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.     

Ein Grundriß wirksamer Aids-Prävention

Policy-deficits are the most important factor contributing to the ongoing spread, and associated dynamics, of the HIV/AIDS pandemic and its numerous sub-epidemics around the world. Drawing upon ten years experience, observation, and evaluation of AIDS policies, both the general design and core elements of an effective AIDS policy, as well as typical policy impediments, are outlined. Successful AIDS policies follow a strategy of social learning by inclusion and cooperation, are decentralized, and incorporate the motivation and competencies of those affected. Key elements of such a strategy are timely risk perception and assessment; priority to primary prevention; and the formulation of a coherent policy which is integrated into the more general public health programs     

First-Trimester Working Conditions and Birthweight: A Prospective Cohort Study

Objectives. We investigated the relationship between women''s first-trimester working conditions and infant birthweight.Methods. Pregnant women (N = 8266) participating in the Amsterdam Born Children and Their Development study completed a questionnaire gathering information on employment and working conditions. After exclusions, 7135 women remained in our analyses. Low birthweight and delivery of a small-for-gestational-age (SGA) infant were the main outcome measures.Results. After adjustment, a workweek of 32 hours or more (mean birthweight decrease of 43 g) and high job strain (mean birthweight decrease of 72 g) were significantly associated with birthweight. Only high job strain increased the risk of delivering an SGA infant (odds ratio [OR] = 1.5; 95% confidence interval [CI] = 1.1, 2.2). After adjustment, the combination of high job strain and a long workweek resulted in the largest birthweight reduction (150 g) and the highest risk of delivering an SGA infant (OR = 2.0; 95% CI = 1.2, 3.2).Conclusions. High levels of job strain during early pregnancy are associated with reduced birthweight and an increased risk of delivering an SGA infant, particularly if mothers work 32 or more hours per week.Delivery of a low-birthweight or small-for-gestational-age (SGA) infant as a result of fetal growth restriction is one of the principal adverse pregnancy outcomes. In the short term, low birthweight and small size for gestational age are major determinants of infant mortality and morbidity¹ and impaired neonatal development.² In the long term, they increase metabolic and cardiovascular disease risk.^3–5 Prevention of fetal growth restriction is therefore of undisputed clinical and economic importance.Maternal factors, obstetric factors (e.g., placental dynamics), and social factors,⁵ including employment-related factors, can all play a role in fetal growth impairment.^6–24 Although employment in general is associated with enhanced outcomes,^6,20,21 certain working conditions represent potential risk factors for the mother and child. Increased levels of risk resulting from long working hours,^{12,13,17,18,24} high physical workloads,^13–16 prolonged standing,^13,18 and psychosocial job strain^7,9,10,24 have been suggested, but the findings in this area are not unequivocal.^8,11,22,23 So far, 2 reviews have been conducted that focused on physical workload and delivery of an SGA infant. Mozurkewich et al.¹⁶ concluded from their review of 29 studies that physically demanding work is associated with SGA births (pooled odds ratio [OR] = 1.37; 95% confidence interval [CI] = 1.30, 1.44). Bonzini et al.¹⁹ reached the same conclusion in their study. To our knowledge, job strain has not been considered in any published review.Limitations in research designs,^6,8,19–21 variability in definitions and measurement of work-related factors,^6,18–20 and true variability across countries and cultures may account for the inconsistent results observed to date. Another important limitation of occupational hazard research is the focus on third-trimester exposures.^11,13 Experimental data and emerging theory point to the first rather than the second or third trimester as a crucial period for regulating the relevant fetal hormonal set points, in particular the hypothalamic pituitary axis (HPA).^25–27 Stress-dependent dysregulation of the HPA affects birthweight and a child''s subsequent growth and development.^25–31 From this perspective, employment during pregnancy is perhaps the most prevalent potential stress factor, given that few working women quit their jobs early in pregnancy.In an effort to overcome the limitations of previous studies, we explored the association between infant birthweight and employment-related conditions (e.g., hours worked per week, hours standing or walking, physical demands of work, and job strain) in an unselected urban cohort of pregnant women. We hypothesized that after adjustment for all known major cofactors, first-trimester work-related effects on birthweight would exceed the third-trimester effects reported in previous research.     

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.     

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.     

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.     

