Breastfeeding Trends Among Very Low Birth Weight, Low Birth Weight, and Normal Birth Weight Infants.

OBJECTIVE: To examine the change in breastfeeding behaviors over time, among low birth weight (LBW), very low birth weight (VLBW), and normal birth weight (NBW) infants using nationally representative US data. STUDY DESIGN: Univariate statistics and bivariate logistic models were examined using the Early Child Longitudinal Study-Birth Cohort (2001) and National Study of Children's Health (2007 and 2011/2012). RESULTS: Breastfeeding behaviors improved for infants of all birth weights from 2007 to 2011/2012. In 2011/2012, a higher percentage of VLBW infants were ever breastfed compared with LBW and NBW infants. In 2011/2012, LBW infants had a 28% lower odds (95% CI, 0.57-0.92) of ever breastfeeding and a 52% lower odds (95% CI, 0.38-0.61) of breastfeeding for ≥6 months compared with NBW infants. Among black infants, a larger percentage of VLBW infants were breastfed for ≥6 months (26.2%) compared with LBW infants (14.9%). CONCLUSIONS: Breastfeeding rates for VLBW and NBW infants have improved over time. Both VLBW and NBW infants are close to meeting the Healthy People 2020 ever breastfeeding goal of 81.9%. LBW infants are farther from this goal than VLBW infants. The results suggest a need for policies that encourage breastfeeding specifically among LBW infants.

Citizenship, length of stay, and screening for breast, cervical, and colorectal cancer in women, 2000-2010.

BACKGROUND: Two factors jointly account for significant gaps in access to health care among immigrants who are present in the U.S.-legal status, and length of residence. The objective of this study is to examine the association between citizenship and length of residence in the U.S. and cancer screening (breast, cervical, and colorectal) among women. METHODS: We analyzed 11 years (2000-2010) of consolidated data from the Medical Expenditure Panel Survey linked with the National Health Interview Survey. Multivariate analyses compared cancer screening among U.S.-born citizens (n = 58,484), immigrant citizens (n = 8,404), and immigrant non-citizens (n = 6,564). RESULTS: Immigrant non-citizens living in the U.S. for less than 5 years were less likely to receive guideline-concordant breast (OR = 0.68 [0.53-0.88]), cervical (OR = 0.65 [0.54-0.78]), and colorectal (OR = 0.31 [0.19-0.50]) cancer screening compared to U.S.-born citizens. Immigrant citizens and non-citizens living in the U.S. for 5 years or more had higher odds of being screened for breast and cervical cancer compared to U.S.-born citizens; (OR = 1.26 [1.13-1.41] and OR = 1.17 [1.06-1.29]) for immigrant citizens, (OR = 1.28 [1.13-1.45] and OR = 1.23 [1.09-1.38]) for non-citizens. Immigrant non-citizens living in the U.S. for 5 years or more had lower odds of being screened for colorectal cancer compared to U.S.-born citizens (OR = 0.76 [0.65-0.90]). CONCLUSIONS: Based on these findings, duration mandates in immigration policy may indirectly influence future pathways to preventive health care and cancer disparities disproportionately affecting immigrant women. We suggest that limits of duration mandates be reevaluated, as they may offer pathways to preventive health care for this vulnerable population, and prevent future cancer disparities.

Reports of self-rated health by citizenship and homeownership, United States 2000-2010.

Citizenship facilitates home ownership, which promotes access to additional resources and structures social context, factors that improve the health of individuals and communities. The objective of this study was to examine whether citizenship moderated the association between homeownership and self-rated health. We used multivariate logistic regression models and propensity score matching techniques to examine this association using pooled years 2000-2010 of the Medical Expenditure Panel Survey data linked with the National Health Interview Survey to examine U.S. adults aged 18 and older (N=170,429). Rates of fair/poor health among homeowners vs. non-homeowners were comparable for foreign-born non-citizens. However, native- and foreign-born citizen non-homeowners showed significantly higher rates of reporting fair/poor health, with native-born citizens having the highest rates of poor health. While homeownership is protective for self-rated health, not meeting the "American Dream" of home ownership may be embodied more in the health of native-born citizens as "failure" and translate into poorer self-rated health. However, the economic privileges of homeownership and its association with better self-rated health are limited to citizens. Non-citizens may be disadvantaged despite socioeconomic position, particularly wealth as considered by homeownership, placing citizenship at the forefront as the most proximate and important burden besides socioeconomic status that needs further investigation as a fundamental health determinant.

