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

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

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

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

Correlates of incarceration among young methamphetamine users in Chiang Mai, Thailand

Objectives. We examined correlates of incarceration among young methamphetamine users in Chiang Mai, Thailand in 2005 to 2006.Methods. We conducted a cross-sectional study among 1189 young methamphetamine users. Participants were surveyed about their recent drug use, sexual behaviors, and incarceration. Biological samples were obtained to test for sexually transmitted and viral infections.Results. Twenty-two percent of participants reported ever having been incarcerated. In multivariate analysis, risk behaviors including frequent public drunkenness, starting to use illicit drugs at an early age, involvement in the drug economy, tattooing, injecting drugs, and unprotected sex were correlated with a history of incarceration. HIV, HCV, and herpes simplex virus type 2 (HSV-2) infection were also correlated with incarceration.Conclusions. Incarcerated methamphetamine users are engaging in behaviors and being exposed to environments that put them at increased risk of infection and harmful practices. Alternatives to incarceration need to be explored for youths.Over the past decade, methamphetamine use has increased exponentially and reached epidemic proportions, particularly in North America¹ and Southeast Asia.² The methamphetamine epidemic has been concentrated among adolescents and young adults and has significant public health implications² because methamphetamine use has been associated with high-risk behaviors including multiple sexual partners, contractual sex, polydrug use, and aggression.^3,4Thailand has experienced a steadily increasing methamphetamine epidemic since 1996.⁵ By 2003, an estimated 3 500 000 Thais had ever used methamphetamines.⁶ In 1996, Thailand criminalized methamphetamines, treating the trafficking, possession, and use of methamphetamines with the same severity as heroin-related offenses.⁷ In 2003 the government began a “war on drugs” in an attempt to control the epidemic.^8,9 In combination, these events led to a doubling in the number of incarcerated individuals between 1996 and 2004.^7,10 In 2005, 64% of Thai inmates were drug offenders,¹¹ and in 2006, 75% of drug-related arrests and charges were related to methamphetamines.¹² Treatment for methamphetamine use is limited. Institutional management of methamphetamine users includes the use of rehabilitation centers, military-style boot camps, compulsory drug treatment centers, and prisons.¹¹A history of incarceration has been associated with negative health outcomes, including sexually transmitted infections (STIs) and blood-borne viruses, particularly syphilis,¹³ herpes,¹⁴ HIV,^10,15,16 hepatitis b (HBV),^17,18 and HCV.^18–21 The prevalence of these pathogens has been found to be much higher in prisons than in the general population.^22–26 Although these infections may be a result of a high-risk lifestyle leading to incarceration, it is also clear that the prison system exposes individuals to environments and behaviors that increase their risk of acquiring these infections, such as tattooing,^{10,18,21,27–29} unprotected sex as a result of limited condom availability,²⁷ and using shared needles to inject drugs.^27,30,31With so many young methamphetamine users entering the judicial system, it is important to understand the characteristics of this group so that appropriate public health interventions can be designed. Young methamphetamine users need to be diverted away from the judicial system to decrease high-risk behaviors that may impact their own well-being and that of the community.As part of a randomized controlled trial to reduce the risks associated with methamphetamine use among youths in Chiang Mai, Thailand, we investigated behavioral and viral correlates of incarceration among a sample of 1189 young adults aged 18 to 25 years.     

Walking and Cycling to Health: A Comparative Analysis of City, State, and International Data

Objectives. We sought to determine the magnitude, direction, and statistical significance of the relationship between active travel and rates of physical activity, obesity, and diabetes.Methods. We examined aggregate cross-sectional health and travel data for 14 countries, all 50 US states, and 47 of the 50 largest US cities through graphical, correlation, and bivariate regression analysis on the country, state, and city levels.Results. At all 3 geographic levels, we found statistically significant negative relationships between active travel and self-reported obesity. At the state and city levels, we found statistically significant positive relationships between active travel and physical activity and statistically significant negative relationships between active travel and diabetes.Conclusions. Together with many other studies, our analysis provides evidence of the population-level health benefits of active travel. Policies on transport, land-use, and urban development should be designed to encourage walking and cycling for daily travel.Many nations throughout the world have experienced large increases in obesity rates over the past 30 years.^1,2 The World Health Organization estimates that more than 300 million adults are obese,³ putting them at increased risk for diseases such as diabetes, hypertension, cardiovascular disease, gout, gallstones, fatty liver, and some cancers.^4,5 Several studies have linked the increase in obesity rates to physical inactivity^6–8 and to widespread availability of inexpensive, calorie-dense foods and beverages.^1,9The importance of physical activity for public health is well established. A US Surgeon General''s report in 1996, Physical Activity and Health,¹⁰ summarized evidence from cross-sectional studies; prospective, longitudinal studies; and clinical investigations. The report concluded that physical inactivity contributes to increased risk of many chronic diseases and health conditions. Furthermore, the research suggested that even 30 minutes per day of moderate-intensity physical activity, if performed regularly, provides significant health benefits. Subsequent reports have supported these conclusions.^11–13The role of physical activity in prevention of weight gain is well documented.¹⁴ Strong evidence from cross-sectional studies has established an inverse relationship between physical activity and body mass index.^15,16 In addition, longitudinal studies have shown that exercisers gain less weight than do their sedentary counterparts.^6,8 Thus, the obesity epidemic may be explained partly by declining levels of physical activity.^1,17,18A growing body of evidence suggests that differences in the built environment for physical activity (e.g., infrastructure for walking and cycling, availability of public transit, street connectivity, housing density, and mixed land use) influence the likelihood that people will use active transport for their daily travel.^19,20 People who live in areas that are more conducive to walking and cycling are more likely to engage in these forms of active transport.^21–25 Walking and cycling can provide valuable daily physical activity.^26–30 Such activities increase rates of caloric expenditure,³¹ and they generally fall into the moderate-intensity range that provides health benefits.^32–35 Thus, travel behavior could have a major influence on health and longevity.^29,30,36,37Over the past decade, researchers have begun to identify linkages between active travel and public health.^38–40 Cross-sectional studies indicate that walking and cycling for transport are linked to better health. The degree of reliance on walking and cycling for daily travel differs greatly among countries.^39,41 European countries with high rates of walking and cycling have less obesity than do Australia and countries in North America that are highly car dependent.²⁶ In addition, walking and cycling for transport are directly related to improved health in older adults.⁴² The Coronary Artery Risk Development in Young Adults Study found that active commuting was positively associated with aerobic fitness among men and women and inversely associated with body mass index, obesity, triglyceride levels, resting blood pressure, and fasting insulin among men.^26,39,41,43Further evidence of the link between active commuting and health comes from prospective, longitudinal studies.⁴⁴ Matthews et al. examined more than 67 000 Chinese women in the Shanghai women''s health study and followed them for an average of 5.7 years.³⁷ Women who walked (P < .07) and cycled (P < .05) for transport had lower rates of all-cause mortality than did those who did not engage in such behaviors. Similarly, Andersen et al. observed that cycling to work decreased mortality rates by 40% among Danish men and women.³⁶ A recent analysis of a multifaceted cycling demonstration project in Odense, Denmark, reported a 20% increase in cycling levels from 1996 to 2002 and a 5-month increase in life expectancy for males.⁴⁵We analyzed recent evidence from a variety of data sources that supports the crucial relationship between active travel, physical activity, obesity, and diabetes. We used city- and state-level data from the United States and national aggregate data for 14 countries to determine the magnitude, direction, and statistical significance of each relationship.     

