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

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

Family History of Cancer and Its Association With Breast Cancer Risk Perception and Repeat Mammography

Objectives. We examined the strength of association between family history of breast cancer and family history of other cancers with breast cancer risk perception and repeat mammography.Methods. The sample included 6706 women, aged 46 to 74 years, with no breast cancer history. Multinomial logistic regression assessed the association between family history of cancer and breast cancer risk perception. Structural equation modeling estimated the relationship between family history of cancer and repeat mammography.Results. Breast cancer risk perception was strongly associated with family history of breast cancer in the mother or mother and sister (odds ratio [OR] = 32.15; P < .001); family history of breast cancer in the sister, daughter, or male first-degree relative (OR = 6.6–8.4; P < .001); and maternal history of other cancers (OR = 1.38–2.73; P < .001). For repeat mammography, women with maternal history of breast cancer had a mean increase of 0.50 more mammograms in the past 6 years compared with women without maternal history of breast cancer (P < .001).Conclusions. Breast cancer risk perception was associated with the type of cancer found in first-degree relatives and with the person’s relationship to the family member with cancer. Family history of breast cancer affected repeat mammography behavior.Estimated to be diagnosed in 1 of every 8 women in their lifetime, breast cancer continues to present a public health concern.1 Secondary prevention in the form of screening mammography has been shown to be the most effective population-wide approach to reducing the morbidity and mortality associated with breast cancer,2–7 and studies indicate that each year of delay between screening mammograms decreases the life-sparing potential of screening by approximately 33%.2,4–7Lower breast cancer morbidity and mortality are associated with repeat mammography. Because delays between screenings can affect the efficacy of mammography screening programs, it becomes important to understand the overall pattern of women’s mammography use—the question is not only whether a woman had a mammogram, nor when was her last mammogram, but rather, has she been having mammograms at regular intervals since she was eligible for routine screening? Has she established a behavioral pattern of repeat mammography?Studies on repeat mammography, using medical records, have shown that the majority of eligible women are not screened annually. In one of the largest studies of its kind, Blanchard et al.2 found that over a 10-year period only 6% of women received all annual mammograms. The mean number of mammograms was 5.06, consistent with the new United States Preventive Service Task Force recommendations, but half that of most screening guidelines at the time of the study.2,8 When these results were stratified by age, race/ethnicity, zip code, income, language, insurance status, previous screening use, and medical history, no grouping of women showed a propensity toward repeat annual screening.2 These results were echoed in 2 other studies using medical records to ascertain levels of repeat mammography over a minimum of 5 years: 16% in women aged 50 to 74 years enrolled in a health maintenance organization in Michigan9 and 30% in women aged 65 years and older enrolled in the California Fee-for-Service Medicare plan10 received 5 mammograms in a 5-year period.In attempting to increase participation in a health behavior (in this case, mammography), health behavior theorists often include the concept of risk perception or constructs related to risk perception in their frameworks. Because risk perception is a subjective judgment made at an individual level regarding the characteristics and severity of a risk, the framework of this research relies on both a psychological and public health approach. The psychological (individual) approach is based on early psychometric research by Tversky and Kahneman,11 who identified heuristics that individuals rely on when making judgments of the comparative risk of an event, including availability (events that are easily brought to mind), anchoring (anchoring the known information to the unknown), and threshold effect (determining how much of a risk reduction is worthwhile). The public health approach relies on the concept of risk perception or susceptibility found in multiple health behavior models, including, but not limited to, the health belief model,12 protection motivation theory,13 the self-regulation model,14 the theory of reasoned action,15 the theory of planned behavior,16 and expected utility theory.17Multiple studies indicate that family history of breast cancer is the risk factor that women base their own risk perception on.18–20 However, breast cancers resulting from familial or genetic predisposition are thought to account for only 15% to 20% of all diagnosed cases; this means that 80% to 85% of breast cancers are occurring in women with no family history of the disease. Overreliance on family history of breast cancer to determine one’s own breast cancer risk may skew not only breast cancer risk perception, but may also affect rates of repeat mammography screening.Given the importance that women place on family history of breast cancer, the aim of this research was to determine the strength of the relationship between family history of breast cancer and family history of cancer other than breast cancer to perceived risk of developing cancer and to repeat mammography. It was hypothesized that differences in risk perception were associated with a family history of breast cancer, and that a family history of breast cancer predicted increased repeat mammography. The results might serve to elucidate the role family history of cancer plays in secondary prevention of breast cancer.     

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

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

Adherence to Mammography Screening Guidelines Among Transgender Persons and Sexual Minority Women

We used retrospective (2012–2013) chart review to examine breast cancer screening among transgender persons and sexual minority women (n = 1263) attending an urban community health center in Massachusetts. Transgender were less likely than cisgender patients and bisexuals were less likely than heterosexuals and lesbians to adhere to mammography screening guidelines (respectively, adjusted odds ratios = 0.53 and 0.56; 95% confidence intervals = 0.31, 0.91 and 0.34, 0.92) after adjustment for sociodemographics. Enhanced cancer prevention outreach is needed among gender and sexual minorities.Sexual minority women (those who report partnering with women or identify as lesbian or bisexual) may experience elevated breast cancer risk1; however, research suggests they obtain screening mammography less often than other women.2–5 Little is known about mammography use among transgender persons (those whose gender identity is incongruent with their birth-assigned sex). Consensus groups recommend that female-to-male transmen without bilateral mastectomy follow screening guidelines for cisgender women.6–8 Recommendations for male-to-female transwomen are less clear.9 Some experts suggest following similar guidelines for transwomen,7 especially for those with additional risk factors, such as being older than 50 years,8 family history, body mass index greater than 35 kilograms per meters squared, or estrogen or progestin use for 5 or more years.6 Understanding mammography utilization among these often-marginalized groups is important in addressing breast cancer disparities. We investigated adherence to mammography screening guidelines at an urban community health center in Massachusetts that serves a large population of gender and sexual minorities.     

Racial/Ethnic and Socioeconomic Differences in Short-Term Breast Cancer Survival Among Women in an Integrated Health System

Objectives. We examined the combined influence of race/ethnicity and neighborhood socioeconomic status (SES) on short-term survival among women with uniform access to health care and treatment.Methods. Using electronic medical records data from Kaiser Permanente Northern California linked to data from the California Cancer Registry, we included 6262 women newly diagnosed with invasive breast cancer. We analyzed survival using multivariable Cox proportional hazards regression with follow-up through 2010.Results. After consideration of tumor stage, subtype, comorbidity, and type of treatment received, non-Hispanic White women living in low-SES neighborhoods (hazard ratio [HR] = 1.28; 95% confidence interval [CI] = 1.07, 1.52) and African Americans regardless of neighborhood SES (high SES: HR = 1.44; 95% CI = 1.01, 2.07; low SES: HR = 1.88; 95% CI = 1.42, 2.50) had worse overall survival than did non-Hispanic White women living in high-SES neighborhoods. Results were similar for breast cancer–specific survival, except that African Americans and non-Hispanic Whites living in high-SES neighborhoods had similar survival.Conclusions. Strategies to address the underlying factors that may influence treatment intensity and adherence, such as comorbidities and logistical barriers, should be targeted at low-SES non-Hispanic White and all African American patients.Breast cancer is the most common cancer among women in the United States, and it is the second leading cause of cancer death.1 Despite significant improvements in breast cancer survival from 1992 to 2009,1,2 racial/ethnic and socioeconomic survival disparities have persisted.3,4 African American women have consistently been found to have worse survival after breast cancer,3,5–11 Hispanic women have worse or similar survival,3,9,11,12 and Asian women as an aggregated group have better or similar survival3,9,11,12 than do non-Hispanic White women. Underlying factors thought to contribute to these racial/ethnic disparities include differences in stage at diagnosis,8,12,13 distributions of breast cancer subtypes,14–16 comorbidities,12,13,17 access to and utilization of quality care,13,18 and treatment.12,13Numerous studies also have found poorer survival after breast cancer diagnosis among women residing in neighborhoods of lower socioeconomic status (SES).6,9,19,20 Research has shown that inadequate use of cancer screening services, and consequent late stage diagnosis and decreased survival, contribute to the SES disparities.21,22 Similar to racial/ethnic disparities, SES disparities have been attributed to inadequate treatment and follow-up care and comorbidities.18 Previous population-based studies have continued to observe racial/ethnic survival disparities after adjusting for neighborhood SES, but these studies have not considered the combined influence of neighborhood SES and race/ethnicity.3,9,11,12,23 These disparities may remain because information on individual-level SES, health insurance coverage, comorbidities, quality of care, and detailed treatment regimens have typically not been available.3,8,9,11,13 Even among studies using national Surveillance Epidemiology and End Results–Medicare linked data, in which more detailed information on treatment and comorbidities are available among some patients aged 65 years and older, survival disparities have remained.12,23,24 However, not all data on medical conditions and health care services are captured in Medicare claims, including data on Medicare beneficiaries enrolled in HMOs (health maintenance organizations).25,26Using electronic medical records data from Kaiser Permanente Northern California (KPNC) linked to data from the population-based California Cancer Registry (CCR), we recently reported that chemotherapy use followed practice guidelines but varied by race/ethnicity and neighborhood SES in this integrated health system.27 Therefore, to overcome the limitations of previous studies and address simultaneously the multiple social28 and clinical factors affecting survival after breast cancer diagnosis, we used the linked KPNC–CCR database to determine whether racial/ethnic and socioeconomic differences in short-term overall and breast cancer–specific survival persist in women in a membership-based health system. Our study is the first, to our knowledge, to consider the combined influence of neighborhood SES and race/ethnicity and numerous prognostic factors, including breast cancer subtypes and comorbidities, thought to underlie these long-standing survival disparities among women with uniform access to health care and treatment.     

