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

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

Effects of Statewide Job Losses on Adolescent Suicide-Related Behaviors

Objectives. We investigated the impact of statewide job loss on adolescent suicide-related behaviors.Methods. We used 1997 to 2009 data from the Youth Risk Behavior Survey and the Bureau of Labor Statistics to estimate the effects of statewide job loss on adolescents’ suicidal ideation, suicide attempts, and suicide plans. Probit regression models controlled for demographic characteristics, state of residence, and year; samples were divided according to gender and race/ethnicity.Results. Statewide job losses during the year preceding the survey increased girls’ probability of suicidal ideation and suicide plans and non-Hispanic Black adolescents’ probability of suicidal ideation, suicide plans, and suicide attempts. Job losses among 1% of a state’s working-age population increased the probability of girls and Blacks reporting suicide-related behaviors by 2 to 3 percentage points. Job losses did not affect the suicide-related behaviors of boys, non-Hispanic Whites, or Hispanics. The results were robust to the inclusion of other state economic characteristics.Conclusions. As are adults, adolescents are affected by economic downturns. Our findings show that statewide job loss increases adolescent girls’ and non-Hispanic Blacks’ suicide-related behaviors.Suicide among young people has been identified as a serious public health concern. Among youths and young adults 10 to 24 years of age, suicide is the third leading cause of death, resulting in 4600 deaths each year.1 Every year, 157 000 young people in the 10- to 24-year age group are treated for self-inflicted injuries.1A number of individual characteristics and circumstances serve as risk factors for suicide and suicide-related behaviors among adolescents, including suicidal ideation and suicide attempts. Risk factors for suicide-related behaviors include a history of previous suicide attempts, a family history of suicide, a history of depression or other mental illness, alcohol or drug use, stressful life events, and exposure to the suicidal behavior of others.2 In addition, low levels of parental monitoring and engagement in risk-taking behaviors are associated with increased suicidal ideation and suicide attempts.3 What is less well understood, however, is how broader contextual factors, such as economic conditions, alter adolescents’ risk for suicide and suicide-related behaviors.Economic downturns such as the recent “Great Recession” represent large changes in the economic context and have well-known effects on adults’ physical and mental health, although these physical and mental effects work in opposite directions.4–6 Economic downturns have been shown to improve adults’ physical health, including decreasing health risk behaviors such as smoking and decreasing mortality.4–6 In contrast, however, economic downturns worsen adults’ mental health, including increasing suicide, one of the most serious mental health consequences.6–8 A recent review article concluded that the economic context of a geographic area is related to the area’s overall suicide rate.9 Across many studies of different geographic areas, the review showed that, at any given point in time, areas with worse economic contexts have higher suicide rates. Work that has considered changes in economic contexts, rather than static conditions, has shown that recessions and unemployment rate increases are positively correlated with suicide rates.6–8,10Despite the well-known associations between economic contractions and adult suicide rates and the great public concern around adolescent suicide, the relationships between changes in economic circumstances and the suicide-related behaviors of adolescents have received relatively little attention. Evidence exists that adolescent suicide and suicide-related behaviors are more likely to occur in neighborhoods with increased levels of economic disadvantage.11 In addition, recent studies suggest that adolescents’ mental health is affected by changes in local economic contexts. Research focused on one US state showed that job losses attributable to mass layoffs increased use of emergency psychiatric care among young people, and increases were especially large among Black youths.12–14Statewide job loss may increase adolescent suicide-related behaviors through changes in parental well-being as well as through changes in the broader community context. Within families, parental job loss has been associated with increased mental health problems and lower quality parent–child interactions, which in turn affect adolescents’ mental health.15–17 Adolescents may be more aware of their families’ worsening economic circumstances than younger children and may be more likely to bear the brunt of their families’ increased stress. In the broader community context, changes in the economic and psychological well-being of adults outside of the family may lead indirectly to changes in adolescent functioning.18 When parents, teachers, coaches, and other adults with whom adolescents interact experience increased stress, this increase in stress may affect adolescents’ mental health. Statewide job loss could also lead to loss of resources that affect adolescents’ neighborhood, school, or extracurricular activities.Previous literature suggests that risk of adolescent suicide and suicide-related behaviors varies according to gender and race/ethnicity. Boys are more likely than girls to commit suicide, but girls are more likely to attempt suicide.2 Among all racial and ethnic groups, non-Hispanic Black adolescents are least likely to have planned or attempted suicide,19 and they also display lower levels of mental disorder.20,21Racial/ethnic differences in suicide-related behaviors may be particularly relevant given that economic downturns disproportionately affect minority households.22 In addition, because non-Hispanic Black and Hispanic adolescents are more likely than non-Hispanic White adolescents to live in households with lower incomes and fewer assets,23 they may be less able to buffer the economic consequences of downturns. Even in the case of families who do not experience household job loss, minority adolescents may be more worried than non-Hispanic White adolescents about their future job prospects, insofar as minority workers are more vulnerable to economic downturns than are White workers.22 Consistent with these theories, Black youths’ use of emergency psychiatric care has been shown to increase more after statewide job losses than that of White youths.12,14In our study, we sought to build on previous literature by considering how changes over time in statewide job loss rates across the United States affect the suicide-related behaviors of a nationally representative survey of adolescents in high school. We used the state as the geographic unit because data on suicide-related behaviors for smaller areas of aggregation are not readily available across the country and over time. An important component of the study was our examination of 3 behaviors that are precursors to suicide: suicidal ideation, suicide planning, and suicide attempts.2 Understanding factors that influence these precursors may facilitate suicide prevention efforts.Our measure of economic downturns, statewide job losses attributable to mass layoffs and closings, offers several advantages over more conventionally used measures such as unemployment rates. For example, our measure of job loss, unlike the unemployment rate, can be considered an unanticipated “shock” to a community and is therefore likely to be exogenously related to suicide-related behaviors. Research in economics has demonstrated that statewide job losses typically reflect global changes in technology and trade rather than being driven by changes in either individual or community characteristics that might themselves be related to adolescent suicide-related behaviors.24–26In addition, a change in our measure of job loss represents an unequivocally bad piece of economic news. In contrast, the unemployment rate can change for either positive or negative reasons. For example, it can decrease because workers become discouraged and stop looking for work. This “positive” change in the unemployment rate may reflect worker discouragement rather than job growth. The reverse may also be true: as economic conditions improve, workers may decide to reenter the labor market, leading the unemployment rate to increase.     

