Influenza vaccine during pregnancy, recommendations from healthcare providers, and race/ethnicity in the United States

OBJECTIVES

We examined racial/ethnic differences in the association between influenza vaccine recommendations from healthcare providers and maternal vaccination uptake.

METHODS

This cross-sectional study examined data from the Pregnancy Risk Assessment Monitoring System. We categorized respondents as non-Hispanic (NH) Whites, NH-Blacks, NH-Asians, American Indians/Alaska Natives, NH Other non-Whites, and Hispanics. We conducted multivariable logistical regression models to evaluate adjusted odds ratios (AOR) and 95% confidence intervals (CI). Covariates included maternal age, marital status, education, insurance status before pregnancy, the number of previous live births, the number of prenatal care visits, and smoking status during pregnancy.

RESULTS

The prevalences of receiving influenza vaccine recommendations from healthcare providers and maternal vaccine were 80.01% and 50.42%, respectively. NH-Blacks are less likely to receive provider recommendations (AOR = 0.82; 95%CI 0.77-0.87) and be vaccinated (AOR = 0.76; 95%CI 0.72-0.80) than NH-Whites. Receiving provider recommendations was significantly associated with increased maternal influenza vaccine uptake (AOR = 15.50; 95% CI 14.51-16.55). The associations were significant for all racial/ethnic groups, with the highest among NH-Asians (AOR = 22.04; 95% CI 17.88-27.16) and the lowest among NH Other non-Whites (AOR = 11.07; 95% CI 8.25-14.86). Within NH-Asians, effectiveness among Chinese was highest (AOR = 29.39; 95% CI 18.10-47.71).

CONCLUSIONS

Racial/ethnic disparities in maternal influenza vaccine uptake and receiving vaccine recommendations from healthcare providers persisted. Further studies on the racial/ethnic disparities in maternal vaccination were warranted and tailored strategies are required to reduce this health disparity.

Stress During Pregnancy Associated with Newborn Low Birth Weight: Experiences from the State of Rhode Island

PURPOSE

Prenatal stress is a known risk for poor birth outcomes. This study specifically looked at reported stress during pregnancy and low birth weight (LBW) in Rhode Island.

METHODS

Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2016 to 2018 for the state of Rhode Island was utilized. Stress during most recent pregnancy was dichotomized as: 'none to minimal' and 'moderate to high.' LBW was defined as less than 2,500 g. Multivariable regression analysis was performed, accounting for complex survey design.

RESULTS

In this cohort, 24% of pregnant people reported moderate to high stress leading to an adjusted odds of 1.70 (95% CI 1.43-2.03) of having a LBW newborn compared to those with none to minimal stress. Primiparity, previous preterm birth, racism, smoking history, and history of chronic medical problems were also associated with LBW newborns.

CONCLUSION

We recommend screening and provision of support services for stress in all settings where pregnant people access care.

The association between adverse birth outcomes and smoking cessation during pregnancy across the United States-43 States and New York City, 2012-2017

PURPOSE

This cross-sectional study aimed to estimate the risks of adverse birth outcomes among pregnant smokers and the benefits of smoking cessation during pregnancy on birth outcomes across the United States.

METHODS

We performed an analysis of 203,437 pregnant women using data collected by the Pregnancy Risk Assessment Monitoring System (PRAMS) from 2012 to 2017. PRAMS uses questionnaires and birth certificates to collect information about the socio-demographic characteristics of pregnant women, smoking status before and during pregnancy, and birth outcomes. We assessed the relationship between self-reported smoking status during pregnancy and preterm birth, low birth weight, and small-for-gestational-age using multivariable logistic regression models.

RESULTS

In our study population, 80.43% of pregnant women never smoked, 10.55% of pregnant women quit smoking during pregnancy, and 9.02% continued smoking during pregnancy. Puerto Rico had the highest prevalence of non-smokers (94.12%), while West Virginia had the lowest prevalence of non-smokers (60.54%). Pregnant women who had a higher education level, were married, had less than 5 types of stress, and had government or private insurance before pregnancy had a higher prevalence of smokers who quit during pregnancy (quit smokers) than those that continued smoking (continuous smokers). Compared to non-smokers, continuous smokers had a significantly higher risk of low birth weight (AOR: 1.91, 95% CI 1.80, 2.03), preterm birth (AOR: 1.31, 95% CI 1.21, 1.41), and small-for-gestational-age (AOR: 2.22, 95% CI 2.07, 2.39). However, the relationships between quitting smoking and preterm birth and small-for-gestational-age were not significant.

