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

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

Responses to Discrimination and Psychiatric Disorders Among Black,Hispanic, Female,and Lesbian,Gay, and Bisexual Individuals

Objectives. We examined associations between perceived discrimination due to race/ethnicity, sexual orientation, or gender; responses to discrimination experiences; and psychiatric disorders.Methods. The sample included respondents in the 2004–2005 National Epidemiologic Survey on Alcohol and Related Conditions (n = 34 653). We analyzed the associations between self-reported past-year discrimination and past-year psychiatric disorders as assessed with structured diagnostic interviews among Black (n = 6587); Hispanic (n = 6359); lesbian, gay, and bisexual (LGB; n = 577); and female (n = 20 089) respondents.Results. Black respondents reported the highest levels of past-year discrimination, followed by LGB, Hispanic, and female respondents. Across groups, discrimination was associated with 12-month mood (odds ratio [ORs] = 2.1–3.1), anxiety (ORs = 1.8–3.3), and substance use (ORs = 1.6–3.5) disorders. Respondents who reported not accepting discrimination and not discussing it with others had higher odds of psychiatric disorders (ORs = 2.9–3.9) than did those who did not accept discrimination but did discuss it with others. Black respondents and women who accepted discrimination and did not talk about it with others had elevated rates of mood and anxiety disorders, respectively.Conclusions. Psychiatric disorders are more prevalent among individuals reporting past-year discrimination experiences. Certain responses to discrimination, particularly not disclosing it, are associated with psychiatric morbidity.The role of discrimination as a health determinant has increasingly become a focus of scholarly inquiry. Accumulating evidence points to the deleterious consequences of discrimination experiences on health.^1–6 The damaging effects of discrimination on mental health, in particular, are increasingly evident.^6–9 Experiences of discrimination, whether based on race/ethnicity, sexual orientation, or gender, have been linked to elevations in psychological distress and symptoms of psychopathology.^1,8,10–13 Although the relation between discrimination and psychiatric disorders has been studied less frequently, significant associations with major depression,^9,13 generalized anxiety disorder (GAD),⁹ early initiation of substance abuse,¹⁴ and a composite index of psychiatric morbidity¹⁵ have been reported.This research provides empirical documentation of the role of discrimination in shaping the distribution of adverse mental health outcomes at a population level, but numerous questions regarding these associations remain. Despite widespread exposure to discrimination, most members of stigmatized groups do not ultimately develop psychiatric disorders, which suggests the presence of factors that buffer some individuals against the negative mental health consequences of discrimination. How an individual responds to and copes with discrimination is one factor that may help to identify those most vulnerable to the development of psychiatric disorders after exposure to discrimination. Although several studies have examined coping strategies that members of stigmatized groups use in response to status-based discrimination,^16,17 few studies have considered the impact of these strategies on psychiatric disorders. Previous research has reported associations between responses to discrimination and blood pressure,^3,5 self-esteem, and psychological distress,^6,16 which suggest that such responses may have implications for psychiatric morbidity.Two dimensions of discrimination responses relevant to health outcomes are acceptance and disclosure. Previous research has suggested that these responses interact in complex ways. Among individuals who accept discrimination, disclosing the experience is associated with elevated blood pressure among Black men, whereas not disclosing the experience predicts higher blood pressure among Black women.³ Aside from that study, however, the extent to which responses to discrimination and their associations with health outcomes vary across stigmatized groups has rarely been examined empirically. Given the heterogeneity across groups in experiences of discrimination,^18–20 it is likely that members of stigmatized groups have developed divergent social norms or beliefs regarding appropriate responses to discriminatory actions. Consequently, it remains unclear (1) whether members of different stigmatized groups respond differently to discrimination, and (2) wct 6 whether these variations in responses translate into differential vulnerability to psychiatric disorders when discrimination is experienced. Such information may help to more effectively target preventive interventions, an important public health priority given group-based disparities in psychiatric morbidity.²¹In the present study, we addressed these gaps in the literature by examining whether psychiatric disorders were associated with perceived discrimination due to race/ethnicity, sexual orientation, or gender and with responses to discrimination experiences. We first examined the prevalence of past-year self-reported discrimination experiences based on race/ethnicity, sexual orientation, or gender in a US national sample. Second, we estimated the associations between discrimination experiences and the prevalence of psychiatric disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV),²² including mood, anxiety, and substance use disorders, thus providing the first such estimates across a range of disorders. Third, we examined the distribution of responses to discrimination across 2 domains (acceptance–nonacceptance and disclosure–nondisclosure). Finally, we estimated the associations between responses to discrimination and psychiatric disorders among individuals exposed to past-year discrimination.     

Stigma,Discrimination, or Symptomatology Differences in Self-Reported Mental Health Between US-Born and Somalia-Born Black Americans

