Providing shelter to nursing home evacuees in disasters: lessons from Hurricane Katrina

Objectives. We examined nursing home preparedness needs by studying the experiences of nursing homes that sheltered evacuees from Hurricane Katrina.Methods. Five weeks after Hurricane Katrina, and again 15 weeks later, we conducted interviews with administrators of 14 nursing homes that sheltered 458 evacuees in 4 states. Nine weeks after Katrina, we conducted site visits to 4 nursing homes and interviewed 4 administrators and 38 staff members. We used grounded theory analysis to identify major themes and thematic analysis to organize content.Results. Although most sheltering facilities were well prepared for emergency triage and treatment, we identified some major preparedness shortcomings. Nursing homes were not included in community planning or recognized as community health care resources. Supplies and medications were inadequate, and there was insufficient communication and information about evacuees provided by evacuating nursing homes to sheltering nursing homes. Residents and staff had notable mental health–related needs after 5 months, and maintaining adequate staffing was a challenge.Conclusions. Nursing homes should develop and practice procedures to shelter and provide long-term access to mental health services following a disaster. Nursing homes should be integrated into community disaster planning and be classified in an emergency priority category similar to hospitals.During and after disasters, the adequacy of response by public health agencies, medical providers, and public safety officials is influenced by the degree to which planning has addressed needs of special populations, such as vulnerable older people.1^–7 Previous research has found that nursing homes received notably less support than did hospitals from federal, state, and local response agencies during and after disasters.1^,2 Nearly 2 million Americans reside in about 18000 nursing homes.8 In the coming decades, nursing homes will care for many more frail older people with increasingly complex health needs.7^,9^,10 The disaster following Hurricane Katrina further demonstrated that our nation’s disaster management system does not respond adequately to the needs of frail older persons in nursing homes. About 70 nursing home residents died in 13 nursing homes during the immediate aftermath of Katrina.11 In addition to hurricanes, nursing homes are vulnerable to earthquakes, tornados, chemical spills from train accidents, and widespread lasting power outages caused by ice storms. The public health system and nursing homes need to incorporate the special needs of older populations into disaster planning, training, and education.1^–7^,9^,12^–14We present experiences and perspectives of administrators and staff at nursing homes in the Gulf Coast region that sheltered evacuees from Hurricane Katrina’s path. Such facilities are often called “sheltering” nursing homes. From their experiences, we sought to identify needs for preparedness training in nursing homes that may shelter evacuees from disaster areas and related practice and policy needs of the public health system.     

The role of race/ethnicity in the relationship between emergency department use and intimate partner violence: findings from the 2002 National Survey on Drug Use and Health

Objectives. We examined the relationship between intimate partner violence victimization among women in the general population and emergency department use. We sought to discern whether race/ethnicity moderates this relationship and to explore these relationships in race/ethnic–specific models.Methods. We used data on non-Hispanic White, Non-Hispanic Black, and His-panic married or cohabiting women from the 2002 National Survey on Drug Use and Health. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated using logistic regression.Results. Women who reported intimate partner violence victimization were 1.5 times more likely than were nonvictims to use the emergency department, after we accounted for race/ethnicity and substance use. In race/ethnic–specific analyses, only Hispanic victims were more likely than their nonvictim counterparts to use the emergency department (AOR = 3.68; 95% CI = 1.89, 7.18), whereas substance use factors varied among groups.Conclusions. Our findings suggest that the emergency department is an opportune setting to screen for intimate partner violence victimization, especially among Hispanic women. Future research should focus on why Hispanic victims are more likely to use the emergency department compared with nonvictims, with regard to socioeconomic and cultural determinants of health care utilization.Intimate partner violence (IPV) against women has been associated with increased healthcare utilization overall1^–5 and with non–primary care services in particular.6^–8 For example, nearly 40% of the approximately 4.8 million rape and violent physical incidents perpetrated by intimate partners each year result in injury and about 30% of injured women receive medical care.7 The majority of these women receive treatment in a hospital setting, with more than half treated in an emergency department. Multiple medical care visits are frequently required for each incident, resulting in nearly 500 000 emergency department visits each year by women victims, as well as costs to consumers, employers, and the public health system of more than $168.5 million per year for emergency department visits alone.7Although racial and ethnic disparities in the relationship between IPV and emergency department utilization have not been reported in studies of nonclinical samples, several related paths of research point in this direction. First, the extant literature overall suggests that IPV occurs more frequently among Blacks and, to a lesser extent, Hispan-ics compared with Whites in general population surveys.9 Second, alcohol use is associated with IPV, especially among Black women. The 1995 National Study of Couples,10 for example, found that women exposed to male-perpetrated IPV were more likely than were nonexposed women to report alcohol problems and drug use, particularly women of Black or “other” race/ethnicity who experienced severe IPV. Likewise, Cae-tano et al.11 found social consequences of drinking, but not dependence symptoms, among female partners to be associated with male-to-female IPV only among Black couples. However, White and Chen12 found a woman’s problem drinking to be associated with her victimization in a study among a predominately White population. All of these analyses controlled for partner drinking. It remains unclear whether substance use precedes or follows IPV, but the current literature suggests that women may “self-medicate” to alleviate the effects of partner violence.13^–16Third, race/ethnicity is a factor in the utilization of emergency department services and in alcohol-related emergency department use. Black and Hispanic women are more likely to utilize emergency department and in-patient hospital services compared with non-Hispanic White women,17^–24 and alcohol-related visits to the emergency department for Blacks are approximately twice that of Whites overall.25 Further, women’s (and their partners’) use of illicit drugs and alcohol abuse are associated with IPV among ethnic minorities who attend urban emergency departments, with IPV-related injury among women victims in emergency department studies, and with severe IPV in female trauma patients.26^–30 Taken together, these findings suggest that Black and Hispanic women are more likely than are White women to utilize the emergency department, that Black and Hispanic women who have experienced IPV are more likely than their non-victim counterparts to utilize the emergency department, and that substance abuse may play a role in these relationships.Many of the studies that have addressed the relationship between IPV and emergency department utilization have been clinic- or hospital-based studies. These studies may introduce detection bias by differentially including those individuals who lack access to primary care or those who have the ability to pay (or have insurance) for emergency department services, depending on the socioeconomic status of the population served.19^,21^,31^–36 Few population-based self-report surveys have examined health care utilization,37^–39 aside from those focused on IPV incident–specific care, such as the National Violence Against Women Survey conducted 10 years ago.To address these gaps in the literature, we aimed to (1) examine the relationship between IPV victimization among women and emergency department utilization in the general population, while accounting for race/ ethnicity and substance use; (2) discern whether race/ethnicity is a moderator in the relationship between IPV and emergency department use; and (3) examine the relationship between IPV and emergency department use in race/ethnic–specific analyses in the event race/ethnicity was found to be a moderating factor.     

