Addressing social determinants of oral health, structural racism and discrimination and intersectionality among immigrant and non-English speaking Hispanics in the United States.

BACKGROUND: The Hispanic population is the largest (18.5%) and fastest growing non-majority ethnic group in the United States (US), about half of whom are non-US born, and bears one of the highest oral disease burdens. Most current knowledge around oral health disparities in Hispanic populations examine the individual factors of culture, acculturation, and socioeconomic status. However, the root causes of this inequity; oral health literacy (OHL), social determinants of health (SDOH), structural racism and discrimination (SRD) and the intersectionality among the three, have not been well-studied. Addressing this critical gap will be central to advancing health equity and reducing oral health-related disparities in the Hispanic population, especially among immigrant and non-English speaking Hispanics. RESULTS: Recommendations for future OHL/SDOH/SRD-related research in oral health targeting Hispanic populations should include: (1) examining the direct and indirect effects of OHL/SDOH/SRD-related factors and intersectionality, (2) assessing the impact of SRD on oral health using zip-code level measures, (3) examining the role of OHL and SDOH as potential effect modifiers on the relationship between SRD and oral health outcomes, (4) conducting secondary data analysis to identify demographic, social and structural-level variables and correlations between and among variables to predict oral health outcomes, and (5) obtaining a deeper understanding of how OHL/SDOH and SRD factors are experienced among Hispanic immigrant and migrant populations. CONCLUSION: It is hoped these recommendations will lead to a better understanding of the mechanisms through which OHL, SDOH and SRD impact oral health outcomes among the largest minority population in the US so they can be addressed.

Effects of a Laboratory Health Information Exchange Intervention on Antiretroviral Therapy Use, Viral Suppression, and Racial/Ethnic Disparities.

BACKGROUND: Although antiretroviral therapy (ART) is available to treat HIV+ persons and prevent transmission, ineffective delivery of care may delay ART use, impede viral suppression (VS), and contribute to racial/ethnic disparities along the continuum of care. This study tested the effects of a bi-directional laboratory health information exchange (LHIE) intervention on each of these outcomes. METHODS: We used a quasi-experimental, interrupted time-series design to examine whether the LHIE intervention improved ART use and VS, and reduced racial/ethnic disparities in these outcomes among HIV+ patients (N = 1181) in a comprehensive HIV/AIDS clinic in Southern California. Main outcome measures were ART pharmacy fill and HIV viral load laboratory data extracted from the medical records over 3 years. Race/ethnicity and an indicator for the intervention (after vs. before) were the main predictors. The analysis involved 3-stage, multivariable logistic regression with generalized estimating equations. RESULTS: Overall, the intervention predicted greater odds of ART use (odds ratio [OR] = 2.50; 95% confidence interval: 2.29 to 2.73; P < 0.001) and VS (OR = 1.12; 95% confidence interval: 1.04 to 1.21; P < 0.05) in the final models that included sociodemographic, behavioral, and clinical covariates. Before the intervention, there were significant black/white disparities in ART use OR = 0.75 (0.58-0.98; P = 0.04) and VS OR = 0.75 (0.61-0.92; P = 0.001). After the intervention, the black/white disparities decreased after adjusting for sociodemographics and the number of HIV care visits, and Latinos had greater odds than whites of ART use and VS, adjusting for covariates. CONCLUSIONS: The intervention improved overall ART treatment and VS, and reduced black/white disparities. LHIE interventions may hold promise if implemented among similar patients.

Operationalizing treatment as prevention in Los Angeles County: antiretroviral therapy use and factors associated with unsuppressed viral load in the Ryan White system of care.