Racial/Ethnic Disparities in Influenza Vaccination of Chronically Ill US Adults: The Mediating Role of Perceived Discrimination in Health Care.

BACKGROUND: Despite well-established programs, influenza vaccination rates in US adults are well below federal benchmarks and exhibit well-documented, persistent racial and ethnic disparities. The causes of these disparities are multifactorial and complex, though perceived racial/ethnic discrimination in health care is 1 hypothesized mechanism. OBJECTIVES: To assess the role of perceived discrimination in health care in mediating influenza vaccination RACIAL/ETHNIC disparities in chronically ill US adults (at high risk for influenza-related complications). RESEARCH DESIGN: We utilized 2011-2012 data from the Aligning Forces for Quality Consumer Survey on health and health care (n=8127), nationally representative of chronically ill US adults. Logistic regression marginal effects examined the relationship between race/ethnicity and influenza vaccination, both unadjusted and in multivariate models adjusted for determinants of health service use. We then used binary mediation analysis to calculate and test the significance of the percentage of this relationship mediated by perceived discrimination in health care. RESULTS: Respondents reporting perceived discrimination in health care had half the uptake as those without discrimination (32% vs. 60%, P=0.009). The change in predicted probability of vaccination given perceived discrimination experiences (vs. none) was large but not significant in the fully adjusted model (-0.185; 95% CI, -0.385, 0.014). Perceived discrimination significantly mediated 16% of the unadjusted association between race/ethnicity and influenza vaccination, though this dropped to 6% and lost statistical significance in multivariate models. CONCLUSIONS: The causes of persistent racial/ethnic disparities are complex and a single explanation is unlikely to be sufficient. We suggest reevaluation in a larger cohort as well as potential directions for future research.

Food shopping behaviours and exposure to discrimination.

OBJECTIVE: The present study examined food shopping behaviours, particularly distance to grocery shop, and exposure to discrimination. DESIGN: Cross-sectional observational study utilizing data from a community survey, neighbourhood food environment observations and the decennial census. SETTING: Three communities in Detroit, Michigan, USA. SUBJECTS: Probability sample of 919 African-American, Latino and white adults in 146 census blocks and sixty-nine census block groups. RESULTS: On average, respondents shopped for groceries 3·1 miles (4·99 km) from home, with 30·9 % shopping within 1 mile (1·61 km) and 22·3 % shopping more than 5 miles (8·05 km) from home. Longer distance to shop was associated with being younger, African-American (compared with Latino), a woman, higher socio-economic status, lower satisfaction with the neighbourhood food environment, and living in a neighbourhood with higher poverty, without a large grocery store and further from the nearest supermarket. African-Americans and those with the lowest incomes were particularly likely to report unfair treatment at food outlets. Each mile (1·61 km) increase in distance to shop was associated with a 7 % increase in the odds of unfair treatment; this relationship did not differ by race/ethnicity. CONCLUSIONS: The study suggests that unfair treatment in retail interactions warrants investigation as a pathway by which restricted neighbourhood food environments and food shopping behaviours may adversely affect health and contribute to health disparities. Efforts to promote 'healthy' and equitable food environments should emphasize local availability and affordability of a range of healthy food products, as well as fair treatment while shopping regardless of race/ethnicity or socio-economic status.

Medical expenditures among immigrant and nonimmigrant groups in the United States: findings from the Medical Expenditures Panel Survey (2000-2008).

