Are Recent Cohorts Getting Worse? Trends in US Adult Physiological Status, Mental Health, and Health Behaviors Across a Century of Birth Cohorts

Morbidity and mortality have been increasing among middle-aged and young-old Americans since the turn of the century. We investigated whether these unfavorable trends extend to younger cohorts and their underlying physiological, psychological, and behavioral mechanisms. Applying generalized linear mixed-effects models to data from 62,833 adults from the National Health and Nutrition Examination Surveys (1988-2016) and 625,221 adults from the National Health Interview Surveys (1997-2018), we found that for all sex and racial groups, physiological dysregulation has increased continuously from Baby Boomers through late-Generation X and Generation Y. The magnitude of the increase was higher for White men than for other groups, while Black men had a steepest increase in low urinary albumin (a marker of chronic inflammation). In addition, Whites underwent distinctive increases in anxiety, depression, and heavy drinking, and they had a higher level than Blacks and Hispanics of smoking and drug use in recent cohorts. Smoking is not responsible for the increasing physiological dysregulation across cohorts. The obesity epidemic contributes to the increase in metabolic syndrome but not in low urinary albumin. The worsening physiological and mental health profiles among younger generations imply a challenging morbidity and mortality prospect for the United States, one that might be particularly inauspicious for Whites.

Infant Feeding Practices During the First Postnatal Year and Risk of Asthma and Allergic Disease During the First 6 Years of Life

Background: Breastfeeding may protect against childhood asthma and allergic diseases. Studies have not focused on the mode of feeding human milk and followed children to school age although feeding human milk from a bottle rather than the breast may alter the risk of disease. Materials and Methods: At 12 months' postpartum, women in the Moms2Moms study (Columbus, OH) completed a survey assessing sociodemographic and infant feeding behaviors. At 6 years' postpartum, they completed a survey and pediatric medical records were abstracted to assess asthma and allergic disease diagnoses. Logistic regression models were used to estimate associations between infant feeding behaviors and asthma or allergic disease. Results: Of 285 children, 16% had asthma and 44% ever had ≥1 allergy diagnosis. Longer durations of each infant feeding behavior were not clearly associated with increased odds of asthma or allergic disease by age 6. Results suggested that longer durations of breast milk feeding (regardless of the mode of feeding) may be related to a lower risk of food allergy (e.g., odds ratio [OR]1-month, adjusted = 0.96, 95% confidence interval [CI] = 0.87-1.05; OR12-month, adjusted = 0.57, 95% CI = 0.19-1.74), but that the mode of feeding (regardless of the substance fed) may be more meaningful for environmental allergies (e.g., exclusive direct breast milk feeding OR12-month, adjusted = 0.32, 95% CI = 0.06-1.81). However, effect estimates were imprecise and CIs included the null. Conclusions: Although no clear associations between mode of breast milk feeding (breast versus expressed) and asthma and allergy outcomes were observed, future research with larger samples should further evaluate these associations.

Feeding Infants at the Breast or Feeding Expressed Human Milk: Long-Term Cognitive, Executive Function, and Eating Behavior Outcomes at Age 6 Years

OBJECTIVE

To examine how expressed milk feeding diverges from feeding at the breast in its association with neurodevelopment and behavior. We hypothesized that longer and exclusive feeding at the breast only (ie, no formula, no feeding expressed milk) would be associated with the optimal cognitive developmental, executive function, and eating behaviors and that expressed milk feeding would be associated with less-optimal outcomes.

STUDY DESIGN

The Moms2Moms cohort (Ohio, US) reported infant feeding practices at 12 months postpartum and children's global cognitive ability, executive function, and eating behaviors at 6 years. Linear and log-binomial regression models estimated associations with durations of feeding at the breast, expressed milk, human milk (modes combined), and formula.

RESULTS

Among 285 participants, each month of exclusive feeding at the breast only was associated with a decreased risk of clinically meaningful executive function (working memory) deficit (adjusted relative risk [RR] 0.78, 95% CI 0.63-0.96) but was unassociated with inhibition (adjusted RR 0.92, 95% CI 0.85-1.01). Feeding expressed milk was not clearly related to executive function outcomes. No associations with global cognitive ability were observed. Weak associations were observed with eating behaviors for some feeding practices.

