Behavioral assessments in Russian addiction treatment inpatients: a comparison of audio computer-assisted self-interviewing and interviewer-administered questionnaires.

PURPOSE: Assess agreement between reported sex and drug use behaviors from audio computer-assisted self-interviewing (ACASI) and interviewer-administered questionnaire (IAQ). METHOD: Participants (N = 180) enrolled in an HIV intervention trial in Russia completed ACASI and IAQ on the same day. Agreement between responses was evaluated. RESULTS: Of the 13 sex behavior questions, 10 items had excellent agreement (kappas/ICC 0.80-0.95) and 3 items had moderate agreement (kappas/ICC 0.59-0.75). The 3 drug behavior questions had excellent agreement (kappas/ICC 0.94-0.97). Among HIV-specific questions asked of HIV-positive participants (n = 21) only, 2 items had excellent agreement (kappas 1.0) and 3 items had moderate agreement (kappas 0.40-0.71). CONCLUSIONS: Assessment of drug and sex risk behaviors by ACASI and IAQ had generally strong agreement for the majority of items. The lack of discrepancy may result from these Russian subjects' perception that computers do not ensure privacy. Another potential explanatory factor is that both interviews were delivered on the same day. These data raise questions as to whether use of ACASI is uniformly beneficial in all settings, and what influence cultural factors have on its utility.

Mitigating risky sexual behaviors among Russian narcology hospital patients: the PREVENT (Partnership to Reduce the Epidemic Via Engagement in Narcology Treatment) randomized controlled trial.

AIM: To assess the effectiveness of a sexual risk reduction intervention in the Russian narcology hospital setting. DESIGN, SETTING AND PARTICIPANTS: This was a randomized controlled trial from October 2004 to December 2005 among patients with alcohol and/or heroin dependence from two narcology hospitals in St Petersburg, Russia. INTERVENTION: Intervention subjects received two personalized sexual behavior counseling sessions plus three telephone booster sessions. Control subjects received usual addiction treatment, which did not include sexual behavior counseling. All received a research assessment and condoms at baseline. MEASUREMENTS: Primary outcomes were percentage of safe sex episodes (number of times condoms were used / by number of sexual episodes) and no unprotected sex (100% condom use or abstinence) during the previous 3 months, assessed at 6 months. FINDINGS: Intervention subjects reported higher median percentage of safe sex episodes (unadjusted median difference 12.7%; P = 0.01; adjusted median difference 23%, P = 0.07); a significant difference was not detected for the outcome no unprotected sex in the past 3 months [unadjusted odds ratio (OR) 1.6, 95% confidence interval (CI) 0.8-3.1; adjusted OR 1.5, 95% CI 0.7-3.3]. CONCLUSIONS: Among Russian substance-dependent individuals, sexual behavior counseling during addiction treatment should be considered as one potential component of efforts to decrease risky sexual behaviors in this HIV at-risk population.

Household food insecurity: associations with at-risk infant and toddler development.

OBJECTIVES: In this study, we evaluated the relationship between household food security status and developmental risk in young children, after controlling for potential confounding variables. METHODS: The Children's Sentinel Nutritional Assessment Program interviewed (in English, Spanish, or Somali) 2010 caregivers from low-income households with children 4 to 36 months of age, at 5 pediatric clinic/emergency department sites (in Arkansas, Massachusetts, Maryland, Minnesota, and Pennsylvania). Interviews included demographic questions, the US Food Security Scale, and the Parents' Evaluations of Developmental Status. The target child from each household was weighed, and weight-for-age z score was calculated. RESULTS: Overall, 21% of the children lived in food-insecure households and 14% were developmentally "at risk" in the Parents' Evaluations of Developmental Status assessment. In logistic analyses controlling for interview site, child variables (gender, age, low birth weight, weight-for-age z score, and history of previous hospitalizations), and caregiver variables (age, US birth, education, employment, and depressive symptoms), caregivers in food-insecure households were two thirds more likely than caregivers in food-secure households to report that their children were at developmental risk. CONCLUSIONS: Controlling for established correlates of child development, 4- to 36-month-old children from low-income households with food insecurity are more likely than those from low-income households with food security to be at developmental risk. Public policies that ameliorate household food insecurity also may improve early child development and later school readiness.

Breastfeeding and health outcomes among citizen infants of immigrant mothers.

