The persistent gap in health-care coverage between low- and high-income workers in Washington State: BRFSS, 2003-2007

Objectives

We examined the disparities in health-care coverage between low- and high-income workers in Washington State (WA) to provide support for possible policy decisions for uninsured workers.

Methods

We examined data from the WA Behavioral Risk Factor Surveillance System 2003–2007 and compared workers aged 18–64 years of low income (annual household income <$35,000) and high income (annual household income ≥$35,000) on proportions and sources of health-care coverage. We conducted multivariable logistic regression analyses on factors that were associated with the uninsured.

Results

Of the 54,536 survey respondents who were working-age adults in WA, 13,922 (25.5%) were low-income workers. The proportions of uninsured were 38.2% for low-income workers and 6.3% for high-income workers. While employment-based health benefits remained a dominant source of health insurance coverage, they covered only 40.2% of low-income workers relative to 81.5% of high-income workers. Besides income, workers were more likely to be uninsured if they were younger; male; Hispanic; less educated; not married; current smokers; self-employed; or employed in agriculture/forestry/fisheries, construction, and retail. More low-income workers (28.7%) reported cost as an issue in paying for health services than did their high-income counterparts (6.7%).

Conclusion

A persistent gap in health-care coverage exists between low- and high-income workers. The identified characteristics of these workers can be used to implement policies to expand health insurance coverage.Socioeconomic disparities in health and health care have increased since the 1990s.^1–3 In the U.S., while employment-based insurance is the major source of paying for health care,^4,5 the increase in health insurance premiums has outpaced workers'' earnings and inflation rates. The average cost of health insurance rose 9.6% annually from 2003 to 2007, a rate that was much higher than the overall rate of inflation (2.8%) or the increase in workers'' earnings (2.9%) during the same time period (author calculation based on a 2007 report by the Kaiser Family Foundation⁴). Rising costs impose a greater burden on low-income workers than their higher-income counterparts because low-income workers are less likely to work for a company that offers health insurance coverage.^5–9 Without employer-sponsored health insurance, few low-income workers are able to afford private coverage on their own.^7,10 Further, most of these low-income workers are ineligible for public health insurance programs.^6,10,11 This ineligibility is because in most states, income eligibility is lower for parents than for children and for those adults without dependent children.¹⁰Many factors affect the likelihood of an individual having health insurance and the source of that coverage. Work status and income play a dominant role in determining an individual''s likelihood of having health insurance.^5,7–9,12 Uninsured workers were found disproportionately in the agriculture, construction, and trade industries,^5,8,9,13 and in the farming, operators/fabricators/labors, and services sectors.^8,9 Uninsured workers also were more likely to be self-employed,^8,14 to work for small firms,^{5,7–9,13,15,16} and to be employed as part-time or temporary workers.^5,14,17,18 Socioeconomic characteristics related to lack of health-care coverage include being male, younger, from a racial/ethnic minority group, less educated, and in a low-wage or low-income job.^5,8,12,14,19 Consequently, uninsured workers were less likely to have a usual source of care and receive timely preventive services, and more likely to experience a decline in overall health.^{7,9,12,20–22}Although national uninsured trends are well documented, published work concurrently considering workers'' socioeconomics, industry, and occupation characteristics in Washington State (WA) is lacking. In an effort to expand the current knowledge on uninsured workers in WA and provide support for possible policy decisions, we conducted a multivariate analysis on health-care coverage comparing low-income workers with high-income workers by pooling the five-year WA Behavioral Risk Factor Surveillance System (BRFSS) data. Because most of the uninsured come from working families and have low incomes,^4,6,10 we identified characteristics of workers who did not have health-care coverage and examined how low-income workers have fared in health-related outcomes. The analysis presents trends, examines multiple factors that affect health insurance coverage, and discusses policy implications. We hypothesized that even after controlling the multiple factors associated with being uninsured, less health-care coverage and increased health-care costs would impose a greater burden for low-income workers and families.     

The complex web of health: relationships among chronic conditions, disability, and health services

Objectives

A critical issue in health-care reform concerns how to realign health-care delivery systems to manage medical care services for people with ongoing and costly needs for care. We examined the overlapping health-care needs of two such population groups among the U.S. working-age population (those aged 18–64 years): people with chronic medical conditions and people with disabilities.

Methods

Using the Medical Expenditure Panel Survey (2002–2004), we examined differences in health status, service use, and access to care among and between working-age adults reporting disabilities and/or one or more chronic conditions. We also analyzed people with three key chronic conditions: arthritis, diabetes, and depression.

Results

More than half of working-age people with disabilities reported having more than one chronic condition. Among those with activities of daily living or instrumental activities of daily living limitations, 35% reported four or more chronic conditions at a time. We found considerable variability in access problems and service use depending on how we accounted for the overlap of multiple conditions among people with arthritis, diabetes, and depression. However, disability consistently predicted higher emergency department use, higher hospitalization rates, and greater access problems.

Conclusions

The overall prevalence of chronic conditions among the U.S. working-age population, coupled with the high concentration of multiple chronic conditions among those with disabilities, underscores the importance of reforming health-care delivery systems to provide person-centered care over time. New policy-relevant measures that transcend diagnosis are required to track the ongoing needs for health services that these populations present.As the United States considers dramatic changes in the way its health-care delivery system is organized, two groups merit particular attention: individuals with disabilities and individuals with chronic health conditions. At a time when health-care costs are escalating at an unsustainable pace, both groups consume health-care services at a disproportionately high rate^1–6 while also experiencing less than optimal health outcomes.^7–9 Furthermore, health-care resources are not equitably distributed,¹⁰ calling for substantive changes in the way in which services are provided.The health of people with disabilities gained additional visibility on the national health agenda via the Healthy People 2010 objectives¹¹ and the Surgeon General''s Call to Action to Improve the Health and Wellness of Persons with Disabilities.¹² At the same time, the growing number of adults with chronic conditions has led to a proliferation of disease management programs,^13–17 as well as a substantial body of research describing chronic disease, its consequences, and associated responses.^1,2,9,18,19 What remains less articulated in the scientific literature is that these are actually overlapping groups. While adults with disabilities are likely to have multiple chronic conditions, adults with chronic conditions are likely to develop limitations in functioning or participation, particularly as conditions accumulate over time. In this study, we directly analyzed this overlap, with a focus on health, access to care, and service use in the U.S.Previous research shows that a substantial number of adults have multiple chronic conditions and may also have limitations in activities or functioning. For instance, in 1997, nearly 25% of Medicare beneficiaries had limitations in activities of daily living (ADLs).³ Within this group, the prevalence of cancer, stroke, diabetes, and rheumatoid arthritis was each more than 20%, and the prevalence of hypertension and osteoarthritis was higher than 50%. Treatment of these conditions required up to one health-care visit a week, and these individuals were twice as likely to be dissatisfied with the coordination of their care.²⁰Whether one considers the new medical home initiatives,²¹ obesity reduction,²² disease self-management,²³ prevention of secondary conditions among people with disabilities,²⁴ or any number of further priority items on the nation''s public health agenda,²⁵ there remains a pressing need to quantify the extent of comorbidity in the U.S. population and to clarify its associations with disability. About half of all Americans have at least one chronic condition, and given that roughly half of those individuals actually have more than one such condition at a time, the pursuit of these agenda items may be hampered if approached only one disease at a time.² Furthermore, when individuals accrue limitations in how they function or the activities they can do, additional interventions may be required to assure their access to health-care services, to coordinate the providers involved in their care, or to craft treatment regimens that accommodate their functional needs.²⁶To build upon the existing literature, we analyzed a nationally representative sample of working-age Americans, clarifying the way in which health, access to care, and service use is impacted by a single chronic condition vs. multiple chronic conditions, with or without self-reported disability limitations. As exemplars, we also examined three conditions in greater detail: arthritis, diabetes, and depression. Among the most highly prevalent chronic conditions in the U.S., these three conditions were selected because they potentially result in a wide range of health and functional impacts across different body systems, are accompanied by differing constellations of comorbid conditions, and may require care from providers in differing specialties or settings.^27–29 Thus, we examined the relative contributions of a single primary diagnosis, multiple comorbidities, and disability limitations to several key health-care measures, including access to care, ambulatory visits, hospitalizations, and emergency department (ED) use.While substantial health services research has been conducted on the impact of chronic conditions on older Americans^3,30,31 and children,^32–34 less is known about these phenomena among the working-aged, particularly for people with disabilities. Additionally, the impact of chronic conditions and disability on major life activities, such as school or work, necessarily varies with life course stage. Given the large size of the working-age population, additional concerns regarding their insurance coverage, and their distinct role expectations relative to older adults or children, we limited our analysis to people aged 18–64 years.     

