Male Perpetration of Intimate Partner Violence and Involvement in Abortions and Abortion-Related Conflict

Men aged 18 to 35 years (n = 1318) completed assessments of perpetration of intimate partner violence (IPV), abortion involvement, and conflict regarding decisions to seek abortion. IPV was associated with greater involvement by men in pregnancies ending in abortion and greater conflict regarding decisions to seek abortion. IPV should be considered within family planning and abortion services; policies requiring women to notify or obtain consent of partners before seeking an abortion should be reconsidered; they may facilitate endangerment and coercion regarding such decisions.Intimate partner violence (IPV) is a major public health issue that affects the lives and health of approximately 20% to 25% of adolescent and adult US women,^1,2 with women of reproductive age at greatest risk.^3,4 Major reproductive health concerns associated with experiences of IPV include unintended⁵ and rapid repeat pregnancies.^6–8 Given that unintended and unwanted pregnancies are the primary reason for seeking abortion,^7,9 abused women are thought to be more likely to experience abortion than are their nonabused counterparts.^10–12 Recent qualitative research suggests there is a broad role played by abusive male partners in controlling women''s reproductive health,^13–15 including attempts to control abortion-related decisions.^13,15 However, quantitative data on this issue have primarily been collected from women attending abortion services, which therefore precludes comparisons to women with no abortion history.^10–12 Given the increasing recognition of the role of male partners in controlling a woman''s reproductive health and decision-making, coupled with the continuing public debate concerning both women''s access to abortion and the role of family members in decisions regarding abortion (e.g., spousal consent),¹⁶ it is critical to understand to what extent abuse from male partners may relate to both women''s seeking abortion and coercion regarding abortion-related decisions. We examined the association of young adult men''s reports of perpetration of IPV and their participation in pregnancies ending in abortion as well as conflict surrounding abortion-related decisions.     

Health Among Caregivers of Children With Health Problems: Findings From a Canadian Population-Based Study

Objectives. We used population-based data to evaluate whether caring for a child with health problems had implications for caregiver health after we controlled for relevant covariates.Methods. We used data on 9401 children and their caregivers from a population-based Canadian study. We performed analyses to compare 3633 healthy children with 2485 children with health problems. Caregiver health outcomes included chronic conditions, activity limitations, self-reported general health, depressive symptoms, social support, family functioning, and marital satisfaction. Covariates included family (single-parent status, number of children, income adequacy), caregiver (gender, age, education, smoking status, biological relationship to child), and child (age, gender) characteristics.Results. Logistic regression showed that caregivers of children with health problems had more than twice the odds of reporting chronic conditions, activity limitations, and elevated depressive symptoms, and had greater odds of reporting poorer general health than did caregivers of healthy children.Conclusions. Caregivers of children with health problems had substantially greater odds of health problems than did caregivers of healthy children. The findings are consistent with the movement toward family-centered services recognizing the link between caregivers'' health and health of the children for whom they care.Caring for a child with health problems can entail greater than average time demands,^1,2 medical costs,^3,4 employment constraints,^5,6 and childcare challenges.^6–8 These demands may affect the health of caregivers, a notion supported by a variety of small-scale observational studies that have shown increased levels of stress, distress, emotional problems, and depression among caregivers of children with health problems.^1,2,5,9–12Whether these problems are caused by the additional demands of caring for children with health problems or by confounding variables is difficult to answer definitively. The literature reports the identification of a variety of factors purported to be associated with caregiver health, including contextual factors such as socioeconomic status^13–17; child factors such as level of disability,^{1,11,13,18–21} presence of behavior problems,^22–25 and overall child adjustment²⁶; and caregiver-related characteristics such as coping strategies^11,22,27 and support from friends and family.^15,17,28,29 In general, this work has been based on small clinic-based samples^9,30 or specific child populations (e.g., cerebral palsy,^5,25 attention-deficit/hyperactivity disorder^31,32), and typically has been hampered by limited generalizability and a lack of careful, multivariate analysis. Furthermore, most studies have focused on caregivers'' psychological health,^1,2,5,9–12 although physical health effects may also exist among caregivers.^5,19,25,33One of the few studies to involve large-scale, population-based data compared the health of 468 caregivers of children with cerebral palsy to the health of a population-based sample of Canadian parents.⁵ The study showed that caregivers of children with cerebral palsy had poorer health on a variety of physical and psychological health measures. Furthermore, the data were consistent with a stress process model,^5,25 which proposes that additional stresses associated with caring for a child with cerebral palsy directly contribute to poorer caregiver health. However, these findings were based on a specific subpopulation of caregivers and univariate comparisons that could not control for potentially important confounders such as variation in caregiver education, income, and other demographic factors.We used population-based data to test the hypothesis that the health of caregivers of children with health problems would be significantly poorer than that of caregivers of healthy children, even after we controlled for relevant covariates. Our approach of using large-scale, population-based data representing a broad spectrum of childhood health problems³⁴ makes 4 key contributions to the current literature. First, our use of population-based data rather than small-scale, clinic-based studies yielded results that are potentially generalizable to a wide group of caregivers caring for children with health problems. Second, our examination of children with and without health problems allowed us to examine caregiver health effects across a wide variety of caregiving situations. Third, consideration of physical health outcomes (in addition to more regularly studied psychological outcomes) increased our knowledge of the breadth of caregiver health issues. Finally, controlling for relevant covariates allowed us to rule out a number of alternative explanations for caregiver health effects.     

Life-Course Socioeconomic Position and Incidence of Diabetes Mellitus Among Blacks and Whites: The Alameda County Study, 1965�C1999

Objectives. We examined associations between several life-course socioeconomic position (SEP) measures (childhood SEP, education, income, occupation) and diabetes incidence from 1965 to 1999 in a sample of 5422 diabetes-free Black and White participants in the Alameda County Study.Methods. Race-specific Cox proportional hazard models estimated diabetes risk associated with each SEP measure. Demographic confounders (age, gender, marital status) and potential pathway components (physical inactivity, body composition, smoking, alcohol consumption, hypertension, depression, access to health care) were included as covariates.Results. Diabetes incidence was twice as high for Blacks as for Whites. Diabetes risk factors independently increased risk, but effect sizes were greater among Whites. Low childhood SEP elevated risk for both racial groups. Protective effects were suggested for low education and blue-collar occupation among Blacks, but these factors increased risk for Whites. Income was protective for Whites but not Blacks. Covariate adjustment had negligible effects on associations between each SEP measure and diabetes incidence for both racial groups.Conclusions. These findings suggest an important role for life-course SEP measures in determining risk of diabetes, regardless of race and after adjustment for factors that may confound or mediate these associations.Diabetes mellitus is a major cause of morbidity and mortality in the United States.^1,2 Type 2 diabetes disproportionately affects Hispanics, as well as non-Hispanic Black Americans, American Indians/Alaska Natives, and some Asian/Pacific Islander groups. In the United States, members of racial and ethnic minority groups are almost twice as likely to develop or have type 2 diabetes than are non-Hispanic Whites.^2–5 Significant racial and ethnic differences also exist in the rates of diabetes-related preventive services, quality of care, and disease outcomes.^6–10Researchers have attempted to determine why, relative to Whites, members of racial and ethnic minority groups are disproportionately affected by diabetes. For example, compared with White Americans, Black Americans are presumed to have stronger genetic^5,11 or physiological^11–13 susceptibility to diabetes, or greater frequency or intensity of known diabetes risk factors, such as obesity, physical inactivity, and hypertension.^14–17Black Americans also are more likely than are White Americans to occupy lower socioeconomic positions.¹⁸ Low socioeconomic position (SEP) across the life course is known to influence the prevalence^19–24 and incidence^3,19,25–30 of type 2 diabetes. The risk of diabetes also is greater for people who are obese,^3,17,31 physically inactive,^3,32 or have hypertension,^33,34 all of which are conditions more common among people with lower SEP.^16,35–37Several studies have focused on the extent to which socioeconomic factors, body composition (i.e., weight, height, body mass index, and waist circumference), and behaviors explain the excess risk of diabetes attributed to race.^4,12,19,30 For example, 2 separate studies, one with data from the Health and Retirement Study¹⁹ and the other with data from the Atherosclerosis Risk in Communities Study,³⁰ used race to predict diabetes incidence. Attempting to separate the direct and indirect effects of race on diabetes,³⁸ these studies assessed, via statistical adjustment, which socioeconomic measures and diabetes-related risk factors, when adjusted, could account for the excess risk among Black participants relative to White participants.^19,30 Adjustment for education lessened the effect of Black race on diabetes incidence in the Atherosclerosis Risk in Communities Study.³⁰ In the Health and Retirement Study, excess risk attributed to Black race was not explained by early-life socioeconomic disadvantage, but it was reduced after adjustment for education and later-life economic resources.¹⁹ The validity of this analytic approach has been challenged, however, because the socioeconomic measures used were assumed to have the same meaning across all racial/ethnic groups, a questionable assumption³⁸ in the United States, especially in 1965.We sought to explore the predictive effects of several life-course socioeconomic factors on the incidence of diabetes among both Black and White Americans. We examined demographic confounders (age, gender, marital status) and diabetes risk factors (obesity, large waist circumference, physical inactivity, high blood pressure, depression, access to health care) as possible mediators of the observed associations between SEP and incident diabetes (i.e., the development of new cases of diabetes over time).     