OBJECTIVE: To examine the associations between breastfeeding and child health outcomes among citizen infants of mothers immigrant to the United States. DESIGN/METHODS: From September 1998 through June 2004, as part of the Children's Sentinel Nutrition Assessment Program, a sentinel sample of 3,592 immigrant mothers with infants aged 0 to 12 months were interviewed in emergency departments or pediatric clinics in six sites. Mothers reported breastfeeding history, child health history, household demographics, government assistance program participation, and household food security. Infants' weight and length were recorded at the time of visit. Bivariate analyses identified confounders associated with breastfeeding and outcomes, which were controlled in logistic regression. Additional logistic regressions examined whether food insecurity modified the relationship between breastfeeding and child outcomes. RESULTS: Eighty-three percent of infants of immigrants initiated breastfeeding. Thirty-six percent of immigrant households reported household food insecurity. After controlling for potential confounding variables, breastfed infants of immigrant mothers were less likely to be reported in fair/poor health (adjusted odds ratio [AOR] 0.65, 95% confidence interval [CI] 0.50 to 0.85; P=0.001) and less likely to have a history of hospitalizations (AOR 0.72, CI 0.56 to 0.93, P=0.01), compared to nonbreastfed infants of immigrant mothers. Compared to nonbreastfed infants, the breastfed infants had significantly greater weight-for-age z scores (0.185 vs 0.024; P=0.006) and length-for-age z scores (0.144 vs -0.164; P<0.0001), but there was no significant difference in risk of overweight (weight-for-age >95th percentile or weight-for-length >90th percentile) between the two groups (AOR 0.94, CI 0.73 to 1.21; P=0.63). Household food insecurity modified the association between breastfeeding and child health status, such that the associations between breastfeeding and child health were strongest among food-insecure households. CONCLUSIONS: Breastfeeding is associated with improved health outcomes for infants of immigrant mothers. Breastfeeding is an optimal strategy in the first year of life to improve all infants' health and growth, especially for children of immigrants who are at greater risk for experiencing food insecurity.

Heat or eat: the Low Income Home Energy Assistance Program and nutritional and health risks among children less than 3 years of age.