HIV testing and management: findings from a national sample of Asian/Pacific islander men who have sex with men

Objectives

We examined reasons for and barriers to participating in HIV voluntary counseling and testing for Asian/Pacific Islander (A/PI) men who have sex with men (MSM) in the U.S.

Methods

We collected data between June 2007 and September 2009 in a study known as Men of Asia Testing for HIV, using a cross-sectional community-based participatory design. This national study was conducted in seven U.S. metropolitan cities through a coalition of seven community-based organizations.

Results

Participants included 445 self-identified A/PI MSM aged ≥18 years. Perception of being at risk was the number one reason for testing behaviors. For first-time testers, structural barriers (e.g., language barriers with health professionals) and fear of disclosure (e.g., sexual orientation not known to parents) were deterrents for nontesting in the past. Among previously known HIV-positive men, 22% were not seeing a doctor and 19% were not taking any HIV medications.

Conclusions

HIV testing, care, and treatment policies would be less than optimal without addressing barriers to testing, including stigma related to sexual orientation, among A/PI MSM.Men who have sex with men (MSM) continue to have the highest human immunodeficiency virus (HIV) infection rates in the U.S., with MSM of color being disproportionately affected by the disease.¹ Compared with MSM of other racial/ethnic groups, Asian/Pacific Islander (A/PI) MSM have the highest proportion of acquired immunodeficiency syndrome (AIDS) cases, with a majority of them being non-U.S.-born.^2,3 Research attributes this disparity to low testing rates^4–6 and late diagnosis, which are often associated with advanced AIDS symptoms⁷ as well as late entry into care.^8,9Voluntary counseling and testing (VCT) has been a successful standard of HIV prevention since the emergence of the epidemic in the U.S. and other developed countries.^10–14 This prevention strategy has also been adopted by other developing countries.¹⁵ Nonetheless, the uptake of VCT is still less then optimal.¹⁶ For example, combining multiple datasets from the 2000 to 2005 National Health Interview Surveys, Ostermann et al. found little change in lifetime and past year testing, respectively. However, individuals who perceived higher risks of contracting HIV were more likely to plan for and engage in actual HIV testing.¹⁷Meanwhile, the literature consistently indicates that the stigma of having HIV and/or being a sexual minority is a major barrier or determinant for efficacious or effective prevention, intervention, and treatment, especially among marginalized, vulnerable, or underserved populations.¹⁸ Using a qualitative methodology (i.e., in-depth interview), Yoshioka and Schustack found three major barriers to disclosure of HIV status among a sample of HIV-positive men of Asian descent in the U.S.: (1) protection of family from shame, (2) protection of family from obligation to help, and (3) avoidance of communication regarding highly personal information (including same-sex sexual orientation).¹⁹Collectively, these articles in the literature lend to the postulation that the effectiveness of VCT hinges on at-risk individuals having well-informed information regarding the attitudes, beliefs, and practices of HIV testing.²⁰ Although a small number of cross-sectional studies have been conducted,^6,7,9,21 little to no national data are available addressing HIV testing and HIV management among A/PI MSM. To that end, we used data from a national study of HIV prevention to describe and examine (1) reasons for and barriers to HIV testing among a national sample of A/PI MSM, and (2) care and treatment among those who have tested HIV-positive in the past, by nativity (U.S.-born vs. non-U.S.-born).     

Obesity Among Chronically Homeless Adults: Is It a Problem?

Objective

We examined rates of obesity and associated characteristics in the chronically homeless population to explore how a range of factors, including sociodemographics, housing, food source, physical and mental health, and health service use, were related to being overweight or obese.

Methods

We conducted multivariate regression analyses on a community sample of 436 chronically homeless adults across 11 U.S. cities to examine the prevalence of obesity.

Results

The majority (57%) of chronically homeless adults were overweight or obese. Chronically homeless adults who were female or Hispanic appeared to be at particular risk for obesity. There were few differences on physical and mental health by weight group. Although overweight and obese chronically homeless adults were more likely to discuss exercise with a health-care provider, they reported engaging in less exercise than those who were underweight or normal weight.

Conclusion

These findings underscore the need for greater attention to obesity in chronically homeless adults and demonstrate a food insecurity-obesity paradox or poverty-obesity link.Obesity has become a worldwide epidemic.^1–3 In the United States, 34% of adults are obese and 34% are overweight, meaning 68% are either overweight or obese.⁴ Obesity has been linked to various health problems, many of which have high morbidity and mortality, including diabetes, musculoskeletal disorders, cardiovascular disease, pulmonary disorders, and cancer.^3,5 Thus, identifying and intervening with people who are overweight or obese has become important for primary and secondary prevention.^6–8There has been little study of obesity among chronically homeless adults. Homeless adults represent a marginalized, neglected segment of the population and are known to experience poorer physical health than the general population.^9,10 Because adults who are chronically homeless lack a stable, secure residence and often cannot afford regular, healthy meals,^11–13 they are presumed to be underweight. However, this assumption has not been empirically examined, and there is evidence to suggest there may be an obesity problem among the homeless.A nationally representative survey of 1,704 homeless adults and 400 soup kitchens and shelter providers in 20 cities found that 63% of homeless adults reported obtaining meals from soup kitchens and 51% from shelters in a one-week period.¹⁴ Only 17% of soup kitchens, food pantries, and shelters surveyed were working with a nutritionist or dietician. The nutritional value of food served in many soup kitchens and shelters has been found to be low in vitamins and to exceed fat, energy, and protein content recommendations.^15,16A growing literature in the past decade has reported on a food insecurity-obesity paradox, whereby food insecurity, which often results from inadequate economic resources to purchase food, is associated with obesity, which is a consequence of overconsumption of food.^17,18 Many theories have been proposed to explain this correlation, including the low cost of energy-dense foods, binge eating habits as an adaptive physiological response to food scarcity, and childhood poverty leading to obesity in adulthood.^17,19 Related literature has also suggested a poverty-obesity link, finding that populations with high poverty rates and low education levels have the highest obesity rates.^1,20–22Yet the question remains whether there is an obesity problem among chronically homeless adults, and no prior study could be found directly addressing this question. Thus, this study aimed to examine the prevalence of obesity in a multisite community sample of chronically homeless adults and explore how a range of variables known to be related to weight, including sociodemographics, income and insurance, housing, food source, physical and mental health, and health service use, may be related to being overweight or obese.     

Barriers to routine HIV testing among Massachusetts community health center personnel

Objectives

We assessed the extent to which Centers for Disease Control and Prevention (CDC) recommendations have influenced routine HIV testing among Massachusetts community health center (CHC) personnel, and identified specific barriers and facilitators to routine testing.

Methods

Thirty-one CHCs were enrolled in the study. We compared those that did and did not receive funding support from the federal Ryan White HIV/AIDS Program. An anonymous survey was administered to a maximum five personnel from each CHC, including a senior administrator, the medical director, and three medical providers. Overall, 137 participants completed the survey.

