The synergistic effect of concomitant schistosomiasis, hookworm, and trichuris infections on children's anemia burden.

OBJECTIVE: To estimate the degree of synergism between helminth species in their combined effects on anemia. METHODS: Quantitative egg counts using the Kato-Katz method were determined for Ascaris lumbricoides, hookworm, Trichuris trichiura, and Schistosoma japonicum in 507 school-age children from helminth-endemic villages in The Philippines. Infection intensity was defined in three categories: uninfected, low, or moderate/high (M+). Anemia was defined as hemoglobin <11 g/dL. Logistic regression models were used to estimate odds ratios (OR), 95% confidence intervals (CI), and synergy index for pairs of concurrent infections. RESULTS: M+ co-infection of hookworm and S. japonicum (OR = 13.2, 95% CI: 3.82-45.5) and of hookworm and T. trichiura (OR = 5.34, 95% CI: 1.76-16.2) were associated with higher odds of anemia relative to children without respective M+ co-infections. For co-infections of hookworm and S. japonicum and of T. trichiura and hookworm, the estimated indices of synergy were 2.9 (95% CI: 1.1-4.6) and 1.4 (95% CI: 0.9-2.0), respectively. CONCLUSION: Co-infections of hookworm and either S. japonicum or T. trichiura were associated with higher levels of anemia than would be expected if the effects of these species had only independent effects on anemia. This suggests that integrated anti-helminthic treatment programs with simultaneous deworming for S. japonicum and some geohelminths could yield a greater than additive benefit for reducing anemia in helminth-endemic regions.

Race disparities in childhood asthma: does where you live matter?

OBJECTIVE: This study investigates whether racial/ethnic disparities in childhood asthma prevalence can be explained by differences in family and neighborhood socioeconomic position (SEP). METHODS: Data were from the 2001 Rhode Island Health Interview Survey (RI HIS), a statewide representative sample of 2,600 Rhode Island households, and the 2000 U.S. Census. A series of weighted multivariate models were fitted using generalized estimating equations (GEE) for the logistic case to analyze the independent and joint effects of race/ethnicity and SEP on doctor-diagnosed asthma among 1,769 white, black and Hispanic children <18 years old. RESULTS: Compared with white children, black children were at increased odds for asthma and this effect persisted when measures of family and neighborhood SEP were included in multivariate models (AOR: 2.49; 95% Cl: 1.30-4.77). Black children living in poverty neighborhoods had substantially higher odds of asthma than Hispanic and white children in poverty areas and children in moderate- and high-income neighborhoods (AOR: 3.20: 95% Cl: 1.62-6.29). CONCLUSION: The high prevalence of asthma among black children in poor neighborhoods is consistent with previous research on higher-than-average prevalence of childhood asthma in poor urban minority communities. Changing neighborhood social structures that contribute to racial disparities in asthma prevalence remains a challenge.

Perceived discrimination in clinical care in a nationally representative sample of HIV-infected adults receiving health care.

BACKGROUND: Perceived discrimination in clinical settings could discourage HIV-infected people from seeking health care, adhering to treatment regimens, or returning for follow-up. OBJECTIVES: This study aims to determine whether HIV-infected people perceive that physicians and other health care providers have discriminated against them. DESIGN, PARTICIPANTS: Cross-sectional data (1996 to 1997) from the HIV Cost and Services Utilization Study (HCSUS), which conducted in-person interviews with a nationally representative probability sample of 2,466 HIV-infected adults receiving health care within the contiguous U.S. MEASUREMENTS: Reports of whether health care providers have been uncomfortable with the respondent, treated the respondent as an inferior, preferred to avoid the respondent, or refused the respondent service. Questions also covered the types of providers who engaged in these behaviors. RESULTS: Twenty-six percent of HIV-infected adults receiving health care reported experiencing at least 1 of 4 types of perceived discrimination by a health care provider since becoming infected with HIV, including 8% who had been refused service. White respondents (32%) were more likely than others (27%) and Latinos (21%) and nearly twice as likely as African Americans (17%) to report perceived discrimination (P < .001). Respondents whose first positive HIV test was longer ago were also more likely to report discrimination (P < .001). Respondents who reported discrimination attributed it to physicians (54%), nurses and other clinical staff (39%), dentists (32%), hospital staff (31%), and case managers or social workers (8%). CONCLUSIONS: Many HIV-infected adults believe that their clinicians have discriminated against them. Clinicians should make efforts to address circumstances that lead patients to perceive discrimination, whether real or imagined.