Neighborhoods and obesity in later life

Objectives. We examined the influence of neighborhood environment on the weight status of adults 55 years and older.Methods. We conducted a 2-level logistic regression analysis of data from the 2002 wave of the Health and Retirement Study. We included 8 neighborhood scales: economic advantage, economic disadvantage, air pollution, crime and segregation, street connectivity, density, immigrant concentration, and residential stability.Results. When we controlled for individual- and family-level confounders, living in a neighborhood with a high level of economic advantage was associated with a lower likelihood of being obese for both men (odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.80, 0.94) and women (OR = 0.83; 95% CI = 0.77, 0.89). Men living in areas with a high concentration of immigrants and women living in areas of high residential stability were more likely to be obese. Women living in areas of high street connectivity were less likely to be overweight or obese.Conclusions. The mechanisms by which neighborhood environment and weight status are linked in later life differ by gender, with economic and social environment aspects being important for men and built environment aspects being salient for women.Over the past few decades the prevalence of obesity has been rising for men and women across all age groups, including the elderly.¹ For example, in 2001 to 2002 in the United States, about 1 in 3 adults 60 years or older was obese.² This trend raises concerns because excess weight is associated with a number of chronic health conditions, including diabetes, high blood pressure, asthma, and arthritis.³ Moreover, obesity can have very important implications for publicly financed health care.⁴ Recent research suggests that a number of demographic, socioeconomic, and family factors⁵ influence obesity, but the role of the neighborhood context has not been fully explored.Excess weight results from an energy imbalance in which caloric intake exceeds energy expenditures, the latter closely related to physical activity. The neighborhood environment may influence energy intake (through its influence on food availability⁶) and energy expenditure (by facilitating or impeding physical activity). For example, the presence of supermarkets in the neighborhood is associated with higher fruit and vegetable intake,⁷ whereas eating at fast-food restaurants is associated with a high-fat diet and higher body mass index (BMI; weight in kilograms divided by height in meters squared).⁸ In terms of physical activity, individuals living in neighborhoods with less crime,^9–13 higher land-use mix,¹⁴ higher street connectivity,^11,14,15 higher residential density,^11,14 a greater number of destinations,^9,16 better aesthetics,^9,10,17 and sidewalks^10,12,17,18 tend to walk more often.^19,20Only a handful of studies linking neighborhood features to late-life obesity have focused on older adults.^{11,13,16,21–23} National studies are particularly lacking for the elderly. Yet evidence from national studies of adults of all ages suggests plausible connections between obesity and neighborhood factors. Using the 1990 to 1994 waves of the National Health Interview Survey, for example, Boardman et al.²⁴ found that adults residing in neighborhoods with a high concentration of poverty and in neighborhoods with a high percentage of Blacks were more likely to be obese. In another study, Robert and Reither²⁵ found that higher community socioeconomic disadvantage was related to higher BMI among women but not among men. Because these studies had very limited characterizations of the neighborhoods, the mechanism through which poor neighborhoods result in obesity remains unclear. It could be, for instance, that poor neighborhoods tend to have fewer supermarkets^26–28 and more-limited access to places for physical activity.^29,30Using a large, nationally representative survey, we examined the relationship between the economic, built, and social environments and weight status among men and women 55 years and older. We included 8 previously validated neighborhood scales reflecting neighborhood safety and segregation, concentration of immigrants, air pollution, residential stability, connectivity, density or access, and high and low neighborhood socioeconomic status.³¹ We modeled both obesity and overweight status by using multilevel modeling techniques in which we controlled for detailed individual- and family-level confounders.     

Novice Drivers' Risky Driving Behavior, Risk Perception, and Crash Risk: Findings From the DRIVE Study

