Contribution of Etiologic Cofactors to CIN3+ Risk Among Women With Human Papillomavirus-Positive Screening Test Results.

OBJECTIVE: The US screening and management guidelines for cervical cancer are based on the absolute risk of precancer estimated from large clinical cohorts and trials. Given the widespread transition toward screening with human papillomavirus (HPV) testing, it is important to assess which additional factors to include in clinical risk assessment to optimize management of HPV-infected women. MATERIALS AND METHODS: We analyzed data from HPV-infected women, ages 30-65 years, in the National Cancer Institute-Kaiser Permanente Northern California Persistence and Progression study. We estimated the influence of HPV risk group, cytology result, and selected cofactors on immediate risk of cervical intraepithelial neoplasia grade 3 or higher (CIN 3+) among 16,094 HPV-positive women. Cofactors considered included, age, race/ethnicity, income, smoking, and hormonal contraceptive use. RESULTS: Human papillomavirus risk group and cytology test result were strongly correlated with CIN 3+ risk. After considering cytology and HPV risk group, other cofactors (age, race/ethnicity, income, smoking, and hormonal contraceptive use) had minimal impact on CIN 3+ risk and did not change recommended management based on accepted risk thresholds. We had insufficient data to assess the impact of long-duration heavy smoking, parity, history of sexually transmitted infection, or immunosuppression. CONCLUSIONS: In our study at the Kaiser Permanente Northern California, the risk of CIN 3+ was determined mainly by HPV risk group and cytology results, with other cofactors having limited impact in adjusted analyses. This supports the use of HPV and cytology results in risk-based management guidelines.

Utilizing Student Health and Academic Data: A County-Level Demonstration Project.

Students with chronic health conditions miss more school days than their peers and are at increased risk for performing worse on standardized tests and not completing a high school degree. University-based researchers, state government leaders, and a local county school system collaborated to use existing health and academic data to (1) evaluate the strength of the relationship between health status and school performance (absenteeism, grades) and (2) describe the health status of students who are chronically absent. Analyses included descriptive statistics, chi-square tests, negative binomial regression models, and estimated marginal means. The most common health conditions among the 3,663 kindergarten through Grade 12 students were ADD (attention deficit disorder)/ADHD (attention deficit hyperactivity disorder), asthma, migraine headaches, mental health conditions, and eczema/psoriasis/skin disorders. After controlling for covariates, having asthma or a mental health diagnosis was positively associated with absences; and having an ADD/ADHD or mental health diagnosis was negatively associated with GPA (grade point average). Chronically absent students had significantly lower GPAs, and a higher number of health conditions than other students. The success of this demonstration project encourages strengthening existing collaborations and establishing new multidisciplinary partnerships to analyze existing data sources to learn more about the relationship between student health and academic achievement. Moreover, connecting health status to academic achievement might be a chief tactic for advocating for additional resources to improve the care and management of chronic disease conditions among students.

A study of type-specific HPV natural history and implications for contemporary cervical cancer screening programs.

BACKGROUND: HPV testing is replacing cytology for cervical cancer screening because of greater sensitivity and superior reassurance following negative tests for the dozen HPV genotypes that cause cervical cancer. Management of women testing positive is unresolved. The need for identification of individual HPV genotypes for clinical use is debated. Also, it is unclear how long to observe persistent infections when precancer is not initially found. METHODS: In the longitudinal NCI-Kaiser Permanente Northern California Persistence and Progression (PaP) Study, we observed the clinical outcomes (clearance, progression to CIN3+, or persistence without progression) of 11,573 HPV-positive women aged 30-65 yielding 14,158 type-specific infections. FINDINGS: Risks of CIN3+ progression differed substantially by type, with HPV16 conveying uniquely elevated risk (26% of infections with seven-year CIN3+ risk of 22%). The other carcinogenic HPV types fell into 3 distinct seven-year CIN3+ risk groups: HPV18, 45 (13% of infections, risks >5%, with known elevated cancer risk); HPV31, 33, 35, 52, 58 (39%, risks >5%); and HPV39, 51, 56, 59, 68 (23%, risks <5%). In the absence of progression, HPV clearance rates were similar by type, with 80% of infections no longer detected within three years; persistence to seven years without progression was uncommon. The predictive value of abnormal cytology was most evident for prevalent CIN3+, but less evident in follow-up. A woman's age did not modify risk; rather it was the duration of persistence that was important. INTERPRETATION: HPV type and persistence are the major predictors of progression to CIN3+; at a minimum, distinguishing HPV16 is clinically important. Dividing the other HPV types into three risk-groups is worth considering.

