The complex web of health: relationships among chronic conditions, disability, and health services

Objectives

A critical issue in health-care reform concerns how to realign health-care delivery systems to manage medical care services for people with ongoing and costly needs for care. We examined the overlapping health-care needs of two such population groups among the U.S. working-age population (those aged 18–64 years): people with chronic medical conditions and people with disabilities.

Methods

Using the Medical Expenditure Panel Survey (2002–2004), we examined differences in health status, service use, and access to care among and between working-age adults reporting disabilities and/or one or more chronic conditions. We also analyzed people with three key chronic conditions: arthritis, diabetes, and depression.

Results

More than half of working-age people with disabilities reported having more than one chronic condition. Among those with activities of daily living or instrumental activities of daily living limitations, 35% reported four or more chronic conditions at a time. We found considerable variability in access problems and service use depending on how we accounted for the overlap of multiple conditions among people with arthritis, diabetes, and depression. However, disability consistently predicted higher emergency department use, higher hospitalization rates, and greater access problems.

Conclusions

The overall prevalence of chronic conditions among the U.S. working-age population, coupled with the high concentration of multiple chronic conditions among those with disabilities, underscores the importance of reforming health-care delivery systems to provide person-centered care over time. New policy-relevant measures that transcend diagnosis are required to track the ongoing needs for health services that these populations present.As the United States considers dramatic changes in the way its health-care delivery system is organized, two groups merit particular attention: individuals with disabilities and individuals with chronic health conditions. At a time when health-care costs are escalating at an unsustainable pace, both groups consume health-care services at a disproportionately high rate^1–6 while also experiencing less than optimal health outcomes.^7–9 Furthermore, health-care resources are not equitably distributed,¹⁰ calling for substantive changes in the way in which services are provided.The health of people with disabilities gained additional visibility on the national health agenda via the Healthy People 2010 objectives¹¹ and the Surgeon General''s Call to Action to Improve the Health and Wellness of Persons with Disabilities.¹² At the same time, the growing number of adults with chronic conditions has led to a proliferation of disease management programs,^13–17 as well as a substantial body of research describing chronic disease, its consequences, and associated responses.^1,2,9,18,19 What remains less articulated in the scientific literature is that these are actually overlapping groups. While adults with disabilities are likely to have multiple chronic conditions, adults with chronic conditions are likely to develop limitations in functioning or participation, particularly as conditions accumulate over time. In this study, we directly analyzed this overlap, with a focus on health, access to care, and service use in the U.S.Previous research shows that a substantial number of adults have multiple chronic conditions and may also have limitations in activities or functioning. For instance, in 1997, nearly 25% of Medicare beneficiaries had limitations in activities of daily living (ADLs).³ Within this group, the prevalence of cancer, stroke, diabetes, and rheumatoid arthritis was each more than 20%, and the prevalence of hypertension and osteoarthritis was higher than 50%. Treatment of these conditions required up to one health-care visit a week, and these individuals were twice as likely to be dissatisfied with the coordination of their care.²⁰Whether one considers the new medical home initiatives,²¹ obesity reduction,²² disease self-management,²³ prevention of secondary conditions among people with disabilities,²⁴ or any number of further priority items on the nation''s public health agenda,²⁵ there remains a pressing need to quantify the extent of comorbidity in the U.S. population and to clarify its associations with disability. About half of all Americans have at least one chronic condition, and given that roughly half of those individuals actually have more than one such condition at a time, the pursuit of these agenda items may be hampered if approached only one disease at a time.² Furthermore, when individuals accrue limitations in how they function or the activities they can do, additional interventions may be required to assure their access to health-care services, to coordinate the providers involved in their care, or to craft treatment regimens that accommodate their functional needs.²⁶To build upon the existing literature, we analyzed a nationally representative sample of working-age Americans, clarifying the way in which health, access to care, and service use is impacted by a single chronic condition vs. multiple chronic conditions, with or without self-reported disability limitations. As exemplars, we also examined three conditions in greater detail: arthritis, diabetes, and depression. Among the most highly prevalent chronic conditions in the U.S., these three conditions were selected because they potentially result in a wide range of health and functional impacts across different body systems, are accompanied by differing constellations of comorbid conditions, and may require care from providers in differing specialties or settings.^27–29 Thus, we examined the relative contributions of a single primary diagnosis, multiple comorbidities, and disability limitations to several key health-care measures, including access to care, ambulatory visits, hospitalizations, and emergency department (ED) use.While substantial health services research has been conducted on the impact of chronic conditions on older Americans^3,30,31 and children,^32–34 less is known about these phenomena among the working-aged, particularly for people with disabilities. Additionally, the impact of chronic conditions and disability on major life activities, such as school or work, necessarily varies with life course stage. Given the large size of the working-age population, additional concerns regarding their insurance coverage, and their distinct role expectations relative to older adults or children, we limited our analysis to people aged 18–64 years.     

Health,Chronic Conditions,and Behavioral Risk Disparities Among U.S. Immigrant Children and Adolescents

Objective

We examined differentials in the prevalence of 23 parent-reported health, chronic condition, and behavioral indicators among 91,532 children of immigrant and U.S.-born parents.

Methods

We used the 2007 National Survey of Children''s Health to estimate health differentials among 10 ethnic-nativity groups. Logistic regression yielded adjusted differentials.

Results

Immigrant children in each racial/ethnic group had a lower prevalence of depression and behavioral problems than native-born children. The prevalence of autism varied from 0.3% among immigrant Asian children to 1.3%–1.4% among native-born non-Hispanic white and Hispanic children. Immigrant children had a lower prevalence of asthma, attention deficit disorder/attention deficit hyperactivity disorder; developmental delay; learning disability; speech, hearing, and sleep problems; school absence; and ≥1 chronic condition than native-born children, with health risks increasing markedly in relation to mother''s duration of residence in the U.S. Immigrant children had a substantially lower exposure to environmental tobacco smoke, with the odds of exposure being 60%–95% lower among immigrant non-Hispanic black, Asian, and Hispanic children compared with native non-Hispanic white children. Obesity prevalence ranged from 7.7% for native-born Asian children to 24.9%–25.1% for immigrant Hispanic and native-born non-Hispanic black children. Immigrant children had higher physical inactivity levels than native-born children; however, inactivity rates declined with each successive generation of immigrants. Immigrant Hispanic children were at increased risk of obesity and sedentary behaviors. Ethnic-nativity differentials in health and behavioral indicators remained marked after covariate adjustment.

Conclusions

Immigrant patterns in child health and health-risk behaviors vary substantially by ethnicity, generational status, and length of time since immigration. Public health programs must target at-risk children of both immigrant and U.S.-born parents.Monitoring the extent and causes of child health disparities among different population subgroups has long represented an important area of public health research and policy in the United States.^1–3 While data on important health, disease, and behavioral risk factors are routinely available by gender, race/ethnicity, and socioeconomic status (SES) in the U.S.,^1–3 such information is generally not categorized according to nativity/immigrant status. The immigrant or foreign-born population in the U.S. has grown considerably in the last four decades. In 2011, there were 40.4 million immigrants, an increase of 30.8 million since 1970.^4–8 Immigrants now account for 13.0% of the total U.S. population.^4,8 The increase in the number of children with foreign-born parents has also been substantial. The number of U.S. children in immigrant families more than doubled in the past two decades, from 8.2 million in 1990 to 17.5 million in 2011.^8,9 In 2011, 24.4% of U.S. children had at least one foreign-born parent.^8,9As the immigrant population continues to grow in numbers and as a share of the total population, there is an increasing need to focus on the health of immigrants. Although reducing social inequalities in health remains the primary focus of Healthy People 2020, this national initiative in health promotion and disease prevention does not include a single policy objective that explicitly targets the health of immigrants in the U.S.^10,11 Moreover, the nation''s premier and most comprehensive annual report on health statistics, “Health, United States,” does not contain any data on the U.S. immigrant population.¹Health, disease, behavioral, and socioeconomic profiles of immigrants differ substantially from those of the U.S.-born.^12–17 There is also evidence that acculturation modifies the health and behavioral risks of immigrants.^13,15–19 The purposes of this study were, therefore, (1) to estimate the prevalence and risks of poor physical and mental health, chronic conditions, and behavioral risk factors (including obesity and physical inactivity) among immigrant and U.S.-born children and adolescents after adjusting for age, gender, race/ethnicity, place of residence, household composition, and SES using a large, nationally representative sample of U.S. children and adolescents; and (2) to examine the extent to which immigrant health, chronic disease, and behavioral patterns vary by ethnicity and level of acculturation.     

Who Are California's Late HIV Testers? An Analysis of State AIDS Surveillance Data, 2000–2006

Objectives

Late HIV testing leads to preventable, severe clinical and public health outcomes. California, lacking a mature HIV surveillance system, has been excluded from documented analyses of late HIV testers in the United States. We identified factors associated with late HIV testing in the California AIDS surveillance data to inform programs of HIV testing and access to treatment.

Methods

We analyzed data from California AIDS cases diagnosed between 2000 and 2006 and reported through November 1, 2007. Late testers were people diagnosed with HIV within 12 months before their AIDS diagnosis. We identified factors significantly associated with late HIV testing using multivariable logistic regression.

