Evaluating Cognitive/Emotional and Behavioral Mediators of Oral Health Outcomes in Vulnerable Older Adults.

Inconsistent outcomes of oral hygiene interventions require testable theories combining cognitive and behavioral domains to guide intervention and improve results. This article evaluates the integrated model as a cognitive-behavioral approach to improve oral health clinical outcomes in ethnically diverse low-income older adults. Baseline data from a clinical trial utilizing the integrative model (IM) model evaluated predictors of gingival index (GI) and plaque score (PS). Individual logistic regression was performed for all predictors in relation to GI and PS. Multiple logistic regression was performed with significant predictors of GI and PS only. Greater locus of control and more brushing predicted lower GI; greater locus of control predicted lower PS. Both cognitive and behavioral domains impact GI, requiring more prolonged effort for improvement while locus of control, a cognitive variable, predicts PS, immediately improved by daily brushing/flossing. A streamlined IM including locus of control and tooth brushing should improve oral hygiene of low-income older adults.

Evaluating mechanisms of change in an oral hygiene improvement trial with older adults.

BACKGROUND: This paper compares the relationship between theoretically-driven mechanisms of change and clinical outcomes across two different interventions to improve oral hygiene of older adults participating in a group randomized trial. METHODS: Six low-income senior residences were paired and randomized into two groups. The first received a face to face counseling intervention (AMI) and the second, a peer-facilitated health campaign (three oral health fairs). Both were based on Fishbein's Integrated Model. 331 participants were recruited at baseline and 306 completed the post-assessment one month after intervention. Clinical outcomes were Gingival Index (GI) and Plaque score (PS), collected by calibrated dental hygienists. Surveys obtained data on patient background characteristics and ten mechanisms of change including oral health beliefs, attitudes, norms and behaviors. GLMM was used to assess the effects of time, intervention arm, participant characteristics, intervention mechanisms and differences between the two interventions over time in relation to outcomes. RESULTS: At baseline, both groups had similar background characteristics. Both groups improved significantly in outcomes. Overall GI scores changed from baseline mean of 0.38 (SD = .032) to .26 (SD = .025) and PS scores changed from baseline mean of 71.4 (SD = 18%) to 59.1% (SD = 21%). T-tests showed that fears of oral disease, oral health intentionality, oral health norms, worries about self-management of oral health, flossing frequency and sugar control improved significantly in both interventions from baseline to post intervention. Oral health self-efficacy, perceived risk of oral health problems, oral health locus of control and brushing frequency improved significantly only in the counseling intervention. GLMM models showed that the significant predictors of GI improvement were intentionality to perform oral hygiene, locus of control, and improvement in frequency of brushing and flossing in association with the counseling intervention. Predictors of PS improvement were worries about oral hygiene self-management and fear of oral diseases, in association with the counseling intervention. In the reduced final models, only oral health locus of control (predicting GI) and fears of oral diseases (predicting PS) were significant in association with the counseling intervention. Locus of control, a key concept in oral hygiene interventions including the IM was the main contributing mechanism for GI improvement. Fear, an emotional response, drove improvement in PS, reinforcing the importance of cognitive/emotional mechanisms in oral hygiene interventions. CONCLUSIONS: Though both groups improved in outcomes, GI and PS outcomes improved more in response to the counseling intervention than the campaign. The counseling intervention had an impact on more mechanisms of change than the campaign. Improvements in intervention mechanisms across both interventions however, suggest a closer examination of the campaign intervention impact on outcomes over time. TRIAL REGISTRATION: Clinicaltrials.gov NCT02419144, first posted April 17, 2015.

Black-White Disparities in Social and Behavioral Determinants of Health Index and Their Associations with Self-rated Health and Functional Limitations in Older Adults.