Being poor and coping with stress: health behaviors and the risk of death

Objectives. Individuals may cope with perceived stress through unhealthy but often pleasurable behaviors. We examined whether smoking, alcohol use, and physical inactivity moderate the relationship between perceived stress and the risk of death in the US population as a whole and across socioeconomic strata.Methods. Data were derived from the 1990 National Health Interview Survey’s Health Promotion and Disease Prevention Supplement, which involved a representative sample of the adult US population (n=40335) and was linked to prospective National Death Index mortality data through 1997. Gompertz hazard models were used to estimate the risk of death.Results. High baseline levels of former smoking and physical inactivity increased the impact of stress on mortality in the general population as well as among those of low socioeconomic status (SES), but not middle or high SES.Conclusions. The combination of high stress levels and high levels of former smoking or physical inactivity is especially harmful among low-SES individuals. Stress, unhealthy behaviors, and low SES independently increase risk of death, and they combine to create a truly disadvantaged segment of the population.Perceived stress is a negative affective state that individuals may attempt to relieve or cope with through unhealthy but often pleasurable behaviors.1^–9 High levels of perceived stress are associated with smoking initiation, increased smoking levels, less successful smoking cessation attempts, drinking alcohol more often and in heavier quantities, increased problem drinking, and reports of positive attitudes toward drinking.4^,10^–23 Some people exercise to control their stress,24 but most individuals respond to stress by exercising less frequently and at lower levels because sedentary behavior is more rewarding in the short term.4^,10^,23^,25Stress and unhealthy behaviors each increase the risk of death.15^,26^–36 Numerous social stressors and high levels of perceived stress have been shown to be positively associated with mortality.15^,26 Current and former smoking and physical inactivity are also positively associated with mortality.27^–32 Alcohol consumption has a J-shaped relationship with mortality; abstainers and heavy drinkers are at increased risk of death relative to moderate drinkers.29^,33^–36 To our knowledge, no research has examined whether unhealthy behaviors moderate the relationship between stress and mortality.Our first aim in this study was to examine whether unhealthy behaviors moderate the stress–mortality relationship in a nationally representative sample of US adults. There are 3 possible relationships between stress, health behaviors, and the risk of death. First, the “double jeopardy” perspective suggests that multiple risk factors combine to increase the risk of death more than a single risk factor alone would indicate.37^,38 Smoking, alcohol use, and physical inactivity may be pleasurable but deleterious strategies for coping with perceived stress, and they may inadvertently increase the effects of stress on mortality.39^,40 Second, unhealthy behaviors may allow individuals to cope effectively with stress.3^,5^,7^,8^,41 Unhealthy behaviors and high stress levels are each associated with increased mortality, but unhealthy behaviors may nevertheless reduce the effects of stress on mortality. Finally, the null hypothesis implies that unhealthy behaviors will not moderate the stress–mortality relationship.Our second aim was to examine whether unhealthy behaviors moderate the impact of stress on mortality differently across different socioeconomic strata. The social vulnerability hypothesis suggests that the combination of unhealthy behaviors and high stress levels may be particularly risky among individuals of low socioeconomic status (SES), who might be more vulnerable, or less resilient, to accumulating health risks.42^,43 Those who are less advantaged “experience multiple threats to their health, with each threat making the other more serious.”43^(p302)By contrast, the “Blaxter hypothesis” posits that unhealthy behaviors may be less harmful among those in low-SES groups, precisely because members of these groups already face numerous insults resulting from unsafe housing, work, and neighborhood environments.44 Improving unhealthy behaviors without ameliorating underlying socioeconomic disadvantages may yield few health benefits.3^,45^–47 Thus, if unhealthy behaviors increase the relationship between stress and mortality, their influence may be attenuated among low-SES individuals.     

Maternal nonstandard work schedules and adolescent overweight

Objectives. We investigated whether nonstandard work schedules by mothers were associated with adolescent overweight.Methods. We conducted multiple regression analyses using a sample of mother–child pairs (n=2353) from the National Longitudinal Survey of Youth to examine the association between the number of years mothers worked at nonstandard schedules and adolescent overweight at age 13 or 14 years. Separate analyses were also conducted by family income and family type.Results. Child’s body mass index increased significantly if mothers worked either a few years or many years at nonstandard schedules. Risk of overweight was also significantly associated with 1 to 4 and 10 or more years of maternal nonstandard work schedules. In both cases, results were driven by those families with predicted incomes in the 2nd quartile (“near-poor”), with a few or many years of nonstandard work schedules also associated with increased risk of adolescent overweight in 2-parent families.Conclusions. Results indicate the importance of the overlooked association between maternal nonstandard work schedules and adolescent overweight at age 13 or 14 years. Nonstandard work schedules among near-poor families and in 2-parent families may disrupt the work–family balance, affecting adolescent overweight.Overweight among young people is one of the most publicized public health issues of the current generation. Although only about 5% of children in the United States aged 2 to 19 years were considered overweight in 1974,1 by 2003 to 2004 this figure was 17.1%2. Among adolescents aged 12 to 19 years, overweight rose from 5% in 1960 to 11% from 1988 to 1994,3 and recently increased from 14.8% in 1999 to 2000 to 17.4% in 2003 to 2004.Overweight has been linked to a host of physical, social, and psychological problems for adolescents including type 2 diabetes,4 sleep problems,5 asthma,6 hypertension, and depression,7 among others. Moreover, overweight in childhood and adolescence has been found to be associated with adult overweight8^–10 and numerous health and social problems that attend to it.Although genetic and environmental factors and their interactions are generally identified as being responsible for increases in adolescent overweight, the large increases among a relatively stable population suggest changes in the environment are largely responsible.11 Furthermore, although a growing caloric imbalance12 (expending fewer calories than are consumed) prompted by a more sedentary lifestyle is understood to be at the root of the obesity epidemic for both young people and adults,13 the exact nature of this imbalance remains unclear.Some have suggested that among other causes, parental work may be associated with adolescent overweight1^,14^,15 through a greater reliance on fast food (e.g., if parental work hours interfere with the time needed to prepare healthy meals)16 or television watching by children.1 Whereas one early study found no association between maternal work and nutrient intake by children,17 recent analyses have demonstrated a positive association between American maternal work hours and child overweight by age 11 years.18^,19 A study of Canadian children aged 6 to 11 years found similar results, although no association was found with fathers’ work hours.20 Finally, a recently published British study found that maternal work was positively associated with early childhood overweight.21Parental nonstandard work schedules (“nonstandard shifts”) may be particularly likely to place children at risk of overweight. We defined “nonstandard” as work shifts other than day shifts (see “Methods” section). For example, parents working evening or early morning hours may have less time or energy to take children to sports practice or games and may be more likely to provide their children with pre-prepared foods or fast food. Although some previous studies have examined associations between maternal nonstandard shifts and children’s well-being,22^–24 none have examined how such work is related to children’s overweight. Given estimates that over one third of dual-earner households have at least 1 parent working nonstandard shifts,25^–27 it is vital to examine this relationship.Given the evidence just reviewed, we hypothesized that maternal nonstandard shifts are positively associated with children’s body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) and overweight at age 13 or 14 years. Although childhood and adult overweight are only moderately correlated, research has found overweight at 13 or 14 years of age and adulthood adiposity to be highly correlated.10 Adolescence is a period when young people are at high risk for becoming overweight11; moreover, independent of adult weight, adolescent overweight is associated with adulthood morbidity such as colorectal cancer and gout for men and arthritis in women,28 making it a period of critical importance when considering the public health implications of the overweight epidemic.29     

Childhood socioeconomic position, gender, adult body mass index, and incidence of type 2 diabetes mellitus over 34 years in the Alameda County Study

