The Effect of a “Maintain,Don’t Gain” Approach to Weight Management on Depression Among Black Women: Results From a Randomized Controlled Trial

Objectives. We evaluated the effect of a weight gain prevention intervention (Shape Program) on depression among socioeconomically disadvantaged overweight and obese Black women.Methods. Between 2009 and 2012, we conducted a randomized trial comparing a 12-month electronic health–based weight gain prevention intervention to usual primary care at 5 central North Carolina community health centers. We assessed depression with the Patient Health Questionnaire (PHQ-8). We analyzed change in depression score from baseline to 12- and 18-month follow-up across groups with mixed models. We used generalized estimating equation models to analyze group differences in the proportion above the clinical threshold for depression (PHQ-8 score ≥ 10).Results. At baseline, 20% of participants reported depression. Twelve-month change in depression scores was larger for intervention participants (mean difference = −1.85; 95% confidence interval = −3.08, −0.61; P = .004). There was a significant reduction in the proportion of intervention participants with depression at 12 months with no change in the usual-care group (11% vs 19%; P = .035). All effects persisted after we controlled for weight change and medication use. We saw similar findings at 18 months.Conclusions. The Shape Program, which includes no mention of mood, improved depression among socioeconomically disadvantaged Black women.Depression is one of the most common and disabling, yet treatable, mental health conditions in the United States.1,2 Women are twice as likely as men to be affected,3 and more than 1 in 7 (14.9%) Black women will experience major depression in their lifetime.4 Observational evidence suggests that, although the prevalence of major depression is lower among Blacks than Whites, its severity is greater for Blacks.5 This is likely a result of racial disparities in access to depression treatment.6 Indeed, compared with their White counterparts, Black adults with depression are less likely to receive treatment for depression (39.7% vs 54.0%).6 Of those who do seek treatment, Blacks are less likely than Whites to receive care that corresponds to clinical practice guidelines.6,7 These racial disparities are magnified by socioeconomic disadvantage.8 Depression is 3 times more common for those with incomes below the federal poverty level, compared with those with higher incomes.9 As a consequence, the challenge remains how to effectively treat socioeconomically disadvantaged Black women with depression.Obesity is also disproportionately prevalent among Black women relative to other racial/ethnic groups.10 The high burden of obesity among Black women not only indicates a higher prevalence of obesity-related chronic diseases (e.g., diabetes, heart disease),11 but it may also have an impact on psychosocial outcomes such as depression.12 As such, interventions focusing on behavioral weight control may present a useful opportunity to address both obesity and depression.Behavioral weight loss interventions typically include frequent contact with a weight loss counselor; self-monitoring of diet, exercise, and weight; and lessons that cover various topics such as problem solving, relapse prevention, and stress management. Indeed, across numerous studies, behavioral weight loss interventions have been shown to promote reductions in depression.13,14 Such findings are generally believed to be related to weight loss15 and mediated by improvements in body satisfaction; that is, for many, weight loss might enhance body satisfaction and, thus, improve depression outcomes.16,17 However, this finding has most frequently been demonstrated in predominantly socioeconomically advantaged White women, who tend to exhibit strong relations between body size and mood.16,18 In contrast, Black women have greater social acceptance of overweight, less body weight dissatisfaction, and higher body weight ideals compared with White women.19–22 Thus, it is unclear whether Black women would experience a similar reduction in depression as a result of obesity treatment.Although weight loss is indicated for those with obesity, promoting clinically meaningful weight change among Black women has been a major challenge.23 Across various studies, Black women achieve less weight loss relative to White women.24–26 The reason for this racial disparity in weight loss outcomes is unclear, but may be influenced in part by differences in sociocultural norms related to weight, diet, and physical activity.27 As a result, interventions that focus on preventing weight gain may be a useful alternative treatment approach among overweight and obese Black women.27We recently conducted a study titled the Shape Program, a 12-month randomized controlled trial with follow-up at 18 months, evaluating an electronic health weight gain prevention intervention among Black women compared with usual care in the primary care setting.27 The Shape intervention was found to be effective in staving off weight gain at 12 and 18 months.28 It is unclear whether a weight gain prevention approach, as was tested in Shape, would be helpful for treating depression among Black women. As such, we sought to examine the potential spillover benefits produced by this “maintain, don’t gain” approach on depression, compared with usual care.     

