Posttraumatic Stress Disorder and Incident Heart Failure Among a Community-Based Sample of US Veterans

Objectives. We investigated the association between posttraumatic stress disorder (PTSD) and incident heart failure in a community-based sample of veterans.Methods. We examined Veterans Affairs Pacific Islands Health Care System outpatient medical records for 8248 veterans between 2005 and 2012. We used multivariable Cox regression to estimate hazard ratios and 95% confidence intervals for the development of heart failure by PTSD status.Results. Over a mean follow-up of 7.2 years, veterans with PTSD were at increased risk for developing heart failure (hazard ratio [HR] = 1.47; 95% confidence interval [CI] = 1.13, 1.92) compared with veterans without PTSD after adjustment for age, gender, diabetes, hyperlipidemia, hypertension, body mass index, combat service, and military service period. Additional predictors for heart failure included age (HR = 1.05; 95% CI = 1.03, 1.07), diabetes (HR = 2.54; 95% CI = 2.02, 3.20), hypertension (HR = 1.87; 95% CI = 1.42, 2.46), overweight (HR = 1.72; 95% CI = 1.25, 2.36), obesity (HR = 3.43; 95% CI = 2.50, 4.70), and combat service (HR = 4.99; 95% CI = 1.29, 19.38).Conclusions. Ours is the first large-scale longitudinal study to report an association between PTSD and incident heart failure in an outpatient sample of US veterans. Prevention and treatment efforts for heart failure and its associated risk factors should be expanded among US veterans with PTSD.Posttraumatic stress disorder (PTSD) is a psychiatric illness that affects approximately 7.7 million Americans aged older than 18 years.1 PTSD typically results after the experience of severe trauma, and veterans are at elevated risk for the disorder. The National Vietnam Veterans Readjustment Study reported the prevalence of PTSD among veterans who served in Vietnam as 15.2% among men and 8.1% among women.2 In fiscal year 2009, nearly 446 045 Veterans Administration (VA) patients had a primary diagnosis of PTSD, a threefold increase since 1999.3 PTSD is of growing clinical concern as evidence continues to link psychiatric illnesses to conditions such as arthritis,4 liver disease,5 digestive disease,6 and cancer.6 When the postwar health status of Vietnam veterans was examined, those with PTSD had higher rates of diseases of the circulatory, nervous, digestive, musculoskeletal, and respiratory systems.7The evidence linking PTSD to coronary heart disease (CHD) is substantial.8–10 Veterans with PTSD are significantly more likely to have abnormal electrocardiograph results, myocardial infarctions, and atrioventricular conduction deficits than are veterans without PTSD.11 In a study of 605 male veterans of World War II and the Korean War, CHD was more common among veterans with PTSD than among those without PTSD.12 Worldwide, adults exposed to the disaster at Chernobyl experienced increased rates of CHD up to 10 years after the event,13 and studies of stressors resulting from the civil war in Lebanon found elevated CHD mortality.14,15Although the exact biological mechanism by which PTSD contributes to CHD remains unclear, several hypotheses have been suggested, including autonomic nervous system dysfunction,16 inflammation,17 hypercoagulability,18 cardiac hyperreactivity,19 altered neurochemistry,20 and co-occurring metabolic syndrome.16 One of the hallmark symptoms of PTSD is hyperarousal,21 and the neurobiological changes brought on from sustained sympathetic nervous system activation affect the release of neurotransmitters and endocrine function.22 These changes have negative effects on the cardiovascular system, including increased blood pressure, heart rate, and cardiac output.22,23Most extant literature to date examining cardiovascular sequelae has shown a positive association between PTSD and coronary artery disease.8–10 Coronary artery disease is well documented as one of the most significant risk factors for future development of heart failure.24 Despite burgeoning evidence for the role of PTSD in the development of coronary artery disease, there are few studies specifically exploring the relationship between PTSD and heart failure. Limited data suggest that PTSD imparts roughly a threefold increase in the odds of developing heart failure in both the general population5 and in a sample of the elderly.25 These investigations, however, have been limited by cross-sectional study design, a small proportion of participants with PTSD, and reliance on self-reported measures for both PTSD and heart failure.5,25 Heart failure is a uniquely large public health issue, as nearly 5 million patients in the United States are affected and there are approximately 500 000 new cases each year.26 Identifying predictors of heart failure can aid in early detection efforts while simultaneously increasing understanding of the mechanism behind development of heart failure.To mitigate the limitations of previous investigations, we undertook a large-scale prospective study to further elucidate the role of prevalent PTSD and development of incident heart failure among veterans, while controlling for service-related and clinical covariates. Many studies investigating heart failure have relied on inpatient records; we leveraged outpatient records to more accurately reflect the community burden of disease.     

Racial/Ethnic Disparities in Health Care Receipt Among Male Cancer Survivors

Objectives. We examined racial/ethnic disparities in health care receipt among a nationally representative sample of male cancer survivors.Methods. We identified men aged 18 years and older from the 2006–2010 National Health Interview Survey who reported a history of cancer. We assessed health care receipt in 4 self-reported measures: primary care visit, specialist visit, flu vaccination, and pneumococcal vaccination. We used hierarchical logistic regression modeling, stratified by age (< 65 years vs ≥ 65 years).Results. In adjusted models, older African American and Hispanic survivors were approximately twice as likely as were non-Hispanic Whites to not see a specialist (odds ratio [OR] = 1.78; 95% confidence interval [CI] = 1.19, 2.68 and OR = 2.09; 95% CI = 1.18, 3.70, respectively), not receive the flu vaccine (OR = 2.21; 95% CI = 1.45, 3.37 and OR = 2.20; 95% CI = 1.21, 4.01, respectively), and not receive the pneumococcal vaccine (OR = 2.24; 95% CI = 1.54, 3.24 and OR = 3.10; 95% CI = 1.75, 5.51, respectively).Conclusions. Racial/ethnic disparities in health care receipt are evident among older, but not younger, cancer survivors, despite access to Medicare. These survivors may be less likely to see specialists, including oncologists, and receive basic preventive care.Gender and racial/ethnic disparities in health care utilization are prevalent. Men are less likely than are women to use health care services, including physician office visits and preventive care visits.1,2 Minorities are also less likely to use health care services than are non-Hispanic Whites.3–6 Contributors to these disparities include low socioeconomic status7–10 and lack of health insurance.7,8,11,12 Even after controlling for socioeconomic status and health insurance coverage, racial/ethnic disparities in health care utilization persist.4 These disparities are associated with poorer health and higher mortality rates among minorities and have important implications for survival and well-being for men with serious and chronic health conditions such as cancer.5Although numerous studies have documented racial/ethnic disparities in cancer screening, diagnosis, treatment, and mortality,10,13–18 little is known about how racial/ethnic disparities in health care among posttreatment cancer survivors influence follow-up care. Such care includes monitoring and managing late and long-term effects and follow-up tests to monitor for recurrence and detect second cancers. Management of noncancer comorbidities (e.g., diabetes) and preventive health care19 (e.g., vaccinations) are also recommended for cancer survivors.20–22 Follow-up care may include visits to both primary care and specialist providers.13,23–25 It is strongly recommended that cancer survivors receive lifelong follow-up care because of increased risk of recurrence, morbidity, and mortality.19Prior studies have used administrative data to explore this issue,13,24,26,27 but few of these studies have focused on male cancer survivors and none included younger survivors who are not covered by Medicare. Additionally, it is not known how patterns of health care receipt might differ among men with and without a history of cancer.We assessed racial/ethnic disparities in health care receipt among adult male cancer survivors and men without cancer using the National Health Interview Survey (NHIS).28 We first wanted to compare cancer survivors to a noncancer group to shed light on whether the disparities are specific to cancer or reflect underlying disparities. We explored (1) racial/ethnic disparities in health care receipt among cancer survivors compared with men with no cancer history, (2) racial/ethnic disparities in cancer survivors, and (3) the extent to which predisposing, enabling, and need factors explain racial/ethnic disparities in health care receipt among male cancer survivors.     