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

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

Longitudinal Associations Between Types of Childhood Trauma and Suicidal Behavior Among Substance Users: A Cohort Study

Objectives. We examined the longitudinal associations between different types and severities of childhood trauma and suicide attempts among illicit drug users.Methods. Data came from 2 prospective cohort studies of illicit drug users in Vancouver, Canada, in 2005 to 2010. We used recurrent event proportional means models to estimate adjusted and weighted associations between types and severities of childhood maltreatment and suicide attempts.Results. Of 1634 participants, 411 (25.2%) reported a history of suicidal behavior at baseline. Over 5 years, 80 (4.9%) participants reported 97 suicide attempts, a rate of 2.6 per 100 person-years. Severe to extreme levels of sexual abuse (adjusted hazard ratio [AHR] = 2.5; 95% confidence interval [CI] = 1.4, 4.4), physical abuse (AHR = 2.0; 95% CI = 1.1, 3.8), and emotional abuse (AHR = 3.5; 95% CI = 1.4, 8.7) predicted suicide attempts. Severe forms of physical and emotional neglect were not significantly associated with an increased risk of suicidal behavior.Conclusions. Severe sexual, physical, and emotional childhood abuse confer substantial risk of repeated suicidal behavior in adulthood. Illicit drug users require intensive secondary suicide prevention efforts, particularly among those with a history of childhood trauma.The global burden of suicide is considerable and is the tenth leading cause of death worldwide, with annual mortality estimated at 14.5 deaths per 100 000.1 Suicide is a major and preventable public health problem among young people aged 15 to 24 years in Canada (second leading cause of death2) and the United States (third leading cause of death3). Each year, approximately 1 million adults in the United States attempt suicide, resulting in 35 000 deaths and more than 320 000 emergency department visits.4 The societal, financial, and public health burdens associated with suicide are therefore substantial.The epidemiology of suicide is multifactorial and complex.1 The 2012 National Strategy for Suicide Prevention identifies several groups at particularly high risk of suicide in the United States, including individuals with a past history of suicidal behavior, members of the armed forces and veterans, American Indians/Alaska Natives, men in midlife, and individuals in justice and child welfare settings.5 Of public health concern in Canada, suicide rates among Aboriginal Peoples are 2 to 3 times that observed in the nonaboriginal population.6,7 A large body of literature has also demonstrated high rates of suicidal behavior among lesbian, gay, bisexual, and transgender populations.8–10People who use illicit drugs are particularly vulnerable to suicidal ideation and behavior, and suicide is a leading cause of death in drug-using populations.11,12 Furthermore, the relationship between substance abuse and increased suicide risk has been well established.13,14 A growing body of research has examined various correlates of suicide attempts among drug users. In treatment-seeking samples of drug and alcohol abusers, major depressive disorder and other psychiatric conditions (e.g., borderline personality disorder, anxiety, agoraphobia) have been associated with a history of suicide attempts.15–20 Furthermore, markers of social disadvantage and marginalization, such as unemployment and homelessness, are associated with a heightened risk of suicide and are common among drug users.11 Specific typologies of drug use have also been linked to a greater likelihood of attempting suicide, including longer durations of substance use,18,21 polysubstance use,20,22 and injection methamphetamine use.23In recent years, childhood maltreatment has emerged as a consistent correlate of suicidal ideation and behavior among drug users.19,24,25 These studies provide preliminary evidence that childhood abuse and neglect are important determinants of suicide in drug-using populations. However, it is unclear whether certain types of childhood maltreatment are more strongly associated with suicidal behavior than others. The majority of studies to date have examined suicide and early traumatic experiences among clinical samples, which may be subject to selection bias if being in treatment is a common effect of both exposure (i.e., childhood maltreatment) and other, unmeasured factors that may cause suicidal behavior (e.g., genetic or familial susceptibility to psychiatric disorders such as depression). To our knowledge no studies have prospectively examined suicidal behavior in a community-recruited cohort of drug users. Drug-using cohorts are particularly well suited to examining the relationship between childhood maltreatment and recurrent suicidal behavior because of their high rates of suicide. We used recurrent event survival models to determine the longitudinal associations between exposure to different types and severities of childhood trauma and suicide attempts, measured prospectively in a cohort of drug users in Vancouver, British Columbia.     

