Exploring neighborhood inequality in female breast cancer incidence in Tehran using Bayesian spatial models and a spatial scan statistic

OBJECTIVES

The aim of this study was to explore the spatial pattern of female breast cancer (BC) incidence at the neighborhood level in Tehran, Iran.

METHODS

The present study included all registered incident cases of female BC from March 2008 to March 2011. The raw standardized incidence ratio (SIR) of BC for each neighborhood was estimated by comparing observed cases relative to expected cases. The estimated raw SIRs were smoothed by a Besag, York, and Mollie spatial model and the spatial empirical Bayesian method. The purely spatial scan statistic was used to identify spatial clusters.

RESULTS

There were 4,175 incident BC cases in the study area from 2008 to 2011, of which 3,080 were successfully geocoded to the neighborhood level. Higher than expected rates of BC were found in neighborhoods located in northern and central Tehran, whereas lower rates appeared in southern areas. The most likely cluster of higher than expected BC incidence involved neighborhoods in districts 3 and 6, with an observed-to-expected ratio of 3.92 (p<0.001), whereas the most likely cluster of lower than expected rates involved neighborhoods in districts 17, 18, and 19, with an observed-to-expected ratio of 0.05 (p<0.001).

CONCLUSIONS

Neighborhood-level inequality in the incidence of BC exists in Tehran. These findings can serve as a basis for resource allocation and preventive strategies in at-risk areas.

Weight gain during pregnancy and the black-white disparity in preterm birth

PURPOSE

To quantify the relationship between pregnancy weight gain with early and late preterm birth and evaluate whether associations differed between non-Hispanic (NH) black and NH white women.

METHODS

We analyzed a retrospective cohort of all live births to NH black and NH white women in the United States 2011-2015 (n = 10,714,983). We used weight gain z-scores in multiple logistic regression models stratified by prepregnancy body mass index (BMI) and race to calculate population attributable risk (PAR) percentages for the contribution of high and low pregnancy weight gain to early and late preterm birth.

RESULTS

Pregnancy weight gain was related to early and late preterm birth, but associations varied by BMI and race. For early preterm birth, the PAR percentage for high pregnancy weight gain ranged from 8 to 10% in NH black women and from 6 to 8% in NH white women. There was little evidence of racial differences in late preterm birth: PAR percentages ranged from 2 to 7% in NH black women and from 3 to 7% in NH white women.

CONCLUSIONS

Moderate gestational weight gain is associated with lower rate of preterm birth, with greatest reductions for early preterm birth in NH black women.

Lung cancer incidence trends in California by race/ethnicity, histology, sex, and neighborhood socioeconomic status: An analysis spanning 28 years

OBJECTIVES

Lung cancer incidence trends by histology, sex, race/ethnicity, and neighborhood socioeconomic status (nSES) have not been previously reported. We conducted a population-based study of lung cancer incidence over three peri-censal periods: 1988-1992, 1998-2002, and 2008-2012.

MATERIALS AND METHODS

We abstracted lung cancer cases from the California Cancer Registry and used US Census and American Community Survey data to develop multidimensional nSES indices for each census period. We calculated nSES tertile-specific incidence rates and rate ratios for each peri-censal period and used incidence rate ratios (IRR) to assess changes in rates from 1988 to 1992 to 1998-2002 and 2008-2012.

RESULTS

There were a total of 231,205 lung cancer cases. Males: Among males, incidence rates of lung cancer decreased over time, all race/ethnicities, and all nSES tertiles, with larger declines among males in higher nSES areas. Rates either declined or were stable for adenocarcinoma, with larger declines for other histologic subtypes. Females: Among females, declines in incidence rates of lung cancer were more pronounced for females in higher nSES areas, but diverged more so than for males, with variations by histology and race/ethnicity. Incidence rates of adenocarcinoma increased over time among all females, with greater increase among females in low nSES areas.

CONCLUSIONS

Our findings demonstrate differences in incidence trends over three decades by histology, gender, race/ethnicity, and nSES. While incidence rates consistently declined over time for males, there were greater declines in incidence for high nSES populations. In contrast, among females, there was evidence of increases in lung cancer incidence among low SES API females, and for adenocarcinoma.

Lower educational level and unemployment increase the impact of cardiometabolic conditions on the quality of life: results of a population-based study in South Australia

PURPOSE

To investigate if sociodemographic characteristics increase the adverse effects of cardiovascular diseases (CVD) and cardiometabolic risk factors (CMRF) on health-related quality of life (HRQoL).

