A Matter of Time: Racialized Time and the Production of Health Disparities

An expansive and methodologically varied literature designed to investigate racial disparities in health now exists. Empirical evidence points to an overlapping, complex web of social conditions that accelerate the pace of aging and erodes long-term health outcomes among people of color, especially Black Americans. However, a social exposure-or lack thereof-that is rarely mentioned is time use. The current paper was specifically designed to address this shortcoming. First, we draw on extant research to illustrate how and why time is a critical source of racial disparities in health. Second, we employ fundamental causes theory to explain the specific mechanisms through which the differential distribution of time across race is likely to give rise to unequal health outcomes. Finally, we introduce a novel conceptual framework that identifies and distinguishes between four distinct forms of time use likely to play an outsized role in contributing to racial disparities in health.

Intersectional Stigma as a Fundamental Cause of Health Disparities: A case study of how drug use stigma intersecting with racism and xenophobia creates health inequities for Black and Hispanic persons who use drugs over time

Recent evidence points to racial and ethnic disparities in drug-related deaths and health conditions. Informed by stigma, intersectionality, intersectional stigma, and fundamental cause theories, we aimed to explore whether intersectional stigma was a fundamental cause of health. We document key events and policies over time and find that when progress is made new mechanisms emerge that negatively affect health outcomes for Black and Hispanic persons. We then focus on intersectional stigma targeting Black and Hispanic persons who use drugs. We document that when a person, or group of people, occupy multiple stigmatized identities the processes of stigmatization and scapegoating are particularly persistent and pernicious since people and groups can be stigmatized and scapegoated on varying intersections. We propose that an intersectional stigma framework allows for a better understanding of observed patterns over time, thereby providing a better guide for policies and interventions designed to reduce disparities. As a framework, intersectional stigma aims to recognize that when different sources of stigma collide, a new set of circumstances is created for those who reside in the intersection. We conclude that intersectional stigma is a fundamental cause of health inequities and provide policy recommendations aimed at dismantling intersectional stigma processes and mitigating the effects of intersectional stigmas to ultimately promote better health outcomes for Black and Hispanic persons who use drugs.

Sanctuary city policies and Latinx immigrant mental health in California

This quasi-experimental study examined whether "sanctuary city" policies are an effective mechanism for reducing mental health inequalities by immigrant origin status in Latinx populations in California. Ample evidence indicates that people experience mental health problems when restrictive immigration policies are imposed. It remains unclear whether sanctuary city policies can improve population mental health in the groups targeted by restrictive immigration policies: undocumented immigrant Latinxs, documented immigrant Latinxs, and native-born Latinxs. We combined data on California's 482 cities concerning whether and when they implemented a sanctuary policy with health data on approximately 142,000 adults, 6400 adolescents and 13,000 children from the multi-year California Health Interview Survey. After using propensity score matching to identify non-sanctuary cities comparable to sanctuary cities, we estimated respondent-level difference-in-differences models to determine whether sanctuary city policies had beneficial mental health effects on three age groups: adults, adolescents, and children during the period 2007-2018. There was a trend toward improved mental health in sanctuary cities after policy enactment, but the patterns of mental health in the three Latinx immigration sub-groups of each age group did not conform to our hypotheses. Buffering the adverse effects of harsh federal immigration policies may need to involve other approaches, such as expanded local mental health care access. We discuss these results in terms of alternative treatment interference, residents' policy awareness, the policy's capacity to address past health impacts, methodological issues, and potential policy momentum.

The Long Arm of Prospective Childhood Income for Mature Adult Health in the United States

Pioneering scholarship links retrospective childhood conditions to mature adult health. We distinctively provide critical evidence with prospective state-of-the-art measures of parent income observed multiple times during childhood in the 1970s to 1990s. Using the Panel Study of Income Dynamics, we analyze six health outcomes (self-rated health, heart attack, stroke, life-threatening chronic conditions, non-life-threatening chronic conditions, and psychological distress) among 40- to 65-year-olds. Parent relative income rank has statistically and substantively significant relationships with five of six outcomes. The relationships with heart attack, stroke, and life-threatening chronic conditions are particularly strong. Parent income rank performs slightly better than alternative prospective and retrospective measures. At the same time, we provide novel validation on which retrospective measures (i.e., father's education) perform almost as well as prospective measures. Furthermore, we inform several perennial debates about how relative versus absolute income and other measures of socioeconomic status and social class influence health.

Conservative treatment versus reversed shoulder prothesis for proximal humerus fractures in the elderly: A meta-analysis of observational studies and randomised clinical trials

Objective

The treatment of complex proximal humerus fractures in elderly patients is not yet fully eluci-dated. Of all treatment options reverse shoulder arthroplasty (RSA) and non operative treat-ment (NOT) appear to provide the best results. Evidence to guide the choice between the two is sparse. Therefore, this review provides an overview of the available evidence on RSA versus non-operative treatment.

Methods

Studies comparing RSA and NOT were included for direct comparison by systematic re-view and pooled analysis for patient rated outcome and range of motion. Additionally, indirect comparison of case-series and non-comparative studies on either treatment modalities was performed separately.

