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

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

Maternal Exposure to Intimate Partner Violence and the Risk of Undernutrition Among Children Younger Than 5 Years in Bangladesh

Objectives. We examined the association between maternal experiences of intimate partner violence (IPV) and the risk of undernutrition among children younger than 5 years in Bangladesh.Methods. We used data from the 2007 Bangladesh Demographic Health Survey. Our analyses were based on the responses of 1851 married women living with at least 1 child younger than 5 years. Exposure was determined from maternal reports of physical and sexual IPV. Outcomes included underweight, stunting, and wasting.Results. Twenty-nine percent of the respondents had experienced IPV in the year preceding the survey. Maternal experience of any physical or sexual IPV was associated with an increased risk of stunting (adjusted odds ratio [AOR] = 1.59; 95% confidence interval [CI] = 1.23, 2.08) and underweight (AOR = 1.33; 95% CI = 1.04, 1.71) but was not significantly associated with wasting (AOR = 1.08; 95% CI = 0.78, 1.49).Conclusions. The association between maternal exposure to physical or sexual IPV and child underweight and stunting suggests that partner violence plays a significant role in compromising child health by impairing child nutrition. Our findings reinforce the evidence that improving child nutrition is an additional reason to strengthen efforts to protect women from physical and sexual IPV.There has been substantial progress over the past decade in reducing child undernutrition. However, Bangladesh continues to have one of the highest rates of child undernutrition in the world,1,2 and this condition is the leading cause of child morbidity and mortality in the country.3,4 In 2005, nearly half of Bangladeshi children were underweight or stunted, and roughly two thirds of deaths among children younger than 5 years were attributed to undernutrition.4Although biological,5,6 environmental,7,8 and socioeconomic9–11 risk factors for child undernutrition are well documented, research has only begun to investigate the influence of other aspects of the social environment. Intimate partner violence (IPV), defined as the range of sexually, physically, and psychologically coercive acts perpetrated against women by current or former male intimate partners,12 is considered to be one of the psychosocial factors that might influence child undernutrition.13 IPV can place psychological stress on children who observe IPV, and stress in turn can affect immune reactivity, predisposing children to severe and chronic infections, most commonly infectious diarrhea.14 These infections further compromise children''s nutritional status. More directly, IPV can affect child nutritional status through familial circumstances such as the withholding of food by abusive family members15 or through physical or psychological maternal health outcomes13 that prevent proper care of the child.16Within and outside of South Asia, increasing evidence has shown a linkage between high rates of IPV among women17–20 and poor infant and child health outcomes such as miscarriage,21,22 morbidity,23–25 and mortality.26–29 However, few studies have been conducted in South Asia to assess the relationship between maternal experiences of IPV and poor child nutritional outcomes. The only study examining this issue was an investigation in India involving a statewide sample. It revealed an association between experiences of physical IPV in the preceding year and chronic undernutrition among children.30 In addition, outside of South Asia, results from a hospital-based study in Brazil indicated a 3-fold increase in the risk of severe acute malnutrition among children aged 1 to 24 months in families with severe and recurrent physical partner abuse.31However, the Indian study measured only physical IPV and did so via only a single global question, and the study in Brazil measured only physical IPV via hospital-based data. There is a clear need to use behaviorally specific questions and nationally representative data to better understand whether physical and sexual IPV are associated with child undernutrition. We examined the association of physical and sexual IPV with child underweight, stunting, and wasting in a nationally representative sample of households in Bangladesh.     

Influence of Community Social Norms on Spousal Violence: A Population-Based Multilevel Study of Nigerian Women

