Showing papers in "American Journal of Public Health in 1992"

Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease.

Abstract: BACKGROUND. Socioeconomic status (SES) is usually measured by determining education, income, occupation, or a composite of these dimensions. Although education is the most commonly used measure of SES in epidemiological studies, no investigators in the United States have conducted an empirical analysis quantifying the relative impact of each separate dimension of SES on risk factors for disease. METHODS. Using data on 2380 participants from the Stanford Five-City Project (85% White, non-Hispanic), we examined the independent contribution of education, income, and occupation to a set of cardiovascular disease risk factors (cigarette smoking, systolic and diastolic blood pressure, and total and high-density lipoprotein cholesterol). RESULTS. The relationship between these SES measures and risk factors was strongest and most consistent for education, showing higher risk associated with lower levels of education. Using a forward selection model that allowed for inclusion of all three SES measures after adjust...

Overcoming the absence of socioeconomic data in medical records: validation and application of a census-based methodology

Abstract: BACKGROUND. Most US medical records lack socioeconomic data, hindering studies of social gradients in health and ascertainment of whether study samples are representative of the general population. This study assessed the validity of a census-based approach in addressing these problems. METHODS. Socioeconomic data from 1980 census tracts and block groups were matched to the 1985 membership records of a large prepaid health plan (n = 1.9 million), with the link provided by each individual's residential address. Among a subset of 14,420 Black and White members, comparisons were made of the association of individual, census tract, and census block-group socioeconomic measures with hypertension, height, smoking, and reproductive history. RESULTS. Census-level and individual-level socioeconomic measures were similarly associated with the selected health outcomes. Census data permitted assessing response bias due to missing individual-level socioeconomic data and also contextual effects involving the interactio...

The accuracy of Medicare's hospital claims data: progress has been made, but problems remain.

Abstract: BACKGROUND. Health care databases provide a widely used source of data for health care research, but their accuracy remains uncertain. We analyzed data from the 1985 National DRG Validation Study, which carefully reabstracted and reassigned ICD-9-CM diagnosis and procedure codes from a national sample of 7050 medical records, to determine whether coding accuracy had improved since the Institute of Medicine studies of the 1970s and to assess the current coding accuracy of specific diagnoses and procedures. METHODS. We defined agreement as the proportion of all reabstracted records that had the same principal diagnosis or procedure coded on both the original (hospital) record and on the reabstracted record. We also evaluated coding accuracy in 1985 using the concepts of diagnostic test evaluation. RESULTS. Overall, the percentage of agreement between the principal diagnosis on the reabstracted record and the original hospital record, when analyzed at the third digit, improved from 73.2% in 1977 to 78.2% in ...

Childhood chronic illness: prevalence, severity, and impact.

Abstract: BACKGROUND. Using data from the 1988 National Health Interview Survey, this article presents national estimates of the prevalence and impact of childhood chronic conditions. METHODS. Proxy responses to a checklist of child health conditions administered for 17,110 children under 18 years of age were used. Conditions were classified as chronic if they were first noticed more than 3 months prior to the interview or if they were the type that would ordinarily be of extended duration, such as arthritis. RESULTS. An estimated 31% of children were affected by chronic conditions. Among these children, highly prevalent conditions included respiratory allergies 9.7 per 100, repeated ear infections 8.3 per 100 and asthma 4.3 per 100. These children can be divided into three groups: 66% with mild conditions that result in little or no bother or activity limitation; 29% with conditions of moderate severity that result in some bother or limitation of activity, but not both; and 5% with severe conditions that cause fre...

Body fatness and risk for elevated blood pressure, total cholesterol, and serum lipoprotein ratios in children and adolescents.

Abstract: BACKGROUND. Recent studies have shown considerable variation in body fatness among children and adolescents defined as obese by a percentile rank for skinfold thickness. METHODS. We examined the relationship between percent body fat and risk for elevated blood pressure, serum total cholesterol, and serum lipoprotein ratios in a biracial sample of 3320 children and adolescents aged 5 to 18 years. Equations developed specifically for children using the sum of subscapular (S) and triceps (T) skinfolds were used to estimate percent fat. The S/T ratio provided an index of trunkal fat patterning. RESULTS. Significant overrepresentation (greater than 20%) of the uppermost quintile (UQ) for cardiovascular disease (CVD) risk factors was evident at or above 25% fat in males (32.2% to 37.3% in UQ) and at or above 30% fat in females (26.6% to 45.4% in UQ), even after adjusting for age, race, fasting status, and trunkal fat patterning. CONCLUSIONS. These data support the concept of body fatness standards in White and ...

