Out Yonder: Sexual-Minority Adolescents in Rural Communities in British Columbia

Objectives. We compared sexual-minority adolescents living in rural communities with their peers in urban areas in British Columbia, exploring differences in emotional health, victimization experiences, sexual behaviors, and substance use.Methods. We analyzed a population-based sample of self-identified lesbian, gay, or bisexual respondents from the British Columbia Adolescent Health Survey of 2003 (weighted n = 6905). We tested rural–urban differences separately by gender with the χ² test and logistic regressions.Results. We found many similarities and several differences. Rural sexual-minority adolescent boys were more likely than were their urban peers to report suicidal behaviors and pregnancy involvement. Rural sexual-minority adolescents, especially girls, were more likely to report various types of substance use. Rural status was associated with a lower risk of dating violence and higher risk of early sexual debut for sexual-minority girls and a higher risk of dating violence and lower risk of early sexual debut for sexual-minority boys.Conclusions. Location should be a demographic consideration in monitoring the health of sexual-minority adolescents. Lesbian, gay, and bisexual adolescents in rural communities may need additional support and services as they navigate adolescence.Adolescence is marked by many developmental tasks, including the unfolding of sexual identity. Adolescents who are lesbian, gay, or bisexual (LGB) face the additional challenge of being members of a sexual minority in a heterosexually dominant world. This may be an especially complex task in a rural environment, where heterosexism may be more pronounced¹ and supportive resources limited.² Scant research has compared the experiences of LGB adolescents in rural and urban areas.In the past decade, a growing number of population-based studies of LGB adolescents addressed the methodological criticisms of earlier studies that relied on urban samples, convenience samples, and samples of adolescents who may have been of legal adult age.^2–5 Population-based research on LGB adolescents has demonstrated that they face health disparities when compared with heterosexual adolescents. For example, LGB adolescents are at increased risk of being stigmatized and victimized.^3,6–11 LGB adolescents also experience higher rates of emotional distress and suicidality,^{3,6,8,11–16} substance use,^3,6,8,11,17 and risky sex,^6,8 which may put them at increased risk for HIV infection^18,19 and pregnancy.⁹Rural communities have several characteristics that may affect the experiences of LGB adolescents. Social isolation may be greater in rural regions, because the chance to identify with an LGB peer group may be limited or nonexistent.^2,20,21 Adolescents and their families may also lack access to resources for information and support.^2,20 Furthermore, more conservative attitudes in general, and negative attitudes or misconceptions about nonheterosexual orientations specifically, and less anonymity in small communities may make it harder for adolescents to openly express same-gender affections² and risk public disclosure.²² Thus, LGB adolescents in rural areas may face greater disparities and challenges compared with their urban counterparts.Results of research on rural–urban differences in the general population have been mixed. For example, a study of multiple data sets by the US National Center on Addiction and Substance Abuse found substance-use rates among rural adolescents to be generally higher.²³ Likewise, a study of more than 2000 students from urban, suburban, and rural schools in upstate New York found that rural adolescents were twice as likely as their suburban and urban counterparts to frequently use tobacco, alcohol, and other drugs and to have had sex.²⁴ Conversely, analyses of the 1999 US Youth Risk Behavior Survey found no differences among urban and nonurban adolescents on several substance-use and sexual behavior variables.²⁵ A separate report on health in the United States found that adolescent childbearing rates were lowest in suburban areas.²⁶ Studies of dating violence have also had mixed results, finding rural adolescents at higher risk²⁷ or lower risk.²⁸Only a few studies have directly compared LGB adolescents living in rural areas with those living in urban areas. Waldo et al. studied LGB rural and urban young people aged 15 to 21 years.²⁹ Urban participants were recruited through metropolitan community centers and rural participants through university student groups in a politically conservative town more than an hour away from a metropolitan center. They found rates of assault were lower for rural young people, but suicidality did not differ between rural and urban participants. In an analysis of population-based data from the US National Longitudinal Study of Adolescent Health, Galliher et al. defined urban, suburban, and rural from interviewers’ observations of the immediate are around the participant''s residence.¹² They found that rural sexual-minority adolescent girls reported more depressive symptoms, but rural adolescent boys, regardless of attraction status, reported a greater sense of school belonging, greater self-esteem, and fewer depressive symptoms.We used school-based representative data from British Columbia to explore differences in health and risk between LGB adolescents in rural communities and their urban counterparts. We focused on LGB adolescents only, because previous research has documented the health disparities between LGB and heterosexual adolescents. In contrast to previous studies,^12,29 we looked at a broader range of behaviors and used a standardized definition of rurality to categorize location.     

