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

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

Self-Reported Health Among Recently Incarcerated Mothers

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

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

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

Perceived Discrimination and DSM-IV–Based Alcohol and Illicit Drug Use Disorders

Objectives. We examined the relationship between everyday and major discrimination and alcohol and drug use disorders in a nationally representative sample of African Americans and Black Caribbeans.Methods. With data from the National Survey of American Life Study, we employed multivariable logistic regression analyses—while controlling for potential confounders—to examine the relationship between everyday and major discrimination and substance use disorders on the basis of Diagnostic and Statistical Manual of Mental Disorders criteria.Results. Every 1 unit increase in the everyday discrimination scale positively predicted alcohol (odds ratio [OR] = 1.02; P < .01) and drug use (OR = 1.02; P < .05) disorders. Similarly, each additional major discrimination event positively predicted alcohol (OR = 1.10; P < .05) and drug use (OR = 1.15; P < .01) disorders.Conclusions. To our knowledge, this study is the first to examine problematic usage patterns rather than infrequent use of alcohol and drugs in a national sample of African American and Black Caribbean adults and the first to examine this particular relationship in a national sample of Black Caribbeans.Alcohol and drug abuse and dependence are risky health behaviors not only to the individuals who engage in these behaviors and their loved ones but also to society. Estimates from the 2000 National Survey on Drug Use and Health suggest that of persons aged 18 years or older, approximately 12.7 million (6.3%) were either dependent on or abused both alcohol and illicit drugs, 3.3 million (1.6%) were dependent on or abused illicit drugs but not alcohol, and 10.9 million (5.5%) were dependent on or abused alcohol but not illicit drugs.1 It is estimated that the overall economic cost of substance abuse in 1992 was $246 billion2 and in 2001 $414 billion.3 Psychoanalytically informed hypotheses, like the self-medication hypothesis, suggest that substance use and abuse are self-soothing behaviors among some individuals who are psychologically distressed. Individuals may use or abuse substances such as alcohol, cigarettes, and illicit and licit drugs to manage emotional pain and anxiety to achieve emotional stability.4–8On the basis of these stress-coping frameworks, a small number of studies suggests that perceived experiences of interpersonal discrimination, a psychosocial stressor, are associated with various risky health behaviors.9,10 Specifically, previous studies posit that in response to perceived experiences of interpersonal discrimination (“discrimination”), some individuals may engage in risky coping behaviors such as alcohol,11–13 tobacco,13–18 and prescribed19 and illicit drug use.13,19 Yen et al.,11,12 for example, showed that Whites who experienced racial/ethnic discrimination (e.g., at school, getting a job) in 5 or more domains consumed more alcoholic drinks than did peers who had not experienced discrimination. Using the CAGE questionnaire,20 Martin et al.21 showed that African American adults who experienced racial/ethnic discrimination were twice as likely to have a problematic drinking behavior as were African Americans who reported no discrimination. Similarly, using a standardized survey for mental illness diagnosis derived from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria, Gee et al.19 reported that Filipino Americans who experienced chronic discrimination were more likely to be dependent on alcohol. With regard to tobacco use, similar to other studies,16,17 Landrine and Klonoff14 reported that African Americans who experienced racial/ethnic discrimination and appraised their experiences as more stressful were more likely to smoke cigarettes than were African Americans who did not report discrimination. Beyond alcohol and tobacco use, recent investigations have reported positive associations between discrimination and licit (e.g., medically prescribed medication) and illicit (e.g., marijuana) drug abuse.13,19 Specifically, Borrell et al.13 reported that racial discrimination was associated with increased lifetime use of marijuana and cocaine among African Americans but not among Whites. Gee et al.19 reported that discrimination was positively associated with the usage of illicit drugs among Filipino American adults. Although these studies are not directly comparable, taken together they suggest a relationship between experiences of discrimination and substance use.Despite a growing literature base in this area, our understanding of the relationship between discrimination and clinically diagnosed alcohol and drug use disorders is limited. Although most will agree that alcohol use and illicit drug use (regardless of frequency and quantity) are potential health risk behaviors, infrequent usage patterns, such as those currently studied in most of the published literature, may not indicate the damaging behavior patterns that are associated with a clinical diagnosis of abusing or being dependent on alcohol or drugs, such as recurrently driving an automobile when impaired or continued drinking despite knowledge of a serious physical or psychological problem.22Using the 2001 National Study of American Life (NSAL), we aimed to extend previous research in 2 important ways. The first concerns the generalizability of the current findings in this area. We are aware of only 1 study that has examined problematic usage patterns of alcohol use and none examining problematic drug usage among African Americans.19,21 In a sample of employed African Americans, Martin et al.18 showed that discrimination was positively associated with problematic drinking behavior; however, the sample was not representative of the general population of African Americans in the United States. To date, we are unaware of any studies that have examined the relationship between discrimination and substance use disorders among Black Caribbeans, the second largest subgroup of Blacks living in the United States. To fill these gaps, we examined the relationship between discrimination and alcohol and illicit drug use disorders in a nationally representative sample of African Americans and Black Caribbeans, 2 groups that traditionally report relatively high levels of discrimination.23–25 We subsequently examined whether interpersonal discrimination was related to the co-occurrence of alcohol and drug use disorders, given that alcohol and drug use disorders often co-occur.26–29     

