Financial Hardship and Sleep Quality Among Black American Women With and Without Systemic Lupus Erythematosus.

OBJECTIVE: To compare dimensions of financial hardship and self-reported sleep quality among Black women with versus without systemic lupus erythematosus (SLE). METHODS: Participants were 402 Black women (50% with validated diagnosis of SLE) living in Georgia between 2017 and 2020. Black women with SLE were recruited from a population-based cohort established in Atlanta, and Black women without SLE were recruited to be of comparable age and from the same geographic areas as SLE women. Financial hardship was measured using three different scales: financial adjustments, financial setbacks, and financial strain. Sleep was assessed continuously using the Pittsburgh Sleep Quality Index (PSQI) scale. Each dimension of financial hardship was analyzed separately in SLE-stratified multivariable linear regression models and adjusted by sociodemographic and health status factors. RESULTS: Dimensions of financial hardship were similarly distributed across the two groups. Sleep quality was worse in Black women with, versus without, SLE (p < .001). Among Black women with SLE, financial adjustment was positively associated with a 0.40-unit increase in poor sleep quality (95% CI = 0.12-0.67, p = .005). When accounting for cognitive depressive symptoms, financial setbacks and strain were somewhat attenuated for Black women with SLE. Overall, no associations between financial hardships and sleep quality were observed for the women without SLE. CONCLUSIONS: Black women with SLE who experience financial hardships may be more at risk for poor sleep quality than Black women without SLE. Economic interventions targeting this population may help improve their overall health and quality of life.

Impact of School Start Time Delays and Learning Modality on Sleep Timing and Duration During COVID-19.

OBJECTIVES: To assess the impact of a school start time (SST) delay on adolescent sleep health during the COVID-19 pandemic, and whether there were differences by learning modality. METHODS: Data were collected from a longitudinal study evaluating sleep, education, and health among high school students in Georgia in 2020. Paired t-tests and multivariable linear regression analyses were conducted to examine changes in sleep duration and timing among 9th grade students (n = 134) and their association with the learning modality (remote vs. in-person learner). RESULTS: Students' school day wake times were 1.5 hours later, school night sleep duration was 1.2 hours longer, and social jetlag was 0.9 hours shorter after the school start time delay (all P < .05). The learning modality was a significant predictor of changes in sleep timing but was not associated with changes in sleep duration. CONCLUSIONS: Delayed school start time was associated with positive changes in adolescent sleep health during the COVID-19 pandemic. Sleep timing was affected by the learning modality, however in-person and virtual students had similar gains in sleep duration. Learning modality may be more beneficial for adolescents with early school start times to promote healthier sleep habits.

Racial/Ethnic and Sex/Gender Differences in Sleep Duration Trajectories From Adolescence to Adulthood in a US National Sample.

Racial/ethnic and sex/gender disparities in sleep duration have been documented in adolescence and adulthood. Identifying racial/ethnic and sex/gender differences in sleep duration trajectories from adolescence to adulthood can inform interventions on the developmental periods individuals are most at risk for short sleep duration. We examined racial/ethnic and sex/gender differences in self-reported sleep duration trajectories from adolescence to adulthood using data from waves I, III, IV, and V of the National Longitudinal Study of Adolescent to Adult Health (1994-2018; n = 12,593). Multigroup growth mixture modeling was used to enumerate sleep duration trajectories from adolescence to adulthood. There were 3 common trajectory types across race/ethnicity and sex/gender groups: 1) consistent increasing short sleepers (i.e., increasing probability of short sleep into adulthood) (67.3%); 2) late-onset short sleepers (i.e., no probability of short sleep duration in adolescence until adulthood) (20.2%); and 3) early-onset short sleepers (i.e., declining probability of short sleep duration from adolescence into adulthood) (12.5%). The prevalence of the consistent-increasing trajectory was highest among Black male respondents, while late onset was highest among White female respondents and early onset greatest among Latinx male respondents. Findings underscore the need to intervene in early adolescence to prevent short sleep duration in adulthood.

