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.     

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.     

Income Inequality, Trust, and Population Health in 33 Countries

Objectives. I examined the association between income inequality and population health and tested whether this association was mediated by interpersonal trust or public expenditures on health.Methods. Individual data on trust were collected from 48 641 adults in 33 countries. These data were linked to country data on income inequality, public health expenditures, healthy life expectancy, and adult mortality. Regression analyses tested for statistical mediation of the association between income inequality and population health outcomes by country differences in trust and health expenditures.Results. Income inequality correlated with country differences in trust (r = −0.51), health expenditures (r = −0.45), life expectancy (r = −0.74), and mortality (r = 0.55). Trust correlated with life expectancy (r = 0.48) and mortality (r = −0.47) and partly mediated their relations to income inequality. Health expenditures did not correlate with life expectancy and mortality, and health expenditures did not mediate links between inequality and health.Conclusions. Income inequality might contribute to short life expectancy and adult mortality in part because of societal differences in trust. Societies with low levels of trust may lack the capacity to create the kind of social supports and connections that promote health and successful aging.Social inequalities in health are closely aligned with individual differences in income. At every level of socioeconomic status, health tends to be better on the level above and poorer on the level below, even among those who are not poor and enjoy equal access to health services.^1,2 Research also shows that health problems that are associated with socioeconomic status are more common in societies that have wider distributions of personal income.³ It is well-documented that international differences in income inequality (i.e., size of the gap between rich and poor) are associated with rates of mortality⁴ and with various mental and physical health problems.^5–8Opinions are divided regarding the contextual mechanisms that might account for the association between income inequality and health. One line of research focuses on the psychosocial impact of inequality and the breakdown of “social capital,” which is defined as features of social organization—such as networks, norms, and interpersonal trust—that facilitate coordination and cooperation for mutual benefit.^2,9 Wilkinson, Kawachi, and others have suggested that large income differences intensify social hierarchies and increase class conflict and feelings of relative deprivation while simultaneously reducing levels of interpersonal trust, social cohesion, and other dimensions of social capital that promote health.^3,10–12 The alternative “neomaterialist” hypothesis suggests that income inequality inhibits public expenditures on important services and infrastructure that promote health.^13–17 In the United States, for instance, state expenditures on public health and education negatively correlate with income inequality and adult mortality.^13,16 It remains undetermined whether international differences in public expenditures account for the association between income inequality and health.The neomaterialist and social capital hypotheses are not mutually exclusive. Kawachi and Kennedy observed that US state populations with low levels of trust are also characterized by values that support a minimal role for government in reducing health inequalities.¹⁸ Putnam''s index of health and health care in the United States (which included expenditures on health care) was highly correlated with an index of social capital.⁹ Therefore, it could be the case that more equal, more trusting societies are also more willing to support government spending on goods and services that advance the common good, compared with less equal, less trusting societies.It is important to understand which factors account for the association between income inequality and population health. A piecemeal evidence base shows inconsistent findings for mediation by psychosocial and neomaterial paths. Inconsistencies among studies with regard to sample selection criteria, tests of mediated effects, and measures of income inequality have made it difficult to weigh the evidence in favor of either hypothesis.^11,19–21 As a result, previous claims that the relationship between income inequality and poor health is mediated by trust, social capital, or public expenditures²²—or that the relation is simply a statistical artifact caused by confounding effects of individual income,²³ race,²⁴ or education²⁵—have not all been based on rigorous tests of statistical mediation.One issue in particular muddies the water when testing mediated effects: small changes in a regression slope or correlation coefficient that occur when a third variable is controlled can easily cause the statistic to change from significance (P < .05) to nonsignificance (P > .05), even when the third variable does not account for a significant proportion of shared variance. Negligible change from significance to nonsignificance does not, in itself, establish mediation.²⁶ Kawachi et al. addressed this issue by using path analysis to show significant mediated effects of income inequality (via social capital) on mortality¹¹ and births to adolescents.²⁰ However, these studies did not include similar mediation analyses of public expenditures.There has not been a direct comparison of psychosocial and neomaterial paths in accounting for the association between income inequality and health. Therefore, my aim in the current study was to test the association between income inequality and 2 indicators of population health—healthy life expectancy and adult mortality—and then test how much this association was mediated by differences in a proxy indicator of social capital (interpersonal trust) and by public expenditures on health. Of course, trust is just a single aspect of social capital that could mediate links between inequality and health, and expenditures on services other than health might also relate to health. But by using a consistent set of data on income inequality and population health, I explored whether their association (if significant) was better explained by a psychosocial path or a neomaterial path. In disadvantaged populations, healthy life expectancy (also referred to as “disability-free life expectancy”) represents the burden of ill health better than total life expectancy does, according to the World Health Organization,²⁷ so I used healthy life expectancy as an indicator of population health. Adult mortality was used as a general indicator of population health.     

Tackling Health Inequities in Chile: Maternal, Newborn, Infant, and Child Mortality Between 1990 and 2004