Gasoline Prices and Their Relationship to Rising Motorcycle Fatalities, 1990�C2007

Motor vehicle accidents are the leading cause of death among young adults. Although automobile fatalities have declined in recent years, motorcycle fatalities are rapidly increasing. The purpose of our research was to quantify the relationship between changing fuel prices and motorcycle fatalities.Our findings suggest that people increasingly rely on motorcycles to reduce their fuel costs in response to rising gasoline prices. We estimate that use of motorcycles and scooters instead of 4-wheeled vehicles results in over 1500 additional motorcycle fatalities annually for each dollar increase in gas prices. Motorcycle safety should receive more attention as a leading public health issue.MOTOR VEHICLE FATALITIES are a leading cause of death and a major public health problem in the United States, particularly among young adults. Forty-one percent of all injury-related fatalities in 2005 resulted from motor vehicle crashes among individuals aged 15 to 24 years.^1,2 However, rising gas prices have had a substantial impact in reshaping consumers’ choices of transportation, and this has significant implications for motor vehicle fatalities. From 1998 to 2007, gasoline prices more than doubled in real terms, with much of the increase occurring from 2004 to 2007.³ Whereas demand outstripped supply for hybrid gas-electric cars in the summer of 2008, automobile manufacturers continue to face difficulty in selling large, low-mile-per-gallon vehicles.⁴ Other modes of transportation, such as public transportation, are becoming increasingly popular.^5,6 Research suggests that the decline in the number of miles driven in response to higher fuel prices has led to significant reductions in automobile fatality rates.⁷Another consequence of the higher prices, however, has been increased demand for motorcycles and motored scooters, which use less fuel than cars and trucks. According to a recent survey, 26% of consumers considered substituting a motorcycle or scooter for a car in response to escalating fuel prices.⁸ Motorcycle fatalities have risen substantially since the mid-1990s. We examine the extent to which rising gasoline prices explain increasing road fatalities from motorcycle crashes and call for greater attention to motorcycle safety.The average fuel economy of new cars has never exceeded 30 miles per gallon in any model year.⁴ For sport utility vehicles (SUVs), fuel economy ranged as low as 12 miles per gallon in 2008, and the most fuel-efficient standard truck for 2008 only managed 18 miles per gallon. By using electric motors to supplement power from a conventional gasoline engine, hybrid cars can achieve significantly higher fuel efficiency than equivalent gasoline-powered vehicles. The most fuel-efficient hybrid averages 48 miles per gallon in the city;⁹ however, hybrids cost significantly more than conventional vehicles.^10,11By contrast, motorcycles and scooters are known for significant fuel savings because of their smaller engines. In 2006, according to the National Highway Traffic Safety Administration, the average motorcycle fuel economy was 56.1 miles per gallon.¹² A commuter choosing to ride a motorcycle instead of driving the average car would reduce his or her fuel costs by almost 50%, or by nearly two thirds compared with the average SUV.⁴ Scooters commonly achieve higher levels of fuel efficiency than most motorcycles, with some as high as 100 miles per gallon.¹³New motorcycles and scooters are also typically priced much lower than cars and trucks. Retail prices for the most fuel-efficient scooters and motorcycles available from major manufacturers range from $2000 to $4000. Approximately half of motorized scooter and motorcycle models from the 4 largest Japanese manufacturers retail for less than $10 000. Considering both their significant fuel savings and lower ownership costs, it is not surprising that sales of motorcycles and scooters have been booming.¹³Motorcycles and scooters are more dangerous than 4-wheeled vehicles. An individual switching from a car to a motorcycle with no prior experience or training faces a high risk of injury or death. In fact, over 90% of motorcycle riders involved in a crash do not have formal training, relying instead on family or friends or being self-taught.¹⁴ A high level of riding skill is necessary because 2-wheeled vehicles are more dangerous than 4-wheeled vehicles in situations involving hazards such as road debris, rain, snow, and significant pavement imperfections. Furthermore, many popular motorcycles have higher performance in terms of acceleration and braking than most sports cars, requiring highly developed throttle and braking skills. Riding a motorcycle also leaves less room for mistakes arising from distraction or impairments such as alcohol consumption or fatigue. In fact, two thirds of motorcycle crashes are caused solely by motorcycle rider error.¹⁴ Using the Fatality Accident Reporting System (FARS) database, which contains information on every vehicular fatality occurring on public roads in the United States, we examined the extent to which rising gasoline prices contributed to increasing numbers of motorcycle road fatalities.     