The Association of Sleep Duration with Grade Point Averages and Absences Among 9th Graders in Georgia, USA.

This study aimed to examine the association between sleep measures (self-reported sleep duration and weekend catch-up sleep) and grade point average (GPA) and absences among 9th grade students from two racially and economically diverse high schools in a semi-rural county of north-central Georgia. Linear and Poisson regression models estimated the association between sleep measures and GPA and absences (separately), respectively. Analyses adjusted for gender, race/ethnicity, free/reduced-price school lunch status, and parental education. Sleep duration was significantly associated with both GPA and absences, such that for every one additional hour of sleep, GPA increased by 0.8 percentage points (b=0.8, 95% CI:0.1,1.5) while the number of absences was lower by 6% (b=-0.05; OR=0.94, 95% CI:0.91,0.98). Weekend catch-up sleep was also significantly and positively associated with absences (b=0.04; OR=1.04, 95% CI; 1.02, 1.07). Increasing sleep may be a strategy to improve GPA and reduce absences among teenagers. Future research should identify effective measures to lengthen sleep.

Gendered Racial Microaggressions and Black Women's Sleep Health.

Gendered racial microaggressions reflect historical and contemporary gendered racism that Black women encounter. Although gendered racial microaggressions are related to psychological outcomes, it is unclear if such experiences are related to sleep health. Moreover, the health effects of gendered racial microaggressions dimensions are rarely investigated. Using a cohort of Black women (N = 400), this study employs an intracategorical intersectional approach to (1) investigate the association between gendered racial microaggressions and sleep health, (2) assess whether gendered racial microaggressions dimensions are related to sleep health, and (3) examine whether the gendered racial microaggressions-sleep health association persists after accounting for depressive symptoms and worry. Gendered racial microaggressions were associated with poor sleep quality overall and four specific domains: subjective sleep quality, latency, disturbance, and daytime sleepiness. Two gendered racial microaggressions dimensions were especially detrimental for sleep: assumptions of beauty/sexual objectification and feeling silenced and marginalized. After accounting for mental health, the effect of gendered racial microaggressions on sleep was reduced by 47 percent. Future research implications are discussed.

Associations of Chronic Burden, Sleep Characteristics, and Metabolic Syndrome in the Coronary Artery Risk Development in Young Adults Study.

OBJECTIVE: Chronic exposure to stress is associated with metabolic syndrome (MetS), but the mechanism is unclear. We investigated the associations between chronic burden, sleep, and MetS in the Coronary Artery Risk Development in Young Adults Study. METHODS: Chronic burden was self-reported (2000-2001) according to experiences with stressors for longer than 6 months. Wrist actigraphy-measured sleep duration and sleep efficiency were collected for 6 days; sleep duration, sleep quality, and daytime sleepiness were self-reported (2003-2004). MetS was measured during the clinic visit, from 2005 to 2006. Multivariable logistic and Cox proportional hazard models were fit to determine the associations of interest. Mediation by sleep was assessed using the product of coefficients approach. RESULTS: Among participants ( n = 606), the average (standard deviation) age was 40 (3.6) years, 58% were female, and 43% were Black. The prevalences of chronic burden, short sleep (≤6 hours), and MetS were 35%, 43% and 20.5%, respectively. High versus low chronic burden was associated with shorter self-reported sleep duration and higher daytime sleepiness. Chronic burden was associated with 1.85 higher odds (95% confidence interval = 1.11-3.09) of MetS. Sleep characteristics were not associated with MetS. There was no evidence that sleep mediated the chronic burden-MetS relation. CONCLUSION: Burden of chronic stress may be an emerging novel risk factor for both poor sleep and MetS.

Association of Depressive Symptoms with Sleep Disturbance: A Co-twin Control Study.