Objectives. We examined whether social norms toward spousal violence in Nigeria, at the state level, are associated with a woman’s exposure to physical and sexual violence perpetrated by her husband.Methods. Using data from the 2008 Demographic and Health Survey, we fit four 3-level random intercepts models to examine contextual factors associated with spousal violence while accounting for individual-level predictors.Results. Of the 18 798 ever-married Nigerian women in our sample, 18.7% reported exposure to spousal sexual or physical violence. The prevalence was geographically patterned by state and ranged from 3% to 50%. Permissive state-level social norms toward spousal violence were positively associated with a woman’s report of physical and sexual violence perpetrated by her husband (odds ratio [OR] = 1.80; 95% confidence interval [CI] = 1.17, 2.77), after adjusting for individual-level characteristics. A number of individual-level variables were significantly associated with victimization, including a woman’s accepting beliefs toward spousal violence (OR = 1.11; 95% CI = 1.09, 1.14). Women living in states with Sharia law were less likely to report spousal violence (OR = 0.58; 95% CI = 0.35, 0.95).Conclusions. Efforts to end violence against women, particularly spousal violence, should consider broader social and contextual determinants of violence including social norms.Intimate partner violence (IPV) directed against women is both a severe challenge to promoting gender equality and a significant public health problem impacting the lives of women throughout the world.1 It is associated with a multitude of adverse physical, reproductive, and mental health outcomes for women and their children, and is a significant health burden for communities.2–7 To date, research on IPV perpetration and victimization has primarily examined individual-level predictors,8,9 although, increasingly, contextual factors that may allow for the perpetuation of such behavior are also being explored, including the role of neighborhood disadvantage, political violence, and lack of collective efficacy.9–13 This article draws on a social determinants approach and, using multilevel modeling, builds on this literature to examine the role of community-level social norms on spousal violence.Recognizing that in many countries across the globe a significant proportion of both women and men continue to view spousal violence perpetrated by the husband as a normal and justified occurrence in marriage,14 we questioned whether social norms justifying IPV were positively associated with a woman’s risk of becoming a victim of such violence. A study comparing 17 sub-Saharan African countries found that in most countries, more than half the women surveyed justified spousal violence in certain scenarios; however, the rates varied from as low as 28% in Madagascar to as high as 74% in Ethiopia.15 Similarly, in Asia, rates of acceptance of spousal violence among women ranged from 29% in Nepal to 57% in India.16 Studies from the Middle East also indicated a broad acceptance of spousal abuse, reaching as high as 87% in Jordan.17–19Social norm theories have been forwarded in a number of different disciplines, including economics, political science, and social psychology.20,21 Public health research, especially research on behavioral interventions, has often drawn on such literature to explain the prevalence of “negative” behaviors, such as heavy drinking or smoking. Social norms can constrain individual behaviors, through social enforcement or the sanctioning of certain behaviors based on implied consequences of not complying.22,23 We may therefore expect higher rates of spousal violence in communities with more accepting norms around such violence. Some recent community-based interventions to combat violence against women focused on changing attitudes and norms as a key component.24,25 However, there has been little quantitative research on the relationship between social norms around spousal violence and women’s health. Some recent studies showed a positive association at the individual level between a woman’s accepting attitudes toward spousal violence and her report of such violence, including in Nigeria.17,26 However, to our knowledge, only 2 studies, both from India, examined social norms toward spousal violence at the societal level in relation to women’s risk of victimization, independent of her personal attitudes toward spousal violence.27,28In this article, we examined the hypothesis that permissive state-level social norms around spousal violence in Nigeria were positively associated with a woman’s risk of victimization. It was inherently a multilevel question because we were interested in understanding the role of this contextual variable on spousal violence victimization, while also accounting for individual-level predictors. We selected Nigeria not only because it is the most populous country in Africa, with over 140 million people, but also because of the ethnic and religious diversity. There are about 374 ethnic groups, and about half the population is Muslim, 40% is Christian, and 10% follow indigenous religious practices.29 As a federalist country, Nigeria is made up of 36 states and a Federal Capital Territory (FCT), with each having its own legal codes and unique sociopolitical and economic context. Sharia law is enforced in 12 states in the North, where the population is predominantly Muslim, and civil and customary law is practiced in the other states. Given this heterogeneity in the legal system, including family law, as well as the geographical patterning by religious and ethnic affiliation, we expected that social norms toward IPV would vary by state, and that the prevalence of spousal violence would not be uniform across the country. To our knowledge, this was the first study to examine this question in a sub-Saharan African context.     

Racial Differences in Breast Cancer Stage at Diagnosis in the Mammography Era

Objectives. We assessed racial differences in breast cancer mortality by stage at diagnosis, since mammography became available.Methods. We calculated adjusted odds of distant (versus local or regional) tumors for 143 249 White and 13 571 Black women aged 50 to 69 years, diagnosed with breast cancer between 1982 and 2007 and living in a Surveillance, Epidemiology, and End Results region. We compared linear trends in stage at diagnosis before and after 1998.Results. Distant-stage cancer was diagnosed in 5.8% of White and 10.2% of Black participants. The Black–White disparity in distant tumors narrowed until 1998 (1998 adjusted difference = 0.65%), before increasing. Between 1982 and 1997, the proportion of distant tumors decreased for Blacks (adjusted odds ratio [AOR]/y = 0.973; 95% confidence interval [CI] = 0.960, 0.987) and Whites (AOR/y = 0.978; 95% CI = 0.973, 0.983), with no racial differences (P = .47). From 1998 to 2007, the odds of distant versus local or regional tumors increased for Blacks (AOR/y = 1.036; 95% CI = 1.013, 1.060) and Whites (AOR/y = 1.011; 95% CI = 1.002, 1.021); the rate of increase was greater for Blacks than Whites (P = .04).Conclusions. In the mammography era, racial disparities remain in stage at diagnosis.Despite a lower incidence of invasive breast cancer, Black women in the United States are more likely than are White women to die of the disease.1,2 Since 1992, although breast cancer deaths have declined in both White and Black women, the overall disparity in mortality has increased.3 Stage at diagnosis is the strongest predictor of survival in breast cancer,4–6 and Black women are more often diagnosed with advanced-stage disease than are White women.7–10Mammography is an important tool in the early detection of breast cancer.11–13 First introduced in the United States in the early 1980s,14 mammography was initially most prevalent among White women. Racial disparities in mammography rates narrowed by the mid-1990s,12,15 and Black women had rates equivalent to or greater than those of White women between 1996 and 2000.10,15,16 From 2000 to 2005, mammography use declined nationally in women aged 50 to 64 years (78.6% to 71.8%), with a slightly larger decrement for White (−4.0%) than Black (−3.3%) women.13The survival benefit of any screening program, including mammography, is related to its ability to detect tumors at earlier stages. Meta-analyses continue to find mortality benefit for mammography, although uncertainty remains regarding both the appropriate target population and the optimal screening interval.11,17,18 Consistent with the expected effect of screening, an observational cohort analysis found that improvements in screening rates for both Black and White women during the 1990s contributed to diagnosis at an earlier stage in both groups.10Nevertheless, despite generally equivalent rates of mammography for the past 15 years, the racial disparity in breast cancer mortality between Black and White women persists. Although previous meta-analyses suggested a mortality benefit for mammography, randomized controlled data regarding the efficacy of screening programs in minority populations are limited.18,19 Because stage at diagnosis is an important predictor of survival in breast cancer, we assessed temporal changes in the distribution of stage at diagnosis between 1982 and 2007, in both Black and White women, adjusting for covariates known to affect stage at diagnosis.     