Social Branding to Decrease Smoking Among Young Adults in Bars

Objectives. We evaluated a Social Branding antitobacco intervention for “hipster” young adults that was implemented between 2008 and 2011 in San Diego, California.Methods. We conducted repeated cross-sectional surveys of random samples of young adults going to bars at baseline and over a 3-year follow-up. We used multinomial logistic regression to evaluate changes in daily smoking, nondaily smoking, and binge drinking, controlling for demographic characteristics, alcohol use, advertising receptivity, trend sensitivity, and tobacco-related attitudes.Results. During the intervention, current (past 30 day) smoking decreased from 57% (baseline) to 48% (at follow-up 3; P = .002), and daily smoking decreased from 22% to 15% (P < .001). There were significant interactions between hipster affiliation and alcohol use on smoking. Among hipster binge drinkers, the odds of daily smoking (odds ratio [OR] = 0.44; 95% confidence interval [CI] = 0.30, 0.63) and nondaily smoking (OR = 0.57; 95% CI = 0.42, 0.77) decreased significantly at follow-up 3. Binge drinking also decreased significantly at follow-up 3 (OR = 0.64; 95% CI = 0.53, 0.78).Conclusions. Social Branding campaigns are a promising strategy to decrease smoking in young adult bar patrons.Tobacco companies1 and public health authorities2–5 recognize young adulthood as a critical time when experimenters either quit or transition to regular tobacco use. Young adults are also aspirational role models for youths.1,6,7 Tobacco companies devote considerable resources to reaching young adults to encourage tobacco use,1,8–11 and young adults have a high prevalence of smoking.12 In California in 2011, young adults had the highest smoking prevalence of any age group, and the Department of Health estimated that 32% of California smokers started smoking between the ages of 18 and 26 years.13 Although they are more likely to intend to quit and successfully quit than older adults,14–17 young adults are less likely to receive assistance with smoking cessation.18,19 Although there are few proven interventions to discourage young adult smoking,20 cessation before age 30 years avoids virtually all of the long-term adverse health effects of smoking.21Tobacco companies have a long history of using bars and nightclubs to reach young adults and to encourage smoking.1,6,9–11,22–24 Bar attendance and exposure to tobacco bar marketing is strongly associated with smoking.25 The 1998 Master Settlement Agreement and Food and Drug Administration regulations that limit tobacco advertising to youths, explicitly permit tobacco marketing in “adult only” venues, including bars and nightclubs.26,27Aggressive tobacco marketing may actually be more intensive in smoke-free bars: a 2010 study of college students attending bars found that students in the community with a smoke-free bar law were more likely to be approached by tobacco marketers, offered free gifts, and to take free gifts for themselves than in communities without a smoke-free bar law.28 Bars and nightclubs also attract young adults who are more likely to exhibit personality traits such as sensation seeking,29 increasing their risk30 independently of receptivity to tobacco advertising; tobacco promotional messages resonate with these personality traits.8,31 Tobacco marketing campaigns are tailored to specific segments of the population defined by psychographics (e.g., values, attitudes, shared interests, such as tastes in music and fashion, and friend groups) and demographic criteria, and they aim to create positive smoker images, identities, and social norms for smoking.1,8 Tobacco marketing campaigns also focus on young adult trendsetters to leverage peer influence to promote smoking.6,10In contrast to the tobacco companies’ efforts, most young adult health interventions take place in colleges or health centers rather than social environments.32–39 Bars and nightclub venues represent an opportunity to reach those at highest risk for long-term smoking morbidity and mortality.40 We evaluated the effectiveness of an intervention to decrease cigarette smoking by countering tobacco industry marketing strategies targeting young adults attending bars and nightclubs in the San Diego, California, “hipster” scene. Because tobacco and alcohol use are strongly linked,41,42 we also examined the effects of the intervention on alcohol use and among binge drinkers. We found a significant decrease in smoking in the community where the intervention took place, including significant decreases among nondaily smokers and binge drinkers, as well as a significant decrease in binge drinking.     