Reductions in HIV risk-associated sexual behaviors among black male adolescents: effects of an AIDS prevention intervention.

Abstract: BACKGROUND. The number of reported cases of acquired immune deficiency syndrome (AIDS) is increasing disproportionately among Blacks in the United States. The relatively high incidence of sexually transmitted diseases among Black adolescents suggest the need for AIDS prevention programs to reduce their risk of sexually transmitted human immunodeficiency virus (HIV) infection. METHODS. Black male adolescents (n = 157) were randomly assigned to receive an AIDS risk reduction intervention aimed at increasing AIDS-related knowledge and weakening problematic attitudes toward risky sexual behavior, or to receive a control intervention on career opportunities. RESULTS. The adolescents who received the AIDS intervention subsequently had greater AIDS knowledge, less favorable attitudes toward risky sexual behavior, and lower intentions to engage in such behavior than did those in the control condition. Follow-up data collected 3 months later revealed that the adolescents who had received the AIDS intervention repo...

The cost and frequency of hospitalization for fall-related injuries in older adults.

Abstract: Using a population-based hospital discharge registry with E codes, we examine the 1989 hospitalizations of older adults in Washington State for fall-related injuries. Fall-related trauma accounted for 5.3% of all hospitalizations of older adults, with hospital charges totaling $53,346,191, and resulted in discharge to nursing care more often than other such hospitalizations. An annual hospitalization rate of 13.5 per 1000 persons and an annual cost of $92 per person is reported. The importance of preventing fall-related injuries in older adults is discussed.

Rotating shift work, sleep, and accidents related to sleepiness in hospital nurses.

Abstract: A hospital-based survey on shift work, sleep, and accidents was carried out among 635 Massachusetts nurses. In comparison to nurses who worked only day/evening shifts, rotators had more sleep/wake cycle disruption and nodded off more at work. Rotators had twice the odds of nodding off while driving to or from work and twice the odds of a reported accident or error related to sleepiness. Application of circadian principles to the design of hospital work schedules may result in improved health and safety for nurses and patients.

Chlorination, chlorination by-products, and cancer: a meta-analysis.

Abstract: OBJECTIVES. Individual epidemiological investigations into the association between chlorination by-products in drinking water and cancer have been suggestive but inconclusive. Enough studies exist to provide the basis for a meaningful meta-analysis. METHODS. An extensive literature search was performed to identify pertinent case-control studies and cohort studies. Consumption of chlorinated water, surface water, or water with high levels of chloroform was used as a surrogate for exposure to chlorination by-products. Relative risk estimates were abstracted from the individual studies and pooled. RESULTS. A simple meta-analysis of all cancer sites yielded a relative risk estimate for exposure to chlorination by-products of 1.15 (95% CI: 1.09, 1.20). Pooled relative risk estimates for organ-specific neoplasms were 1.21 (95% CI: 1.09, 1.34) for bladder cancer and 1.38 (95% CI: 1.01, 1.87) for rectal cancer. When studies that adjusted for potential confounders were pooled separately, estimates of relative risk...

Community AIDS/HIV risk reduction: the effects of endorsements by popular people in three cities.

Abstract: OBJECTIVES. It is critical to extend community-level acquired immunodeficiency syndrome (AIDS) prevention efforts beyond education alone and to develop models that better encourage behavioral changes. Gay men in small cities are vulnerable to human immunodeficiency virus (HIV) infection due to continued high rates of risk behavior. This research introduced an intervention that trained popular people to serve as behavioral change endorsers to peers sequentially across three different cities. METHODS. Populationwide surveys were conducted of all men patronizing gay clubs in each city to establish risk behavior base rates. After a small cadre of popular "trendsetters" were identified, they received training in approaches for peer education and then contracted to communicate risk reduction recommendations and endorsements to friends. Surveys were repeated at regular intervals in all cities, with the same intervention introduced in lagged fashion across each community. RESULTS. Intervention consistently produc...