BACKGROUND: Few studies have comprehensively evaluated the association of depression with sleep disturbance using a controlled twin study design. PURPOSE: To cross-sectionally evaluate the association of depression with both objective and subjective sleep disturbance. METHODS: We studied 246 members of the Vietnam Era Twin Registry. We measured depressive symptoms using the Beck Depression Inventory-II (BDI) and assessed major depression using structured clinical interviews. Twins underwent one-night polysomnography and 7-day actigraphy to derive measures of objective sleep and completed the Pittsburgh Sleep Quality Index for subjective sleep. Multivariable mixed-effects models were used to examine the association. RESULTS: Twins were all male, mostly white (97%), with a mean (SD) age of 68 (2). The mean (SD) BDI was 5.9 (6.3), and 49 (20%) met the criteria for major depression. For polysomnography, each 5-unit higher BDI, within-pair, was significantly associated with 19.7 min longer rapid eye movement (REM) sleep latency, and 1.1% shorter REM sleep after multivariable adjustment. BDI was not associated with sleep architecture or sleep-disordered breathing. For actigraphy, a higher BDI, within-pair, was significantly associated with lower sleep efficiency, more fragmentation and higher variability in sleep duration. BDI was associated with almost all dimensions of self-reported sleep disturbance. Results did not differ by zygosity, and remained consistent using major depression instead of BDI and were independent of the presence of comorbid posttraumatic stress disorder and antidepressant use. CONCLUSIONS: Depression is associated with REM sleep disruption in lab and sleep fragmentation and sleep variability at home, but not with sleep architecture or sleep-disordered breathing.

Racial-ethnic Differences in Actigraphy, Questionnaire, and Polysomnography Indicators of Healthy Sleep: The Multi-Ethnic Study of Atherosclerosis.

A paradigm shift in sleep science argues for a systematic, multidimensional approach to investigate sleep's association with disease and mortality and to address sleep disparities. We utilized the comprehensive sleep assessment of the Multi-Ethnic Study of Atherosclerosis (2010- 2013), a cohort of U.S. White, Black, Chinese, and Hispanic adults and older adults (n=1,736; mean age=68.3), to draw 13 sleep dimensions and create composite Sleep Health Scores to quantify multidimensional sleep health disparities. After age and sex adjustment in linear regression, compared to White participants, Black participants showed the greatest global sleep disparity, then Hispanic and Chinese participants. We estimated relative 'risk' of obtaining favorable sleep compared to White adults at the component level by race/ethnicity (lower is worse). The largest disparities were in objectively-measured sleep timing regularity (RRBlack [95% CI]: 0.37 [0.29,0.47], RRHispanic: 0.64 [0.52,0.78], RRChinese: 0.70 [0.54,0.90]) and duration regularity (RRBlack: 0.55 [0.47,0.65], RRHispanic: 0.76 [0.66,0.88], RRChinese: 0.74 [0.61,0.90]), after sex and age adjustment. Disparities in duration and continuity were also apparent, and Black adults were additionally disadvantaged in %N3 (slow wave sleep), sleepiness, and sleep timing (24-hour placement). Sleep timing regularity, duration regularity, duration, and continuity may comprise a multidimensional cluster of targets to reduce racial-ethnic sleep disparities.

A Longitudinal Evaluation of Goal-Striving Stress and Sleep Duration Among African Americans in the Jackson Heart Study.

OBJECTIVE: The purposes of this study were to assess the association between changes in goal-striving stress (GSS) and changes in sleep duration in African Americans (AAs) and to determine if the association varies by sex, age, and/or educational attainment. METHODS: We completed a longitudinal analysis using examination 1 (2000-2004, n = 5306) and examination 3 (2009-2013, n = 3819) data from the Jackson Heart Study, with a final sample of 3500. Changes in GSS and changes in sleep duration were calculated by subtracting examination 1 GSS from examination 3 GSS. Mean differences (ß [standard error]) between changes in GSS and changes in sleep duration were assessed using linear regression models that adjusted for length of follow-up, sociodemographics, health behaviors/risk factors, and stressors. RESULTS: In the fully adjusted models, the increase in GSS from examination 1 to examination 3 was associated with a decrease in sleep duration (in minutes) from examination 1 to examination 3 in the overall cohort (ß = -7.72 [2.44], p < .002), in high school graduates (ß = -21.23 [5.63], p < .001), and in college graduates (ß = -7.57 [3.75], p = .044) but not in those with less than a high school education (ß = 1.49 [8.35], p = .86) or those who attended college but did not graduate (ß = 0.44 [4.94], p = .93). CONCLUSIONS: Changes in GSS were inversely associated with changes in sleep duration over a mean period of 8 years in AA subgroups. Interventions that reduce stress related to goal striving should be considered to help improve sleep health in AAs.

