Peer Reviewed: Awareness of Racial and Socioeconomic Health Disparities in the United States: The National Opinion Survey on Health and Health Disparities, 2008-2009

Introduction

Recent initiatives aim to improve public awareness of health disparities. However, little research has actually documented the US public''s awareness of racial/ethnic and socioeconomic health disparities. We sought to determine 1) whether the US public is aware of racial, educational, and income disparities in health, 2) whether awareness differs across these disparity domains, and 3) what respondent characteristics are associated with awareness of racial, educational, and income disparities in health.

Methods

We conducted the National Opinion Survey on Health and Health Disparities with 2,791 US adults. We asked respondents to answer questions about disparities in health between 1 of several pairs of population subgroups: African Americans versus whites, non–high school graduates versus high school graduates, high school graduates versus college graduates, the poor versus the middle class, or the middle class versus the rich. We used χ² tests and logistic regression to compare correlates of respondents'' awareness of disparities across the different pairs of population subgroups.

Results

Most respondents were aware of health disparities between the poor and middle class (73%); fewer were aware of health disparities between African Americans and whites (46%). Although respondents recognized that education is associated with many positive life outcomes, they were less aware of the link between education and health. Respondents who were younger, less educated, lower-income, healthier, or politically conservative were less likely to be aware of health disparities.

Conclusion

Public awareness of disparities in health differs depending on both the type of disparity and the characteristics of the individual respondent.     

On the Outskirts of National Health Reform: A Comparative Assessment of Health Insurance and Access to Care in Puerto Rico and the United States

Context

Puerto Rico is the United States’ largest territory, home to nearly 4 million American citizens. Yet it has remained largely on the outskirts of US health policy, including the Affordable Care Act (ACA). This article presents an overview of Puerto Rico’s health care system and a comparative analysis of coverage and access to care in Puerto Rico and the mainland United States.

Methods

We analyzed 2011-2012 data from the Behavioral Risk Factor Surveillance System, and 2012 data from the American Community Survey and its counterpart, the Puerto Rico Community Survey. Among adults 18 and older, we examined health insurance coverage; access measures, such as having a usual source of care and cost-related delays in care; self-reported health; and the receipt of recommended preventive services, such as cancer screening and glucose testing. We used multivariate regression models to compare Puerto Rico and the mainland United States, adjusted for age, income, race/ethnicity, and other demographic variables.

Findings

Uninsured rates were significantly lower in Puerto Rico (unadjusted 7.4% versus 15.0%, adjusted difference: −12.0%, p < 0.001). Medicaid was far more common in Puerto Rico. Puerto Rican residents were more likely than those in the mainland United States to have a usual source of care and to have had a checkup within the past year, and fewer experienced cost-related delays in care. Screening rates for diabetes, mammograms, and Pap smears were comparable or better in Puerto Rico, while colonoscopy rates were lower. Self-reported health was slightly worse, but obesity and smoking rates were lower.

Conclusions

Despite its far poorer population, Puerto Rico outperforms the mainland United States on several measures of coverage and access. Congressional policies capping federal Medicaid funds to the territory, however, have contributed to major budgetary challenges. While the ACA has significantly increased federal resources in Puerto Rico, ongoing restrictions on Medicaid funding and premium tax credits are posing substantial health policy challenges in the territory.     

Peer Reviewed: Factors Associated With Cervical Cancer Screening in Puerto Rico

Introduction

Racial/ethnic disparities in cervical cancer screening exist in the United States; rates are lowest among women who live in Puerto Rico. We identified factors associated with cervical cancer screening among women aged 18 years or older living in Puerto Rico.

Methods

We included women who participated in the Puerto Rico Behavioral Risk Factor Surveillance System in 2006 who had not had a hysterectomy (n = 2,206). We calculated the weighted population prevalence estimates of Papanicolaou (Pap) test screening in the past 3 years and used logistic regression models to assess factors associated with screening.

Results

Most participants (71.9% [95% confidence interval (CI)Most participants (71.9% [95% confidence interval (CI) = 69.4%-74.4%]) reported having had a Pap test in the preceding 3 years. Factors associated with screening in multivariate analysis included routine checkup in the past year and leisure-time physical activity. Compared with women with a household income less than $15,000, those with higher incomes were more likely to have had a Pap test. Similarly, divorced or separated women were more likely to have been screened (odds ratio [OR] = 1.13; 95% CI = 1.12-1.15) than those who were married/living together. We did not find associations between screening behavior and education, health care coverage, body mass index, or smoking status.