Disparities in prenatal HIV testing: evidence for improving implementation of CDC screening guidelines.

OBJECTIVES: We investigated the within-group and between-group variation in prenatal HIV testing in a sample of low-income pregnant and recently postpartum women. METHODS: Multivariable linear regression was used to estimate proportional differences in prenatal HIV testing for the total sample and stratified by race. RESULTS: In bivariate analyses, race and site of care jointly affected the probability of being tested. Hispanic women had the highest probability of being tested in public practice settings but relative to white women, black women had a higher probability of being tested in public and private practice settings. Predictors of prenatal HIV testing differed by race. Receiving prenatal care in a community health center or hospital outpatient clinic increased the probability of testing for Hispanics. Being a recent victim of intimate partner violence was associated with less frequent testing for blacks. Positive beliefs about HIV screening, while significant for blacks and Hispanics, was the only factor associated with testing for whites. CONCLUSION: Our data suggest that racial biases may be influencing providers' approach to testing, rather than CDC's 2001 guidelines for HIV screening of pregnant women. Study findings are being used to modify social marketing campaigns and improve provider trainings regarding prenatal HIV testing.

Longitudinal study of the inception of perimenopause in relation to lifetime history of sexual or physical violence.

STUDY OBJECTIVE: To investigate of the extent to which violence over the life course accelerates the onset of perimenopause, as measured by menstrual changes. DESIGN: Prospective cohort study. SETTING: Boston, Massachusetts. PARTICIPANTS: 603 premenopausal women aged 36-45 years at baseline who completed a cross sectional survey on childhood and adult violence history. MAIN OUTCOME MEASURE: Time to perimenopause, defined as time in months from baseline interview to a woman's report of (1) an absolute change of at least seven days in menstrual cycle length from baseline or subjective report of menstrual irregularity; (2) a change in menstrual flow amount or duration; or (3) cessation of periods for at least three months, whichever came first. MAIN RESULTS: Experience of abuse was associated with delayed onset of menstrual changes indicative of onset of perimenopause. Women reporting childhood or adolescent abuse entered perimenopause about 35% slower than women who reported no abuse (IRR(adj) = 0.65, 95% CI 0.45 to 0.95) after adjusting for age, age at menarche, ever live birth, ability to maintain living standard, smoking, BMI, and depression. There was a similar association among women who reported first abuse during adulthood (IRR(adj) = 0.72, 95% CI 0.28 to 1.80). These findings persisted when the cohort was restricted to non-depressed women (childhood/adolescent IRR(adj) = 0.57, 95% CI 0.36 to 0.90; adulthood IRR(adj) = 0.63, 95% CI 0.23 to 1.77). CONCLUSIONS: This study is the first longitudinal analysis of the timing of perimenopause to show an association with a history of physical or sexual abuse. Further study of the relation between violence and reproductive aging is needed.

Homicide risk across race and class: a small-area analysis in Massachusetts and Rhode Island.

Areas with higher absolute poverty and higher income inequality have been associated with higher risk of homicide victimization. In addition, studies of differential homicide rates have indicated that black persons are at a higher risk of homicide compared to white persons. However, few studies directly compared risk of homicide offending or victimization between Hispanic persons and non-Hispanic white persons, and few studies have attempted to examine the interaction between race and residential neighborhood socioeconomic measures on homicide risk. This population-based retrospective study comprised all white, black, and Hispanic 15- to 44-year-old men included in the 1990 US Census as Rhode Island or Massachusetts residents. Vital statistics registries were linked to 1990 US Census data to provide information on small-area characteristics. Overall, we observed a trend of increasing homicide risk as block-group socioeconomic position descended. The data indicated that block-group poverty, female-headed households, home ownership, and higher education were all strongly associated with homicide risk after stratifying by race and age of victim and adjusting for other block-group socioeconomic characteristics. Race was a strong modifier for absolute risk difference for the relation between risk of homicide and socioeconomic surroundings. Our analyses suggested that area-based interventions that would improve neighborhood social and economic conditions would be effective in decreasing risk of homicide for men.