Objectives. We examined differences in self-reported mental health (SRMH) between US-born and Somalia-born Black Americans compared with White Americans. We tested how SRMH was affected by stigma toward seeing a mental health provider, discrimination in the health care setting, or symptoms of depression.Methods. Data were from a 2008 survey of adults in Minnesota and were limited to US-born and Somalia-born Black and White Americans (n = 938).Results. Somalia-born adults were more likely to report better SRMH than either US-born Black or White Americans. They also reported lower levels of discrimination (18.6%) than US-born Black Americans (33.4%), higher levels of stigma (23.6% vs 4.7%), and lower levels of depressive symptoms (9.1% vs 31.6%). Controlling for stigma, discrimination, and symptomatology, Somalia-born Black Americans reported better SRMH than White and Black Americans (odds ratio = 4.76).Conclusions. Mental health programming and health care providers who focus on Black Americans’ mental health might be missing important sources of heterogeneity. It is essential to consider the role of race and ethnicity, but also of nativity, in mental health policy and programming.Black Americans are at lower risk than White Americans for common mental disorders, such as anxiety and mood disorders, and substance use.1 Evidence is less clear that there are differences for rates of psychological distress or depressive symptoms,2 with some research indicating that Black Americans may fare worse on these measures,3,4 and other studies showing that they may do better.5 Recent research examined diversity within the Black American population and highlighted important differences in mental health outcomes by nativity.5 For example, Williams et al.,6 using data from the National Survey of American Life, found that Caribbean-born Black males had higher risk of 12-month psychiatric disorders than did US-born Black men, whereas the opposite pattern held for women. The study by Williams7 in 1986 described the historical development of epidemiological studies of mental illness in this population. Using data from the National Institute of Mental Health Epidemiological Catchment Area study, he concluded that there was a paucity of studies that documented the variation in mental illness among Black Americans of different backgrounds.7These studies illustrated the need for research to differentiate between the experiences of US-born and foreign-born Black individuals. To date, no large studies have focused exclusively on immigrants from Africa, who made up about 4% of the total foreign-born population and 49% of the foreign-born Black population in the United States in 2010.8 This study provided an opportunity to examine mental health among Somalia-born Black adults compared with US-born Black and White adults. Data were from a representative sample of adults enrolled in public health care programs in Minnesota, thereby focusing on primarily low-income adults.Studies generally found that foreign-born adults had lower rates of mental illness and psychological distress than US-born adults.5,9 One explanation was that having strong social ties and a strong sense of belonging to a particular ethnic group might protect against mental illness.10 An alternative explanation was that healthy people were more likely to take on the challenge of immigrating (the “healthy migrant” effect).11Although most research on the healthy immigrant paradox has focused on Hispanic or Latino populations, important differences exist between such populations and the Somalia-born population. Most Somalia-born individuals immigrated in the midst of civil war. In their study of Somali and Oromo (Ethiopian) immigrants to the United States, Jaranson et al.12 found that 25% to 69% had experienced torture before immigrating. Because exposure to conflict leads to vulnerability toward mental health problems, Somalia-born individuals might be expected to report worse mental health than their US-born counterparts. Specifically, exposure to trauma and stress that accompany leaving conflict zones could be expected to predict higher rates of posttraumatic stress disorder and depression. Many refugee populations do exhibit higher rates of such disorders.12,13Some studies indicated that foreign-born Black immigrants had better mental and physical health than their US-born counterparts.14,15 Furthermore, foreign-born Black adults demonstrated lower rates of chronic disease16 and fewer risk factors than US-born Black adults.17 However, these studies largely focused on Caribbean-born Black immigrants and not their Somalia-born counterparts, who might have markedly different immigration experiences. Additionally, these populations might hold different attitudes toward mental illness and have different experiences within the health care arena. To better understand differences between groups, we investigated the role of stigma, discrimination, and symptomatology.Stigma can lead to understated self-reports of mental illness and might prevent people with mental illness from seeking, engaging in, or following through with treatment.18,19 Previous work suggested that Black Americans in the United States hold less stigmatized attitudes toward mental health care than do White Americans,20 but research has not explored this issue in as much depth in the immigrant population. Qualitative research suggested that some Somali immigrants might be reluctant to admit to mental health problems and might experience shame, guilt, or even suicidal ideation in response to experiencing mental illness.21 Such stigma and reticence to admit to mental illness might manifest itself as embarrassment to see a mental health provider.22Although the mental health of Somalia-born individuals might be closely tied to immigration and acculturation, US-born Black adults face prolonged exposure to racism that negatively affects mental health.23 The link between discrimination toward US-born Black Americans and physical and mental health outcomes has been well documented,24 including myriad studies that documented the association between self-reports of discrimination and mental health.25 Yet, there is a paucity of research that has sought to understand the role that discrimination plays in the mental health of foreign-born Black immigrants.23International studies suggested that African immigrant populations outside of the United States experience social exclusion, which might contribute to poor mental health. Although UK and US ethnic minority groups have different cultural and social contexts and histories of migration, they share experiences of social exclusion that can potentially contribute to mental disorders. There are also similarities in the pattern of interaction and experiences of mental health services by ethnic minority groups in the United Kingdom and the United States.26–28 For example, the existence of inequalities in diagnosis and treatment of Afro-Caribbeans in the United Kingdom is well-established. Studies found that perceptions of discriminatory treatment by health services deterred Afro-Caribbeans from accessing such services.29,30In the United States, there is evidence that foreign-born Black adults report experiencing less discrimination than their counterparts born in the United States. A 2009 study, for example, found that of pregnant US-born and foreign-born Black Americans, the US-born cohort was significantly more likely to report experiencing racial discrimination.31 In addition to discrimination and racism generally, it is important to understand the role of unfair treatment within the health care setting. If individuals do not feel that they are given fair treatment, it may lead to reticence to seek help or follow treatment recommendations.An alternative explanation for differences in self-reported mental health (SRMH) is that groups experience different symptoms of mental illness and that SRMH is an accurate reflection of mental health status. The Patient Health Questionnaire-2 (PHQ-2) has proved effective in detecting mental illness symptomatology in clinical settings32,33 and can be compared with SRMH to gain a more complete picture of mental health status. Some research found that despite experiencing discrimination, Black Americans demonstrated lower rates of many common mental illnesses than did White Americans.25 The healthy immigrant paradox found that, despite low socioeconomic and social standing, some immigrants had better health outcomes than more advantaged groups.14,15 However, much of this research focused on this effect among Hispanic populations.34 Research among Somalia-born immigrants found that mental illness was often somaticized, with symptoms of physical, rather than mental, ailments.21This article addressed the following research questions. (1) Do US-born and Somalia-born Black Americans differ from White Americans in SRMH? (2) Do stigma, discrimination in a health care setting, and symptoms of mental illness explain differences in SRMH? (3) Do interactions between race or nativity and stigma, discrimination, and symptomatology mediate these relationships? Answering these questions will allow us to develop a richer understanding of the mental health experiences of these populations while gaining a better understanding of how stigma around mental health and experiences within the health care system might affect individuals’ perceptions of their mental health.     

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

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

Pathways and Correlates Connecting Latinos' Mental Health With Exposure to the United States

Objectives. We examined potential pathways by which time in the United States may relate to differences in the predicted probability of past-year psychiatric disorder among Latino immigrants as compared with US-born Latinos.Methods. We estimated predicted probabilities of psychiatric disorder for US-born and immigrant groups with varying time in the United States, adjusting for different combinations of covariates. We examined 6 pathways by which time in the United States could be associated with psychiatric disorders.Results. Increased time in the United States is associated with higher risk of psychiatric disorders among Latino immigrants. After adjustment for covariates, differences in psychiatric disorder rates between US-born and immigrant Latinos disappear. Discrimination and family cultural conflict appear to play a significant role in the association between time in the United States and the likelihood of developing psychiatric disorders.Conclusions. Increased perceived discrimination and family cultural conflict are pathways by which acculturation might relate to deterioration of mental health for immigrants. Future studies assessing how these implicit pathways evolve as contact with US culture increases may help to identify strategies for ensuring maintenance of mental health for Latino immigrants.It has been shown that Latino immigrants have better mental health than their US-born counterparts and non-Latino Whites, despite having disadvantaged socioeconomic status^1–3 (the “immigrant paradox”). It has also been shown that the mental health of immigrants declines over time in the host country³ (the “acculturation hypothesis”). Our findings from the National Latino and Asian American Study (NLAAS) on the prevalence of psychiatric disorders among Latinos in the United States indicate that foreign nativity is protective for some Latino groups (e.g., Mexicans) but not others (e.g., Puerto Ricans),⁴ implying that other factors besides nativity play a part in US Latinos'' risk of psychiatric disorders. Also, there is evidence that risk of psychopathology is the result of differences in immigrants'' length of residence in the United States and age at arrival. For example, Mexican immigrants in the United States for 13 years or more had higher rates of any mental health disorder, any mood disorder, alcohol abuse, and drug abuse than Mexican immigrants in the United States for fewer than 13 years.³ Findings from the NLAAS indicate that the longer that Latino immigrants remain in their country of origin, the less cumulative risk of onset of psychiatric disorders they experience, resulting in lower lifetime rates of disorders.⁵There is a lack of consensus about which aspects of US exposure are relevant for mental health.⁵ A number of hypotheses have linked years in the United States and mental illness among Latinos.³ US-born Latinos may have a weaker affiliation with traditional Latino values that buffer against mental illness than do Latino immigrants. When individuals come into contact with US culture, there may be negative outcomes such as increased intergenerational conflict,⁶ augmenting their risk for psychopathology. Although family factors have been hypothesized to be a protective factor for immigrant Latinos,^7,8 few empirical studies have actually tested this hypothesis with regard to psychiatric disorders. Another hypothesis is that US-born Latinos may have higher expectations for their quality of life than immigrant Latinos because of their citizenship status and their acquisition of skills similar to those possessed by non-Latino Whites.⁹ However, over time, these expectations may remain unfulfilled because of discrimination, resulting in social stress and declining levels of mental health.¹ Also, as time passes, immigrants may have perceptions of low social status¹⁰ that may be associated with higher risk of psychopathology.Other immigration-related factors could also affect adaptation experiences when integrating into the United States. Specifically, those arriving in the United States at early formative ages (0–10 years) may have weaker identification with Latino cultural values¹¹ and may confront significant pressure to acquire English as their dominant language.¹² English language dominance represents a strong cultural anchor for socially constructed meaning¹³ that may enable immigrants to join certain peer networks and not others. The neighborhoods where Latinos typically live are less safe than those inhabited by non-Latino Whites,¹⁴ which may increase Latinos'' likelihood of psychiatric disorders¹⁵ by increasing ambient hazards. In addition, exposure to racial/ethnic based discrimination^16,17 has been associated with negative mental health outcomes. The NLAAS study provides a unique opportunity to explore these pathways because these domains have been assessed for both Latino immigrants and US-born Latino respondents.We assessed the association of time in the United States with past-year risk for psychiatric disorder, with and without adjustment for potentially influential covariates. Then we tested different pathways explaining the link between time in the United States and psychiatric disorders.     

