Effect of health care system distrust on breast and cervical cancer screening in Philadelphia, Pennsylvania

Objectives. We investigated whether health care system distrust is a barrier to breast and cervical cancer screening and whether different dimensions of distrust—values and competence—have different impacts on cancer screening.Methods. We utilized data on 5268 women aged 18 years and older living in Philadelphia, Pennsylvania, and analyzed their use of screening services via logistic and multinomial logistic regression.Results. High levels of health care system distrust were associated with lower utilization of breast and cervical cancer screening services. The associations differed by dimensions of distrust. Specifically, a high level of competence distrust was associated with a reduced likelihood of having Papanicolaou tests, and women with high levels of values distrust were less likely to have breast examinations within the recommended time period. Independent of other covariates, individual health care resources and health status were associated with utilization of cancer screening.Conclusions. Health care system distrust is a barrier to breast and cervical cancer screening even after control for demographic and socioeconomic determinants. Rebuilding confidence in the health care system may improve personal and public health by increasing the utilization of preventive health services.Cancer is a leading cause of death in the United States. Approximately 1.5 million Americans are diagnosed with cancer per year and 1 in 4 deaths are attributed to cancer.¹ Among women, an estimated 192 000 breast and 11 000 cervical cancer cases are detected each year, and in 2009 more than 40 000 women died of breast cancer and approximately 4000 of cervical cancer.¹ To effectively reduce the morbidity and mortality resulting from breast and cervical cancer, efforts need to be made to increase the proportion of women who comply with screening recommendations²; according to a recent report, a third of women are not in compliance with screening guidelines for breast cancer, and more than a fifth are not in compliance for cervical cancer.³ Our goal was to investigate whether health care system distrust (hereafter referred to as distrust) is a barrier to breast and cervical cancer screening.The late 20th century saw many changes in the theoretical underpinnings of research on health in general and women''s health in particular. The prevailing biomedical model was criticized for ignoring social determinants of health, such as social class, gender roles, and poverty,⁴ and health determinants models that incorporated multiple social, economic, and demographic dimensions were embraced.^5–7 The multiple determinants of health perspective emphasizes the relationships between socioeconomic factors and health outcomes,⁴ but the role of psychological factors (i.e., depression and distrust) in cancer screening has only recently been recognized.^8–11 Relatively little is known about whether distrust affects health outcomes, and specifically whether it influences cancer screening behaviors among women.¹¹Americans’ overall confidence in their health care system has declined markedly in recent decades. In 2010, only 34% of adults reported “a great deal” of confidence in the health system, down from over 70% in 1966.¹² More than 80% of Americans, however, held high levels of trust in their personal physicians or providers,¹³ a paradox that has been widely documented in the literature.^14–17 Previous studies suggest that trust in physicians is associated with seeking timely medical care, maintaining appropriate health care, and adhering to medical advice,^18–20 but it is unclear whether trust or its converse, distrust, affects the adoption of preventive health services among women.¹¹The emerging distrust research in health care shows that distrust is a multidimensional concept.^21–23 For example, Shea et al. used focus groups, pilot testing, and a telephone survey to develop a highly reliable 9-item distrust scale that includes 2 subscales: competence distrust and values distrust.²² Competence distrust is expected to be high when the quality of service fails to meet patient expectations and does not improve health. Values distrust is expected to be high when the integrity of the health care system is questioned (e.g., ethical issues, financial priorities, transparency of care). Although dimensions of distrust may influence the use of preventive health services in different ways, little research has addressed this issue explicitly.A range of individual characteristics has been found to be associated with the use of breast and cervical cancer screening, including age,^5,24 race/ethnicity,^11,25 socioeconomic factors,^5,24 marital status,^5,11,24 and availability and utilization of health care resources.^11,24 Access to insurance and health care providers is associated with higher likelihood of interaction with the health care system and has been hypothesized to be related to levels of distrust and to individuals’ health-related behaviors.²⁶ Personal health status has been found to be related to levels of distrust,²⁷ although the underlying causal mechanisms have not been well documented. Evidence concerning the association of health status with use of preventive health services is inconclusive.¹¹ An important contribution of our study is the investigation of the association of distinct aspects of distrust—values distrust and competence distrust—with receipt of 2 preventive health services for adult women: the Papanicolaou (Pap) test for cervical cancer and clinical breast examination to screen for breast cancer. We tested the following 2 hypotheses: after we controlled for individual socioeconomic and demographic characteristics, (1) high levels of distrust are associated with low utilization of cancer screening services and (2) the negative relationship between distrust and cancer screening utilization holds for the values and competence dimensions of distrust.     

Impact of individual-, environmental-, and policy-level factors on health care utilization among US farmworkers

Objectives. We examined individual-, environmental-, and policy-level correlates of US farmworker health care utilization, guided by the behavioral model for vulnerable populations and the ecological model.Methods. The 2006 and 2007 administrations of the National Agricultural Workers Survey (n = 2884) provided the primary data. Geographic information systems, the 2005 Uniform Data System, and rurality and border proximity indices provided environmental variables. To identify factors associated with health care use, we performed logistic regression using weighted hierarchical linear modeling.Results. Approximately half (55.3%) of farmworkers utilized US health care in the previous 2 years. Several factors were independently associated with use at the individual level (gender, immigration and migrant status, English proficiency, transportation access, health status, and non-US health care utilization), the environmental level (proximity to US–Mexico border), and the policy level (insurance status and workplace payment structure). County Federally Qualified Health Center resources were not independently associated.Conclusions. We identified farmworkers at greatest risk for poor access. We made recommendations for change to farmworker health care access at all 3 levels of influence, emphasizing Federally Qualified Health Center service delivery.US farmworkers face significant disease burden¹ and excessive mortality rates for some diseases (e.g., certain cancers and tuberculosis) and injuries.² Disparities in health outcomes likely stem from occupational exposures and socioeconomic and political vulnerabilities. US farmworkers are typically Hispanic with limited education, income, and English proficiency.³ Approximately half are unauthorized to work in the United States.³ Despite marked disease burden, health care utilization appears to be low.^1,4–9 For example, only approximately half of California farmworkers received medical care in the previous year.⁶ This rate parallels that of health care utilization for US Hispanics, of whom approximately half made an ambulatory care visit in the previous year, compared with 75.7% of non-Hispanic Whites.¹⁰ Disparities in dental care have a comparable pattern.^6,8,11,12 However, utilization of preventive health services is lower for farmworkers^5,7,13,14 than it is for both US Hispanics and non-Hispanic Whites.^15,16Farmworkers face numerous barriers to health care^1,4,17: lack of insurance and knowledge of how to use or obtain it,^6,18 cost,^{5,6,12,13,18–20} lack of transportation,^{6,12,13,19–21} not knowing how to access care,^6,18,20,21 few services in the area or limited hours,^12,20,21 difficulty leaving work,¹⁹ lack of time,^5,13,19 language differences,^6,8,18–20 and fear of the medical system,¹³ losing employment,⁶ and immigration officials.²¹ Few studies have examined correlates of health care use among farmworkers. Those that have are outdated or limited in representativeness.^5,7,14,22,23 Thus, we systematically examined correlates of US health care use in a nationally representative sample of farmworkers, using recently collected data. The sampling strategy and application of postsampling weights enhance generalizability. We selected correlates on the basis of previous literature and the behavioral model for vulnerable populations.²⁴ The behavioral model posits that predisposing, enabling, and need characteristics influence health care use.²⁵ The ecological model, which specifies several levels of influence on behavior (e.g., policy, environmental, intrapersonal),²⁶ provided the overall theoretical framework. To our knowledge, we are the first to extensively examine multilevel correlates of farmworker health care use. We sought to identify farmworkers at greatest risk for low health care use and to suggest areas for intervention at all 3 levels of influence so that farmworker service provision can be improved.     