Variations in asthma hospitalizations and deaths in New York City.

Abstract: BACKGROUND. Recent reports have identified New York City as having asthma mortality rates that are substantially higher than expected based on US rates. This study investigates the problems of asthma morbidity and mortality in New York City. METHODS. Data on asthma hospitalizations (1982 to 1986) and deaths (1982 to 1987) among persons aged 0 to 34 years were studied. Descriptive and multivariate techniques were used to examine differences in rates among subgroups and across geographic areas. RESULTS. The average annual hospitalization rate was 39.2 per 10,000; the mortality rate was 1.2 per 100,000. Hospitalization and death rates among Blacks and Hispanics were 3 to 5.5 times those of Whites. Large geographic variations in hospitalizations and mortality occurred. Asthma hospitalization and mortality rates were highly correlated (r = .67), with the highest rates concentrated in the city's poorest neighborhoods. Household income, percentage of population Black, and percentage of population Hispanic were s...

The social impact of dental problems and visits.

Abstract: OBJECTIVES. The purpose of this analysis was to assess selected social consequences of maintaining oral health and treating oral diseases. The associations among socioeconomic and demographic factors with time lost from work or school and reductions in normal activities are explored. METHODS. Data were gathered as part of the 1989 National Health Interview Survey from 50,000 US households (117,000 individuals), representing 240 million persons. The oral health care supplement was analyzed using the software SUDAAN to produce standard errors for estimates based on complex multistage sample designs. RESULTS. Because of dental visits or problems, 148,000 hours of work were lost per 100,000 workers, 117,000 hours of school were lost per 100,000 school-age children, and 17,000 activity days beyond work and school time were restricted per 100,000 individuals in 1989. Exploratory analyses suggest that sociodemographic groups have different patterns of such time loss and of reduced normal activities. CONCLUSIONS....

Misclassification of smoking status in the CARDIA study: a comparison of self-report with serum cotinine levels.

Abstract: BACKGROUND. Although widely used in epidemiological studies, self-report has been shown to underestimate the prevalence of cigarette smoking in some populations. METHODS. In the CARDIA study, self-report of cigarette smoking was validated against a biochemical marker of nicotine uptake, serum cotinine. RESULTS. The prevalence of smoking was slightly lower when defined by self-report (30.9%) than when defined by cotinine levels equal to or greater than 14 ng/mL (32.2%, P less than .05). The misclassification rate (proportion of reported nonsmokers with cotinine levels of at least 14 ng/mL) was 4.2% and was significantly higher among subjects who were Black, had a high school education or less, or were reported former smokers. Possible reasons for misclassification include reporting error, environmental tobacco smoke, and an inappropriate cutoff point for delineation of smoking status. Using self-report as the gold standard, the cotinine cutoff points that maximized sensitivity and specificity were 14, 9, a...

The epidemiology of low back pain in an adolescent population

Abstract: We assessed the prevalence of low back pain (LBP) in a cohort of 1242 adolescents (aged 11 through 17) currently participating in a 4-year prospective study of medically treated injuries. Overall, 30.4% of the adolescents reported LBP. The impact of LBP in adolescents was considerable, with one third resulting in restricted activity and 7.3% seeking medical attention. Life-table analysis demonstrated that by age 15, the prevalence of LBP increased to 36%. There were few differences by gender or race. These results suggest that LBP in adolescents is a serious public health problem.

Communitywide smoking prevention : long-term outcomes of the Minnesota heart health program and the class of 1989 study

Abstract: OBJECTIVES. The Class of 1989 Study is part of the Minnesota Heart Health Program (MHHP), a populationwide research and demonstration project designed to reduce cardiovascular disease in three educated communities from 1980 to 1993. This paper describes an intensive, school-based behavioral intervention on cigarette smoking, comparing long-term outcomes in one of the intervention communities with those in a matched reference community. METHODS. Beginning in sixth grade (1983), seven annual waves of cohort and cross-sectional behavioral measurements were taken from one MHHP intervention community and its matched pair. All students in each community were eligible to participate (baseline n = 2401). Self-reported data collected at each period described prevalence and intensity of cigarette smoking. RESULTS. There were no differences at baseline for either weekly smoking prevalence or intensity of smoking. Throughout the follow-up period, however, smoking rates as determined by these measures were significant...

