The ecology of urban violence: its relationship to health promotion behaviors in low-income black and Latino communities

Racial Differences in the Risk of Prenatal Depression Among Women Experiencing Childhood and Adult Stressors

INTRODUCTION

Stress exposure during a woman's own childhood and adulthood likely elevate risk of prenatal depression (PND). However, most PND screening tools fail to assess for events prior to conception. This study examined the differential effects of adverse childhood experiences (ACE) and adult life stressors on PND.

METHODS

This cross-sectional study was conducted among 199 racially diverse pregnant women, ages 18 to 43, recruited from clinics and ongoing university-based studies between 2012 and 2018. The ACE Scale assessed maternal childhood trauma exposure. Validated scales examining subjective stressors assessed for chronic adult stressors. PND was assessed with the Edinburgh Depression Scale, with the Rini Pregnancy-Related Anxiety Scale as a covariate. Associations were measured using multivariable linear regression modeling. Results were stratified by self-identified Black or white race.

RESULTS

Among 199 participants, mean age was 26.8 years and 67.8% were Black. Controlling for age, race, education, and prenatal anxiety, all participants reporting both childhood trauma and adult stressors were at increased risk for PND (p < 0.0001). PND risk was increased among Black women with childhood stressors (p < 0.01) or three or more adult stressors (p < 0.0001) and among White women following any number of adult stressors (p < 0.001).

DISCUSSION

These findings highlight the importance of cumulative exposure to stress and trauma across the life span as indicators of risk for PND. Black and white participants had differential development of risk, depending on timing and number of exposures. Prenatal depression risk screening during routine prenatal care should include an assessment of current and historical trauma and stressors.

Recovery From Severe Mental Health Problems: A Systematic Review of Service User and Informal Caregiver Perspectives

Introduction: The recovery approach aims to have users' perspectives at the heart of service development and research; it is a holistic perspective that considers social needs, personal growth and inclusion. In the last decade recovery-oriented research and practice has increased greatly, however, a comprehensive model of recovery considering exclusively the perspectives of people with lived experience has not been devised. Aims: This review aimed to develop a framework and contextualize service users' and informal caregivers' understanding of recovery from severe mental health problems. Methods: We systematically searched 6 databases including key terms related to knowledge, experience and narratives AND mental health AND personal recovery. The search was supplemented with reference sourcing through gray literature, reference tracking and expert consultation. Data analysis consisted of a qualitative meta-synthesis using constant comparative methods. Results: Sixty-two studies were analyzed. A pattern emerged regarding the recovery paradigms that the studies used to frame their findings. The resulting recovery framework included the domains Social recovery; Prosperity (Legal, political, and economic recovery); Individual Recovery; and Clinical Recovery Experience (SPICE). Service users' definitions of recovery tended to prioritize social aspects, particularly being accepted and connecting with others, while caregivers focused instead on clinical definitions of recovery such as symptom remission. Both groups emphasized individual aspects such as becoming self-sufficient and achieving personal goals, which was strongly linked with having economic means for independence. Conclusions: The recovery model provided by this review offers a template for further research in the field and a guide for policy and practice. Predominant definitions of recovery currently reflect understandings of mental health which focus on an individual perspective, while this review found an important emphasis on socio-political aspects. At the same time, only a small number of studies took place in low-income countries, focused on minoritized populations, or included caregivers' perspectives. These are important gaps in the literature that require further attention. Systematic Review Registration: The review protocol was registered on PROSPERO (CRD42017076450); https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=76450.

Interpersonal violence in a deprived Scottish urban area with aggregations of physical health risks and psychiatric morbidity: an ecological study

Background

Glasgow, Scotland, has previously shown exceptional levels of violence among young men, shows aggregations of health conditions, with shortened life expectancy. Health conditions can be both causes and consequences of violence, of shared community-level socio-economic risk factors, and can result from large-scale social forces beyond the control of populations with high levels of violence. The aim of the study was to provide an in depth understanding of the Public Health problem of violence among young adult men in Glasgow East.