CONCLUSION

Our models suggest that smoking cessation during pregnancy can prevent adverse birth outcomes by significantly reducing the risk of preterm birth and small-for-gestational-age to almost comparable to not smoking.

The association between maternal influenza vaccination during pregnancy and adverse birth outcomes in the United States: Pregnancy risk Assessment Monitoring System (PRAMS)

OBJECTIVE

Influenza vaccination during pregnancy is highly recommended. We examined the association between maternal influenza vaccination and adverse birth outcomes.

METHODS

This cross-sectional study used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) during 2012-2017. The primary exposure was the receipt of influenza vaccination during pregnancy. Low birth weight (LBW), preterm birth (PTB), and small for gestational age (SGA) were the primary outcomes. We conducted multivariable logistic regression models to estimate the adjusted odds ratios (AOR) and 95% confidence intervals (CI). Covariates used to adjust confounding included maternal age, marital status, education, race and ethnicity, insurance status before pregnancy, and smoking status. For a subgroup in 2012-2015, we analyzed the association between influenza vaccination in each trimester and adverse birth outcomes.

RESULTS

During 2012-2017, compared with unvaccinated women, women vaccinated during pregnancy had a lower risk of LBW and PTB. During 2012-2015, maternal influenza vaccination in the 1st and 3rd trimesters was associated with a reduced risk of LBW and PTB, and vaccination in the 3rd trimester had a greater protective effect than in the 1st trimester. Influenza vaccination was not associated with SGA regardless of trimester.

CONCLUSIONS

Our findings suggest that influenza vaccination during pregnancy is a safe and effective way to protect newborns.

The Association of Antenatal Depression and Cesarean Delivery among First-Time Parturients: A Population-Based Study

OBJECTIVE

Antenatal depression (AD) has been considered a risk factor for cesarean delivery (CD); however, the supporting data are inconsistent. We used a large, nationally representative dataset to evaluate whether there is an association between AD and CD among women delivering for the first time.

STUDY DESIGN

We utilized the 2016 to 2019 Multistate Pregnancy Risk Assessment Monitoring System (PRAMS) from the Centers for Disease Control. First-time parturients who reported depression in the 3 months prior to or at any point during their recent pregnancy were compared with those who did not. The mode of delivery was obtained through the birth certificate. Maternal demographics, pregnancy characteristics, and delivery characteristics were compared by the report of AD using bivariable analyses. Population-weighted multivariable regression was performed, adjusting for maternal age, race/ethnicity, insurance, pregnancy complications, preterm birth, and body mass index (BMI).

RESULTS

Of the 61,605 people who met the inclusion criteria, 18.3% (n = 11,896) reported AD and 29.8% (n = 19,892) underwent CD. Parturients with AD were younger, more likely to be non-Hispanic white, publicly insured, use tobacco in pregnancy, deliver earlier, have lower levels of education, higher BMIs, and more medical comorbidities (hypertension and diabetes). After adjustment for these differences, there was no difference in risk of CD between those with AD compared with those without (adjusted odds ratio: 1.04; 95% confidence interval: 0.97-1.13).

CONCLUSION

In a large, population-weighted, nationally representative sample of first-time parturients, there was no association between AD and CD.

KEY POINTS

· Antenatal depression is increasingly common and has multiple known morbidities.. · Prior data on antenatal depression and cesarean delivery are mixed.. · We found no association between depression and cesarean delivery..

2215. Pre-pregnancy STI Counseling and HIV Testing Among Married Women: PRAMS 2016-2019

Background

Chlamydia, gonorrhea, and syphilis are one of the most reported and curable sexually transmitted infections (STIs) in the US, but rates continue to rise. STI during pregnancy can lead to perinatal infections. The best time to address this is at pre-conception. This study aims to examine health care visit practices among women before pregnancy and compare pre-pregnancy STI counseling and HIV testing rates among married women.

Methods

We utilized the Pregnancy Risk Assessment Monitoring System (PRAMS) 2016-2019, a population-based survey of postpartum women. Mothers self-reported if any health care worker talked to them about STIs or tested for HIV during any health care visit in the 12 months before pregnancy. Marital status was obtained from birth certificate records. Multivariable logistic regression analysis was performed adjusting for age, race, Hispanic ethnicity, education, insurance, income, and previous live birth.

