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

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

Transitions in Smoking Behavior During Emerging Adulthood: A Longitudinal Analysis of the Effect of Home Smoking Bans

Objectives. We studied the effect of home smoking bans on transitions in smoking behavior during emerging adulthood.Methods. We used latent transition analysis to examine movement between stages of smoking from late adolescence (ages 16–18 years) to young adulthood (ages 18–20 years) and the effect of a home smoking ban on these transitions. We used data from the Minnesota Adolescent Community Cohort study collected in 2004 to 2006.Results. Overall, we identified 4 stages of smoking: (1) never smokers, (2) experimental smokers, (3) light smokers, and (4) daily smokers. Transition probabilities varied by stage. Young adults with a home ban during late adolescence were less likely to be smokers and less likely to progress to higher use later. Furthermore, the protective effect of a home smoking ban on the prevalence of smoking behavior was evident even in the presence of parental smoking. However, this effect was less clear on transitions over time.Conclusions. In addition to protecting family members from exposure to secondhand smoke, home smoking bans appear to have the additional benefit of reducing initiation and escalation of smoking behavior among young adults.Cigarette smoking, particularly among young people, continues to be a major public health concern. Although initiation rates have declined for adolescents, initiation rates among young adults have risen.1 Also, of all age groups, young adults have the highest prevalence of current cigarette smoking.2 Therefore, developing effective interventions for this population is a public health priority.Young or emerging adulthood is typically defined as 18 to 25 years of age and is marked by important transitions such as increased autonomy in decision-making and fewer social constraints than during adolescence.3 It also represents a time for increased vulnerability for both the initiation of smoking and nicotine addiction.4 This period of emerging adulthood may be an important, yet often overlooked, age for formation of long-term health behaviors such as smoking.Relatively little research has examined transitions and trajectories of smoking behaviors among young adults.5 Most researchers have used person-centered techniques such as growth curve and growth mixture modeling to explicitly model the heterogeneity in developmental processes and, in the process, have identified several distinct patterns of smoking trajectories from adolescence to young adulthood.6–9 These approaches assume progression to be continuous instead of incremental (i.e., stage sequential); therefore, smoking must be modeled as a continuous function of time. Growth curves and growth mixture modeling are not as appropriate in situations characterized by a high degree of movement into and out of stages over time, which may be especially relevant to the onset and progression of smoking during emerging adulthood.10 An alternative approach is to take a person-centered approach such as Markov models10,11 and latent transition analysis2 to examine person-specific patterns of developmental stages. This approach has been applied to the study of smoking behavior2,11 but not extensively to the study of smoking behaviors in emerging adulthood.Multiple social, psychological, and environmental factors have been found to influence smoking progression and have been extensively studied as antecedents or correlates of trajectories of smoking.6,8 Among these, home smoking bans have emerged as an important yet understudied protective factor. Although the primary goal of a home ban is to protect children and adult nonsmokers from secondhand smoke,12 recent evidence suggests that home smoking restrictions promote antismoking attitudes and reduce initiation and progression of smoking behavior among adolescents by changing norms about the prevalence and social acceptability of smoking.13–15 Additionally, adult smokers with a home ban are more likely to quit and remain nonsmokers.16 As noted by Albers et al.,17 youths with a smoking ban in their parental homes are more likely to prefer smoke-free housing as independently living young adults. In essence, establishing a home ban has a long-term and even intergenerational effect on promoting nonsmoking attitudes and norms among young adults.17 Individuals with home bans also are more likely to support clean indoor air laws, crucial to tobacco prevention efforts.18A recent literature review on the association between home bans and youth smoking reported reduced smoking among adolescents with a home ban.19 As noted by Emory et al.,19 a few studies also investigated the moderating effect of parental smoking, and most studies found either an association or a stronger association between home smoking restrictions and reduced smoking in homes without parental smoking or an adult smoker. However, 2 studies found that home bans significantly lowered smoking rates, regardless of parental smoking, underscoring the salience of a home ban.14,20 All but 2 of the studies in this review were cross-sectional, and more important, none of the studies examined the effect of a home ban on stage-sequential transitions or the effect on smoking behaviors in emerging adulthood. Therefore, despite previous important findings, relatively little is known about the prospective effect of home smoking restrictions on smoking behavior during emerging adulthood, especially in the presence of parental smoking.19The main goals of this study were to (1) identify distinct stages of smoking behavior and examine within-individual transitions in smoking from late adolescence (ages 16–18 years) to young adulthood (ages 18–20 years) in a population-based cohort sample and (2) evaluate whether a home smoking ban during late adolescence influences the prevalence of smoking and transitions into and out of smoking stages in young adulthood and whether the effect of a home ban differs by parental smoking status.     

Relationship Between Alcohol Use and Violent Behavior Among Urban African American Youths From Adolescence to Emerging Adulthood: A Longitudinal Study

Objectives. We examined developmental trajectories of alcohol use and violent behavior among urban African American youths and the longitudinal relationship between these behaviors from adolescence to emerging adulthood.Methods. Our sample included 649 African American youths (49% male) followed for 8 years. We assessed violent behavior and alcohol use by asking participants how often they had engaged in each behavior in the preceding 12 months. Growth curve analyses were conducted to identify the developmental trajectories of the 2 behaviors and to explore the longitudinal relationship between them.Results. Violent behavior peaked in middle to late adolescence and declined thereafter, whereas the frequency of alcohol use increased steadily over time. These developmental trajectories varied according to gender. Among both male and female participants, early violent behavior predicted later alcohol use, and early alcohol use predicted later violent behavior. Moreover, changes in one behavior were associated with changes in the other.Conclusions. Our results support a bidirectional relationship between alcohol use and violent behavior. Efforts to reduce one problem can be expected to reduce the other. Programs and policies aimed at reducing violence or alcohol use among adolescents should take into account this relationship.Both alcohol use and violent behaviors are prevalent among urban adolescents and are important public health problems in the United States,^1,2 with violent injury being the leading cause of death among African American adolescents.³ According to a nationwide survey of high school students, 36% of students reported having committed violent acts in the preceding 12 months, and 19% reported having carried a weapon in the preceding 30 days.⁴ Another survey showed that two thirds of 12th-grade students had consumed alcohol in the past 12 months, and nearly half (45%) were current drinkers (i.e., they reported having consumed alcohol in the 30 days prior to the survey).² These problems have continued to receive increased attention in recent years.In general, 4 competing theoretical explanations have been proposed for the relationship between alcohol use and violent behavior.^5,6 According to the first model, alcohol use causes violent behavior owing to psychopharmacological effects⁷ or a criminal subculture.⁸ The second model postulates that alcohol use is caused by violent behavior and is a consequence of a violent lifestyle because aggressive individuals are more likely to select or be pushed into social situations that encourage heavy drinking.⁹The third model combines the first 2 models and argues that alcohol use and violence reinforce each other; in other words, alcohol use causes violence, and vice versa.¹⁰ The final model postulates that the relationship between alcohol use and violence is spurious.^10,11 Both behaviors are predicted by the same common set of risk factors and cluster together as a result of a single general problem behavior syndrome.^12,13The relationship between alcohol use and violence has been documented in many studies.^5,6,14 In a large number of these studies, however, alcohol use and violence have been assessed at a single time point, and lead-lag effects (one variable correlating with another variable at a subsequent point in time) could not be studied. In the few studies that have examined longitudinal associations between alcohol use and violent behavior, findings have been mixed.For example, some researchers have found that early alcohol use predicts later violent behavior,^15–18 and others have found that early violent behavior predicts later alcohol use.^11,19,20 White et al.,¹⁰ in their study of high-risk adolescent boys, demonstrated a bidirectional rather than unidirectional association between alcohol use and violent behavior. Other researchers^21–23 have also found that the relationship between alcohol use and violent behavior involves reciprocal influences.In a meta-analysis of existing longitudinal studies examining the correlations between alcohol use and violence, Lipsey et al.²⁴ found that when common risk factors were taken into account, the strengths of the relationships were attenuated. In contrast, White et al.¹⁰ found that the strengths of cross-lagged associations between alcohol and aggression were not reduced significantly when they controlled for common risk factors.One problem with existing research is that many of these studies have involved somewhat limited samples.^5,25 Some researchers draw their samples from the juvenile justice system, which may not be representative of youths more generally. Others draw their samples from schools but exclude dropouts and absentees, which may lead to undersampling of the most heavy alcohol users and delinquents. Most studies have included predominantly White youths in their samples. Little is known about the longitudinal relationship between alcohol use and violent behavior among African American youths. Perhaps most important, few studies have addressed the critical developmental period of emerging adulthood (age 18–29 years), which would allow an examination of associations between these 2 behaviors across different stages in the life cycle.The objectives of our study were to address these gaps in the literature and test the 4 competing theories on the relationship between alcohol use and violent behavior with more than 600 African American youths followed for 8 years. Because our data were collected at multiple time points, we were able to examine the developmental trajectories of these behaviors, the lead-lag relationship between alcohol use and violent behavior, and how changes in one behavior were associated with changes in the other.We investigated whether early alcohol use or violent behavior predicted later violent behavior or alcohol use from adolescence to emerging adulthood. We also examined the relationship between alcohol use and violent behavior from a developmental life course perspective in an attempt to determine whether the association differed in adolescence and emerging adulthood.Researchers have found that rates of violent behavior²⁶ and use of alcohol and other drugs²⁷ are higher among adolescent boys than among adolescent girls. Violent behavior peaks in middle to late adolescence and declines thereafter,²⁶ whereas the frequency of alcohol and other drug use continues to increase throughout adolescence and declines in emerging adulthood.²⁸ In this study, we also assessed whether the developmental trajectories of alcohol use and violent behavior and the longitudinal associations between the 2 behaviors differ according to gender.In our analyses, we controlled for several common risk factors for both alcohol use and violence described in the literature.²⁹ We included participants'' academic achievement and depressive symptoms, parental drug use and violent behavior, family conflict, and peer drug use and violent behavior, as well as whether participants had sold illegal drugs. All of these measures were assessed at wave 1 of the study unless otherwise noted. We attempted to determine whether the relationship between alcohol and violent behavior could be explained by these common risk factors.     

