Conclusions. Disability status was strongly associated with risk of nonoccupational and occupational injuries among US workers. The safety issues facing US workers with disability in the workplace warrant future research. Federal agencies with an interest in the employment of workers with disability and their safety in the workplace should take a lead in further assessing injury risk and in promoting a safe working environment for workers with disability.In the United States, persons with disabilities constitute 12.0% of the population.1 Both the World Health Organization and the US surgeon general have released reports addressing disparities in the health of persons with disabilities.2,3 These reports identify community participation and health promotion as societal priorities. According to the 2008 American Community Survey, about 4.6 million adults (aged 16–64 years) with disabilities are employed in the United States, and the number of workers with disabilities is expected to increase in the coming years as the workforce ages.4 A public health concern is that workers with disabilities may be at high risk of occupational injuries.5–8 Reducing the proportion of individuals with disabilities who report nonfatal injuries is among the objectives of US Healthy People 2020.9A number of studies have shown that adults with disabilities are more vulnerable to injuries than nondisabled adults.10–14 Studies using nationally representative data sets have found that the odds of injury increased with increasing severity of disability10,12 and with the number of disabilities.13 The settings and external causes of these injuries differed between individuals with and without disabilities.11,12 Falls, for example, were a leading mechanism of injury reported more frequently among those with disabilities.10–12Occupational injuries among workers with disabilities have also been previously studied.5,15–19 A number of studies from the 1990s showed an elevated risk of injury among workers with disabilities.5,15–17,19 However, much of the prior research examined only those with specific types of disabilities.15–19 For example, older workers with poor hearing and poor vision were shown to have an elevated risk for occupational injuries.17 By contrast, recent research based on workers’ compensation insurance claims found that workers with cognitive disabilities sustained fewer injuries and experienced fewer absences due to injury than workers without cognitive disabilities.18Previous work has also been critiqued because of the conceptualization and definition of disability5 and because environmental factors or work accommodations for workers with disability could not be taken into account.20,21 Zwerling et al. found that approximately 12% of workers with impairments reported receiving some type of workplace accommodation.22 Recent work by Leff et al. explored the role of environmental factors (e.g., societal attitudes, the natural environment, and policies) in the functioning and societal participation of people with disabilities.14 Environmental factors were found to be independently associated with injury regardless of disability status; however, disability status remained a risk factor for injury, although environmental factors attenuated the association. One current conceptualization of disability, the World Health Organization’s International Classification of Functioning, Disability and Health (ICF), emphasizes environmental factors and has been used in recent studies to evaluate injury risks of persons with disabilities.10,12,23 The ICF defines disability as physical impairments, activity limitations, and participation restrictions that affect one’s interaction with the physical and social environment.24 However, the impact of this refined definition on the number of injuries to workers with disabilities has yet to be determined.Given the significant number of US workers with disabilities and the advancements in disability and injury definitions,25 we compared medically attended nonoccupational and occupational injuries among workers with and without disabilities, using data from the 2006–2010 National Health Interview Survey (NHIS). Our current study improves on previous studies by our team and other researchers by examining both nonoccupational and occupational injuries to workers with disabilities using a single data source and a newer definition of disability based on the ICF.     

The Impact of a Free Older Persons’ Bus Pass on Active Travel and Regular Walking in England

Objectives. We assessed the potential public health benefit of the National Bus Pass, introduced in 2006, which permits free local bus travel for older adults (≥ 60 years) in England.Methods. We performed regression analyses with annual data from the 2005–2008 National Travel Survey. Models assessed associations between being a bus pass holder and active travel (walking, cycling, and use of public transport), use of buses, and walking 3 or more times per week.Results. Having a free pass was significantly associated with greater active travel among both disadvantaged (adjusted odds ratio [AOR] = 4.06; 95% confidence interval [CI] = 3.35, 4.86; P < .001) and advantaged groups (AOR = 4.72; 95% CI = 3.99, 5.59; P < .001); greater bus use in both disadvantaged and advantaged groups (AOR = 7.03; 95% CI = 5.53, 8.94; P < .001 and AOR = 7.11; 95% CI = 5.65, 8.94; P < .001, respectively); and greater likelihood of walking more frequently in the whole cohort (AOR = 1.15; 95% CI = 1.07, 1.12; P < .001).Conclusions. Public subsidies enabling free bus travel for older persons may confer significant population health benefits through increased incidental physical activity.Physical activity levels are decreasing globally.1 In 2008, 31% of people worldwide were insufficiently active contributing to 3.2 million deaths each year related to physical inactivity.2 Remaining physically active is as important in older as in younger adults because it reduces the risk of loss of mobility and muscle strength, falls, and fractures, and promotes social and mental well-being.3 Responding to this evidence, the US Surgeon General recommends regular moderate physical activity for older adults,4 and the UK Department of Health recommends at least 30 minutes of moderate exercise 5 times a week.3 Even lower activity levels may have significant benefits: the relative risk of disability is reduced by 7% for each additional hour of relatively gentle physical activity undertaken each week,5 and 15 minutes of moderate daily exercise is associated with a 12% decrease in all-cause mortality in persons older than 60 years.6Incidental physical activity may be defined as physical activity that is a byproduct of an activity with a different primary purpose. There is increasing interest in the promotion of incidental physical activity, including greater use of active transport—walking, cycling, and use of public transport.7–9 By swapping private vehicle travel for public transport—which may involve walking or cycling to transport access points or interchanges—physical activity levels are raised, offering significant health benefits, such as a reduced risk of obesity and cardiovascular ill health.10–12 Research from the United States finds that those commuting on public transport walk for an average of 19 minutes each day, and that nearly one third of commuters reach recommended daily physical activity levels just through active transport.13 In the United Kingdom, 19% of adults achieve recommended activity levels through active transport alone.14 Although commuting may not be as relevant to retired populations,15 incidental active travel may still have a key role to play in keeping older adults physically fit.16,17     