Neighborhood environment, racial position, and risk of police-reported domestic violence: a contextual analysis.

OBJECTIVES: The purpose of this study was to examine the contribution of neighborhood socioeconomic conditions to risk of police-reported domestic violence in relation to victim's race. Data on race came from police forms legally mandated for the reporting of domestic violence and sexual assault. METHODS: Using 1990 U.S. census block group data and data for the years 1996-1998 from Rhode Island's domestic violence surveillance system, the authors generated annual and relative risk of police-reported domestic violence and estimates of trends stratified by age, race (black, Hispanic, or white), and neighborhood measures of socioeconomic conditions. Race-specific linear regression models were constructed with average annual risk of police-reported domestic violence as the dependent variable. RESULTS: Across all levels of neighborhood poverty (< 5% to 100% of residents living below the federal poverty level), the risk of police-reported domestic violence was higher for Hispanic and black women than for white women. Results from the linear regression models varied by race. For black women, living in a census block group in which fewer than 10% of adults ages > or = 25 years were college-educated contributed independently to risk of police-reported domestic violence. Block group measures of relative poverty (> or = 20% of residents living below 200% of the poverty line) and unemployment (> or = 10% of adults ages > or = 16 years in the labor force but unemployed) did not add to this excess. For Hispanic women, three neighborhood-level measures were significant: percentage of residents living in relative poverty, percentage of residents without college degrees, and percentage of households monolingual in Spanish. A higher degree of linguistic isolation, as defined by the percentage of monolingual Spanish households, decreased risk among the most isolated block groups for Hispanic women. For white women, neighborhood-level measures of poverty, unemployment, and education were significant determinants of police-reported domestic violence. CONCLUSION: When data on neighborhood conditions at the block group level and their interaction with individual racial position are linked to population-based surveillance systems, domestic violence intervention and prevention efforts can be improved.

Effect of violence on utilization of services and access to care in persons with HIV.

We analyzed the HIV Costs and Service Utilization Study data to determine the association of violence, assessed at baseline, with utilization of and access to health care at follow-up, among gay/bisexual male, heterosexual female, and heterosexual male HIV/AIDS patients. In multivariate analyses, male gay/bisexual violence victims had increased odds of reporting emergency department visits (odds ratio [OR], 1.74; 95% confidence interval [95% CI], 1.20 to 2.52), going without needed medical care because of expense (OR, 1.83; 95% CI, 1.06 to 3.18), and having poor ability to access medical specialists (OR, 1.96; 95% CI, 1.05 to 3.67). Further research is required to understand the association of violence with health care among gay/bisexual men with HIV/AIDS.

Incidence of violence against HIV-infected and uninfected women: findings from the HIV Epidemiology Research (HER) study.

The effect of human immunodeficiency virus (HIV) infection on the incidence of violence against women was addressed in a prospective cohort of HIV-infected and uninfected women. Participants were enrolled between 1993 and 1995 in four US cities and followed up semiannually through 1998. Among 1,087 women with a total accrual of 2,988 person-years (PY) of follow-up, there were 185 reports of abuse (incidence rate = 6.19 per 100 PY). The rate of abuse among HIV-infected women with a CD4+ count less than 350 cells/ micro L was lower than that among HIV-infected women with more CD4+ cells/ micro L or among uninfected women (4.87, 6.92, and 6.44 per 100 PY, respectively). In multivariate analysis, being separated or divorced, having a history of abuse in adulthood, using marijuana, using crack, and having multiple sex partners were each significantly associated with an elevated abuse rate; being older was inversely associated with abuse. Among HIV-infected women, those with fewer CD4+ cells/ micro L continued to show a decreased abuse rate (hazard ratio = 0.55, 95% CI = 0.36, 0.82) after adjustment for these factors. It is important to complement existing and future HIV prevention and intervention strategies with efforts to reduce violence against women.