Method

Ecological investigation of violence and its associations with health conditions in areas of contrasting socioeconomic deprivation. National survey of 1916 British men aged 18–34 years, augmented by a sub-sample of 765 men in Glasgow East (GE). Participants completed questionnaires covering current physical and sexual health, psychiatric symptoms, substance misuse, lifestyle, and crime and violence.

Results

The 5-year prevalence of violence was similar in both surveys but fights involving weapons (AOR 3.32, 95% CI 2.29–4.79), gang fights (AOR 2.30, 95% CI 1.77–2.98), and instrumental violence supporting criminal lifestyles were more common in GE, where 1 in 9 men had been in prison. Violent men in both samples reported poorer physical and sexual health and all types of psychiatric morbidity except depression, with multiple high-risk behaviours for both future poor health and violence. Associations between drug and alcohol dependence and violence in GE could not be entirely explained by deprivation.

Conclusion

Violence in deprived urban areas is one among many high-risk behaviours and lifestyle factors leading to, as well as resulting from, aggregations of both psychiatric and physical health conditions. Poverty partly explained raised levels of violence in GE. Other factors such as drug and alcohol misuse and macho attitudes to violence, highly prevalent among men in this socially excluded community, also contributed. Multi-component preventive interventions may be needed in deprived areas and require future investigations into how multiple co-existing risk factors produce multimorbidity, including psychiatric disorders, substance misuse, poor physical health and violence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11167-z.

A preliminary prospective study of health-related quality of life among Chinese-American breast cancer survivors

PURPOSE

This study examined the predictors of health-related quality of life (HRQOL) and changes in HRQOL over a 1-year period among Chinese-American breast cancer survivors (BCS).

METHODS

A two-wave longitudinal research design included participants from hospital-based cancer registries and community organizations in Los Angeles. Participants completed mailed questionnaires at baseline and 12-month follow-up. HRQOL was measured using the Functional Assessment of Cancer Therapy-General (FACT-G v.4). Change in HRQOL was assessed using a 7-point meaningful change score.

RESULTS

Participants were 73 Chinese-American BCS, a majority of whom were middle-aged (M = 54.6, SD = 9.2), lower income (63% < 45K), and diagnosed with stage I-II (83%) breast cancer. Regression analyses showed that multilevel contextual factors including general health perception, quality of care, life stress, and improvement in general health perception significantly predicted HRQOL at baseline and follow-up. The final model explained 72% of the variance of HRQOL. The examination of meaningful change indicated that improvement was reported by 32% (n = 22) and deterioration by 25% (n = 17); the majority indicated minimal change (43%, n = 30). Improvement was associated with increases in family communication, social support, and general health perception, while deterioration was associated with declines in social support, family communication, and general health perception.

CONCLUSION

Findings indicate that among Chinese-American BCS, HRQOL is influenced by socioecological factors such as family communication and life stress. Results suggest that cancer survivorship outcomes research may benefit from theoretical foundations that examine the broader contextual dimensions that seem to impact and predict HRQOL. Implications for research are discussed.

A longitudinal analysis of violence and healthcare service utilization in Mexico

OBJECTIVES

We analyze the degree to which community violence in Mexico, largely due to organized crime violence, affects health care service utilization.

METHODS

This study exploits temporal and geographic variation in monthly county-level homicide rates, matching outpatient service utilization from individual longitudinal measures. Sensitivity analyses test for an age specific concentration of violence, respiratory conditions that are likely unrelated to violence, insurance status and health center availability per capita. We test for distributional responses to violence by urban and rural localities.

RESULTS

The likelihood of service utilization increases by 5.2% with each additional homicide per 100,000. When we include self-reported health conditions in the model, our main coefficient remains significant at 4.5%. We find no added effect to our results from interaction terms for age specific concentration of violence, respiratory conditions, insurance status, or health center availability. A substantial increase of 11.7% in the likelihood of service utilization occurs in localities with > = 100,000 inhabitants, suggesting that service utilization is sensitive to the location of violence.