Results

Among 28,382 AIDS cases, 61.2% were late HIV testers. Late testing was significantly associated with those ≥35 years of age, heterosexual contact or unknown/other reported transmission risk, and being born outside of the U.S. When further classified by country of birth, people born in Mexico were most likely to be HIV late testers who progressed to AIDS.

Conclusions

Our findings support wider implementation of opt-out HIV testing and HIV testing based in emergency departments. Services for HIV testing and treatment should be inclusive of all populations, but especially targeted to populations that may have more limited access.Among the more than one million people in the United States estimated to be infected with human immunodeficiency virus (HIV), nearly one-quarter remain undiagnosed.¹ Increasing evidence suggests that earlier antiretroviral therapy (ART) for HIV improves survival compared with deferred therapy.^2,3 The benefits of HIV diagnosis well before acquired immunodeficiency syndrome (AIDS) diagnosis are clearly documented and include survival benefit for asymptomatic HIV-infected people with early initiation as compared with deferred initiation of ART,² decreased viral transmission due to lower-serum HIV-1 ribonucleic acid levels⁴ as well as risk modification in people who know their HIV serostatus,⁵ and decreased health expenditures.⁶ In Canada, the estimated annual medical cost of a late presenter, after adjusting for patient characteristics, was more than twice that of a non-late presenter, with a difference of more than $8,000 per person. This discrepancy is mostly due to hospital care costs, which are 15 times higher for those diagnosed late.⁷Given that the period from primary HIV infection to AIDS is estimated at seven to eight years⁸ and the Centers for Disease Control and Prevention (CDC) guidelines advocate routine HIV testing for all U.S. adults,⁹ late HIV testing (defined as the first diagnosis of HIV within one year of an AIDS diagnosis)¹⁰ should be an unusual clinical outcome. However, national estimates from CDC reported that 45% of people with AIDS at 16 sites in the U.S. were late testers.¹⁰ Among AIDS surveillance cases in San Francisco and South Carolina, 39% and 41%, respectively, were late testers.^11,12 In the U.S., AIDS diagnoses can be arguably regarded as a measure of diagnostic or treatment failure.In California, approximately 85% of adult HIV cases are male, 28% are Hispanic, 20% are African American, and 50% are white. Men who have sex with men (MSM) comprise the main risk exposure for men (77%). For women, heterosexual contact is the main risk exposure (52%), followed by injection drug use (23%).¹³ California is home to about 4.4 million Mexican immigrants, about 40% of the total immigrant population in the U.S., and is a key destination for Mexican migrants.^11,14 Both the U.S. and Mexico have concentrated HIV epidemics, where prevention and testing campaigns prioritize traditionally high-risk groups such as MSM and injection drug users (IDUs).The role of migration on the vulnerability of immigrants in California, historically considered a low-risk group, is complex and poorly understood but may have a significant impact on the likelihood of becoming infected with HIV while in the U.S.¹⁵ The denominator of Mexican immigrants in California likely varies by structural factors such as agricultural season. The effect and extent of this varying denominator on HIV/AIDS estimates is not well characterized. In this analysis of California AIDS surveillance data, we identified factors that are significantly associated with late HIV testing in the state.     

HIV testing and management: findings from a national sample of Asian/Pacific islander men who have sex with men

Objectives

We examined reasons for and barriers to participating in HIV voluntary counseling and testing for Asian/Pacific Islander (A/PI) men who have sex with men (MSM) in the U.S.

Methods

We collected data between June 2007 and September 2009 in a study known as Men of Asia Testing for HIV, using a cross-sectional community-based participatory design. This national study was conducted in seven U.S. metropolitan cities through a coalition of seven community-based organizations.

Results

Participants included 445 self-identified A/PI MSM aged ≥18 years. Perception of being at risk was the number one reason for testing behaviors. For first-time testers, structural barriers (e.g., language barriers with health professionals) and fear of disclosure (e.g., sexual orientation not known to parents) were deterrents for nontesting in the past. Among previously known HIV-positive men, 22% were not seeing a doctor and 19% were not taking any HIV medications.

Conclusions

HIV testing, care, and treatment policies would be less than optimal without addressing barriers to testing, including stigma related to sexual orientation, among A/PI MSM.Men who have sex with men (MSM) continue to have the highest human immunodeficiency virus (HIV) infection rates in the U.S., with MSM of color being disproportionately affected by the disease.¹ Compared with MSM of other racial/ethnic groups, Asian/Pacific Islander (A/PI) MSM have the highest proportion of acquired immunodeficiency syndrome (AIDS) cases, with a majority of them being non-U.S.-born.^2,3 Research attributes this disparity to low testing rates^4–6 and late diagnosis, which are often associated with advanced AIDS symptoms⁷ as well as late entry into care.^8,9Voluntary counseling and testing (VCT) has been a successful standard of HIV prevention since the emergence of the epidemic in the U.S. and other developed countries.^10–14 This prevention strategy has also been adopted by other developing countries.¹⁵ Nonetheless, the uptake of VCT is still less then optimal.¹⁶ For example, combining multiple datasets from the 2000 to 2005 National Health Interview Surveys, Ostermann et al. found little change in lifetime and past year testing, respectively. However, individuals who perceived higher risks of contracting HIV were more likely to plan for and engage in actual HIV testing.¹⁷Meanwhile, the literature consistently indicates that the stigma of having HIV and/or being a sexual minority is a major barrier or determinant for efficacious or effective prevention, intervention, and treatment, especially among marginalized, vulnerable, or underserved populations.¹⁸ Using a qualitative methodology (i.e., in-depth interview), Yoshioka and Schustack found three major barriers to disclosure of HIV status among a sample of HIV-positive men of Asian descent in the U.S.: (1) protection of family from shame, (2) protection of family from obligation to help, and (3) avoidance of communication regarding highly personal information (including same-sex sexual orientation).¹⁹Collectively, these articles in the literature lend to the postulation that the effectiveness of VCT hinges on at-risk individuals having well-informed information regarding the attitudes, beliefs, and practices of HIV testing.²⁰ Although a small number of cross-sectional studies have been conducted,^6,7,9,21 little to no national data are available addressing HIV testing and HIV management among A/PI MSM. To that end, we used data from a national study of HIV prevention to describe and examine (1) reasons for and barriers to HIV testing among a national sample of A/PI MSM, and (2) care and treatment among those who have tested HIV-positive in the past, by nativity (U.S.-born vs. non-U.S.-born).     

The persistent gap in health-care coverage between low- and high-income workers in Washington State: BRFSS, 2003-2007

Objectives

We examined the disparities in health-care coverage between low- and high-income workers in Washington State (WA) to provide support for possible policy decisions for uninsured workers.

Methods

We examined data from the WA Behavioral Risk Factor Surveillance System 2003–2007 and compared workers aged 18–64 years of low income (annual household income <$35,000) and high income (annual household income ≥$35,000) on proportions and sources of health-care coverage. We conducted multivariable logistic regression analyses on factors that were associated with the uninsured.

Results

Of the 54,536 survey respondents who were working-age adults in WA, 13,922 (25.5%) were low-income workers. The proportions of uninsured were 38.2% for low-income workers and 6.3% for high-income workers. While employment-based health benefits remained a dominant source of health insurance coverage, they covered only 40.2% of low-income workers relative to 81.5% of high-income workers. Besides income, workers were more likely to be uninsured if they were younger; male; Hispanic; less educated; not married; current smokers; self-employed; or employed in agriculture/forestry/fisheries, construction, and retail. More low-income workers (28.7%) reported cost as an issue in paying for health services than did their high-income counterparts (6.7%).

Conclusion

A persistent gap in health-care coverage exists between low- and high-income workers. The identified characteristics of these workers can be used to implement policies to expand health insurance coverage.Socioeconomic disparities in health and health care have increased since the 1990s.^1–3 In the U.S., while employment-based insurance is the major source of paying for health care,^4,5 the increase in health insurance premiums has outpaced workers'' earnings and inflation rates. The average cost of health insurance rose 9.6% annually from 2003 to 2007, a rate that was much higher than the overall rate of inflation (2.8%) or the increase in workers'' earnings (2.9%) during the same time period (author calculation based on a 2007 report by the Kaiser Family Foundation⁴). Rising costs impose a greater burden on low-income workers than their higher-income counterparts because low-income workers are less likely to work for a company that offers health insurance coverage.^5–9 Without employer-sponsored health insurance, few low-income workers are able to afford private coverage on their own.^7,10 Further, most of these low-income workers are ineligible for public health insurance programs.^6,10,11 This ineligibility is because in most states, income eligibility is lower for parents than for children and for those adults without dependent children.¹⁰Many factors affect the likelihood of an individual having health insurance and the source of that coverage. Work status and income play a dominant role in determining an individual''s likelihood of having health insurance.^5,7–9,12 Uninsured workers were found disproportionately in the agriculture, construction, and trade industries,^5,8,9,13 and in the farming, operators/fabricators/labors, and services sectors.^8,9 Uninsured workers also were more likely to be self-employed,^8,14 to work for small firms,^{5,7–9,13,15,16} and to be employed as part-time or temporary workers.^5,14,17,18 Socioeconomic characteristics related to lack of health-care coverage include being male, younger, from a racial/ethnic minority group, less educated, and in a low-wage or low-income job.^5,8,12,14,19 Consequently, uninsured workers were less likely to have a usual source of care and receive timely preventive services, and more likely to experience a decline in overall health.^{7,9,12,20–22}Although national uninsured trends are well documented, published work concurrently considering workers'' socioeconomics, industry, and occupation characteristics in Washington State (WA) is lacking. In an effort to expand the current knowledge on uninsured workers in WA and provide support for possible policy decisions, we conducted a multivariate analysis on health-care coverage comparing low-income workers with high-income workers by pooling the five-year WA Behavioral Risk Factor Surveillance System (BRFSS) data. Because most of the uninsured come from working families and have low incomes,^4,6,10 we identified characteristics of workers who did not have health-care coverage and examined how low-income workers have fared in health-related outcomes. The analysis presents trends, examines multiple factors that affect health insurance coverage, and discusses policy implications. We hypothesized that even after controlling the multiple factors associated with being uninsured, less health-care coverage and increased health-care costs would impose a greater burden for low-income workers and families.     