OBJECTIVES: Public funding for the Low Income Home Energy Assistance Program has never been sufficient to serve more than a small minority of income-eligible households. Low Income Home Energy Assistance Program funding has not increased with recent rapidly rising energy costs, harsh winter conditions, or higher child poverty rates. Although a national performance goal for the Low Income Home Energy Assistance Program is to increase the percentage of recipient households having > or = 1 member < or = 5 years of age, the association of income-eligible households' receipt of the Low Income Home Energy Assistance Program with indicators of well-being in young children has not been evaluated previously. The goal of the current study was to evaluate the association between a family's participation or nonparticipation in the Low Income Home Energy Assistance Program and the anthropometric status and health of their young children. METHODS: In the ongoing Children's Sentinel Nutrition Assessment Project from June 1998 through December 2004, caregivers with children < 3 years of age in 2 emergency departments and 3 primary care clinics in 5 urban sites participated in cross-sectional surveys regarding household demographics, child's lifetime history of hospitalizations, and, for the past 12 months, household public assistance program participation and household food insecurity, measured by the US Food Security Scale. This scale, in accordance with established procedures, classifies households as food insecure if they report that they cannot afford enough nutritious food for all of the members to lead active, healthy lives. On the day of the interview, children's weight, length, and whether the children were admitted acutely to the hospital from the emergency departments were documented. The study sample consisted only of Low Income Home Energy Assistance Program income-eligible renter households without private insurance who also participated in > or = 1 other means-tested program. RESULTS: In this sample of 7074 caregivers, 16% of families received the Low Income Home Energy Assistance Program, similar to the national rate of 17%. Caregivers who received the Low Income Home Energy Assistance Program were more likely to be single (63% vs 54%), US born (77% vs 68%), and older (mother's mean age: 28.1 vs 26.7 years) but were less likely to be employed (44% vs 47%). Households who received the Low Income Home Energy Assistance Program were more likely to receive Supplemental Nutrition Program for Women, Infants, and Children (85% vs 80%), Supplemental Security Income (13% vs 9%), Temporary Assistance for Needy Families (38% vs 23%), and food stamps (59% vs 37%) and to live in subsidized housing (38% vs 19%) compared with nonrecipients. Children in families participating in the Low Income Home Energy Assistance Program were older than children in nonparticipating families (13.6 vs 12.5 months), were less likely to be uninsured (5% vs 9%), and were more likely to have had a low birth weight < or = 2500 g (17% vs 14%). Families participating in the Low Income Home Energy Assistance Program reported more household food insecurity (24% vs 20%) There were no significant group differences between recipients and nonrecipients in caregiver's education or child's gender. After controlling for these potentially confounding variables, including receipt of other means-tested programs, compared with children in recipient households, those in nonrecipient households had greater adjusted odds of being at aggregate nutritional risk for growth problems, defined as children with weight-for-age below the 5th percentile or weight-for-height below the 10th percentile, with significantly lower mean weight-for-age z scores calculated from age- and gender-specific values from the Centers for Disease Control and Prevention 2000 reference data. However, in adjusted analyses, children aged 2 to 3 years in recipient households were not more likely to be overweight (BMI > 95th percentile) than those in nonrecipient households. Rates of age-adjusted lifetime hospitalization excluding birth and the day of the interview did not differ between Low Income Home Energy Assistance Program recipient groups. Among the 4445 of 7074 children evaluated in the 2 emergency departments, children from eligible households not receiving the Low Income Home Energy Assistance Program had greater adjusted odds than those in recipient households of acute hospital admission on the day of the interview. CONCLUSIONS: Even within a low-income renter sample, Low Income Home Energy Assistance Program benefits seem to reach families at the highest social and medical risk with more food insecurity and higher rates of low birth-weight children. Nevertheless, after adjustment for differences in background risk, living in a household receiving the Low Income Home Energy Assistance Program is associated with less anthropometric evidence of undernutrition, no evidence of increased overweight, and lower odds of acute hospitalization from an emergency department visit among young children in low-income renter households compared with children in comparable households not receiving the Low Income Home Energy Assistance Program. The Low Income Home Energy Assistance Program in many states shuts down early each winter when their funding is exhausted. From a clinical perspective, pediatric health providers caring for children from impoverished families should consider encouraging families of these children to apply for the Low Income Home Energy Assistance Program early in the season before funding is depleted. From a public policy perspective, although this cross-sectional study design can only demonstrate associations and not causation, these findings suggest that, particularly as fuel costs and children's poverty rates increase, expanding the Low Income Home Energy Assistance Program funding and meeting the national Low Income Home Energy Assistance Program performance goal of increasing the percentage of recipient households with young children might potentially benefit such children's growth and health.

Barriers to following the supine sleep recommendation among mothers at four centers for the Women, Infants, and Children Program.

OBJECTIVES: The risk for sudden infant death syndrome in black infants is twice that of white infants, and their parents are less likely to place them in the supine position for sleep. We previously identified barriers for parents to follow recommendations for sleep position. Our objective with this study was to quantify these barriers, particularly among low-income, primarily black mothers. DESIGN/METHODS: We conducted face-to-face interviews with 671 mothers, 64% of whom were black, who attended Women, Infants, and Children Program centers in Boston, Massachusetts, Dallas, Texas, Los Angeles, California, and New Haven, Connecticut. We used univariate analyses to quantify factors that were associated with choice of sleeping position and multivariate logistic regression to calculate adjusted odds ratios for the 2 outcome variables: "ever" (meaning usually, sometimes, or last night) put infant in the prone position for sleep and "usually" put infant in the supine position to sleep. RESULTS: Fifty-nine percent of mothers reported supine, 25% side, 15% prone, and 1% other as the usual position. Thirty-four percent reported that they ever placed infants in the prone position. Seventy-two percent said that a nurse, 53% a doctor, and 38% a female friend or relative provided source of advice. Only 42% reported that a nurse, only 36% a doctor, and only 15% a female friend or relative recommended the supine position for sleep. When a female friend or relative recommended the prone position, mothers were more likely ever to place their infants in the prone position and less likely usually to choose supine compared with those who received no advice from friends or relatives. When a doctor or a nurse recommended a nonsupine position, the mothers were less likely to choose supine compared with those who received no advice from a doctor or a nurse. Mothers who trusted the opinion of a doctor or a nurse about infant sleeping position were more likely to place their infants in the supine position. Half of the mothers believed that infants were more likely to choke when supine, and they were less likely to place their infants supine. Mothers who believed that infants are more comfortable in the prone position (36%) were more likely to place their infants prone. Twenty-nine percent believed that having their infants sleep with an adult helps prevent sudden infant death syndrome, and only 43% believed that sudden infant death syndrome is related to sleeping position. CONCLUSIONS: We identified specific barriers to placing infants in the supine position for sleep (lack of or wrong advice, lack of trust in providers, knowledge and concerns about safety and comfort) in low-income, primarily black mothers that should be considered when designing interventions to get more infants onto their back for sleep.