The Effect of a “Maintain,Don’t Gain” Approach to Weight Management on Depression Among Black Women: Results From a Randomized Controlled Trial

Objectives. We evaluated the effect of a weight gain prevention intervention (Shape Program) on depression among socioeconomically disadvantaged overweight and obese Black women.Methods. Between 2009 and 2012, we conducted a randomized trial comparing a 12-month electronic health–based weight gain prevention intervention to usual primary care at 5 central North Carolina community health centers. We assessed depression with the Patient Health Questionnaire (PHQ-8). We analyzed change in depression score from baseline to 12- and 18-month follow-up across groups with mixed models. We used generalized estimating equation models to analyze group differences in the proportion above the clinical threshold for depression (PHQ-8 score ≥ 10).Results. At baseline, 20% of participants reported depression. Twelve-month change in depression scores was larger for intervention participants (mean difference = −1.85; 95% confidence interval = −3.08, −0.61; P = .004). There was a significant reduction in the proportion of intervention participants with depression at 12 months with no change in the usual-care group (11% vs 19%; P = .035). All effects persisted after we controlled for weight change and medication use. We saw similar findings at 18 months.Conclusions. The Shape Program, which includes no mention of mood, improved depression among socioeconomically disadvantaged Black women.Depression is one of the most common and disabling, yet treatable, mental health conditions in the United States.1,2 Women are twice as likely as men to be affected,3 and more than 1 in 7 (14.9%) Black women will experience major depression in their lifetime.4 Observational evidence suggests that, although the prevalence of major depression is lower among Blacks than Whites, its severity is greater for Blacks.5 This is likely a result of racial disparities in access to depression treatment.6 Indeed, compared with their White counterparts, Black adults with depression are less likely to receive treatment for depression (39.7% vs 54.0%).6 Of those who do seek treatment, Blacks are less likely than Whites to receive care that corresponds to clinical practice guidelines.6,7 These racial disparities are magnified by socioeconomic disadvantage.8 Depression is 3 times more common for those with incomes below the federal poverty level, compared with those with higher incomes.9 As a consequence, the challenge remains how to effectively treat socioeconomically disadvantaged Black women with depression.Obesity is also disproportionately prevalent among Black women relative to other racial/ethnic groups.10 The high burden of obesity among Black women not only indicates a higher prevalence of obesity-related chronic diseases (e.g., diabetes, heart disease),11 but it may also have an impact on psychosocial outcomes such as depression.12 As such, interventions focusing on behavioral weight control may present a useful opportunity to address both obesity and depression.Behavioral weight loss interventions typically include frequent contact with a weight loss counselor; self-monitoring of diet, exercise, and weight; and lessons that cover various topics such as problem solving, relapse prevention, and stress management. Indeed, across numerous studies, behavioral weight loss interventions have been shown to promote reductions in depression.13,14 Such findings are generally believed to be related to weight loss15 and mediated by improvements in body satisfaction; that is, for many, weight loss might enhance body satisfaction and, thus, improve depression outcomes.16,17 However, this finding has most frequently been demonstrated in predominantly socioeconomically advantaged White women, who tend to exhibit strong relations between body size and mood.16,18 In contrast, Black women have greater social acceptance of overweight, less body weight dissatisfaction, and higher body weight ideals compared with White women.19–22 Thus, it is unclear whether Black women would experience a similar reduction in depression as a result of obesity treatment.Although weight loss is indicated for those with obesity, promoting clinically meaningful weight change among Black women has been a major challenge.23 Across various studies, Black women achieve less weight loss relative to White women.24–26 The reason for this racial disparity in weight loss outcomes is unclear, but may be influenced in part by differences in sociocultural norms related to weight, diet, and physical activity.27 As a result, interventions that focus on preventing weight gain may be a useful alternative treatment approach among overweight and obese Black women.27We recently conducted a study titled the Shape Program, a 12-month randomized controlled trial with follow-up at 18 months, evaluating an electronic health weight gain prevention intervention among Black women compared with usual care in the primary care setting.27 The Shape intervention was found to be effective in staving off weight gain at 12 and 18 months.28 It is unclear whether a weight gain prevention approach, as was tested in Shape, would be helpful for treating depression among Black women. As such, we sought to examine the potential spillover benefits produced by this “maintain, don’t gain” approach on depression, compared with usual care.     

Initiation of Human Papillomavirus Vaccination Among Predominantly Minority Female and Male Adolescents at Inner-City Community Health Centers

