Risk Factors for Incident Hospitalized Heart Failure With Preserved Versus Reduced Ejection Fraction in a Multiracial Cohort of Postmenopausal Women.

BACKGROUND: Heart failure is an important and growing public health problem in women. Risk factors for incident hospitalized heart failure with preserved ejection fraction (HFpEF) compared with heart failure with reduced ejection fraction (HFrEF) in women and differences by race/ethnicity are not well characterized. METHODS AND RESULTS: We prospectively evaluated the risk factors for incident hospitalized HFpEF and HFrEF in a multiracial cohort of 42 170 postmenopausal women followed up for a mean of 13.2 years. Cox regression models with time-dependent covariate adjustment were used to define risk factors for HFpEF and HFrEF. Differences by race/ethnicity about incidence rates, baseline risk factors, and their population-attributable risk percentage were analyzed. Risk factors for both HFpEF and HFrEF were as follows: older age, white race, diabetes mellitus, cigarette smoking, and hypertension. Obesity, history of coronary heart disease (other than myocardial infarction), anemia, atrial fibrillation, and more than one comorbidity were associated with HFpEF but not with HFrEF. History of myocardial infarction was associated with HFrEF but not with HFpEF. Obesity was found to be a more potent risk factor for African American women compared with white women for HFpEF (P for interaction=0.007). For HFpEF, the population-attributable risk percentage was greatest for hypertension (40.9%) followed by obesity (25.8%), with the highest population-attributable risk percentage found in African Americans for these risk factors. CONCLUSIONS: In this multiracial cohort of postmenopausal women, obesity stands out as a significant risk factor for HFpEF, with the strongest association in African American women. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000611.

Multi-generational perspectives on health, cancer, and biomedicine: Northeastern Native American perspectives shaped by mistrust.

Cancer is the second leading cause of death among Native Americans, who have-some of the poorest cancer survival rates of any race/ethnicity nationwide. Considering the cancer burden experienced by Native Americans and the lack of research exploring Northeastern tribal communities' cancer experiences, a qualitative investigation of Native Americans' cancer coping strategies and health education needs was undertaken. Data were collected through group (74) and individual (17) interviews with 91 Native Americans from the Northeast. Relationships between intergenerational mistrust, individual mistrust, and utilization of biomedical health care systems for Northeastern Native Americans are presented. Trust is central to the provider-patient relationship and the foundation for developing and maintaining connections to Native American communities. Intergenerational mistrust, shaped by historical and contemporary issues of prejudice and miscommunication, affect cancer health experiences and views. Approaches for reducing mistrust and building relationships between health care providers and Native communities are highlighted.

Clinical risk factors for fractures in multi-ethnic women: the Women's Health Initiative.

UNLABELLED: To identify risk factors for fractures in multi-ethnic women, we studied 159,579 women enrolled in the Women's Health Initiative. In general, risk factors for fractures were similar across ethnic groups. However, irrespective of their ethnicity, women with multiple risk factors have a high risk of fracture. Targeting these high-risk women for screening and intervention could reduce fractures. INTRODUCTION: Fracture rates tend to be lower in minority women, but consequences may be greater. In addition, the number of fractures is expected to increase in minority women because of current demographic trends. There are limited prospective data on risk factors for fractures in minority women. MATERIALS AND METHODS: We studied 159,579 women 50-79 yr of age enrolled in the Women's Health Initiative. Information on risk factors was obtained by questionnaire or examination. Nonspine fractures that occurred after study entry were identified over an average follow-up of 8 +/- 2.6 (SD) yr. RESULTS: Annualized rates (%) of fracture in whites, blacks, Hispanics, Asians, and American Indians were 2.0, 0.9, 1.3, 1.2, and 2.0, respectively. Significant predictors [HR (95% CI)] of fractures by ethnic group were as follows: blacks: at least a high school education, 1.22 (1.0, 1.5); (+) fracture history, 1.7 (1.4, 2.2); and more than two falls, 1.7 (1.9, 2.0); Hispanics: height (>162 cm), 1.6 (1.1, 2.2); (+) fracture history, 1.9 (1.4, 2.5); more than two falls, 1.8 (1.4, 2.3); arthritis, 1.3 (1.1, 1.6); corticosteroid use, 3.9 (1.9, 8.0); and parental history of fracture, 1.3 (1.0, 1.6); Asians: age (per 5 yr), 1.2 (1.0, 1.3); (+) fracture history, 1.5 (1.1, 2.0); current hormone therapy (HT), 0.7 (0.5, 0.8); parity (at least five), 1.8 (1.1, 3.0); more than two falls, 1.4 (1.1, 1.9); American Indian: (+) fracture history, 2. 9 (1.5, 5.7); current HT, 0.5 (0.3, 0.9). Women with eight or more risk factors had more than a 2-fold higher rate of fracture compared with women with four or fewer risk factors. Two ethnicity x risk factor interactions were identified: age and fall history. CONCLUSIONS: Irrespective of their ethnicity, women with multiple risk factors have a high risk of fracture. Targeting these high-risk women for screening and intervention could reduce fractures.

Factors associated with adherence to recommendations for screening mammography among American Indian women in Colorado.