Sexual Minority Women and Depressive Symptoms Throughout Adulthood

Objectives. We examined the associations between depressive symptoms and sexual identity and behavior among women with or at risk for HIV.Methods. We analyzed longitudinal data from 1811 participants in the Women’s Interagency HIV Study (WIHS) from 1994 to 2013 in Brooklyn and the Bronx, New York; Chicago, Illinois; Washington, DC; and Los Angeles and San Francisco, California, by comparing depressive symptoms by baseline sexual identity and ongoing sexual behavior. We controlled for age, socioeconomic status, violence history, and substance use.Results. In separate analyses, bisexual women and women who reported having sex with both men and women during follow-up had higher unadjusted odds of depressive symptoms compared with heterosexuals and women who reported only having male sexual partners (adjusted odd ratio [AOR] = 1.36; 95% confidence interval [CI]  = 1.10, 1.69 and AOR = 1.21; 95% CI = 1.06, 1.37, respectively). Age was a significant effect modifier in multivariable analysis; sexual minority women had increased odds of depressive symptoms in early adulthood, but they did not have these odds at midlife. Odds of depressive symptoms were lower among some sexual minority women at older ages.Conclusions. Patterns of depressive symptoms over the life course of sexual minority women with or at risk for HIV might differ from heterosexual women and from patterns observed in the general aging population.Depression is a major health concern for women. According to the Centers for Disease Control and Prevention (CDC), 10% of US women reported any depression and 5% reported major depression in the previous 2 weeks.1 Depression has been reported in 19% to 62%2–4 of HIV-infected women and is associated with reduced cognitive function,5 decreased adherence to highly active antiretroviral therapy (HAART),6 higher rates of unprotected sex among substance users,7 and increased mortality.2,6Women with or at risk for HIV are often exposed to factors such as poverty,8 substance use, and violence,9–11 which can independently and jointly contribute to depression. A recent study found that any combination of intimate partner violence (IPV), substance use, and HIV infection increased the odds of depression.12 Lower socioeconomic status (SES) in women12 and HIV infection4,5 were also independently associated with depression. However, studies showed no association among HIV stage, HAART use,4,8 CD4 count,8,13 or viral load and depression.4,8,13There is a strong association between sexual minority status (i.e., women who identify as lesbian or bisexual or have female sex partners) and poor mental health. In a US survey, lifetime major depression was reported by 42% of lesbians, 52% of bisexuals, and 27% of heterosexual women (P < .01); in the same study, major depression was reported by 15% of women who have sex with women (WSW), 51% of women who have sex with men and women (WSMW), and 27% of women who have sex with men (WSM; P < .01).14 In this study, we examined 2 aspects of sexual orientation15–17: sexual identity and sexual behavior. Although sexual attraction is also considered part of an individual’s sexual orientation, data on attraction was not collected in the original study.Despite the strong association between sexual minority status and depression, it is unknown whether sexual minority status acts as an independent predictor or effect modifier of depressive symptoms among women affected by HIV, substance use, and violence. Our original hypothesis was that lesbian, bisexual, and WSMW (but not WSW) would have higher odds of depression, with race/ethnicity acting as a potential effect modifier.     

Effect of Depression on Risky Drinking and Response to a Screening,Brief Intervention,and Referral to Treatment Intervention

We assessed alcohol consumption and depression in 234 American Indian/Alaska Native women (aged 18–45 years) in Southern California. Women were randomized to intervention or assessment alone and followed for 6 months (2011–2013). Depression was associated with risk factors for alcohol-exposed pregnancy (AEP). Both treatment groups reduced drinking (P < .001). Depressed, but not nondepressed, women reduced drinking in response to SBIRT above the reduction in response to assessment alone. Screening for depression may assist in allocating women to specific AEP prevention interventions.Women who consume alcohol and do not practice effective contraception are at risk for an alcohol-exposed pregnancy (AEP). AEPs can lead to fetal alcohol spectrum disorders, the leading known cause of developmental disabilities.1–3 Prepregnancy drinking, particularly heavy episodic or binge drinking, is a robust predictor of AEP.4 Depression has been linked to problem alcohol consumption in women5–7 and appears to predate8,9 and perhaps predict10 alcohol problems. Among American Indian/Alaska Native (AI/AN) women, studies have linked depression to problem drinking.11–13 However, risk factors for an AEP and interventions to reduce risk for AEP have not been well studied in AI/AN women.14 This is further complicated by variability among AI/AN populations in the prevalence of alcohol consumption11,15–20 and depression.13,21–23One approach to prevention of AEPs is screening, brief intervention, and referral to treatment (SBIRT).24,25 We previously tested the effectiveness of an SBIRT intervention in AI/AN women and found that whether women received an assessment followed by the SBIRT intervention or assessment alone, they reported a significant reduction in alcohol use. We examined depression as a predictor of vulnerability to having an AEP and explored whether depressed AI/AN women respond differently than nondepressed women to an SBIRT intervention.     

