Racial disparities in fifth-grade sun protection: Evidence from the Healthy Passages study.

BACKGROUND/OBJECTIVES: Despite rising skin cancer rates in children, multiple studies reveal inadequate youth sun-protective behavior (eg, sunscreen use). Using Healthy Passages data for fifth-graders, we set out to determine sunscreen adherence in these children and investigated factors related to sunscreen performance. METHODS: Survey data were collected from 5119 fifth-graders and their primary caregivers. Logistic regression was used to assess associations between sunscreen adherence and performance of other preventive health behaviors (eg, flossing, helmet use) and examine predictors of sunscreen adherence. Analyses were repeated in non-Hispanic black, Hispanic, and non-Hispanic white subgroups. RESULTS: Five thousand one hundred nineteen (23.4%) children almost always used sunscreen, 5.9% of non-Hispanic blacks (n = 1748), 23.7% of Hispanics (n = 1802), and 44.8% of non-Hispanic whites (n = 1249). Performing other preventive health behaviors was associated with higher odds of sunscreen adherence (all P < .001), with the greatest association with flossing teeth (odds ratio = 2.41, 95% confidence interval = 1.86-3.13, P < .001). Factors for lower odds of sunscreen adherence included being male and non-Hispanic black or Hispanic and having lower socioeconomic status. School-based sun-safety education and involvement in team sports were not significant factors. CONCLUSION: Our data confirm low use of sun protection among fifth-graders. Future research should explore how public health success in increasing prevalence of other preventive health behaviors may be applied to enhance sun protection messages. Identifying risk factors for poor adherence enables providers to target patients who need more education. Improving educational policies and content in schools may be an effective way to address sun safety.

Racial and ethnic health disparities among fifth-graders in three cities.

BACKGROUND: For many health-related behaviors and outcomes, racial and ethnic disparities among adolescents are well documented, but less is known about health-related disparities during preadolescence. METHODS: We studied 5119 randomly selected public-school fifth-graders and their parents in three metropolitan areas in the United States. We examined differences among black, Latino, and white children on 16 measures, including witnessing of violence, peer victimization, perpetration of aggression, seat-belt use, bike-helmet use, substance use, discrimination, terrorism worries, vigorous exercise, obesity, and self-rated health status and psychological and physical quality of life. We tested potential mediators of racial and ethnic disparities (i.e., sociodemographic characteristics and the child's school) using partially adjusted models. RESULTS: There were significant differences between black children and white children for all 16 measures and between Latino children and white children for 12 of 16 measures, although adjusted analyses reduced many of these disparities. For example, in unadjusted analysis, the rate of witnessing a threat or injury with a gun was higher among blacks (20%) and Latinos (11%) than among whites (5%), and the number of days per week on which the student performed vigorous exercise was lower among blacks (3.56 days) and Latinos (3.77 days) than among whites (4.33 days) (P<0.001 for all comparisons). After statistical adjustment, these differences were reduced by about half between blacks and whites and were eliminated between Latinos and whites. Household income, household highest education level, and the child's school were the most substantial mediators of racial and ethnic disparities. CONCLUSIONS: We found that harmful health behaviors, experiences, and outcomes were more common among black children and Latino children than among white children. Adjustment for socioeconomic status and the child's school substantially reduced most of these differences. Interventions that address potentially detrimental consequences of low socioeconomic status and adverse school environments may help reduce racial and ethnic differences in child health. (Funded by the Centers for Disease Control and Prevention.).

Gender role orientation is associated with health-related quality of life differently among African-American, Hispanic, and White youth.