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     

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.     

Modeling the Injury Prevention Impact of Mandatory Alcohol Ignition Interlock Installation in All New US Vehicles

Objectives. We estimated the injury prevention impact and cost savings associated with alcohol interlock installation in all new US vehicles.Methods. We identified fatal and nonfatal injuries associated with drinking driver vehicle crashes from the Fatality Analysis Reporting System and National Automotive Sampling System’s General Estimates System data sets (2006–2010). We derived the estimated impact of universal interlock installation using an estimate of the proportion of alcohol-related crashes that were preventable in vehicles < 1 year-old. We repeated this analysis for each subsequent year, assuming a 15-year implementation. We applied existing crash-induced injury cost metrics to approximate economic savings, and we used a sensitivity analysis to examine results with varying device effectiveness.Results. Over 15 years, 85% of crash fatalities (> 59 000) and 84% to 88% of nonfatal injuries (> 1.25 million) attributed to drinking drivers would be prevented, saving an estimated $342 billion in injury-related costs, with the greatest injury and cost benefit realized among recently legal drinking drivers. Cost savings outweighed installation costs after 3 years, with the policy remaining cost effective provided device effectiveness remained above approximately 25%.Conclusions. Alcohol interlock installation in all new vehicles is likely a cost-effective primary prevention policy that will substantially reduce alcohol-involved crash fatalities and injuries, especially among young vulnerable drivers.Despite significant reductions in the 1980s, alcohol-involved motor vehicle crashes (AI-MVCs) remain a significant public health problem.1–3 Since 1994, even as overall fatalities from crashes have declined, AI-MVC fatalities, as a proportion of all traffic fatalities, have remained higher than 30%.1–3 In 2011, 9878 fatalities resulted from a crash with at least 1 intoxicated driver (blood alcohol content [BAC] ≥ 0.08 g/dL).4 AI-MVCs are also a significant economic burden to communities, with societal costs estimated to be as high as $59 billion annually, which is 21% of the total annual economic cost ($277 billion) associated with MVC-related injury.5Previous success reducing fatal and nonfatal injuries resulting from drink driving is largely attributable to successful enforcement of alcohol availability and alcohol-related driving laws (e.g., license suspension, minimum legal drinking age laws, 0.08 grams per deciliter BAC limits, zero tolerance laws, sobriety checkpoints), as well as the general deterrence effect conferred by impaired driving penalties.6–9 However, these laws are difficult to enforce because they rely on police identification of impaired drivers.3 As a result, alcohol-impaired driving arrests are rare, with estimates that an impaired driver drives an average of 80 times before being stopped for driving while intoxicated (DWI).1,2 Even license suspension, which has previously provided the strongest evidence for reducing DWI recidivism, with reductions of impaired driver fatal crash risk by as much as 50%,10–12 has limited impact. Previous studies have indicated that as many as 50% to 75% of offenders continue to operate a vehicle despite license suspension.13–15 Furthermore, half of convicted DWI drivers continue to drive without a license even after they are eligible for reinstatement, citing successful evasion of police during their license suspension period.16,17Difficulty detecting impaired drivers has led to the development of in-vehicle technological solutions that can