Objectives. We explored the risky driving behaviors and risk perceptions of a cohort of young novice drivers and sought to determine their associations with crash risk.Methods. Provisional drivers aged 17 to 24 (n = 20 822) completed a detailed questionnaire that included measures of risk perception and behaviors; 2 years following recruitment, survey data were linked to licensing and police-reported crash data. Poisson regression models that adjusted for multiple confounders were created to explore crash risk.Results. High scores on questionnaire items for risky driving were associated with a 50% increased crash risk (adjusted relative risk = 1.51; 95% confidence interval = 1.25, 1.81). High scores for risk perception (poorer perceptions of safety) were also associated with increased crash risk in univariate and multivariate models; however, significance was not sustained after adjustment for risky driving.Conclusions. The overrepresentation of youths in crashes involving casualties is a significant public health issue. Risky driving behavior is strongly linked to crash risk among young drivers and overrides the importance of risk perceptions. Systemwide intervention, including licensing reform, is warranted.The overrepresentation of youths in crashes involving casualties is a significant public health issue in most high-income countries.^1,2 As a result, prevention of crashes by novice drivers is a key focus for many jurisdictions, policymakers, and researchers. The introduction of graduated driver licensing, which gradually introduces full driving privileges for novice drivers, has brought about significant reductions in crashes, particularly in settings where more stringent conditions such as restrictions on passenger numbers and night driving have been introduced.^3,4 Research on novice drivers'' risky behaviors and risk perceptions is crucial to understanding how this initiative can be improved or how complementary interventions can be developed.There is much to be learned about the impact of novice drivers'' risky driving and how it is associated with their increased risk of crash. Recent research confirms that certain risky driving behaviors are more prevalent among younger drivers than older drivers, especially among men.^5–12 These include high-level speeding and speeding for the thrill of it,^6,11,13–16 following too closely to the vehicle ahead,⁵ violating traffic rules,⁹ not using seatbelts,^17–19 using mobile phones while driving^20–22 (including text messaging^23,24), driving during high-risk nighttime hours,^2,25,26 and driving older vehicles.^14,27,28In addition, certain driving behaviors have been demonstrated to be of higher risk for young novice drivers than for experienced adult drivers; these include carrying peer passengers or multiple passengers^2,29–32 and driving under the influence of alcohol, even at low concentrations.^26,33,34Paradoxically, given higher levels of risk taking, young drivers are often found to be more aware of driving risks than drivers of other age groups, particularly regarding alcohol,^18,35–39 although young males tend to have poorer perceptions of risk than females.^{6,35,37,39–41} Nonetheless, young people who undertake or are exposed to risky driving behaviors tend also to perceive driving risks as low.^15,35,39,42 In a prevalence study conducted recently in Australia, McEvoy et al. reported that those who reported mobile phone use while driving regarded a range of risky driving practices as significantly less dangerous than those who did not report phone use.⁴³Young people''s risk perceptions, however, can be dependent on context. For example, although speeding per se or under usual conditions is typically viewed as risky,^6,39 speeding on a clear, dry day is not.⁶ Driving fast because one is in a hurry is considered not as risky as driving fast to test a car''s speed, whereas racing other cars ranks among the highest perceived risks.³⁵ Likewise, studies have found that the general public considers only small excess rates of speed (64 km/h in a 60-km/h zone and 105 km/h in a 100-km/h zone) to be acceptable¹⁸ but that high school students of driving age accept higher speeds: in one study, one quarter of students accepted 70 km/h or more in a 60-km/h zone as safe and one quarter accepted 120 km/h or more in a 100-km/h zone as safe if conditions were good.³⁷ In another study, when asked how much over a 60 km/h speed limit a driver would have to be going to be considered “stupid,” young drivers reported a significantly higher speed threshold than older drivers, but there were no differences in reported thresholds for a driver to be considered “irresponsible” or “criminal.”⁶Differences in young drivers'' perceptions of other risks have also been found. For example, ratings of perceived risk have increased from very low when peer passengers are in the car to higher ratings when passengers have been drinking alcohol, smoking marijuana, or are not wearing seatbelts to highest ratings when passengers are trying to get the driver to speed or are acting wild.³⁵ Regarding driving while using a mobile phone, hands-free use has been considered less risky than manual use^18,44 and answering a call, dialing, or text messaging as more risky than talking on a phone.^35,45Such findings raise questions about whether risk perception and risky driving behaviors are strongly related and whether either is directly associated with crashes. Few recent studies of novice drivers have explored these issues, particularly the utility of either risk perception or risky driving behaviors for predicting the risk of a crash. An earlier study conducted in Australia found that self-reported risky driving behaviors were linked to increased risk of crashes in the first year of driving, but this study did not examine the impact of risk perception on crash risk.⁴⁶ Our aim was to explore the risky driving behaviors and risk perceptions of a cohort of young, newly licensed drivers and to determine the associations between these factors and crash risk.     

