Revisiting the Role of the Urban Environment in Substance Use: The Case of Analgesic Overdose Fatalities

Objectives. We examined whether neighborhood social characteristics (income distribution and family fragmentation) and physical characteristics (clean sidewalks and dilapidated housing) were associated with the risk of fatalities caused by analgesic overdose.Methods. In a case-control study, we compared 447 unintentional analgesic opioid overdose fatalities (cases) with 3436 unintentional nonoverdose fatalities and 2530 heroin overdose fatalities (controls) occurring in 59 New York City neighborhoods between 2000 and 2006.Results. Analgesic overdose fatalities were less likely than nonoverdose unintentional fatalities to have occurred in higher-income neighborhoods (odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.70, 0.96) and more likely to have occurred in fragmented neighborhoods (OR = 1.35; 95% CI = 1.05, 1.72). They were more likely than heroin overdose fatalities to have occurred in higher-income (OR = 1.31; 95% CI = 1.12, 1.54) and less fragmented (OR = 0.71; 95% CI = 0.55, 0.92) neighborhoods.Conclusions. Analgesic overdose fatalities exhibit spatial patterns that are distinct from those of heroin and nonoverdose unintentional fatalities. Whereas analgesic fatalities typically occur in lower-income, more fragmented neighborhoods than nonoverdose fatalities, they tend to occur in higher-income, less unequal, and less fragmented neighborhoods than heroin fatalities.Rates of fatal overdoses caused by analgesic opioids have increased dramatically in the United States, particularly over the past 5 years.1–3 The prevalence of nonmedical analgesic drug abuse is second only to that of marijuana abuse, and currently the number of fatal overdoses attributed to opioid analgesics, such as oxycodone, hydrocodone, and codeine, is greater than the number attributed to heroin and cocaine combined.4Urban areas have long been associated with elevated risks of substance abuse and subsequent mortality from unintentional drug poisoning. From 1997 to 2002, the number of overdose deaths involving opioid analgesics increased 97% in urban areas during a time when the rate of overdose from all drugs increased 27%.5 From a public health burden standpoint, understanding the determinants of analgesic overdose mortality in large urban areas is critical to help stem the tide of mortality from analgesics, as all available data suggest that analgesic overdose mortality in these areas will continue to increase in the coming years.6Extant epidemiological research in the area has predominantly been concerned with the role of individual characteristics in explaining the prevalence of analgesic overdose throughout the United States.5,7–12 Analgesic opiate overdose decedents have been reported to be primarily White, male, and adult (ranging in age from 25 to 54 years) and to exhibit a high prevalence of concurrent psychotherapeutic drug use.5,7–10 However, several organizing frameworks in the field (principally rooted in ecosocial theory) suggest that environments operate jointly with individual factors to influence the risk of substance use.13–15In addition to individual characteristics such as psychiatric morbidity, genetic vulnerability, gender, and age,16–20 these frameworks suggest that interconnected components of influence shape drug use. These components include social policies and regulations that affect the allocation of social and health resources21–26; social and physical features of the neighborhood environment that structure the availability of drugs, influence norms around use, and generate sources of stress that contribute to drug use13,14,27–37; and interpersonal characteristics, such as social support and social networks, that mediate the relationship between the neighborhood environment and drug use.28,31,38–42 Despite this conceptual orientation, few studies have attempted to provide an understanding of the contextual factors that may explain the geographic distribution of analgesic overdose in an urban