Results

Of the the162,558 surveyed women, only 66.1% had any health care visit within 12 months pre-pregnancy (Figure1). Among those with a health care visit and STI screening response (n=104,256), approximately 70% of women reported never receiving pre-pregnancy STI counseling or HIV testing. Puerto Rico and D.C. had the highest pre-pregnancy screening rates while Utah had the lowest (Figure 2). Married women were less likely to receive pre-pregnancy STI counseling (OR 0.6: 95% CI 0.56, 0.64) or HIV testing (OR 0.65: 95% CI 0.61, 0.69) compared to unmarried women (Figure 3). Other risk factors for missing pre-pregnancy STI screening were older age, having more education, private insurance, higher income, and previous live birth. Black and Hispanic women were 2-3 times more likely to receive STI screening compared to White women. Figure 1:Any health care visit and visit type within 12 months before pregnancy (n=162,558)Figure 2:Pre-pregnancy STI counseling and HIV testing across 43 states, DC, NYC, and PR (n=104,256)Figure 3:Adjusted odds of receiving pre-pregnancy STI counseling and HIV testing among recent mothers, PRAMS 2016-2019 (n=104,256)

Conclusion

Married women were less likely to receive pre-pregnancy STI counseling and HIV testing. Our study highlights the lack of preconception care among women who recently gave birth. Marital status, demographics, and socioeconomic factors continue to affect a woman’s likelihood of receiving STI screening. Risk-based, selective STI screening creates gaps and missed opportunities to address STIs before pregnancy. Universal screening should be adopted for all women regardless of their preconceived risk or assumptions.

Disclosures

All Authors: No reported disclosures.

Relationship Between Risks for Obstructive Sleep Apnea, Resistant Hypertension, and Aldosterone Among African American Adults in the Jackson Heart Study

BACKGROUND

African Americans have a higher prevalence of resistant hypertension compared with Caucasians. Racial differences in obstructive sleep apnea (OSA) and increased aldosterone level may explain the racial disparity in resistant hypertension prevalence. Therefore, the purpose of this study is to investigate if aldosterone level and hypertension status differ by risks for OSA (e.g., obesity, loud snoring, and daytime sleepiness) and how aldosterone level varies with hypertension severity and control among African Americans.

METHODS

A cross-sectional analysis was performed using baseline data on 5,052 African American adults in the Jackson Heart Study to investigate the relationships of interest using multivariable linear and multinomial logistic regression models adjusted for potential confounders. Risks for OSA were defined by a "risk score" consisting of the number of risks for OSA.

RESULTS

Of the 5,052 participants, 623 had no risks for OSA. Body mass index was the highest among those with a risk score of 6. About 39% of the sample had no hypertension, 29% had controlled hypertension, 26% had uncontrolled hypertension, and 6% had resistant hypertension. Higher odds of having uncontrolled hypertension or resistant hypertension were present in those with a higher risk score compared with those without risks for OSA. Log-aldosterone level increased with each additional risk for OSA (P-trend <0.05). Similarly, log-aldosterone also increased with more severe hypertension (P-trend <0.001). The highest aldosterone level was found in those with resistant hypertension that was inadequately controlled with medications.

CONCLUSIONS

Risks for OSA were positively associated with resistant hypertension and higher aldosterone level in African American adults.

Antenatal Depression and Cesarean Delivery Among Recently-Delivered Nulliparous Women in Rhode Island

OBJECTIVE

Antenatal depression (AD) is frequently cited as a risk factor for cesarean delivery (CD) with limited supporting data.

STUDY DESIGN

We utilized 2016-2018 data from the Pregnancy Risk Assessment Monitoring System (PRAMS) survey for the state of Rhode Island. Nulliparous women who reported AD (n=242) were compared to women who did not (n=1,081). Maternal demographics, pregnancy and delivery characteristics were compared by AD status using population-weighted bivariable analyses and multivariable logistic regression.

RESULTS

17.7% reported AD, and 34% underwent CD. There was no difference in CD based on reported AD status (aOR 1.04; 95% CI 0.69, 1.56). However, there were significant differences between those reporting AD compared to those who did not: less education, more public insurance, use of Women, Infants and Children (WIC) benefits, tobacco use, and pre-gestational hypertension/diabetes.

CONCLUSION

In this large, population-based, state representative sample, we found no difference in CD among recently delivered nulliparous women with and without AD.