OBJECTIVE: The objective of the study was to examine time trends and differences in medical expenditures between noncitizens, foreign-born, and US-born citizens. METHODS: We used multi-year Medical Expenditures Panel Survey (2000-2008) data on noninstitutionalized adults in the United States (N=190,965). Source specific and total medical expenditures were analyzed using regression models, bootstrap prediction techniques, and linear and nonlinear decomposition methods to evaluate the relationship between immigration status and expenditures, controlling for confounding effects. RESULTS: We found that the average health expenditures between 2000 and 2008 for noncitizens immigrants ($1836) were substantially lower compared with both foreign-born ($3737) and US-born citizens ($4478). Differences were maintained after controlling for confounding effects. Decomposition techniques showed that the main determinants of these differences were the availability of a usual source of health care, insurance, and ethnicity/race. CONCLUSIONS: Lower health care expenditures among immigrants result from disparate access to health care. The dissipation of demographic advantages among immigrants could prospectively produce higher pressures on the US health care system as immigrants age and levels of chronic conditions rise. Barring a shift in policy, the brunt of the effects could be borne by an already overextended public health care system.

Using colorectal trends in the U.S. to identify unmet primary care needs of vulnerable populations.

BACKGROUND: Colorectal cancer screening (CRC) disparities have worsened in recent years. OBJECTIVE: To examine progress toward Healthy People 2010 goals for CRC screening among ethnic/racial groups, including disaggregated Latino groups. METHODS: Multivariate logistic regressions examined associations between ethnicity/race and primary outcomes of self-reported guideline-concordant CRC screenings considering time trends for 65,947 respondents of the Medical Expenditure Panel Survey from 2000 to 2007 age 50-years and older from six groups (non-Latino White, non-Latino Black, Puerto Rican, Cuban, Mexican, and Other Latino). We also tested for modification effects by education, income, and health insurance. RESULTS: Most groups approached Healthy People 2010 CRC screening rate goals, including non-Latino Whites (47%), non-Latino Blacks (42%) and Puerto Ricans (40%), while Mexicans remained disparately lower (28%). Higher education, income and insurance coverage, partially attenuated this lower likelihood, but Mexican rates remained significantly lower than non-Latino Whites for receiving endoscopy in the past 5 years {OR(95% CI)=0.68(0.59-0.77)} and having received any CRC screening {0.70(0.62-0.79)}. CONCLUSIONS: Among ethnic/racial groups examined, only Mexicans met healthcare disparity criteria in CRC screening. Findings suggest that healthcare equity goals can be attained if resources affecting continuity of care or ability to pay for preventive services are available, and targeted populations are adequately identified.

Breast cancer screening and ethnicity in the United States: implications for health disparities research.

Ethnic and racial minority women within the U.S. are less likely to use breast cancer screening (BCS) procedures than non-Latina White women, and are more likely to be diagnosed with cancer at later stages of disease. Previous studies examining Latina rates of screening and disease have used aggregated populations for comparison, possibly attenuating important ethnic healthcare disparities and yielding misleading findings. The purpose of this study was to examine if ethnicity matters in understanding current estimates of BCS patterns among U.S. women; to test if healthcare disparities in BCS are present, and if any ethnic/racial groups are primarily affected. The authors used multivariate multinomial regression to examine self-reported mammogram and clinical breast exam in the 2007 full-year U.S. Medical Expenditure Panel Survey. Mexican origin women reported the lowest rates of past-year mammograms and clinical breast examination. Factors enabling healthcare moderated the group's lower likelihood of mammograms and clinical breast examination. Some breast cancer screening parity appears to have been achieved in 2007 for Black and some Latina groups; however, those rates lag behind for the largest Latino ethnic group, Mexican. Factors enabling healthcare access, such as education, income and insurance, attenuated the BCS inequalities found for Mexican origin women. Findings suggest that successful efforts to reduce BCS disparities be strategically redirected to include women of Mexican origin in addition to other underserved populations.

Research article: Antidepressant use among Asians in the United States.