Minority health and small numbers epidemiology: a case study of living conditions and the health of children in 5 foreign Romá camps in Italy

Objective. We sought to test methods for generating epidemiological evidence on health conditions of small, dispersed minority communities.Methods. We used community-based mixed methods including a cross-sectional survey in 5 purposely selected settlements of Khorakané Romá (Gypsies of Muslim culture) in Italy to study the living conditions and health status of children aged from birth to 5 years.Results. In the 15 days prior to the survey, 32% of the children had suffered diarrhea and 55% had had a cough. Some 17% had experienced respiratory difficulties during the past year. Risk factors associated with these outcomes included years spent living at the camp, overcrowding, housing conditions, use of wood-burning stoves, presence of rats, and issues related to quality of sanitation and drains. Qualitative information helped define the approach and the design, and in the interpretation and consolidation of quantitative results.Conclusions. Guided by the priorities expressed by dispersed minority communities, small studies with little resources can provide a solid base to advocate for evidence-based participatory planning. Exact intervals appeared to be robust and conservative enough compared with other intervals, conferring solidity to the results.Minority groups and socially marginalized populations often live in small communities, widely dispersed over both rural and urban areas.¹ Their numbers can be statistically insignificant in relation to the rest of the population.² Routine data or large studies carried out to represent the total population are often of little help in identifying the problems of minorities and in designing appropriate responses to their needs.³ However, minority health issues need particular attention,^4,5 especially those of marginalized groups⁶ because social exclusion has distinctive effects on the excluded groups.⁷ To reduce health disparities in a culturally appropriate and sustainable way,^8,9 these groups need to be involved in and contribute to¹⁰ the gathering and analysis of evidence to support decisionmaking processes that affect them.¹¹Community-based participatory research has proved useful in such cases.^12–15 However, a full participatory approach needs time and funds to be developed to its full potential.^12,16,17 Alternative approaches are often needed as initial steps toward participatory research.^18,19 Sound methods should be designed to go with community-based participatory research approaches and to fit specific local needs.^{12,13,15,20,21}The distrust on the side of minority communities^21–24 caused by a long history of research on excluded groups being affected by prejudice and paradigms that often perpetrate exclusion,^15,25 the distance between researchers and communities,^23,26,27 the lack of funds,^12,23 the need to develop good relations,^28–30 and the need to share decisions and to balance expectations, resources, and impact, all require time and patience to be tackled.In Italy, the living conditions of about 20 000 foreign Romá living segregated in so-called “nomad camps” present serious causes for concern.^31–38 Even if camps are in most cases recognized and managed by local institutions, they are often located in impoverished and isolated areas on the outskirts of towns, they do not generally meet minimum housing standards, and they present serious problems because of inappropriate drainage systems and insufficient sanitation and showers. According to a study conducted in 2001,³⁹ foreign Romá living in camps were mainly Bosnians, Serbs, Kosovans, and Macedonians; however, in recent years the number of Romanian Romá has increased and today probably represents the largest group. In 2001, Macedonian and Kosovan Romá represented 25% of the population of Romá living in camps.Although these settlements are commonly called “nomad camps,” foreign Romá are not nomads but simply migrants. The inappropriate heteronym or adjective “nomad,” commonly used in Italy when speaking about Romá and Sinti (Italian Gypsies living in central and northern Italy) reflects the distance society at large tends to keep from the frequently mentioned “gypsy problem” (problema zingaro).^40–42 This distance often ends up affecting the quality and the type of health research carried out on Romá communities.^43,44 Research on nontransmittable diseases, for example, that affect Romá communities living in marginal contexts, remains underfunded, understudied, and a neglected public health concern.^45–47Our main objective was to develop and test a research method to narrow the gap between small dispersed minority communities (foreign Romá living in camps in our case) and social and health researchers and institutions. We proposed to do this by generating quality evidence that communities could use to advocate for change.     

Risks of Recreational Exposure to Waterborne Pathogens Among Persons With HIV/AIDS in Baltimore, Maryland