Do Unmet Health Needs Drive Pediatric Emergency Department Utilization?: A Population-Based Assessment

OBJECTIVE

Lack of access to basic health services is thought to increase emergency department (ED) utilization. This study assessed the relationship between unmet health care needs and pediatric ED utilization in the United States.

METHODS

The National Survey of Children's Health was used (2016-2017; n = 71,360). Parent/guardians reported number of ED visits and the presence of unmet health needs (medical, dental, mental health, vision, hearing, other) in the last 12 months. Associations were analyzed using multinomial logistic regression modeling and accounted for the weighting and complex survey design of the National Survey of Children's Health.

RESULTS

Children with 2 or more unmet health needs had 3.72 times (95% confidence interval, 2.25-6.16) risk of ≥2 ED visits when compared with those with 0 unmet health needs. This risk became nonsignificant when adjusted for race, ethnicity, age, insurance, having asthma, current medication status, health description, number of preventative health visits, and place to go for preventative health (aRR, 1.77; 95% confidence interval, 0.96-3.27). The adjusted association was also nonsignificant for specific types of unmet needs. Race, insurance status, age 0 to 3 years, current medication status, having asthma, ≥2 preventative visits, and poorer health were associated with ≥2 ED visits.

CONCLUSIONS

Unmet health needs were not found to be a significant driving force for ED utilization. Other factors were found to be more strongly associated with it. Future studies to understand the perception, motives, and complex interaction of various factors leading to ED use in high-risk populations may optimize care for these children.

1356. Association Between Marital Status and Pre-pregnancy STI Counseling Among Women Who Have Recently Given Birth: RI PRAMS 2016-2018

Background

As rates of sexually transmitted infections (STIs) continue to rise, all women of reproductive age can suffer from complications particularly during pregnancy which can lead to adverse neonatal outcomes. Currently, data on STI counseling among married women are limited. This study aims to assess differences in pre-pregnancy STI counseling based on marital status among women who have recently given birth.

Methods

We utilized the Rhode Island Pregnancy Risk Assessment Monitoring System (RI PRAMS) 2016-2018, a population-based survey of postpartum women. Mothers self-reported if they have received STI counseling for chlamydia, gonorrhea, and syphilis during any health care visit in the 12 months before becoming pregnant. Marital status was obtained from the birth certificate. Multivariable logistic regression analysis was performed adjusting for age, race, Hispanic ethnicity, education, insurance, income, and previous live birth. We accounted for weighting and complex survey design.

Results

Our analytic sample included 2,361 mothers. More than half of the women reported never having received pre-pregnancy STI counseling about the 3 most reported and curable STIs in the US. Among them, an estimated 78.9% (n=1,207) of married women did not receive pre-pregnancy STI counseling compared to 53.6% (n=429) of unmarried women (Table 1). Married women had 0.61 (95% CI: 0.46, 0.81) odds of receiving STI counseling before pregnancy compared to unmarried women (Figure 1). Other risk factors for not receiving STI counseling included having a college education or higher or having a previous live birth.

Table 1. Characteristics of Women who have Recently Given Birth by Marital Status, RI PRAMS 2016-2018 (n=2,361)

Conclusion

Selective STI counseling creates gaps and missed opportunities to address STIs early before pregnancy. All women regardless of their perceived risk for STI or assumptions based on their marital status should receive proper STI counseling as all women are vulnerable and at higher risk of developing complications. Health care providers should increase efforts to address this gap and counsel all women about STIs during every visit irrespective of their marital status.

Disclosures

All Authors: No reported disclosures

Frequent Emergency Department Use by Children

OBJECTIVES

Frequent use of the emergency department (ED) is often targeted as a quality improvement metric. The objective of this study was to assess ED visit frequency by the demographic and health characteristics of children who visit the ED to better understand risk factors for high ED utilization.

METHODS

The majority of pediatric ED services in Rhode Island are provided by a hospital network that includes the state's only children's hospital. Using 10 years of data (2005-2014) from this statewide hospital network, we examined ED use in this network for all children aged 0 to 17 years. Patients' home addresses were geocoded to assess their neighborhood characteristics.

RESULTS

Between 2005 and 2014, 17,844 children visited 1 or more of the network EDs at least once. In their year of maximum use, 67.8% had only 1 ED visit, 20.1% had 2 visits, 6.9% had 3 visits, and 5.2% had 4 or more visits. In the adjusted multinomial logistic regression model, age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the ED were found to be significantly associated with increased visit frequency.