BACKGROUND: To characterize cumulative risk scores of social and behavioral determinants of health (SDoH) and examine their association with self-rated general health and functional limitations between non-Hispanic black and white older adults in the United States. METHOD: We used data from the 2013-2014 National Health and Nutrition Examination Survey (NHANES), with a nationally representative sample of black and white adults aged 65 or older (n = 954 unweighted). We quantified the cumulative risk scores of SDoH (eg, food insecurity, education and poverty), ranging from 0 (no risk at all) to 8 (highest risk), and used multivariable-adjusted logistic and Poisson regression analyses to assess the association of SDoH by racial group with self-rated health and functional limitations, adjusting for other covariates. RESULTS: Black older adults had a higher mean cumulative risk score than white counterparts (2.3 ± 2.1 vs 1.5 ± 1.0; p < .001). Black older adults were more likely to report lower self-rated health than white older adults in each of SDoH domains (p < .01 for each). In multivariable-adjusted analyses, black older adults were more likely to report lower self-rated health than white older adults (p < .01 for all) regardless of SDoH risk factors. However, those with high SDoH risk factors (ie, ≥3 risk factors) were more likely to report functional limitations than those in the low-risk group (ie, <3 risk factors) in both racial groups (p < .01 for all). CONCLUSION: SDoH-related black-white disparities remain persistent in older age. In particular, SDoH index scores for black and white older adults were differentially associated with functional limitations. Addressing SDoH should be an important consideration in reducing gaps in black-white disparities of functioning.

Building a new scale to measure worries about oral hygiene self-management in vulnerable older adults.

OBJECTIVE: This paper describes a new scale to measure worries about self-management of oral hygiene in low-income older adults. BACKGROUND: Oral hygiene that prevents oral diseases and worsening of chronic conditions improves with instruction, but other cognitive/emotional factors impede oral hygiene practice especially among older adults. Many scales measure dental anxiety, but none measures oral hygiene self-management worries. MATERIALS AND METHODS: Formative research with diverse older adults 55-95 in low-income housing identified scale items. A 23-item scale was tested in a pilot intervention study (n = 84) and formalised with a new sample (N = 331). RESULTS: In both studies, PCA/factor analysis produced two subscales: (a) worries about cleaning teeth and (b) consequences of cleaning. Chronbach's alpha coefficient evaluated internal consistency, and Pearson's r and Kendall tau/Spearman's rho evaluated scale predictability, convergent and divergent validity. The scale and subscales showed good internal consistency in both studies (over 0.90) and stability T0 0.90; T1: 0.90). In the larger sample, statistically significant correlations between the scale, subscales; plaque score, and similar scales (perceived risk of oral health problems, and fears of oral diseases) demonstrated convergent validity. For divergent validity, the worries scale, not the GOHAI, a similar scale measuring oral health life quality, was associated with Plaque Score. Each scale was associated with different mediators suggesting different constructs. CONCLUSION: The overall scale has good internal consistency, test-retest reliability, predictability and convergent and divergent validity. It captures a psycho-emotional construct useful in oral health research and hygiene education with older adults.

Moving Beyond Age: An Exploratory Qualitative Study on the Context of Young African American Men and Women's Sexual Debut.

African American youth continue to be disproportionately affected by HIV. Early sexual debut has been identified as a major determinant of HIV risk. However, emerging research suggests that the overarching context in which first sex occurs may have greater implications for sexual health than simply age alone. The purpose of this exploratory, qualitative study was to better understand the broader context of African Americans' sexual debut. In-depth, semi-structured interviews were conducted with 10 African American men and women aged 18-24 years. Thematic analysis was used to analyze the data. The mean age at sexual debut for the sample was 15.4 (SD = 3.3), and youth framed their sexual debut as positive (50%), negative (30%), and both positive and negative (20%). The majority of youth initiated pre-sex conversations with their partners to gauge potential interest in engaging in sexual activity, and all youth utilized at least one HIV/sexually transmitted infection and pregnancy prevention method. However, most youth failed to talk to their partners prior to sex about their past sexual histories and what the experience meant for their relationship. Key differences emerged between youth who framed the experience as positive and those who framed the experience as negative or both positive and negative in terms of their motivations for initiating sex (i.e., readiness to initiate sex, pressure, and emotionally safety) and post-sex emotions (i.e., remorse and contentment). Findings provide further support for examining the broader sexual context of African American's sexual debut. A more comprehensive understanding of sexual debut will aid in the development and tailoring of sexual risk reduction programs targeting African American youth.

Community Involvement in Health Systems Strengthening to Improve Global Health Outcomes: A Review of Guidelines and Potential Roles.