Sexual Minority Women and Depressive Symptoms Throughout Adulthood

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

Male Perpetration of Intimate Partner Violence and Involvement in Abortions and Abortion-Related Conflict

Men aged 18 to 35 years (n = 1318) completed assessments of perpetration of intimate partner violence (IPV), abortion involvement, and conflict regarding decisions to seek abortion. IPV was associated with greater involvement by men in pregnancies ending in abortion and greater conflict regarding decisions to seek abortion. IPV should be considered within family planning and abortion services; policies requiring women to notify or obtain consent of partners before seeking an abortion should be reconsidered; they may facilitate endangerment and coercion regarding such decisions.Intimate partner violence (IPV) is a major public health issue that affects the lives and health of approximately 20% to 25% of adolescent and adult US women,^1,2 with women of reproductive age at greatest risk.^3,4 Major reproductive health concerns associated with experiences of IPV include unintended⁵ and rapid repeat pregnancies.^6–8 Given that unintended and unwanted pregnancies are the primary reason for seeking abortion,^7,9 abused women are thought to be more likely to experience abortion than are their nonabused counterparts.^10–12 Recent qualitative research suggests there is a broad role played by abusive male partners in controlling women''s reproductive health,^13–15 including attempts to control abortion-related decisions.^13,15 However, quantitative data on this issue have primarily been collected from women attending abortion services, which therefore precludes comparisons to women with no abortion history.^10–12 Given the increasing recognition of the role of male partners in controlling a woman''s reproductive health and decision-making, coupled with the continuing public debate concerning both women''s access to abortion and the role of family members in decisions regarding abortion (e.g., spousal consent),¹⁶ it is critical to understand to what extent abuse from male partners may relate to both women''s seeking abortion and coercion regarding abortion-related decisions. We examined the association of young adult men''s reports of perpetration of IPV and their participation in pregnancies ending in abortion as well as conflict surrounding abortion-related decisions.     

Area-Level Social Fragmentation and Walking for Exercise: Cross-Sectional Findings From the Quebec Adipose and Lifestyle Investigation in Youth Study

Objectives. We determined whether social fragmentation, which is linked to the concept of anomie (or normlessness), was associated with a decreased likelihood of willingness to walk for exercise.Methods. Data were collected from mothers and fathers of 630 families participating in the Quebec Adipose and Lifestyle Investigation in Youth Cohort, an ongoing longitudinal study investigating the natural history of obesity and insulin resistance in children. Social fragmentation was defined as the breakdown of social bonds between individuals and their communities. We used log-binomial multiple regression models to estimate the association between social fragmentation and walking for exercise.Results. Higher social fragmentation was associated with a decreased likelihood of walking for exercise among women but not men. Compared with women living in neighborhoods with the lowest social fragmentation scores (first quartile), those living in neighborhoods in the second (relative risk [RR] = 0.91; 95% confidence interval [CI] = 0.78, 1.05), third (RR = 0.83; 95% CI = 0.70, 1.00), and fourth (RR = 0.80; 95% CI = 0.65, 0.99) quartiles were less likely to walk for exercise (P = .02).Conclusions. Social fragmentation is associated with reduced walking among women. Increasing neighborhood stability may increase walking behavior, especially among women.Features of the social and physical environment influence physical activity behavior over and above individual characteristics.1–4 More specifically, features of the built environment—such as greater density of destinations,5–8 population density,5,6,9,10 greater street connectivity,9,11,12 access to transit,10,13 and mixed land use in residential neighborhoods6,9,10,14,15—are associated with greater frequency and duration of walking. A meta-analysis of studies identified job–housing balance and intersection density as being associated with the decision to walk.13 Conversely, lack of neighborhood safety was associated with a decreased likelihood of walking.8,14,16–27However, the built environment represents only 1 dimension of the neighborhood environment that promotes or hinders walking. Conceptually, neighborhood environments consist of not only physical dimensions (walkability) but also social (interactions between neighbors) and service (access to physical activity amenities and resources) dimensions. Although these 3 dimensions tend to cluster by neighborhood socioeconomic level, they have different implications for interventions. For example, even if an intervention such as installing sidewalks to increase walking was implemented, it might not promote walking if other elements, such as crime rate, remain high.In this study, we focused on whether social fragmentation, an indicator of the social environment, relates to walking for exercise. Social fragmentation is linked to the concept of anomie, which Durkheim defined as a state of normlessness,28 or the breakdown of social bonds between individuals and their communities, with fragmentation of social identity and rejection of self-regulatory values.28 Researchers have used census variables to describe specific social conditions, such as using the proportion of residents moving out of a residential area within the past 5 years to describe stability. Rather than being a proxy for poverty, these variables relate to rapid population turnover, single-person households, and rented tenancy (which is thought to be associated with greater residential instability). Building on work by Congdon,29 researchers have used census indicators such as proportion of residents living in the same area within the past 5 years, proportion of residents who are foreign born; proportion of owner-occupied houses, proportion of single-person households, proportion of unmarried people, and fewer school-aged children30–35 to develop a social fragmentation index.Although researchers have identified social fragmentation as a risk factor for suicide and poor mental health,31–33 only 1 previous study has been conducted in the United States that examined the relationship between social fragmentation and physical activity among adolescents.32 In theory, social fragmentation might be linked to physical activity by its association with neighborhood crime rate. That is, high social fragmentation may lead to a higher rate of crime, which may then lead to a low rate of walking. Alternatively, residents in a socially fragmented neighborhood may not have the social ties or exposure to norms that support regular physical activity.In this study, we investigated the relationship between social fragmentation and the willingness to walk for exercise among mothers and fathers of children who responded to a baseline questionnaire in a cohort study conducted in Quebec, Canada. We tested the hypothesis that high social fragmentation is associated with a decreased likelihood of willingness to walk for exercise.     