Protective School Climates and Reduced Risk for Suicide Ideation in Sexual Minority Youths

Objectives. We examined whether sexual minority students living in states and cities with more protective school climates were at lower risk of suicidal thoughts, plans, and attempts.Methods. Data on sexual orientation and past-year suicidal thoughts, plans, and attempts were from the pooled 2005 and 2007 Youth Risk Behavior Surveillance Surveys from 8 states and cities. We derived data on school climates that protected sexual minority students (e.g., percentage of schools with safe spaces and Gay–Straight Alliances) from the 2010 School Health Profile Survey, compiled by the Centers for Disease Control and Prevention.Results. Lesbian, gay, and bisexual students living in states and cities with more protective school climates reported fewer past-year suicidal thoughts than those living in states and cities with less protective climates (lesbians and gays: odds ratio [OR] = 0.68; 95% confidence interval [CI] = 0.47, 0.99; bisexuals: OR = 0.81; 95% CI = 0.66, 0.99). Results were robust to adjustment for potential state-level confounders. Sexual orientation disparities in suicidal thoughts were nearly eliminated in states and cities with the most protective school climates.Conclusions. School climates that protect sexual minority students may reduce their risk of suicidal thoughts.Suicide is the third leading cause of death among youths aged 15 to 24 years.1 Decades of research have identified multiple risk factors for adolescent suicide ideation and attempts.2 One of the most consistent findings is that lesbian, gay, and bisexual (LGB, or sexual minority) adolescents are more likely than heterosexual adolescents to endorse suicidal thoughts3,4 and to report having a suicide plan.5 Additionally, a recent review of the epidemiological literature found that LGB youths are between 2 and 7 times more likely to attempt suicide than their heterosexual peers.6Given the elevated risk of suicidal ideation, plans, and attempts among sexual minority youths, researchers have focused on identifying factors that explain these marked disparities. Theories of minority stress7 and stigma8 have highlighted the important roles that social-structural contexts as well as institutional practices and policies play in contributing to mental health disparities. Consistent with these theories, LGB adults who live in states with fewer protective social policies have higher rates of psychiatric and substance use disorders than LGB adults living in states with more protective policies.9,10 For instance, LGB adults in states that passed constitutional amendments banning same-sex marriage experienced a 37% increase in mood disorders, a 40% increase in alcohol use disorders, and nearly a 250% increase in generalized anxiety disorders in the year following the enactment of the amendments.10 These and other studies11 have shown that the broader social contexts surrounding LGB adults shape their mental health.Among adolescents, schools are an important social context that contributes to developmental and health outcomes.12 For sexual and gender minority youths in particular, the social context of schools can promote both vulnerability and resilience.13–16 A variety of methodological approaches have been used to evaluate the mental health consequences of school climates for LGB students. The predominant approach is to ask LGB adolescents to report on the supportiveness of their schools.17–19 Studies using this approach have indicated that LGB youths who report greater school connectedness and school safety also report lower suicidal ideation and fewer suicide attempts.18 Although informative, this research may introduce bias because information is self-reported for both the exposure and the outcome.20 Studies using alternative methodologies may therefore improve the validity of the inferences on the relationship between the social environment and individual health outcomes.An alternative methodological approach has been to develop indicators of school climate that do not rely on self-report, such as geographic location of the school (i.e., urban vs rural)21 and the presence of Gay–Straight Alliances in the school.22 Although this approach has received comparatively less attention in the literature, recent studies have documented associations between these more objective measures of school climate and sexual minority mental health. For example, lesbian and gay adolescents are at lower risk for attempting suicide if they live in counties where a greater proportion of school districts have antibullying policies that include sexual orientation.23 Although they provide important initial insights, existing studies have been limited by examining only 1 aspect of school climate (e.g., antibullying policies or presence of Gay–Straight Alliances),16,22,23 relying on nonprobability samples,16,22 and using a single location,16,22,23 all of which can restrict generalizability.We built on this previous research by using data on multiple school climate variables relevant to LGB students that we obtained from the 2010 School Health Profile Survey, compiled by the Centers for Disease Control and Prevention (CDC).24 We then linked this information on school climate to population-based data of adolescents living in 8 states and cities across the United States. We hypothesized that LGB adolescents living in states and cities with school climates that are more protective of sexual minority youths would be less likely to report past-year suicidal thoughts, plans, and attempts than LGB youths living in areas with less protective school climates.     