Objectives. We analyzed trends in maternal, newborn, and child mortality in Chile between 1990 and 2004, after the introduction of national interventions and reforms, and examined associations between trends and interventions.Methods. Data were provided by the Chilean Ministry of Health on all pregnancies between 1990 and 2004 (approximately 4 000 000). We calculated yearly maternal mortality ratios, stillbirth rates, and mortality rates for neonates, infants (aged > 28 days and < 1 year), and children aged 1 to 4 years. We also calculated these statistics by 5-year intervals for Chile''s poorest to richest district quintiles.Results. During the study period, the maternal mortality ratio decreased from 42.1 to 18.5 per 100 000 live births. The mortality rate for neonates decreased from 9.0 to 5.7 per 1000 births, for infants from 7.8 to 3.1 per 1000 births, and for young children from 3.1 to 1.7 per 1000 live births. The stillbirth rate declined from 6.0 to 5.0 per 1000 births. Disparities in these mortality statistics between the poorest and richest district quintiles also decreased, with the largest mortality reductions in the poorest quintile.Conclusions. During a period of socioeconomic development and health sector reforms, Chile experienced significant mortality and inequity reductions.Despite Latin America''s overall declines in mortality and gains in life expectancy over the past few decades, inequity remains a leading health problem.^1–7 Data from the region on maternal, newborn, infant, and child health show better outcomes among women with higher socioeconomic status.^8,9 Available evidence on the coverage rates of maternal and child health initiatives similarly shows a regressive distribution of services, with the wealthiest groups disproportionately benefiting from the introduction of new programs.^2,10–13 Although maternal and child health inequities are prevalent throughout Latin America, their extent differs, with some countries making strides in their reduction in recent years.⁸Studies examining the success of some Latin American countries (e.g., Chile, Costa Rica, Cuba) in narrowing the gaps between the richest and poorest population groups attribute much of this success to improvements in women''s access to education and increases in the coverage of public health measures.^2,3,14–16 Findings indicate that significant reductions in maternal and child health inequities in Latin American countries can be achieved under diverse political and economic conditions. Other countries in the region (e.g., Mexico, Colombia) have introduced health reforms to ensure that typically underserved groups are better targeted.^2,17 These efforts are further proof that maternal and child health inequities in Latin America are not immutable.Chile has been heralded for its achievements in improving maternal and child health.^3,7 We analyzed the declining trends in maternal and child mortality in Chile between 1990 and 2004 and the variances in mortality trends across district quintiles of socioeconomic status to determine whether and how these inequities changed. We explored reasons for the downward mortality trends and changes in the mortality differentials between district quintiles, such as national-level interventions and changes in key demographic indicators known to influence pregnancy outcomes.Our goal was to document Chile''s declining maternal, newborn and child mortality trends during 1990 to 2004 and explore possible associations between these trends, health sector reforms, and improvements in the socioeconomic status of mothers. We expected to confirm overall declines in mortality and persistent inequities. Given the growing global interest in combating health disparities, our assessment of maternal and child mortality indicators in Chile—the first for this country—is an important first step toward identifying both coverage gaps across the continuum of care¹⁸ and successful strategies in reducing inequities. Our findings may inform efforts in other countries to implement integrated maternal and children''s health service packages and to achieve Millennium Development Goals 4 and 5 (reducing child mortality and improving maternal health, respectively).¹⁹     

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.     

Social gradients in oral health in older adults: findings from the English longitudinal survey of aging

Objectives. We examined prospective associations between socioeconomic position (SEP) markers and oral health outcomes in a national sample of older adults in England.Methods. Data were from the English Longitudinal Survey of Aging, a national cohort study of community-dwelling people aged 50 years and older. SEP markers (education, occupation, household income, household wealth, subjective social status, and childhood SEP) and sociodemographic confounders (age, gender, and marital status) were from wave 1. We collected 3 self-reported oral health outcomes at wave 3: having natural teeth (dentate vs edentate), self-rated oral health, and oral impacts on daily life. Using multivariate logistic regression models, we estimated associations between each SEP indicator and each oral health outcome, adjusted for confounders.Results. Irrespective of SEP marker, there were inverse graded associations between SEP and edentulousness, with proportionately more edentate participants at each lower SEP level. Lower SEP was also associated with worse self-rated oral health and oral impacts among dentate, but not among edentate, participants.Conclusions. There are consistent and clear social gradients in the oral health of older adults in England, with disparities evident throughout the SEP hierarchy.The inverse linear relationship between socioeconomic position (SEP) and health is well established.^1–4 The uneven distribution of health across socioeconomic strata has been observed in both industrialized and less developed countries and for most common diseases and causes of death.^1,5–8 In most cases, the association between SEP and health is characterized by a linear graded pattern, with people in each lower SEP category having successively worse levels of health and dying earlier than those that are better off, a characteristic known as the social gradient in health.⁹Although there is clear and consistent evidence about the existence of the social gradient in working-age adults,^10,11 studies in older adults are less consistent, with some showing attenuation of the gradient^12,13 and others reporting that it persisted^14,15 or even increased¹⁶ in magnitude.Oral health is particularly important at older ages with tooth loss shown to be independently associated with disability and mortality.^17–20 Oral health status in older people is also an important determinant of nutritional status.²¹Socioeconomic disparities in oral health have been consistently demonstrated for various indicators, mostly clinical and disease related^22–31 but also subjective measures of oral health and quality of life.^30,32–38 Some of these studies have explicitly assessed the existence of an oral health gradient,^{23,25–31,34–37} but almost all were carried out on adolescents and adults, with very few focusing on older people.^33,36 These few relevant studies are cross-sectional and inconclusive and have used a limited number of SEP indicators (typically, education and occupational class), thereby hindering any comprehensive analysis on the relationship between SEP and oral health.We addressed the gap in the literature about the existence of an oral health gradient at older ages by examining the prospective associations between a wide range of SEP indicators (education, occupation, household income, household wealth, subjective social status [SSS], and childhood SEP) and various oral health outcomes (presence of natural teeth, self-rated oral health, and oral impacts) in a national sample of older adults from the English Longitudinal Survey of Aging (ELSA). We explored whether there are any significant socioeconomic inequalities in oral health among older people in England and, if so, whether these take the form of a gradient.     

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

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

The Long-Term Health Consequences of Relationship Violence in Adulthood: An Examination of Low-Income Women From Boston, Chicago, and San Antonio