Hombres Sanos: evaluation of a social marketing campaign for heterosexually identified Latino men who have sex with men and women

Objectives. We evaluated the effectiveness of Hombres Sanos [Healthy Men] a social marketing campaign to increase condom use and HIV testing among heterosexually identified Latino men, especially among heterosexually identified Latino men who have sex with men and women (MSMW).Methods. Hombres Sanos was implemented in northern San Diego County, California, from June 2006 through December 2006. Every other month we conducted cross-sectional surveys with independent samples of heterosexually identified Latino men before (n = 626), during (n = 752), and after (n = 385) the campaign. Respondents were randomly selected from 12 targeted community venues to complete an anonymous, self-administered survey on sexual practices and testing for HIV and other sexually transmitted infections. About 5.6% of respondents (n = 98) were heterosexually identified Latino MSMW.Results. The intervention was associated with reduced rates of recent unprotected sex with both females and males among heterosexually identified Latino MSMW. The campaign was also associated with increases in perception of HIV risk, knowledge of testing locations, and condom carrying among heterosexual Latinos.Conclusions. Social marketing represents a promising approach for abating HIV transmission among heterosexually identified Latinos, particularly for heterosexually identified Latino MSMW. Given the scarcity of evidence-based HIV prevention interventions for these populations, this prevention strategy warrants further investigation.In the United States, adult and adolescent Latino males represent 5.6% of the total population¹ but 18.7% of HIV/AIDS cases.² Low rates of condom use^3–5 and limited HIV testing^5–7 likely contribute to the risk for infection and transmission among Latinos.Sex between men continues to account for the majority of new HIV infections in the United States.² HIV prevention efforts have traditionally targeted gay and bisexual men. However, individuals’ self-identified sexual orientation frequently does not correspond to their sexual behavior,^8–12 and recent research has been focused on men who self-identify as heterosexual but have sex with men. The results of studies on men who have sex with both men and women (MSMW) suggest that, regardless of sexual identity, this population is at greater risk for HIV than are men who exclusively have sex with men; likewise, MSMW are at greater risk than are men who exclusively have sex with women (MSW).^11,13–16 Reasons for greater risk among MSMW may include lower rates of condom use^11,16 and having sexual partners who engage in high-risk sexual practices.¹¹Previous studies have suggested that Latino men are more likely than are White men to engage in bisexual sexual behavior^9,11,17,18 but less likely than are White men to self-identify as gay or bisexual or to disclose their sexual orientation.^19–23 Cultural factors such as homophobia, social stigma related to same-sex practices, and sexual conservatism may inhibit Latino men from self-identifying as homosexual or bisexual.^{10,13,23–26} The degree to which Latinos integrate same-sex sexual practices into their sexual identities may influence their risk for HIV infection.²⁷ Latino MSMW who identify as heterosexual may perceive that they are at lower risk for sexually transmitted infections (STIs) than are gay or bisexual men, and Latino MSMW may thus be less likely to use condoms to protect themselves or their partners. Latino MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.^19,27Nondisclosure of same-sex sexual practices among MSMW also has significant implications for the health of their female sexual partners.^9,17 More than 70% of Latinas living with HIV/AIDS in the United States were infected via heterosexual contact.² Most cases of heterosexual transmission to Latinas are related to sex with partners who use injection drugs,²⁸ but unprotected sex with men who have multiple partners, including MSMW, has likely contributed to a subset of HIV cases among Latina women.^2,29Social marketing involves applying the principles and techniques of commercial marketing to the promotion of behavioral change for the good of a target audience.^30,31 Social marketing has been successfully used for HIV prevention with gay and bisexual males,^32,33 racial and ethnic minorities,³⁴ and youths.^35–38 Interventions using social marketing have been associated with improvements in HIV/STI testing^32,34 and condom use.^36,37,39,40 To our knowledge, no social marketing campaigns have been designed to reduce HIV risk among heterosexually identified Latino MSMW. Because of the secrecy of their sexual practices and the perceived association of HIV infection with homosexuality,^24,41,42 heterosexually identified Latino MSMW are difficult to reach with HIV prevention efforts. This population is not likely to be exposed to prevention messages or programs targeted to the gay and bisexual communities.¹⁸ Moreover, interventions requiring active recruitment of heterosexually identified MSMW may fail to reach sufficient numbers or may not reach those who are most secretive about their same-sex sexual practices.⁴¹ We sought to evaluate the effectiveness of a social marketing campaign to increase condom use and HIV testing among heterosexual Latino men in northern San Diego County, California, with a special emphasis on heterosexually identified Latino MSMW.     