PURPOSE: This study examined the association between gender role orientation (GRO) and health-related quality of life (HRQOL) in youth, and how this relationship may differ between males and females as well as among African-American, White, and Hispanic individuals. GRO has been reported to influence serious health outcomes including cancer, heart disease, mental illness, and mortality rates. However, few studies have examined the link between GRO and health outcomes for children, even though gender identity is formed in childhood. METHODS: Data were examined from 4824 participants in the Healthy Passages™ project, a population-based survey of fifth-grade children in three US metropolitan areas. Children reported their own HRQOL using the PedsQL and degree of female, male, and androgynous GRO using the Children's Sex Role Inventory. RESULTS: Based on structural equations analysis, male GRO was positively associated with HRQOL for all racial/ethnic groups, regardless of sex, whereas female GRO was associated with better HRQOL for Hispanic and White females and poorer HRQOL for Hispanic males. Androgynous GRO was associated with better HRQOL among Hispanic and White females, but not males nor African-Americans of either sex. CONCLUSIONS: Racial/ethnic differences emerged for female and androgynous, but not male, GROs. Hispanic males are the only group for which GRO (female) was associated with poorer HRQOL. Future research should find ways to help youth overcome negative effects on health from gender beliefs and behavior patterns with sensitivity to racial/ethnic membership.

Effects of the It's Your Game . . . Keep It Real program on dating violence in ethnic-minority middle school youths: a group randomized trial.

OBJECTIVES: We examined whether It's Your Game . . . Keep It Real (IYG) reduced dating violence among ethnic-minority middle school youths, a population at high risk for dating violence. METHODS: We analyzed data from 766 predominantly ethnic-minority students from 10 middle schools in southeast Texas in 2004 for a group randomized trial of IYG. We estimated logistic regression models, and the primary outcome was emotional and physical dating violence perpetration and victimization by ninth grade. RESULTS: Control students had significantly higher odds of physical dating violence victimization (adjusted odds ratio [AOR] = 1.52; 95% confidence interval [CI] = 1.20, 1.92), emotional dating violence victimization (AOR = 1.74; 95% CI = 1.36, 2.24), and emotional dating violence perpetration (AOR = 1.58; 95% CI = 1.11, 2.26) than did intervention students. The odds of physical dating violence perpetration were not significantly different between the 2 groups. Program effects varied by gender and race/ethnicity. CONCLUSIONS: IYG significantly reduced 3 of 4 dating violence outcomes among ethnic-minority middle school youths. Although further study is warranted to determine if IYG should be widely disseminated to prevent dating violence, it is one of only a handful of school-based programs that are effective in reducing adolescent dating violence behavior.

It's Your Game Keep It Real: can innovative public health prevention research thrive within a comparative effectiveness research framework?

The federal comparative effectiveness research (CER) initiative is designed to evaluate best practices in health care settings where they can be disseminated for immediate benefit to patients. The CER strategic framework comprises four categories (research, human and scientific capital, data infrastructure, and dissemination) with three crosscutting themes (conditions, patient populations, and types of intervention). The challenge for the field of public health has been accommodating the CER framework within prevention research. Applying a medicine-based, research-to-practice CER approach to public health prevention research has raised concerns regarding definitions of acceptable evidence (an evidence challenge), effective intervention dissemination within heterogeneous communities (a dissemination and implementation challenge), and rewards for best practice at the cost of other promising but high-risk approaches (an innovation challenge). Herein, a dynamic operationalization of the CER framework is described that is compatible with the development, evaluation, and dissemination of innovative public health prevention interventions. An effective HIV, STI, and pregnancy prevention program, It's Your Game…Keep It Real, provides a case study of this application, providing support that the CER framework can compatibly coexist with innovative, community-based public health prevention research.

The association between problematic parental substance use and adolescent substance use in an ethnically diverse sample of 9th and 10th graders.

Adolescents of parents who use substances are at an increased risk for substance use themselves. Both parental monitoring and closeness have been shown to mediate the relationship between parents' and their adolescents' substance use. However, we know little about whether these relationships vary across different substances used by adolescents. Using structural equation modeling, we examined these associations within a racially and ethnically diverse sample of 9th and 10th graders (N = 927). Path analyses indicated that maternal closeness partially mediated the association between maternal problematic substance use and adolescent alcohol use. Parental monitoring partially mediated the relationship between paternal problematic substance use and adolescent alcohol, cigarette, marijuana, inhalant, and illicit prescription drug use. These results were consistent across gender and race/ethnicity. These findings suggest that parental interventions designed to increase closeness and monitoring may help to reduce adolescent substance use.