Need for ensuring cultural competence in medical programmes of European universities.

BACKGROUND: Europe is becoming more social and cultural diverse as a result of the increasing migration, but the medical doctors are largely unprepared. The medical education programmes and teachers have not evolved in line with development of the population. Culturally competent curricula and teachers are needed, to ensure cultural competence among medical doctors and to tackle inequalities in health between different ethnic groups. The objective of this EU financed study is therefore to provide a snapshot of the role of cultural competence in European medical educational programmes. METHODS: A questionnaire was developed in order to uncover strengths and weaknesses regarding cultural competence in the European medical education programmes. The questionnaire consisted of 32 questions. All questions had an evidence box to support the informants' understanding of the questions. The questionnaire was sent by email to the 12 European project partners. 12 completed questionnaires were returned. RESULTS: Though over half of the participating medical programmes have incorporated how to handle social determinants of health in the curriculum most are lacking focus on how medical professionals' own norms and implicit attitudes may affect health care provision as well as abilities to work effectively with an interpreter. Almost none of the participating medical programmes evaluate the students on cultural competence learning outcomes. Most medical schools participating in the survey do not offer cultural competence training for teachers, and resources spent on initiatives related to cultural competences are few. Most of the participating medical programmes acknowledge that the training given to the medical students is not adequate for future jobs in the health care service in their respective country regarding cultural competence. CONCLUSIONS: Our results indicate that there are major deficiencies in the commitment and practice within the participating educational programs and there are clear potentials for major improvements regarding cultural competence in programmes. Key challenges include making lasting changes to the curriculum and motivating and engaging stakeholders (teachers, management etc.) within the organisation to promote and allocate resources to cultural competence training for teachers.

Case-crossover analysis of short-term particulate matter exposures and stroke in the health professionals follow-up study.

BACKGROUND: Stroke is a leading cause of morbidity and mortality in the United States. Associations between short-term exposures to particulate matter (PM) air pollution and stroke are inconsistent. Many prior studies have used administrative and hospitalization databases where misclassification of the type and timing of the stroke event may be problematic. METHODS: In this case-crossover study, we used a nationwide kriging model to examine short-term ambient exposure to PM10 and PM2.5 and risk of ischemic and hemorrhagic stroke among men enrolled in the Health Professionals Follow-up Study. Conditional logistic regression models were used to obtain estimates of odds ratios (OR) and 95% confidence intervals (CI) associated with an interquartile range (IQR) increase in PM2.5 or PM10. Lag periods up to 3 days prior to the stroke event were considered in addition to a 4-day average. Stratified models were used to examine effect modification by patient characteristics. RESULTS: Of the 727 strokes that occurred between 1999 and 2010, 539 were ischemic and 122 were hemorrhagic. We observed positive statistically significant associations between PM10 and ischemic stroke (ORlag0-3 = 1.26; 95% CI: 1.03-1.55 per IQR increase [14.46 µg/m3]), and associations were elevated for nonsmokers, aspirin nonusers, and those without a history of high cholesterol. However, we observed no evidence of a positive association between short-term exposure to PM and hemorrhagic stroke or between PM2.5 and ischemic stroke in this cohort. CONCLUSIONS: Our study provides evidence that ambient PM10 may be associated with higher risk of ischemic stroke and highlights that ischemic and hemorrhagic strokes are heterogeneous outcomes that should be treated as such in analyses related to air pollution.

Validation of a Human Papillomavirus (HPV) DNA Cervical Screening Test That Provides Expanded HPV Typing.