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

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

Association of Smoking in Adolescence With Abdominal Obesity in Adulthood: A Follow-Up Study of 5 Birth Cohorts of Finnish Twins

Objectives. We studied the association of adolescent smoking with overweight and abdominal obesity in adulthood.Methods. We used the FinnTwin16, a prospective, population-based questionnaire study of 5 consecutive and complete birth cohorts of Finnish twins born between 1975 and 1979 (N = 4296) and studied at four points between the ages of 16 and 27 years to analyze the effect of adolescent smoking on abdominal obesity and overweight in early adulthood.Results. Smoking at least 10 cigarettes daily when aged 16 to 18 years increased the risk of adult abdominal obesity (odds ratio [OR]=1.77; 95% confidence interval [CI] = 1.39, 2.26). After we adjusted for confounders, the OR was 1.44 (95% CI = 1.11, 1.88), and after further adjustment for current body mass index (BMI), the OR was 1.34 (95% CI = 0.95, 1.88). Adolescent smoking significantly increased the risk of becoming overweight among women even after adjustment for possible confounders, including baseline BMI (OR = 1.74; 95% CI = 1.06, 2.88).Conclusions. Smoking is a risk factor for abdominal obesity among both genders and for overweight in women. The prevention of smoking during adolescence may play an important role in promoting healthy weight and in decreasing the morbidity related to abdominal obesity.Smoking and obesity are major causes of preventable death in developed countries.¹ The life expectancy of obese smokers is reduced by as much as 13 years.² Obesity-related excess mortality may mainly be caused by abdominal obesity.³ The association between smoking and obesity is complex: smoking has been associated with both low and high body mass index (BMI; weight in kilograms divided by height in meters squared) and also with adverse fat distribution. In most cross-sectional studies, adult smokers were leaner than were nonsmokers but had a larger waist circumference or smaller waist-to-hip ratio.^4–8 Also, among smokers, a greater number of cigarettes smoked per day was related to waist circumference and BMI.⁵ In one large Australian study of women, smokers were found to be more likely to gain weight during the follow-up than were women who had never smoked.⁹ Age, duration of smoking, and socioeconomic status have been shown to modify the effect of smoking on body weight.^4,8,10,11Among adolescents, the results of studies of the association between smoking and BMI have been inconsistent. In some studies, the relation between smoking and lower body weight often observed in adults was found to be reduced or absent among youth.^12,13 Adolescence is a critical age for the development of obesity¹⁴ and the establishment of health habits such as smoking, eating behaviors, and physical activity. Only a few studies dealing with the association between smoking and later abdominal obesity have spanned the age period from adolescence to adulthood. Those studies were all beset with methodologic problems, however, and no associations were found.^15–17On the basis of previous studies of adults, it seems reasonable to assume that tobacco smoking is associated with changes in body weight and shape even though the possible biological mechanisms remain unclear. Because the time span from adolescence to adulthood is an important period in stabilizing health habits and in the development of obesity, we examined the effect of smoking during late adolescence on overweight and abdominal obesity in early adulthood. To examine the independent effects of smoking on subsequent measures of obesity, we controlled our analyses for several potential confounders.     

Longitudinal Associations Between Adolescent Alcohol Use and Adulthood Sexual Risk Behavior and Sexually Transmitted Infection in the United States: Assessment of Differences by Race