The association between perceived discrimination and obesity in a population-based multiracial and multiethnic adult sample

Objectives. We examined whether perceived chronic discrimination was related to excess body fat accumulation in a random, multiethnic, population-based sample of US adults.Methods. We used multivariate multinomial logistic regression and logistic regression analyses to examine the relationship between interpersonal experiences of perceived chronic discrimination and body mass index and high-risk waist circumference.Results. Consistent with other studies, our analyses showed that perceived unfair treatment was associated with increased abdominal obesity. Compared with Irish, Jewish, Polish, and Italian Whites who did not experience perceived chronic discrimination, Irish, Jewish, Polish, and Italian Whites who perceived chronic discrimination were 2 to 6 times more likely to have a high-risk waist circumference. No significant relationship between perceived discrimination and the obesity measures was found among the other Whites, Blacks, or Hispanics.Conclusions. These findings are not completely unsupported. White ethnic groups including Polish, Italians, Jews, and Irish have historically been discriminated against in the United States, and other recent research suggests that they experience higher levels of perceived discrimination than do other Whites and that these experiences adversely affect their health.It is estimated that 2 of every 3 adults in the United States are overweight or obese.^1,2 Obesity is a major risk factor for chronic health conditions, such as type 2 diabetes, coronary heart disease, hypertension, stroke, some forms of cancer, and osteoarthritis.³ Although it is widely accepted that high-fat diets and physical inactivity are preventable risk factors,⁴ obesity continues to increase.^1,2,5There is a growing interest in the relationship between psychosocial risk factors and excess body fat accumulation.^6–16 In particular, some evidence suggests that psychosocial stressors may play a role in disease progression in general and in excess body fat in particular.^7,8,17 The key factors underlying physiological reactions to psychosocial stress have not been completely elucidated, but McEwen and Seeman¹⁷ and others^7,18,19 posit that the continued adaptation of the physiological system to external challenges alters the normal physiological stress reaction pathways and that these changes are related to adverse health outcomes.^8,17,18,20 For example, in examining the association between psychosocial stress and excess body fat accumulation, Björntorp and others have suggested that psychosocial stress is linked to obesity, especially in the abdominal area.^7,8Perceived discrimination, as a psychosocial stressor, is now receiving increased attention in the empirical health literature.^21–24 Such studies suggest perceived discrimination is inversely related to poor mental and physical health outcomes and risk factors, including hypertension,^24,25 depressive symptoms,^26–28 smoking,^29–31 alcohol drinking,^32,33 low birthweight,^34,35 and cardiovascular outcomes.^36–38Internalized racism, the acceptance of negative stereotypes by the stigmatized group,³⁹ has also been recognized as a race-related psychosocial risk factor.⁴⁰ Recent studies have also suggested that race-related beliefs and experiences including perceived discrimination might be potentially related to excess body fat accumulation. Three of these studies^9,13,41 showed that internalized racism was associated with an increased likelihood of overweight or abdominal obesity among Black Caribbean women in Dominica⁴¹ and Barbados¹³ and adolescent girls in Barbados.⁹ These researchers posit that individuals with relatively high levels of internalized racism have adopted a defeatist mindset, which is believed to be related to the physiological pathway associated with excess body fat accumulation. However, Vines et al.¹⁶ found that perceived racism was associated with lower waist-to-hip ratios among Black women in the United States. Although the assessment of race-related risk factors varied across these studies, the findings suggest that the salience of race-related beliefs and experiences may be related to excess body fat accumulation.Collectively, the results of these studies are limited. First, because they examined the relationship between race-related beliefs and experiences and excess body fat only among women, we do not know if this relationship is generalizable to men.^13,16,41 Second, these studies only examined this relationship among Blacks, even though perceived unfair treatment because of race/ethnicity has been shown to be adversely related to the health of multiple racial/ethnic population groups in the United States^42–49 and internationally.^27,50–55 Third, none of the studies have examined the relationship between excess body fat accumulation and perceived nonracial/nonethnic experiences of interpersonal discrimination. Some evidence suggests that the generic perception of unfair treatment or bias is adversely related to health, regardless of whether it is attributed to race, ethnicity, or some other reason.^45,55,56 Fourth, none of these studies included other measures of stress. We do not know if the association between race-related risk factors and obesity is independent of other traditional indicators of stress.Using a multiethnic, population-based sample of adults, we examined the association of perceived discrimination and obesity independent of other known risk factors for obesity, including stressful major life events. Additionally, because reports of perceived racial/ethnic discrimination and non-racial/ethnic discrimination vary by racial/ethnic groups^24,45,46,57 and because Whites tend to have less excess body fat than do Blacks and Hispanics,^1,3 we examined the relationships between perceived discrimination and excess body fat accumulation among Hispanics, non-Hispanic Whites, and non-Hispanic Blacks.     

State-level health care access and use among children in US immigrant families

Objectives. We examined the association between children''s state of residence and their access to health care among specific types of immigrant families: foreign-born children, US-born children with 1 foreign-born parent, US-born children with both foreign-born parents, and nonimmigrant families.Methods. We analyzed data from 12 400 children from the 2003 National Survey of Children''s Health in the 6 states with the highest proportion of immigrants (California, Florida, Illinois, New York, New Jersey, and Texas).Results. Multivariable analyses indicated that among foreign-born children, those living in California, Illinois, and Texas were more likely to lack access to health care compared with those living in New York. Among foreign-born children with 1 or 2 US-born parents, Texas children were most likely to lack health insurance. Within nonimmigrant families, children from California, Florida, and Texas had significantly more access and use problems.Conclusions. Our findings document differential health care access and use among states for specific immigrant family types.The United States saw the highest 5-year period of immigration in its history between 2000 and 2005.¹ Census data indicate that 20% of children lived with a foreign-born householder in 2002, an increase from 15% since 1994, although only 4% of all US children were themselves foreign born.² In 2005, an estimated 3.1 million children lived in “mixed-status” families that included both citizen and noncitizen members, making the children''s health care access and eligibility for public benefits more complex.³ Five of 6 undocumented families with children are in this category. Children living with foreign-born householders tend to be younger and are more likely to live in poverty than those living with US-born householders.⁴ Regardless of nativity, children in immigrant families are a special population because their well-being is very much influenced by the immigrant attributes of their parents, including those of language and cultural, health care–seeking behavior, and public program access and eligibility.^5,6 Previous studies have shown that noncitizen children had the most difficulty accessing health care, followed by US-born children with at least 1 foreign-born parent, compared with nonimmigrant families.^7,8 Hence the notion of “immigrant family type” is important in immigrant health care access studies. Within the last decade, immigrants also have dispersed to many states that previously did not have a large foreign-born population.⁹Among many health issues faced by immigrants, those related to health care access and insurance are the most challenging.^10–15 Despite studies showing lower mortality and morbidity risks among immigrants compared with US-born infants, children, and adults,^16–22 other measures of health and well-being have been less favorable. In 2005, nearly 20% of children younger than 18 years with immigrant mothers were uninsured, compared with 9.1% of children with native-born mothers.¹ Child and parental birthplace have been found to affect insurance status and access to preventive health and dental services among children and adolescents in the United States.^23–25 The American Academy of Pediatrics recently updated its policy statement describing the unique and complex medical and psychosocial risk faced by immigrant children and recommended that children not be denied needed services on the basis of immigration status.²⁶Recently in California, parental English proficiency has been shown to have profound effects on children''s health care access.^27,28 Even in Canada, where health insurance is universal, new immigrants lack access to formal and informal support to help them use services effectively, and lack of access has been linked to linguistic isolation.^29,30 Moreover, these children''s parents are limited in their ability to act as advocates for their children in the health care setting.^31,32Passage of the 1996 Personal Responsibility and Work Opportunity Reconciliation Act limited immigrants’ access to many public benefits (Public Law 104-193).^8,33 Undocumented immigrants and legal immigrants within 5 years of entry into the United States are barred from receiving services other than emergency care.³⁴ This law has been shown to have the unintended consequences of deterring eligible immigrants from accessing benefits.³⁵ States are left to handle the challenge of providing care to immigrants by allocating their own resources, resulting in considerable variability in the access of immigrant care. Furthermore, the burden of care varies with the proportion of immigrants in each state, ranging from more than 27.8% in California to just 0.4% in Montana.¹ Currently, considerable variability exists on the benefits available to immigrants by state. Federal and state benefits are generally available only to US citizens, although states vary on the availability of benefits on public health insurance, State Children''s Health Insurance Program, prenatal care, Temporary Assistance for Needy Families cash assistance, and state-funded Food Stamps to Legal Permanent Residents.³⁶Despite national evidence on the health care access disparities faced by immigrant families, state-specific information has been lacking.³⁷ The 2003 National Survey of Children''s Health (NSCH) was the first national survey to provide both reliable state- and national-level estimates on the health of children.³⁸ Using data from the 2003 NSCH, we studied the health status and health care access of children from immigrant families in 6 states with the highest proportion of immigrants and examined the independent effects of state of residence on health care access and use while controlling for confounding variables. To our knowledge, our study is the first that characterizes state-level differentials in health care access of children from different immigrant family types.     