Clustering of Midlife Lifestyle Behaviors and Subsequent Cognitive Function: A Longitudinal Study

Objectives. We examined the association between individual and clustered lifestyle behaviors in middle age and later in cognitive functioning.Methods. Middle-aged participants (n = 2430) in the Supplémentation en Vitamines et Minéraux Antioxydant study self-reported their low physical activity, sedentary behavior, alcohol use, smoking, low fruit and vegetable consumption, and low fish consumption. We assessed cognition 13 years later via 6 neuropsychological tests. After standardization, we summed the scores for a composite cognitive measure. We estimated executive functioning and verbal memory scores using principal component analysis. We estimated the mean differences (95% confidence intervals [CIs]) in cognitive performance by the number of unhealthy behaviors using analysis of covariance. We identified latent unhealthy behavior factor via structural equation modeling.Results. Global cognitive function and verbal memory were linearly, negatively associated with the number of unhealthy behaviors: adjusted mean differences = −0.36 (95% CI = −0.69, −0.03) and −0.46 (95% CI = −0.80, −0.11), respectively, per unit increase in the number of unhealthy behaviors. The latent unhealthy behavior factor with low fruit and vegetable consumption and low physical activity as main contributors was associated with reduced verbal memory (RMSEA = 0.02; CFI = 0.96; P = .004). No association was found with executive functioning.Conclusions. Comprehensive public health strategies promoting healthy lifestyles might help deter cognitive aging.Noncommunicable diseases with notable lifestyle components are the leading causes of death worldwide.1,2 There is also growing evidence of the critical role of different midlife health and risk behaviors in cognitive aging.3–7 Because lifestyles are inherently modifiable and no treatment of cognitive decline is available, such findings argue for the paramount importance of prevention.8,9Current data support a deleterious effect of alcohol abstinence or abuse (compared with moderate alcohol consumption),10 smoking,7 low fruit and vegetable intake,11 low fish intake,12 and low physical activity (PA) levels13 on cognitive aging. However, it has been widely documented that lifestyle factors are strongly correlated with each other, forming a cluster of healthy or unhealthy behaviors.14 Traditionally, such interrelations have been accounted for by statistical adjustment; however, it is of major public health interest to consider the cumulative and combined effect of the various lifestyle behaviors on health by using multidimensional strategies.14Research that examines the combined effect of lifestyle factors on mortality is plentiful, and data have been colligated in a recent meta-analysis.15 These authors reported a 66% reduction in mortality risk by comparing adherence to 4 or more healthy lifestyle behaviors versus engagement in any number of unhealthy behaviors.The combined effect of lifestyle factors has also been explored in relation to cardiovascular diseases,16–18 cancer,18–22 diabetes,18,23 memory complaints,24 and dementia25–27; however, very few studies have reported findings regarding cognition.28,29 Despite heterogeneity in the definition of a healthy lifestyle, study design, and residual confounding, available, but scarce, data support a critical, protective role of healthy lifestyles in cognitive health through their beneficial properties via oxidative, inflammatory, vascular, and other neuroprotective pathways.30–33Our objectives in this study were to examine the association between individual and clustered lifestyle behaviors and later cognitive functioning. We employed traditional and innovative techniques (structural equation modeling) in our epidemiological pursuit.     

Prevalence of HCV Infection Among Clients in Community-Based Health Settings in Hawaii, 2002–2010: Assessing Risk Factors

Objectives. We sought to determine the prevalence of HCV infection and identify risk factors associated with HCV infection among at-risk clients presenting to community-based health settings in Hawaii.Methods. Clients from 23 community-based sites were administered risk factor questionnaires and screened for HCV antibodies from December 2002 through May 2010. We performed univariate and multivariate logistic regression analyses.Results. Of 3306 participants included in the analysis, 390 (11.8%) tested antibody positive for HCV. Highest HCV antibody prevalence (17.0%) was in persons 45 to 64 years old compared with all other age groups. Significant independent risk factors were current or prior injection drug use (P < .001), blood transfusion prior to July 1992 (P = .002), and having an HCV-infected sex partner (P = .03). Stratification by gender revealed sexual exposure to be significant for males (P = .001).Conclusions. Despite Hawaii’s ethnic diversity, high hepatocellular carcinoma incidence, and a statewide syringe exchange program in place since the early 1990s, our HCV prevalence and risk factor findings are remarkably consistent with those reported from the mainland United States. Hence, effective interventions identified from US mainland population studies should be generalizable to Hawaii.Hepatitis C is the most prevalent chronic blood-borne viral infection in the United States, with an estimated 1.3% of the population chronically infected.1 Chronic HCV infection is often asymptomatic; approximately 75% of infected persons may be unaware that they are infected.2 Transmission is mainly through direct blood-to-blood contact, and the most common risk factor in the United States is the sharing of injection drug use equipment.1,2 Complications from HCV infection include cirrhosis, hepatocellular carcinoma (HCC), and end-stage liver disease; more than one third of liver transplants in the United States can be attributed to HCV.3 There is currently no vaccine,4 and until recently, standard therapy with pegylated interferon and ribavirin achieved a sustained virologic response in only 40% to 50% of patients.5,6In May 2011, the US Food and Drug Administration approved 2 new HCV-specific protease inhibitors for the treatment of chronic genotype 1 HCV infections: boceprevir7,8 and telaprevir.9,10 In combination with standard therapy, these drugs have achieved significantly higher rates of sustained virologic response: up to 67% to 75%.7,10 Achieving sustained virologic response is key to reducing mortality, HCC, and other comorbidities.11,12 With such a large percentage of HCV-infected individuals unaware of their status and new successful treatments available, there is now increased rationale for health providers to screen their clients for chronic HCV infection.The population of Hawaii differs from that of the mainland United States on a number of key factors related to HCV and HCC. Hawaii has the highest incidence of HCC nationally.13 Asian/Pacific Islanders have the highest incidence of HCC in the United States,13 and 57% of the Hawaii’s population is Asian, either alone or in combination with other ethnic groups.14 The high HCC incidence among Asian/Pacific Islanders is attributed in large part to chronic hepatitis B virus (HBV) infection,13,15 and the identification and treatment of persons with chronic HBV or HCV infection is an important public health priority in Hawaii. In addition, Hawaii implemented a statewide syringe exchange program in the early 1990s, the first state to do so.16 The risk factor demonstrating the strongest association with HCV infection in the United States is injection drug use,1,17 and syringe exchange programs have demonstrated efficacy in reducing HCV infection among injection drug users.18,19To our knowledge, only 3 HCV prevalence studies have been conducted in Hawaii; however, each focused on a specific well-defined subgroup population: patients with HCC,20 HIV-infected persons enrolled in a state drug assistance plan,21 and adults from a homeless shelter.22The Adult Viral Hepatitis Prevention Program of the Hawaii State Department of Health, which offers risk-based HCV antibody testing based on reported national risk factors,1,23 has been collecting data on persons undergoing screening since 2002. We investigated the prevalence of HCV antibody positivity among at-risk clients of community-based health programs in Hawaii and identified demographic characteristics and independent risk factors associated with HCV infection.     