Disparities in infectious disease hospitalizations for American Indian/ Alaska Native people

Objectives

We described disparities in infectious disease (ID) hospitalizations for American Indian/Alaska Native (AI/AN) people.

Methods

We analyzed hospitalizations with an ID listed as the first discharge diagnosis in 1998–2006 for AI/AN people from the Indian Health Service National Patient Information Reporting System and compared them with records for the general U.S. population from the Nationwide Inpatient Survey.

Results

The ID hospitalization rate for AI/AN people declined during the study period. The 2004–2006 mean annual age-adjusted ID hospitalization rate for AI/AN people (1,708 per 100,000 populiation) was slightly higher than that for the U.S. population (1,610 per 100,000 population). The rate for AI/AN people was highest in the Southwest (2,314 per 100,000 population), Alaska (2,063 per 100,000 population), and Northern Plains West (1,957 per 100,000 population) regions, and among infants (9,315 per 100,000 population). ID hospitalizations accounted for approximately 22% of all AI/AN hospitalizations. Lower-respiratory--tract infections accounted for the largest proportion of ID hospitalizations among AI/AN people (35%) followed by skin and soft tissue infections (19%), and infections of the kidney, urinary tract, and bladder (11%).

Conclusions

Although the ID hospitalization rate for AI/AN people has declined, it remains higher than that for the U.S. general population, and is highest in the Southwest, Northern Plains West, and Alaska regions. Lower-respiratory-tract infections; skin and soft tissue infections; and kidney, urinary tract, and bladder infections contributed most to these health disparities. Future prevention strategies should focus on high-risk regions and age groups, along with illnesses contributing to health disparities.Infectious diseases (IDs) have historically caused widespread morbidity and mortality both worldwide and in the United States.^1–3 IDs remain a public health issue and are of particular concern for the American Indian/Alaska Native (AI/AN) population, which has had excessive ID morbidity and mortality for several decades.^4–9 Both hospitalizations and outpatient visits due to IDs have been disproportionately higher in the AI/AN population compared with the U.S. population.^7,10–13 These disparities affect all ages, especially infants and older adults.^6,8,13 Studies of specific IDs, including lower-respiratory-tract infections (LRTIs), diarrhea-related infections, and skin and ear infections, have also shown a disparity between AI/AN people and the general U.S. population.^{10,11,14–16} However, the trends and disparities of ID hospitalizations for AI/AN people have not been analyzed since an evaluation of 1994 ID hospitalizations.⁷We determined the epidemiology and trends of ID hospitalizations for AI/AN people in 1998–2006 using Indian Health Service (IHS) inpatient data to assess any changes in their ID burden, and to determine high-risk regions and age groups that should be targeted for further intervention. We also compared the trends and rates for AI/AN people with those for the general U.S. population to determine whether health disparities in ID hospitalizations remain for AI/AN people.     

Legionnaires' Disease and Associated Comorbid Conditions as Causes of Death in the U.S., 2000–2010

ObjectiveRecent U.S. outbreaks of Legionnaires'' disease (LD) underscore the virulent nature of this infectious pneumonia. To date, only a paucity of literature has described the mortality burden of LD. This study updates LD mortality using U.S. multiple-cause-of-death data from 2000–2010.MethodsWe calculated crude and age-adjusted rates for LD mortality for age, sex, race, state, Census region, and year. We conducted Poisson regression to assess seasonal and temporal trends. We generated matched odds ratios (MORs) to describe the association between LD-related deaths and other comorbid conditions listed on the death certificates.ResultsWe identified a total of 1,171 LD-related deaths during 2000–2010. The age-adjusted mortality rate remained relatively static from 2000 (0.038 per 100,000 population, 95% confidence interval [CI] 0.031, 0.046) to 2010 (0.040 per 100,000 population, 95% CI 0.033, 0.047). The absolute number increased from 107 to 135 deaths during this period, with adults ≥45 years of age having the highest caseload. Overall, LD mortality rates were 2.2 times higher in men than in women. White people accounted for nearly 83.3% of all LD-related deaths, but the age-adjusted mortality rates for black and white people were similar. Comorbid conditions such as leukemia (MOR=4.8, 95% CI 3.5, 6.6) and rheumatoid arthritis (MOR=5.6, 95% CI 3.3, 9.4) were associated with LD diagnosis on death certificates.ConclusionComorbid conditions that could lead to an immunocompromised state were associated with fatal LD on U.S. death certificates. Characterization of LD mortality burden and related comorbidities has practice implications for clinical medicine and public health surveillance.Legionnaires'' disease (LD) is a severe form of pneumonia that can become fatal in vulnerable individuals.^1–5 The condition is caused by the gram-negative bacterium Legionella pneumophila, a naturally occurring organism found in water.^2,3 The organism is primarily transmitted to humans through inhalation of contaminated aerosolized water droplets. Typical sources of outbreaks include, but are not limited to, hot tubs, hot water tanks, large plumbing systems, decorative fountains, and cooling towers. The pneumophila species is generally not found in car or window air-conditioners.^1–4 To date, no person-to-person transmission has been documented.^1–4,6,7Risk factors that increase susceptibility to LD include advanced age, smoking, chronic lung disease, and having a weak or suppressed immune system.^1–4,6,7 Among individuals with a weakened immunity, those with cancer, diabetes, or kidney failure are particularly at risk. Although human immunodeficiency virus (HIV) infection has been linked to more severe infections, LD is generally not more common among people with HIV/acquired immunodeficiency syndrome (AIDS).^1,8,9 More than 20% of cases in the United States reported to the Centers for Disease Control and Prevention (CDC) each year are travel-related.³ Nosocomial transmissions of LD can be problematic, as at-risk individuals are plentiful and plumbing in hospital facilities is often old.^1,4 Because in-house diagnostic testing is readily available, detection of LD is more likely in the hospital setting.⁴ Currently, CDC recommends urinary antigen assay and a culture of respiratory secretions on selective media as the diagnostic tests of choice for confirming Legionella infection.³Annually, CDC estimates that as many as 18,000 individuals are hospitalized with LD in the U.S.³ However, this number is considered an underestimate, as the disease is often underreported due in part to its diagnostic complexity and its resemblance to other pneumonias with similar symptom presentations.^3,7 Symptoms of LD include cough, shortness of breath, fever, muscle aches, and headaches; they often start shortly after exposure to the bacteria.^1–4,6Recent LD outbreaks in the Veterans Affairs (VA) Medical Center in Pittsburgh, Pennsylvania, and in a retirement community in Ohio affirm the virulent nature of this infection and underscore the importance of the causative infectious pathogen to clinical practice and public health surveillance.^10,11 Based on hospitalizations and treatment data, the annual costs for LD have been estimated at nearly $684 million.¹² Few studies have recently examined LD mortality and its associated comorbid conditions. This study contributes to the closing of this gap in the literature by analyzing the national multiple-cause-of-death (MCD) data to describe the current mortality profile of LD in the U.S., for the period 2000–2010.     

Prospectively assessed posttraumatic stress disorder and associated physical activity

Objectives

We examined the association of physical activity with prospectively assessed posttraumatic stress disorder (PTSD) symptoms in a military cohort.

Methods

Using baseline and follow-up questionnaire data from a large prospective study of U.S. service members, we applied multivariable logistic regression to examine the adjusted odds of new-onset and persistent PTSD symptoms associated with light/moderate physical activity, vigorous physical activity, and strength training at follow-up.

Results

Of the 38,883 participants, 89.4% reported engaging in at least 30 minutes of physical activity per week. At follow-up, those who reported proportionately less physical activity were more likely to screen positive for PTSD. Vigorous physical activity had the most consistent relationship with PTSD. Those who reported at least 20 minutes of vigorous physical activity twice weekly had significantly decreased odds for new-onset (odds ratio [OR] = 0.58, 95% confidence interval [CI] 0.49, 0.70) and persistent (OR=0.59, 95% CI 0.42, 0.83) PTSD symptoms.