As cervical cancer screening shifts from cytology to human papillomavirus (HPV) testing, a major question is the clinical value of identifying individual HPV types. We aimed to validate Onclarity (Becton Dickinson Diagnostics, Sparks, MD), a nine-channel HPV test recently approved by the FDA, by assessing (i) the association of Onclarity types/channels with precancer/cancer; (ii) HPV type/channel agreement between the results of Onclarity and cobas (Roche Molecular Systems, Pleasanton, CA), another FDA-approved test; and (iii) Onclarity typing for all types/channels compared to typing results from a research assay (linear array [LA]; Roche). We compared Onclarity to histopathology, cobas, and LA. We tested a stratified random sample (n = 9,701) of discarded routine clinical specimens that had tested positive by Hybrid Capture 2 (HC2; Qiagen, Germantown, MD). A subset had already been tested by cobas and LA (n = 1,965). Cervical histopathology was ascertained from electronic health records. Hierarchical Onclarity channels showed a significant linear association with histological severity. Onclarity and cobas had excellent agreement on partial typing of HPV16, HPV18, and the other 12 types as a pool (sample-weighted kappa value of 0.83); cobas was slightly more sensitive for HPV18 and slightly less sensitive for the pooled high-risk types. Typing by Onclarity showed excellent agreement with types and groups of types identified by LA (kappa values from 0.80 for HPV39/68/35 to 0.97 for HPV16). Onclarity typing results corresponded well to histopathology and to an already validated HPV DNA test and could provide additional clinical typing if such discrimination is determined to be clinically desirable.

Science, Politics, and Communication: The Case of Community Water Fluoridation in the US.

Community water fluoridation (CWF) and its effect in reducing the burden of dental caries (tooth decay) is considered one of the 10 public health achievements in the 20th century. In the U.S., three-quarters (74.4%) of people on community water supplies have optimally fluoridated water, and each year approximately 90 communities actively consider starting or discontinuing CWF. CWF exists within the policy environment and includes actions taken by local community councils, health and water boards, and groups; state legislatures and health departments; national regulatory and science agencies; independent science entities; and professional and nonprofit organizations. Epidemiologists have been in the forefront of CWF. Experience with the past 70 years reveals that the coming decades will bring additional questions, recommendations, and challenges for CWF. The continued involvement of epidemiologists as part of multidisciplinary teams is needed in research, surveillance, peer review of studies, assessment of systematic review findings, and in the translation and communication of science findings to audiences with limited science/health literacy. This chapter's purpose is to 1) examine how epidemiologic evidence regarding CWF has been translated into practice and policy, 2) examine how recommendations for and challenges to CWF have affected epidemiologic research and community decision-making, and 3) identify lessons learned for epidemiologists.

Addressing refugee health through evidence-based policies: a case study.

The cumulative total of persons forced to leave their country for fear of persecution or organized violence reached an unprecedented 24.5 million by the end of 2015. Providing equitable access to appropriate health services for these highly diverse newcomers poses challenges for receiving countries. In this case study, we illustrate the importance of translating epidemiology into policy to address the health needs of refugees by highlighting examples of what works as well as identifying important policy-relevant gaps in knowledge. First, we formed an international working group of epidemiologists and health services researchers to identify available literature on the intersection of epidemiology, policy, and refugee health. Second, we created a synopsis of findings to inform a recommendation for integration of policy and epidemiology to support refugee health in the United States and other high-income receiving countries. Third, we identified eight key areas to guide the involvement of epidemiologists in addressing refugee health concerns. The complexity and uniqueness of refugee health issues, and the need to develop sustainable management information systems, require epidemiologists to expand their repertoire of skills to identify health patterns among arriving refugees, monitor access to appropriately designed health services, address inequities, and communicate with policy makers and multidisciplinary teams.

Association of Types of Life Events with Depressive Symptoms among Puerto Rican Youth.

The main objective of this study was to examine the association between four types of adverse life events (family environment, separation, social adversity, and death) and the development of depressive symptoms among Puerto Rican youth. This was a secondary analysis using three waves (2000-2004) of interview data from the Boricua Youth Study of 10-13 year old Puerto Rican youth residing in New York and Puerto Rico with no depressive symptoms at baseline (n = 977). Depressive symptoms increased with an increase in social adversity, separation, death, and death events. Youth support from parents was a significant protective factor for all adverse events and parent coping was a protective factor in social adversity events. Relying on standard diagnostic tools is ideal to identify youth meeting the criteria for a diagnosis of depression but not useful to detect youth who present with subclinical levels of depression. Youth with sub-clinical levels of depression will not get treated and are at increased risk of developing depression later in life. Adverse life events are potentially relevant to use in conjunction with other screening tools to identify Puerto Rican youth who have subclinical depression and are at risk of developing depression in later adolescence.