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.     

Previous Exposure to HCV Among Persons Born During 1945–1965: Prevalence and Predictors,United States, 1999–2008

Objectives. We examined HCV exposure prevalence and predictors among persons in the United States born during 1945–1965.Methods. With data from the 1999–2008 National Health and Nutrition Examination Survey, we calculated the proportion of persons born during 1945–1965 who tested positive for HCV antibody (anti-HCV) and analyzed the prevalence by sociodemographic and behavioral risk factors.Results. Anti-HCV prevalence in the 1945–1965 birth cohort was 3.2% (95% confidence interval [CI] = 2.8%, 3.8%), substantially higher than among other adults (0.9%). Within the cohort, anti-HCV prevalence was higher among non-Hispanic Blacks (6.4%; 95% CI = 5.3%, 7.7%), persons with injection drug use histories (56.8%; 95% CI = 48.4%, 64.8%), and persons with elevated alanine aminotransferase levels (12.7%; 95% CI = 10.7%, 15.1%). Injection drug use (adjusted odds ratio = 98.4; 95% CI = 58.8, 164.5) was the strongest anti-HCV prevalence predictor. Among anti-HCV–positive persons, 57.8% reported having 2 or more alcoholic drinks daily.Conclusions. With the high prevalence of HCV among persons born during 1945–1965, the increasing morbidity and mortality associated with HCV, and reductions in liver cancer and HCV-related mortality when HCV is eradicated, it is critically important to identify persons with HCV and link them to appropriate care.In the United States, the incidence of HCV infection rose dramatically through the 1970s and 1980s reaching more than 200 000 new infections per year through the mid- to late-1980s.1 This high incidence resulted in a disproportionately high burden of HCV infection among Americans who were born between the mid-1940s and the mid-1960s, a birth cohort popularly referred to as the baby boom generation.2 Alter et al. first documented the relatively high prevalence of HCV infection among this cohort in their analysis of 1988–1994 National Health and Nutrition Examination Survey (NHANES) data, reporting that 65% of persons with HCV infection were aged 30 to 49 years during the survey period.3 In an analysis of NHANES data from 1999 to 2002, a similarly high proportion of all persons with HCV antibody had been born from 1945 through 1964.1 This cohort effect on the high prevalence of HCV infection in the baby boom generation has been attributed largely to exposures (principally injection drug use [IDU] and blood transfusion before 1992) that occurred many years before the survey periods.1,3 However, a significant proportion of HCV-infected persons do not report any risk factors,4–6 perhaps because of fear of being stigmatized,7 or simply lack of recall or knowledge of exposures such as those that may occur in health care settings.8,9A validated Markov model forecasting lifetime morbidity and mortality attributable to HCV infection projected that of 2.9 million persons with untreated HCV infection who did not have cirrhosis of the liver in 2005, 1 071 000 (36.8%) will die from complications of HCV.10 In the United States, HCV-associated disease is the leading indication for liver transplantation and HCV infection is a leading cause of hepatocellular carcinoma.11–14 Approximately 73.9% of HCV-associated mortality occurs among persons born from 1945 to 1965.15In 1998, the Centers for Disease Control and Prevention recommended16 that persons with certain risk factors (e.g., any history of IDU) or medical conditions (e.g., persistently elevated alanine aminotransferase [ALT] levels) be tested for HCV infection. Despite these recommendations, testing practices over the past decade have had limited success in identification of HCV infection in the United States as estimates of the proportion of persons who are unaware of their infection range from 40% to 85%.17–20 Contributing to the limited success of the recommendations is the difficulty in obtaining risk behavior history that occurred in the distant past, the primarily asymptomatic nature of the infection, and a less than optimal level of physician knowledge regarding the natural history and prevalence of infection, the current recommendations for testing, and interpretation of test results.21–24In 2011, the prospects for successful medical treatment of HCV infection were significantly improved with the US Food and Drug Administration licensure of 2 direct-acting antiviral medications, both in the protease inhibitor class. In clinical trials, the rates of sustained viral response—equivalent to a “virological cure”—increased from 44% with use of the current standard regimen, to 75% when a direct-acting antiviral medication was added to that regimen in treatment of persons infected with HCV genotype 1, the genotype that is most common in the United States.25 Since this article was accepted for publication, the US Food and Drug Administration has approved new HCV medications26,27 that have further increased cure rates to as high as 90% in clinical trials.Persons who achieve a sustained viral response after treatment experience significantly less liver-related morbidity (including hepatocellular carcinoma),28 less liver-related mortality,29 and reductions in all-cause mortality.30 However, the potential population benefits from these improvements in treatment effectiveness will be limited unless there are concurrent increases in the rate of identification and treatment of HCV-infected persons.31Because of the limited effectiveness of risk-based testing strategies to date and the high prevalence of HCV infection and projected disease burden, the Centers for Disease Control and Prevention recently issued the Recommendations for the Identification and Initial Care of Chronic Hepatitis C Virus Infection Among Persons Born During 1945–196532 with the goal of identifying persons with HCV infection who are undiagnosed. The recommendation was subsequently made by the US Preventive Services Task Force.33 The purpose of the current study was to determine the proportion of persons in the birth cohort who were positive for antibody to HCV (anti-HCV), and to examine the sociodemographic and behavioral risk factors associated with anti-HCV prevalence.     