CONCLUSIONS

Feeding at the breast may offer advantages to some aspects of executive function that expressed milk may not. Large, prospective studies exploring mechanisms could further distinguish the effect of feeding mode from that of nutrients.

Life-long body mass index trajectories and mortality in two generations

PURPOSE

To identify life-long body mass index (BMI) trajectories across two related generations and estimate their associated mortality risks and population attributable deaths.

METHODS

We use prospective cohort data from the Framingham Heart Study (1948-2011) original (4576 individuals, 3913 deaths) and offspring (3753 individuals, 967 deaths) cohorts and latent trajectory models to model BMI trajectories from age 31 to 80 years. Survival models are used to estimate trajectory-specific mortality risk.

RESULTS

We define seven BMI trajectories among original cohort and six among offspring cohort. Among original cohort, people who are normal weight at age 31 years and gradually move to overweight status in middle or later adulthood have the lowest mortality risk even compared to those who maintain normal weight throughout adulthood, followed by overweight stable, lower level of normal weight, overweight downward, class I obese upward, and class II/III upward trajectories. Mortality risks associated with obesity trajectories have declined across cohorts, while the prevalence of high-risk trajectories has increased.

CONCLUSIONS

The mortality impact of weight gain depends on an individual's BMI trajectory. Population attributable deaths associated with unhealthy weight trajectories have grown over generations because the prevalence has increased, offsetting the decline in trajectory-specific mortality risks.

Unobserved Population Heterogeneity and Dynamics of Health Disparities

BACKGROUND

A growing body of literature has reported widening educational health disparities across birth cohorts or time periods in the United States, but has paid little attention to the implication of mortality selection on the cohort trend in health disparities.

OBJECTIVE

This study investigates how changes in the variance of unobserved frailty over time may complicate the interpretation of cohort trends in health disparities and life expectancy.

METHODS

We use the microsimulation method to test the effect of mortality selection and further propose a counterfactual simulation procedure to estimate its contribution. Data used in the simulations are based on Panel Studies of Income Dynamics 1968-2013, National Health and Nutrition Examination Survey data 1999-2012, and National Health Interview Survey data 1986-2011.

RESULTS

Simulation shows that mortality selection may generate seemingly contradictory trends in health disparities and life expectancy across birth cohorts at the group and individual level. Life expectancy can change even when individual mortality curve is fixed. In the absence of a change in the causal effect of education on mortality at the individual level, an educational life expectancy gap can change across cohorts as a result of the change in frailty variance. Empirical analysis shows that mortality selection accounts for a sizeable amount of contribution to the widening educational life expectancy gap from the 1950s to 1960s birth cohorts in the United States.

CONTRIBUTION

We demonstrate mortality selection can complicate the cohort trend in health disparities and life expectancy and propose a counterfactual simulation method to evaluate its contribution.

Reliability of Maternal Recall of Feeding at the Breast and Breast Milk Expression 6 Years After Delivery

Background: The reliability of long-term maternal recall of breastfeeding has been assessed previously, but not maternal milk expression (pumping) and child consumption of expressed milk. Objective: To examine the reliability of maternal recall of feeding at the breast, maternal milk expression, and child consumption of expressed milk 6 years after delivery using the Brief Breastfeeding and Milk Expression Recall Survey (BaByMERS). Methods: At 12 months postpartum, women who delivered a singleton, live-born infant at >24 weeks of gestation at a major U.S. academic hospital completed BaByMERS. Five years later, they were recontacted to complete the same questionnaire. Kappa statistics (κ), intraclass correlation coefficient (ICC), and Bland/Altman plots examined agreement. Sociodemographics were examined through stratified comparisons. Results: Of 299 women who completed both questionnaires, 35% had a postgraduate education and 82% identified as white/Caucasian. Kappa statistics showed substantial agreement for ever breastfeeding or feeding breast milk (combined) (κ = 0.71, 95% confidence interval [CI]: 0.44-0.98) and ever feeding at the breast (κ = 0.76, 95% CI: 0.62-0.89). Recall for duration of feeding at the breast was excellent (ICC = 0.96, 95% CI: 0.95-0.97), and of maternal milk expression was slightly less so (ICC = 0.83, 95% CI: 0.80-0.97). Maternal minority race/ethnicity, lower educational attainment, unmarried marital status, public/no health insurance, and smoking were associated with lower reliability; these differences were usually small and not consistent across all feeding practices. Conclusions: Maternal recall of contemporary lactation and infant feeding using BaByMERS was strongly reliable 6 years after delivery. BaByMERS may be useful to collect recall data, with attention to subpopulations that may exhibit lower recall reliability.

