Health Literacy: A Pathway to Better Oral Health

Objectives. We examined whether health literacy was associated with self-rated oral health status and whether the relationship was mediated by patient–dentist communication and dental care patterns.Methods. We tested a path model with data collected from 2 waves of telephone surveys (baseline, 2009–2010; follow-up, 2011) of individuals residing in 36 rural census tracts in northern Florida (final sample size n = 1799).Results. Higher levels of health literacy were associated with better self-rated oral health status (B = 0.091; P < .001). In addition, higher levels of health literacy were associated with better patient–dentist communication, which in turn corresponded with patterns of regular dental care and better self-rated oral health (B = 0.003; P = .01).Conclusions. Our study showed that, beyond the often-reported effects of gender, race, education, financial status, and access to dental care, it is also important to consider the influence of health literacy and quality of patient–dentist communication on oral health status. Improved patient–dentist communication is needed as an initial step in improving the population’s oral health.Oral health status is inexorably linked with general health,1 as evidenced by the association between poor oral health and chronic diseases, such as diabetes,2 cardiovascular disease,3 and respiratory disease.4 Among US adults, the burden of oral disease falls heaviest on vulnerable population groups,5–7 particularly those living in rural areas.8 Although improving oral health is named as one of the top 5 health priorities in Rural Healthy People 2010,9 little progress has been made in establishing public health programs to address this priority area. To achieve the goal of improved oral health, it is essential to study the risk factors associated with the oral health status of individuals residing in rural areas and to understand the relationships among these risk factors.The association between low dental care utilization and poor oral health outcomes has been proposed as a partial explanation for urban–rural disparities in oral health status.10–13 The rate of dental care utilization is lower among US rural than general populations, and dental visits tend to be problem—rather than prevention—oriented.14–17 Low levels of financial security and a lack of dental providers in rural areas are cited as major reasons for the low utilization rates in rural populations.12,18,19 However, evidence that individuals with dental insurance benefits choose to forgo regular preventive dental care suggests the presence of additional determinants in dental care utilization.20Previous research showed that communication between dentists and their patients plays an important role in the use of dental services.21–24 Effective patient–dentist communication increases utilization of dental services by lessening dental anxiety and, as a result, increasing patient perceptions of provider competence.25 Conversely, deficient communication skills, on either side of the patient–provider equation, are likely to increase dental anxiety and overall dissatisfaction with care.Health literacy deficits can interfere with effective patient–dentist communication. Individuals with low health literacy skills often have difficulty describing dental problems to their dentist and understanding dental conditions described by the dentist.26 Rozier et al. surveyed about 2000 dentists in the United States regarding the use of the 5 domains of communication techniques: interpersonal communication, teach-back method, patient-friendly materials and aids, assistance, and patient-friendly practice.27 Findings revealed low routine use by dentists of each communication technique, including those thought to be most effective with patients who demonstrate low health literacy.The association between low health literacy and poor health outcomes is well established.28–30 However, in the context of oral health, the literature offers few studies identifying the relationship between health literacy and oral health outcomes. It has been suggested that those with low health literacy are at highest risk for oral diseases and problems31 and that low health literacy may be associated with barriers to accessing care and with oral health behaviors such as seeking preventive care.32 Furthermore, rural residents have lower health literacy skills than urban residents.33 However, how health literacy is related to oral health status among rural populations remains an unanswered question.Frequently acknowledged risk factors for poor oral health include gender (male), race (Black), educational attainment (low), financial status (low), and access to dental care (none). We controlled for these factors in an examination of the effects of health literacy, patient–dentist communication, and dental care patterns on self-rated oral health status. In addition, we tested mediational pathways between health literacy and self-rated oral health. We hypothesized that greater health literacy would be associated with better patient–dentist communication, and in turn, that better patient–dentist communication would be associated with an increased likelihood of seeking regular dental care, ultimately leading to better self-rated oral health.     

Neighborhood Social Capital,Neighborhood Attachment,and Dental Care Use for Los Angeles Family and Neighborhood Survey Adults