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.     

Predictors of Active Injection Drug Use in a Cohort of Patients Infected With Hepatitis C Virus

Objectives. We investigated potential risk factors for active injection drug use (IDU) in an inner-city cohort of patients infected with hepatitis C virus (HCV).Methods. We used log-binomial regression to identify factors independently associated with active IDU during the first 3 years of follow-up for the 289 participants who reported ever having injected drugs at baseline.Results. Overall, 142 (49.1%) of the 289 participants reported active IDU at some point during the follow-up period. In a multivariate model, being unemployed (prevalence ratio [PR] = 1.93; 95% confidence interval [CI] = 1.24, 3.03) and hazardous alcohol drinking (PR = 1.67; 95% CI = 1.34, 2.08) were associated with active IDU. Smoking was associated with IDU but this association was not statistically significant. Patients with all 3 of those factors were 3 times as likely to report IDU during follow-up as those with 0 or 1 factor (PR = 3.3; 95% CI = 2.2, 4.9). Neither HIV coinfection nor history of psychiatric disease was independently associated with active IDU.Conclusions. Optimal treatment of persons with HCV infection will require attention to unemployment, alcohol use, and smoking in conjunction with IDU treatment and prevention.Hepatitis C virus (HCV) infection is a major cause of chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma. About 130 million people are estimated to be infected worldwide with HCV,1 including 3.2 million in the United States,2 and mortality from HCV in the United States is increasing.3 Injection drug use (IDU) is the single most important risk factor for HCV infection in the United States 2,4 with an estimated 40% to 50% of infections attributable to IDU.5 Of increasing concern is the substantial proportion of HCV-infected patients who are coinfected with HIV.6 Because HIV and HCV are each transmitted by blood-contaminated needles and syringes, approximately 30% of all HIV-infected individuals are also infected with HCV1,7; in cohorts of intravenous drug users, the proportion of HCV-infected persons with HIV coinfection can be as high as 41%.8Because IDU is a significant risk factor for HCV transmission, ongoing drug abuse is common in HCV-infected populations. Such ongoing drug use has been documented as a potential barrier in managing the infection.9,10 Moreover, former IDUs can be concerned about relapse with performing self-injection as part of interferon treatment.11 Thus, understanding factors associated with active IDU may inform pragmatic approaches to improving acceptability of HCV treatment and increasing patients’ chances of successfully treating their disease.Other barriers to treatment of HCV infection have been described and are associated with IDU, such as alcohol use, psychiatric disease, and HIV coinfection.9,10,12–14 Concurrent alcohol abuse has, in some studies, distinguished persistence of IDU from cessation of IDU; however, in other reports, the association of heavy alcohol use did not remain after adjustment for known risk factors.15,16 Co-occurring mental disorders are frequently associated with poorer health and worse treatment outcomes among drug users and may lead to an increased level of drug use and riskier drug use behavior.17 HIV infection has been hypothesized to be associated with IDU in contrasting ways. Those who are HIV-infected may have more frequent contact with health services and thus referral to drug treatment; conversely, increased depression following diagnosis may lead to increased drug use.16Individual patterns of drug use vary over time. Whereas some studies have indicated a trend toward decreased IDU over time in longer-term cohort studies, others have found that many injection drug users are unable to maintain sustained cessation of IDU.17–23 In addition to the direct morbidity and mortality associated with IDU, continued use may make it more difficult for patients to effectively manage their disease. Evaluating predictors of ongoing IDU in these populations may help identify avenues to facilitate long-term cessation of IDU. Our goals were to investigate risk factors for active IDU in a cohort of patients infected with hepatitis C, with specific focus on alcohol use, smoking, psychiatric disease, and HIV coinfection.     