United States National Pain Strategy for Population Research: Concepts, Definitions, and Pilot Data.

UNLABELLED: National Pain Strategy population research objectives include: estimating chronic pain prevalence, studying pain treatment with electronic health care data, and developing metrics to assess progress in reducing chronic pain impact. In this article, the National Pain Strategy Population Research Workgroup reviews concepts relevant to achieving these aims. High-impact chronic pain was defined as persistent pain with substantial restriction of life activities lasting 6 months or more. In pilot work, we tested a brief assessment of high-impact chronic pain, and used electronic health records data to describe pain-related health care. A mail survey of adult health plan enrollees (N = 770) reported that 14% had high-impact chronic pain. Relative to persons with lower-impact chronic pain, those with high-impact chronic pain were more often frequent users of health care for pain, reported lower quality of life, greater pain-related interference with activities, and more often reported pain at multiple anatomic locations. Analyses of health care data (N = 289,464) reported that pain patients had higher health care costs compared with others and that pain services were typically delivered in primary care. These results support the feasibility of developing data on chronic pain through national health interview surveys and large electronic health care databases. PERSPECTIVE: Pilot analyses supported the feasibility of brief chronic pain assessments suitable for national health surveys and use of electronic health care databases to develop data regarding trends in the delivery of pain treatments, costs, and effectiveness. These methods are relevant to achieving the aims of the US National Pain Strategy.

Association of child maltreatment and depressive symptoms among Puerto Rican youth.

This article compares multiple types of child maltreatment among Puerto Rican youth. We seek to expand the limited knowledge of the effects of multiple types of maltreatment on depressive symptoms in a specific Latino population as emerging studies indicate that children who are exposed to one type of maltreatment are often exposed to other types. This study examines the predictive strength of different and multiple types of lifetime child maltreatment (i.e., physical, sexual, and emotional abuse; and neglect), and the effect of youth support from parents, youth coping, youth self-esteem, and place of residence on depressive symptoms among Puerto Rican youth. Secondary data analyses were performed using three annual waves (2000-2004) of data from the Boricua Youth Study. The analytic sample consists of 1041 10-13 year old Puerto Rican youth living in New York and Puerto Rico. Results indicate that: (1) youth who experienced 'sexual abuse only', 'multiple maltreatment' (2 or more types of maltreatment), 'physical abuse only' have a significant increase in depressive symptoms (75.1%, 61.6%, and 40.5% respectively) compared to those without maltreatment; and (2) place of residence, exposure to violence, and mental disorders were significant risk factors. When developing psychosocial interventions, professionals should particularly focus on youth who report past lifetime experience with child maltreatment. Particular attention should be given to children living in the Bronx, New York and similar urban low-income areas who report past lifetime experience with multiple types of child maltreatment and who present symptoms or a diagnosis of co-occurring mental health problems.

Overweight status of the primary caregivers of orphan and vulnerable children in 3 Southern African countries: a cross sectional study.

BACKGROUND: Africa is facing a nutritional transition where underweight and overweight coexist. Although the majority of programs for orphan and vulnerable children (OVC) focus on undernourishment, the association between OVC primary caregiving and the caregivers' overweight status remains unclear. We investigated the association between OVC primary caregiving status with women's overweight status in Namibia, Swaziland and Zambia. METHODS: Demographic Health Survey (DHS) cross-sectional data collected during 2006-2007 were analyzed using weighted marginal means and logistic regressions. We analyzed data from 20-49 year old women in Namibia (N 6638), Swaziland (N 2875), and Zambia (N 4497). RESULTS: The overweight prevalence of the primary caregivers of OVC ranged from 27.0% (Namibia) to 61.3% (Swaziland). In Namibia, OVC primary caregivers were just as likely or even less likely to be overweight than other primary caregivers. In Swaziland and Zambia, OVC primary caregivers were just as likely or more likely to be overweight than other primary caregivers. In Swaziland and Zambia, OVC primary caregivers were more likely to be overweight than non-primary caregivers living with OVC (Swaziland AOR = 1.56, Zambia AOR = 2.62) and non-primary caregivers not living with OVC (Swaziland AOR = 1.92, Zambia AOR = 1.94). Namibian OVC caregivers were less likely to be overweight than non-caregivers not living with an OVC only in certain age groups (21-29 and 41-49 years old). CONCLUSIONS: African public health systems/OVC programs may face an overweight epidemic alongside existing HIV/AIDS, tuberculosis and malaria epidemics. Future studies/interventions to curb overweight should consider OVC caregiving status and address country-level differences.