Racial and ethnic differences in health and health care: lessons from an inner-city patient population actively using heroin and cocaine.

This study describes differences in health care utilization and recorded diagnoses in a racially and ethnically diverse sample of 1175 out-of-treatment patients who screened positive for heroin and cocaine use during an outpatient visit to a drop-in clinic at an urban hospital. Blacks averaged more ED visits than Whites and higher average yearly ED charges than Hispanics (1,991 dollars vs. 1,603 dollars). Charges over two years totaled 6,111,660 dollars. Blacks were most likely to be diagnosed with injury, hypertension, cardiac disease, alcohol abuse/dependency, and sexually transmitted disease, and least likely to be diagnosed with psychiatric disease. Hispanics were most likely to be diagnosed with HIV, dental disease and drug overdoses, and least likely to be injured. Only 34% of this group of drug users was identified with a diagnosis of drug abuse or dependency.

Child food insecurity increases risks posed by household food insecurity to young children's health.

The US Food Security Scale (USFSS) measures household and child food insecurity (CFI) separately. Our goal was to determine whether CFI increases risks posed by household food insecurity (HFI) to child health and whether the Food Stamp Program (FSP) modifies these effects. From 1998 to 2004, 17,158 caregivers of children ages 36 mo were interviewed in six urban medical centers. Interviews included demographics, the USFSS, child health status, and hospitalization history. Ten percent reported HFI, 12% HFI and CFI (H&CFI). Compared with food-secure children, those with HFI had significantly greater adjusted odds of fair/poor health and being hospitalized since birth, and those with H&CFI had even greater adverse effects. Participation in the FSP modified the effects of FI on child health status and hospitalizations, reducing, but not eliminating, them. Children in FSP-participating households that were HFI had lower adjusted odds of fair/poor health [1.37 (95% CI, 1.06-1.77)] than children in similar non-FSP households [1.61 (95% CI, 1.31-1.98)]. Children in FSP-participating households that were H&CFI also had lower adjusted odds of fair/poor health [1.72 (95% CI, 1.34-2.21)] than in similar non-FSP households [2.14 (95% CI, 1.81-2.54)]. HFI is positively associated with fair/poor health and hospitalizations in young children. With H&CFI, odds of fair/poor health and hospitalizations are even greater. Participation in FSP reduces, but does not eliminate, effects of FI on fair/poor health.

Predictors of disclosure of continued cocaine use.

Lack of disclosure of substance use is common in research and treatment settings and is frequently higher at follow-up than at baseline interviews. The aim of this study was to determine predictors of cocaine use disclosure at follow-up among 525 individuals who reported and tested positive for baseline use. Measurements included self-reported quantity and frequency of use, and hair analysis by radioimmune assay. Forty-two percent of individuals with biochemical evidence of continued cocaine use denied this use. In adjusted analyses, self-reported substance abuse treatment contact after enrollment was associated with lower disclosure (OR 0.63, 95% CI 0.43, 0.93). Other predictors were race, hair cocaine level, and opiates in hair. Failure to stop use after seeking treatment may result in reduced disclosure of continued use, possibly because of unwillingness to admit failure.

Racial and ethnic diversity among a heroin and cocaine using population: treatment system utilization.

Knowledge about the meanings and consequences of behaviors associated with drug use among diverse populations is essential for developing effective public health and clinical strategies. In this study we identify racial/ethnic variations in patterns of drug use, Addiction Severity Index (ASI) scores, response to intervention, concordance between self-report of drug use and biochemical confirmation, and treatment system contacts in a sample of 1175 out-of-treatment cocaine and heroin users drawn from a trial of brief motivation in the outpatient clinics of an inner-city academic hospital. Key differences were identified in drug of choice, in all of the ASI domains except medical, in validity of self-report of use, and in rate of treatment contact. Differences related to race and ethnicity should be evaluated to determine needs for a variety of substance abuse treatment modalities, assure timely access to culturally competent care, and develop policies that are tailored to real conditions.