Results

Among all CHCs, 53% of administrators reported having implemented routine HIV testing at their CHCs; however, only 33% of medical directors/providers reported having implemented routine HIV testing in their practices (p<0.05). Among administrators, 60% of those from Ryan White-supported CHCs indicated that both they and their CHCs were aware of CDC''s recommendations, compared with 27% of administrators from non-Ryan White-supported CHCs. The five most frequently reported barriers to the implementation of routine HIV testing were (1) constraints on providers'' time (68%), (2) time required to administer counseling (65%), (3) time required to administer informed consent (52%), (4) lack of funding (35%), and (5) need for additional training (34%). In a multivariable logistic regression model, the provision of on-site HIV testing by nonmedical staff resulted in increased odds of conducting routine HIV testing (odds ratio [OR] = 9.84, 95% confidence interval [CI] 1.77, 54.70). However, the amount of time needed to administer informed consent was associated with decreased odds of providing routine testing (OR=0.21, 95% CI 0.05, 0.92).

Conclusions

Routine HIV testing is not currently being implemented uniformly among Massachusetts CHCs. Future efforts to increase implementation should address personnel concerns regarding time and staff availability.In the United States, more than one million people are estimated to be living with human immunodeficiency virus (HIV); 21% are undiagnosed and/or remain unaware of their HIV infection.^1–3 Almost 40% are diagnosed late in the course of infection and receive an acquired immunodeficiency syndrome (AIDS) diagnosis within one year of their first positive HIV test result.³ To address the large number of undiagnosed HIV cases and high proportion of individuals presenting late to care, the Centers for Disease Control and Prevention (CDC) published revised recommendations in September 2006 that sought to establish HIV testing as a routine component of medical care similar to other screening procedures. Specifically, the CDC guidelines recommend that providers in all health-care settings, including hospital emergency departments, primary care practices, and community clinics, offer voluntary HIV testing to all patients aged 13–64 years and all pregnant women as an opt-out procedure, meaning that patients are to be notified that an HIV test will be conducted unless the patient declines.⁴ Separate written consent and prevention counseling as prerequisites for testing are no longer recommended.Release of the revised recommendations has sparked a national debate, and responses among the medical community have been mixed, with a majority of U.S. health professional organizations endorsing all or parts of the CDC recommendations.^5–7 While potentially increasing rates of HIV testing by streamlining consent⁸ and reducing associated stigma through normalization as a routine clinical procedure,^9,10 the elimination of a separate consent process and mandatory prevention counseling remains incompatible with several state laws or regulations and has been met with some concern.^5,11–14 Physician barriers to HIV testing include insufficient time, burdensome consent process, lack of knowledge/training about HIV testing and the CDC revised recommendations, difficulty locating HIV testing consent forms, lack of patient acceptance, competing priorities, and inadequate reimbursement.^15,16A growing body of research has examined efforts to improve HIV testing rates in a variety of health-care settings, including a public, urban medical care system,¹⁷ U.S. Department of Veterans Affairs health-care facilities,^18,19 hospital emergency departments,²⁰ a sexually transmitted disease (STD) clinic,²¹ and community health centers (CHCs).^22–24 However, while studies of CHCs have described programs to implement routine testing and largely reported patient-level data, little research to date has examined barriers to implementation among CHC personnel. CHCs represent an important source of primary care for people who are low-income, from racial/ethnic and sexual minority groups, immigrants, and those seeking mental health and substance abuse treatment services.²⁵ These populations are also disproportionately affected by HIV/AIDS, suggesting that CHCs can and do serve as an important resource for HIV/AIDS prevention and treatment.²⁶ In fact, from 1999 to 2004, CHCs conducted 7% of the total HIV tests supported by CDC yet identified 12% of the total HIV-positive results.²⁷In Massachusetts, providers face unique barriers to implementing routine testing. Despite the issuance of a June 2009 clinical advisory by the state health department supporting routine HIV testing in primary and urgent care settings, state law requires specific written informed consent before testing a patient for HIV, which is inconsistent with CDC''s recommendation to no longer require separate informed consent.^28–31 Consequently, written informed consent may be perceived as a barrier for providers to offer routine testing to patients, as this process typically requires a detailed conversation and providers are often working under already limited time constraints.^8,16 Understanding the facilitators and barriers to the implementation of routine HIV testing among CHCs in Massachusetts may have relevance to other U.S. states, where laws remain inconsistent with CDC HIV testing guidelines.^30,31We sought to gain a better understanding of HIV testing efforts among Massachusetts CHC personnel, including awareness of the CDC revised recommendations and any efforts to implement and support routine HIV testing in primary care settings. Analyses were stratified by respondent type (i.e., medical provider, administrator, and director) and funding mechanism, comparing health centers that did and did not receive support from the Ryan White HIV/AIDS Program, the federal program primarily responsible for HIV-related health services.³² Understanding the barriers and facilitators to implementing CDC''s revised recommendations may prove useful for designing educational materials and structural or individual-level interventions that will aid in conducting testing procedures in a more effective and efficient way.     

Patient-Physician Language Concordance and Use of Preventive Care Services Among Limited English Proficient Latinos and Asians

ObjectivesPatient-physician language concordance among limited English proficient (LEP) patients is associated with better outcomes for specific clinical conditions. Whether or not language concordance contributes to use of specific preventive care services is unclear.MethodsWe pooled data from the 2007 and 2009 California Health Interview Surveys to examine mammography, colorectal cancer (CRC) screening, and influenza vaccination use among self-identified LEP Latino and Asian (i.e., Chinese, Korean, and Vietnamese) immigrants. We defined language concordance by respondents reporting that their physician spoke their non-English language. Analyses were completed in 2013–2014.ResultsLanguage concordance did not appear to facilitate mammography use among Latinas (adjusted odds ratio [AOR] = 1.02, 95% confidence interval [CI] 0.72, 1.45). Among Asian women, we could not definitively exclude a negative association of language concordance with mammography (AOR=0.55, 95% CI 0.27, 1.09). Patient-physician language concordance was associated with lower odds of CRC screening among Asians but not Latinos (Asian AOR=0.50, 95% CI 0.29, 0.86; Latino AOR=0.85, 95% CI 0.56, 1.28). Influenza vaccination did not differ by physician language use among either Latinos or Asians.ConclusionsPatient-physician language concordance was not associated with higher use of mammography, CRC screening, or influenza vaccination. Language concordance was negatively associated with CRC screening among Asians for reasons that require further research. Future research should isolate the impact of language concordance on the use of preventive care services from health system factors.Language barriers in health care may reduce the quality of care received by limited English proficient (LEP) patients, serve as a hurdle to the receipt of preventive care services, and contribute to health disparities.^1–3 Patient-physician communication is enhanced by language concordance (i.e., when the physician is fluent in the patient''s non-English language). Language concordant care is associated with patient trust in physicians and greater satisfaction,^4,5 increased medication adherence,⁶ and higher rates of glycemic control among diabetic patients.⁷ In contrast, language barriers are not associated with other conditions, such as mortality or length of stay in patients with myocardial infarction.⁸Latinos and Asians are the fastest-growing racial/ethnic minority groups in the United States.⁹ Preventive care services use, such as mammography for breast cancer screening, colorectal cancer (CRC) screening, and influenza vaccination, are suboptimal in both populations.^10–16 Studies of the association between patient-physician language concordance and completion of preventive care practices report inconsistent findings. Prior work, while limited in scope, suggests that language concordance may be negatively associated with receipt of CRC screening and positively associated in some groups with mammography and influenza vaccination.^17–20 However, this work has been limited by sampling selection and by significant variation in key definitions such as LEP or language concordance itself.^18–20The California Health Interview Survey (CHIS) includes representative samples of major racial/ethnic minority groups and is conducted in multiple languages including English, Spanish, Mandarin, Cantonese, Korean, and Vietnamese. We used CHIS to examine the associations between patient report of patient-physician language concordance and patient report of use of mammography, CRC screening, and influenza vaccination among LEP Latino and Asian Americans in California.     

Evaluation of a Community Health Worker Intervention to Reduce HIV/AIDS Stigma and Increase HIV Testing Among Underserved Latinos in the Southwestern U.S.