Objectives. We examined the prevalence and correlates of human papillomavirus (HPV) vaccine initiation among adolescents in low-income, urban areas.Methods. The study consisted of electronic health record data on HPV vaccination for 3180 adolescents (aged 10–20 years) at a multisite community health center in 2011.Results. Only 27% initiated the HPV vaccine. The adjusted odds ratio (AOR) of HPV vaccination was lower among older adolescents (AOR = 0.552; 95% confidence interval [CI] = 0.424, 0.718) and those seen by nonpediatric health care providers (HCPs; AOR = 0.311; 95% CI = 0.222, 0.435), and higher among non-English speakers (AOR = 1.409; 95% CI = 1.134, 1.751) and those seen at 2 site locations (AOR = 1.890; 95% CI = 1.547, 2.311). Insurance status was significant only among female and Hispanic adolescents. Language was not a predictor among Hispanic adolescents. Across all analyses, the interaction of age and HCP specialty was associated with HPV vaccination. Dramatically lower HPV vaccination rates were found among older adolescents seen by nonpediatric HCPs (3%–5%) than among other adolescents (23%–45%).Conclusions. Improving HPV vaccination initiation in low-income urban areas is critical to reducing disparities in cervical and other HPV-related cancer, especially among Black, Hispanic, and low-income populations.Human papillomavirus (HPV) infection is a known risk factor for the development of several cancers. Between 2004 and 2008, there was a national average of 33 369 HPV-associated cancers annually, including cervical, vulvar, vaginal, penile, anal, and oropharyngeal cancers.1 The Centers for Disease Control and Prevention estimates 26 000 new HPV-associated cancers each year, 18 000 for women and 8000 for men,1 which could be prevented through the HPV vaccine.According to the US Cancer Statistics Working Group,2 there are pervasive disparities in national morbidity and mortality rates of HPV-related cancers for Black and Hispanic individuals. Cervical cancer is more common among Black and Hispanic women and results in disproportionately higher mortality for Black women. In 2009, the national age-adjusted cervical cancer incidence rates (per 100 000) for Hispanic and Black women (10.9 and 10.0, respectively) were higher than the rate for White women (7.6).2 The national age-adjusted cervical cancer mortality rate (per 100 000) for Black women (4.2) is considerably higher than the rates for White and Hispanic women (2.1 and 2.9, respectively).2 Also, Black women have higher morbidity and mortality rates of vaginal cancer. Morbidity and mortality rates of penile cancers are significantly higher among Black and Hispanic men. Black men have higher morbidity and mortality rates of anal cancer.2 In addition to race/ethnicity, incidence rates of penile, cervical, and vaginal cancers increase with higher poverty rates.3 Factors that contribute to cancer disparities among Black, Hispanic, and low-income populations include higher exposure to risk factors such as smoking, physical inactivity, and HPV infection as well as lack of access to early detection and treatment services.4New Jersey had the 10th highest morbidity rate for cervical cancer nationally for 2006 through 2010.5 According to the New Jersey State Cancer Registry, cervical cancer morbidity from 2005 to 2009 was significantly higher in the Greater Newark area (relative risk = 1.86; the study target area) than other areas in the state, as well as among women who are Black, Hispanic, foreign-born, non–English-speaking, uninsured, with lower income and education, unmarried, unemployed, and living in a rented residence.6 According to a community health needs assessment for the City of Newark in 2013,7 52.4% of the residents are Black, 33.8% are Hispanic, and 30% are foreign-born, compared with 13%, 18%, and 20%, respectively, in the state. Also, 28.4% of the residents are below the federal poverty level compared with 9.4% statewide, and 28% are uninsured compared with 8.4% statewide. A significant proportion of the residents has less than a high-school education (30%) and a low level of English proficiency (25%).7Transmission of HPV can be reduced through limiting the number of sexual partners, delaying the initiation of sexual activity, practicing safe sex, and getting vaccinated.8 Two vaccines have been approved by the Food and Drug Administration for protection against HPV: the quadrivalent vaccine (Gardasil, Merck, Kenilworth, NJ) for female and male individuals aged 9 to 26 years,9 and the bivalent vaccine (Cervarix, GlaxoSmithKline, Middlesex, England) for female individuals aged 10 to 25 years.10 The HPV vaccine requires a series of 3 injections within 6 months. Markowitz et al.11 examined the rates of HPV infection among female individuals before and after the vaccine was introduced in 2006, by using data from the National Health and Nutrition Examination Surveys for 2003 through 2010. They found that for female adolescents aged 14 to 19 years, there was a 55.7% reduction in vaccine-type HPV infection rate (HPV types 6, 11, 16, and 18) and a 50% reduction in high-risk vaccine-type HPV infection rate (HPV types 16 and 18). There was also an 88% decrease among the sexually active women in their rate of vaccine-type HPV infection when they compared those who were vaccinated to those who were not vaccinated.11 Niccolai et al.12 also found significant decline in the rates of high-grade cervical lesions from 2008 to 2011 among women aged 21 to 24 years in Connecticut. Unfortunately, this trend was attenuated in urban areas as well as areas with higher concentrations of Black, Hispanic, and low-income populations.12According to the National Immunization Survey—Teen (NIS-Teen),13 HPV vaccine initiation rates for female adolescents were 44.3% in 2009, 48.7% in 2010, 53.0% in 2011, and 53.8% in 2012. This reflects minimal improvement in 2011, no improvement in 2012, and reaching a plateau for female vaccination at a level dramatically lower than the goal of 80% completion rate for girls aged 13 to 15 years set by Healthy People 2020. In site-based studies, HPV vaccine initiation among female adolescents ranged between 9.4% and 62.9%.14–21 Also, initiation for female adolescents was lower for Spanish speakers,22 those who were uninsured,23–25 those with shorter duration of enrollment in health insurance,26 in nonpediatric settings,21,24 among those who have not had a preventive visit in the past 12 months,21,24,27–30 and with mothers’ lack of knowledge about HPV infection or vaccine.18,27,28,31,32 Some studies reported lower initiation among younger female adolescents,15,18,21,24,29,30 whereas others reported the opposite.21,26 Several studies have shown the importance of health care providers’ (HCPs’) recommendations for HPV vaccine initiation among female adolescents.16,28,30,31,33According to NIS-Teen,13 HPV vaccine initiation rates for male adolescents were 1.4% in 2010, 8.3% in 2011, and 20.8% in 2012. This reflects low but steady improvement in HPV vaccination rates among male adolescents. In site-based studies, HPV vaccine initiation among male adolescents ranged between 1.1% and 30%.14,34–37 Literature is lacking on factors associated with HPV vaccine initiation among male adolescents. One study reported lower levels of knowledge among Black and Hispanic parents about the use of HPV vaccine for male adolescents.35 A few studies indicated the importance of HCPs’ recommendation for HPV vaccine initiation among male adolescents.14,35,36,38Pervasive disparities exist in HPV vaccination among Black, Hispanic, and low-income groups, and more specifically in the study target area. Even though the NIS-Teen data for 2011 and 2012 show slightly higher HPV vaccination among Black and low-income groups,39,40 several studies have demonstrated a significant and continuing trend of lower HPV vaccination among Black and Hispanic adolescents,14,15,17,24,26,41,42 as well as in low-income and urban areas.22,33,41,43 Vaccination disparities in urban areas (compared with suburban or rural areas) may be attributed to residential segregation, differential distribution of health clinics and health professionals, and unequal access to a broad range of services.44–46 As urban areas, particularly the Greater Newark area, have high proportions of immigrants who may be hesitant to seek health care services because of cultural or language barriers or concerns about immigration status,7 a study of adolescents’ adherence to public health recommendations in underserved, inner-city areas is warranted and important.Literature is lacking information on correlates of HPV vaccination among Black and Hispanic adolescents in low-income urban areas, who represent populations with the greatest disparities in cervical cancer and other HPV-related cancers compared with White and higher-income groups. Therefore, the purpose of this study was to examine the correlates of HPV vaccine initiation in a sample of predominantly Black and Hispanic adolescents at inner-city community health centers. The study addresses gaps in knowledge about the correlates of HPV vaccination among both male and female adolescents as well as a low-income predominantly minority population with pervasive disparities in cervical cancer morbidity and mortality.1–3,5,6     

Socioeconomic Status,Race, and Mortality: A Prospective Cohort Study

Objectives. We evaluated the independent and joint effects of race, individual socioeconomic status (SES), and neighborhood SES on mortality risk.Methods. We conducted a prospective analysis involving 52 965 non-Hispanic Black and 23 592 non-Hispanic White adults taking part in the Southern Community Cohort Study. Cox proportional hazards modeling was used to determine associations of race and SES with all-cause and cause-specific mortality.Results. In our cohort, wherein Blacks and Whites had similar individual SES, Blacks were less likely than Whites to die during the follow-up period (hazard ratio [HR] = 0.78; 95% confidence interval [CI] = 0.73, 0.84). Low household income was a strong predictor of all-cause mortality among both Blacks and Whites (HR = 1.76; 95% CI = 1.45, 2.12). Being in the lowest (vs highest) category with respect to both individual and neighborhood SES was associated with a nearly 3-fold increase in all-cause mortality risk (HR = 2.76; 95% CI = 1.99, 3.84). There was no significant mortality-related interaction between individual SES and neighborhood SES among either Blacks or Whites.Conclusions. SES is a strong predictor of premature mortality, and the independent associations of individual SES and neighborhood SES with mortality risk are similar for Blacks and Whites.From birth through approximately age 85 years, there is a mortality rate disparity between Blacks and Whites in the United States that peaks in early adulthood and slowly narrows thereafter.1–4 Most of the excess deaths among Blacks occur in middle-aged adults, given the confluence of rising mortality rates and the disparity at those ages. During much of the 20th century, this disparity was unyielding,4–6 but recent data point to some narrowing of the gap beginning in the 1990s.7–9 Still, in 2011 the highest age-standardized death rate in the United States was that among non-Hispanic Blacks (877.4 per 100 000 standard population), followed by non-Hispanic Whites (738.1 per 100 000 standard population).10 Also, average life expectancies at birth in 2011 were 4.5 years shorter for Black than White men and 3.1 years shorter for Black than White women.10Although national mortality data are routinely reported by race/ethnicity, their interpretation must consider the determinants of race-specific mortality rates, including behavioral, social, economic, and political factors that determine the resources available to maintain health and prolong life.3 Whether socioeconomic status (SES) completely accounts for mortality differences between Blacks and Whites is not clear. Previous studies have reported that SES alone cannot fully account for the disparity, although in settings where Blacks and Whites are drawn from considerably different SES strata, confounding by SES may be difficult to overcome.11–14 By contrast, in settings where race-specific SES differences are minimal (including the current study), it has been suggested that important health indicators are quite similar by race.15–17 Individual-level SES aside, neighborhood-level SES has also been reported to influence mortality rates,18 but fewer investigations have assessed the joint contribution of individual and neighborhood SES,19–22 and analyses assessing the interplay of these 2 SES domains with race are rare.19,21We thus took the opportunity, within a large prospective study of non-Hispanic Black and White adults (residing in a large area of the United States, enrolled mainly in low-income settings but also non-low-income settings, and representing a range of SES levels), to evaluate the independent and joint contributions of race, individual SES, and neighborhood SES to overall and cause-specific mortality risk.     