Objectives. We assessed the prevalence of recreational activities in the waterways of Baltimore, MD, and the risk of exposure to Cryptosporidium among persons with HIV/AIDS.Methods. We studied patients at the Johns Hopkins Moore Outpatient AIDS Clinic. We conducted oral interviews with a convenience sample of 157 HIV/AIDS patients to ascertain the sites used for recreational water contact within Baltimore waters and assess risk behaviors.Results. Approximately 48% of respondents reported participating in recreational water activities (fishing, crabbing, boating, and swimming). Men and women were almost equally likely to engage in recreational water activities (53.3% versus 51.3%). Approximately 67% (105 of 157) ate their own catch or that of friends or family members, and a majority (61%, or 46 of 75) of respondents who reported recreational water contact reported consumption of their own catch.Conclusions. Baltimoreans with HIV/AIDS are engaging in recreational water activities in urban waters that may expose them to waterborne pathogens and recreational water illnesses. Susceptible persons, such as patients with HIV/AIDS, should be cautioned regarding potential microbial risks from recreational water contact with surface waters.Persons with HIV/AIDS are at high risk for increased morbidity and mortality associated with a range of opportunistic infections, some of which are caused by Cryptosporidium. Cryptosporidium species are of particular public health and medical importance because they are prevalent in surface waters of the United States,^1–7 are efficiently transmitted via water,⁸ and can be consumed in foods contaminated by fecal matter.^9–11 Exposures to Cryptosporidium are common in the US population,¹² and past studies have demonstrated that Cryptosporidium infections significantly contribute to illness and mortality in persons with HIV/AIDS.^13–15 In the 1980s, Cryptosporidium was identified as a major opportunistic pathogen.^16–21 Infection continues to be frequently diagnosed in persons with HIV/AIDS.^22–27 Before the advent of highly active antiretroviral therapy, Cryptosporidium was a relatively common opportunistic infection even in developed countries.^28,29Cryptosporidiosis manifests as an acute gastroenteritis, accompanied by cramps, anorexia, vomiting, abdominal pains, fever, and chills²⁹ and by histological presentation of gastrointestinal mucosal injury.^30,31 Persons with AIDS who become infected with this parasite are at increased risk of developing chronic and often life-threatening diarrhea, biliary tract diseases, pancreatitis, colitis, and chronic asymptomatic infection and recurrence. These developments are especially likely in those who are severely immunosuppressed (CD4 counts < 150 cells/mL).^29,32–35 Infection is diagnosed by the presence of oocysts in unpreserved or preserved stools.³⁶ Histological and ultrastructural examination of biopsy material for different Cryptosporidium life stages, detection of Cryptosporidium DNA and antigens, and identification of species through molecular techniques can also aid in diagnosis.^36–38Cryptosporidium species are enteric protozoan organisms and are prevalent in US watersheds, especially in urban waters.^1,6,39 These parasites have natural hosts in domestic and wild animals such as cattle (especially newborn calves), horses, fish, and birds.^5,40–42 These parasites cause cryptosporidiosis by infecting and damaging the cells of the small intestine and other organs.^13,41 For persons with HIV/AIDS, increased risk for infection by Cryptosporidium has been related to sexual practices such as engaging in sexual intercourse within the past 2 years, having multiple partners during that time, and engaging in anal intercourse.⁴³ Use of spas and saunas has also been identified as a risk factor.⁴³In the United States, Cryptosporidium is the most commonly identified pathogen in cases of recreationally acquired gastroenteritis⁴⁴; the majority of those affected are children. Increased risk of cryptosporidiosis in persons with HIV/AIDS has been associated with swimming.^45,46 US residents make an estimated 360 million annual visits to recreational water venues such as swimming pools, spas, and lakes; swimming is the second most popular physical activity in the country and the most popular among children.⁴⁷Recreational swimming, even in highly chlorinated water, carries a high risk of exposure to enteric pathogens, including Cryptosporidium, Norovirus, Shigella, Escherichia coli, and Giardia.⁴⁸ Cryptosporidiosis and some other enteric illnesses are seasonal, with spikes in occurrence in the summer months from contact with recreational water venues.⁴⁹ Extreme precipitation⁵⁰ and high ambient temperatures⁵¹ can also affect patterns of disease outbreaks. Because not all infections with Cryptosporidium lead to apparent illness or symptoms, infected persons may unknowingly transmit these pathogens to others, such as household members and other recreationists.^12,52 Cryptosporidiosis from swimming, wading, and splashing is prevalent in the United States.^44,46,53,54Risks from the presence of pathogens in waterways include (1) waterborne gastroenteritis and other recreational water illnesses in anglers and other recreationists^44,55–59; (2) transmission of pathogens to humans from caught seafood acting as fomites, or surface carriers⁶⁰; (3) food-borne gastroenteritis from consumption of raw or improperly cooked fish and shellfish^61,62; and (4) hand-to-mouth transmission of pathogens while eating, drinking, or smoking during activities such as fishing and crabbing.⁷Recreational water activities in the Baltimore, Maryland, area take place in Jones Falls and Baltimore Harbor. These and other waterways are used for angling, crabbing, swimming, kayaking, and boating (including paddle boating).^7,63 In addition, Baltimore-area residents often catch and consume fish and crabs from the Baltimore Harbor and local waterways, many of which are already highly contaminated by persistent chemicals such as mercury and polychlorinated biphenyls.⁶⁴ These activities are known to increase risks of exposure to waterborne pathogens through direct contact with contaminated waters or through contact with or handling and consumption of caught seafood (fish, crabs, oysters).^7,65,66To investigate the potential contribution of recreational water contact to Cryptosporidium exposures among persons with HIV/AIDS, we carried out a cross-sectional study at the Johns Hopkins Moore Outpatient AIDS Clinic. The Baltimore metropolitan area has a high prevalence rate of HIV/AIDS among both men and women,⁶⁷ and its population makes intensive recreational use of a contaminated watershed. In addition, laboratory experiments have indicated that crabs can become superficially contaminated by Cryptosporidium and transfer the pathogen to hands.⁶⁸ Local anglers are at risk from Cryptosporidium on wild-caught fish.⁷Our objective was to address the risks of exposure to Cryptosporidium for an urban subpopulation, persons with HIV/AIDS, as a result of recreational contact with Baltimore waterways. We also assessed the patterns and locations of recreational water activities in Baltimore waters.     

Hombres Sanos: evaluation of a social marketing campaign for heterosexually identified Latino men who have sex with men and women