Institutionalization of older adults after the death of a spouse

Objectives. We investigated the risk of entering long-term institutional care after the death of a spouse in relation to the duration of widowhood among older Finnish men and women. We also examined whether high levels of education or household income buffered the effects of bereavement on institutionalization.Methods. We used linked register-based data on Finnish adults 65 years or older who were living with a spouse at the beginning of the study period (n=140902) and were followed from January 1998 to December 2002.Results. The excess risk of institutionalization was highest during the first month following a spouse’s death compared with still living with a spouse (adjusted hazard ratio=3.31 for men, 3.62 for women). This risk decreased over time among both men and women. The relative effect of the duration of widowhood on institutionalization did not significantly vary according to the level of education or income.Conclusions. Risk of institutionalization is particularly high immediately after the death of a spouse, demonstrating the importance of loss of social and instrumental support.Previous studies showed that older adults who live alone or without a spouse have an increased probability of entering institutional care, independent of baseline health status.1^–4 These findings indicate the importance of social and instrumental support provided by a spouse in reducing the need for institutionalization. In addition, never-married, widowed, and divorced older persons have been shown to have a higher probability of institutionalization than their married counterparts.5^,6 However, few studies have analyzed how the death of a spouse affects the probability of entering institutional care.The death of a spouse has been shown to be associated with poor mental health, such as depression and anxiety,7^,8 and with poor physical health.7 Because poor mental and physical health have both been found to be associated with an increased risk of institutionalization,1^,2 it is likely that the death of a spouse also increases the need for institutional care. In addition, some studies have found an association between the death of a spouse and a decline in cognitive status (e.g., memory functioning),9 which is shown to be an important risk factor for admission to institutional care.1^,10 Because mental health may improve again after despair and disorganization diminish with time following bereavement,11 it is possible that the risk of institutionalization is highest immediately after the loss of a spouse and decreases over time.One study from the United States indicated that becoming widowed during a prospective follow-up was associated with an increased probability of nursing home admission, but the recency of widowhood, measured retrospectively at the time of the baseline interviews, was not.12 The latter finding may be misleading, especially if the effect of widowhood is short term and a large proportion of the recently widowed were already institutionalized before the baseline interviews. However, we know of no large-scale prospective studies testing whether the effect of a spouse’s death on institutionalization varies according to the duration of widowhood, and the existence and the magnitude of these effects are unknown.The effect of widowhood and widowerhood on mortality is well established: the recently bereaved have been shown to have a higher risk of death than the currently married,13^–20 especially from alcohol-related diseases, suicides, and other accidents and violence.19 Because both mortality and institutionalization are related to poor health (e.g., poor self-perceived health predicts mortality and institutionalization,3^,21 depression predicts mortality,22 and depressive symptoms predict institutionalization among men23), it is possible that the effect of the duration of widowhood is similar for both. Previous studies indicated that excess mortality is highest during the first weeks18^,24 or months13^,14^,16^,20^,25 after a spouse’s death. Some studies found that excess mortality among the bereaved decreases to the level of the married with time from bereavement among men,13 but others indicated that it continues, although at a lower level, for 10 years and longer.15The excess risk of death among the recently bereaved may be related to psychosocial mechanisms, such as emotional stress and grief, and to the loss of social, instrumental, and material support.18^,19^,26 However, previous mortality studies suggested that the bereaved gradually adapt to the loss and learn to cope in their changed social environment. Furthermore, bereaved persons with disabilities may be more likely to be institutionalized immediately after the death of the spouse because there is no longer anybody to take care of them.High levels of education and income, as well as other social and economic resources, may buffer against the harmful effect of spousal loss on institutionalization and mortality. However, persons with higher education20^,27^,28 and income27 were not found to suffer less excess mortality after a spouse’s death in previous studies. Although high socioeconomic status is associated with lower mortality, it has not been shown to prevent or even buffer the harmful effects of spousal loss. On the contrary, a study of the Israeli Jewish population indicated that the relative excess mortality among those recently bereaved was higher for men with more education.20Perhaps socioeconomic buffering of the effects of bereavement is greater on institutionalization than on mortality, because the loss of spousal support and access to substitute assistance, such as home help services, are likely to be more effective predictors of institutionalization than of death. However, empirical evidence for this hypothesis is not available. Because older adults with savings and higher incomes may be better able to afford home help services, a high household income at the beginning of a study could also buffer the harmful effects of spousal loss.We used population-based survival data with a continuous time scale of institutionalization to assess the risk of entering institutional care after the death of a spouse in relation to the duration of widowhood and widowerhood among adults 65 years or older. We analyzed Finnish register-based data containing information on each individual’s dates of first admission into long-term institutional care and death and on the spouse’s date of death during a 5-year follow-up from January 1998 to December 2002. We sought to assess (1) whether recently bereaved older adults had a higher risk of entering institutional care than did those living with a spouse, independent of sociodemographic controls and preexisting medical conditions; (2) how the duration of widowhood was associated with the risk of entering institutional care; and (3) whether the relative effects of a spouse’s death were smaller among persons with a higher level of education or a higher household income. The first 2 analyses were performed separately for men and women.     

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.     