Age at Menarche: 50-Year Socioeconomic Trends Among US-Born Black and White Women

Objectives. We investigated 50-year US trends in age at menarche by socioeconomic position (SEP) and race/ethnicity because data are scant and contradictory.Methods. We analyzed data by income and education for US-born non-Hispanic Black and White women aged 25 to 74 years in the National Health Examination Survey (NHES) I (1959–1962), National Health Examination and Nutrition Surveys (NHANES) I–III (1971–1994), and NHANES 1999–2008.Results. In NHES I, average age at menarche among White women in the 20th (lowest) versus 80th (highest) income percentiles was 0.26 years higher (95% confidence interval [CI] = −0.09, 0.61), but by NHANES 2005–2008 it had reversed and was −0.33 years lower (95% CI = −0.54, −0.11); no socioeconomic gradients occurred among Black women. The proportion with onset at younger than 11 years increased only among women with low SEP, among Blacks and Whites (P for trend < .05), and high rates of change occurred solely among Black women (all SEP strata) and low-income White women who underwent menarche before 1960.Conclusions. Trends in US age at menarche vary by SEP and race/ethnicity in ways that pose challenges to several leading clinical, public health, and social explanations for early age at menarche and that underscore why analyses must jointly include data on race/ethnicity and socioeconomic position. Future research is needed to explain these trends.Age at menarche is of clinical, public health, and social importance,1–4 but in the United States scant and contradictory data exist as to whether trends in the overall declining age at menarche1,2 vary by race/ethnicity and socioeconomic position (SEP), singly and combined.5–9 Highlighting the biological relevance of age at menarche, evidence indicates age at menarche is influenced by nutrition from gestation through childhood, which is germane to girls’ risk of becoming pregnant and predictive of chronic disease, for example, early age associated with increased risk for breast cancer and cardiovascular disease.1–3 Socially, age at menarche matters for both girls’ sense of themselves and how they are treated by others, with early maturation increasing the likelihood of girls being precociously sexualized and sexually harassed.3,4Factors hypothesized to affect age at menarche range from material (e.g., impact of economic deprivation on nutrition) to psychosocial (e.g., association between childhood sexual abuse and earlier age of onset).1,2,5 Consistent with trends in improved nutrition, robust evidence indicates that age at menarche has overall declined since the early 20th century in North America and Europe.1,2,5 European and Latin American studies likewise indicate that lower age at menarche, once more common among affluent girls, has become more common among more impoverished girls, with the decline in age fastest among impoverished girls.1,10–13 In the United States, however, although some studies have reported that age at menarche and its decline are higher and faster among Black than among White girls (consistent with higher rates of poverty among the Black than among the White population), other studies have reported the reverse.6–9 No US studies have analyzed US socioeconomic trends in age at menarche overall or by race/ethnicity.To address gaps and inconsistencies in evidence, we have presented novel data on 50-year social patterns and trends in age at menarche among US-born non-Hispanic Black and White women, stratified by SEP. Additionally, we have employed a metric developed in evolutionary biology—the haldane14–16—which scales the pace of change in population traits (phenotypic or genotypic) to biological generation, rather than calendar year, and which, although rarely used in human health research, provides a benchmark for gauging the tempo of change within and across humans and other species.14     

Impact of an Exercise Intervention on Physical Activity During Pregnancy: The Behaviors Affecting Baby and You Study

Objectives. We examined the impact of a prenatal exercise intervention on physical activity in 260 women at risk for gestational diabetes mellitus.Methods. We randomized participants in the Behaviors Affecting Baby and You (BABY) Study, which took place from 2007 to 2012, to either a 12-week individually tailored, motivationally matched exercise intervention (n = 132) or to a comparison health and wellness intervention (n = 128). We assessed physical activity with the Pregnancy Physical Activity Questionnaire. We used linear mixed models to evaluate the impact of the interventions on change in physical activity according to intensity and type, total walking, and sedentary behavior.Results. Compared with the health and wellness arm, the exercise arm had significantly greater increases in sports or exercise activity (0.3 vs 5.3 metabolic equivalent of task [MET] hours/week; P < .001), and smaller declines in total activity (–42.7 vs –2.1 MET hours/week; P = .02) and activities of moderate to vigorous intensity (–30.6 vs −10.6 MET hours/week; P = .05), and was more likely to achieve recommended guidelines for physical activity (odds ratio = 2.12; 95% confidence interval = 1.45, 3.10).Conclusions. These findings extend the previous literature by demonstrating the benefits of a clinically feasible exercise intervention in an ethnically and socio-economically diverse population. Given the increased risk of adverse maternal health outcomes in ethnic minority groups, these findings may have important implications for reducing health disparities.The American College of Obstetricians and Gynecologists (ACOG) recommends that all women who are free from medical or obstetric complications engage in 30 minutes or more of moderate intensity physical activity on most days of the week.1 Physical activity during pregnancy is associated with reduced risk for excess gestational weight gain,2–4 and a reduced risk of gestational diabetes mellitus (GDM)5 and preeclampsia.6 Despite the benefits of physical activity, pregnant women are less likely to meet physical activity recommendations than nonpregnant women of childbearing age.7,8 Furthermore, physical activity levels decline throughout pregnancy, even in women who were active before pregnancy.9,10 Physical activity levels are even lower in Hispanic women; Hispanic women are 40% less likely to meet recommended levels of physical activity than are non-Hispanic White women.11 These numbers are concerning because of the excess risk of adverse maternal outcomes, such as GDM, in Hispanic women.12 Thus, it is important to develop culturally adapted interventions that can engage pregnant women in more active lifestyles.The impact of exercise interventions during pregnancy has been conflicting. Several interventions have been successful at attenuating the decrease in physical activity levels over the course of pregnancy13–15; however, most studies have observed no impact.16–20 In addition, the majority of the successful interventions to date have been conducted in predominantly White non-Hispanic study populations or have used intensive interventions that may not be feasible in clinical practice.21Individually tailored, motivationally matched interventions have been shown to be cost-effective approaches to increasing physical activity in nonpregnant women in community settings.22,23 These interventions are also readily translatable to clinical practice. However, whether these programs are effective at increasing physical activity during pregnancy is unknown. Therefore, we assessed the effectiveness of an individually tailored, motivationally matched exercise intervention on physical activity levels in an ethnically diverse sample of pregnant women at high risk for GDM.     

What “Price” Means When Buying Food: Insights From a Multisite Qualitative Study With Black Americans