The Statin–Iron Nexus: Anti-Inflammatory Intervention for Arterial Disease Prevention

Objectives. We postulated the existence of a statin–iron nexus by which statins improve cardiovascular disease outcomes at least partially by countering proinflammatory effects of excess iron stores.Methods. Using data from a clinical trial of iron (ferritin) reduction in advanced peripheral arterial disease, the Iron and Atherosclerosis Study, we compared effects of ferritin levels versus high-density lipoprotein to low-density lipoprotein ratios (both were randomization variables) on clinical outcomes in participants receiving and not receiving statins.Results. Statins increased high-density lipoprotein to low-density lipoprotein ratios and reduced ferritin levels by noninteracting mechanisms. Improved clinical outcomes were associated with lower ferritin levels but not with improved lipid status.Conclusions. There are commonalities between the clinical benefits of statins and the maintenance of physiologic iron levels. Iron reduction may be a safe and low-cost alternative to statins.Statins, prescribed widely for primary and secondary prevention of cardiovascular disease (CVD),1,2 have been recommended for expanded use in apparently healthy individuals at risk for CVD.3 On February 8, 2010 the US Food and Drug Administration approved rosuvastatin (Crestor) for

reducing the likelihood of a heart attack or stroke or the need for a procedure to treat blocked or narrowed arteries in patients who have never been told they have heart disease but are nevertheless at increased risk of a cardiac event.3

The target population included men older than 50 years and women older than 60 years with elevated levels of high-sensitivity C-reactive protein and an additional CVD risk factor such as smoking, hypertension, a family history of premature CVD, or low levels of high-density lipoprotein (HDL) cholesterol.4Computational studies concluded that a “treat-all” approach to CVD prevention is cost-effective.5–7 However, misgivings over widespread statin use have been expressed on the basis of overall societal impact, including cost and toxicity, especially with the extension of treatment to children.8–10 The wholesale cost of a 40-milligram rosuvastatin tablet at a local pharmacy recently was $4.22. Side effects of statins involve primarily liver11 and muscle12 damage. Statins also have been associated with risk of diabetes,13 nonmelanotic skin cancer,14 and adverse drug interactions.15–17 Although statins are of proven efficacy,1,2 CVD remains a major public health problem beckoning further innovative approaches to prevention and treatment.18The clinical benefits of statins relate to their ability to reduce cholesterol levels by inhibiting the rate-limiting cholesterol biosynthetic enzyme 3-hydroxy-3-methylglutaryl-CoA reductase.1,2 However, drugs other than statins that effectively lower lipids have not improved clinical outcomes.19 Statins are effective in individuals with normal lipid levels1,2 exhibiting pleiotropic properties unrelated to lipid reduction.20,21 These properties include stimulation of new blood vessel22 and bone formation23 and the reduction of inflammation and oxidative stress.24–35Mascitelli and Goldstein provided evidence that the beneficial effects of statins may result from their ability to favorably alter iron homeostasis.36 Pathologic cellular iron retention has been implicated in systemic oxidative stress, vascular inflammation, and atherogenesis. Statins reduce ferritin levels in patients with advanced CVD,37–39 renal disease,40 and diabetes.41 Data from a randomized trial of iron (ferritin) reduction (the Iron and Atherosclerosis Study [FeAST]) in participants with advanced peripheral arterial disease (PAD) showed significant improvement in all-cause mortality and combined death plus nonfatal myocardial infarction and stroke with iron reduction.42 There is evidence suggesting that iron reduction may provide an alternative to statins for reducing inflammation associated with atherosclerosis.     

Risks of Recreational Exposure to Waterborne Pathogens Among Persons With HIV/AIDS in Baltimore, Maryland

Objectives. We assessed the prevalence of recreational activities in the waterways of Baltimore, MD, and the risk of exposure to Cryptosporidium among persons with HIV/AIDS.Methods. We studied patients at the Johns Hopkins Moore Outpatient AIDS Clinic. We conducted oral interviews with a convenience sample of 157 HIV/AIDS patients to ascertain the sites used for recreational water contact within Baltimore waters and assess risk behaviors.Results. Approximately 48% of respondents reported participating in recreational water activities (fishing, crabbing, boating, and swimming). Men and women were almost equally likely to engage in recreational water activities (53.3% versus 51.3%). Approximately 67% (105 of 157) ate their own catch or that of friends or family members, and a majority (61%, or 46 of 75) of respondents who reported recreational water contact reported consumption of their own catch.Conclusions. Baltimoreans with HIV/AIDS are engaging in recreational water activities in urban waters that may expose them to waterborne pathogens and recreational water illnesses. Susceptible persons, such as patients with HIV/AIDS, should be cautioned regarding potential microbial risks from recreational water contact with surface waters.Persons with HIV/AIDS are at high risk for increased morbidity and mortality associated with a range of opportunistic infections, some of which are caused by Cryptosporidium. Cryptosporidium species are of particular public health and medical importance because they are prevalent in surface waters of the United States,^1–7 are efficiently transmitted via water,⁸ and can be consumed in foods contaminated by fecal matter.^9–11 Exposures to Cryptosporidium are common in the US population,¹² and past studies have demonstrated that Cryptosporidium infections significantly contribute to illness and mortality in persons with HIV/AIDS.^13–15 In the 1980s, Cryptosporidium was identified as a major opportunistic pathogen.^16–21 Infection continues to be frequently diagnosed in persons with HIV/AIDS.^22–27 Before the advent of highly active antiretroviral therapy, Cryptosporidium was a relatively common opportunistic infection even in developed countries.^28,29Cryptosporidiosis manifests as an acute gastroenteritis, accompanied by cramps, anorexia, vomiting, abdominal pains, fever, and chills²⁹ and by histological presentation of gastrointestinal mucosal injury.^30,31 Persons with AIDS who become infected with this parasite are at increased risk of developing chronic and often life-threatening diarrhea, biliary tract diseases, pancreatitis, colitis, and chronic asymptomatic infection and recurrence. These developments are especially likely in those who are severely immunosuppressed (CD4 counts < 150 cells/mL).^29,32–35 Infection is diagnosed by the presence of oocysts in unpreserved or preserved stools.³⁶ Histological and ultrastructural examination of biopsy material for different Cryptosporidium life stages, detection of Cryptosporidium DNA and antigens, and identification of species through molecular techniques can also aid in diagnosis.^36–38Cryptosporidium species are enteric protozoan organisms and are prevalent in US watersheds, especially in urban waters.^1,6,39 These parasites have natural hosts in domestic and wild animals such as cattle (especially newborn calves), horses, fish, and birds.^5,40–42 These parasites cause cryptosporidiosis by infecting and damaging the cells of the small intestine and other organs.^13,41 For persons with HIV/AIDS, increased risk for infection by Cryptosporidium has been related to sexual practices such as engaging in sexual intercourse within the past 2 years, having multiple partners during that time, and engaging in anal intercourse.⁴³ Use of spas and saunas has also been identified as a risk factor.⁴³In the United States, Cryptosporidium is the most commonly identified pathogen in cases of recreationally acquired gastroenteritis⁴⁴; the majority of those affected are children. Increased risk of cryptosporidiosis in persons with HIV/AIDS has been associated with swimming.^45,46 US residents make an estimated 360 million annual visits to recreational water venues such as swimming pools, spas, and lakes; swimming is the second most popular physical activity in the country and the most popular among children.⁴⁷Recreational swimming, even in highly chlorinated water, carries a high risk of exposure to enteric pathogens, including Cryptosporidium, Norovirus, Shigella, Escherichia coli, and Giardia.⁴⁸ Cryptosporidiosis and some other enteric illnesses are seasonal, with spikes in occurrence in the summer months from contact with recreational water venues.⁴⁹ Extreme precipitation⁵⁰ and high ambient temperatures⁵¹ can also affect patterns of disease outbreaks. Because not all infections with Cryptosporidium lead to apparent illness or symptoms, infected persons may unknowingly transmit these pathogens to others, such as household members and other recreationists.^12,52 Cryptosporidiosis from swimming, wading, and splashing is prevalent in the United States.^44,46,53,54Risks from the presence of pathogens in waterways include (1) waterborne gastroenteritis and other recreational water illnesses in anglers and other recreationists^44,55–59; (2) transmission of pathogens to humans from caught seafood acting as fomites, or surface carriers⁶⁰; (3) food-borne gastroenteritis from consumption of raw or improperly cooked fish and shellfish^61,62; and (4) hand-to-mouth transmission of pathogens while eating, drinking, or smoking during activities such as fishing and crabbing.⁷Recreational water activities in the Baltimore, Maryland, area take place in Jones Falls and Baltimore Harbor. These and other waterways are used for angling, crabbing, swimming, kayaking, and boating (including paddle boating).^7,63 In addition, Baltimore-area residents often catch and consume fish and crabs from the Baltimore Harbor and local waterways, many of which are already highly contaminated by persistent chemicals such as mercury and polychlorinated biphenyls.⁶⁴ These activities are known to increase risks of exposure to waterborne pathogens through direct contact with contaminated waters or through contact with or handling and consumption of caught seafood (fish, crabs, oysters).^7,65,66To investigate the potential contribution of recreational water contact to Cryptosporidium exposures among persons with HIV/AIDS, we carried out a cross-sectional study at the Johns Hopkins Moore Outpatient AIDS Clinic. The Baltimore metropolitan area has a high prevalence rate of HIV/AIDS among both men and women,⁶⁷ and its population makes intensive recreational use of a contaminated watershed. In addition, laboratory experiments have indicated that crabs can become superficially contaminated by Cryptosporidium and transfer the pathogen to hands.⁶⁸ Local anglers are at risk from Cryptosporidium on wild-caught fish.⁷Our objective was to address the risks of exposure to Cryptosporidium for an urban subpopulation, persons with HIV/AIDS, as a result of recreational contact with Baltimore waterways. We also assessed the patterns and locations of recreational water activities in Baltimore waters.     