Barriers to following the back-to-sleep recommendations: insights from focus groups with inner-city caregivers.

BACKGROUND: African American infants have a higher incidence of SIDS and increased risk of being placed in the prone position for sleep. OBJECTIVE: To determine new barriers and more information about previously identified barriers that interfere with adherence to the Back-to-Sleep recommendations among inner-city, primarily African Americans. DESIGN/METHODS: We conducted 9 focus groups with caregivers of infants and young children from women, infants, and children centers and clinics in New Haven and Boston. Themes were identified using standard qualitative techniques. RESULTS: Forty-nine caregivers participated, of whom 86% were African American, 6% were Hispanic, 4% were white, and 4% were other. Four themes were identified: 1) SAFETY: Participants chose the position for their infants based on which position they believed to be the safest. Some participants did not choose to put their infants in the supine position for sleep because they feared their infants would choke; 2) Advice: Participants relied on the advice of more experienced female family members. Health care providers were not uniformly a trusted source of advice; 3) Comfort: Participants made choices about their infants sleeping positions based on their perceptions of whether the infants appeared comfortable. Participants thought that their infants appeared more comfortable in the prone position; 4) Knowledge: Some participants had either limited or erroneous knowledge about the Back-to-Sleep recommendations. CONCLUSIONS: We identified multiple barriers to adherence to recommendations regarding infant sleep position. Data obtained from these focus groups could be used to design educational interventions aimed at improving communication about and adherence to the Back-to-Sleep recommendations.

Subsidized housing and children's nutritional status: data from a multisite surveillance study.

BACKGROUND: A critical shortage of affordable housing for low-income families continues in the United States. Children in households that are food insecure are at high risk for adverse nutritional and health outcomes and thus may be more vulnerable to the economic pressures exerted by high housing costs. Only about one fourth of eligible families receive a federally financed housing subsidy. Few studies have examined the effects of such housing subsidies on the health and nutritional status of low-income children. OBJECTIVE: To examine the relationship between receiving housing subsidies and nutritional and health status among young children in low-income families, especially those that are food insecure. DESIGN: Cross-sectional observational study. SETTING AND PARTICIPANTS: From August 1998 to June 2003, the Children's Sentinel Nutrition Assessment Program interviewed caregivers of children younger than 3 years in pediatric clinics and emergency departments in 6 sites (Arkansas, California, Maryland, Massachusetts, Minnesota, and Washington, DC). Interviews included demographics, perceived child health, the US Household Food Security Scale, and public assistance program participation. Children's weight at the time of the visit was documented. The study sample consisted of all renter households identified as low income by their participation in at least 1 means-tested program. MAIN OUTCOME MEASURES: Weight for age, self-reported child health status, and history of hospitalization. RESULTS: Data were available for 11 723 low-income renter families; 27% were receiving a public housing subsidy, and 24% were food insecure. In multivariable analyses, stratified by household food security status and adjusted for potential confounding variables, children of food-insecure families not receiving housing subsidies had lower weight for age (adjusted mean z score, -0.025 vs 0.205; P<.001) compared with children of food-insecure families receiving housing subsidies. Compared with children in food-insecure, subsidized families, the adjusted odds ratio (95% confidence interval) for weight-for-age z score more than 2 SDs below the mean was 2.11 (1.34-3.32) for children in food-insecure, nonsubsidized families. CONCLUSIONS: In a large convenience sentinel sample, the children of low-income renter families who receive public housing subsidies are less likely to have anthropometric indications of undernutrition than those of comparable families not receiving housing subsidies, especially if the family is not only low income but also food insecure.

Brief motivational intervention at a clinic visit reduces cocaine and heroin use.