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.     

Perceived Discrimination and Longitudinal Increases in Adolescent Substance Use: Gender Differences and Mediational Pathways

Objectives. This study was designed to test hypotheses about the prospective association of adolescents’ perceptions of discrimination with increases in substance use and the processes that mediate this association.Methods. African American youths residing in rural Georgia (n = 573; mean age = 16.0 years) provided longitudinal data on their experiences with discrimination, substance use, school engagement, and affiliations with substance-using peers.Results. For male youths, perceived discrimination was significantly related to increases in substance use, and, as hypothesized, this association was mediated by the contributions of perceived discrimination to decreases in school engagement and increases in affiliations with substance-using peers. Analyses also indicated that discrimination influences substance use rather than vice versa.Conclusions. Results are consistent with the hypothesis that high levels of discrimination are linked to increases in substance use for African American male adolescents.Historically, rural residence has protected African American adolescents from high-risk behaviors prevalent in urban areas. Recent epidemiologic data, however, indicate that African American adolescents in rural areas are engaging in substance use at rates equal to or exceeding those of youths who live in densely populated inner cities.1–3 Substance use is a leading cause of accidents, injuries, and disability among African Americans aged 15 to 24 years.4 It predicts the likelihood of infection with HIV/AIDS and other sexually transmitted infections; affects future educational attainment, behavior problems, depressive symptoms, unintended pregnancies, involvement with the criminal justice system, ability to find and keep employment, establishment and maintenance of family relationships; and leads to drug abuse and dependence during adulthood.5–8 The experience of discrimination has been identified as a stressor with the potential to increase African American youths’ vulnerability to a host of problems during adolescence, including substance use.9 The primary purpose of this study was to test hypotheses regarding the influence of perceived discrimination on substance use and the psychosocial processes that account for these effects.Research has established that the experience of unfair treatment based on race is common among African American adults10 and adolescents.11 Associations have been documented between self-reported discrimination and various forms of substance use, including smoking,12 alcohol consumption,13 and use and abuse of other drugs.14 The stress-coping model that has framed much of the research on the effects of discrimination15,16 posits that frequent experiences with discrimination deplete coping resources and increase the attractiveness of avoidant coping strategies, such as substance use, because drug use offers temporary respite from discrimination-induced stress. Almost all of these studies, however, were cross-sectional (see Gibbons et al.17 for an exception), which limits their ability to determine whether substance use is a consequence or a cause of discrimination and to examine the intermediate processes that account for the influence of discrimination on substance use. The primary purposes of this study were to test the hypothesis that perceived discrimination will forecast increases in substance use across adolescence rather than the reverse. Recent research suggests that racial discrimination may affect male and female youths differently.9,18 For example, Brody et al.9 found that discrimination was a more powerful predictor of conduct problems for male adolescents than for female adolescents. Given the comorbidity of substance use and conduct problems, we hypothesized that the influence of discrimination would be more apparent among male than female youths.A secondary purpose of this study was to investigate the processes through which perceived discrimination results in increases in substance use. We propose that African American adolescents who feel devalued and demoralized by perceived discrimination become less inclined to accept conventional values and pursuits; hence, they come to view school, a major social institution, as irrelevant and gravitate toward peers who also reject conventional values. This is consistent with findings that youths who experience racial discrimination report more negative beliefs about the usefulness of school, lower academic efficacy,19 and lower grade point averages.20 These youths subsequently become more prone to affiliate with like-minded peers who sanction and encourage nonconventional and risky behavior.21 Because declines in school engagement and affiliations with substance-using peers are proximal risk mechanisms known for onset and escalation of substance use,21 we expected an indirect effect of perceived discrimination on increases in substance use mediated through its effect on decreasing school engagement and increasing affiliations with substance-using peers.22,23     