environment.Of particular interest in the urban context are the features of neighborhoods that can shape drug overdose. Established conceptual frameworks suggest 2 such features: primary determinants of infrastructure, employment, education, and health care resources, including residential segregation, income distribution, and neighborhood deprivation, and secondary determinants that are consequences of these fundamental conditions and may mediate their impact on drug use, including the quality of the built environment, social norms around drug use, and family fragmentation.15 Drawing on this framework, we examined 3 features of the neighborhood environment that have been previously linked with drug overdose: income distribution, quality of the built environment, and family fragmentation.35,37,43,44First, neighborhood income distribution has been consistently linked to drug abuse or overdose fatalities.27,35,44,45 For example, research has shown that in New York City neighborhoods with more unequal income distributions, drug overdoses are more likely than other causes to lead to unintentional deaths.35,44 The erosion of social capital and greater mistrust of authority found in more unequal neighborhoods may lead to a greater reluctance to seek medical help in cases of overdose.46 Furthermore, underinvestment in health and social resources could contribute to longer response times on the part of paramedics and limited access to substance abuse treatment. It is plausible that these same processes may drive a higher risk for analgesic opiate overdose in more unequal neighborhoods.Second, studies have shown a positive association between poor quality of the built environment (dilapidated buildings, vandalism of public property, and littering) and risk of drug overdose.43,44,46 Deterioration of the built environment has been linked with higher levels of distress.47 In turn, people with higher levels of distress may be more vulnerable to drug abuse and overdose than people low in distress.48,49 Moreover, reduced social capital reflected in a vandalized and littered built environment may discourage neighborhood residents from interacting with each other and from developing relationships that would enable to them to intervene to prevent the development of drug distribution networks in the neighborhood.50Third, family fragmentation (e.g., a high prevalence of divorced, separated, or single-parent families) represents a social mechanism through which neighborhoods may influence analgesic overdose. Disruption of the neighborhood social fabric may manifest in personal forms of disorganization within adult relationships.51,52 Studies of crime have shown that family disruption influences the collective ability of local residents to promote adult and youth conformity to local norms and laws.53–55 A high prevalence of fragmented families in a neighborhood reduces the neighborhood’s ability to monitor young people and respond to delinquency and crime.56 Such disorganization may have direct consequences in terms of access to and consumption of analgesics, given that the formation of drug-selling and drug-consuming networks may be more likely in neighborhoods where residents do not monitor delinquent activity consistently.57Furthermore, disrupted families may be less likely to exert informal control over the abuse of analgesics by other family members.57 Given that consumption of analgesics occurs most frequently at home,58 the absence of a family support and control net is particularly problematic.This study had 2 aims. First, we examined the roles that the 3 features of the neighborhood social and physical environment just described—income distribution, the quality of the built environment, and family fragmentation—play in the risk of unintentional death from analgesic overdose in New York City. Second, we examined whether analgesic opiate overdoses in New York City are driven by distinct neighborhood factors than heroin overdose, the historically most prevalent form of illicit opiate overdose in urban areas.59,60     