prevent alcohol-impaired driving, including such devices as alcohol ignition interlocks.1 Current interlock devices are designed as an alcohol breath-testing unit connected to the ignition switch of the vehicle that prevents driving if the driver’s breath contains more than a predetermined limit of alcohol (typically BAC > 0.02 g/dL).18–20 They are used in all 50 states for multiple DWI offenders, either as a Department of Motor Vehicles mandated condition of license reinstatement or as a component of DWI judicial sentencing. Interlocks are highly effective while installed on the vehicle, with a systematic review finding a 67% median reduction in DWI recidivism.20–24 Limited evidence is available examining their associated impact on MVCs, but recent studies suggest that AI-MVCs may also decrease while interlocks are installed.25–27Despite the clear public health benefit and existence of the technology for several decades, widespread interlock use is limited. In 2013, only 300 000 interlock devices were actively in use throughout the United States, representing less than a quarter of DWI offenders.28 Limited usage is thought to result from low DWI conviction rates, state policies restricting interlocks to repeat DWI offenders, and a preference among offenders to have their license suspended rather than install devices that prevent impaired driving.20 The weaknesses in the current enforcement model, combined with technological improvements in interlock devices, has generated interest in interlock use as a primary prevention tool. In 2008, the National Highway Traffic Safety Administration (NHTSA) launched the Driver Alcohol Detection System for Safety (DADSS) program, a 5-year collaborative industry and government program to explore the feasibility, benefits, and public policy challenges associated with widespread use of in-vehicle alcohol detection technologies. Application of alcohol interlocks to all new vehicles is one primary prevention strategy under discussion.Literature examining interlock use as a primary prevention tool is limited. Bjerre et al26 studied the installation of 300 interlocks in commercial vehicles (buses, taxis, trucks) in Sweden, finding that they prevented 3.4 drunk driving trips (BAC > 0.02 g/dL) for every 1000 potential car trips.26 Lahausse and Fildes29 modeled the injury prevention benefit associated with alcohol interlock installation in all newly registered Australian vehicles; they found that interlocks would prevent up to 24% of all fatalities and 11% of serious injuries annually. This study, however, was limited by the inability to analyze comprehensive Australian crash data, necessitating extrapolation of fatality data from a single Australian state, as well as the use of an estimated fatal-to-nonfatal injury ratio for the derivation of serious injury estimates. Furthermore, although these studies demonstrated the potential injury prevention impact of interlocks, no previous studies have analyzed fatal and nonfatal crash data to examine the primary prevention impact within the United States.Our objectives for the present study were (1) to estimate the potential impact on fatalities and nonfatal injuries of alcohol interlock installation in all new vehicles, and (2) to estimate the potential decrease in economic costs associated with injury prevention by a universal alcohol-ignition interlock policy. Such data have the potential to provide a better understanding of how the mandatory installation of alcohol interlocks in new vehicles, as proposed within the DADSS program, might contribute to reducing AI-MVC fatalities and nonfatal injuries.     

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.     

Route Infrastructure and the Risk of Injuries to Bicyclists: A Case-Crossover Study