Despite extensive prevention efforts, an estimated 21% of individuals with HIV/AIDS in the United States are unaware of their status, placing them at greater risk for spreading the virus to others. HIV treatment as prevention (TasP) is rapidly becoming an important public health strategy to reduce HIV transmission at the population level. Data for this study were collected on a sample of 11,397 HIV-positive individuals in the Ryan White system, a publicly funded system of care for HIV-positive individuals in Los Angeles County who are uninsured, in 2009 to examine two components of TasP: baseline rates and factors associated with antiretroviral therapy (ART) use and viral load (VL) suppression in a publicly funded system of care. ART coverage among our sample was 90%. In multivariate analyses, those with a higher odds of having unsuppressed VL included: females compared to males (adjusted odds ratio [AOR]=1.25; 95% confidence interval [CI]=1.06, 1.47); African Americans compared to whites (AOR=1.42; 95% CI=1.24, 1.62); men who have sex with men compared to heterosexuals (AOR=1.15; 95% CI=1.00, 1.32); recent substance abusers compared to nonsubstance abusers (AOR=1.35; 95% CI=1.17, 1.55); those recently incarcerated or ever incarcerated compared to those never incarcerated (AOR=1.37; 95% CI=1.15, 1.63; and AOR=1.28; 95% CI=1.09, 1.50); and those retained in care compared to those not retained in care (AOR=1.98; 95% CI=1.76, 2.22). Understanding the key sociodemographic, geographic and behavioral factors associated with ART use as well as HIV VL suppression will be useful for informing the development and deployment of targeted programming and policies that may further enhance the implementation of the TasP approach in communities across the United States.

Evaluation of a statewide public health nursing training in Utah.

Public health nurses continue to struggle to provide culturally relevant services that focus on the multiple needs of an ethnically diverse population while at the same time providing services to the population at large. This article describes the formative research, implementation, and results of a statewide effort to broaden UtahAEs public health nurses perception about their role and responsibility in addressing and serving the emerging needs of underserved and atrisk populations in Utah. A total of 51% of Utah state and local health department public health nurses participated in the training. There was a statistically significant increase in the mean level of perceived understanding of topic material from pretest to posttest, and 80% of participants reported applying what they learned in the training to their practice. Our experience demonstrates that even with limited resources, it is possible to deliver high quality training to a large proportion of public health nurses practicing in urban, rural, and frontier populations; observe significant results in their comprehension of training material and, most importantly; see application of what they learned in the training to their health care practice.

Using conjoint analysis to measure the acceptability of rectal microbicides among men who have sex with men in four South American cities.

Conjoint Analysis (CJA), a statistical market-based technique that assesses the value consumers place on product characteristics, may be used to predict acceptability of hypothetical products. Rectal Microbicides (RM)-substances that would prevent HIV infection during receptive anal intercourse-will require acceptability data from potential users in multiple settings to inform the development process by providing valuable information on desirable product characteristics and issues surrounding potential barriers to product use. This study applied CJA to explore the acceptability of eight different hypothetical RM among 128 MSM in Lima and Iquitos, Peru; Guayaquil, Ecuador; and Rio de Janeiro, Brazil. Overall RM acceptability was highest in Guayaquil and lowest in Rio. Product effectiveness had the greatest impact on acceptability in all four cities, but the impact of other product characteristics varied by city. This study demonstrates that MSM from the same region but from different cities place different values on RM characteristics that could impact uptake of an actual RM. Understanding specific consumer preferences is crucial during RM product development, clinical trials and eventual product dissemination.

Effects of a school-based nutrition program diffused throughout a large urban community on attitudes, beliefs, and behaviors related to fruit and vegetable consumption.

BACKGROUND: Obesity among US children has increased in recent years. Although increased fruit and vegetable consumption has not been directly linked to obesity prevalence, it has been posited that more fruits and vegetables (FV) could reduce the consumption of high-fat, energy-dense foods and may protect against childhood illnesses including asthma and other respiratory diseases. The purpose of this current research was to assess the impact of a large public school district's hybrid approach to nutrition education programming on attitudes, beliefs, and behaviors related to fruit and vegetable consumption. METHODS: A total of 12 elementary schools from the Los Angeles Unified School District (9 intervention schools, 3 control schools) were randomly selected to participate in a "hybrid" school-based nutrition education program. Data were collected at baseline (beginning of school year) and postintervention data (end of school year 9 months later). Linear mixed models were developed to assess the impact of the intervention. RESULTS: The intervention resulted in a significant change in teacher influence on students' attitudes toward FV (p < .05) and students' attitudes toward vegetables (p < .01), even after adjusting for gender, grade, and race/ethnicity. Although not statistically significant, there was a slight increase in fruit and vegetable consumption from pretest to posttest for both the intervention and control schools. CONCLUSION: The hybrid model reflects a more accurate representation of school-based interventions. More research is needed to identify the specific components of this model that are most successful in impacting fruit and vegetable consumption among US children.