Results

Comparative: Reverse shoulder arthroplasty resulted in better patient rated outcome scores and better range of motion. Pain and treatment satisfaction scores were better after RSA. Non comparative studies reported similar patient rated and range of motion scores for both RSA and after NOT.

Conclusion

The functional and range of motion outcomes after RSA seem satisfactory and potentially superior to NOT in elderly patients. The complication rate is acceptably low and an overall revision rate of 5% was found. These results should however be viewed in light of distinct differences in patient characteristics between treatment groups.

Comparing different operationalizations of allostatic load measured in mid-life and their patterning by race and cumulative life course socioeconomic status

Since its conceptualization, there has been a lack of consensus on the best way to operationalize allostatic load (AL). As a marker of the cumulative, physiological wear and tear on the body resulting from chronic exposure to stressors, it follows that AL should be higher among people who have faced more stressful life experiences. Thus, the purpose of this study was to construct AL scores using different operationalizations and, as a measure of construct validity, compare whether each construction produced expected disparities in AL by race and a composite socioeconomic status (SES) variable which accounts for measures over the life course; we also explored differences by sex. We conducted the study in a sample of 45-52-year-old offspring from the Child Health and Development Studies, a longitudinal birth cohort established in the early 1960s. AL scores were constructed in 6 different ways and included 10 biomarkers from inflammatory, neuroendocrine, cardiovascular, and metabolic systems. Our main approach to constructing AL was to sum across high-risk biomarker quartiles, correct for medication use, and use sex-specific high-risk quartiles for specific biomarkers. Alternative constructions did not use sex-specific quartiles and/or weighted biomarkers within subsystems and/or did not correct for medication use. We estimated differences in AL scores by race, SES, sex and their pairwise interactions. All constructions of AL, including the main approach, produced expected disparities by race (higher scores for Black vs. non-Black participants) and life course SES (higher scores for low vs. high SES participants). However, disparities by sex only emerged when the AL score was constructed via approaches that did not use sex-specific high-risk quartiles; for these alternative constructions, overall, female participants had higher AL scores than male participants and Black female participants had the highest AL scores in the sample. For most constructions, the pairwise interaction between sex and SES, showed a stronger disparity in AL scores between low and high-SES female compared with low- and high-SES male participants; this suggests that, in terms of lowering AL, high life course SES may be more important for female than male participants. In conclusion, our results suggest that the basic AL concept is consistently expressed in different operationalizations, making it an especially useful and robust tool for understanding disparities by race and SES.

ORIF versus nailing for humeral shaft fractures: A meta-analysis and systematic review of randomised clinical trials and observational studies

Objective

This meta-analysis aims to compare open reduction and internal fixation with a plate (ORIF) versus nailing for humeral shaft fractures in terms of healing, complications, general quality of life and shoulder/elbow function.

Methods

PubMed/Medline/Embase/CENTRAL/CINAHL was searched for both randomised clinical trials (RCT) and observational studies comparing ORIF with nailing for humeral shaft fractures. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio (OR) or risk difference (RD) with corresponding 95% confidence interval (95%CI). Subgroup analysis was performed stratified by study design (RCTs and observational studies).

Results

A total of ten RCT's (525 patients) and eighteen observational studies (4906 patients) were included. The effect estimates obtained from observational studies and RCT's were similar in direction and magnitude. More patients treated with nailing required re-intervention (RD: 2%; OR 2.0, 95%CI 1.0 – 3.8) with shoulder impingement being the most predominant indication (17%). Temporary radial nerve palsy secondary to operation occurred less frequently in the nailing group (RD: 2%; OR 0.4, 95% CI 0.3 – 0.6). Notably, all but one of the radial nerve palsies resolved sponta-neously in each groups. Nailing leads to a faster time to union (mean difference: -1.9 weeks, 95%CI -2.9 – -0.9), lower infection rate (RD: 2%; OR: 0.5, 95%CI 0.3 – 0.7) and shorter operation duration (mean difference: -26 minutes, 95%CI -37 – -14). No differences were found regarding non-union, general quality of life, functional shoulder scores, and total upper extremity scores.

Conclusion

Nailing carries a lower risk of infection, postoperative radial nerve palsy, shorter operation duration, and time to union. Absolute differences, however, are small and almost all patients with radial nerve palsy recovered spontaneously. Satisfactory results can be achieved with both treatment modalities and both techniques have their inherent pros and cons.

Impact of Police Violence on Mental Health: A Theoretical Framework

Police violence has increasingly been recognized as a public health concern in the United States, and accumulating evidence has shown police violence exposure to be linked to a broad range of health and mental health outcomes. These associations appear to extend beyond the typical associations between violence and mental health, and to be independent of the effects of co-occurring forms of trauma and violence exposure. However, there is no existing theoretical framework within which we may understand the unique contributions of police violence to mental health and illness.This article aims to identify potential factors that may distinguish police violence from other forms of violence and trauma exposure, and to explore the possibility that this unique combination of factors distinguishes police violence from related risk exposures. We identify 8 factors that may alter this relationship, including those that increase the likelihood of overall exposure, increase the psychological impact of police violence, and impede the possibility of coping or recovery from such exposures.On the basis of these factors, we propose a theoretical framework for the further study of police violence from a public mental health perspective.