OBJECTIVES: We examined the prevalence and predictors of past-year antidepressant use in a nationally representative sample of Asian Americans and non-Latino Whites. METHODS: Analyses of 12-month antidepressant medication use were based on data from the Collaborative Psychiatric Epidemiology Surveys that surveyed Asian (Chinese, Filipino, Vietnamese, and others; N=2,284) and non-Latino White (N=6,696) household residents ages 18 years and older in the 48 contiguous United States and Hawaii. RESULTS: Prevalence rates for 12-month antidepressant use for Asians with major depression ranged from 8.7% among Vietnamese to 17% among Chinese respondents. Compared to non-Latino Whites (32.4%), all Asians (10.9%) meeting criteria for 12-month depressive and anxiety disorders, but especially Filipinos (8.8%) were less likely to report past-year antidepressant use. CONCLUSIONS: We found disparities in past-year antidepressant use among all the examined major Asian groups meeting criteria for 12-month depressive and anxiety disorders. These disparities were not explained by mental health need or socioeconomic factors that enable access to care.

A hidden vulnerable population: Young children up-to-date on vaccine series recommendations except influenza vaccines.

Very young children (under 2 years old) have high risk for influenza-related complications. Children 6 months or older in the US are recommended to receive influenza vaccination annually, yet uptake is substantially lower than other routinely-recommended vaccines. Existing nationally-representative studies on very young child influenza vaccine uptake has several limitations: few examine provider-verified influenza vaccination (relying on parental report), few contain parental vaccine attitudes variables (known to be crucial to vaccine uptake), and none to our knowledge consider intersectionality of social disadvantage nor how influenza vaccine determinants differ from those of other recommended vaccines. This nationally-representative study examines provider-verified data on 7,246 children aged 6-23 months from the most recent (2011) National Immunization Survey to include the restricted Parental Concerns module, focusing on children up-to-date on a series of vaccines (the 4:3:1:3:3:1:4 series) but not influenza vaccines ("hidden vulnerability to influenza"). About 71% of children were up-to-date on the series yet only 33% on influenza vaccine recommendations by their second birthday; 44% had hidden vulnerability to influenza. Independent of parental history of vaccine refusal and a myriad of health services use factors, no parental history of delaying vaccination was associated with 7.5% (2.6-12.5) higher probability of hidden vulnerability to influenza despite being associated with 15.5% (10.8-20.2) lower probability of being up-to-date on neither the series nor influenza vaccines. Thus, parental compliance with broad child vaccine recommendations and lack of vaccine hesitancy may not indicate choice to vaccinate children against influenza. Examination of intersectionality suggests that maternal college education may not confer improved vaccination among non-Hispanic Black and Hispanic children despite that it does for non-Hispanic White children. Policymakers and researchers from public health, sociology, and other sectors need to collaborate to further examine how vaccine hesitancy and intersectional social disadvantage interact to affect influenza vaccine uptake in young US children.

Child Influenza Vaccination and Adult Work Loss: Reduced Sick Leave Use Only in Adults With Paid Sick Leave.

INTRODUCTION: Children are a population of interest for influenza. They are at increased risk for severe influenza, comprise a substantial portion of influenza morbidity, and significantly contribute to its transmission in the household and subsequent parental work loss. The association between influenza vaccination and work loss prevention, however, has rarely been studied, and the sparse existing literature has very limited generalizability to U.S. adults, thus requiring better characterization. METHODS: Using pooled National Health Interview Survey data (2013-2015, analyses conducted in 2018) nationally representative of working U.S. adults with household children (n=23,014), zero-inflated negative binomial regression examined the association of child influenza vaccination (exposure) with sick days (outcome) stratified by paid sick leave (no: n=10,741, yes: n=12,273). RESULTS: Child influenza vaccination was associated with significantly lower sick day usage, but only among adults with paid sick leave (prevalence rate ratio=0.79, 95% CI=0.67, 0.93), equating to average annual sick days of 4.07 vs 3.29 in adults with unvaccinated versus vaccinated household children (difference=0.78 fewer days annually). CONCLUSIONS: Influenza vaccination of children is associated with reduced sick leave in household adults, helping to keep the workforce healthy and reduce influenza's costly annual economic burden. This only occurred among adults with paid sick leave, however, which is distributed inequitably by income, education, gender, occupation, and race/ethnicity. Health in All Policies considers downstream health effects of social and economic policy; the failure of federal policy to ensure paid sick leave likely contributes to propagating influenza and health inequities.