Objectives

Latinos are at an elevated risk for HIV infection. Continued HIV/AIDS stigma presents barriers to HIV testing and affects the quality of life of HIV-positive individuals, yet few interventions addressing HIV/AIDS stigma have been developed for Latinos.

Methods

An intervention led by community health workers (promotores de salud, or promotores) targeting underserved Latinos in three southwestern U.S. communities was developed to decrease HIV/AIDS stigma and increase HIV knowledge and perception of risk. The intervention was led by HIV-positive and HIV-affected (i.e., those who have, or have had, a close family member or friend with HIV/AIDS) promotores, who delivered interactive group-based educational sessions to groups of Latinos in Spanish and English. To decrease stigma and motivate behavioral and attitudinal change, the educational sessions emphasized positive Latino cultural values and community assets. The participant pool comprised 579 Latino adults recruited in El Paso, Texas (n=204); San Ysidro, California (n=175); and Los Angeles, California (n=200).

Results

From pretest to posttest, HIV/AIDS stigma scores decreased significantly (p<0.001). Significant increases were observed in HIV/AIDS knowledge (p<0.001), willingness to discuss HIV/AIDS with one''s sexual partner (p<0.001), and HIV risk perception (p=0.006). Willingness to test for HIV in the three months following the intervention did not increase. Women demonstrated a greater reduction in HIV/AIDS stigma scores when compared with their male counterparts, which may have been related to a greater increase in HIV/AIDS knowledge scores (p=0.016 and p=0.007, respectively).

Conclusion

Promotores interventions to reduce HIV/AIDS stigma and increase HIV-related knowledge, perception of risk, and willingness to discuss sexual risk with partners show promise in reaching underserved Latino communities.Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) has disproportionately affected U.S. Latinos during the last 25 years. Although Latinos constitute 16% of the U.S. population, they account for 19% of those living with HIV and 21% of new HIV infections.¹ Since 2006, the Centers for Disease Control and Prevention (CDC) has recommended HIV testing for all people aged 13–64 years.² However, nearly half (46%) of Latino adults aged 18–64 years have never been tested, compared with 23% of black and 50% of white adults.³ Additionally, HIV testing often occurs at a late stage among HIV-positive Latinos. More than one-third (36%) of HIV-positive Latinos were diagnosed with AIDS within one year of learning their HIV status, compared with 32% of white people and 31% of black people.³ Late HIV testing hinders treatment options and may contribute to unknowing HIV transmission.Factors contributing to low HIV testing rates among Latinos include poverty, lack of health-care access, and limited availability of culturally and linguistically responsive services.^1,4–6 HIV/AIDS stigma is another factor.^7,8 UNAIDS (Joint United Nations Programme on AIDS) defines HIV stigma as the “devaluation of people either living with or associated with HIV/AIDS.”⁹ Stigma often results from fears about HIV as well as the associations of HIV with stigmatized groups such as homosexuals, sex workers, and injection drug users.^9,10HIV/AIDS stigma has negative consequences both at a population level and for individuals who are its targets, including people living with HIV/AIDS. Stigmatizing attitudes toward people living with HIV/AIDS are associated with decreased HIV testing, limited utilization of HIV prevention services, and high-risk sexual behaviors.^7,10,11 Additionally, for people living with HIV/AIDS, the stigma associated with HIV/AIDS contributes to unwillingness to disclose HIV status, unsafe sexual behaviors, delays in care seeking, reduced treatment adherence, mental health issues, and difficulties obtaining social support.^9,11–14Despite significant implications, few interventions have been developed to reduce HIV/AIDS stigma.^10,11,15 Existing interventions have often focused on specific populations (e.g., university students and health-care providers), with few interventions focused on Latinos,^11,15,16 who have high levels of stigmatizing attitudes toward people living with HIV/AIDS^1,17,18 that contribute to negative outcomes.^7,19Among Latinos, research indicates that community health workers (promotores de salud, hereinafter “promotores”) are an effective and culturally acceptable means of reaching the population with health information and motivating health behaviors.^20,21 Promotores are well positioned to promote changes in their communities because they share language and cultural values, are held in high esteem, and are perceived as role models.²¹ Promotores have been used to address health conditions ranging from chronic diseases to preventive screenings.^20–22 Several interventions have incorporated promotores into HIV prevention, finding significant changes in HIV risk behaviors, HIV counseling and testing, and other psychosocial constructs important to prevention.^16,23–29 To date, few studies have used promotores in interventions to reduce HIV stigma among Latinos.¹⁶We describe and report findings of an intervention using promotores to reduce HIV/AIDS stigma and increase willingness to seek HIV testing among Latinos in three communities in the southwestern United States: Los Angeles, California; San Ysidro, California; and El Paso, Texas.     

What Predicts Dissemination Efforts Among Public Health Researchers in the United States?

Objectives

We identified factors related to dissemination efforts by researchers to non-research audiences to reduce the gap between research generation and uptake in public health practice.

Methods

We conducted a cross-sectional study of 266 researchers at universities, the National Institutes of Health (NIH), and CDC. We identified scientists using a search of public health journals and lists from government-sponsored research. The scientists completed a 35-item online survey in 2012. Using multivariable logistic regression, we compared self-rated effort to disseminate findings to non-research audiences (excellent/good vs. poor) across predictor variables in three categories: perceptions or reasons to disseminate, perceived expectation by employer/funders, and professional training and experience.

Results

One-third of researchers rated their dissemination efforts as poor. Many factors were significantly related to whether a researcher rated him/herself as excellent/good, including obligation to disseminate findings (odds ratio [OR] = 2.7, 95% confidence interval [CI] 1.1, 6.8), dissemination important for their department (OR=2.3, 95% CI 1.2, 4.5), dissemination expected by employer (OR=2.0, 95% CI 1.2, 3.2) or by funder (OR=2.1, 95% CI 1.3, 3.2), previous work in a practice/policy setting (OR=4.4, 95% CI 2.1, 9.3), and university researchers with Prevention Research Center affiliation vs. NIH researchers (OR=4.7, 95% CI 1.4, 15.7). With all variables in the model, dissemination expected by funder (OR=2.0, 95% CI 1.2, 3.1) and previous work in a practice/policy setting (OR=3.5, OR 1.7, 7.1) remained significant.

Conclusions

These findings support the need for structural changes to the system, including funding agency priorities and participation of researchers in practice- and policy-based experiences, which may enhance efforts to disseminate by researchers.Significant investment is put toward research in public health. Ideally, the findings of this investment should improve public health practice.^1–5 Unfortunately, there is a lingering gap between research and practice.^6–10 Glasgow and Emmons identified barriers to translation of research findings into practice, such as research programs not being “packaged or manualized” for ease of implementation nor including adequate information for adapting implementation materials.⁶ The barriers have been attributed to a lack of fit between interventions and the settings in which they are implemented, as well as the information provided by the researcher and that needed by the practitioner tasked with implementation.^6,11,12 The lack of fit stems, in part, from a lack of emphasis among researchers on creating resources aimed at practitioners to ensure that the products of their research are disseminated.^6,13Many factors may influence the extent to which researchers disseminate their findings to non-research audiences.^8,11,13–15 These factors include lack of capacity among practitioners to apply research evidence, lack of practice experience among academics, lack of priority in the published literature for effectiveness and dissemination research, and, importantly, limited funds for dissemination.¹³ Another influential factor could be a lack of priority on dissemination for individual researchers and their academic settings.¹⁴ This disconnect could also stem from broader, system-wide factors such as funding structures, which contribute to less-than-optimal dissemination.^14,16,17Because numerous barriers to dissemination exist at multiple levels, there is also a gradient of options to enhance and encourage such efforts (e.g., designing for dissemination, training in dissemination, and implementation research) that fall along a spectrum of efforts to promote and enhance the capacity of researchers to disseminate findings.^14,17,18 The feasibility of these options, particularly regarding those at structural and setting levels, is accordingly variable. It is therefore important to identify malleable factors within the system to suggest feasible approaches to enhancing dissemination efforts. These factors are both at the individual researcher level, such as having had practice-based work experience, and at the system level, including funding opportunities. Few studies have explored factors associated with research dissemination efforts in large samples that cross settings. We aimed to identify factors related to public health researchers'' self-rated excellence in dissemination of research findings to non-research audiences.     