Soft Drink Consumption and Mental Health in Adolescents: A Longitudinal Examination.

PURPOSE: Previous studies showed associations between soft drink consumption and mental health problems in adolescents, but the direction of these effects is unknown. This study examines the hypotheses that soft drink consumption predicts aggression and depressive symptoms over time and that these mental health problems predict soft drink consumption. METHODS: Interviews were conducted with 5,147 children and their caregivers from three sites at child ages 11, 13, and 16. At each time point, youth reported on their frequency of consuming soft drinks, aggressive behavior, and depressive symptoms. An autoregressive cross-lagged path model tested reciprocal relationships between soft drink consumption, aggressive behavior, and depressive symptoms over time. RESULTS: More frequent consumption of soft drinks was associated with more aggressive behavior at each time point and depressive symptoms at ages 11 and 13 (r = .04 to .18, p ≤ .002). After adjusting for covariates and stability of each behavior over time, soft drink consumption at ages 11 and 13 predicted more aggressive behavior at the next time point (ß = .08 and .06, p < .001). Aggressive behavior at age 13 also predicted more soft drink consumption at age 16 (ß = .06, p = .002). Soft drink consumption at age 13 predicted fewer depressive symptoms (ß = -.04, p = .007), but depressive symptoms did not predict soft drink consumption. CONCLUSIONS: More frequent consumption of soft drinks may contribute to aggressive behavior in adolescents over time; there is some support for reciprocal relationships. There is no evidence for soft drink consumption contributing to adolescents' depression. Future research should examine longitudinal effects over shorter intervals.

Influences of physical and social neighborhood environments on children's physical activity and obesity.

OBJECTIVES: We investigated the association between physical and social neighborhood environments and fifth-grade students' physical activity and obesity. METHODS: We collected data on 650 children and their primary caregivers during phase 1 of Healthy Passages, a multisite, community-based, cross-sectional study of health risk behaviors and health outcomes in children. We conducted independent systematic neighborhood observations to measure neighborhood physical characteristics, and we analyzed survey data on social processes. We modeled children's physical activity and obesity status with structural equation models that included latent variables for the physical and social environments. RESULTS: After we controlled for children's sociodemographic factors, we found that a favorable social environment was positively associated with several measures of physical activity and that physical activity was negatively associated with obesity in these children. Physical environment was not significantly associated with physical activity. CONCLUSIONS: Our findings suggest that neighborhood social factors as well as the physical environment should be considered in the development of health policy and interventions to reduce childhood obesity.

Perceived racial/ethnic discrimination among fifth-grade students and its association with mental health.

OBJECTIVES: We sought to describe the prevalence, characteristics, and mental health problems of children who experience perceived racial/ethnic discrimination. METHODS: We analyzed cross-sectional data from a study of 5147 fifth-grade students and their parents from public schools in 3 US metropolitan areas. We used multivariate logistic regression (overall and stratified by race/ethnicity) to examine the associations of sociodemographic factors and mental health problems with perceived racial/ethnic discrimination. RESULTS: Fifteen percent of children reported perceived racial/ethnic discrimination, with 80% reporting that discrimination occurred at school. A greater percentage of Black (20%), Hispanic (15%), and other (16%) children reported perceived racial/ethnic discrimination compared with White (7%) children. Children who reported perceived racial/ethnic discrimination were more likely to have symptoms of each of the 4 mental health conditions included in the analysis: depression, attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder. An association between perceived racial/ethnic discrimination and depressive symptoms was found for Black, Hispanic, and other children but not for White children. CONCLUSIONS: Perceived racial/ethnic discrimination is not an uncommon experience among fifth-grade students and may be associated with a variety of mental health disorders.

Prevalence, characteristics, and associated health and health care of family homelessness among fifth-grade students.