Route Infrastructure and the Risk of Injuries to Bicyclists: A Case-Crossover Study

Objectives. We compared cycling injury risks of 14 route types and other route infrastructure features.Methods. We recruited 690 city residents injured while cycling in Toronto or Vancouver, Canada. A case-crossover design compared route infrastructure at each injury site to that of a randomly selected control site from the same trip.Results. Of 14 route types, cycle tracks had the lowest risk (adjusted odds ratio [OR] = 0.11; 95% confidence interval [CI] = 0.02, 0.54), about one ninth the risk of the reference: major streets with parked cars and no bike infrastructure. Risks on major streets were lower without parked cars (adjusted OR = 0.63; 95% CI = 0.41, 0.96) and with bike lanes (adjusted OR = 0.54; 95% CI = 0.29, 1.01). Local streets also had lower risks (adjusted OR = 0.51; 95% CI = 0.31, 0.84). Other infrastructure characteristics were associated with increased risks: streetcar or train tracks (adjusted OR = 3.0; 95% CI = 1.8, 5.1), downhill grades (adjusted OR = 2.3; 95% CI = 1.7, 3.1), and construction (adjusted OR = 1.9; 95% CI = 1.3, 2.9).Conclusions. The lower risks on quiet streets and with bike-specific infrastructure along busy streets support the route-design approach used in many northern European countries. Transportation infrastructure with lower bicycling injury risks merits public health support to reduce injuries and promote cycling.Bicycling is an active mode of transportation with a range of individual and public health benefits.1–5 However, bicycling is underused for transportation in Australia, Canada, Ireland, the United States, and the United Kingdom, constituting an estimated 1% to 3% of trips, compared with 10% to 27% of trips in Denmark, Germany, Finland, the Netherlands, and Sweden.6–8 The reasons for low bicycle share of trips are multifaceted, but safety is one of the most frequently cited deterrents.9–11 These concerns are well founded: bicycling injury rates are higher in countries where cycling for transportation is less common.8,12,13To reduce bicycling injuries, the first step is to understand the determinants of risk. Studies in many English-speaking countries have focused on head injury reductions afforded by helmets.14–17 However, helmet use cannot explain the risk difference because helmets are rarely used in the European countries with lower injury rates.8,18,19 Typical route infrastructure (physical transportation structures and facilities) in countries with low bicycle share of trips differs from that in countries with high trip shares. In Germany, Denmark, and the Netherlands, bicycle-specific infrastructure is frequently available,20 so this is a promising avenue for investigating injury risks. In a review of route infrastructure and injury risk,21 we found some evidence that bicycle-specific infrastructure was associated with reduced risk. However, the studies reviewed had problems that have compromised confidence in the results: grouping of route categories that may have different risks, unclear definitions of route infrastructure, and difficulty controlling for characteristics of cyclists and for exposure to various route types. Debates continue about the contribution of route design to safety and about the safety of various route types.12,13,20,21Here we present a study designed to overcome these limitations.22 We examined injury risk of 14 route types using a case-crossover design in which injured participants served as their own controls. The design compared route characteristics at the location where the injury event occurred to those at a randomly selected point on the same trip route where no injury occurred. By randomly selecting the control site in this way, the probability that a specific infrastructure type would be chosen was proportional to its relative length on the trip (e.g., on a 4-km trip, there would be a 25% chance of selecting a control site on a 1-km section that was on a bike path). Because comparisons were within-trip, personal characteristics such as age, gender, and propensity for risk-taking behavior were matched, as were trip conditions such as bicycle type, clothing visibility, helmet use, weather, and time of day. This allowed the comparisons to focus on between-site infrastructure differences.     

The Impact of a Free Older Persons’ Bus Pass on Active Travel and Regular Walking in England

Objectives. We assessed the potential public health benefit of the National Bus Pass, introduced in 2006, which permits free local bus travel for older adults (≥ 60 years) in England.Methods. We performed regression analyses with annual data from the 2005–2008 National Travel Survey. Models assessed associations between being a bus pass holder and active travel (walking, cycling, and use of public transport), use of buses, and walking 3 or more times per week.Results. Having a free pass was significantly associated with greater active travel among both disadvantaged (adjusted odds ratio [AOR] = 4.06; 95% confidence interval [CI] = 3.35, 4.86; P < .001) and advantaged groups (AOR = 4.72; 95% CI = 3.99, 5.59; P < .001); greater bus use in both disadvantaged and advantaged groups (AOR = 7.03; 95% CI = 5.53, 8.94; P < .001 and AOR = 7.11; 95% CI = 5.65, 8.94; P < .001, respectively); and greater likelihood of walking more frequently in the whole cohort (AOR = 1.15; 95% CI = 1.07, 1.12; P < .001).Conclusions. Public subsidies enabling free bus travel for older persons may confer significant population health benefits through increased incidental physical activity.Physical activity levels are decreasing globally.1 In 2008, 31% of people worldwide were insufficiently active contributing to 3.2 million deaths each year related to physical inactivity.2 Remaining physically active is as important in older as in younger adults because it reduces the risk of loss of mobility and muscle strength, falls, and fractures, and promotes social and mental well-being.3 Responding to this evidence, the US Surgeon General recommends regular moderate physical activity for older adults,4 and the UK Department of Health recommends at least 30 minutes of moderate exercise 5 times a week.3 Even lower activity levels may have significant benefits: the relative risk of disability is reduced by 7% for each additional hour of relatively gentle physical activity undertaken each week,5 and 15 minutes of moderate daily exercise is associated with a 12% decrease in all-cause mortality in persons older than 60 years.6Incidental physical activity may be defined as physical activity that is a byproduct of an activity with a different primary purpose. There is increasing interest in the promotion of incidental physical activity, including greater use of active transport—walking, cycling, and use of public transport.7–9 By swapping private vehicle travel for public transport—which may involve walking or cycling to transport access points or interchanges—physical activity levels are raised, offering significant health benefits, such as a reduced risk of obesity and cardiovascular ill health.10–12 Research from the United States finds that those commuting on public transport walk for an average of 19 minutes each day, and that nearly one third of commuters reach recommended daily physical activity levels just through active transport.13 In the United Kingdom, 19% of adults achieve recommended activity levels through active transport alone.14 Although commuting may not be as relevant to retired populations,15 incidental active travel may still have a key role to play in keeping older adults physically fit.16,17     

Latent Tuberculosis Infection Screening in Foreign-Born Populations: A Successful Mobile Clinic Outreach Model

Objectives. We evaluated the efficacy of a mobile medical clinic (MMC) screening program for detecting latent tuberculosis infection (LTBI) and active tuberculosis.Methods. A LTBI screening program in a MMC in New Haven, Connecticut, used medical surveys to examine risk factors and tuberculin skin test (TST) screening eligibility. We assessed clinically relevant correlates of total (prevalent; n = 4650) and newly diagnosed (incident; n = 4159) LTBI from 2003 to 2011.Results. Among 8322 individuals, 4159 (55.6%) met TST screening eligibility criteria, of which 1325 (31.9%) had TST assessed. Similar to LTBI prevalence (16.8%; 779 of 4650), newly diagnosed LTBI (25.6%; 339 of 1325) was independently correlated with being foreign-born (adjusted odds ratio [AOR] = 8.49; 95% confidence interval [CI] = 5.54, 13.02), Hispanic (AOR = 3.12; 95% CI = 1.88, 5.20), Black (AOR = 2.16; 95% CI = 1.31, 3.55), employed (AOR = 1.61; 95% CI = 1.14, 2.28), and of increased age (AOR = 1.04; 95% CI = 1.02, 1.05). Unstable housing (AOR = 4.95; 95% CI = 3.43, 7.14) and marijuana use (AOR = 1.57; 95% CI = 1.05, 2.37) were significantly correlated with incident LTBI, and being male, heroin use, interpersonal violence, employment, not having health insurance, and not completing high school were significantly correlated with prevalent LTBI.Conclusions. Screening for TST in MMCs successfully identifies high-risk foreign-born, Hispanic, working, and uninsured populations and innovatively identifies LTBI in urban settings.Foreign-born populations are at greatest risk for having both latent tuberculosis infection (LTBI) and developing tuberculosis (TB) disease within high-income countries and, in 2012, accounted for 63.0% of the 9951 TB cases in the United States.1 Newly diagnosed and reactivated TB infection among foreign-born individuals in the United States is currently 12 times greater (15.8 vs 1.4 cases per 100 000 population) than among US-born persons.1 Among foreign-born individuals, LTBI often reactivates within 5 to 10 years after arrival to the United States.2,3 Undocumented migrants and visitors from high-TB-prevalence countries, however, do not undergo routine LTBI screening and thus remain outside traditional health care screening and treatment programs in primary or specialty care settings except when they are acutely ill.3,4 Thus, identifying and treating LTBI cases among these high-risk populations before transforming to TB disease and resultant transmission to others is crucial to ending the cycle of ongoing TB infection within the United States.Workplace screening,4,5 mandatory criminal justice system screening,6–8 screening for entry into medication-assisted therapy and drug treatment programs,9 and refugee and naturalization programs10,11 have been successful for reaching legal and domestic populations, but innovative options are needed to target foreign-born populations that are not yet integrated into mainstream care.Culturally and geographically isolated foreign-born groups may be overlooked especially if there is low self-perception of tuberculosis risk.12 Tuberculin skin testing (TST), though imperfect, is internationally recognized and has been shown to be a reasonably accurate assessment of LTBI status in immunocompetent adults, despite receiving previous Bacillus Calmette-Guérin vaccine.13 Whereas other studies have focused on traditional clinics or statewide programs,14 we present an innovative mobile medical clinic (MMC) as a model to target “hidden” foreign-born populations for LTBI screening.New Haven, Connecticut, the country’s fourth poorest city for its size, with a census of 130 000, is a medium-sized urban setting in New England that has experienced extraordinary social and medical disparities including a high prevalence of poverty, drug addiction, HIV/AIDS, and unemployment and is disproportionately comprised of people of color, including 35.4% and 27.4% being Black or Hispanic, respectively.15 As New Haven is an industrial city with low-paying jobs, there has been an influx of foreign-born people, now officially comprising 11.6% of the population, with many having an undocumented residency status. Health care access for this group is absent unless individuals pay directly for fee-for-service, and concern for deportation and arrest further hinders willingness to seek care.16The Community Health Care Van (CHCV) is an MMC that provides free health care 5 days per week in 4 impoverished neighborhoods in New Haven. Though at inception the program was linked to the needle and syringe exchange program,17 it has since expanded over 20 years to become a vital bridge to a diverse array of health and addiction treatment services that includes services for medically underserved populations, including directly administered antiretroviral therapy to treat HIV,18–21 buprenorphine maintenance therapy,22–25 community transitional programs from the criminal justice system,26–33 hepatitis B vaccination,34 rapid hepatitis C screening,35 and other ongoing primary health care programs such as screening and monitoring of sexually transmitted infections,36 diabetes, and hypertension. In addition, the CHCV provides outreach and intensive case management services.37 Screening for LTBI and TB disease began in 2003 to target high-risk undocumented and foreign-born clients, as well as clients entering drug treatment programs or homeless shelters, who were concerned about TB infection yet were reluctant to seek care in traditional health care settings for fear of deportation, prohibitive cost, or language barriers. The LTBI screening program shortly thereafter became successfully incorporated into the country’s first mobile buprenorphine maintenance therapy program.9     

