Caregiving Intensity and Mortality in Older Women, Accounting for Time-Varying and Lagged Caregiver Status: The Caregiver-Study of Osteoporotic Fractures Study.

BACKGROUND AND OBJECTIVES: Caregiving is associated with reduced mortality in recent studies. Investigations of caregiving intensity may reveal an underlying mechanism. However, studies of caregiving intensity and mortality have mixed results, perhaps due to imprecise measurement of caregiving intensity, not accounting for healthier persons likely having greater caregiving involvement, or temporal changes in intensity. We examined the relationship between caregiving intensity (based on tasks performed) and mortality, treating intensity and health status as time-varying, and lagging exposure. RESEARCH DESIGN AND METHODS: Caregiving tasks among 1,069 women in the Caregiver-Study of Osteoporotic Fractures study (35% caregivers) were assessed at 5 interviews conducted between 1999 and 2009. Caregivers were categorized as high intensity if they assisted a person with dressing, transferring, bathing, or toileting; or as low intensity if they assisted with other instrumental or basic activities of daily living (I/ADLs). Alternatively, high intensity was defined as assisting with more than the median number of I/ADL tasks (median-based measure). Mortality was assessed through 2011. Cox proportional hazards models estimated adjusted hazard ratios (aHR) and 95% confidence intervals based on concurrent intensity, and lagging exposure 2 years. RESULTS: High-intensity caregivers had significantly lower mortality using the median-based measure after lagging exposure (aHR = 0.55, 0.34-0.89). Similar, but not statistically significant associations were observed in non-lagged analyses (aHR = 0.54, 0.29-1.04) and task-specific intensity (aHRs were 0.61 and 0.51). Low-intensity caregivers had similar mortality rates to noncaregivers in all analyses. DISCUSSION AND IMPLICATIONS: Among older women, high-intensity caregivers had lower mortality rates than noncaregivers. Whether this association extends to other populations merits investigation.

Age of Onset, Current Use of Alcohol, Tobacco or Marijuana and Current Polysubstance Use Among Male and Female Mexican Students.

AIMS: This study aimed to examine alcohol, tobacco or marijuana use onset and associations between age of onset and current use, and between age of onset and current polysubstance use among a sample of Mexican young people aged 17-20 years. METHODS: Alcohol, tobacco, marijuana and other substance use were identified in a 2012 cross-sectional survey of male and female students entering first year university in Mexico City. Chi-square tests and logistic regression models examined associations between gender, age of onset, order of onset, family substance use and current polysubstance use among 22,224 students. RESULTS: The largest proportions of males and females initiated alcohol at age 15, tobacco at ages 15-16 and marijuana at ages 16-17. Earlier alcohol and tobacco initiation was associated with past 30-day use of the same substance. Gender differences in alcohol and tobacco use were small but males were significantly more likely than females to use marijuana and be polysubstance users. Family substance use was associated with earlier onset. There was a significant association between the earliest age of any of the three substances and current polysubstance use. CONCLUSIONS: A number of contextual and cultural factors in Mexico may be contributing to early onset, continued use and polysubstance use and deserve attention in research and by prevention programs.

Parental monitoring and family relations: associations with drinking patterns among male and female Mexican students.

INTRODUCTION: Parental monitoring and family relations are recognized as protective factors for youth alcohol use. The purpose of this study was to investigate perceived parental monitoring and family relations among subgroups of Mexican youths with different patterns of drinking behaviors and consequences. METHODS: A latent profile analysis (LPA) identified profiles of drinking behavior in a cross-sectional survey of entering first year university students. Multinomial regression examined associations between parental monitoring, family relations and drinking profiles among 22,224 students. RESULTS: Both lower perceived parental monitoring and weaker perceived family relations were associated with heavier drinking profiles among males and females, but more strongly associated with female than male heavier drinking profiles. Being older, having parents with lower education, and not living with parents were also associated with lower parental monitoring and weaker family relations. There was a general trend of lower parental monitoring and weaker family relations as the profiles increased from Non/Infrequent-No Consequences to Excessive-Many Consequences Drinkers. Lower perceived parental monitoring and weaker perceived family relations were more strongly associated with drinking profiles among females than among males. Both the parental monitoring and family relations scales had similar associations with drinking profiles. CONCLUSIONS: Findings suggest that drinking norms and values may contribute to any protective influences of parental monitoring and family relations on Mexican youths' drinking. Research about changes in drinking norms, contextual factors, and youth-parent trust would inform the utility of parental monitoring or family relations as protective strategies against alcohol misuse among Mexican and Mexican American youths and also youths from other backgrounds.