Definitions of health systems strengthening (HSS) have been limited in their inclusion of communities, despite evidence that community involvement improves program effectiveness for many health interventions. We review 15 frameworks for HSS, highlighting how communities are represented and find few delineated roles for community members or organizations. This review raises the need for a cohesive definition of community involvement in HSS and well-described activities that communities can play in the process. We discuss how communities can engage with HSS in four different areas-planning and priority-setting; program implementation; monitoring, evaluation, and quality improvement; and advocacy-and how these activities could be better incorporated into key HSS frameworks. We argue for more carefully designed interactions between health systems policies and structures, planned health systems improvements, and local communities. These interactions should consider local community inputs, strengths, cultural and social assets, as well as limitations in and opportunities for increasing capacity for better health outcomes.

Betting on the fastest horse: Using computer simulation to design a combination HIV intervention for future projects in Maharashtra, India.

OBJECTIVE: To inform the design of a combination intervention strategy targeting HIV-infected unhealthy alcohol users in Maharashtra, India, that could be tested in future randomized control trials. METHODS: Using probabilistic compartmental simulation modeling we compared intervention strategies targeting HIV-infected unhealthy alcohol users on antiretroviral therapy (ART) in Maharashtra, India. We tested interventions targeting four behaviors (unhealthy alcohol consumption, risky sexual behavior, depression and antiretroviral adherence), in three formats (individual, group based, community) and two durations (shorter versus longer). A total of 5,386 possible intervention combinations were tested across the population for a 20-year time horizon and intervention bundles were narrowed down based on incremental cost-effectiveness analysis using a two-step probabilistic uncertainty analysis approach. RESULTS: Taking into account uncertainty in transmission variables and intervention cost and effectiveness values, we were able to reduce the number of possible intervention combinations to be used in a randomized control trial from over 5,000 to less than 5. The most robust intervention bundle identified was a combination of three interventions: long individual alcohol counseling; weekly Short Message Service (SMS) adherence counseling; and brief sex risk group counseling. CONCLUSIONS: In addition to guiding policy design, simulation modeling of HIV transmission can be used as a preparatory step to trial design, offering a method for intervention pre-selection at a reduced cost.

Place Still Matters: Racial/Ethnic and Geographic Disparities in HIV Transmission and Disease Burden.

Neighborhood-level structural interventions are needed to address HIV/AIDS in highly affected areas. To develop these interventions, we need a better understanding of contextual factors that drive the pandemic. We used multinomial logistic regression models to examine the relationship between census tract of current residence and mode of HIV transmission among HIV-positive cases. Compared to the predominantly white high HIV prevalence tract, both the predominantly black high and low HIV prevalence tracts had greater odds of transmission via injection drug use and heterosexual contact than male-to-male sexual contact. After adjusting for current age, gender, race/ethnicity, insurance status, and most recently recorded CD4 count, there was no statistically significant difference in mode of HIV transmission by census tract. However, heterosexual transmission and injection drug use remain key concerns for underserved populations. Blacks were seven times more likely than whites to have heterosexual versus male-to-male sexual contact. Those who had Medicaid or were uninsured (versus private insurance) were 23 and 14 times more likely, respectively, to have injection drug use than male-to-male sexual contact and 10 times more likely to have heterosexual contact than male-to-male sexual contact. These findings can inform larger studies for the development of neighborhood-level structural interventions.

Stakeholder conceptualisation of multi-level HIV and AIDS determinants in a Black epicentre.

HIV has reached epidemic proportions among African Americans in the USA but certain urban contexts appear to experience a disproportionate disease burden. Geographic information systems mapping in Philadelphia indicates increased HIV incidence and prevalence in predominantly Black census tracts, with major differences across adjacent communities. What factors shape these geographic HIV disparities among Black Philadelphians? This descriptive study was designed to refine and validate a conceptual model developed to better understand multi-level determinants of HIV-related risk among Black Philadelphians. We used an expanded ecological approach to elicit reflective perceptions from administrators, direct service providers and community members about individual, social and structural factors that interact to protect against or increase the risk for acquiring HIV within their community. Gender equity, social capital and positive cultural mores (e.g., monogamy, abstinence) were seen as the main protective factors. Historical negative contributory influences of racial residential segregation, poverty and incarceration were among the most salient risk factors. This study was a critical next step toward initiating theory-based, multi-level community-based HIV prevention initiatives.

Use of smokeless tobacco by Indian women aged 18-40 years during pregnancy and reproductive years.