Objectives. We examined the long-term health consequences of relationship violence in adulthood.Methods. Using data from the Welfare, Children, and Families project (1999 and 2001), a probability sample of 2402 low-income women with children living in disadvantaged neighborhoods in Boston, Massachusetts; Chicago, Illinois; and San Antonio, Texas, we predicted changes in the frequency of intoxication, psychological distress, and self-rated health over 2 years with baseline measures of relationship violence and a host of relevant background variables.Results. Our analyses showed that psychological aggression predicted increases in psychological distress, whereas minor physical assault and sexual coercion predicted increases in the frequency of intoxication. There was no evidence to suggest that relationship violence in adulthood predicted changes in self-rated health.Conclusions. Experiences with relationship violence beyond the formative and developmental years of childhood and adolescence can have far-reaching effects on the health status of disadvantaged urban women.Over the past 2 decades, numerous studies have examined the long-term health consequences of relationship violence during childhood. This body of research suggests that physical and sexual abuse in early life can be devastating to health in adulthood, contributing to poor mental^1–6 and physical health^3–5,7 and to higher rates of substance abuse.^5,6,8,9 These patterns are remarkably consistent across studies and notably persistent through the life course. In a recent study of more than 21 000 older adults, Draper et al.³ reported that physical and sexual abuse before 15 years of age is associated with poor mental and physical health well into late life.Although previous research has made significant contributions to our understanding of the lasting effects of abuse in early life, few studies have considered the long-term health consequences of relationship violence in adulthood. Our review of the literature revealed 5 longitudinal studies of relationship violence and health in adulthood. Not surprisingly, research suggests that women who experience relationship violence in adulthood are vulnerable to poor health trajectories, including increases in depressive symptoms,^10–12 functional impairment,^10,12 and alcohol consumption.^13,14Relationship violence is an important issue in all segments of society; however, studies consistently show that women of low socioeconomic status exhibit higher rates of intimate partner victimization than do their more affluent counterparts.^15–17 For example, Tolman and Raphael¹⁷ reported that between 34% and 65% of women receiving welfare report having experienced some form of relationship violence in their lifetime, and between 8% and 33% experience some form of relationship violence each year, levels that surpass those for women overall.¹⁸ Research also shows that residence in disadvantaged neighborhoods^19,20 and the presence of children in the household^21,22 may elevate the odds of relationship violence. Given their high violence-risk profile, attention must be directed to the patterns and health consequences of intimate partner victimization in the lives of disadvantaged urban women with children.^23–25Building on previous research, we used data collected from a large probability sample of low-income women with children living in low-income neighborhoods in Boston, Massachusetts, Chicago, Illinois, and San Antonio, Texas, to predict changes in the frequency of intoxication, psychological distress, and self-rated health over 2 years with measures of relationship violence in early life and adulthood and a host of relevant background variables. In accordance with previous research, we expected that intimate partner victimization in adulthood would predict increases in psychological distress and the frequency of intoxication and decreases in self-rated health over the study period.     

Effect of health care system distrust on breast and cervical cancer screening in Philadelphia, Pennsylvania

Objectives. We investigated whether health care system distrust is a barrier to breast and cervical cancer screening and whether different dimensions of distrust—values and competence—have different impacts on cancer screening.Methods. We utilized data on 5268 women aged 18 years and older living in Philadelphia, Pennsylvania, and analyzed their use of screening services via logistic and multinomial logistic regression.Results. High levels of health care system distrust were associated with lower utilization of breast and cervical cancer screening services. The associations differed by dimensions of distrust. Specifically, a high level of competence distrust was associated with a reduced likelihood of having Papanicolaou tests, and women with high levels of values distrust were less likely to have breast examinations within the recommended time period. Independent of other covariates, individual health care resources and health status were associated with utilization of cancer screening.Conclusions. Health care system distrust is a barrier to breast and cervical cancer screening even after control for demographic and socioeconomic determinants. Rebuilding confidence in the health care system may improve personal and public health by increasing the utilization of preventive health services.Cancer is a leading cause of death in the United States. Approximately 1.5 million Americans are diagnosed with cancer per year and 1 in 4 deaths are attributed to cancer.¹ Among women, an estimated 192 000 breast and 11 000 cervical cancer cases are detected each year, and in 2009 more than 40 000 women died of breast cancer and approximately 4000 of cervical cancer.¹ To effectively reduce the morbidity and mortality resulting from breast and cervical cancer, efforts need to be made to increase the proportion of women who comply with screening recommendations²; according to a recent report, a third of women are not in compliance with screening guidelines for breast cancer, and more than a fifth are not in compliance for cervical cancer.³ Our goal was to investigate whether health care system distrust (hereafter referred to as distrust) is a barrier to breast and cervical cancer screening.The late 20th century saw many changes in the theoretical underpinnings of research on health in general and women''s health in particular. The prevailing biomedical model was criticized for ignoring social determinants of health, such as social class, gender roles, and poverty,⁴ and health determinants models that incorporated multiple social, economic, and demographic dimensions were embraced.^5–7 The multiple determinants of health perspective emphasizes the relationships between socioeconomic factors and health outcomes,⁴ but the role of psychological factors (i.e., depression and distrust) in cancer screening has only recently been recognized.^8–11 Relatively little is known about whether distrust affects health outcomes, and specifically whether it influences cancer screening behaviors among women.¹¹Americans’ overall confidence in their health care system has declined markedly in recent decades. In 2010, only 34% of adults reported “a great deal” of confidence in the health system, down from over 70% in 1966.¹² More than 80% of Americans, however, held high levels of trust in their personal physicians or providers,¹³ a paradox that has been widely documented in the literature.^14–17 Previous studies suggest that trust in physicians is associated with seeking timely medical care, maintaining appropriate health care, and adhering to medical advice,^18–20 but it is unclear whether trust or its converse, distrust, affects the adoption of preventive health services among women.¹¹The emerging distrust research in health care shows that distrust is a multidimensional concept.^21–23 For example, Shea et al. used focus groups, pilot testing, and a telephone survey to develop a highly reliable 9-item distrust scale that includes 2 subscales: competence distrust and values distrust.²² Competence distrust is expected to be high when the quality of service fails to meet patient expectations and does not improve health. Values distrust is expected to be high when the integrity of the health care system is questioned (e.g., ethical issues, financial priorities, transparency of care). Although dimensions of distrust may influence the use of preventive health services in different ways, little research has addressed this issue explicitly.A range of individual characteristics has been found to be associated with the use of breast and cervical cancer screening, including age,^5,24 race/ethnicity,^11,25 socioeconomic factors,^5,24 marital status,^5,11,24 and availability and utilization of health care resources.^11,24 Access to insurance and health care providers is associated with higher likelihood of interaction with the health care system and has been hypothesized to be related to levels of distrust and to individuals’ health-related behaviors.²⁶ Personal health status has been found to be related to levels of distrust,²⁷ although the underlying causal mechanisms have not been well documented. Evidence concerning the association of health status with use of preventive health services is inconclusive.¹¹ An important contribution of our study is the investigation of the association of distinct aspects of distrust—values distrust and competence distrust—with receipt of 2 preventive health services for adult women: the Papanicolaou (Pap) test for cervical cancer and clinical breast examination to screen for breast cancer. We tested the following 2 hypotheses: after we controlled for individual socioeconomic and demographic characteristics, (1) high levels of distrust are associated with low utilization of cancer screening services and (2) the negative relationship between distrust and cancer screening utilization holds for the values and competence dimensions of distrust.     