Natural mentors and youth drinking: a qualitative study of Mexican youths.

Parental influences on youth drinking are well documented but not the influence of extended family members. This article explores extended family influences on alcohol use among Mexican youths and whether extended family members can be considered natural mentors. We conducted a qualitative study using ethnographic open ended interviews with 117 first year university students in Mexico City. The ethnographic interviews revealed six drinking groups: excessive, heavy, regular, occasional, abstainers and non drinkers. Youths reported close relationships with extended family members who provided counsel and acted as representatives of familial norms and values. The alcohol beliefs and behaviors of these family members, including their alcohol misuse, had a positive influence on youths' alcohol attitudes. The naturally occurring mentoring relationships of Mexican extended family members can positively influence moderate youth drinking. Natural mentoring relationships should be encouraged and facilitated in prevention efforts for Mexican youths, Mexican-American youths and potentially other Hispanic/Latino youths.

Alcohol Use among Mexican Youths: Is Familismo Protective for Moderate Drinking?

The construct of familismo has been identified as a potential protective cultural value in Hispanic cultures. This paper considers familismo and alcohol use among young people in Mexico. We conducted a qualitative study using ethnographic open ended interviews with 117 first year students at a large free public university in Mexico City between April-May 2011. The findings indicate that dimensions of familismo can act as protective factors against misuse of alcohol among Mexican youths and may be protective for moderate drinking. Future research should explore the relationship of familismo to gender roles and other cultural values during adolescence. Given the enduring influence of Mexican cultural values among Mexican Americans the research has implications for prevention programs for both Mexican and Mexican American youths.

Drinking patterns and victimization among male and female students in Mexico.

AIMS: The purpose of this study is to estimate the prevalence of alcohol use and alcohol-related consequences, identify drinking profiles using latent profile analysis (LPA), and investigate associations between profiles and violent victimization among young people in Mexico. METHODS: LPA identified profiles of drinking behavior in a survey of entering first year university students. Multinomial and logistic regression examined associations between drinking patterns, socio-demographic variables and violent victimization. RESULTS: The LPA identified five profiles of behaviors and consequences among the 22,224 current, former and never drinkers: Non/Infrequent-No Consequences, Occasional-Few Consequences, Regular-Some Consequences, Heavy-Many Consequences and Excessive-Many Consequences drinkers. The Occasional-Few Consequences profile comprised the largest, and the Excessive-Many Consequences profile the smallest, group of drinkers. Multinomial regression showed males and older students more likely to be Heavy or Excessive-Many Consequences drinkers. Living alone was associated with higher odds, and higher maternal education with lower odds, of being a Non/Infrequent-No Consequences drinker. Heavier drinking profiles were more likely to experience violent victimization adverse consequences. Logistic regression showed male and female Heavy and Excessive-Many Consequences drinkers had the highest odds, and Non/Infrequent drinkers the lowest odds, of experiencing any victimization. CONCLUSION: Findings suggest changes in male and female drinking behavior and a continuation of the established pattern of infrequent but high consumption among Mexican youths. Both male and female Heavy and Excessive-Many Consequences drinkers were at elevated risk for experiencing victimization. Identifying cultural gender norms about drinking including drinker expectations and drinking context that contribute to these patterns can inform prevention efforts.