A Multilevel Analysis of Individual, Household, and Neighborhood Correlates of Intimate Partner Violence Among Low-Income Pregnant Women in Jefferson County, Alabama

Objectives. We examined individual, household, and neighborhood correlates of intimate partner violence (IPV) before and during pregnancy.Methods. We used multilevel modeling to investigate IPV among 2887 pregnant women in 112 census tracts who sought prenatal care in 8 public clinics in Jefferson County, Alabama, from 1997 through 2001. Data were collected from the Perinatal Emphasis Research Center project, the 2000 Census, and the local Sheriff and Police Departments Uniform Crime Reports for 1997 through 2001.Results. Participants were predominantly young, African American, on Medicaid, and residents of low-income neighborhoods. The prevalence of past-year male partner–perpetrated physical or sexual violence was 7.4%. Neighborhood residential stability, women performing most of the housework (lack of involvement among partners), being unmarried (being in an uncommitted relationship), and alcohol use were positively associated with elevated IPV risk. Significant protective factors for IPV included older age at first vaginal intercourse and a greater sense of mastery (e.g., the perception of oneself as an effective person).Conclusions. Both neighborhood contextual and individual and household compositional effects are associated with IPV among low-income pregnant women. The results imply that combined interventions to improve neighborhood conditions and strengthen families may effectively reduce IPV.Intimate partner violence (IPV) experienced by pregnant women is a public health concern in the United States because of its high prevalence and its potential for severe physical harm, including injury and death, to both the mother and unborn child. The prevalence of violence against pregnant women has been estimated at 3.9% to 8.3%, depending on the populations, specific periods of pregnancy, and screening tools.¹ Thus, an estimated 152 000 to 324 000 abused women deliver live-born infants annually.² Serious consequences of IPV include delayed prenatal care, miscarriage and spontaneous abortion, and adverse birth and child outcomes.³ Homicide was the second leading cause of injury deaths among pregnant and postpartum women,⁴ and women abused during pregnancy are 3 times more likely to be murdered over the course of their lifetime than women who were abused outside pregnancy.⁵The US Department of Health and Human Services has identified reducing the rate of physical assault by current or former intimate partners to 3.3 per 1000 persons aged 12 years and older to be a Healthy People 2010 health objective.⁶ Achieving this national goal will require further study of the factors associated with IPV, including the family characteristics that promote healthy relationships within a broad ecological systems context,^7–9 and prevention targeted at potentially accessible populations for which IPV has both serious consequences and high prevalence. More than 95% of pregnant women make routine prenatal care visits, providing a stable opportunity in the community to screen and prevent IPV within a primary care setting.^10,11 Because intimate partner violence during pregnancy occurs more often among couples of low socioeconomic status,^1,3,12 low-income households may require special attention in a community to prevent IPV experienced by pregnant women.Whereas most IPV prevention strategies focus on secondary and tertiary prevention based on identified individual-level risk factors, the national IPV prevention agenda highlights the importance of primary prevention and both contextual and protective factors for IPV.^13,14 The use of an ecological systems framework holds promise for the study of IPV because it recognizes the complexity of IPV and puts a equal, joint focus on both the male–female dyad and multiple contexts.^15,16 Prior research has identified neighborhood as an important context in understanding the prevalence of IPV. Significant neighborhood influences include low per capita income, high unemployment rate, resource deprivation, and concentrated disadvantage.^17–23 Inconsistent findings have been reported for neighborhood residential mobility and neighborhood crime.^{18,20,23–25} Compared with the contextual study of IPV in developing countries,²⁶ this line of research in the United States has benefited from a long history of social science studies examining neighborhood context and crime or delinquency.Despite providing useful insights concerning study design, theoretical perspectives, and analytical methods, previous contextual studies of IPV have important methodological limitations. One ecological study measured IPV on the neighborhood level, but did not allow inferences about IPV at the individual level.¹⁸ Other studies^{20–22,24,27,28} examined clustered data with logistic regression models, which fail to account for the clustering inherent in the data. Several studies that used multilevel modeling^17,19,23,25 had small samples with an average of about 1.6 to 2.5 study participants per neighborhood, resulting in numerous clusters with a single observation and unstable estimates of variances for binary outcomes.²⁹ Whereas some studies have underrepresented low-income households in probability samples,^{19–21,25,27,28} others have overrepresented them in convenience samples, including reported incidents from police, screened events in hospitals, and parent studies on HIV.^{17,18,22–24} One contextual study of IPV has focused on women during pregnancy and postpartum.¹⁷Improved understanding of how low-income couples can cope with environmental stressors and prevent IPV from occurring will greatly enhance the development of primary prevention programs. However, little is known about couple-level protective factors.¹³ Previous research has focused on individual- and household-level risk factors for IPV. Although IPV prevalence estimates varied by maternal race and age, consistent risk factors included low socioeconomic status, low educational attainment, and use of alcohol.^1,3,12,19 Household-level risk factors for IPV included social norms (e.g., male dominance in the family), first-time parenting, unplanned or unwanted pregnancy, lack of social support, partner drug use, poor conflict management, stress, and resource inadequacy.^{15,17,23,27,28,30}Family is the primary proximal context for human development.³¹ Strong social bonds and good marriages have been shown to reduce street crimes and IPV primarily through informal social control process.^32–40 Social bonds refer to “internalization of accepted norms, awareness, and sensitivity to the needs of others which promote conformity in society.”^40(p534) Each dimension of the bonds among partners—for example, commitment and involvement—ties partners to conventional society and societal rules, thus informally controlling and preventing IPV.^32,33,40Research designed to increase our understanding of the association of neighborhood contextual and couple-level factors with IPV among low-income pregnant women is needed. We conceptualized that IPV occurs within an ecological framework (Figure 1) that considers the interplay of neighborhood context, household factors (stressors, resources, and bonds among partners), and individual correlates of IPV. We designed this study to determine whether features of neighborhoods, being in an uncommitted relationship, and lack of involvement among partners were associated with a higher prevalence of IPV at the individual level among low-income pregnant women, when we controlled for relevant individual and household factors.Open in a separate windowFIGURE 1The ecological model of neighborhood and household contexts and influences on the experience of intimate partner violence among low-income pregnant women: Perinatal Emphasis Research Center Project, Jefferson County, Alabama, 1997–2001.Note. Solid arrows depict hypothesized strong connections between 2 domains in the sequence. Broken lines represent weaker associations. Double arrows indicate a mutual influence between 2 domains.     