Conclusion

The prevalence of cervical cancer screening in Puerto Rico is below the 90% recommendation established by Healthy People 2010. Our findings regarding factors associated with Pap screening behavior identified population subgroups who are underscreened and who may benefit from targeted interventions and screening programs.     

Peer Reviewed: Assessing Colorectal Cancer Screening Knowledge at Tribal Fairs

Introduction

Increasing public awareness and knowledge about the need for colorectal cancer (CRC) screening among American Indians is key to reducing health disparities. The objective of this study was to assess Navajo adults'' knowledge of CRC risk factors and prevention, CRC screening, and self-reported experience with CRC screening.

Methods

We collected data generated by a self-administered survey given to Navajo adults, most of whom lived on the reservation. Data were collected at 2 annual tribal fairs in 2006. Fair attendees who visited an exhibit booth completed a CRC knowledge survey. The study design was nonrandomized.

Results

Of the 285 Navajo adults who participated, most were bilingual (74%) and female (80%). Of the respondents aged 50 years or older, 77% had heard of CRC screening and 28% reported being screened for colon or colorectal cancer. Knowledge was high (mean, 5.78 [standard deviation (SD), 1.28]) (8.0 was the highest possible knowledge score). Respondents with little or no formal schooling had lower scores (mean, 5.4), indicating less knowledge of CRC and associated screening tests than did those with more education (mean, 6.0).

Conclusion

Among a sample of Navajo adults aged 50 years or older, participants with more education were more likely to be knowledgeable about CRC and to have received screening. This survey, led by a Navajo investigator with Navajo surveyors, revealed a high awareness of CRC and screening, but overall CRC screening was low. CRC education for Navajo adults who have little or no formal schooling should be improved.     

Peer Reviewed: Awareness, Use, and Perceptions of Low-Carbohydrate Diets

Introduction

Low-carbohydrate diets (LCDs) have regained popularity in recent years, but public awareness and perceived healthfulness of LCDs have not been explored. We describe population awareness, use, and perceptions of the healthfulness of LCDs and examine differences by sociodemographic and communication variables.

Methods

Nationally representative data from the Health Information National Trends Survey (HINTS 2005) were analyzed by using multivariate logistic regression to examine independent correlates of awareness, use, and perceptions of the healthfulness of LCDs.

Results

Awareness of LCDs in the United States was high (86.6%). Independent correlates of awareness included being a college graduate, being non-Hispanic white, and having a high body mass index (BMI). Among respondents who were aware of LCDs, approximately 17% had tried LCDs during the last year. Independent correlates of LCD use included being a woman and having a high BMI. One-third of respondents who were aware of LCDs agreed that they are a healthy way to lose weight. Independent correlates of perceived LCD healthfulness included not being a high school graduate and being likely to change behavior in response to new nutrition recommendations.

Conclusion

This study is among the first to explore correlates of awareness, use, and perceptions of LCDs in a nationally representative sample. Despite high levels of awareness of LCDs, these diets are not used frequently and are not perceived as being healthy.     

Epidemiology of hypertension in Serbia: results of a National Survey

Background

We evaluated the prevalence of high blood pressure and the level of awareness, treatment, and control of hypertension in a Serbian population.

Methods

A cross-sectional study of an adult population was carried out across Serbia in 2006. The study involved 14 204 adults aged 20 years or older. Interviews and measurements of blood pressure were performed at participants’ homes.

Results

Overall, 47% of the Serbian adult population had hypertension: 25.3% had stage 1 hypertension and 18.1% had stage 2 hypertension. Only 58.0% of the hypertensive population were aware that they had the disease, and 60.4% were receiving medical treatment. Among those receiving medical treatment, only 20.9% had a blood pressure within the normal range. One in 10 participants with hypertension were not treated because, among other reasons, they thought treatment was unnecessary (55.3%) or they lacked money for medication (19.3%).