Low-risk lifestyle behaviors and all-cause mortality: findings from the National Health and Nutrition Examination Survey III Mortality Study

Objectives. We examined the relationship between 4 low-risk behaviors—never smoked, healthy diet, adequate physical activity, and moderate alcohol consumption—and mortality in a representative sample of people in the United States.Methods. We used data from 16958 participants aged 17 years and older in the National Health and Nutrition Examination Survey III Mortality Study from 1988 to 2006.Results. The number of low-risk behaviors was inversely related to the risk for mortality. Compared with participants who had no low-risk behaviors, those who had all 4 experienced reduced all-cause mortality (adjusted hazard ratio [AHR]=0.37; 95% confidence interval [CI]=0.28, 0.49), mortality from malignant neoplasms (AHR=0.34; 95% CI=0.20, 0.56), major cardiovascular disease (AHR=0.35; 95% CI=0.24, 0.50), and other causes (AHR=0.43; 95% CI=0.25, 0.74). The rate advancement periods, representing the equivalent risk from a certain number of years of chronological age, for participants who had all 4 high-risk behaviors compared with those who had none were 11.1 years for all-cause mortality, 14.4 years for malignant neoplasms, 9.9 years for major cardiovascular disease, and 10.6 years for other causes.Conclusions. Low-risk lifestyle factors exert a powerful and beneficial effect on mortality.Lifestyle behaviors lie at the root of many chronic diseases.^1–3 Smoking, unhealthy diets, and sedentary behavior predispose numerous people to diseases that rank among the leading causes of death such as heart disease, cancer, stroke, and diabetes. The costs associated with these behaviors are enormous.^4–7Previous studies have generally examined the independent effect of these lifestyle behaviors in isolation on a variety of adverse health outcomes. Yet, optimal health is only achieved by maximizing the number of healthy behaviors. Therefore, examining the joint effect of multiple lifestyle behaviors on health outcomes yields valuable insights into the improvements in health that are potentially achievable in populations. Starting around 2000, research appeared that examined the impact of multiple low-risk lifestyle behaviors on various health outcomes including cardiovascular disease,^8–15 diabetes,^16–18 all-cause mortality,^19–25 and mortality from cancer.^23–25Few studies relating multiple low-risk lifestyle factors to all-cause mortality have been conducted in the United States or have included substantial samples of racial/ethnic minorities.^22,24 Therefore, we examined the relationship between 4 lifestyle behaviors—never smoked, healthy diet, adequate physical activity, and moderate alcohol consumption—and all-cause mortality in a national sample of people in the United States.     

Health inequalities in Rio de Janeiro, Brazil: lower healthy life expectancy in socioeconomically disadvantaged areas

Objectives. We investigated deprivation and inequalities in life expectancy and healthy life expectancy by location in Rio de Janeiro, Brazil.Methods. We conducted a health survey of 576 adults in 2006. Census tracts were stratified by income level and categorization as a slum. We determined health status by degree of functional limitation, according to the approach proposed by the World Health Organization. We calculated healthy life expectancies by Sullivan''s method with abridged life table.Results. We found the worst indicators in the slum stratum. The life expectancy at birth of men living in the richest parts of the city was 12.8 years longer than that of men living in deprived areas. For both men and women older than age 65 years, healthy life expectancy was more than twice as high in the richest sector as in the slum sector.Conclusions. Our analysis detailed the excess burden of poor health experienced by disadvantaged populations of Rio de Janeiro. Policy efforts are needed to reduce social inequalities in health in this city, especially among the elderly.Recent studies on health inequality have focused on individual characteristics such as education, income, or ethnicity, as well as group characteristics, to explain social and spatial variations in health.^1–7 Highlighting inequalities at the local level is especially important, because social and environmental conditions have been shown to be significant determinants of health status.⁸The majority of geographical health studies have analyzed mortality data, largely because they are readily accessible. However, increased longevity in developed countries has resulted in a greater emphasis on the quality of the later years.^9,10 A long life does not necessarily mean a healthy life, as an increase in years lived is often accompanied by an increase in chronic morbidity and disability.¹¹ As such, it is generally agreed upon that mortality indicators alone are insufficient to appropriately characterize the state of a population''s health.¹² Newer, more relevant indicators such as quality-adjusted life years and disability-adjusted life years, which combine mortality data with morbidity and disability data, provide methods to investigate and compare the burden of diseases.¹³Over the past 4 decades, different health indicators that consider morbidity, functional limitations, and disabilities along with mortality have been proposed.^14–16 A single measure of morbidity and mortality obtained by the Sullivan method (healthy life expectancy)¹⁷ has been the most frequently used.¹⁴ It estimates the number of years a person of a given population may expect to enjoy full health. Variations of this measure are established by different definitions of healthy, which are usually based on self-perceived health, long-term illness or disability, and functional or cognitive limitations.The summarized measures of morbidity and mortality obtained by the Sullivan method have been adopted for monitoring health inequalities in many developed countries.¹⁸ In the United Kingdom, the regional variation in healthy life expectancy (as measured by limiting long-standing illness) has been found to be much greater than are the regional variations in life expectancy.¹⁹ Studies in other countries have produced similar findings.^20,21 Substantial inequalities in healthy life years among persons aged 50 years were also found in European Union countries, with greater variation in healthy life expectancy than in life expectancy.²²In Brazil, differences in mortality across regions have been well documented, often with a steep north–south gradient.^23,24 These inequalities persist; the more prosperous southern states have lower infant mortality and higher life expectancies. Small-area variations in health indicators in large Brazilian cities are also evident, reflecting socioeconomic and environmental inequalities.^25–28In Rio de Janeiro, Brazil, mortality studies have established an association between adverse health outcomes and residential concentration of poverty. The worst health indicators were found in the sector of the city with the highest concentration of slum residents, which also had an extremely high homicide rate.²⁹ A geographic study in Goiânia, a newly urbanized city of Brazil, also detected a spatial cluster of violent deaths on its outskirts.³⁰ This cluster had a significantly higher proportion of people with the lowest educational level and income and the worst housing conditions in the city.Whether these conditions are associated with differences in quality of life for older adults has been less well studied. In Brazil, healthy life expectancy was estimated for the total adult population^31,32 and for the elderly in the city of São Paulo,³³ but this measure has not been used to monitor inequalities in quality of life among older persons.We examined deprivation and inequalities in total life expectancy and healthy life expectancy by location in the municipality of Rio de Janeiro. We calculated healthy life expectancy with the approach developed by the World Health Organization (WHO),³⁴ in which healthy status is established by degree of functional limitation, with data from a survey carried out in the city during 2006.     