Examining Mammography Use by Breast Cancer Risk, Race, Nativity, and Socioeconomic Status.

Minority and foreign-born women report lower rates of mammograms compared to non-Hispanic white, U.S.-born women, even though they have increased risk for developing breast cancer. We examine disparities in mammography across breast cancer risk groups and determine whether disparities are explained by socioeconomic factors. Propensity score methodology was used to classify individuals from the 2000, 2005, and 2010 National Health Interview Survey according to their risk for developing breast cancer. Logistic regression models were used to predict the likelihood of mammography. Compared to non-Hispanic white women, Mexicans, Asians and "other" racial/ethnic origins were less likely to have undergone a mammogram. After controlling for breast cancer risk, socioeconomic status and health care resources, Mexican, Cuban, Dominican, Central American, Black, and foreign-born women had an increased likelihood of receiving a mammogram. Using propensity scores makes an important contribution to the literature on sub-population differences in the use of mammography by addressing the confounding risk of breast cancer. While other factors related to ethnicity or culture may account for lower breast cancer screening rates in Asian and Mexican women, these findings highlight the need to consider risk, in addition to socioeconomic factors, that may pose barriers to screening in determining mammography disparities.

Inter-rater and test-retest reliability: methods and results for the neighborhood observational checklist.

The popularity of direct or systematic social observation as a method to evaluate the mechanisms by which neighborhood environments impact health and contribute to health disparities is growing. The development of measures with adequate inter-rater and test-retest reliability is essential for this research. In this paper, based on our experiences conducting direct observation of neighborhoods in Detroit, MI, we describe strategies to promote high inter-rater and test-retest reliability and methods to evaluate reliability. We then present the results and discuss implications for future research efforts using direct observation in four areas: methods to evaluate reliability, instrument content and design, observer training, and data collection.

Using mammograms to predict preventive health services behavior and mortality in women.

This study examined whether mammography receipt was associated with mortality due to causes other than breast cancer, hypothesizing that mammography screening was a proxy for the predisposition to seek preventive health behaviors. Using data on 89,574 women from the 2000 National Health Interview Survey and National Death Index, a discrete-time hazard model estimated the mortality from any cause except breast cancer as a function of screening status. Receiving a mammogram was associated with a 24% reduction in the likelihood of death all causes except breast cancer. These odds were reduced to 21.1% when demographic and socioeconomic variables are added and reduced further to 20.9% when health resource variables were added. The final adjusted model shows that women who received a mammogram had reduced their probability of death by 20%. These results suggest women who undergo mammograms may be more likely to seek other preventive health services or engage in healthy behaviors that affect mortality. While the use of mammograms to predict breast cancer mortality merits further consideration, if a proxy for a woman's predisposition for additional preventive screenings, encouraging mammography may be a pivotal pathway for preventing mortality due to other causes for women.

Disparities in Patient- and Family-Centered Care During US Children's Health Care Encounters: A Closer Examination.

OBJECTIVE: Patient- and family-centered care (PFCC), which recognizes the family as an integral partner in high-quality clinical decision-making, is important to improving children's health care. Studies examining PFCC disparities in the general US pediatric population, however, are sparse, and use methodology that might mislead readers to overestimate effect sizes because of the high prevalence of high-quality PFCC. We address these issues using improved statistical modeling of conceptually-grounded disparity domains on more recent data. METHODS: This study examined 22,942 children in the 2011 to 2013 Medical Expenditure Panel Surveys (pooled cross-section) with at least 1 health care visit in the previous year (eligible for PFCC questions). We used robust-adjusted multivariable Poisson regression to estimate prevalence rate ratios-closer estimates of true risk ratios of highly prevalent outcomes-of 4 measures of high-quality PFCC and a composite measure. RESULTS: Overall, PFCC quality prevalences were high, ranging from 95% to 97% across the 4 PFCC measures with 92% of parents reporting the composite measure. In multivariable analyses, lower prevalence of high-quality PFCC was consistently observed among publicly insured children (relative to the privately insured, prevalence rate ratios ranging from 0.978 to 0.984 across the PFCC measures; 0.962 in the composite) and children living in families below the poverty line (children at ≥400% of the poverty line had 1.018-1.045 times the prevalence of high-quality PFCC across the PFCC measures; 1.056 in the composite). CONCLUSIONS: Although prevalence rate ratio methodology revealed smaller and perhaps clinically insignificant disparities in US children's PFCC quality than previously portrayed, nonetheless, several statistically significant disparities remain. The most consistent disparities identify those most vulnerable to PFCC quality: publicly insured and impoverished children.