CONCLUSIONS

Results highlight the relationship between and increase in violence at the local level and an increase in health care service utilization. This study is among the first to examine this relationship empirically in Mexico. Future research is needed to shed more light on this relationship and its mechanisms.

Psychosocial and Clinical Risk Factors Associated with Substance Use in Observational Cohort of Patients with Sickle Cell Disease

BACKGROUND

Patients with sickle cell disease (SCD) experience high rates of chronic pain, and have a high burden of mental health comorbidities shown to negatively influence health. There is limited research on substance use among individuals with SCD. Objective: The aim of this study is to measure the prevalence of substance use in patients with SCD and determine whether psychosocial or clinical risk factors are associated with substance use. Methods: This study was conducted as part of an observational study of patients with SCD at two academic medical centers. We asked participants (ages 15 and older) about the lifetime use of heroin, cocaine, amphetamines, and marijuana/cannabis. We measured stigma, depression, urban life stress, pain catastrophizing, and asked about a brief pain inventory. Results: Of 258 participants, 24.9% (n = 71) reported substance use. Marijuana was the most common substance used (22.5%; n = 65). The mean depressive score met criteria for positive screen amongst individuals who reported a history of substance use (mean 10.7(5.76)). Adjusting for age, sex, yearly family income, and education level, odds of substance use increased with higher levels of internalized stigma (aOR: 1.38; 95% CI: 1.07, 1.77; p = 0.012); higher urban life stress scores (aOR 1.06; 95% CI: 1.01, 1.12; p = 0.017) and higher pain catastrophizing scores (aOR: 1.03; 95% CI: 1.01, 1.06; p = 0.008). Conclusions: Among individuals with SCD who endorse substance use, there was markedly more stress and distress with higher rates of depression and poorer quality of life. Interventions focusing on improving distress tolerance and coping to not only pain, but also social stressors, might reduce substance use.

Violent crime and socioeconomic deprivation in shaping asthma-related pollution susceptibility: a case-crossover design

Background

The objective of this study was to quantify and compare the relative influence of community violent crime and socioeconomic deprivation in modifying associations between ozone and emergency department (ED) visits for asthma among children.

Methods

We used a spatiotemporal case-crossover analysis for all New York City EDs for the months May–September from 2005 to 2011 from a statewide administrative ED dataset. The data included 11 719 asthmatic children aged 5–18 years, and the main outcome measure was percentage of excess risk of asthma ED visit based on Cox regression analysis.

Results

Stronger ozone–asthma associations were observed for both elevated crime and deprivation (eg, on lag day 2, we found 20.0% (95% CI 10.2% to 30.6 %) and 21.0% (10.5% to 32.5%) increased risk per 10 ppb ozone, for communities in the highest vs lowest quartiles of violent crime and deprivation, respectively). However, in varied models accounting for both modifiers, only violence retained significance.

Conclusions

The results suggest stronger spatiotemporal ozone–asthma associations in communities of higher violent crime or deprivation. Notably, violence was the more consistent and significant modifier, potentially mediating a substantial portion of socioeconomic position–related susceptibility.

Acute Changes in Community Violence and Increases in Hospital Visits and Deaths From Stress-responsive Diseases

BACKGROUND

Community violence may affect a broad range of health outcomes through physiologic stress responses and changes in health behaviors among residents. However, existing research on the health impacts of community violence suffers from problems with bias.

METHODS

We examined the relations of acute changes in community violence with hospital visits and deaths due to stress-responsive diseases (mental, respiratory, and cardiac conditions) in statewide data from California 2005-2013. The community violence exposure was measured as both binary spikes and continuous acute changes. We applied a combined fixed-effects and time-series design that separates the effects of violence from those of community- and individual-level confounders more effectively than past research. Temporal patterning was removed from community violence rates and disease rates in each place using a Kalman smoother, resulting in residual rates. We used linear regression with place fixed-effects to examine within-place associations of acute changes in community violence with residual rates of each outcome, controlling for local time-varying covariates.