Urban upbringing and psychotic experiences in the United States: A racial and geographic comparison

Urban upbringing has been associated with greater risk for psychotic experiences, though research is needed to confirm whether this is true in the U.S., and whether the association depends on race, type of experience, and region of the country. We analyzed data from the National Comorbidity Survey Replication (White respondents only) and the National Survey of American Life (Black respondents). Multivariable logistic regression models found that urban upbringing was not significantly associated with lifetime psychotic experiences for Whites, but was significantly associated with lower odds for Blacks, adjusting for socio-demographic covariates and common mental disorders. Rural upbringing was associated with greater odds of lifetime auditory hallucinatory experiences for Blacks. Exploratory analyses suggested growing up in a large city or 'other' environment were associated with greater odds of lifetime psychotic experiences among Whites currently residing in the Northeast, but lower odds among Whites residing in the South. For Blacks currently residing in the West, rural upbringing was associated with significantly greater odds of lifetime psychotic experiences when compared with growing up in a large city. White and Blacks may have different lived experiences in urban and rural settings, calling for more race- and location- specific research to explain these diverging patterns.

Stigmatize the use, not the user? Attitudes on opioid use, drug injection, treatment, and overdose prevention in rural communities

Stigma is a known barrier to treating substance use disorders and dramatically diminishes the quality of life of people who use drugs (PWUD) nonmedically. Stigma against PWUD may be especially pronounced in rural areas due to their decreased anonymity and residents' limited access, or resistance, to "neutralizing" information on factors associated with drug use. Stigma often manifests in the attitudes of professionals whom stigmatized individuals regularly interact with and often materially impact. We analyzed interviews conducted between July 2018 and February 2019 with professional stakeholders in rural southern Illinois who interact with PWUD, specifically those who use opioids nonmedically or who inject drugs (n = 30). We further analyzed interview data from a complementary PWUD sample (n = 22). Interviews addressed perspectives around nonmedical drug use and treatment/harm reduction, with analysis centered around the Framework Integrating Normative Influences on Stigma and its focus on micro, meso and macro level stigmatization processes. Stakeholder participants included professionals from local law enforcement, courts, healthcare organizations, emergency management services, and faith-based and social services organizations. Most stakeholders, particularly law enforcement, negatively perceived PWUD and nonmedical drug use in general, questioned the character, agency and extrinsic value of PWUD, and used labels (e.g. "addict," "abuser," etc.) that may be regarded as stigmatizing. Further, most respondents, including PWUD, characterized their communities as largely unaware or dismissive of the bio-medical and sociocultural explanations for opioid use, drug injection and towards harm reduction services (e.g., syringe exchanges) and naloxone, which were frequently framed as undeserved usages of taxpayer funds. In conclusion, rural stigma against PWUD manifested and was framed as a substantial issue, notably activating at micro, meso and macro levels. Stigma prevention efforts in these communities should aim to improve public knowledge on the intricate factors contributing to opioid use and drug injection and harm reduction programming's moral and fiscal value.

'Mothers moving towards empowerment' intervention to reduce stigma and improve treatment adherence in pregnant women living with HIV in Botswana: study protocol for a pragmatic clinical trial

BACKGROUND

With high rates of HIV and multiple vulnerable subgroups across diverse settings, there is a need for culturally based, HIV stigma reduction interventions. Pregnant women who are living with HIV are especially in need of services to protect not only their own but also their children's lives. Uptake of HIV services worldwide is hindered by stigma towards persons living with HIV/AIDS. While cultural context plays a key role in shaping HIV stigma, these insights have not yet been fully integrated into stigma reduction strategies. By utilizing the "What Matters Most" stigma framework, we propose that an intervention to counter culturally salient aspects of HIV stigma will improve treatment adherence and other relevant outcomes. A pragmatic clinical trial in Botswana will evaluate the "Mothers Moving towards Empowerment" (MME) intervention, which seeks to address HIV stigma in Botswana and to specifically engage pregnant mothers so as to promote antiretroviral therapy (ART) adherence in the postpartum period.

METHODS

This study will test MME against treatment as usual (TAU) among pregnant mothers diagnosed with HIV and their infants. Outcomes will be assessed during pregnancy and 16 weeks postpartum. Women who meet eligibility criteria are assigned to MME or TAU. Women assigned to MME are grouped with others with similar estimated delivery dates, completing up to eight intervention group sessions scheduled before week 36 of their pregnancies. Primary outcomes among mothers include (i) reducing self-stigma, which is hypothesized to mediate improvements in (ii) psychological outcomes (quality of life, depression and social functioning), and (iii) adherence to antenatal care and ART. We will also examine a set of follow-up infant birth outcomes (APGAR score, preterm delivery, mortality (at < 16 weeks), birth weight, vaccination record, and HIV status).

DISCUSSION

Our trial will evaluate MME, a culturally based HIV stigma reduction intervention using the "What Matters Most" framework, to reduce stigma and improve treatment adherence among pregnant women and their infants. This study will help inform further refinement of MME and preparation for a future large-scale, multisite, randomized controlled trial (RCT) in Botswana.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03698981 . Registered on October 8, 2018.