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

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

H1N1 Influenza Vaccination During Pregnancy and Fetal and Neonatal Outcomes

Objectives. We evaluated the relationship between maternal H1N1 vaccination and fetal and neonatal outcomes among singleton births during the 2009–2010 H1N1 pandemic.Methods. We used a population-based perinatal database in Ontario, Canada, to examine preterm birth (PTB), small-for-gestational-age (SGA) births, 5-minute Apgar score below 7, and fetal death via multivariable regression. We compared outcomes between women who did and did not receive an H1N1 vaccination during pregnancy.Results. Of the 55 570 mothers with a singleton birth, 23 340 (42.0%) received an H1N1 vaccination during pregnancy. Vaccinated mothers were less likely to have an SGA infant based on the 10th (adjusted risk ratio [RR] = 0.90; 95% confidence interval [CI] = 0.85, 0.96) and 3rd (adjusted RR = 0.81; 95% CI = 0.72, 0.92) growth percentiles; PTB at less than 32 weeks’ gestation (adjusted RR = 0.73; 95% CI = 0.58, 0.91) and fetal death (adjusted RR = 0.66; 95% CI = 0.47, 0.91) were also less likely among these women.Conclusions. Our results suggest that second- or third-trimester H1N1 vaccination was associated with improved fetal and neonatal outcomes during the recent pandemic. Our findings need to be confirmed in future studies with designs that can better overcome concerns regarding biased estimates of vaccine efficacy.During the 2009–2010 H1N1 influenza pandemic, early case reports documented more severe illness among pregnant women than among the general population, as well as higher rates of hospitalization and intensive care unit admissions.1,2 Later reports confirmed the disproportionately severe clinical course among pregnant women infected with H1N1 influenza.3–6 Public health organizations7–9 and professional associations10,11 strongly encouraged pregnant women to receive an H1N1 vaccination, and recent evidence suggests that the intensive vaccination campaign resulted in higher maternal vaccination rates during the pandemic than had been documented in previous influenza seasons.12–14Recommendations for routine vaccination of all pregnant women with inactivated influenza vaccine have been in place in Canada and the United States for a number of years.15–18 Nevertheless, seasonal vaccination rates prior to the 2009–2010 pandemic year were low in the United States,19–22 ranging from 0.7% to 20% (estimates were not available for Canada). In both countries, misconceptions about the risk of complications from influenza infection during pregnancy23 and concerns about safety12,23 are commonly cited reasons for not receiving an influenza vaccination, whereas care provider recommendations have been shown to increase vaccination rates.12,14,24Despite ongoing maternal concerns about vaccine safety, no evidence of serious harmful effects following influenza vaccination during pregnancy has been reported in the available studies on this topic19–21,25–32; thus, vaccination is promoted as the best way of preventing maternal morbidity from influenza infection.31 Theoretically, maternal influenza vaccination should also benefit the fetus by averting maternal illness and associated hyperthermia and other morbidity.28,31 Recent studies have reported a lower risk of preterm birth (PTB)33 and small-for-gestational-age (SGA) infants33,34 among women receiving an influenza vaccination during their pregnancy. However, the impact of maternal influenza vaccination on fetal and neonatal outcomes has not been extensively evaluated, possibly as a result of low immunization rates and limited sample sizes that preclude assessment of rare outcomes.In Ontario, Canada, the 2009 pandemic H1N1 vaccination campaign started on October 26, 2009; high-priority groups, including pregnant women, were targeted. During the pandemic, Better Outcomes Registry & Network (BORN) Ontario collected influenza immunization information from all pregnant women who gave birth in the province. Using this large, population-based birth cohort, we examined the association between maternal H1N1 influenza vaccination and fetal and neonatal outcomes.     