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.     

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.     

A Randomized Trial of a Hepatitis Care Coordination Model in Methadone Maintenance Treatment

Objectives. We evaluated the efficacy of a hepatitis care coordination intervention to improve linkage to hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination and clinical evaluation of hepatitis C virus (HCV) infection among methadone maintenance patients.Methods. We conducted a randomized controlled trial of 489 participants from methadone maintenance treatment programs in San Francisco, California, and New York City from February 2008 through June 2011. We randomized participants to a control arm (n = 245) and an intervention arm (n = 244), which included on-site screening, motivational-enhanced education and counseling, on-site vaccination, and case management services.Results. Compared with the control group, intervention group participants were significantly more likely (odds ratio [OR] = 41.8; 95% confidence interval [CI] = 19.4, 90.0) to receive their first vaccine dose within 30 days and to receive an HCV evaluation within 6 months (OR = 4.10; 95% CI = 2.35, 7.17). A combined intervention adherence outcome that measured adherence to HAV–HBV vaccination, HCV evaluation, or both strongly favored the intervention group (OR = 8.70; 95% CI = 5.56, 13.61).Conclusions. Hepatitis care coordination was efficacious in increasing adherence to HAV–HBV vaccination and HCV clinical evaluation among methadone patients.Viral hepatitis is a major public health problem among drug users in the United States. Drug users are at high risk of infection with hepatitis A, B, and C viruses (HAV, HBV, and HCV, respectively) through unsterile injection practices and high-risk sexual activity.1–3 HCV infection can be acquired rapidly by injection drug users, with prevalence rates of 70% or higher among recent-onset injectors.4,5 Cirrhosis, hepatocellular carcinoma, and death are important sequelae of HCV and chronic HBV infection.6,7 Superimposed HBV and HAV infection may exacerbate liver disease among those with chronic HCV infection.8 HIV infection can accelerate disease progression in HCV- and HBV-infected persons.9–11 Given that a significant proportion of this population remains at risk for these infections, HAV–HBV vaccination programs that effectively engage drug users are needed.2,12 Treatment options for HCV are rapidly improving with the introduction of direct-acting antivirals (e.g., telaprevir and boceprevir) and the prospect of interferon-free regimens.13–16The integration of primary medical care and case management services within drug treatment programs has been associated with increased utilization of outpatient health care services among HIV- and HCV-seropositive drug users. Studies have found increased rates of the use of HIV/AIDS- and HCV-related medical care services in the methadone treatment setting17–19; however, most drug treatment programs do not have the infrastructure to provide on-site HCV treatment.20 Despite advances in HCV treatment, many HCV-positive drug users are not engaged in HCV care,21,22 and many drug users experience missed opportunities for HAV and HBV vaccination.2,23Drug users experience multiple complex individual, social, and structural barriers to HCV evaluation and treatment. Barriers include lack of knowledge about available effective treatments, low perceived risk of potential long-term adverse health consequences, fear of possible side effects of treatment, high treatment costs, lack of insurance, negative peer norms regarding HCV medications, medical mistrust, and potential provider concerns about treating active drug users.24–31 As has been observed for HIV infection, with HCV infection there is a cascade of care, with decreasing proportions of infected persons knowing their status, having had a clinical evaluation, being engaged in care, being on treatment, completing treatment, and having an optimal virological response.21,30,32HCV drug efficacy trials focus on optimizing outcomes among those treated, whereas adherence interventions frequently focus on assisting individuals to complete initiated therapy. For drug users with HCV infection, the initial steps in the cascade of care, including screening, identifying those HCV positive, and engaging infected persons in care, remain a substantial gap.21 Care coordination approaches such as case management and patient navigation services have shown promise in engaging and retaining patients in cancer screening and care and have been used in HIV primary care with promising but inconsistent results.33–39 There is a need for rigorously designed research to examine the efficacy of care coordination approaches such as case management and patient navigation as a strategy for improving the efficiency of the HCV cascade of care.We evaluated the impact of a hepatitis care coordination model integrated in the methadone maintenance treatment (MMT) setting on the following primary outcomes: (1) receipt of the first dose of HAV–HBV vaccine and (2) adherence to an initial appointment with a hepatitis C health care provider. We hypothesized that hepatitis care coordination, including on-site screening, education and counseling, motivational interviewing, on-site vaccination, and case management, would increase rates of adherence to HAV–HBV vaccination and initial appointment with a hepatitis C health care provider more than a control intervention that reflected standard recommendations for the care of drug users.40     