Conclusions

The prevalence of undiagnosed and untreated hypertension is high in the adult population of Serbia. Further action is required to hasten detection and treatment of high blood pressure. Attention should be directed toward educational programs that improve knowledge, attitudes, and awareness of hypertension among adults.Key words: hypertension, adult population, Serbia     

The Use of Task-based Cognitive Tests for Defining Vocational Aptness of Individuals with Disabilities

Objectives

The purpose of this study was to demonstrate the use of task-based cognitive tests to detect potential problems in the assessment of work training for vocational rehabilitation.

Methods

Eleven participants with a normal range of cognitive functioning scores were recruited for this study. Participants were all trainees who participated in a vocational training program. The Rey Complex Figure Test and the Allen Cognitive Level Screen were randomly administered to all participants. Responses to the tests were qualitatively analyzed with matrix and scatter charts.

Results

Observational outcomes derived from the tests indicated that response errors, distortions, and behavioral problems occurred in most participants. These factors may impede occupational performance despite normal cognitive function. These findings suggest that the use of task-based tests may be beneficial for detecting potential problems associated with the work performance of people with disabilities.

Conclusion

Specific analysis using the task-based tests may be necessary to complete the decision-making process for vocational aptness. Furthermore, testing should be led by professionals with a higher specialization in this field.     

Peer Reviewed: Prevalence of Self-Reported Prediabetes Among Adults Participating in a Community-Based Health Awareness Program,New York State

Introduction

The purpose of this study was to assess crude, age-adjusted, and risk-factor–specific prevalences of self-reported prediabetes and to identify factors associated with self-reported prediabetes in an adult population.

Methods

Data were collected through questionnaires completed by a racially diverse sample of diabetes-free adult participants in the statewide community-based wellness and diabetes awareness program in New York State during 2006 (N = 2,572). Prediabetes was determined by the affirmative answer to the question, "Have you ever been told by a doctor that you have prediabetes?"

Results

The overall crude prevalence of self-reported prediabetes was 9.1%, and the age-adjusted prevalence was 7.6%. The age-adjusted prevalence of prediabetes was significantly lower among non-Hispanic blacks (4.2%) and significantly higher among American Indians (22.4%), compared with the prevalence among non-Hispanic whites (7.3%). The prevalence of self-reported prediabetes was uniformly higher among older (aged ≥45 years) adults than younger (aged <45 years) adults, overall and in each racial/ethnic group. In all age and racial/ethnic groups, the prevalence significantly increased with the number of additional risk factors. The best fit multivariate logistic regression model identified that self-reported prediabetes was associated with family history of diabetes (odds ratio [OR], 3.65), body mass index 25.0 kg/m² or higher (OR, 2.79), age 45 years or older (OR, 2.77), and having health insurance (OR, 2.38).

Conclusion

This study found that adults who were at high risk for diabetes and had health insurance were more likely to report having prediabetes. Community-based diabetes prevention needs to consider strategies to increase detection of prediabetes in high-risk uninsured people and to raise general awareness of prediabetes.     

Peer Reviewed: Prevalence,Awareness, Treatment,and Control of High LDL Cholesterol in New York City, 2004

Introduction

Low-density lipoprotein (LDL) cholesterol is a major contributor to coronary heart disease and the primary target of cholesterol-lowering therapy. Substantial disparities in cholesterol control exist nationally, but it is unclear how these patterns vary locally.

Methods

We estimated the prevalence, awareness, treatment, and control of high LDL cholesterol using data from a unique local survey of New York City''s diverse population. The New York City Health and Nutrition Examination Survey 2004 was administered to a probability sample of New York City adults. The National Health and Nutrition Examination Survey 2003-2004 was used for comparison. High LDL cholesterol and coronary heart disease risk were defined using National Cholesterol Education Program Adult Treatment Panel III (ATP III) guidelines.

Results

Mean LDL cholesterol levels in New York City and nationally were similar. In New York City, 28% of adults had high LDL cholesterol, 71% of whom were aware of their condition. Most aware adults reported modifying their diet or activity level (88%), 64% took medication, and 44% had their condition under control. More aware adults in the low ATP III risk group than those in higher risk groups had controlled LDL cholesterol (71% vs 33%-42%); more whites than blacks and Hispanics had controlled LDL cholesterol (53% vs 31% and 32%, respectively).