METHODS

Cross-sectional, face-to-face survey investigating 2379 adults living in South Australia in 2015 (57.1 ± 14 years; 51.7% females). Questions included diagnosis of CMRF (obesity, diabetes, hypertension, dyslipidaemia) and CVD. Physical and mental HRQoL were assessed using the SF-12v1 questionnaire. Multiple linear regression models including confounders (sociodemographic, lifestyle, use of preventive medication) and interaction terms between sociodemographic variables and cardiometabolic conditions were used in adjusted analysis.

RESULTS

The prevalence of CMRF (one or more) was 54.6% and CVD was 13.0%. The physical HRQoL reduced from 50.8 (95%CI 50.2-51.4) in healthy individuals to 45.1 (95%CI 44.4-45.9) and 39.1 (95%CI 37.7-40.5) among those with CMRF and CVD, respectively. Adjustment for sociodemographic variables reduced these differences in 33%, remaining stable after controlling for lifestyle and use of preventive medications (p < 0.001). Differences in physical HRQoL according to cardiometabolic conditions were twice as high among those with lower educational level, or if they were not working. Among unemployed, having a CMRF or a CVD had the same impact on the physical HRQoL (9.7 lower score than healthy individuals). The inverse association between cardiometabolic conditions and mental HRQoL was subtle (p = 0.030), with no evidence of disparities due to sociodemographic variables.

CONCLUSIONS

A lower educational level and unemployment increase the adverse effects of cardiometabolic conditions on the physical HRQoL. Targeted interventions for reducing CMRF and/or CVD in these groups are necessary to improve HRQoL.

[Trends in social inequities in diabetes care in the Provence-Alpes-Côte-d'Azur region of France between 2008 and 2011]

BACKGROUND

Social inequities in healthcare are known to exist for the management of many chronic diseases in France, including diabetes. The recession that began in 2008 has led to increased income disparities but has it also exacerbated health inequities. The aim of this study was to describe trends in inequities in diabetes-related healthcare between 2008 and 2011 in the PACA region (Provence-Alpes-Côte-d'Azur).

METHODS

This analysis used two sources of data: the regional national health insurance fund (PACA region) reimbursement database and the socio-demographic databases of the national statistics office (INSEE) for four full years (2008 to 2011). It included individuals who had been reimbursed for three purchases of oral diabetes drugs during the previous year and assessed the association between the median household income (weighted by number and age of household members) of each patient's municipality of residence and seven indicators of diabetes monitoring and care. Using adjusted mixed logistic models, including an interaction term between time (number of years) and the median household income of the municipality, we examined the performance of the indicators for each year.

RESULTS

The total number of patients with diabetes in the 941 municipalities of the PACA region varied by year from 142,055 to 164,929. Models showed that living in a town with a high or intermediate household income was significantly associated with better performance of the seven indicators and that the interaction term was significant for six of them. The effect of the municipal median income decreased significantly between 2008 and 2011 for five indicators: HbA1c, LDL-cholesterol, microalbuminuria, ophthalmoscopy and diabetes specialist visit.

CONCLUSION

Social inequities in diabetes-related healthcare persisted between 2008 and 2011 but appeared to be decreasing, despite the recession.

The impact of religiosity on dietary habits and physical activity in minority women participating in the Health is Power (HIP) study

African American (AA) and Hispanic/Latina (HL) women report lower rates of physical activity (PA) and poorer dietary habits compared to their white counterparts. Religiosity can act as a protective factor for health; however, the relationship between religiosity, PA, and diet is unclear. This study aimed to investigate the influence of religiosity on PA and fruit and vegetable (FV) and fat consumption in minority women. Health is Power (HIP) was a 6-month intervention where participants (AA: 63%; HL: 37%) were randomized to a PA or FV group. Questionnaires assessed religiosity at baseline and PA, FV and fat consumption at baseline and post-intervention. Hierarchical linear regression models were used to investigate religiosity as a predictor of change in PA, FV and fat, while controlling for demographics. AA women had significantly higher religiosity scores (M = 44.15, SD = 10.66) compared to H/L women (M = 35.11, SD = 12.82; t(251) = 5.86, p < 0.001). Across both groups, PA increased by 15%, FV intake increased by 27%, and consumption of calories by fat decreased by 5%. Religiosity was not a significant predictor of PA or diet (p < 0.05). The results of this study found no association between religiosity and change in PA and diet. More longitudinal studies are needed to explore the role of religiosity in the health of minority women.

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Religiosity or spirituality may influence some health behaviors in minority women.

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Religiosity or spirituality did not influence adoption of physical activity.

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Religiosity or spirituality did not influence adoption of healthy eating.