Objectives. We examined race differences in the longitudinal associations between adolescent alcohol use and adulthood sexually transmitted infection (STI) risk in the United States.Methods. We estimated multivariable logistic regression models using Waves I (1994–1995: adolescence) and III (2001–2002: young adulthood) of the National Longitudinal Study of Adolescent Health (n = 10 783) to estimate associations and assess differences between Whites and African Americans.Results. In adjusted analyses, adolescent alcohol indicators predicted adulthood inconsistent condom use for both races but were significantly stronger, more consistent predictors of elevated partnership levels for African Americans than Whites. Among African Americans but not Whites, self-reported STI was predicted by adolescent report of any prior use (adjusted odds ratio [AOR] = 1.47; 95% confidence interval [CI] = 1.00, 2.17) and past-year history of getting drunk (AOR = 1.53; 95% CI = 1.01, 2.32). Among Whites but not African Americans, biologically confirmed STI was predicted by adolescent report of past-year history of getting drunk (AOR = 1.68; 95% CI = 1.07, 2.63) and consistent drinking (AOR = 1.65; 95% CI = 1.03, 2.65).Conclusions. African American and White adolescent drinkers are priority populations for STI prevention. Prevention of adolescent alcohol use may contribute to reductions in adulthood STI risk.Sexually transmitted infections (STIs) disproportionately infect youths aged 15 to 24 years,1 with the highest rates of the most common reportable infections among young adults aged 20 to 24 years.2 Young adult African Americans are disproportionately infected.3 Adolescence, the period preceding young adulthood, is marked by rapid emotional and cognitive growth and exploration of identity.4–7 Risk behaviors that may influence STI often are initiated during this period,8 which is thus critical for implementation of STI prevention interventions.9,10 There is a need to identify the adolescent factors that drive STI risk and to develop adolescent interventions that reduce young adult STI and the race disparity in infection.Adolescent alcohol use—the most common adolescent substance use in the United States, reported by more than one third of 8th-grade students and 71% of 12th-grade students11—is associated with sexual risk behaviors12–16 and self-reported STI16,17 among young adults. Adolescent alcohol use is hypothesized to influence STI risk by working through a number of pathways (Figure 1). It is thought to negatively influence cognitive, neurological, and psychosocial development,18–23 which may lead to inhibited judgment and increased impulsivity,24–26 as well as involvement in high-risk behaviors and environments.27,28 Alcohol-related effects on developmental and contextual factors may lead to sexual risk behaviors in adulthood by increasing adolescent sexual risk-taking15,29–31 (which continues into adulthood12,14) or by contributing to long-term cognitive and psychosocial deficits that drive sexual risk-taking during adulthood. In addition, alcohol use may lead to STI risk in adulthood by increasing involvement in high-risk behaviors and social environments, including deviant peer networks, in which risky sexual behavior is normative and risk of sex with an STI-infected partner is elevated.32–36 Finally, adolescent alcohol use may lead to continued alcohol use in young adulthood,37,38 an established risk factor of STI risk in adulthood.31Open in a separate windowFIGURE 1—Hypothesized pathways linking alcohol use in adolescence and risk of sexually transmitted infection in young adulthood.Current research on alcohol use in adolescence and STI risk in adulthood has been marked by 3 important limitations. First, there is limited understanding of the link between adolescent alcohol use and adulthood STI risk in minority US populations. To our knowledge, no study has assessed race differences in the associations between adolescent alcohol use and adult STI risk, an important limitation given cross-sectional evidence suggesting that in the United States, such associations differ by race. Although there is evidence to suggest that alcohol use is more strongly associated with multiple partnerships among African American than White youths,39 findings also indicate that substance use is associated with STI among White but not African American youths.40Second, most existing research measuring the longitudinal associations between adolescent alcohol use and STI risk in young adulthood has been conducted in convenience samples, geographically specific populations, or study populations limited by relatively modest sample size.12–15,32 Given the high prevalence of adolescent alcohol use in the United States, along with current evidence of the link between adolescent alcohol use and adult STI risk, there is a need to measure the association using a large, nationally representative sample. Third, to our knowledge, no prior study has examined the association between adolescent alcohol use and biologically confirmed STI, an important limitation given the bias associated with self-reported STI.41We sought to address these research gaps by using Waves I and III of the National Longitudinal Study of Adolescent Health (Add Health) to examine, in a nationally representative sample, race differences (Whites vs African Americans) in the longitudinal associations between multiple dimensions of adolescent alcohol use and adulthood STI risk outcomes. Such outcomes include multiple partnerships, inconsistent condom use, and sex with an STI-infected partner, as well as indicators of infection, including self-reported curable and viral STI and biologically confirmed curable STI. Figure 1 highlights the variables that are explored in the current study.     

Asian American Problem Drinking Trajectories During the Transition to Adulthood: Ethnic Drinking Cultures and Neighborhood Contexts

Objectives. We aimed to identify problem drinking trajectories and their predictors among Asian Americans transitioning from adolescence to adulthood. We considered cultural and socioeconomic contextual factors, specifically ethnic drinking cultures, neighborhood socioeconomic status, and neighborhood coethnic density, to identify subgroups at high risk for developing problematic drinking trajectories.Methods. We used a sample of 1333 Asian Americans from 4 waves of the National Longitudinal Study of Adolescent to Adult Health (1994–2008) in growth mixture models to identify trajectory classes of frequent heavy episodic drinking and drunkenness. We fitted multinomial logistic regression models to identify predictors of trajectory class membership.Results. Two dimensions of ethnic drinking culture—drinking prevalence and detrimental drinking pattern in the country of origin—were predictive of problematic heavy episodic drinking and drunkenness trajectories. Higher neighborhood socioeconomic status in adolescence was predictive of the trajectory class indicating increasing frequency of drunkenness. Neighborhood coethnic density was not predictive of trajectory class membership.Conclusions. Drinking cultures in the country of origin may have enduring effects on drinking among Asian Americans. Further research on ethnic drinking cultures in the United States is warranted for prevention and intervention.Alcohol use disorders among Asian American young adults are important public health concerns. Although drinking prevalence is low for Asian Americans overall,1 Asian American young adults, particularly those in some ethnic groups such as Korean and Japanese, have higher rates of alcohol abuse and dependence than most other racial groups and other Asian ethnic groups such as Chinese.1–6 Asian Americans, including adolescents and young adults, are an underinvestigated population in alcohol research. Much of the small body of alcohol research, with college samples of mostly Korean and Chinese descent, has focused on genes involved in alcohol metabolism2,3,5,7,8 and the psychosocial moderators or mediators of their effects.2,9,10 Longitudinal studies on developmental trajectories of Asian American drinking are particularly rare.Past research indicates that alcohol consumption tends to escalate after high school in emerging adulthood (ages 18–25 years)11 and then begins to decline.12–14 Although problem drinking during emerging adulthood in itself is an important public health concern,15,16 continued or escalating problem drinking beyond this period is of even greater concern because of potential long-term health and social consequences. We aimed to identify developmental trajectories of problem drinking among Asian Americans transitioning from adolescence to adulthood that will help distinguish normative and problematic long-term drinking patterns. We also identified predictors of problematic drinking trajectories, with special attention to contextual factors concerning the broader cultural and socioeconomic environments of drinking, as these have received little research attention in this understudied population.Our investigation of ethnic drinking cultures addressed some of the documented limitations of acculturation research, including the common presumption that alcohol consumption and other risky health behaviors following an immigrant’s arrival in the United States are largely attributable to the influence of US culture,17 little understanding of ethnic cultures that may influence these behaviors,18 and the use of acculturation measures without clear bearings on the specific health issue at hand,19 which makes it difficult to elucidate the specific mechanisms through which acculturation influences health behaviors.20 In our view, the lack of understanding of the conditions within immigrant communities, along with preoccupation with how immigrant communities respond to US culture outside their communities, is critical.21 The approach we take here puts the focus squarely back on the cultural conditions within immigrant communities that specifically concern drinking—namely, ethnic drinking cultures, defined as cultural norms and behavioral practices of drinking in an immigrant’s country of origin.22 Our approach was informed by transnationalism theories, which suggest that immigrants often maintain socioeconomic ties with their homelands and retain elements of their cultural heritage, some of which may also appeal to their US-born descendants.23,24 In the context of drinking, transnationalism theories suggest that ethnic drinking culture from the country of origin may have enduring influence on immigrants and their children.A focus on ethnic drinking cultures has other significance in current research on immigrant health. Heterogeneity in drinking and other health outcomes across ethnic or national groups has been highlighted in recent research,25–27 which has used ethnicity as an implicit proxy of underlying yet undefined cultural or socioeconomic conditions that are assumed to vary across ethnic groups. Yet efforts to clarify the underlying conditions that may lead to diverse outcomes have been lacking.22 The 2 dimensions of ethnic drinking cultures used in this study, drinking prevalence and detrimental drinking pattern, express in quantifiable terms drinking-related cultural conditions that may explain the diverse drinking outcomes across Asian American subgroups. In our pioneering cross-sectional studies, we found robust associations of these dimensions with alcohol consumption among Asian American adults28 and young adults.22 Building on this research, in this longitudinal study, we examined the influence of ethnic drinking cultures on developmental trajectories of problem drinking among Asian Americans transitioning to adulthood in an effort to demonstrate their effects more conclusively.We also considered 2 neighborhood contextual factors as predictors of drinking trajectories, socioeconomic status (SES) and coethnic density. Neighborhood socioeconomic disadvantage may lead to problem drinking through several mechanisms including stress associated with a high level of poverty and often-accompanying social disorganization,29,30 a lack of social control on deviant behaviors associated with weaker community ties in disadvantaged neighborhoods,31,32 and increased density of bars and liquor stores in lower-income areas.33,34 Studies of effects of neighborhood disadvantage on substance use outcomes are decidedly mixed, as studies show less of an effect, or even an inverse association, of neighborhood disadvantage with adolescent substance use compared with adult substance use.35 Most adolescent substance users are in an experimental stage, and problematic trajectories of use are not evident until early adulthood, which is one impetus for the current study. Neighborhood coethnic density has been found to have protective buffering effects on health and health behaviors, including drinking,36 attributed to enhanced social cohesion, mutual social support, and a stronger sense of community and belongingness.37–41 Little research has been reported on the influence of these contextual factors on alcohol use over time among Asian American adolescents and young adults.Summarily stated, we addressed the following specific research question in this study: do ethnic drinking cultures, neighborhood SES, and neighborhood coethnic density predict problematic drinking trajectories for Asian Americans transitioning from adolescence to adulthood? We controlled for several key individual-level predictors of alcohol use during adolescence in our multivariate models—namely, US nativity, individual-level SES, age of drinking initiation, attachment to mother, and peer drinking in adolescence. This research helps identify specific profiles of subgroups at high risk for developing problematic, long-term patterns of drinking to guide prevention and intervention efforts targeted at the subgroups most likely to benefit. This is of great practical significance given the wide diversity among Asian Americans, both cultural42 and socioeconomic.43,44     