Objectives. We examined the association between childhood socioeconomic position and incidence of type 2 diabetes and the effects of gender and adult body mass index (BMI).Methods. We studied 5913 participants in the Alameda County Study from 1965 to 1999 who were diabetes free at baseline (1965). Cox proportional hazards models estimated diabetes risk associated with childhood socioeconomic position and combined childhood socioeconomic position–adult BMI categories in pooled and gender-stratified samples. Demographic confounders and potential pathway components (physical inactivity, smoking, alcohol consumption, hypertension, depression, health care access) were included as covariates.Results. Low childhood socioeconomic position was associated with excess diabetes risk, especially among women. Race and body composition accounted for some of this excess risk. The association between childhood socioeconomic position and diabetes incidence differed by adult BMI category in the pooled and women-only groups. Adjustment for race and behaviors attenuated the risk attributable to low childhood socioeconomic position among the obese group only.Conclusions. Childhood socioeconomic position was a robust predictor of incident diabetes, especially among women. A cumulative risk effect was observed for both childhood socioeconomic position and adult BMI, especially among women.In recent years, much effort has gone into characterizing biological and social exposures during gestation and childhood that may lead to adult chronic diseases. Childhood socioeconomic disadvantage has been associated with mortality1^–4 and several adult physical5^–7 and mental health5^,7^–9 outcomes.Studies investigating the relationship between childhood socioeconomic disadvantage and diabetes have shown inconsistent results. Childhood socioeconomic position (SEP) was linked to prevalent type 2 diabetes,10^–14 insulin resistance,15 higher glucose levels,16^,17 and metabolic syndrome18^,19 in some studies, yet showed no association with impaired glucose tolerance20^,21 or metabolic syndrome22 in others. Three studies investigated the association between childhood SEP and incident diabetes in adulthood and reported either modest11^,23 or no effects.12Although the evidence thus far is insufficient to establish a causal link between childhood SEP and incident type 2 diabetes, the hypothesis is plausible. Childhood disadvantage has been linked to illnesses, such as cardiovascular diseases,24 that have overlapping pathologies with diabetes. Persons exposed to socioeconomic disadvantage in childhood are more likely to be of lower socioeconomic means as adults.25^,26 Several studies have shown inverse, graded associations between different measures of adult SEP and the prevalence11^,13^,22^,27^,28 and incidence11^,12^,23^,29^–34 of type 2 diabetes. Childhood SEP also influences adult body composition35^–41 and several behaviors20^,42^–45 that are risk factors for type 2 diabetes.Obesity is a strong predictor of type 2 diabetes.46^–48 Therefore, the effect of childhood SEP on diabetes incidence may differ by body mass index (BMI; weight in kilograms divided my height in meters squared) in adulthood. For example, low childhood SEP and adult obesity together may impart a greater risk of type 2 diabetes than the risk imparted by low childhood SEP alone. Such exposure patterns may represent an accumulation of risk over time or a risk pathway. In addition, several studies have shown that the effects of childhood circumstances on adult health and risk behaviors differ by gender.37^,38^,40^,49^–52 The question remains whether childhood SEP differentially influences diabetes risk for women and men.Previous studies of childhood SEP and incident diabetes had short follow-up periods,11^,12^,23 and one was limited to women.23 Our approach complemented these studies by using 5 waves of data collected in a population-based sample from 1965 to 1999 to examine the association between childhood SEP and the incidence of type 2 diabetes and how this association may differ by gender or adult BMI.     

Returning to the "homeland": work-related ethnic discrimination and the health of Japanese Brazilians in Japan

Objectives. We investigated whether self-reported ethnic discrimination in the workplace was associated with well-being among Japanese Brazilians who had returned to Japan. Further, we examined interactions between discrimination and education on well-being.Methods. We obtained data from a cross-sectional survey of Japanese Brazilian workers (n = 313) conducted in 2000 and 2001. Outcomes were self-rated health, psychological symptoms as measured by the 12-item General Health Questionnaire (GHQ-12) score, and a checklist of somatic symptoms.Results. Reports of ethnic discrimination were associated with increased risk of poor self-rated health and psychological symptoms (GHQ-12 score), after we controlled for self-assessed workload, supportive relations at work, physically dangerous working conditions, workplace environmental hazards, shift work, number of working hours, age, gender, marital status, income, education, Japanese lineage, length of residence, and Japanese language proficiency. Further, the relationship between discrimination and self-rated health and somatic symptoms was most robust for those with the least education.Conclusions. Ethnic discrimination appears to be a correlate of morbidity among Japanese Brazilian migrants. Future research should investigate how educational and workplace interventions may reduce discrimination and possibly improve health.Many emigrants dream of returning to the homeland of their ancestors. Romantic as this notion is, returnees are not always welcome. They may encounter stigma and discrimination, which in turn may contribute to illness.Since the 1907 authorization by the Brazilian state of São Paulo that permitted the exchange of contract workers, Japan has been sending emigrants to Brazil, most of whom have been employed on contract with coffee and sugar plantations.1 Upon fulfilling their contracts, many have remained to raise their families in Brazil. Today, with an estimated 1.3 million people of Japanese descent, Brazil has the highest concentration of ethnic Japanese outside of Japan.A shortage of workers in the 1980s prompted the Japanese government to amend its immigration policy. Although still not enjoying the same rights as citizens, Japanese Brazilian immigrants were granted residence status that privileged them over other immigrants. Whereas most immigrants were restricted in their employment opportunities, Japanese Brazilians, because of their Japanese heritage, were allowed to work in any sector. Indeed, many employers preferred Japanese Brazilian workers because of their cultural lineage. Many Japanese Brazilians emigrated to Japan, and by 2000, there were approximately 250 000 Japanese Brazilians in Japan. In this context, Japanese Brazilians occupy a structurally and socially superior niche compared with most other immigrants in Japan.2This relatively high status, however, is qualified: although Japanese by heritage, Japanese Brazilians are generally viewed as outsiders.3^–5 Despite being favored over other immigrants, Japanese Brazilians continue to occupy a low social position, taking jobs that most Japanese find undesirable.5^–7 They are often stereotyped as ignorant, dirty, and culturally inferior and seen as failures for emigrating from Japan. Many are even seen as double failures (regardless of whether they were first- or later-generation emigrants) for migrating back to Japan as laborers.3^,4 These stereotypes can lead to ethnic discrimination.Prior studies have found that self-reported discrimination, the recounting of events that one perceives as being unfair and related to one’s social group membership, may be an important stressor and marker of structural disadvantage.8^–11 Stressors may contribute to allostatic load—the “wear and tear” on organ systems.12^,13 Discrimination may also harm mental health by injuring one’s self-concept, sense of safety, and sense of belonging.14^,15 Because stressors may influence a variety of body systems, researchers have long argued that the study of stressors should include a range of health outcomes.16^,17Consistent with this perspective, self-reported discrimination has been associated with problems ranging from coronary calcification18 to low birthweight19 to mood disorders.20 Reports of discrimination are associated with job stressors.21 Workplace discrimination and other occupational stressors are associated with hypertension, distress, and other problems.22^–24 Given this diversity of outcomes, it is not surprising that self-reported discrimination is also associated with global markers of illness, including self-rated health, psychological well-being, and total number of health problems.25Associations between discrimination and morbidity have been found in a variety of groups, including African Americans, Latinos, and American Indians.10^,26^–28 Studies have also examined discrimination among Asians in the United States,29^,30 Canada,31^,32 and the United Kingdom.33^,34 However, these studies have focused on Asians who are phenotypically (visually) dissimilar to the “majority” population.For our study, we focused on Japanese Brazilians, which allowed us to investigate an ethnic group whose phenotype is arguably similar to that of the majority group but whose immigration history makes them socially distinct.5^,7 These considerations lead to the hypothesis that self-reported ethnic discrimination in the workplace will be associated with increased morbidity, as indicated by psychological symptoms, self-rated health status, and somatic symptoms. Because our study focused on workplace discrimination, we also included several other psychosocial and physical hazards in the workplace as potential confounders. This permitted us to evaluate whether ethnic discrimination is a risk factor distinct from other important factors.Additionally, we investigated whether the association between discrimination and morbidity is stronger among those with less education. This interaction between multiple forms of disadvantage has been called the “double jeopardy” hypothesis.35^,36 One of the major stereotypes of Japanese Brazilians is that they are ignorant.3^,4 For well-educated Japanese Brazilians, academic achievements can temper the effects of discrimination. Those with less formal education, however, may not have such resources at their disposal. We therefore examined interactions between discrimination and education.     