Objectives. We compared cycling injury risks of 14 route types and other route infrastructure features.Methods. We recruited 690 city residents injured while cycling in Toronto or Vancouver, Canada. A case-crossover design compared route infrastructure at each injury site to that of a randomly selected control site from the same trip.Results. Of 14 route types, cycle tracks had the lowest risk (adjusted odds ratio [OR] = 0.11; 95% confidence interval [CI] = 0.02, 0.54), about one ninth the risk of the reference: major streets with parked cars and no bike infrastructure. Risks on major streets were lower without parked cars (adjusted OR = 0.63; 95% CI = 0.41, 0.96) and with bike lanes (adjusted OR = 0.54; 95% CI = 0.29, 1.01). Local streets also had lower risks (adjusted OR = 0.51; 95% CI = 0.31, 0.84). Other infrastructure characteristics were associated with increased risks: streetcar or train tracks (adjusted OR = 3.0; 95% CI = 1.8, 5.1), downhill grades (adjusted OR = 2.3; 95% CI = 1.7, 3.1), and construction (adjusted OR = 1.9; 95% CI = 1.3, 2.9).Conclusions. The lower risks on quiet streets and with bike-specific infrastructure along busy streets support the route-design approach used in many northern European countries. Transportation infrastructure with lower bicycling injury risks merits public health support to reduce injuries and promote cycling.Bicycling is an active mode of transportation with a range of individual and public health benefits.1–5 However, bicycling is underused for transportation in Australia, Canada, Ireland, the United States, and the United Kingdom, constituting an estimated 1% to 3% of trips, compared with 10% to 27% of trips in Denmark, Germany, Finland, the Netherlands, and Sweden.6–8 The reasons for low bicycle share of trips are multifaceted, but safety is one of the most frequently cited deterrents.9–11 These concerns are well founded: bicycling injury rates are higher in countries where cycling for transportation is less common.8,12,13To reduce bicycling injuries, the first step is to understand the determinants of risk. Studies in many English-speaking countries have focused on head injury reductions afforded by helmets.14–17 However, helmet use cannot explain the risk difference because helmets are rarely used in the European countries with lower injury rates.8,18,19 Typical route infrastructure (physical transportation structures and facilities) in countries with low bicycle share of trips differs from that in countries with high trip shares. In Germany, Denmark, and the Netherlands, bicycle-specific infrastructure is frequently available,20 so this is a promising avenue for investigating injury risks. In a review of route infrastructure and injury risk,21 we found some evidence that bicycle-specific infrastructure was associated with reduced risk. However, the studies reviewed had problems that have compromised confidence in the results: grouping of route categories that may have different risks, unclear definitions of route infrastructure, and difficulty controlling for characteristics of cyclists and for exposure to various route types. Debates continue about the contribution of route design to safety and about the safety of various route types.12,13,20,21Here we present a study designed to overcome these limitations.22 We examined injury risk of 14 route types using a case-crossover design in which injured participants served as their own controls. The design compared route characteristics at the location where the injury event occurred to those at a randomly selected point on the same trip route where no injury occurred. By randomly selecting the control site in this way, the probability that a specific infrastructure type would be chosen was proportional to its relative length on the trip (e.g., on a 4-km trip, there would be a 25% chance of selecting a control site on a 1-km section that was on a bike path). Because comparisons were within-trip, personal characteristics such as age, gender, and propensity for risk-taking behavior were matched, as were trip conditions such as bicycle type, clothing visibility, helmet use, weather, and time of day. This allowed the comparisons to focus on between-site infrastructure differences.     

Trust,Medication Adherence,and Hypertension Control in Southern African American Men

We examined the relationship between trust in the medical system, medication adherence, and hypertension control in Southern African American men. The sample included 235 African American men aged 18 years and older with hypertension. African American men with higher general trust in the medical system were more likely to report better medication adherence (odds ratio [OR] = 1.06), and those with higher self-efficacy were more likely to report better medication adherence and hypertension control (OR = 1.08 and OR = 1.06, respectively).Trust remains an important issue with African Americans (AAs), particularly in the South where its history of mistreatment and racial discrimination at times were highly prevalent.1 Racial and ethnic minorities are more prone than are Whites to distrust the health care establishment, and historically, minority men have had less access to culturally competent providers.2–4 Southern AAs are more likely than are Whites to report perceived racial barriers to care,5 and AA men are more likely than are AA women to report perceived discrimination.6–10 Perceived discrimination and mistreatment are associated with poorer medical adherence and delays in seeking health care.11–14 In addition, higher levels of trust in the health care system are associated with better adherence to recommended care, greater patient satisfaction, and better outcomes.15–18 This has significant implications considering that AA men develop hypertension (HTN) at an earlier age, have higher rates of advanced (stage 3) HTN, are more likely to experience HTN complications, and are less likely to achieve HTN-control compared with White men.19–21 The rates of HTN are even higher in the South for AA men, accounting, in part, for higher stroke (80% higher) and cardiovascular mortality (50% higher) in this subpopulation compared with other groups in other regions.21–23The goal of this brief study was to assess the relationship between trust in the medical, medication adherence,24 and HTN control25 among Southern AA men. Other covariates were perceived discrimination, perceived racism, self-efficacy, and participation in medical decision-making. This study is based on the Race and Health Outcomes Model developed by Williams et al.26     