OBJECTIVES: We describe the lifetime prevalence and associated health-related concerns of family homelessness among fifth-grade students. METHODS: We used a population-based, cross-sectional survey of 5147 fifth-grade students in 3 US cities to analyze parent-reported measures of family homelessness, child health status, health care access and use, and emotional, developmental, and behavioral health and child-reported measures of health-related quality of life and exposure to violence. RESULTS: Seven percent of parents reported that they and their child had experienced homelessness (i.e., staying in shelters, cars, or on the street). Black children and children in the poorest families had the highest prevalence of homelessness (11%). In adjusted analyses, most general health measures were similar for children who had and had not been homeless. Children who had ever experienced homelessness were more likely to have an emotional, behavioral, or developmental problem (odds ratio [OR] = 1.7; 95% confidence interval [CI] = 1.1, 2.6; P = .01), to have received mental health care (OR = 2.2; 95% CI = 1.6, 3.2; P < .001), and to have witnessed serious violence with a knife (OR = 1.6; 95% CI = 1.1, 2.3; P = .007) than were children who were never homeless. CONCLUSIONS: Family homelessness affects a substantial minority of fifth-grade children and may have an impact on their emotional, developmental, and behavioral health.

Safer choices 2: rationale, design issues, and baseline results in evaluating school-based health promotion for alternative school students.

BACKGROUND: Students attending 'alternative' high schools form relatively small, highly mobile high-risk populations, presenting challenges for the design and implementation of HIV-, other STI-, and pregnancy-prevention interventions. This paper describes the rationale, study design, and baseline results for the Safer Choices 2 program. STUDY DESIGN: Modified group-randomized intervention trial with cross-over of schools but not of students. The study cohort was defined a priori as those who completed the baseline measures and were still enrolled at the time of first follow-up. DESIGN RESULTS: Of 940 students initially enrolled in the study, 711 (76%) formed the study cohort. There were significant demographic differences between those included and those excluded from the study cohort in sex, age, sexual experience, experience with pregnancy, drug use, and some psychosocial measures. There were no significant differences between the intervention and control groups within the study cohort. The only significant difference between those students excluded from the intervention group and those excluded from the control group was reported age at first intercourse. BASELINE DATA RESULTS: Students (n=940) enrolled were predominately African-American (29.7%) and Hispanic (61.3%); 57.3% were female; 66% had ever had sex; and reported drug use in the previous 30 days ran from 4.3% (cocaine) to 26.9% (marijuana). Of the 627 sexually experienced, 41.8% reported their age at first intercourse as 13 years or younger; 28.5% reported ever being or having gotten someone pregnant; 74% reported sex in the past 3 months. Of the 464 sexually active in the last 3 months, 55.4% reported unprotected intercourse and 31.3% reported using drugs beforehand. CONCLUSION: The cross-over design will provide a rigorous test of the intervention; however, loss to follow-up of this population can result in some selection bias. Students attending dropout prevention and recovery schools are at high risk for HIV, STIs, and pregnancy, and are in need of interventions.

Unequal interactions: Examining the role of patient-centered care in reducing inequitable diffusion of a medical innovation, the human papillomavirus (HPV) vaccine.

RATIONALE: Studies of inequities in diffusion of medical innovations rarely consider the role of patient-centered care. OBJECTIVE: We used uptake of the human papillomavirus (HPV) vaccine shortly after its licensing to explore the role of patient-centered care. METHODS: Using a longitudinal multi-site survey of US parents and adolescents, we assessed whether patient-centered care ratings might shape racial/ethnic and socioeconomic gaps at two decision points in the HPV vaccination process: (1) Whether a medical provider recommends the vaccine and (2) whether a parent decides to vaccinate. RESULTS: We did not find evidence that the association of patient-centeredness with vaccination varies by parent education. In contrast, parent ratings of providers' patient-centeredness were significantly associated with racial/ethnic disparities in parents' reports of receiving a HPV vaccine recommendation from a provider: Among parents who rate patient-centered care as low, white parents' odds of receiving such a recommendation are 2.6 times higher than black parents' odds, but the racial/ethnic gap nearly disappears when parents report high patient-centeredness. Moderated mediation analyses suggest that patient-centeredness is a major contributor underlying vaccination uptake disparities: Among parents who report low patient-centeredness, white parents' odds of vaccinating their child are 8.1 times higher than black parents' odds, while both groups are equally likely to vaccinate when patient-centeredness is high. CONCLUSION: The results indicate that patient-centered care, which has been a relatively understudied factor in the unequal diffusion of medical innovations, deserves more attention. Efforts to raise HPV vaccination rates should explore why certain patient groups may be less likely to receive recommendations and should support providers to consistently inform all patient groups about vaccination.