Violence Against Women in Selected Areas of the United States

Objectives. We determined the prevalence of recent emotional, physical, and sexual violence against women and their associations with HIV-related risk factors in women living in the United States.Methods. We performed an assessment of women ages 18 to 44 years with a history of unprotected sex and 1 or more personal or partner HIV risk factors in the past 6 months from 2009 to 2010. We used multivariable logistic regression to examine the association of experiencing violence.Results. Among 2099 women, the prevalence of emotional abuse, physical violence, and sexual violence in the previous 6 months was 31%, 19%, and 7%, respectively. Nonmarried status, food insecurity, childhood abuse, depression symptomology, and posttraumatic stress disorder were significantly associated with multiple types of violence. All types of violence were associated with at least 3 different partner or personal HIV risk behaviors, including unprotected anal sex, previous sexually transmitted infection diagnosis, sex work, or partner substance abuse.Conclusions. Our data suggested that personal and partner HIV risk behaviors, mental illness, and specific forms of violence frequently co-occurred in the lives of impoverished women. We shed light on factors purported to contribute to a syndemic in this population. HIV prevention programs in similar populations should address these co-occurring issues in a comprehensive manner.Violence against women is increasingly recognized as a critical national public health concern in the United States, as evidenced by the recent signing of the Violence Against Women Act by President Obama.1 Based on nationally representative samples, it is estimated that in their lifetime, nearly 1 in 3 US women has survived physical violence, and 1 in 10 has survived rape.2 Women who experience emotional, physical, and sexual violence not only experience the injury of the initial trauma, but also have higher rates of depression, posttraumatic stress disorder (PTSD), substance abuse, re-victimization, and high-risk sexual behaviors.3–7There is strong evidence that supports the relationship between experiencing intimate partner violence (IPV) and HIV risk, as well as acquiring HIV.8–20 In the United States, the relationship between IPV, especially sexual violence, and HIV came to light almost 20 years ago.5 Several studies6,10,17,18,20,21 during the past decade reported high co-occurring rates of violence, HIV risk, mental illness, and substance use in the United States among incarcerated women,22 female substance users,19 women in shelters,23,24 women living in impoverished areas,25–28 and women engaging in prostitution.29 Not only do these conditions frequently co-occur, but the presence of one may magnify the effects of the others, thus demonstrating the notion of a “syndemic,” which is a term used to refer to a set of synergistic or intertwined and mutually enhancing health and social problems facing vulnerable populations such as women living in poverty.30 However, interpretation and generalizability across studies has been difficult because of small sample sizes, convenience samples (e.g., women in methadone treatment, shelters, or clinics), narrowly defined study populations, the inclusion of both women living with HIV and women living without HIV, and poorly standardized study variables that typically did not include emotional abuse (e.g., combining different types of violence or combining childhood and adult violent experiences).5,6,10,31Overall, most published US data have suggested that women living with HIV experience IPV at the same rate as women not living with HIV from the same population, but that women living with HIV experience such violence more frequently and with increased severity.9,31 In addition, substance abuse, poverty, and other HIV risk factors were associated with experiencing violence and therefore, also contribute to the HIV and IPV relationship.9,32 However, many of these studies focused on “intimate” partner violence specifically and not on violence overall. For example, using a large representative sample of US women (n = 13 928), Sareen et al.8 found that women who experienced any IPV in the past year were more than 3 times as likely to report an HIV/AIDS diagnosis by a health professional as women who had not experienced IPV. They postulated that nearly 12% of HIV/AIDS infections among US women in intimate relationships was caused by IPV. Despite its novel contribution to the examination of the relationship between HIV infection and IPV among US women, this study was limited because it only examined physical and sexual IPV in the past 12 months. Another large-scale domestic study by Stockman et al. assessed specific types of sexual coercion in a nationally representative sample of 5857 US women and found positive associations among coerced sex, using drugs and alcohol, and having multiple sexual partners.20 However, this study was limited in the way it assessed HIV risk by not examining perceived partner risk factors. Other recent studies have further elucidated this complex clustering of risk factors, but sample sizes have remained small, and measures of sexual HIV risk behaviors have varied widely.9,33,34Because of the concentration of HIV/AIDS in key areas of the United States, the HIV Prevention Trials Network (HPTN) study 064 was uniquely designed to recruit a representative sample of women living in US areas with high poverty and a high prevalence of HIV.26,27 Unlike the more diffuse HIV epidemics seen in other countries, HIV in the United States has striking socioeconomic and racial disparities that are concentrated in key “hot spots” of the Northeast, South, and West. However, HIV among women in the United States is still not fully appreciated in the current HIV prevention research.26,27 HPTN 064 made a significant public health contribution by assessing key social and behavioral factors that contribute to HIV acquisition among women in the United States by exploring the risk of HIV infection among certain populations of US women and providing information about their risk behaviors.35 We used this large data set to assess the following: (1) the prevalence of emotional abuse, physical violence, forced sex, and experiencing 2 or more types of violence; and (2) sociodemographic characteristics, personal HIV-risk behaviors, and perceived sex partner behaviors associated with each type of violence.     

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

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

Severe Physical Violence and Black Women’s Health and Well-Being

Objectives. We evaluated the association between intimate partner violence and the mental and physical health status of US Caribbean Black and African American women.Methods. We used 2001 to 2003 cross-sectional data from the National Survey of American Life—the most detailed study to date of physical and mental health disorders of Americans of African descent. We assessed participants’ health conditions by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (Washington, DC; American Psychological Association) Composite International Diagnostic Interview.Results. We found differences in health conditions between abused African American and Caribbean Black women. There were increased risks for lifetime dysthymia, alcohol dependence, drug abuse, and poor perceived health for African American victims of partner abuse, and binge eating disorder was associated with partner violence among Caribbean Black women.Conclusions. Severe intimate partner violence was associated with negative mental and physical health outcomes for US Black women, with different patterns between African American and Caribbean Blacks. Understanding intimate partner violence experiences of US Black women requires recognition of key intragroup differences, including nativity and immigrant status, and their differential relationships to women’s health.Intimate partner violence (IPV) is a serious public health problem that has devastating consequences for the health and well-being of women.1 Nearly 28% of women in the United States have experienced IPV.2 The risk is heightened for Black women, with an estimated 4 in 10 experiencing physical abuse by a partner in their lifetimes.2 The long- and short-term effects of partner violence may be greater for women within this population, who not only experience violence at much higher rates than do other ethnic groups (e.g., White, Hispanic)1,3–9 but also are exposed to external factors and social conditions that increase their chances for poorer outcomes.4,9–14Previous studies have indicated that associated mental conditions of IPV include depression, posttraumatic stress disorder, anxiety, suicide, and tendencies for substance use (both legal and illegal).15–27 Along with these possible mental disorders, IPV victims are prone to physical health problems, such as increased risk for back, limb, gastrointestinal, stomach, and gynecological problems.22,28–31Despite the various health problems that are associated with IPV toward women in general, research devoted to understanding the influences on US Black women is limited.19,32–34 The few studies conducted have primarily used unstructured clinical assessment and are determined by clinical and community-based samples.33,35 Studies using national samples and structured clinical tools are rare, limiting valid assessments and definitive statements on the resulting effects of IPV on women within this population.In addition to these shortcomings, previous research has typically aggregated Blacks into a single category, which may obscure key intragroup differences.5,11,36 This is especially problematic because groups may have culturally distinct behaviors, practices, and experiences that may exacerbate certain health conditions or, conversely, serve as protective factors. Evidence suggests that health conditions may vary according to race and ethnicity.10,13,28,37–39 These differences, in particular, have become more apparent between African Americans and Caribbean Blacks.40 To date, however, we have less knowledge about the differences in health outcomes that may exist among abused women within these populations. Importantly, the impact of IPV on the health and well-being of US Caribbean women, one of the largest and fastest growing ethnic groups in the United States,41 has not been explored in depth.We addressed 2 underlying questions: (1) What are the associations between IPV, mental health disorders, and the physical health of African American and US Caribbean Black women? and (2) Are there differences in health outcomes between abused African American and US Caribbean Black women?     