Objectives. We tested the hypothesis that neighborhood-level social capital and individual-level neighborhood attachment are positively associated with adult dental care use.Methods. We analyzed data from the 2000–2001 Los Angeles Family and Neighborhood Survey that were linked to US Census Bureau data from 2000 (n = 1800 adults aged 18–64 years across 65 neighborhoods). We used 2-level hierarchical logistic regression models to estimate the odds of dental use associated with each of 4 forms of social capital and neighborhood attachment.Results. After adjusting for confounders, the odds of dental use were significantly associated with only 1 form of social capital: social support (adjusted odds ratio [AOR] = 0.85; 95% confidence interval [CI] = 0.72, 0.99). Individual-level neighborhood attachment was positively associated with dental care use (AOR = 1.05; 95% CI = 1.01, 1.10).Conclusions. Contrary to our hypothesis, adults in neighborhoods with higher levels of social capital, particularly social support, were significantly less likely to use dental care. Future research should identify the oral health–related attitudes, beliefs, norms, and practices in neighborhoods and other behavioral and cultural factors that moderate and mediate the relationship between social capital and dental care use.Oral health is an indicator of general health and social justice.1,2 Common dental diseases such as tooth decay and gum disease are linked to chronic health conditions, including cardiovascular disease, stroke, diabetes, obesity, and kidney disease.3–7 When left untreated, dental diseases can lead to difficulties chewing food, pain, systemic infections, hospitalization, and, in rare cases, death. Less visible are the social consequences of poor oral health, such as lost work hours,8 functional limitations,9,10 and poor quality of life.11A comprehensive strategy for optimal oral health involves exposure to topical fluorides (e.g., in optimally fluoridated water, toothpaste), limited fermentable carbohydrate intake, tobacco use prevention, and regular dental visits.12 Professional dental care is particularly important because dentists have opportunities to assess a patient’s risk level for oral health problems, provide diagnostic and preventive care as well as needed restorative care, deliver patient-centered anticipatory guidance, and screen for systemic health conditions.13–16 However, not all individuals in the United States have equal access to dental care.17Most dental utilization studies focus on children younger than 18 years and seniors aged 65 years and older, even though data from the National Health and Nutrition Examination Survey indicate a decline in dental care use for US adults aged 18 to 64 years.18 Between 1988 and 1994 and 1999 and 2004, there were significant drops in the proportions of adults who had an annual dental visit for those aged 20 to 34 years (from 63.5% to 54.6%) and those aged 35 to 49 years (from 69.0% to 62.5%).18 The factors related to these declines are unknown.The 2008 World Health Organization report Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health calls for policies and interventions targeting the social determinants of health to reduce and eliminate health disparities.19 Social determinants of health are the structural and environmental conditions that shape human welfare and well-being,20 with health inequalities attributed to unequal distribution of and access to power, money, and resources.21 Although social factors contribute to disparities in dental care use,22 relevant studies focus mostly on individual-level determinants.23–37 There has been less emphasis on the area-level social determinants of adult dental care use.Social capital is an important health determinant38–41 and is defined as the material, affective, and informational resources inherent in social networks. Most health research has focused on social capital in neighborhoods. Neighborhood-based social capital can be operationalized into 4 forms: (1) social support (provisions that help residents cope with everyday challenges), (2) social leverage (sharing information on health- and non–health-related issues), (3) informal social control (maintenance of safety and norms), and (4) neighborhood organization participation (organized efforts that address community quality of life and personal well-being).42 Social capital has direct and interactive associations with a range of positive and negative health-related outcomes.43,44 In some cases, these resources may not help individuals pursue a desirable health outcome or may inhibit an individual’s efforts through negative influences in the community.45Although investigators have examined social capital and access to health care services,46 fewer oral health–related studies have focused on social capital. In 2 multilevel studies of elderly persons in Japan, number of teeth was positively associated with higher levels of neighborhood friendship networks47 and a higher prevalence of neighborhood peer group activities.48 Neighborhood social capital also moderated the relationship between income inequality and self-reported oral health but not the number of teeth present among the Japanese elderly.49 A study of Japanese students aged 18 to 19 years found that poor self-reported oral health was associated with lower levels of neighborhood trust and with higher levels of neighborhood informal social control.50 Among Brazilians aged 14 to 15 years, a 5-dimension measure showed that social capital (social trust, social control, empowerment, neighborhood security, and political efficacy) was inversely associated with odds of dental injury.51Although social capital was not the primary focus, there are 2 relevant US publications. The first reported positive associations between neighborhood social capital and self-reported oral health for children younger than 18 years.52 In the second, neighborhood social capital was identified as a potential source of oral health disparities between Black children and White children aged 3 to 17 years (measured as having a dental problem and poor self-reported oral health) but not for disparities in preventive dental care use.53 Collectively, these studies suggest that neighborhood social capital is an important determinant of oral health.54–56 However, they have 2 main limitations: (1) none of the operationalizations of social capital considered the extent of neighborhood social ties, the resources linked to these ties, or unequal access to resources42; and (2) none focused on dental care use for adults aged 18 to 64 years, a US population subgroup that has exhibited declines in dental care use.18We addressed previous limitations by adopting a multilevel conceptual model of social capital42,43,45 to examine how neighborhood social capital is associated with dental care use for US adults (Figure 1). We operationalized neighborhood-level social capital as the 4 forms identified earlier (social support, social leverage, informal social control, and neighborhood organization participation). Individual-level neighborhood attachment is the extent to which an individual knows and socializes with neighbors42–44; this moderates the effects of social capital.57 On the basis of this model, we tested 3 hypotheses: (1) higher levels of each form of neighborhood social capital are associated with greater odds of dental use, (2) neighborhood attachment is associated with greater odds of dental care use, and (3) there are interactions between social capital and neighborhood attachment. This study represents an important first step in understanding the social determinants of an important oral health behavior. Our long-term goal is to develop and test neighborhood-based interventions and policies aimed at improving the oral health of individuals at greatest risk for disparities in dental care use.Open in a separate windowFIGURE 1—Conceptual model and proposed study hypotheses tested using data from the Los Angeles Family and Neighborhood Survey, 2000–2001.Note. H1 = hypothesis 1 (there is a direct relationship between the 4 social capital forms and adult dental care use); H2 = hypothesis 2 (there is a direct relationship between neighborhood attachment and adult dental care use); H3 = hypothesis 3 (in modeling adult dental care use, there is an interaction between the four forms of social capital and neighborhood attachment).     

Dental Examinations as an Untapped Opportunity to Provide HIV Testing for High-Risk Individuals

We used data from the 2005 National Health Interview Survey to examine the potential role of dental care in reaching untested individuals at self-reported risk for HIV. An estimated 3.6 million Americans report that they are at significant HIV risk yet have never been HIV tested. Three quarters of these people have seen a dentist within the past 2 years. Dental care offers opportunities to serve at-risk individuals who are otherwise unlikely to be tested or to receive preventive care services.Among the estimated 1 million Americans living with HIV and AIDS, roughly one fifth are unaware of their infected status.^1,2 Early diagnosis, combined with other prevention services, could decrease HIV incidence and reduce morbidity and mortality.^3–6 Recent Centers for Disease Control and Prevention guidelines make it a priority to bring HIV screening into many medical and social service settings.⁷ Key professional associations have set similar priorities.⁸Rapid oral HIV testing offers a promising innovation for early HIV diagnosis. These rapid oral-testing technologies permit a highly sensitive and specific, fast, simple, minimally invasive, cost-effective way to screen for HIV serostatus.For several reasons, dental offices provide a promising venue for such testing.^9–14 First, the oral health provider is already conducting an examination. A rapid oral fluid test could be administered at the start of a routine visit, with results available within 20 minutes. Second, oral health providers are becoming involved in other primary-care screening efforts (e.g., hypertension, oral cancer, glycosylated hemoglobin).^15–17 Rapid HIV testing could be a logical extension of such activities. Third, some oral health providers practice in community health care settings that are especially well-equipped to link newly diagnosed patients to HIV primary care. Finally, persons may be more likely to regularly visit dentists than to frequent other settings where HIV testing is offered.Data from the 2005 National Health Interview Survey (NHIS) were used to investigate whether persons at self-identified risk for HIV visit dental settings. In particular, we examined (1) the frequency with which persons at risk for HIV visit dental offices, and (2) whether dental settings reach at-risk persons who have not been tested in other clinical settings.     