Changes in alcohol use among first year university students in Mexico.

BACKGROUND: Alcohol use and misuse is widespread among university students in many countries. Specific cultural factors may impact alcohol use after entering university. OBJECTIVE: This paper considers changes in alcohol use among first year university students in Mexico. METHODS: A qualitative study using ethnographic interviews with 57 female and 60 male student drinkers in Mexico City from March to June 2011. Each interview was evaluated by a set of thematic codes developed inductively from the interviews. Findings from excessive, heavy, regular, occasional drinkers, abstainers, and non-drinkers were analyzed to explore whether or not linkages existed between and/or among particular themes. RESULTS: Students reported factors associated with changes in role and status, friendships, and increased autonomy as reasons for increasing or decreasing their alcohol use after entering university. CONCLUSIONS/IMPORTANCE: Understanding the influence of Mexican cultural norms on alcohol use among Mexican and Mexican Americans can be helpful in informing studies and preventive efforts among both Mexican and Mexican American young people.

Evaluating the impact of prevention of mother-to-child transmission of HIV in Malawi through immunization clinic-based surveillance.

BACKGROUND: Prevention of mother-to-child transmission of HIV (PMTCT) programs can greatly reduce the vertical transmission rate (VTR) of HIV, and Malawi is expanding PMTCT access by offering HIV-infected pregnant women life-long antiretroviral therapy (Option B+). There is currently no empirical data on the effectiveness of Malawian PMTCT programs. This study describes a surveillance approach to obtain population-based estimates of the VTR of infants <3 months of age in Malawi immediately after the adoption of Option B+. METHODS AND FINDINGS: A sample of caregivers and infants <3 months from 53 randomly chosen immunization clinics in 4 districts were enrolled. Infant dried blood spot (DBS) samples were tested for HIV exposure with an antibody test to determine maternal seropositivity. Positive samples were further tested using DNA PCR to determine infant infection status and VTR. Caregivers were surveyed about maternal receipt of PMTCT services. Of the 5,068 DBS samples, 764 were ELISA positive indicating 15.1% (14.1-16.1%) of mothers were HIV-infected and passed antibodies to their infant. Sixty-five of the ELISA-positive samples tested positive by DNA PCR, indicating a vertical transmission rate of 8.5% (6.6-10.7%). Survey data indicates 64.8% of HIV-infected mothers and 46.9% of HIV-exposed infants received some form of antiretroviral prophylaxis. Results do not include the entire breastfeeding period which extends to almost 2 years in Malawi. CONCLUSIONS: The observed VTR was lower than expected given earlier modeled estimates, suggesting that Malawi's PMTCT program has been successful at averting perinatal HIV transmission. Challenges to full implementation of PMTCT remain, particularly around low reported antiretroviral prophylaxis. This approach is a useful surveillance tool to assess changes in PMTCT effectiveness as Option B+ is scaled-up, and can be expanded to track programming effectiveness for young infants over time in Malawi and elsewhere.

Parental monitoring and alcohol use among Mexican students.

Parental monitoring has been described as a protective factor and useful strategy to prevent substance misuse among youths. The aim of this study was to examine whether perceived parental monitoring influences frequency of alcohol use, age of drinking onset and risky drinking among entering public high school and university students in Mexico City. The study is a cross-sectional survey of entering first year students in the high school and university school system of a large public university in Mexico City conducted during registration at the beginning of the school year. In 2008, of 34,840 students accepted to the affiliated high schools, 28,996 students (51.8% female) completed the alcohol survey and of 37,683 students accepted into university 30,084 students (51.5% female) completed the alcohol survey. The findings suggest that compared to students with higher perceived parental monitoring those reporting lower perceived parental monitoring were more likely to report risky behavior. They were more likely to be ever drinkers, frequent drinkers, have earlier age of onset and high AUDIT scores. Overall, higher parental monitoring was strongly associated with being female and lower parental monitoring with being male. Our findings suggest that more research on parental monitoring as a protective strategy against alcohol misuse is needed. Research focusing on cultural factors including gender and age-related norms and familismo would increase knowledge of the association of parental monitoring and alcohol use among Mexican youths, Mexican American youths and potentially youths from other Hispanic backgrounds.