Changes in the relationship between marriage and preterm birth, 1989-2006

ObjectiveMaternal marriage has historically been protective against preterm birth (PTB); however, social norms and behaviors surrounding marriage have changed over time in the United States. We analyzed secular trends in the relationship between marriage and PTB.MethodsWe collected data about all births in Michigan between 1989 and 2006 to assess (1) the relationship between marital status and PTB and moderately PTB risk by year, and (2) the relationship between married and unmarried status and PTB and moderately PTB by year relative to similar marital status in 1989.ResultsAmong nearly 2.4 million births between 1989 and 2006, PTB risk among married mothers increased while risk among unmarried mothers decreased. In adjusted models, married status became less protective against PTB relative to unmarried status over time by year, and was associated with higher risk of PTB over time. Moderately PTB risk increased among both married and unmarried groups, but more so among married mothers.ConclusionOur findings suggest that marriage is becoming less protective against PTB over time. The influence of social factors on risk for adverse birth outcomes is likely dynamic, suggesting that ongoing revisions to our understanding are in order.Defined by the World Health Organization as birth before 37 completed weeks of gestation, preterm birth (PTB) is a major contributor to perinatal and neonatal mortality, serious neonatal morbidity, and moderate to severe childhood disability.¹ In wealthy countries such as the United States, 6%–10% of all births are preterm, and deaths to preterm infants comprise more than two-thirds of all neonatal deaths.²Married status has long been associated with a lower risk of PTB,^1,3,4 as well as other adverse perinatal outcomes including low birthweight,^3,5,6 small-for-gestational-age infants,^3,5,7,8 and fetal and neonatal mortality.⁹ Several factors may explain the relationship between marital status and risk for adverse birth outcomes, including differences between married and unmarried mothers in financial security,^10–12 health-care access,^4,13 social support, and mental health.^14–18The presumed health-promoting effect of marriage has led to its promotion as a positive social construct that may improve the health of populations.^19–22 However, in the past two decades, the role of marriage has changed in North America. Bumpass and Cherlin independently contended that marriage has undergone a “decline in significance” and a deinstitutionalization as a result of a deterioration of the marital norms that shape partners’ social behaviors and a trend toward individuation, personal choice, and self-development.^23,24 It is plausible, therefore, that as norms governing partners’ marital behaviors have deteriorated over time, mechanisms mediating the relationship between marriage and PTB risk may have weakened, thereby altering the relationship between marital status and the risk of PTB. For example, as partners involved in marital relationships become more independent and self-oriented, and therefore invest fewer of their resources (e.g., money, time, and attention) in one another, it follows that the financial and social support afforded married mothers via their marriages may diminish, with plausible downstream effects on maternal mental health and access to health-care services.In addition, the increasing incidence of PTB in wealthy countries in the past two decades has been shown to be partially attributable to the increasing rate of obstetric interventions,²⁵ such as cesarean section and induced labor.²⁶ Compared with unmarried mothers, married mothers have been shown to have more ready access to health services.^4,13 It is possible that a higher rate of later-term obstetric interventions among married vs. unmarried mothers could change the relationship between marital status and PTB over time by increasing the incidence of obstetrically induced PTB among married vs. unmarried mothers.We hypothesized that the apparent protective effect of marriage on risk of PTB has decreased with time as a result of the aforementioned mechanisms. We analyzed secular trends in PTB, very PTB, and moderately PTB risk among married and unmarried mothers over time using data from one U.S. state between 1989 and 2006.     

Health,Chronic Conditions,and Behavioral Risk Disparities Among U.S. Immigrant Children and Adolescents

Objective

We examined differentials in the prevalence of 23 parent-reported health, chronic condition, and behavioral indicators among 91,532 children of immigrant and U.S.-born parents.

Methods

We used the 2007 National Survey of Children''s Health to estimate health differentials among 10 ethnic-nativity groups. Logistic regression yielded adjusted differentials.

Results

Immigrant children in each racial/ethnic group had a lower prevalence of depression and behavioral problems than native-born children. The prevalence of autism varied from 0.3% among immigrant Asian children to 1.3%–1.4% among native-born non-Hispanic white and Hispanic children. Immigrant children had a lower prevalence of asthma, attention deficit disorder/attention deficit hyperactivity disorder; developmental delay; learning disability; speech, hearing, and sleep problems; school absence; and ≥1 chronic condition than native-born children, with health risks increasing markedly in relation to mother''s duration of residence in the U.S. Immigrant children had a substantially lower exposure to environmental tobacco smoke, with the odds of exposure being 60%–95% lower among immigrant non-Hispanic black, Asian, and Hispanic children compared with native non-Hispanic white children. Obesity prevalence ranged from 7.7% for native-born Asian children to 24.9%–25.1% for immigrant Hispanic and native-born non-Hispanic black children. Immigrant children had higher physical inactivity levels than native-born children; however, inactivity rates declined with each successive generation of immigrants. Immigrant Hispanic children were at increased risk of obesity and sedentary behaviors. Ethnic-nativity differentials in health and behavioral indicators remained marked after covariate adjustment.

Conclusions

Immigrant patterns in child health and health-risk behaviors vary substantially by ethnicity, generational status, and length of time since immigration. Public health programs must target at-risk children of both immigrant and U.S.-born parents.Monitoring the extent and causes of child health disparities among different population subgroups has long represented an important area of public health research and policy in the United States.^1–3 While data on important health, disease, and behavioral risk factors are routinely available by gender, race/ethnicity, and socioeconomic status (SES) in the U.S.,^1–3 such information is generally not categorized according to nativity/immigrant status. The immigrant or foreign-born population in the U.S. has grown considerably in the last four decades. In 2011, there were 40.4 million immigrants, an increase of 30.8 million since 1970.^4–8 Immigrants now account for 13.0% of the total U.S. population.^4,8 The increase in the number of children with foreign-born parents has also been substantial. The number of U.S. children in immigrant families more than doubled in the past two decades, from 8.2 million in 1990 to 17.5 million in 2011.^8,9 In 2011, 24.4% of U.S. children had at least one foreign-born parent.^8,9As the immigrant population continues to grow in numbers and as a share of the total population, there is an increasing need to focus on the health of immigrants. Although reducing social inequalities in health remains the primary focus of Healthy People 2020, this national initiative in health promotion and disease prevention does not include a single policy objective that explicitly targets the health of immigrants in the U.S.^10,11 Moreover, the nation''s premier and most comprehensive annual report on health statistics, “Health, United States,” does not contain any data on the U.S. immigrant population.¹Health, disease, behavioral, and socioeconomic profiles of immigrants differ substantially from those of the U.S.-born.^12–17 There is also evidence that acculturation modifies the health and behavioral risks of immigrants.^13,15–19 The purposes of this study were, therefore, (1) to estimate the prevalence and risks of poor physical and mental health, chronic conditions, and behavioral risk factors (including obesity and physical inactivity) among immigrant and U.S.-born children and adolescents after adjusting for age, gender, race/ethnicity, place of residence, household composition, and SES using a large, nationally representative sample of U.S. children and adolescents; and (2) to examine the extent to which immigrant health, chronic disease, and behavioral patterns vary by ethnicity and level of acculturation.     

Assessing the Validity and Reliability of Three Indicators Self-Reported on the Pregnancy Risk Assessment Monitoring System Survey

Objectives

We investigated the reliability and validity of three self-reported indicators from the Pregnancy Risk Assessment Monitoring System (PRAMS) survey.