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     

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

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

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

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

Directly Observed Antidepressant Medication Treatment and HIV Outcomes Among Homeless and Marginally Housed HIV-Positive Adults: A Randomized Controlled Trial

Objectives. We assessed whether directly observed fluoxetine treatment reduced depression symptom severity and improved HIV outcomes among homeless and marginally housed HIV-positive adults in San Francisco, California, from 2002 to 2008.Methods. We conducted a nonblinded, randomized controlled trial of once-weekly fluoxetine, directly observed for 24 weeks, then self-administered for 12 weeks (n = 137 persons with major or minor depressive disorder or dysthymia). Hamilton Depression Rating Scale score was the primary outcome. Response was a 50% reduction from baseline and remission a score below 8. Secondary measures were Beck Depression Inventory-II (BDI-II) score, antiretroviral uptake, antiretroviral adherence (measured by unannounced pill count), and HIV-1 RNA viral suppression (< 50 copies/mL).Results. The intervention reduced depression symptom severity (b = −1.97; 95% confidence interval [CI] = −0.85, −3.08; P < .001) and increased response (adjusted odds ratio [AOR] = 2.40; 95% CI = 1.86, 3.10; P < .001) and remission (AOR = 2.97; 95% CI = 1.29, 3.87; P < .001). BDI-II results were similar. We observed no statistically significant differences in secondary HIV outcomes.Conclusions. Directly observed fluoxetine may be an effective depression treatment strategy for HIV-positive homeless and marginally housed adults, a vulnerable population with multiple barriers to adherence.Depressive, pain, and substance use disorders are highly prevalent among persons living with HIV/AIDS1,2 and among the homeless and marginally housed.3–5 The triple diagnosis of depression, HIV, and substance use poses unique treatment challenges for clinicians: successful management of one condition is often dependent on successful management of the others, and the optimal sequencing of depression treatment, substance use treatment, and stabilization of psychosocial comorbidities remains unclear. Adherence to the entire continuum of HIV care is often hampered by depression6–8 and substance use.9,10 For homeless persons, the need to address subsistence concerns such as obtaining food and shelter may not only adversely affect mental well-being11 but may also divert attention away from medication adherence and regular clinic attendance.12 Timely and effective depression treatment is critical for HIV-positive persons, because depression has been associated with CD4⁺ T-lymphocyte cell count decline,13 progression to AIDS,14 and AIDS-related mortality.15 Yet depression remains pervasively underdiagnosed and undertreated among the homeless16–18 and among HIV-positive persons.19,20Depression treatment might be expected to improve virological or immunologic outcomes through improved adherence, but this has not been conclusively demonstrated.21–23 We therefore sought to determine whether treatment with once-weekly fluoxetine reduced depression symptom severity among homeless and marginally housed persons with comorbid depression and HIV. Because this population faces many psychosocial barriers to successful medication adherence,12,24 in addition to depression,25 we employed a directly observed treatment strategy similar to that used for treatment and management of patients with tuberculosis and HIV.26 This strategy reduced the potential for incomplete adherence to reduce the effectiveness of antidepressant treatment. A secondary aim was to determine whether depression treatment improved antiretroviral therapy (ART) uptake among persons eligible for treatment and ART adherence and viral suppression among treated persons.     