RESULTS

We found acute increases in hospital visits and deaths due to anxiety disorders (0.31 per 100,000; 95% confidence interval [CI] = 0.02, 0.59), substance use (0.47 per 100,000; 95% CI = 0.14, 0.80), asthma (0.56 per 100,000; 95% CI = 0.16, 0.95), and fatal acute myocardial infarction (0.09 per 100,000; 95% CI = 0.00, 0.18) co-occurring with violence spikes. The pattern of findings was similar for the exposure of continuous acute violence changes.

CONCLUSIONS

Although the associations were small, the identified increases in stress-responsive conditions suggest the possibility of health impacts of acute changes in community violence.

The Assets and Challenges of Formerly Incarcerated Latino Men's Social Support Networks in Promoting Healthy Behaviors

After being exposed to high-risk environments in correctional facilities, formerly incarcerated Latino men (FILM) encounter new risks upon reentering their community of residence including drug use and sexual risk behaviors. Families and close social support networks are critical in potentially mitigating the stressors and risks associated with reentry and reducing the likelihood of recidivism. We conducted a study to examine the material and cognitive assets that familial networks can use to provide support to FILM to engage in health-promoting practices. This analysis is based on linear and logistic regression modeling of cross-sectional data collected through a computer-administered survey with dyads of FILM (ages 18-49, who had been in jail or prison within the past 5 years) and their nominated social network (n = 130 dyads). We found that both male and female social supports (MSS and FSS) have significantly higher levels of structural resources (education and employment) than FILM. Though FSS reported higher self-efficacy on health-promoting practices than FILM, contrary to what we predicted, FILM and FSS/MSS reported similar levels of mental health and behavioral risks. Our results suggest a number of limitations in designing family-based intervention strategies, but they also provided insight into the specificities needed to enhance the social support networks of FILM.

Experiences of chronic stress and mental health concerns among urban Indigenous women

We measured stress, depression and post-traumatic stress disorder (PTSD) levels of urban Indigenous women living with and without HIV in Ontario, Canada, and identified correlates of depression. We recruited 30 Indigenous women living with HIV and 60 without HIV aged 18 years or older who completed socio-demographic and health questionnaires and validated scales assessing stress, depression and PTSD. Descriptive statistics were conducted to summarize variables and linear regression to identify correlates of depression. 85.6 % of Indigenous women self-identified as First Nation. Co-morbidities other than HIV were self-reported by 82.2 % (n = 74) of the sample. High levels of perceived stress were reported by 57.8 % (n = 52) of the sample and 84.2 % (n = 75) had moderate to high levels of urban stress. High median levels of race-related (51/88, IQR 42-68.5) and parental-related stress (40.5/90, IQR 35-49) scores were reported. 82.2 % (n = 74) reported severe depressive symptoms and 83.2 % (n = 74) severe PTSD. High levels of perceived stress was correlated with high depressive symptoms (estimate 1.28 (95 % CI 0.97-1.58), p < 0.001). Indigenous women living with and without HIV reported elevated levels of stress and physical and mental health concerns. Interventions cutting across diverse health care settings are required for improving and preventing adverse health outcomes.

Adolescent Alcohol, Tobacco, and Marijuana Use: The Influence of Neighborhood Disorder and Hope

Purpose.

To investigate relationships between adolescents' current alcohol, tobacco, and marijuana use; perceptions of neighborhood disorder; and sense of hope.

Design.

Questionnaires were administered to a nonrandom sample of middle school students during the spring of 1999.

Subjects.

The ethnically and geographically diverse sample (n = 369), from a range of low socioeconomic status backgrounds, was considered to be at high risk for alcohol, tobacco, and other drug use because of previous enrollment in low socioeconomic status elementary schools.

Measures.

Alcohol, tobacco, and marijuana use were dichotomized into current and never/no use. Six variables described neighborhood social disorder. Sense of hope was assessed using the Children's Hope Scale.

Results.