OBJECTIVES: This paper discusses patterns of daily smokeless tobacco (SLT) use and correlates of poly SLT use among married women aged 18-40 years in a Mumbai slum community with implications for tobacco control. METHODS: Using a mixed methods approach, the study included a structured survey with 409 daily SLT users and in-depth interviews with 42 women. Participants for the survey were selected using a systematic sampling procedure (one woman in every fourth eligible household). Univariate and bivariate analysis, and multiple logistic regressions were conducted to identify demographic and social factors associated with women's use of poly SLT products. To illustrate survey results, in-depth interviews were analyzed using Atlas ti software. RESULTS: Sixty-four percent of the women surveyed used only one type of SLT; of these, 30% used mishri, 32% used pan with tobacco and the rest used chewed tobacco (11%), gul (17%) or gutkha (10%). Thirty-six percent used more than one type of SLT. Poly SLT users chewed or rubbed 50% more tobacco as compared to single users (mean consumption of tobacco per day: 9.54 vs. 6.49 grams; p<0.001). Women were more likely to be poly SLT users if they were illiterate as compared to literate (adjusted odds ratio [AOR]=1.67; 95% confidence interval [CI]=1.07-2.71), if they had lived in Mumbai for 10 years or more, versus less than ten years (AOR=1.67, 95% CI=1.03-2.71); and if their husband was a poly SLT user as compared to a non SLT user (AOR=2.78, 95% CI=1.63-4.76). No differences were noted between pregnant and non-pregnant women in SLT consumption patterns. CONCLUSIONS: Tobacco control policies and programs must focus specifically on both social context and use patterns to address SLT use among women of reproductive age with special attention to poly SLT users, an understudied and vulnerable population.

An approach to mental health in low and middle income countries: a case example from urban India.

Women in low and middle income countries (LMICs) facing poverty, challenging living conditions and gender inequality often express their emotional difficulties through physical health concerns and seek care at primary health facilities. However, primary care providers in LMICs only treat the physical health symptoms and lack appropriate services to address women's mental health problems. This paper, presents data from the counseling component of a multilevel, research and intervention project in a low income community in Mumbai, India whose objective was to improve sexual health and reduce HIV/STI risk among married women. Qualitative data from counselor notes shows that poor mental health, associated with negative and challenging life situations, is most often expressed by women as gynecological concerns through the culturally-based syndrome of tenshun. A path analysis was conducted on baseline quantitative data that confirmed the relationships between sources of tenshum, emotional status and symptoms of common mental disorders (CMDs). Based on these findings, the authors propose a need for culturally appropriate primary care services for LMICs that would integrate mental and physical health. This approach would reduce mental health morbidity among women through early intervention and prevention of the development of CMDs.

A pilot study to assess oral health literacy by comparing a word recognition and comprehension tool.

BACKGROUND: Oral health literacy is important to oral health outcomes. Very little has been established on comparing word recognition to comprehension in oral health literacy especially in older adults. Our goal was to compare methods to measure oral health literacy in older adults by using the Rapid Estimate of Literacy in Dentistry (REALD-30) tool including word recognition and comprehension and by assessing comprehension of a brochure about dry mouth. METHODS: 75 males and 75 females were recruited from the University of Connecticut Dental practice. Participants were English speakers and at least 50 years of age. They were asked to read the REALD-30 words out loud (word recognition) and then define them (comprehension). Each correctly-pronounced and defined word was scored 1 for total REALD-30 word recognition and REALD-30 comprehension scores of 0-30. Participants then read the National Institute of Dental and Craniofacial Research brochure "Dry Mouth" and answered three questions defining dry mouth, causes and treatment. Participants also completed a survey on dental behavior. RESULTS: Participants scored higher on REALD-30 word recognition with a mean of 22.98 (SD = 5.1) compared to REALD-30 comprehension with a mean of 16.1 (SD = 4.3). The mean score on the brochure comprehension was 5.1 of a possible total of 7 (SD = 1.6). Pearson correlations demonstrated significant associations among the three measures. Multivariate regression showed that females and those with higher education had significantly higher scores on REALD-30 word-recognition, and dry mouth brochure questions. Being white was significantly related to higher REALD-30 recognition and comprehension scores but not to the scores on the brochure. CONCLUSIONS: This pilot study demonstrates the feasibility of using the REALD-30 and a brochure to assess literacy in a University setting among older adults. Participants had higher scores on the word recognition than on comprehension agreeing with other studies that recognition does not imply understanding.