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.     

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

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

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

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

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.     

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).     

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.     

Consistency and Change in Club Drug Use by Sexual Minority Men in New York City, 2002 to 2007

We used repeated cross-sectional data from intercept surveys conducted annually at lesbian, gay, and bisexual community events to investigate trends in club drug use in sexual minority men (N = 6489) in New York City from 2002 to 2007. Recent use of ecstasy, ketamine, and γ-hydroxybutyrate decreased significantly. Crystal methamphetamine use initially increased but then decreased. Use of cocaine and amyl nitrates remained consistent. A greater number of HIV-positive (vs HIV-negative) men reported recent drug use across years. Downward trends in drug use in this population mirror trends in other groups.“Club drugs” are illicit substances consumed in social or party situations¹ to increase social disinhibition and heighten sensual and sexual experiences.^2,3 This category typically includes ecstasy (3,4 methylenedioxymethamphetamine), γ-hydroxybutyrate (GHB), and ketamine,⁴ although recent reports also have included cocaine⁵ and crystal methamphetamine.⁶Concern about club drug use has increased because of consistent associations with unprotected sexual intercourse.^7–9 Given the high rates of use⁴ among men who have sex with men, most club drug research has focused on this population—and on identified gay and bisexual men specifically.^10,11 Published prevalence estimates are quite variable, ranging, for example, from 6% to 65% for crystal methamphetamine^9,12 and from 7% to 93% for ecstasy.^13,14 However, epidemiological trends remain unknown, and most studies contributing prevalence data have 1 or more significant limitations, including use of cross-sectional designs or small sample sizes, recruitment solely at bars or circuit parties, or investigation of some but not all club drugs.We used a repeated cross-sectional design¹⁵ to investigate trends in the prevalence of recent club drug use (and amyl nitrates or “poppers”) between 2002 and 2007 among urban sexual minority men. Given consistent differences in rates of use between HIV-positive and HIV-negative men, we reported differences by HIV serostatus.     

Promoters and Barriers to Fruit, Vegetable, and Fast-Food Consumption Among Urban, Low-Income African Americans��A Qualitative Approach