Changes over time in the health of caregivers of children with health problems: growth-curve findings from a 10-year Canadian population-based study

Objectives. We used Canadian population-based data to examine changes in the health of caregivers of children with complex health problems compared with caregivers of healthy children over a 10-year time period.Methods. The National Longitudinal Survey of Children and Youth collected data biennially from 9401 children and their caregivers in 6 waves from 1994–1995 to 2004–2005. We conducted growth-curve analyses of these data to model self-reported general health and depressive symptoms for 4 groups of caregivers: caregivers of healthy children, and caregivers of children with 1, 2, or at least 3 of 4 conceptually distinct indicators of child health problems. We modeled covariates for children (age, gender, only-child status) and caregivers (age, gender, education, income, marital status).Results. After we controlled for covariates, caregiver health outcomes worsened incrementally with increasing complexity of child health problems. Change in self-reported general health and depressive symptoms over the 10-year period was consistent across all groups of caregivers.Conclusions. Poorer health among caregivers of children with health problems can persist for many years and is associated with complexity of child health problems. Attention to parental health should form a component of health care services for children with health problems.Caring for any child is a demanding task, but parents of children with chronic physical or psychological health problems can face significantly greater caregiving challenges, including greater time demands,^1,2 higher medical and other related costs,^3–5 child care challenges,^6–8 lower incomes,^7,9,10 and employment constraints.^8,9 Coupled with these challenges are societal changes (smaller family units, more single-parent families¹¹) and trends in health care (innovations that increase life expectancy of children with severe disabilities,¹² family-centered models of health care,^13,14 increased emphasis on value for money spent on health care^15,16) that may inadvertently increase the burden on caregivers of children with chronic health problems.Evidence is now accumulating that these challenges have implications for caregiver health.^{1,2,5,9,17–20} For example, we recently showed that caregivers of children with health problems had more than twice the odds of having chronic health problems, activity limitations, and depressive symptoms compared with the population of caregivers of healthy children.²¹ Our broad definition of child “health problems” included approximately 26% of Canadian families, but we still found strong caregiver health effects, suggesting that the health of caregivers of children with health problems is an important public health issue.Previous work examining the relationship between the caregiving situation and caregiver health has provided many cross-sectional snapshots of caregiver health, but relatively few controlled studies have examined whether these relationships change over time. Longitudinal studies that do exist have yielded strikingly diverse, if not contradictory, results. Initial findings among elderly caregivers of people with Alzheimer''s disease^22–24 and among caregivers of children^25,26 have suggested that caregivers might experience worsening health over time as wear and tear accumulates, but these findings have been challenged by studies showing that both the physical and the psychological health of these caregivers remains relatively stable over the study periods (typically < 2 years).^2,22,27,28In other circumstances, caregiver health can improve over time. Mothers of children with cancer reported lower anxiety scores 20 months after the diagnosis than they did at the time of diagnosis.^29,30 Similarly, levels of distress were initially elevated in mothers and fathers of children diagnosed with diabetes, but their symptoms resolved over a 12-month period.³¹ Other studies have demonstrated positive aspects of parenting—including decreases in anxiety, depression, and mortality—that may be tied to feelings of empowerment when the caregiver is able to provide effective help.^32–36Several methodological issues may have contributed to this variability in results. Studies have typically focused on relatively small samples that are limited in their power to demonstrate change. Many studies did not include control groups, making it impossible to examine relative changes in health. Existing longitudinal studies have often involved elderly caregivers or have only included children with specific health problems, producing results that may not generalize well to caregivers of children with a broader range of health problems. Most studies have also typically been limited to relatively short time frames (< 2 years; but see Brehaut et al.,⁹ Seltzer et al.,²⁶ and Brown et al.³⁶), and therefore may not be sensitive to processes that manifest over longer periods of time.We examined a large-scale Canadian sample of children and caregivers to determine changes in the health of caregivers of children with health problems. By employing data from a population-based national study, we were able to conduct more sensitive analyses on a broader sample than has existed in the literature to date. We examined the extent to which the complexity of the child health problem affects caregiver health compared with a healthy comparison group. We examined the scope of caregiver health effects across a wide spectrum of childhood illness rather than limiting our study to a single clinical area. And because the data source offers 6 cycles of repeated measurements of caregiver health over the course of 10 years, we had an unprecedented opportunity to examine whether these effects change over a longer period of time.     

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).     

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.     

Social gradients in oral health in older adults: findings from the English longitudinal survey of aging

Objectives. We examined prospective associations between socioeconomic position (SEP) markers and oral health outcomes in a national sample of older adults in England.Methods. Data were from the English Longitudinal Survey of Aging, a national cohort study of community-dwelling people aged 50 years and older. SEP markers (education, occupation, household income, household wealth, subjective social status, and childhood SEP) and sociodemographic confounders (age, gender, and marital status) were from wave 1. We collected 3 self-reported oral health outcomes at wave 3: having natural teeth (dentate vs edentate), self-rated oral health, and oral impacts on daily life. Using multivariate logistic regression models, we estimated associations between each SEP indicator and each oral health outcome, adjusted for confounders.Results. Irrespective of SEP marker, there were inverse graded associations between SEP and edentulousness, with proportionately more edentate participants at each lower SEP level. Lower SEP was also associated with worse self-rated oral health and oral impacts among dentate, but not among edentate, participants.Conclusions. There are consistent and clear social gradients in the oral health of older adults in England, with disparities evident throughout the SEP hierarchy.The inverse linear relationship between socioeconomic position (SEP) and health is well established.^1–4 The uneven distribution of health across socioeconomic strata has been observed in both industrialized and less developed countries and for most common diseases and causes of death.^1,5–8 In most cases, the association between SEP and health is characterized by a linear graded pattern, with people in each lower SEP category having successively worse levels of health and dying earlier than those that are better off, a characteristic known as the social gradient in health.⁹Although there is clear and consistent evidence about the existence of the social gradient in working-age adults,^10,11 studies in older adults are less consistent, with some showing attenuation of the gradient^12,13 and others reporting that it persisted^14,15 or even increased¹⁶ in magnitude.Oral health is particularly important at older ages with tooth loss shown to be independently associated with disability and mortality.^17–20 Oral health status in older people is also an important determinant of nutritional status.²¹Socioeconomic disparities in oral health have been consistently demonstrated for various indicators, mostly clinical and disease related^22–31 but also subjective measures of oral health and quality of life.^30,32–38 Some of these studies have explicitly assessed the existence of an oral health gradient,^{23,25–31,34–37} but almost all were carried out on adolescents and adults, with very few focusing on older people.^33,36 These few relevant studies are cross-sectional and inconclusive and have used a limited number of SEP indicators (typically, education and occupational class), thereby hindering any comprehensive analysis on the relationship between SEP and oral health.We addressed the gap in the literature about the existence of an oral health gradient at older ages by examining the prospective associations between a wide range of SEP indicators (education, occupation, household income, household wealth, subjective social status [SSS], and childhood SEP) and various oral health outcomes (presence of natural teeth, self-rated oral health, and oral impacts) in a national sample of older adults from the English Longitudinal Survey of Aging (ELSA). We explored whether there are any significant socioeconomic inequalities in oral health among older people in England and, if so, whether these take the form of a gradient.     