Weight loss attempts in adults: goals, duration, and rate of weight loss.

Abstract: OBJECTIVES: Although attempted weight loss is common, little is known about the goals and durations of weight loss attempts and the rates of achieved weight loss in the general population. METHODS. Data were collected by telephone in 1989 from adults aged 18 years and older in 39 states and the District of Columbia. Analyses were carried out separately for the 6758 men and 14,915 women who reported currently trying to lose weight. RESULTS. Approximately 25% of the men respondents and 40% of the women respondents reported that they were currently trying to lose weight. Among men, a higher percentage of Hispanics (31%) than of Whites (25%) or Blacks (23%) reported trying to lose weight. Among women, however, there were no ethnic differences in prevalence. The average man wanted to lose 30 pounds and to weigh 178 pounds; the average woman wanted to lose 31 pounds and to weigh 133 pounds. Black women wanted to lose an average of 8 pounds more than did White women, but Black women's goal weight was 10 pounds h...

A new definition of maternal depletion syndrome.

Abstract: BACKGROUND. Although the term "maternal depletion syndrome" has been commonly used to explain poor maternal and infant health, whether such a syndrome actually exists remains unclear. This uncertainty may be due to the lack of a clear definition of the syndrome and the absence of theoretical frameworks that account for the many factors related to reproductive nutrition. METHODS. We propose a new definition of maternal depletion syndrome within a framework that accounts for potential confounding factors. RESULTS. Our conceptual framework distinguishes between childbearing pattern and inadequate diet as causes of poor maternal health; hence, our definition of maternal depletion syndrome has both biological and practical meaning. The new definition is based on overall change in maternal nutritional status over one reproductive cycle in relation to possible depletion and repletion phases and in relation to initial nutritional status. CONCLUSIONS. The empirical application of this approach should permit the te...

Birth weight and perinatal mortality: the effect of gestational age.

Abstract: BACKGROUND. The strong association between birth weight and perinatal mortality is due both to gestational age and to factors unrelated to gestational age. Conventional analysis obscures these separate contributions to perinatal mortality, and overemphasizes the role of birth weight. An alternative approach is used here to separate gestational age from other factors. METHODS. Data are from 400,000 singleton births in the Norwegian Medical Birth Registry. The method of Wilcox and Russell is used to distinguish the contributions to perinatal mortality made by gestational age and by relative birth weight at each gestational age. RESULTS. Gestational age is a powerful predictor of birth weight and perinatal survival. After these effects of gestational age are controlled for, relative birth weight retains a strong association with survival. CONCLUSIONS. Current public health policies in the United States emphasize the prevention of low birth weight. The present analysis suggests that the prevention of early de...

Race and sex differences in mortality following fracture of the hip.

Abstract: This paper describes the all-cause mortality experience, following a fracture of the hip, of 712,027 persons covered by the Medicare program from 1984 through 1987. White women experienced the lowest mortality rate (17.2 per 1000 person-months), followed by Black women (22.9 per 1000 person-months), Black men (33.5 per 1000 person-months), and White men (33.7 per 1000 person-months). The observed race-sex differences in survival were found at all ages and regardless of the number of comorbid conditions listed with the discharge diagnosis. While these data demonstrate marked race-sex differences in survival following hip fracture, the cause of these differences is not immediately apparent and demands further investigation.

Ultraviolet light exposure and lens opacities: the Beaver Dam Eye Study.

Abstract: OBJECTIVES. Exposure to sunlight may be a risk factor for the development of cataract. The relationships between exposure to sunlight and to the ultraviolet-B (UVB) component of light and the prevalence of lens opacities were examined in the Beaver Dam Eye Study. METHODS. Persons 43 to 84 years of age residing in Beaver Dam, Wisconsin, were examined using standardized photographic assessments of lens opacities. A questionnaire about medical history and exposure to light was administered. RESULTS. After adjusting for other risk factors, men who had higher levels of average annual ambient UVB light were 1.36 times more likely to have more severe cortical opacities than men with lower levels. However, UVB exposure was not found to be associated with nuclear sclerosis or posterior subcapsular opacities in men. Moreover, no associations with UVB exposure were found for women, who were less likely to be exposed to UVB. CONCLUSIONS: Exposure to UVB light may be associated with the severity of cortical opacities ...