Racial Differences in Breast Cancer Stage at Diagnosis in the Mammography Era

Objectives. We assessed racial differences in breast cancer mortality by stage at diagnosis, since mammography became available.Methods. We calculated adjusted odds of distant (versus local or regional) tumors for 143 249 White and 13 571 Black women aged 50 to 69 years, diagnosed with breast cancer between 1982 and 2007 and living in a Surveillance, Epidemiology, and End Results region. We compared linear trends in stage at diagnosis before and after 1998.Results. Distant-stage cancer was diagnosed in 5.8% of White and 10.2% of Black participants. The Black–White disparity in distant tumors narrowed until 1998 (1998 adjusted difference = 0.65%), before increasing. Between 1982 and 1997, the proportion of distant tumors decreased for Blacks (adjusted odds ratio [AOR]/y = 0.973; 95% confidence interval [CI] = 0.960, 0.987) and Whites (AOR/y = 0.978; 95% CI = 0.973, 0.983), with no racial differences (P = .47). From 1998 to 2007, the odds of distant versus local or regional tumors increased for Blacks (AOR/y = 1.036; 95% CI = 1.013, 1.060) and Whites (AOR/y = 1.011; 95% CI = 1.002, 1.021); the rate of increase was greater for Blacks than Whites (P = .04).Conclusions. In the mammography era, racial disparities remain in stage at diagnosis.Despite a lower incidence of invasive breast cancer, Black women in the United States are more likely than are White women to die of the disease.1,2 Since 1992, although breast cancer deaths have declined in both White and Black women, the overall disparity in mortality has increased.3 Stage at diagnosis is the strongest predictor of survival in breast cancer,4–6 and Black women are more often diagnosed with advanced-stage disease than are White women.7–10Mammography is an important tool in the early detection of breast cancer.11–13 First introduced in the United States in the early 1980s,14 mammography was initially most prevalent among White women. Racial disparities in mammography rates narrowed by the mid-1990s,12,15 and Black women had rates equivalent to or greater than those of White women between 1996 and 2000.10,15,16 From 2000 to 2005, mammography use declined nationally in women aged 50 to 64 years (78.6% to 71.8%), with a slightly larger decrement for White (−4.0%) than Black (−3.3%) women.13The survival benefit of any screening program, including mammography, is related to its ability to detect tumors at earlier stages. Meta-analyses continue to find mortality benefit for mammography, although uncertainty remains regarding both the appropriate target population and the optimal screening interval.11,17,18 Consistent with the expected effect of screening, an observational cohort analysis found that improvements in screening rates for both Black and White women during the 1990s contributed to diagnosis at an earlier stage in both groups.10Nevertheless, despite generally equivalent rates of mammography for the past 15 years, the racial disparity in breast cancer mortality between Black and White women persists. Although previous meta-analyses suggested a mortality benefit for mammography, randomized controlled data regarding the efficacy of screening programs in minority populations are limited.18,19 Because stage at diagnosis is an important predictor of survival in breast cancer, we assessed temporal changes in the distribution of stage at diagnosis between 1982 and 2007, in both Black and White women, adjusting for covariates known to affect stage at diagnosis.     

Intimate Partner Violence and Socioeconomic Deprivation in England: Findings From a National Cross-Sectional Survey

Objectives. We examined the prevalence of intimate partner violence (IPV) and its association with social deprivation in England.Methods. We used multivariable logistic regression to investigate IPV correlates among 21 226 men and women aged 16 to 59 years in the 2008 nationally representative cross-sectional British Crime Survey.Results. Lifetime IPV was reported by 23.8% of women and 11.5% of men. Physical IPV was reported by 16.8% and 7.0%, respectively; emotional-only IPV was reported by 5.8% and 4.2%, respectively. After adjustment for demographic confounders, lifetime physical IPV experienced by women was associated with social housing tenure (odds ratio [OR] = 2.3; 95% confidence interval [CI] = 2.0, 2.7), low household income (OR = 2.2; 95% CI = 1.8, 2.7), poor educational attainment (OR = 1.2; 95% CI = 1.0, 1.5), low social class (OR = 1.5; 95% CI = 0.3, 1.7), and living in a multiply deprived area (OR = 1.4; 95% CI = 1.1, 1.7). Physical IPV experienced by men and emotional IPV experienced by either gender were generally not associated with deprivation factors.Conclusions. Physical and emotional IPV are very common among adults in England. Emotional IPV prevention policies may be appropriate across the social spectrum; those for physical IPV should be particularly accessible to disadvantaged women.The World Health Organization highlights intimate partner violence (IPV) as a pressing public health and human rights issue.1 The World Health Organization defines IPV as physical or sexual violence, emotional abuse, or controlling behavior by a current or former intimate partner.2 In nearly 50 populationwide surveys globally some 10% to 69% of women report having ever experienced physical abuse by an intimate partner.2 In the United Kingdom, a 2009 review found that the prevalence of lifetime IPV against women was 13% to 31% in community studies, and 13% to 41% in clinical populations.3 The health impact of IPV extends beyond mortality and direct injury4 to poor overall self-rated health, mental health problems, and gynecological and sexual health problems.5,6 The annual UK domestic violence cost was estimated at £ 16 billion in 2008.7Often, IPV is seen in terms of physical or sexual violence perpetrated by men against women.1 As a consequence, most UK and international IPV prevention policies are targeted at women.1,8 However, some recent national surveys found a near-equal prevalence of physical IPV reported by men and women, mainly in North America and New Zealand, and there are calls for more services for male victims.9,10 Many have argued that this finding reflects measurement artifact, ignoring important differences in the nature and context of abuse.11 Further detailed examination of IPV as reported by both genders in national studies is needed to inform this debate.Policies for prevention of IPV also tend to emphasize that all women are at risk, regardless of their socioeconomic background.1,12 This is perhaps in an effort to decrease stigma associated with IPV. However, many studies show that both male perpetrators and female victims of physical IPV are more likely to come from disadvantaged backgrounds.13–15 The association with social deprivation depends on the broader social context, with more empowered women being at higher risk in some settings.16 There is little evidence on the socioeconomic profile of male victims. Finally, although central to the World Health Organization’s definition of IPV, emotional abuse is not well-described in the current literature among either gender. This is an important knowledge gap, as emotional abuse has a significant public health impact that can be as great as that of physical abuse.17,18 Understanding how social deprivation is associated with different types of abuse in both sexes will inform the need for targeted versus universal interventions.The British Crime Survey (BCS), a large national victimization survey in England and Wales, provides a detailed assessment of IPV. Home Office BCS reports examined associations between social deprivation and IPV victimization during the past year,19–21 but did not examine associations with lifetime IPV or IPV subtypes. To our knowledge there are no IPV studies using BCS data in the peer-reviewed scientific or public health literature, and only 1 UK national study using data other than the BCS, focusing on physical IPV.3,22 We used BCS data to describe the prevalence of both recent and lifetime IPV among men and women in England, and to explore whether different types of lifetime IPV were associated with social deprivation among either gender.To facilitate interpretation of our empirical findings we generated hypotheses in advance, following our review of theoretical and empirical literature. We expected to find that (1) women would report a higher prevalence of all types of IPV than men, particularly severe, prolonged, and controlling types of abuse11,23; (2) social deprivation would be associated with being a victim of lifetime IPV in both men and women13,15; and (3) social deprivation would be more strongly associated with being a victim of physical than of emotional lifetime IPV.17,24     