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

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

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

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

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

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

Health Among Caregivers of Children With Health Problems: Findings From a Canadian Population-Based Study

Objectives. We used population-based data to evaluate whether caring for a child with health problems had implications for caregiver health after we controlled for relevant covariates.Methods. We used data on 9401 children and their caregivers from a population-based Canadian study. We performed analyses to compare 3633 healthy children with 2485 children with health problems. Caregiver health outcomes included chronic conditions, activity limitations, self-reported general health, depressive symptoms, social support, family functioning, and marital satisfaction. Covariates included family (single-parent status, number of children, income adequacy), caregiver (gender, age, education, smoking status, biological relationship to child), and child (age, gender) characteristics.Results. Logistic regression showed that caregivers of children with health problems had more than twice the odds of reporting chronic conditions, activity limitations, and elevated depressive symptoms, and had greater odds of reporting poorer general health than did caregivers of healthy children.Conclusions. Caregivers of children with health problems had substantially greater odds of health problems than did caregivers of healthy children. The findings are consistent with the movement toward family-centered services recognizing the link between caregivers'' health and health of the children for whom they care.Caring for a child with health problems can entail greater than average time demands,^1,2 medical costs,^3,4 employment constraints,^5,6 and childcare challenges.^6–8 These demands may affect the health of caregivers, a notion supported by a variety of small-scale observational studies that have shown increased levels of stress, distress, emotional problems, and depression among caregivers of children with health problems.^1,2,5,9–12Whether these problems are caused by the additional demands of caring for children with health problems or by confounding variables is difficult to answer definitively. The literature reports the identification of a variety of factors purported to be associated with caregiver health, including contextual factors such as socioeconomic status^13–17; child factors such as level of disability,^{1,11,13,18–21} presence of behavior problems,^22–25 and overall child adjustment²⁶; and caregiver-related characteristics such as coping strategies^11,22,27 and support from friends and family.^15,17,28,29 In general, this work has been based on small clinic-based samples^9,30 or specific child populations (e.g., cerebral palsy,^5,25 attention-deficit/hyperactivity disorder^31,32), and typically has been hampered by limited generalizability and a lack of careful, multivariate analysis. Furthermore, most studies have focused on caregivers'' psychological health,^1,2,5,9–12 although physical health effects may also exist among caregivers.^5,19,25,33One of the few studies to involve large-scale, population-based data compared the health of 468 caregivers of children with cerebral palsy to the health of a population-based sample of Canadian parents.⁵ The study showed that caregivers of children with cerebral palsy had poorer health on a variety of physical and psychological health measures. Furthermore, the data were consistent with a stress process model,^5,25 which proposes that additional stresses associated with caring for a child with cerebral palsy directly contribute to poorer caregiver health. However, these findings were based on a specific subpopulation of caregivers and univariate comparisons that could not control for potentially important confounders such as variation in caregiver education, income, and other demographic factors.We used population-based data to test the hypothesis that the health of caregivers of children with health problems would be significantly poorer than that of caregivers of healthy children, even after we controlled for relevant covariates. Our approach of using large-scale, population-based data representing a broad spectrum of childhood health problems³⁴ makes 4 key contributions to the current literature. First, our use of population-based data rather than small-scale, clinic-based studies yielded results that are potentially generalizable to a wide group of caregivers caring for children with health problems. Second, our examination of children with and without health problems allowed us to examine caregiver health effects across a wide variety of caregiving situations. Third, consideration of physical health outcomes (in addition to more regularly studied psychological outcomes) increased our knowledge of the breadth of caregiver health issues. Finally, controlling for relevant covariates allowed us to rule out a number of alternative explanations for caregiver health effects.     

Intergenerational relationships between the smoking patterns of a population-representative sample of US mothers and the smoking trajectories of their children