Workplace discrimination and health among Filipinos in the United States

Objectives. We examined the association between work discrimination and morbidity among Filipinos in the United States, independent of more-global measures of discrimination.Methods. Data were collected from the Filipino American Community Epidemiological Survey. Our analysis focused on 1652 participants who were employed at the time of data collection, and we used negative binomial regression to determine the association between work discrimination and health conditions.Results. The report of workplace discrimination specific to being Filipino was associated with an increased number of health conditions. This association persisted even after we controlled for everyday discrimination, a general assessment of discrimination; job concerns, a general assessment of unpleasant work circumstances; having immigrated for employment reasons; job category; income; education; gender; and other sociodemographic factors.Conclusions. Racial discrimination in the workplace was positively associated with poor health among Filipino Americans after we controlled for reports of everyday discrimination and general concerns about one’s job. This finding shows the importance of considering the work setting as a source of discrimination and its effect on morbidity among racial minorities.Previous research suggests that social factors associated with racial/ethnic minority group status may influence health and, thus, health disparities. One such factor is racial discrimination, an important correlate of health.1^,2 Among minority groups in the United States, self-reported racial discrimination is associated with a wide range of health outcomes, including high blood pressure, depression, substance use, and other health problems.3^–6 Most studies of health and discrimination have focused on global experiences of discrimination. For example, Krieger and Sidney7 examined how a measure of discrimination at school, in getting a job, at work, in acquiring housing, in getting medical care, on the street, or by police was associated with blood pressure. Williams et al.8 reported that everyday discrimination, a measure that captured general experiences of routine unfair treatment, was associated with poor mental health. Gee et al.9 found that the everyday discrimination scale was associated with chronic health conditions among Filipino Americans. Other studies have found associations between discrimination and numerous health problems, including coronary calcification,10 alcohol dependence,11 depressive disorder,12 and low birthweight.13Given that stressors in general are known to have nonspecific effects,14^,15 it is not surprising that a range of outcomes have been associated with discrimination.1^,2^,6^,16 In fact, stress researchers have long argued that focusing on particular outcomes may underestimate the potential effect of stressors.2^,17^,18 Although these and other studies have been invaluable in advancing our understanding of discrimination, the study of discrimination in specific contexts is important and may aid the development of targeted interventions.1^,2 One such context is the workplace.Workplace discrimination may influence health both directly, as a stressor, and indirectly through income and advancement. The workplace is among the most frequently noted areas in which discrimination occurs, but there are relatively few studies of work-place discrimination and health outcomes.1^,2 Mays et al.19^,20 reported discrimination to be associated with job stress among working African American women. Jackson et al.21 found that a specific type of workplace discrimination, tokenism, was associated with depression and anxiety among African Americans. Workplace discrimination has also been associated with alcohol use among a multiracial sample of public transit operators22 and with job dissatisfaction among African Americans.23 These studies call attention to the importance of discrimination specific to the workplace aside from more-generic experiences of discrimination; however, they did not include both a measure for workplace discrimination and a measure for generic experiences of discrimination. That is, the association between workplace discrimination and health might arise from more-global experiences with discrimination. Should an association between workplace discrimination and health persist independent of more-global experiences, this would suggest that workplace-specific policies that protect against discrimination are important not only for the preservation of workers’ rights but also to promote their health. Accordingly, we examined whether workplace discrimination was associated with health, independent of a more-global measure of discrimination, in a sample of Filipino American workers.Our study focused on Filipino American workers (this includes US citizen and non—US citizen Filipinos working in America) for several compelling reasons. Filipinos have historically emigrated to America and elsewhere, providing significant numbers of workers throughout a variety of industries.24^–32 In 2000, approximately 2.4 million Filipinos resided in the United States, making them the second largest Asian ethnic group population.33 Moreover, discrimination may be particularly relevant for this population. Compared with Chinese and Vietnamese Americans, Filipino Americans appear to perceive the highest levels of discrimination, and these levels are fairly similar to those of African Americans.34 A survey of Filipino American workers found that 81% said racism was a significant or very significant barrier to their upward mobility.35Several high-profile cases feature the importance of work discrimination among Filipinos. English-only rules in workplaces have explicitly targeted immigrants and some have focused on Filipinos.36 In Carino v. University of Oklahoma Board of Regents (750 F.2d 815 [10th Cir 1984]) the court found that a Filipino man was unlawfully demoted because of his Filipino accent. Regardless of their legality, these language rules serve to remind immigrants of their secondary status and may contribute to employment outcomes that foster work stress. Also, some evidence suggests Filipinos earn less than do their White and other Asian peers.37 Moreover, Asian Americans may encounter a “bamboo ceiling” that impedes advancement into higher level positions.38 Taken together, these observations suggest that discrimination in the workplace does occur and may influence the health of Filipino Americans.     

Mortality from Alzheimer's, motor neuron and Parkinson's disease in relation to magnetic field exposure: findings from the study of UK electricity generation and transmission workers, 1973-2004

Background

There are a number of reports linking magnetic field exposure to increased risks of Alzheimer''s disease and motor neuron disease.