Self-Reported Health Among Recently Incarcerated Mothers

Objectives. We examined self-reported health among formerly incarcerated mothers.Methods. We used data from the Fragile Families and Child Wellbeing Study (n = 4096), a longitudinal survey of mostly unmarried parents in urban areas, to estimate the association between recent incarceration (measured as any incarceration in the past 4 years) and 5 self-reported health conditions (depression, illicit drug use, heavy drinking, fair or poor health, and health limitations), net of covariates including health before incarceration.Results. In adjusted logistic regression models, recently incarcerated mothers, compared with their counterparts, have an increased likelihood of depression (odds ratio [OR] = 1.60; 95% confidence interval [CI] = 1.18, 2.17), heavy drinking (OR = 1.79; 95% CI = 1.19, 2.68), fair or poor health (OR = 1.49; 95% CI = 1.08, 2.06), and health limitations (OR = 1.78; 95% CI = 1.27, 2.50). This association is similar across racial/ethnic subgroups and is larger among mothers who share children with fathers who have not been recently incarcerated.Conclusions. Recently incarcerated mothers struggle with even more health conditions than expected given the disadvantages they experience before incarceration. Furthermore, because incarceration is concentrated among those who are most disadvantaged, incarceration may increase inequalities in population health.The US incarceration rate, though recently stabilized, has increased rapidly over the past 4 decades. Accordingly, researchers have become acutely aware of the sheer number of individuals who experience incarceration and the vulnerabilities these individuals face before, during, and after incarceration.1 In particular, a growing literature has documented the consequences of mass incarceration, defined as the historically and comparatively extreme rates of incarceration in the United States, for population health.2–5 Formerly incarcerated individuals, compared with their counterparts, have elevated rates of mortality,6 infectious diseases,7 cardiovascular diseases,8 and disability,9 as well as an array of mental health problems including depression,10 anxiety,9 and life dissatisfaction.11Despite the fact that, since the early 1980s, women’s incarceration rates have increased faster than men’s incarceration rates,12,13 very little research has explicitly considered the health of formerly incarcerated women. Instead, research on incarcerated women often focuses on the consequences of incarceration for their families and children.14–19 The dearth of research on formerly incarcerated women’s health is an important oversight because these women are an extremely vulnerable population and present a pressing public health concern. Formerly incarcerated mothers are an especially important group because poor physical and mental health among mothers may have deleterious consequences for their children.20–23We used data from the Fragile Families and Child Wellbeing Study, a longitudinal study of mostly unmarried parents living in urban areas, to provide the first examination of the relationship between recent incarceration, measured as any incarceration experience in the past 4 years, and 5 self-reported health conditions among mothers: depression, illicit drug use, heavy drinking, fair or poor health, and health limitations. First, we estimated the association between recent incarceration and self-reported health. We then estimated this association by race/ethnicity and by romantic partner’s incarceration history. Our analyses adjusted for a large number of individual characteristics that may render the association between recent incarceration and health conditions spurious (including health before incarceration). Adjusting for these characteristics is especially important because incarcerated mothers are at risk for poor physical and mental health before incarceration.5,24–26     

H1N1 Influenza Vaccination During Pregnancy and Fetal and Neonatal Outcomes

Objectives. We evaluated the relationship between maternal H1N1 vaccination and fetal and neonatal outcomes among singleton births during the 2009–2010 H1N1 pandemic.Methods. We used a population-based perinatal database in Ontario, Canada, to examine preterm birth (PTB), small-for-gestational-age (SGA) births, 5-minute Apgar score below 7, and fetal death via multivariable regression. We compared outcomes between women who did and did not receive an H1N1 vaccination during pregnancy.Results. Of the 55 570 mothers with a singleton birth, 23 340 (42.0%) received an H1N1 vaccination during pregnancy. Vaccinated mothers were less likely to have an SGA infant based on the 10th (adjusted risk ratio [RR] = 0.90; 95% confidence interval [CI] = 0.85, 0.96) and 3rd (adjusted RR = 0.81; 95% CI = 0.72, 0.92) growth percentiles; PTB at less than 32 weeks’ gestation (adjusted RR = 0.73; 95% CI = 0.58, 0.91) and fetal death (adjusted RR = 0.66; 95% CI = 0.47, 0.91) were also less likely among these women.Conclusions. Our results suggest that second- or third-trimester H1N1 vaccination was associated with improved fetal and neonatal outcomes during the recent pandemic. Our findings need to be confirmed in future studies with designs that can better overcome concerns regarding biased estimates of vaccine efficacy.During the 2009–2010 H1N1 influenza pandemic, early case reports documented more severe illness among pregnant women than among the general population, as well as higher rates of hospitalization and intensive care unit admissions.1,2 Later reports confirmed the disproportionately severe clinical course among pregnant women infected with H1N1 influenza.3–6 Public health organizations7–9 and professional associations10,11 strongly encouraged pregnant women to receive an H1N1 vaccination, and recent evidence suggests that the intensive vaccination campaign resulted in higher maternal vaccination rates during the pandemic than had been documented in previous influenza seasons.12–14Recommendations for routine vaccination of all pregnant women with inactivated influenza vaccine have been in place in Canada and the United States for a number of years.15–18 Nevertheless, seasonal vaccination rates prior to the 2009–2010 pandemic year were low in the United States,19–22 ranging from 0.7% to 20% (estimates were not available for Canada). In both countries, misconceptions about the risk of complications from influenza infection during pregnancy23 and concerns about safety12,23 are commonly cited reasons for not receiving an influenza vaccination, whereas care provider recommendations have been shown to increase vaccination rates.12,14,24Despite ongoing maternal concerns about vaccine safety, no evidence of serious harmful effects following influenza vaccination during pregnancy has been reported in the available studies on this topic19–21,25–32; thus, vaccination is promoted as the best way of preventing maternal morbidity from influenza infection.31 Theoretically, maternal influenza vaccination should also benefit the fetus by averting maternal illness and associated hyperthermia and other morbidity.28,31 Recent studies have reported a lower risk of preterm birth (PTB)33 and small-for-gestational-age (SGA) infants33,34 among women receiving an influenza vaccination during their pregnancy. However, the impact of maternal influenza vaccination on fetal and neonatal outcomes has not been extensively evaluated, possibly as a result of low immunization rates and limited sample sizes that preclude assessment of rare outcomes.In Ontario, Canada, the 2009 pandemic H1N1 vaccination campaign started on October 26, 2009; high-priority groups, including pregnant women, were targeted. During the pandemic, Better Outcomes Registry & Network (BORN) Ontario collected influenza immunization information from all pregnant women who gave birth in the province. Using this large, population-based birth cohort, we examined the association between maternal H1N1 influenza vaccination and fetal and neonatal outcomes.     

Prenatal,Perinatal, Early Life,and Sociodemographic Factors Underlying Racial Differences in the Likelihood of High Body Mass Index in Early Childhood

Objectives. We investigated early childhood disparities in high body mass index (BMI) between Black and White US children.Methods. We compared differences in Black and White children’s prevalence of sociodemographic, prenatal, perinatal, and early life risk and protective factors; fit logistic regression models predicting high BMI (≥ 95th percentile) at age 4 to 5 years to 2 nationally representative samples followed from birth; and performed separate and pooled-survey estimations of these models.Results. After adjustment for sample design–related variables, models predicting high BMI in the 2 samples were statistically indistinguishable. In the pooled-survey models, Black children''s odds of high BMI were 59% higher than White children''s (odds ratio [OR] = 1.59; 95% confidence interval [CI]= 1.32, 1.92). Sociodemographic predictors reduced the racial disparity to 46% (OR = 1.46; 95% CI = 1.17, 1.81). Prenatal, perinatal, and early life predictors reduced the disparity to nonsignificance (OR = 1.18; 95% CI = 0.93, 1.49). Maternal prepregnancy obesity and short-duration or no breastfeeding were among predictors for which racial differences in children’s exposures most disadvantaged Black children.Conclusions. Racial disparities in early childhood high BMI were largely explained by potentially modifiable risk and protective factors.Over recent decades, as the prevalence of high body mass index (BMI; defined as at or above the Centers for Disease Control and Prevention 95th percentile1) has increased dramatically among all children,2,3 racial disparities have been documented in nationally representative samples of children at very young ages.4–7 Reviews and prevalence studies highlight the need for a better understanding of the predictors of these disparities in BMI and other indicators of childhood obesity,8,9 especially in early childhood.7Previous research on high BMI in early childhood with racially and ethnically diverse samples has identified risk and protective factors at multiple developmental stages. In the prenatal and perinatal period, risks include higher birth weight,10–13 maternal prepregnancy BMI,14 and maternal smoking during pregnancy.14,15 In infancy and early life, risks include maternal employment,11 especially among highly educated women,12,16 nonparent child care,13,17,18 and television viewing hours.12,19–21 Protective factors include breastfeeding10,12,14 and family meals.12,21,22Studies have shown that young racial/ethnic minority children are exposed to more of these risks and fewer of these protections.23,24 Nevertheless, in analyses of nationally representative samples, high BMI remains more common among Black than White children even after adjusting for sociodemographic characteristics and risk and protective factors.6,11,12,14,16 We suspect that the persistence of racial disparities in these studies might be attributable to omitted predictors or less detailed measurement of the age and duration of children’s exposures. This type of comprehensive assessment is methodologically challenging because of the number of variables and observations required to draw statistically valid inferences.We employed a novel 2-survey methodological design to overcome these challenges. We used data from 2 nationally representative samples of US children followed from birth to age 4 to 5 years in separate and pooled-survey analyses to identify prenatal, perinatal, early life, and sociodemographic factors that may explain Black–White disparities in early childhood high BMI. The separate analyses in 2 surveys that cover a historical period of more than 10 years increased the robustness of our findings to differences in sample design, measurement protocols, and period variability in unobserved confounders. The pooled-survey analyses enhanced the statistical power of our study and thereby strengthened our conclusions about which factors explain Black–White disparities in early childhood high BMI.     