Elevated Risk of Posttraumatic Stress in Sexual Minority Youths: Mediation by Childhood Abuse and Gender Nonconformity

Objectives. We examined whether lifetime risk of posttraumatic stress disorder (PTSD) was elevated in sexual minority versus heterosexual youths, whether childhood abuse accounted for disparities in PTSD, and whether childhood gender nonconformity explained sexual-orientation disparities in abuse and subsequent PTSD.Methods. We used data from a population-based study (n = 9369, mean age = 22.7 years) to estimate risk ratios for PTSD. We calculated the percentage of PTSD disparities by sexual orientation accounted for by childhood abuse and gender nonconformity, and the percentage of abuse disparities by sexual orientation accounted for by gender nonconformity.Results. Sexual minorities had between 1.6 and 3.9 times greater risk of probable PTSD than heterosexuals. Child abuse victimization disparities accounted for one third to one half of PTSD disparities by sexual orientation. Higher prevalence of gender nonconformity before age 11 years partly accounted for higher prevalence of abuse exposure before age 11 years and PTSD by early adulthood in sexual minorities (range = 5.2%–33.2%).Conclusions. Clinicians, teachers, and others who work with youths should consider abuse prevention and treatment measures for gender-nonconforming children and sexual minority youths.Posttraumatic stress disorder (PTSD) has severe sequelae that can particularly affect youths by disrupting the achievement of adulthood milestones. PTSD negatively affects career prospects through elevated risk of substance abuse1 and unemployment,2 reduces educational attainment by increasing the risk of school dropout,2 and affects family formation by increasing the risk of relationship instability and adolescent pregnancy.2 Studies have also indicated that the course of PTSD is chronic in one third of cases2; identifying risk factors in children and early adulthood is therefore particularly important for public health because PTSD in adolescence or early adulthood may affect health and well-being throughout adulthood. Research indicates that lesbian, gay, and bisexual youths have higher prevalence of mental health problems than heterosexuals, including anxiety, depression, and suicidality3–6; to our knowledge, however, no studies of youths have examined the association between sexual orientation and probable PTSD in samples including both sexual minorities and heterosexuals.Childhood abuse greatly increases risk of developing PTSD.7–9 Child abuse can directly trigger PTSD,10 increase the risk of exposure to subsequent stressful events,8 and increase the conditional risk of developing PTSD following exposure to subsequent stressful events.11,12 Sexual minorities—lesbians, gay men, bisexuals, and “mostly heterosexuals”—experience higher rates of childhood abuse than do heterosexuals.13–18 Thus, disparities in childhood abuse may be a cause of higher prevalence of PTSD among sexual minority youths compared with heterosexuals.Additionally, gender-nonconforming appearance and behavior in childhood is more common among persons who will later have a minority sexual orientation.19–21 Differences in gender nonconformity may contribute to sexual-orientation disparities in maltreatment in early and middle childhood, before sexual identity has developed, as childhood gender nonconformity has been associated with parental rejection, harassment, and physical and verbal victimization related to sexual orientation.22–26We examine whether there are disparities in lifetime probable PTSD in youths by sexual orientation and whether greater exposure to child abuse may account for differences in PTSD. Additionally, we examine whether gender nonconformity accounts for higher prevalence of abuse before age 11 years and possible increased risk of PTSD among sexual minorities compared with heterosexuals. Because gender nonconformity has been associated with psychosocial stressors other than childhood abuse—namely, harassment and bullying—nonconformity may increase the risk of PTSD above and beyond its possible effects on childhood abuse. Given the high population prevalence of PTSD, its chronicity, and its associated impairment,2 identifying factors that put children and youths at risk for PTSD is vital.Although several studies have separately noted elevated prevalence of both child maltreatment and adulthood PTSD in sexual minorities,17,22 to date, only 1 study in adults has shown that higher rates of childhood abuse may partially account for higher prevalence of PTSD in sexual minorities.15 Very few studies have examined whether childhood gender nonconformity might explain elevated exposure to child abuse before adolescence24,27 or probable PTSD among sexual minorities. We examine possible sexual-orientation disparities in childhood abuse and PTSD separately by gender because studies have found gender differences in PTSD and childhood abuse.28,29 We further examine possible gender-by-sexual-orientation interactions in risk of PTSD and abuse.     

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.     