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

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

Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work

Objectives. We determined racial/ethnic differences in social support and exposure to violence and transphobia, and explored correlates of depression among male-to-female transgender women with a history of sex work (THSW).Methods. A total of 573 THSW who worked or resided in San Francisco or Oakland, California, were recruited through street outreach and referrals and completed individual interviews using a structured questionnaire.Results. More than half of Latina and White participants were depressed on the basis of Center For Epidemiologic Studies Depression Scale scores. About three quarters of White participants reported ever having suicidal ideation, of whom 64% reported suicide attempts. Half of the participants reported being physically assaulted, and 38% reported being raped or sexually assaulted before age 18 years. White and African American participants reported transphobia experiences more frequently than did others. Social support, transphobia, suicidal ideation, and levels of income and education were significantly and independently correlated with depression.Conclusions. For THSW, psychological vulnerability must be addressed in counseling, support groups, and health promotion programs specifically tailored to race/ethnicity.The term “transgender” has been used as an umbrella term, capturing people who do not conform with a binary male–female gender category.¹ In this study, we use the term “transgender women” or “male-to-female transgender women” to describe individuals who were born biologically male but self-identify as women and desire to live as women.² Although transgender persons or those who identify their gender other than male or female have been historically reported in many cultures around the world, their social roles, status, and acceptance have varied across time and place.³ In the United States, as part of the gay rights movement in the 1970s, a transgender civil rights movement emerged to advocate for transgender people''s equal rights and to eradicate discrimination and harassment in their daily lives.⁴ However, transphobia—institutional, societal, and individual-level discrimination against transgender persons—is still pervasive in the United States and elsewhere. It often takes the form of laws, regulations, violence (physical, sexual, and verbal), harassment, prejudices, and negative attitudes directed against transgender persons.^5–7Studies have reported that transgender persons lack access to gender-sensitive health care^6,8,9 and often experience transphobia in health care and treatment.^5,9 Transgender persons are frequently exposed to violence, sexual assault, and harassment in everyday life, mainly because of transphobia.^5–7,9–11 Physical and sexual assaults and violence, and verbal and nonphysical harassment, derive from various perpetrators (e.g., strangers, acquaintances, partners, family members, and police officers). Transgender persons suffer from assaults, rape, and harassment at an early age, and these experiences persist throughout life.¹ A number of studies have examined violence and harassment against sexual minorities, although these have mainly focused on gay men.^12–15 A limited literature has described the prevalence of violence, transphobia, and health disparities among transgender persons.^7–9Psychological indicators such as depression and suicidal ideation and attempts have been reported among transgender persons.^{5,6,10,16–18} Transgender women of color, such as African Americans, Latinas, and Asians/Pacific Islanders (APIs), are at high risk for adverse health outcomes because of racial/ethnic minority status and gender identity,⁶ as well as for depression through exposure to transphobia.¹⁹ Although transgender persons have reported relatively high rates of using basic health care services,²⁰gender-appropriate mental health services are needed,⁵ particularly among African Americans.²¹ A lack of social support, specifically from the biological family, is commonly reported among transgender persons and is associated with discomfort and lack of security and safety in public settings.²² Sparse research exists on social support among transgender persons, although such support could ameliorate adverse psychological consequences associated with transphobia and also mitigate racial discrimination for transgender persons of color.Because of relatively high rates of unemployment, lack of career training and education, and discrimination in employment, many transgender women engage in sex work for survival.^23,24 Sex work is linked to high-risk situations, including substance abuse, unsafe sex, and sexual and physical abuse.²⁵ Physical abuse, social isolation, and the social stigma associated with sex work exacerbate transgender women''s vulnerability to mental illness and HIV risk.^5,17 High HIV seroprevalence rates among transgender women have been reported,^5,20,26–28 particularly among racial/ethnic minorities,⁵ substance users,²⁷ and sex workers.^{20,24,25,29–31} Transgender women of color face multiple adversities, such as racial and gender discrimination; transphobia; economic challenges including unemployment, substance abuse, HIV and other sexually transmitted infections; and mental illness. However, few studies have investigated racial/ethnic differences in psychological status among transgender women of color in relation to social support and exposure to transphobia.To develop culturally appropriate and transgender specific mental health promotion programs, we describe the prevalence of violence, transphobia, and social support in relation to racial/ethnic background among transgender women with a history of sex work (THSW). We also investigated the role of social support and exposure to transphobia on participants’ levels of depression.     

Use of a Social and Character Development Program to Prevent Substance Use, Violent Behaviors, and Sexual Activity Among Elementary-School Students in Hawaii

Objectives. We assessed the effectiveness of a 5-year trial of a comprehensive school-based program designed to prevent substance use, violent behaviors, and sexual activity among elementary-school students.Methods. We used a matched-pair, cluster-randomized, controlled design, with 10 intervention schools and 10 control schools. Fifth-graders (N = 1714) self-reported on lifetime substance use, violence, and voluntary sexual activity. Teachers of participant students reported on student (N = 1225) substance use and violence.Results. Two-level random-effects count models (with students nested within schools) indicated that student-reported substance use (rate ratio [RR] = 0.41; 90% confidence interval [CI] = 0.25, 0.66) and violence (RR = 0.42; 90% CI = 0.24, 0.73) were significantly lower for students attending intervention schools. A 2-level random-effects binary model indicated that sexual activity was lower (odds ratio = 0.24; 90% CI = 0.08, 0.66) for intervention students. Teacher reports substantiated the effects seen for student-reported data. Dose-response analyses indicated that students exposed to the program for at least 3 years had significantly lower rates of all negative behaviors.Conclusions. Risk-related behaviors were substantially reduced for students who participated in the program, providing evidence that a comprehensive school-based program can have a strong beneficial effect on student behavior.Substance use, violent behaviors, and early initiation of sexual activity occur at problematic levels among American youths.^1–4 Early initiation of substance use and engaging in violent behaviors during childhood place children at a greater risk of psychopathology, aggressive behaviors, and continuation of substance use during adolescence and into adulthood.^5–10 National estimates have indicated that approximately 43.3% of high school students had consumed alcohol, 35.9% had been in a physical fight, and 46.8% had engaged in sexual intercourse over the previous 12 months.⁵ Thus, prevention programs that can reduce the incidence of such behaviors should provide clear public health benefits.Appropriately designed and implemented school-based prevention programs can prevent or reduce negative behaviors,^2,11,12 but some programs have not been evaluated for efficacy and effectiveness,^9,13 criteria deemed crucial in determining whether a program is ready for widespread adoption by schools.^14,15 Although studies indicate positive treatment effects for school-based prevention programs, the magnitude of effects is often modest.^16,17 The average effect size for such programs is 0.20¹⁸ (comparable to a success rate of 9.5%), suggesting that there is considerable room for improvement in the effectiveness of prevention programs in reducing negative behaviors. In addition, accumulating evidence indicates that negative behaviors do not exist in isolation from one another,^2,19 so programs that address multiple co-occurring negative behaviors are likely to be of greater overall benefit.^20,21Our goal was to evaluate the preventive benefits of the Positive Action program, a comprehensive schoolwide social and character development program. We hypothesized that the Positive Action program would result in lower rates of student substance use, violence, and voluntary sexual activity, as measured by student self-reports and teacher reports. Previous quasi-experimental studies of the Positive Action program^22,23 reported beneficial school-level effects on student achievement and serious problem behaviors (e.g., suspensions and violence). We build on previous research by reporting on a matched-pair, cluster-randomized controlled study.¹⁴ These features of a study are important when examining the scientific credibility of intervention findings.     