Suicidal Behavior Among Female Sex Workers in Goa, India: The Silent Epidemic

Objectives. We sought to study suicidal behavior prevalence and its association with social and gender disadvantage, sex work, and health factors among female sex workers in Goa, India.Methods. Using respondent-driven sampling, we recruited 326 sex workers in Goa for an interviewer-administered questionnaire regarding self-harming behaviors, sociodemographics, sex work, gender disadvantage, and health. Participants were tested for sexually transmitted infections. We used multivariate analysis to define suicide attempt determinants.Results. Nineteen percent of sex workers in the sample reported attempted suicide in the past 3 months. Attempts were independently associated with intimate partner violence (adjusted odds ratio [AOR] = 2.70; 95% confidence interval [CI] = 1.38, 5.28), violence from others (AOR = 2.26; 95% CI = 1.15, 4.45), entrapment (AOR = 2.76; 95% CI = 1.11, 6.83), regular customers (AOR = 3.20; 95% CI = 1.61, 6.35), and worsening mental health (AOR = 1.05; 95% CI = 1.01, 1.11). Lower suicide attempt likelihood was associated with Kannad ethnicity, HIV prevention services, and having a child.Conclusions. Suicidal behaviors among sex workers were common and associated with gender disadvantage and poor mental health. India''s widespread HIV-prevention programs for sex workers provide an opportunity for community-based interventions against gender-based violence and for mental health services delivery.Suicide is a public health priority in India. Rates of suicide in India are 5 times higher than in the developed world,^1,2 with particularly high rates of suicide among young women.^3–5 Verbal autopsy surveillance from southern India suggests that suicide accounts for 50% to 75% of all deaths among young women, with average suicide rates of 158 per 100 000.²Common mental disorders such as depressive and anxiety disorders, and social disadvantage such as gender-based violence and poverty, are major risk factors for suicide among women.^1,3,6–8 Although research from high-income countries shows that common mental disorders are a major contributor to the risk of suicidal behavior, their role is less clear in low- and middle-income countries in which social disadvantage has been found to be at least as important.^1,3,6–8 Gender disadvantage is increasingly seen as an important contributing factor to the high rates of suicide seen among women in Asia.^1,3,6,7 Gender-based violence is a common manifestation of gender disadvantage and has been linked with common mental disorders and suicide in population-based studies of women and young adults in Goa, India.^4,5,9 Lack of autonomy, early sexual debut, limited sexual choices, poor reproductive health, and social isolation are other manifestations of gender disadvantage.Sex work in India is common. An estimated 0.6% to 0.7% of the female adult urban population are engaged in commercial sexual transactions.¹⁰ Studies from developed nations have found a high prevalence of self-harming behaviors in people engaged in transactional sexual activity.¹¹ There is also growing evidence suggesting that HIV-positive individuals from traditionally stigmatized groups report higher rates of violence exposure and suicidal ideation.^12,13 Female sex workers in India are a traditionally stigmatized group, with high prevalence of HIV¹⁰ and levels of stigma and violence that relate to the context of their work.¹⁴ Yet, despite substantial investigation of their reproductive and sexual health needs, there is virtually no information on suicide and its determinants among female sex workers from low- and middle-income countries.¹⁵As demonstrated in the hierarchical conceptual framework outlined in Figure 1,^4,5,9 we hypothesized that gender disadvantage, sex work, and health factors together with factors indicative of social disadvantage are distal determinants of female sex workers'' vulnerability to suicidal behaviors,^4,5,9,15 the effects of which would be mediated though poor mental health.³ We studied the burden of suicidal behaviors in a cross-sectional sample of female sex workers in Goa, India. We explored the association of sociodemographic factors, type of sex work, sexual health, and gender disadvantage, with and without measures of poor mental health, on suicide attempts in the past 3 months.Open in a separate windowFIGURE 1A conceptual framework for social risk factors for suicide among female sex workers in India.Note. STI = sexually transmitted infection.     

Timeliness of Breast Cancer Diagnosis and Initiation of Treatment in the National Breast and Cervical Cancer Early Detection Program, 1996�C2005