Demonstrating the Importance and Feasibility of Including Sexual Orientation in Public Health Surveys: Health Disparities in the Pacific Northwest

Objectives. We identified health disparities for a statewide population of lesbian, gay, and bisexual (LGB) men and women compared with their heterosexual counterparts.Methods. We used data from the 2003–2006 Washington State Behavioral Risk Factor Surveillance System to examine associations between sexual orientation and chronic health conditions, health risk behaviors, access to care, and preventive services.Results. Lesbian and bisexual women were more likely than were heterosexual women to have poor physical and mental health, asthma, and diabetes (bisexuals only), to be overweight, to smoke, and to drink excess alcohol. They were also less likely to have access to care and to use preventive services. Gay and bisexual men were more likely than were heterosexual men to have poor mental health, poor health-limited activities, and to smoke. Bisexuals of both genders had the greatest number and magnitude of disparities compared with heterosexuals.Conclusions. Important health disparities exist for LGB adults. Sexual orientation can be effectively included as a standard demographic variable in public health surveillance systems to provide data that support planning interventions and progress toward improving LGB health.A limited number of studies have described chronic disease health risks among lesbian, gay, and bisexual (LGB) adults. Few of these studies have been population based, and those were often conducted in limited geographic areas or did not include a heterosexual comparison group. Most have relied on convenience samples or other targeted study designs and studied only specific health issues such as smoking or HIV risk factors.The patchwork of available studies indicates that LGB adults have important health disparities. Compared with heterosexual women, lesbian and bisexual women have been shown to have poorer overall health and mental health^1–3; higher rates of smoking,^4–11 alcohol consumption,^8,11–13 asthma,^3,13 and obesity²; and less access to health care,¹² including routine preventive screenings such as Papanicolaou (Pap) tests or mammograms,^14–16 although they were more likely to have had HIV tests.¹⁵ Gay and bisexual men have reported higher rates of smoking^4–6,9 and alcohol use⁸ and poorer general health and mental health^1,3 compared with heterosexual men. An LGB companion document to the Healthy People 2010 initiative identified 29 specific objectives that prioritized sexual minorities, but data by sexual orientation were not available in public health surveillance systems to track most of those objectives.¹⁷ In a recent review of sexual and gender minority health issues, Mayer et al.¹⁸ called for more inclusion of sexual minority identifiers in national data sets as a necessary next step in elimination of health disparities.In 2003, Washington began to include a question about sexual orientation in its Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is a telephone-based survey of adults that is sponsored by the Centers for Disease Control and Prevention (CDC) and implemented throughout the United States.¹⁹For previous analyses, we combined data from 2 states (Washington and Oregon) collecting LGB information in BRFSS since 2003 into a single data set to gain sufficient numbers to describe LGB smoking behaviors.⁶ After 4 years of data collection, we now have enough LGB respondents from Washington alone to examine a variety of indicators. The purpose of this study was to describe a variety of health indicators for a statewide population of LGB men and women compared with their heterosexual counterparts. By demonstrating the feasibility and relevance of collecting information on sexual orientation in the BRFSS, we provide justification for public health surveillance systems to progress beyond “don''t ask, don''t tell” policies.     

Health status, neighborhood socioeconomic context, and premature mortality in the United States: The National Institutes of Health-AARP Diet and Health Study

Objectives. We examined whether the risk of premature mortality associated with living in socioeconomically deprived neighborhoods varies according to the health status of individuals.Methods. Community-dwelling adults (n = 566 402; age = 50–71 years) in 6 US states and 2 metropolitan areas participated in the ongoing prospective National Institutes of Health–AARP Diet and Health Study, which began in 1995. We used baseline data for 565 679 participants on health behaviors, self-rated health status, and medical history, collected by mailed questionnaires. Participants were linked to 2000 census data for an index of census tract socioeconomic deprivation. The main outcome was all-cause mortality ascertained through 2006.Results. In adjusted survival analyses of persons in good-to-excellent health at baseline, risk of mortality increased with increasing levels of census tract socioeconomic deprivation. Neighborhood socioeconomic mortality disparities among persons in fair-to-poor health were not statistically significant after adjustment for demographic characteristics, educational achievement, lifestyle, and medical conditions.Conclusions. Neighborhood socioeconomic inequalities lead to large disparities in risk of premature mortality among healthy US adults but not among those in poor health.Research dating back to at least the 1920s has shown that the United States has experienced persistent and widening socioeconomic disparities in premature mortality over time.^1–5 However, it has been unclear whether socioeconomic inequalities affect the longevity of persons in good and poor health equally. Socioeconomic status (SES) and health status are interrelated,^6–8 and both are strong independent predictors of mortality.⁹ Low SES is associated with greater risk of ill health and premature death,^{1–5,8,10–13} partly attributable to disproportionately high prevalence of unhealthful lifestyle practices^10,14,15 and physical and mental health conditions.^13,16 Correspondingly, risk of premature mortality is higher in poor than in more affluent areas.^16,17 Although the association between neighborhood poverty and mortality is independent of individual-level SES,^17,18 aggregation of low-SES populations in poor areas may contribute to variations in health outcomes across neighborhoods. Conversely, economic hardships resulting from ill health may lead persons in poor physical or mental health to move to poor neighborhoods.¹⁹ This interrelatedness may create spurious associations between neighborhood poverty and mortality.Although previous studies have found that the risk of premature death associated with poor health status varies according to individuals'' SES,^20,21 no published studies have examined whether the relative risks for premature mortality associated with living in neighborhoods with higher levels of socioeconomic deprivation vary by health status of individuals. Clarifying these relationships will inform social and public health policies and programs that aim to mitigate the health consequences of neighborhood poverty.^22,23We used data from a large prospective study to examine whether the risk of premature mortality associated with neighborhood socioeconomic context differs according to health status at baseline and remains after adjustment for person-level risk factors for mortality, such as SES, lifestyle practices, and chronic medical illnesses.     