Flavored Alcoholic Beverage Use,Risky Drinking Behaviors,and Adverse Outcomes Among Underage Drinkers: Results From the ABRAND Study

Objectives. We examined associations between consumption of different types of flavored alcoholic beverages (FABs) and risky drinking and drinking-related harms among underage drinkers.Methods. For the Alcohol Brand Research among Underage Youth study, we applied multivariable logistic regression analyses to data from underage drinkers (n = 1031, aged 13–20 years), recruited from a national Internet panel in 2011 to 2012, to estimate associations between consumption of malt-based drinks; spirits-based, premixed- or ready-to-drink cocktails; and supersized alcopops, alone or in combination, and alcohol-related outcomes.Results. After adjustment for confounding variables, the exclusive consumption of alcopops was associated with episodic heavy drinking (odds ratio [OR] = 4.35; 95% confidence interval [CI] = 1.24, 15.31; P < .05) and alcohol-related injuries (OR = 6.25; 95% CI = 1.34, 29.10; P < .05). Exclusive consumption of cocktails was associated with episodic heavy drinking (odds ratio [OR] = 2.61; 95% CI = 1.26, 5.41; P < .05) and injuries requiring medical attention (OR = 6.50; 95% CI = 2.09, 20.17; P < .001. Exclusive consumption of 2 or more FABs was associated with episodic heavy drinking (OR = 2.78; 95% CI = 1.25, 6.16; P < .05), fighting (OR = 3.30; 95% CI = 1.46, 7.47; P < .001), and alcohol-related injuries (OR = 2.83; 95% CI = 1.43, 5.58; P < .001).Conclusions. FABs present an emerging public health problem among youths.Alcohol continues to be the most commonly used drug among youths in the United States and is responsible for more than 4300 annual deaths among underage drinkers.1 Approximately 33% of eighth graders and 70% of 12th graders have consumed alcohol, and 13% of eighth graders and 40% of 12th graders drank during the past month.2 Close to 200 000 emergency department visits by persons younger than 21 years are reported annually for injuries and other conditions linked to alcohol.3 An important trend in underage drinking is the popularity of flavored alcoholic beverages (FABs).4–12 Despite their popularity, little is known about associations between FAB consumption, risky drinking behaviors, and related harms among underage drinkers.FAB brands can be classified into 3 categories: malt-based beverages; spirits-based, premixed- or ready-to-drink cocktails; and supersized alcopops.4 Although these products are widely classified as FABs, distinctions between them are important because these beverages differ in serving size (e.g., the supersized alcopops can contain 2 to 3 times the alcohol volume of other brands) and average alcohol content by volume (malt beverages, 7.8%; premixed- or ready-to-drink cocktails, 14.2%; supersized alcopops, 10.8%).4We used ABRAND (Alcohol Brand Research among Underage Youth) data collected by GfK Knowledge Networks13 to analyze the brands of alcoholic beverages a national sample of youth drinkers aged 13 to 20 years reported consuming and found that nearly half of young drinkers (n = 515) had consumed FABs in the past 30 days.4 These results roughly matched those of the 2012 Monitoring the Future report, which found that more than half (57.5%) of students in grades 8, 10, and 12 who reported past 30-day alcohol use had consumed at least 1 FAB during that time.2 The ABRAND data also showed that 43% of drinkers aged 13 to 15 years, 48.9% of those aged 16 to 18 years, and 52% of those aged 19 to 20 years consumed FABs.4 Consumption prevalence was greatest for malt beverages (33.8%), followed by premixed- or ready-to-drink cocktails (23.9%) and supersized alcopops (8.6%). Almost one quarter of respondents (24.5%) had consumed at least 1 FAB during a heavy-drinking episode (defined as consuming ≥ 5 drinks in a row).4FABs'' high alcohol content, low price, sweet flavoring, attractive packaging, and targeted marketing strategies have caused concern that FAB consumption might disproportionately contribute to alcohol-related emergency department visits by underage drinkers.5 One case study found that consumption of supersized alcopops such as Four Loko contributed to alcohol-related emergencies involving drinkers as young as 13 years.14We used the ABRAND sample of underage drinkers to examine the relationship between consumption of different types and combinations of FABs and risky drinking behaviors and adverse outcomes among youths aged 13 to 20 years.     

Directly Observed Antidepressant Medication Treatment and HIV Outcomes Among Homeless and Marginally Housed HIV-Positive Adults: A Randomized Controlled Trial

Objectives. We assessed whether directly observed fluoxetine treatment reduced depression symptom severity and improved HIV outcomes among homeless and marginally housed HIV-positive adults in San Francisco, California, from 2002 to 2008.Methods. We conducted a nonblinded, randomized controlled trial of once-weekly fluoxetine, directly observed for 24 weeks, then self-administered for 12 weeks (n = 137 persons with major or minor depressive disorder or dysthymia). Hamilton Depression Rating Scale score was the primary outcome. Response was a 50% reduction from baseline and remission a score below 8. Secondary measures were Beck Depression Inventory-II (BDI-II) score, antiretroviral uptake, antiretroviral adherence (measured by unannounced pill count), and HIV-1 RNA viral suppression (< 50 copies/mL).Results. The intervention reduced depression symptom severity (b = −1.97; 95% confidence interval [CI] = −0.85, −3.08; P < .001) and increased response (adjusted odds ratio [AOR] = 2.40; 95% CI = 1.86, 3.10; P < .001) and remission (AOR = 2.97; 95% CI = 1.29, 3.87; P < .001). BDI-II results were similar. We observed no statistically significant differences in secondary HIV outcomes.Conclusions. Directly observed fluoxetine may be an effective depression treatment strategy for HIV-positive homeless and marginally housed adults, a vulnerable population with multiple barriers to adherence.Depressive, pain, and substance use disorders are highly prevalent among persons living with HIV/AIDS1,2 and among the homeless and marginally housed.3–5 The triple diagnosis of depression, HIV, and substance use poses unique treatment challenges for clinicians: successful management of one condition is often dependent on successful management of the others, and the optimal sequencing of depression treatment, substance use treatment, and stabilization of psychosocial comorbidities remains unclear. Adherence to the entire continuum of HIV care is often hampered by depression6–8 and substance use.9,10 For homeless persons, the need to address subsistence concerns such as obtaining food and shelter may not only adversely affect mental well-being11 but may also divert attention away from medication adherence and regular clinic attendance.12 Timely and effective depression treatment is critical for HIV-positive persons, because depression has been associated with CD4⁺ T-lymphocyte cell count decline,13 progression to AIDS,14 and AIDS-related mortality.15 Yet depression remains pervasively underdiagnosed and undertreated among the homeless16–18 and among HIV-positive persons.19,20Depression treatment might be expected to improve virological or immunologic outcomes through improved adherence, but this has not been conclusively demonstrated.21–23 We therefore sought to determine whether treatment with once-weekly fluoxetine reduced depression symptom severity among homeless and marginally housed persons with comorbid depression and HIV. Because this population faces many psychosocial barriers to successful medication adherence,12,24 in addition to depression,25 we employed a directly observed treatment strategy similar to that used for treatment and management of patients with tuberculosis and HIV.26 This strategy reduced the potential for incomplete adherence to reduce the effectiveness of antidepressant treatment. A secondary aim was to determine whether depression treatment improved antiretroviral therapy (ART) uptake among persons eligible for treatment and ART adherence and viral suppression among treated persons.     