Objectives. To determine the effects of program policy changes, we examined service delivery benchmarks for breast cancer screening in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).Methods. We analyzed NBCCEDP data for women with abnormal mammogram or clinical breast examination (n = 382 416) from which 23 701 cancers were diagnosed. We examined time to diagnosis and treatment for 2 time periods: 1996 to 2000 and 2001 to 2005. We compared median time for diagnostic, treatment initiation, and total intervals with the Kruskal–Wallis test. We calculated adjusted proportions (predicted marginals) with logistic regression to examine diagnosis and treatment within program benchmarks (≤ 60 days) and time from screening to treatment (≤ 120 days).Results. Median diagnostic intervals decreased by 2 days (25 vs 23; P < .001). Median treatment initiation intervals increased by 2 days (12 vs 14; P < .001). Total intervals decreased by 3 days (43 vs 40; P < .001). Women meeting the 60-day benchmark for diagnosis improved the most for women with normal mammograms and abnormal clinical breast examinations from 77% to 82%.Conclusions. Women screened by the NBCCEDP received diagnostic follow-up and initiated treatment within preestablished program guidelines.Screening for breast cancer reduces morbidity and mortality from breast cancer when women receive timely follow-up and appropriate treatment.¹ There are few data to indicate what the optimal diagnostic and treatment intervals are that might ensure the best chances of survival from breast cancer detected by screening with mammography.^2,3 Recent information from organized screening programs in Canada and the United Kingdom showed that women who waited longer than 6 to 12 months for diagnostic workup were more likely to have larger cancers and more positive lymph nodes, which might lead to poorer survival.^2,3 In the case of symptomatic women, delays greater than 3 to 6 months to start therapy are associated with poorer survival.⁴Recent modeling studies have shown that the declines in mortality are attributable to both early detection and subsequent treatment.¹ Minority women, uninsured women, and women from lower socioeconomic backgrounds often do not have access to early detection.^5–7 These women are less likely to participate in mammography screening,⁸ less likely to have timely and complete follow-up after an abnormal screening test result,^9,10 more likely to be diagnosed with late-stage breast cancer,^6,7,11 more likely to die from breast cancer once diagnosed,^6,7 and might be more likely to receive suboptimal treatment.^12–15The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was authorized by Congress in 1990 to reach underserved women.¹⁶ Since the inception of the program, the NBCCEDP has established service delivery benchmarks to ensure timely and complete diagnostic follow-up and treatment initiation for underserved women screened through the program.¹⁷ Previous analysis of program benchmarks demonstrated that the national program was meeting its predefined quality standards of having a diagnosis within 60 days of an abnormal screening test result and initiation of treatment within 60 days of diagnosis.¹⁸ Legislation for program enhancements that added case management services, which was fully implemented in 2000, and a Medicaid waiver authorized by Congress in 2000 and fully implemented in 2003, should have improved the program''s ability to meet these standards.^19–22Accordingly, we hypothesized that NBCCEDP service delivery benchmarks would improve over time with shortening of time intervals after an abnormal mammogram or clinical breast examination (CBE) finding to final diagnosis, as well as the interval to treatment initiation after diagnosis, and the interval to treatment initiation after abnormal screening test result. We investigated this by using 2 time periods, 1996 to 2000 and 2001 to 2005,²⁰ to examine the effects of program policy changes on intervals in the 2001–2005 period.^20–22     

The Long-Term Health Consequences of Relationship Violence in Adulthood: An Examination of Low-Income Women From Boston, Chicago, and San Antonio

Objectives. We examined the long-term health consequences of relationship violence in adulthood.Methods. Using data from the Welfare, Children, and Families project (1999 and 2001), a probability sample of 2402 low-income women with children living in disadvantaged neighborhoods in Boston, Massachusetts; Chicago, Illinois; and San Antonio, Texas, we predicted changes in the frequency of intoxication, psychological distress, and self-rated health over 2 years with baseline measures of relationship violence and a host of relevant background variables.Results. Our analyses showed that psychological aggression predicted increases in psychological distress, whereas minor physical assault and sexual coercion predicted increases in the frequency of intoxication. There was no evidence to suggest that relationship violence in adulthood predicted changes in self-rated health.Conclusions. Experiences with relationship violence beyond the formative and developmental years of childhood and adolescence can have far-reaching effects on the health status of disadvantaged urban women.Over the past 2 decades, numerous studies have examined the long-term health consequences of relationship violence during childhood. This body of research suggests that physical and sexual abuse in early life can be devastating to health in adulthood, contributing to poor mental^1–6 and physical health^3–5,7 and to higher rates of substance abuse.^5,6,8,9 These patterns are remarkably consistent across studies and notably persistent through the life course. In a recent study of more than 21 000 older adults, Draper et al.³ reported that physical and sexual abuse before 15 years of age is associated with poor mental and physical health well into late life.Although previous research has made significant contributions to our understanding of the lasting effects of abuse in early life, few studies have considered the long-term health consequences of relationship violence in adulthood. Our review of the literature revealed 5 longitudinal studies of relationship violence and health in adulthood. Not surprisingly, research suggests that women who experience relationship violence in adulthood are vulnerable to poor health trajectories, including increases in depressive symptoms,^10–12 functional impairment,^10,12 and alcohol consumption.^13,14Relationship violence is an important issue in all segments of society; however, studies consistently show that women of low socioeconomic status exhibit higher rates of intimate partner victimization than do their more affluent counterparts.^15–17 For example, Tolman and Raphael¹⁷ reported that between 34% and 65% of women receiving welfare report having experienced some form of relationship violence in their lifetime, and between 8% and 33% experience some form of relationship violence each year, levels that surpass those for women overall.¹⁸ Research also shows that residence in disadvantaged neighborhoods^19,20 and the presence of children in the household^21,22 may elevate the odds of relationship violence. Given their high violence-risk profile, attention must be directed to the patterns and health consequences of intimate partner victimization in the lives of disadvantaged urban women with children.^23–25Building on previous research, we used data collected from a large probability sample of low-income women with children living in low-income neighborhoods in Boston, Massachusetts, Chicago, Illinois, and San Antonio, Texas, to predict changes in the frequency of intoxication, psychological distress, and self-rated health over 2 years with measures of relationship violence in early life and adulthood and a host of relevant background variables. In accordance with previous research, we expected that intimate partner victimization in adulthood would predict increases in psychological distress and the frequency of intoxication and decreases in self-rated health over the study period.     

Ethical Considerations in HIV/AIDS Biobehavioral Surveys That Use Respondent-Driven Sampling: Illustrations From Lebanon

Respondent-driven sampling is especially useful for reaching hidden populations and is increasingly used internationally in public health research, particularly on HIV. Respondent-driven sampling involves peer recruitment and has a dual-incentive structure: both recruiters and their peer recruits are paid.Recent literature focusing on the ethical dimensions of this method in the US context has identified integral safeguards that protect against ethical violations. We analyzed a study of 3 groups in Lebanon who are at risk for HIV (injection drug users, men who have sex with men, female sex workers) and the ethical issues that arose.More explicit attention should be given to ethical issues involved in research implementing respondent-driven sampling of at-risk populations in developing countries, where ethical review mechanisms may be weak.RESPONDENT-DRIVEN SAMpling is a relatively new technique that has been effective in sampling difficult-to-reach or invisible populations for which there is no sampling frame.^1–3 This chain-referral method—led by network peers—was developed to avoid many of the problems and biases of other such methods (e.g., snowball sampling). Respondent-driven sampling begins with nonrandomly selected seeds and proceeds in waves: the first wave of participants is referred by seeds from their social networks, the second wave by the first-wave participants, and so on. Critically, for ethical considerations, respondent-driven sampling operates with a dual-incentive structure in which a modest financial incentive is given to all who complete the survey (primary incentive) as well as to recruiters (secondary incentive).Developed initially in the United States as a method for reaching injection drug users (IDUs),⁴ respondent-driven sampling is being widely adopted in developing countries for HIV prevention research among a range of vulnerable groups and for other areas of public health research. This method has been used in more than 30 countries.⁵ The literature includes papers about both the method itself^6,7 and findings from respondent-driven sampling studies,^8–12 but discussions of the ethical aspects of such studies have appeared only recently and only in relation to US contexts and studies of IDUs.^5,13 As Semaan et al. acknowledged, social and cultural factors may affect the ethical considerations of respondent-driven sampling studies in other countries.⁵ Addressing these concerns is especially important when research is conducted in places where national ethical boards are weak or nonexistent.We examined ethical concerns arising from an HIV biobehavioral study that used respondent-driven sampling with 3 population groups at high risk of HIV exposure in Lebanon: IDUs, female sex workers, and men who have sex with men (MSM). During the course of this study, which was approved by a university institutional review board, ethical dilemmas emerged. Here we review the recent international literature on ethical dimensions of respondent-driven sampling, describe the methodology of the Lebanese study, and discuss ethical issues we confronted that may be relevant to other respondent-driven sampling studies, particularly in developing countries.     