Conclusions

Engagement in physical activity, especially vigorous activity, is significantly associated with decreased odds of PTSD symptoms among U.S. service members. While further longitudinal research is necessary, a physical activity component may be valuable to PTSD treatment and prevention programs.Recent military operations in Iraq and Afghanistan have been characterized by sustained ground combat, persistent risk, and multiple protracted deployments. Increased psychological symptom reporting has engendered heightened concern for the postdeployment mental health of service members and, in particular, the public health burden of posttraumatic stress disorder (PTSD).^1–4 A previous study using data from all U.S. service branches identified new-onset self-reported PTSD symptoms in 7.6%–8.7% of deployers who reported combat exposures, 1.4%–2.1% of deployers who did not report combat exposures, and 2.3%–3.0% of nondeployers.⁴PTSD is associated with poor physical health as well as negative health behaviors, such as tobacco use and problem alcohol drinking.^5–11 The extent to which behavioral correlates of PTSD mitigate or mediate PTSD symptoms and associated morbidities is currently under investigation.¹² While research has focused on adverse health behaviors, the relationship between positive health behaviors (e.g., physical activity) and PTSD has not been fully explored.Studies of depression and anxiety have pointed to the mental health benefits of physical activity, and researchers have postulated a number of mechanisms by which physical activity may modulate mood and the stress response.^13–19 While previous research indicates that physical activity may mitigate PTSD and related symptoms, other studies indicate that exercise habits of PTSD patients may be substandard.^20–23 In a retrospective study among Brazilians, physical activity levels decreased after the onset of PTSD.²⁴ These previous studies, however, were limited by small sample sizes, retrospective designs, and an inability to control for possible confounders.^20,22–25 The purpose of this study was to investigate new-onset, resolution, and persistence of PTSD symptoms in relation to type and quantity of physical activity in a large, population-based cohort of U.S. military service members.     

Evaluation of a Community Health Worker Intervention to Reduce HIV/AIDS Stigma and Increase HIV Testing Among Underserved Latinos in the Southwestern U.S.

Objectives

Latinos are at an elevated risk for HIV infection. Continued HIV/AIDS stigma presents barriers to HIV testing and affects the quality of life of HIV-positive individuals, yet few interventions addressing HIV/AIDS stigma have been developed for Latinos.

Methods

An intervention led by community health workers (promotores de salud, or promotores) targeting underserved Latinos in three southwestern U.S. communities was developed to decrease HIV/AIDS stigma and increase HIV knowledge and perception of risk. The intervention was led by HIV-positive and HIV-affected (i.e., those who have, or have had, a close family member or friend with HIV/AIDS) promotores, who delivered interactive group-based educational sessions to groups of Latinos in Spanish and English. To decrease stigma and motivate behavioral and attitudinal change, the educational sessions emphasized positive Latino cultural values and community assets. The participant pool comprised 579 Latino adults recruited in El Paso, Texas (n=204); San Ysidro, California (n=175); and Los Angeles, California (n=200).

Results

From pretest to posttest, HIV/AIDS stigma scores decreased significantly (p<0.001). Significant increases were observed in HIV/AIDS knowledge (p<0.001), willingness to discuss HIV/AIDS with one''s sexual partner (p<0.001), and HIV risk perception (p=0.006). Willingness to test for HIV in the three months following the intervention did not increase. Women demonstrated a greater reduction in HIV/AIDS stigma scores when compared with their male counterparts, which may have been related to a greater increase in HIV/AIDS knowledge scores (p=0.016 and p=0.007, respectively).

Conclusion

Promotores interventions to reduce HIV/AIDS stigma and increase HIV-related knowledge, perception of risk, and willingness to discuss sexual risk with partners show promise in reaching underserved Latino communities.Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) has disproportionately affected U.S. Latinos during the last 25 years. Although Latinos constitute 16% of the U.S. population, they account for 19% of those living with HIV and 21% of new HIV infections.¹ Since 2006, the Centers for Disease Control and Prevention (CDC) has recommended HIV testing for all people aged 13–64 years.² However, nearly half (46%) of Latino adults aged 18–64 years have never been tested, compared with 23% of black and 50% of white adults.³ Additionally, HIV testing often occurs at a late stage among HIV-positive Latinos. More than one-third (36%) of HIV-positive Latinos were diagnosed with AIDS within one year of learning their HIV status, compared with 32% of white people and 31% of black people.³ Late HIV testing hinders treatment options and may contribute to unknowing HIV transmission.Factors contributing to low HIV testing rates among Latinos include poverty, lack of health-care access, and limited availability of culturally and linguistically responsive services.^1,4–6 HIV/AIDS stigma is another factor.^7,8 UNAIDS (Joint United Nations Programme on AIDS) defines HIV stigma as the “devaluation of people either living with or associated with HIV/AIDS.”⁹ Stigma often results from fears about HIV as well as the associations of HIV with stigmatized groups such as homosexuals, sex workers, and injection drug users.^9,10HIV/AIDS stigma has negative consequences both at a population level and for individuals who are its targets, including people living with HIV/AIDS. Stigmatizing attitudes toward people living with HIV/AIDS are associated with decreased HIV testing, limited utilization of HIV prevention services, and high-risk sexual behaviors.^7,10,11 Additionally, for people living with HIV/AIDS, the stigma associated with HIV/AIDS contributes to unwillingness to disclose HIV status, unsafe sexual behaviors, delays in care seeking, reduced treatment adherence, mental health issues, and difficulties obtaining social support.^9,11–14Despite significant implications, few interventions have been developed to reduce HIV/AIDS stigma.^10,11,15 Existing interventions have often focused on specific populations (e.g., university students and health-care providers), with few interventions focused on Latinos,^11,15,16 who have high levels of stigmatizing attitudes toward people living with HIV/AIDS^1,17,18 that contribute to negative outcomes.^7,19Among Latinos, research indicates that community health workers (promotores de salud, hereinafter “promotores”) are an effective and culturally acceptable means of reaching the population with health information and motivating health behaviors.^20,21 Promotores are well positioned to promote changes in their communities because they share language and cultural values, are held in high esteem, and are perceived as role models.²¹ Promotores have been used to address health conditions ranging from chronic diseases to preventive screenings.^20–22 Several interventions have incorporated promotores into HIV prevention, finding significant changes in HIV risk behaviors, HIV counseling and testing, and other psychosocial constructs important to prevention.^16,23–29 To date, few studies have used promotores in interventions to reduce HIV stigma among Latinos.¹⁶We describe and report findings of an intervention using promotores to reduce HIV/AIDS stigma and increase willingness to seek HIV testing among Latinos in three communities in the southwestern United States: Los Angeles, California; San Ysidro, California; and El Paso, Texas.     

Obesity Among Chronically Homeless Adults: Is It a Problem?

Objective

We examined rates of obesity and associated characteristics in the chronically homeless population to explore how a range of factors, including sociodemographics, housing, food source, physical and mental health, and health service use, were related to being overweight or obese.

Methods

We conducted multivariate regression analyses on a community sample of 436 chronically homeless adults across 11 U.S. cities to examine the prevalence of obesity.

Results

The majority (57%) of chronically homeless adults were overweight or obese. Chronically homeless adults who were female or Hispanic appeared to be at particular risk for obesity. There were few differences on physical and mental health by weight group. Although overweight and obese chronically homeless adults were more likely to discuss exercise with a health-care provider, they reported engaging in less exercise than those who were underweight or normal weight.

Conclusion

These findings underscore the need for greater attention to obesity in chronically homeless adults and demonstrate a food insecurity-obesity paradox or poverty-obesity link.Obesity has become a worldwide epidemic.^1–3 In the United States, 34% of adults are obese and 34% are overweight, meaning 68% are either overweight or obese.⁴ Obesity has been linked to various health problems, many of which have high morbidity and mortality, including diabetes, musculoskeletal disorders, cardiovascular disease, pulmonary disorders, and cancer.^3,5 Thus, identifying and intervening with people who are overweight or obese has become important for primary and secondary prevention.^6–8There has been little study of obesity among chronically homeless adults. Homeless adults represent a marginalized, neglected segment of the population and are known to experience poorer physical health than the general population.^9,10 Because adults who are chronically homeless lack a stable, secure residence and often cannot afford regular, healthy meals,^11–13 they are presumed to be underweight. However, this assumption has not been empirically examined, and there is evidence to suggest there may be an obesity problem among the homeless.A nationally representative survey of 1,704 homeless adults and 400 soup kitchens and shelter providers in 20 cities found that 63% of homeless adults reported obtaining meals from soup kitchens and 51% from shelters in a one-week period.¹⁴ Only 17% of soup kitchens, food pantries, and shelters surveyed were working with a nutritionist or dietician. The nutritional value of food served in many soup kitchens and shelters has been found to be low in vitamins and to exceed fat, energy, and protein content recommendations.^15,16A growing literature in the past decade has reported on a food insecurity-obesity paradox, whereby food insecurity, which often results from inadequate economic resources to purchase food, is associated with obesity, which is a consequence of overconsumption of food.^17,18 Many theories have been proposed to explain this correlation, including the low cost of energy-dense foods, binge eating habits as an adaptive physiological response to food scarcity, and childhood poverty leading to obesity in adulthood.^17,19 Related literature has also suggested a poverty-obesity link, finding that populations with high poverty rates and low education levels have the highest obesity rates.^1,20–22Yet the question remains whether there is an obesity problem among chronically homeless adults, and no prior study could be found directly addressing this question. Thus, this study aimed to examine the prevalence of obesity in a multisite community sample of chronically homeless adults and explore how a range of variables known to be related to weight, including sociodemographics, income and insurance, housing, food source, physical and mental health, and health service use, may be related to being overweight or obese.     