Obesity-mortality link over the life course: the contribution of population compositional changes

A key uncertainty in the obesity-mortality association continues to be how this association changes over the life course. Prior studies tend to rely on cross-sectional design with static weight status taken at the time of the survey. This study tracks a cohort of individuals and employs lifelong body mass index information from the Framingham Heart Study original cohort (1948-2010). We focus on respondents who were younger than age 45 at time of their first survey (n = 2,176) and evaluate how the mortality risk associated with obesity changes over three age groups (below 45, 45-59, and 60 and above) and how population compositions may contribute to this pattern. We find the hazard ratio associated with obesity compared to normal weight decreases over three age groups, but this pattern is influenced by different ages of onset of obesity, inconsistency in the reference group (normal weight) over ages, and mortality selection effects. These factors explain away the decreasing effect of obesity (with onset before age 45) on mortality up to age 60; after age 60, the detrimental effect still declines, but to a much less degree. Later onset of obesity, however, is not significantly associated with excess mortality risks after age 60.

Improved Estimation of Breastfeeding Rates Using a Novel Breastfeeding and Milk Expression Survey

Background: Increasing the proportion of infants who are breastfed and extending breastfeeding duration are high-priority U.S. goals. Evaluation of progress is based on federal survey data, but federal survey questions do not reflect contemporary feeding practices. Materials and Methods: Our objective was to evaluate the Brief Breastfeeding and Milk Expression Recall Survey (BaByMERS) in estimating breast milk feeding and milk expression practices and compare to estimates from simultaneously administered federal survey questions. We surveyed women with child(ren) younger than the age of 6 years attending a large children's hospital for urgent or primary care. We estimated the proportions who participated in various breast milk feeding and milk expression practices and the durations of each and examined agreement between the surveys. We compared respondents with high versus low disagreement using log-binomial regression. Results: Of 225 respondents, 51% had less than a Bachelor's degree, and 44% identified as a race other than white. Similar proportions on each survey reported ever having breastfed or fed breast milk (84%). Proportions still breastfeeding or feeding breast milk at 6 and 12 months differed slightly by survey. Dyads (9%) who fed at the breast and fed expressed milk for nonidentical periods had estimates for the duration of breastfeeding or feeding breast milk that were lower per the federal survey. Respondents who answered the federal survey before the BaByMERS were more likely to provide discrepant responses (risk ratio = 3.40, 95% confidence interval: 1.18-9.80). Conclusions: This study offers further validation of brief interviewer-administered questions to collect quality data recalled about infant feeding and lactation for research purposes.

Recent trends in US mortality in early and middle adulthood: racial/ethnic disparities in inter-cohort patterns

BACKGROUND

A striking increase in the all-cause mortality of US middle-aged non-Hispanic Whites in the past two decades has been documented by previous studies. The inter-cohort patterns in US mortality, as well as their racial/ethnic disparities, are still unclear.

METHODS

Using official mortality data, we study US annual mortality rates for ages 25-54 from 1990 to 2016 by gender and race/ethnicity. We conduct an age-period-cohort analysis to disentangle the period and cohort forces driving the absolute changes in mortality across cohorts. Nine leading causes of death are also explored to explain the inter-cohort mortality patterns and their racial/ethnic disparities.

RESULTS

We find cohort-specific elevated mortality trends for gender- and race/ethnicity-specific populations. For non-Hispanic Blacks and Hispanics, Baby Boomers have increased mortality trends compared with other cohorts. For non-Hispanic White females, it is late-Gen Xers and early-Gen Yers for whom the mortality trends are higher than other cohorts. For non-Hispanic White males, the elevated mortality pattern is found for Baby Boomers, late-Gen Xers, and early-Gen Yers. The mortality pattern among Baby Boomers is at least partially driven by mortality related to drug poisoning, suicide, external causes, chronic obstructive pulmonary disease and HIV/AIDS for all race and gender groups affected. The elevated mortality patterns among late-Gen Xers and early-Gen Yers are at least partially driven by mortality related to drug poisonings and alcohol-related diseases for non-Hispanic Whites. Differential patterns of drug poisoning-related mortality play an important role in the racial/ethnic disparities in these mortality patterns.