Insurer Views on Reimbursement of Preventive Services in the Dental Setting: Results From a Qualitative Study

Objectives. We explored insurers’ perceptions regarding barriers to reimbursement for oral rapid HIV testing and other preventive screenings during dental care.Methods. We conducted semistructured interviews between April and October 2010 with a targeted sample of 13 dental insurance company executives and consultants, whose firms’ cumulative market share exceeded 50% of US employer-based dental insurance markets. Participants represented viewpoints from a significant share of the dental insurance industry.Results. Some preventive screenings, such as for oral cancer, received widespread insurer support and reimbursement. Others, such as population-based HIV screening, appeared to face many barriers to insurance reimbursement. The principal barriers were minimal employer demand, limited evidence of effectiveness and return on investment specific to dental settings, implementation and organizational constraints, lack of provider training, and perceived lack of patient acceptance.Conclusions. The dental setting is a promising venue for preventive screenings, and addressing barriers to insurance reimbursement for such services is a key challenge for public health policy.Health care providers, the public health community, payers, and health services researchers are increasingly recognizing oral health as a crucial component of the medical home, as well as the potential role of dentists as partners to perform public health screening and to engage patients who may not be receiving regular preventive health services.1–7 Previous research demonstrated high dental care utilization among key populations such as smokers, individuals at elevated risk for HIV, and individuals at risk for diabetes; many at-risk individuals use dental services even when they do not regularly receive primary medical care services.8–11 Furthermore, rapid advances have been made in salivary diagnostics for early disease detection and routine health monitoring. Emergence of the oral rapid HIV and hepatitis C tests has prompted calls for more aggressive screening in the dental setting.12,13 Increased attention is also focusing on the use of clinical periodontal markers and self-reported risk factors to detect undiagnosed diabetes.5,9,14The dental venue has been identified as an untapped resource for the provision of oral rapid HIV screening.8 The Centers for Disease Control and Prevention’s revised 2006 guidelines advocated routine opt-out HIV screening and near-universal screening in diverse settings.15 The oral health component of the Healthy People 2020 initiative includes the aim to “increase the proportion of adults who receive preventive interventions in dental offices [OH-14],” specifically, smoking cessation services [OH-14.1], oral cancer screenings [OH-14.2], and tests and referrals for glycemic control [OH-14.3].16 In a survey of dentists, the majority of respondents endorsed the importance of dental screening for specified systemic conditions, such as cardiovascular disease, hypertension, diabetes, and HIV; almost all respondents highly valued chairside medical screening in dental settings.4Despite this broadening view of dentists’ professional role, actual provision of preventive screenings, including cardiovascular and HIV screenings, is low.17 Low provision of routine tobacco cessation service delivery has also been documented, despite high perceived importance as part of the dentist’s professional responsibility.11 Furthermore, research has shown that dentists are not fully assuming the responsibility of conducting thorough oral cancer screenings, although this screening has been characterized as the single most essential service a dentist can offer and is one of the few dental services that can save a patient’s life when routinely performed.18Dentists’ reluctance to perform medical screenings in their clinical practice is multifactorial; cited barriers to performing HIV oral rapid screening, oral cancer examinations, and tobacco cessation services are lack of training and expertise, time constraints, scope of practice, confidentiality, low perceived disease prevalence, and low index of suspicion.4,19–23Limited insurance reimbursement is another major barrier to broad implementation of comprehensive public health screening in the dental setting.24 From a payer perspective, the feasibility and cost-effectiveness of broad dental chairside screenings remain unclear.8 Insurer perspectives regarding such questions are rarely explored. We investigated attitudes of dental insurers toward expanding routine screening, including oral rapid HIV testing, in the dental setting to promote early diagnosis and treatment of prevalent systemic diseases.     

Socioeconomic Status,Food Security,and Dental Caries in US Children: Mediation Analyses of Data From the National Health and Nutrition Examination Survey, 2007–2008