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

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

Protective Factors in the Lives of Bisexual Adolescents in North America

Objectives. We compared protective factors among bisexual adolescents with those of heterosexual, mostly heterosexual, and gay or lesbian adolescents.Methods. We analyzed 6 school-based surveys in Minnesota and British Columbia. Sexual orientation was measured by gender of sexual partners, attraction, or self-labeling. Protective factors included family connectedness, school connectedness, and religious involvement. General linear models, conducted separately by gender and adjusted for age, tested differences between orientation groups.Results. Bisexual adolescents reported significantly less family and school connectedness than did heterosexual and mostly heterosexual adolescents and higher or similar levels of religious involvement. In surveys that measured orientation by self-labeling or attraction, levels of protective factors were generally higher among bisexual than among gay and lesbian respondents. Adolescents with sexual partners of both genders reported levels of protective factors lower than or similar to those of adolescents with same-gender partners.Conclusions. Bisexual adolescents had lower levels of most protective factors than did heterosexual adolescents, which may help explain their higher prevalence of risky behavior. Social connectedness should be monitored by including questions about protective factors in youth health surveys.Adolescence is a key developmental period with long-term effects on physical and psychological health, and adolescents negotiate a variety of environmental challenges during these years. Although public health practice often focuses on preventing or decreasing health risks, in the past decade increasing attention has been paid to identifying protective factors that can foster healthy development. Protective factors are events, circumstances, and life experiences that promote confidence and competence among adolescents and help to protect them from negative developmental risks and health outcomes.^1,2 Such protective resources enhance resilience among adolescents who face adversities,³ and they arise from individual characteristics and social environments such as families, schools, and communities.⁴Several individual assets and external resources have been identified as protective factors that reduce the likelihood of risky behaviors such as suicidality, substance use, unprotected sexual behavior, and disordered eating. Individual-level protective factors include higher levels of self-esteem, psychological well-being, and religiosity.^5–8 Relational factors such as strong connectedness to family^5,7–13 and school^{5,7,9,10,12,13} also reduce the likelihood of engaging in behaviors that compromise health. Some community-level factors also appear to be protective against risk taking among adolescents; these include the presence of a caring adult role model outside the family^8,13 and community involvement, including volunteering.⁸Most studies focus on adolescents in general, but some populations, such as lesbian, gay, and bisexual adolescents, face greater environmental challenges in negotiating adolescence and navigating developmental tasks. LGB adolescents are disproportionately subjected to violence and harassment at school^14–16 and to physical and sexual abuse.^17,18 In addition, LGB adolescents are more likely than their heterosexual peers to be involved in health-compromising behaviors, including substance use,^14–17 risky sexual behaviors and injection drug use,^14,19,20 and suicide attempts.^{10,14,15,17,21–24}Researchers have recently started illuminating relationships between lower levels of protective factors and negative health outcomes among LGB adolescents. In an analysis of the 2004 Minnesota Student Survey, Eisenberg and Resnick found that LGB students were less likely than were other students to report high levels of family connectedness, teacher caring, other adult caring, and perceived safety at school.²⁵ However, these protective factors, when present, decreased the likelihood of suicidal ideation and attempts, and protective factors accounted for more of the variation in suicide behaviors than did sexual orientation. Similarly, in his analysis of the National Longitudinal Study of Adolescent Health, Ueno found that less-positive relationships with parents, school, and friends explained higher levels of psychological distress among sexual-minority students than among heterosexual students.²⁶ Homma and Saewyc found that higher levels of perceived family caring and more-positive perceptions of school climate were linked to lower levels of emotional distress among Asian American LGB high school students in Minnesota.²⁷These studies provide some evidence that protective factors may work in similar ways for LGB adolescents as for other adolescents, but not consistently; for example, high levels of religious involvement in a faith with negative attitudes about nonheterosexual orientations might actually be more harmful than protective. Further, if LGB adolescents as a group experience lower levels of these assets, this might help explain their higher risks. Only a handful of population-based studies have focused on sexual-minority adolescents and protective factors, and they provide limited information about protective factors among bisexual adolescents separately from gay or lesbian adolescents; most research combines these groups because of small samples. Measuring sexual orientation during adolescence can be difficult; sexual identity development is a task of adolescence, and many youths engage in exploration of romantic attraction, sexual behavior, or identity labels during the adolescent years. Behavior and self-labeling may be discordant at various times, and there is evidence that some adolescents’ perception of their orientation and labels will shift during adolescence and young adulthood.In the few studies that have disaggregated the groups, bisexual adolescents were more likely than were heterosexual peers to report risky sexual behaviors,^19,20 suicide attempts,¹⁶ victimization,¹⁶ delinquency,²⁸ and substance use^16,28; in some cases gay and lesbian adolescents did not significantly differ from their heterosexual peers in these risks.^16,19,28 Some studies used romantic attraction as a measure of orientation,^23,24,26 some used self-labels,^18,22 and some used gender of sexual partners.^{16,20,25,27,28} Few studies offer the opportunity to incorporate correlates for orientation measured in different ways in the same data set.No matter how it is measured, it is important to examine levels of protective factors among bisexual adolescents separately, given the greater likelihood of risk-taking behavior and negative experiences at school among bisexual students. Drawing on data from different waves of the National Longitudinal Study of Adolescent Health, 2 studies have found lower levels of connectedness to family and school and lower perceived caring by other adults among bisexual than among heterosexual adolescents.^29,30 Bisexual and gay or lesbian adolescents generally did not differ in their levels of protective factors, but this may have been partly attributable to relatively small samples of LGB adolescents in the longitudinal study cohort, which limits statistical power for comparisons between the 2 groups. Furthermore, the study is nationally representative of US adolescents in general but may not reflect the full ethnic diversity of LGB populations across the United States or Canada. Studies analyzing larger regional population-based surveys offer opportunities to confirm those findings for specific regions.Identifying whether protective factors work similarly for bisexual adolescents and their peers is useful, but it is equally important to monitor whether bisexual adolescents have the same levels of those protective factors in their lives. We therefore explored levels of protective factors among bisexual adolescents compared with heterosexual, mostly heterosexual, and gay or lesbian peers in 6 school-based surveys in the midwestern United States and western Canada. We posed 3 questions: (1) Are levels of protective factors different between bisexual adolescents and heterosexual adolescents? (2) Are levels of protective factors different between bisexual adolescents and gay or lesbian adolescents? (3) Are these patterns consistent across varying measures of sexual orientation?     

Education associations with smoking and leisure-time physical inactivity among Hispanic and Asian young adults

Objectives. We assessed whether associations between education and 2 health behaviors—smoking and leisure-time physical inactivity (LTPI)—depended on nativity and age at immigration among Hispanic and Asian young adults.Methods. Data came from the 2000–2008 National Health Interview Survey. The sample included 13 345 Hispanics and 2528 Asians aged 18 to 30 years. Variables for smoking and LTPI were based on self-reported data. We used logistic regression to examine education differentials in these behaviors by nativity and age at immigration.Results. The association of education with both smoking and LTPI was weaker for foreign-born Hispanics than for US-born Hispanics but did not vary by nativity for Asians. Education associations for smoking and LTPI among foreign-born Hispanics who had immigrated at an early age more closely resembled those of US-born Hispanics than did education associations among foreign-born Hispanics who had immigrated at an older age. A similar pattern for smoking was evident among Asians.Conclusions. Health-promotion efforts aimed at reducing disparities in key health behaviors among Hispanic and Asian young adults should take into account country of residence in childhood and adolescence as well as nativity.An extensive literature has established the existence of a social gradient in health, whereby health improves with each increment in socioeconomic status (SES).^1,2 Although most health outcomes show social gradients, research has increasingly suggested that SES may not have the same effect on health for all US populations.^3–6 In particular, researchers have found more modest socioeconomic differentials in health outcomes and related health behaviors for foreign-born populations than for corresponding US-born populations.^4,5,7One explanation for this pattern proposes that weaker social gradients in health and health behaviors among the foreign-born are rooted in lifestyle-related norms and practices in sending countries for US immigration, which may continue to shape outcomes along socioeconomic lines after arrival.⁴ We sought to extend the research in this area by assessing whether the relationship between education and some health behaviors depends not only on nativity but also on country of residence during childhood and adolescence. Although a recent study found that the association between subjective social status and mood dysfunction among Asian immigrants varied by age at immigration,⁶ to our knowledge no research has examined patterns for objective measures of SES and health behaviors. The results of this analysis may improve understanding of differences between social gradients in health behaviors in US populations and may inform efforts to target interventions to groups at higher risk for unhealthy practices.Our conceptual framework is informed by several areas of research. Numerous studies suggest that some health behaviors, such as smoking, are heavily influenced by early life experiences.^8–10 In addition, disparities in some health behaviors begin to form in childhood and adolescence, both within and outside the United States.^10–13 Mechanisms that shape health behaviors by SES (e.g., access to and affordability of unhealthy lifestyles among individuals with lower versus higher SES, variation in norms and sanctions surrounding particular practices by SES) may operate differently in the sending countries for US immigration. Finally, research on acculturation suggests that as immigrants enter new contexts, their health behaviors shift toward patterns observed among native-born populations, a process that may be especially influential during childhood and adolescence.^14–17 Although these changes may affect immigrants across the socioeconomic spectrum, they may also vary by SES if young immigrants adopt the health behaviors of native-born youths with similar socioeconomic backgrounds.We focused our analysis on education gradients in smoking and leisure-time physical inactivity (LTPI). The identification of consistencies in the influence of education, nativity, and age at immigration across health behaviors may inform a more comprehensive approach to addressing disparities. We selected these behaviors for study because of their associations with education and nativity and because both are shaped in part by mechanisms operating during childhood and adolescence.^11,18–20 Additionally, smoking and physical inactivity are among the leading actual causes of death in the United States.²¹We examined associations between these health behaviors and education, rather than income or occupational status, because education may better represent SES for individuals who do not work consistently in the paid workforce, an issue that is particularly relevant for immigrant populations.^5,22,23 Education also provides an indicator of the family socioeconomic environment during childhood and adolescence. We focused on young adults (aged 18–30 years) partly because of limitations on data available to determine age at immigration (explained in detail in the Methods section). However, patterns in young adulthood may provide insights into patterns for related health outcomes in older populations.We first determined whether differences in education gradients in smoking and LTPI by nativity (documented for adults of all ages) were evident among young adults.^4,5 If education gradients in smoking and LTPI are influenced by exposures in early life, then variation by nativity should be evident by young adulthood. Second, and more important, we investigated whether associations between education and both smoking and LTPI among foreign-born young adults who immigrated in childhood or adolescence more closely resembled associations among the US-born than was the case for the foreign-born who immigrated after adolescence. We focused on Hispanics and Asians because these groups include large immigrant populations. Finally, we assessed whether patterns varied by Hispanic and Asian subgroup and by gender.     