Sun-seeking behavior to increase cutaneous vitamin D synthesis: when prevention messages conflict

Objectives

The public has long been encouraged to engage in sun-safe practices to minimize exposure to sunlight, the major cause of nonmelanoma skin cancer. More recently, some have advocated unprotected sun exposure to increase cutaneous synthesis of vitamin D as a way to promote health. We assessed the net result of these conflicting messages.

Methods

In a cross-sectional survey in 2007, questionnaires were mailed to participants of an ongoing cohort study in Washington County, Maryland. The study population consisted of 8,027 adults (55% response rate).

Results

Thirty percent of respondents were aware that unprotected sun exposure increased endogenous vitamin D levels. Among those who were aware of this benefit, 42% reported going out into the sun to increase vitamin D levels. Sun-seeking to increase vitamin D production did not significantly differ according to self-reported personal history of skin cancer, but was significantly higher among women, older age groups, those with less education, and vitamin D supplement users.

Conclusion

A substantial proportion of respondents reported sun-seeking behavior expressly to increase endogenous vitamin D levels. The message about sun exposure and vitamin D is reaching the general public; however, this finding poses challenges to skin cancer prevention efforts.Among all human malignancies, skin cancers are by far the most common^1,2 and in the U.S. are among the most costly.³ With exposure to solar ultraviolet (UV) radiation as the major cause of nonmelanoma skin cancer,² prevention strategies have emphasized sun avoidance and skin-protection behaviors such as use of sunscreen and skin-protective clothing. Longstanding public education campaigns have sought to reduce sunlight exposure with the goal of reducing skin cancer incidence rates.^4,5In addition to being the primary cause of human skin cancer, solar UV radiation is also responsible for stimulating cutaneous vitamin D synthesis. In turn, vitamin D is critical for calcium homeostasis and skeletal maintenance.⁶ The observation that hypovitaminosis D was common in general medical inpatients, even in those with vitamin D intakes exceeding the recommended daily allowance and those without apparent risk factors for vitamin D deficiency, led to the hypothesis that the general population may have suboptimal levels of vitamin D.^6,7 As understanding of this topic progressed, it gradually gave rise to the observation that sun avoidance, with the goal of preventing skin cancer, may compromise vitamin D sufficiency.⁷ For bone health, consensus has been achieved concerning the definition of vitamin D deficiency (<25 nanograms per milliliter [ng/ml] 25-hydroxyvitamin D [25(OH)D]). For overall health, however, the general definition of vitamin D insufficiency varies.^6,7Both interest and concern regarding vitamin D has increased as evidence has accumulated that its potential health benefits may extend beyond skeletal health. The public''s concerns about vitamin D insufficiency have been raised as studies reporting health benefits have received media coverage, touting the health benefits of the “sunshine vitamin.”^4,8,9 Based on the premise that vitamin D is important to overall health and well-being, some reports have extolled the benefits of regular sun exposure^6,10 and even tanning bed use.¹⁰ For example, vitamin D deficiency and decreased exposure to sunlight have been hypothesized to increase the risks of many common cancers, type 1 diabetes, rheumatoid arthritis, and multiple sclerosis.^6,10 Based on these potentially wide-ranging health benefits of vitamin D, some have suggested that the benefits of sun exposure to increase cutaneous vitamin D synthesis may outweigh the risks (e.g., skin cancer) associated with unprotected exposure to solar UV radiation.^6,10The importance of understanding the public''s perceptions of these issues is accentuated by the fact that the actual relationship between sun exposure and cutaneous vitamin D synthesis and metabolism is complex and incompletely understood even by the scientific community. In a study of highly sun-exposed (average weekly sun exposure of 29 hours) young adults in Hawaii, approximately one-half had 25(OH)D concentrations <30 ng/ml, and 9% had concentrations <20 ng/ml.¹¹ Under tightly controlled experimental conditions among adults in the United Kingdom, UV radiation exposure of approximately 35% of the total skin surface area at doses similar to summer sunlight three days a week for 13 minutes per day resulted in 25(OH)D concentrations of ≥20 ng/ml (“sufficient”) in 10% and concentrations of ≥32 ng/ml (“optimal”) in 74% of the adults.¹² Thus, in addition to factors affecting UV radiation dose, such as season of year, time of day, latitude, altitude, and atmospheric conditions,^13,14 results such as these suggest there is considerable inter-individual variability in cutaneous vitamin D synthesis in response to sunlight. The determinants of these inter-individual differences in vitamin D synthesis and metabolism are undoubtedly complex and multifactorial, but contributors appear to be factors such as age, race, vitamin D supplement use, calcium intake, body mass index (BMI), skin type, and genetic characteristics.^7,8,13,15 Advances are being made in understanding how genetic variants contribute to inter-individual differences in vitamin D status; for example, the results of a recent genome-wide association study revealed variants at three loci that were associated with a significantly higher likelihood of vitamin D insufficiency.¹⁶Further complicating matters, some researchers currently recommend lower-level sun exposure of approximately 15 minutes per day with face and hands exposed,^13,17 but the evidence described previously adds uncertainty with respect to the extent to which this level of sun exposure results in the desired increase in circulating vitamin D concentrations. Furthermore, application of this recommendation is controversial given that solar UV radiation is the major cause of skin cancer.² Additionally, even those who engage in sun-protective behaviors (e.g., sunscreen use) may not apply the sunscreen in a manner that would prevent vitamin D synthesis to the degree theoretically possible on the basis of the sun protection factor.^14,15,18The small but growing body of evidence on this topic indicates that lack of attention to this issue may lead to further escalation in the incidence of skin cancer. Few studies have examined the impact on the general population of the mixed medical and media messages that range from sun avoidance for skin cancer prevention to the sun-seeking, pro-vitamin D message. We addressed this evidence gap by describing the prevalence of (1) awareness of unprotected sun exposure to increase vitamin D and (2) the extent to which concerns about vitamin D may be influencing sun exposure behaviors.     

A Public Health Economic Assessment of Hospitals' Cost to Screen Newborns for Critical Congenital Heart Disease

Objective

Critical congenital heart disease (CCHD) was recently added to the U.S. Recommended Uniform Screening Panel for newborns. This evaluation aimed to estimate screening time and hospital cost per newborn screened for CCHD using pulse oximetry as part of a public health economic assessment of CCHD screening.

Methods

A cost survey and time and motion study were conducted in well-newborn and special/intensive care nurseries in a random sample of seven birthing hospitals in New Jersey, where the state legislature mandated CCHD screening in 2011. The sample was stratified by hospital facility level, hospital birth census, and geographic location. At the time of the evaluation, all hospitals had conducted CCHD screening for at least four months.

Results

Mean screening time per newborn was 9.1 (standard deviation = 3.4) minutes. Hospitals'' total mean estimated cost per newborn screened was $14.19 (in 2011 U.S. dollars), consisting of $7.36 in labor costs and $6.83 in equipment and supply costs.

Conclusions

This federal agency-state health department collaborative assessment is the first state-level analysis of time and hospital costs for CCHD screening using pulse oximetry conducted in the U.S. Hospitals'' cost per newborn screened for CCHD with pulse oximetry is comparable with cost estimates of existing newborn screening tests. Hospitals'' equipment costs varied substantially based on the pulse oximetry technology employed, with lower costs among hospitals that used reusable screening sensors. In combination with estimates of screening accuracy, effectiveness, and avoided costs, information from this evaluation suggests that CCHD screening is cost-effective.In September 2011, the U.S. Secretary of Health and Human Services approved the addition of critical congenital heart disease (CCHD) to the Recommended Uniform Screening Panel for newborns.¹ Just before that approval, New Jersey became the first state to implement mandatory pulse oximetry screening in all licensed birthing facilities to improve detection and early intervention for newborns with CCHD.² Similar legislation has since been introduced or enacted in many other states. Though clinical evidence supports routine CCHD screening,^3,4 at least one earlier attempt at passing state legislation was stymied by reservations that included cost concerns.⁵Congenital heart disease affects an estimated nine per 1,000 live births in the United States; approximately one-quarter of those children have critical conditions requiring surgery or catheter intervention during infancy.^3,6 Newborns with untreated CCHD are at risk for cardiovascular collapse within the first days of life,³ although some newborns do not present obvious physical signs of their condition before birth hospital discharge. Newborns with CCHD not detected during prenatal screening or postnatal examinations may benefit from routine screening at birth hospitals.