Condom use in multi-ethnic neighborhoods of San Francisco : the population-based AMEN (AIDS in multi-ethnic neighborhoods) study

Abstract: We examined the prevalence and correlates of condom use in a community-based sample of unmarried heterosexual and gay/bisexual Whites, Blacks, and Hispanics (aged 20 to 44 years) in San Francisco (n = 1229). Only 9% of heterosexual males reported always using condoms, and fewer of those with multiple sexual partners (6%) reported always using condoms compared with those in monogamous relationships (12%). Much higher proportions of gay/bisexual men reported always using condoms (48%). Racial differences in condom use were observed only among women. Sexual communication and the sexual enjoyment value of condoms were consistent correlates of condom use across gender and sexual orientation, while other condom-related beliefs were significant predictors of condom use only for men. In general, condom promotion programs should build sexual communication skills, teach people how to enhance enjoyment with condoms, and reduce psychological barriers to condom acquisition and use.

Prevention of cigarette smoking through mass media intervention and school programs.

Abstract: OBJECTIVES. In this study we tested the ability of mass media interventions to enhance the efficacy of school cigarette smoking prevention programs. METHODS. For 4 years, students in one pair of communities received media interventions and school programs that had common educational objectives. Students in a matched pair of communities received only the school programs. The combined cohort of 5458 students was surveyed at baseline in grades 4, 5, and 6 and was followed up annually for 4 years. RESULTS. Significant reductions in reported smoking, along with consistent effects on targeted mediating variables, were observed for the media-and-school group. For cigarettes per week the reduction was 41% (2.6 vs 4.4); for smoking cigarettes yesterday the reduction was 34% (8.6% vs 13.1%); and for smoking in the past week the reduction was 35% (12.8% vs 19.8%). No effects were observed for substance use behaviors not targeted by the interventions. CONCLUSIONS. These results provide evidence that mass media interv...

Correlates of nonadherence to hypertension treatment in an inner-city minority population.

Abstract: OBJECTIVE. Adherence to treatment is a key factor in achieving blood pressure control among hypertensives. We examined correlates of nonadherence to hypertension treatment in an inner-city minority population. METHODS. Subjects (n = 202) were interviewed as part of a case-control study of severe, uncontrolled hypertension conducted in two New York City hospitals in 1989-91. All subjects were African American or Hispanic. Self-reported nonadherence to drug treatment for hypertension was measured using a five-item scale, and the sample was dichotomized as more (n = 87) or less (n = 115) adherent. Multiple logistic regression analysis was used to adjust for demographic and other covariates. RESULTS. Nonadherence was associated with having blood pressure checked in an emergency room (adjusted odds ratio [OR] = 7.9; 95% confidence interval [CI] = 1.75, 35.77; P < .01), lack of a primary care physician (adjusted OR = 2.9; 95% CI = 1.37, 6.02; P < .01), current smoking (adjusted OR = 2.4; 95% CI = 1.10, 5.22; P ...

Mortality, disability, and falls in older persons: the role of underlying disease and disability.

Abstract: BACKGROUND. Falls are prevalent in older persons and can have serious consequences. METHODS. Data from the Longitudinal Study on Aging were analyzed to study the relationship between falls and both mortality and functional status in 4270 respondents age 70 and over. The effects of demographic traits, chronic conditions, and disability present at baseline were controlled for by means of multivariable analyses. RESULTS. Risk of death within 2 years was greater for both single fallers (crude odds ratio OR., 1.5; 95% confidence interval CI., 1.1-2.0) and multiple fallers (crude OR, 2.2; 95% CI, 1.7-2.8). This excess risk was dissipated when selected covariates were added to the model. No crude or adjusted association was evident between single falls and functional impairment; however, multiple falls were an independent risk factor (adjusted OR, 1.6; 95% CI, 1.2-2.0). CONCLUSIONS. Multiple falls in older persons increase risk of functional impairment and may indicate underlying conditions that increase risk of death. Language: en

Cigarette, alcohol, and coffee consumption and spontaneous abortion.