Association of Exposure to Police Violence With Prevalence of Mental Health Symptoms Among Urban Residents in the United States

IMPORTANCE

Police violence is reportedly widespread in the United States and may pose a significant risk to public mental health.

OBJECTIVE

To examine the association between 12-month exposure to police violence and concurrent mental health symptoms independent of trauma history, crime involvement, and other forms of interpersonal violence exposure.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional, general population survey study of 1221 eligible adults was conducted in Baltimore, Maryland, and New York City, New York, from October through December 2017. Participants were identified through Qualtrics panels, an internet-based survey administration service using quota sampling.

EXPOSURES

Past 12-month exposure to police violence, assessed using the Police Practices Inventory. Subtypes of violence exposure were coded according to the World Health Organization domains of violence (ie, physical, sexual, psychological, and neglectful).

MAIN OUTCOMES AND MEASURES

Current Kessler Screening Scale for Psychological Distress (K6) score, past 12-month psychotic experiences (World Health Organization Composite International Diagnostic Interview), and past 12-month suicidal ideation and attempts.

RESULTS

Of 1221 eligible participants, there were 1000 respondents (81.9% participation rate). The sample matched the adult population of included cities on race/ethnicity (non-Hispanic white, 339 [33.9%]; non-Hispanic black/African American, 390 [39.0%]; Hispanic/Latino, 178 [17.8%]; other, 93 [9.3%]), age (mean [SD], 39.8 [15.2] years), and gender (women, 600 [60.0%]; men, 394 [39.4%]; transgender, 6 [0.6%]) within 10% above or beyond 2010 census distributions. Twelve-month prevalence of police violence was 3.2% for sexual violence, 7.5% for physical violence without a weapon, 4.6% for physical violence with a weapon, 13.2% for psychological violence, and 14.9% for neglect. Police violence exposures were higher among men, people of color, and those identified as homosexual or transgender. Respondents reported suicidal ideation (9.1%), suicide attempts (3.1%), and psychotic experiences (20.6%). The mean (SD) K6 score was 5.8 (6.1). All mental health outcomes were associated with police violence exposure in adjusted logistic regression analyses. Physical violence with a weapon and sexual violence were associated with greater odds of psychotic experiences (odds ratio [95% CI]: 4.34 [2.05-9.18] for physical violence with a weapon; 6.61 [2.52-17.36] for sexual violence), suicide attempts (odds ratio [95% CI]: 7.30 [2.94-18.14] for physical violence with a weapon; 6.63 [2.64-16.64] for sexual violence), and suicidal ideation (odds ratio [95% CI]: 2.72 [1.30-5.68] for physical violence with a weapon; 3.76 [1.72-8.20] for sexual violence).

CONCLUSIONS AND RELEVANCE

Police violence was commonly reported, especially among racial/ethnic and sexual minorities. Associations between violence and mental health outcomes did not appear to be explained by confounding factors and appeared to be especially pronounced for assaultive forms of violence.

Understanding stigma as a barrier to accessing cancer treatment in South Africa: implications for public health campaigns

Introduction

Cancer contributes to significant illness burden in South Africa, with delayed diagnosis resulting from limited knowledge of cancer, lack of biomedical treatment and stigma. This study examines ways in which people are identified as having cancer through perspectives of traditional healing or the biomedical model. Additionally, we sought to understand the stigma associated with cancer, including stereotypes, anticipated discrimination and coping styles.

Methods

Livestrong Foundation conducted 11 semi-structured focus groups with key community stakeholders in three South African townships. Interviews examined the negative consequences of being labeled with a cancer diagnosis as well as causes of, possible prevention of and barriers and methods to improve access to cancer treatment. Analyses were completed using directed content analysis.

Results

Revealed three main labeling mechanisms: physical appearance of perceived signs/symptoms of cancer, diagnosis by a traditional healer, or a biomedical diagnosis by a Western physician. Being labeled led to anticipated discrimination in response to prevalent cancer stereotypes. This contributed to delayed treatment, use of traditional healers instead of biomedical treatment and secrecy of symptoms and/or diagnosis. Further, perceptions of cancer were commonly conflated with HIV/TB owing to prior educational campaigns.

Conclusion

Our study deepens the understanding of the cancer labeling process in South Africa and the resulting negative effects of stigma. Future anti-stigma interventions should partner with traditional healers due to their respected community status and consider how previous health interventions may significantly impact current understandings of illness.

Psychotic Experiences in the Context of Police Victimization: Data From the Survey of Police-Public Encounters

Social defeat has been proposed as the common mechanism underlying several well-replicated risk factors for sub-threshold psychotic experiences (PEs) identified in epidemiological research. Victimization by the police may likewise be socially defeating among vulnerable individuals and, therefore, may be associated with elevated risk for PEs. However, no prior studies have examined the relation between police victimization and PEs. We tested the hypothesis that exposure to police victimization (ie, physical, sexual, psychological, and neglect) would be associated with increased odds for PEs in the Survey of Police-Public Encounters data (N = 1615), a general population sample of adults from 4 US cities. Respondents who reported each type of police victimization were more likely to report PEs in logistic regression analyses (all P < .01), most of which were significant even when adjusting for demographic variables, psychological distress, and self-reported crime involvement (adjusted OR range: 1.30 to 7.16). Furthermore, the prevalence of PEs increased with greater exposure to police victimization in a linear dose-response relation, OR (95% CI) = 1.44 (1.24-1.66). These findings suggest that police victimization is a clinically important and previously unreported risk factor for PEs in the urban US population. These findings support the need for community-based outreach efforts and greater police training to reduce the prevalence of this exposure, particularly in socially disadvantaged urban communities.