CONCLUSIONS

We find substantial racial/ethnic disparities in inter-cohort mortality patterns. Our findings also point to the unique challenges faced by younger generations.

A simulation study of the role of cohort forces in mortality patterns

This study uses the micro-simulation method to investigate the role of cohort forces in age-dependent mortality pattern. We test the micro mechanisms for cohort evolution and mortality selection, and how these two biological and demographic forces may interact with epidemiologic transition to shape the cohort age-dependence of mortality pattern in both early- and later-transition countries. We show that cohort evolution is due to the declining rate of mortality acceleration at the individual level, which is associated with lower initial mortality rates but not smaller variance of frailty distribution in later birth cohorts. The steeper slope of mortality acceleration at the population level among later birth cohorts is due to mortality selection mechanism associated with smaller variance of frailty distribution but not lower initial mortality rates. These two forces jointly shape the non-crossover cohort age-dependence of mortality pattern regardless of the differential mechanisms of epidemiologic transition in early- and later-transition countries.

Is BMI a valid measure of obesity in postmenopausal women?

OBJECTIVE

Body mass index (BMI) is a widely used indicator of obesity status in clinical settings and population health research. However, there are concerns about the validity of BMI as a measure of obesity in postmenopausal women. Unlike BMI, which is an indirect measure of obesity and does not distinguish lean from fat mass, dual-energy x-ray absorptiometry (DXA) provides a direct measure of body fat and is considered a gold standard of adiposity measurement. The goal of this study is to examine the validity of using BMI to identify obesity in postmenopausal women relative to total body fat percent measured by DXA scan.

METHODS

Data from 1,329 postmenopausal women participating in the Buffalo OsteoPerio Study were used in this analysis. At baseline, women ranged in age from 53 to 85 years. Obesity was defined as BMI ≥ 30 kg/m and body fat percent (BF%) greater than 35%, 38%, or 40%. We calculated sensitivity, specificity, positive predictive value, and negative predictive value to evaluate the validity of BMI-defined obesity relative BF%. We further explored the validity of BMI relative to BF% using graphical tools, such as scatterplots and receiver-operating characteristic curves. Youden's J index was used to determine the empirical optimal BMI cut-point for each level of BF% defined obesity.

RESULTS

The sensitivity of BMI-defined obesity was 32.4% for 35% body fat, 44.6% for 38% body fat, and 55.2% for 40% body fat. Corresponding specificity values were 99.3%, 97.1%, and 94.6%, respectively. The empirical optimal BMI cut-point to define obesity is 24.9 kg/m for 35% BF, 26.49 kg/m for 38% BF, and 27.05 kg/m for 40% BF according to the Youden's index.

CONCLUSIONS

Results demonstrate that a BMI cut-point of 30 kg/m does not appear to be an appropriate indicator of true obesity status in postmenopausal women. Empirical estimates of the validity of BMI from this study may be used by other investigators to account for BMI-related misclassification in older women.

The role of obesity in exceptionally slow US mortality improvement

Recent studies have described a reduction in the rate of improvement in American mortality. The pace of improvement is also slow by international standards. This paper attempts to identify the extent to which rising body mass index (BMI) is responsible for reductions in the rate of mortality improvement in the United States. The data for this study were obtained from subsequent cohorts of the National Health and Nutrition Examination Survey (NHANES III, 1988-1994; NHANES continuous, 1999-2010) and from the NHANES linked mortality files, which include follow-up into death records through December 2011. The role of BMI was estimated using Cox models comparing mortality trends in the presence and absence of adjustment for maximum lifetime BMI (Max BMI). Introducing Max BMI into a Cox model controlling for age and sex raised the annual rate of mortality decline by 0.54% (95% confidence interval 0.45-0.64%). Results were robust to the inclusion of other variables in the model, to differences in how Max BMI was measured, and to how trends were evaluated. The effect of rising Max BMI is large relative to international mortality trends and to alternative mortality futures simulated by the Social Security Administration. The increase in Max BMI over the period 1988-2011 is estimated to have reduced life expectancy at age 40 by 0.9 years in 2011 (95% confidence interval 0.7-1.1 years) and accounted for 186,000 excess deaths that year. Rising levels of BMI have prevented the United States from enjoying the full benefits of factors working to improve mortality.