Abstract: We analyzed data from a survey of occupational factors and pregnancy outcome to examine the effects of cigarette, alcohol, and coffee consumption on pregnancy outcome. Clear and statistically significant associations were found between cigarette and alcohol consumption and spontaneous abortion. There was a weaker but statistically significant association with coffee consumption: If the associations were casual, 11% of the spontaneous abortions could be attributed to smoking, 5% to alcohol, and 2% to coffee.

Weight gain prevention and smoking cessation: cautionary findings.

Abstract: OBJECTIVES. Weight gain is a consistent sequela of smoking cessation. A successful intervention might attract smokers who fear weight gain. If the gain causes smoking relapse, such an intervention might reduce smoking relapse risk. METHODS. Using a sample of 158 smokers who completed a 2-week smoking treatment program, we compared an innovative weight gain prevention intervention with both a nonspecific treatment and standard treatment. Subjects were assessed on weight and smoking behavior and followed for 1 year. RESULTS. A disturbing, unexpected finding was that subjects in both the innovative and nonspecific conditions had a higher risk of smoking relapse than did standard treatment subjects. Some differences were observed between abstinent and smoking subjects in weight gain by treatment condition. CONCLUSIONS. Both active interventions may have been so complicated that they detracted from nonsmoking. Also, caloric restriction may increase the reinforcing value of nicotine, a psychoactive drug, thereby increasing smoking relapse risk. The magnitude of weight gain after smoking cessation may not merit interventions that increase smoking risk. Perhaps attitudinal modifications are the most appropriate.

National mortality rates : the impact of inequality ?

Abstract: Although health is closely associated with income differences within each country there is, at best, only a weak link between national mortality rates and average income among the developed countries. On the other hand, there is evidence of a strong relationship between national mortality rates and the scale of income differences within each society. These three elements are coherent if health is affected less by changes in absolute material standards across affluent populations than it is by relative income or the scale of income differences and the resulting sense of disadvantage within each society. Rather than socioeconomic mortality differentials representing a distribution around given national average mortality rates, it is likely that the degree of income inequality indicates the burden of relative deprivation on national mortality rates.

Cigarette, alcohol, and coffee consumption and prematurity.

Abstract: We analyzed data from a survey of occupational and other factors in pregnancy to assess the effects of cigarette, alcohol, and coffee consumption on pregnancy outcome. The risk of low birth weight for gestational age was found to increase substantially with smoking. Occasional consumers of alcohol had a slightly reduced risk relative to total abstainers. In more frequent drinkers, there was a small increase in risk. Risk increased slightly with coffee consumption.

Stage at diagnosis in breast cancer: race and socioeconomic factors.

Abstract: Cancer incidence data from three US metropolitan areas were coupled with census tract indicators of education and income. The data suggest that both Black and White cancer patients living in census tracts with lower median education/income values are diagnosed in later disease stages than are patients in tracts with higher median education/income values. Within education and income strata, Black women had a less favorable stage of disease at diagnosis than Whites. The exception was in upper education/income levels, where the disadvantage for Blacks disappeared. These data provide additional evidence that women of low socioeconomic status could benefit from targeted screening.

High-risk sexual behavior and condom use among gay and bisexual African-American men.

Abstract: OBJECTIVES. Little is known about the human immunodeficiency virus (HIV) high-risk sexual practices of gay and bisexual African-American men. These data are needed so that better interventions can be developed and implemented in this population. METHODS. The frequency and correlates of unprotected anal intercourse were examined among 250 gay and bisexual African-American men in the San Francisco Bay Area. The cohort was recruited in 1990 from bars, bathhouses, and erotic bookstores, and through African-American gay organizations, street outreach, advertisements in gay mainstream and African-American newspapers, health clinics, and personal referral from other participants. RESULTS. More than 50% of the men in our sample reported having unprotected anal intercourse in the past 6 months, a considerably higher percentage than that among gay White men in San Francisco through 1988 and 1989. Men who practiced unprotected anal intercourse were more likely to be poor, to have been paid for sex, or to have used i...