Methods

We used 2008 PRAMS (n=15,646) data from 12 states that had implemented the 2003 revised U.S. Certificate of Live Birth. We estimated reliability by kappa coefficient and validity by sensitivity and specificity using the birth certificate data as the reference for the following: prenatal participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); Medicaid payment for delivery; and breastfeeding initiation. These indicators were examined across several demographic subgroups.

Results

The reliability was high for all three measures: 0.81 for WIC participation, 0.67 for Medicaid payment of delivery, and 0.72 for breastfeeding initiation. The validity of PRAMS indicators was also high: WIC participation (sensitivity = 90.8%, specificity = 90.6%), Medicaid payment for delivery (sensitivity = 82.4%, specificity = 85.6%), and breastfeeding initiation (sensitivity = 94.3%, specificity = 76.0%). The prevalence estimates were higher on PRAMS than the birth certificate for each of the indicators except Medicaid-paid delivery among non-Hispanic black women. Kappa values within most subgroups remained in the moderate range (0.40–0.80). Sensitivity and specificity values were lower for Hispanic women who responded to the PRAMS survey in Spanish and for breastfeeding initiation among women who delivered very low birthweight and very preterm infants.

Conclusion

The validity and reliability of the PRAMS data for measures assessed were high. Our findings support the use of PRAMS data for epidemiological surveillance, research, and planning.The Pregnancy Risk Assessment Monitoring System (PRAMS) is one of the largest state-based surveillance systems of women with live births documenting experiences before, during, and after pregnancy. The data from PRAMS surveys are linked to the birth certificate information. The birth certificate is an important source of data for examining infant health at the state and national levels and is used widely.^1–3 Many studies have examined the reliability and validity of data from the U.S. birth certificate and other data sources such as postpartum surveys, medical records, and registry data.^1–19 Some indicators on the birth certificate are found to be more reliable than others, such as maternal demographics, insurance, and birthweight.^{4,5,7,13,15,19} Birth certificate data have been reported to have lower sensitivity for tobacco and alcohol use;^6,10 birth defects;²⁰ prenatal care;¹¹ and maternal weight gain, medical risks, and obstetric complications,^2,8,9,12,13 although the sensitivity varies by subgroups of women and birth outcomes for many items.^16,17Because PRAMS data are self-reported, it is important to examine the reliability and validity with other population-based data-collection systems such as the birth certificate, which is an established system mandated to assess the health of mothers and babies in the U.S. According to state laws, each live birth must be registered and a birth certificate must be filed. Federal law mandates the national collection and publication of birth certificate data.²¹ A new electronic birth certificate reporting standard was implemented in 2003, replacing the version that had been in place since 1989.²² The 2003 version updated the birth certificate by revising or dropping items and adding new elements with detailed guidance provided on coding data.²³States participating in the Centers for Disease Control and Prevention''s (CDC''s) PRAMS project sample women with recent live-born deliveries using the state birth certificate files. Selected data from the state birth certificate file are linked to the PRAMS survey of women with live-born infants. Some of the measures on the new birth certificate reporting standard are the same as or similar to those on the PRAMS survey. Several studies have compared the validity of measures on PRAMS with birth certificate data, and this study examines additional indicators that had not been assessed previously.^7,18Little has been available on the validity and reliability of information on participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) during pregnancy; Medicaid payment for delivery; and breastfeeding initiation in the early postpartum period, comparing PRAMS data with other data sources. WIC and Medicaid are important sources of services for low-income women and, because these data are used to examine research and programming questions, we investigated the reliability and validity of these indicators. The PRAMS data were compared with the birth certificate as the standard because the comparison of PRAMS data might provide insight about improving the accuracy and quality of PRAMS data. In addition, this investigation may provide insight into using both sources of data in concert to maximize the accuracy of information on women and children. Two research questions guided this investigation: (1) What degree of agreement/reliability exists between PRAMS survey responses and the birth certificate on participation in prenatal WIC services, Medicaid payment for delivery, and breastfeeding initiation? and (2) Do the reliability and validity vary by selected maternal characteristics and birth outcomes as suggested by previous research?¹⁷     

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

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

Sun-seeking behavior to increase cutaneous vitamin D synthesis: when prevention messages conflict

Objectives

The public has long been encouraged to engage in sun-safe practices to minimize exposure to sunlight, the major cause of nonmelanoma skin cancer. More recently, some have advocated unprotected sun exposure to increase cutaneous synthesis of vitamin D as a way to promote health. We assessed the net result of these conflicting messages.

Methods

In a cross-sectional survey in 2007, questionnaires were mailed to participants of an ongoing cohort study in Washington County, Maryland. The study population consisted of 8,027 adults (55% response rate).

Results

Thirty percent of respondents were aware that unprotected sun exposure increased endogenous vitamin D levels. Among those who were aware of this benefit, 42% reported going out into the sun to increase vitamin D levels. Sun-seeking to increase vitamin D production did not significantly differ according to self-reported personal history of skin cancer, but was significantly higher among women, older age groups, those with less education, and vitamin D supplement users.

Conclusion

A substantial proportion of respondents reported sun-seeking behavior expressly to increase endogenous vitamin D levels. The message about sun exposure and vitamin D is reaching the general public; however, this finding poses challenges to skin cancer prevention efforts.Among all human malignancies, skin cancers are by far the most common^1,2 and in the U.S. are among the most costly.³ With exposure to solar ultraviolet (UV) radiation as the major cause of nonmelanoma skin cancer,² prevention strategies have emphasized sun avoidance and skin-protection behaviors such as use of sunscreen and skin-protective clothing. Longstanding public education campaigns have sought to reduce sunlight exposure with the goal of reducing skin cancer incidence rates.^4,5In addition to being the primary cause of human skin cancer, solar UV radiation is also responsible for stimulating cutaneous vitamin D synthesis. In turn, vitamin D is critical for calcium homeostasis and skeletal maintenance.⁶ The observation that hypovitaminosis D was common in general medical inpatients, even in those with vitamin D intakes exceeding the recommended daily allowance and those without apparent risk factors for vitamin D deficiency, led to the hypothesis that the general population may have suboptimal levels of vitamin D.^6,7 As understanding of this topic progressed, it gradually gave rise to the observation that sun avoidance, with the goal of preventing skin cancer, may compromise vitamin D sufficiency.⁷ For bone health, consensus has been achieved concerning the definition of vitamin D deficiency (<25 nanograms per milliliter [ng/ml] 25-hydroxyvitamin D [25(OH)D]). For overall health, however, the general definition of vitamin D insufficiency varies.^6,7Both interest and concern regarding vitamin D has increased as evidence has accumulated that its potential health benefits may extend beyond skeletal health. The public''s concerns about vitamin D insufficiency have been raised as studies reporting health benefits have received media coverage, touting the health benefits of the “sunshine vitamin.”^4,8,9 Based on the premise that vitamin D is important to overall health and well-being, some reports have extolled the benefits of regular sun exposure^6,10 and even tanning bed use.¹⁰ For example, vitamin D deficiency and decreased exposure to sunlight have been hypothesized to increase the risks of many common cancers, type 1 diabetes, rheumatoid arthritis, and multiple sclerosis.^6,10 Based on these potentially wide-ranging health benefits of vitamin D, some have suggested that the benefits of sun exposure to increase cutaneous vitamin D synthesis may outweigh the risks (e.g., skin cancer) associated with unprotected exposure to solar UV radiation.^6,10The importance of understanding the public''s perceptions of these issues is accentuated by the fact that the actual relationship between sun exposure and cutaneous vitamin D synthesis and metabolism is complex and incompletely understood even by the scientific community. In a study of highly sun-exposed (average weekly sun exposure of 29 hours) young adults in Hawaii, approximately one-half had 25(OH)D concentrations <30 ng/ml, and 9% had concentrations <20 ng/ml.¹¹ Under tightly controlled experimental conditions among adults in the United Kingdom, UV radiation exposure of approximately 35% of the total skin surface area at doses similar to summer sunlight three days a week for 13 minutes per day resulted in 25(OH)D concentrations of ≥20 ng/ml (“sufficient”) in 10% and concentrations of ≥32 ng/ml (“optimal”) in 74% of the adults.¹² Thus, in addition to factors affecting UV radiation dose, such as season of year, time of day, latitude, altitude, and atmospheric conditions,^13,14 results such as these suggest there is considerable inter-individual variability in cutaneous vitamin D synthesis in response to sunlight. The determinants of these inter-individual differences in vitamin D synthesis and metabolism are undoubtedly complex and multifactorial, but contributors appear to be factors such as age, race, vitamin D supplement use, calcium intake, body mass index (BMI), skin type, and genetic characteristics.^7,8,13,15 Advances are being made in understanding how genetic variants contribute to inter-individual differences in vitamin D status; for example, the results of a recent genome-wide association study revealed variants at three loci that were associated with a significantly higher likelihood of vitamin D insufficiency.¹⁶Further complicating matters, some researchers currently recommend lower-level sun exposure of approximately 15 minutes per day with face and hands exposed,^13,17 but the evidence described previously adds uncertainty with respect to the extent to which this level of sun exposure results in the desired increase in circulating vitamin D concentrations. Furthermore, application of this recommendation is controversial given that solar UV radiation is the major cause of skin cancer.² Additionally, even those who engage in sun-protective behaviors (e.g., sunscreen use) may not apply the sunscreen in a manner that would prevent vitamin D synthesis to the degree theoretically possible on the basis of the sun protection factor.^14,15,18The small but growing body of evidence on this topic indicates that lack of attention to this issue may lead to further escalation in the incidence of skin cancer. Few studies have examined the impact on the general population of the mixed medical and media messages that range from sun avoidance for skin cancer prevention to the sun-seeking, pro-vitamin D message. We addressed this evidence gap by describing the prevalence of (1) awareness of unprotected sun exposure to increase vitamin D and (2) the extent to which concerns about vitamin D may be influencing sun exposure behaviors.     