Challenges to parent nutrition education: a qualitative study of parents of urban children attending low-income schools.

OBJECTIVE: The present study was undertaken to learn more about parents' (i) knowledge regarding healthy foods, factors associated with food purchasing and preparation, and current nutrition education resources, (ii) barriers to and promoters for establishing healthy eating habits for children and families, and (iii) interest in participating in nutrition interventions. DESIGN: Focus group interviews were conducted with parents of low-income children from the Los Angeles Unified School District (LAUSD). SETTING: LAUSD Title 1 elementary schools where 50 % or more of students are eligible for free/reduced-price meals. SUBJECTS: Sixty-four parents (93 % female; 84 % Hispanic/Latino) of elementary-school students. RESULTS: The most common barriers to eating healthy foods were cost, difficulty in getting children to eat healthier foods and easy access to fast food. Parents had a basic knowledge about what foods are healthy and received most of their nutrition education through the media. Parents expressed a desire for nutrition classes and almost all of them said they would attend a nutrition programme at their child's school. Topic areas of interest included what to purchase, how to cook healthier foods, how to encourage their children to eat healthier and how to read food labels. Parents also requested classes that engage the whole family, especially fathers. CONCLUSIONS: Parents in our study were interested in participating in nutrition education programmes. The information from these focus groups was used to design a parent nutrition education programme especially designed to respond to the needs of the LAUSD parents, the majority of whom are low-income and Hispanic/Latino.

The impact of acculturation on utilization of HIV prevention services and access to care among an at-risk Hispanic population.

INTRODUCTION: HIV/AIDS disproportionately affects Hispanics in the United States, a diverse and heterogeneous population. The purpose of this study was to evaluate the relationship of acculturation with HIV and hepatitis C testing, and access to care among Hispanics at risk for HIV. METHODS: We recruited 600 Hispanics from STD clinics, community-based organizations, and needle exchange programs in Los Angeles County. RESULTS: Low levels of acculturation were significantly associated with having fewer HIV tests (OR 1.98, 95% CI 1.24, 3.15), no hepatitis C tests (OR 2.61, 95% CI 1.77, 3.84), testing positive for HIV (OR 2.67, 95% CI 1.04, 6.83), and low levels of access to care (beta=0.06; p<.05). CONCLUSIONS: Low levels of acculturation are an important barrier to the use of HIV-related health care services. Our findings may inform the development of effective interventions that address the cultural and behavioral differences among Hispanic subgroups.

The effect of perceived stigma from a health care provider on access to care among a low-income HIV-positive population.

Perceived stigma in clinical settings may discourage HIV-infected individuals from accessing needed health care services. Having good access to care is imperative for maintaining the health, well being, and quality of life of persons living with HIV/AIDS (PLWHAs). The purpose of this prospective study, which took place from January 2004 through June 2006, was to evaluate the relationship between perceived stigma from a health care provider and access to care among 223 low income, HIV-infected individuals in Los Angeles County. Approximately one fourth of the sample reported perceived stigma from a health care provider at baseline, and about one fifth reported provider stigma at follow up. We also found that access to care among this population was low, as more than half of the respondents reported difficulty accessing care at baseline and follow up. Perceived stigma was found to be associated with low access to care both at baseline (odds ratio [OR] = 3.29; 95% confidence interval [CI] = 1.55, 7.01) and 6-month follow up (2.85; 95% CI = 1.06, 7.65), even after controlling for sociodemographic characteristics and most recent CD4 count. These findings are of particular importance because lack of access or delayed access to care may result in clinical presentation at more advanced stages of HIV disease. Interventions are needed to reduce perceived stigma in the health care setting. Educational programs and modeling of nonstigmatizing behavior can teach health care providers to provide unbiased care.