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

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

Impact of Rurality,Broiler Operations,and Community Socioeconomic Factors on the Risk of Campylobacteriosis in Maryland

Objectives. We evaluated the combined impact of community-level environmental and socioeconomic factors on the risk of campylobacteriosis.Methods. We obtained Campylobacter case data (2002–2010; n = 3694) from the Maryland Foodborne Diseases Active Surveillance Network. We obtained community-level socioeconomic and environmental data from the 2000 US Census and the 2007 US Census of Agriculture. We linked data by zip code. We derived incidence rate ratios by Poisson regressions. We mapped a subset of zip code–level characteristics.Results. In zip codes that were 100% rural, incidence rate ratios (IRRs) of campylobacteriosis were 6 times (IRR = 6.18; 95% confidence interval [CI] = 3.19, 11.97) greater than those in urban zip codes. In zip codes with broiler chicken operations, incidence rates were 1.45 times greater than those in zip codes without broilers (IRR = 1.45; 95% CI = 1.34, 1.58). We also observed higher rates in zip codes whose populations were predominantly White and had high median incomes.Conclusions. The community and environment in which one lives may significantly influence the risk of campylobacteriosis.Campylobacter is a leading cause of bacterial gastroenteritis in much of the developed and developing world.1,2 In addition to the diarrhea and vomiting associated with gastroenteritis, infection with Campylobacter can lead to more serious sequelae, such as Guillain-Barré syndrome, a demyelinating autoimmune disorder that can sometimes lead to death.3 Scallan et al.4 estimated that Campylobacter causes approximately 845 000 domestically acquired illnesses in the United States each year, along with 8463 hospitalizations and 76 deaths. Although the majority of these illnesses are estimated to be foodborne,4 attributing specific infections to specific sources has been challenging.Commonly reported risk factors for Campylobacter outbreaks include exposure to undercooked poultry,5 unpasteurized milk,6,7 and contaminated water.8 Eating in restaurants,9 not observing proper food preparation practices,10 and traveling abroad9,11 have also been associated with both outbreaks and sporadic (nonoutbreak) cases of campylobacteriosis. Additional risk factors for sporadic infections include contact with pets,5,12 contact with farm animals and livestock,13,14 and contact with animal feces.15 Significant associations of living in rural areas with risk of campylobacteriosis also have been identified in Europe and Canada.16–18 Moreover, a specific feature of rural environments—animal density—has been identified as a significant predictor of Campylobacter incidence in Canada and New Zealand.16,17Several sociodemographic risk factors for campylobacteriosis have also been identified, the 2 most consistent being gender (males) and age (< 5 years).8,16–19 Previous studies have also evaluated socioeconomic factors associated with the incidence of Campylobacter infection, and the findings suggest that these infections may occur more frequently among individuals characterized by higher socioeconomic status.16,20 Moreover, Samuel et al.21 reported that the incidence of campylobacteriosis among African Americans was lower than that among other ethnic groups across multiple sites in the United States, although hospitalization rates for this group were higher. These findings, however, may be influenced by differentials in illness reporting among varying races and ethnic groups.Nonetheless, these previous reports have largely resulted from population-based case–control studies focused on individual-level data. To our knowledge, no US study has examined the combined effect of community-level environmental and socioeconomic risk factors on the risk of campylobacteriosis. Such an analysis can be useful in (1) identifying (and possibly predicting) “hot spot” communities that bear high burdens of this illness, and (2) addressing significant research gaps concerning potential health disparities in the risk of infectious diseases.22 We linked Maryland Foodborne Diseases Active Surveillance (FoodNet) data to US Census data and US Department of Agriculture Census of Agriculture data at the zip code level to evaluate associations between community-level environmental and socioeconomic risk factors and the incidence of Campylobacter infections in Maryland.     

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     

Social Branding to Decrease Smoking Among Young Adults in Bars

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

Efficacy of Initiating Tobacco Dependence Treatment in Inpatient Psychiatry: A Randomized Controlled Trial