Objectives. We examined associations of household socioeconomic status (SES) and food security with children’s oral health outcomes.Methods. We analyzed 2007 and 2008 US National Health and Nutrition Examination Survey data for children aged 5 to 17 years (n = 2206) to examine the relationship between food security and untreated dental caries and to assess whether food security mediates the SES–caries relationship.Results. About 20.1% of children had untreated caries. Most households had full food security (62%); 13% had marginal, 17% had low, and 8% had very low food security. Higher SES was associated with significantly lower caries prevalence (prevalence ratio [PR] = 0.77; 95% confidence interval = 0.63, 0.94; P = .01). Children from households with low or very low food security had significantly higher caries prevalence (PR = 2.00 and PR = 1.70, respectively) than did children living in fully food-secure households. Caries prevalence did not differ among children from fully and marginally food-secure households (P = .17). Food insecurity did not appear to mediate the SES–caries relationship.Conclusions. Interventions and policies to ensure food security may help address the US pediatric caries epidemic.Tooth decay (dental caries) is the most prevalent disease worldwide and the most common pediatric disease in the United States.1,2 From 1999 to 2004, the prevalence of untreated tooth decay was 24.5% for children aged 6 to 11 years and 19.6% for adolescents aged 12 to 19 years.3 Untreated tooth decay can lead to difficulties eating and sleeping, pain, the need for invasive restorative treatment, emergency department visits and inpatient hospitalizations, poor quality of life, systemic health problems, and, in rare cases, death.4–7 To date, most public health efforts aimed at addressing the pediatric caries epidemic have focused on tooth-level interventions (e.g., topical fluorides, dental sealants). Although disparities in oral health are considered a measure of social injustice,8 comparatively less research has been conducted on the social determinants of pediatric oral health.9Low socioeconomic status (SES), one of the strongest determinants of caries in children,10–12 is associated with food insecurity,10–17 defined as inadequate access to food resulting in food shortages, disrupted eating patterns, and hunger.18 Food insecurity, in turn, is associated with oral health–related behaviors, including increased fermentable carbohydrate intake,19,20 a risk factor for dental caries.21,22 The American Dietetic Association recognizes the link between nutrition and oral health,23 and numerous studies have drawn associations between dietary factors and disparities in dental caries.24 Collectively, these studies suggest that food insecurity is related to caries and is a potential mechanism linking SES and caries, but these relationships have not yet been evaluated empirically. We used nationally representative data from the United States to test 3 hypotheses: (1) food insecurity is positively associated with untreated dental caries, (2) food insecurity mediates the SES–caries relationship, and (3) food insecurity mediates the SES–caries relationship differentially for children from higher- versus lower-SES households.     

The Impact of Functional Health Literacy and Acculturation on the Oral Health Status of Somali Refugees Living in Massachusetts

Objectives. We assessed the impact of health literacy and acculturation on oral health status of Somali refugees in Massachusetts.Methods. Between December 2009 and June 2011, we surveyed 439 adult Somalis who had lived in the United States 10 years or less. Assessments included oral examinations with decayed, missing, and filled teeth (DMFT) counts and measurement of spoken English and health literacy. We tested associations with generalized linear regression models.Results. Participants had means of 1.4 decayed, 2.8 missing, and 1.3 filled teeth. Among participants who had been in the United States 0 to 4 years, lower health literacy scores correlated with lower DMFT (rate ratio [RR] = 0.78; P = .016). Among participants who had been in the country 5 to 10 years, lower literacy scores correlated with higher DMFT (RR = 1.37; P = .012). Literacy was not significantly associated with decayed teeth. Lower literacy scores correlated marginally with lower risk of periodontal disease (odds ratio = 0.22; P = .047).Conclusions. Worsening oral health of Somali refugees over time may be linked to less access to preventive care and less utilization of beneficial oral hygiene practices.Among refugees newly arrived in Massachusetts, oral abnormalities are the most common health problem in children1 and the second most common problem in adults. One major determinant of oral health disparities is access to preventive and restorative dental care.2 Other determinants include oral hygiene practices and diet.2 Linguistic and cultural factors may play important roles in determining access to oral health services as well as personal oral hygiene practices, and limited literacy skills have been hypothesized as a likely barrier to better oral health outcomes.3Health literacy, reflecting an individual’s capacity to obtain, process, and understand basic health information and services, affects a variety of determinants of oral health and is thought to play a pervasive role in all aspects of health care and oral health status.3,4 Inadequate health literacy has been associated with a long and growing list of adverse health outcomes.5 Inadequate literacy has been associated with limited access and utilization of care,6,7 poor clinical outcomes,8 hospitalization,9 and mortality.10 However, the relationship between health literacy and oral health has never been studied in a refugee population.Somalis compose one of the largest refugee populations to have entered the United States in recent years. As a result of civil war over the past 20 years, many Somalis have lived in refugee camps for long periods. More recently arrived Somalis have very low English literacy.11 Somalis are almost all practicing Muslims and have relative homogeneity of language, culture, and religion.12,13 In the United States, Somali refugees have also tended to cluster geographically through a process known as secondary migration to create cohesive communities. Past research indicated a strong role for such social structures as moderators of health literacy and its impact on health status.14 A refugee with low literacy may be able to effectively access care with the help of the community network. Thus, health literacy may function differently in the context of the Somali community, with its strong social support network. The degree to which an individual identifies with the traditional community and social structure or that of the dominant, host community varies and may affect how an individual negotiates competing priorities related to personal oral hygiene, diet, and access to dental care.Behavioral acculturation is a measure of such factors as with whom people spend time, the types of media they are exposed to, the language in which they feel most comfortable conversing and reading, and with whom they identify. The effects of acculturation on oral health have been studied in Haitian immigrants in the United States who had a low baseline rate of caries. Acculturation was found to be associated with lower rates of development of caries.15 In Australia, a study of Vietnamese refugees revealed associations between acculturation and dental health status.16 The Vietnamese also had very good oral health status, and those with extensive acculturation had even better oral health status. This finding suggested that more acculturation led to protective practices and care that added to those of the refugees’ traditional culture.However, the findings documented a nonlinear relationship in which refugees with moderate levels of acculturation had worse oral health status. The researchers hypothesized that the cultural marginality model, previously applied to oral health research,17,18 offered an explanation: refugees with moderate levels of acculturation were alienated from their traditional culture without adequate integration into the dominant culture. Thus, moderately acculturated refugees might adopt behaviors deleterious to oral health, such as Western dietary habits, without adopting preventive aspects of Western oral hygiene and related behaviors.16 By contrast, individuals with a low level of acculturation may have continued beneficial traditional practices and not adopted a cariogenic Western diet. In the Somali community, one such practice might be use of a stick brush (miswak or aday). Studies have found stick brushes to be effective in removing plaque.11,19 These brushes also have an inhibitory effect on oral cariogenic streptococci20,21 and periodontal pathogens.21In light of the importance of health literacy to health in the general population, we sought to determine the relationship of health literacy (assessed in English) with oral health clinical outcomes of Somali refugees in Massachusetts. We hypothesized that after control for acculturation, participants with high health literacy would be more likely than others to have (1) less lifetime history of decay, untreated dental decay, and periodontal disease; (2) a higher rate of traditional or Western personal hygiene practices and behaviors known to be associated with better oral health outcomes; and (3) more utilization of professional dental care for preventive services. We also assessed functional and mental health outcomes and a variety of social and cultural factors relevant to the effects of literacy, acculturation, oral health care, and personal hygiene practices on oral health status in the Somali community.     