The Symptoms of Trauma Scale (SOTS): Psychometric evaluation and gender differences with adults diagnosed with serious mental illness

A new clinician rating measure, the Symptoms of Trauma Scale (SOTS), was administered to adult psychiatric outpatients (46 men, 47 women) with severe mental illness who reported a history of trauma exposure and had recently been discharged from inpatient psychiatric treatment. SOTS composite severity scores for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, posttraumatic stress disorder (PTSD), complex PTSD (cPTSD), and total PTSD/cPTSD severity had acceptable internal consistency reliability. SOTS scores' construct and convergent validity was supported by correlations with self-report measures of childhood and adult trauma history and PTSD, dissociation, and anger symptoms. For men, SOTS scores were associated with childhood sexual and emotional abuse and self-reported anger problems, whereas for women SOTS scores were most consistently and strongly associated with childhood family adversity and self-reported PTSD symptoms. Results provide preliminary support for the reliability and validity of the SOTS with adults with severe mental illness and suggest directions for replication, measure refinement, and research on gender differences.

Stigma as an Unrecognized Determinant of Population Health: Research and Policy Implications

Stigma processes play an underrecognized role in the distribution of life chances, influencing health through the production of disadvantage and the induction of stress. Policies enact stigma processes, mitigate them, or ignore them. If each of these two statements is correct, the intersection of stigma and policy demands our attention. We propose a change of perspective from an approach that considers one stigmatized status and one outcome at a time to a perspective that considers the full range of stigmatized statuses and outcomes so as to reveal stigma's full impact. Concerning the second statement, literature addressing "structural stigma" provides compelling evidence that policy enacts stigma and harms health in some circumstances and mitigates stigma and improves health in others. In addition to the effects of active policies, we also bring attention to policy inattention-doing nothing. A core feature of stigma is a discounting-a mattering less-that allows and even fosters policy inattention toward the concerns of stigmatized groups. We end by engaging David Mechanic and Linda H. Aiken's ideas concerning how social science influences policy by changing how people think about problems and hope that our consideration of stigma and policy might ultimately have such a consequence.

Homelessness among a nationally representative sample of US veterans: prevalence, service utilization, and correlates

PURPOSE

To examine the prevalence of lifetime homelessness among veterans and use of Veterans Affairs (VA) homeless services, as well as their association with sociodemographic and clinical characteristics.

METHODS

A nationally representative sample of 1533 US veterans was surveyed July-August 2015.

RESULTS

Among all veterans, 8.5 % reported any lifetime homelessness in their adult life, but only 17.2 % of those reported using VA homeless services. Prevalence of homelessness and VA homeless service use did not significantly differ by gender. Being low income, aged 35-44, and having poor mental and physical health were each independently associated with lifetime homelessness. Veterans who were White or lived in rural areas were significantly less likely to have used VA homeless services.

CONCLUSIONS

Homelessness remains a substantial problem across different generations of veterans. The low reported uptake of VA homeless services suggests there are barriers to care in this population, especially for veterans who live in rural areas. Governmental resources dedicated to veteran homelessness should be supported, and obtaining accurate prevalence estimates are important to tracking progress over time.

Caregiver burden as a predictor of depression among family and friends who provide care for persons with bipolar disorder

OBJECTIVES

Over one-third of caregivers of people with bipolar disorder report clinically significant levels of depressive symptoms. This study examined the causal relationship between depression and caregiver burden in a large sample of caregivers of adult patients with bipolar disorder.

METHODS

Participants were 500 primary caregivers of persons with bipolar disorder enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).This study evaluates the strength and direction of the associations between caregiver burden and depressive symptoms at baseline and at six- and 12-month follow-up using cross-lagged panel analyses, controlling for the clinical status of patients and sociodemographic variables.

RESULTS

Higher levels of overall caregiver burden at baseline were associated with increased levels of depressive symptoms among caregivers at follow-up (F = 8.70, df = 1,290, p < 0.001), after controlling for baseline caregiver depression, gender, race, age, social support, and patients' clinical status. By contrast, caregiver depression at baseline was not significantly associated with caregiver burden at follow-up (F = 1.65, p = 0.20).

CONCLUSIONS

Caregiver burden is a stronger predictor of caregiver depressive symptoms over time than the reverse. Interventions that help alleviate caregiver burden may decrease depressive symptoms.