Objectives. We evaluated the effectiveness of Hombres Sanos [Healthy Men] a social marketing campaign to increase condom use and HIV testing among heterosexually identified Latino men, especially among heterosexually identified Latino men who have sex with men and women (MSMW).Methods. Hombres Sanos was implemented in northern San Diego County, California, from June 2006 through December 2006. Every other month we conducted cross-sectional surveys with independent samples of heterosexually identified Latino men before (n = 626), during (n = 752), and after (n = 385) the campaign. Respondents were randomly selected from 12 targeted community venues to complete an anonymous, self-administered survey on sexual practices and testing for HIV and other sexually transmitted infections. About 5.6% of respondents (n = 98) were heterosexually identified Latino MSMW.Results. The intervention was associated with reduced rates of recent unprotected sex with both females and males among heterosexually identified Latino MSMW. The campaign was also associated with increases in perception of HIV risk, knowledge of testing locations, and condom carrying among heterosexual Latinos.Conclusions. Social marketing represents a promising approach for abating HIV transmission among heterosexually identified Latinos, particularly for heterosexually identified Latino MSMW. Given the scarcity of evidence-based HIV prevention interventions for these populations, this prevention strategy warrants further investigation.In the United States, adult and adolescent Latino males represent 5.6% of the total population¹ but 18.7% of HIV/AIDS cases.² Low rates of condom use^3–5 and limited HIV testing^5–7 likely contribute to the risk for infection and transmission among Latinos.Sex between men continues to account for the majority of new HIV infections in the United States.² HIV prevention efforts have traditionally targeted gay and bisexual men. However, individuals’ self-identified sexual orientation frequently does not correspond to their sexual behavior,^8–12 and recent research has been focused on men who self-identify as heterosexual but have sex with men. The results of studies on men who have sex with both men and women (MSMW) suggest that, regardless of sexual identity, this population is at greater risk for HIV than are men who exclusively have sex with men; likewise, MSMW are at greater risk than are men who exclusively have sex with women (MSW).^11,13–16 Reasons for greater risk among MSMW may include lower rates of condom use^11,16 and having sexual partners who engage in high-risk sexual practices.¹¹Previous studies have suggested that Latino men are more likely than are White men to engage in bisexual sexual behavior^9,11,17,18 but less likely than are White men to self-identify as gay or bisexual or to disclose their sexual orientation.^19–23 Cultural factors such as homophobia, social stigma related to same-sex practices, and sexual conservatism may inhibit Latino men from self-identifying as homosexual or bisexual.^{10,13,23–26} The degree to which Latinos integrate same-sex sexual practices into their sexual identities may influence their risk for HIV infection.²⁷ Latino MSMW who identify as heterosexual may perceive that they are at lower risk for sexually transmitted infections (STIs) than are gay or bisexual men, and Latino MSMW may thus be less likely to use condoms to protect themselves or their partners. Latino MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.^19,27Nondisclosure of same-sex sexual practices among MSMW also has significant implications for the health of their female sexual partners.^9,17 More than 70% of Latinas living with HIV/AIDS in the United States were infected via heterosexual contact.² Most cases of heterosexual transmission to Latinas are related to sex with partners who use injection drugs,²⁸ but unprotected sex with men who have multiple partners, including MSMW, has likely contributed to a subset of HIV cases among Latina women.^2,29Social marketing involves applying the principles and techniques of commercial marketing to the promotion of behavioral change for the good of a target audience.^30,31 Social marketing has been successfully used for HIV prevention with gay and bisexual males,^32,33 racial and ethnic minorities,³⁴ and youths.^35–38 Interventions using social marketing have been associated with improvements in HIV/STI testing^32,34 and condom use.^36,37,39,40 To our knowledge, no social marketing campaigns have been designed to reduce HIV risk among heterosexually identified Latino MSMW. Because of the secrecy of their sexual practices and the perceived association of HIV infection with homosexuality,^24,41,42 heterosexually identified Latino MSMW are difficult to reach with HIV prevention efforts. This population is not likely to be exposed to prevention messages or programs targeted to the gay and bisexual communities.¹⁸ Moreover, interventions requiring active recruitment of heterosexually identified MSMW may fail to reach sufficient numbers or may not reach those who are most secretive about their same-sex sexual practices.⁴¹ We sought to evaluate the effectiveness of a social marketing campaign to increase condom use and HIV testing among heterosexual Latino men in northern San Diego County, California, with a special emphasis on heterosexually identified Latino MSMW.     

Childbearing Intentions of HIV-Positive Women of Reproductive Age in Soweto,South Africa: The Influence of Expanding Access to HAART in an HIV Hyperendemic Setting

Objectives. We investigated whether the intention to have children varied according to HIV status and use of highly active antiretroviral therapy (HAART) among women in Soweto, South Africa.Methods. We used survey data from 674 women aged 18 to 44 years recruited from the Perinatal HIV Research Unit in Soweto (May through December 2007); 217 were HIV-positive HAART users (median duration of use = 31 months; interquartile range = 28, 33), 215 were HIV-positive and HAART–naive, and 242 were HIV negative. Logistic regression models examined associations between HIV status, HAART use, and intention to have children.Results. Overall, 44% of women reported intent to have children, with significant variation by HIV status: 31% of HAART users, 29% of HAART-naive women, and 68% of HIV-negative women (P < .001). In adjusted models, HIV-positive women were nearly 60% less likely to report childbearing intentions compared with HIV-negative women (for HAART users, adjusted odds ratio [AOR] = 0.40; 95% confidence interval [CI] = 0.23, 0.69; for HAART-naive women, AOR = 0.35; 95% CI = 0.21, 0.60), with minimal differences according to use or duration of HAART.Conclusions. Integrated HIV, HAART, and reproductive health services must be provided to support the rights of all women to safely achieve their fertility goals.In sub-Saharan Africa, women of childbearing age comprise 61% of people living with HIV, accounting for over 12 million women.¹ In many regions, HIV incidence is increasing most dramatically among young women aged 18 to 30 years,^1,2 which coincides with their peak reproductive years.³ Globally, a plethora of evidence indicates that many women living with HIV continue to desire children,^4–8 become pregnant,^5,6,9 and give birth^5,6,10 after knowing their HIV-positive status.Childbearing decision making can be complex regardless of HIV seropositivity¹¹; among HIV-infected women, however, reproduction introduces additional personal, public health, and clinical care issues.¹² The vast majority of conceptions occur without the use of reproductive technologies such as sperm washing and artificial insemination.¹³ Thus, the unprotected sexual activity required for conception carries a risk of HIV transmission to uninfected sexual partners.¹⁴ Reproduction among HIV-positive women also carries a risk of vertical transmission during pregnancy and labor and through breastfeeding.^15,16 Moreover, HIV-positive women have a lower life expectancy than HIV-negative women,¹⁷ increasing the risk of maternal orphanhood.¹⁸ In light of these concerns, early reproductive guidelines for people living with HIV were dissuasive,¹⁹ and HIV-positive women who express a desire to have children continue to encounter the disapproval of the community and of health care workers.^4,20Nonetheless, although the potential health risks may have dampened the fertility intentions of some HIV-positive women, stigma associated with childlessness in many societies²¹ and the strong personal desires for biological parenthood⁴ remain potent drivers of childbearing intentions, despite an HIV-positive status. Indeed, in some cultural contexts, remaining childless can be a violation of societal norms more stigmatizing than the HIV infection itself.^4,22Expanding access to highly active antiretroviral therapy (HAART) is changing the landscape of childbearing decision making for people living with HIV.²³ HAART increases life expectancy,^24–26 decreases morbidity,^25,27 and dramatically reduces the risks of vertical²⁸ and horizontal^29,30 transmission. In this era of expanding access to HAART, the significant reduction in health risks and barriers to reproduction among people living with HIV has coincided with increased calls for a rights- and evidenced-based approach to reproduction.^31,32 Since childbearing intentions are among the strongest predictors of eventual childbearing,³³ creating effective and responsive sexual and reproductive health services for HIV-positive women in the context of expanding access to HAART requires a clear understanding of expressed childbearing intentions.Existing evidence concerning the influence of expanding access to HAART on childbearing intentions is largely incomplete. Although recent regional studies have shown that HAART use is associated with higher childbearing intentions, these studies neglected to consider the duration of HAART use^6,7 and tended only to compare the childbearing intentions of HIV-positive women without conducting a comparison with HIV-negative women from the same community.^6–8 Moreover, the lack of an HIV-negative control group precludes the opportunity to assess whether HAART users begin to resemble HIV-negative women in their childbearing intentions, particularly as HIV is increasingly recognized as a manageable chronic disease.Given the high HIV prevalence among women of reproductive age in Soweto, South Africa,¹ we aimed to assess the prevalence of childbearing intentions and to determine whether they varied according to HIV status and HAART use among women. We hypothesized that HIV-positive women would have lower childbearing intentions than would HIV-negative women. In addition, we hypothesized that HIV-positive women receiving HAART would have higher childbearing intentions than would HIV-positive HAART-naive women, with increasing duration of HAART treatment associated with incrementally higher childbearing intentions. Overall, we hypothesized that HAART use would narrow the measurable differences in childbearing intentions between HIV-positive and HIV-negative women.²³     