The Collateral Damage of Mass Incarceration: Risk of Psychiatric Morbidity Among Nonincarcerated Residents of High-Incarceration Neighborhoods

Objectives. We examined whether residence in neighborhoods with high levels of incarceration is associated with psychiatric morbidity among nonincarcerated community members.Methods. We linked zip code–linked information on neighborhood prison admissions rates to individual-level data on mental health from the Detroit Neighborhood Health Study (2008–2012), a prospective probability sample of predominantly Black individuals.Results. Controlling for individual- and neighborhood-level risk factors, individuals living in neighborhoods with high prison admission rates were more likely to meet criteria for a current (odds ratio [OR] = 2.9; 95% confidence interval [CI] = 1.7, 5.5) and lifetime (OR = 2.5; 95% CI = 1.4, 4.6) major depressive disorder across the 3 waves of follow-up as well as current (OR = 2.1; 95% CI = 1.0, 4.2) and lifetime (OR = 2.3; 95% CI = 1.2, 4.5) generalized anxiety disorder than were individuals living in neighborhoods with low prison admission rates. These relationships between neighborhood-level incarceration and mental health were comparable for individuals with and without a personal history of incarceration.Conclusions. Incarceration may exert collateral damage on the mental health of individuals living in high-incarceration neighborhoods, suggesting that the public mental health impact of mass incarceration extends beyond those who are incarcerated.The United States leads the world in the percentage of its population that serves time in prison or jail.1,2 As of 2012, nearly 7 million men and women are on probation, parole, or under some other form of community supervision, which means that nearly 3% of the American adult population is currently involved in correctional supervision.3 The burden of incarceration in the United States is not equally distributed in the population. Current estimates from the Bureau of Justice Statistics indicate that 1 of every 3 Black men will serve time in prison in their lifetimes.4 In some communities, these figures are even starker. In Washington, DC, for example, more than 95% of Black men have been in prison in their lifetimes.1 Because of the scope of incarceration within particular subgroups, the current state of the US criminal justice system has been described in such terms as mass imprisonment5 and hyperincarceration.6Research on the health consequences of incarceration falls largely into 2 broad categories. The first, which has received the most empirical attention, has focused on individuals directly involved in the criminal justice system. Individual incarceration exposure is associated with adverse mental7–9 and physical10 health outcomes. A second line of inquiry has evaluated the broader health consequences of incarceration—what has been variously called the “long arm” of corrections,11 the collateral consequences of mass incarceration,5 and “spillover” effects related to incarceration.12 For example, female partners of recently released male prisoners experience depression and anxiety symptoms,13,14 and the children of incarcerated parents are at increased risk for behavioral and mental health problems.15,16 The deleterious health effects of incarceration are not merely confined to the family members of incarcerated individuals, however. Nonincarcerated individuals living in the communities from which inmates are drawn also appear to be at heightened risk for a variety of adverse outcomes, including increased crime rates17 and infectious diseases.18Although this research provides important initial insights into some of the negative consequences of incarceration at the community level, it remains largely unknown whether incarceration influences the mental health of community members who reside in neighborhoods with high-incarceration rates. How might incarceration affect community mental health? High levels of incarceration in neighborhoods can alter the social ecology of communities by eroding social capital and disrupting the kinds of social and family networks and relationships that are necessary for sustaining individuals’ mental health as well as the well-being of communities.1,19–22We examined whether high levels of incarceration in neighborhoods affect the mental health of individuals living in these neighborhoods. We treated incarceration as an ecological or contextual effect, rather than as an individual-level risk factor, which has characterized the majority of research on incarceration and mental health.7,23 That is, rather than examining the mental health consequences of incarceration among those who have themselves been incarcerated or among their family members, we examined the mental health of individuals living in communities that have been exposed to elevated levels of incarceration.     

Assessing the Connection Between Health and Education: Identifying Potential Leverage Points for Public Health to Improve School Attendance

Objectives. We examined multiple variables influencing school truancy to identify potential leverage points to improve school attendance.Methods. A cross-sectional observational design was used to analyze inner-city data collected in Los Angeles County, California, during 2010 to 2011. We constructed an ordinal logistic regression model with cluster robust standard errors to examine the association between truancy and various covariates.Results. The sample was predominantly Hispanic (84.3%). Multivariable analysis revealed greater truancy among students (1) with mild (adjusted odds ratio [AOR] = 1.57; 95% confidence interval [CI] = 1.22, 2.01) and severe (AOR = 1.80; 95% CI = 1.04, 3.13) depression (referent: no depression), (2) whose parents were neglectful (AOR = 2.21; 95% CI = 1.21, 4.03) or indulgent (AOR = 1.71; 95% CI = 1.04, 2.82; referent: authoritative parents), (3) who perceived less support from classes, teachers, and other students regarding college preparation (AOR = 0.87; 95% CI = 0.81, 0.95), (4) who had low grade point averages (AOR = 2.34; 95% CI = 1.49, 4.38), and (5) who reported using alcohol (AOR = 3.47; 95% CI = 2.34, 5.14) or marijuana (AOR = 1.59; 95% CI = 1.06, 2.38) during the past month.Conclusions. Study findings suggest depression, substance use, and parental engagement as potential leverage points for public health to intervene to improve school attendance.Truancy, defined as any intentional unauthorized or illegal absence from school, is associated with a variety of adverse behavioral and health outcomes, including school dropout, crime, violence, incarceration, adolescent pregnancy, and substance abuse.1,2 Truancy is a major problem in the United States. Nationally, 11% of students report skipping school in the past month.3 In California, the truancy rate—the percentage of students who missed more than 30 minutes of instruction without an excuse for 3 or more days in a given school year—was 28% during the 2009–2010 school year.4 Truancy rates are frequently higher among Black and Hispanic youths, as compared with Whites, and among youths from lower-income households.3School truancy is a complex phenomenon often resulting from a variety of factors including (1) community and home environments; (2) social relationships, including relationships with parents, teachers, and peers; (3) school variables such as student-to-teacher ratio, educational style, safety, and disciplinary procedures; and (4) individual characteristics such as students’ level of engagement with learning, academic performance, risk behaviors (e.g., substance abuse), and mental health problems.2,5,6 The multifaceted nature of this phenomenon has attracted a number of researchers, as well as professionals, from different sectors (e.g., criminal justice, education, and community-based organizations) to study this problem. However, public health representation is often missing from this important dialogue. In spite of emerging evidence suggesting the interdependence between education and health, only a paucity of public health authorities have regularly engaged school districts, local law enforcement, or the courts to address this social determinant of health.5,7Despite significant investments by researchers, practitioners, schools, and policymakers to address truancy over the past several decades, there is little evidence that any positive impact has been made to improve school attendance.8 Many non-health sector researchers have called for the use of interdisciplinary models to reduce school truancy. Beyond modifying student factors, these models focus on a broader catchment, to include family, school, and community interventions.9,10 However, in spite of growing interest, much remains unknown about the key steps, design, or program features that are necessary to effectively implement cross-sector strategies. Identifying leverage points where nontraditional, noneducation partners (e.g., public health) can intervene represents a critical need.Although previous research has examined the association between truancy and a variety of modifiable school, student, and health characteristics, most have collected data only on a narrowly defined set of risk factors, independent from one another.3,11,12 Even among studies that have concurrently considered multiple risk factors for truancy, the analyses have often excluded important information about leverage points for nontraditional partners to act.13,14 The present study helps fill these gaps in public health research and practice, examining the relative importance of different school, student, and health-related variables in influencing school truancy. This study focused on inner-city, low-income youths, a group that is particularly vulnerable to being chronically truant, dropping out of school, and experiencing health disparities.4,15     