Association of Strong Smoke-Free Laws With Dentists’ Advice to Quit Smoking, 2006–2007

Objectives. We examined the association of smoke-free laws with dentists’ advice to quit smoking and referral to a quit line, among smokers who reported visiting the dentist in the past 12 months.Methods. We used the 2006 to 2007 Tobacco Use Supplement of the Current Population Survey merged with the American Nonsmokers'' Rights Foundation Local Ordinance Database of smoke-free laws. The dependent variables were advice from a dentist to quit smoking and referral to a quit line, and the independent variable of interest was 100% smoke-free law coverage. We controlled for respondent demographics and an index of state-level smoking ban attitudes (included to ensure that the effect detected was not the result of social attitudes).Results. Smoke-free law coverage was associated with dental advice to quit smoking (odds ratio [OR] = 1.27; 95% confidence interval [CI] = 1.01, 1.59; P = .041), but not with referral to a quit line (OR = 1.33; 95% CI = 0.79, 2.25; P = .283).Conclusions. Interventions with dentists are needed to increase referrals to quit lines and other smoking cessation efforts.Smoking causes oral disease and dental therapy failures.1–8 Tobacco cessation interventions delivered by dentists during oral examination are associated with cessation.9–12 Although dentists can effectively promote cessation, particularly when they receive training to do so,13–17 such practices are not widespread.18–22 The US Public Health Service clinical practice guidelines promote the 5A''s—ask about tobacco use, advise to quit, assess willingness to make a quit attempt, assist in the quit attempt, and arrange follow-up—as a standard tobacco use intervention.1 Implementing just part of the 5A''s, such as advising patients to quit, can affect patient behavior.16,17,23,24Several studies found that although oral health care providers are willing to implement the first 2 steps of the 5A''s (ask, advise) they are reluctant to implement the last 3 (assess, assist, and arrange).10,16,18,23,25 A survey of dentists in California, Pennsylvania, and West Virginia found that most dentists reported asking patients about tobacco use and advising them to quit, but fewer than half the dentists who asked about smoking provided follow-up or assistance with quitting.25 These low rates are similar to those of health care providers in other areas.18 As a result, some organizations advocate the 2A''s+R (ask, advise, refer to a quit line) model of intervention.26 A study that compared the effectiveness of the 5A''s and 2A''s+R models in dental settings found that a greater proportion of patients receiving the 5A''s intervention quit but that the 2 groups showed no significant difference in abstinence at the 12-month follow-up.26Strong smoke-free laws are associated with changes in norms, attitudes, and behaviors surrounding tobacco use. These smoke-free laws may also encourage dental care providers to perceive smoking as denormalized or increase the salience of tobacco use for these providers, so that they are more likely to recommend a smoking cessation intervention. In the United States, implementation of 100% smoke-free laws is associated with a reduction in smoking prevalence and consumption,27 decreased cardiovascular and pulmonary hospital admissions,28 voluntary smoke-free home rules,29 and reduced maternal smoking.30,31 We hypothesized that the implementation of 100% smoke-free laws would affect not only individual health-related behavior, but also health care provider behavior, particularly in an area, such as oral health, where cessation training is not yet routinely implemented. We examined the effect of 100% smoke-free laws on dentist implementation of the 2A''s+R model of intervention, particularly dental advice to quit and referral to a quit line, or cessation help line.     

Innovative Primary Care Training: The Cambridge Health Alliance Oral Physician Program

We evaluated the Oral Physician Program, a dental residency sponsored by Harvard Medical School, Harvard School of Dental Medicine, and the Cambridge Health Alliance that offers an innovative model for training dentists to provide limited primary care. The didactic and clinical experiences increased residents'' medical knowledge and interviewing skills, and faculty assessments supported their role as oral physicians. Oral physicians could increase patients''—especially patients from underserved groups—access to integrated oral and primary care services.Static and fragmented curricula are failing to prepare graduates of health professional schools for current population health challenges, including the growing burden of chronic diseases.1 Primary care must be a pillar of clinical training,1,2 and dentists, as oral physicians, should be trained to provide limited preventive primary care and disease prevention.3 During their predoctorate clinical training years, dentists learn about the oral manifestations of more than 100 genetic and systemic disorders,4 including developmental and eating disorders, cardiovascular disease, diabetes, osteoporosis, and cancers, as well as substance and child abuse.5 Thus, dentists should be well positioned to identify numerous systemic conditions in addition to oral diseases, often at an early stage, through oral manifestations.Advanced oral physician training following dental school can provide skill strengthening and the practice necessary to adapt to the changing health needs of today’s most vulnerable populations by increasing early disease detection and referral. Dentists practice as oral physicians, for example, when providing or overseeing complete dental care and aspects of primary care,6 such as taking vital signs, screening for diabetes and other major health problems, and administering vaccines.7 By providing a range of preventive health care services, dentists can help increase access to care and improve the health of the community as part of the primary care prevention and referral system.8 The training model of the oral physician decompartmentalizes oral and general health and meets the primary care training objective of “interprofessional and transprofessional education that breaks down professional silos.”1^(p1924)     

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

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

Gender-Stratified Models to Examine the Relationship Between Financial Hardship and Self-Reported Oral Health for Older US Men and Women