Objectives. We assessed intergenerational transmission of smoking in mother-child dyads.Methods. We identified classes of youth smoking trajectories using mixture latent trajectory analyses with data from the Children and Young Adults of the National Longitudinal Survey of Youth (n = 6349). We regressed class membership on prenatal and postnatal exposure to maternal smoking, including social and behavioral variables, to control for selection.Results. Youth smoking trajectories entailed early-onset persistent smoking, early-onset experimental discontinued smoking, late-onset persistent smoking, and nonsmoking. The likelihood of early onset versus late onset and early onset versus nonsmoking were significantly higher among youths exposed prenatally and postnatally versus either postnatally alone or unexposed. Controlling for selection, the increased likelihood of early onset versus nonsmoking remained significant for each exposure group versus unexposed, as did early onset versus late onset and late onset versus nonsmoking for youths exposed prenatally and postnatally versus unexposed. Experimental smoking was notable among youths whose mothers smoked but quit before the child''s birth.Conclusions. Both physiological and social role-modeling mechanisms of intergenerational transmission are evident. Prioritization of tobacco control for pregnant women, mothers, and youths remains a critical, interrelated objective.Women who smoke during pregnancy are more likely to have offspring who become adolescent smokers.^1–7 Studies link mother''s smoking during pregnancy with youths'' earlier smoking initiation,^3,7–9 greater persistence in regular smoking,^3,7 and stronger nicotine dependency.^6,8,10,11Hypothesized physiological pathways for mother-to-child transmission of smoking are reviewed elsewhere^12–14 and may include inherited susceptibility to addiction alone or in combination with in utero neurodevelopmental exposure and scarring that activates nicotine susceptibility. Furthermore, because few women who smoke during pregnancy quit after delivery^15,16 higher rates of smoking among offspring may reflect role modeling of maternal smoking behavior. Notably, parental smoking is hypothesized to demonstrate pro-smoking norms and solidify pro-smoking attitudes.^17,18Studies considering both smoking during pregnancy and subsequent maternal smoking outcomes have sought to distinguish between these proposed social and physiological transmission pathways.^{1–4,6,7,9,19} Similarly, studies controlling for family sociodemographic factors^{1,2,4,5,7,8,10,11,19,20} or maternal propensity for health or risk taking^1,2,9,10 have sought to further distinguish direct physiological or social transmission from selection. Studies considering children''s cognitive and behavioral outcomes have shown that selection by maternal social and behavioral precursors to smoking during pregnancy strongly biases findings on smoking during pregnancy^21,22; however, it remains unclear whether this is also the case for youth smoking. Some studies^2,3,5,6,19 have observed that smoking during pregnancy operates independently of subsequent maternal smoking. A few have found that smoking during pregnancy is only independently associated in select analyses (e.g., for initiation but not frequency or number of cigarettes^6,9 or only among females^7,20). Several have found that smoking during pregnancy does not operate independently of subsequent maternal smoking behavior,^1,4 and the remaining studies do not address postnatal maternal smoking.^8,9,11We explored whether these inconsistencies in findings supporting social or physiological mechanisms for intergenerational transmission can be accounted for by more comprehensively examining maternal and child smoking behavior. Previous work has established the advantages of statistical models for youth smoking trajectories that capture initiation, experimentation, cessation, or continued use.^23–28 Studies focusing on parental smoking concurrent with youth smoking suggest that postnatal exposures may differentially predispose youths for specific smoking trajectories.^24,26–28 Only 3 known studies have considered whether smoking during pregnancy influences youth smoking progression, and these have shown greater likelihood of early regular use^3,11 and telescoping to dependence.⁸ However, limitations of sample selectivity and measurement and modeling of maternal and youth smoking outcomes restrict the generalizability and scope of these findings.²⁹ To specifically address these limitations and more comprehensively assess hypothesized intergenerational transmission pathways, we used US population–representative data, latent variable techniques, and a rich set of data on maternal and youth smoking and social and behavioral selection factors. We characterized trajectories of youth smoking from adolescence through young adulthood and considered exposure to various maternal smoking patterns from prebirth to the child''s early adolescence.     