Preventing cancer: a community-based program for youths in public housing.

PURPOSE: This article describes a feasibility study of a program that mentors boys aged 14-18 living in inner city public housing, engages them in a basketball league, and provides educational sessions on life skills and ways to resolve conflicts without violence. Such programs have the potential to engage adolescent males living in public housing in activities that reduce cancer-related behaviors and increase protective behaviors. METHODS: We conducted a feasibility evaluation of the program, which included a survey of participants, interviews with coaches, and observations of games and practices. RESULTS: Lifetime and previous-30-day substance use was common among participants, and many were exposed to and had experienced various forms of violence. Keeping youths active helps prevent their joining gangs and using drugs. CONCLUSIONS: Youths from disadvantaged backgrounds are at a high risk for cancer because they are at greater risk for obesity and other adverse health-related conditions than are more affluent youths. Implementing and sustaining community programs for youths in public housing can reduce the effects of exposure to factors that put them at risk for cancer during adulthood: chronic poverty, lack of safe areas for recreation, easy access to alcohol and drugs, and exposure to violence. In addition, workshops to prevent substance use and violence and to teach leadership, sportsmanship, conflict resolution, and healthy youth development are needed for youths, coaches, and parents or guardians.

Using resident health advocates to improve public health screening and follow-up among public housing residents, Boston, 2007-2008.

INTRODUCTION: Promoting screening for hypertension, high cholesterol, diabetes, and dental disease, particularly among residents of public housing, is a key strategy for achieving the objectives of Healthy People 2010. This community-based participatory research study tested a resident health advocate (RHA) intervention in public housing to increase use of mobile screening and to assess postscreening follow-up care for people with positive screening results. METHODS: During the summers of 2007 and 2008, a mobile health unit screened residents at 4 housing developments for hypertension, high cholesterol, diabetes risk, and dental disease. In the first summer, at 2 intervention sites, RHAs used personal contacts and repeated flyers to recruit residents; 2 control sites received standard recruitment, which was to leave flyers with the development manager. In the second summer, the 2 control sites from the previous year became intervention sites. For both summers combined, we calculated the number of people at intervention and control sites who used the van and we examined rates of appointments made and kept for residents who had positive screening test results. RESULTS: Screening rates were higher in the intervention condition compared with the control condition (relative risk [RR], 1.55; 95% confidence interval [CI], 1.12-2.15). Approximately 65% of participants screened positive for at least 1 condition. The proportion of participants with screen-positive findings who had follow-up appointments increased from 15% in 2007 to 55% in 2008. CONCLUSION: The use of RHAs increased participation in health screening among public housing residents and rates of follow-up medical visits for people with positive screening results.

Mental health service utilization of Somali adolescents: religion, community, and school as gateways to healing.

This mixed-method study examines the utility of the Gateway Provider Model (GPM) in understanding service utilization and pathways to help for Somali refugee adolescents. Somali adolescents living in the Northeastern United States, and their caregivers, were interviewed. Results revealed low rates of use of mental health services. However other sources of help, such as religious and school personnel, were accessed more frequently. The GPM provides a helpful model for understanding refugee youth access to services, and an elaborated model is presented showing how existing pathways to help could be built upon to improve refugee youth access to services.

Discrimination and mental health among Somali refugee adolescents: the role of acculturation and gender.

This study examines the role of social identity (acculturation and gender) in moderating the association between discrimination and Somali adolescent refugees' mental health. Participants were English-speaking Somali adolescent refugees between the ages of 11 and 20 (N = 135). Perceived discrimination, trauma history, posttraumatic stress disorder (PTSD), depressive symptoms, and behavioral acculturation were assessed in structured interviews. Fourteen in-depth qualitative interviews and 3 focus groups were also conducted. Results indicated that discrimination was common and associated with worse mental health. For girls, greater Somali acculturation was associated with better mental health. Also, the association between discrimination and PTSD was less strong for girls who showed higher levels of Somali acculturation. For boys, greater American acculturation was associated with better mental health, and the association between discrimination and depression was less strong for boys with higher levels of American acculturation.