Out Yonder: Sexual-Minority Adolescents in Rural Communities in British Columbia

Objectives. We compared sexual-minority adolescents living in rural communities with their peers in urban areas in British Columbia, exploring differences in emotional health, victimization experiences, sexual behaviors, and substance use.Methods. We analyzed a population-based sample of self-identified lesbian, gay, or bisexual respondents from the British Columbia Adolescent Health Survey of 2003 (weighted n = 6905). We tested rural–urban differences separately by gender with the χ² test and logistic regressions.Results. We found many similarities and several differences. Rural sexual-minority adolescent boys were more likely than were their urban peers to report suicidal behaviors and pregnancy involvement. Rural sexual-minority adolescents, especially girls, were more likely to report various types of substance use. Rural status was associated with a lower risk of dating violence and higher risk of early sexual debut for sexual-minority girls and a higher risk of dating violence and lower risk of early sexual debut for sexual-minority boys.Conclusions. Location should be a demographic consideration in monitoring the health of sexual-minority adolescents. Lesbian, gay, and bisexual adolescents in rural communities may need additional support and services as they navigate adolescence.Adolescence is marked by many developmental tasks, including the unfolding of sexual identity. Adolescents who are lesbian, gay, or bisexual (LGB) face the additional challenge of being members of a sexual minority in a heterosexually dominant world. This may be an especially complex task in a rural environment, where heterosexism may be more pronounced¹ and supportive resources limited.² Scant research has compared the experiences of LGB adolescents in rural and urban areas.In the past decade, a growing number of population-based studies of LGB adolescents addressed the methodological criticisms of earlier studies that relied on urban samples, convenience samples, and samples of adolescents who may have been of legal adult age.^2–5 Population-based research on LGB adolescents has demonstrated that they face health disparities when compared with heterosexual adolescents. For example, LGB adolescents are at increased risk of being stigmatized and victimized.^3,6–11 LGB adolescents also experience higher rates of emotional distress and suicidality,^{3,6,8,11–16} substance use,^3,6,8,11,17 and risky sex,^6,8 which may put them at increased risk for HIV infection^18,19 and pregnancy.⁹Rural communities have several characteristics that may affect the experiences of LGB adolescents. Social isolation may be greater in rural regions, because the chance to identify with an LGB peer group may be limited or nonexistent.^2,20,21 Adolescents and their families may also lack access to resources for information and support.^2,20 Furthermore, more conservative attitudes in general, and negative attitudes or misconceptions about nonheterosexual orientations specifically, and less anonymity in small communities may make it harder for adolescents to openly express same-gender affections² and risk public disclosure.²² Thus, LGB adolescents in rural areas may face greater disparities and challenges compared with their urban counterparts.Results of research on rural–urban differences in the general population have been mixed. For example, a study of multiple data sets by the US National Center on Addiction and Substance Abuse found substance-use rates among rural adolescents to be generally higher.²³ Likewise, a study of more than 2000 students from urban, suburban, and rural schools in upstate New York found that rural adolescents were twice as likely as their suburban and urban counterparts to frequently use tobacco, alcohol, and other drugs and to have had sex.²⁴ Conversely, analyses of the 1999 US Youth Risk Behavior Survey found no differences among urban and nonurban adolescents on several substance-use and sexual behavior variables.²⁵ A separate report on health in the United States found that adolescent childbearing rates were lowest in suburban areas.²⁶ Studies of dating violence have also had mixed results, finding rural adolescents at higher risk²⁷ or lower risk.²⁸Only a few studies have directly compared LGB adolescents living in rural areas with those living in urban areas. Waldo et al. studied LGB rural and urban young people aged 15 to 21 years.²⁹ Urban participants were recruited through metropolitan community centers and rural participants through university student groups in a politically conservative town more than an hour away from a metropolitan center. They found rates of assault were lower for rural young people, but suicidality did not differ between rural and urban participants. In an analysis of population-based data from the US National Longitudinal Study of Adolescent Health, Galliher et al. defined urban, suburban, and rural from interviewers’ observations of the immediate are around the participant''s residence.¹² They found that rural sexual-minority adolescent girls reported more depressive symptoms, but rural adolescent boys, regardless of attraction status, reported a greater sense of school belonging, greater self-esteem, and fewer depressive symptoms.We used school-based representative data from British Columbia to explore differences in health and risk between LGB adolescents in rural communities and their urban counterparts. We focused on LGB adolescents only, because previous research has documented the health disparities between LGB and heterosexual adolescents. In contrast to previous studies,^12,29 we looked at a broader range of behaviors and used a standardized definition of rurality to categorize location.     

The Role of Young Adults’ Pleasure Attitudes in Shaping Condom Use

Condoms can help young adults protect themselves from sexually transmitted infections and unintended pregnancy. We examined young people’s attitudes about whether condoms reduced pleasure and how these attitudes shape condom practices. We used a nationally representative sample of 2328 heterosexually active, unmarried 15- to 24-year-old young adults to document multivariate associations with condom nonuse at the last sexual episode. For both young men and women, pleasure-related attitudes were more strongly associated with lack of condom use than all sociodemographic or sexual history factors. Research and interventions should consistently assess and address young people’s attitudes about how condoms affect pleasure.Because of their unique ability to prevent both pregnancy and sexually transmitted infections (STIs), male condoms are a vital public health tool. For decades, researchers have worked to understand and promote young adults’ consistent condom use. Although 15- to 24-year-old young adults represent only 25% of the sexually experienced population in the United States, they account for 53% of all unintended pregnancies1 and nearly half of all new STI cases.2Many studies document the sociodemographic and sexual history factors most associated with young adults’ condom use,3–5 including age, education, and number of sexual partners.6 Research also explores psychosocial factors such as self-esteem7,8 and condom self-efficacy,9 as well as gender inequality that may render condom use especially difficult for young women.10 Relatively little research explores young people’s attitudes about condoms and sexual pleasure.Burgeoning research among samples of “older” adults11,12 and college students13,14 has suggested that attitudes about how condoms affected sexual pleasure might influence condom use practices, although this work has primarily focused on men.15,16 One exploratory mixed-gender study documented that both adult women and men who reported that condoms undermine arousal and enjoyment were least likely to use them.17 However, fewer studies have explored such pleasure attitudes among adolescents and young adults, especially among young women,18 and no nationally representative studies of this topic exist for any age group. We addressed these limitations using a nationally representative sample of young adult women and men to assess how attitudes about condoms and sexual pleasure might be related to condom practices.     

Lack of predictability at work and risk of acute myocardial infarction: an 18-year prospective study of industrial employees

Objectives. We examined whether the distinctive components of job control—decision authority, skill discretion, and predictability—were related to subsequent acute myocardial infarction (MI) events in a large population of initially heart disease–free industrial employees.Methods. We prospectively examined the relation between the components of job control and acute MI among private-sector industrial employees. During an 18-year follow-up, 56 fatal and 316 nonfatal events of acute MI were documented among 7663 employees with no recorded history of cardiovascular disease at baseline (i.e., 1986).Results. After adjustment for demographics, psychological distress, prevalent medical conditions, lifestyle risk factors, and socioeconomic characteristics, low decision autonomy (P < .53) and skill discretion (P < .10) were not significantly related to subsequent acute MI. By contrast, low predictability at work was associated with elevated risk of acute MI (P = .02). This association was driven by the strong effect of predictability on acute MI among employees aged 45 to 54 years.Conclusions. Prospective evidence suggests that low predictability at work is an important component of job control, increasing long-term risk of acute MI among middle-aged employees.Cardiovascular diseases account for approximately 40% of deaths in developed countries.¹ Acute myocardial infarctions (MIs) account for nearly half of all the cardiovascular mortality.² According to current knowledge, acute MI is predicted by not only well-known risk factors, such as smoking and lack of physical activity, but also psychosocial factors.³Most working-age adults in industrialized countries spend about one third of their waking hours at work during an average period of more than 30 years.⁴ Work environments often entail various stressful characteristics.⁵ Correspondingly, recent reviews proposed that adverse work-related psychosocial risk factors may contribute to poor cardiac health.^6,7In occupational epidemiology, the job strain model⁸ has dominated research on cardiovascular risk factors. This model postulates that a combination of high work demands and low control at work (i.e., job strain), if prolonged, increases the risk of heart disease. Although some follow-up studies have supported this model,^9,10 many large-scale prospective studies with null findings also have been reported.^11–14 Poor job control may be more detrimental to heart health than high job demands,¹⁵ but evidence on the independent predictive role of job control in coronary heart disease is scarce and mixed.^13,16,17Several factors may explain the conflicting findings. First, dimensions of job control, such as decision authority (i.e., decision latitude concerning one''s work pace and phases, and independence from other workers while carrying out tasks) and skill discretion (i.e., the level of cognitive challenges and variety of tasks at work), could contribute differently to health outcomes.¹⁸ Predictability on the job (i.e., the clarity of work goals and opportunity to foresee changes and problems at one''s work) has been suggested to represent a further component of job control, but empirical research on this component is largely lacking.^19–21 Predictability involves relatively high stability of work and a lack of unexpected changes, which characterized the earlier industrial era which had stable production systems.²² Predictable outcomes are less common in today''s turbulent work life; thus, lack of predictability may represent a salient health hazard^23,24 and may contribute to myocardial risk.²⁵Second, research indicates that physiological stress, especially exposure to long-term environmental stressors, can cause detrimental prolonged neurohormonal reactions as well as pathological physiological changes by adversely affecting the process of atherosclerosis,^16,26,27 thereby increasing the risk of acute MI.^28,29 However, most prospective studies on stressful work environment and subsequent cardiovascular disease have used follow-up periods of less than 10 years^6,7 or have studied all-cause cardiovascular outcomes rather than mortality and morbidity resulting from acute MI.⁹ Thus, potential long-term effects of work-related psychosocial factors on acute MI events have not been examined.Third, age may play a role in the association between job strain and acute MI risk. Weaker effects have been found among older workers; plausible reasons for this are healthy worker survivor bias; retirement during follow-up may remove job strain and cause exposure misclassification (i.e., healthier older employees survive, retire, and are no longer exposed to work-related characteristics); and an increasing number of other age-related causes of acute MI.³⁰ Among younger employees, job strain may be associated with shorter exposures to harmful job characteristics than among middle-aged employees. Long-term prospective age-specific studies are therefore needed to determine whether current psychosocial risks of work environment predict acute MI events and whether the influence of work characteristics is stronger among middle-aged employees.The objective of our 18-year follow-up study was to examine whether the distinctive components of job control—decision authority, skill discretion, and predictability—were related to subsequent acute MI events in a large population of initially heart disease–free industrial employees after the effects of established risk factors were taken into account. We further tested age-specific vulnerability among these employees.     