BACKGROUND: Brief intervention is effective for alcohol misuse, but not adequately tested in the clinical setting with drug using patients. This study tested the impact of a single, structured encounter targeting cessation of drug use, conducted between peer educators and out-of-treatment cocaine and heroin users screened in the context of a routine medical visit. METHODS: A randomized, controlled trial was conducted in inner-city teaching hospital outpatient clinics with 3 and 6 months follow-up by blinded observers. Drug abstinence was documented by RIA hair testing. Analysis was limited to enrollees with drug-positive hair at baseline. RESULTS: Among 23,669 patients screened 5/98-11/00, 1232 (5%) were eligible, and 1175 enrolled. Enrollees (mean age 38 years) were 29% female, 62% non-hispanic black, 23% hispanic, 46% homeless. Among those with positive hair at entry, the follow-up rate was 82%. The intervention group was more likely to be abstinent than the control group for cocaine alone (22.3% versus 16.9%), heroin alone (40.2% versus 30.6%), and both drugs (17.4% versus 12.8%), with adjusted OR of 1.51-1.57. Cocaine levels in hair were reduced by 29% for the intervention group and only 4% for the control group. Reductions in opiate levels were similar (29% versus 25%). CONCLUSIONS: Brief motivational intervention may help patients achieve abstinence from heroin and cocaine.

Special Supplemental Nutrition Program for Women, Infants, and Children participation and infants' growth and health: a multisite surveillance study.

CONTEXT: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is the largest food supplement program in the United States, serving almost 7 500 000 participants in 2002. Because the program is a grant program, rather than an entitlement program, Congress is not mandated to allocate funds to serve all eligible participants. Little is known about the effects of WIC on infant growth, health, and food security. OBJECTIVE: To examine associations between WIC participation and indicators of underweight, overweight, length, caregiver-perceived health, and household food security among infants < or =12 months of age, at 6 urban hospitals and clinics. DESIGN AND SETTING: A multisite study with cross-sectional surveys administered at urban medical centers in 5 states and Washington, DC, from August 1998 though December 2001. PARTICIPANTS: A total of 5923 WIC-eligible caregivers of infants < or =12 months of age were interviewed at hospital clinics and emergency departments. MAIN OUTCOME MEASURES: Weight-for-age, length-for-age, weight-for-length, caregiver's perception of infant's health, and household food security. RESULTS: Ninety-one percent of WIC-eligible families were receiving WIC assistance. Of the eligible families not receiving WIC assistance, 64% reported access problems and 36% denied a need for WIC. The weight and length of WIC assistance recipients, adjusted for age and gender, were consistent with national normative values. With control for potential confounding family variables (site, housing subsidy, employment status, education, and receipt of food stamps or Temporary Assistance for Needy Families) and infant variables (race/ethnicity, birth weight, months breastfed, and age), infants who did not receive WIC assistance because of access problems were more likely to be underweight (weight-for-age z score = -0.23 vs 0.009), short (length-for-age z score = -0.23 vs -0.02), and perceived as having fair or poor health (adjusted odds ratio: 1.92; 95% confidence interval: 1.29-2.87), compared with WIC assistance recipients. Rates of overweight, based on weight-for-length of >95th percentile, varied from 7% to 9% and did not differ among the 3 groups but were higher than the 5% expected from national growth charts. Rates of food insecurity were consistent with national data for minority households with children. Families that did not receive WIC assistance because of access problems had higher rates of food insecurity (28%) than did WIC participants (23%), although differences were not significant after covariate control. Caregivers who did not perceive a need for WIC services had more economic and personal resources than did WIC participants and were less likely to be food-insecure, but there were no differences in infants' weight-for-age, perceived health, or overweight between families that did not perceive a need for WIC services and those that received WIC assistance. CONCLUSIONS: Infants < or =12 months of age benefit from WIC participation. Health care providers should promote WIC utilization for eligible families and advocate that WIC receive support to reduce waiting lists and eliminate barriers that interfere with access.

Food insecurity is associated with adverse health outcomes among human infants and toddlers.

The U.S. Household Food Security Scale, developed with federal support for use in national surveys, is an effective research tool. This study uses these new measures to examine associations between food insecurity and health outcomes in young children. The purpose of this study was to determine whether household food insecurity is associated with adverse health outcomes in a sentinel population ages < or = 36 mo. We conducted a multisite retrospective cohort study with cross-sectional surveys at urban medical centers in 5 states and Washington DC, August 1998-December 2001. Caregivers of 11,539 children ages < or = 36 mo were interviewed at hospital clinics and emergency departments (ED) in central cities. Outcome measures included child's health status, hospitalization history, whether child was admitted to hospital on day of ED visit (for subsample interviewed in EDs), and a composite growth-risk variable. In this sample, 21.4% of households were food insecure (6.8% with hunger). In a logistic regression, after adjusting for confounders, food-insecure children had odds of "fair or poor" health nearly twice as great [adjusted odds ratio (AOR) = 1.90, 95% CI = 1.66-2.18], and odds of being hospitalized since birth almost a third larger (AOR = 1.31, 95% CI = 1.16-1.48) than food-secure children. A dose-response relation appeared between fair/poor health status and severity of food insecurity. Effect modification occurred between Food Stamps and food insecurity; Food Stamps attenuated (but did not eliminate) associations between food insecurity and fair/poor health. Food insecurity is associated with health problems for young, low-income children. Ensuring food security may reduce health problems, including the need for hospitalizations.