Prevalence, Characteristics, and Associated Health and Health Care of Family Homelessness Among Fifth-Grade Students

Objectives. We describe the lifetime prevalence and associated health-related concerns of family homelessness among fifth-grade students.Methods. We used a population-based, cross-sectional survey of 5147 fifth-grade students in 3 US cities to analyze parent-reported measures of family homelessness, child health status, health care access and use, and emotional, developmental, and behavioral health and child-reported measures of health-related quality of life and exposure to violence.Results. Seven percent of parents reported that they and their child had experienced homelessness (i.e., staying in shelters, cars, or on the street). Black children and children in the poorest families had the highest prevalence of homelessness (11%). In adjusted analyses, most general health measures were similar for children who had and had not been homeless. Children who had ever experienced homelessness were more likely to have an emotional, behavioral, or developmental problem (odds ratio [OR] = 1.7; 95% confidence interval [CI] = 1.1, 2.6; P = .01), to have received mental health care (OR = 2.2; 95% CI = 1.6, 3.2; P < .001), and to have witnessed serious violence with a knife (OR = 1.6; 95% CI = 1.1, 2.3; P = .007) than were children who were never homeless.Conclusions. Family homelessness affects a substantial minority of fifth-grade children and may have an impact on their emotional, developmental, and behavioral health.An estimated 23% of homeless persons in the United States are children younger than 18 years.¹ Of individuals who have experienced an episode of homelessness and used a homelessness assistance program over the course of a year, an estimated 38% are children living with parents.² Families defined as homeless may be literally homeless (spending the night in emergency shelters, abandoned buildings, cars, on the street, and so on) or precariously housed (at imminent risk of literal homelessness).^3,4 Data available on the prevalence of literal homelessness (henceforth referred to as “homelessness”) are generally based on emergency shelter use, requests for emergency shelter use, and nighttime counts of those living on the streets.⁵ The prevalence of homelessness in US cities ranges from a 1-day prevalence of 0.3% to a 3-year prevalence of 3% (prevalence rates increase as the period of time increases because of rapid turnover among the homeless).^4,6–8Population-based studies have estimated the prevalence of episodic homelessness among adults.^9–11 One random-digit-dialing survey of US adults found a 7% lifetime prevalence of homelessness.⁹ A Philadelphia population-based study linked emergency shelter intake records to all adult women with a recorded live birth over a 2-year period and reported 11% homelessness between 3 years before and 4 years after the birth.¹⁰ Unlike studies of currently homeless people, these population-based estimates include individuals who have a history of homelessness.^6,8 There are no population-based data that estimate the lifetime prevalence of family homelessness among children.Studies of children in sheltered, homeless families have shown that many have poor health status, high rates of asthma, high rates of emergency department visits, delays in obtaining preventive care, and high rates of emotional, developmental, and behavioral problems.^7,12–17 In most studies, health and health-related outcomes were worse for children in sheltered, homeless families compared with children in the general population. In most studies, homeless children also had worse outcomes compared with low-income housed children, although in a few studies the 2 groups had similar outcomes.¹⁸ In a study of 82 families using shelters and transitional housing in King County, Washington, 59% of children had no usual health care provider; these children experienced rates of emergency department visits higher than that of the national rate for children.¹³ In another study of 220 homeless families in shelters in Worcester, Massachusetts, homeless children were more likely to be reported in poor to fair health and made more frequent emergency department and outpatient visits than did low-income housed children.¹² Other studies have found high rates of developmental delay and emotional or behavioral problems among sheltered children.^13,14,19,20Most data on the health status and needs of homeless children compare currently homeless children and their families residing in emergency shelters with low-income housed children or the general population.^12–14 Many poor families may experience 1 or more episodes of homelessness over a period of time, but most studies have only examined currently homeless children.^3,21 No published studies to date have described the lifetime prevalence of homelessness and the associated health and health-related problems of a school-aged, nonsheltered, population-based sample of children. We aimed to describe (1) the lifetime prevalence and characteristics of family homelessness among fifth-grade students and (2) the health and health-related concerns of these students.     

Ethnic Density Effects on Birth Outcomes and Maternal Smoking During Pregnancy in the US Linked Birth and Infant Death Data Set