The association of BMI and social distance towards obese individuals is mediated by sympathy and understanding

The desire for social distance towards individuals with obesity as part of the stigmatization process has not been investigated. The aims of this study include: (a) determining the prevalence of social distance and its domains in a population-based sample; (b) reporting levels of emotional response; and (c) investigating the association of BMI, emotional response and social distance. The data were derived from a large population based telephone survey in Germany (total n = 3,003, this sub-sample n = 1008). Emotional response to individuals with obesity was assessed for the emotions discomfort, pity, insecurity, amusement, sympathy, help and incomprehension (5-point Likert scale). Social distance was measured on a 5-point Likert scale covering different areas of social interaction. This served as the dependent variable for a linear regression model and mediation models that included BMI and emotional response. Social distance was highest for job recommendation, introduction to a friend, someone with obesity marrying into the family and renting out a room. Means of emotional responses were highest for pity (Mean = 2.58), sympathy (Mean = 2.87) and wanting to help (M = 2.76). In regression analyses, incomprehension (b = 1.095, p < 0.001) and sympathy (b = -0.833, p < 0.001) and the respondents' own BMI (b = -0.145, p < 0.001) were significantly associated to the overall amount of social distance. Mediation models revealed a significant mediation effect of BMI through sympathy (b = -0.229, % of total effect through mediation = 10.3%) and through incomprehension (b = -0.057, % of total effect through mediation = 27.5%) on social distance. Social distance towards individuals with obesity is prevalent in the general public in Germany and it is associated with emotional responses. Altering the emotional responses may, therefore, be a starting point in anti-stigma interventions. Evoking sympathy and lowering incomprehension may result in lower overall social distance.

Use of psychotropic medication groups in people with severe mental illness and stressful childhood experiences

Stressful childhood experiences (SCE) are associated with a variety of health and social problems. In people with severe mental illness (SMI) traumatic childhood experiences have been linked to more severe and treatment refractory forms of psychiatric symptoms, including psychotic symptoms. This study evaluates the use of psychotropic medication groups in a population of people with SMI and SCE, testing the association between SCE and prescription medication in an SMI population. A sample of 183 participants with SMI was divided into 2 exposure groups: high SCE (4 to 7 categories of SCE) and low SCE (0 to 3 categories of SCE). Both groups were compared in regard to prescribed dosing of psychotropic medications (antipsychotics, mood stabilizers, antidepressants, and anxiolytics/hypnotics). Participants who endorsed high SCE received higher doses of antipsychotic medications and mood stabilizers than those with low exposure. The results demonstrate that people with higher SCE categories received a higher dosing of psychotropic medication, specifically antipsychotic medication and mood stabilizers.

A theoretical and empirical framework for constructing culture-specific stigma instruments for Chile

Different cultural contexts contribute to substantial variation in the stigma faced by people with psychosis globally. We propose a new formulation of how culture affects stigma to create psychometrically-validated tools to assess stigma's culture-specific effects. We propose to construct culture-specific stigma measures for the Chilean context via: 1) open-ended administration of 'universal' stigma scales to a sample of individuals with psychosis, relatives, and community respondents; 2) qualitative analyses to identify how culture shapes stigma and to derive initial 'culture-specific' stigma items; 3) construction and pilot-testing of final 'culture-specific' stigma measures; 4) initial psychometric validation among a sample of individuals with psychosis. We identify initial hypotheses for how stigma might threaten the capacities to participate in fundamental activities that 'matter most' in the Chilean context. These include mental illness stigma threatening the man's ability to protect the honor of the family, and the woman's ability to be a 'holy and pure' mother. Mental illness stigma may further endanger the ability of the family to uphold reciprocal obligations within their social network. Developing such measures promises to aid efforts to address culture-specific forms of stigma, and to facilitate implementation of community mental health services, in Chile and other Latin American contexts.

Fresh Start: a multilevel community mobilization plan to promote youth development and prevent violence

While much has been written about community mobilization for health, few detailed expositions of the formation of community mobilization, especially focused on youth violence prevention exist. The Columbia Center for Youth Violence Prevention, in collaboration with the UNIDOS Inwood Coalition, developed a Community mobilization plan to guide youth violence prevention in Inwood. The plan was developed within the context of an evidence-based organizing framework-Communities that Care (CTC) and takes a multi-level approach to service coordination that includes activities at the Individual, Family, Block, Organizational and Built Environment levels. This article describes how the Community mobilization plan was created, illustrates the use of evidence-based practices to lead to the development of the plan, outlines the plan's community/organizational activities, and summarizes the principles and processes that can be replicated in other communities seeking to start their own community mobilization efforts to reduce youth violence.

Evaluation of Client Services (ECS): a measure of treatment satisfaction for people with chronic mental illnesses

This article describes the development and psychometric assessment of the Evaluation of Client Services (ECS) measure of treatment satisfaction for people with chronic mental illnesses in community treatment settings. The ECS, a 20-item instrument, was validated in a sample of 184 individuals receiving outpatient mental health treatment in New York City. The four dimensions of the ECS, (1) treatment management and treatment outcome, (2) treatment relationship, (3) communication and information exchange, and (4) reachability of treatment facilities are internally consistent and stable over time. Analyses also show that the ECS is a valid indicator of satisfaction with mental health services which meaningfully correlates with quality of life and another measure of treatment satisfaction. The ECS is a brief and easy to understand treatment satisfaction tool with good psychometric properties.