Objectives. We evaluated the relationship between financial hardship and self-reported oral health for older men and women.Methods. We focused on adults in the 2008 Health and Retirement Study (n = 1359). The predictor variables were 4 financial hardship indicators. We used Poisson regression models to estimate the prevalence ratio of poor self-reported oral health.Results. In the non–gender-stratified model, number of financial hardships was not significantly associated with self-reported oral health. Food insecurity was associated with a 12% greater prevalence of poor self-reported oral health (95% confidence interval [CI] = 1.04, 1.21). In the gender-stratified models, women with 3 or more financial hardships had a 24% greater prevalence of poor self-reported oral health than women with zero (95% CI = 1.09, 1.40). Number of hardships was not associated with self-reported oral health for men. For men, skipping medications was associated with 50% lower prevalence of poor self-reported oral health (95% CI = 0.32, 0.76).Conclusions. Number of financial hardships was differentially associated with self-reported oral health for older men and women. Most financial hardship indicators affected both genders similarly. Future interventions to improve vulnerable older adults’ oral health should account for gender-based heterogeneity in financial hardship experiences.The Institute of Medicine’s 1998 publication Gender Differences in Susceptibility of Environmental Factors called attention to how socioeconomic factors differentially affect health outcomes for men and women.1 Gender-based health disparities are pronounced among older adults.2,3 In 2010, 25% of the US population was aged 55 years or older, a 15% increase from 2000.4 Advances in chronic disease management have improved adult life expectancy,5–12 making older adults the fastest growing subgroup in the United States. The close relationship between oral and systemic health13–15 has motivated interest in addressing oral health disparities in older adults, particularly among those who are financially vulnerable.16Poverty and low socioeconomic status (SES) are associated with tooth decay, gum diseases, and oral cancers—all of which are indicators of poor oral health.17–28 Older men and women are at differential risk for dental diseases and conditions.29,30 For instance, older men are more likely to have untreated tooth decay,31,32 gum disease,33 and oropharyngeal cancer34 whereas older women are more likely to have missing teeth and to be edentulous.29 Dental care use by women partially explains this heterogeneity in disease risk35 although the mechanisms underlying gender-based differences have not been elucidated. Differential risk for dental disease may translate to differences in self-reported oral health. Based on 1999–2004 US National Health and Nutrition Examination Survey data, a larger proportion of men aged 65 years and older reported fair or poor oral health compared with women (40.1% and 36.9%, respectively).29 Although 2 studies suggest that self-reported oral health measures are weakly associated with dental disease status as assessed by a dentist,36,37 most studies have concluded that self-reported oral health is a valid and reliable measure of clinical oral health.38–41There is a growing body of literature on gender, socioeconomic inequality, and health disparities.42–45 Most studies have focused on traditional measures of SES such as education, income, or occupation.46–48 However, these measures do not adequately capture the multiple pathways by which socioeconomic and financial circumstances influence health.49–53 For example, focusing on income alone may not fully capture an individual’s ability to garner resources to meet financial obligations.54 Alternative SES measures such as financial hardship have been shown to have an impact on health over and above traditional measures of SES.55,56 Furthermore, recent studies suggest that alternative SES measures, which account for economic resources, assets, and household material conditions, are moderated by gender on outcomes such as self-rated health, psychological distress, musculoskeletal disorders, and mortality.55–58 This interaction is particularly relevant for older adults, many of whom are retired or are preparing to exit the workforce.59Currently, there is little understanding of how gender and financial hardship interact on oral health outcome measures. In addition, the studies relevant to adult oral health have 2 limitations: (1) the inclusion of both younger and older adults in the same models, which assumes that the relationship between socioeconomic indicators and oral health is homogeneous across the adult life span20,22,27,47; and (2) the lack of gender-stratified models,28 which treats gender as a confounder rather than as an effect modifier.The aim of the present study was to test the hypothesis that the association between financial hardship and self-reported oral health is different for women and men. This research continues the line of work aimed at identifying ways to improve the oral health of vulnerable older adults, and has important implications in the development of interventions and policies that address gender-based disparities in adult oral health.60,61     

Prevalence of Undiagnosed Acute and Chronic HIV in a Lower-Prevalence Urban Emergency Department

Objectives. We estimated the seroprevalence of both acute and chronic HIV infection by using a random sample of emergency department (ED) patients from a region of the United States with low-to-moderate HIV prevalence.Methods. This cross-sectional seroprevalence study consecutively enrolled patients aged 18 to 64 years within randomly selected sampling blocks in a Midwestern urban ED in a region of lower HIV prevalence in 2008 to 2009. Participants were compensated for providing a blood sample and health information. After de-identification, we assayed samples for HIV antibody and nucleic acid.Results. There were 926 participants who consented and enrolled. Overall, prevalence of undiagnosed HIV was 0.76% (95% confidence interval [CI] = 0.30%, 1.56%). Three participants (0.32%; 95% CI = 0.09%, 0.86%) were nucleic acid–positive but antibody-negative and 4 (0.43%; 95% CI = 0.15%, 1.02%) were antibody-positive.Conclusions. Even when the absolute prevalence is low, a considerable proportion of undetected HIV cases in an ED population are acute. Identification of acute HIV in ED settings should receive increased priority.HIV screening is recommended by the US Centers for Disease Control and Prevention as an essential component of the nation’s HIV prevention effort.1,2 Emergency departments (EDs) are particularly emphasized as venues for HIV screening.3–5 Emergency departments serve more than 100 million patients annually, readily accessing vulnerable populations with a high prevalence of undetected HIV.1,4–8To date, most attention has been focused on detection of HIV in the chronic phase, after seroconversion, by assay for antibodies. Yet identification of patients during acute HIV infection could have a significant impact on further transmission.9,10 Testing for acute HIV infection is accomplished by assays that detect viral proteins or viral genetic material before antibody detection is possible. This testing is more expensive, complex, or may delay results compared with antibody testing.9,11,12 Despite these disadvantages, screening for acute HIV is increasingly suggested by various authors.9,13–19 Acute HIV infection is thought to contribute disproportionately to HIV incidence because of high viral replication and increased infectiousness during this phase.15,20–22 Diagnosis prompts many individuals to reduce transmission behaviors,23 and partner notification efforts may be more successful.24 There is also renewed interest in treatment during acute HIV infection, to lower infectiousness and improve long-term patient health outcomes.21,25–27 In light of these benefits, screening for acute HIV infection may ultimately be cost-effective and worthy of increased logistical challenges.9,28Unfortunately, the controversies and implementation barriers in HIV screening have yet to be fully resolved,29–35 particularly in ED settings where patient volumes exceed capacity and acute stabilization takes precedence over preventive health.36–38 Screening in the ED for acute HIV infection will be even more challenging than screening for chronic HIV if it entails additional complexity and expense. Motivation to surmount such barriers is likely to be less in regions of lower HIV prevalence, in which disease incidence would also be presumed lower. Improving our understanding of acute HIV epidemiology in ED settings is fundamental for guiding potential implementation of ED screening interventions targeting acute HIV infection. We estimated the seroprevalence of both acute and chronic HIV infection by using a random sample of ED patients from a low-to-moderate HIV prevalence region of the United States.     