Let’s Get Physical: Sexual Orientation Disparities in Physical Activity,Sports Involvement,and Obesity Among a Population-Based Sample of Adolescents

Objectives. We examined sexual orientation disparities in physical activity, sports involvement, and obesity among a population-based adolescent sample.Methods. We analyzed data from the 2012 Dane County Youth Assessment for 13 933 students in grades 9 through 12 in 22 Wisconsin high schools. We conducted logistic regressions to examine sexual orientation disparities in physical activity, sports involvement, and body mass index among male and female adolescents.Results. When we accounted for several covariates, compared with heterosexual females, sexual minority females were less likely to participate in team sports (adjusted odds ratio [AOR] = 0.44; 95% confidence interval [CI] = 0.37, 0.53) and more likely to be overweight (AOR = 1.28; 95% CI = 1.02, 1.62) or obese (AOR = 1.88; 95% CI = 1.43, 2.48). Sexual minority males were less likely than heterosexual males to be physically active (AOR = 0.62; 95% CI = 0.46, 0.83) or to participate in team sports (AOR = 0.26; 95% CI = 0.20, 0.32), but the 2 groups did not differ in their risk of obesity.Conclusions. Sexual orientation health disparities in physical activity and obesity are evident during adolescence. Culturally affirming research, interventions, and policies are needed for sexual minority youths.Obesity is an increasing and serious health problem among adolescents.1,2 This is of major concern because obesity has many health and social consequences and it affects adolescents’ overall well-being.3,4 Obesity among adolescents also has a high likelihood of continuing into adulthood.5 Recent population-based and longitudinal research has demonstrated that there are disparities in obesity between sexual minority and heterosexual adolescents.6–8 Research has also documented sexual orientation disparities in physical activity and sports involvement in adolescence.9,10 Despite this increased attention, the overall empirical base remains limited, and findings also suggest some gender nuances that need further exploration. More population-based research is needed to investigate these disparities, consistent with federal health priorities.7,11There are sexual orientation–based disparities in physical activity and sports involvement among adolescents; however, there are mixed findings for females. One study reported that sexual minority females are less likely than heterosexual females to participate in moderate to vigorous physical activity and team sports,9 whereas another study found no such differences in physical activity.10 Findings are more consistent for sexual minority male adolescents, who are less likely than heterosexual males to engage in moderate to vigorous physical activity, to engage in recommended levels of physical activity, and to participate in team sports.9,10 More research is needed because of the paucity of studies and mixed results. This is especially important given that adolescents’ physical activity has been shown to relieve stress and protect against many mental and physical health conditions, including obesity,12,13 for which sexual minority adolescents are at greater risk.Research on sexual orientation disparities in obesity suggests that there are some gender nuances. Many studies have found that sexual minority female adolescents have higher risk of obesity than heterosexual females (e.g., higher body mass index [BMI], defined as weight in kilograms divided by the square of height in meters).6,8,10,14 These sexual orientation disparities in obesity among adolescent females parallel those among sexual minority adult women.15,16Findings of elevated obesity risk among sexual minority male adolescents are mixed. Some studies show that sexual minority males, specifically bisexual males, have higher odds of obesity than heterosexuals,14 whereas other studies have documented no differences.10 By contrast, some studies have found that heterosexual males have increases in BMI during adolescence compared with sexual minority males.6,8 These mixed findings for sexual minority males might be attributed to physical maturation and developmental changes in adolescence that some of the cross-sectional studies could not examine.10,14 Specifically, one study found that sexual minority males had higher obesity risk than heterosexual males in early adolescence, but their risk of obesity became lower than for heterosexual males later in adolescence.6 The authors postulated that, compared with heterosexual males, sexual minority males reach puberty maturation earlier in adolescence but make less substantial weight gains later in adolescence.6Sexual orientation health disparities have been explained through the minority stress model: sexual minority youths experience unique stressors and stigma related to their sexual identity (e.g., homophobic bullying), which lead to poorer health.17 Sexual minority adolescents might therefore be less likely to be physically active or involved in team sports because of potential minority stressors that they often experience at school, especially bias and heightened discrimination experienced in the context of sports or in their communities.18–20 More recently, the negative effects of minority stress and stigma on physical health disparities have been documented,21,22 including their effects on obesity for sexual minority women.23 However, the minority stress model is not sufficient in explaining how sexual minority adolescent females, but not males, are at greater risk for obesity compared with their heterosexual peers.Another potential explanation of these obesity disparities is related to cultural norms and sexual minority females’ experiences of internalizing ideals for femininity and appearance8 and sexual minority males’ ideals for muscularity and body image.24 For instance, compared with heterosexual women, sexual minority women are more likely to be satisfied with their bodies and attracted to women with greater body mass,25,26 whereas sexual minority men are less likely to be satisfied with their bodies compared with heterosexual men and are more likely to be attracted to muscular men.25,27 Therefore, these 2 groups might engage (or not engage) in differing body weight management and dieting behaviors compared with their heterosexual peers; concomitantly, these behaviors might render differing risks for obesity.Sexual minority adolescents’ lack of physical activity and sports involvement might be influenced by traditional gender norms associated with athleticism and sports, which has implications for their athletic self-esteem and involvement. For adolescent males, team sports are a means to define masculinity28; however, adolescent males often engage in homophobic banter to prove their masculinity and heterosexuality and to enforce traditional gender norms.29,30 Sexual prejudice is pervasive in athletic settings,19,20 making sports contexts unwelcoming and unsafe for many sexual minority males. Traditional feminine gender norms and homophobia also affect sexual minority females’ involvement in sports.31 However, sexual minority adolescent females have unique gendered experiences in relation to sports. Because women’s athleticism can be a stereotype for being a lesbian,32 sexual minority females might avoid sports involvement. Expecting or experiencing exclusion in sports settings might also affect sexual minority adolescents’ athletic self-esteem, consequently preventing them from engaging in future sports or physical activity.9 In fact, athletic self-esteem has been found to contribute to sexual orientation disparities in sports involvement and physical activity.9Emerging evidence of sexual orientation disparities in physical activity, sports involvement, and obesity among adolescents, in addition to potential gender nuances in these disparities, points to the need for more population-based research in this area. We therefore examined sexual orientation disparities among a large adolescent population-based sample and tested for gender differences. While accounting for variables commonly associated with physical activity and obesity among adolescents,4,33 we hypothesized that sexual minority adolescents would be less likely to report physical activity and sports involvement than would their heterosexual peers. We also hypothesized that sexual minority females would be at higher risk for being overweight and obese than their heterosexual peers. Because of mixed findings in existing sexual orientation disparities research among adolescent males, we hypothesized that sexual minority males would be at equal risk for being overweight and obese than their heterosexual male peers.     