Expanded Access to Naloxone Among Firefighters,Police Officers,and Emergency Medical Technicians in Massachusetts

Naloxone is a medication that reverses respiratory depression from opioid overdose if given in time. Paramedics routinely administer naloxone to opioid overdose victims in the prehospital setting, and many states are moving to increase access to the medication. Several jurisdictions have expanded naloxone administration authority to nonparamedic first responders, and others are considering that step. We report here on policy change in Massachusetts, where several communities have equipped emergency medical technicians, law enforcement officers, and firefighters with naloxone.Fatal poisonings, more than 90% of which are drug overdoses, have increased by nearly 600% in the past 3 decades to become the leading cause of injury death in the United States.1This rise has been driven largely by opioid analgesic medications, which now account for more overdose deaths than heroin and cocaine combined.2 Although first responders are not always contacted in time to reverse overdose, emergency department encounters associated with opioids and other sedatives have increased markedly over the past decade.3To address this epidemic, many states are moving to increase community access to the opioid antagonist naloxone, which can reverse opioid overdose if administered in time.4,5 Nearly 200 community-based overdose prevention programs dispensed naloxone as of 2010, and participants reported reversing more than 10 000 overdoses.6 In Massachusetts, communities participating in a community naloxone access program had lower opioid overdose death rates than those that did not, strongly suggesting that increased access to naloxone can reduce fatal opioid overdose.7Naloxone is the standard medication for reversing opioid overdose, and is routinely administered by paramedics for that purpose. Although paramedics typically administer naloxone intramuscularly (IM) or intraveneously (IV), it can also be administered intranasally (IN) via a needleless atomizer. IN administration of naloxone has been shown to be similarly effective as IV administration in the prehospital setting,8–10 and in one study, IN naloxone administration was faster, better accepted, and perceived to be safer than IV administration.11In many areas, the first emergency personnel to respond to overdose calls are not paramedics but law enforcement officers, firefighters, and emergency medical technicians (EMTs; medical first responders who have a lower level of training than paramedics). The National Drug Control Strategy has called for equipping first responders to recognize and manage overdoses since 2010, and the Office of National Drug Control Policy has stated that naloxone “should be in the patrol cars of every law enforcement professional across the nation.”12 Although these first responders in most states are not authorized to administer naloxone, this is rapidly changing; in 2013, 5 states changed law or policy to permit EMTs to administer naloxone, bringing the total up to 13 states.13 Access to emergency prehospital care, including the provision of naloxone, may be an important piece in the overdose prevention puzzle. Nationwide, EMTs outnumber paramedics by approximately 3-to-1, and law enforcement officers are even more numerous.14 In rural areas, EMTs may be the only medical first responders, and hospital transport times can be long.15 A study in one large county demonstrated that EMT nasal naloxone administration could reduce time to naloxone delivery by between 5.7 and 10.2 minutes.16 In tiered EMS departments with high overdose call volume, efficiencies may be created by dispatching EMTs instead of paramedics to overdose calls, reducing response time, and making paramedics available to respond to emergencies that require a higher level of skill and training.16,17We provide an overview of policy change in 3 communities in Massachusetts that expanded naloxone access to firefighters, EMTs, and police officers, and offer some brief thoughts on what this change might mean for other jurisdictions.     

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.     

Consistency and Change in Club Drug Use by Sexual Minority Men in New York City, 2002 to 2007

We used repeated cross-sectional data from intercept surveys conducted annually at lesbian, gay, and bisexual community events to investigate trends in club drug use in sexual minority men (N = 6489) in New York City from 2002 to 2007. Recent use of ecstasy, ketamine, and γ-hydroxybutyrate decreased significantly. Crystal methamphetamine use initially increased but then decreased. Use of cocaine and amyl nitrates remained consistent. A greater number of HIV-positive (vs HIV-negative) men reported recent drug use across years. Downward trends in drug use in this population mirror trends in other groups.“Club drugs” are illicit substances consumed in social or party situations¹ to increase social disinhibition and heighten sensual and sexual experiences.^2,3 This category typically includes ecstasy (3,4 methylenedioxymethamphetamine), γ-hydroxybutyrate (GHB), and ketamine,⁴ although recent reports also have included cocaine⁵ and crystal methamphetamine.⁶Concern about club drug use has increased because of consistent associations with unprotected sexual intercourse.^7–9 Given the high rates of use⁴ among men who have sex with men, most club drug research has focused on this population—and on identified gay and bisexual men specifically.^10,11 Published prevalence estimates are quite variable, ranging, for example, from 6% to 65% for crystal methamphetamine^9,12 and from 7% to 93% for ecstasy.^13,14 However, epidemiological trends remain unknown, and most studies contributing prevalence data have 1 or more significant limitations, including use of cross-sectional designs or small sample sizes, recruitment solely at bars or circuit parties, or investigation of some but not all club drugs.We used a repeated cross-sectional design¹⁵ to investigate trends in the prevalence of recent club drug use (and amyl nitrates or “poppers”) between 2002 and 2007 among urban sexual minority men. Given consistent differences in rates of use between HIV-positive and HIV-negative men, we reported differences by HIV serostatus.     