Statistically significant relationships were found between perceived neighborhood disorder and current alcohol (p = .01), tobacco (p = .001), and marijuana (p < .001) use. A statistically significant and independent relationship was found between sense of hope and current alcohol (p = .02), tobacco (p = .02), and marijuana (p = .06) use. Results indicated linear trends in participants' increased use of alcohol, tobacco, and marijuana and (1) perception of higher neighborhood disorder and (2) lower sense of hope.

Conclusion.

Substance use prevention programs for youth might usefully be directed not only to agdolescents but also to the neighborhoods in which they live. Additionally, it would be important to emphasize creating safer neighborhood environments that support the development of a stronger sense of hope for the future.

Immigrants and Violence: The Importance of Neighborhood Context

This study examined the relationship between violence and immigration. The importance of neighborhood context, including alcohol availability, was also investigated. Using data from block groups, these relationships were examined in three California communities with significant immigrant populations. Data on socioeconomic characteristics were combined with police data concerning youth and data on alcohol availability. These data were geocoded in a block group, and population-based rates were calculated. A specialized regression package was used to examine these relationships. Results indicated that immigration and youth violence were not related, but that violence was predicted by alcohol availability. Contextual factors such as family breakdown and professional role models were also found to be significant predictors of youth violence. Furthermore, the context of violence is important in understanding why violence varies within communities. Violence prevention efforts may benefit from regulatory efforts to reduce the high concentrations of alcohol outlets that exist in Latino neighborhoods.

Another Look at HIV in African American Women: The Impact of Psychosocial and Contextual Factors

This study tested a conceptual model that integrates structural and psychological determinants of HIV prevention for African American women. The sample consisted of African American mothers (N = 129) of children in Head Start programs. Higher levels of perceived stress were associated with higher levels of HIV risk; higher levels of perceived racism were related to higher HIV prevention behavior. A combined psychological functioning score, representing levels of depression and anger, significantly moderated the relationships of perceived stress and racism to prevention behavior. This study confirms the importance of interactions between sociostructural factors and psychological factors as predictors of health behavioral outcomes and reinforces the need to examine the impact of structural factors on psychological functioning, perceived HIV risk, and HIV prevention behavior in African American women.

Gender and crime victimization modify neighborhood effects on adolescent mental health

OBJECTIVE

Leverage an experimental study to determine whether gender or recent crime victimization modify the mental health effects of moving to low-poverty neighborhoods.

METHODS

The Moving to Opportunity (MTO) study randomized low-income families in public housing to an intervention arm receiving vouchers to subsidize rental housing in lower-poverty neighborhoods or to controls receiving no voucher. We examined 3 outcomes 4 to 7 years after randomization, among youth aged 5 to 16 years at baseline (n = 2829): lifetime major depressive disorder (MDD), psychological distress (K6), and Behavior Problems Index (BPI). Treatment effect modification by gender and family's baseline report of recent violent crime victimization was tested via interactions in covariate-adjusted intent-to-treat and instrumental variable adherence-adjusted regression models.

RESULTS

Gender and crime victimization significantly modified treatment effects on distress and BPI (P < .10). Female adolescents in families without crime victimization benefited from MTO treatment, for all outcomes (Distress B = -0.19, P = .008; BPI B = -0.13, P = .06; MDD B = -0.036, P = .03). Male adolescents in intervention families experiencing crime victimization had worse distress (B = 0.24, P = .004), more behavior problems (B = 0.30, P < .001), and nonsignificantly higher MDD (B = 0.022, P = .16) versus controls. Other subgroups experienced no effect of MTO treatment. Instrumental variable estimates were similar but larger.

CONCLUSIONS

Girls from families experiencing recent violent crime victimization were significantly less likely to achieve mental health benefits, and boys were harmed, by MTO, suggesting need for cross-sectoral program supports to offset multiple stressors.