Exploring potential pathways between parity and tooth loss among American women

Objectives. We assessed the impact of parity on tooth loss among American women and examined mediators of this relationship.Methods. The study sample comprised 2635 White and Black non-Hispanic women who had taken part in the third National Health and Nutrition Examination Survey. We examined the relationship between parity and tooth loss, by age and by socioeconomic position, and tested a theoretical model focusing on direct and indirect influences of parity on dental disease. Robust regression techniques were used to generate path coefficients.Results. Although parity was associated with tooth loss, the relationship was not moderated through dental care, psychosocial factors, or dental health–damaging behaviors.Conclusions. Parity is related to tooth loss among American women, but the mechanisms of the association remain undefined. Further investigation is warranted to determine whether disparities in dental health among women who have been pregnant are caused by differences in parity or to physiological and societal changes (e.g., factors related to pregnant women’s access to care) paralleling reproductive choices.“Jedes kind kostet die mutter einen zahn,” an old German saying that literally means “every child costs the mother one tooth,” embodies a pervasive belief in many cultures, including that of the United States, that tooth loss is a natural consequence of pregnancy.1^,2 This belief stems, in part, from the popular view that pregnancy weakens teeth as a result of calcium depletion; such a notion, although wholly unsupported,3^–5 is given credibility by findings indicating that pregnancy actually does have an adverse impact on oral tissues.6^–13Despite this widespread conviction, few investigations have explored the association between parity (i.e., the number of live-born children a woman has delivered) and tooth loss. Whereas some have found no association between parity and tooth loss,14^–16 others have found that increased parity is related to increased levels of edentulism and fewer teeth.17^–19 To our knowledge, however, no studies have examined the mechanisms by which parity may affect tooth loss. Accordingly, our primary goal was to identify mediators of the relationship between parity and tooth loss in a large sample of White and Black American women.     

The healthy migrant effect: new findings from the Mexican Family Life Survey

Objectives. We used nationally representative longitudinal data from the Mexican Family Life Survey to determine whether recent migrants from Mexico to the United States are healthier than other Mexicans. Previous research has provided little scientific evidence that tests the “healthy migrant” hypothesis.Methods. Estimates were derived from logistic regressions of whether respondents moved to the United States between surveys in 2002 and 2005, by gender and urban versus rural residence. Covariates included physical health measurements, self-reported health, and education measured in 2002. Our primary sample comprised 6446 respondents aged 15 to 29 years.Results. Health significantly predicted subsequent migration among females and rural males. However, the associations were weak, few health indicators were statistically significant, and there was substantial variation in the estimates between males and females and between urban and rural dwellers.Conclusions. On the basis of recent data for Mexico, the largest source of migrants to the United States, we found generally weak support for the healthy migrant hypothesis.Questions about who does and who does not migrate to the United States remain fundamental and unresolved issues in immigration research. There is evidence that international migrants are not a random sample from their home countries.1^–3 Moreover, research suggests that most prime-aged migrants move in search of better labor market opportunities and, because they have the motivation and resources to undertake a move, they are “positively selected”—that is, they are more educated and in better psychological and physical health than are nonmigrants.2^,4 We used newly collected data to examine evidence for this “healthy migrant” hypothesis in the United States. The topic is of particular interest in the United States because studies have appealed to this type of selection process as a plausible explanation for the widely documented “Hispanic paradox.” The paradox refers to the mortality advantage of Hispanic adults relative to non-Hispanic Whites despite the lower socioeconomic status of Hispanics.2^,5^,6In spite of the popularity of the healthy migrant hypothesis, evidence for it is weak and conclusions about its importance in the United States are premature, at best. Because few studies of international migration contain information about migrants before they arrived in the United States or information about comparable nonmigrants, most have relied on comparisons between the native born and foreign born; in some cases, the latter group was restricted to legal immigrants.7^–10 These studies, which generally demonstrated that the foreign born were in better health than were natives, did not provide scientific evidence about the healthy migrant hypothesis for at least 3 reasons.11 First, the appropriate comparison group to test the hypothesis is nonmigrants from the home country rather than natives in the United States. Second, previous studies have typically examined the health of migrants after they moved to the United States rather than prior to migrating. Third, most existing research relied on self-reports of health, information that has been shown to depend upon cultural factors, ethnicity, and access to health care.12Our study focused on recent migration from Mexico to the United States, a migration stream that accounts for about 30% of all immigrants to the United States and more than half of undocumented immigrants.13 Our analysis was based on survey data collected in Mexico that were well suited to test the healthy migrant hypothesis.     

Disentangling the effects of racial and weight discrimination on body mass index and obesity among Asian Americans

Objectives. We examined whether racial discrimination is associated with increased body mass index (BMI) and obesity among Asian Americans. Further, we explored whether this association strengthens with increasing time in the United States.Methods. We analyzed data from the 2002 to 2003 National Latino and Asian American Study (n=1956). Regression models tested whether reports of racial discrimination were associated with BMI and obesity, after accounting for weight discrimination, age, gender, marital status, ethnicity, generation, employment, health status, and social desirability bias (the tendency to seek approval by providing the most socially desirable response to a question).Results. We found that (1) racial discrimination was associated with increased BMI and obesity after we controlled for weight discrimination, social desirability bias, and other factors and (2) the association between racial discrimination and BMI strengthened with increasing time in the United States.Conclusions. Racial discrimination may be an important factor related to weight gain among ethnic minorities.Stress caused by disadvantaged social status may be related to obesity. Two elements provide the foundation for this observation. First, stress may have adverse physiological consequences, including increased risk for obesity and allostatic load, the “wear and tear” on organ systems that contributes to health problems.1 Stressors activate the hypothalamic–pituitary–adrenal axis system, releasing cortisol and other glucocorticoids. Glucocorticoids may stimulate appetite and blunt the satiety system.2 Cortisol increases fat retention, particularly in the abdominal region.3 Moreover, stressors may selectively increase the intake of “comfort foods” over other foods among humans and other animals.4^,5Stress may also be related to abdominal and general obesity. Daily stress,6 anxiety,7 and depressed mood8^,9 are related to visceral obesity. Among monozygotic twins, stress-induced hormonal changes result in greater intra-abdominal fat deposits in the twin with higher stress.10 Further, obesity, indicated by a high body mass index (BMI), has been associated with work stress11^,12 and early childhood trauma.13 In a prospective study of British civil servants, job stress was associated with metabolic syndrome (a group of risk factors that includes abdominal obesity, elevated blood pressure, and atherogenic dyslipidemia)8 and general and visceral obesity.12Second, social disadvantage, such as experiences with racial discrimination, may produce stress.14 Self-reported discrimination appears to be related to several stress-related and obesity-related outcomes, including high blood pressure,15 depression and anxiety,16 sleep problems,17 and coronary calcification.18 Individuals may also use alcohol to cope with discrimination,19^–21 and alcohol can contribute to obesity.22 Hence, discrimination may directly produce weight gain by activating the stress system and by influencing behavior change. Discrimination also may act indirectly by hindering socioeconomic advancement23^,24 and by segregating individuals into communities with fewer healthy food options25^,26 and fewer safe places for physical activity.27^,28Consistent with these observations, several studies have suggested that discrimination is associated with weight gain and metabolic problems. Tull et al. found that reports of internalized racism were associated with greater obesity among women in Barbados.29 Similarly, Chambers et al. found associations between internalized racism and insulin resistance among girls in Barbados.30 Butler et al. found associations between internalized racism and greater waist circumference and higher fasting glucose among Dominica women.31We tested the first hypothesis that reports of discrimination are associated with higher BMI and the risk of obesity and build on previous research in 3 primary ways. First, overweight people may encounter weight discrimination,32 and associations between racial discrimination and weight might therefore be confounded by weight discrimination. To reduce the chance of spurious findings, we controlled for weight discrimination and other factors.Second, we examined whether findings from Black populations generalize to Asian Americans. Among Asian Americans, discrimination is associated with outcomes related to obesity, including cardiovascular conditions,33^,34 depression,35^–37 and substance use,19 but no study has directly examined whether discrimination is associated with BMI and obesity in this population.Third, we tested the main effects of discrimination and investigated whether discrimination is moderated by time spent in the United States. US-born Asians appear to have higher rates of obesity than their foreign-born counterparts, but the rates of obesity among the foreign born increase with years in the United States.38^–40 Additionally, immigrants often report less racial discrimination than do nonimmigrants, but reports of discrimination increase with years spent in the United States, perhaps because immigrants are more likely to encounter and recognize discrimination over time.41^–43 A recent study found that among African and Latino immigrants, the association between racial discrimination and mental health strengthened with increasing time in the United States.44 These observations motivate the second hypothesis that time spent in the United States will interact with the association between racial discrimination, such that the association between racial discrimination and BMI among immigrant Asians will strengthen with increasing time spent in the United States.     