Walking and Cycling to Health: A Comparative Analysis of City, State, and International Data

Objectives. We sought to determine the magnitude, direction, and statistical significance of the relationship between active travel and rates of physical activity, obesity, and diabetes.Methods. We examined aggregate cross-sectional health and travel data for 14 countries, all 50 US states, and 47 of the 50 largest US cities through graphical, correlation, and bivariate regression analysis on the country, state, and city levels.Results. At all 3 geographic levels, we found statistically significant negative relationships between active travel and self-reported obesity. At the state and city levels, we found statistically significant positive relationships between active travel and physical activity and statistically significant negative relationships between active travel and diabetes.Conclusions. Together with many other studies, our analysis provides evidence of the population-level health benefits of active travel. Policies on transport, land-use, and urban development should be designed to encourage walking and cycling for daily travel.Many nations throughout the world have experienced large increases in obesity rates over the past 30 years.^1,2 The World Health Organization estimates that more than 300 million adults are obese,³ putting them at increased risk for diseases such as diabetes, hypertension, cardiovascular disease, gout, gallstones, fatty liver, and some cancers.^4,5 Several studies have linked the increase in obesity rates to physical inactivity^6–8 and to widespread availability of inexpensive, calorie-dense foods and beverages.^1,9The importance of physical activity for public health is well established. A US Surgeon General''s report in 1996, Physical Activity and Health,¹⁰ summarized evidence from cross-sectional studies; prospective, longitudinal studies; and clinical investigations. The report concluded that physical inactivity contributes to increased risk of many chronic diseases and health conditions. Furthermore, the research suggested that even 30 minutes per day of moderate-intensity physical activity, if performed regularly, provides significant health benefits. Subsequent reports have supported these conclusions.^11–13The role of physical activity in prevention of weight gain is well documented.¹⁴ Strong evidence from cross-sectional studies has established an inverse relationship between physical activity and body mass index.^15,16 In addition, longitudinal studies have shown that exercisers gain less weight than do their sedentary counterparts.^6,8 Thus, the obesity epidemic may be explained partly by declining levels of physical activity.^1,17,18A growing body of evidence suggests that differences in the built environment for physical activity (e.g., infrastructure for walking and cycling, availability of public transit, street connectivity, housing density, and mixed land use) influence the likelihood that people will use active transport for their daily travel.^19,20 People who live in areas that are more conducive to walking and cycling are more likely to engage in these forms of active transport.^21–25 Walking and cycling can provide valuable daily physical activity.^26–30 Such activities increase rates of caloric expenditure,³¹ and they generally fall into the moderate-intensity range that provides health benefits.^32–35 Thus, travel behavior could have a major influence on health and longevity.^29,30,36,37Over the past decade, researchers have begun to identify linkages between active travel and public health.^38–40 Cross-sectional studies indicate that walking and cycling for transport are linked to better health. The degree of reliance on walking and cycling for daily travel differs greatly among countries.^39,41 European countries with high rates of walking and cycling have less obesity than do Australia and countries in North America that are highly car dependent.²⁶ In addition, walking and cycling for transport are directly related to improved health in older adults.⁴² The Coronary Artery Risk Development in Young Adults Study found that active commuting was positively associated with aerobic fitness among men and women and inversely associated with body mass index, obesity, triglyceride levels, resting blood pressure, and fasting insulin among men.^26,39,41,43Further evidence of the link between active commuting and health comes from prospective, longitudinal studies.⁴⁴ Matthews et al. examined more than 67 000 Chinese women in the Shanghai women''s health study and followed them for an average of 5.7 years.³⁷ Women who walked (P < .07) and cycled (P < .05) for transport had lower rates of all-cause mortality than did those who did not engage in such behaviors. Similarly, Andersen et al. observed that cycling to work decreased mortality rates by 40% among Danish men and women.³⁶ A recent analysis of a multifaceted cycling demonstration project in Odense, Denmark, reported a 20% increase in cycling levels from 1996 to 2002 and a 5-month increase in life expectancy for males.⁴⁵We analyzed recent evidence from a variety of data sources that supports the crucial relationship between active travel, physical activity, obesity, and diabetes. We used city- and state-level data from the United States and national aggregate data for 14 countries to determine the magnitude, direction, and statistical significance of each relationship.     

Lifting boats without closing gaps: child health outcomes in distressed US cities from 1992-2002

Objectives. We compared cause-specific mortality and birth rates for children and youths aged younger than 18 years in 100 US cities from 1992 through 2002.Methods. We used 5 census indicators to categorize the 100 most populous US cities in 1990 as economically distressed or nondistressed. We used Poisson regression to calculate rate ratios for cause-specific mortality and birth rates, comparing distressed cities to nondistressed cities overall and by race/ethnicity from 1992 through 2002. We also calculated rates of change in these variables within each city over this period.Results. Despite improvements in health for the study population in all cities, disparities between city groups held steady or widened over the study period. Gaps in outcomes between Whites and Blacks persisted across all cities. Living in a distressed city compounded the disparities in poor outcomes for Black children and youths.Conclusions. A strong national economy during the study period may have facilitated improvements in health outcomes for children and youths in US cities, but these benefits did not close gaps between distressed and nondistressed cities.Substantial evidence has demonstrated that city residence in the late 19th and early to mid-20th centuries was associated with high rates of injury and infectious diseases.^1–6 Researchers have noted that cities have continued to impose a health penalty on their residents, with poorer outcomes among children and youth in cities than in the rest of the United States.^7–11Some have argued that this penalty was associated with the period of urban decline after 1970, during which physical infrastructures deteriorated and city government services shrank. Yet a number of scholars have noted that the decline from 1970 to 1990 set cities on different demographic and economic trajectories.^12–17 In this formulation, some cities suffered substantively different qualities of economic distress. One group of cities endured ongoing “White flight,” increasing crime rates, poorly performing schools, shrinking populations, an eroding tax base, and greater demand for health and social services.^18–22 A second group of cities experienced the same ills but less severely, and they were buoyed by new immigration.^23,24 These trajectories may have positioned cities differently to benefit from the economic prosperity that the United States experienced from 1992 through 2001.Surprisingly, even within the field of urban health, little attention has been paid to the ways in which economic and population differences among cities may be associated with poorer health outcomes and racial/ethnic health disparities among cities. To be sure, investigators have extensively studied the racial/ethnic disparities that persist despite overall gains in life expectancy and in specific health indicators in the last 15 years.^25–29 However, to our knowledge, health scholars have not investigated the different trajectories of city distress as a factor explaining health disparities and urban health. Several influential studies have demonstrated that health disparities exist between Blacks and Whites within cities,^30–32 and that the health of Blacks in cities is worse than that of Blacks in rural areas.^33,34 Much recent scholarship has demonstrated that neighborhoods of concentrated poverty in cities impose an additional health disadvantage beyond that explained by a resident''s individual poverty level.^35–39 The independent effects of neighborhood residence in urban areas have been documented across educational and social outcomes as well.^40–44We investigated the impact of different patterns of urban distress on selected mortality and birth outcomes for children and youths from 1992 through 2002. First, we assessed whether there were differences in health outcomes for children and youths in economically distressed versus nondistressed cities at the beginning of this period and whether there were racial disparities for these outcomes between different groups of cities in 1992. Next we asked whether, as the period of economic prosperity ended, all boats had risen to the same degree. That is, did improvements in health over this period narrow differences between economically distressed and nondistressed cities? Further, did disparities in health outcomes between Black and White children and youths residing in these 2 groups of cities decrease during this period? To address these questions, we investigated selected causes of mortality and birth rates for children and youths in 1992 and 2002 in 100 US cities. We also compared mortality and birth rates for Whites and Blacks in economically distressed cities versus nondistressed cities, to assess differences across this time period.     

