Associations among Neighborhood, Race, and Sleep Apnea Severity in Children. A Six-City Analysis.

RATIONALE: Prior researchers found that individual-level environmental and social indicators did not explain the racial disparity in obstructive sleep apnea syndrome. Neighborhood socioeconomic variables, as well as risk factors for a range of adverse behavioral and health outcomes, may better explain this racial disparity and help identify modifiable intervention targets. OBJECTIVES: To evaluate the associations of neighborhood socioeconomic variables with obstructive sleep apnea severity and to assess whether the neighborhood variables explain the association between race and obstructive sleep apnea severity. METHODS: We performed a cross-sectional analysis of data of 774 children in six cities who participated in the Childhood Adenotonsillectomy Trial. The outcome variable was the apnea-hypopnea index (AHI). Neighborhood socioeconomic variables were obtained on the basis of the children's residential addresses and information in the American Community Survey. Regression models were used to assess the associations among neighborhood conditions, race, and AHI. MEASUREMENTS AND MAIN RESULTS: Higher poverty rate and percentage of single-female-headed households were associated with higher AHI (P = 0.008 and 0.002, respectively). African American race was associated with a 1.33 (1.08-1.64 95% confidence interval)-fold increase in AHI, adjusting for age and sex. After controlling for poverty rate or percentage of single-female-headed households with children, the association between race and AHI levels was no longer significant (P = 0.15 and 0.26, respectively), and the magnitude of race association decreased 34 or 55%, suggesting that the association between race and AHI levels was largely explained by poverty rate or percentage of single-female-headed households with children. CONCLUSIONS: Neighborhood socioeconomic variables in comparison with individual-level socioeconomic indicators provides better explanations for the racial disparity in pediatric obstructive sleep apnea syndrome. Further research aimed at identifying factors that aggregate in disadvantaged neighborhoods and increase sleep apnea risk may suggest modifiable intervention targets. Clinical trial registered with clinicaltrials.gov (NCT00560859).

Accuracy of race, ethnicity, and language preference in an electronic health record.

BACKGROUND: Collection of data on race, ethnicity, and language preference is required as part of the "meaningful use" of electronic health records (EHRs). These data serve as a foundation for interventions to reduce health disparities. OBJECTIVE: Our aim was to compare the accuracy of EHR-recorded data on race, ethnicity, and language preference to that reported directly by patients. DESIGN/SUBJECTS/MAIN MEASURES: Data collected as part of a tobacco cessation intervention for minority and low-income smokers across a network of 13 primary care clinics (n = 569). KEY RESULTS: Patients were more likely to self-report Hispanic ethnicity (19.6 % vs. 16.6 %, p < 0.001) and African American race (27.0 % vs. 20.4 %, p < 0.001) than was reported in the EHR. Conversely, patients were less likely to complete the survey in Spanish than the language preference noted in the EHR suggested (5.1 % vs. 6.3 %, p < 0.001). Thirty percent of whites self-reported identification with at least one other racial or ethnic group, as did 37.0 % of Hispanics, and 41.0 % of African Americans. Over one-third of EHR-documented Spanish speakers elected to take the survey in English. One-fifth of individuals who took the survey in Spanish were recorded in the EHR as English-speaking. CONCLUSION: We demonstrate important inaccuracies and the need for better processes to document race/ ethnicity and language preference in EHRs.

Proactive tobacco cessation outreach to smokers of low socioeconomic status: a randomized clinical trial.

IMPORTANCE: Widening socioeconomic disparities in mortality in the United States are largely explained by slower declines in tobacco use among smokers of low socioeconomic status (SES) than among those of higher SES, which points to the need for targeted tobacco cessation interventions. Documentation of smoking status in electronic health records (EHRs) provides the tools for health systems to proactively offer tobacco treatment to socioeconomically disadvantaged smokers. OBJECTIVE: To evaluate a proactive tobacco cessation strategy that addresses sociocontextual mediators of tobacco use for low-SES smokers. DESIGN, SETTING, AND PARTICIPANTS: This prospective, randomized clinical trial included low-SES adult smokers who described their race and/or ethnicity as black, Hispanic, or white and received primary care at 1 of 13 practices in the greater Boston area (intervention group, n = 399; control group, n = 308). INTERVENTIONS: We analyzed EHRs to identify potentially eligible participants and then used interactive voice response (IVR) techniques to reach out to them. Consenting patients were randomized to either receive usual care from their own health care team or enter an intervention program that included (1) telephone-based motivational counseling, (2) free nicotine replacement therapy (NRT) for 6 weeks, (3) access to community-based referrals to address sociocontextual mediators of tobacco use, and (4) integration of all these components into their normal health care through the EHR system. MAIN OUTCOMES AND MEASURES: Self-reported past-7-day tobacco abstinence 9 months after randomization ("quitting"), assessed by automated caller or blinded study staff. RESULTS: The intervention group had a higher quit rate than the usual care group (17.8% vs 8.1%; odds ratio, 2.5; 95% CI, 1.5-4.0; number needed to treat, 10). We examined whether use of intervention components was associated with quitting among individuals in the intervention group: individuals who participated in the telephone counseling were more likely to quit than those who did not (21.2% vs 10.4%; P < .001). There was no difference in quitting by use of NRT. Quitting did not differ by a request for a community referral, but individuals who used their referral were more likely to quit than those who did not (43.6% vs 15.3%; P < .001). CONCLUSIONS AND RELEVANCE: Proactive, IVR-facilitated outreach enables engagement with low-SES smokers. Providing counseling, NRT, and access to community-based resources to address sociocontextual mediators among smokers reached in this setting is effective. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01156610.