Protective Factors in the Lives of Bisexual Adolescents in North America

Objectives. We compared protective factors among bisexual adolescents with those of heterosexual, mostly heterosexual, and gay or lesbian adolescents.Methods. We analyzed 6 school-based surveys in Minnesota and British Columbia. Sexual orientation was measured by gender of sexual partners, attraction, or self-labeling. Protective factors included family connectedness, school connectedness, and religious involvement. General linear models, conducted separately by gender and adjusted for age, tested differences between orientation groups.Results. Bisexual adolescents reported significantly less family and school connectedness than did heterosexual and mostly heterosexual adolescents and higher or similar levels of religious involvement. In surveys that measured orientation by self-labeling or attraction, levels of protective factors were generally higher among bisexual than among gay and lesbian respondents. Adolescents with sexual partners of both genders reported levels of protective factors lower than or similar to those of adolescents with same-gender partners.Conclusions. Bisexual adolescents had lower levels of most protective factors than did heterosexual adolescents, which may help explain their higher prevalence of risky behavior. Social connectedness should be monitored by including questions about protective factors in youth health surveys.Adolescence is a key developmental period with long-term effects on physical and psychological health, and adolescents negotiate a variety of environmental challenges during these years. Although public health practice often focuses on preventing or decreasing health risks, in the past decade increasing attention has been paid to identifying protective factors that can foster healthy development. Protective factors are events, circumstances, and life experiences that promote confidence and competence among adolescents and help to protect them from negative developmental risks and health outcomes.^1,2 Such protective resources enhance resilience among adolescents who face adversities,³ and they arise from individual characteristics and social environments such as families, schools, and communities.⁴Several individual assets and external resources have been identified as protective factors that reduce the likelihood of risky behaviors such as suicidality, substance use, unprotected sexual behavior, and disordered eating. Individual-level protective factors include higher levels of self-esteem, psychological well-being, and religiosity.^5–8 Relational factors such as strong connectedness to family^5,7–13 and school^{5,7,9,10,12,13} also reduce the likelihood of engaging in behaviors that compromise health. Some community-level factors also appear to be protective against risk taking among adolescents; these include the presence of a caring adult role model outside the family^8,13 and community involvement, including volunteering.⁸Most studies focus on adolescents in general, but some populations, such as lesbian, gay, and bisexual adolescents, face greater environmental challenges in negotiating adolescence and navigating developmental tasks. LGB adolescents are disproportionately subjected to violence and harassment at school^14–16 and to physical and sexual abuse.^17,18 In addition, LGB adolescents are more likely than their heterosexual peers to be involved in health-compromising behaviors, including substance use,^14–17 risky sexual behaviors and injection drug use,^14,19,20 and suicide attempts.^{10,14,15,17,21–24}Researchers have recently started illuminating relationships between lower levels of protective factors and negative health outcomes among LGB adolescents. In an analysis of the 2004 Minnesota Student Survey, Eisenberg and Resnick found that LGB students were less likely than were other students to report high levels of family connectedness, teacher caring, other adult caring, and perceived safety at school.²⁵ However, these protective factors, when present, decreased the likelihood of suicidal ideation and attempts, and protective factors accounted for more of the variation in suicide behaviors than did sexual orientation. Similarly, in his analysis of the National Longitudinal Study of Adolescent Health, Ueno found that less-positive relationships with parents, school, and friends explained higher levels of psychological distress among sexual-minority students than among heterosexual students.²⁶ Homma and Saewyc found that higher levels of perceived family caring and more-positive perceptions of school climate were linked to lower levels of emotional distress among Asian American LGB high school students in Minnesota.²⁷These studies provide some evidence that protective factors may work in similar ways for LGB adolescents as for other adolescents, but not consistently; for example, high levels of religious involvement in a faith with negative attitudes about nonheterosexual orientations might actually be more harmful than protective. Further, if LGB adolescents as a group experience lower levels of these assets, this might help explain their higher risks. Only a handful of population-based studies have focused on sexual-minority adolescents and protective factors, and they provide limited information about protective factors among bisexual adolescents separately from gay or lesbian adolescents; most research combines these groups because of small samples. Measuring sexual orientation during adolescence can be difficult; sexual identity development is a task of adolescence, and many youths engage in exploration of romantic attraction, sexual behavior, or identity labels during the adolescent years. Behavior and self-labeling may be discordant at various times, and there is evidence that some adolescents’ perception of their orientation and labels will shift during adolescence and young adulthood.In the few studies that have disaggregated the groups, bisexual adolescents were more likely than were heterosexual peers to report risky sexual behaviors,^19,20 suicide attempts,¹⁶ victimization,¹⁶ delinquency,²⁸ and substance use^16,28; in some cases gay and lesbian adolescents did not significantly differ from their heterosexual peers in these risks.^16,19,28 Some studies used romantic attraction as a measure of orientation,^23,24,26 some used self-labels,^18,22 and some used gender of sexual partners.^{16,20,25,27,28} Few studies offer the opportunity to incorporate correlates for orientation measured in different ways in the same data set.No matter how it is measured, it is important to examine levels of protective factors among bisexual adolescents separately, given the greater likelihood of risk-taking behavior and negative experiences at school among bisexual students. Drawing on data from different waves of the National Longitudinal Study of Adolescent Health, 2 studies have found lower levels of connectedness to family and school and lower perceived caring by other adults among bisexual than among heterosexual adolescents.^29,30 Bisexual and gay or lesbian adolescents generally did not differ in their levels of protective factors, but this may have been partly attributable to relatively small samples of LGB adolescents in the longitudinal study cohort, which limits statistical power for comparisons between the 2 groups. Furthermore, the study is nationally representative of US adolescents in general but may not reflect the full ethnic diversity of LGB populations across the United States or Canada. Studies analyzing larger regional population-based surveys offer opportunities to confirm those findings for specific regions.Identifying whether protective factors work similarly for bisexual adolescents and their peers is useful, but it is equally important to monitor whether bisexual adolescents have the same levels of those protective factors in their lives. We therefore explored levels of protective factors among bisexual adolescents compared with heterosexual, mostly heterosexual, and gay or lesbian peers in 6 school-based surveys in the midwestern United States and western Canada. We posed 3 questions: (1) Are levels of protective factors different between bisexual adolescents and heterosexual adolescents? (2) Are levels of protective factors different between bisexual adolescents and gay or lesbian adolescents? (3) Are these patterns consistent across varying measures of sexual orientation?     

Rates and Predictors of Suicidal Ideation During the First Year After Traumatic Brain Injury

Objectives. We examined rates of suicidal ideation (SI) after traumatic brain injury (TBI) and investigated whether demographic characteristics, preinjury psychiatric history, or injury-related factors predicted SI during the first year after injury.Methods. We followed a cohort of 559 adult patients who were admitted to Harborview Medical Center in Seattle, Washington, with a complicated mild to severe TBI between June 2001 and March 2005. Participants completed structured telephone interviews during months 1 through 6, 8, 10, and 12 after injury. We assessed SI using item 9 of the Patient Health Questionnaire (PHQ-9).Results. Twenty-five percent of the sample reported SI during 1 or more assessment points. The strongest predictor of SI was the first PHQ-8 score (i.e., PHQ-9 with item 9 excluded) after injury. Other significant multivariate predictors included a history of a prior suicide attempt, a history of bipolar disorder, and having less than a high school education.Conclusions. Rates of SI among individuals who have sustained a TBI exceed those found among the general population. Increased knowledge of risk factors for SI may assist health care providers in identifying patients who may be vulnerable to SI after TBI.Suicide is a major public health problem among the 1.7 million people who sustain traumatic brain injury (TBI) each year in the United States.1 People with a history of TBI in both civilian and military populations are 1.55 to 4.05 times more likely to die by suicide than the general population.2–5 In a study of Australian outpatients with a history of TBI, the majority of whom had no preinjury history of suicide attempts, suicide attempts were reported by 17.4% (30 of 172) of the sample over a 5-year period.6 Nearly half of the individuals who attempted suicide had made multiple attempts.6,7 The Centers for Disease Control and Prevention recently called for investigations of individual-level risk and protective factors for self-directed violence among people with TBI as an important component of improving long-term outcomes.8Rates of suicidal ideation (SI) after TBI have been found to exceed 20% in some studies6,9–14; however, in a recent systematic review of SI and behavior after TBI, Bahraini et al. highlighted the paucity of research in this area.15 They concluded that additional research is needed to determine the prevalence of SI and behavior after brain injury, as well as to ascertain patient-level factors that may be associated with increased suicide risk. Studies examining whether injury severity predicts post-TBI suicidality have yielded inconclusive findings.6,13,16,17 In perhaps the most thorough study on this topic to date, Tsaousides et al.12 surveyed 356 community-dwelling adults with a self-reported history of TBI and found that preinjury substance abuse was the only correlate of current SI. Risk factors for SI after TBI have been underinvestigated. Research in this area has been limited by reliance on retrospective reporting and self-reported history of TBI,12,18–20 with only a few studies including objective indicators of TBI severity.6 Most studies have involved cross-sectional designs and have included participants whose time since injury varied from several months to many years.12,21 Finally, because most existing studies have included relatively small, potentially biased samples21 recruited from outpatient clinics or TBI survivor programs,6,7,12 they may not be representative of the population of people who sustain TBI.Given these gaps in the existing literature, our objectives were (1) to investigate rates of SI during the first year after complicated mild to severe TBI in a representative sample of adults who had been admitted to a level I trauma center and (2) to investigate whether demographic characteristics, preinjury psychiatric history, or injury-related factors predicted SI.     