Participatory Design of Mass Health Communication in Three Languages for Seniors and People With Disabilities on Medicaid

Objectives. We used participatory design methods to develop and test guidebooks about health care choices intended for 600 000 English-, Spanish-, and Chinese-speaking seniors and people with disabilities receiving Medicaid in California.Methods. Design and testing processes were conducted with consumers and professionals; they included 24 advisory group interviews, 36 usability tests, 18 focus groups (105 participants), 51 key informant interviews, guidebook readability and suitability testing, linguistic adaptation, and iterative revisions of 4 prototypes.Results. Participatory design processes identified preferences of intended audiences for guidebook content, linguistic adaptation, and format; guidebook readability was scored at the sixth- to eighth-grade level and suitability at 95%. These findings informed the design of a separate efficacy study that showed high guidebook usage and satisfaction, and better gains in knowledge, confidence, and intended behaviors among intervention participants than among control participants.Conclusions. Participatory design can be used effectively in mass communication to inform vulnerable audiences of health care choices. The techniques described can be adapted for a broad range of health communication interventions.Reaching vulnerable populations and communicating effectively with them is a critical public health challenge. The estimated 55.6 million Medicaid beneficiaries¹ are one of the most vulnerable US populations and face serious communication barriers related to limited literacy, language, culture, and disability.^2,3 Of this population, the most at-risk subgroups are the more than 13.5 million seniors and people with disabilities.¹ Their communication barriers are even greater: many have limited health literacy skills (difficulty accessing, understanding, and acting on health information), limited English proficiency,^2,4 or physical or cognitive conditions that impede access to information.With the rapid proliferation of “consumer choice models” in many states, millions of Medicaid beneficiaries are now required to make complex decisions about health plan options and effectively using health care.³ These decisions have important implications for the targeted beneficiaries regarding access to needed preventive, curative, and supportive services.^3,5–9 However, studies show that these populations have difficulty making such decisions—in part because of the poor quality of information they receive.^3–6,8,9 For example, in studies in which seniors on Medicaid used printed materials about health care choices, only 32% of those in Florida³ and 25% of those in California¹⁰ could understand the information. This is not surprising, as more than 250 studies indicate that printed materials related to health are written at reading levels greatly exceeding the average literacy skills of adults in the United States.¹¹Theoretical guidance from socio-ecological,¹² social cognitive,¹³ and transtheoretical models,¹⁴ as well as 40 years of empirical research, suggest that health communication is more effective when it is relevant to people''s personal and social contexts.^15–29 For this reason, interpersonal and tailored computer-mediated communication, which can be personalized, typically show better results than materials-based mass communication.^{18,22,24,25,30–32} However, Medicaid programs primarily communicate with seniors and people with disabilities through printed materials, given the need for low-cost mass distribution and this population''s limited access to both in-person advice and the Internet. Is there a way to reach these highly vulnerable groups effectively and affordably?Research from the past 20 years shows that using strategies to adapt printed mass communication resources more closely to the needs of population subgroups can improve outcomes.^15–29 These design principles include matching readability more closely to users'' literacy levels and using “clear communication” formatting criteria,^33–35 incorporating culturally relevant concepts and graphics,^{4,17,19,23,36–40} and adapting rather than literally translating material into other languages.^{4,19,23,39,41}Such design principles are invaluable, but they can only approximate how real audiences use and react to health communication. For this reason, increasing emphasis is being placed on “participatory” or “user-centered” design—a structured approach that employs varied formative research methods to involve intended consumer and professional audiences as codevelopers of communication.^{4,19,25,42–45}Guidelines from the US Department of Health and Human Services and its centers, including the Centers for Disease Control and Prevention and the National Cancer Institute, recommend participatory design as a primary strategy to develop health communication.^{33–35,43,46} For the past 20 years, our center (Health Research for Action, www.uchealthaction.org) has leveraged such guidance to create large-scale mass communication materials by and for diverse populations.Two decades of studies confirm that when users participate in designing and testing communication, outcomes are more successful, including those for vulnerable groups.^{4,25,28,42,44,47–51} However, limited research is available about the detailed, iterative methods and steps involved in developing user-centered, materials-based mass communication—especially about how to adapt it for specific situations.In California, the Department of Health Care Services (DHCS) was concerned that fewer than 25% of Medicaid beneficiaries who were seniors or people with disabilities made active choices about health plans. By default, many beneficiaries could have plans ill suited for their health care needs. In 2006, the DHCS commissioned our center to use participatory processes to develop and test a guidebook about choosing and navigating health plans, intended for approximately 600 000 statewide Medicaid beneficiaries who were seniors and people with disabilities, in multiple language versions. Our objectives were to determine the (1) importance of participatory design in improving mass communication for diverse and vulnerable audiences, (2) methods to engage consumers and professionals in communication design and testing, (3) processes and outcomes of a project to create a user-designed guidebook for Medicaid beneficiaries, and (4) implications for health communication researchers and practitioners.     

Effectiveness of a community health worker intervention among African American and Latino adults with type 2 diabetes: a randomized controlled trial

Objectives. We tested the effectiveness of a culturally tailored, behavioral theory–based community health worker intervention for improving glycemic control.Methods. We used a randomized, 6-month delayed control group design among 164 African American and Latino adult participants recruited from 2 health systems in Detroit, Michigan. Our study was guided by the principles of community-based participatory research. Hemoglobin A1c (HbA1c) level was the primary outcome measure. Using an empowerment-based approach, community health workers provided participants with diabetes self-management education and regular home visits, and accompanied them to a clinic visit during the 6-month intervention period.Results. Participants in the intervention group had a mean HbA1c value of 8.6% at baseline, which improved to a value of 7.8% at 6 months, for an adjusted change of -0.8 percentage points (P < .01). There was no change in mean HbA1c among the control group (8.5%). Intervention participants also had significantly greater improvements in self-reported diabetes understanding compared with the control group.Conclusions. This study contributes to the growing evidence for the effectiveness of community health workers and their role in multidisciplinary teams engaged in culturally appropriate health care delivery.African American and Latino adults experience a 50% to 100% higher burden of illness and mortality as a result of type 2 diabetes than do White Americans.^1–5 Both African American and Latino adults with diabetes have worse glycemic control and report experiencing more barriers to diabetes self-management than do non-Latino White adults.^6–9 Community health worker (CHW) interventions have demonstrated promise in improving health behaviors and outcomes, particularly for racial and ethnic minority communities and those who have traditionally lacked access to adequate health care.^10–17 CHW interventions enlist and train community members who work as bridges between their ethnic, cultural, or geographic communities and health care providers to promote health.^18–20 In chronic disease care, CHWs often educate patients, identify resources, provide case management, coordinate care in partnership with the health care system, and become part of the individual''s support network.¹⁶Although initial results from CHW programs are encouraging,^11,12,16 many have had methodological limitations, including lack of grounding in behavioral theory and inadequately rigorous evaluation.^11,16,20 In particular, as noted in a recent Cochrane review of evaluations of CHW programs,²¹ most have not used a randomized controlled trial design and thus have not adequately addressed potential threats to their external validity, such as selection bias and unmeasured differences between intervention and control groups. Moreover, in most prior evaluations of diabetes self-management interventions targeting underserved populations, the participating communities were not actively involved in identifying needs or in developing, implementing, and evaluating the interventions, which may have limited their effectiveness and potential sustainability.The intervention that we describe sought to address these deficiencies. The current intervention is among several diabetes interventions conducted since 2000 by the REACH Detroit Partnership, as part of the Centers for Disease Control and Prevention (CDC)-funded Racial and Ethnic Approaches to Community Health (REACH) Initiative. Using community-based participatory research (CBPR) principles,^22–26 community, health system, and academic partners completed a 1-year planning process to develop interventions to improve diabetes prevention and treatment in the participating communities.²⁷ Using a socioecological model, family, health system, and community-level interventions were developed to address sources of diabetes disparities at each level.^12,27,28 CHWs were central to each intervention. Interventions were grounded in empowerment theory, which emphasizes a collaborative approach to facilitating the self-directed behavior change of patients.^29–36 The empowerment philosophy includes self-determination and autonomy motivation theory, which postulates that an individual will be more successful in a disease-management plan if that individual''s goals, objectives, and resources guide the development of that plan.^37–39 Empowerment-based approaches have been found to be effective in improving chronic disease self-management among racial and ethnic minority patients.^29–36To date, we have completed 2 cohorts of the study intervention. Our first cohort included 180 African American and Latino participants who received CHW services and were compared with a historical control. Participants in that study had improved hemoglobin A1c (HbA1c) values compared with the control group at 6 months follow-up.¹² These encouraging findings led to the approval by our community partners of the 6-month randomized controlled trial design used in the current study. We report the results of a randomized controlled trial that tested whether a culturally tailored CHW intervention for diabetes self-management improved HbA1c levels, blood pressure, lipid levels, diabetes knowledge, diabetes self-management behavior, and diabetes-related distress more than usual care among low-income, inner-city African Americans and Latinos with diabetes.     