Role of Depressive Symptoms in Mediating Socioeconomic Disparities in Diabetes Risk Misperception.

OBJECTIVES: In the U.S., type 2 diabetes awareness remains low among individuals at risk. Unawareness poses risk of developing comorbidities, commonly depression, which would harm physical and mental health and well-being. This study builds off previous findings identifying significant differences in accurate diabetes perception by race/ethnicity, sex, age, and self-rated health. This study explores depressive symptoms as a mediator and potential explanation for significant associations between determinants of risk and incorrect perception of risk when at risk. METHODS: This study uses 2011-2012 & 2013-2014 National Health and Nutrition Examination Survey data (NHANES). The sampling frame includes individuals identified with clinical risk of diabetes, who report not perceiving risk (N = 3238). Summary statistics, bivariates by outcome and mediator, unadjusted and adjusted logistic regression were conducted. The Sobel test was used for mediation analysis. RESULTS: Depressive symptoms, female sex, Mexican American ethnicity or other/multiple race, younger age, or worse self-rated health were independently associated with lower odds of incorrectly perceiving no clinical risk. Depressive symptoms moderated most socioeconomic disparities. CONCLUSIONS: Findings demonstrate that depressive symptoms explain disparities in incorrectly perceiving no diabetes risk by sex, age, and self-rated health but not race/ethnicity.

Healthcare Use and Mammography Among Latinas With and Without Health Insurance Near the US-Mexico Border.

INTRODUCTION: Among Latinas, lacking health insurance and having lower levels of acculturation are associated with disparities in mammography screening. OBJECTIVE: We seek to investigate whether differences in lifetime mammography exist between Latina border residents by health insurance status and health care site (i.e., U.S. only or a combination of U.S. and Mexican health care). METHODS: Using data from the 2009 to 2010 Ecological Household Study on Latino Border Residents, mammography screening was examined among (n = 304) Latinas >40 years old. RESULTS: While more acculturated women were significantly (p < .05) more likely to report ever having a mammogram than less acculturated women, ever having a mammogram was not predicted by health care site or insurance status. CONCLUSION: Latinas who utilize multiple systems of care have lower levels of acculturation and health insurance, thus representing an especially vulnerable population for experiencing disparities in mammography screening.

Complementary and Alternative Medicine and Influenza Vaccine Uptake in US Children.

BACKGROUND: Complementary and alternative medicine (CAM) is increasingly used in the United States. Although CAM is mostly used in conjunction with conventional medicine, some CAM practitioners recommend against vaccination, and children who saw naturopathic physicians or chiropractors were less likely to receive vaccines and more likely to get vaccine-preventable diseases. Nothing is known about how child CAM usage affects influenza vaccination. METHODS: This nationally representative study analyzed ∼9000 children from the Child Complementary and Alternative Medicine File of the 2012 National Health Interview Survey. Adjusting for health services use factors, it examined influenza vaccination odds by ever using major CAM domains: (1) alternative medical systems (AMS; eg, acupuncture); (2) biologically-based therapies, excluding multivitamins/multiminerals (eg, herbal supplements); (3) multivitamins/multiminerals; (4) manipulative and body-based therapies (MBBT; eg, chiropractic manipulation); and (5) mind-body therapies (eg, yoga). RESULTS: Influenza vaccination uptake was lower among children ever (versus never) using AMS (33% vs 43%; P = .008) or MBBT (35% vs 43%; P = .002) but higher by using multivitamins/multiminerals (45% vs 39%; P < .001). In multivariate analyses, multivitamin/multimineral use lost significance, but children ever (versus never) using any AMS or MBBT had lower uptake (respective odds ratios: 0.61 [95% confidence interval: 0.44-0.85]; and 0.74 [0.58-0.94]). CONCLUSIONS: Children who have ever used certain CAM domains that may require contact with vaccine-hesitant CAM practitioners are vulnerable to lower annual uptake of influenza vaccination. Opportunity exists for US public health, policy, and medical professionals to improve child health by better engaging parents of children using particular domains of CAM and CAM practitioners advising them.