Geographic Variation in Condom Availability and Accessibility

Identifying predictors that contribute to geographic disparities in sexually transmitted infections (STIs) is necessary in order to reduce disparities. This study assesses the spatial relationship condom availability and accessibility in order to better identify determinants of geographic disparities in STIs. We conducted a telephone-based audit among potential-condom selling establishments. Descriptive analyses were conducted to detect differences in condom-selling characteristics by stores and by store type. Geocoding, mapping, and spatial analysis were conducted to measure the availability of condoms. A total of 850 potential condom-selling establishments participated in the condom availability and accessibility audit in St. Louis city; 29 % sold condoms. There were several significant geographic clusters of stores identified across the study area. The first consisted of fewer convenience stores and gas stations that sold condoms in the northern section of the city, whereas condoms were less likely to be sold in non-convenience store settings in the southwestern and central parts of the city. Additionally, locations that distributed free condoms clustered significantly in city center. However, there was a dearth of businesses that were neither convenience stores nor gas stations in the northern region of the city, which also had the highest concentration of condoms sold. This initial study was conducted to provide evidence that condom availability and accessibility differ by geographic region, and likely are a determinant of social norms surrounding condom use and ultimately impact STI rates.

Toward the Elimination of Colorectal Cancer Disparities Among African Americans

BACKGROUND

In the USA, race and socioeconomic status are well-known factors associated with colorectal cancer incidence and mortality rates. These are higher among blacks than whites and other racial/ethnic groups.

METHODS

In this article, we review opportunities to address disparities in colorectal cancer incidence, mortality, and survivorship among African Americans.

RESULTS

First, we summarize the primary prevention of colorectal cancer and recent advances in the early detection of the disease and disparities in screening. Then, we consider black-white disparities in colorectal cancer treatment and survival including factors that may contribute to such disparities and the important roles played by cultural competency, patient trust in one's physician, and health literacy in addressing colorectal cancer disparities, including the need for studies involving the use of colorectal cancer patient navigators who are culturally competent.

CONCLUSION

To reduce these disparities, intervention efforts should focus on providing high-quality screening and treatment for colorectal cancer and on educating African Americans about the value of diet, weight control, screening, and treatment. Organized approaches for delivering colorectal cancer screening should be accompanied by programs and policies that provide access to diagnostic follow-up and treatment for underserved populations.

Socioeconomic variation in incidence of primary and secondary major cardiovascular disease events: an Australian population-based prospective cohort study

BACKGROUND

Cardiovascular disease (CVD) disproportionately affects disadvantaged people, but reliable quantitative evidence on socioeconomic variation in CVD incidence in Australia is lacking. This study aimed to quantify socioeconomic variation in rates of primary and secondary CVD events in mid-age and older Australians.

METHODS

Baseline data (2006-2009) from the 45 and Up Study, an Australian cohort involving 267,153 men and women aged ≥ 45, were linked to hospital and death data (to December 2013). Outcomes comprised first event - death or hospital admission - for major CVD combined, as well as myocardial infarction and stroke, in those with and without prior CVD (secondary and primary events, respectively). Cox regression estimated hazard ratios (HRs) for each outcome in relation to education (and income and area-level disadvantage), separately by age group (45-64, 65-79, and ≥ 80 years), adjusting for age and sex, and additional sociodemographic factors.

RESULTS

There were 18,207 primary major CVD events over 1,144,845 years of follow-up (15.9/1000 person-years), and 20,048 secondary events over 260,357 years (77.0/1000 person-years). For both primary and secondary events, incidence increased with decreasing education, with the absolute difference between education groups largest for secondary events. Age-sex adjusted hazard ratios were highest in the 45-64 years group: for major CVDs, HR (no qualifications vs university degree) = 1.62 (95% CI: 1.49-1.77) for primary events, and HR = 1.49 (1.34-1.65) for secondary events; myocardial infarction HR = 2.31 (1.87-2.85) and HR = 2.57 (1.90-3.47) respectively; stroke HR = 1.48 (1.16-1.87) and HR = 1.97 (1.42-2.74) respectively. Similar but attenuated results were seen in older age groups, and with income. For area-level disadvantage, CVD gradients were weak and non-significant in older people (> 64 years).

CONCLUSIONS

Individual-level data are important for quantifying socioeconomic variation in CVD incidence, which is shown to be substantial among both those with and without prior CVD. Findings reinforce the opportunity for, and importance of, primary and secondary prevention and treatment in reducing socioeconomic variation in CVD and consequently the overall burden of CVD morbidity and mortality in Australia.