Population-attributable fractions of Axis I and Axis II mental disorders for suicide attempts: findings from a representative sample of the adult, noninstitutionalized US population

Objectives. We aimed to determine the percentage of suicide attempts attributable to individual Axis I and Axis II mental disorders by studying population-attributable fractions (PAFs) in a nationally representative sample.Methods. Data were from the National Epidemiologic Survey on Alcohol and Related Conditions Wave 2 (NESARC; 2004–2005), a large (N = 34 653) survey of mental illness in the United States. We used multivariate logistic regression to compare individuals with and without a history of suicide attempt across Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I disorders (anxiety, mood, psychotic, alcohol, and drug disorders) and all 10 Axis II personality disorders. PAFs were calculated for each disorder.Results. Of the 25 disorders we examined in the model, 4 disorders had notably high PAF values: major depressive disorder (PAF = 26.6%; 95% confidence interval [CI] = 20.1, 33.2), borderline personality disorder (PAF = 18.1%; 95% CI = 13.4, 23.5), nicotine dependence (PAF = 8.4%; 95% CI = 3.4, 13.7), and posttraumatic stress disorder (PAF = 6.3%; 95% CI = 3.2, 10.0).Conclusions. Our results provide new insight into the relationships between mental disorders and suicide attempts in the general population. Although many mental illnesses were associated with an increased likelihood of suicide attempt, elevated rates of suicide attempts were mostly attributed to the presence of 4 disorders.With almost 1 million deaths worldwide every year and a rate increase of 60% over the past 45 years, suicide is clearly a major public health problem.¹ Although the US Surgeon General has prioritized suicide prevention,² suicidal behavior has not significantly decreased in the United States.³ Suicide attempts are strong risk factors for eventual suicide completion^4–6; therefore, understanding and modifying risk factors for suicide attempts remain a promising approach to reducing suicide rates.Unfortunately, our understanding of the risk factors for suicide attempts is plagued by poor specificity. Vigorous study efforts have identified multiple risk factors, including several sociodemographic factors and mental disorders.^3,7–10 However, significant associations between candidate risk factors and suicide attempts are tempered by low positive predictive values.¹¹ The population-attributable fraction (PAF; also known as the population-attributable risk) has emerged as a promising statistical tool to better quantify the effect of risk factors on a given outcome at the population level. The PAF describes the reduction in incidence of a particular outcome if the entire population was not exposed to the examined risk factor.¹²The PAF has been underused in the study of suicide risk factors.^13,14 A recent review of the PAF in suicide research¹⁵ showed that existing studies examining the PAFs of risk factors for suicide attempts have focused primarily on depression and mood disorders, with PAFs ranging from 28% to 74%.^14,16–21 A small number of studies have investigated the PAFs of substance use disorders and anxiety disorders for suicide attempts, also with mixed findings.^14,18,22 Other findings suggest that the risk of suicide attempts attributable to mental disorders is largely explained by the association between mental disorders and suicidal ideation.⁹ A major limitation in the literature is that relatively few mental disorders have been examined by using PAFs for suicide attempts. Despite substantial evidence for the causative role of personality disorders in suicidal behavior,^23–25 the PAF of personality disorders has been examined in only 1 study to date, and that study was unable to examine the effects of individual personality disorders.¹⁸ Borderline personality disorder is a strong risk factor for suicide attempts,²⁵ yet the PAF of borderline personality disorder for suicide attempts is unknown. Posttraumatic stress disorder (PTSD) is another disorder associated with suicide attempts,^26,27 yet the proportion of suicide attempts attributable to PTSD has not been examined. Furthermore, many previous studies included limited adjustment for confounding factors. Even though several mental disorders have been labeled as risk factors for suicidal behavior,⁷ many studies using the PAF do not adjust for mental disorders other than the disorder of interest. The PAF is based on the assumption that the examined risk factor is causally related to the outcome,¹² and given the high rates of comorbidity of mental disorders,²⁸ multivariate models examining a comprehensive range of mental disorders are needed to provide a more realistic assessment of the PAF for a specific mental illness.Our primary objective was to examine the proportion of suicide attempts attributable to specific mental disorders. To address the limitations of the existing literature, we used the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC),²⁹ wave 2, as the data set. This data set features a very large sample size (N = 34 653), includes a comprehensive assessment of Axis I disorders and all 10 Axis II personality disorders, and is representative of the US population. On the basis of existing literature showing high PAF values for major depressive disorder and other mood disorders, we hypothesized that whereas several mental disorders would be independently associated with suicide attempts, major depressive disorder and other mood disorders would account for the highest proportion of suicide attempts.^16,21 We further hypothesized that anxiety and substance use disorders would have lower PAF values for suicide attempts, on the basis of previous studies that often showed lower PAF values.^14,18,22 The limited literature on the PAFs of personality disorders for suicide attempts suggested that we would find low PAF values; however, because of its consistently demonstrated association with suicide attempts, we anticipated that borderline personality disorder would have a relatively high PAF value.     

Walking and Cycling to Health: A Comparative Analysis of City, State, and International Data

Objectives. We sought to determine the magnitude, direction, and statistical significance of the relationship between active travel and rates of physical activity, obesity, and diabetes.Methods. We examined aggregate cross-sectional health and travel data for 14 countries, all 50 US states, and 47 of the 50 largest US cities through graphical, correlation, and bivariate regression analysis on the country, state, and city levels.Results. At all 3 geographic levels, we found statistically significant negative relationships between active travel and self-reported obesity. At the state and city levels, we found statistically significant positive relationships between active travel and physical activity and statistically significant negative relationships between active travel and diabetes.Conclusions. Together with many other studies, our analysis provides evidence of the population-level health benefits of active travel. Policies on transport, land-use, and urban development should be designed to encourage walking and cycling for daily travel.Many nations throughout the world have experienced large increases in obesity rates over the past 30 years.^1,2 The World Health Organization estimates that more than 300 million adults are obese,³ putting them at increased risk for diseases such as diabetes, hypertension, cardiovascular disease, gout, gallstones, fatty liver, and some cancers.^4,5 Several studies have linked the increase in obesity rates to physical inactivity^6–8 and to widespread availability of inexpensive, calorie-dense foods and beverages.^1,9The importance of physical activity for public health is well established. A US Surgeon General''s report in 1996, Physical Activity and Health,¹⁰ summarized evidence from cross-sectional studies; prospective, longitudinal studies; and clinical investigations. The report concluded that physical inactivity contributes to increased risk of many chronic diseases and health conditions. Furthermore, the research suggested that even 30 minutes per day of moderate-intensity physical activity, if performed regularly, provides significant health benefits. Subsequent reports have supported these conclusions.^11–13The role of physical activity in prevention of weight gain is well documented.¹⁴ Strong evidence from cross-sectional studies has established an inverse relationship between physical activity and body mass index.^15,16 In addition, longitudinal studies have shown that exercisers gain less weight than do their sedentary counterparts.^6,8 Thus, the obesity epidemic may be explained partly by declining levels of physical activity.^1,17,18A growing body of evidence suggests that differences in the built environment for physical activity (e.g., infrastructure for walking and cycling, availability of public transit, street connectivity, housing density, and mixed land use) influence the likelihood that people will use active transport for their daily travel.^19,20 People who live in areas that are more conducive to walking and cycling are more likely to engage in these forms of active transport.^21–25 Walking and cycling can provide valuable daily physical activity.^26–30 Such activities increase rates of caloric expenditure,³¹ and they generally fall into the moderate-intensity range that provides health benefits.^32–35 Thus, travel behavior could have a major influence on health and longevity.^29,30,36,37Over the past decade, researchers have begun to identify linkages between active travel and public health.^38–40 Cross-sectional studies indicate that walking and cycling for transport are linked to better health. The degree of reliance on walking and cycling for daily travel differs greatly among countries.^39,41 European countries with high rates of walking and cycling have less obesity than do Australia and countries in North America that are highly car dependent.²⁶ In addition, walking and cycling for transport are directly related to improved health in older adults.⁴² The Coronary Artery Risk Development in Young Adults Study found that active commuting was positively associated with aerobic fitness among men and women and inversely associated with body mass index, obesity, triglyceride levels, resting blood pressure, and fasting insulin among men.^26,39,41,43Further evidence of the link between active commuting and health comes from prospective, longitudinal studies.⁴⁴ Matthews et al. examined more than 67 000 Chinese women in the Shanghai women''s health study and followed them for an average of 5.7 years.³⁷ Women who walked (P < .07) and cycled (P < .05) for transport had lower rates of all-cause mortality than did those who did not engage in such behaviors. Similarly, Andersen et al. observed that cycling to work decreased mortality rates by 40% among Danish men and women.³⁶ A recent analysis of a multifaceted cycling demonstration project in Odense, Denmark, reported a 20% increase in cycling levels from 1996 to 2002 and a 5-month increase in life expectancy for males.⁴⁵We analyzed recent evidence from a variety of data sources that supports the crucial relationship between active travel, physical activity, obesity, and diabetes. We used city- and state-level data from the United States and national aggregate data for 14 countries to determine the magnitude, direction, and statistical significance of each relationship.     