Objectives. We explored the role of price in the food purchasing patterns of Black adults and youths.Methods. We analyzed qualitative data from interviews and focus groups with socioeconomically diverse, primarily female, Black adults or parents (n = 75) and youths (n = 42) in 4 US cities. Interview protocols were locality specific, but all were designed to elicit broad discussion of food marketing variables. We performed a conventional qualitative content analysis by coding and analyzing data from each site to identify common salient themes.Results. Price emerged as a primary influence on food purchases across all sites. Other value considerations (e.g., convenience, food quality, healthfulness of product, and family preferences) were discussed, providing a more complex picture of how participants considered the price of a product.Conclusions. Food pricing strategies that encourage consumption of healthful foods may have high relevance for Black persons across income or education levels. Accounting for how price intersects with other value considerations may improve the effectiveness of these strategies.In recent years, increasing attention has been given to the role that the marketing of high-calorie, low-nutrient foods and beverages has in the development of obesity, especially childhood obesity.1,2 Marketing is multifaceted, including the types of products available, where they are available, where and how they are promoted, and what they cost (the “marketing mix”).3 Food marketing variables shape the environments in which food preferences develop and in which consumers make purchasing decisions. These variables must be understood to design policies and programs to facilitate calorically and nutritionally appropriate eating patterns.Although much of the concern about food marketing has focused on children, evidence suggests that food and beverage marketing practices contribute to the higher-than-average risk of obesity and other diet-related diseases in Black persons at all ages.4,5 Black persons are more likely than White persons to be exposed to advertising and other promotions for high-calorie, low-nutrient foods and beverages, and less likely to encounter promotions for healthier alternatives.6–9 In addition, on average, Black neighborhoods have relatively fewer retail food stores that offer a wide variety of foods and relatively more fast-food outlets than other types of restaurants compared with predominantly White neighborhoods.10–15 A higher percentage of Black than White Americans have incomes near the poverty line16 and are, therefore, also affected by the disproportionate promotion and availability of high-calorie, low-nutrient foods in lower-income neighborhoods.10,13,15,17 However, the excess risks of obesity and other diet-related diseases in Black persons are not confined to the lower-income segment of the population.18–21The objective of this study was to explore the role of price in the food purchasing patterns of Black adults and youths. Price is among the strongest, if not the strongest, influences on food purchases (particularly among low-income consumers) and on caloric overconsumption.22,23 Food price may affect caloric consumption through the types or quantities of foods purchased. For example, people may buy relatively inexpensive snack foods and convenience foods that are high in fat and sugar.24 They also may feel less guilty about buying unhealthy foods if they are discounted and may eat relatively more of the products acquired at low cost or stockpiled because of quantity discounts.22,23 Price is mentioned routinely as a major influence on food purchasing decisions by Black consumers and by consumers in general.22,25–31 However, compared with other aspects of marketing, ways in which the price of products affects diet-related disparities experienced by Black adults and youths have been less well studied.Although the foods available and marketed in Black neighborhoods are relatively less healthful compared with foods marketed in White neighborhoods, available evidence does not support the hypothesis of systematic differences in food prices between Black and White neighborhoods.9,32–35 Yet these price comparison studies have not adjusted for neighborhood differences in income, which would determine what prices residents might consider affordable. Nor have they considered several other factors such as the mix of retail outlets available, availability of time and transportation to shop in other neighborhoods, price discounts, consumer food preferences, or food-specific or more general shopping patterns, all of which might influence what people buy at a given cost.22,36 This dearth of comprehensive inquiry calls for a deeper understanding of the role of food prices in purchasing behavior among Black consumers, which will inform potential marketing-related strategies for addressing obesity.     

A Heavy Burden: The Cardiovascular Health Consequences of Having a Family Member Incarcerated

Objectives. We examined the association of family member incarceration with cardiovascular risk factors and disease by gender.Methods. We used a sample of 5470 adults aged 18 years and older in the National Survey of American Life, a 2001–2003 nationally representative cross-sectional survey of Blacks and Whites living in the United States, to examine 5 self-reported health conditions (diabetes, hypertension, heart attack or stroke, obesity, and fair or poor health).Results. Family member incarceration was associated with increased likelihood of poor health across all 5 conditions for women but not for men. In adjusted models, women with family members who were currently incarcerated had 1.44 (95% confidence interval [CI] = 1.03, 2.00), 2.53 (95% CI = 1.80, 3.55), and 1.93 (95% CI = 1.45, 2.58) times the odds of being obese, having had a heart attack or stroke, and being in fair or poor health, respectively.Conclusions. Family member incarceration has profound implications for women’s cardiovascular health and should be considered a unique risk factor that contributes to racial disparities in health.Over the course of the prison boom, imprisonment has become a common event in the life course for Black men,1 especially those with low levels of education2 who reside in poor neighborhoods,3 and their families.4 Although there is no official figure for women who have a family member imprisoned, it has been estimated that as many as 3 million women annually have an incarcerated partner.5 This is likely a conservative estimate because it includes neither inmates who have multiple concurrent relationships nor other women affected by male incarceration, such as mothers, sisters, and adult children. Because 60% to 70% of Black men who did not complete high school will experience imprisonment by their early 30s,2,4 poor, minority women disproportionately experience family member imprisonment. Yet the only research that has considered the impact of male incarceration on the health of these women has focused on mental rather than physical health.6,7 This is a surprising omission because much research examines the physical and mental health consequences of imprisonment for men8–15 as well as their communities16,17 and children.18,19This oversight is problematic for 2 reasons. First, because the experience of incarceration is concentrated among men, incarceration’s indirect consequences on women’s health—transmitted through the incarceration of a family member—are likely more relevant for health among women than are their own experiences of incarceration at the aggregate level. Because the lifetime risks of imprisonment for Black men2 and paternal imprisonment for Black children20 hover around 20% to 25%, whereas risks of maternal imprisonment for Black children barely exceed 3%, mass incarceration’s indirect effects on health inequalities among women are likely larger than its direct effects. In other words, because women are at least 5 times more likely to have a family member incarcerated than to be incarcerated themselves, the effects of their own incarceration would have to dwarf the effects of having a family member incarcerated to have the same aggregate effect. Likewise, as the cumulative risks of paternal and maternal imprisonment for White children—at 3.3% and 0.6%, respectively—are far lower than are risks for Black children, the consequences are likely much more pronounced for the Black community.20Second, there is a host of reasons to expect the incarceration of a family member to harm women’s physical health beyond increasing their risk of contracting sexually transmitted disease.16,17 Indeed, exposure to family member imprisonment may compromise the physical health, particularly cardiovascular disease–related health outcomes, of women via (1) lowered socioeconomic status and family functioning, (2) reduced social support, and (3) higher levels of chronic stress.21 The incarceration of a family member brings with it not only increases in household expenses22–24 but also substantial decreases in household income25 and increases in material hardship.26 Furthermore, the incarceration of a family member often dramatically increases the stress and social isolation women feel as they struggle to deal with their family member’s absence.22,23,27 The preponderance of research suggests that because of the independent and negative effects of low socioeconomic status, chronic stress, and social isolation on health, the incarceration of a family member may contribute to a novel form of weathering—the early health deterioration of Blacks as a consequence of the accumulation of repeated experience with social and economic adversity28,29—among disadvantaged Black women (Lee and Wildeman21 provide a detailed discussion).We hypothesized that family member incarceration would be positively associated with cardiovascular disease and related risk factors among women but not men. Women shoulder the burden of childcare and household management and maintain connections to their imprisoned male family members or romantic partners.21 In addition, women are more likely to engage in overeating and sedentary behaviors as coping behaviors for stress than are men.30,31 Family member incarceration may lead to racial disparities in physical health among women because of the disproportionate experiences of this stressful life event among Black women.Using data from the National Survey of American Life (NSAL), we tested whether having a family member incarcerated is a distinct stressor that has consequences for cardiovascular risk factors and disease among women and men.     

Network Mixing and Network Influences Most Linked to HIV Infection and Risk Behavior in the HIV Epidemic Among Black Men Who Have Sex With Men