Objectives. We investigated whether mothers from ethnic minority groups have better pregnancy outcomes when they live in counties with higher densities of people from the same ethnic group—despite such areas tending to be more socioeconomically deprived.Methods. In a population-based US study, we used multilevel logistic regression analysis to test whether same-ethnic density was associated with maternal smoking in pregnancy, low birthweight, preterm delivery, and infant mortality among 581 151 Black and 763 201 Hispanic mothers and their infants, with adjustment for maternal and area-level characteristics.Results. Higher levels of same-ethnic density were associated with reduced odds of infant mortality among Hispanic mothers, and reduced odds of smoking during pregnancy for US-born Hispanic and Black mothers. For Black mothers, moderate levels of same-ethnic density were associated with increased risk of low birthweight and preterm delivery; high levels of same ethnic density had no additional effect.Conclusions. Our results suggest that for Hispanic mothers, in contrast to Black mothers, the advantages of shared culture, social networks, and social capital protect maternal and infant health.Numerous studies have shown that living in a socioeconomically deprived neighborhood exerts a contextual effect on the health of individual residents beyond their own socioeconomic status.^1,2 This is likely to have a differential impact on some ethnic minority groups, such as African Americans and Hispanics. (Throughout this paper we have defined “ethnicity” as a global indicator of a person''s heritage including both racial and ethnic origins.) Whereas the majority of poor White people live in nondeprived areas, poor African Americans are concentrated in areas of high poverty.³ Thus, it might be paradoxical to suggest that members of ethnic minority groups might be healthier when they live in areas with a high concentration of people of the same ethnicity.^4,5 However, there is some evidence that living in communities that contain proportionally more people from the same ethnic group is protective for some health outcomes, once material deprivation is accounted for. The evidence for the protective effects of same-ethnic density is strongest for mental health,^4,5 with the evidence for maternal and infant health outcomes more mixed.The majority of studies that have investigated the impact of same-ethnic density on maternal and infant health have focused on African Americans or Black families (in this article, we use whichever term was used in the studies we describe). Two older ecological studies^6,7 found that increasing levels of same-ethnic density for New York City African Americans were associated with increased fetal and neonatal mortality but not postneonatal mortality. Another study found no association between ethnic density measured in US cities and postneonatal mortality.⁸ More recent studies have tended to use multilevel analyses that controlled for individual-level measures of socioeconomic status, and focused on measures of morbidity, such as low birthweight (LBW), with less consistent results.^9–14One study of Chicago neighborhoods found that an increasing proportion of African American residents was associated with a reduced risk of LBW.¹³ Two other studies found that an increasing proportion of Black residents was associated with increased risk of LBW.^11,14 However, other studies have found no significant associations between same-ethnic density and LBW.^9,10,12Five studies have investigated the impact of ethnic density on preterm delivery rates among African Americans.^{9,10,12,15,16} Studies of neighborhoods in Minnesota⁹ and North Carolina¹⁵ found same-ethnic density to be associated with increased risk of preterm delivery after adjustment for individual but not area measures of socioeconomic circumstances. Three other studies found no association between same-ethnic density and preterm delivery in models that included individual-level maternal education and area-level measures of socioeconomic circumstances.^10,12,16We are aware of only 1 study that has investigated the impact of same-ethnic density on maternal smoking during pregnancy, which found that it was associated with reduced risk of maternal smoking after adjustment for both individual and area measures of socioeconomic conditions.¹⁷We found only 2 studies that have investigated the impact of ethnic density on Hispanic maternal and infant health. The first, conducted in the states of Arizona, California, New Mexico, and Texas, found lower rates of infant mortality for US-born Mexican-origin mothers living in counties with high concentrations of mothers of the same ethnicity.¹⁸ However, this effect was not found for mothers born outside the United States. The second study found no associations between same-ethnic density, as measured in Chicago census tracts, and LBW, preterm delivery, and maternal smoking after adjustment for economic disadvantage, maternal education, and violent crime.¹²Further support for the protective effects of Hispanic density comes from the “Hispanic paradox.”¹⁹ Compared with the White majority population, Hispanic mothers tend to have better or equal pregnancy outcomes and better health-related behaviors despite generally having more disadvantaged socioeconomic circumstances.^20–24 It has been proposed that this “paradox” can be explained by dietary factors, social support and cohesion, and cultural differences in relation to the importance of motherhood.^23,24 However, long-term US residents who move away from ethnic enclaves²⁵ are more likely to adopt Western health behaviors and values²⁶ and may lose any protective effects of Hispanic culture. Thus, the protective effects of Hispanic culture are more likely to be maintained in communities of higher Hispanic density.We hypothesized that maternal smoking during pregnancy, infant mortality, LBW, and preterm birth would be lower for non-Hispanic Black and Hispanic White (hereafter referred to as “Hispanic mothers”) mothers living in counties with a higher percentage of people of the same ethnicity, relative to their counterparts living in counties with a low percentage of people of the same ethnicity.     

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.     