Methods

The mortality experienced by a cohort of 83 997 employees of the former Central Electricity Generating Board of England and Wales was investigated for the period 1973–2004. All employees were employed for at least six months with some employment in the period 1973–82. Computerised work histories were available for 79 972 study subjects for the period 1971–93. Information on job and facility (location) were used to estimate exposures to magnetic fields. Two analytical approaches were used to evaluate risks, indirect standardisation (n = 83 997) and Poisson regression (n = 79 972).

Results

Based on serial mortality rates for England and Wales, deaths from Alzheimer''s disease and motor neuron disease were unexceptional. There was an excess of deaths from Parkinson''s disease of borderline significance. No statistically significant trends were shown for risks of any of these diseases to increase with lifetime cumulative exposure to magnetic fields (RR per 10 μT-y: Alzheimer''s disease 1.10 (95% CI 0.90 to 1.33); motor neuron disease 1.06 (95% CI 0.86 to 1.32); Parkinson''s disease 0.88 (95% CI 0.74 to 1.05))

Conclusions

There is no convincing evidence that UK electricity generation and transmission workers have suffered increased risks from neurodegenerative diseases as a consequence of exposure to magnetic fields.A large number of studies have investigated risks of cancer and other diseases in “electrical and electronic” workers. In addition, large-scale cohort mortality studies of electric utility workers that incorporate magnetic field exposure assessments are also available.^1,2,3,4,5 The question has also been raised as to whether employment in “electrical” occupations or exposure to magnetic fields might have an effect on risks of neurodegenerative disease. The literature relating to Alzheimer''s disease and magnetic fields is difficult to assess. It was suggested that increased risks could be substantial.⁶ Although this initial report was based on the combined results of three sub-studies, it should be regarded only as hypothesis forming, as the findings were much influenced by the reclassification of exposure groups. The Alzheimer''s/magnetic fields hypothesis was supported by the findings of another case-control study⁷ and was weakly supported by a proportional mortality ratio analysis of causes of death as recorded on US death certificates.⁸ The hypothesis was not supported, however, by the three studies that were able to provide quantified estimates of individual exposures.^9,10,11 One case-control study⁹ did not show risk to be associated with the individual''s primary occupation, but did show a substantial and statistically significant risk with the last recorded occupation, which would have been the association recorded in the death certificate study.⁸ Neither of the cohort studies,^10,11 however, provided evidence of a risk with increasing exposure, nor, in the one study that provided such information, was there any excess mortality in power plant workers. However, these studies relied on mortality records that are known to under-report Alzheimer''s disease and the distinction between Alzheimer''s disease and dementia is not always clearly made on death certificates. Three more recent studies also provided mixed findings: one providing weak evidence of a risk for males in the highest exposure group,¹² another (overlapping) study focusing on resistance welders showed a positive effect,¹³ and a third study showed an effect in males, but not in females.¹⁴ While initial, hypothesis-generating studies indicated a potential threefold risk, most of the subsequent research has found risks at or below unity, with only a few elevated risks of around 2.0 in selected subgroups. Thus the hypothesis that 50–60 Hz electromagnetic fields (EMFs) increase the risk of Alzheimer''s disease is neither proven nor excluded.More consistent evidence is available for motor neuron disease (some studies are concerned with its principal subtype amyotrophic lateral sclerosis (ALS)).^{8,10,11,12,13,15,16,17,18,19,20,21,22} A number of reports investigating the relation between electrical work or the experience of electrical shocks have been published since the original suggestion was made that electric shocks might increase the risk of the disease.²⁰ Two early studies from Japan (reported in a single paper), where the prevalence both of electrical work (as recorded in medical histories) and electrical shock was low, failed to provide any support for the hypothesis.²¹ However, an increased risk of ALS from electric shocks has been reported in several later studies.^16,22 The US study also found an increased risk associated with the employment in electrical occupations¹⁶ and this was supported by other studies from Sweden¹⁸ and the USA.⁸ Later studies focused on magnetic field exposure^10,11,15 and found twofold risks to be associated with exposure, albeit these excess risks were not always statistically significant. Recent and overlapping studies from Sweden focusing on magnetic field exposure and electric shock are inconsistent, with one showing no effect and the other indicting a twofold risk in the two highest exposure categories.^12,13 The epidemiological evidence suggests that employment in electrical occupations may increase the risk of ALS. However, separating any increased risk as a result of receiving an electric shock from any increased exposure to magnetic fields is important, albeit difficult.A number of epidemiological studies have been carried out on environmental associations with Parkinson''s disease.^{8,10,11,12,13,19,23} No study has provided clear evidence of an association with above average exposures to extremely low frequency EMFs (most risks close to unity) and, in the absence of laboratory evidence to the contrary, it seems unlikely that such exposures are involved in the disease process. Nevertheless, Parkinson''s disease was included as a health outcome of interest in this study for the sake of completeness.This paper seeks to obtain important new information on the topic of occupational magnetic field exposure and risks of mortality from neurodegenerative diseases by examining data from the ongoing epidemiological study of UK electric utility workers; this topic has been identified as a priority in recent reviews.^23,25     