Social and Structural Determinants of Cervical Health among Women Engaged in HIV Care

Cervical cancer prevention/control efforts among women living with HIV/AIDS (WLH) are socially and structurally challenging. Healthcare access and perceived HIV stigma and discrimination are factors that may challenge risk reduction efforts. This study examined socio-structural determinants of cervical cancer screening among women engaged in HIV care. One hundred forty-five WLH seeking health/social services from AIDS Service Organizations in the southeastern US completed a questionnaire assessing factors related to cervical cancer prevention/control. Ninety percent were African American, mean age 46.15 ± 10.65 years. Eighty-one percent had a Pap test <1 year ago. Low healthcare access was positively associated with having a Pap test <1 year ago, (Odds ratio [OR] 3.80; 95 % Confidence interval [CI] 1.34-10.78). About 36 % reported ≥2 Pap tests during the first year after HIV diagnosis. Lower educational attainment was positively associated with having ≥2 Pap tests, OR 3.22; CI 1.08-9.62. Thirty-five percent reported more frequent Pap tests after diagnosis. Lower income was moderately associated with more frequent Pap tests post-diagnosis, OR 2.47; CI .98-6.23. Findings highlight the successes of HIV initiatives targeting socio-economically disadvantaged women and provide evidence that health policy aimed at providing and expanding healthcare access for vulnerable WLH has beneficial health implications.

Patterns of cervical cytological abnormalities according to the Human Development Index in the northeast region of Brazil

BACKGROUND

Disparities in cancer incidence and mortality rates between regions arise due to differences in socioeconomic conditions and in human development factors. The major purpose of this study was to measure the role of the Human Development Index (HDI) in the pattern of cervical cytological abnormalities (CCAs).

METHODS

This was an analytical sectional study involving a review of secondary cervical cytology data collected from women living in the state of Maranhão, Brazil, in 2007-2012 and collected from the Cervical Cancer Information System (Sistema de Informação do Câncer do Colo do Útero - SISCOLO). The cervical screening results were classified according to the Brazilian Classification of Cervical Reporting (Nomenclatura Brasileira para Laudos Cervicais), an adaptation of the Bethesda System. The Municipal Human Development Index (MHDI) was used, which is an adaptation of the global HDI. The association between CCAs and MHDI was evaluated using the chi-squared test and odds ratios (ORs) with 95 % confidence intervals (95 % CI). The significance level used for all tests was 5 %.

RESULTS

We analysed 1,363,689 examinations of women living in the state of Maranhão. CCAs were identified in 2.0 % of smears in municipalities with high MHDI, 2.2 % in those with medium or low MHDI and 4.1 % in those with very low MHDI. In addition, potentially malignant changes and suspected cervical cancer (HSIL+) were 40.0 % more frequent (0.3 %) in municipalities with medium or low MHDI and 3.6 times more frequent (0.8 %) in municipalities with very low MHDI compared to those with high MHDI (0.2 %).

CONCLUSION

The association between MHDI and the occurrence of CCAs and HSIL+ shows that more developed areas with more effective health services have a lower prevalence of these lesions. To control cervical cancer, it is necessary to reduce social inequality and improve the availability of health services.

Association of missing paternal demographics on infant birth certificates with perinatal risk factors for childhood obesity

BACKGROUND

The role of fathers in the development of obesity in their offspring remains poorly understood. We evaluated associations of missing paternal demographic information on birth certificates with perinatal risk factors for childhood obesity.

METHODS

Data were from the Linked CENTURY Study, a database linking birth certificate and well-child visit data for 200,258 Massachusetts children from 1980-2008. We categorized participants based on the availability of paternal age, education, or race/ethnicity and maternal marital status on the birth certificate: (1) pregnancies missing paternal data; (2) pregnancies involving unmarried women with paternal data; and (3) pregnancies involving married women with paternal data. Using linear and logistic regression, we compared differences in smoking during pregnancy, gestational diabetes, birthweight, breastfeeding initiation, and ever recording a weight for length (WFL) ≥ the 95th percentile or crossing upwards ≥2 WFL percentiles between 0-24 months among the study groups.

RESULTS

11,989 (6.0 %) birth certificates were missing paternal data; 31,323 (15.6 %) mothers were unmarried. In adjusted analyses, missing paternal data was associated with lower birthweight (β -0.07 kg; 95 % CI: -0.08, -0.05), smoking during pregnancy (AOR 4.40; 95 % CI: 3.97, 4.87), non-initiation of breastfeeding (AOR 0.39; 95 % CI: 0.36, 0.42), and with ever having a WFL ≥ 95th percentile (AOR 1.10; 95 % CI: 1.01, 1.20). Similar associations were noted for pregnancies involving unmarried women with paternal data, but differences were less pronounced.