Using GIS and Secondary Data to Target Diabetes-Related Public Health Efforts

Objectives

To efficiently help communities prevent and manage diabetes, health departments need to be able to target populations with high risk but low resources. To aid in this process, we mapped county-level diabetes-related rates and resources/use using publicly available secondary data to identify Michigan counties with high diabetes prevalence and low or no medical and/or community resources.

Methods

We collected county-level diabetes-related rates and resources from Web-based sources and mapped them using geographic information systems (GIS) software. Data included age-adjusted county diabetes rates, diabetes-related medical resource and resource use (i.e., the number of endocrinologists and percentage of Medicare patients with diabetes who received hemoglobin A1c testing in the past year), community resources (i.e., the number of certified diabetes self-management education and diabetes support groups), as well as population estimates and demographics (e.g., rural residence, education, poverty, and race/ethnicity). We created GIS maps highlighting areas that had higher-than-median rates of disease and lower-than-median resources. We also conducted linear, logistic, and Poisson regression analyses to confirm GIS findings.

Results

There were clear regional trends in resource distribution across Michigan. The 15 counties in the Upper Peninsula were lacking in medical resources but higher in community resources compared with the 68 counties in the Lower Peninsula. There was little apparent association between need (diabetes prevalence) and diabetes-related resources/use. Specific counties with high diabetes prevalence and low resources were easily identified using GIS mapping.

Conclusion

Using public data and mapping tools identified diabetes health-service shortage areas for targeted public health programming.Diabetes is endemic in the United States and its prevalence is increasing. From 2004 to 2010, the age-adjusted rate of diabetes among adults rose from 7.3% to 8.4%, and annual incidence rates continue to rise.^1,2 Type 2 diabetes accounts for approximately 95% of diabetes cases,³ and this increased prevalence has been attributed primarily to lifestyle changes and the increasing rates of obesity in the U.S.^4–6Diabetes is a chronic condition that involves a considerable amount of medical care as well as careful disease self-management.⁷ In addition to regularly scheduled primary care visits and endocrinology visits for complicated cases,⁸ those with diabetes must adhere to appropriate self-management practices, including glucose monitoring; foot self-examinations; and regimens for nutrition, exercise, and prescribed medications.^9,10 These lifestyle changes can be confusing, especially regarding nutrition, and adherence is difficult.^11,12 However, public health strategies, such as individual and group health education within clinic and community settings, have proven effective in facilitating these changes.^13–16 As a result, diabetes self-management education (DSME) programs are recommended by the American Diabetes Association (ADA) for all people diagnosed with diabetes.^17,18 Diabetes support groups have also emerged as a popular community resource for diabetes management.¹⁹Unfortunately, demand for these services is rising at a time that public health budgets are shrinking.^20,21 In the face of limited public health funds, developing strategies to accurately target services is crucial. Historically, public health data have played a key role, frequently through large-scale surveillance efforts and longitudinal survey studies.^22,23 However, the expense of collecting these data places them outside the reach of most state and local public health efforts. The increased availability of electronically, publicly accessible health-related information^24,25 can allow state and local systems to more efficiently target diabetes programming.²⁶ This study describes one such method that was conducted using county-level Michigan data coupled with geographic information systems (GIS), a powerful tool for identifying and communicating problem areas. The purpose of this study was to demonstrate the utility of secondary data analysis and GIS in determining if diabetes rates were associated with diabetes-related resources and resource use, as well as to identify diabetes-related high need/low resource counties within Michigan.     

Legionnaires' Disease and Associated Comorbid Conditions as Causes of Death in the U.S., 2000–2010

ObjectiveRecent U.S. outbreaks of Legionnaires'' disease (LD) underscore the virulent nature of this infectious pneumonia. To date, only a paucity of literature has described the mortality burden of LD. This study updates LD mortality using U.S. multiple-cause-of-death data from 2000–2010.MethodsWe calculated crude and age-adjusted rates for LD mortality for age, sex, race, state, Census region, and year. We conducted Poisson regression to assess seasonal and temporal trends. We generated matched odds ratios (MORs) to describe the association between LD-related deaths and other comorbid conditions listed on the death certificates.ResultsWe identified a total of 1,171 LD-related deaths during 2000–2010. The age-adjusted mortality rate remained relatively static from 2000 (0.038 per 100,000 population, 95% confidence interval [CI] 0.031, 0.046) to 2010 (0.040 per 100,000 population, 95% CI 0.033, 0.047). The absolute number increased from 107 to 135 deaths during this period, with adults ≥45 years of age having the highest caseload. Overall, LD mortality rates were 2.2 times higher in men than in women. White people accounted for nearly 83.3% of all LD-related deaths, but the age-adjusted mortality rates for black and white people were similar. Comorbid conditions such as leukemia (MOR=4.8, 95% CI 3.5, 6.6) and rheumatoid arthritis (MOR=5.6, 95% CI 3.3, 9.4) were associated with LD diagnosis on death certificates.ConclusionComorbid conditions that could lead to an immunocompromised state were associated with fatal LD on U.S. death certificates. Characterization of LD mortality burden and related comorbidities has practice implications for clinical medicine and public health surveillance.Legionnaires'' disease (LD) is a severe form of pneumonia that can become fatal in vulnerable individuals.^1–5 The condition is caused by the gram-negative bacterium Legionella pneumophila, a naturally occurring organism found in water.^2,3 The organism is primarily transmitted to humans through inhalation of contaminated aerosolized water droplets. Typical sources of outbreaks include, but are not limited to, hot tubs, hot water tanks, large plumbing systems, decorative fountains, and cooling towers. The pneumophila species is generally not found in car or window air-conditioners.^1–4 To date, no person-to-person transmission has been documented.^1–4,6,7Risk factors that increase susceptibility to LD include advanced age, smoking, chronic lung disease, and having a weak or suppressed immune system.^1–4,6,7 Among individuals with a weakened immunity, those with cancer, diabetes, or kidney failure are particularly at risk. Although human immunodeficiency virus (HIV) infection has been linked to more severe infections, LD is generally not more common among people with HIV/acquired immunodeficiency syndrome (AIDS).^1,8,9 More than 20% of cases in the United States reported to the Centers for Disease Control and Prevention (CDC) each year are travel-related.³ Nosocomial transmissions of LD can be problematic, as at-risk individuals are plentiful and plumbing in hospital facilities is often old.^1,4 Because in-house diagnostic testing is readily available, detection of LD is more likely in the hospital setting.⁴ Currently, CDC recommends urinary antigen assay and a culture of respiratory secretions on selective media as the diagnostic tests of choice for confirming Legionella infection.³Annually, CDC estimates that as many as 18,000 individuals are hospitalized with LD in the U.S.³ However, this number is considered an underestimate, as the disease is often underreported due in part to its diagnostic complexity and its resemblance to other pneumonias with similar symptom presentations.^3,7 Symptoms of LD include cough, shortness of breath, fever, muscle aches, and headaches; they often start shortly after exposure to the bacteria.^1–4,6Recent LD outbreaks in the Veterans Affairs (VA) Medical Center in Pittsburgh, Pennsylvania, and in a retirement community in Ohio affirm the virulent nature of this infection and underscore the importance of the causative infectious pathogen to clinical practice and public health surveillance.^10,11 Based on hospitalizations and treatment data, the annual costs for LD have been estimated at nearly $684 million.¹² Few studies have recently examined LD mortality and its associated comorbid conditions. This study contributes to the closing of this gap in the literature by analyzing the national multiple-cause-of-death (MCD) data to describe the current mortality profile of LD in the U.S., for the period 2000–2010.     