Macrolevel stressors, terrorism, and mental health outcomes: broadening the stress paradigm

Objectives. We examined the extent to which the stress paradigm linking psychosocial stressors to mental health status has focused disproportionate attention on microlevel social stressors to the detriment of macrolevel stressors. Also, we assessed the effects of the terrorist attacks of September 11, 2001, on subsequent mental health among participants in a Midwestern cohort study.Methods. Respondents in a 6-wave longitudinal mail survey completed questionnaires before September 11, 2001, and again in 2003 and 2005. Regression analyses focused on measures of negative terrorism-related beliefs and fears, as well as psychological distress and deleterious alcohol use outcomes measured both before and after September 11.Results. Negative terrorism-related beliefs and fears assessed in 2003 predicted distress and drinking outcomes in 2005 after control for sociodemographic characteristics and pre–September 11 distress and drinking.Conclusions. The events of September 11 continue to negatively affect the mental health of the American population. Our results support the utility of according greater attention to the effects of such macrolevel social stressors in population studies embracing the stress paradigm.The stress paradigm guiding research on the effects of psychosocial stressors on mental health outcomes1^–4 initially addressed exposure to stressful life experiences involving acute life events, such as the death of significant others, or chronic stressors, such as financial difficulties, as predictors of negative mental health outcomes. An important limitation of stress research has been its narrow focus on micro- or individual-level stressors to the detriment of broader macrolevel social stressors.Stress researchers3^,5^,6 reviewing the stressors typically studied in large representative samples have noted the predominant focus on individual-level stressors (e.g., stress caused by life-changing events). Although some studies have also addressed more macrolevel stressors such as economic recessions7 and adverse living conditions,8 Wheaton5 noted that the macro–micro distinction highlights the fact that typical life event or role strain scales have excluded macrolevel traumas such as war stress, nuclear accidents, and natural disasters. For example, Holahan et al.,9 in their longitudinal study of stress, coping, and depression, addressed acute and chronic stressors involving experiences in 8 life domains: spouse, children, extended family, physical health, home, neighborhood, finances, and work. With the exception of neighborhood, all of these constitute microlevel domains.In Wheaton’s review of the social stress literature, he further emphasized the continuing predominant focus on individual stressors and noted that “we also can and should consider political, military and social events and conditions that act as social stressors.”6^(p288) A few researchers have included more macrolevel experiences. For example, the work of Turner et al. has addressed adversities such as “[being] in combat in a war, [living] near a war-zone, [being] present during a political uprising [and being] in a major fire, flood, earthquake or other natural disaster.”10^(p232) However, this focus constitutes more the exception than what is typical in the overall literature.In a different although related perspective on the evolution of the stress paradigm, Link and Phelan argued that the stress literature has gradually shifted from interest in “social conditions as fundamental causes of diseases”11^(p85) to intervening mechanisms involving the ways in which individuals cope with these conditions. They concluded that “while the current approach focuses on the individual, it can readily be seen that economic and political forces shape individuals’ exposure to risks.”11^(p85) This perspective suggests the importance of historical contexts and changes over time in social conditions, which play etiological roles in detrimental mental health outcomes (e.g., the extent to which social institutions such as the state may be viewed as unable to provide a sense of safety for their citizens).12The events of September 11, 2001, signaled a major change in the sociopolitical context in the United States, highlighting the salience of political terrorism as a continuing threat to individuals’ sense of safety and well-being. A sizable literature has demonstrated that the September 11 attacks adversely affected the mental health of individuals across the nation13^–16 as well as those most directly affected in New York, Washington, DC, and western Pennsylvania.17^–19 These empirical studies, conducted in the immediate aftermath of the attacks, demonstrated elevated symptoms of depression, anxiety, and posttraumatic stress disorder (PTSD) and increased alcohol consumption.Subsequent studies conducted between 2 months20 and 6 months21^,22 after September 11 demonstrated lingering feelings of distress and increased use of alcohol and other substances, including cigarettes and marijuana, relative to the period before September 11. It should be noted that research addressing alcohol use outcomes has been much more limited than research addressing manifestations of psychological distress alone. However, one national study, conducted shortly after September 11, showed decreased rather than increased alcohol consumption.12The extent to which the relatively immediate mental health effects of September 11 revealed in most studies have lingered is just beginning to be addressed. Boscarino et al.23 found that exposure to psychological trauma related to the World Trade Center attack in New York City was associated with increased alcohol consumption 2 years after the attack. Richman et al.24 demonstrated that a substantial percentage of a Midwestern population maintained negative beliefs and fears about their future safety linked to threats of future terrorist attacks in 2003 and that, after they controled for distress and drinking before September 11, these beliefs were significantly associated with distress and problematic drinking. However, a major limitation of that study was that terrorism-related beliefs and fears were measured at the same time point as distress and drinking outcomes, and thus the causal direction of the relationship between terrorism-related fears and mental health was ambiguous.In this study, we further address the salience of post–September 11 beliefs and fears in terms of mental health outcomes. That is, we examined the extent to which these fears and beliefs, as assessed in 2003, predicted a range of distress and alcohol use outcomes in 2005 after controlling for previous distress and alcohol use. We also examined gender differences given evidence indicating that such post–September 11 effects are more pronounced among women than among men.13^,17     

Comparing diabetes prevalence between African Americans and Whites of similar socioeconomic status