Objectives. We evaluated network mixing and influences by network members upon Black men who have sex with men.Methods. We conducted separate social and sexual network mixing analyses to determine the degree of mixing on risk behaviors (e.g., unprotected anal intercourse [UAI]). We used logistic regression to assess the association between a network “enabler” (would not disapprove of the respondent’s behavior) and respondent behavior.Results. Across the sample (n = 1187) network mixing on risk behaviors was more assortative (like with like) in the sexual network (r_sex, 0.37–0.54) than in the social network (r_social, 0.21–0.24). Minimal assortativity (heterogeneous mixing) among HIV-infected men on UAI was evident. Black men who have sex with men reporting a social network enabler were more likely to practice UAI (adjusted odds ratio = 4.06; 95% confidence interval = 1.64, 10.05) a finding not observed in the sexual network (adjusted odds ratio = 1.31; 95% confidence interval = 0.44, 3.91).Conclusions. Different mixing on risk behavior was evident with more disassortativity among social than sexual networks. Enabling effects of social network members may affect risky behavior. Attention to of high-risk populations’ social networks is needed for effective and sustained HIV prevention.The HIV epidemic among men who have sex with men (MSM) has not only grown to alarming levels overall, but it also is one that demonstrates significant and marked racial disparities. In 2008, 28% of MSM with new HIV infection were Black, and among MSM aged 13 to 29 years, the number of new infections in Black MSM was nearly twice that of White MSM.1,2Traditional epidemiological approaches have made limited headway in explaining these findings because they tend to focus on the role of individual risk behaviors in shaping rates of HIV infection. The higher rates of HIV among Black MSM may not be explained by individual-level risk behaviors alone, and instead may be attributed in part to social and sexual network factors.3,4 But efforts to further illuminate these factors have been largely unsuccessful as they have often used sampling methodologies that can distort accurate measurement of existing networks of these MSM (e.g., lack of weighting and focus on most recent sexual partner).5,6 Furthermore, up until now, network analyses have not examined Black MSM’s nonsexual social networks; such networks may contribute to the disparities observed (e.g., lack of embedded social network members7) and might provide opportunities for future interventions.Some research has explained disparities in HIV rates by examining sexual network mixing patterns within and between racial subgroups.8,9 Previously, we demonstrated that higher rates of sexually transmitted infections (STIs) within the African American community were related to sexual network mixing patterns.10 Higher levels of disassortative mixing—core high-risk groups mixing with peripheral low-risk groups—within the African American community, combined with limited interracial mixing, was a major contributor for the disproportionately higher rates of STIs among Blacks than among Whites. Similar sexual network mixing explanations have been demonstrated among Blacks in the Southeastern United States.11 Drug use behavior was found to be highly assortative (like behavior with like), whereas sexual behavior in the form of concurrent (or simultaneous) partnerships was minimally assortative.In contrast to the attention devoted to sexual12–17 and drug-use networks,18–23 comparatively little research has been conducted on how nonrisk social networks comprising MSM’s close friends and family members can affect STI and HIV transmission, with a few notable exceptions.7,24,25 Social learning and differential association theories26,27 hold that risky behaviors, including rationalizations for them, diffuse through social networks of close ties. Furthermore, network members influence high-risk behavior by virtue of the behavioral examples they provide, the normative pressures they exert, and MSM’s perceptions of these influences.28–30 Research has shown in a variety of contexts that risky sexual and substance use behavior is affected by individuals’ perceptions of what their network members do, regardless of whether those perceptions are accurate.31–33 Studying Black MSM’s normative contexts may help researchers identify not only those social conditions that facilitate risky behavior, but also potential network influences that can be exploited or modified to encourage the spread of HIV prevention behavior through modification of a social network. To date, most work that has examined the indirect role of social networks on the spread of HIV has focused primarily on the role of having social network ties in general, but has not specified the mechanisms through which social network ties affect the risk behavior of MSM.34,35Formal social network analysis of high-risk populations has focused on MSM and injecting drug users in general and not specifically on Black MSM.25,36 One recent pilot study37 demonstrated that sexual partners of Black MSM were mostly introduced through friends. Known risk behaviors associated with HIV infection and that could be “transmitted” through a social network include sex-drug use38 and unprotected anal intercourse (UAI). Moreover, group sexual intercourse has also recently gained increased attention as an important risk practice39,40 that can complicate network analysis.41 Important influences and practices such as these, however, have not been previously explored through social network analysis within Black MSM despite this population’s position as a group with the highest risk of HIV infection in the United States. Furthermore, network patterns that potentially confer risk, such as disassortative social mixing, have also not been explored within this population as opposed to the larger Black community.10,11 We conducted a detailed analysis of close social and sexual networks of Black MSM to determine the salient properties and components of these networks that are most related to HIV risk and preventive behavior among these men.     

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

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

A Novel Look at Racial Health Disparities: The Interaction Between Social Disadvantage and Environmental Health

Objectives. We explored the notion that social disadvantage increases vulnerability to the health effects of environmental hazards. Specifically, we examined (1) whether race modifies the association between blood lead and blood pressure and (2) whether socioeconomic status (SES) plays a role in this modifying effect.Methods. Using the National Health and Nutrition Examination Survey (2001–2008) and linear regression, we estimated the association between blood lead and blood pressure. Using interactions among race, SES, and lead, we estimated this association by levels of social disadvantage.Results. Black men and women showed a 2.8 (P < .001) and 4.0 (P < .001) millimeters mercury increase in SBP, respectively, for each doubling of blood lead. White adults showed no association. This lead–SBP association exhibited by Blacks was primarily isolated to Blacks of low SES. For example, poor but not nonpoor Black men showed a 4.8 millimeters mercury (P < .001) increase in SBP for each doubling of blood lead.Conclusions. Our results suggest that social disadvantage exacerbates the deleterious health effects of lead. Our work provides evidence that social and environmental factors must be addressed together to eliminate health disparities.Black–White disparities in hypertension have been well-documented for decades.1–3 A 2010 American Heart Association report put nationwide prevalence estimates at roughly 33% for White adults but 43% for Black adults.4 Economically, if Black Americans had the hypertension rates of White Americans, about $400 million would have been saved in out-of-pocket health care expenses, about $2 billion would have been saved in private insurance costs, and $375 million would have been saved from Medicare and Medicaid—per year.5 More seriously, disparities are also seen in outcomes related to hypertension. For example, mortality rates because of hypertension are roughly 15 deaths per 100 000 people for White men and women; but 40 and more than 50 per 100 000 for Black men and women, respectively.4 Disparities in hypertension account for the greatest disparities in years of lost life compared with any other health condition.6A growing body of literature in different disciplines indicates that both social and environmental factors are important in the production and maintenance of hypertension disparities.7–10 There are racial disparities in numerous social factors, such as socioeconomic status (SES), that have a robust association with hypertension.2 For example, 2009 estimates put 26% of Blacks living in poverty compared with only 12% of Whites.11 Importantly, however, controlling for poverty does not attenuate the racial disparities in hypertension, indicating that there are complex mechanisms at work.12 There are also racial disparities in numerous environmental hazards, some of which are associated with hypertension. For example, lead is causally associated with a modest increase in blood pressure and risk of hypertension in a dose-dependent manner13–16 through several biological mechanisms, including increases in oxidative stress and alterations in control of the cardiovascular system.17 Furthermore, racial disparities in lead have been reported for decades.18,19In the environmental health literature, researchers have described the notion of differential vulnerability to the deleterious health effects of environmental hazards.20,21 Some have shown that psychosocial stress and social stressors potentiate the association between lead and blood pressure. For example, in 1 study, men who report high levels of perceived stress show an association between bone lead and blood pressure, whereas men who do not report high levels of stress do not reveal this association.22 Similarly, those adults who have higher allostatic load scores, a measure of stress-related wear and tear on the body, show a stronger association between blood lead and the odds of hypertension compared with adults with lower allostatic load scores.23,24It may be that this differential vulnerability, resulting from differential exposure to social factors, contributes to racial disparities in hypertension.25 In other words, it may be that the greater social stressors and psychosocial stress experienced by Black compared with White Americans may exacerbate the health effects of environmental hazards, including lead. In fact, researchers have reported that there is a modifying effect of race on the association between blood lead and blood pressure. Specifically, Black adults exhibit a roughly 1 millimeter mercury increase in systolic blood pressure for every 3 micrograms increase in blood lead.26 Yet, no such association is seen for Whites.19,26,27 It may be that, compared with White adults, Black adults show a stronger association between lead and blood pressure because they experience greater social stressors, such as higher levels of poverty.In the present study, we have updated and expanded on previous work by examining the notion that social disadvantage, as marked by race and SES, modifies the association between blood lead and blood pressure. Specifically, we first updated the literature on the modifying effect of race on the association between blood lead and blood pressure. The most recent work in this area is based on data from 1988 to 1991. Blood lead levels have continued to decline for both Blacks and Whites.19 Because there is a dose-dependent association between lead and blood pressure, it is not known whether blood lead and blood pressure are associated for Black adults using current data (2001 to 2008). Second, we examined the role of SES, specifically education and poverty, in the stronger association between blood lead and blood pressure seen in Black compared with White adults.     