To identify promoters of and barriers to fruit, vegetable, and fast-food consumption, we interviewed low-income African Americans in Philadelphia. Salient promoters and barriers were distinct from each other and differed by food type: taste was a promoter and cost a barrier to all foods; convenience, cravings, and preferences promoted consumption of fast foods; health concerns promoted consumption of fruits and vegetables and avoidance of fast foods. Promoters and barriers differed by gender and age. Strategies for dietary change should consider food type, gender, and age.Diet-related chronic diseases—the leading causes of death in the United States^1,2—disproportionately affect African Americans^3–7 and those having low income.^8–10 Low-income African Americans tend to have diets that promote obesity, morbidity, and premature mortality^3,4,11,12; are low in fruits and vegetables^13–18; and are high in processed and fast foods.^19–23Factors that may encourage disease-promoting diets include individual tastes and preferences, cultural values and heritage, social and economic contexts, and systemic influences like media and marketing.^24–30 Because previous research on dietary patterns among low-income African Americans has largely come from an etic (outsider) perspective, it has potentially overlooked community-relevant insights, missed local understanding, and failed to identify effective sustainable solutions.³¹ Experts have therefore called for greater understanding of an emic (insider) perspective through qualitative methods.³¹ However, past qualitative research on dietary patterns among low-income African Americans has been limited, focusing mostly or exclusively on ethnic considerations,^28,29 workplace issues,¹⁰ women,^32–38 young people,^38,39 or only those with chronic diseases^34,36,39,40 and neglecting potentially important differences by age and gender.^31,41–43To build on prior research, we conducted interviews in a community-recruited sample using the standard anthropological technique of freelisting.^44–46 Our goals were (1) to identify the promoters of and barriers to fruit, vegetable, and fast-food consumption most salient to urban, low-income African Americans and (2) to look for variation by gender and age.     

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.     

First-Trimester Working Conditions and Birthweight: A Prospective Cohort Study

Objectives. We investigated the relationship between women''s first-trimester working conditions and infant birthweight.Methods. Pregnant women (N = 8266) participating in the Amsterdam Born Children and Their Development study completed a questionnaire gathering information on employment and working conditions. After exclusions, 7135 women remained in our analyses. Low birthweight and delivery of a small-for-gestational-age (SGA) infant were the main outcome measures.Results. After adjustment, a workweek of 32 hours or more (mean birthweight decrease of 43 g) and high job strain (mean birthweight decrease of 72 g) were significantly associated with birthweight. Only high job strain increased the risk of delivering an SGA infant (odds ratio [OR] = 1.5; 95% confidence interval [CI] = 1.1, 2.2). After adjustment, the combination of high job strain and a long workweek resulted in the largest birthweight reduction (150 g) and the highest risk of delivering an SGA infant (OR = 2.0; 95% CI = 1.2, 3.2).Conclusions. High levels of job strain during early pregnancy are associated with reduced birthweight and an increased risk of delivering an SGA infant, particularly if mothers work 32 or more hours per week.Delivery of a low-birthweight or small-for-gestational-age (SGA) infant as a result of fetal growth restriction is one of the principal adverse pregnancy outcomes. In the short term, low birthweight and small size for gestational age are major determinants of infant mortality and morbidity¹ and impaired neonatal development.² In the long term, they increase metabolic and cardiovascular disease risk.^3–5 Prevention of fetal growth restriction is therefore of undisputed clinical and economic importance.Maternal factors, obstetric factors (e.g., placental dynamics), and social factors,⁵ including employment-related factors, can all play a role in fetal growth impairment.^6–24 Although employment in general is associated with enhanced outcomes,^6,20,21 certain working conditions represent potential risk factors for the mother and child. Increased levels of risk resulting from long working hours,^{12,13,17,18,24} high physical workloads,^13–16 prolonged standing,^13,18 and psychosocial job strain^7,9,10,24 have been suggested, but the findings in this area are not unequivocal.^8,11,22,23 So far, 2 reviews have been conducted that focused on physical workload and delivery of an SGA infant. Mozurkewich et al.¹⁶ concluded from their review of 29 studies that physically demanding work is associated with SGA births (pooled odds ratio [OR] = 1.37; 95% confidence interval [CI] = 1.30, 1.44). Bonzini et al.¹⁹ reached the same conclusion in their study. To our knowledge, job strain has not been considered in any published review.Limitations in research designs,^6,8,19–21 variability in definitions and measurement of work-related factors,^6,18–20 and true variability across countries and cultures may account for the inconsistent results observed to date. Another important limitation of occupational hazard research is the focus on third-trimester exposures.^11,13 Experimental data and emerging theory point to the first rather than the second or third trimester as a crucial period for regulating the relevant fetal hormonal set points, in particular the hypothalamic pituitary axis (HPA).^25–27 Stress-dependent dysregulation of the HPA affects birthweight and a child''s subsequent growth and development.^25–31 From this perspective, employment during pregnancy is perhaps the most prevalent potential stress factor, given that few working women quit their jobs early in pregnancy.In an effort to overcome the limitations of previous studies, we explored the association between infant birthweight and employment-related conditions (e.g., hours worked per week, hours standing or walking, physical demands of work, and job strain) in an unselected urban cohort of pregnant women. We hypothesized that after adjustment for all known major cofactors, first-trimester work-related effects on birthweight would exceed the third-trimester effects reported in previous research.     