Associations Between Orphan and Vulnerable Child Caregiving, Household Wealth Disparities, and Women's Overweight Status in Three Southern African Countries Participating in Demographic Health Surveys.

This study examines whether orphan and vulnerable children (OVC) primary caregivers are facing absolute household wealth (AWI) disparities, the association between AWI and women's overweight status, and the modifying role of OVC primary caregiving status on this relationship. Demographic Health Surveys data (2006-2007) from 20 to 49 year old women in Namibia (n = 6,305), Swaziland (n = 2,786), and Zambia (n = 4,389) were analyzed using weighted marginal means and logistic regressions. OVC primary caregivers in Namibia and Swaziland had a lower mean AWI than other women in the same country. In Zambia, OVC primary caregivers had a lower mean AWI score than non-primary caregivers living with an OVC but a higher mean AWI score than non-OVC primary caregivers. In Swaziland and Zambia, even small increases in household wealth were associated with higher odds for being overweight regardless of women's caregiving status. Only in Namibia, OVC primary caregiving modified the effect of the previous association. Among Namibian OVC primary caregivers, women who had at least medium household wealth (4 or more AWI items) were more likely to be overweight than their poorest counterparts (0 or 1 AWI items). OVC primary caregivers are facing household wealth disparities as compared to other women from their communities. Future studies/interventions should consider using population-based approaches to reach women from every household wealth level to curb overweight in Swaziland and Zambia and to focus on specific household wealth characteristics that are associated with OVC primary caregivers' overweight status in Namibia.

Association of school social networks' influence and mass media factors with cigarette smoking among asthmatic students.

BACKGROUND: Around 10% of adolescent students under 18 years have current asthma. Asthmatic adolescents smoke as much or more than non-asthmatic adolescents. We explored the association between exposure to mass media and social networks' influence with asthmatic student smoking, and variations of these exposures by sex. METHODS: This study included 9755 asthmatic and 38,487 non-asthmatic middle and high school students. Secondary data analysis incorporated the complex sample design; and univariate, bivariate, and logistic regression statistics. RESULTS: Asthmatic students had greater odds of smoking than non-asthmatic students. Asthmatic female students were more likely than asthmatic male students to have been exposed to secondhand smoke in rooms or cars and to smoking actors, but less likely to associate smoking with intent to wear tobacco-marketing products, or with looking cool/fitting in. Asthmatic male and female students, who have smoking friends, were exposed to secondhand smoke in rooms (only girls) or cars, intended to smoke if best friends offered cigarettes, or received/bought tobacco marketing products had greater odds of smoking than other asthmatic students. CONCLUSIONS: The observed associations suggest the need for general interventions to reduce middle and high school students' cigarette smoking as well as targeted interventions for asthmatic adolescent students.

Parallel tracks: reflections on the need for collaborative health disparities research on race/ethnicity and disability.

Public policy driving health disparities research has overwhelmingly focused on racial and ethnic populations other than non-Hispanic whites; these groups have historically been and continue to be disproportionately impacted by health disparities. Only recently has public policy focused on the inclusion of people with disabilities as a distinct health disparities population. These 2 areas of research have traveled parallel paths with little recognition of the health disparities that affect people at the intersection of race, ethnicity, and disability. This commentary reflects on the history, foci, and current status of these 2 separate tracks of health disparities research. We conclude the commentary with suggestions for merging the 2 tracks to develop research that addresses both disability as well as race and ethnicity.

Orphan/vulnerable child caregiving moderates the association between women's autonomy and their BMI in three African countries.