Objectives. We evaluated the efficacy of a motivational tobacco cessation treatment combined with nicotine replacement relative to usual care initiated in inpatient psychiatry.Methods. We randomized participants (n = 224; 79% recruitment rate) recruited from a locked acute psychiatry unit with a 100% smoking ban to intervention or usual care. Prior to hospitalization, participants averaged 19 (SD = 12) cigarettes per day; only 16% intended to quit smoking in the next 30 days.Results. Verified smoking 7-day point prevalence abstinence was significantly higher for intervention than usual care at month 3 (13.9% vs 3.2%), 6 (14.4% vs 6.5%), 12 (19.4% vs 10.9%), and 18 (20.0% vs 7.7%; odds ratio [OR] = 3.15; 95% confidence interval [CI] = 1.22, 8.14; P = .018; retention > 80%). Psychiatric measures did not predict abstinence; measures of motivation and tobacco dependence did. The usual care group had a significantly greater likelihood than the intervention group of psychiatric rehospitalization (adjusted OR = 1.92; 95% CI = 1.06, 3.49).Conclusions. The findings support initiation of motivationally tailored tobacco cessation treatment during acute psychiatric hospitalization. Psychiatric severity did not moderate treatment efficacy, and cessation treatment appeared to decrease rehospitalization risk, perhaps by providing broader therapeutic benefit.Tobacco use among persons with mental illness is 2 to 4 times as great as among the general US population, with costly and deadly consequences.1–3 Persons with serious mental illness have an average life expectancy 25 years shorter than in the general population; the chief causes of death are chronic tobacco-related diseases such as cardiovascular disease, lung disease, and cancer.4 Annually, 200 000 of the 435 000 deaths in the United States attributed to smoking are believed to be among individuals with mental illness or addictive disorders.5Despite the significant health effects, smoking remains ignored or—even worse—encouraged in mental health settings.6,7 A minority of patients with mental illness report that a mental health provider has advised them to quit smoking, and some report active discouragement of quitting.8,9 Staff at some psychiatric hospitals still smoke with patients, rationalized as effective for building clinician–client rapport.10Since 1993, US hospitals have banned tobacco use under mandate of the Joint Commission on the Accreditation of Healthcare Organizations.11 In response to outcries from patient advocacy groups, however, the commission permitted an exception for inpatient psychiatry; similar policy exemptions have been granted to psychiatric facilities in Europe and Australia.12–14 Nearly 20 years later, more than half of state inpatient psychiatry units in the United States permit smoking, and half sell cigarettes to patients.15 Even among hospitals that ban tobacco use, cessation advice and treatment are rare.15,16 Without intervention, almost all patients return to smoking after a smoke-free psychiatric hospitalization, most within minutes of hospital discharge.8 Integrated treatments are needed.Nearly 8800 studies inform tobacco treatment clinical practice guidelines,17 and an extensive literature documents the efficacy of initiating treatment of tobacco dependence in hospital settings with general medical patients.18 Yet fewer than 2 dozen randomized clinical trials have treated smoking in persons with current mental illness,19 and the only published randomized trial examining inpatient psychiatry for initiating tobacco treatment was conducted with adolescents. The intervention group increased in motivation to quit, but the treatment effect on abstinence was not significant.20 The American Psychiatric Association identifies psychiatric hospitalizations as an ideal opportunity to treat tobacco dependence.21 Hospital-based tobacco treatment trials with the seriously mentally ill are needed to inform clinical practice guidelines.An obstacle to tobacco treatment in mental health settings has been concern that termination of cigarette smoking will increase psychiatric symptoms. Many in the clinical, research, and public arenas believe that tobacco use serves as a form of self-medication for persons with psychiatric disorders.22,23 If this were true, psychiatric symptoms would be expected to worsen and mental health service use to increase following treatment of tobacco use. Tobacco treatment trials with smokers with clinical depression, posttraumatic stress disorder, and schizophrenia, however, have demonstrated no adverse effect of treating tobacco dependence or of quitting smoking on mental health recovery.24–29Research has not examined the impact of treating tobacco dependence during an acute psychiatric hospitalization on mental health recovery. Patients for whom inpatient psychiatric care is deemed necessary typically present as suicidal, homicidal, or gravely disabled. The average length of inpatient psychiatric stay in the United States is about a week, and readmissions are common.8,16 Among patients hospitalized for mental illness in California in 2005 and 2006, 44% were rehospitalized within 12 months, reflecting the remitting and recurring natural course of many mental illnesses.30 In the literature, predictors of psychiatric hospitalization include psychosis, race/ethnicity (higher for African Americans), low socioeconomic status, and previous hospitalizations.24,31We evaluated the efficacy of a tobacco cessation intervention initiated with adult smokers during an acute inpatient psychiatric hospitalization. The setting was a locked unit with a complete smoking ban that managed patients’ nicotine withdrawal with nicotine replacement therapy (NRT) during hospitalization but did not provide cessation services, discharge NRT, or treatment referrals. Hospitalization in the acute psychiatric setting tends to be brief and unrelated to smoking. Furthermore, few patients hospitalized for psychiatric illness intend to quit smoking in the next 30 days.8,32,33 For this reason, we focused on increasing motivation and engagement during a brief period of institutionalized abstinence and offered cessation treatment and access to 10 weeks of NRT up to 6 months following hospital discharge.Our primary hypothesis was that participants randomized to the smoking cessation intervention would achieve greater 7-day point prevalence tobacco abstinence over 18 months after hospitalization than participants randomized to the usual care control condition. We examined psychiatric variables predictive of cessation success or failure. Our secondary aim was to assess the impact of the tobacco cessation intervention on mental health recovery and prediction of rehospitalization over the 18-month study follow-up, with adjustment for relevant clinical covariates.