Hair testing and self-report of cocaine use by heroin users.

AIM: Failure to disclose cocaine use can have a negative impact on medical care and research validity. This study was performed to identify predictors of cocaine non-disclosure among individuals who self-reported heroin use during a medical care encounter. DESIGN: A prospective comparison of self-report of cocaine use among heroin users and hair analysis for cocaine. SETTING: Four health-care clinics at an academic, inner-city hospital. PARTICIPANTS: Patients presenting for a health-care visit who were willing to self-report use of heroin and were not engaged in any form of drug treatment. MEASUREMENTS: (1) Self-report using standardized instruments: the Drug Addiction Severity Test (DAST), the Addiction Severity Index (ASI) and quantity/frequency questions for heroin and cocaine use. (2) Biochemical evidence: analysis of hair by radioimmunoassay (RIA) for cocaine and opiate levels. FINDINGS: Among 336 heroin users who tested positive for cocaine in hair, 34.2% did not report their recent cocaine use. The mean cocaine level for discordant individuals was significantly lower than for concordant individuals (109.6 ng/10 mg versus 470.57 ng/10 mg; P < 0.0001). Multivariate predictors of disclosure included opiate and cocaine levels in hair and the ASI drug severity subscore. CONCLUSIONS: Although self-report has been validated for treatment system patients, almost a third of the out-of-treatment heroin users in this medical clinic study failed to disclose concomitant cocaine use. The likelihood of non-disclosure was greatest for heavy users of heroin and light users of cocaine. Confirmation of self-report with biochemical analysis in the medical setting may be necessary to improve both clinical care and research validity.

Maternal depression, changing public assistance, food security, and child health status.

OBJECTIVE: To examine the association of positive report on a maternal depression screen (PDS) with loss or reduction of welfare support and foods stamps, household food insecurity, and child health measures among children aged < or =36 months at 6 urban hospitals and clinics. METHODS: A convenience sample of 5306 mothers, whose children <36 months old were being seen in hospital general clinics or emergency departments (EDs) at medical centers in 5 states and Washington, District of Columbia, were interviewed from January 1, 2000 until December 31, 2001. Questions included items on sociodemographic characteristics, federal program participation and changes in federal benefits, child health status rating, child's history of hospitalizations since birth, household food security status, and a 3-question PDS. For a subsample interviewed in the ED, whether the child was admitted to the hospital that day was recorded. RESULTS: PDS status was associated with loss or reduction of welfare support and food stamps, household food insecurity, fair/poor child health rating, and history of child hospitalization since birth but not low child growth status measures or admission to the hospital at the time of ED visit. After controlling for study site, maternal race, education, and insurance type as well as child low birth weight status, mothers with PDS were more likely to report fair/poor child health (adjusted odds ratio [AOR]: 1.58; 95% confidence interval [CI]: 1.33-1.88) and hospitalizations during the child's lifetime (AOR: 1.20; 95% CI: 1.03-1.39), compared with mothers without PDS. Controlling for the same variables, mothers with PDS were more likely to report decreased welfare support (AOR: 1.52; 95% CI: 1.03-2.25), to have lost food stamps (AOR: 1.56; 95% CI: 1.06-2.30), and reported more household food insecurity (AOR: 2.69; 95% CI: 2.33-3.11) than mothers without PDS. CONCLUSION: Positive maternal depression screen status noted in pediatric clinical samples of infants and toddlers is associated with poorer reported child health status, household food insecurity, and loss of federal financial support and food stamps. Although the direction of effects cannot be determined in this cross-sectional survey, child health providers and policy makers should be aware of the potential impact of maternal depression on child health in the context of welfare reform.

Welfare reform and the health of young children: a sentinel survey in 6 US cities.