CONCLUSIONS

Missing paternal data on the birth certificate is associated with perinatal risk factors for childhood obesity. Efforts to understand and reduce obesity risk factors in early life may need to consider paternal factors.

Identifying areas at risk of low birth weight using spatial epidemiology: A small area surveillance study

OBJECTIVES

To assess the geographic distribution of Low Birth Weight (LBW) in New York State among singleton births using a spatial regression approach in order to identify priority areas for public health actions.

METHODS

LBW was defined as birth weight less than 2500g. Geocoded data from 562,586 birth certificates in New York State (years 2008-2012) were merged with 2010 census data at the tract level. To provide stable estimates and maintain confidentiality, data were aggregated to yield 1268 areas of analysis. LBW prevalence among singleton births was related with area-level behavioral, socioeconomic and demographic characteristics using a Poisson mixed effects spatial error regression model.

RESULTS

Observed low birth weight showed statistically significant auto-correlation in our study area (Moran's I 0.16 p value 0.0005). After over-dispersion correction and accounting for fixed effects for selected social determinants, spatial autocorrelation was fully accounted for (Moran's I-0.007 p value 0.241). The proportion of LBW was higher in areas with larger Hispanic or Black populations and high smoking prevalence. Smoothed maps with predicted prevalence were developed to identify areas at high risk of LBW. Spatial patterns of residual variation were analyzed to identify unique risk factors.

CONCLUSION

Neighborhood racial composition contributes to disparities in LBW prevalence beyond differences in behavioral and socioeconomic factors. Small-area analyses of LBW can identify areas for targeted interventions and display unique local patterns that should be accounted for in prevention strategies.

A critical review of methods for assessing cancer survival disparities in indigenous population

PURPOSE

An increasing cancer burden among indigenous populations has led to a growing literature about survival disparities between indigenous and nonindigenous persons. We aim to describe and appraise methods used to measure cancer survival in indigenous persons in the United States, Canada, Australia, and New Zealand.

METHODS

We searched Medline, Web of Science, and EMBASE for articles published between 1990 and 2015 that estimated survival in populations indigenous to one of these four countries. We gathered information about data sources, analytical methods, and the extent to which threats to validity were discussed.

RESULTS

The search retrieved 83 articles. The most common approach to survival analysis was cause-specific survival (n = 49). Thirty-eight articles measured all-cause survival and 11 measured excess mortality attributable to cancer (relative survival). Three sources of information bias common to all studies (ethnic misclassification, incomplete case ascertainment, and incomplete death ascertainment) were acknowledged in a minority of articles.

CONCLUSIONS

The methodological considerations we present here are shared with studies of cancer survival across other subpopulations. We urge future researchers on this and related topics to clearly describe their data sources, to justify analytic choices, and to fully discuss the potential impact of those choices on the results and interpretation.

Socioeconomic gradients in general and oral health of primary school children in Shiraz, Iran

Background: Health status is largely determined by socio-economic status. The general health of individuals at higher social hierarchy is better than people in lower levels. Likewise, people with higher socio-economic status have better oral health than lower socio-economic groups. There has not been much work regarding the influence of socio-economic status on the health conditions of children in developing countries, particularly in Iran. The aim of this study was to compare the oral and general health conditions of primary school children of three different socio-economic areas in the city of Shiraz, Iran.

Methods: This cross-sectional study was conducted on 335, 8- to 11-year-old primary schoolchildren in Shiraz. The children were selected by a three-stage cluster sampling method from three socio-economically different areas. Tools and methods used by the United Kingdom’s Medical Research Council were used to obtain anthropometric variables as indicators of general health. The Decay, Missing, Filled Teeth (DMFT) Index for permanent teeth, dmft Index for primary teeth, the Modified Developmental Defects of Enamel (DDE) Index, the Gingival Index (GI) and the Debris Index-Simplified (DI-S) were used for oral health assessment. 

Results: Height (P<0.001), weight (P<0.001), and BMI (P=0.001) significantly increased as the socio-economic status of area increased. GI score (P<0.001), DI-S score (P<0.001), number of permanent teeth with DDE (P=0.008), and number of DDE lesions in permanent teeth (P=0.008) significantly decreased as the socio-economic status of area increased.

Discussion: Findings of this study generally confirmed that social gradients exist in both general and oral health status of the primary schoolchildren of Shiraz. The influence of socio-economic status on health condition means children have different life chances based on their socio-economic conditions. These findings emphasize the significance of interventions for tackling socio-economic inequalities in order to improve the health status of children in lower socio-economic areas.