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

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

The California Endowment's Healthy Eating, Active Communities Program: A Midpoint Review

Objectives. We conducted a midpoint review of The California Endowment''s Healthy Eating, Active Communities (HEAC) program, which works in 6 low-income California communities to prevent childhood obesity by changing children''s environments. The HEAC program conducts interventions in 5 key childhood environments: schools, after-school programs, neighborhoods, health care, and marketing and advertising.Methods. We measured changes in foods and beverages sold at schools and in neighborhoods in HEAC sites; changes in school and after-school physical activity programming and equipment; individual-level changes in children''s attitudes and behaviors related to food and physical activity; and HEAC-related awareness and engagement on the part of community members, stakeholders, and policymakers.Results. Children''s environments changed to promote healthier lifestyles across a wide range of domains in all 5 key childhood environments for all 6 HEAC communities. Children in HEAC communities are also engaging in more healthy behaviors than they were before the program''s implementation.Conclusions. HEAC sites successfully changed children''s food and physical activity environments, making a healthy lifestyle a more viable option for low-income children and their families.Childhood obesity is at epidemic levels in the United States. More than 1 in 7 children and adolescents aged 6 to 17 years are considered obese.¹ Additionally, disparities in obesity rates exist among ethnic groups. Black, Hispanic, and Native American children and adolescents have higher rates of diabetes and obesity than do White children and adolescents.¹ Poor diet and inadequate physical activity have been linked to obesity and preventable chronic illnesses.^2,3 Overweight and obese children may develop a number of risk factors for chronic disease and are increasingly diagnosed with diseases that have historically had their onset in adulthood, such as type 2 diabetes, hypertension, and high cholesterol.⁴Most strategies to prevent or reduce childhood obesity have focused on individual behavior modification and pharmacological treatment, with limited success.⁵ Current research suggests that childhood dietary habits and physical activity levels are influenced by a variety of environmental factors,⁶ such as increasing portion sizes,^7–10 increasing availability of fast food and soft drinks,^11–20 availability of soda and unhealthy food on school campuses,^21–29 curtailment or elimination of physical education and recess in schools,³⁰ insufficient or inadequate parks and recreational facilities,³¹ public policy favoring personal transportation over mass transit,^32–39 limited access to healthy foods and ready availability of unhealthy foods,^37,40–44 and disproportionate advertising of low-nutrient-dense foods and sedentary activities to children and their families.^25,45–49Many of these factors are exacerbated in low-income communities, where healthy and affordable food options and safe opportunities for physical activity are noticeably absent.^40,42 These factors are contributing to high levels of diseases related to nutrition and physical activity among Black and Latino populations.^34,40,42,50A better understanding of the underlying factors that lead to obesity has led to the emergence of a new type of initiative that seeks to reduce childhood obesity by making environmental improvements that promote healthy eating and physical activity, rather than focusing on changing individual eating and activity patterns. Although this type of environmental intervention is relatively new, early results are encouraging.^51–53 It has been demonstrated that better access to healthy foods and opportunities for physical activity results in healthier diets and increased physical activity: people in the presence of supermarkets eat more fruits and vegetables,^40,42,54 and when a venue for physical activity is available, people are more likely to be physically active.^34,55To help prevent obesity and type 2 diabetes among children and adolescents, the Healthy Eating, Active Communities (HEAC) program was established to promote public health environmental change in 6 California communities. We conducted a midpoint review of HEAC''s progress to assess how well these communities were translating models for change into on-the-ground practices resulting in real improvements in the food and physical activity opportunities available to low-income children and families.     

Reinforcement of smoking and drinking: tobacco marketing strategies linked with alcohol in the United States

Objectives. We investigated tobacco companies’ knowledge about concurrent use of tobacco and alcohol, their marketing strategies linking cigarettes with alcohol, and the benefits tobacco companies sought from these marketing activities.Methods. We performed systematic searches on previously secret tobacco industry documents, and we summarized the themes and contexts of relevant search results.Results. Tobacco company research confirmed the association between tobacco use and alcohol use. Tobacco companies explored promotional strategies linking cigarettes and alcohol, such as jointly sponsoring special events with alcohol companies to lower the cost of sponsorships, increase consumer appeal, reinforce brand identity, and generate increased cigarette sales. They also pursued promotions that tied cigarette sales to alcohol purchases, and cigarette promotional events frequently featured alcohol discounts or encouraged alcohol use.Conclusions. Tobacco companies’ numerous marketing strategies linking cigarettes with alcohol may have reinforced the use of both substances. Because using tobacco and alcohol together makes it harder to quit smoking, policies prohibiting tobacco sales and promotion in establishments where alcohol is served and sold might mitigate this effect. Smoking cessation programs should address the effect that alcohol consumption has on tobacco use.Smoking remains the leading preventable cause of premature mortality in the United States, accounting for more than 440 000 deaths annually.¹ Alcohol consumption is the third-leading cause of mortality in the nation.² Each year, approximately 79 000 deaths are attributable to excessive alcohol use.³ The concurrent use of cigarettes and alcohol further increases risks for certain cancers, such as cancer of the mouth, throat, and esophagus.^4,5 In addition, the use of both tobacco and alcohol makes it more difficult to quit either substance.⁶Smoking and drinking are strongly associated behaviors.^7–13 Smokers are more likely to drink alcohol,¹¹ drink more frequently,^8,11 consume a higher quantity of alcohol,^8,11,14 and demonstrate binge drinking (5 or more drinks per episode) than are nonsmokers.^9,11,12 Alcohol drinkers, especially binge drinkers, are also more likely to smoke^7,8,10 and are more likely to smoke half a pack of cigarettes or more per day.¹⁰The association between tobacco use and alcohol use becomes stronger with the heavier use of either substance.^8,15,16 Alcohol consumption increases the desire to smoke,^17,18 and nicotine consumption increases alcohol consumption.¹⁹ Experimental studies have demonstrated that nicotine and alcohol enhance each other''s rewarding effects.^16,18 Alcohol increases the positive subjective effects of smoking,^8,15,16,20 and smoking while using alcohol is more reinforcing than is smoking without concurrent alcohol use.⁸ Smokers smoke more cigarettes while drinking alcohol,^8,15,18 especially during binge-drinking episodes.^8,15 This behavior has also been observed among nondaily smokers^8,15 and light smokers.¹⁷The concurrent use of alcohol and tobacco is common among young adults,^8,10,12,21 including nondaily smokers,^19,22–24 nondependent smokers,⁸ and novice smokers.¹³ Young adult smokers have reported that alcohol increases their enjoyment of and desire for cigarettes^8,25 and that tobacco enhances the effect of alcohol: it “brings on the buzz” or “gave you a double buzz.”^13,23,26 Young adult nondaily smokers described the pairing of alcohol and cigarettes as resembling “milk and cookies” or “peanut butter with jelly.”²⁴ Young adults have also been the focus of aggressive tobacco promotional efforts in places where alcohol is consumed, such as bars and nightclubs.^27,28Consumer products often fall into cohesive groups (sometimes referred to as “Diderot unities”) that may reinforce certain patterns of consumption,²⁹ and these groupings may be influenced by marketing activities. In the case of tobacco and alcohol, these product links may have been further enhanced by cooperation between tobacco and alcohol companies (e.g., cosponsorship) or corporate ownership of both tobacco and alcohol companies (e.g., Philip Morris''s past ownership of Miller Brewing Company).We used tobacco industry documents to explore tobacco companies’ knowledge regarding linked tobacco and alcohol use and the companies’ marketing strategies that linked cigarettes with alcohol. We were interested in 3 basic issues: (1) what tobacco companies knew about the association between drinking and smoking, especially about smokers’ drinking behaviors, (2) how tobacco and alcohol companies developed cross promotions featuring cigarettes and alcohol, and (3) how tobacco companies linked cigarettes with alcohol in their marketing activities and the benefits they expected to gain from those activities.     