Latent Tuberculosis Infection Screening in Foreign-Born Populations: A Successful Mobile Clinic Outreach Model

Objectives. We evaluated the efficacy of a mobile medical clinic (MMC) screening program for detecting latent tuberculosis infection (LTBI) and active tuberculosis.Methods. A LTBI screening program in a MMC in New Haven, Connecticut, used medical surveys to examine risk factors and tuberculin skin test (TST) screening eligibility. We assessed clinically relevant correlates of total (prevalent; n = 4650) and newly diagnosed (incident; n = 4159) LTBI from 2003 to 2011.Results. Among 8322 individuals, 4159 (55.6%) met TST screening eligibility criteria, of which 1325 (31.9%) had TST assessed. Similar to LTBI prevalence (16.8%; 779 of 4650), newly diagnosed LTBI (25.6%; 339 of 1325) was independently correlated with being foreign-born (adjusted odds ratio [AOR] = 8.49; 95% confidence interval [CI] = 5.54, 13.02), Hispanic (AOR = 3.12; 95% CI = 1.88, 5.20), Black (AOR = 2.16; 95% CI = 1.31, 3.55), employed (AOR = 1.61; 95% CI = 1.14, 2.28), and of increased age (AOR = 1.04; 95% CI = 1.02, 1.05). Unstable housing (AOR = 4.95; 95% CI = 3.43, 7.14) and marijuana use (AOR = 1.57; 95% CI = 1.05, 2.37) were significantly correlated with incident LTBI, and being male, heroin use, interpersonal violence, employment, not having health insurance, and not completing high school were significantly correlated with prevalent LTBI.Conclusions. Screening for TST in MMCs successfully identifies high-risk foreign-born, Hispanic, working, and uninsured populations and innovatively identifies LTBI in urban settings.Foreign-born populations are at greatest risk for having both latent tuberculosis infection (LTBI) and developing tuberculosis (TB) disease within high-income countries and, in 2012, accounted for 63.0% of the 9951 TB cases in the United States.1 Newly diagnosed and reactivated TB infection among foreign-born individuals in the United States is currently 12 times greater (15.8 vs 1.4 cases per 100 000 population) than among US-born persons.1 Among foreign-born individuals, LTBI often reactivates within 5 to 10 years after arrival to the United States.2,3 Undocumented migrants and visitors from high-TB-prevalence countries, however, do not undergo routine LTBI screening and thus remain outside traditional health care screening and treatment programs in primary or specialty care settings except when they are acutely ill.3,4 Thus, identifying and treating LTBI cases among these high-risk populations before transforming to TB disease and resultant transmission to others is crucial to ending the cycle of ongoing TB infection within the United States.Workplace screening,4,5 mandatory criminal justice system screening,6–8 screening for entry into medication-assisted therapy and drug treatment programs,9 and refugee and naturalization programs10,11 have been successful for reaching legal and domestic populations, but innovative options are needed to target foreign-born populations that are not yet integrated into mainstream care.Culturally and geographically isolated foreign-born groups may be overlooked especially if there is low self-perception of tuberculosis risk.12 Tuberculin skin testing (TST), though imperfect, is internationally recognized and has been shown to be a reasonably accurate assessment of LTBI status in immunocompetent adults, despite receiving previous Bacillus Calmette-Guérin vaccine.13 Whereas other studies have focused on traditional clinics or statewide programs,14 we present an innovative mobile medical clinic (MMC) as a model to target “hidden” foreign-born populations for LTBI screening.New Haven, Connecticut, the country’s fourth poorest city for its size, with a census of 130 000, is a medium-sized urban setting in New England that has experienced extraordinary social and medical disparities including a high prevalence of poverty, drug addiction, HIV/AIDS, and unemployment and is disproportionately comprised of people of color, including 35.4% and 27.4% being Black or Hispanic, respectively.15 As New Haven is an industrial city with low-paying jobs, there has been an influx of foreign-born people, now officially comprising 11.6% of the population, with many having an undocumented residency status. Health care access for this group is absent unless individuals pay directly for fee-for-service, and concern for deportation and arrest further hinders willingness to seek care.16The Community Health Care Van (CHCV) is an MMC that provides free health care 5 days per week in 4 impoverished neighborhoods in New Haven. Though at inception the program was linked to the needle and syringe exchange program,17 it has since expanded over 20 years to become a vital bridge to a diverse array of health and addiction treatment services that includes services for medically underserved populations, including directly administered antiretroviral therapy to treat HIV,18–21 buprenorphine maintenance therapy,22–25 community transitional programs from the criminal justice system,26–33 hepatitis B vaccination,34 rapid hepatitis C screening,35 and other ongoing primary health care programs such as screening and monitoring of sexually transmitted infections,36 diabetes, and hypertension. In addition, the CHCV provides outreach and intensive case management services.37 Screening for LTBI and TB disease began in 2003 to target high-risk undocumented and foreign-born clients, as well as clients entering drug treatment programs or homeless shelters, who were concerned about TB infection yet were reluctant to seek care in traditional health care settings for fear of deportation, prohibitive cost, or language barriers. The LTBI screening program shortly thereafter became successfully incorporated into the country’s first mobile buprenorphine maintenance therapy program.9     