Towards an understanding of the structural determinants of oral health inequalities: A comparative analysis between Canada and the United States

Objective

To compare the magnitude of, and contributors to, income-related inequalities in oral health outcomes within and between Canada and the United States over time.

Methods

The concentration index was used to estimate income-related inequalities in three oral health outcomes from the Nutrition Canada National Survey 1970–1972, Canadian Health Measures Survey 2007–2009, Health and Nutrition Examination Survey I 1971–1974, and National Health and Nutrition Examination Survey 2007–2008. Concentration indices were decomposed to determine the contribution of demographic and socioeconomic factors to oral health inequalities.

Results

Our estimates show that over time in both countries, inequalities in decayed teeth and edentulism were concentrated among the poor and inequalities in filled teeth were concentrated among the rich. Over time, inequalities in decayed teeth increased and decreased for measures of filled teeth and edentulism in both countries. Inequalities were higher in the United States compared to Canada for filled and decayed teeth outcomes. Socioeconomic characteristics (education, income) contributed greater to inequalities than demographic characteristics (age, sex). As well, income contributed more to inequalities in recent surveys in both Canada and the United States.

Conclusions

Inequalities in oral health have persisted over the past 35 years in Canada and the United States, and are associated with age, sex, education, and income and have varied over time.

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Highlights changes and contributors to oral health inequalities in Canada and the U.S. since 1970.

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Provides a comparative framework for analysing income-related oral health inequalities.

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Hypotheses-generating findings on contributors to income-related oral health inequalities.

Racial disparities in endometrial cancer mortality-to-incidence ratios among Blacks and Whites in South Carolina

PURPOSE

Endometrial cancer (EC) exhibits striking racial disparities with higher mortality in Blacks compared to Whites. The mortality-to-incidence ratio (MIR) provides a population-based measure of survival which accounts for incidence. The objective of this study was to map EC MIRs by race for eight health regions within South Carolina (SC) and chart EC incidence by race and grade across the four cancer stages.

METHODS

Cancer incidence and mortality data were obtained from the SC Community Access Network (SCAN), the online data query system provided by the SC Department of Health and Environmental Control (DHEC). The underlying data for SCAN were generated from the SC Central Cancer Registry and SC DHEC Vital Records and used to construct MIRs. ArcGIS 10.1 was used to map EC MIRs by race for eight health regions within SC. Four categories of MIR were derived using the national MIR for EC among Whites as the reference category.

RESULTS

Blacks had higher levels of poorly differentiated tumors across all stages and higher incidence and mortality rates. In all eight health regions, Blacks were in the highest MIR category. By contrast, the MIRs for Whites were more evenly represented over the four categories.

CONCLUSIONS

The MIR proved useful for identifying disparities in EC incidence and mortality among Black and White women in SC. Cancer surveillance programs may use the MIR to monitor disparities across racial/ethnic groups and geographic regions going forward. MIRs have the potential to serve as an indicator of the long-term success of cancer surveillance programs.

Racial-ethnic disparities in the association between risk factors and diabetes: The Northern Manhattan Study

PURPOSE

To identify risk factors (RF) for diabetes within a multiethnic cohort and to examine whether race-ethnicity modified their effects.

METHODS

Participants in the Northern Manhattan Study without diabetes at baseline were studied from 1993 to 2014 (n=2430). Weibull regression models with interval censoring data were fit to calculate hazard ratios and 95% confidence intervals for incident diabetes. We tested for interactions between RF and race-ethnicity.

RESULTS

During a mean follow-up period of 11years, there were 449 diagnoses of diabetes. Being non-Hispanic black (HR 1.69 95% CI 1.11-2.59) or Hispanic (HR 2.25 95% CI 1.48-3.40) versus non-Hispanic white, and body mass index (BMI; HR 1.34 per SD 95% CI 1.21-1.49) were associated with greater risk of diabetes; high-density lipoprotein cholesterol (HR 0.75 95% CI 0.66-0.86) was protective. There were interactions by race-ethnicity. In stratified models, the effects of BMI, current smoking, and C-reactive protein (CRP) on risk of diabetes differed by race-ethnicity (p for interaction <0.05). The effects were greater among non-Hispanic whites than non-Hispanic blacks and Hispanics.

CONCLUSIONS

Although Hispanics and non-Hispanic blacks had a greater risk of diabetes than whites, there were variations by race-ethnicity in the association of BMI, smoking, and CRP with risk of diabetes. Unique approaches should be considered to reduce diabetes as traditional RF may not be as influential in minority populations.