Income Disparities in Obesity Trends Among California Adolescents

Objectives. We assessed income-specific trends in obesity rates among a diverse population of California adolescents.Methods. We used data from 17 535 adolescents who responded to the California Health Interview Survey between 2001 and 2007 to examine disparities in obesity prevalence by family income and gender.Results. Between 2001 and 2007, obesity prevalence significantly increased among lower-income adolescents but showed no statistically significant differences among higher-income adolescents after adjustment for age, gender, and race/ethnicity. Although the overall disparity in obesity by family income doubled in this time period, trends were more consistent among male adolescents than among female adolescents.Conclusions. The magnitude of the income disparity in obesity prevalence among California adolescents more than doubled between 2001–2007. The overall leveling off of adolescent obesity prevalence rates could indicate that efforts to decrease childhood obesity are having an impact; however, our results suggest that efforts to prevent childhood obesity may be failing to help adolescents from lower-income families, particularly male adolescents.The prevalence of childhood obesity in the United States has risen dramatically over the past 30 years, increasing from 6% to 17% among those aged 12 to 19 years between the early 1970s and 2003–2004.^1–4 Recent data from the National Health and Nutrition Examination Survey indicate that there was no significant change in obesity prevalence rates between 2003–2004 and 2005–2006, and no significant trend since 1999 in the 12–19–year age group, suggesting that the prevalence of childhood obesity could be leveling off nationally.⁵ However, rates remain high, with approximately 18% of US adolescents considered to be obese.⁵Overweight and obesity in childhood are associated with an increased risk of developing a number of serious health conditions, including type 2 diabetes, heart disease, hypertension, and a variety of musculoskeletal disorders, as well as a higher risk of obesity in adulthood.^6–9 The rise in obesity and comorbid conditions has also led experts to predict a decrease in life expectancy and increased health care costs.^10–12Cross-sectional data have shown an inverse relationship between family income and obesity prevalence among children and adolescents, although some studies suggest that the relationship differs according to race/ethnicity and gender.^4,13–16 In addition, research conducted by Goodman et al. suggests that the public health impact of family income on obesity among children is large in terms of the number of cases that could be prevented if families living in poverty had higher incomes.¹⁶ Related research suggests significant trends in obesity prevalence over time as a function of family income among older adolescents but not among younger ones.¹⁷ However, other studies have suggested that the association between socioeconomic status (SES) and obesity has been weakening in recent years.¹⁵Similar disparities have been noted among the racial/ethnic groups most likely to live in poverty. Although obesity prevalence rates have increased among all racial/ethnic groups, the increase has been noticeably greater among African Americans and Latinos, including adolescents in these groups.^18,19Recent evidence suggests that the prevalence of childhood obesity may no longer be increasing. This leveling off could indicate that recent efforts aimed at reducing childhood obesity have been effective. However, trends in the overall population can mask important differences in trends among groups at increased risk of obesity, such as low-income adolescents, and examining changes in obesity across different levels of SES is important in evaluating efforts to reduce health disparities.We used data from the California Health Interview Survey (CHIS) to test for differential trends in obesity over time among lower-income adolescents relative to higher-income adolescents. Specifically, we tested the hypothesis that obesity prevalence has increased more among lower-income adolescents than among higher-income adolescents. Adolescents in families with higher incomes are likely to have access to greater resources that may better protect them from preventable conditions.^20,21 Other recent studies assessing trends in adolescent obesity rates either did not examine SES differences⁵ or used less recent data than that used in our study.^15,22 In addition, because environmental influences on obesity have been shown to differ among male and female adolescents, we examined whether any changes in the income disparity in obesity rates might vary by gender.^15,22,23     