Women's empowerment and its differential impact on health in low-income communities in Mumbai, India.

This paper examines the relationship of empowerment to women's self-reported general health status and women's self-reported health during pregnancy in low-income communities in Mumbai. The data on which this paper is based were collected in three study communities located in a marginalised area of Mumbai. We draw on two data sources: in-depth qualitative interviews conducted with 66 married women and a survey sample of 260 married women. Our analysis shows that empowerment functions differently in relation to women's reproductive status. Non-pregnant women with higher levels of empowerment experience greater general health problems, while pregnant women with higher levels of empowerment are less likely to experience pregnancy-related health problems. We explain this non-intuitive finding and suggest that a globally defined empowerment measure for women may be less useful that one that is contextually and situationally defined.

The role of MDMA (Ecstasy) in coping with negative life situations among urban young adults.

This article examines the role of Ecstasy (MDMA or 3, 4-methylenedioxymethamphetamine) as a drug used for self-medication and coping with both short- and long-term negative life situations. We show that urban youth who do not have a specific diagnosed mental illness are more likely than those who have been diagnosed and have received treatment to use Ecstasy to cope with both situational stress and lifetime trauma. Diagnosed and treated youth sometimes self-medicate with other drugs, but do not choose Ecstasy for mediation of their psychological stress. We discuss the implications of self-medication with Ecstasy for mental health services to urban youth experiencing mental health disparities, and for the continued testing and prescription of MDMA for therapeutic use in controlled clinical settings.

Advancing the science of community-level interventions.

Community interventions are complex social processes that need to move beyond single interventions and outcomes at individual levels of short-term change. A scientific paradigm is emerging that supports collaborative, multilevel, culturally situated community interventions aimed at creating sustainable community-level impact. This paradigm is rooted in a deep history of ecological and collaborative thinking across public health, psychology, anthropology, and other fields of social science. The new paradigm makes a number of primary assertions that affect conceptualization of health issues, intervention design, and intervention evaluation. To elaborate the paradigm and advance the science of community intervention, we offer suggestions for promoting a scientific agenda, developing collaborations among professionals and communities, and examining the culture of science.

Individual, contextual, and social network factors affecting exposure to HIV/AIDS risk among older residents living in low-income senior housing complexes.

This study examines the influence of individual, contextual (building location and characteristics), and social network characteristics on HIV prevalence and risk behavior among people older than 50 years of age living in low-income senior housing in two cities, Hartford, Connecticut and Chicago, Illinois. The authors' study focuses on older residents of six buildings located in impoverished neighborhoods with high rates of HIV transmission through injection drug use and unprotected sexual activity, including the exchange of sex for drugs and money. The article is organized into three sections. First, the authors explore the HIV prevalence, distribution, and risk behaviors that may contribute to new infections among the buildings' older residents in general. These practices include unprotected sexual intercourse, sex with commercial sex workers, casual or multiple partners, regular use of alcohol and/or illicit drugs, and other high-risk activities that expose older residents to HIV, sexually transmitted diseases, and other negative health consequences. Next, the authors examine the relationship between building and neighborhood characteristics, the internal social organization of buildings, and the risk behaviors of individual residents by building residency. Finally, the authors use a social network analysis to identify possible entry points and transmission routes for HIV infection through drug and sexual exchanges between and among building residents and visitors. This approach also reveals variations in building structures that may facilitate the diffusion of HIV prevention efforts.

Sex-related health risks and implications for interventions with hospitality women in Hainan, China.

This article describes the living situations of sex workers (hospitality girls) in a typical rural town in southern China; their personal, social, financial, and psychological needs and expectations; and the social and economic factors that place them at risk for STIs/HIV and unwanted pregnancy, based on the qualitative and quantitative data collected prior to and during a preventive intervention. Though some similarities to knowledge, attitudes, and behaviors of sex workers reported in other Asian countries were identified, this study identified some differences distinctive to the China context, such as how economic factors, kinship, and friendship networks function in the service industry, and how the culture of reproduction and birth control policy interact with and affect sex workers' health and decision-making options. Understanding these factors is critical for design of a culturally and contextually tailored intervention for the reduction of sex-related health risks of women in the sex service industry.