Self-Reported Experience of Racial Discrimination and Health Care Use in New Zealand: Results From the 2006/07 New Zealand Health Survey

Objectives. We investigated whether reported experience of racial discrimination in health care and in other domains was associated with cancer screening and negative health care experiences.Methods. We used 2006/07 New Zealand Health Survey data (n = 12 488 adults). We used logistic regression to examine the relationship of reported experience of racial discrimination in health care (unfair treatment by a health professional) and in other domains (personal attack, unfair treatment in work and when gaining housing) to breast and cervical cancer screening and negative patient experiences adjusted for other variables.Results. Racial discrimination by a health professional was associated with lower odds of breast (odds ratio [OR] = 0.37; 95% confidence interval [CI] = 0.14, 0.996) and cervical cancer (OR = 0.51; 95% CI = 0.30, 0.87) screening among Maori women. Racial discrimination by a health professional (OR = 1.57; 95% CI = 1.15, 2.14) and racial discrimination more widely (OR = 1.55; 95% CI = 1.35, 1.79) were associated with negative patient experiences for all participants.Conclusions. Experience of racial discrimination in both health care and other settings may influence health care use and experiences of care and is a potential pathway to poor health.Racism is increasingly recognized as an important determinant of health and driver of ethnic health inequalities.1 Regardless of its health effects, racism breaches fundamental human rights and is morally wrong. It is important to understand how racism operates as a health risk to develop interventions that reduce ethnic inequalities in health within a context of eliminating racism.2Racism is an organized system that categorizes racial/ethnic groups and structures opportunity, leading to inequities in societal goods and resources and a racialized social order.3–5 Racism operates via institutional and individual practices (racial discrimination) and varies in form and type.6,7 The pathways whereby racism leads to poor health are also multiple, with direct and indirect mechanisms such as race-based assaults and violence, physiological and psychological stress mechanisms, differential exposures to health risk factors, differential access to and experiences of health care, and differential access to goods, resources, and power in society.6,8–10Research on racism and health, particularly self-reported racism, has increased. Self-reported experience of racism has been linked to multiple health measures (including mental and physical health outcomes and health risk factors) across a variety of countries and for different ethnic groups.10–12 Research on how self-reported experience of racism may negatively affect health has largely focused on racism as a stressor with mental and physical health consequences.10,13 Comparatively less evidence is available on how experience of racism may influence health service use,10 although this is another potentially important pathway to poor health.14,15Studies on the association between self-reported racism and health care experience and use have included racism experienced within the health care system, outside of the health care system, or both.16–19 Health care measures have included use of specific services such as cancer screening19–24 and receipt of optimal care,20,25 measures of unmet need,16,26 measures of adherence to care,17,27,28 and measures of satisfaction and experiences with care.18,29–31Various mechanisms have been suggested to explain how the experience of racism may negatively affect health care use, experiences of health care, and subsequent poor health. Experiences of racism within the health care system may influence health by shaping decision making of both providers and patients and influencing future health behaviors, including future health care use behaviors and potential disengagement from the health care system.14,18,26 Experiences of racism in wider society also may lead to general mistrust and avoidance of dominant culture institutions, including health care systems.15,30 This is supported by evidence that both experiences of racism and general discrimination within and outside of health care have been associated with negative health care use measures.15,16,19,22New Zealand has a population of approximately 4.4 million people, with the major ethnic groupings being Maori (indigenous peoples, 15% of the population), European (77%), Pacific (7%), and Asian (10%).32 Ethnic inequalities in health and socioeconomic status persist, with racism a potentially important contributor to these inequalities.33 Previous research in New Zealand has shown reported experience of racial discrimination by a health professional to be higher among non-European ethnic groups with experiences of racial discrimination in different settings associated with multiple health outcomes and risk factors.34In this study, we focused on the relationship between racial discrimination and health service use and experience, an area not previously examined in New Zealand. We provide important information on how racial discrimination may affect health care use as a possible pathway to poor health outcomes and ethnic health inequalities in New Zealand. In addition, our study contributes to the limited evidence on racial discrimination and health care internationally.Primary health care in New Zealand is available to all residents and is usually provided at general practices. Costs of visits are universally subsidized by government to enable lower patient copayments with additional limited provision for extra funding based on high need.35 Currently, 2 publicly funded national cancer screening programs are available.36 Breast cancer screening is free to all eligible women through BreastScreen Aotearoa. Cervical cancer screening usually incurs a fee and is available through patients’ usual primary care provider or specific cervical cancer screening providers.We specifically examined the association between self-reported experience of racial discrimination and the use of health care in 2 domains—cancer screening and negative patient perceptions of health care encounters. We hypothesized that experience of racial discrimination both within and outside the health care system may negatively affect how individuals use and experience health care.     