State Firearm Legislation and Nonfatal Firearm Injuries

Objectives. We investigated whether stricter state-level firearm legislation was associated with lower hospital discharge rates for nonfatal firearm injuries.Methods. We estimated discharge rates for hospitalized and emergency department–treated nonfatal firearm injuries in 18 states in 2010 and used negative binomial regression to determine whether strength of state firearm legislation was independently associated with total nonfatal firearm injury discharge rates.Results. We identified 26 744 discharges for nonfatal firearm injuries. The overall age-adjusted discharge rate was 19.0 per 100 000 person-years (state range = 3.3–36.6), including 7.9 and 11.1 discharges per 100 000 for hospitalized and emergency department–treated injuries, respectively. In models adjusting for differences in state sociodemographic characteristics and economic conditions, states in the strictest tertile of legislative strength had lower discharge rates for total (incidence rate ratio [IRR] = 0.60; 95% confidence interval [CI] = 0.44, 0.82), assault-related (IRR = 0.58; 95% CI = 0.34, 0.99), self-inflicted (IRR = 0.18; 95% CI = 0.14, 0.24), and unintentional (IRR = 0.53; 95% CI = 0.34, 0.84) nonfatal firearm injuries.Conclusions. There is significant variation in state-level hospital discharge rates for nonfatal firearm injuries, and stricter state firearm legislation is associated with lower discharge rates for such injuries.Each year from 2005 to 2010, an average of 103 000 Americans were injured or killed by a firearm—approximately 282 individuals per day.1 Most public attention and research has focused on fatal firearm injuries because they are a leading cause of injury death and account for more than 30 000 deaths annually.1 Firearm injuries were the third leading cause of injury-related deaths in 2010 after poisoning and motor vehicle accidents and were the second most frequent cause of traumatic death related to a consumer product.1,2 However, a majority of firearm-related injuries in the United States are nonfatal.1,3,4 In 2010, nearly 5 individuals suffered nonfatal firearm injuries for every 2 who died as a result of firearm violence.1 The age-adjusted fatal firearm injury rate in that year was 10.1 per 100 000 person-years, less than half of the age-adjusted nonfatal injury rate (24.0 per 100 000 person-years).1 This high prevalence of nonfatal firearm injuries in the United States is associated with significant physical and psychological morbidity among injury survivors.5–7 It is also a substantial economic burden for victims, taxpayers, and the United States.8–12Numerous state and federal laws have been implemented in attempts to reduce firearm-related violence in the United States.13 Household firearm ownership rates have been shown to be associated with states’ rates of firearm-related suicides and homicides; thus, legislation might reduce firearm injuries by limiting overall firearm ownership.14,15 A strong association has also been demonstrated between safer firearm storage practices and a lower risk of suicide and unintentional firearm deaths.16–19 Hence, legislation aimed at increasing safe firearm storage may decrease firearm-related injuries, particularly in homes with children and adolescents. In addition, laws that promote background checks before firearm purchase and those that limit private firearm transactions and transfers may help limit firearm access by those most likely to harm themselves or others.Overall, the effectiveness of these laws individually or as a whole remains unclear. Two studies evaluated the relationship between state firearm legislation and firearm injuries using measures of state firearm legislation on the basis of annual scorecards created by the Brady Center to Prevent Gun Violence.20,21 These studies found lower rates of total firearm deaths, including homicides and suicides,20 as well as lower rates of firearm injuries in children,21 in states with more restrictive firearm legislation. Previous studies have also shown that laws related to background checks and limitations on handgun possession and transfer are associated with lower rates of firearm deaths, including suicides and homicides.22–25 A study of the 1994 Brady Handgun Violence Prevention Act (Pub L. No. 103-159, 107 Stat. 1536, USC 921–922, HR 1025, 103rd Congress), which established a mandatory waiting period and background check requirement for handgun sales through licensed firearm dealers, found that the law led to a decline in the suicide rate for those aged 55 years and older, although these findings may have been driven by the implementation of the waiting period rather than the background check itself.26Laws focused on preventing children’s access to firearms are associated with lower rates of both unintentional deaths and suicides.27,28 A cross-sectional, time series analysis of pooled data from 1979 to 2000 found that unintentional firearm deaths among children were declining nationally and that most states that enacted child access laws experienced greater declines in those injuries than did states that had not.29 Notably, state-level comparisons of child access laws can be driven largely by the few states with the strictest child access legislation (e.g., felony conviction for violations).29,30Additionally, several studies suggest that laws aimed at easing access to and use of firearms may be associated with higher rates of firearm injuries, including homicides.31–33 One study found that the 2007 repeal of Missouri’s permit to purchase law requiring firearm purchasers to obtain a license verifying that they passed a background check led to an increase in firearm-related homicides.33 Conversely, other studies have observed no association between stricter firearm laws and firearm violence,26,34,35 and a recent systematic review of various federal and state firearm laws found insufficient evidence to determine their effectiveness in reducing firearm-related violence and injuries.36Several studies have examined the relationship between firearm legislation and fatal firearm injuries, although little is known about the relationship between firearm legislation and nonfatal firearm outcomes.37 This relationship may differ from that observed with fatal injuries because of the different circumstances under which nonfatal firearm injuries occur, including differences in the age of the injured,1,3 the type of firearms involved,38 and injury intent.3 For instance, unintentional shootings are more likely to prove nonfatal than are intentional shootings, and a vast majority of self-inflicted injuries (i.e., suicide attempts) result in death.3,39 Because of the higher prevalence of nonfatal firearm injuries, studies of nonfatal injuries may also have greater statistical power to determine associations between legislation and firearm outcomes that might not be observed in studies of fatal injuries.We have described state variation in discharge rates for nonfatal firearm injuries in 2010 and determined whether stricter state-level firearm legislation was associated with lower discharge rates for nonfatal firearm injuries.     

Clustering of Midlife Lifestyle Behaviors and Subsequent Cognitive Function: A Longitudinal Study

Objectives. We examined the association between individual and clustered lifestyle behaviors in middle age and later in cognitive functioning.Methods. Middle-aged participants (n = 2430) in the Supplémentation en Vitamines et Minéraux Antioxydant study self-reported their low physical activity, sedentary behavior, alcohol use, smoking, low fruit and vegetable consumption, and low fish consumption. We assessed cognition 13 years later via 6 neuropsychological tests. After standardization, we summed the scores for a composite cognitive measure. We estimated executive functioning and verbal memory scores using principal component analysis. We estimated the mean differences (95% confidence intervals [CIs]) in cognitive performance by the number of unhealthy behaviors using analysis of covariance. We identified latent unhealthy behavior factor via structural equation modeling.Results. Global cognitive function and verbal memory were linearly, negatively associated with the number of unhealthy behaviors: adjusted mean differences = −0.36 (95% CI = −0.69, −0.03) and −0.46 (95% CI = −0.80, −0.11), respectively, per unit increase in the number of unhealthy behaviors. The latent unhealthy behavior factor with low fruit and vegetable consumption and low physical activity as main contributors was associated with reduced verbal memory (RMSEA = 0.02; CFI = 0.96; P = .004). No association was found with executive functioning.Conclusions. Comprehensive public health strategies promoting healthy lifestyles might help deter cognitive aging.Noncommunicable diseases with notable lifestyle components are the leading causes of death worldwide.1,2 There is also growing evidence of the critical role of different midlife health and risk behaviors in cognitive aging.3–7 Because lifestyles are inherently modifiable and no treatment of cognitive decline is available, such findings argue for the paramount importance of prevention.8,9Current data support a deleterious effect of alcohol abstinence or abuse (compared with moderate alcohol consumption),10 smoking,7 low fruit and vegetable intake,11 low fish intake,12 and low physical activity (PA) levels13 on cognitive aging. However, it has been widely documented that lifestyle factors are strongly correlated with each other, forming a cluster of healthy or unhealthy behaviors.14 Traditionally, such interrelations have been accounted for by statistical adjustment; however, it is of major public health interest to consider the cumulative and combined effect of the various lifestyle behaviors on health by using multidimensional strategies.14Research that examines the combined effect of lifestyle factors on mortality is plentiful, and data have been colligated in a recent meta-analysis.15 These authors reported a 66% reduction in mortality risk by comparing adherence to 4 or more healthy lifestyle behaviors versus engagement in any number of unhealthy behaviors.The combined effect of lifestyle factors has also been explored in relation to cardiovascular diseases,16–18 cancer,18–22 diabetes,18,23 memory complaints,24 and dementia25–27; however, very few studies have reported findings regarding cognition.28,29 Despite heterogeneity in the definition of a healthy lifestyle, study design, and residual confounding, available, but scarce, data support a critical, protective role of healthy lifestyles in cognitive health through their beneficial properties via oxidative, inflammatory, vascular, and other neuroprotective pathways.30–33Our objectives in this study were to examine the association between individual and clustered lifestyle behaviors and later cognitive functioning. We employed traditional and innovative techniques (structural equation modeling) in our epidemiological pursuit.     