CONTEXT: Welfare reform under the 1996 Personal Responsibility and Work Opportunity Reconciliation Act replaced entitlement to cash assistance for low-income families with Temporary Assistance to Needy Families, thereby terminating or decreasing cash support for many participants. Proponents anticipated that continued receipt of food stamps would offset the effects of cash benefit losses, although access to food stamps was also restricted. OBJECTIVE: To examine associations of loss or reduction of welfare with food security and health outcomes among children aged 36 months or younger at 6 urban hospitals and clinics. DESIGN AND SETTING: A multisite retrospective cohort study with cross-sectional surveys at urban medical centers in 5 states and Washington, DC, from August 1998 through December 2000. PARTICIPANTS: The caregivers of 2718 children aged 36 months or younger whose households received welfare or had lost welfare through sanctions were interviewed at hospital clinics and emergency departments. MAIN OUTCOME MEASURES: Household food security status, history of hospitalization, and, for a subsample interviewed in emergency departments, whether the child was admitted to the hospital the day of the visit. RESULTS: After controlling for potential confounding factors, children in families whose welfare was terminated or reduced by sanctions had greater odds of being food insecure (adjusted odds ratio [AOR], 1.5; 95% confidence interval [CI], 1.1-1.9), of having been hospitalized since birth (AOR, 1.3; 95% CI, 1.0-1.7) and, for the emergency department subsample, of being admitted the day of an emergency department visit (AOR, 1.9; 95% CI, 1.2-3.0) compared with those without decreased benefits. Children in families whose welfare benefits were decreased administratively because of changes in income or expenses had greater odds of being food insecure (AOR, 1.5; 95% CI, 1.1-2.2) and of being admitted the day of an emergency department visit (AOR, 2.8; 95% CI, 1.4-5.6). Receiving food stamps does not mitigate the effects of the loss or reduction of welfare benefits on food security or hospitalizations. CONCLUSION: Terminating or reducing welfare benefits by sanctions, or decreasing benefits because of changes in income or expenses, is associated with greater odds that young children will experience food insecurity and hospitalizations.

Late life function and disability instrument: I. Development and evaluation of the disability component.

BACKGROUND: Efforts to evaluate the effectiveness of clinical and community-based interventions designed to impact late-life disability have been hindered significantly by limitations in current instrumentation. More conceptually sound and responsive measures of disability are needed. METHODS: Applying Nagi's disablement model, we wrote questionnaire items that assessed disability in terms of frequency and limitation in performance of 25 life tasks. We evaluated their validity and test-retest reliability with 150 ethnically and racially diverse adults aged 60 and older who had a range of functional limitations, using factor analysis and Rasch analytic techniques to examine and refine the instrument. RESULTS: Our analyses resulted in a 16-item disability component with two dimensions, one focused on frequency of performance and the other addressing limitation in performance of life tasks, with two disability domains within each dimension. The frequency dimension consisted of a personal and a social role domain, and the limitation dimension consisted of an instrumental and a management role domain. Expected differences in summary scores of known-functional limitation groups support the validity of this instrument. Test-retest intraclass correlations of the reproducibility of each overall dimension summary score were moderate to high (intraclass correlation coefficients .68-.82). CONCLUSIONS: The Late-Life Function and Disability Instrument has potential to assess meaningful concepts of disability across a wide variety of life tasks with relatively few items.

Late Life Function and Disability Instrument: II. Development and evaluation of the function component.

BACKGROUND: Self-reported capability in physical functioning has long been considered an important focus of research for older persons. Current measures have been criticized, however, for conceptual confusion, lack of sensitivity to change, poor reproducibility, and inability to capture a wide range of upper and lower extremity functioning. METHODS: Using Nagi's disablement model, we wrote physical functioning questionnaire items that assessed difficulty in 48 common daily tasks. We constructed the instrument using factor analysis and Rasch analytic techniques and evaluated its validity and test-retest reliability with 150 ethnically and racially diverse adults aged 60 years and older who had a range of functional limitations. RESULTS: Our analyses resulted in a 32-item function component with three dimensions--upper extremity, basic lower extremity, and advanced lower extremity functions. Expected differences in summary scores of known-functional limitation groups support its validity. Test-retest stability over a 1- to 3-week period was extremely high (intraclass correlation coefficients =.91 to.98). CONCLUSIONS: The Late-Life Function and Disability Instrument has potential to assess activity concepts related to upper and lower extremity functioning across a wide variety of daily physical tasks and individual levels of physical functioning.