Stigma and treatment for alcohol disorders in the United States

Among a nationally representative sample of adults with an alcohol use disorder, the authors tested whether perceived stigmatization of alcoholism was associated with a lower likelihood of receiving alcohol-related services. Data were drawn from a face-to-face epidemiologic survey of 34,653 adults interviewed in 2004-2005 who were aged 20 years or older and residing in households and group quarters in the United States. Alcohol abuse/dependence was diagnosed by using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, version (AUDADIS-IV). The stigma measure used was the Perceived Devaluation-Discrimination Scale. The main outcome was lifetime intervention including professional services and 12-step groups for alcohol disorders. Individuals with a lifetime diagnosis of an alcohol use disorder were less likely to utilize alcohol services if they perceived higher stigma toward individuals with alcohol disorders (odds ratio = 0.37, 95% confidence interval: 0.18, 0.76). Higher perceived stigma was associated with male gender (β = -0.75; P < 0.01), nonwhite compared with non-Hispanic white race/ethnicity, lower income (β = 1.0; P < 0.01), education (β = 1.48; P < 0.01), and being previously married (β = 0.47; P = 0.02). Individuals reporting close contact with an alcohol-disordered individual (e.g., relative with an alcohol problem) reported lower perceived stigma (β = -1.70; P < 0.01). A link between highly stigmatized views of alcoholism and lack of services suggests that stigma reduction should be integrated into public health efforts to promote alcohol treatment.

Abstract 990: Fundamental causes of colorectal cancer outcomes

Introduction Colorectal Cancer is a major cause of mortality with 16.2 people out of 10,000 dying in 2009. Treatments for colorectal cancer exist, with screening done by physicians at clinics and hospitals around the US. Social inequalities in Colorectal Cancer mortality are well studied. However, three theories have arisen that may help to explain why these inequalities have arisen. Fundamental Cause Theory posits that these inequalities arise due to unequal access to resources while this may work in part with differential access to healthcare, and finally differential Diffusion of Knowledge is posited to speed and slow uptake of new medical innovations.

Method Using administrative and census data from 2005, mortality rates per county in 3139 counties were stratified by socio-economic status (SES), volume of acute care hospitals (ACHs), volume of primary care physicians (PCPs), and groups of states considered slow to fast diffusion. We controlled for race and gender.

Preliminary Results There were 4,683 ACHs and 278,961 PCPs in the analyses. White male averaged 6.42 deaths per 10,000 people, White female at 4.27, Black male at 4.42, Black female at 3.24, Other male at 2.14, and Other female at 2.93. For hospital volume, the average mortality for counties with zero acute hospitals was 7.32 deaths per 10,000, one hospital was 6.20, two hospitals was 6.44, three to fifty hospitals was 5.62, and fifty-five to eighty-nine hospitals was 4.55. For counties with PCPs, areas with zero to four PCPs had an average mortality of 7.48 deaths per 10,000 people, five to thirteen PCPs was 6.06, fourteen to fifty PCPs was 6.17, and fifty-one to eight thousand eight hundred sixty three PCPs was 5.93. The average mortality for PCPs per 100,000 between 0-50 was 7.16 per 10,000, 51-100 was 6.10, 101-149 was 5.78, and more than 150 was 5.08. Counties with high SES and few hospitals had an average mortality of 6.64 per 10,000, where high SES and high volume of hospitals had 5.62, low SES and low volume had 6.19, and low SES and high volume had 7.34. States with slow diffusion had a mortality of 6.33 per 10,000, medium-slow had 6.13, medium-fast had 6.61, and fast had 5.86.

Conclusion In this study, we show varying support for each of the three major theories. Fundamental cause theory suggests that SES was correlated with lower mortality rates, but SES played the greatest role in counties with large numbers of hospitals and primary care physicians. Access to healthcare clearly mattered, with more hospitals and primary care physicians correlating to lower colorectal mortality rates. Finally, being in an area typified as quick diffusing was related to lower mortality. This study thus suggests that fundamental cause theory works in part through access to health care. There are long term implications for policy makers looking to reduce social inequalities in colorectal cancer mortality.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 990.

Multidisciplinary management of Hunter syndrome

Hunter syndrome is a rare, X-linked disorder caused by a deficiency of the lysosomal enzyme iduronate-2-sulfatase. In the absence of sufficient enzyme activity, glycosaminoglycans accumulate in the lysosomes of many tissues and organs and contribute to the multisystem, progressive pathologies seen in Hunter syndrome. The nervous, cardiovascular, respiratory, and musculoskeletal systems can be involved in individuals with Hunter syndrome. Although the management of some clinical problems associated with the disease may seem routine, the management is typically complex and requires the physician to be aware of the special issues surrounding the patient with Hunter syndrome, and a multidisciplinary approach should be taken. Subspecialties such as otorhinolaryngology, neurosurgery, orthopedics, cardiology, anesthesiology, pulmonology, and neurodevelopment will all have a role in management, as will specialty areas such as physiotherapy, audiology, and others. The important management topics are discussed in this review, and the use of enzyme-replacement therapy with recombinant human iduronate-2-sulfatase as a specific treatment for Hunter syndrome is presented.

[Sensitization to airborne ragweed pollen--a cause of allergic respiratory diseases in Germany?]