Association of Depressive Symptoms and Substance Use With Risky Sexual Behavior and Sexually Transmitted Infections Among African American Female Adolescents Seeking Sexual Health Care

Objectives. We examined how depression and substance use interacted to predict risky sexual behavior and sexually transmitted infections (STIs) among African American female adolescents.Methods. We measured depressive symptoms, substance use, sexual behavior, and STIs in 701 African American female adolescents, aged 14 to 20 years, at baseline and at 6-month intervals for 36 months in Atlanta, Georgia (2005–2007). We used generalized estimating equation models to examine effects over the 36-month follow-up period.Results. At baseline, more than 40% of adolescents reported significant depressive symptoms; 64% also reported substance use in the 90 days before assessment. Depression was associated with recently incarcerated partner involvement, sexual sensation seeking, unprotected sex, and prevalent STIs (all P < .001). In addition, adolescents with depressive symptoms who reported any substance use (i.e., marijuana, alcohol, Ecstasy) were more likely to report incarcerated partner involvement, sexual sensation seeking, unprotected sex, and have an incident STI over the 36-month follow-up (all P < .05).Conclusions. African American female adolescents who reported depressive symptoms and substance use were more likely to engage in risky behavior and acquire incident STIs. This population might benefit from future prevention efforts targeting the intersection of depression and substance use.Although self-exploration and identity seeking are healthy aspects of adolescence, certain adverse behaviors, such as substance use and risky sexual behavior, have also been associated with adolescence. HIV, other sexually transmitted infections (STIs), and adolescent pregnancy are significant contributors to female adolescents’ morbidity and mortality in the United States.1 Adolescents aged 15 to 24 years account for approximately 50% of new STI cases each year,2 and it is estimated that 24.1% of adolescent girls aged 14 to 19 years have 1 of 5 commonly reported STIs (herpes simplex virus, trichomonaisis, chlamydia, gonorrhea, and human papilloma virus).3 Minority adolescents are disproportionately at higher risk for HIV and other STIs relative to their White counterparts.4 For example, African American adolescents account for 65% of HIV diagnoses among individuals aged 13 to 24 years.5 Among African American female adolescents aged 14 to 19 years, a national study found that 44% had at least 1 STI.3 Because African American female adolescents are at heightened risk for engaging in risky sexual behavior and STI acquisition, it is important to gain a better understanding of factors that may be associated with these risks. Two such factors are depressive symptoms and substance use or abuse.6–15In a national survey, 4.3% of youths, aged 12 to 17 years, reported current depression, and girls, regardless of age, were more likely to report depression than boys (6.7% vs 4.0%).16 In addition, 1 study found that among adolescents in mental health treatment, girls were more likely to use condoms inconsistently and were more than 9 times likely to contract an STI than were boys.17 The National Longitudinal Study of Adolescent Health found that 19.7% of African American female adolescents reported recent and chronic depressive symptoms compared with 13% among White female adolescents.18 Other studies found rates of depressive symptoms ranging from 40% to 55% among African American female adolescents.6,7,19 Previous research among African American female adolescents reported that depressive symptoms were associated with inconsistent condom use,6,10,12 multiple sexual partners,7,9,10 risky male sexual partners,6 sexual contact while high on alcohol or drugs,6,7,9,11 low frequency of sexual communication,6,7 fear of communication about condoms,6,7 self-reported previous or current STI,7,8,10 and biologically confirmed STIs.6With regards to substance use, a national survey revealed that among African American female 9th to 12th graders, 31.3% reported current alcohol use (vs 35.7% for White and 39.7% for Hispanic), 11.5% reported 5 or more drinks in a sitting (vs 21.1% for White and 22.6% for Hispanic), 27.1% reported current marijuana use (vs 18% for White and 27.4% for Hispanic), and 2.1% reported ever using Ecstasy (vs 4.6% for White and 10.1% for Hispanic).20 Another study found that approximately 27% of African American female adolescents reported having 3 or more drinks in a sitting.13 Substance use often co-occurred with sexual risk behaviors,20 placing adolescents at increased risk for less condom use. Among young African American women, substance use was associated with inconsistent condom use,13,15 sexual sensation seeking,13 multiple sexual partners,13,15 risky sexual partners,15 having sexual intercourse while high on alcohol or drugs,13 and STIs.13–15Previous studies established the relationship between depression, substance use, and risky sexual behavior, and although limited, some studies examined the longitudinal effects of depressive symptoms and substance use on sexual risk-taking among African American female adolescents.7,11–13,15 However, to our knowledge, there is scant research available on the interaction of depressive symptoms and substance use to longitudinally predict sexual risk-taking and STIs among this population. A previous study found that substance use mediated the relationship between depression and substance use, but this effect was only significant for male adolescents and not for female adolescents.8 In addition, this previous study sample included adolescents from multiple ethnicities; thus, the findings might not be applicable to African American adolescents.Because of the impact of these 2 factors on sexual risk-taking, combined with increased HIV/STI vulnerability among African American female adolescents, we aimed to expand upon the existing literature on depression, substance use, and risky sexual behavior in African American female adolescents. To advance the current knowledge and inform HIV/STI prevention efforts among this group, we examined the longitudinal effects of depression and substance use on risky sexual behavior and STI contraction, as well as the interaction between these 2 factors among a clinic-based sample of African American female adolescents over an extended period (36-month follow-up).     