Agent-Based Modeling of Noncommunicable Diseases: A Systematic Review

We reviewed the use of agent-based modeling (ABM), a systems science method, in understanding noncommunicable diseases (NCDs) and their public health risk factors.We systematically reviewed studies in PubMed, ScienceDirect, and Web of Sciences published from January 2003 to July 2014. We retrieved 22 relevant articles; each had an observational or interventional design. Physical activity and diet were the most-studied outcomes. Often, single agent types were modeled, and the environment was usually irrelevant to the studied outcome. Predictive validation and sensitivity analyses were most used to validate models.Although increasingly used to study NCDs, ABM remains underutilized and, where used, is suboptimally reported in public health studies. Its use in studying NCDs will benefit from clarified best practices and improved rigor to establish its usefulness and facilitate replication, interpretation, and application.There has been an increasing interest in using systems science approaches such as agent-based modeling (ABM) to investigate and understand complex public health problems.1–4 Complex systems are systems that are not fully explained by just understanding the individual elements of the system.4 In other words, these systems cannot be reduced to their component parts because of the interactions among the parts.5Complex systems are made of heterogeneous elements or agents (e.g., individuals, organizations) whose interactions with one another yield an unpredictable yet organized emerging behavior that can persist over time.5–7 When agents are capable of adapting to changing circumstances, the systems are said to be adaptive and thus called complex adaptive systems (CAS).7,8 Examples of such complex systems include stock markets, insect colonies, immune systems, social systems, traffic jams, epidemics, and pandemics. All these phenomena have been studied in various fields such as economy, ecology, molecular biology, sociology, and epidemiology.5,9Noncommunicable diseases (NCDs) are by far the leading cause of mortality in the world, killing 36 million people in 2008 worldwide, which accounted for about 63% of all deaths.10 Cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes represent about 80% of all NCD deaths.10 These diseases constitute a huge health and economic burden across the world. Four main behavioral risk factors—tobacco use, physical inactivity, unhealthy diet, and harmful use of alcohol—are responsible for most NCDs.10 Noncommunicable diseases are diseases that are not passed from person to person10 and can have a chronic or acute progression.11 They differ from chronic diseases in that the latter can be communicable or not and they require a long-term management.11The study of NCDs can be recast as one of complex systems. Noncommunicable diseases are caused by factors that are influenced by one’s individual behaviors as well as interaction with the physical, social, or economic environment.12–14 Researchers have described obesity as a health problem that exhibits attributes that are characteristic of a CAS and have argued that techniques used to model such systems can and should be used to model obesity.15 Importantly, obesity involves substantial diversity and heterogeneity in relevant actors at many different levels of scales (e.g., individuals, communities, policy), with a multiplicity of mechanisms in which actors interact with one another with dynamic feedback loops and changes over time.2,15,16To study complex systems, traditional analysis (e.g., multivariate analyses) will often not suffice. The latter often assumes linearity (at least on some scale), normality, homogeneity, and independence between individuals and over time, and is concerned with variables often representing a single-level system.4 This type of analysis is said to be reductionist or top-down.4 In contrast, complex systems are often nonlinear, nonnormal, and involve heterogeneous actors or agents that interact at different levels with possibility of dynamic feedback loops. These systems approaches are said to be holistic and, in particular, bottom-up in the case of ABM.17Besides ABM, other key systems science approaches have been developed to study complex systems and include systems dynamics and network analysis, as well as discrete event simulation.4,18 Briefly, system dynamics uses computer simulation models to uncover and understand endogenous sources of complex system behavior.4 They are based on the premise that complex behaviors of a system result from the interplay of feedback loops, stocks, and flows that all occur within the bounded endogenous system.4,19 Unlike ABM, which is an individual-based modeling technique, systems dynamics is an aggregate-level modeling type. Network analysis, on the other hand, focuses on the measurement and analysis of relationships and flows among a set of actors.4 Discrete event simulation is a type of modeling simulation that models the system as a sequence of discrete events over time. It is most known for being used in clinical care settings to determine patient flow through the system.20These systems science approaches have been used for decades in different fields but have only been recently introduced to public health, with the exception of infectious diseases and epidemics.2 In fact, ABM is most known to public health for its use in the study of epidemics and infectious disease dynamics.4,21 Unfortunately, the use of ABM in behavioral health and NCDs is relatively new and perhaps lagging.2,22 Among the few NCDs and related risk factors being explored, physical activity; diet, smoking, and drinking behaviors; and obesity have taken the spotlight.4,23–25 Increasingly, researchers are advocating the use of such systems science approaches—namely, ABM—in understanding the complexities of NCDs.2,3,15,16,22To fill the gap on whether and how ABM is being used in studying NCDs in public health, we conducted a systematic review examining the use of ABM in understanding various NCDs and their risk factors.     

Temporal and regional trends in the prevalence of healthy lifestyle characteristics: United States, 1994-2007

Objectives. We examined temporal and regional trends in the prevalence of health lifestyles in the United States.Methods. We used 1994 to 2007 data from the Behavioral Risk Factor Surveillance System to assess 4 healthy lifestyle characteristics: having a healthy weight, not smoking, consuming fruits and vegetables, and engaging in physical activity. The concurrent presence of all 4 characteristics was defined as a healthy overall lifestyle. We used logistic regression to assess temporal and regional trends.Results. The percentages of individuals who did not smoke (4% increase) and had a healthy weight (10% decrease) showed the strongest temporal changes from 1994 to 2007. There was little change in fruit and vegetable consumption or physical activity. The prevalence of healthy lifestyles increased minimally over time and varied modestly across regions; in 2007, percentages were higher in the Northeast (6%) and West (6%) than in the South (4%) and Midwest (4%).Conclusions. Because of the large increases in overweight and the declines in smoking, there was little net change in the prevalence of healthy lifestyles. Despite regional differences, the prevalence of healthy lifestyles across the United States remains very low.In developed countries, and increasingly in developing countries, chronic diseases account for the majority of the population disease burden in terms of mortality, morbidity, and medical expenditures.1 Most major chronic diseases share multiple, common lifestyle characteristics or behaviors, particularly smoking, inadequate fruit and vegetable consumption, physical inactivity, and obesity.^2,3 There is now an overwhelming body of clinical and epidemiological evidence illustrating the dramatic impact of a healthy lifestyle on reducing all-cause mortality and preventing chronic diseases such as coronary heart disease, stroke, diabetes, and cancer.^4–9The definition of a healthy lifestyle varies across studies but generally includes a combination of healthy lifestyle characteristics such as having a healthy weight, not smoking, and engaging in regular physical activity. Despite the known benefits of following a healthy lifestyle, the available data consistently show that very few Americans are able to do so. Previous work has shown, depending on the definition of healthy lifestyle used, that only between 3% and 10% of US residents have a healthy lifestyle^10,11 despite the presence of substantial public health investments in programs designed to promote healthy lifestyles over the past few decades.^12–14 Some of these investments have resulted in sustained improvements in individual healthy lifestyle characteristics, particularly tobacco use,^14,15 whereas others, such as physical activity promotion and obesity prevention programs, have met with limited success.^16,17In the United States, strong temporal trends in individual healthy lifestyle characteristics—particularly declines in tobacco use and increases in obesity—have been described.^14,16,17 Marked regional differences in the prevalence of certain individual healthy lifestyle characteristics have also been demonstrated. For example, in 2007 the prevalence of cigarette smoking ranged from 9% to 31% across states, and the prevalence of recommended physical activity ranged from 31% to 61%.¹⁸Although much information exists on individual healthy lifestyle characteristics, there has been little reported on temporal and regional differences in the prevalence of individuals with healthy lifestyles. Using Reeves and Rafferty''s definition of a healthy lifestyle¹⁰—the presence of 4 modifiable healthy lifestyle characteristics—we examined temporal and regional US trends in the prevalence of healthy lifestyles as well as these 4 individual characteristics from 1994 to 2007.     