Health Information–Seeking Behaviors,Health Indicators,and Health Risks

Objectives. We examined how different types of health information–seeking behaviors (HISBs)—no use, illness information only, wellness information only, and illness and wellness information combined—are associated with health risk factors and health indicators to determine possible motives for health information seeking.Methods. A sample of 559 Seattle–Tacoma area adults completed an Internet-based survey in summer 2006. The survey assessed types of HISB, physical and mental health indicators, health risks, and several covariates. Covariate-adjusted linear and logistic regression models were computed.Results. Almost half (49.4%) of the sample reported HISBs. Most HISBs (40.6%) involved seeking a combination of illness and wellness information, but both illness-only (28.6%) and wellness-only (30.8%) HISBs were also widespread. Wellness-only information seekers reported the most positive health assessments and the lowest occurrence of health risk factors. An opposite pattern emerged for illness-only information seekers.Conclusions. Our findings reveal a unique pattern of linkages between the type of health information sought (wellness, illness, and so on) and health self-assessment among adult Internet users in western Washington State. These associations suggest that distinct health motives may underlie HISB, a phenomenon frequently overlooked in previous research.Internet access is a widely available technology in the United States.^1,2 Among the variety of online activities, searching for and using health information appear to be particularly prevalent, undertaken by between 40% and 70% of US adults.^1,3–7 Hoping to take advantage of the Internet''s potential,⁸ public health practitioners, clinicians, and researchers have contributed to an emerging literature detailing characteristics of individuals engaging in health information–seeking behaviors (HISBs), exploring motives for engaging in HISBs, and documenting the types of health and medical information being sought.^9–11Previous HISB research has primarily examined how patients seek and use health information across diverse health care contexts, yielding the recurrent observation that individuals striving to deal with stressful health challenges—such as a recent illness diagnosis or chronic disease management—were strongly motivated to engage in Internet HISBs.^9,10,12–14 Several population-based studies,^9,15–21 many of which have also conceptualized HISB primarily as “a key coping strategy in health-promotive activities and psychosocial adjustment to illness,”^22(p1006) have yielded corresponding evidence. It should be recognized, however, that a cluster of these studies^17–19,21 were informed by a common evidentiary resource (i.e., 2000–2002 Pew Internet and American Life Project data), potentially exaggerating the apparent consistency of the “disease and illness” motivation for HISB.Although informative, the predominant focus in previous research on a “disease and illness” motive for HISB has left the hypothesis that healthy individuals may pursue information to maximize positive health outcomes essentially unexplored.²³ A small but growing body of findings suggests, however, that many individuals actively seek out wellness information (e.g., information promoting a healthy lifestyle). Specifically, emerging evidence reveals a positive association between a self-reported “health-conscious” or “health-active” orientation and engaging in wellness information–seeking behavior.^20,24–27 Indeed, since 2000, the proportion of American adults reporting that they have looked online for diet, exercise, or fitness information has increased substantially and generally exceeds the proportion seeking online information about disease and illness topics (e.g., cancer, arthritis, diabetes).^28,29Pandey et al. have asked, “Is it a disease or an affliction that motivates the use of the internet, or is it that the well and the healthy use the internet in a proactive manner?”^23(p180) As this question highlights, the nearly exclusive focus in previous research on Internet HISB as a response to health-threatening situations has left questions regarding the potential positive health outcomes motivating HISB unanswered.²² We aimed to fill this knowledge gap and further expand understanding of linkages between HISB and health perceptions and behaviors. Specifically, we compared mental and physical health indicators and health risk factors across 4 discrete categories of Internet HISBs—no use, illness content only, wellness content only, and illness and wellness content combined—among a sample of adults in the Seattle–Tacoma, Washington area to explore motivations of HISB.     