The Health of Older Mexican Americans in the Long Run

Objectives. We compared risk for several medical illnesses between immigrant and US-born older Mexican Americans to determine the relationship between functional health and years of US residency among immigrants.Methods. Cross-sectional, multistage probability sample data for 3050 Mexican Americans aged 65 years or older from 5 US southwestern states were analyzed. Self-rated health, medical illnesses, and functional measures were examined in multivariate regression models that included nativity and years of US residency as key predictors.Results. Self-rated health and medical illnesses of immigrant and US-born groups did not differ significantly. Immigrants with longer US residency had significantly higher cognitive functioning scores and fewer problems with functional activities after adjustment for predisposing and medical need factors.Conclusions. Among older Mexican Americans, immigrant health advantages over their US-born counterparts were not apparent. Immigrants had better health functioning with longer US residency that may derive from greater socioeconomic resources. Our findings suggest that the negative acculturation–health relationship found among younger immigrant adults may become a positive relationship in later life.More than 30 years ago, Teller and Clyburn reported more favorable birth outcomes in Bexar County, Texas, for Spanish-surnamed residents than for non-Latino White and African American residents.¹ Despite the disadvantaged economic and social position of many Latinos, additional reports appeared of unexpected favorable birth and longevity outcomes for Latinos (primarily Mexican Americans) compared with other ethnic groups.^2–5 These findings were considered paradoxical, since they ran contrary to the negative socioeconomic health gradient documented in the public health literature.^6,7 The Latino health paradox contends that despite experiencing disproportionate exposure to risk factors for excess morbidity and mortality associated with low socioeconomic position, Latinos, primarily Mexican American immigrants, generally have more favorable health outcomes than Mexican Americans born in the United States, most other minorities, and nonminorities.⁸ The longer these healthy immigrants resided in the United States and acculturated, the more likely they were to report deterioration in health status indicators compared with recent immigrants.⁹The mental health researchers Rogler et al. referred to “acculturation as an exogenous force shaping the conditions for the rise to psychological distress.”^10(p588) This phenomenon was later coined the “acculturative stress” hypothesis and widely used in mental health research of the Latino population. However, acculturative stress models have important limitations in health research because they confound the effects of cultural change on health behaviors with pathology. In addition, they are temporally unspecific and thus inconsistent with developmental models of health. We offer an alternative, the “acculturation–health” hypothesis, to emphasize that health outcomes are instead conditional on multiple life-course contingencies that vary in importance as determinants over one''s life span. The temporal relationships between acculturation and health can range from negative to positive during the lifespan of an individual. Although the negative effects of acculturation are commonly described in the literature, positive outcomes are observed as well and also require explanations.^11–15 Acculturative stress assumes a cumulative, linear, dose–response association of acculturation with health. An acculturation–health hypothesis accounts for transactions between endogenous (individual-level) and exogenous (external) factors that affect health differentially over the life course. These factors are systematically influenced by acculturation across multiple domains of life activity.The proposed acculturation–health model assumes that there are multiple points in the life course that are critical for improving health and lowering the risk of weathering effects seen in aging among minority groups.¹⁶ Carefully focused research could lead to timely and effective interventions that improve health outcomes across the life course. The assumption that a constant acculturation–health relationship is generally negative and leads to declines in health among Mexican Americans is limiting because it is overly deterministic and restricts opportunities for identifying determinants of long-range outcomes and life-course stages when they are most consequential. Although we can assume that living in a new society introduces behavioral, social, and environmental changes that may negatively influence health, there may be benefits as well, such as acquisition of new occupational skills, greater exposure to public health information, and use of preventive medicine. Nevertheless, it is unclear how these changes are expressed in the long run in the health of older Mexican Americans.Mexican Americans represent more than two-thirds of US Latinos and, perhaps accordingly, most previous studies have focused on the relationship between Mexican American acculturation (or various proxies of acculturation, such as language preference and years of US residency) and health.¹⁷ For younger Mexican Americans, most studies have reported negative relationships between acculturation and health¹¹—for example, for birth outcomes^18,19 and perinatal health behaviors,^20,21 general health behaviors (e.g., nutrition and physical exercise),²² vascular disease risks (e.g., diabetes),^23,24 and substance abuse and mental disorders.^25,26 Several reports have shown positive associations between acculturation and higher use of preventive medical services, which may relate to the higher economic position of more acculturated and US-born Mexican Americans.^27–30 Among older adults, the prevalence of depression and dementia are reportedly lower among acculturated Mexican Americans.^12,13 Furthermore, there is evidence that greater social assimilation, as evidenced by English-language acquisition and more years of education, are associated with lower disability rates and higher self-esteem.^14,15,31These general findings have led scientists to hypothesize that immigrants are somehow healthier than US-born Mexican Americans and non-Latino Whites and that with longer US residency, acculturation erodes immigrants'' health.^9,32 The negative aspects of the acculturation–health relationship dominate current thinking about Mexican American health, especially regarding acculturation-related changes in risk behaviors such as diet, exercise, and substance abuse.³³ However, if the association between acculturation and health is conditional and predicated on various endogenous and exogenous life-course factors, recent work among older adults may better inform us about the long-term acculturation–health relationship.Our first aim was to examine whether the “healthy immigrant” phenomenon persists among older Mexican Americans by comparing the rates of several medical conditions between US-born and immigrant groups. Second, we sought to determine if functional health was negatively associated with longer exposure to the host country within a representative sample of immigrant Mexican Americans. On the basis of previous work,^12–14,31 we expected that the health status of US-born and immigrant older Mexican Americans would not differ. Third, we sought to examine if longer US residency would be associated with better functional health among older Mexican American immigrants. We expected that increased wealth, access to healthcare and services would facilitate or mediate better health functioning.^6,34,35 Finally, in examining the health of older Mexican Americans, we aimed to compare the acculturative stress hypothesis and the acculturation–health hypothesis for a better understanding of their utility for the study of health.     

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

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

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

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

Posttraumatic stress disorder and HIV risk among poor, inner-city women receiving care in an emergency department