Reducing Psychosocial and Behavioral Pregnancy Risk Factors: Results of a Randomized Clinical Trial Among High-Risk Pregnant African American Women

Objectives. We evaluated the efficacy of a primary care intervention targeting pregnant African American women and focusing on psychosocial and behavioral risk factors for poor reproductive outcomes (cigarette smoking, secondhand smoke exposure, depression, and intimate partner violence).Methods. Pregnant African American women (N = 1044) were randomized to an intervention or usual care group. Clinic-based, individually tailored counseling sessions were adapted from evidence-based interventions. Follow-up data were obtained for 850 women. Multiple imputation methodology was used to estimate missing data. Outcome measures were number of risks at baseline, first follow-up, and second follow-up and within-person changes in risk from baseline to the second follow-up.Results. Number of risks did not differ between the intervention and usual care groups at baseline, the second trimester, or the third trimester. Women in the intervention group more frequently resolved some or all of their risks than did women in the usual care group (odds ratio = 1.61; 95% confidence interval = 1.08, 2.39; P = .021).Conclusions. In comparison with usual care, a clinic-based behavioral intervention significantly reduced psychosocial and behavioral pregnancy risk factors among high-risk African American women receiving prenatal care.Adverse pregnancy outcomes are particularly common among women who are members of racial/ethnic minority groups.^1–4 African American infants are 3.4 times more likely than are White infants to die in the neonatal period, a disadvantage that persists even when mothers have appropriately early and equal access to prenatal care.⁵ In Washington, DC, death rates among non-Hispanic African American infants remain unacceptably high (17.0 per 1000 live births in 2005) despite an overall decline in infant mortality from 18.6 per 1000 live births in 1992 to 14.0 per 1000 births in 2005.⁶ Psychosocial and behavioral risks are recognized as potential contributors to poor reproductive outcomes.^7–9 Poverty,¹⁰ limited social support,¹¹ smoking,¹² illicit drug use,¹³ depression,¹⁴ anxiety,^14,15 and intimate partner violence (IPV)^16,17 are all associated to varying degrees with pregnancy complications, premature and low-birthweight deliveries, stillbirths, and infant mortality.There is increasing recognition of the role of primary care in screening, diagnosis, and treatment of behavioral, mental health, and psychosocial concerns,^18–27 because of the significant association between medical morbidity and behavioral and mental health problems.²⁸ Although interventions involving primary care providers may have limited success, they can be cost-effective.^18,24 Because access to and use of behavioral and mental health care remain problematic, especially among members of underserved minority groups,^29–32 making such care available through primary care services may avert missed opportunities.Prenatal care may be a venue to address behavioral and mental health issues that can potentially affect the health of pregnant women and their unborn children.³³ The guidelines of the American College of Obstetrics and Gynecology and the American Academy of Pediatrics^34,35 suggest ways primary care providers can screen for behavioral and psychosocial risk factors. Despite these guidelines, many providers still fail to screen pregnant women,^35–38 with screening rates varying according to type of provider,^36,39 risk factors,³⁶ population group,⁴⁰ and provider risk perceptions.⁴¹ Furthermore, when implemented, psychosocial and behavioral interventions have been only moderately successful.^42,43Such inconsistent results may arise from multiple factors, including differences in study design, participant engagement, and intervention content or implementation, including approaches that address only 1 of multiple, co-occurring psychosocial or behavioral risk factors. Behavioral and psychosocial factors associated with poor pregnancy outcomes are related to and serve as risk factors for one another⁴⁴; therefore, an alternative approach would be to provide an intervention simultaneously addressing multiple psychosocial and behavioral risk factors among pregnant women, as has been done in relation to other health risks.^45–47A recent study focusing on 3569 Medicaid-eligible pregnant women examined the effects of the Prenatal Plus Program in Colorado with respect to smoking, inadequate prenatal weight gain, and “psychosocial problems” (defined as “significant or severe stress as a result of personal or family safety needs, lack of support systems, or an inability to meet basic needs”).^48(p1955) Women who had at least 10 Prenatal Plus visits were more likely than were women who did not to reduce these risks; in addition, only 7.0% of women who resolved all of their risks delivered low-birthweight infants, whereas 13.2% of those who resolved none of their risks did so. In spite of these promising results, the nonexperimental nature of the Colorado study may have created unquantifiable biases favoring the intervention.Moreover, only 4% of all births in Colorado, and 7% of Prenatal Plus deliveries, occurred among African American women, the group at greatest risk of adverse pregnancy outcomes. Thus, further experimental investigations in which rigorous randomized trial designs are used to assess vulnerable African American women are needed to better appreciate the potential merits of an integrated intervention focusing on psychosocial and behavioral risk factors during pregnancy.We conducted a randomized clinical trial testing the efficacy of an integrated intervention targeting multiple behavioral and psychosocial risk factors among pregnant African American women in the District of Columbia. The risk factors we chose to address were cigarette smoking, secondhand smoke exposure, depression, and IPV.     