The Relationship Between Discrimination and Substance Use Disorders Among Lesbian, Gay, and Bisexual Adults in the United States

Objectives. We examined the associations between 3 types of discrimination (sexual orientation, race, and gender) and substance use disorders in a large national sample in the United States that included 577 lesbian, gay, and bisexual (LGB) adults.Methods. Data were collected from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, which used structured diagnostic face-to-face interviews.Results. More than two thirds of LGB adults reported at least 1 type of discrimination in their lifetimes. Multivariate analyses indicated that the odds of past-year substance use disorders were nearly 4 times greater among LGB adults who reported all 3 types of discrimination prior to the past year than for LGB adults who did not report discrimination (adjusted odds ratio = 3.85; 95% confidence interval = 1.71, 8.66).Conclusions. Health professionals should consider the role multiple types of discrimination plays in the development and treatment of substance use disorders among LGB adults.Substance use disorders have been shown to be more prevalent among lesbian, gay, and bisexual (LGB) adults than among heterosexual adults in the United States.^1–6 Despite this evidence, little empirical work has focused on why such differences exist between LGB and heterosexual adults. Many studies have posited that differences in rates of mental health problems and substance abuse are related to social stressors such as discrimination,^7–11 yet no large-scale national studies have examined the relationship between multiple types of discrimination and substance use disorders. Meyer''s minority stress model posits that discrimination, internalized homophobia, and social stigma can create a hostile and stressful social environment for LGB adults that contributes to mental health problems, including substance use disorders.^10,11 An assumption of this model is that minority stress is unique and additive to general stressors that all people experience.Meyer''s model connects the literature demonstrating higher odds of mental health problems and substance use disorders among LGB populations with well-established social science research that demonstrates the link between stress or stressful life events and poor health outcomes.^12–15 Lesbian, gay, and bisexual adults experience discrimination at the structural and institutional level, such as in access to housing, employment, medical care, and basic civil rights,^16,17 as well as at the individual level in the form of harassment and violence.^18–22 Discriminatory experiences have been shown to operate as stressors in the lives of LGB people and, in turn, they are significantly associated with psychiatric disorders,⁹ psychological distress,^9,20,23 and depressive symptoms.^20,24Although the minority stress model provides a useful theoretical framework for understanding health disparities among LGB adults, only a handful of studies have directly assessed discrimination among LGB populations, and even fewer have examined the relationships between discrimination and health outcomes. Extant research on health outcomes related to discrimination has focused on blood pressure,¹⁷ psychological distress,^24,25 mental health disorders,⁹ and general psychological and physical health.²⁶ Given that exposure to both acute and chronic stress has long been associated with substance abuse and relapse in the general population,^26,27 research on the association between experiences of discrimination and substance use disorders among LGB adults is warranted.In our investigation, we assumed that LGB adults are at heightened risk for substance use disorders as a consequence of cultural and environmental factors associated with being part of a stigmatized and marginalized population, not because of their sexual orientation. Building on previous work documenting the impact of multiple stigmatized statuses among sexual minority people^11,28,29 as well as the work of Krieger et al.,¹⁶ we sought to examine the relationships between 3 types of discrimination (sexual orientation, race/ethnicity, and gender) and substance use disorders. We used data from wave 2 of the 2004–2005 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to test the hypothesis that LGB adults who reported more types of discrimination would be more likely to meet criteria for substance use disorders than would those who reported fewer types or who did not report discrimination.     

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

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

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

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

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

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

Participatory Design of Mass Health Communication in Three Languages for Seniors and People With Disabilities on Medicaid