Universal Health Insurance and Health Care Access for Homeless Persons

Objectives. We examined the extent of unmet needs and barriers to accessing health care among homeless people within a universal health insurance system.Methods. We randomly selected a representative sample of 1169 homeless individuals at shelters and meal programs in Toronto, Ontario. We determined the prevalence of self-reported unmet needs for health care in the past 12 months and used regression analyses to identify factors associated with unmet needs.Results. Unmet health care needs were reported by 17% of participants. Compared with Toronto''s general population, unmet needs were significantly more common among homeless individuals, particularly among homeless women with dependent children. Factors independently associated with a greater likelihood of unmet needs were younger age, having been a victim of physical assault in the past 12 months, and lower mental and physical health scores on the 12-Item Short Form Health Survey.Conclusions. Within a system of universal health insurance, homeless people still encounter barriers to obtaining health care. Strategies to reduce nonfinancial barriers faced by homeless women with children, younger adults, and recent victims of physical assault should be explored.Homeless people are among the most marginalized groups in society, and large numbers of homeless individuals are found in the United States, Canada, and throughout the world.^1,2 Although the majority of homeless people are men, women and parents with children represent substantial segments of the homeless population.³ Homeless people suffer from many serious threats to their health, including an increased risk of all-cause mortality.⁴ Common medical conditions in this population include epilepsy, chronic obstructive pulmonary disease, hypertension, diabetes, and musculoskeletal disorders.⁵ Substance abuse, mental illness, and related comorbidities are also highly prevalent.⁵Despite high levels of morbidity and mortality, homeless people face numerous financial and nonfinancial barriers to obtaining needed health services.^6,7 A 1996 nationwide survey of homeless people across the United States found that 57% were uninsured, and lack of health insurance was associated with significantly lower odds of using ambulatory health care.⁷ Nonfinancial barriers have also been described. Competing priorities such as securing adequate food and shelter may lead to delays in seeking health care.⁸ Lack of transportation to health visits, long waiting times in clinics, and feelings of being stigmatized by health care professionals are also obstacles frequently reported by homeless people.^6,9 Lack of appropriate health care for homeless people may contribute to deterioration in health status, prolonged homelessness, and even death.^10,11Most studies of unmet needs for care among homeless individuals have been conducted in the United States.^6,7,12 Unmet needs for medical care in the past year were reported by 25% of respondents in a nationwide survey of homeless people in the United States and were somewhat more common among homeless families than among single homeless persons (27% vs 24%, respectively).^7,13 Studies conducted in various US urban centers have found even higher rates of unmet needs for care. Among homeless people living in urban encampments in Los Angeles, California, 41% felt there was a time in the past 6 months when they had needed to go to a doctor but did not.¹² A study of homeless women in Los Angeles County in 1997 found that 37% of participants had unmet needs for health care in the past 60 days.⁶ In a survey of low-income adults in Baltimore, Maryland, 57% of whom were homeless, 51% reported having difficulty accessing health care services.¹⁴ A recent study conducted in Birmingham, Alabama, found that the prevalence of unmet needs for care among homeless people rose from 32% in 1995 to 54% in 2005.¹⁵ This overall pattern suggests inadequacy of the US health care safety net for low-income and uninsured individuals.¹⁵Canada has a publicly funded system of universal health insurance that consists of single-payer plans administered by each province. All medically necessary physician services and hospital-based care are fully covered with no copayments. However, the extent to which such a system meets the needs of severely disadvantaged individuals has not been well defined.^16,17 Our objectives were to determine the prevalence of unmet needs for health care among homeless single men, single women, and women with dependent children within Canada''s universal health insurance system and to identify individual characteristics associated with having unmet needs.     

Variations in Health and Health Behaviors by Nativity Among Pregnant Black Women in Philadelphia

Objectives. We compared health behaviors and health outcomes among US-born, African-born, and Caribbean-born pregnant Black women and examined whether sociodemographic and psychosocial characteristics explained differences among these population subgroups.Methods. We analyzed data from a prospective cohort study conducted in Philadelphia, Pennsylvania, with a series of nested logistic regression models predicting tobacco, alcohol, and marijuana use and measures of physical and mental health.Results. Foreign-born Black women were significantly less likely to engage in substance use and had better self-rated physical and mental health than did native-born Black women. These findings were largely unchanged by adjustment for sociodemographic and psychosocial characteristics. The foreign-born advantage varied by place of birth: it was somewhat stronger for African-born women than for Caribbean-born women.Conclusions. Further studies are needed to gain a better understanding of the role of immigrant selectivity and other characteristics that contribute to more favorable health behaviors and health outcomes among foreign-born Blacks than among native-born Blacks in the United States.Studies examining health differences among immigrant subgroups and their native-born counterparts have largely focused on Hispanics. This literature consistently shows that Hispanics born outside the United States have lower mortality rates and better health and reproductive outcomes than do US-born Hispanics.^1–3 These studies also reveal that the protective effect of foreign-born status varies by country of origin.^4,5 For example, Cho et al. found that Mexican immigrants had better self-reported health status, fewer activity limitations, and fewer sick days confined to bed than did persons from Cuba and Central America,⁴ and Hummer et al. reported a similar variation for infant mortality rates.³Far less is known about the health of foreign-born Black immigrants, who make up an expanding proportion of US immigrants. For example, in 1960 fewer than 1% of Black US residents were foreign born; by 2005 this figure increased to 8%.^6,7 Studying health differentials among native-born and foreign-born Blacks may shed light on factors that contribute to racial health disparities in the United States.Previous studies showed that health behaviors, health status, and reproductive outcomes were more favorable among foreign-born Blacks than among native-born Blacks.^3,8–10 However, only a handful of studies have examined health status¹¹ or birth outcomes^12–15 among foreign-born Blacks by region of birth. These studies found that foreign-born Black women, whether from the Caribbean¹⁴ or Africa,¹² were less likely than US-born Black women to have low-birth-weight infants. A recent study of 2000 vital records for New York, New York, observed that although the risk of low birth weight was lower among infants of foreign-born Black mothers than among infants of native-born Black mothers, that risk varied by the foreign-born mothers'' place of birth: infants born to women from the Dominican Republic had the lowest risk, and infants born to women from Haiti had the highest risk.¹⁵ Proposed explanations for more favorable birth outcomes and better health status among the foreign-born include selective migration, greater social support, and fewer adverse health behaviors.^{4,5,9,13,14,16–18}We examined the role of nativity in health behaviors and health status among pregnant Black women in Philadelphia, Pennsylvania. We compared health behaviors and status among Black women born in the United States, the Caribbean, and Africa. Our data, collected through extensive face-to-face interviews, allowed us to examine whether individual-level sociodemographic and psychosocial characteristics explained differences in behavior and health among Black women by region of birth.     