Objectives. We investigated whether racial disparities in the prevalence of type 2 diabetes exist beyond what may be attributable to differences in socioeconomic status (SES) and other modifiable risk factors.Methods. We analyzed data from 34331 African American and 9491 White adults aged 40 to 79 years recruited into the ongoing Southern Community Cohort Study. Participants were enrolled at community health centers and had similar socioeconomic circumstances and risk factor profiles. We used logistic regression to estimate the association between race and prevalence of self-reported diabetes after taking into account age, SES, health insurance coverage, body mass index, physical activity, and hypertension.Results. Multivariate analyses accounting for several diabetes risk factors did not provide strong support for higher diabetes prevalence rates among African Americans than among Whites (men: odds ratio [OR]=1.07; 95% confidence interval [CI]=0.95, 1.20); women: OR=1.13, 95% CI=1.04, 1.22).Conclusions. Our findings suggest that major differences in diabetes prevalence between African Americans and Whites may simply reflect differences in established risk factors for the disease, such as SES, that typically vary according to race.Members of racial and ethnic minority groups in the United States, including African Americans, suffer disproportionately from many chronic diseases, including type 2 diabetes (hereafter “diabetes”).1^–3 Prevailing statistics suggest that African American adults are 50% to 100% more likely to have diabetes than are Whites,3^–8 with evidence that diabetes precursors may even be more common in African American than in White children.9^,10 Reasons for racial disparities in diabetes prevalence are not clear, but behavioral, environmental, socioeconomic, physiological, and genetic contributors have all been postulated.3^,8^,11Because of the high prevalence of diabetes in the African American community, it has been suggested that African Americans may be more susceptible to the disease compared with Whites through direct genetic propensity or unfavorable gene–environment interactions.11 The fact that diabetes prevalence rates among Whites exceeded those among African Americans through at least the first half of the 20th century12 has led to the hypothesis that modern lifestyle factors (especially those that promote obesity) may have a greater effect on African Americans than on Whites.11^,13However, treating race as an etiological factor has been the subject of debate,14^–16 and it has been argued that despite some genotypic delineations, race largely represents a complex mixture of behavioral, environmental, and social exposures.17^,18 In comparison with Whites, African Americans often are poorer, have less education, are more likely to live in distressed households and communities, are less able to access quality health care, and have a less favorable risk factor profile for many diseases.18^–20 Because socioeconomic (and associated environmental) differences between racial groups are so pervasive, attempts to isolate an effect of race will typically involve substantial confounding,16 resulting in difficulty estimating the relative contributions of genetic and environmental factors.There have been several attempts to evaluate whether the disparity between African Americans and Whites with regard to diabetes can be attributed to factors other than racial background.7^,13^,21^–27 Studies involving nationally representative sampling frames7^,21^,23^–25^,27 provided the platform for many of these analyses, which poses a challenge in that the average African American is of substantially lower socioeconomic status (SES) than the average White American. Because racial disparities persisted in these studies after adjustment for known diabetes risk factors, including some measures of SES, a possible genetic explanation has been invoked for the residual association, although the precise biological mechanisms remain speculative. Many of the studies conducted to evaluate the underlying reasons for racial disparities in diabetes prevalence have included fewer than 1000 each of African American men and women.7^,13^,21^,23^,25Using the study population from the ongoing Southern Community Cohort Study (SCCS), which includes large numbers of African Americans and members of other racial/ethnic groups from generally similar socioeconomic circumstances, we had a unique opportunity to evaluate racial disparities in diabetes in a context in which confounding by extraneous factors related to race and SES would be limited by design. If racial disparities are driven by SES, one would expect little racial difference in diabetes prevalence rates within this population. We addressed the question of whether differences in diabetes prevalence between African Americans and Whites can be fully explained by SES or by adjustment for other correlates of diabetes risk.     

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.     

Health status, health care use, medication use, and medication adherence among homeless and housed people living with HIV/AIDS

Objectives. We sought to compare health status, health care use, HIV anti-retroviral medication use, and HIV medication adherence among homeless and housed people with HIV/AIDS.Methods. Data were obtained from a cross-sectional, multisite behavioral survey of adults (N=7925) recently reported to be HIV positive.Results. At the time interviews were conducted, 304 respondents (4%) were homeless. Self-ratings of mental, physical, and overall health revealed that the health status of homeless respondents was poorer than that of housed respondents. Also, homeless respondents were more likely to be uninsured, to have visited an emergency department, and to have been admitted to a hospital. Homeless respondents had lower CD4 counts, were less likely to have taken HIV anti-retroviral medications, and were less adherent to their medication regimen. Homeless respondents needed more HIV social and medical services, but nearly all respondents in both groups had received needed services. Housing status remained a significant predictor of health and medication outcomes after we controlled for potential confounding variables.Conclusions. Homeless people with HIV/AIDS are at increased risk of negative health outcomes, and housing is a potentially important mechanism for improving the health of this vulnerable group.Homeless people are at a disproportionate risk for negative health consequences. For instance, they typically have more chronic diseases and more physical and mental health problems than do the general population, and they are at greater risk for infectious diseases.1^–13 Homelessness is often coincident with poverty, mental illness, and alcohol and drug use, compounding the other health problems experienced by these individuals.14^–17Homeless people are also more likely than other groups to engage in behaviors that place them at risk for HIV infection, including risky sexual practices, injection drug use and needle sharing, and performing sexual acts in exchange for money, drugs, or a place to stay.18^–25 Perhaps not surprisingly, previous research has shown that HIV is 3 to 9 times more prevalent among homeless individuals than among individuals in stable housing situations.18^,20^,21^,26^–29It may be difficult for homeless people, who are often faced with immediate subsistence needs (e.g., finding adequate food and shelter), to obtain medical care and adhere to treatment regimens.30^,31 As a result, homeless individuals are less likely than are the general population to have stable sources of care, and they often rely on emergency departments or ambulatory care settings for their health care needs.32^,33 Delayed medical care or lack of care has negative effects such as delayed HIV diagnoses and higher rates of serious opportunistic infections.7^,31^,34People who are living with HIV/AIDS and are homeless face additional burdens not faced by homeless people without HIV/AIDS. For instance, individuals with HIV/AIDS need greater access to comprehensive health care, and barriers to care—including lack of financial resources, lack of transportation, and insufficient (or nonexistent) health insurance coverage—may be compounded among homeless people living with the disease.30^,34People with HIV/AIDS also may have difficulty adhering to prescribed HIV antiretroviral medication regimens.35^,36 These regimens can be complex and often involve restrictions on when and how the medications should be taken and stored.31^,34 In addition, these medications can have side effects, such as recurring diarrhea, that are especially problematic for homeless individuals. Medical providers may believe that homeless individuals will not be adherent, and thus they may be reluctant to prescribe antiretroviral medications for these individuals37 given that inadequate adherence can lead to drug resistance.34 Despite its importance, few studies have investigated the issue of adherence to antiretroviral medication regimens in this population.35^,36^,38^–42Overall, minimal research has been conducted on the health of homeless people living with HIV/AIDS.15^,43^,44 We used data from a large, multisite investigation to (1) assess differences between homeless and housed persons living with HIV/AIDS regarding sociodemographic, health care, and medication adherence variables and (2) examine associations between housing status and health, and medication adherence outcomes after controlling for potential confounding factors.     