Objectives. We used participatory design methods to develop and test guidebooks about health care choices intended for 600 000 English-, Spanish-, and Chinese-speaking seniors and people with disabilities receiving Medicaid in California.Methods. Design and testing processes were conducted with consumers and professionals; they included 24 advisory group interviews, 36 usability tests, 18 focus groups (105 participants), 51 key informant interviews, guidebook readability and suitability testing, linguistic adaptation, and iterative revisions of 4 prototypes.Results. Participatory design processes identified preferences of intended audiences for guidebook content, linguistic adaptation, and format; guidebook readability was scored at the sixth- to eighth-grade level and suitability at 95%. These findings informed the design of a separate efficacy study that showed high guidebook usage and satisfaction, and better gains in knowledge, confidence, and intended behaviors among intervention participants than among control participants.Conclusions. Participatory design can be used effectively in mass communication to inform vulnerable audiences of health care choices. The techniques described can be adapted for a broad range of health communication interventions.Reaching vulnerable populations and communicating effectively with them is a critical public health challenge. The estimated 55.6 million Medicaid beneficiaries¹ are one of the most vulnerable US populations and face serious communication barriers related to limited literacy, language, culture, and disability.^2,3 Of this population, the most at-risk subgroups are the more than 13.5 million seniors and people with disabilities.¹ Their communication barriers are even greater: many have limited health literacy skills (difficulty accessing, understanding, and acting on health information), limited English proficiency,^2,4 or physical or cognitive conditions that impede access to information.With the rapid proliferation of “consumer choice models” in many states, millions of Medicaid beneficiaries are now required to make complex decisions about health plan options and effectively using health care.³ These decisions have important implications for the targeted beneficiaries regarding access to needed preventive, curative, and supportive services.^3,5–9 However, studies show that these populations have difficulty making such decisions—in part because of the poor quality of information they receive.^3–6,8,9 For example, in studies in which seniors on Medicaid used printed materials about health care choices, only 32% of those in Florida³ and 25% of those in California¹⁰ could understand the information. This is not surprising, as more than 250 studies indicate that printed materials related to health are written at reading levels greatly exceeding the average literacy skills of adults in the United States.¹¹Theoretical guidance from socio-ecological,¹² social cognitive,¹³ and transtheoretical models,¹⁴ as well as 40 years of empirical research, suggest that health communication is more effective when it is relevant to people''s personal and social contexts.^15–29 For this reason, interpersonal and tailored computer-mediated communication, which can be personalized, typically show better results than materials-based mass communication.^{18,22,24,25,30–32} However, Medicaid programs primarily communicate with seniors and people with disabilities through printed materials, given the need for low-cost mass distribution and this population''s limited access to both in-person advice and the Internet. Is there a way to reach these highly vulnerable groups effectively and affordably?Research from the past 20 years shows that using strategies to adapt printed mass communication resources more closely to the needs of population subgroups can improve outcomes.^15–29 These design principles include matching readability more closely to users'' literacy levels and using “clear communication” formatting criteria,^33–35 incorporating culturally relevant concepts and graphics,^{4,17,19,23,36–40} and adapting rather than literally translating material into other languages.^{4,19,23,39,41}Such design principles are invaluable, but they can only approximate how real audiences use and react to health communication. For this reason, increasing emphasis is being placed on “participatory” or “user-centered” design—a structured approach that employs varied formative research methods to involve intended consumer and professional audiences as codevelopers of communication.^{4,19,25,42–45}Guidelines from the US Department of Health and Human Services and its centers, including the Centers for Disease Control and Prevention and the National Cancer Institute, recommend participatory design as a primary strategy to develop health communication.^{33–35,43,46} For the past 20 years, our center (Health Research for Action, www.uchealthaction.org) has leveraged such guidance to create large-scale mass communication materials by and for diverse populations.Two decades of studies confirm that when users participate in designing and testing communication, outcomes are more successful, including those for vulnerable groups.^{4,25,28,42,44,47–51} However, limited research is available about the detailed, iterative methods and steps involved in developing user-centered, materials-based mass communication—especially about how to adapt it for specific situations.In California, the Department of Health Care Services (DHCS) was concerned that fewer than 25% of Medicaid beneficiaries who were seniors or people with disabilities made active choices about health plans. By default, many beneficiaries could have plans ill suited for their health care needs. In 2006, the DHCS commissioned our center to use participatory processes to develop and test a guidebook about choosing and navigating health plans, intended for approximately 600 000 statewide Medicaid beneficiaries who were seniors and people with disabilities, in multiple language versions. Our objectives were to determine the (1) importance of participatory design in improving mass communication for diverse and vulnerable audiences, (2) methods to engage consumers and professionals in communication design and testing, (3) processes and outcomes of a project to create a user-designed guidebook for Medicaid beneficiaries, and (4) implications for health communication researchers and practitioners.     

Alcohol advertising at Boston subway stations: an assessment of exposure by race and socioeconomic status