Participant-level characteristics differ by recruitment setting when evaluating a behavioral intervention targeting adolescents with asthma.

OBJECTIVE: The recruitment setting plays a key role in the evaluation of behavioral interventions. We evaluated a behavioral intervention for urban adolescents with asthma in three randomized trials conducted separately in three different settings over the course of 8 years. We hypothesized that characteristics of trial participants recruited from the ED and clinic settings would be significantly different from that of youth participating in the school-based trials. The intervention evaluated was Puff City, a web-based program that uses tailoring to improve asthma management behaviors. METHODS: The present analysis includes youth aged 13-19 years who reported a physician diagnosis of asthma and symptoms at trial baseline. In the three trials, all participants were randomized post-baseline to a web-based, tailored intervention (treatment) or generic web-based asthma education (control). RESULTS: Compared to school-based trial participants, ED participants had significantly more acute-care visits for asthma (p < 0.001) and more caregiver depression (p < 0.001). Clinic-based participants were more likely to have computer/ internet access than participants from the school-based trial (p < 0.001). Both ED and clinic participants were more likely to report controller medication (p's < 0.001) and higher teen emotional support (p's < 0.01) when compared to the schools, but were less likely to report Medicaid (p's < 0.014) and exposure to environmental tobacco smoke (p < 0.001). CONCLUSION: Compared to participants in the school-based trials, participants recruited from ED and clinic settings differed significantly in terms of healthcare use, as well as psychosocial and sociodemographic factors. These factors can inform intervention content, and may impact external validity of behavioral interventions for asthma.

Association Between Sleep Apnea and Blood Pressure Control Among Blacks.

BACKGROUND: Blacks have a high prevalence of hypertension and uncontrolled blood pressure (BP), each of which may be partially explained by untreated sleep apnea. We investigated the association of sleep apnea with uncontrolled BP and resistant hypertension in blacks. METHODS: Between 2012 and 2016, Jackson Heart Sleep Study participants (N=913) underwent an in-home Type 3 sleep apnea study, clinic BP measurements, and anthropometry. Moderate or severe obstructive sleep apnea (OSA) was defined as a respiratory event index ≥15, and nocturnal hypoxemia was quantified as percent sleep time with <90% oxyhemoglobin saturation. Prevalent hypertension was defined as either a systolic BP ≥130 mm Hg or diastolic BP >80mm Hg, use of antihypertensive medication, or self-report of a diagnosis of hypertension. Controlled BP was defined as systolic BP <130 mm Hg and diastolic BP <80 mm Hg; uncontrolled BP as systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg with use of 1 to 2 classes of antihypertensive medication; and resistant BP as systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg with the use of ≥3 classes of antihypertensive medication (including a diuretic) or use of ≥4 classes of antihypertensive medication regardless of BP level. Multinomial logistic regression models were fit to determine the association between OSA severity and uncontrolled BP or resistant hypertension (versus controlled BP) after multivariable adjustment. RESULTS: The analytic sample with hypertension (N=664) had a mean age of 64.0 (SD,10.6) years, and were predominately female (69.1%), obese (58.6%), and college educated (51.3%). Among the sample, 25.7% had OSA, which was untreated in 94% of participants. Overall, 48% of participants had uncontrolled hypertension and 14% had resistant hypertension. After adjustment for confounders, participants with moderate or severe OSA had a 2.0 times higher odds of resistant hypertension (95% confidence interval [CI], 1.14-3.67). Each standard deviation higher than <90% oxyhemoglobin saturation was associated with an adjusted odds ratio for resistant hypertension of 1.25 (95% CI 1.01-1.55). OSA and <90% oxyhemoglobin saturation were not associated with uncontrolled BP. CONCLUSION: Untreated moderate or severe OSA is associated with increased odds of resistant hypertension. These results suggest that untreated OSA may contribute to inadequate BP control in blacks.