Intergenerational relationships between the smoking patterns of a population-representative sample of US mothers and the smoking trajectories of their children

Objectives. We assessed intergenerational transmission of smoking in mother-child dyads.Methods. We identified classes of youth smoking trajectories using mixture latent trajectory analyses with data from the Children and Young Adults of the National Longitudinal Survey of Youth (n = 6349). We regressed class membership on prenatal and postnatal exposure to maternal smoking, including social and behavioral variables, to control for selection.Results. Youth smoking trajectories entailed early-onset persistent smoking, early-onset experimental discontinued smoking, late-onset persistent smoking, and nonsmoking. The likelihood of early onset versus late onset and early onset versus nonsmoking were significantly higher among youths exposed prenatally and postnatally versus either postnatally alone or unexposed. Controlling for selection, the increased likelihood of early onset versus nonsmoking remained significant for each exposure group versus unexposed, as did early onset versus late onset and late onset versus nonsmoking for youths exposed prenatally and postnatally versus unexposed. Experimental smoking was notable among youths whose mothers smoked but quit before the child''s birth.Conclusions. Both physiological and social role-modeling mechanisms of intergenerational transmission are evident. Prioritization of tobacco control for pregnant women, mothers, and youths remains a critical, interrelated objective.Women who smoke during pregnancy are more likely to have offspring who become adolescent smokers.^1–7 Studies link mother''s smoking during pregnancy with youths'' earlier smoking initiation,^3,7–9 greater persistence in regular smoking,^3,7 and stronger nicotine dependency.^6,8,10,11Hypothesized physiological pathways for mother-to-child transmission of smoking are reviewed elsewhere^12–14 and may include inherited susceptibility to addiction alone or in combination with in utero neurodevelopmental exposure and scarring that activates nicotine susceptibility. Furthermore, because few women who smoke during pregnancy quit after delivery^15,16 higher rates of smoking among offspring may reflect role modeling of maternal smoking behavior. Notably, parental smoking is hypothesized to demonstrate pro-smoking norms and solidify pro-smoking attitudes.^17,18Studies considering both smoking during pregnancy and subsequent maternal smoking outcomes have sought to distinguish between these proposed social and physiological transmission pathways.^{1–4,6,7,9,19} Similarly, studies controlling for family sociodemographic factors^{1,2,4,5,7,8,10,11,19,20} or maternal propensity for health or risk taking^1,2,9,10 have sought to further distinguish direct physiological or social transmission from selection. Studies considering children''s cognitive and behavioral outcomes have shown that selection by maternal social and behavioral precursors to smoking during pregnancy strongly biases findings on smoking during pregnancy^21,22; however, it remains unclear whether this is also the case for youth smoking. Some studies^2,3,5,6,19 have observed that smoking during pregnancy operates independently of subsequent maternal smoking. A few have found that smoking during pregnancy is only independently associated in select analyses (e.g., for initiation but not frequency or number of cigarettes^6,9 or only among females^7,20). Several have found that smoking during pregnancy does not operate independently of subsequent maternal smoking behavior,^1,4 and the remaining studies do not address postnatal maternal smoking.^8,9,11We explored whether these inconsistencies in findings supporting social or physiological mechanisms for intergenerational transmission can be accounted for by more comprehensively examining maternal and child smoking behavior. Previous work has established the advantages of statistical models for youth smoking trajectories that capture initiation, experimentation, cessation, or continued use.^23–28 Studies focusing on parental smoking concurrent with youth smoking suggest that postnatal exposures may differentially predispose youths for specific smoking trajectories.^24,26–28 Only 3 known studies have considered whether smoking during pregnancy influences youth smoking progression, and these have shown greater likelihood of early regular use^3,11 and telescoping to dependence.⁸ However, limitations of sample selectivity and measurement and modeling of maternal and youth smoking outcomes restrict the generalizability and scope of these findings.²⁹ To specifically address these limitations and more comprehensively assess hypothesized intergenerational transmission pathways, we used US population–representative data, latent variable techniques, and a rich set of data on maternal and youth smoking and social and behavioral selection factors. We characterized trajectories of youth smoking from adolescence through young adulthood and considered exposure to various maternal smoking patterns from prebirth to the child''s early adolescence.     

Improving the health and mental health of people living with HIV/AIDS: 12-month assessment of a behavioral intervention in Thailand

Objectives. We examined findings from a randomized controlled intervention trial designed to improve the quality of life of people living with HIV in Thailand.Methods. A total of 507 people living with HIV were recruited from 4 district hospitals in northern and northeastern Thailand and were randomized to an intervention group (n = 260) or a standard care group (n = 247). Computer-assisted personal interviews were administered at baseline and at 6 and 12 months.Results. At baseline, the characteristics of participants in the intervention and standard care conditions were comparable. The mixed-effects models used to assess the impact of the intervention revealed significant improvements in general health (B = 2.51; P = .001) and mental health (B = 1.57; P = .02) among participants in the intervention condition over 12 months and declines among those in the standard care condition.Conclusions. Our results demonstrate that a behavioral intervention was successful in improving the quality of life of people living with HIV. Such interventions must be performed in a systematic, collaborative manner to ensure their cultural relevance, sustainability, and overall success.People living with HIV/AIDS in Thailand face multiple challenges, including coping with HIV-related disclosure and stigma and maintaining positive family relationships. HIV disclosure has been identified as a key stressor for people living with HIV in Thailand^1–3; when patients do not disclose their serostatus, their odds of becoming depressed increase 3-fold.⁴ Disclosure is also a key issue among Thai HIV support groups.⁵ Once individuals disclose their serostatus to their partners and family members, treatment becomes a challenge for the entire family.In addition to disclosure, it is necessary to address stigma as an HIV-related stressor. We have documented a high level of perceived stigma in Thailand and associations with other conditions, including a significant association between stigma and depression.⁶ People living with HIV in Thailand also face challenges with respect to maintaining general health routines,⁷ including medical visits, prophylactic treatment of symptoms (e.g., hepatitis C virus, pneumonia, tuberculosis),⁸ adherence to antiretroviral therapy (ART),⁹ knowledge of the course of their disease, and effective communication with doctors.By contrast, other factors have been shown to have a positive effect on management of HIV. For example, Thailand is a strongly family-oriented society, and typical Thai families are tightly knit. Therefore, family social support may help people living with HIV increase their adherence to ART and decrease their risk of depression.^9,10 Parents of children living with HIV need information about how their children may respond to their illness, how to parent children while dealing with their own illness, how to maintain positive family routines, and how to generate positive parental bonds with their children. Knowledge in such areas is hypothesized to improve patients’ quality of life and their children''s long-term adjustment.^11–13Past behavioral interventions in Thailand have framed HIV as an individual stressor for people living with the disease.^14,15 To address the multiple negative and positive factors faced by people living with HIV and their families in Thailand, we conducted a randomized controlled intervention trial in the northern and northeastern areas of the country. On the basis of the work of Rotheram-Borus et al.,^13,16–21 we identified common factors, processes, and principles shared across evidence-based interventions^22–24 and adapted them to address the specific needs of people living with HIV in Thailand. Here we describe findings based on data collected at baseline, 6 months, and 12 months to assess the efficacy of a cognitive-based intervention designed to improve the quality of life of people living with HIV.