[The intervention mapping protocol: A structured process to develop, implement and evaluate health promotion programs]

BACKGROUND

Health promotion programs are expected to improve population health and reduce social inequalities in health. However, their theoretical foundations are frequently ill-defined, and their implementation faces many obstacles. The aim of this article is to describe the intervention mapping protocol in health promotion programs planning, used recently in several countries.

METHODS

The challenges of planning health promotion programs are presented, and the six steps of the intervention mapping protocol are described with an example. Based on a literature review, the use of this protocol, its requirements and potential limitations are discussed.

RESULTS

The intervention mapping protocol has four essential characteristics: an ecological perspective (person-environment), a participative approach, the use of theoretical models in human and social sciences and the use of scientific evidence. It comprises six steps: conduct a health needs assessment, define change objectives, select theory-based change techniques and practical applications, organize techniques and applications into an intervention program (logic model), plan for program adoption, implementation, and sustainability, and generate an evaluation plan. This protocol was used in different countries and domains such as obesity, tobacco, physical activity, cancer and occupational health. Although its utilization requires resources and a critical stance, this protocol was used to develop interventions which efficacy was demonstrated.

CONCLUSION

The intervention mapping protocol is an integrated process that fits the scientific and practical challenges of health promotion. It could be tested in France as it was used in other countries, in particular to reduce social inequalities in health.

Cost Effectiveness of Colorectal Cancer Screening Interventions with Their Effects on Health Disparity Being Considered

Purpose

The purpose of this study was to evaluate the cost effectiveness of colorectal cancer screening interventions with their effects on health disparity being considered.

Materials and Methods

Markov cohort simulation was conducted with the cycle/duration of 1/40 year(s). Data came from the results of randomized trials and others. Participants were hypothetical cohorts aged 50 years as of year 2013 in 16 Korean provinces. The interventions until the age of 80 were annual organized fecal occult blood test (FOBT) (standard screening), annual FOBT with basic reminders for provinces with higher mortalities than the national average (targeted reminder) and annual FOBT with basic/enhanced reminders for all provinces (universal reminder 1 and 2). The comparison was non-screening, the outcome was quality-adjusted life years, and only medical costs for screening and treatment were considered from a societal perspective. The Atkinson incremental cost effectiveness ratio (Atkinson ICER), the incremental cost effectiveness ratio adjusted by the Atkinson Inequality Index, was used to evaluate the cost effectiveness of the four interventions with their impacts on regional health disparity being considered.

Results

Health disparity was smallest (or greatest) in non-screening (or the standard screening). The targeted reminder had smaller health disparity, and smaller Atkinson ICER with respect to standard screening, than did the universal reminder 1 and 2.

Conclusion

The targeted reminder might be more cost effective than the universal reminders with their effects on health disparity being considered. This study helps to develop promotional effort for colorectal cancer screening with both the greatest cost effectiveness and the smallest health disparity

Disparities in meeting physical activity guidelines for Asian-Americans in two metropolitan areas in the United States

PURPOSE

Physical activity (PA) levels in Asian-American adults may be lower than other racial or ethnic groups. This analysis tested the hypothesis that Asian-Americans are less likely to meet PA guidelines than other racial or ethnic groups regardless of location of residence.

METHODS

The New York City (NYC) Community Health Survey (2010, 2012) and Los Angeles County (LAC) Health Survey (2011) are cross-sectional surveys conducted with similar sampling strategies (NYC: n = 17,462; LAC: n = 8036). Meeting PA guidelines was calculated using self-reported moderate or vigorous minutes per week; multivariable regression models adjusted for demographics, insurance, nativity and language spoken at home. Data were weighted to be representative of their respective geographies.

RESULTS

In both areas, Asian-Americans had a low prevalence of meeting PA guidelines (NYC: 42.7 [39.2-46.3]; LAC: 55.8 [51.2-60.2]). Other racial or ethnic groups were more likely to meet PA guidelines versus Asian-Americans after adjustment for covariates in NYC (white odds ratio [OR]: 1.35 [1.09-1.68]; black OR: 1.61 [1.28-2.02]; Hispanic OR: 2.14 [1.74-2.62]) and in LAC (white OR: 1.45 [1.13-1.86]; Hispanic OR: 1.71 [1.32-2.22]).

CONCLUSIONS

Asian-Americans were less likely to meet PA guidelines compared with other racial or ethnic groups in NYC and LAC. Description of cultural and neighborhood-level factors and of types of PA in specific Asian subgroups is needed.

Exploring trends in and determinants of educational inequalities in self-rated health

AIMS

Educational inequalities in self-rated health (SRH) in European welfare countries are documented, but recent trends in these inequalities are less well understood. We examined educational inequalities in SRH in different age groups, and the contribution of selected material, behavioural and psychosocial determinants from 2000 to 2008.