Conclusions

High prevalence of high LDL cholesterol and inadequate treatment and control contribute to preventable illness and death, especially among those at highest risk. Population approaches — such as making the food environment more heart-healthy — and aggressive clinical management of cholesterol levels are needed.     

Psychological distress and the perception of radiation risks: the Fukushima health management survey

Objective

To assess relationships between the perception of radiation risks and psychological distress among evacuees from the Fukushima nuclear power plant disaster.

Methods

We analysed cross-sectional data from a survey of evacuees conducted in 2012. Psychological distress was classified as present or absent based on the K6 scale. Respondents recorded their views about the health risks of exposure to ionizing radiation, including immediate, delayed and genetic (inherited) health effects, on a four-point Likert scale. We examined associations between psychological distress and risk perception in logistic regression models. Age, gender, educational attainment, history of mental illness and the consequences of the disaster for employment and living conditions were potential confounders.

Findings

Out of the 180 604 people who received the questionnaire, we included 59 807 responses in our sample. There were 8717 respondents reporting psychological distress. Respondents who believed that radiation exposure was very likely to cause health effects were significantly more likely to be psychologically distressed than other respondents: odds ratio (OR) 1.64 (99.9% confidence interval, CI: 1.42–1.89) for immediate effects; OR: 1.48 (99.9% CI: 1.32–1.67) for delayed effects and OR: 2.17 (99.9% CI: 1.94–2.42) for genetic (inherited) effects. Similar results were obtained after controlling for individual characteristics and disaster-related stressors.

Conclusion

Among evacuees of the Fukushima nuclear disaster, concern about radiation risks was associated with psychological distress.     

Peer Reviewed: Changes in Tobacco Quitlines in the United States, 2005-2006

Introduction

Telephone quitlines are an effective way to provide evidence-based tobacco dependence treatment services at the population level. Information about what services quitlines offer and how those services are used may improve their reach to the smoking population.

Methods

The North American Quitline Consortium surveyed state quitlines in 2005 and 2006 to get information about quitline services, funding, and use. We report changes between 2005 and 2006.

Results

By 2006, all 50 states, the District of Columbia, and Puerto Rico had quitlines, and annual mean reach was approximately 1% of US adult smokers (aged 18 years or older). Significant increases were seen in mean quitline reach, mean per capita funding for quitline services, and provision of free cessation medications; otherwise, few changes were seen in quitline services.

Conclusions

Quitlines have the potential to serve a large percentage of smokers. Between 2005 and 2006, gains in the number, reach, and per capita funding for quitline services in the United States were seen. Although this represents progress, further research and investment to optimize quitline service delivery and reach are required for quitlines to fulfill their potential of improving the health of the American population.     

Genetic Vulnerability as a Distal Risk Factor for Suicidal Behaviour: Historical Perspective and Current Knowledge

Introduction

Suicide is a multidimensional problem. Observations of family history of suicide suggest the existence of a genetic vulnerability to suicidal behaviour.

Aim

Starting with a historical perspective, the article reviews current knowledge of a genetic vulnerability to suicidal behaviour, distinct from the genetic vulnerability to psychiatric disorders, focused on clinical and population-based studies, and findings from recent molecular genetics association studies.

Method

The review includes peer-reviewed research articles and review papers from the professional literature in English language, retrieved from PubMed/Medline and PsycINFO.

Results

The research literature confirms a existence of a genetic vulnerability to suicidal behaviour. Even though the results of individual studies are difficult to compare, genetic influences could explain up to half of the variance of the occurrence of suicide.

Conclusion

Genetic vulnerability could be a distal risk factor for suicide, which helps us to understand the occurrence of suicide among vulnerable people. Ethical implications of such vulnerability are highlighted.     

Peer Reviewed: Adult Tobacco Use Among Racial and Ethnic Groups Living in the United States, 2002–2005

Introduction

U.S. data on adult tobacco use and the relationship between such use and tobacco-related health disparities are primarily limited to broad racial or ethnic populations. To monitor progress in tobacco control among adults living in the United States, we present information on tobacco use for both aggregated and disaggregated racial and ethnic subgroups.