Cognitive Testing of the Brief Breastfeeding and Milk Expression Recall Survey

BACKGROUND

Major U.S. federal maternal and child health surveys collect an infant feeding history for children under 6 years of age using survey questions that have changed little over decades. Yet, infant feeding and lactation practices have changed with the increasing popularity of milk expression (pumping).

SUBJECTS AND METHODS

Cognitive interviews were conducted to test the 9-item Brief Breastfeeding and Milk Expression Recall Survey (BaByMERS) with a diverse sample of 15 U.S. mothers of children 1-5 years of age. A 42-item coding scheme was applied to identify interviewer and respondent problems in fielding and answering the questions. Problems were examined in relation to demographics and infant feeding and lactation history.

RESULTS

The extent of problems was modest. Of 42 possible problem codes, only 9 were identified as actual problems for one or more respondents on one or more questions. The most common problems involved uncertainty about the timing of when one started expressing milk, making a mental shift to realize that maternal milk expression and the child's consumption of that milk could be distinct concepts, and difficulty with certain terms or phrases. Problems tended to arise among mothers with more complex infant feeding or lactation histories, who also tended to be those with higher levels of education.

CONCLUSIONS

BaByMERS is a promising, brief tool for collecting a recalled infant feeding or lactation history among mothers with young children. Future research can evaluate additional characteristics of the tool to further confirm its utility for large epidemiological studies of maternal and child health.

Why does college education matter? Unveiling the contributions of selection factors

This study investigates the contributions of pre-college selection factors that may partially lead to the college degree - health link by using longitudinal data from the National Longitudinal Survey of Youth (1979) cohort. Propensity score matching method finds that the effects of college degree on various health outcomes (self-rated health, physical component summary index, health limitations, CESD scale) are reduced by 51% on average (range: 37%-70%) in the matched sample. Among these observed factors, cognitive skill is the biggest confounder, followed by pre-college health and socioeconomic characteristics (marital aspiration, years of schooling, marriage, fertility, poverty status) and non-cognitive skills (e.g., self-esteem). Rotter Internal-External Locus of Control scale is not significantly associated with all four health measures. The effects of most indicators of family background (parental education, family stability, family size, religious background) on the health of adult children are not direct but through offspring's early adulthood health and socioeconomic status.

The contribution of rising adiposity to the increasing prevalence of diabetes in the United States

OBJECTIVE

We assessed the contribution of increasing adiposity to the rising prevalence of diabetes in the United States over the period 1988-2014.

RESEARCH DESIGN AND METHODS

Data from NHANES III (1988-1994) and continuous waves (1999-2014) were pooled for the current study. Diabetes status was assessed using data on Hemoglobin A1c. We estimated a multivariable logistic regression model that predicted the odds of having diabetes as a function of age, sex, racial/ethnic group, educational attainment, and period of observation. At a second stage, we introduced measures of general and abdominal adiposity into the model. Changes in coefficients pertaining to period of observation between the first and second models were interpreted as indicating the extent to which adiposity can account for trends in the prevalence of diabetes. Sensitivity analyses were conducted to investigate how alternative definitions of adiposity and diabetes status would affect results.

RESULTS

The predicted prevalence of diabetes rose by 2.59%/yr between 1988 and 2014 after adjusting for changes in population composition. Increasing adiposity explained 72% of the rise in diabetes. Results were consistent for men and women.

CONCLUSIONS

Rising levels of adiposity explained the large majority of the rise in diabetes prevalence between 1988 and 2014.

NEW SURVEY QUESTIONS AND ESTIMATORS FOR NETWORK CLUSTERING WITH RESPONDENT-DRIVEN SAMPLING DATA

Respondent-driven sampling (RDS) is a popular method for sampling hard-to-survey populations that leverages social network connections through peer recruitment. While RDS is most frequently applied to estimate the prevalence of infections and risk behaviors of interest to public health, such as HIV/AIDS or condom use, it is rarely used to draw inferences about the structural properties of social networks among such populations because it does not typically collect the necessary data. Drawing on recent advances in computer science, we introduce a set of data collection instruments and RDS estimators for network clustering, an important topological property that has been linked to a network's potential for diffusion of information, disease, and health behaviors. We use simulations to explore how these estimators, originally developed for random walk samples of computer networks, perform when applied to RDS samples with characteristics encountered in realistic field settings that depart from random walks. In particular, we explore the effects of multiple seeds, without replacement versus with replacement, branching chains, imperfect response rates, preferential recruitment, and misreporting of ties. We find that clustering coefficient estimators retain desirable properties in RDS samples. This paper takes an important step toward calculating network characteristics using nontraditional sampling methods, and it expands the potential of RDS to tell researchers more about hidden populations and the social factors driving disease prevalence.