The Society for Epidemiologic Research and the Future of Diversity and Inclusion in Epidemiology.

"The mission of the Diversity and Inclusion Committee (D&I) in the Society for Epidemiologic Research is to foster the diversity of our membership and work towards the engagement of all members, from diverse backgrounds at all stages of their careers, in the Society's activities, with the intent of enhancing discovery in public health." As a foundational step in implementing our mission, the D&I Committee conducted a survey of SER membership. Here we report on the efforts we have undertaken to expand the diversity and inclusiveness of our Society and our aspirations for future efforts in support of D&I. Early on, we established the SERvisits program to conduct outreach to institutions and students that have historically been underrepresented at SER; we hope this program continues to grow in its reach and impact. We have also taken steps to increase the inclusiveness of SER activities, for example, by engaging members on issues of D&I through symposia and workshops at SER annual meetings and through social media. DeVilbiss et al. (Am J Epidemiol. 2020;189(10):998-1010) have demonstrated that there is substantial room for improvement with regards to diversity and inclusion within SER. We invite SER members to become involved and collaborate on this long-term goal.

Assessing Representation and Perceived Inclusion among Members in the Society for Epidemiologic Research.

Using web-based survey data collected June - August 2018 from the Society for Epidemiologic Research (SER) members, we characterized numerous dimensions of social identity and lived experience, and assessed relationships between these characteristics and perceptions of inclusion and society participation. We quantified associations between characteristics, feeling very welcomed, high (top 25th percentile) self-initiated participation, and any (top 10th percentile) society-initiated participation. Racial/ethnic and religious minority categories were blinded to preserve anonymity and we accounted for missing data. Most 2018 SER members (n = 1631) were white (62%) or female (66%). Females with racial/ethnic non-response were least likely, while white males were most likely to report feeling very welcomed. Members who did not report race, identified with a specific racial/ethnic minority, or were politically conservative/right-leaning were less likely than white or liberal/left-leaning members to have high self-initiated participation. Women and individuals of a specific racial/ethnic minority or minority religious affiliations were less likely to participate in events initiated by the society. These data represent a baseline for assessing trends and the impact of future initiatives aimed at improving diversity, inclusion, representation and participation within SER.

Objective Measures of Sleep Apnea and Actigraphy-Based Sleep Characteristics as Correlates of Subjective Sleep Quality in an Epidemiologic Study: The Jackson Heart Sleep Study.

OBJECTIVE: Self-reported "sleep quality" often is assessed in epidemiologic studies. However, the bases for variation in sleep quality is not fully understood. We quantified the extent to which subjective sleep quality was related to sleep disorders and sleep characteristics among 795 African American adults. METHOD: Between 2012 and 2016, participants underwent home sleep apnea testing and 1-week actigraphy (estimating sleep duration, efficiency, fragmentation, latency). Sleep quality, insomnia and restless legs syndrome symptoms, sleepiness, and physician diagnosis of sleep disorders were self-reported. We fit linear regression models to determine the extent to which subjective and objective sleep measures as well as depressive symptoms and anxiety were related to subjective sleep quality. RESULTS: After adjustment for covariates, worse sleep quality scores were associated with insomnia and restless legs syndrome symptoms, sleep apnea, physician diagnosis of a sleep disorder, and actigraphy-based fragmented sleep, lower sleep efficiency, and shorter sleep duration. Insomnia symptoms explained the most variance in subjective sleep quality, 21%. Other sleep measures each explained 3% to 7% and psychosocial factors explained 8% to 9% of the variance in subjective sleep quality after adjustment for confounders. CONCLUSIONS: The weak associations of sleep quality with sleep disorders and objectively measured sleep disturbances are consistent with concepts of "sleep health" as a multidimensional construct. Sleep quality is a patient-centered outcome that provides unique information over objective measurements of sleep disturbances.