Why might adverse childhood experiences lead to underage drinking among US youth? Findings from an emergency department-based qualitative pilot study.

Research suggests that adverse childhood experiences (e.g., child abuse, interparental violence) predispose youth to early drinking initiation, but specifics about how and why adolescents progress from these exposures to alcohol use are not well understood. This National Institute on Alcohol Abuse and Alcoholism supported study presents data from semistructured interviews with 22 adolescents who reported both initiating drinking ≤18 years old and ≥2 adverse childhood experiences. Data were collected in 2007 as part of a formative research effort for an emergency department-based intervention to reduce adolescent drinking. Findings suggest that prevention initiatives for youth from challenging environments may need to do more than address conformity and social motivations for underage alcohol initiation. Study limitations are noted and future research is suggested.

The GirlStars program: challenges to recruitment and retention in a physical activity and health education program for adolescent girls living in public housing.

BACKGROUND: Although physical inactivity is a concern for all adolescents, physical activity levels are especially low among minority adolescents and minimal among girls from low-income families. After-school programs can reduce high-risk behaviors and strengthen schools, families, and communities. CONTEXT: We conducted an operational research project that provided free access to a program of regular, organized physical activity combined with health education sessions for adolescent girls in 2 public housing developments in Boston, Massachusetts. METHODS: From July 2002 through October 2005, at each of 2 public housing sites, the GirlStars program participants met each week for two 2-hour sessions, 1 dedicated to physical activity and 1 dedicated to health education. Sessions were led by the project coordinator and a resident assistant at each development. OUTCOME: Participants in the GirlStars program increased their health knowledge, self-confidence, and decision-making skills, but rates of participation were low. Factors that affected participation included safety concerns, lack of community support for the program, interpersonal conflicts, attrition in staff, and conflicts with other activities. INTERPRETATION: Programs in public housing developments that address these barriers to recruitment and retention may be more successful and reach more girls.

Observing the work of an urban safety-net psychiatric emergency room: managing the unmanageable.

Staff in the psychiatric emergency room (PER) have demanding jobs requiring a complex balance between the needs and safety of the individual and the community, systemic resources, and job responsibilities while providing timely, effective care. Little research exists concerning day-to-day work activities of PER staff, their interaction, and their perceptions of their work. This study explored the work of PER staff and the organisational context of the PER work setting. Observations of staff were conducted in the public spaces of a public urban PER using two observational techniques. The first was designed to measure the types of work activities staff engaged in and the time spent in these work activities (work task data). The second technique was the gathering of observational data by a peripheral-member-researcher (participant observation data). Analyses were conducted of both the work task and participant observation data. Results indicate that most PER staff time is spent in administrative and phone tasks, while less than a third is spent on direct clinical work. Four important issues for PER work were identified: a workload that is unmanageable, managing the unmanageable, bogus referrals and dumping and insurance problems. The PER remains the front-line of the medical and social service systems. Work done in these settings is of critical importance; however little attention is paid to the content and nature of the work. Our study demonstrates that staff of the PER face challenges on many levels as they struggle with the task of working with people presenting in psychiatric and social crisis.

Social status, gender and alcohol-related problems: the black young adult experience.