All Rural Places Are Not Created Equal: Revisiting the Rural Mortality Penalty in the United States

Objectives. I investigated mortality disparities between urban and rural areas by measuring disparities in urban US areas compared with 6 rural classifications, ranging from suburban to remote locales.Methods. Data from the Compressed Mortality File, National Center for Health Statistics, from 1968 to 2007, was used to calculate age-adjusted mortality rates for all rural and urban regions by year. Criteria measuring disparity between regions included excess deaths, annual rate of change in mortality, and proportion of excess deaths by population size. I used multivariable analysis to test for differences in determinants across regions.Results. The rural mortality penalty existed in all rural classifications, but the degree of disparity varied considerably. Rural–urban continuum code 6 was highly disadvantaged, and rural–urban continuum code 9 displayed a favorable mortality profile. Population, socioeconomic, and health care determinants of mortality varied across regions.Conclusions. A 2-decade long trend in mortality disparities existed in all rural classifications, but the penalty was not distributed evenly. This constitutes an important public health problem. Research should target the slow rates of improvement in mortality in the rural United States as an area of concern.Recent research has identified a new trend in rural–urban, macrolevel mortality disparities in the United States, called the rural mortality penalty.1,2 Historically, there has been a penalty associated with urban places; however, in recent decades, a reversal has occurred. Beginning in the mid-1980s, rural and urban mortality rates diverged, and the gap between them has grown for more than 2 decades. According to previous publications that introduced the rural mortality penalty, the rural United States is an aggregation of 6 nonmetropolitan designations distinguished by population size and adjacency to an urban area; this is a typology used in many previous studies.3,4 This research uncovers the disproportionate mortality burden across these rural classifications.Throughout the 19th and early 20th centuries, there was a mortality penalty associated with urban areas.5 The urban mortality penalty was largely attributed to the spread of contagious and infectious disease,6,7 poor water quality,8 and inadequate sewage disposal9 in densely populated areas.10,11 The first half of the 20th century transformed urban cities because of public works projects that improved water quality and sanitation8 and public health advancements that included vaccinations, quarantines, physical examinations, health education, workplace safety, food quality, and controlling medication.5 The result was unprecedented improvements in urban health from 1900 to 1940, highlighted by a 40% decline in mortality, an increased life expectancy from 47 to 63 years,8,12 and generally equivalent rural and urban mortality rates.5 This pattern persisted until the mid-1980s, when the rural mortality penalty emerged. Public health advances, however important, did not encompass all determinants of mortality.The major determinants of mortality in the rural United States exist at the individual, structural, or contextual levels. Individual-level determinants include use of self-care,13,14 low satisfaction of care,14,15 lack of a regular source of care,15,16 and lifestyle and behaviors.17,18 Structural and contextual determinants include poverty,15 high rates of female-headed households,19 degree of urbanization,15 age structure of the population,20,21 income inequality,22 high rates of chronic illnesses,23 access to care,13,15,24,25 physician and hospital shortages,26–28 and unique cultural characteristics,29,30 including an identity of resiliency.31 Furthermore, macrolevel restructuring because of immigration and suburbanization has occurred in many rural communities. These changes create diverse economic opportunities,19,32–34 populations,34–37 and changing demographic characteristic structures.34,37 Traditional social, racial, and ethnic boundaries have blurred,34–37 and the cultural gap between rural and urban places has shrunk,34,37 changing how we understand the dynamics among demographic, social, and economic processes, resources, constraints, and health policies in people’s pursuit of better health.37Innovative research investigating regional disparities in health outcomes has been published in the last decade, but there remains a gap in understanding intrarural differences. A recent study of life expectancy found widening disparities across rural–urban categories over a 40-year period, with poor rural Blacks having the lowest survival probability.38 Another regional study of mortality, titled “Eight Americas” uncovered disparities in life expectancy, mortality, health insurance, and health care utilization by regions based on race, county, population density, race-specific county level per capita income, and homicide rate.39,40 This work highlighted the complexity of “place” and its role in eliminating health disparities across population segments.41 The rural United States is complex, and is often treated as a “nonurban” residual category lacking a clear conceptualization of poverty, opportunity structure, and other social processes.42–44 With the emergent rural mortality penalty, it is paramount to understand the context and conditions unique to the rural part of the country.29,30 I sought to uncover differing mortality profiles and determinants across rural regions.     