Serious psychological distress among parenting and nonparenting adults

Objectives. We compared the prevalence of serious psychological distress among parenting adults with the prevalence among nonparenting adults and the sociodemographic correlates of serious psychological distress between these 2 populations.Methods. We drew data from 14240 parenting adults and 19224 nonparenting adults who responded to the 2002 National Survey on Drug Use and Health. We used logistic regression procedures in our analysis.Results. An estimated 8.9% of parenting adults had serious psychological distress in the prior year compared with 12.0% of nonparenting adults of similar age. In both groups, the adjusted odds of having serious psychological distress were higher among adults who were women, younger (between the ages of 18 and 44 years), low income, or receiving Medicaid. We found some differences in the correlates of serious psychological distress between parenting adults and nonparenting adults. The odds of having serious psychological distress were lower among parenting adults after we controlled for demographic characteristics.Conclusions. Serious psychological distress is fairly prevalent among parenting adults, and high-risk sociodemographic groups of parenting adults should be targeted to ensure access to coordination of services.The public health burden of mental illness is significant. Mental illness among parenting adults has potential negative effects on child-rearing practices, overall family functioning, and children’s development. Mentally ill parents raising children are at high risk of being hostile, insensitive, unresponsive, and of using harsh, coercive, or inconsistent disciplinary methods,1^–5 all of which have been linked to psychological and behavioral problems in children later in life.6^–13 Parental mental illness is especially important to identify and treat, because 23% to 50% of adults with psychiatric disorders have co-occurring substance use problems,14^,15 which have also been linked to a plethora of poor child-rearing practices, family problems, and negative child development outcomes.16^–27Children of parents with psychiatric disorders experience elevated risks for psychiatric disturbance and academic, social, and emotional impairments.3^,13^,28^–32 Rates of psychiatric disorders among children with mentally ill parents range from 30% to 50%,33^,34 compared with 20% among children overall.35 Consequences of parental mental health problems include insecure mother–child attachment and delayed development in infants; aggression, destructive behavior, and impaired development in toddlers; and physical and psychological problems, school failure, substance use, suicidal behaviors, social withdrawal, cognitive impairment, and poor overall adjustment for school-aged children.28 Unfortunately, many mental health agencies do not collect basic information on clients’ parenting status, which could be used to assess potential risk to their children,36 and assistance with appropriate parenting skills is rarely provided.30^,37^–41Mental illness among parents has drawn national attention in recent years.36^,42^–44 Data from the National Comorbidity Survey (NCS) show that the lifetime prevalence of psychiatric disorders is similar for mothers and for all women in the general population, but the prevalence for fathers is lower than for all men in the general population.40^,44 However, parents in the NCS were older and more educated than the general population, and the data examined biological parents, regardless of the child’s age or whether the child lived with the parent; step-parents, adoptive parents, and foster parents raising children were not included. Another recent analysis of parenting and mental illness used 1987–1988 data,43 which could not address changes in family demographics, social policy, and mental health treatment practices that have occurred during the past 19 years.Identifying subgroups of parenting adults most vulnerable to mental illness is important for prioritizing risk factors for targeted interventions; it can also be a first step toward identifying parents with co-occurring mental illness and substance use problems. However, correlates of mental illness among parenting adults have not been examined. Among the general population, the prevalence of mental illness is significantly higher among women, young adults (those aged 18–34 years), those with lower income or education, divorced or separated individuals, and Medicaid recipients.40^,41^,45^–48 Findings about the prevalence of mental health problems by race/ethnicity, employment status, and urbanicity have been mixed.41^,46^,49^–51 A recent analysis using a national sample considered multiple risk factors in a regression model and identified younger age (ages 18–49 years), divorced or never married status, poorer perceived overall health, and lack of social support as correlates of mental illness; Black or Hispanic race/ethnicity was a protective factor.14To better plan for mental health services for parenting adults, we examined the prevalence and sociodemographic correlates of serious psychological distress, which is highly correlated with affective and anxiety disorders,52 among adults interviewed in a nationally representative survey of the US population. We sought to answer 5 questions: (1) What is the prevalence of past-year serious psychological distress among parenting adults? (2) Among parenting adults, what subgroups were most likely to have serious psychological distress? (3) Were there differences between parenting and nonparenting adults in the prevalence of serious psychological distress? (4) Were there differences between parenting and nonparenting adults in the correlates of serious psychological distress? (5) Do differences in prevalence of serious psychological distress between parenting and nonparenting adults exist after control for sociodemographic characteristics?We were particularly interested in comparisons between parenting and nonparenting adults by race/ethnicity, employment status, and urbanicity, because the literature on the general population is inconclusive about these potential correlates. On the basis of NCS findings, we hypothesized that any differences between parenting and nonparenting adults would not be statistically significant after we controlled for sociodemographic differences. To our knowledge, comparisons between parenting and nonparenting adults regarding past-year risk of serious psychological distress and high-risk subgroups have not been addressed in previous research.     

Smoking cessation rates in the United States: a comparison of young adult and older smokers

Objectives. We compared smoking quit rates by age in a nationally representative sample to determine differences in cessation rates among younger and older adults.Methods. We used data on recent dependent smokers aged 18 to 64 years from the 2003 Tobacco Use Supplement to the Current Population Survey (n=31625).Results. Young adults (aged 18–24 years) were more likely than were older adults (aged 35–64 years) to report having seriously tried to quit (84% vs 66%, P<.01) and to have quit for 6 months or longer (8.5% vs 5.0%, P<.01). Among those who seriously tried to quit, a smoke-free home was associated with quitting for 6 months or longer (odds ratio [OR]=4.13; 95% confidence interval [CI]=3.25, 5.26). Compared with older smokers, young adults were more likely to have smoke-free homes (43% vs 30%, P<.01), were less likely to use pharmaceutical aids (9.8% vs 23.7%, P<.01), and smoked fewer cigarettes per day (13.2% vs 17.4%, P<.01).Conclusions. Young adults were more likely than were older adults to quit smoking successfully. This could be explained partly by young adults, more widespread interest in quitting, higher prevalence of smoke-free homes, and lower levels of dependence. High cessation rates among young adults may also reflect changing social norms.A key goal of tobacco control is to increase smoking cessation among young adults, because quitting at an early age increases the chances that a smoker will avoid the more serious health consequences of smoking.1 During the 1980s and 1990s, older smokers (50 years and older) were the most successful quitters,2^,3 and annual rates of successful quitting increased for all age groups.2 However, increases in cessation rates in the 1990s were greatest among young adults aged 20 to 34 years.2 Furthermore, among young adult smokers, but not older smokers, the increase in cessation rates was higher in states with higher cigarette prices and highest of all in California, which had a comprehensive statewide tobacco control program,2 suggesting that environmental factors may especially influence cessation rates among young adults. Projecting these national trends, we hypothesized that by 2003, young adults may have been the most successful quitters of any age group. Understanding recent changing influences on successful quitting could help increase the effectiveness of public health programs that aim to encourage cessation.Rates of successful quitting can differ between age groups because of differences in the proportion of smokers who try to quit, or because of differences in success rates among those who try. There is evidence that changes in the social norms surrounding smoking can lead to changes in the proportion of smokers who try to quit and that these norms can be influenced by tobacco-related news coverage4 and mass media advertising campaigns,5 both of which increased in the United States in the late 1990s with the Master Settlement Agreement and with the start of the American Legacy Foundation campaign.6 Young people (aged 0–29 years) may be particularly responsive to such influences,7 and throughout the 1990s, California’s tobacco control program used targeted media campaigns to specifically influence social norms about smoking.8Changes in social norms can also influence behavior associated with success in quitting. In particular, a decrease in levels of nicotine dependence among recent cohorts of smokers could partly explain higher rates of successful quitting among younger adults. Less-dependent smokers are more likely to successfully quit, presumably because of less-intense withdrawal symptoms.9^–11 Following the 1992 Environmental Protection Agency report classifying environmental tobacco smoke as a carcinogen,12 there was a rapid increase in social norms supporting restrictions on smoking,13 and increased restrictions on smoking at work and in public places have been associated with reduced levels of daily cigarette consumption.14^,15During the 1990s, an increasing proportion of smokers, particularly parents, banned smoking in the home.16 There is a strong association between smoke-free homes and successful quitting,17^,18 perhaps in part because a lapse, for example after a meal, is less likely. It is possible that recent birth cohorts who took up smoking under these restrictions at home and work may develop lower levels of dependence than previous cohorts,19 and they may themselves be more likely to live in a smoke-free home.During the 1990s, pharmaceutical aids became available to help overcome withdrawal symptoms, and these aids were associated with quitting success.20^,21 However, once these aids became easily available over the counter in 1996, their apparent effectiveness in population studies disappeared.22^,23 More in-depth analysis has suggested that effective use of pharmaceutical aids may be limited to smokers who are motivated to quit, such as those with a smoke-free home.24 Thus, differences in patterns of use of pharmaceutical aids between age groups may also contribute to recent differences in quitting success rates.We used a large nationally representative survey to compare US smoking cessation rates and associated tobacco-related behaviors between age groups. We compared attempted quitting rates across age groups each year as well as success rates among those who tried to quit smoking and explored whether there were important differences between age groups in prevalence of known correlates of cessation. We used multivariate logistic regression to establish whether differences in such correlates could account for differences in cessation rates, or whether younger smokers were quitting at higher rates than might be predicted by, for example, lower levels of addiction and a higher prevalence of smoke-free homes.     