Neighborhood Context and Infant Birthweight Among Recent Immigrant Mothers: A Multilevel Analysis

Objectives. We compared the influence of the residential environment and maternal country of origin on birthweight and low birthweight of infants born to recent immigrants to urban Ontario.Methods. We linked delivery records (1993–2000) to an immigration database (1993–1995) and small-area census data (1996). The data were analyzed with cross-classified random-effects models and standard multilevel methods. Higher-level predictors included 4 independent measures of neighborhood context constructed by factor analysis and maternal world regions of origin.Results. Births (N = 22 189) were distributed across 1396 census tracts and 155 countries of origin. The associations between neighborhood indices and birthweight disappeared after we controlled for the maternal country of origin in a cross-classified multilevel model. Significant associations between world regions and birthweight and low birthweight persisted after we controlled for neighborhood context and individual characteristics.Conclusions. The residential environment has little, if any, influence on birthweight among recent immigrants to Ontario. Country of origin appears to be a much more important factor in low birthweight among children of recent immigrants than current neighborhood. Findings of neighborhood influences among recent immigrants should be interpreted with caution.Socioeconomic disparities in birth outcomes are well documented,^1–3 even in countries with universal access to health care,^4,5 such as Canada. An increasing body of literature, including several multilevel studies, suggests that context affects birth outcomes, particularly neighborhood influences in predominantly urban areas.^6–16 Little is known, however, about neighborhood influences among immigrants.^15,17–19There are theoretical and practical reasons to explore this issue. It has been suggested that exposure to neighborhoods may take some time to affect human health.²⁰ Even if neighborhood influences are detected among the offspring of recent immigrant women exposed to neighborhoods during their entire pregnancy, a life-course perspective suggests that early life experiences and premigration exposures may still affect birth outcomes of migrants in the new country.^19,21 The maternal country of origin thus constitutes another relevant context to be considered when analyzing differences in birthweight among recent immigrants, because substantial differences in birthweight have been reported by geographical region and nativity status.^22–24 It is important to clarify the role of the pre- and postmigration exposures, because the proportion of live births to immigrant women has been showing an upward trend during recent decades in several industrialized countries.^24–27We compared the influence of the residential environment at the time of delivery with that of the maternal country of origin on birthweight and the proportion of low birthweights among infants born to women who recently immigrated to Canada and settled in Ontario census metropolitan areas from 1993 to 1995. We hypothesized that the maternal country of origin would have a greater effect on birthweight than would the residential environment in which immigrants currently resided in urban Ontario.     

Prevalence of HCV Infection Among Clients in Community-Based Health Settings in Hawaii, 2002–2010: Assessing Risk Factors

Objectives. We sought to determine the prevalence of HCV infection and identify risk factors associated with HCV infection among at-risk clients presenting to community-based health settings in Hawaii.Methods. Clients from 23 community-based sites were administered risk factor questionnaires and screened for HCV antibodies from December 2002 through May 2010. We performed univariate and multivariate logistic regression analyses.Results. Of 3306 participants included in the analysis, 390 (11.8%) tested antibody positive for HCV. Highest HCV antibody prevalence (17.0%) was in persons 45 to 64 years old compared with all other age groups. Significant independent risk factors were current or prior injection drug use (P < .001), blood transfusion prior to July 1992 (P = .002), and having an HCV-infected sex partner (P = .03). Stratification by gender revealed sexual exposure to be significant for males (P = .001).Conclusions. Despite Hawaii’s ethnic diversity, high hepatocellular carcinoma incidence, and a statewide syringe exchange program in place since the early 1990s, our HCV prevalence and risk factor findings are remarkably consistent with those reported from the mainland United States. Hence, effective interventions identified from US mainland population studies should be generalizable to Hawaii.Hepatitis C is the most prevalent chronic blood-borne viral infection in the United States, with an estimated 1.3% of the population chronically infected.1 Chronic HCV infection is often asymptomatic; approximately 75% of infected persons may be unaware that they are infected.2 Transmission is mainly through direct blood-to-blood contact, and the most common risk factor in the United States is the sharing of injection drug use equipment.1,2 Complications from HCV infection include cirrhosis, hepatocellular carcinoma (HCC), and end-stage liver disease; more than one third of liver transplants in the United States can be attributed to HCV.3 There is currently no vaccine,4 and until recently, standard therapy with pegylated interferon and ribavirin achieved a sustained virologic response in only 40% to 50% of patients.5,6In May 2011, the US Food and Drug Administration approved 2 new HCV-specific protease inhibitors for the treatment of chronic genotype 1 HCV infections: boceprevir7,8 and telaprevir.9,10 In combination with standard therapy, these drugs have achieved significantly higher rates of sustained virologic response: up to 67% to 75%.7,10 Achieving sustained virologic response is key to reducing mortality, HCC, and other comorbidities.11,12 With such a large percentage of HCV-infected individuals unaware of their status and new successful treatments available, there is now increased rationale for health providers to screen their clients for chronic HCV infection.The population of Hawaii differs from that of the mainland United States on a number of key factors related to HCV and HCC. Hawaii has the highest incidence of HCC nationally.13 Asian/Pacific Islanders have the highest incidence of HCC in the United States,13 and 57% of the Hawaii’s population is Asian, either alone or in combination with other ethnic groups.14 The high HCC incidence among Asian/Pacific Islanders is attributed in large part to chronic hepatitis B virus (HBV) infection,13,15 and the identification and treatment of persons with chronic HBV or HCV infection is an important public health priority in Hawaii. In addition, Hawaii implemented a statewide syringe exchange program in the early 1990s, the first state to do so.16 The risk factor demonstrating the strongest association with HCV infection in the United States is injection drug use,1,17 and syringe exchange programs have demonstrated efficacy in reducing HCV infection among injection drug users.18,19To our knowledge, only 3 HCV prevalence studies have been conducted in Hawaii; however, each focused on a specific well-defined subgroup population: patients with HCC,20 HIV-infected persons enrolled in a state drug assistance plan,21 and adults from a homeless shelter.22The Adult Viral Hepatitis Prevention Program of the Hawaii State Department of Health, which offers risk-based HCV antibody testing based on reported national risk factors,1,23 has been collecting data on persons undergoing screening since 2002. We investigated the prevalence of HCV antibody positivity among at-risk clients of community-based health programs in Hawaii and identified demographic characteristics and independent risk factors associated with HCV infection.     