Question Context and Priming Meaning of Health: Effect on Differences in Self-Rated Health Between Hispanics and Non-Hispanic Whites

Objectives. We examined the implications of the current recommended data collection practice of placing self-rated health (SRH) before specific health-related questions (hence, without a health context) to remove potential context effects, between Hispanics and non-Hispanics.Methods. We used 2 methodologically comparable surveys conducted in English and Spanish that asked SRH in different contexts: before and after specific health questions. Focusing on the elderly, we compared the influence of question contexts on SRH between Hispanics and non-Hispanics and between Spanish and English speakers.Results. The question context influenced SRH reports of Spanish speakers (and Hispanics) significantly but not of English speakers (and non-Hispanics). Specifically, on SRH within a health context, Hispanics reported more positive health, decreasing the gap with non-Hispanic Whites by two thirds, and the measurement utility of SRH was improved through more consistent mortality prediction across ethnic and linguistic groups.Conclusions. Contrary to the current recommendation, asking SRH within a health context enhanced measurement utility. Studies using SRH may result in erroneous conclusions when one does not consider its question context.Hispanics in the United States have emerged as an important group for public health research because of their noteworthy population growth. The past decade saw a rapid increase of the Hispanic population from 35.3 million to 50.5 million, corresponding to 12.5% and 16.3% of the total population.1 In states such as California, New Mexico, and Texas, Hispanics make up more than 35% of the population. Although not the majority in the general population, Hispanics contributed more than half of the US population growth.One distinctive characteristic of Hispanics is their language use. Four out of 10 Hispanics are reported to speak English less than very well, hence being classified as “linguistically isolated.”2 The linguistic isolation rate is estimated to be more than 90% for some Hispanic subgroups, such as older low-income Cuban women in Miami.3 Although not a health risk factor itself, low English proficiency (LEP) is related to many health outcomes through the socioeconomic gradient, such as education, poverty, and access to health care. Because the failure to capture LEP persons produces data misrepresenting the population,4–6 it has become standard practice for government and academic surveys in the United States to conduct interviews in both English and Spanish. The National Health Interview Survey (NHIS), for example, has conducted Spanish interviews consistently since 1997 and with standardized translated questionnaires since 2004.Hispanics’ health has been compared with that of other racial/ethnic groups,7–11 creating a famous term, “Hispanic paradox.” Even though correlates of health, such as income and education, are estimated to be lower for Hispanics than for non-Hispanic Whites, Hispanics show better health outcomes than non-Hispanic Whites or comparable health outcomes to non-Hispanic Whites.12–18 One exception to the paradox is the measure self-rated health (SRH), which consistently shows less favorable outcomes for Hispanics compared with non-Hispanic Whites.7,19,20 Self-rated health is a simple survey item asking respondents for their subjective assessment about their own health by using some variations of a 4- or 5-point Likert response scale. One of the scales ranging from “excellent,” “very good,” “good,” “fair,” to “poor” is popular in the United States, and another scale using “very good” to “very poor,” supported by the World Health Organization, is popular elsewhere.21The popularity of SRH not only in health research22–26 but also in other social sciences27–31 led the US National Center for Health Statistics to organize a conference dedicated to this particular item, the Conference on the Cognitive Aspects of the Self-Rated Health Status, in 1993.32 Because of its proven utility as a strong and independent predictor of subsequent mortality,33–39 various health conditions,40-43 and health care utilization,44–46 the World Health Organization,47 the US Centers for Disease Control and Prevention,48 and the European Commission49 have recommended SRH as a reliable measure of monitoring population health.Self-rated health is also used as a practical tool for comparing various population groups associated with country,50–52 gender,53 race,41 socioeconomic status,54,55 educational attainment,56 poverty status,57 and immigration status,58 often leading to discussions about health disparities. Although it is critical to use items with comparable measurement properties across comparison groups, the measurement utility of SRH has been mostly examined with English speakers or northern Europeans.44,59–61 Beyond these groups, the performance of SRH has been found to be inconsistent, leading to questionable comparability.9,21,25,29,62–68The literature on the utility of SRH for US Hispanics is spotty and does not provide clear conclusions and appears to have overlooked methodological limitations in the data.8,10,64,69 Some studies have used data that did not include LEP Hispanics,64 and some used SRH asked in different contexts.8,10,69 The former is no longer a serious issue because the current survey practice accommodates LEP Hispanics. However, the question context may raise a concern as it has been suggested as a future research topic for SRH,70,71 including the seminal work by Idler and Benyamini.36Particularly for Hispanics, a recent study by Lee and Grant72 suggests troublesome implications. They conducted an experiment where the order of SRH in a questionnaire was randomized: SRH was asked as either a first health-related item after a few demographic questions (i.e., without a health context) or after a series of questions on chronic health conditions (i.e., within a health context). Whereas English-speaking respondents’ SRH reports remained consistent regardless of the question context, Spanish-speaking respondents’ reports were found to be unstable depending on the context. Specifically, Spanish-speaking respondents reported significantly and substantively better health on SRH asked within than without a health context. Reflecting LEP among Hispanics, their SRH rating was also affected by the question context. The question context effect is of concern in its own right. When the context interacts with interview language or respondents’ cultural background as in this example, it becomes even more important, because systematic incomparability is introduced.We further examined the effect of SRH question contexts with the US elderly population. Using data from surveys conducted in both English and Spanish, we examined how the question context affects (1) the estimates of SRH for each linguistic group, (2) the comparisons of health between 2 linguistic groups, and (3) the predictive power of SRH for subsequent mortality. Because Spanish-language use is tightly related to ethnicity, we also included Hispanics and non-Hispanics in the study.     