Psychosocial stress and cigarette smoking persistence, cessation, and relapse over 9-10 years: a prospective study of middle-aged adults in the United States.

PURPOSE: Year-to-year decreases in smoking in the US have been observed only sporadically in recent years, which suggest a need for intensified efforts to identify those at risk for persistent smoking. To address this need, we examined the association between a variety of psychosocial stressors and smoking persistence, cessation, and relapse over 9-10 years among adults in the United States (n = 4,938, ages 25-74). METHODS: Using information provided at baseline and follow-up, participants were categorized as non-smokers, persistent smokers, ex-smokers, and relapsed smokers. Stressors related to relationships, finances, work-family conflict, perceived inequality, neighborhood, discrimination, and past-year family problems were assessed at baseline and follow-up. RESULTS: High stress at both assessments was associated with greater odds of persistent smoking for stressors related to relationships, finances, work, perceived inequality, past-year family problems, and a summary score. Among respondents who were smokers at baseline, high stress at both time points for relationship stress, perceived inequality, and past-year family problems was associated with nearly double the odds of failure to quit. CONCLUSIONS: Interventions to address psychosocial stress may be important components within smoking cessation efforts.

Use of practice-based research network data to measure neighborhood smoking prevalence.

INTRODUCTION: Practice-Based Research Networks (PBRNs) and health systems may provide timely, reliable data to guide the development and distribution of public health resources to promote healthy behaviors, such as quitting smoking. The objective of this study was to determine if PBRN data could be used to make neighborhood-level estimates of smoking prevalence. METHODS: We estimated the smoking prevalence in 32 greater Boston neighborhoods (population = 877,943 adults) by using the electronic health record data of adults who in 2009 visited one of 26 Partners Primary Care PBRN practices (n = 77,529). We compared PBRN-derived estimates to population-based estimates derived from 1999-2009 Behavioral Risk Factor Surveillance System (BRFSS) data (n = 20,475). RESULTS: The PBRN estimates of neighborhood smoking status ranged from 5% to 22% and averaged 11%. The 2009 neighborhood-level smoking prevalence estimates derived from the BRFSS ranged from 5% to 26% and averaged 13%. The difference in smoking prevalence between the PBRN and the BRFSS averaged -2 percentage points (standard deviation, 3 percentage points). CONCLUSION: Health behavior data collected during routine clinical care by PBRNs and health systems could supplement or be an alternative to using traditional sources of public health data.

Contribution of communication inequalities to disparities in human papillomavirus vaccine awareness and knowledge.

OBJECTIVES: We examined the association of Internet-related communication inequalities on human papillomavirus (HPV) vaccine awareness and infection knowledge. METHODS: We drew data from National Cancer Institute's 2007 Health Information National Trends Survey (n = 7674). We estimated multivariable logistic regression models to assess Internet use and Internet health information seeking on HPV vaccine awareness and infection knowledge. RESULTS: Non-Internet users, compared with general Internet users, had significantly lower odds of being aware of the HPV vaccine (odds ratio [OR] = 0.42; 95% confidence interval [CI] = 0.34, 0.51) and knowing that HPV causes cervical cancer (OR = 0.70; 95% CI = 0.52, 0.95). Among general health information seekers, non-Internet seekers compared with Internet information seekers exhibit significantly lower odds of HPV vaccine awareness (OR = 0.59; 95% CI = 0.46, 0.75), and of knowing about the link between HPV infection and cervical cancer (OR = 0.79; 95% CI = 0.63, 0.99) and the sexual transmission of HPV (OR = 0.71; 95% CI = 0.57, 0.89). Among cancer information seekers, there were no differences in outcomes between Internet seekers and non-Internet seekers. CONCLUSIONS: Use of a communication channel, such as the Internet, whose use is already socially and racially patterned, may widen observed disparities in vaccine completion rates.