Lessons learned in research, collaboration, and dissemination in a national institute of nursing research-funded research center

This article provides the key findings of interviews and focus groups with researchers and administrators throughout a P30 Center on the issues of collaboration among researchers, multidisciplinary research, center support, and dissemination. The most notable findings confirmed throughout this process include methods of collaboration and shared strategies for subject recruitment. Specifically, the researchers participating in the P30 Center recommended that a research-intensive environment facilitate the ability of investigators to discuss their methods, struggles, and findings in ways that unite investigators toward a common goal to advance the science and improve health care. Researchers become isolated easily, thus running the risk of losing valuable time by duplicating others' work, falling short in fulfilling their commitments to scientific research, and losing opportunities to learn from each others' experiences. Especially in the realm of subject recruitment and study design, researchers often have similar problems and can benefit from both informal conversations and structured forums. Based on these findings, the authors provide recommendations for future collaborative research in schools of nursing. These include establishing certain key institutional structures and mechanisms by which established researchers can interact with junior investigators to train and mentor them.

Integration of social epidemiology and community-engaged interventions to improve health equity

The past quarter century has seen an explosion of concern about widening health inequities in the United States and worldwide. These inequities are central to the research mission in 2 arenas of public health: social epidemiology and community-engaged interventions. Yet only modest success has been achieved in eliminating health inequities. We advocate dialogue and reciprocal learning between researchers with these 2 perspectives to enhance emerging transdisciplinary language, support new approaches to identifying research questions, and apply integrated theories and methods. We recommend ways to promote transdisciplinary training, practice, and research through creative academic opportunities as well as new funding and structural mechanisms.

Racial discrimination: a continuum of violence exposure for children of color

This article reviews and examines findings on the impact of racial discrimination on the development and functioning of children of color in the US. Based on current definitions of violence and child maltreatment, exposure to racial discrimination should be considered as a form of violence that can significantly impact child outcomes and limit the ability of parents and communities to provide support that promotes resiliency and optimal child development. In this article, a conceptual model of the effects of racial discrimination in children of color is presented. The model posits that exposure to racial discrimination may be a chronic source of trauma in the lives of many children of color that negatively influences mental and physical outcomes as well as parent and community support and functioning. Concurrent exposure to other forms of violence, including domestic, interpersonal and/or community violence, may exacerbate these effects. The impact of a potential continuum of violence exposure for children of color in the US and the need for future research and theoretical models on children's exposure to violence that attend to the impact of racial discrimination on child outcomes are discussed.

How does violence exposure affect the psychological health and parenting of young African-American mothers?

Urban, minority, adolescent mothers are particularly vulnerable to violence exposure, which may increase their children's developmental risk through maternal depression and negative parenting. The current study tests a conceptual model of the effects of community and contextual violence exposure on the mental health and parenting of young, African-American mothers living in Washington, DC. A path analysis revealed significant direct effects of witnessed and experienced violence on mothers' depressive symptoms and general aggression. Experiences of discrimination were also associated with increased depressive symptoms. Moreover, there were significant indirect effects of mothers' violence exposure on disciplinary practices through depression and aggression. These findings highlight the range of violence young African-American mothers are exposed to and how these experiences affect their mental health, particularly depressive symptoms, and thus disciplinary practices.

Building international research partnerships to develop HIV programs for women of color in the context of social inequalities and human rights

This article examines relationships among social inequality, drug use, and HIV risk for women of color in the United States and South Africa. In the first section, social and cultural factors that may place women of color at risk for drug use and exposure to HIV are identified. In the second section, lessons learned while developing HIV prevention research protocols for women of color in South Africa are presented and discussed. Experience suggests that to effectively address women's risks of drug use and AIDS requires specific theoretical models and methodological approaches that acknowledge the critical interface that may exist among social inequality, drug use, and AIDS risk for women worldwide. Successful HIV prevention and intervention programs for women of color worldwide also require international research partnerships that are based on mutual respect between partners and attention to the needs and priorities of the target populations.