Objectives. We investigated the frequency of alcohol ads at all 113 subway and streetcar stations in Boston and the patterns of community exposure stratified by race, socioeconomic status, and age.Methods. We assessed the extent of alcohol advertising at each station in May 2009. We measured gross impressions and gross rating points (GRPs) for the entire Greater Boston population and for Boston public school student commuters. We compared the frequency of alcohol advertising between neighborhoods with differing demographics.Results. For the Greater Boston population, alcohol advertising at subway stations generated 109 GRPs on a typical day. For Boston public school students in grades 5 to 12, alcohol advertising at stations generated 134 GRPs. Advertising at stations in low-poverty neighborhoods generated 14.1 GRPs and at stations in high-poverty areas, 63.6 GRPs.Conclusions. Alcohol ads reach the equivalent of every adult in the Greater Boston region and the equivalent of every 5th- to 12th-grade public school student each day. More alcohol ads were displayed in stations in neighborhoods with high poverty rates than in stations in neighborhoods with low poverty rates.Excessive alcohol use is the third-leading lifestyle-related cause of death in the United States.¹ Immediate health risks include unintentional injuries,² violence,^2,3 risky sexual behaviors,^4,5 miscarriage and stillbirth among pregnant women,^6,7 fetal alcohol syndrome,⁷ and alcohol poisoning.⁸ Long-term health risks include neurological,^9,10 cardiovascular,^11,12 and psychiatric problems,¹³ as well as an increased risk of cancer,^12,14 liver disease,^12,15,16 and pancreatitis.^12,17,18 Excessive alcohol use is also linked to a variety of social problems, including increased unemployment¹⁹ and frequency of violent crime and incarceration.^20,21 Drinking among underage youths is increasing.^22–25 Excessive alcohol use also has economic consequences. Alcohol-related health care utilization (e.g., motor vehicle crashes, fires), productivity losses, social welfare (e.g., food stamps), and criminal justice cost the United States an estimated $184.6 billion in 1998 alone.^12,26Alcohol advertising has historically been linked to increased consumption of alcohol in youths,^25,27–31 and a more recent study also shows an increase in consumption by adults.³² These data come from studies of advertising in a variety of media, including television, music video, public transit, and outdoor advertising.^25–31 Alcohol is disproportionately advertised in low-income neighborhoods^33,34 and in neighborhoods with a high proportion of racial and ethnic minorities.^32,34–36Studies have shown that people of color experience poorer health outcomes and shorter life expectancies than do Whites.³⁷ Individuals of lower socioeconomic status also have been found to have higher morbidity and mortality and more risk factors for heart disease and stroke than do people of higher socioeconomic status.³⁸ Minorities are more likely to live in poverty, which exacerbates the negative consequences of alcohol use.³⁹ Because racial and ethnic minorities and individuals of lower socioeconomic status are at a higher risk for poor health and have been identified as targets of alcohol advertising, it is critical that advertising policies change to protect these disadvantaged groups. Hackbarth et al. suggest that reducing alcohol consumption among disadvantaged groups through community intervention, such as banning alcohol advertising, would be one way to eliminate such health disparities.³⁶In 2007 Kwate et al. determined that Black neighborhoods in New York City had more advertising space than White neighborhoods and that these spaces were disproportionately used to market alcohol and tobacco products.³⁵ However, they did not find a significant relationship between median income and ad density, which suggests that relative affluence did not protect Black neighborhoods from targeted outdoor advertising.Advertising on public transportation has received little attention in the literature. In 2007, a report issued by the Marin Institute documented the advertising practices of 20 public transit agencies nationwide. The report found that 2 major cities, Boston, Massachusetts and New York City, lagged far behind other cities that had policies in place to protect children from alcohol advertising.²⁵ Chicago, Illinois; Los Angeles, California; San Francisco, California; Washington, DC; and other places explicitly prohibit alcohol advertising on public transit systems. For example, San Francisco imposes a $5000 per day fine for violating advertising policies.²⁵ By contrast, the Massachusetts Bay Transit Authority (MBTA), which serves the Boston area, has no such restrictions against alcohol advertising, although it claims to prohibit all “adult-oriented goods and services.” The MBTA bans advertising that features tobacco, violence, or nudity because they are considered inappropriate for viewing by minors.²⁵ It is disturbing that one of the largest cities in the United States has not yet adopted stricter policies to protect its riders from potentially harmful alcohol ads.In 2009, Nyborn et al. studied the frequency of alcohol advertising on MBTA train cars and found that alcohol advertisers were able to reach the equivalent of nearly half of all transit passengers each day.⁴⁰ These data showed that roughly 315 000 people, or 11% of the entire adult population in the greater Boston area (Suffolk, Middlesex, and Norfolk counties; total 2008 population = 2 841 374⁴¹) may be exposed to alcohol ads on the MBTA train lines alone. However, that study focused on ads on moving trains and did not consider the frequency of alcohol ads at train stations and how this frequency might differ between neighborhoods. We expanded the focus to include train stations to investigate whether alcohol advertising targeted particular socioeconomic or racial/ethnic groups.We aimed to (1) quantify exposure to alcohol advertising at MBTA train stations among adults in the greater Boston area and among Boston public school students in grades 5 to 12 and (2) compare the frequency of alcohol ads in different MBTA train stations to determine whether minority or poor populations were disproportionately exposed.     

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

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

Medication Prescribing Practices for Older Prisoners in the Texas Prison System

Objectives. We sought to assess appropriateness of medication prescribing for older Texas prisoners.Methods. In this 12-month cross-sectional study of 13 117 prisoners (aged ≥ 55 years), we assessed medication use with Zhan criteria and compared our results to prior studies of community prescribing. We assessed use of indicated medications with 6 Assessing Care of Vulnerable Elders indicators.Results. Inappropriate medications were prescribed to a third of older prisoners; half of inappropriate use was attributable to over-the-counter antihistamines. When these antihistamines were excluded, inappropriate use dropped to 14% (≥ 55 years) and 17% (≥ 65 years), equivalent to rates in a Department of Veterans Affairs study (17%) and lower than rates in a health maintenance organization study (26%). Median rate of indicated medication use for the 6 indicators was 80% (range = 12%–95%); gastrointestinal prophylaxis for patients on nonsteroidal anti-inflammatories at high risk for gastrointestinal bleed constituted the lowest rate.Conclusions. Medication prescribing for older prisoners in Texas was similar to that for older community adults. However, overuse of antihistamines and underuse of gastrointestinal prophylaxis suggests a need for education of prison health care providers in appropriate prescribing practices for older adults.More than 1 in 100 Americans are incarcerated in a US prison or jail¹ and older prisoners are among the most rapidly growing correctional populations.^1–4 With high rates of chronic disease,^5–7 older prisoners cost on average 2 to 3 times more than younger prisoners to incarcerate.^1,8 Yet prisons are often ill-equipped to care for older prisoners with complex medical problems, such as functional or cognitive impairments.^9–12 This is largely because older adults have substantively different health care needs than younger adults who have traditionally been the focus of prison health care.¹² Despite the increasing numbers and cost of older prisoners, research about the quality of geriatric care in prisons is sparse.One important difference in the care of younger and older adults is medication prescribing.^13,14 Older adults often require medications for multiple chronic diseases, whereas younger adults typically require short-term medications for acute injuries or infection. Although older patients are at increased risk for medication-related adverse events leading to morbidity, mortality, and high costs,^15,16 underuse of indicated medications can deny older adults improved quality and length of life.¹⁵ Despite the safety concerns and high cost associated with inappropriate medication use in older adults, little is known about medication prescribing practices for older prisoners.We assessed medication prescribing practices among older prisoners in the Texas Department of Criminal Justice (TDCJ)—one of the nation''s largest state prison systems. Since 1994, when the TDCJ implemented an academic-based managed care system run by the University of Texas Medical Branch, it has reported substantial improvements in health care and has been proposed as a nationwide model.^17,18 It is unknown if this improved quality has extended to elements of care of the older prisoners, such as medication prescribing quality.     

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

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