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

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

Health status, neighborhood socioeconomic context, and premature mortality in the United States: The National Institutes of Health-AARP Diet and Health Study

Objectives. We examined whether the risk of premature mortality associated with living in socioeconomically deprived neighborhoods varies according to the health status of individuals.Methods. Community-dwelling adults (n = 566 402; age = 50–71 years) in 6 US states and 2 metropolitan areas participated in the ongoing prospective National Institutes of Health–AARP Diet and Health Study, which began in 1995. We used baseline data for 565 679 participants on health behaviors, self-rated health status, and medical history, collected by mailed questionnaires. Participants were linked to 2000 census data for an index of census tract socioeconomic deprivation. The main outcome was all-cause mortality ascertained through 2006.Results. In adjusted survival analyses of persons in good-to-excellent health at baseline, risk of mortality increased with increasing levels of census tract socioeconomic deprivation. Neighborhood socioeconomic mortality disparities among persons in fair-to-poor health were not statistically significant after adjustment for demographic characteristics, educational achievement, lifestyle, and medical conditions.Conclusions. Neighborhood socioeconomic inequalities lead to large disparities in risk of premature mortality among healthy US adults but not among those in poor health.Research dating back to at least the 1920s has shown that the United States has experienced persistent and widening socioeconomic disparities in premature mortality over time.^1–5 However, it has been unclear whether socioeconomic inequalities affect the longevity of persons in good and poor health equally. Socioeconomic status (SES) and health status are interrelated,^6–8 and both are strong independent predictors of mortality.⁹ Low SES is associated with greater risk of ill health and premature death,^{1–5,8,10–13} partly attributable to disproportionately high prevalence of unhealthful lifestyle practices^10,14,15 and physical and mental health conditions.^13,16 Correspondingly, risk of premature mortality is higher in poor than in more affluent areas.^16,17 Although the association between neighborhood poverty and mortality is independent of individual-level SES,^17,18 aggregation of low-SES populations in poor areas may contribute to variations in health outcomes across neighborhoods. Conversely, economic hardships resulting from ill health may lead persons in poor physical or mental health to move to poor neighborhoods.¹⁹ This interrelatedness may create spurious associations between neighborhood poverty and mortality.Although previous studies have found that the risk of premature death associated with poor health status varies according to individuals'' SES,^20,21 no published studies have examined whether the relative risks for premature mortality associated with living in neighborhoods with higher levels of socioeconomic deprivation vary by health status of individuals. Clarifying these relationships will inform social and public health policies and programs that aim to mitigate the health consequences of neighborhood poverty.^22,23We used data from a large prospective study to examine whether the risk of premature mortality associated with neighborhood socioeconomic context differs according to health status at baseline and remains after adjustment for person-level risk factors for mortality, such as SES, lifestyle practices, and chronic medical illnesses.     

Mitigating HIV Health Disparities: The Promise of Mobile Health for a Patient-Initiated Solution

The HIV epidemic is an ongoing public health problem fueled, in part, by undertesting for HIV. When HIV-infected people learn their status, many of them decrease risky behaviors and begin therapy to decrease viral load, both of which prevent ongoing spread of HIV in the community.Some physicians face barriers to testing their patients for HIV and would rather their patients ask them for the HIV test. A campaign prompting patients to ask their physicians about HIV testing could increase testing.A mobile health (mHealth) campaign would be a low-cost, accessible solution to activate patients to take greater control of their health, especially populations at risk for HIV. This campaign could achieve Healthy People 2020 objectives: improve patient–physician communication, improve HIV testing, and increase use of mHealth.World AIDS Day each December reminds us of the ongoing HIV epidemic in the United States and its disproportionate toll on racial and ethnic minority communities. HIV testing is an essential strategy to curb the ongoing epidemic. When people infected with HIV learn their status, many of them decrease risky behaviors to prevent spread to others1 and begin antiretroviral therapy to decrease viral load, the main biological predictor of the ongoing spread of HIV in the community.2 Despite national recommendations to make HIV testing routine for all adults,3–6 HIV testing rates—particularly among the racial and ethnic communities hardest hit—remain low.7 Patients want to be tested.8 However, physicians face numerous HIV testing barriers, including physician discomfort with initiating HIV testing discussions,9 physicians not realizing that patients expect HIV testing to be done,8 time,10,11 and competing clinical priorities.11,12A pioneering intervention to improve HIV testing in health care settings may be a patient-initiated approach. The push–pull capacity model offers a framework to guide a solution to improve patient-initiated HIV testing.13,14 With a push–pull model, health information can be provided—or pushed—to many patients. This push creates a demand—or pull—for health services that address patient concerns. The ubiquity of cell phones and the pervasive use of text messaging provide an innovative platform for promoting an effective HIV testing campaign. Operationalizing the push–pull model through mobile health (mHealth) could be a novel approach to improving HIV testing in health care settings. This initiative would reduce demands on physicians, increase patients’ engagement in their own health, and address a significant ongoing public health problem.15 Goals of Healthy People 2020 include eliminating health disparities and increasing the number of people who have been tested for HIV.16     

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.     

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

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