Previous estimates of screening time and cost

Estimates of the time and cost of pulse oximetry screening have appeared in the recent literature. Two studies—both from the United Kingdom—reported observations of the time spent by staff engaged in the screening process. One study reported a mean screening time of 2.0 minutes per newborn, where screening included one pulse oximetry reading conducted by a doctor during a clinical examination.^7,8 The second study reported a mean screening time per newborn of 6.9 minutes, based on a survey completed by midwives who conducted the screening.^9,10 The two studies reported an estimated cost per newborn screened—including labor and equipment—of $6.13 and $9.97, respectively (both estimates expressed as 2011 U.S. dollars^11,12). Recent U.S. studies provided estimates of mean screening times per newborn ranging from 45 seconds to 3.5 minutes (where screening usually included one pulse oximetry reading), and estimates of equipment-only screening costs per newborn ranging from “negligible” to $11.00.^{3,5,6,13–15} No previous estimates were based on reported systematic studies in which observers objectively recorded screening times.Robust estimates of hospitals'' costs to conduct routine newborn screening for CCHD using pulse oximetry may inform hospitals'' and states'' decisions on such screening. We aimed to estimate the screening time and cost—including labor and equipment—for hospitals to screen newborns for CCHD using pulse oximetry. This information was collected as part of a broader public health economic assessment of CCHD screening, which is summarized hereafter.     

Barriers to Care and Comorbidities Along the U.S.-Mexico Border

Objective

While limited access to care is associated with adverse health conditions, little research has investigated the association between barriers to care and having multiple health conditions (comorbidities). We compared the financial, structural, and cognitive barriers to care between Mexican-American border residents with and without comorbidities.

Methods

We conducted a stratified, two-stage, randomized, cross-sectional health survey in 2009–2010 among 1,002 Mexican-American households. Measures included demographic characteristics; financial, structural, and cognitive barriers to health care; and prevalence of health conditions.

Results

Comorbidities, most frequently cardiovascular and metabolic conditions, were reported by 37.7% of participants. Controlling for demographics, income, and health insurance, six financial barriers, including direct measures of inability to pay for medical costs, were associated with having comorbidities (odds ratios [ORs] ranged from 1.7 to 4.1, p<0.05). The structural barrier of transportation (OR=3.65, 95% confidence interval [CI] 1.91, 6.97, p<0.001) was also associated with higher odds of comorbidities, as were cognitive barriers of difficulty understanding medical information (OR=1.71, 95% CI 1.10, 2.66, p=0.017), being confused about arrangements (OR=1.82, 95% CI 1.04, 3.21, p=0.037), and not being treated with respect in medical settings (OR=1.63, 95% CI 1.05, 2.53, p=0.028). When restricting analyses to participants with at least one health condition (comparing one condition vs. having ≥2 comorbid conditions), associations were maintained for financial and transportation barriers but not for cognitive barriers.

Conclusion

A substantial proportion of adults reported comorbidities. Given the greater burden of barriers to medical care among people with comorbidities, interventions addressing these barriers present an important avenue for research and practice among Mexican-American border residents.Limited access to health care has been associated with a wide range of adverse health consequences including premature mortality^1,2 and increased risk for many common chronic conditions.^3–5 Despite prior research documenting associations between sustained lack of access and many health conditions independently,^6,7 very little research has described whether people with more than one health condition (i.e., comorbidities) experience greater barriers to obtaining health care.Prior research based on information from the Medical Expenditure Panel Survey has further indicated that people with multiple chronic conditions incur far greater health-care costs (up to seven times as many) as patients with only one chronic condition.⁸ It is essential, therefore, to understand the barriers to care that are disproportionately faced by people with comorbidities who need ongoing care, particularly among populations at high risk for developing comorbidities.Populations at high risk for having multiple health conditions include most minority populations in the U.S. and, in particular, Hispanic people, the largest and most rapidly growing minority group in the U.S.⁹ For example, the largest subgroup of Hispanic people, Mexican-Americans, has been found to have the highest incidence (an estimated 33.2%) of metabolic syndrome,¹⁰ a cluster of risk factors placing people at higher risk for heart disease, type 2 diabetes, and stroke.¹¹ Although there is substantial variability among Hispanic subgroups, based on information from the National Health Interview Survey, Mexican-American populations have the poorest access to care and the lowest use of health services of all Hispanic subgroups.^12,13 An estimated 32% of Hispanic people in the U.S. do not have health insurance compared with 15% of non-Hispanic white people.¹⁴ Besides economic limitations, Hispanic populations often face additional barriers to accessing health services. Factors that have been reported to impede Hispanic populations from obtaining medical care include, but are not limited to, language and literacy barriers,^15–17 lack of transportation and geographic inaccessibility,^15,17 the perception of being treated without respect in medical settings, and the perception that they would have received better quality care if they belonged to a difference racial/ethnic group.¹⁸A valuable guiding framework for the current study that provides a comprehensive overview of modifiable factors associated with access to health care is the recently developed Health Care Access Barriers model, an evidence-based analytical framework developed by Carillo and colleagues.¹⁹ This model describes the assessment of three categories of barriers to health care (financial, structural, and cognitive) that have been shown to be associated with poor health outcomes.Given the limited access to health care and high risk for comorbidities, gaining insight into which financial, structural, and cognitive barriers to care are associated with comorbidities among Mexican-Americans can provide valuable information for preventive efforts. Therefore, based on information from a randomized household survey conducted in a large city along the U.S.-Mexico border, the primary aim of the current study was to compare barriers to health care of participants with and without comorbidities. We hypothesized that people reporting comorbidities would be disproportionately affected by financial, cognitive, and structural barriers to care.     

Changes in the relationship between marriage and preterm birth, 1989-2006

ObjectiveMaternal marriage has historically been protective against preterm birth (PTB); however, social norms and behaviors surrounding marriage have changed over time in the United States. We analyzed secular trends in the relationship between marriage and PTB.MethodsWe collected data about all births in Michigan between 1989 and 2006 to assess (1) the relationship between marital status and PTB and moderately PTB risk by year, and (2) the relationship between married and unmarried status and PTB and moderately PTB by year relative to similar marital status in 1989.ResultsAmong nearly 2.4 million births between 1989 and 2006, PTB risk among married mothers increased while risk among unmarried mothers decreased. In adjusted models, married status became less protective against PTB relative to unmarried status over time by year, and was associated with higher risk of PTB over time. Moderately PTB risk increased among both married and unmarried groups, but more so among married mothers.ConclusionOur findings suggest that marriage is becoming less protective against PTB over time. The influence of social factors on risk for adverse birth outcomes is likely dynamic, suggesting that ongoing revisions to our understanding are in order.Defined by the World Health Organization as birth before 37 completed weeks of gestation, preterm birth (PTB) is a major contributor to perinatal and neonatal mortality, serious neonatal morbidity, and moderate to severe childhood disability.¹ In wealthy countries such as the United States, 6%–10% of all births are preterm, and deaths to preterm infants comprise more than two-thirds of all neonatal deaths.²Married status has long been associated with a lower risk of PTB,^1,3,4 as well as other adverse perinatal outcomes including low birthweight,^3,5,6 small-for-gestational-age infants,^3,5,7,8 and fetal and neonatal mortality.⁹ Several factors may explain the relationship between marital status and risk for adverse birth outcomes, including differences between married and unmarried mothers in financial security,^10–12 health-care access,^4,13 social support, and mental health.^14–18The presumed health-promoting effect of marriage has led to its promotion as a positive social construct that may improve the health of populations.^19–22 However, in the past two decades, the role of marriage has changed in North America. Bumpass and Cherlin independently contended that marriage has undergone a “decline in significance” and a deinstitutionalization as a result of a deterioration of the marital norms that shape partners’ social behaviors and a trend toward individuation, personal choice, and self-development.^23,24 It is plausible, therefore, that as norms governing partners’ marital behaviors have deteriorated over time, mechanisms mediating the relationship between marriage and PTB risk may have weakened, thereby altering the relationship between marital status and the risk of PTB. For example, as partners involved in marital relationships become more independent and self-oriented, and therefore invest fewer of their resources (e.g., money, time, and attention) in one another, it follows that the financial and social support afforded married mothers via their marriages may diminish, with plausible downstream effects on maternal mental health and access to health-care services.In addition, the increasing incidence of PTB in wealthy countries in the past two decades has been shown to be partially attributable to the increasing rate of obstetric interventions,²⁵ such as cesarean section and induced labor.²⁶ Compared with unmarried mothers, married mothers have been shown to have more ready access to health services.^4,13 It is possible that a higher rate of later-term obstetric interventions among married vs. unmarried mothers could change the relationship between marital status and PTB over time by increasing the incidence of obstetrically induced PTB among married vs. unmarried mothers.We hypothesized that the apparent protective effect of marriage on risk of PTB has decreased with time as a result of the aforementioned mechanisms. We analyzed secular trends in PTB, very PTB, and moderately PTB risk among married and unmarried mothers over time using data from one U.S. state between 1989 and 2006.     