Life-Course Socioeconomic Position and Incidence of Diabetes Mellitus Among Blacks and Whites: The Alameda County Study, 1965�C1999

Objectives. We examined associations between several life-course socioeconomic position (SEP) measures (childhood SEP, education, income, occupation) and diabetes incidence from 1965 to 1999 in a sample of 5422 diabetes-free Black and White participants in the Alameda County Study.Methods. Race-specific Cox proportional hazard models estimated diabetes risk associated with each SEP measure. Demographic confounders (age, gender, marital status) and potential pathway components (physical inactivity, body composition, smoking, alcohol consumption, hypertension, depression, access to health care) were included as covariates.Results. Diabetes incidence was twice as high for Blacks as for Whites. Diabetes risk factors independently increased risk, but effect sizes were greater among Whites. Low childhood SEP elevated risk for both racial groups. Protective effects were suggested for low education and blue-collar occupation among Blacks, but these factors increased risk for Whites. Income was protective for Whites but not Blacks. Covariate adjustment had negligible effects on associations between each SEP measure and diabetes incidence for both racial groups.Conclusions. These findings suggest an important role for life-course SEP measures in determining risk of diabetes, regardless of race and after adjustment for factors that may confound or mediate these associations.Diabetes mellitus is a major cause of morbidity and mortality in the United States.^1,2 Type 2 diabetes disproportionately affects Hispanics, as well as non-Hispanic Black Americans, American Indians/Alaska Natives, and some Asian/Pacific Islander groups. In the United States, members of racial and ethnic minority groups are almost twice as likely to develop or have type 2 diabetes than are non-Hispanic Whites.^2–5 Significant racial and ethnic differences also exist in the rates of diabetes-related preventive services, quality of care, and disease outcomes.^6–10Researchers have attempted to determine why, relative to Whites, members of racial and ethnic minority groups are disproportionately affected by diabetes. For example, compared with White Americans, Black Americans are presumed to have stronger genetic^5,11 or physiological^11–13 susceptibility to diabetes, or greater frequency or intensity of known diabetes risk factors, such as obesity, physical inactivity, and hypertension.^14–17Black Americans also are more likely than are White Americans to occupy lower socioeconomic positions.¹⁸ Low socioeconomic position (SEP) across the life course is known to influence the prevalence^19–24 and incidence^3,19,25–30 of type 2 diabetes. The risk of diabetes also is greater for people who are obese,^3,17,31 physically inactive,^3,32 or have hypertension,^33,34 all of which are conditions more common among people with lower SEP.^16,35–37Several studies have focused on the extent to which socioeconomic factors, body composition (i.e., weight, height, body mass index, and waist circumference), and behaviors explain the excess risk of diabetes attributed to race.^4,12,19,30 For example, 2 separate studies, one with data from the Health and Retirement Study¹⁹ and the other with data from the Atherosclerosis Risk in Communities Study,³⁰ used race to predict diabetes incidence. Attempting to separate the direct and indirect effects of race on diabetes,³⁸ these studies assessed, via statistical adjustment, which socioeconomic measures and diabetes-related risk factors, when adjusted, could account for the excess risk among Black participants relative to White participants.^19,30 Adjustment for education lessened the effect of Black race on diabetes incidence in the Atherosclerosis Risk in Communities Study.³⁰ In the Health and Retirement Study, excess risk attributed to Black race was not explained by early-life socioeconomic disadvantage, but it was reduced after adjustment for education and later-life economic resources.¹⁹ The validity of this analytic approach has been challenged, however, because the socioeconomic measures used were assumed to have the same meaning across all racial/ethnic groups, a questionable assumption³⁸ in the United States, especially in 1965.We sought to explore the predictive effects of several life-course socioeconomic factors on the incidence of diabetes among both Black and White Americans. We examined demographic confounders (age, gender, marital status) and diabetes risk factors (obesity, large waist circumference, physical inactivity, high blood pressure, depression, access to health care) as possible mediators of the observed associations between SEP and incident diabetes (i.e., the development of new cases of diabetes over time).     

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

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

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

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