User Perceptions of ¡Protéjase!: An Intervention Designed to Increase Protective Equipment Use Among Mexican Immigrant and Mexican American Farmworkers.

BACKGROUND: Farmworkers' exposures to pesticides are reduced when they wear personal protective equipment (PPE), and mobile health (mHealth) platforms can potentially deliver information to farmworkers to help promote PPE use. However, little is known about the feasibility of using mHealth platforms to promote farmworkers' use of PPE. OBJECTIVE: The objective of the study was to describe the development and feasibility-testing of Protect Yourself! (¡Protéjase!), an intervention designed to increase PPE use. As the vast majority of farmworkers in the United States are from Mexico, we examined the intervention in a primarily Mexican-origin farmworker population. METHODS: ¡Protéjase was developed in several steps. First, we performed ethnographic observations to understand what prevents PPE use. Next, we developed program components that met the challenges uncovered in the ethnographic observations, seeking direct feedback from farmworkers on each component. Feasibility was assessed using surveys and focus groups. Material was provided in Spanish or English at the preference of the participant. Finally, we pilot tested each component of the intervention, including: (1) PPE that was provided to each worker for their personal use during the intervention trial, and (2) delivery of an application-based tool that promoted the use of PPE through daily individualized messaging. RESULTS: 55 farmworkers enrolled in the study, but only 41 of 55 (75%) completed the entire pilot intervention trial. Results focus on the evaluation of the intervention, and include only those who completed the entire trial. Among farmworkers who completed the entire intervention trial, all but two farmworkers were born in Mexico and were Spanish speaking. Still, all study participants self-identified as Mexican or Mexican-American. When asked what changes were needed in the intervention's messaging or delivery to increase user satisfaction, 22 out of 41 participants (54%) felt that no changes were needed. However, 16 of 41 participants (39%) suggested small changes to messaging (eg, refer to long pants as pants only) to improve their understanding of the messages. Finally, a small number (3 of 41 participants, 7%) felt that messages were difficult to read, primarily due to low literacy. CONCLUSIONS: The ¡Protéjase! mHealth program demonstrated very good feasibility, satisfaction, and acceptance; potential improvements (eg, small modifications in messaging to increase farmworkers' use) were noted. Overall, the PPE provided to workers as well as the mHealth platform were both perceived as useful for promoting PPE use.

Trends in cancer screening by citizenship and health insurance, 2000-2010.

While early detection through screenings for breast, cervical, and colorectal cancer is essential in improving cancer survival, it is not evenly utilized across class, race, ethnicity, or nativity. Given that utilization of early detection through screenings is not evenly distributed, immigrants who have much lower rates of health insurance coverage are at a disadvantage. We use National Health Interview Survey data linked with the Medical Expenditures Panel Survey to examine the trend in screening rates for breast, cervical, and colorectal cancer from 2000 to 2010, comparing U.S.-born natives, foreign-born citizens, and foreign-born non-citizens. We find that citizenship is clearly advantageous for the foreign-born, and that screening rates are higher among citizens compared to non-citizens overall, but uninsured non-citizens sometimes have higher screening rates that uninsured natives. Health insurance is pivotal for higher screening rates with clear differences among the insured and uninsured. Policies aimed at reducing disparities in cancer screening need to take into account nativity, citizenship, and access to health insurance.