OBJECTIVE: To compare adherence to screening mammography recommendations of American Indian and non-Hispanic White women in the Denver, Colorado, area. DESIGN/SETTING/PARTICIPANTS: This study retrospectively examined adherence patterns in 229 American Indian and 60,197 non-Hispanic White women > or = 40 years and older, with at least one screening mammogram in the Colorado Mammography Project (CMAP), from January 1, 1999, to December 31, 2003. The CMAP was a prospective study of women receiving mammograms at participating clinics around Denver. MAIN OUTCOME MEASURES: Using logistic mixed models, we defined two dependent variables as annual and biennial adherence from the intervals between screening mammograms for each woman. RESULTS: Biennial adherence was substantially higher than annual adherence for both American Indian and non-Hispanic White women in our analyses. American Indian women were less likely than non-Hispanic White women to adhere to biennial recommendations in multivariate models controlling for age, family history of breast cancer, and economic status (zip code): odds ratio (OR) .4 and 95% confidence interval (CI) .2-.6. The association between American Indian race/ethnicity and annual adherence was similar, although not as strong (OR .5, 95% CI .3-.8). CONCLUSIONS: American Indian women in the CMAP cohort were less likely than non-Hispanic White women to adhere to recommendations for screening mammography, both annually and biennially. Additional research is needed to explore the effect of biennial screening and other barriers among American Indian women.

Breast cancer survival of American Indian/Alaska Native women, 1973-1996.

OBJECTIVE: To assess breast cancer mortality rates among American Indian/Alaska Native women compared with non-Hispanic White women in the five years after diagnosis. METHODS: Surveillance, Epidemiology, and End Results data from 1973-1996 were used to compare survival in the two races, controlling for age, marital status, stage, and therapy. RESULTS: The adjusted relative hazard of death was 58% higher for American Indian/Alaska Native women than for non-Hispanic White women (HR = 1.58, 95% Cl 1.26-2.00). The survival disparity persisted even when limited to women who received definitive therapy, i.e. mastectomy with axillary node dissection or breast-conserving surgery with axillary node dissection and radiation treatment (HR = 1.88, 95% Cl 1.40-2.52). CONCLUSIONS: American Indian/Alaska Native women were at greater risk for breast cancer mortality than non-Hispanic White women, even when restricted to women who received definitive breast cancer therapy.

Bone mineral density of American Indian and Alaska Native women compared with non-Hispanic white women: results from the Women's Health Initiative Study.

OBJECTIVE: To compare bone mineral density (BMD) of American Indian/Alaska Native (AI/AN) women with that of non-Hispanic white women. DESIGN: This cross-sectional study compared mean BMD between AI/AN women and a random sample of non-Hispanic white women matched on geographic region in the Women's Health Initiative Study, a prospective study of postmenopausal women. We analyzed baseline BMD measurements for the total hip, spine, and whole body from 139 AI/AN women and 1,431 non-Hispanic white women. RESULTS: Unadjusted mean spine and whole body BMDs were not significantly different between the two races. Controlling for age, education, and hormone therapy use, adjusted mean BMD was similar by race among women who were underweight, normal, or obese. We found a significant interaction of race by body mass index on spine (P = 0.003) and whole body (P = 0.0003) BMD; thus, analyses were stratified by body mass index. Overweight AI/AN women had slightly lower adjusted mean whole body and spine BMD than overweight non-Hispanic white women (whole body: 0.97 vs 1.03 g/cm, P = 0.02; spine: 0.96 versus 1.03 g/cm, P = 0.001). Among extremely obese (body mass index: > or =40.0 kg/m) women, adjusted mean total hip BMD was higher in the AI/AN women (1.07 vs 0.97 g/cm, respectively, P = 0.03). CONCLUSIONS: Overall, AI/AN and non-Hispanic white women had similar BMDs. This study suggests that extremely obese AI/AN women may have higher BMD at certain skeletal sites compared with extremely obese non-Hispanic white women. However, these results need to be confirmed by additional research.

Employment barriers among welfare recipients and applicants with chronically ill children.

OBJECTIVES: This study evaluated the association of chronic child illness with parental employment among individuals who have had contact with the welfare system. METHODS: Parents of children with chronic illnesses were interviewed. RESULTS: Current and former welfare recipients and welfare applicants were more likely than those with no contact with the welfare system to report that their children's illnesses adversely affected their employment. Logistic regression analyses showed that current and former receipt of welfare, pending welfare application, and high rates of child health care use were predictors of unemployment. CONCLUSIONS: Welfare recipients and applicants with chronically ill children face substantial barriers to employment, including high child health care use rates and missed work. The welfare reform reauthorization scheduled to occur later in 2002 should address the implications of chronic child illness for parental employment.

Chronic illness among poor children enrolled in the temporary assistance for needy families program.

OBJECTIVES: This study assessed chronic child illness among recipients of Temporary Assistance for Needy Families (TANF) benefits and poor families not receiving benefits. METHODS: Data from the 1998 National Health Interview Survey were used to examine chronic child illness, enrollment in TANF, health insurance status, and selected access indicators. RESULTS: One quarter of TANF-enrolled children had chronic illnesses. Unenrolled children were 3 times as likely as TANF-enrolled children to be uninsured. Among the chronically ill, 31.7% of unenrolled and 14.3% of enrolled children experienced gaps in insurance coverage that were associated with access barriers. CONCLUSIONS: Welfare policies should consider the effects of chronic illness and gaps in insurance coverage on the health of poor children.

Knowledge of welfare reform program provisions among families of children with chronic conditions.

OBJECTIVES: This study examined the knowledge of and application for health-related welfare program provisions among beneficiaries with children who have chronic conditions. METHODS: We administered a survey to 143 parents of children aged 3 to 16 years with asthma or sickle cell anemia in 2 clinical settings. RESULTS: Respondents indicated incomplete knowledge of work requirements (69.9%) and work exemptions (50.3%). Applications for work exemptions were rare, even among Supplemental Security Income recipients (30%). CONCLUSIONS: Welfare beneficiaries with children who have chronic conditions show limited knowledge and use of program provisions, placing them at risk for penalties or benefit termination.