Sleep and Resistant Hypertension.

PURPOSE OF REVIEW: The goal of the present review is to describe the current findings on the association of sleep with resistant hypertension (hypertension that remains uncontrolled despite the use of three or more antihypertensive medications from different classes, including a diuretic). RECENT FINDINGS: Sleep disturbances, particularly obstructive sleep apnea (OSA), are highly prevalent among adults who have resistant hypertension. Randomized controlled trials indicate that treating OSA has modest effects on blood pressure lowering among those with the highest initial blood pressure. There is a paucity of research on the association of habitual sleep and other sleep disturbances with resistant hypertension. Of note, the most recent observational studies describing the association of OSA with resistant hypertension are comprised primarily of non-white race/ethnic groups who are far more likely to have resistant hypertension. OSA is associated with resistant hypertension, but there is limited data on associations between sleep characteristics and resistant hypertension. Future studies should investigate whether treating OSA can reduce disparities in resistant hypertension and whether other aspects of sleep also contribute to resistant hypertension.

Associations Between the Built Environment and Objective Measures of Sleep: The Multi-Ethnic Study of Atherosclerosis.

Although dense neighborhood built environments support increased physical activity and lower obesity, these features may also disturb sleep. Therefore, we sought to understand the association between the built environment and objectively measured sleep. From 2010 to 2013, we analyzed data from examination 5 of the Multi-Ethnic Study of Atherosclerosis, a diverse population from 6 US cities. We fit multilevel models that assessed the association between the built environment (Street Smart Walk Score, social engagement destinations, street intersections, and population density) and sleep duration or efficiency from 1-week wrist actigraphy in 1,889 individuals. After adjustment for covariates, a 1-standard-deviation increase in Street Smart Walk Score was associated with 23% higher odds of short sleep duration (≤6 hours; odds ratio = 1.2, 95% confidence interval: 1.0, 1.4), as well as shorter average sleep duration (mean difference = -8.1 minutes, 95% confidence interval: -12.1, -4.2). Results were consistent across other built environment measures. Associations were attenuated after adjustment for survey-based measure of neighborhood noise. Dense neighborhood development may have multiple health consequence. In promoting denser neighborhoods to increase walkability, it is important to also implement strategies that reduce the adverse impacts of this development on sleep, such as noise reductions efforts.

Association Between Discrimination and Objective and Subjective Sleep Measures in the Midlife in the United States Study Adult Sample.

OBJECTIVE: Evidence suggests that sleep quality is worse in nonwhite minorities compared with whites. Poor sleep is associated with higher levels of perceived interpersonal discrimination, which is consistently reported among minorities. However, the literature is limited in exploring discrimination with both objective and subjective sleep outcomes in the same sample. We examined the relationship between discrimination and markers of subjective and objective sleep in a racially diverse sample. METHODS: The analytic sample included 441 participants of the Midlife in the United States II (MIDUS) study (M [SD] age, 46.6 [1.03]; female, 57.9%; male, 42.1%; nonwhite, 31.7%). Complete data were available for 361 participants. Sleep measures included the Pittsburgh Sleep Quality Index, sleep latency, wake after sleep onset, and sleep efficiency derived from 7-day actigraphy. Discrimination was measured with the Williams Everyday Discrimination Scale. Ordinary least squares and logistic regression models were used to assess the relationship between discrimination and the subjective and objective measures of sleep. RESULTS: After adjusting for covariates, respondents with higher discrimination scores were significantly more likely to experience poor sleep efficiency (odds ratio, 1.12; p = .005) and report poorer sleep quality (odds ratio, 1.09; p = .029) on the basis of the Pittsburgh Sleep Quality Index. Higher discrimination scores were also associated with longer wake after sleep onset (b = 0.032, p < .01) and more sleep difficulties (b = 0.049, p = .01). Discrimination attenuated all differences in the sleep measures between whites and nonwhites except for sleep efficiency. CONCLUSIONS: The findings support the model that discrimination acts as a stressor that can disrupt subjective and objective sleep. These results suggest that interpersonal discrimination explains some variance in worse sleep among nonwhites compared with whites.

