Biomarkers of Psychological Stress in Health Disparities Research.

Psychological stress can contribute to health disparities in populations that are confronted with the recurring stress of everyday life. A number of biomarkers have been shown to be affected by psychological stress. These biomarkers include allostatic load, which is a summary measure of the cumulative biological burden of the repeated attempts to adapt to daily stress. Allostatic load includes effects on the hypothalamic-pituitary axis, the sympathetic nervous system and the cardiovascular system. These in turn affect the immune system via bidirectional signaling pathways. Evidence is also building that psychological stress, perhaps via heightened inflammatory states, can increase oxidative stress levels and DNA damage. The inter-relationships of ethnicity, genotype, gene expression and ability to adequately mitigate stress response are just starting to be appreciated. The need to conduct these studies in disadvantaged populations is clear and requires methods to address potential logistical barriers. Biomarkers can help characterize and quantify the biological impact of psychological stress on the etiology of health disparities.

Advancing the science of health disparities research.

Research to eliminate health disparities in the United States is best approached from the perspective of population health. The objectives of this paper are to: (a) describe how ongoing research at the eight national Centers for Population Health and Health Disparities (CPHHD) is using a population health perspective and a community-based approach to advance the field of health disparities research; and (b) to discuss potential implications of such research for health policies that target some of the determinants of population health.

Early-life conditions and mechanisms of population health vulnerabilities.

The social status of groups is key to determining health vulnerability at the population level. The impact of material and psychological stresses imposed by social inequities and marginalization is felt most intensely during perinatal/early childhood and puberty/adolescent periods, when developmental genes are expressed and interact with social-physical environments. The influence of chronic psychosocial stresses on gene expression via neuroendocrine regulatory dysfunction is crucial to understanding the biological bases of adult health vulnerability. Studying childhood biology vulnerabilities to neighborhood environments will aid the crafting of multifaceted, multilevel public policy interventions providing immediate benefits and compounded long-term population health yields.

Mailings timed to patients' appointments: a controlled trial of fecal occult blood test cards.

BACKGROUND: Fecal occult blood testing (FOBT) programs cost-effectively reduce colon cancer mortality. To improve the rate of colon cancer screening with FOBT, we tested the effect of mailing FOBT cards timed to appointments on the rates of completion of FOBT. DESIGN: Controlled trial. SETTING/PARTICIPANTS: A total of 119 patients with primary care appointments scheduled in May or June 2000 for an urban, public hospital clinic that serves predominantly low-income, African Americans with chronic diseases. The patients in the study were selected by linking a quality improvement registry, the appointment system database, and an FOBT database to generate a list of clinic patients who had not completed an FOBT in the preceding year. INTERVENTION: Subjects were assigned to either a system of mailing FOBT cards and reminders 2 weeks prior to a scheduled appointment or usual care. MAIN OUTCOME MEASURES: The primary outcomes were the rate of screening at the index appointment and during the year beginning with the date of the index appointment. RESULTS: The rate of return of the FOBT cards during the year beginning with the index appointment was 40.7% for the intervention group compared to 5% for the usual care group (odds ratio [OR]=13.0, p <0.001). The difference was accounted for largely by increases in screening at the index appointment (35.6% compared to 3.3%, OR=16.0, p <0.001). CONCLUSIONS: Using computer databases to generate a list of patients due for FOBT and then mailing FOBT cards timed to a scheduled appointment significantly increased the rate of colon cancer screening. This may be an efficient approach to increasing colon cancer screening with FOBT.

Primary care access decreases nonurgent hospital visits for indigent diabetics.

The objective was to determine the relationship between the source of primary care and utilization of health services among public hospital walk-in clinic patients. A group of 218 adults with diabetes mellitus presenting to a walk-in hospital clinic was followed prospectively with baseline and 3-, 6-, and 12-month surveys; baseline and 6-month hemoglobin A1Cs; and chart reviews. Sites of care, acquisition of primary care, and report of four diabetes services were recorded. Individuals with a visit to a primary care site by 3 months after enrollment had more primary care visits and fewer walk-in clinic visits over the subsequent 9 months than those without one. Those with a primary care visit within 3 months of enrollment received more of the four diabetes services during the study year than those without. Access to primary care was associated with decreased utilization of nonurgent episodic care services and better quality of diabetes care.