Severe back pain among farmworker high school students from Starr County, Texas: baseline results.

PURPOSE: This cohort study is among the first to estimate the prevalence of and examine potential risk factors for severe back pain (resulting in medical care, 4+ hours of time lost, or pain lasting 1+ weeks) among adolescent farmworkers. These youth often perform tasks requiring bent/stooped postures and heavy lifting. METHODS: Of 2536 students who participated (response rate across the three public high schools, 61.2% to 83.9%), 410 students were farmworkers (largely Hispanic and migrant). Students completed a self-administered Web-based survey including farm work/nonfarm work and back-pain items relating to a 9-month period. RESULTS: The prevalence of severe back pain was 15.7% among farmworkers and 12.4% among nonworkers. The prevalence increased to 19.1% among farm workers (n = 131) who also did nonfarm work. A multiple logistic regression for farmworkers showed that significantly increased adjusted odds ratios for severe back pain were female sex (4.59); prior accident/back injury (9.04); feeling tense, stressed, or anxious sometimes/often (4.11); lifting/carrying heavy objects not at work (2.98); current tobacco use (2.79); 6+ years involved in migrant farm work (5.02); working with/around knives (3.87); and working on corn crops (3.40). CONCLUSIONS: Areas for further research include ergonomic exposure assessments and examining the effects of doing farm work and nonfarm work simultaneously.

Health-Related Issues in Latina Youth: Racial/Ethnic, Gender, and Generational Status Differences.

PURPOSE: Few studies have examined the early development of a broad range of health issues of importance in adolescence in Latina (female) youth, despite their being potentially a vulnerable group. This study compared suicide and depressive symptoms, substance use, violence exposure, injury prevention, obesity, and health-related quality of life among Latina, African-American, and white females as well as Latino (male) youth in fifth grade, as well as differences related to immigrant generational status for Latinas. METHODS: Data were from the Healthy Passages study, including 3,349 African-American, Latina, and white females as well as Latino male fifth graders in three U.S. metropolitan areas. Self-report items and scales were used to compare status on health-related issues. Generational status was classified based on the parent report of birth location. Logistic and linear regression analyses were conducted, including adjustment for sociodemographic differences. RESULTS: Latinas showed higher vulnerability than white females for several health issues, whereas few remained after adjustments for sociodemographic differences (higher obesity, lower bike helmet use, and lower physical health-related quality of life). Latina's lower vulnerability compared with African-American females generally persisted after adjustments. Third generation Latinas, after adjustments, reported lower prevalence of alcohol use and fewer friends using alcohol, yet higher future intentions of alcohol use, than first and second generation Latinas. There were few differences between Latina and Latino youth. CONCLUSIONS: Latina youth generally report low vulnerability across health issues in preadolescence. To the extent they appear at higher vulnerability than white females, this may be related to their disadvantaged sociodemographic status.

Generational status and social factors predicting initiation of partnered sexual activity among Latino/a youth.