The Relationship Between Discrimination and Substance Use Disorders Among Lesbian, Gay, and Bisexual Adults in the United States

Objectives. We examined the associations between 3 types of discrimination (sexual orientation, race, and gender) and substance use disorders in a large national sample in the United States that included 577 lesbian, gay, and bisexual (LGB) adults.Methods. Data were collected from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, which used structured diagnostic face-to-face interviews.Results. More than two thirds of LGB adults reported at least 1 type of discrimination in their lifetimes. Multivariate analyses indicated that the odds of past-year substance use disorders were nearly 4 times greater among LGB adults who reported all 3 types of discrimination prior to the past year than for LGB adults who did not report discrimination (adjusted odds ratio = 3.85; 95% confidence interval = 1.71, 8.66).Conclusions. Health professionals should consider the role multiple types of discrimination plays in the development and treatment of substance use disorders among LGB adults.Substance use disorders have been shown to be more prevalent among lesbian, gay, and bisexual (LGB) adults than among heterosexual adults in the United States.^1–6 Despite this evidence, little empirical work has focused on why such differences exist between LGB and heterosexual adults. Many studies have posited that differences in rates of mental health problems and substance abuse are related to social stressors such as discrimination,^7–11 yet no large-scale national studies have examined the relationship between multiple types of discrimination and substance use disorders. Meyer''s minority stress model posits that discrimination, internalized homophobia, and social stigma can create a hostile and stressful social environment for LGB adults that contributes to mental health problems, including substance use disorders.^10,11 An assumption of this model is that minority stress is unique and additive to general stressors that all people experience.Meyer''s model connects the literature demonstrating higher odds of mental health problems and substance use disorders among LGB populations with well-established social science research that demonstrates the link between stress or stressful life events and poor health outcomes.^12–15 Lesbian, gay, and bisexual adults experience discrimination at the structural and institutional level, such as in access to housing, employment, medical care, and basic civil rights,^16,17 as well as at the individual level in the form of harassment and violence.^18–22 Discriminatory experiences have been shown to operate as stressors in the lives of LGB people and, in turn, they are significantly associated with psychiatric disorders,⁹ psychological distress,^9,20,23 and depressive symptoms.^20,24Although the minority stress model provides a useful theoretical framework for understanding health disparities among LGB adults, only a handful of studies have directly assessed discrimination among LGB populations, and even fewer have examined the relationships between discrimination and health outcomes. Extant research on health outcomes related to discrimination has focused on blood pressure,¹⁷ psychological distress,^24,25 mental health disorders,⁹ and general psychological and physical health.²⁶ Given that exposure to both acute and chronic stress has long been associated with substance abuse and relapse in the general population,^26,27 research on the association between experiences of discrimination and substance use disorders among LGB adults is warranted.In our investigation, we assumed that LGB adults are at heightened risk for substance use disorders as a consequence of cultural and environmental factors associated with being part of a stigmatized and marginalized population, not because of their sexual orientation. Building on previous work documenting the impact of multiple stigmatized statuses among sexual minority people^11,28,29 as well as the work of Krieger et al.,¹⁶ we sought to examine the relationships between 3 types of discrimination (sexual orientation, race/ethnicity, and gender) and substance use disorders. We used data from wave 2 of the 2004–2005 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to test the hypothesis that LGB adults who reported more types of discrimination would be more likely to meet criteria for substance use disorders than would those who reported fewer types or who did not report discrimination.     