Physical education and academic achievement in elementary school: data from the early childhood longitudinal study

Objectives. We examined the association between time spent in physical education and academic achievement in a longitudinal study of students in kindergarten through fifth grade.Methods. We used data from the Early Childhood Longitudinal Study, Kindergarten Class of 1998 to 1999, which employed a multistage probability design to select a nationally representative sample of students in kindergarten (analytic sample = 5316). Time spent in physical education (minutes per week) was collected from classroom teachers, and academic achievement (mathematics and reading) was scored on an item response theory scale.Results. A small but significant benefit for academic achievement in mathematics and reading was observed for girls enrolled in higher amounts (70–300 minutes per week) of physical education (referent: 0–35 minutes per week). Higher amounts of physical education were not positively or negatively associated with academic achievement among boys.Conclusions. Among girls, higher amounts of physical education may be associated with an academic benefit. Physical education did not appear to negatively affect academic achievement in elementary school students. Concerns about adverse effects on achievement may not be legitimate reasons to limit physical education programs.Physically active youth may be less likely than physically inactive youth to experience chronic disease risk factors1 and to become obese,2 and they may be more likely to remain active throughout adolescence3 and possibly into adulthood.4 Physical activity also has beneficial influences on behavior and cognitive functioning that may result in improving students’ academic achievement.5^–7 Direct indicators of academic achievement include grade-point averages, scores on standardized tests, and grades in specific courses; measures of concentration, memory, and classroom behavior provide indirect estimates.1Several cross-sectional studies examined the association between physical activity and direct measures of academic achievement.8^–13 In addition, several intervention studies were conducted to examine the effect of introducing more physical activity and physical education programs during the school day on indirect estimates of behaviors related to academic achievement (e.g., concentration, memory, disruptive behavior) or on direct measures (e.g., standardized tests, academic record, teacher reports).6^,7^,14^–23 These studies had mixed results. Investigators observed either no association6^,8^,13^,14^,16^,18^,23 or a modest-to-moderate positive association6^,7^,9^–12^,15^,17^,19^–22 between physical activity and academic achievement.Physical education classes provide an opportunity for students to be physically active during the school day.1 School-based physical education has many benefits, including increasing physical activity and improving physical fitness and muscular endurance.24^–28 Increasing physical activity through physical education is also a proposed public health strategy to reduce childhood obesity.29 Although there has been no evidence to date to show that maintaining or increasing time in physical education class negatively affects academic achievement in other subjects, there is concern that physical education classes could take time away from those subjects.1^,28^,30 More information is needed to address this concern and support public health objectives to maintain or expand physical education programs.31We examined the influence of physical education in US elementary schools on direct measures of academic achievement in mathematics and reading from kindergarten through fifth grade. Our study was unique in at least 3 ways: first, the measurement of academic achievement was a standardized test administered at 5 time points. Second, we examined the association between physical education and academic achievement with a prospective cohort design. Finally, we examined participation in physical education as it existed in a representative sample of US students entering kindergarten in fall 1998 who were followed through spring 2004.     

Vaccination or immunization? The impact of search terms on the internet

With steadily rising use of the Internet as a source of health information, public health authorities have expressed concern about the increasing visibility of unscientific information promulgated on the Internet by opponents of childhood vaccination. Searches were made on the four most popular Internet search engines using different combinations of the terms, "vaccination," "immunization," "immunisation," "immunize," "immunise," "vaccine," and "shots." Thirty results were tabulated for each search engine. Searching with the keyword "vaccination" resulted in a significantly higher percentage of antivaccination websites as compared with searches with all other keywords. Of all child-related websites retrieved, the single keyword "vaccination" yielded 40% provaccination sites and 60% antivaccination sites. By contrast, the single keyword "immunization" yielded 98% provaccination sites and 2% antivaccination sites. Using a combination of the words "vaccination" and "immunization" produced results between these two extremes. Thus, any use of the term "vaccination" during an Internet search is likely to expose a parent to a significant amount of antivaccination information. Recommendations are discussed for future research and methods to reduce the impact of misinformation on health consumers using the Internet.     