Weight History and All-Cause and Cause-Specific Mortality in Three Prospective Cohort Studies

BACKGROUND

The relationship between body mass index (BMI) and mortality is controversial.

OBJECTIVE

To investigate the relationship between maximum BMI over 16 years and subsequent mortality.

DESIGN

3 prospective cohort studies.

SETTING

Nurses' Health Study I and II and Health Professionals Follow-Up Study.

PARTICIPANTS

225 072 men and women with 32 571 deaths observed over a mean of 12.3 years of follow-up.

MEASUREMENTS

Maximum BMI over 16 years of weight history and all-cause and cause-specific mortality.

RESULTS

Maximum BMIs in the overweight (25.0 to 29.9 kg/m2) (multivariate hazard ratio [HR], 1.06 [95% CI, 1.03 to 1.08]), obese I (30.0 to 34.9 kg/m2) (HR, 1.24 [CI, 1.20 to 1.29]), and obese II (≥35.0 kg/m2) (HR, 1.73 [CI, 1.66 to 1.80]) categories were associated with increases in risk for all-cause death. The pattern of excess risk with a maximum BMI above normal weight was maintained across strata defined by smoking status, sex, and age, but the excess was greatest among those younger than 70 years and never-smokers. In contrast, a significant inverse association between overweight and mortality (HR, 0.96 [CI, 0.94 to 0.99]) was observed when BMI was defined using a single baseline measurement. Maximum overweight was also associated with increased cause-specific mortality, including death from cardiovascular disease and coronary heart disease.

LIMITATION

Residual confounding and misclassification.

CONCLUSION

The paradoxical association between overweight and mortality is reversed in analyses incorporating weight history. Maximum BMI may be a useful metric to minimize reverse causation bias associated with a single baseline BMI assessment.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Deaths Attributable to Diabetes in the United States: Comparison of Data Sources and Estimation Approaches

Objective

The goal of this research was to identify the fraction of deaths attributable to diabetes in the United States.

Research Design and Methods

We estimated population attributable fractions (PAF) for cohorts aged 30–84 who were surveyed in the National Health Interview Survey (NHIS) between 1997 and 2009 (N = 282,322) and in the National Health and Nutrition Examination Survey (NHANES) between 1999 and 2010 (N = 21,814). Cohort members were followed prospectively for mortality through 2011. We identified diabetes status using self-reported diagnoses in both NHIS and NHANES and using HbA1c in NHANES. Hazard ratios associated with diabetes were estimated using Cox model adjusted for age, sex, race/ethnicity, educational attainment, and smoking status.

Results

We found a high degree of consistency between data sets and definitions of diabetes in the hazard ratios, estimates of diabetes prevalence, and estimates of the proportion of deaths attributable to diabetes. The proportion of deaths attributable to diabetes was estimated to be 11.5% using self-reports in NHIS, 11.7% using self-reports in NHANES, and 11.8% using HbA1c in NHANES. Among the sub-groups that we examined, the PAF was highest among obese persons at 19.4%. The proportion of deaths in which diabetes was assigned as the underlying cause of death (3.3–3.7%) severely understated the contribution of diabetes to mortality in the United States.

Conclusion

Diabetes may represent a more prominent factor in American mortality than is commonly appreciated, reinforcing the need for robust population-level interventions aimed at diabetes prevention and care.

Perceived access to health services and provider information and adverse birth outcomes: findings from LaPRAMS, 2007-2008

OBJECTIVES

Despite targeted public health efforts, racial disparities and poor birth outcomes are still apparent, particularly in the southern United States. Previous research through qualitative and modest quantitative research demonstrates a possible link between disparities in patient-provider conversations during prenatal visits, perceived access to prenatal care, and poor birth outcomes.