The Health of Older Mexican Americans in the Long Run

Objectives. We compared risk for several medical illnesses between immigrant and US-born older Mexican Americans to determine the relationship between functional health and years of US residency among immigrants.Methods. Cross-sectional, multistage probability sample data for 3050 Mexican Americans aged 65 years or older from 5 US southwestern states were analyzed. Self-rated health, medical illnesses, and functional measures were examined in multivariate regression models that included nativity and years of US residency as key predictors.Results. Self-rated health and medical illnesses of immigrant and US-born groups did not differ significantly. Immigrants with longer US residency had significantly higher cognitive functioning scores and fewer problems with functional activities after adjustment for predisposing and medical need factors.Conclusions. Among older Mexican Americans, immigrant health advantages over their US-born counterparts were not apparent. Immigrants had better health functioning with longer US residency that may derive from greater socioeconomic resources. Our findings suggest that the negative acculturation–health relationship found among younger immigrant adults may become a positive relationship in later life.More than 30 years ago, Teller and Clyburn reported more favorable birth outcomes in Bexar County, Texas, for Spanish-surnamed residents than for non-Latino White and African American residents.¹ Despite the disadvantaged economic and social position of many Latinos, additional reports appeared of unexpected favorable birth and longevity outcomes for Latinos (primarily Mexican Americans) compared with other ethnic groups.^2–5 These findings were considered paradoxical, since they ran contrary to the negative socioeconomic health gradient documented in the public health literature.^6,7 The Latino health paradox contends that despite experiencing disproportionate exposure to risk factors for excess morbidity and mortality associated with low socioeconomic position, Latinos, primarily Mexican American immigrants, generally have more favorable health outcomes than Mexican Americans born in the United States, most other minorities, and nonminorities.⁸ The longer these healthy immigrants resided in the United States and acculturated, the more likely they were to report deterioration in health status indicators compared with recent immigrants.⁹The mental health researchers Rogler et al. referred to “acculturation as an exogenous force shaping the conditions for the rise to psychological distress.”^10(p588) This phenomenon was later coined the “acculturative stress” hypothesis and widely used in mental health research of the Latino population. However, acculturative stress models have important limitations in health research because they confound the effects of cultural change on health behaviors with pathology. In addition, they are temporally unspecific and thus inconsistent with developmental models of health. We offer an alternative, the “acculturation–health” hypothesis, to emphasize that health outcomes are instead conditional on multiple life-course contingencies that vary in importance as determinants over one''s life span. The temporal relationships between acculturation and health can range from negative to positive during the lifespan of an individual. Although the negative effects of acculturation are commonly described in the literature, positive outcomes are observed as well and also require explanations.^11–15 Acculturative stress assumes a cumulative, linear, dose–response association of acculturation with health. An acculturation–health hypothesis accounts for transactions between endogenous (individual-level) and exogenous (external) factors that affect health differentially over the life course. These factors are systematically influenced by acculturation across multiple domains of life activity.The proposed acculturation–health model assumes that there are multiple points in the life course that are critical for improving health and lowering the risk of weathering effects seen in aging among minority groups.¹⁶ Carefully focused research could lead to timely and effective interventions that improve health outcomes across the life course. The assumption that a constant acculturation–health relationship is generally negative and leads to declines in health among Mexican Americans is limiting because it is overly deterministic and restricts opportunities for identifying determinants of long-range outcomes and life-course stages when they are most consequential. Although we can assume that living in a new society introduces behavioral, social, and environmental changes that may negatively influence health, there may be benefits as well, such as acquisition of new occupational skills, greater exposure to public health information, and use of preventive medicine. Nevertheless, it is unclear how these changes are expressed in the long run in the health of older Mexican Americans.Mexican Americans represent more than two-thirds of US Latinos and, perhaps accordingly, most previous studies have focused on the relationship between Mexican American acculturation (or various proxies of acculturation, such as language preference and years of US residency) and health.¹⁷ For younger Mexican Americans, most studies have reported negative relationships between acculturation and health¹¹—for example, for birth outcomes^18,19 and perinatal health behaviors,^20,21 general health behaviors (e.g., nutrition and physical exercise),²² vascular disease risks (e.g., diabetes),^23,24 and substance abuse and mental disorders.^25,26 Several reports have shown positive associations between acculturation and higher use of preventive medical services, which may relate to the higher economic position of more acculturated and US-born Mexican Americans.^27–30 Among older adults, the prevalence of depression and dementia are reportedly lower among acculturated Mexican Americans.^12,13 Furthermore, there is evidence that greater social assimilation, as evidenced by English-language acquisition and more years of education, are associated with lower disability rates and higher self-esteem.^14,15,31These general findings have led scientists to hypothesize that immigrants are somehow healthier than US-born Mexican Americans and non-Latino Whites and that with longer US residency, acculturation erodes immigrants'' health.^9,32 The negative aspects of the acculturation–health relationship dominate current thinking about Mexican American health, especially regarding acculturation-related changes in risk behaviors such as diet, exercise, and substance abuse.³³ However, if the association between acculturation and health is conditional and predicated on various endogenous and exogenous life-course factors, recent work among older adults may better inform us about the long-term acculturation–health relationship.Our first aim was to examine whether the “healthy immigrant” phenomenon persists among older Mexican Americans by comparing the rates of several medical conditions between US-born and immigrant groups. Second, we sought to determine if functional health was negatively associated with longer exposure to the host country within a representative sample of immigrant Mexican Americans. On the basis of previous work,^12–14,31 we expected that the health status of US-born and immigrant older Mexican Americans would not differ. Third, we sought to examine if longer US residency would be associated with better functional health among older Mexican American immigrants. We expected that increased wealth, access to healthcare and services would facilitate or mediate better health functioning.^6,34,35 Finally, in examining the health of older Mexican Americans, we aimed to compare the acculturative stress hypothesis and the acculturation–health hypothesis for a better understanding of their utility for the study of health.     

Mortality risk associated with disability: a population-based record linkage study

Objectives. We assessed the association between mortality and disability and quantified the effect of disability-associated risk factors.Methods. We linked data from cross-sectional health surveys in the Netherlands to the population registry to create a large data set comprising baseline covariates and an indicator of death. We used Cox regression models to estimate the hazard ratio of disability on mortality.Results. Among men, the unadjusted hazard ratio for activities of daily living, mobility, or mild disability defined by the Organization for Economic Co-operation and Development at age 55 years was 7.85 (95% confidence interval [CI] = 4.36, 14.13), 5.21 (95% CI = 3.19, 8.51), and 1.87 (95% CI = 1.58, 2.22), respectively. People with disability in activities of daily living and mobility had a 10-year shorter life expectancy than nondisabled people had, of which 6 years could be explained by differences in lifestyle, sociodemographics, and major chronic diseases.Conclusions. Disabled people face a higher mortality risk than nondisabled people do. Although the difference can be explained by diseases and other risk factors for those with mild disability, we cannot rule out that more severe disabilities have an independent effect on mortality.Population aging is associated with an increase in the number of people who are disabled. This increase presents a challenge for society because elderly persons disabled in 1 or more domains of life are hospitalized more often,¹ need more medical and long-term care,^2–5 and face a higher risk of death than nondisabled persons do.^6–13Disablement refers to the impact that chronic and acute conditions have on people''s ability to perform tasks necessary for daily living and normal social functioning.¹⁴ In a broader context, the disablement process is described as a causal chain in which the progression of disease leads to functional limitations, loss of mobility, and eventually to inability to perform activities of daily living (ADLs).^14–17 Empirical studies have found numerous risk factors associated with disablement. These factors are usually seen as risks that increase the chance of developing a disability. The major underlying causes are (acute and progressive) chronic diseases,¹⁸ but other risk factors including sociodemographic factors (e.g., age, gender,¹⁹ socioeconomic status²⁰), behavioral factors (e.g., smoking),²¹ nutrition,²² physical activity,²³ comorbidity,¹⁸ self-rated health,²⁴ and cognitive impairment²⁵ are also associated with incident disability.Disability is most often assessed in cross-sectional studies without information on mortality. The few longitudinal studies that have been conducted tend to emphasize incident disability rather than the trajectory of disability following onset because of lack of statistical power.²⁶ Thus, although the onset of disability has been extensively researched, there has been far less investigation into the mortality risk associated with disability. In previous studies, the study populations were often limited to specific disease groups^9,12 or based on small sample sizes with few control variables.^{6–8,10,11,13} Moreover, the focus was often on other determinants of mortality rather than on disability. Nonetheless, disability has been found to be an independent predictor of death after adjustment for heart disease,⁹ depressive symptoms,¹⁰ physical activity,¹¹ socioeconomic status,¹³ or health status.¹⁰ However, no study has assessed the extent to which the relationship between disability and mortality can be explained by risk factors known to be associated with disablement. Assessment of this relationship may enhance understanding of the public health aspects of aging. If disability is found to be independently associated with mortality, developing strategies to prevent disability would not only increase disability-free life expectancy but also total life expectancy.We assessed the association between mortality and 3 disability measures reflecting different levels of disability severity. The linking of cross-sectional health surveys to municipal health registries in the Netherlands permitted the compilation of a large time-to-event data set with covariates measured at baseline.²⁷ We quantified the magnitude of the association between disability and mortality, unadjusted and adjusted for groups of risk factors. These risk factors included distal and proximal risk factors that may influence the speed of disablement.^28–31 We used hazard ratios (HRs) and life expectancy to summarize the association between disability and mortality.     