The Economic Burden of Exposure to Secondhand Smoke for Child and Adult Never Smokers Residing in U.S. Public Housing

ObjectiveThe World Health Organization (WHO) reports that nonsmokers experience disease and death due to secondhand smoke (SHS) exposure in the home. We estimated the total excess burden and costs to society due to SHS exposure in U.S. public housing.MethodsWe quantified the public health burden for outcomes causally related to SHS exposure for nationally representative never-smoking residents in U.S. public housing using (1) WHO-recommended health outcomes and methodology, (2) publicly available and other large databases, and (3) published estimates of morbidity and mortality rates. We used published estimates of direct medical and nonmedical care costs and the value of productivity losses to estimate SHS-related societal costs for disease and death. We estimated the public health and economic burden for two serum cotinine limits of detection (LODs): 0.05 nanograms per milliliter (ng/mL) and 0.015 ng/mL.ResultsIn 2011, an estimated 37,791 never-smoking child and adult U.S. public housing residents experienced illness and death due to SHS exposure at home based on an LOD=0.05 ng/mL (50,967 residents at LOD=0.015 ng/mL). Costs incurred by society for these illnesses and deaths totaled $183 million (LOD=0.05 ng/mL) and $267 million (LOD=0.015 ng/mL) annually. Of the total costs, direct costs (medical and nonmedical) accounted for $128 million and $176 million for LOD=0.05 ng/mL and LOD=0.015 ng/mL, respectively. Medical care accounted for the majority of direct costs—$110 million at LOD=0.05 ng/mL and $153 million at LOD=0.015 ng/mL. Adverse respiratory health outcomes accounted for approximately one-half (56% at LOD=0.05 ng/mL and 52% at LOD=0.015 ng/mL) of total societal costs.ConclusionImplementing smoke-free policies in all U.S. public housing could save lives and decrease SHS-related morbidity and mortality in never-smoking residents, resulting in annual societal savings of $183 million at LOD=0.05 ng/mL and $267 million at LOD=0.015 ng/mL.An estimated 15%–18% of U.S. children are exposed to secondhand smoke (SHS) at home.¹ SHS is a major cause of disease, and there is no safe level of SHS exposure.^1,2 Children and nonsmoking adults living below the federal poverty level (FPL) are more likely to be exposed to SHS than those in higher socioeconomic status households.³ Children are especially vulnerable because their exposure patterns and developmental status enhance absorption of environmental toxicants.⁴ Additionally, because many elderly people with limited mobility live in public housing, they may spend more time indoors, be exposed to more SHS, and suffer more severe adverse health outcomes than the general population.² People with disabilities comprise nearly one-third of the public housing population and have greater SHS exposure than those without a disability.^5,6 Because SHS migrates, residents of multiunit housing who do not allow smoking in their home are at risk for SHS exposure if other residents in their building smoke.⁷ SHS migration has implications for nonsmoking public housing residents, as 88% of public housing is multiunit.⁸The World Health Organization (WHO) reports that there is sufficient evidence of causal relationships between SHS and adverse health outcomes, including lung cancer, heart disease, and asthma in adults; and low birthweight (LBW) (i.e., birthweight ≤2,500 grams), sudden infant death syndrome (SIDS), and lower respiratory infections (LRIs)—including respiratory syncytial virus, bronchitis, otitis media (OM), and asthma—in children.²Smoke-free policies significantly reduce adverse health outcomes caused by SHS.^9–13 In 2009 and 2012, the U.S. Department of Housing and Urban Development (HUD) encouraged public housing authorities to implement smoke-free policies in subsidized housing.^14,15 Recent research suggests that smoke-free policies are supported by a majority of never- and former-smoking subsidized housing residents and are associated with cessation or lower rates of smoking among smokers.^16,17 Recent data indicate that in 2013, more than 300 housing authorities had instituted smoke-free policies.^18,19The health and economic consequences of childhood SHS exposure in the United States are well documented,^20–28 but similar analyses are not available for nonsmoking adults. While there are published estimates of the U.S. public health burden associated with SHS exposure in adults and state-level economic studies on SHS that include nonsmoking adults, information on the national aggregate costs of SHS-related health effects in adults is sparse.^29–36A recent study estimated SHS-related costs in all government-subsidized housing using state-level estimates.³⁷ However, to our knowledge this is the first study to estimate the public health and economic burden of SHS in public housing based on nationally representative and other large-scale databases, including biomarker data. Quantifying the burden of SHS for residents may provide incentives to institute smoke-free policies in public housing.     

Assessing the Validity and Reliability of Three Indicators Self-Reported on the Pregnancy Risk Assessment Monitoring System Survey

Objectives

We investigated the reliability and validity of three self-reported indicators from the Pregnancy Risk Assessment Monitoring System (PRAMS) survey.

Methods

We used 2008 PRAMS (n=15,646) data from 12 states that had implemented the 2003 revised U.S. Certificate of Live Birth. We estimated reliability by kappa coefficient and validity by sensitivity and specificity using the birth certificate data as the reference for the following: prenatal participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); Medicaid payment for delivery; and breastfeeding initiation. These indicators were examined across several demographic subgroups.

Results

The reliability was high for all three measures: 0.81 for WIC participation, 0.67 for Medicaid payment of delivery, and 0.72 for breastfeeding initiation. The validity of PRAMS indicators was also high: WIC participation (sensitivity = 90.8%, specificity = 90.6%), Medicaid payment for delivery (sensitivity = 82.4%, specificity = 85.6%), and breastfeeding initiation (sensitivity = 94.3%, specificity = 76.0%). The prevalence estimates were higher on PRAMS than the birth certificate for each of the indicators except Medicaid-paid delivery among non-Hispanic black women. Kappa values within most subgroups remained in the moderate range (0.40–0.80). Sensitivity and specificity values were lower for Hispanic women who responded to the PRAMS survey in Spanish and for breastfeeding initiation among women who delivered very low birthweight and very preterm infants.

Conclusion

The validity and reliability of the PRAMS data for measures assessed were high. Our findings support the use of PRAMS data for epidemiological surveillance, research, and planning.The Pregnancy Risk Assessment Monitoring System (PRAMS) is one of the largest state-based surveillance systems of women with live births documenting experiences before, during, and after pregnancy. The data from PRAMS surveys are linked to the birth certificate information. The birth certificate is an important source of data for examining infant health at the state and national levels and is used widely.^1–3 Many studies have examined the reliability and validity of data from the U.S. birth certificate and other data sources such as postpartum surveys, medical records, and registry data.^1–19 Some indicators on the birth certificate are found to be more reliable than others, such as maternal demographics, insurance, and birthweight.^{4,5,7,13,15,19} Birth certificate data have been reported to have lower sensitivity for tobacco and alcohol use;^6,10 birth defects;²⁰ prenatal care;¹¹ and maternal weight gain, medical risks, and obstetric complications,^2,8,9,12,13 although the sensitivity varies by subgroups of women and birth outcomes for many items.^16,17Because PRAMS data are self-reported, it is important to examine the reliability and validity with other population-based data-collection systems such as the birth certificate, which is an established system mandated to assess the health of mothers and babies in the U.S. According to state laws, each live birth must be registered and a birth certificate must be filed. Federal law mandates the national collection and publication of birth certificate data.²¹ A new electronic birth certificate reporting standard was implemented in 2003, replacing the version that had been in place since 1989.²² The 2003 version updated the birth certificate by revising or dropping items and adding new elements with detailed guidance provided on coding data.²³States participating in the Centers for Disease Control and Prevention''s (CDC''s) PRAMS project sample women with recent live-born deliveries using the state birth certificate files. Selected data from the state birth certificate file are linked to the PRAMS survey of women with live-born infants. Some of the measures on the new birth certificate reporting standard are the same as or similar to those on the PRAMS survey. Several studies have compared the validity of measures on PRAMS with birth certificate data, and this study examines additional indicators that had not been assessed previously.^7,18Little has been available on the validity and reliability of information on participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) during pregnancy; Medicaid payment for delivery; and breastfeeding initiation in the early postpartum period, comparing PRAMS data with other data sources. WIC and Medicaid are important sources of services for low-income women and, because these data are used to examine research and programming questions, we investigated the reliability and validity of these indicators. The PRAMS data were compared with the birth certificate as the standard because the comparison of PRAMS data might provide insight about improving the accuracy and quality of PRAMS data. In addition, this investigation may provide insight into using both sources of data in concert to maximize the accuracy of information on women and children. Two research questions guided this investigation: (1) What degree of agreement/reliability exists between PRAMS survey responses and the birth certificate on participation in prenatal WIC services, Medicaid payment for delivery, and breastfeeding initiation? and (2) Do the reliability and validity vary by selected maternal characteristics and birth outcomes as suggested by previous research?¹⁷     

Validation of Selected Items on the 2003 U.S. Standard Certificate of Live Birth: New York City and Vermont