Getting to Social Action: The Youth Empowerment Strategies (YES!) Project

This article describes the social action component of the Youth Empowerment Strategies (YES!) project funded by the Centers for Disease Control and Prevention through its community-based prevention research (CBPR) initiative. YES! is designed to promote problem-solving skills, social action, and civic participation among underserved elementary and middle school youth. The after-school program focuses on identifying and building youths' capacities and strengths as a means of ultimately decreasing rates of alcohol, tobacco, and other drug use and other risky behaviors. The article discusses the conceptual models of risk and intervention and factors contributing to successful social action work, including group dynamics, intragroup leadership, facilitator skills, and school-community contexts. Attention is focused on how the nature of the projects themselves played a key role in determining the likelihood of experiencing success. Implications and recommendations for other youth-focused empowerment education projects are discussed, including the effective use of Photovoice in such projects.

A comparative study of mortality among Puerto Rican injection drug users in East Harlem, New York, and Bayamon, Puerto Rico

Drug users have been found to be at high risk of mortality but the mortality experience of Hispanic drug users remains understudied. This study assessed mortality among Puerto Rican injection drug users (IDUs) in New York City (NY), and in Puerto Rico (PR). Study subjects were 637 IDUs from NY and 319 IDUs from PR. Mortality was ascertained using data from the National Death Index. Annual mortality rate of the NY cohort was 1.3 per 100 person years compared to the PR cohort with a rate of 4.8. Compared to the Hispanic population of New York City, the standardized mortality ratio (SMR) of the NY cohort was 4.4. Compared to the population of Puerto Rico, the SMR of the PR cohort was 16.2. The four principal causes of death were: NY-HIV/AIDS (50.0%), drug overdoses (13.3%), cardiovascular conditions (13.3%), and pulmonary conditions (10.0%); PR-HIV/AIDS (37.0%), drug overdoses (24.1%), sepsis (13.0%), and homicide (11.1%). Modeling time to death using Cox proportional hazards regression, the relative risk of mortality of the PR cohort as compared to the NY cohort was 9.2. The other covariates found to be significantly associated with time to death were age, gender, education, social isolation, intoxication with alcohol, and HIV seropositivity. The large disparity in mortality rates found in this study suggests that health disparities research should be expanded to identify intra-group disparities. Furthermore, these results point to an urgent need to reduce excess mortality among IDUs in Puerto Rico.

[Violence is also a public health issue]

In 1996, the World Health Organization declared violence a major and growing public health problem across the world. In Spain, despite the growing incidence of reports of deaths and abuse due to intimate partners violence; the emergent data on school-based violence among children and adolescents; the persisting political violence and the tragic experience of the 11-M attacks in Madrid; a clear positioning over the role of the public health structures in the study and intervention of violence has not taken place. This article provides a characterization of the impact of violence in the health of its victims, as derived from a non-systematic review of the clinical, psychological and social literature. It also includes some prevalence data from Spanish studies. Special emphasis is given to violence against women, and political violence. The article highlights the scarcity of epidemiological data, which hinders the assessment of the health impact of violence in Spain. It brings, instead, the opinions of a number of public health professionals over the role of the Spanish communities of epidemiology and public health in this matter. The article concludes with a call to public health professionals, including the Spanish scientific societies involved in public health, to facilitate the public debate leading to the definition of the role of the Spanish public health in the understanding and reduction of the impact of violence on the health of its victims.

Health behavior change models and their socio-cultural relevance for breast cancer screening in African American women

Models of health behavior provide the conceptual bases for most of the breast cancer screening intervention studies. These models were not designed for and have not been adequately tested with African American women. The models discussed in this paper are: The Health Belief Model, the Theory of Reasoned Action/Theory of Planned Behavior, and the Transtheoretical Model. This paper will examine the socio-cultural relevance of these health behavior models, and discuss specific socio-cultural dimensions that are not accounted for by these paradigms. It is critical that researchers include socio-cultural dimensions, such as interconnectedness, health socialization, ecological factors and health care system factors into their intervention models with African American women. Comprehensive and socio-culturally based investigations are necessary to guide the scientific and policy challenge for reducing breast cancer mortality in African American women.

Quality of life of African-American and white long term breast carcinoma survivors

BACKGROUND

Increasingly, the quality of life (QOL) of women diagnosed with breast carcinoma is being studied. However, there is little information regarding long term survivors among ethnic minority women. The purpose of this study was to describe the QOL of long term breast carcinoma survivors (BCS) and to examine the role of ethnicity in influencing their well-being.