Initiating an online asthma management program in urban emergency departments: the recruitment experience.

BACKGROUND: The emergency department could represent a means of identifying patients with asthma who could benefit from asthma interventions. OBJECTIVE: To assess the initiation of a Web-based tailored asthma intervention in the emergency department of 2 urban tertiary care hospitals. METHODS: In addition to awareness strategies for emergency department staff (eg, attending nursing huddles, division meetings, etc), recruitment experiences are described for 2 strategies: (1) recruitment during an emergency department visit for acute asthma and (2) recruitment from patient listings (mail or telephone). Patient enrollment was defined as baseline completion, randomization, and completion of the first of 4 online sessions. RESULTS: Of 499 eligible patients 13 to 19 years old visiting the emergency department for asthma during the study period, 313 (63%) were contacted in the emergency department (n = 65) or by mail or telephone (n = 350). Of these, 121 (38.6%) were randomized. Mean age of the study sample was 15.4 years and 88.4% were African American. Refusal rates for emergency department recruitment and mail or telephone were 18.5% (12 of 65) and 16.6% (58 of 350), respectively. On average, emergency department enrollment took 44 to 67 minutes, including downtime. When surveyed, emergency department providers were more positive about awareness activities and emergency department recruitment than were research staff. CONCLUSION: Emergency department recruitment was feasible but labor intensive. Refusal rates were similar for the 2 strategies. Targeting patients with acute asthma in the emergency department is one way of connecting with youth at risk of future acute events.

Sexual orientation identity disparities in health behaviors, outcomes, and services use among men and women in the United States: a cross-sectional study.

BACKGROUND: Research shows that sexual minorities (e.g., lesbian, gay, and bisexual individuals) experience higher levels of discrimination, stigma, and stress and are at higher risk of some poor health outcomes and health behaviors compared to their heterosexual counterparts. However, the majority of studies have examined sexual orientation disparities in a narrow range of health outcomes and behaviors using convenience samples comprised of either men or women living in restricted geographic areas. METHODS: To investigate the relationship between sexual orientation identity and health among U.S. women and men, we used Poisson regression with robust variance to estimate prevalence ratios for health behaviors, outcomes, and services use comparing sexual minorities to heterosexual individuals using 2013 and 2014 National Health Interview Survey data (N = 69,270). RESULTS: Three percent of the sample identified as sexual minorities. Compared to heterosexual women, lesbian (prevalence ratio (PR) = 1.65 [95 % confidence interval (CI): 1.14, 2.37]) and bisexual (PR = 2.16 [1.46, 3.18]) women were more likely to report heavy drinking. Lesbians had a higher prevalence of obesity (PR = 1.20 [1.02, 1.42]), stroke (PR = 1.96 [1.14, 3.39]), and functional limitation (PR = 1.17 [1.02, 1.34] than heterosexual women. Gay men were more likely to have hypertension (PR = 1.21 [1.03, 1.43]) and heart disease (PR = 1.39 [1.02, 1.88]). Despite no difference in health insurance status, sexual minorities were more likely than heterosexual individuals to delay seeking healthcare because of cost; however, members of this group were also  more likely to have received an HIV test and initiated HPV vaccination. CONCLUSION: Sexual minorities had a higher prevalence of some poor health behaviors and outcomes.