Temporal trends in self-reported functional limitations and physical disability among the community-dwelling elderly population: the Framingham heart study

Objectives. We sought to determine change in the prevalence of functional limitations and physical disability among the community-dwelling elderly population across 3 decades.Methods. We studied original participants of the Framingham Heart Study, aged 79 to 88 years, at examination 15 (1977–1979; 177 women, 103 men), examination 20 (1988–1990; 159 women, 98 men) and examination 25 (1997–1999; 174 women, 119 men). Self-reported functional limitation was defined using the Nagi scale, and physical disability was defined using the Rosow-Breslau and Katz scales.Results. Functional limitations declined across examinations from 74.6% to 60.5% to 37.9% (P < .001) among women and from 54.2% to 37.8% to 27.8% (P<.001) among men. Physical disability declined from 74.5% to 48.5% to 34.6% (P < .001) among women and 42.3% to 33.3% to 22.8% (P = .009) among men. Among women, improvements in functional limitations (P = .05) were greater from examination 20 to 25, whereas for physical disability (P=.02), improvements were greater from examination 15 to 20. Improvements in function were constant across the 3 examinations in men.Conclusions. Among community-dwelling elders, the prevalence of functional limitations and physical disability declined significantly in both women and men from the 1970s to the 1990s. This may in part be due to improvements in technological devices used to maintain independence. Further work is needed to identify the underlining causes of the decline so preventative measures can be established that promote independence for the elderly population.National surveys and epidemiological studies have reported a significant decline in self-reported functional limitations and physical disability among older adults.1^–7 Despite consensus among reports, uncertainty exists with regard to the magnitude, rate, and specific characteristics of the disability decline.5^,6^,8 Variations in study samples, evolving measures of functional limitation and disability, and differences in study questions and responses contribute to the inconsistencies in disability trends.5^,6 Furthermore, disparities exist in the improvement in function, with marked variations according to age, gender, race, and socioeconomic and educational attainment.1^,9^,10 Compared with men, women report greater difficulty with physical function and less recovery from disability.1 Surveys have reported that declines in functional limitations occurred only among women11 or were larger among women than among men,12 whereas others note that disability declines were about the same among women and men.3^,13 Thus, it remains unclear if the disability gaps between men and women have narrowed or remained stable over time.4The causes for the improved disability trends are not well understood. One possible explanation is the “compression of morbidity” hypothesis, whereby disease and disability are postponed until the end of the lifespan.14^,15 However, the consequences of an increase in life expectancy in the United States in relation to the overall health of older adults continue to be debated. Other divergent paradigms have been proposed to describe the possible health-related consequences of living longer, including a rise in chronic disease and disability16 and a dynamic equilibrium whereby declines in mortality result in increases in chronic disease with lesser severity and disability.17^,18We obtained self-reported information on functional limitations and physical disability among surviving members of the original cohort of the Framingham Heart Study in late life (aged 79–88 years) who attended research examinations over 3 points in time from the 1970s to the 1990s. We hypothesized that the prevalence of functional limitations and physical disability would decline over time among elders, with a greater decline among women than among men. Our study cohort is particularly well suited for this investigation, because the Framingham Disability Study19 introduced questionnaires to measure self-reported functional limitations and physical disability beginning in 1976 that were repeated on successive examinations. Moreover, this cohort has been well characterized for over 50 years, with documentation of validated medical conditions and measurement of risk factors.     

Educational disparities in rates of smoking among diabetic adults: the translating research into action for diabetes study

Objectives. We assessed educational disparities in smoking rates among adults with diabetes in managed care settings.Methods. We used a cross-sectional, survey-based (2002–2003) observational study among 6538 diabetic patients older than 25 years across multiple managed care health plans and states. For smoking at each level of self-reported educational attainment, predicted probabilities were estimated by means of hierarchical logistic regression models with random intercepts for health plan, adjusted for potential confounders.Results. Overall, 15% the participants reported current smoking. An educational gradient in smoking was observed that varied significantly (P<.003) across age groups, with the educational gradient being strong in those aged 25 to 44 years, modest in those aged 45 to 64 years, and nonexistent in those aged 65 years or older. Of particular note, the prevalence of smoking observed in adults aged 25–44 years with less than a high school education was 50% (95% confidence interval: 36% to 63%).Conclusions. Approximately half of poorly educated young adults with diabetes smoke, magnifying the health risk associated with early-onset diabetes. Targeted public health interventions for smoking prevention and cessation among young, poorly educated people with diabetes are needed.Smoking is recognized as the leading preventable cause of death and one of the most potent risk factors for cardiovascular disease and cancer. The total annual direct and indirect costs of smoking in the United States for 1995–1999 were estimated to be $158 billion.1 In the United States during 1997–2001, cigarette smoking and tobacco exposure resulted in approximately 438000 premature deaths, 5.5 million years of potential life lost, and $92 billion in productivity losses annually.2 Diabetes confers a similar burden in annual health care expenditures ($132 billion).3Smoking may be a particularly important risk multiplier for adults with diabetes, because it is associated with hyperglycemia, microvascular complications, insulin resistance, and microalbuminuria4^–6 and greatly increases an already elevated risk of cardiovascular disease,7^,8 end-stage renal disease,9^,10 and death.11^,12 Moreover, although quitting smoking reduces the mortality risk, the detrimental effects can persist for years after quitting, especially for smokers with diabetes.13In the general patient population, poverty and lower educational attainment are linked to a higher prevalence of smoking.14 Nonetheless, relatively little is known about smoking patterns among adults with diabetes and, in particular, about the influence of social disparities, such as educational differences, on the prevalence of smoking in this group. Understanding which subpopulations are most at risk for smoking would help health plans and policymakers target their smoking cessation and prevention interventions among enrollees with diabetes.Translating Research Into Action for Diabetes (TRIAD) is an ongoing study of quality of care and self-care for people with diabetes in managed care settings in 7 US states that began in 2000.15 As part of TRIAD, we examined the relation between socioeconomic status and various health behaviors among people with diabetes. TRIAD surveyed a large cohort of adults with diabetes enrolled in managed care, enabling a detailed examination of smoking and social factors in addition to other factors that contribute to risk for future complications. Here we focus on the relation between educational attainment and smoking.     

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.