All Rural Places Are Not Created Equal: Revisiting the Rural Mortality Penalty in the United States

Objectives. I investigated mortality disparities between urban and rural areas by measuring disparities in urban US areas compared with 6 rural classifications, ranging from suburban to remote locales.Methods. Data from the Compressed Mortality File, National Center for Health Statistics, from 1968 to 2007, was used to calculate age-adjusted mortality rates for all rural and urban regions by year. Criteria measuring disparity between regions included excess deaths, annual rate of change in mortality, and proportion of excess deaths by population size. I used multivariable analysis to test for differences in determinants across regions.Results. The rural mortality penalty existed in all rural classifications, but the degree of disparity varied considerably. Rural–urban continuum code 6 was highly disadvantaged, and rural–urban continuum code 9 displayed a favorable mortality profile. Population, socioeconomic, and health care determinants of mortality varied across regions.Conclusions. A 2-decade long trend in mortality disparities existed in all rural classifications, but the penalty was not distributed evenly. This constitutes an important public health problem. Research should target the slow rates of improvement in mortality in the rural United States as an area of concern.Recent research has identified a new trend in rural–urban, macrolevel mortality disparities in the United States, called the rural mortality penalty.1,2 Historically, there has been a penalty associated with urban places; however, in recent decades, a reversal has occurred. Beginning in the mid-1980s, rural and urban mortality rates diverged, and the gap between them has grown for more than 2 decades. According to previous publications that introduced the rural mortality penalty, the rural United States is an aggregation of 6 nonmetropolitan designations distinguished by population size and adjacency to an urban area; this is a typology used in many previous studies.3,4 This research uncovers the disproportionate mortality burden across these rural classifications.Throughout the 19th and early 20th centuries, there was a mortality penalty associated with urban areas.5 The urban mortality penalty was largely attributed to the spread of contagious and infectious disease,6,7 poor water quality,8 and inadequate sewage disposal9 in densely populated areas.10,11 The first half of the 20th century transformed urban cities because of public works projects that improved water quality and sanitation8 and public health advancements that included vaccinations, quarantines, physical examinations, health education, workplace safety, food quality, and controlling medication.5 The result was unprecedented improvements in urban health from 1900 to 1940, highlighted by a 40% decline in mortality, an increased life expectancy from 47 to 63 years,8,12 and generally equivalent rural and urban mortality rates.5 This pattern persisted until the mid-1980s, when the rural mortality penalty emerged. Public health advances, however important, did not encompass all determinants of mortality.The major determinants of mortality in the rural United States exist at the individual, structural, or contextual levels. Individual-level determinants include use of self-care,13,14 low satisfaction of care,14,15 lack of a regular source of care,15,16 and lifestyle and behaviors.17,18 Structural and contextual determinants include poverty,15 high rates of female-headed households,19 degree of urbanization,15 age structure of the population,20,21 income inequality,22 high rates of chronic illnesses,23 access to care,13,15,24,25 physician and hospital shortages,26–28 and unique cultural characteristics,29,30 including an identity of resiliency.31 Furthermore, macrolevel restructuring because of immigration and suburbanization has occurred in many rural communities. These changes create diverse economic opportunities,19,32–34 populations,34–37 and changing demographic characteristic structures.34,37 Traditional social, racial, and ethnic boundaries have blurred,34–37 and the cultural gap between rural and urban places has shrunk,34,37 changing how we understand the dynamics among demographic, social, and economic processes, resources, constraints, and health policies in people’s pursuit of better health.37Innovative research investigating regional disparities in health outcomes has been published in the last decade, but there remains a gap in understanding intrarural differences. A recent study of life expectancy found widening disparities across rural–urban categories over a 40-year period, with poor rural Blacks having the lowest survival probability.38 Another regional study of mortality, titled “Eight Americas” uncovered disparities in life expectancy, mortality, health insurance, and health care utilization by regions based on race, county, population density, race-specific county level per capita income, and homicide rate.39,40 This work highlighted the complexity of “place” and its role in eliminating health disparities across population segments.41 The rural United States is complex, and is often treated as a “nonurban” residual category lacking a clear conceptualization of poverty, opportunity structure, and other social processes.42–44 With the emergent rural mortality penalty, it is paramount to understand the context and conditions unique to the rural part of the country.29,30 I sought to uncover differing mortality profiles and determinants across rural regions.     

Pervasive Trauma Exposure Among US Sexual Orientation Minority Adults and Risk of Posttraumatic Stress Disorder

Objectives. We assessed sexual orientation disparities in exposure to violence and other potentially traumatic events and onset of posttraumatic stress disorder (PTSD) in a representative US sample.Methods. We used data from 34 653 noninstitutionalized adult US residents from the 2004 to 2005 wave of the National Epidemiologic Survey on Alcohol and Related Conditions.Results. Lesbians and gay men, bisexuals, and heterosexuals who reported any same-sex sexual partners over their lifetime had greater risk of childhood maltreatment, interpersonal violence, trauma to a close friend or relative, and unexpected death of someone close than did heterosexuals with no same-sex attractions or partners. Risk of onset of PTSD was higher among lesbians and gays (adjusted odds ratio [AOR] = 2.03; 95% confidence interval [CI] = 1.34, 3.06), bisexuals (AOR = 2.13; 95% CI = 1.38, 3.29), and heterosexuals with any same-sex partners (AOR = 2.06; 95% CI = 1.54, 2.74) than it was among the heterosexual reference group. This higher risk was largely accounted for by sexual orientation minorities’ greater exposure to violence, exposure to more potentially traumatic events, and earlier age of trauma exposure.Conclusions. Profound sexual orientation disparities exist in risk of PTSD and in violence exposure, beginning in childhood. Our findings suggest there is an urgent need for public health interventions aimed at preventing violence against individuals with minority sexual orientations and providing follow-up care to cope with the sequelae of violent victimization.Sexual orientation disparities in exposure to violence over the life course are well documented.^1–10 Individuals with minority sexual orientation (e.g., gay, lesbian, bisexual) report elevated frequency, severity, and persistence of physical and sexual abuse in childhood.^1,3,4 Throughout their lives, sexual orientation minorities are more likely to experience violence in their communities, including hate crimes.^5,10–12 Intimate partner violence and sexual assault in adulthood are also disproportionately prevalent among sexual orientation minorities.^3,9 It is unknown whether sexual orientation disparities also exist in exposure to other types of potentially traumatic events.Despite the growing recognition of sexual orientation disparities in violence exposure, population-representative research examining possible sexual orientation differences in risk of posttraumatic stress disorder (PTSD) is very limited. PTSD is a mental disorder that develops in response to exposure to a potentially traumatic event, including violence (e.g., childhood abuse, sexual assault) or other negative life experiences (e.g., disasters, accidents). The disorder is characterized by persistent reexperiencing of the event, persistent avoidance of stimuli associated with the event, emotional numbing, and hyperarousal. For PTSD diagnosis according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, symptoms must be present for at least 1 month and result in functional impairment.¹³The public health consequences of PTSD are staggering and include secondary mental disorders, substance dependence,^14,15 impaired role functioning, health problems,^16–18 and reduced life course opportunities (e.g., higher rates of unemployment).¹⁹ The lack of data on PTSD among sexual orientation minorities is a critical gap because, of all civilian traumas, interpersonal violence is associated with the highest conditional risk of developing PTSD.^20,21 We examined sexual orientation disparities in exposure to violence and other potentially traumatic events and in risk of PTSD in a US representative sample.Previous studies have found elevated rates of PTSD among sexual orientation minorities in comparison with heterosexuals.^6,10,22,23 However, our understanding of the burden of PTSD in this vulnerable population is constrained by 3 limitations of extant research. First, as far as we know, only 1 study compared rates of PTSD across sexual orientation groups in a nationally representative sample.²³ Several studies relied on convenience samples; selection factors in such samples could bias observed associations among sexual orientation, violence exposure, and PTSD. Second, the only study of sexual orientation and PTSD in a nationally representative sample categorized members into a sexual orientation group solely by reports of the gender of their sexual partners. Other dimensions of sexual orientation, such as sexual orientation identity and feelings of sexual attraction, which have been shown to be important correlates of physical and mental health,^24,25 were not measured. Third, no previous study attempted to link possible sexual orientation disparities in PTSD directly to elevated risk of exposure to violence and other traumatic events in the minority sexual orientation population. Type of potentially traumatic event exposure—particularly elevated rates of exposure to violence, exposure to multiple events, and younger age at exposure—are all important determinants of PTSD^{20,21,26–28} that may account for the disparities in PTSD by sexual orientation.We designed our study to document the public health burden of potentially traumatic event exposure and PTSD in US residents with minority sexual orientations. We analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a large, nationally representative survey of US adults.²⁹ Respondents were asked to report on 3 dimensions of sexual orientation: identity (i.e., heterosexual, gay, lesbian, or bisexual), same-sex and opposite-sex attractions, and same-sex and opposite-sex sexual partners. We also investigated the causes of observed disparities in PTSD by analyzing NESARC''s detailed information on type of traumatic events and age at first exposure. These are therefore the most comprehensive data reported to date, derived from a nationally representative sample and aimed at quantifying disparities in potentially traumatic events and associated PTSD by sexual orientation.