Objectives. We examined the associations between posttraumatic stress disorder (PTSD) and HIV risk behaviors among a random sample of 241 low-income women receiving care in an urban emergency department.Methods. We recruited participants from the emergency department waiting room during randomly selected 6-hour blocks of time. Multivariate analyses and propensity score weighting were used to examine the associations between PTSD and HIV risk after adjustment for potentially confounding sociodemographic variables, substance use, childhood sexual abuse, and intimate partner violence.Results. A large majority of the sample self-identified as Latina (49%) or African American (44%). Almost one third (29%) of the participants met PTSD criteria. Women who exhibited symptoms in 1 or more PTSD symptom clusters were more likely than women who did not to report having had sex with multiple sexual partners, having had sex with a risky partner, and having experienced partner violence related to condom use in the preceding 6 months.Conclusions. The high rate of PTSD found in this sample and the significant associations between PTSD symptom clusters and partner-related risk behaviors highlight the need to take PTSD into account when designing HIV prevention interventions for low-income, urban women.The relationship between posttraumatic stress disorder (PTSD) and HIV risk behaviors remains relatively underresearched. However, several studies have shown that PTSD is associated with sexual HIV risk behaviors and HIV seropositive status.^1–3 Emergency departments have been identified as the first and primary source of medical treatment of many women infected with or at high risk for HIV^4–6 and for those with high rates of interpersonal violence and trauma, including those suffering from PSTD.^7–11Hutton et al. found that, after adjustment for potentially confounding factors, a PTSD diagnosis was associated with engaging in anal intercourse and exchanging sex for money or drugs in a sample of 177 female inmates.¹² High rates of PTSD have also been found among HIV-positive women,^3,13,14 many of whom have experienced repeated traumas associated with PTSD, such as childhood sexual abuse and intimate partner violence (IPV).^3,13,14 In a study of HIV-positive women, 35% of those with a trauma history met the criteria for PTSD,¹⁵ a rate far exceeding both the lifetime PTSD rate (10.4%) among women in the general population¹⁶ and the PTSD rate (4.6%) in a nationally representative sample of female crime victims.¹⁷The relationship between PTSD and HIV risk behaviors has been found to vary according to the presence of different PTSD symptoms (avoidance, hyperarousal, and reexperiencing trauma). In their study of 64 HIV-positive women and men, Gore-Felton and Koopman found that moderate to severe reexperiencing symptoms were associated with multiple sexual partners and unprotected sex during the preceding 3 months.¹⁸ Individuals with avoidant symptoms were less likely to have engaged in unprotected sex, possibly as a result of deficits in establishing and maintaining intimate partnerships.¹⁸ The presence of hyperarousal symptoms may trigger individuals to seek sexual stimulation and engage in riskier sex, and they may experience difficulty in problem solving and negotiating safe sex.¹⁹The research just described highlights mechanisms of how different PTSD symptom clusters may increase the likelihood of engaging in HIV risks. However, it should also be acknowledged that the relationship may be bidirectional: a traumatic experience (e.g., forced unprotected sex) associated with a risk of HIV may lead to PTSD.Furthermore, research suggests that the relationship between PTSD and HIV risk may be mediated by several factors, including childhood sexual abuse, IPV, and substance abuse. Those who have experienced childhood sexual abuse are at increased risk of developing PTSD,^20–22 engaging in subsequent sexual HIV risk behaviors, and HIV transmission.^3,23 Similarly, IPV has been found to increase the risk of both developing PTSD and engaging in a range of HIV risk behaviors, including unprotected sex,^24–38 sexual practices leading to a high risk of sexually transmitted infections,^6,32,39–42 sex with multiple partners,^31,32,43 trading of sex for money or drugs,^40,44 sex with risky partners,^38,45 and sex with HIV-positive partners.³⁸ Finally, substantial research indicates that drug and alcohol dependencies are associated with both PTSD^46,47 and engaging in a range of HIV risk behaviors.^48–51We examined the relationship between PTSD (and the symptom clusters of avoidance, reexperiencing trauma, and hyperarousal) and sexual HIV risk behaviors in a random sample of 241 women attending an emergency department in a low-income neighborhood of the Bronx, New York. We hypothesized that women who met the criteria for PTSD and the symptom clusters of hyperarousal, reexperiencing trauma, or avoidance would be more likely than women who did not meet these criteria to engage in sexual HIV risk behaviors after adjustment and matching for potentially confounding factors such as sociodemographic characteristics, childhood sexual abuse, substance abuse, and IPV.     

Suicidal Behavior Among Female Sex Workers in Goa, India: The Silent Epidemic

Objectives. We sought to study suicidal behavior prevalence and its association with social and gender disadvantage, sex work, and health factors among female sex workers in Goa, India.Methods. Using respondent-driven sampling, we recruited 326 sex workers in Goa for an interviewer-administered questionnaire regarding self-harming behaviors, sociodemographics, sex work, gender disadvantage, and health. Participants were tested for sexually transmitted infections. We used multivariate analysis to define suicide attempt determinants.Results. Nineteen percent of sex workers in the sample reported attempted suicide in the past 3 months. Attempts were independently associated with intimate partner violence (adjusted odds ratio [AOR] = 2.70; 95% confidence interval [CI] = 1.38, 5.28), violence from others (AOR = 2.26; 95% CI = 1.15, 4.45), entrapment (AOR = 2.76; 95% CI = 1.11, 6.83), regular customers (AOR = 3.20; 95% CI = 1.61, 6.35), and worsening mental health (AOR = 1.05; 95% CI = 1.01, 1.11). Lower suicide attempt likelihood was associated with Kannad ethnicity, HIV prevention services, and having a child.Conclusions. Suicidal behaviors among sex workers were common and associated with gender disadvantage and poor mental health. India''s widespread HIV-prevention programs for sex workers provide an opportunity for community-based interventions against gender-based violence and for mental health services delivery.Suicide is a public health priority in India. Rates of suicide in India are 5 times higher than in the developed world,^1,2 with particularly high rates of suicide among young women.^3–5 Verbal autopsy surveillance from southern India suggests that suicide accounts for 50% to 75% of all deaths among young women, with average suicide rates of 158 per 100 000.²Common mental disorders such as depressive and anxiety disorders, and social disadvantage such as gender-based violence and poverty, are major risk factors for suicide among women.^1,3,6–8 Although research from high-income countries shows that common mental disorders are a major contributor to the risk of suicidal behavior, their role is less clear in low- and middle-income countries in which social disadvantage has been found to be at least as important.^1,3,6–8 Gender disadvantage is increasingly seen as an important contributing factor to the high rates of suicide seen among women in Asia.^1,3,6,7 Gender-based violence is a common manifestation of gender disadvantage and has been linked with common mental disorders and suicide in population-based studies of women and young adults in Goa, India.^4,5,9 Lack of autonomy, early sexual debut, limited sexual choices, poor reproductive health, and social isolation are other manifestations of gender disadvantage.Sex work in India is common. An estimated 0.6% to 0.7% of the female adult urban population are engaged in commercial sexual transactions.¹⁰ Studies from developed nations have found a high prevalence of self-harming behaviors in people engaged in transactional sexual activity.¹¹ There is also growing evidence suggesting that HIV-positive individuals from traditionally stigmatized groups report higher rates of violence exposure and suicidal ideation.^12,13 Female sex workers in India are a traditionally stigmatized group, with high prevalence of HIV¹⁰ and levels of stigma and violence that relate to the context of their work.¹⁴ Yet, despite substantial investigation of their reproductive and sexual health needs, there is virtually no information on suicide and its determinants among female sex workers from low- and middle-income countries.¹⁵As demonstrated in the hierarchical conceptual framework outlined in Figure 1,^4,5,9 we hypothesized that gender disadvantage, sex work, and health factors together with factors indicative of social disadvantage are distal determinants of female sex workers'' vulnerability to suicidal behaviors,^4,5,9,15 the effects of which would be mediated though poor mental health.³ We studied the burden of suicidal behaviors in a cross-sectional sample of female sex workers in Goa, India. We explored the association of sociodemographic factors, type of sex work, sexual health, and gender disadvantage, with and without measures of poor mental health, on suicide attempts in the past 3 months.Open in a separate windowFIGURE 1A conceptual framework for social risk factors for suicide among female sex workers in India.Note. STI = sexually transmitted infection.     

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.