Methods

We used data from the nationally representative sample of adults aged 18 years or older who participated in the National Survey on Drug Use and Health conducted 4 times during 2002–2005. We calculated 2 outcome measures: 1) use of any tobacco product (cigarettes, chewing or snuff tobacco, cigars, or pipes) during the 30 days before each survey and 2) cigarette smoking during the 30 days before each survey.

Results

The prevalence of tobacco use among adults aged 18 years or older varied widely across racial or ethnic groups or subgroups. Overall, about 3 of 10 adults living in the United States were tobacco users during the 30 days before being surveyed. The population groups or subgroups with a tobacco-use prevalence of 30% or higher were African Americans, American Indians or Alaska Natives, Native Hawaiians or other Pacific Islanders, Puerto Ricans, and whites.

Conclusion

These results indicate that the prevalence of adult tobacco use is still high among several U.S. population groups or subgroups. Our results also support the need to design and evaluate interventions to prevent or control tobacco use that would reach distinct U.S. adult population groups or subgroups.     

Care Coordination for the Chronically Ill: Understanding the Patient's Perspective

Objective

To identify factors associated with perception of care coordination problems among chronically ill patients.

Methods

Patient-level data were obtained from a random-digit dial telephone survey of adults with chronic conditions. The survey measured respondents'' self-report of care coordination problems and level of patient activation, using the Patient Activation Measure (PAM-13). Logistic regression was used to assess association between respondents'' self-report of care coordination problems and a set of patient characteristics.

Results

Respondents in the highest activation stage had roughly 30–40 percent lower odds of reporting care coordination problems compared to those in the lowest stage (p < .01). Respondents with multiple chronic conditions were significantly more likely to report coordination problems than those with hypertension only. Respondents'' race/ethnicity, employment, insurance status, income, and length of illness were not significantly associated with self-reported care coordination problems.

Conclusion

We conclude that patient activation and complexity of chronic illness are strongly associated with patients'' self-report of care coordination problems. Developing targeted strategies to improve care coordination around these patient characteristics may be an effective way to address the issue.     

Age at Smoking Initiation in Slovenia

Background

Smoking is initiated mostly by adolescents and young adults. In Slovenia, we have limited data about this. The purpose of this paper is to show data on age at smoking initiation and differences in age at smoking initiation by gender, age groups, education, social class and geographical region among inhabitants of Slovenia.

Methods

We used data from the cross-sectional survey ‘Health-related behaviour 2012’ in Slovenian population aged from 25 to 74 years.

Results

4591 ever smokers, aged 25–74, that gave information about the age at smoking initiation were included in the analysis. At the age of 25 or less, smoking was initiated by 96.7% of Slovene ever smokers, at the age of 18 or less by 71.0%. The average age at smoking initiation was 17.7 years. Male ever smokers initiated smoking at an earlier age compared to female ones. Age at smoking initiation was decreasing in both male and female ever smokers, but was more pronounced in females. In male ever smokers, there were no differences in average smoking initiation age by education, self-reported social class and geographical regions, while in female ever smokers, there were significant differences in terms of education and geographical regions.

Conclusion

The initiation of smoking predominantly occurs in adolescents and young adults. Age at smoking initiation has decreased in recent decades. Our study confirms the importance of early and sustained smoking prevention programmes in youth and the importance of national comprehensive tobacco control programme with effective tobacco control measures to ban tobacco products marketing.     

Peer Reviewed: Lay Representations of Cancer Prevention and Early Detection: Associations With Prevention Behaviors

Introduction

The Common Sense Model of illness representations posits that how people think about an illness affects how they try to prevent the illness. The purpose of this study was to determine whether prevention representations vary by cancer type (colon, lung, and skin cancer) and whether representations are associated with relevant behaviors.

Methods

We analyzed data from the Health Information National Trends Survey (HINTS 2005), a nationally representative survey of American adults (N = 5,586) conducted by telephone interview.

Results

Respondents reported that all 3 types of cancer can be prevented through healthy behaviors; however, fewer did so for colon cancer. More respondents reported screening as a prevention strategy for colon cancer than did so for lung or skin cancer. Representations were associated with colon cancer screening, smoking status, and sunscreen use.