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

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

Community Influences on Young People's Sexual Behavior in 3 African Countries

Objectives. I examined the role of community-level factors in the reporting of risky sexual behaviors among young people aged 15 to 24 years in 3 African countries with varying HIV prevalence rates.Methods. I analyzed demographic and health survey data from Burkina Faso, Ghana, and Zambia during the period 2001 through 2003 to identify individual, household, and community factors associated with reports of risky sexual behaviors.Results. The mechanisms through which the community environment shaped sexual behaviors varied among young men and young women. Community demographic profiles were not associated with reports of risky sexual behavior among young women but were influential in shaping the behavior of young men. Prevailing economic conditions and the behaviors and attitudes of adults in the community were strong influences on young people''s sexual behaviors.Conclusions. These results provide strong support for a focus on community-level influences as an intervention point for behavioral change. Such interventions, however, should recognize specific cultural settings and the different pathways through which the community can shape the sexual behaviors of young men and women.Countries in sub-Saharan Africa are home to only 10% of the world''s population but account for approximately 85% of AIDS deaths worldwide.^1,2 Previous studies have highlighted high levels of sexual activity among young people (i.e., those aged 15–24 years) in many sub-Saharan African countries,^3–7 paralleled by increasing rates of HIV infection among young people.^1,8,9 Although young people in these countries have been shown to have high levels of knowledge regarding HIV/AIDS, studies have demonstrated significant deviation between such knowledge and reported sexual behaviors,^10–12 with high levels of risky sexual activity reported (e.g., failing to use a condom,¹³ engaging in transactional sex,^13,14 having multiple partners.^3,6,15).The health hazards associated with sexual risk taking among young people are well documented, but little is known about the factors associated with sexual behaviors among adolescents in developing countries.^13,15–20 In the few studies that have examined young people''s sexual behavior in these countries, a micro-level approach has been adopted, with a focus on individual characteristics as predictors of behavior²¹ and little consideration of the potential pathways through which the wider community may shape behavior.Condom use has often been the outcome of interest in studies of adolescent sexual behavior,^7,22–25 which is not surprising given the emphasis of many HIV prevention strategies on promoting condom use; other studies have examined factors associated with sexual activity or sexual debut.^1,15,17,26 Higher levels of risky sexual activity have been shown among young people (both male and female) and adult men^24,26 than among adult women.^4,6,27 In many sub-Saharan African countries, young women''s lack of negotiating power in sexual relationships is influenced by the large age differences common in many relationships,^3,14,27,28 the presence of violence or coercion,²⁵ and economic incentives to participate in risky sexual activities.¹⁴Educational attainment has been shown to be associated with young people''s sexual behaviors.^5–7,29 This relationship is more than simply a function of increased knowledge leading to positive health behaviors; the type of educational institution attended and the place of residence of the student have been shown to be influential in determining sexual behaviors,⁵ suggesting that these behaviors are also influenced by the degree of freedom afforded to the young person.Young women from poor households have been shown to be at particular risk of sexual risk taking, with their economic status motivating them to partake in transactional sex and serving as another limitation in their negotiating power with respect to condom use.^6,14 In terms of the influence of knowledge on behavior, some studies have demonstrated a disparity between knowledge regarding HIV risk and sexual behavior^12,22,30 such that many young people, despite knowing the risks associated with unprotected sexual activities, still engage in these activities. There is a limited amount of evidence suggesting that risk knowledge is a more protective factor against risky sexual activity among women than among men,³¹ with fear of unplanned pregnancy providing a greater deterrent for women than for men.Although much is known about the individual characteristics associated with sexual risk taking among young people, the role of the community in shaping such behaviors has been largely overlooked. In a study of adolescents residing in the United States, Billy et al.²¹ suggested that young people''s sexual behavior is strongly influenced by a community''s opportunity structure (i.e., presence of social and economic opportunities), which is composed of 3 key elements. The first element is the presence in the community of reproductive and sexual health services, which determines a young person''s access to information and services. The second element is the demographic profile of the community, which determines the presence of potential sexual partners. The final element is the presence or absence of economic or social opportunities, which influences young people''s perceptions regarding the opportunity costs of sexual behavior.Studies testing the theory of Billy et al. have largely been restricted to developed countries.^21,32 Although some studies have addressed the influence of community factors on young people''s sexual behavior in developing countries, these investigations have focused primarily on indicators of the presence of economic opportunities for young people,^33,34 failing to examine the roles of the cultural and social environments in shaping behavior.I examined community-level factors associated with risky sexual behaviors among young people in the African countries of Burkina Faso, Ghana, and Zambia. The goal of the study was to advance understanding of how the community environment shapes young people''s sexual behavior by considering a broad range of potential community influences, including social, behavioral, and demographic dimensions of the community environment.     