METHODS

A secondary analysis was conducted using data from the 2007-2008 Louisiana Pregnancy Risk Assessment Monitoring System to examine perceived access to healthcare services and information received and its impact on birth outcomes. Respondents consisted of 2460 white and black American women who recently experienced a live birth in the state of Louisiana.

RESULTS

Racial disparities among Louisiana mothers were evident, with black mothers experiencing significant perceived lack of services or access to resources from a healthcare or insurance provider and poorer birth outcomes. White mothers reported experiencing less access based on the lack of vital prenatal care information from a healthcare provider. Self-perceived access was significantly associated with preterm birth for black women (odds ratio 2.94, 95% confidence interval 1-8; P < 0.05) and infant mortality for white women (odds ratio 340.5, confidence interval 36-999); P < 0.05).

CONCLUSIONS

Findings support the need for a better understanding of discriminatory experiences and their impact on women's experiences during prenatal care and poor birth outcomes.

Cumulative neighborhood risk of psychosocial stress and allostatic load in adolescents

The authors examined the impact of cumulative neighborhood risk of psychosocial stress on allostatic load (AL) among adolescents as a mechanism through which life stress, including neighborhood conditions, may affect health and health inequities. They conducted multilevel analyses, weighted for sampling and propensity score-matched, among adolescents aged 12-20 years in the National Health and Nutrition Examination Survey (1999-2006). Individuals (first level, n = 11,886) were nested within families/households (second level, n = 6,696) and then census tracts (third level, n = 2,191) for examination of the contextual effect of cumulative neighborhood risk environment on AL. Approximately 35% of adolescents had 2 or more biomarkers of AL. A significant amount of variance in AL was explained at the neighborhood level. The likelihood of having a high AL was approximately 10% higher for adolescents living in medium-cumulative-risk neighborhoods (adjusted odds ratio (OR) = 1.09, 95% confidence interval (CI): 1.08, 1.09), 28% higher for those living in high-risk neighborhoods (adjusted OR = 1.28, 95% CI: 1.27, 1.30), and 69% higher for those living in very-high-risk neighborhoods (adjusted OR = 1.69, 95% CI: 1.68, 1.70) as compared with adolescents living in low-risk areas. Effect modification was observed by both individual- and neighborhood-level sociodemographic factors. These findings offer support for the hypothesis that neighborhood risks may culminate in a range of biologically mediated negative health outcomes detectable in adolescents.

Social marketing to plan a fall prevention program for Latino construction workers

BACKGROUND

Latino construction workers experience disparities in occupational death and injury rates. The Occupational Safety and Health Administration funded a fall prevention training program at the University of Nevada, Las Vegas in response to sharp increases in fall-related accidents from 2005 to 2007. The grant's purpose was to improve fall protection for construction workers, with a focus on Latinos. This study assessed the effectiveness of social marketing for increasing fall prevention behaviors.

METHODS

A multi-disciplinary team used a social marketing approach to plan the program. We conducted same day class evaluations and follow-up interviews 8 weeks later.

RESULTS

The classes met trainee needs as evidenced by class evaluations and increased safety behaviors. However, Spanish-speaking Latinos did not attend in the same proportion as their representation in the Las Vegas population.

CONCLUSIONS

A social marketing approach to planning was helpful to customize the training to Latino worker needs. However, due to the limitations of behavior change strategies, future programs should target employers and their obligation to provide safer workplaces.

Information chaos in primary care: implications for physician performance and patient safety

PURPOSE

The purpose of this article is to explore the concept of information chaos as it applies to the issues of patient safety and physician workload in primary care and to propose a research agenda.

METHODS

We use a human factors engineering perspective to discuss the concept of information chaos in primary care and explore implications for its impact on physician performance and patient safety.

RESULTS

Information chaos is comprised of various combinations of information overload, information underload, information scatter, information conflict, and erroneous information. We provide a framework for understanding information chaos, its impact on physician mental workload and situation awareness, and its consequences, and we discuss possible solutions and suggest a research agenda that may lead to methods to reduce the problem.

CONCLUSIONS

Information chaos is experienced routinely by primary care physicians. This is not just inconvenient, annoying, and frustrating; it has implications for physician performance and patient safety. Additional research is needed to define methods to measure and eventually reduce information chaos.