Enhancement of women's autonomy is a key factor for improving women's health and nutrition. With nearly 12 million orphan and vulnerable children (OVC) in Africa due to HIV/AIDS, the study of OVC primary caregivers' nutrition is fundamental. We investigated the association between married women's autonomy and their nutritional status; explored whether this relationship was modified by OVC primary caregiving; and analyzed whether decision-making autonomy mediated the association between household wealth and body mass index (BMI). This cross-sectional study used the data from Demographic Health Surveys collected during 2006-2007 from 20- to 49-year-old women in Namibia (n = 2633), Swaziland (n = 1395), and Zambia (n = 2920). Analyses included logistic regression, Sobel, and Goodman tests. Our results indicated that women's educational attainment increased the odds for being overweight (Swaziland and Zambia) and decreased the odds for being underweight (Namibia). In Zambia, having at least primary education increased the odds for being overweight only among child primary caregivers regardless of the OVC status of the child, and having autonomy for buying everyday household items increased the odds for being overweight only among OVC primary caregivers. Decision-making autonomy mediated the association between household wealth and OVC primary caregivers' BMI in Zambia (Z = 2.13, p value = 0.03). We concluded that depending on each country's contextual characteristics, having education can decrease the odds for being an underweight woman or increase the odds for being an overweight woman. Further studies should explore why in Namibia education has an effect on women's overweight status only among women who are caring for a child.

Greater dietary acculturation (dietary change) is associated with poorer current self-rated health among African immigrant adults.

OBJECTIVE: Investigate the relationship between dietary acculturation and current self-rated health (SRH) among African immigrants, by country or region of origin. DESIGN: Cross-sectional, mixed-methods design using baseline data from longitudinal study of immigrants granted legal permanent residence May to November, 2003, and interviewed June, 2003 to June, 2004. SETTING: 2003 New Immigrant Survey. PARTICIPANTS: African immigrants from a nationally representative sample (n = 763) averaged 34.7 years of age and 5.5 years' US residency; 56.6% were male, 54.1% were married, 26.1% were Ethiopian, and 22.5% were Nigerian. MAIN OUTCOME MEASURE(S): Current SRH (dependent variable) was measured using 5-point Likert scale questions; dietary acculturation (independent variable) was assessed using a quantitative dietary change scale. ANALYSIS: Multivariate logistic regression tested the relationship of dietary acculturation with current SRH (α = .05; P < .05 considered significant); exploratory qualitative subset dietary analysis (n = 60) examined food/beverages consumed pre-/post-migration. RESULTS: African immigrants reporting moderate dietary change since arrival in the US had higher odds of poorer SRH status than immigrants reporting low dietary change (odds ratio, 1.903; 95% confidence interval, 1.143-3.170; P = .01). Among most dietary change groups, there was an increase in fast food consumption and decrease in fruit and vegetable consumption. CONCLUSIONS AND IMPLICATIONS: Nutrition educators and public health practitioners should develop targeted nutrition education for African immigrants who are older, less educated, and at increased health risk.

Is depression associated with contraceptive motivations, intentions, and use among a sample of low-income Latinas?

BACKGROUND: Latinas in the United States experience high rates of unintended pregnancy and low rates of contraception use, yet reasons are not completely understood. Depression is common among pregnant and nonpregnant Latinas; its influence on contraceptive motivations, intentions, and use is understudied. OBJECTIVES: We sought to 1) describe Latinas' contraceptive motivations, intentions, and use; 2) use structural equation modeling to test associations between depression and contraceptive self-efficacy/motivations/intentions/use; and 3) determine whether associations differ by pregnancy status. METHODS: This cross-sectional study included Latinas ages 15 to 45 recruited from an urban Federally Qualified Health Center in Baltimore, Maryland. Structured surveys were used to collect data regarding depressive symptoms measured using the PHQ-9. All other constructs were measured with previously validated questions. Constructs included contraceptive self-efficacy, positive and negative contraceptive motivations (perceived advantages and disadvantages of using contraception), contraceptive intentions to begin or continue contraception use, and contraceptive methods currently used. RESULTS: Among pregnant Latinas, depression was associated with negative motivations (ß = 0.16; p < .05), negative motivations were associated with intentions (ß = -0.22; p < .01), and contraceptive self-efficacy was associated with intentions (ß = 0.43; p < .001). Among nonpregnant Latinas, contraceptive self-efficacy was associated with intentions (ß = 0.78; p < .001) and intentions were associated with use (ß = 0.40; p < .05). CONCLUSIONS: Among pregnant Latinas, negative motivations intervene in the association between depression and contraceptive intentions. For nonpregnant Latinas, intentions intervene in the association between self-efficacy and contraceptive use. This study underscores the importance of depression screening during pregnancy and encourages practitioners to target contraceptive motivations to improve contraceptive use.