OBJECTIVE: Examine the longitudinal association of generational status (first = child and parent born outside the United States; second = child born in the United States, parent born outside the United States; third = child and parent born in the United States) and parent and peer social factors considered in 5th grade with subsequent oral, vaginal, and anal intercourse initiation by 7th and 10th grade among Latino/a youth. METHOD: Using data from Latino/a participants (N = 1,790) in the Healthy Passages™ study, the authors measured generational status (first = 18.4%, second = 57.3%, third-generation = 24.3%) and parental (i.e., monitoring, involvement, nurturance) and peer (i.e., friendship quality, social interaction, peer norms) influences in 5th grade and oral, vaginal, and anal intercourse initiation by 7th and 10th (retention = 89%) grade. RESULTS: Among girls, parental monitoring, social interaction, friendship quality, and peer norms predicted sexual initiation. Among boys, parental involvement, social interaction, and peer norms predicted sexual initiation (ps < .05). When ≥1 friend was perceived to have initiated sexual intercourse, third-generation Latinas were more than twice as likely as first- and second-generation Latinas (ps < .05) to initiate vaginal intercourse by 10th grade and almost 5 times as likely as first-generation Latinas to initiate oral intercourse by 7th grade. CONCLUSIONS: Among Latina youth, generational status plays a role in social influences on vaginal and oral intercourse initiation. Moreover, Latinas and Latinos differ in which social influences predict sexual intercourse initiation. Preventive efforts for Latino/a youth may need to differ by gender and generational status. (PsycINFO Database Record

Cervical cancer survival by socioeconomic status, race/ethnicity, and place of residence in Texas, 1995-2001.

OBJECTIVE: The current study explored whether socioeconomic status (SES), race/ethnicity, and rural residence may be linked to poorer cervical cancer survival by stage at diagnosis. METHODS: Data from 7,237 cervical cancer cases reported to the Texas Cancer Registry from 1995-2001 were used to address the association by stage at diagnosis and cause of death. Zip code-level census data were used to classify residence and to develop a composite variable for SES. Multilevel Cox proportional hazards modeling was used to estimate hazard ratios (HR) and 95% confidence intervals (CI). RESULTS: Late stage at diagnosis was a strong predictor of cervical cancer mortality (HR = 6.2, 95% CI 5.5-7.2). SES and race/ethnicity were independently associated with stage at diagnosis. Women residing in areas with lower SES had significantly shorter survival times when diagnosed at an early stage (HR = 3.0, 95% CI 2.1-4.3). Hispanic women had a lower probability of dying from cervical cancer during the follow-up period (HR = 0.7, 95% CI 0.6- 0.8) after adjusting for confounders. The association between lower SES and poorer survival was consistent across all racial/ethnic groups, suggesting the effect of SES may be more important than race. CONCLUSIONS: SES and race/ethnicity were independently associated with poorer cervical cancer survival in this large Texas sample. Further research is needed to investigate the role of optimal treatment and comorbid conditions in the association between SES and cervical cancer survival.

Partners in school asthma management: evaluation of a self-management program for children with asthma.

The "Partners in School Asthma Management" program for inner-city elementary school children comprises (1) case finding; (2) linkage of school nurses, parents, and clinicians; (3) a computer-based tailored educational program; and (4) school environmental assessment and intervention. Case finding identified 1730 children in 60 elementary schools with probable asthma; 835 (96% Hispanic or African American) joined the study. Baseline, posttest, and follow-up measures of asthma knowledge, self-efficacy, and self-management behavior were obtained from the children, and data on symptoms, emergency department visits, and hospitalizations were obtained from their parents. The schools provided data on grades and absences. Each school had a baseline and follow-up environmental assessment. The children in the intervention group showed greater increases in knowledge, self-efficacy, and some aspects of self-management. No differences between groups were found in health status variables, school performance, attendance, or levels of environmental allergens in schools. In 15 schools, an enhanced intervention allowed children and their parents to meet with a project physician, develop an asthma action plan, and receive a 1-month supply of medication; the project physician then followed up with the child's community physician. Children participating in this enhanced intervention had better school performance and fewer absences than the comparison group. Overall, the program was effective in improving children's asthma self-management but not in improving their health status. While the case-finding, computer-based self-management training program and linkage system were successfully implemented, the program failed in creating needed changes in the medical (action plans by community physicians) and physical environments (reduced school allergen levels) of the children.