Connecting Race and Place: A County-Level Analysis of White,Black, and Hispanic HIV Prevalence,Poverty, and Level of Urbanization

Objectives. We evaluated the role of poverty in racial/ethnic disparities in HIV prevalence across levels of urbanization.Methods. Using national HIV surveillance data from the year 2009, we constructed negative binomial models, stratified by urbanization, with an outcome of race-specific, county-level HIV prevalence rates and covariates of race/ethnicity, poverty, and other publicly available data. We estimated model-based Black–White and Hispanic–White prevalence rate ratios (PRRs) across levels of urbanization and poverty.Results. We observed racial/ethnic disparities for all strata of urbanization across 1111 included counties. Poverty was associated with HIV prevalence only in major metropolitan counties. At the same level of urbanization, Black–White and Hispanic–White PRRs were not statistically different from 1.0 at high poverty rates (Black–White PRR = 1.0, 95% confidence interval [CI] = 0.4, 2.9; Hispanic–White PRR = 0.4, 95% CI = 0.1, 1.6). In nonurban counties, racial/ethnic disparities remained after we controlled for poverty.Conclusions. The association between HIV prevalence and poverty varies by level of urbanization. HIV prevention interventions should be tailored to this understanding. Reducing racial/ethnic disparities will require multifactorial interventions linking social factors with sexual networks and individual risks.Within the United States, disparities in diagnosed HIV prevalence among the 3 major racial/ethnic groups (White, Black, and Hispanic) are striking. At the end of 2009, 43% of people living with an HIV diagnosis were Black, 35% White, and 19% Hispanic.1 Concurrently, Blacks constituted only 12% of the population, non-Hispanic Whites 65%, and Hispanics 16%.2 In the 46 states with confidential name-based HIV reporting since at least January 2007, the estimated diagnosed HIV prevalence rate at the end of 2009 was 952 per 100 000 people among Blacks (near the threshold for a generalized epidemic),1 320 per 100 000 among Hispanics, and 144 per 100 000 among Whites; compared with Whites, therefore, Blacks and Hispanics were respectively 6.6 times and 2.2 times more likely to be living with an HIV diagnosis.A number of mechanisms, primarily structural and social factors, have been proposed to explain these stark racial/ethnic disparities in HIV prevalence.3,4 Structural factors, such as oppression and mistrust in government, may hinder receptivity to prevention outreach and increase HIV prevalence.3 Social constructs (e.g., homophobia and HIV stigma) may discourage open discussion of risk behaviors and limit HIV testing and treatment. Additionally, limited access to health care resources has been identified as a key driver of racial/ethnic health disparities.5 Finally, Black men are more likely than White men to be both incarcerated and infected with HIV while incarcerated.6,7 All of these factors are, in turn, associated with poverty.8 However, specific relationships among these multiple factors and racial/ethnic HIV prevalence disparities, and variation of these relationships across levels of urbanization, are not well understood.Previous analyses of national surveillance and survey data in the United States have focused on associations between HIV prevalence rates, poverty, and race exclusively in urban areas, finding no disparities in poverty-adjusted HIV prevalence rates among heterosexuals in urban settings.9,10 Furthermore, among heterosexuals living in US urban areas with high AIDS prevalence, HIV prevalence rates among those living at or below the poverty line were 2.2 times as high as rates among those living above the poverty line.10 A more recent analysis of US surveillance data confirmed the complex associations between demographics, social determinants of health, and AIDS diagnosis rates.8However, variation in these factors across the urban–rural continuum may limit generalizability of these findings to nonurban settings, where similar research is lacking. In 2009, the proportions of Black and Hispanic Americans living in poverty were roughly twice that of White Americans.11 For all races/ethnicities, the proportion living in poverty is greater in rural areas than in urban areas.12 Additionally, rural areas, with lower HIV prevalence, are more likely to be medically underserved, with reduced access to HIV care and treatment.13In the context of these complex sociodemographic associations, previously observed associations in the United States between poverty and racial/ethnic disparities in HIV may differ outside of urban areas. Therefore, using publicly available county-level data, we first describe the association between poverty and HIV prevalence by race/ethnicity across levels of urbanization. We subsequently examine racial/ethnic disparities in HIV prevalence across levels of urbanization, after controlling for poverty. We hypothesized that, in all strata of urbanization, poverty-adjusted Black–White and Hispanic–White HIV prevalence rate ratios (PRRs) would statistically differ from 1.0.     

Enhancing Condom Use Among Black Male Youths: A Randomized Controlled Trial

Objectives. We tested the efficacy of a brief intervention to promote correct and consistent use of condoms among Black male youths attending sexually transmitted infection (STI) clinics in 3 southern US cities.Methods. In 2010 to 2012, we screened (n = 1102) and enrolled (n = 702) youths aged 15 to 23 years who identified as Black and reported recent (past 2 months) sexual activity and randomized them to a private, brief, interactive intervention (n = 349) or an attention-equivalent control condition (n = 353). Assessments occurred at baseline and 2 and 6 months after the intervention.Results. At 6 months, with adjustment for age and pretest nonequivalence of the outcome variable, an estimated odds ratio (EOR) of 1.63 (95% confidence interval [CI] = 1.07, 2.49; P = .02) indicated efficacy for correct condom use. An adjusted generalized estimating equations model with both 2- and 6-month condom use variables produced an EOR of 1.49 (95% CI = 1.06, 2.08; P = .02). We did not observe significant effects on chlamydia and gonorrhea incidence.Conclusions. This brief intervention, delivered as part of STI clinical care, could help alleviate the disproportionate STI–HIV burden among young Black men.In the United States, young Black men continue to be disproportionally affected by sexually transmitted infections (STIs), including HIV.1–3 The problem is exacerbated in the southern United States.4 Unfortunately, a primary method of preventing disease acquisition and transmission among young Black men is vastly underused: the consistent and correct use of male latex condoms.5–7 The correct use of condoms is especially important in light of recent findings that only correct use is protective against STIs.8Unfortunately, most behavioral interventions have focused solely on young women9–13 or on men who have sex with men.14–20 Few behavioral interventions have focused on young Black men who have sex with women.21–23 Focus on the Future (FoF),23 classified by the Centers for Disease Control and Prevention (CDC) as an evidence-based intervention,24 was shown to reduce STI incidence among Black men aged 18 to 29 years. This 1-hour, single-session, clinic-based program was designed for patients testing positive for STIs. We adapted FoF for use with Black male youths aged 15 to 23 years attending STI clinics, regardless of diagnosis.We conducted a randomized, controlled trial of the adapted version of FoF in 3 US cities. We hypothesized that Black male youths randomized to receive FoF would report greater correct and consistent condom use and be less likely to test positive for urethral gonorrhea and chlamydia. Because of the prevalence of STIs and HIV in the southern United States, we conducted our efficacy trial in that region.     

H1N1 Influenza Vaccination During Pregnancy and Fetal and Neonatal Outcomes

Objectives. We evaluated the relationship between maternal H1N1 vaccination and fetal and neonatal outcomes among singleton births during the 2009–2010 H1N1 pandemic.Methods. We used a population-based perinatal database in Ontario, Canada, to examine preterm birth (PTB), small-for-gestational-age (SGA) births, 5-minute Apgar score below 7, and fetal death via multivariable regression. We compared outcomes between women who did and did not receive an H1N1 vaccination during pregnancy.Results. Of the 55 570 mothers with a singleton birth, 23 340 (42.0%) received an H1N1 vaccination during pregnancy. Vaccinated mothers were less likely to have an SGA infant based on the 10th (adjusted risk ratio [RR] = 0.90; 95% confidence interval [CI] = 0.85, 0.96) and 3rd (adjusted RR = 0.81; 95% CI = 0.72, 0.92) growth percentiles; PTB at less than 32 weeks’ gestation (adjusted RR = 0.73; 95% CI = 0.58, 0.91) and fetal death (adjusted RR = 0.66; 95% CI = 0.47, 0.91) were also less likely among these women.Conclusions. Our results suggest that second- or third-trimester H1N1 vaccination was associated with improved fetal and neonatal outcomes during the recent pandemic. Our findings need to be confirmed in future studies with designs that can better overcome concerns regarding biased estimates of vaccine efficacy.During the 2009–2010 H1N1 influenza pandemic, early case reports documented more severe illness among pregnant women than among the general population, as well as higher rates of hospitalization and intensive care unit admissions.1,2 Later reports confirmed the disproportionately severe clinical course among pregnant women infected with H1N1 influenza.3–6 Public health organizations7–9 and professional associations10,11 strongly encouraged pregnant women to receive an H1N1 vaccination, and recent evidence suggests that the intensive vaccination campaign resulted in higher maternal vaccination rates during the pandemic than had been documented in previous influenza seasons.12–14Recommendations for routine vaccination of all pregnant women with inactivated influenza vaccine have been in place in Canada and the United States for a number of years.15–18 Nevertheless, seasonal vaccination rates prior to the 2009–2010 pandemic year were low in the United States,19–22 ranging from 0.7% to 20% (estimates were not available for Canada). In both countries, misconceptions about the risk of complications from influenza infection during pregnancy23 and concerns about safety12,23 are commonly cited reasons for not receiving an influenza vaccination, whereas care provider recommendations have been shown to increase vaccination rates.12,14,24Despite ongoing maternal concerns about vaccine safety, no evidence of serious harmful effects following influenza vaccination during pregnancy has been reported in the available studies on this topic19–21,25–32; thus, vaccination is promoted as the best way of preventing maternal morbidity from influenza infection.31 Theoretically, maternal influenza vaccination should also benefit the fetus by averting maternal illness and associated hyperthermia and other morbidity.28,31 Recent studies have reported a lower risk of preterm birth (PTB)33 and small-for-gestational-age (SGA) infants33,34 among women receiving an influenza vaccination during their pregnancy. However, the impact of maternal influenza vaccination on fetal and neonatal outcomes has not been extensively evaluated, possibly as a result of low immunization rates and limited sample sizes that preclude assessment of rare outcomes.In Ontario, Canada, the 2009 pandemic H1N1 vaccination campaign started on October 26, 2009; high-priority groups, including pregnant women, were targeted. During the pandemic, Better Outcomes Registry & Network (BORN) Ontario collected influenza immunization information from all pregnant women who gave birth in the province. Using this large, population-based birth cohort, we examined the association between maternal H1N1 influenza vaccination and fetal and neonatal outcomes.     