Tapping Into Water: Key Considerations for Achieving Excellence in School Drinking Water Access

Objectives. We examined free drinking water access in schools.Methods. We conducted cross-sectional interviews with administrators from 240 California public schools from May to November 2011 to examine the proportion of schools that met excellent water access criteria (i.e., location, density, type, maintenance, and appeal of water sources), school-level characteristics associated with excellent water access, and barriers to improvements.Results. No schools met all criteria for excellent water access. High schools and middle schools had lower fountain:student ratios than elementary schools (odds ratio [OR] = 0.06; 95% confidence interval [CI] = 0.02, 0.20; OR = 0.30, 95% CI = 0.12, 0.70). Rural schools were more likely to offer a nonfountain water source than city schools (OR = 5.0; 95% CI = 1.74, 14.70). Newer schools were more likely to maintain water sources than older schools (OR = 0.98; 95% CI = 0.97, 1.00). Schools that offered free water in food service areas increased from pre- to postimplementation of California’s school water policy (72%–83%; P < .048). Barriers to improving school water included cost of programs and other pressing concerns.Conclusions. Awareness of the benefits related to school drinking water provision and funding may help communities achieve excellence in drinking water access.Consumption of water is associated with a number of health benefits, including a reduction in energy intake and obesity prevention, dental caries reduction (with fluoridated tap water), and improved cognitive functioning among children.1–11 Access to free, potable, and appealing drinking water in schools is important because children spend substantial time in school settings, and students may come to school already dehydrated.12,13Policymakers have responded to concerns regarding the association of intake of sugar-sweetened beverages, such as sodas and sports drinks, with health conditions such as obesity and dental caries by passing legislation that restricts sales of sugar-sweetened beverages in schools.14 Such policy has led to a change in the product mix of beverages that are available for purchase in schools, including an increase in access to bottled water.14,15 In some cases, bottled water available for purchase may be the only source of potable drinking water in certain school locations, thus creating a conspicuous inequity in which water may only be accessible to students with the means to purchase it. Having schools offer free single-use bottled water to students also poses environmental concerns, particularly for schools that do not recycle used plastic bottles on campus.16Although historically some states did specify that a certain number of water access points (i.e., drinking fountains) be available per a certain number of students, there was generally no guidance regarding the location of those fountains.17 However, now both federal and some state laws require that free water be available in cafeteria areas.18–20 In September 2010, California enacted SB 1413, legislation that requires kindergarten to 12th grade public schools to provide access to free drinking water during meal times in school food service areas (FSAs), defined in California law as locations where meals are served or eaten.18 In December 2010, the president signed the Healthy, Hunger-Free Kids Act of 2010, which includes a provision requiring access to free drinking water where meals are served (but not where they are consumed).19In small studies conducted primarily in California to examine water access in schools, drinking fountains—the primary source of free water access in most schools—were perceived to be inadequate by students, parents, and school staff.21–24 Drinking fountains were viewed as nonfunctional, unclean, having a low flow rate, or dispensing unpalatable water, thereby discouraging student water intake. By contrast, in emerging studies, nonfountain sources of drinking water, such as insulated coolers or built-in water dispensers or stations, appeared to encourage student water consumption.25–27 Unavailability of free drinking water in key school locations such as cafeterias, gyms, and classrooms where students eat, are active, and learn is cited as another barrier to water access at school.21There have been no comprehensive large-scale cross-sectional studies that examine free drinking water access in schools. To gain a better understanding of this issue, we conducted phone interviews with school administrators from a representative sample of public schools in California that spanned from pre- to postimplementation of the 2010 California state water-in-schools regulation. The main objectives of this study were to describe free drinking water access in schools by source (e.g., water fountain, pitcher) and school location, as well as to examine school-level characteristics associated with schools that have excellent drinking water access. We also sought to understand how water access in FSAs changed from pre- to postimplementation of the water-in-FSAs regulation. In addition, we asked questions about barriers to improving water availability that would inform our recommendations for ways to increase drinking water access in school settings.On the basis of prior literature, we hypothesized the following: (1) few schools would have nonfountain sources of drinking water, (2) free water would be most readily accessible in common areas of the schools (i.e., hallways), and (3) schools serving higher-income students would have better drinking water access.     

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

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

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

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

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

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