Conclusion

Representations of cancer were associated with relevant health behaviors, providing a target for health messages and interventions.     

Peer Reviewed: Patterns of Clinically Significant Symptoms of Depression Among Heavy Users of Alcohol and Cigarettes

Introduction

Depression is among the most prevalent and treatable diseases, and it is associated with cigarette smoking and heavy alcohol use. This study estimates the prevalence of depression, its variation among demographic subgroups, and its association with heavy alcohol use and cigarette smoking in California.

Methods

The 2006 California Behavioral Risk Factor Surveillance System (BRFSS) includes the 8-item Patient Health Questionnaire, a standardized instrument used to measure depressive symptoms. We used findings from the 2006 BRFSS to calculate the prevalence of depression in California; we used logistic models to explore the relationships between depression, alcohol use, and smoking.

Results

We found that 9.2% of adults in California had clinically significant depressive symptoms. Logistic models indicated that daily smokers were more than 3 times more likely to have clinically significant depressive symptoms than were nonsmokers, and heavy drinkers were approximately 3 times more likely to have clinically significant depressive symptoms than were nondrinkers.

Conclusion

Because heavy alcohol use and daily smoking are each associated with depression, people who do both may be at an increased risk for depression. This is a public health issue because people who drink alcohol often also smoke and vice versa. Intervention efforts might target persons who are users of both these drugs, and practitioners should be aware that smokers who are heavy alcohol users are at an increased risk for depression.     

Peer Reviewed: Awareness, Treatment, and Control of Hypertension and Hypercholesterolemia Among Insured Residents of New York City, 2004

Introduction

Health care access and sociodemographic characteristics may influence chronic disease management even among adults who have health insurance. The objective of this study was to examine awareness, treatment, and control of hypertension and hypercholesterolemia, by health care access and sociodemographic characteristics, among insured adults in New York City.

Methods

Using data from the 2004 New York City Health and Nutrition Examination Survey, we investigated inequalities in the diagnosis and management of hypertension and hypercholesterolemia among insured adults aged 20 to 64 years (n = 1,334). We assessed differences in insurance type (public, private) and routine place of care (yes, no), by sociodemographic characteristics.

Results

One in 10 participants with hypertension and 3 in 10 with hypercholesterolemia were unaware and untreated. Having a routine place of care was associated with treatment and control of hypertension and with awareness, treatment, and control of hypercholesterolemia, after adjusting for insurance type, age, sex, race/ethnicity, foreign birth, income, and education. Differences in systolic blood pressure and total cholesterol between people with versus without a routine place of care were 2 to 3 times the difference found between people with public versus private insurance. Few differences were associated with sociodemographic characteristics after adjusting for routine place of care and insurance type; however, male sex, younger age, Asian race, and foreign birth with short-term US residence reduced the odds of having a routine place of care. Neither income nor education predicted having a routine place of care.

Conclusion

Sociodemographic characteristics may influence chronic disease management among the insured through health care access factors such as having a routine place of care.     

Disparities in Health,Obesity and Access to Care Among an Insured Population of Asian and Pacific Islander Americans in Hawai‘i

Objective

To examine differences in health status, obesity, and access among Asian and Pacific Islander Americans in Hawai‘i using data from a 2007 health plan survey, including Caucasians, Puerto Ricans, American Indian and Alaska Natives, Chinese, Filipinos, Japanese, Koreans, Native Hawai‘ians, Samoans, and Other Pacific Islanders.

Methods

Data were collected through a stratifified random sample of adult members of a health plan in Hawai‘i (n=119,563) who saw a physician in the past 12 months. Multivariable logistic and ordinary least squares regression analyses were used to examine racial/ethnic differences in health status, access, and obesity and the impact of obesity and access on health status, after controlling for age, gender, and education.

Results

The highest obesity rates were found among Samoans (50%), Puerto Ricans (37%), Native Hawai‘ians (36%), and Other Pacific Islanders (35%). Puerto Ricans and Samoans reported the highest number of poor physical health days (5.4). Samoans reported the highest number of poor mental health days (4.4). Obesity had a stronger impact than access on self-reported health status.

Conclusion

Samoans had the highest rate of obesity, low health ratings, and a high number of days of poor health. Targeted interventions may be needed for this group.