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

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

Effects of a Tobacco Control Intervention for Teachers in India: Results of the Bihar School Teachers Study

Objectives. We assessed a school-based intervention designed to promote tobacco control among teachers in the Indian state of Bihar.Methods. We used a cluster-randomized design to test the intervention, which comprised educational efforts, tobacco control policies, and cessation support and was tailored to the local social context. In 2009 to 2011, we randomly selected 72 schools from participating school districts and randomly assigned them in blocks (rural or urban) to intervention or delayed-intervention control conditions.Results. Immediately after the intervention, the 30-day quit rate was 50% in the intervention and 15% in the control group (P = .001). At the 9-month postintervention survey, the adjusted 6-month quit rate was 19% in the intervention and 7% in the control group (P = .06). Among teachers employed for the entire academic year of the intervention, the adjusted 6-month abstinence rates were 20% and 5%, respectively, for the intervention and control groups (P = .04).Conclusions. These findings demonstrate the potent impact of an intervention that took advantage of social resources among teachers, who can serve as role models for tobacco control in their communities.The global burden of tobacco is rapidly shifting to the developing world. According to the World Health Organization, it is expected that by 2030 more than 8 million people globally will die from tobacco-related causes, 80% of them in low- and middle-income countries.1 As part of growing attention to this issue, the United Nations General Assembly included support for tobacco control in its initiative to reduce noncommunicable diseases.2,3 The World Health Organization created MPOWER as a resource for countries to implement tobacco control efforts4 and negotiated the Framework Convention on Tobacco Control, the first international treaty negotiated under the organization''s auspices.5 These efforts underscore the ongoing significant need for effective strategies that take into account the challenges of resource-poor situations.6India faces particular challenges because multiple forms of tobacco are in widespread use and limited resources are available for tobacco control.7 An estimated 1 million deaths in 2010 alone were attributable to tobacco-related causes in India, with increases projected in the future.8 The prevalence of tobacco use is 48% among men and 20% among women.7 Tobacco-related cancers constitute about half the total cancer incidence among men and about 20% among women.9,10 India also has the highest oral cancer rate in the world.11,12Although India was an early signatory to the Framework Convention on Tobacco Control, few resources are available in India to support tobacco use cessation,13–19 quitting tobacco use is not common practice, and few social norms support quitting.7 Indeed, little attention has been paid to studying, developing, and delivering effective interventions for cessation. Prevalence of former tobacco use is much lower in India than in the United States (3% vs 21%–25%).7,20–23Successful, evidence-based interventions with the potential for widespread implementation, beginning with opinion leaders who contribute to shaping social norms regarding tobacco use, are urgently needed.24 Teachers represent an important vanguard population for tobacco control efforts in India; they are role models for community norms generally and can be instrumental in school-based tobacco control efforts, which are often a community’s first step toward a broad-based control program.25–27We tested the efficacy of a school-based intervention designed to promote tobacco control among teachers in the Indian state of Bihar, where rates of tobacco use are among the highest in the country. In 2000, the Global School Personnel Survey found that 78% of teachers in Bihar used some form of tobacco.28 We randomly assigned schools to either an intervention or a delayed-intervention control condition. We tested the hypothesis that teachers in intervention schools who used tobacco would be more likely than teachers in control schools to (1) have quit for at least 30 days by immediately after the intervention and (2) have quit for 6 months or more by 9 months after the intervention.     

A Heavy Burden: The Cardiovascular Health Consequences of Having a Family Member Incarcerated