OBJECTIVES: Using data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions, this study examined prevalence of drinking and related problems among five racial/ethnic groups aged 18-30. DESIGN: Logistic regression analyses examined influences of gender and social status on alcohol-related problems among blacks, controlling for demographics. RESULTS: Black drinkers were significantly less likely to be high-risk or risky/heavy episodic drinkers than all groups except Asians; and experienced lower prevalence of alcohol-related problems than whites and American Indians. Controlling for drinking, prevalence of alcohol-related problems among blacks was similar to other groups, except native Americans. Analyses of blacks revealed males, unemployed, and heaviest drinkers had highest prevalence of problems. Strong associations between drinking and problems remained consistent across black sub-groups defined by social status and gender. CONCLUSION: While blacks are not as engaged in risky/heavy drinking, they are not shielded from problems conditional on drinking patterns. Focus on alcohol-related problems among black males and unemployed is indicated.

Understanding rehospitalization risk: can hospital discharge be modified to reduce recurrent hospitalization?

BACKGROUND: A high rate of unnecessary rehospitalization has been shown to be related to a poorly managed discharge processes. OBJECTIVE: A qualitative study was conducted in order to understand the phenomenon of frequent rehospitalization from the perspective of discharged patients and to determine if activities at the time of discharge could be designed to reduce the number of adverse events and rehospitalization. DESIGN: Semistructured, open-ended interviews were conducted with 21 patients during their hospital stay at Boston Medical Center. Interviews assessed continuity of care after discharge, need for and availability of social support, and ability to obtain follow-up medical care. RESULTS: Difficult life circumstances posed a greater barrier to recuperation than lack of medical knowledge. All participants were able to describe their medical condition, the reasons they were admitted to the hospital, and the discharge instructions they received. All reported the types of medications being taken or the conditions for which the medications were prescribed. Recuperation was compromised by factors that contribute to undermining the ability of patients to follow their doctors' recommendations including support for medical and basic needs, substance use, and limitations in the availability of transportation to medical appointments. Distress, particularly depression, further contributed to poor health and undermined the ability to follow doctors' recommendations and the discharge plans. CONCLUSIONS: Discharge interventions that assess the need for social support and provide access and services have the potential to reduce chronic rehospitalization.

Country of origin, age of drinking onset, and drinking patterns among Mexican American young adults.

This study examines relationships between country of origin, age of drinking onset, and adverse drinking outcomes among young adult Mexican Americans in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Logistic regression models estimate associations between age of drinking onset, age of onset in relation to age at immigration, and adverse drinking outcomes, controlling for sex, age, employment, education, marital status, and income. Adjusted analyses indicate the odds of adverse drinking outcomes decreased as age of drinking onset increased. Mexican Americans who initiated drinking in Mexico had significantly lower odds of current or lifetime harmful drinking than U.S. born but the odds were not significantly different between foreign-born Mexican Americans who initiated drinking in the U.S. and U.S. born. Irrespective of whether drinking onset was in Mexico or the U.S., foreign-born Mexican Americans had lower odds of alcohol abuse than U.S. born. However, odds of dependence were not significantly different between foreign-born and U.S.-born Mexican Americans. While findings suggest that being foreign born may be protective, further research on social and cultural factors impacting drinking onset and related outcomes among young Mexican Americans may help inform prevention efforts.

The workers' compensation system: worker friend or foe?

BACKGROUND: The workers' compensation system was designed to help injured workers who have substantial medical expenses and perhaps have lost a great deal of income. This study determines both similarities and differences in how workers experience their interactions with the workers' compensation systems in Florida and Wisconsin. METHODS: Ethnographic open-ended interviews with 204 workers from Florida and 198 workers in Wisconsin were conducted. All the workers had back injuries in 1990 and were either paid workers' compensation temporary disability benefits for at least 4 weeks or received permanent disability benefits or compromise settlements. RESULTS: Some interactions with the workers' compensation system were positive. However, the majority of respondents in both states experienced their encounters with the workers' compensation system as cumbersome, frustrating, and demeaning. CONCLUSIONS: Mistrust, stigmatization, payment delays, and refusal of insurer personnel to pay benefits contribute to workers' negative experiences with the workers' compensation system. These insurer behaviors raise the costs to injured workers of workers' compensation benefits and thus may reduce the propensity of eligible workers to apply for benefits.