BACKGROUND AND OBJECTIVE

Allergic skin and respiratory diseases show a high prevalence in most industrial countries. In addition, during the last years ragweed colonization has increased in Europe. Ambrosia pollen ( AMBROSIA ARTEMISIIFOLIA L. - common ragweed) are highly allergenic. Due to the late flowering time (august/September) of ragweed this can result in increasing health threats for allergic populations. This is of particular importance for those who already are sensitive to some grass or tree pollen. These individuals can then suffer from allergies during nearly the whole year. The present study examined the prevalence of sensitization to ragweed in German children and possible health implications.

METHODS

Between 2004 and 2007 sera of 1323 10-years old children in Baden Württemberg were tested in-vitro for specific IgE-antibodies against common aeroallergens including ragweed pollen.

RESULTS

Specific IgE-antibodies to extracts of common ragweed pollen were present in 10 - 17 % of the tested sera depending on the year of investigation.

CONCLUSION

The determined specific IgE-antibodies may be the result of a direct sensitization to ragweed pollen or correspond to cross-reactivity to other plants of the asteraceae subfamily or some nutritional allergens. The detection of sensitization to ragweed pollen does not prove actual allergic disease. However, a ragweed derived allergy should be considered in the differential diagnosis when allergic symptoms are present in direct connection to the flowering-time of ragweed. Ragweed plants should be removed and the spread of the plant 'restricted', as experiences in other countries with already wide spreading show.

Stigma in families of individuals in early stages of psychotic illness: family stigma and early psychosis

AIM

Stigma is pervasive among families of individuals with psychotic disorders and includes both general and 'associative' stigma - that is, the process by which a person is stigmatized by virtue of association with another stigmatized individual. These forms of stigma may present a barrier to help seeking. However, little is known about stigma in the early stages of evolving psychotic disorder.

METHODS

Family members of 11 individuals at clinical high risk and of nine patients with recent-onset psychosis were evaluated for generalized and associative stigma using the Opinions about Mental Illness (modified) and the Family Experiences Interview Schedule.

RESULTS

In this small study, the level of stigma was low, as families endorsed many supportive statements, for example, patients should be encouraged to vote, patients want to work, mental illness should be protected legally as a disability and parity should exist in insurance coverage. Families also endorsed that both talking and a belief in God and prayer can help someone get better. Only ethnic minority families of individuals with recent-onset psychosis endorsed a sense of shame and need to conceal the patient's illness.

CONCLUSIONS

This preliminary study suggests that family stigma is low in the early stages of psychotic disorder, a finding that requires further investigation in a larger and more representative sample. This may be an opportune time to engage young people and families, so as to reduce duration of untreated illness. Ethnic differences in stigma, if replicated, highlight the need for cultural sensitivity in engaging individuals and their families in treatment.

[Mucopolysaccharidoses]

Mucopolysaccharidoses are a family of metabolic disorders characterized by a deficiency in the catabolic lysosomal pathways. They are rare, inherited diseases which lead to progressive cellular, tissue and organ damage across a broad spectrum of phenotypes. To prevent irreversible damage early diagnosis is essential. Typical signs and symptoms are the thoracolumbar gibbus, shortened and plumped metacarpal bones, hip dysplasia, deformed ribs and ovoid vertebral bodies. Due to the typical deformation of the pelvis hip dislocation occurs often in childhood. Bilateral carpal tunnel syndrome is frequent. Bone marrow transplantation and enzyme replacement therapy are available. Orthopaedic interventions are based on individual therapeutic decisions and indications.

Flimmerprovokation im LED-Ganzfeld bei Gesunden und Glaukompatienten

BACKGROUND

Flicker light is an easy method to test sensory function after stress. The aim of this study was to determine the influence of flicker stress on temporal contrast sensitivity in healthy controls and patients with glaucomatous alteration of the optic disk.

METHODS

A commercially available full-field stimulator (Retiport, Roland Consult) equipped with white LEDs was modified to perform psychophysical tests. The patients underwent measurements of the recovery time interval from cessation of flicker stress until recognition of a pregiven flicker contrast after photo stress. In addition, we studied contrast sensitivity with a continuous flickering target and with a flicker burst protocol avoiding adaptation to prevailing flicker. All tests were performed at a constant retinal illumination and at a frequency of 37 Hz for provocation as well as for contrast sensitivity tests.

SUBJECTS

Normal healthy controls (40), "preperimetric" (62), and "perimetric" (52) open-angle glaucoma patients were studied. Exclusion criteria were age lower than 31 years, visual acuity under 0.6, and perimetric mean defect more than 9.5 dB.

RESULTS

Recovery time after flicker stress was significantly longer in patients than in normals and longer in perimetric than in preperimetric patients. Analysis in perimetric patients revealed a larger area under ROC for the provocation test (0.95) than in contrast sensitivity tests (continuous flicker method: 0.90, flicker burst mode: 0.84).

CONCLUSION

High-power LEDs which are installed in modern full-field devices can be used as a helpful tool to study psychophysical properties. In the present study it could be shown that threshold, adaptation, and recovery of temporal transfer characteristics are impaired in many patients with glaucoma.