METHODS

Data were derived from cross-sectional surveys conducted in 2000, 2004 and 2008 including 37,478, 34,876 and 32,982 respondents, respectively, aged 25-75 in mid-Sweden. Inequalities were analysed by age-standardized and age-stratified rate ratios of poor SRH and age-standardized prevalence of determinants, and contribution of determinants by age-adjusted logistic regression.

RESULTS

Relative educational inequalities in SRH increased among women from 2000 (rate ratio (RR) 1.70, 95% CI 1.55-1.85) to 2008 (RR 2.07, 95% CI 1.90-2.26), but were unchanged among men (RR 1.91-2.01). The increase among women was mainly due to growing inequalities in the age group 25-34 years. In 2008, significant age differences emerged with larger inequalities in the youngest compared with the oldest age group in both genders. All determinants were more prevalent in low educational groups; the most prominent were lack of a financial buffer, smoking and low optimism. Educational differences were unchanged over the years for most determinants. In all three surveys, examined determinants together explained a substantial part of the educational inequalities in SRH.

CONCLUSIONS

Increased relative educational health inequalities among women, and persisting inequalities among men, were paralleled by unchanged, large differences in material/structural, behavioural and psychosocial factors. Interventions to reduce these inequalities need to focus on early mid-life.

Disparities in long-term cardiovascular disease risk by sexual identity: The National Longitudinal Study of Adolescent to Adult Health

OBJECTIVE

To examine long-term cardiovascular disease (CVD) risk disparities by sexual identity using a nationally representative sample of young adults in the United States.

METHODS

Data include participants in wave 4 (2008/09; ages 24-34years) of the National Longitudinal Study of Adolescent to Adult Health (7087 females; 6340 males). Sexual identity was self-reported (heterosexual, mostly heterosexual, bisexual, mostly homosexual, homosexual) and a Framingham-based prediction model was used to estimate participants' risk of a CVD event over 30years. Differences in CVD risk by sexual identity, relative to heterosexuals, were calculated with linear regression models adjusted for age, race/ethnicity, education, and financial distress.

RESULTS

Average 30-year CVD risk was 17.2% (95% CI: 16.7, 17.7) in males and 9.0% (95% CI: 8.6, 9.3) in females. Compared to heterosexual females, mostly heterosexual (0.8%; 95% CI: 0.2, 1.4) and mostly homosexual females (2.8%; 95% CI: 0.8, 4.9) had higher CVD risk. Bisexual and homosexual females had higher but not statistically significant CVD risk compared to heterosexuals. Among males, differences in CVD risk by sexual identity were not statistically significant.

CONCLUSION

Sexual identity was associated with CVD risk in sexual minority subgroups. Population- and clinic-based prevention strategies are needed to minimize disparities in subsequent disease.

Longitudinal differences in sleep duration in Hispanic and Caucasian children

BACKGROUND AND AIM

Short sleep duration is associated with significant negative consequences, including poor school performance, behavioral problems, obesity, and hypertension. There is prior evidence that there are disparities in sleep duration related to ethnicity; however, there are no specific data on Hispanic children. We aimed to test the hypothesis that there are ethnic differences in parent-reported sleep duration in a community-based cohort of Hispanic and Caucasian children.

METHODS

We examined the parent-reported sleep patterns of a community-based prospective cohort (Tucson Children's Assessment of Sleep Apnea study [TuCASA]) involving 338 Hispanic and Caucasian children at two time points approximately five years apart.

RESULTS

In the initial phase of the TuCASA study with a cohort median age of 8.8 years (interquartile range (IQR), 7.6-10.1 years), parent-reported sleep duration during weekdays was shorter in Hispanic (median, 9.5 h; IQR, 9.0, 10.0 years) than in Caucasian children (10 h; IQR, 9.5, 10.0 h; p < 0.0001); however, this difference was not seen 5 years later when the cohort was older (median age, 13.3 years; IQR, 11.9-14.6 years; p = 0.43). In addition, Hispanic children had a significantly later bedtime at both time points (p < 0.02). In the initial phase, parent-reported sleep duration during weekends tended to be shorter in Hispanic than in Caucasian children (p = 0.06).

CONCLUSIONS

Short sleep duration in Hispanic children may contribute to health disparities. Our research suggests that in Hispanic children, behavioral interventions toward improving sleep duration accomplished by earlier bedtimes or delayed school start times and mechanistic studies to unravel any inherent tendency toward a delayed sleep phase are needed.