Alcohol consumption in early adulthood and schooling completed and labor market outcomes at midlife by race and gender

Objectives. We assessed the relation of alcohol consumption in young adulthood to problem alcohol consumption 10 years later and to educational attainment and labor market outcomes at midlife. We considered whether these relations differ between Blacks and Whites.Methods. We classified individuals on the basis of their drinking frequency patterns with data from the 1982 to 1984 National Longitudinal Survey of Youth 1979 (respondents aged 19–27 years). We assessed alcohol consumption from the 1991 reinterview (respondents aged 26–34 years) and midlife outcomes from the 2006 reinterview (respondents aged 41–49 years).Results. Black men who consumed 12 or more drinks per week at baseline had lower earnings at midlife, but no corresponding relation for Black women or Whites was found. Black men and Black women who consumed 12 or more drinks per week at baseline had lower occupational attainment than did White male non-drinkers and White female non-drinkers, respectively, but this result was not statistically significant.Conclusions. The relation between alcohol consumption in young adulthood and important outcomes at midlife differed between Blacks and Whites and between Black men and Black women, although Blacks’ alcohol consumption at baseline was lower on average than was that of Whites.Alcohol consumption is relatively high among individuals in college or of college age.^1–4 The short-term consequences of heavy drinking—emergency room visits,⁵ intimate partner violence,^6–8 and motor vehicle fatalities,^9,10 among others—are well documented. With a few exceptions,^11,12 until recently a lack of longitudinal data has inhibited researchers’ ability to track events occurring much later in the life course that are associated with alcohol consumption levels in early adulthood.The alcohol consumption of Blacks tends to be similar to or less than that of Whites.^13–18 However, this generalization obscures more subtle differences. For one, there is less of a decline in alcohol consumption after the early 20s among Blacks than Whites.¹⁹Some studies, for example, of mortality and high-density lipoprotein cholesterol,^20,21 have supported a conclusion of no difference between Blacks and Whites in the relation between alcohol consumption and various outcomes. However, other studies, which focused on alcohol use in early adulthood and subsequent occupational attainment (an index of the occupation''s prestige), have found that heavy alcohol use in early adulthood is associated with lower occupational attainment in Blacks but not in Whites.^22,23 These results came from 1 longitudinal database—the Coronary Artery Risk Development in Young Adults study—which was drawn from residents of 4 geographically disperse US cities.Race is a social, not a biological, construct. There is substantially more variation genetically within than among racial categories.²⁴ Yet previous research has documented racial differences in psychosocial factors, which are highly correlated with both baseline drinking and long-term drinking trajectories.^19,23,25,26 Important differences in outcomes among Blacks versus Whites have also been reported.^{22,23,27–29}We investigated the relations of alcohol consumption to educational attainment and labor market outcomes at midlife and how these relations differ between Blacks and Whites. We used national longitudinal data from the National Longitudinal Survey of Youth 1979 (NLSY79) to assess (1) whether there are relations between an individual alcohol consumption level at 19 to 27 years of age and various outcomes at later stages in the life course (alcohol consumption, abuse, and dependence; educational attainment; occupational attainment; and earnings), and (2) whether these relations differ between Blacks and Whites in the full sample and when stratified by gender.     

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

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

“It’s Not a Priority When We’re in Combat”: Public Health Professionals and Military Tobacco Control Policy

Tobacco use is prevalent among service members, but civilian public health groups have not effectively addressed military tobacco control policy issues. We conducted focus groups in 2010 and 2012 with participants from public health and tobacco control organizations regarding their understanding of the military and of tobacco use in that context. Misperceptions were common. Military personnel were believed to be young, from marginalized populations, and motivated to join by lack of other options. Tobacco use was considered integral to military life; participants were sometimes reluctant to endorse stronger tobacco control policies than those applied to civilians, although some believed the military could be a social policy leader. Engaging public health professionals as effective partners in tobacco-free military efforts may require education about and reframing of military service and tobacco control policy.Tobacco use prevalence is high among service members1 and military tobacco policy conveys mixed messages about tobacco use. For example, military personnel have access to comprehensive cessation services2 but stores on military installations sell tobacco products at discounted prices.3 Though the harms of smoking have been known since the 1950s, civilian public health groups have not effectively addressed military tobacco control policy issues. In 2009, the Institute of Medicine called for the Department of Defense to phase in policies that would lead to a tobacco-free military.2 However, this call was rejected by then–Secretary of Defense Robert Gates.4 More surprisingly, public health and tobacco control leaders were largely silent, the exception being the American Lung Association.5 Recently, Secretary of the Navy Ray Mabus, supported by Secretary of Defense Chuck Hagel,6 proposed eliminating tobacco sales from Navy and Marine Corps commissaries and exchanges.7 The leading voluntary health organizations supported the move,8 but there has been little public activism or engagement to counter efforts in Congress to block the Navy initiative.9 This is only the latest in a long history of efforts by the military to strengthen its tobacco control policies that have been prevented by congressional action while public health groups remained uninvolved.10–12Effectively framing a problem is crucial to gaining support for a proposed solution. Frames define a problem and implicitly or explicitly suggest the solution.13 For example, personal responsibility frames for public health issues suggest that they are the fault of individuals who must solve their problems themselves. The tobacco industry has framed tobacco control advocates as moralizing zealots and tobacco control policies as interfering with civil liberties.14 Industry frames emphasize the freedom of citizens “to pursue happiness . . . by making their own choices,”14^(p321) a value shared by many, including tobacco control advocates. The tobacco industry has also used alliances with veterans’ organizations to help frame military tobacco control issues. Veterans’ groups (sometimes using language crafted by the tobacco industry)15 have opposed clean indoor air laws by referencing rights, freedom, or sacrifice. For example, supporters of legislation mandating smoking areas in veterans’ hospitals argued that veterans had “fought for the right of all Americans, themselves included, to be free from unwarranted interference in their lives by government.”16 This framing can be difficult for civilian groups to counter.Previous research showed that public health and tobacco control leaders were unfamiliar with military tobacco control developments and the role that their organizations might play.17 Although they supported policies such as prohibiting smoking in uniform, they opposed prohibiting tobacco use altogether, as a violation of personnel’s rights. Some believed that policies had to be developed democratically, despite the authoritarian structure of the military. Leaders of organizations who advocate policies may either follow initiatives that arise from the membership, or attempt to educate or persuade the membership to support their own proposals. In either case, for an organization to act effectively on an issue, the opinions and understandings of leaders and membership should agree. To gain further insight into the absence of public health action on this issue, and to explore whether leaders’ perceptions were reflective of those held by public health professionals more generally, we conducted focus groups with members of public health and tobacco control organizations.     

Neighborhood Predictors of Dating Violence Victimization and Perpetration in Young Adulthood: A Multilevel Study

Objectives. We examined whether social processes of neighborhoods, such as collective efficacy, during individual''s adolescent years affect the likelihood of being involved in physical dating violence during young adulthood.Methods. Using longitudinal data on 633 urban youths aged 13 to 19 years at baseline and data from their neighborhoods (collected by the Project on Human Development in Chicago Neighborhoods), we ran multilevel linear regression models separately by gender to assess the association between collective efficacy and physical dating violence victimization and perpetration, controlling for individual covariates, neighborhood poverty, and perceived neighborhood violence.Results. Females were significantly more likely than were males to be perpetrators of dating violence during young adulthood (38% vs 19%). Multilevel analyses revealed some variation in dating violence at the neighborhood level, partly accounted for by collective efficacy. Collective efficacy was predictive of victimization for males but not females after control for confounders; it was marginally associated with perpetration (P = .07). The effects of collective efficacy varied by neighborhood poverty. Finally, a significant proportion (intraclass correlation = 14%–21%) of the neighborhood-level variation in male perpetration remained unexplained after modeling.Conclusions. Community-level strategies may be useful in preventing dating violence.Intimate partner violence (IPV), a serious public health problem worldwide, often begins as adolescent dating violence.¹ In the United States, more than 25 million women and 7 million men have experienced partner violence during their lifetimes.² Young adults have the highest risk for IPV.³ Despite an expansion of studies on IPV in the past 2 decades, prior literature has mainly focused on identifying individual- and relationship-level predictors of violence against women.^4–7 Limited studies have considered the social context of youth within which dating violence is embedded.^8,9 Given that patterns of IPV typically emerge during adolescence and levels increase over time,^1,2 it is important to examine whether neighborhood resources can be leveraged to prevent dating violence during young adulthood.