Relation of Childhood Sexual Abuse,Intimate Partner Violence,and Depression to Risk Factors for HIV Among Black Men Who Have Sex With Men in 6 US Cities

Objectives. We assessed the relation of childhood sexual abuse (CSA), intimate partner violence (IPV), and depression to HIV sexual risk behaviors among Black men who have sex with men (MSM).Methods. Participants were 1522 Black MSM recruited from 6 US cities between July 2009 and December 2011. Univariate and multivariable logistic regression models were used.Results. Participants reported sex before age 12 years with someone at least 5 years older (31.1%), unwanted sex when aged 12 to 16 years (30%), IPV (51.8%), and depression (43.8%). Experiencing CSA when aged 12 to 16 years was inversely associated with any receptive condomless anal sex with a male partner (adjusted odds ratio [AOR] = 0.50; 95% confidence interval [CI] = 0.29, 0.86). Pressured or forced sex was positively associated with any receptive anal sex (AOR = 2.24; 95% CI = 1.57, 3.20). Experiencing CSA when younger than 12 years, physical abuse, emotional abuse, having been stalked, and pressured or forced sex were positively associated with having more than 3 male partners in the past 6 months. Among HIV-positive MSM (n = 337), CSA between ages 12 and 16 years was positively associated with having more than 3 male partners in the past 6 months.Conclusions. Rates of CSA, IPV, and depression were high, but associations with HIV sexual risk outcomes were modest.Despite significant medical advances, the HIV epidemic remains a health crisis in Black communities. The Black population represents only 14% of the total US population but accounted for 44% of all new HIV infection (68.9 of 100 000) in 2010.1 Black men who have sex with men (MSM) are disproportionately impacted by HIV compared with other racial/ethnic groups of MSM.1,2 Male-to-male sexual contact accounted for 72% of new infections among all Black men.1 Young Black MSM (aged 13–24 years) have a greater number of new infections than any other age or racial group among MSM.1 Researchers have been challenged with developing HIV prevention strategies for Black MSM.3–7 Higher frequencies of sexual risk behaviors, substance use, and nondisclosure of sexual identities do not adequately explain this disparity.8,9 High rates of sexually transmitted infections (STIs), which facilitate HIV transmission, and undetected or late diagnosis of HIV infection only partially explain disproportionate HIV rates.8Researchers have begun to examine a constellation of health factors that may contribute to HIV among MSM. For example, syndemic theory or the interaction of epidemics synergistically, such as intimate partner violence (IPV) and depression, may help explain HIV-related sexual risk behaviors among Black MSM.9 Childhood sexual abuse (CSA), IPV, and mental health disorders including depression may comprise such a constellation and warrant further exploration.Experiences of CSA have been identified as being associated with negative sexual health outcomes, with MSM reporting higher CSA rates than the general male population.10–12 Men with CSA experiences are more likely than men without CSA experiences to engage in high-risk sexual behaviors,13–21 have more lifetime sexual partners,13–16 use condoms less frequently,13,14,16 and have higher rates of STIs,13,14,17 exchanging sex for drugs or money,13,14,17 HIV,13,14 alcohol and substance use,13–21 and depression.13–15,18,21 Such findings suggest that sexual risk reduction counseling may need to be tailored for MSM with CSA experiences.15Childhood sexual abuse histories have also been correlated with sexual revictimization, including IPV.22–24 One study with population-based estimates of CSA found that gay and bisexually identified men had higher odds of reporting CSA (9.5 and 12.8, respectively) compared with heterosexual men.25 For sexual minority men, CSA histories were associated with higher HIV and STI incidence.25 However, research examining CSA, revictimization, and sexual risk behaviors is lacking among Black MSM.In one existing study, Black and Latino MSM with CSA histories identified their trauma experiences as influencing their adult sexual decision-making.26 Among Black MSM in 2 additional studies, emotional distress and substance use were attributed to having CSA experiences (Leo Wilton, PhD, written communication, October 2, 2013).27 In an ethnically diverse sample of 456 HIV-positive MSM, CSA was associated with insertive and receptive condomless anal sex.19Similar to CSA, IPV has not been extensively examined among MSM or Black MSM,28 but may be associated with sexual risk behaviors. Intimate partner violence is defined as a pattern of controlling, abusive behavior within an intimate relationship that may include physical, psychological or emotional, verbal, or sexual abuse.29 Little research exists on IPV among same-sex couples despite incidence rates being comparable to or greater than that of heterosexual women.28,30–34 Important IPV information comes from the National Intimate Partner and Sexual Violence Survey, a nationally representative survey for experiences of sexual violence, stalking, and IPV among men and women in the United States.28 Among men who experienced rape, physical violence, or stalking by an intimate partner, perpetrator differences by gender were found among gay, bisexual, and heterosexual men; 78% of bisexual and 99.5% of heterosexual men reported having only female perpetrators, and 90.7% of gay men reported having only male perpetrators.28 Being slapped, pushed, or shoved by an intimate partner during their lifetime was reported by gay (24%), bisexual (27%), and heterosexual (26.3%) men.28Intimate partner violence has been linked to condomless anal sex, HIV infection, substance use, CSA, and depression.35–37 Being an HIV-positive MSM has been linked with becoming a victim of IPV.38,39 Welles et al. found that being an African American MSM who initially disclosed having male partners and early life sexual abuse experiences was associated with IPV victimization.39 Wilton found that a high percentage of Black MSM reported IPV histories: emotional abuse (48.3%), physical abuse (28.3%), sexual abuse (21.7%), and stalking abuse (29.2%; Leo Wilton, PhD, written communication, October 2, 2013). Such findings lend to the importance of exploring, both independently and together, the association of CSA and IPV with sexual risk behaviors.Some studies have reported the influence of mental health (e.g., depression) on sexual risk behaviors among MSM,9,40,41 whereas others have not corroborated such findings.42 Greater rates of depression among MSM than among non-MSM samples43–45 and elevated rates of depression and anxiety among Black MSM have been reported.46 The Urban Men’s Health Study, a cross-sectional sample of MSM in 4 US cities, did not find a significant relationship between high depressive symptoms and condomless anal sex.42 However, the EXPLORE study, a randomized behavioral intervention for MSM in 6 US cities, supported the association between moderate depressive symptoms and an increased risk for HIV infection.47 Moderate levels of depression and higher rates of sexual risk were also reported for HIV-infected MSM over time.48 Another study conducted with 197 Black MSM found that moderate depressive symptoms were associated with having condomless anal sex with a serodiscordant casual partner.49 These mixed findings support the need to better understand the relationship between the severity of depression (i.e., moderate vs severe) and HIV risk behaviors.The HIV Prevention Trials Network 061 study, also known as the BROTHERS (Broadening the Reach of Testing, Health Education, Resources, and Services) Project, was a multisite study to determine the feasibility and acceptability of a multicomponent intervention for Black MSM. The current analysis aims to assess the prevalence of CSA, IPV, and depressive symptomology, and examine the relationships between these factors and insertive and receptive condomless anal sex and number of sexual partners in a large cohort of Black MSM.     

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

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