Objectives. We examined the association of family member incarceration with cardiovascular risk factors and disease by gender.Methods. We used a sample of 5470 adults aged 18 years and older in the National Survey of American Life, a 2001–2003 nationally representative cross-sectional survey of Blacks and Whites living in the United States, to examine 5 self-reported health conditions (diabetes, hypertension, heart attack or stroke, obesity, and fair or poor health).Results. Family member incarceration was associated with increased likelihood of poor health across all 5 conditions for women but not for men. In adjusted models, women with family members who were currently incarcerated had 1.44 (95% confidence interval [CI] = 1.03, 2.00), 2.53 (95% CI = 1.80, 3.55), and 1.93 (95% CI = 1.45, 2.58) times the odds of being obese, having had a heart attack or stroke, and being in fair or poor health, respectively.Conclusions. Family member incarceration has profound implications for women’s cardiovascular health and should be considered a unique risk factor that contributes to racial disparities in health.Over the course of the prison boom, imprisonment has become a common event in the life course for Black men,1 especially those with low levels of education2 who reside in poor neighborhoods,3 and their families.4 Although there is no official figure for women who have a family member imprisoned, it has been estimated that as many as 3 million women annually have an incarcerated partner.5 This is likely a conservative estimate because it includes neither inmates who have multiple concurrent relationships nor other women affected by male incarceration, such as mothers, sisters, and adult children. Because 60% to 70% of Black men who did not complete high school will experience imprisonment by their early 30s,2,4 poor, minority women disproportionately experience family member imprisonment. Yet the only research that has considered the impact of male incarceration on the health of these women has focused on mental rather than physical health.6,7 This is a surprising omission because much research examines the physical and mental health consequences of imprisonment for men8–15 as well as their communities16,17 and children.18,19This oversight is problematic for 2 reasons. First, because the experience of incarceration is concentrated among men, incarceration’s indirect consequences on women’s health—transmitted through the incarceration of a family member—are likely more relevant for health among women than are their own experiences of incarceration at the aggregate level. Because the lifetime risks of imprisonment for Black men2 and paternal imprisonment for Black children20 hover around 20% to 25%, whereas risks of maternal imprisonment for Black children barely exceed 3%, mass incarceration’s indirect effects on health inequalities among women are likely larger than its direct effects. In other words, because women are at least 5 times more likely to have a family member incarcerated than to be incarcerated themselves, the effects of their own incarceration would have to dwarf the effects of having a family member incarcerated to have the same aggregate effect. Likewise, as the cumulative risks of paternal and maternal imprisonment for White children—at 3.3% and 0.6%, respectively—are far lower than are risks for Black children, the consequences are likely much more pronounced for the Black community.20Second, there is a host of reasons to expect the incarceration of a family member to harm women’s physical health beyond increasing their risk of contracting sexually transmitted disease.16,17 Indeed, exposure to family member imprisonment may compromise the physical health, particularly cardiovascular disease–related health outcomes, of women via (1) lowered socioeconomic status and family functioning, (2) reduced social support, and (3) higher levels of chronic stress.21 The incarceration of a family member brings with it not only increases in household expenses22–24 but also substantial decreases in household income25 and increases in material hardship.26 Furthermore, the incarceration of a family member often dramatically increases the stress and social isolation women feel as they struggle to deal with their family member’s absence.22,23,27 The preponderance of research suggests that because of the independent and negative effects of low socioeconomic status, chronic stress, and social isolation on health, the incarceration of a family member may contribute to a novel form of weathering—the early health deterioration of Blacks as a consequence of the accumulation of repeated experience with social and economic adversity28,29—among disadvantaged Black women (Lee and Wildeman21 provide a detailed discussion).We hypothesized that family member incarceration would be positively associated with cardiovascular disease and related risk factors among women but not men. Women shoulder the burden of childcare and household management and maintain connections to their imprisoned male family members or romantic partners.21 In addition, women are more likely to engage in overeating and sedentary behaviors as coping behaviors for stress than are men.30,31 Family member incarceration may lead to racial disparities in physical health among women because of the disproportionate experiences of this stressful life event among Black women.Using data from the National Survey of American Life (NSAL), we tested whether having a family member incarcerated is a distinct stressor that has consequences for cardiovascular risk factors and disease among women and men.     

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

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

Text4baby: Development and Implementation of a National Text Messaging Health Information Service

Text4baby is the first free national health text messaging service in the United States that aims to provide timely information to pregnant women and new mothers to help them improve their health and the health of their babies.Here we describe the development of the text messages and the large public–private partnership that led to the national launch of the service in 2010. Promotion at the local, state, and national levels produced rapid uptake across the United States. More than 320 000 people enrolled with text4baby between February 2010 and March 2012.Further evaluations of the effectiveness of the service are ongoing; however, important lessons can be learned from its development and uptake.The US infant mortality rate (6.59/1000 live births) is higher than in most developed countries.1 In the United States, the infant mortality rate for non-Hispanic African American women is 2.4 times the rate for non-Hispanic White women.1 Rates are also elevated for Native American Indian and Alaska Native women. In 2008, 12.3% of the 4 251 095 babies born in the United States were born prematurely and 8.2% had a low birth weight.2 Health-related behaviors in the prenatal and postnatal periods, such as nutrition, tobacco smoking, breastfeeding, safe sleep practices, and vaccination are known to affect maternal and infant outcomes.3 Women without access to affordable and appropriate care may not be receiving information needed to support prenatal and postnatal pediatric care. Recent studies have also shown limited health literacy in the United States to be related to a lack of prenatal planning, such as taking folic acid, and difficulties with informed parental decision-making.4,5Mobile phones may be an appropriate means for addressing the challenges of health literacy6 and for reaching women from underserved communities. Mobile phone ownership in the United States is similar across racial/ethnic groups (80% of Whites and 87% of African Americans and Hispanics). African Americans (79%) and Hispanic Americans (83%) are more likely than are White Americans (68%) to send text messages.7 Americans living in or near poverty are more likely to live in cell phone–only households (no fixed phone line), and those living in cell phone–only households are more likely to have experienced numerous barriers to health care.8Mobile phone text messaging has been used to support healthy behavior change and health care delivery processes.9–12 Successful behavior change interventions have used text messaging to support smoking cessation,13–15 weight management through diet or physical activity,16–19 and management of anxiety symptoms.20 Health care process interventions have included appointment reminders21–24 and reminders to take medications.25–30Here we describe the development of text4baby, a free national text messaging service that provides timely information to pregnant women and new mothers to help them improve their health and the health of their babies. More than 320 000 people enrolled with text4baby between its launch in February 2010 and March 2012. Little has been published in peer-reviewed journals on mobile health initiatives of this scale in the United States. Published international examples of national-scale services include a text messaging smoking cessation service in New Zealand, which was established after a randomized trial and registered 3905 clients in the first year,13,31 and a public health campaign in South Africa, which sent 968 million HIV/AIDS awareness messages embedded in free “Please call me” text messages over two years.32,33 Lessons from the development of text4baby could guide similar mobile health developments.     

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

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