Integrating multiple social statuses in health disparities research: the case of lung cancer.

OBJECTIVE: To illustrate the complex patterns that emerge when race/ethnicity, socioeconomic status (SES), and gender are considered simultaneously in health care disparities research and to outline the needed research to understand them by using disparities in lung cancer risks, treatment, and outcomes as an example. PRINCIPAL FINDINGS: SES, gender, and race/ethnicity are social categories that are robust predictors of variations in health and health services utilization. These are usually considered separately, but intersectionality theory indicates that the impact of each depends on the others. Each reflects historically and culturally contingent variations in social, economic, and political status. Distinct patterns of risk and resilience emerge at the intersections of multiple social categories and shape the experience of health, health care access, utilization, quality, and outcomes where these categories intersect. Intersectional approaches call for greater attention to understand social processes at multiple levels of society and require the collection of relevant data and utilization of appropriate analytic approaches to understand how multiple risk factors and resources combine to affect the distribution of disease and its management. CONCLUSIONS: Understanding how race/ethnicity, gender, and SES are interactive, interdependent, and social identities can provide new knowledge to enhance our efforts to effectively address health disparities.

Determinants and beliefs of health information mavens among a lower-socioeconomic position and minority population.

People of lower-socioeconomic position (SEP) and most racial/ethnic minorities face significant communication challenges which may negatively impact their health. Previous research has shown that these groups rely heavily on interpersonal sources to share and receive health information; however, little is known about these lay sources. The purpose of this paper is to apply the concept of a market maven to the public health sector with the aims of identifying determinants of high health information mavenism among low-SEP and racial/ethnic minority groups and to assess the information they may be sharing based on their own health beliefs. Data for this study were drawn from the baseline survey (n = 325) of a US randomized control intervention study aimed at eliciting an understanding of Internet-related challenges among lower-SEP and minority individuals. Regression models were estimated to distinguish significant determinants of health information mavenism among the sample. Similarly, bivariate and logistic multivariable models were estimated to determine the association between health information mavenism and accurate health beliefs relating to diet, physical activity and smoking. The data illustrate that having a larger social network, being female and being older were important factors associated with higher mavenism scores. Additionally being a moderate consumer of general media as well as fewer years in the US and lower language acculturation were significant predictors of higher mavenism scores. Mavens were more likely than non-mavens to maintain accurate beliefs regarding diet; however, there was no distinction between physical activity and smoking beliefs between mavens and non-mavens. These results offer a unique understanding of health information mavenism which could better leverage word-of-mouth health communication efforts among lower-SEP and minority groups in order to reduce communication inequalities. Moreover, the data indicate that health information mavens may serve as an ideal point of intervention in attempts to modify health beliefs with the goal of reducing health disparities among these populations.

Cancer-related direct-to-consumer advertising: a critical review.

The direct-to-consumer advertising (DTCA) phenomenon has received attention because of its attempt to reach out to consumers by bypassing important gatekeepers such as physicians. The emergence of new information platforms and the introduction of genetic tests directly to the consumer have heightened the concern with DTCA and its potential consequences. These effects of DTCA are particularly important given the communication inequalities among social groups, with class, race and ethnicity influencing how people access, seek, process and act on information. This Science and Society article reviews the major issues regarding general and cancer-related DTCA and also offers data from a national survey in the United States as an example of the communication inequalities in genetic testing awareness.

Communication inequalities and public health implications of adult social networking site use in the United States.

Social media, and specifically social networking sites (SNSs), are emerging as an important platform for communication and health information exchange. Yet, despite the increase in popularity and use, only a limited number of empirical studies document which segments of the adult population are and are not using social networking sites and with what, if any, affect on health. The purpose of this study is to identify potential communication inequalities in social networking site use among a representative sample of U.S. adults and to examine the association between SNS use and psychological well-being. We analyzed data from the National Cancer Institute's 2007 Health Information National Trends Survey (HINTS). Thirty-five percent of online adults reported SNS use within the past 12 months, and there were no significant differences in SNS use by race/ethnicity or socioeconomic position. Younger age (p = .00) was the most significant predictor of SNS use, while being married (p = .02) and having a history of cancer (p = .02) were associated with a decreased odds of SNS use. SNS use was significantly associated with a 0.80 (p = .00) increment in psychological distress score after controlling for other factors. The absence of inequalities in adult SNS use across race/ethnicity and class offers some support for the continued use of social media to promote public health efforts; however, issues such as the persisting digital divide and potential deleterious effects of SNS use on psychological well-being need to be addressed.