Intergenerational Patterns of Smoking and Nicotine Dependence Among US Adolescents

Objectives. We examined associations between parental and adolescent smoking and nicotine dependence in the United States.Methods. We used data from the 2004 to 2012 National Survey on Drug Use and Health, which ascertained smoking behaviors of 1 parent and 1 adolescent aged 12 to 17 years in 35 000 dyads. We estimated associations between parental and adolescent smoking behaviors, adjusted for covariates.Results. Parental current dependence was strongly associated with adolescents’ lifetime smoking (adjusted odds ratio [AOR] = 2.96; 95% confidence interval [CI] = 2.47, 3.55), whereas parental current nondependent smoking (AOR = 2.26; 95% CI = 1.92, 2.67) and former smoking (AOR = 1.51; 95% CI = 1.31, 1.75) were less strongly associated. Only parental nicotine dependence was associated with adolescent nicotine dependence (AOR = 1.66; 95% CI = 1.00, 2.74). Associations between parental and adolescent smoking did not differ by race/ethnicity. Parents’ education, marital status, and parenting and adolescents'' mental health, beliefs about smoking, perception of schoolmates’ smoking, and other substance use predicted adolescent smoking and dependence.Conclusions. Reducing parental smoking would reduce adolescent smoking. Prevention efforts should encourage parental smoking cessation, improve parenting, address adolescent mental health, and reinforce adolescents'' negative beliefs about smoking.Of the models developed to account for the etiology of substance use and dependence, familial transmission represents an important class.1,2 This is especially the case for tobacco, because most onset begins and ends in adolescence, a period of intense socialization by parents and peers. Parental smoking is an important risk factor for adolescent smoking.3–7Studies of familial influences on adolescent smoking have 2 major limitations, regarding informants and constructs. Parental smoking behaviors are ascertained mostly from offspring; nicotine dependence (ND) is rarely assessed.8 Over the past decade, however, parental self-reports have been used to examine the associations of parental smoking and ND with adolescent smoking5–7,9–19 and dependence.20–29 Parental smoking is associated with smoking by offspring in a dose–response relationship: more extensive parental smoking is associated with more extensive adolescent smoking. Parental current, persistent, and dependent smoking is associated with current, heavy, and dependent smoking by adolescents.5,10,21,22,24 Although some studies have shown specific effects of parental ND on adolescent smoking and ND,22,24–26 others have not.11,23 Former parental smoking is also associated with a slightly increased risk of adolescent lifetime and current smoking in some studies,6,15,19 but not others.10,11Associations between parental and offspring smoking differ by gender and race/ethnicity: associations are stronger for mothers than fathers7,10,13,28,30 and for daughters than sons,4,30 although stronger paternal associations with sons than daughters,11 and no parental or adolescent gender effects,12 have also been reported. Although the prevalence of smoking and ND are consistently higher among Whites than minorities,16,29,31–33 findings for associations between parental and adolescent smoking across racial/ethnic groups vary. Stronger parental influence in White than African American families16,34 and similar influences across racial/ethnic groups have been observed.17,18,35We examined intergenerational associations for cigarette smoking and ND in 9 surveys (2004–2012) of large, nationally representative samples in the National Survey on Drug Use and Health (NSDUH). The sampling of respondent pairs within the same household provides national samples of related family members. The measurement of dependence among parents and adolescents permitted analysis of familial influences on tobacco use that focused on addiction and not only use. Covariates of parental and adolescent smoking and ND4,13–18,20,22,34–48 could be controlled to estimate the unique contribution of parental smoking on offspring. Aggregating multiple surveys permitted analyses in subgroups cross-classified by parental and adolescent gender, and race/ethnicity. No other national data set contains dyadic data on ND.We addressed 3 questions: (1) What is the association between patterns of parental smoking and adolescent lifetime smoking and ND? (2) What are the unique effects of parental smoking and dependence, after adjustment for other risk factors for adolescent smoking? (3) Do the effects of parental smoking and dependence vary by parental and adolescent gender and race/ethnicity?