METHODS

The authors conducted a mailed survey to examine QOL, health perceptions, and life stress among long term BCS. Subjects diagnosed between 1989 and 1990 were identified among respondents to a prior study who were originally recruited from the California Tumor Registry. This survey instrument included standard measures of QOL (e.g., the RAND SF-36 Health Perceptions Scale, the Cancer Rehabilitation and Evaluation Survey-Short Form [CARES-SF], and the Ladder of Life) and new items.

RESULTS

Two hundred and seventy-eight women participated; 117 were African-American, and 161 were white. The initial univariate evaluation of the CARES-SF and the RAND SF-36 Health Perceptions Scale suggested potential ethnicity-related differences in QOL. To control for various medical and demographic characteristics and to examine the potential relation between ethnicity and QOL, multiple regression analyses were conducted. The final model accounted for 45% (R-square = 0.450) of the variance in QOL with general health perception, life stress, income, partnership status, and comorbid conditions included in the model.

CONCLUSIONS

The results of this study suggest that, overall, BCS report favorable health-related QOL. Differences in QOL outcomes are attributable to socioeconomic and life-burden factors and not to ethnicity.

Assessing health in an urban neighborhood: community process, data results and implications for practice

This article examines the community process and data results of a health assessment conducted in an urban neighborhood of a middle-size city in Western Massachusetts. It describes the four-stage development process of the Health Assessment Project (HAP), a collaboration of the UMASS School of Public Health faculty and students, community based organizations and youth residents: (1) planning with a contemporary participatory approach, (2) implementing the data collection with traditional survey methodology, (3) tailoring the data analysis for a presentation at a community forum and report, and (4) incorporating the community's reaction to data results. In addition, it presents selected data results on health conditions of individual household members and perceived community health concerns and resources. Salient data results include high rates of chronic health conditions such as asthma and other respiratory problems among residents 0-18, back pain and other musculoskeletal among younger adults 19-54, and high blood pressure and other cardi-circulatory problems among older adults age 55 and older. The three most prevalent perceived community concerns are substance abuse, gangs and drug dealing. Identified community resources include sources of (1) providers of primary care, (2) health information as family/friends and Spanish media, (3) social activity such as churches and schools. Finally, this paper concludes by discussing implications for community health practice.

Breaking the cycle of violence among youth living in metropolitan Atlanta: a case history of kids alive and loved

More teenagers in the United States die from gunshot wounds than from all natural causes of disease combined. Firearm-related mortality accounts for almost half of all deaths among African American teens. Residents of central cities have the highest probability of experiencing violent crimes. This article describes an innovative community-based intervention designed to break the cycle of violence among youth in metropolitan Atlanta. The intervention, Kids Alive and Loved (KAL), emerged from the African American community as one mother's response to the violent death of her 17-year-old son. The authors describe how her response to tragedy gave birth to a culturally appropriate intervention for youth exposed to violence. This article delineates the evolution of KAL, the role of community partners in the design of the intervention, and how diffusion of innovation theory has implications for understanding the KAL approach to breaking the cycle of violence.

A framework for: what can and should society do?

Researchers strive to better understand the critical periods of brain development. Findings generate clearer descriptions of what the critical periods are and suggest that stress, aggression, and violent behavior affect the development process. But the question remains as to what can and should society do to nurture children through these periods and to support their continued growth and development. Operation Peace in Philadelphia, an urban community-based, violence prevention/reduction initiative using the principals of public health, represents a framework for generating fresh attitudes and innovative support systems that will nurture children through the critical periods of brain development and beyond. This framework enhances understanding of the complexities of societal issues such as violent behavior and uncovers and offers communal solutions. It is a link between research and its practical application--what society can do. Society's challenge echoes Operation Peace's challenge to use the combined strengths of scientific knowledge, multidisciplinary skills, sustained commitment, cultural vitality, community support, and political will to enable youth to achieve their potential, via full and active lives.