ObjectiveWe assessed the validity of selected items on the 2003 revised U.S. Standard Certificate of Live Birth to understand the accuracy of new and existing items.MethodsWe calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of select variables reported on the birth certificate using the medical record as the gold standard for a representative sample of live births in New York City (n=603) and Vermont (n=664) in 2009.ResultsIn both sites, sensitivity was excellent (>90%) for Medicaid coverage at delivery, any previous live births, and current method of delivery; sensitivity was moderate (70%–90%) for gestational diabetes; and sensitivity was poor (<70%) for premature rupture of the membranes and gestational hypertension. In both sites, PPV was excellent for Medicaid coverage, any previous live births, previous cesarean delivery, and current method of delivery, and poor for premature rupture of membranes. In both sites, almost all items had excellent (>90%) specificity and NPV.ConclusionFurther research is needed to determine how best to improve the quality of data on the birth certificate. Future revisions of the birth certificate may consider removing those items that have consistently proven difficult to report accurately.The U.S. Standard Certificate of Live Birth serves as a legal document and a national and state data source for monitoring maternal and infant health. Assessments of the validity of items on the birth certificate can inform researchers and maternal and child health professionals on how best to use and interpret the birth certificate data for surveillance, public health practice, and research purposes. Previous validation studies of the 1989 version of the U.S. birth certificate documented high specificity for most items and high sensitivity or agreement for a limited number of items, including maternal demographics, delivery method, and infant birthweight, and low-to-moderate sensitivity or agreement for obstetric and medical risk factors.^1–5 The sensitivity of some items varied by maternal characteristics; indicators from birth certificates of infants born to Hispanic mothers and those not proficient in English had some of the lowest sensitivity estimates.⁴In 2003, a new revision of the U.S. Standard Certificate of Live Birth was released by the National Center for Health Statistics (NCHS) with some items from the 1989 revision and new items added. The revised certificate incorporated suggestions from a committee that included state vital registration staff, clinicians, medical and public health researchers, and representatives of national organizations. A criticism of the revised certificate is that it would have benefited from additional input from perinatal epidemiologists with clinical experience and that studies with large samples to assess reliability and validity were needed.⁶Since the release of the 2003 birth certificate, uptake of its use by states has been gradual; however, it was mandated that all jurisdictions adopt its use by 2014. Validation of new or revised items on the 2003 birth certificate has been limited, with few published studies. Studies include the examination of obstetric estimate of gestational age in California⁷ and two additional states;⁸ pre-pregnancy weight and height in Florida;⁹ Medicaid coverage for delivery in Iowa,¹⁰ California,¹¹ and two additional states;⁸ and gestational diabetes in several states.^5,8,12–15The most comprehensive evaluation of the 2003 birth certificate, conducted by NCHS, in a total of eight hospitals in two states, found wide variation in the quality of data by item and hospital. We sought to expand the current evidence of the validity of items on the 2003 birth certificate by conducting a validation study in two geographically and demographically distinct jurisdictions—New York City (NYC) and Vermont. We evaluated items that were less studied and for which the prevalence was sufficient and medical records could be considered a valid gold standard. We evaluated a combination of new, revised, and unchanged items.     

Using disability-adjusted life years to assess the burden of disease and injury in Rhode Island

Objectives

Disability-adjusted life years (DALYs) measure the burden of disease and injury in a population. We tested the feasibility of calculating DALYs to assess the burden of disease and injury in Rhode Island (RI).

Methods

We computed DALYs for the 2008 RI population using methods developed by the World Health Organization, Harvard University, and the World Bank. DALYs are a composite measure that sum years of life lost (YLLs) due to premature mortality with years lived with disability (YLDs). We calculated crude mortality, YLLs, YLDs, and DALYs for 90 major health conditions for RI and stratified them by gender and age. Calculations for YLLs and YLDs were based on five-year averages. We compared our results with U.S. and Los Angeles County, California, estimates.

Results

A DALYs ranking produces a different picture of RI''s disease and injury burden than does mortality-based ranking. Of 90 major health conditions assessed for RI, six of the top 10 causes for mortality and DALYs were the same, but were ranked differently: ischemic heart disease, cerebrovascular disease, Alzheimer dementia and other dementias, trachea/bronchus/lung cancer, chronic obstructive pulmonary disease, and diabetes mellitus. These six conditions accounted for 59% of deaths but only 35% of DALYs. Causes and rank orders for DALYs differed between males and females and among age groups.

Conclusions

Including nonfatal health conditions in an assessment of population health provides a different picture than traditional mortality-based assessments. This study demonstrates the feasibility and constraints of using DALYs to assess the burden of disease and injury at the state level.Mortality data have been used traditionally to identify a population''s most important health problems.¹ However, falling death rates often mean people are living longer but with years of illness and disability. Mortality measures provide incomplete information about overall population health, necessitating the development of alternate summary measures.^1,2 The World Health Organization (WHO), Harvard University, and the World Bank introduced disability-adjusted life years (DALYs) in the Global Burden of Disease (GBD) study.^3,4 DALYs reflect the years of life lost (YLLs) to premature death and the years spent in unhealthy states, combining the impacts of mortality and disability.DALYs are a “health gap” measure that represents the gap between the current health status of a population and one in which everyone lives into old age free of disease and injury.^5,6 It includes the impact of usually nonfatal conditions, such as alcohol use, mental disorders, arthritis, and injuries, and provides a different picture of population health than traditional mortality-based assessments.Several studies have implemented DALYs and published disease and injury burden reports for countries and subnational entities, ^1–3,5,7 including for the United States² and for Los Angeles (LA) County, California.³ In this study, we applied DALYs to the Rhode Island (RI) population using the GBD study methods.⁴ We estimated DALYs for major health conditions, compared DALYs results with traditional mortality measures, and assessed the benefits and limitations of estimating DALYs at the state level. To our knowledge, RI is the first U.S. state to attempt the use of DALYs to evaluate the burden of disease and injury at the state level.     

Physical Activity Patterns Among U.S. Adults with and without Serious Psychological Distress

Objective

A physically active lifestyle is recommended for overall health—both physical and mental. Serious psychological distress (SPD) is associated with adverse health behaviors. We compared patterns of physical activity (PA) among adults with and without SPD using current public health guidelines for PA and examined whether adults with SPD were physically active at recommended levels.

Methods

We used data from the 2009 Behavioral Risk Factor Surveillance System (BRFSS) to assess SPD using the Kessler 6 (K6) scale of nonspecific psychological distress and PA categories based on the 2008 U.S. Department of Health and Human Services guidelines. Complete data were available for 78,886 adults in 16 states that used an optional BRFSS mental illness and stigma module containing the K6 scale. We performed multiple logistic regression analyses to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs).

Results

The unadjusted prevalence of SPD was 3.9% (95% CI 3.6, 4.2), and the age-adjusted prevalence of SPD was 3.8% (95% CI 3.5, 4.1). After adjusting for age, sex, race/ethnicity, education, employment, body mass index, smoking status, and heavy drinking, adults with SPD were significantly less likely to be physically active at recommended levels than adults without SPD. PRs were attenuated but remained significant after further adjustment for limitations to PA.

Conclusion

Adults with SPD are less likely to meet current PA recommendations than adults without SPD, highlighting the need for targeted interventions.Serious psychological distress (SPD), while not indicative of a specific mental illness, is associated with anxiety and mood disorders.^1,2 In 2012, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) compared National Survey on Drug Use and Health (NSDUH) mental health data with other data sources.³ SAMHSA reported that the estimated prevalence of past-year SPD was 10.2% using the 2009 NSDUH. The estimated prevalences of past-year serious mental illness and any mental illness (i.e., ≥1 mental disorder excluding substance abuse) were 4.8% and 19.9%, respectively, using NSDUH data, and 5.8% and 24.8%, respectively, using National Comorbidity Survey Replication data.^3,4 Past 30-day estimates of SPD were 3.1% using National Health Interview Survey (NHIS) data, 4.6% using NSDUH data, and 4.8% using Medical Expenditure Panel Survey (MEPS) data.³SPD is frequently comorbid with chronic physical conditions and disabilities, resulting in an increased risk for adverse health outcomes and premature death.^5–7 In addition, SPD is highly associated with adverse health behaviors, such as smoking, physical inactivity, and substance abuse.^8–11 The economic costs of mental disorders are substantial. While an estimated 6.2% of U.S. health-care spending is attributed to mental disorders,¹² the true cost of these disorders is elusive, as they are mainly indirect, such as increased work absenteeism and decreased productivity, increased risk of unemployment and subsequent reliance on social services disability income, and other adverse consequences (e.g., reduced educational attainment, homelessness, and incarceration).^13,14The overall health benefits of physical activity (PA) are well known.^11,15–23 In 2008, the U.S. Department of Health and Human Services (HHS) published revised PA recommendations informed by the most recent scientific evidence available. These new public health guidelines recommend a physically active lifestyle not only for physical health but also for mental health.²³ Similarly, many organizations have recognized the intertwined relationship between mental and physical health, especially the role PA has in improving and maintaining mental health.^{11,15,17–22,24–26} For example, the American Psychiatric Association''s (APA''s) clinical practice guidelines include PA as an initial treatment modality in patients with mild depressive disorder, and as an adjunct therapy for patients no matter the severity of depression.^17,22 Given the comprehensive health benefits of PA, further elucidation of the PA patterns among adults with SPD is needed to establish a baseline and to inform public health strategies; primary care collaborative care models; and clinical protocols designed to prevent adverse health outcomes, treat mental disorders, and improve the quality of life among this population.Thus, this study had two goals: (1) to compare the PA patterns of adults with and without SPD and (2) to examine whether adults with SPD are physically active in accordance with the 2008 HHS PA guidelines.