Utilizing Screening,Brief Intervention,and Referral to Treatment: Teaching Assessment of Substance Abuse

Although social workers regularly encounter clients with substance use problems, social work education rarely addresses addictions with any depth. This pilot study explored the use of screening, brief intervention, and referral to treatment (SBIRT) with 74 social work students. Students completed SBIRT training with pre- and post-questionnaires that assessed attitudes, knowledge, and skills concerning substance misuse. Statistically significant differences were demonstrated with students reporting more confidence in their ability to successfully assess for alcohol misuse and subsequently intervene.Substance misuse in the United States is high; 30% of adults engage in at-risk drinking.1 At-risk drinking (typically categorized as “misuse”) does not meet diagnostic criteria for abuse or dependence and is inconsistently identified. Because approximately 70% of the US adult population sees a primary care physician at least once every 2 years,2 a screening and brief intervention model for substance misuse was developed for primary care settings.Screening, brief intervention, and referral to treatment (SBIRT)3 is based on the transtheoretical model of change,4 incorporating motivational interviewing to “briefly intervene” with patients who are at-risk drinkers. The transtheoretical model presents 5 stages of client readiness to change: precontemplation (change is not considered); contemplation (some awareness of consequences but ambivalence to change); preparation (change is planned); action (change begins); and maintenance (change is managed).4 The idea is to “meet the patient where they are.” SBIRT is efficacious with assessing and intervening with at-risk drinkers in primary care settings5–7 and emergency departments8,9; however, SBIRT has not been integrated into social work education or practice.Social workers are employed in a variety of venues. Like other health care professionals, they are not necessarily trained to identify or treat misuse. Less than 10% of accredited social work programs offer a graduate certificate specific to substance abuse.10 Research shows similar barriers to screening among health care providers: lack of training to assess alcohol misuse, how to or when to screen for it, and what to do if the client indicates a need for treatment.11 Training practitioners can be effective in increasing confidence in screening and intervention as well as improving attitudes toward people with alcohol problems.12–15This pilot study assessed social work students’ attitudes, perceived skills, and knowledge of alcohol misuse before and after receiving training on SBIRT. We hypothesized that students would improve skills and knowledge of substance misuse as well as improve attitudes toward people who misuse alcohol.