Correlates of incarceration among young methamphetamine users in Chiang Mai, Thailand

Objectives. We examined correlates of incarceration among young methamphetamine users in Chiang Mai, Thailand in 2005 to 2006.Methods. We conducted a cross-sectional study among 1189 young methamphetamine users. Participants were surveyed about their recent drug use, sexual behaviors, and incarceration. Biological samples were obtained to test for sexually transmitted and viral infections.Results. Twenty-two percent of participants reported ever having been incarcerated. In multivariate analysis, risk behaviors including frequent public drunkenness, starting to use illicit drugs at an early age, involvement in the drug economy, tattooing, injecting drugs, and unprotected sex were correlated with a history of incarceration. HIV, HCV, and herpes simplex virus type 2 (HSV-2) infection were also correlated with incarceration.Conclusions. Incarcerated methamphetamine users are engaging in behaviors and being exposed to environments that put them at increased risk of infection and harmful practices. Alternatives to incarceration need to be explored for youths.Over the past decade, methamphetamine use has increased exponentially and reached epidemic proportions, particularly in North America¹ and Southeast Asia.² The methamphetamine epidemic has been concentrated among adolescents and young adults and has significant public health implications² because methamphetamine use has been associated with high-risk behaviors including multiple sexual partners, contractual sex, polydrug use, and aggression.^3,4Thailand has experienced a steadily increasing methamphetamine epidemic since 1996.⁵ By 2003, an estimated 3 500 000 Thais had ever used methamphetamines.⁶ In 1996, Thailand criminalized methamphetamines, treating the trafficking, possession, and use of methamphetamines with the same severity as heroin-related offenses.⁷ In 2003 the government began a “war on drugs” in an attempt to control the epidemic.^8,9 In combination, these events led to a doubling in the number of incarcerated individuals between 1996 and 2004.^7,10 In 2005, 64% of Thai inmates were drug offenders,¹¹ and in 2006, 75% of drug-related arrests and charges were related to methamphetamines.¹² Treatment for methamphetamine use is limited. Institutional management of methamphetamine users includes the use of rehabilitation centers, military-style boot camps, compulsory drug treatment centers, and prisons.¹¹A history of incarceration has been associated with negative health outcomes, including sexually transmitted infections (STIs) and blood-borne viruses, particularly syphilis,¹³ herpes,¹⁴ HIV,^10,15,16 hepatitis b (HBV),^17,18 and HCV.^18–21 The prevalence of these pathogens has been found to be much higher in prisons than in the general population.^22–26 Although these infections may be a result of a high-risk lifestyle leading to incarceration, it is also clear that the prison system exposes individuals to environments and behaviors that increase their risk of acquiring these infections, such as tattooing,^{10,18,21,27–29} unprotected sex as a result of limited condom availability,²⁷ and using shared needles to inject drugs.^27,30,31With so many young methamphetamine users entering the judicial system, it is important to understand the characteristics of this group so that appropriate public health interventions can be designed. Young methamphetamine users need to be diverted away from the judicial system to decrease high-risk behaviors that may impact their own well-being and that of the community.As part of a randomized controlled trial to reduce the risks associated with methamphetamine use among youths in Chiang Mai, Thailand, we investigated behavioral and viral correlates of incarceration among a sample of 1189 young adults aged 18 to 25 years.