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.     

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.     

Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work

Objectives. We determined racial/ethnic differences in social support and exposure to violence and transphobia, and explored correlates of depression among male-to-female transgender women with a history of sex work (THSW).Methods. A total of 573 THSW who worked or resided in San Francisco or Oakland, California, were recruited through street outreach and referrals and completed individual interviews using a structured questionnaire.Results. More than half of Latina and White participants were depressed on the basis of Center For Epidemiologic Studies Depression Scale scores. About three quarters of White participants reported ever having suicidal ideation, of whom 64% reported suicide attempts. Half of the participants reported being physically assaulted, and 38% reported being raped or sexually assaulted before age 18 years. White and African American participants reported transphobia experiences more frequently than did others. Social support, transphobia, suicidal ideation, and levels of income and education were significantly and independently correlated with depression.Conclusions. For THSW, psychological vulnerability must be addressed in counseling, support groups, and health promotion programs specifically tailored to race/ethnicity.The term “transgender” has been used as an umbrella term, capturing people who do not conform with a binary male–female gender category.¹ In this study, we use the term “transgender women” or “male-to-female transgender women” to describe individuals who were born biologically male but self-identify as women and desire to live as women.² Although transgender persons or those who identify their gender other than male or female have been historically reported in many cultures around the world, their social roles, status, and acceptance have varied across time and place.³ In the United States, as part of the gay rights movement in the 1970s, a transgender civil rights movement emerged to advocate for transgender people''s equal rights and to eradicate discrimination and harassment in their daily lives.⁴ However, transphobia—institutional, societal, and individual-level discrimination against transgender persons—is still pervasive in the United States and elsewhere. It often takes the form of laws, regulations, violence (physical, sexual, and verbal), harassment, prejudices, and negative attitudes directed against transgender persons.^5–7Studies have reported that transgender persons lack access to gender-sensitive health care^6,8,9 and often experience transphobia in health care and treatment.^5,9 Transgender persons are frequently exposed to violence, sexual assault, and harassment in everyday life, mainly because of transphobia.^5–7,9–11 Physical and sexual assaults and violence, and verbal and nonphysical harassment, derive from various perpetrators (e.g., strangers, acquaintances, partners, family members, and police officers). Transgender persons suffer from assaults, rape, and harassment at an early age, and these experiences persist throughout life.¹ A number of studies have examined violence and harassment against sexual minorities, although these have mainly focused on gay men.^12–15 A limited literature has described the prevalence of violence, transphobia, and health disparities among transgender persons.^7–9Psychological indicators such as depression and suicidal ideation and attempts have been reported among transgender persons.^{5,6,10,16–18} Transgender women of color, such as African Americans, Latinas, and Asians/Pacific Islanders (APIs), are at high risk for adverse health outcomes because of racial/ethnic minority status and gender identity,⁶ as well as for depression through exposure to transphobia.¹⁹ Although transgender persons have reported relatively high rates of using basic health care services,²⁰gender-appropriate mental health services are needed,⁵ particularly among African Americans.²¹ A lack of social support, specifically from the biological family, is commonly reported among transgender persons and is associated with discomfort and lack of security and safety in public settings.²² Sparse research exists on social support among transgender persons, although such support could ameliorate adverse psychological consequences associated with transphobia and also mitigate racial discrimination for transgender persons of color.Because of relatively high rates of unemployment, lack of career training and education, and discrimination in employment, many transgender women engage in sex work for survival.^23,24 Sex work is linked to high-risk situations, including substance abuse, unsafe sex, and sexual and physical abuse.²⁵ Physical abuse, social isolation, and the social stigma associated with sex work exacerbate transgender women''s vulnerability to mental illness and HIV risk.^5,17 High HIV seroprevalence rates among transgender women have been reported,^5,20,26–28 particularly among racial/ethnic minorities,⁵ substance users,²⁷ and sex workers.^{20,24,25,29–31} Transgender women of color face multiple adversities, such as racial and gender discrimination; transphobia; economic challenges including unemployment, substance abuse, HIV and other sexually transmitted infections; and mental illness. However, few studies have investigated racial/ethnic differences in psychological status among transgender women of color in relation to social support and exposure to transphobia.To develop culturally appropriate and transgender specific mental health promotion programs, we describe the prevalence of violence, transphobia, and social support in relation to racial/ethnic background among transgender women with a history of sex work (THSW). We also investigated the role of social support and exposure to transphobia on participants’ levels of depression.