Socioeconomic and ethnic differences in disease burden and disparities in physical function in older adults

Objectives. We investigated whether a greater burden of disease among poorer individuals and ethnic minorities accounted for socioeconomic and racial disparities in self-reported physical functioning among older adults.Methods. We used data from adults aged 60 years or older (n = 5556) in the Third National Health and Nutrition Examination Survey, 1988–1994 to test associations between education level, poverty index, and race/ethnicity and limitations in 11 functions. We adjusted for demographic features and measures of disease burden (comorbid conditions, smoking, hemoglobin level, serum albumin level, knee pain, body mass index, and skeletal muscle index).Results. Associations between education and functional limitations were attenuated after adjustment, but those with 0–8 years of education were more likely than those with 13 or more years of education to have limitations in 3 functions. Poverty was associated with a higher likelihood of limitations despite adjustment. The likelihood of limitations among non-Hispanic Blacks and Mexican Americans was similar to that of non-Hispanic Whites after adjustment.Conclusions. Socioeconomic disparities in functional limitations among older Americans exist independent of disease burden, whereas socioeconomic differences and disease burden account for racial disparities.Although the prevalence of disability among older adults in the United States has generally declined over the past decade, this trend has not extended to all segments of the population.^1–4 Disability among ethnic minorities and economically disadvantaged groups has not declined, resulting in widening ethnic and socioeconomic disparities.^5–11 Racial minorities and those who are economically disadvantaged are up to 3 times more likely to experience disability than are Whites and those who are not economically disadvantaged, respectively.^8,10,12,13 Achieving health equity has been a public policy priority, and collective interventions have been proposed.^12,14,15 Functional limitations in older adults are particularly important because of their prognostic and economic implications.¹⁶ Functional limitations predict further future decline in physical function,¹⁷ an increased risk of dementia,¹⁸ loss of independence, institutionalization, and mortality.^19–21According to the Institute of Medicine model of the enabling–disabling process, disability is a product of the complex interactions between a person and his or her psychological, social, and physical environments.²² In this context, functional limitations are partly a consequence of an individual''s burden of disease. Musculoskeletal conditions, chronic neurological and cardiopulmonary disorders, sensory and cognitive deficits, anemia, sarcopenia, and chronic pain may lead to functional limitations and disability. Many of the chronic health conditions that can affect physical functioning are more common among ethnic minorities and economically disadvantaged groups,^5,6,9–12 raising the question of whether a greater burden of disease can primarily explain the higher prevalence of functional limitations and disability in these groups.Previous studies of socioeconomic and ethnic disparities in functional limitations reported unadjusted data or data adjusted only for differences in demographic characteristics.^{10,11,23–27} Few studies have examined the role of differences in comorbid conditions, obesity, or smoking or simultaneously examined a range of indicators of disease burden.^6,9,28 We sought to determine whether socioeconomic and ethnic differences in functional limitations among noninstitutionalized older adults in the United States remain after adjusting for measures of disease burden.     

Lifetime Segmented Assimilation Trajectories and Health Outcomes in Latino and Other Community Residents

Objectives. Under an ecodevelopmental framework, we examined lifetime segmented assimilation trajectories (diverging assimilation pathways influenced by prior life conditions) and related them to quality-of-life indicators in a diverse sample of 258 men in the Pheonix, AZ, metropolitan area.Methods. We used a growth mixture model analysis of lifetime changes in socioeconomic status, and used acculturation to identify distinct lifetime segmented assimilation trajectory groups, which we compared on life satisfaction, exercise, and dietary behaviors. We hypothesized that lifetime assimilation change toward mainstream American culture (upward assimilation) would be associated with favorable health outcomes, and downward assimilation change with unfavorable health outcomes.Results. A growth mixture model latent class analysis identified 4 distinct assimilation trajectory groups. In partial support of the study hypotheses, the extreme upward assimilation trajectory group (the most successful of the assimilation pathways) exhibited the highest life satisfaction and the lowest frequency of unhealthy food consumption.Conclusions. Upward segmented assimilation is associated in adulthood with certain positive health outcomes. This may be the first study to model upward and downward lifetime segmented assimilation trajectories, and to associate these with life satisfaction, exercise, and dietary behaviors.“Acculturation” refers to a process of cultural change and adaptation that occurs across time.^1–3 Despite this dynamic conception, most acculturation studies have examined acculturation at a single point in time, inferring health-related outcomes from cross-sectional comparisons across levels of acculturation.⁴ Unfortunately, this static approach does not examine temporal changes in the process of acculturation.Segmented assimilation has been defined as “diverse patterns of adaptation whereby immigrant groups differentially adopt the attitudes, beliefs, and behaviors of divergent cultural groups in the United States.”^3,5(p1344) More specifically, segmented assimilation is a process of cultural and economic integration into a “mainstream” society. Individuals and groups thus will differ in how effectively they succeed in their cultural and economic integration, as indicated by different assimilation trajectories (i.e., segmented assimilation).⁵Segmented assimilation theory⁷ has identified 3 basic outcomes in this process of social integration: (1) acculturation change toward mainstream White American culture coupled with upward socioeconomic mobility (upward assimilation); (2) acculturation change and downward socioeconomic mobility into an underclass (downward assimilation); and (3) resistance to acculturation and to assimilation into the mainstream society (resistance to forced assimilation).⁸ Downward assimilation is predicted for groups that have low social or human capital.^9–12 Within the United States, segmented assimilation has typically been examined for Latino populations, and recently it has been examined with Asian Americans.¹³Differing assimilation trajectories may be associated with variations in quality of life, as indicated by differing disease risks and health-related outcomes.^14–16 Among Latinos, acculturation toward mainstream American society has been associated with higher rates of alcohol, tobacco, and illegal drug use,^17–20 and with higher prevalence rates of psychiatric disorders.^21,22 By contrast, among Latinos, greater acculturation has also been associated with enhanced quality of life, including better employment, and access to health insurance and health care.¹⁷