Area-Level Socioeconomic Disadvantage and Severe Pulmonary Tuberculosis: U.S., 2000–2008

Objectives

Lower socioeconomic status (SES) is associated with increased risk of tuberculosis (TB) and diagnostic delays, but the extent to which this association reflects an underlying gradient in advanced status of pulmonary TB is unknown. We conducted a multilevel retrospective cohort analysis examining the relationship between socioeconomic characteristics and pulmonary TB disease status, as measured via sputum smears and chest radiography results.

Methods

We included 862 incident TB patients reported in King County, Washington, from 2000–2008. We abstracted patient-level measures from charts and surveillance data. We obtained socioeconomic characteristics of TB patients, as well as those of the areas where TB patients lived, from the 2000 U.S. Census. A socioeconomic position (SEP) index was derived to measure SES.

Results

Of those with known results, 814 of 849 patients (96%) displayed abnormal radiography findings. A total of 239 graded patients (39%) had positive smears, 136 (57%) of whom had grades of moderate (3+) or numerous (4+) acid-fast bacilli. In unadjusted analyses, patients living in lower SEP areas did not appear to have higher probabilities of more advanced disease. In multivariate models adjusting for individual demographic and socioeconomic measures, as well as area-based demographic variables, block-group SEP was not significantly associated with more advanced pulmonary disease.

Conclusions

Lower SEP was not significantly associated with greater pulmonary disease severity after controlling for individual age, race, sex, and origin, and block-group race, ethnicity, and origin. These findings suggest that the severity of pulmonary TB at diagnosis is not synonymous with delayed diagnosis.Although tuberculosis (TB) incidence continues to decline in the United States, the proportion of advanced pulmonary TB, defined as smear-positive or cavitary disease, has been increasing.^1,2 Advanced clinical presentation may result from delayed diagnosis and treatment and may lead to greater infectivity and likelihood of transmission within a community.^3,4Lower socioeconomic status (SES) has been linked to more severe disease status for a variety of diseases including cystic fibrosis,⁵ sarcoidosis,⁶ subclinical coronary heart disease,⁷ cancers,^8,9 and pulmonary fibrosis.¹⁰ While the presence of other comorbidities, poor access to care, substance abuse, low income, education level, and lack of insurance^11–16 constitute risk factors for delays in TB diagnosis, little work has been done to characterize the association between SES and advanced pulmonary TB disease, as more advanced disease is often seen as characteristic of diagnostic delay. Furthermore, much of the work examining diagnostic delay has been examined outside the U.S. Areas in which people live are likely to have differential access to care, including proximity, cost, and presence of public clinics and transportation.^17,18 Disease status is likely to be impacted by such variations in area-level factors and, in particular, by variations in area-level SES across neighborhoods.Using TB case registry data on incident TB patients combined with chart reviews, we explored the relationship between individual patient demographic and SES attributes, in combination with area-level social characteristics, and two TB severity outcomes at diagnosis—lung cavitation and smear-positive acid-fast bacilli (AFB) in sputum smears. These measures have been linked to impaired pulmonary function, TB treatment failure, or death^19,20 and represent later disease stages.^21,22Specifically, this study was designed to assess whether severity of pulmonary TB disease was positively associated with area-based socioeconomic disadvantage within King County, Washington. By examining socioeconomic and demographic characteristics of block groups, our hope was to identify those factors that might play an important role in predicting disease severity at diagnosis. Such findings could provide insight into pathways by which area-level SES independently affects pulmonary disease severity.     

The Youth Nonfatal Violent Injury Review Panel: An Innovative Model to Inform Policy and Systems Change

Among young people in the United States, nonfatal violent injuries outnumber fatal violent injuries by 171 to 1. The Child Fatality Review Team (CFRT) is a well-established model for informing injury prevention planning. The CFRT''s restricted focus on fatal injuries, however, limits its ability to identify opportunities to prevent violent reinjury and address issues unique to nonfatal violent injuries. We adapted the CFRT model to develop and implement a Youth Nonfatal Violent Injury Review Panel. We convened representatives from 23 agencies (e.g., police, housing, and education) quarterly to share administrative information and confidentially discuss cases of nonfatal violent injury. In this article, we describe the panel model and present preliminary data on participants'' perceptions of the process. Although outcomes research is needed to evaluate its impacts, the Youth Nonfatal Violent Injury Review Panel offers an innovative, promising, and replicable model for interagency collaboration to prevent youth violence and its effects.Nonfatal violent injury is a common, but often under-recognized, problem among young people in the United States. In 2011, among those aged 0–18 years, 354,218 incidents of nonfatal hospital-treated violent injury occurred compared with 2,076 incidents of fatal violent injury (defined as nonsexual, intentional injury inflicted by another person)—a 171:1 ratio.^1,2 In addition to the physical consequences of nonfatal violent injury, young people are at risk for psychological aftereffects, such as posttraumatic stress and depression.^3–9 Many violently injured young people are reinjured after they leave the hospital.¹⁰ The estimated one-year violent reinjury rate among U.S. high school students is 9%,¹¹ and a study of violently injured young people (mean age: 14.5 years) participating in a hospital-based violence intervention program (HVIP) found that 23% had previously sustained a violent injury resulting in medical care.¹² Among adults, the five-year violent reinjury rate is estimated to be as high as 45%.^13–18Despite the high incidence of nonfatal violent injury, its consequences, and recurrent nature, little information exists about the issues that young people encounter after they sustain nonfatal violent injuries. Furthermore, the public health and medical literature provides little guidance about how public policies and systems might most effectively prevent violent reinjury and improve the health and social trajectories of violently injured young people. The Child Fatality Review Team (CFRT) is an established model that can potentially be adapted to facilitate a coordinated, systems-level response to the problem of nonfatal violent injury.A CFRT is a multidisciplinary group of representatives from different sectors, such as education, health care, child welfare, law enforcement, and public health, who regularly convene to systematically discuss cases of child death and, occasionally, serious injuries.^19,20 CFRT participants share data from their agencies about child decedents and the circumstances surrounding their deaths with the aim of identifying prevention opportunities.^21–25 First established in Los Angeles, California, in 1978,²⁶ the CFRT model has been widely adopted. As of 2012, a CFRT existed in every state in the United States²⁷ and in many other countries.^28–31