Health Effects of Neighborhood Demolition and Housing Improvement: A Prospective Controlled Study of 2 Natural Experiments in Urban Renewal

Objectives. We took advantage of a 2-intervention natural experiment to investigate the impacts of neighborhood demolition and housing improvement on adult residents’ mental and physical health.Methods. We identified a longitudinal cohort (n = 1041, including intervention and control participants) by matching participants in 2 randomly sampled cross-sectional surveys conducted in 2006 and 2008 in 14 disadvantaged neighborhoods of Glasgow, United Kingdom. We measured residents’ self-reported health with Medical Outcomes Study Short Form Health Survey version 2 mean scores.Results. After adjustment for potential confounders and baseline health, mean mental and physical health scores for residents living in partly demolished neighborhoods were similar to the control group (mental health, b = 2.49; 95% confidence interval [CI] = −1.25, 6.23; P = .185; physical health, b = −0.24; 95% CI = −2.96, 2.48; P = .859). Mean mental health scores for residents experiencing housing improvement were higher than in the control group (b = 2.41; 95% CI = 0.03, 4.80; P = .047); physical health scores were similar between groups (b = −0.66; 95% CI = −2.57, 1.25; P = .486).Conclusions. Our findings suggest that housing improvement may lead to small, short-term mental health benefits. Physical deterioration and demolition of neighborhoods do not appear to adversely affect residents’ health.The quality of residential environments, at both the home and the neighborhood level, is associated with residents’ physical and mental health.1–7 Some longitudinal studies suggest that exposure to poor housing8 or to neighborhood-level deprivation9–18 increases the risk of morbidity or mortality beyond what might be predicted from individual-level socioeconomic factors. A causal association between residential environments and health would have important public health implications: improvements to residential environments might contribute positively to public health goals, and deteriorating residential environments could be harmful.Policymakers expect that improving home and neighborhood environments, particularly in disadvantaged areas, will benefit population health and help reduce health inequalities.19,20 Terms such as urban renewal and regeneration are used to describe a range of interventions, such as home improvement programs, housing clearance and demolition, and neighborhood-level improvements.19Research supports assumptions that housing-led urban renewal benefits residents’ health.21–29 A systematic review found that improvements in respiratory, general, and mental health followed housing improvement, with particularly robust evidence of health benefits relating to warmth-improvement interventions.21,30–32 More recently, an evaluation of a multisite urban renewal program in the United Kingdom found relative improvements in residents’ Medical Outcomes Study 36-item Short Form Health Survey mental health scores and self-reported general health at 10-year follow-up.33However, the evidence base is neither comprehensive nor conclusive, particularly regarding neighborhood-level renewal. Reviews have noted some evidence that such interventions may have unintended consequences.34 A study of neighborhood renewal in the United Kingdom found that self-reported health satisfaction worsened, possibly reflecting the intervention’s failure to deliver sufficient changes to residents’ lives and opportunities.35 A recent series of reviews identified 11 interventions considered to have sufficient evidence of effectiveness to warrant implementation,24–28 only 1 of which was a neighborhood-level intervention (rental vouchers to assist relocations to more desirable areas36). The reviews identified 34 interventions of unknown or inconclusive health effects and 7 that were potentially ineffective.24 Neighborhood-level interventions such as demolishing and revitalizing poor public housing (e.g., HOPE VI37), relocating residents, and various forms of neighborhood redesign yielded too little evidence to draw conclusions.28Some commentators have emphasized the social harms linked to housing clearance and demolition programs.38 Paris and Blackaby note that such programs have “frequently been accused of the ‘destruction of communities.’”39^(p18) This alleged destruction is partly a social phenomenon involving the separation of neighbors and closing down of amenities that may have been used as social hubs (e.g., schools, community centers, cafés). It is also a physical phenomenon that increases the proportion of derelict properties and turns neighborhoods into worksites and buildings into rubble.39,40 Furthermore, large-scale clearances can take years to complete, while residents waiting to be relocated are exposed to steadily worsening neighborhood environments.41 If deteriorating residential environments are harmful to health, then residents who remain in neighborhoods undergoing demolition risk being harmed. However, we have not identified any experimental or quasi-experimental study that focuses on the potentially harmful effects of continued residence in neighborhoods undergoing demolition and clearance.We studied a multifaceted renewal program implemented across the city of Glasgow, United Kingdom. In many neighborhoods, existing properties were improved to meet new government standards. However, some neighborhoods began a long-term process of demolition and rebuilding, and residents often lived for several years in neighborhoods undergoing clearance and demolition while they awaited relocation to better-quality housing.42 We treated housing improvement and the experience of living in a demolition area as 2 distinct natural experiments, and we used quasi-experimental methods to test our hypotheses: (1) residents who spent 2 years living in neighborhoods undergoing clearance and demolition would experience worsening health, and (2) residents who experienced housing improvement (and who did not live in neighborhoods undergoing clearance and demolition) would experience improved physical and mental health.     

Association of Insurance Status and Age With Cervical Cancer Stage at Diagnosis: National Cancer Database, 2000–2007

Objectives. We examined the relationship of age at diagnosis and insurance status with stage among cervical cancer patients aged 21 to 85 years.Methods. We selected data on women (n = 69 739) diagnosed with invasive cervical cancer between 2000 and 2007 from the National Cancer Database. We evaluated the association between late stage (stage III/IV) and both insurance and age, with adjustment for race/ethnicity and other sociodemographic and clinical factors. We used multivariable log binomial models to estimate risk ratios (RRs) and 95% confidence intervals (CIs).Results. The proportion of late-stage disease increased with age: from 16.53% (21–34 years) to 42.44% (≥ 70 years). The adjusted relative risk of advanced-stage disease among women aged 50 years and older was 2.2 to 2.5 times that of patients aged 21 to 34 years. Uninsured (RR = 1.44; 95% CI = 1.40, 1.49), Medicaid (RR = 1.37, 95% CI = 1.34, 1.41), younger Medicare (RR = 1.12, 95% CI = 1.06, 1.19), and older Medicare (RR = 1.20, 95% CI = 1.15, 1.26) patients had a higher risk of late-stage disease than did privately insured patients.Conclusions. Screening should be encouraged for women at high risk for advanced-stage disease.The American Cancer Society estimates that 12 710 women will be diagnosed with cervical cancer and 4290 women will die from the disease in 2011.1 Although incidence and mortality from cervical cancer have declined since the introduction of the Papanicolaou (Pap) test, approximately 35% of cervical cancer patients are diagnosed with regional disease and 11% with distant-stage disease.2,3 Prognosis is strongly related to stage: the 5-year relative survival rate is 91.2% for patients with localized disease, but only 57.8% for patients with regional disease and 17.0% for those with distant disease.3Socioeconomic status, race, marital status, and geographic location have been identified as factors related to late stage at diagnosis among cervical cancer patients.4–10 Previous studies also documented older age as a significant predictor of advanced stage, although the effects of insurance and age, which are 2 of the strongest predictors of cervical cancer screening, have not been studied together.11,12 Women without health insurance are less likely to receive cervical cancer and other recommended cancer screening tests, yet few studies have examined the association between insurance status and cervical cancer stage at diagnosis, and the existing studies were limited to elderly (aged ≥ 65 years) Medicare recipients or patients from single-state tumor registries.4,13 We examined the relationship of both age and insurance status with late-stage disease after adjustment for other known risk factors. Ours was the first study to our knowledge to examine this relationship in a large national sample of cancer patients.     

Racial/Ethnic Disparities in Hypertension Prevalence: Reconsidering the Role of Chronic Stress

Objectives. We investigated the association between anticipatory stress, also known as racism-related vigilance, and hypertension prevalence in Black, Hispanic, and White adults.Methods. We used data from the Chicago Community Adult Health Study, a population-representative sample of adults (n = 3105) surveyed in 2001 to 2003, to regress hypertension prevalence on the interaction between race/ethnicity and vigilance in logit models.Results. Blacks reported the highest vigilance levels. For Blacks, each unit increase in vigilance (range = 0–12) was associated with a 4% increase in the odds of hypertension (odds ratio [OR] = 1.04; 95% confidence interval [CI] = 1.00, 1.09). Hispanics showed a similar but nonsignificant association (OR = 1.05; 95% CI = 0.99, 1.12), and Whites showed no association (OR = 0.95; 95% CI = 0.87, 1.03).Conclusions. Vigilance may represent an important and unique source of chronic stress that contributes to the well-documented higher prevalence of hypertension among Blacks than Whites; it is a possible contributor to hypertension among Hispanics but not Whites.Racial and ethnic disparities in hypertension are some of the most widely studied and consequential sources of social disparities in health in the United States.1–3 For example, recent prevalence estimates show that roughly 40% of Black adults but only 30% of White adults have hypertension.4 In addition, the incidence of hypertension occurs at younger ages for Blacks than Whites.1 These disparities are reflected in the larger burden of hypertension-related health and economic costs carried by non-White than White Americans. For example, mortality rates attributable to hypertension are roughly 15 deaths per 100 000 people for White men and women; the mortality rate for Black women is 40 per 100 000 and more than 50 per 100 000 for Black men.5 Among all health conditions, hypertension accounts for the greatest portion of disparities in years of lost life.6 Economically speaking, if Black Americans had the hypertension prevalence of White Americans, about $400 million would be saved in out-of-pocket health care expenses, about $2 billion would be saved in private insurance costs, and $375 million would be saved from Medicare and Medicaid—per year.7Despite the tremendous amount of research devoted to clarifying the factors that generate these disparities, most studies find that they persist after adjustment for a wide range of socioeconomic, behavioral, and biomedical risk factors.8 In fact, although disparities exist for several of these risk factors (e.g., socioeconomic status), numerous studies have shown no disparities in many others (e.g., smoking, obesity for men, lipid profile).2 Despite substantial investment in interventions to eliminate hypertension disparities, evidence suggests that these disparities have actually grown over the past few decades,9 suggesting that numerous unknown factors drive disparities in hypertension.3