CONCLUSIONS

Risk factors for frequent ED use by children include age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the hospital. To decrease frequent pediatric ED use, improved medical management of complex medical problems is needed, but it is also essential to address modifiable social determinants of health care utilization in this population.

Children With ADHD Engage in Less Physical Activity

Background: Children with ADHD should engage in physical activity, given its known role as a treatment adjunct. Objective: The main objective of this study is to assess the relationship between ADHD diagnosis and physical activity among children in the United States. Methods: This retrospective population-based cross-sectional study used data from the 2016 caregiver reported, National Survey of Children's Health (NSCH). Results: In the adjusted binary model, children with an ADHD diagnosis had 21% lower odds of engaging in daily physical activity than their nondiagnosed counterparts. In the adjusted multinomial model, children with ADHD were increasingly unlikely to report additional days of physical activity as compared to those without a diagnosis. Conclusion: Given the known benefits of physical activity for those with ADHD, this study underscores the need for enhanced access to an important treatment adjunct for this population.

Childhood Obesity Is Associated with Poor Academic Skills and Coping Mechanisms

OBJECTIVE

To assess the relationship between obesity and select childhood flourishing markers including academic skills and coping strategies.

STUDY DESIGN

Cross-sectional study utilizing parental reported data for children aged 10-17 years (n = 22 914) from the 2016 National Survey of Children's Health. Multiple binary regressions assessed the association between body mass index-for-age and 5 school-related and behavioral childhood flourishing markers independently and combined, including completing homework, showing interest in learning, finishing tasks, staying calm when challenged, and caring about academics. Analyses were adjusted for age, sex, depression, sleep, digital media exposure, poverty, and parental education level.

RESULTS

Only 28.9% of children with obesity were reported to have all 5 markers, compared with 38% with overweight, and 40.5% with normal body mass index. In an adjusted model, children with obesity had significantly decreased odds of demonstrating 4 of 5 markers: showing interest in learning (aOR, 0.78; 95% CI, 0.62-0.97), finishing tasks (aOR, 0.77; 95% CI, 0.63-0.94), staying calm when challenged (aOR, 0.73; 95% CI, 0.59-0.90), and caring about academics (aOR, 0.69; 95% CI, 0.55-0.86). Completing homework was not associated with obesity. Youth with obesity also had 23% decreased odds (aOR, 0.77; 95% CI, 0.61-0.98) of meeting the combined measure for flourishing markers.

CONCLUSIONS

Childhood obesity is associated with poor academic skills and coping strategies which may lead to worse individual and public health outcomes. Further studies are needed to create validated flourishing measures and identify interventions that promote healthy youth behavior and academic success.

Sounding the Alarm on Sleep: A Negative Association Between Inadequate Sleep and Flourishing

OBJECTIVE

To assess the national prevalence of inadequate sleep among school-age children and its relationship with childhood flourishing.

STUDY DESIGN

This cross-sectional study analyzed 49 050 parental responses from the 2016-2017 National Survey of Children's Health for school-age children. Inadequate sleep duration was defined as <9 hours for 6- to 12-year-olds and <8 hours for 13- to 17-year-olds on an average weeknight. Five markers of flourishing were examined individually and as a combined measure. Logistic regression was used with complex survey design and applied weights.

RESULTS

Inadequate sleep was found in 36.4% of 6- to 12-year-olds and in 31.9% of 13- to 17-year-olds. Compared with children with adequate sleep, 6- to 12-year-olds with inadequate sleep had increased odds of not showing interest and curiosity in learning (aOR, 1.61; 95% CI, 1.34-1.94), not caring about doing well in school (aOR, 1.45; 95% CI, 1.23-1.71), not doing homework (aOR, 1.44; 95% CI, 1.24-1.68), and not finishing tasks (aOR, 1.18; 95% CI, 1.03-1.35). Children aged 13-17 years with inadequate sleep had increased odds of not doing homework (aOR, 1.36; 95% CI, 1.17-1.58), not staying calm and in control when challenged (aOR, 1.34; 95% CI, 1.16-1.54), not showing interest and curiosity in learning (aOR, 1.34; 95% CI, 1.14-1.58), not finishing tasks (aOR, 1.20; 95% CI, 1.03-1.40), and not demonstrating the combined flourishing measure (aOR, 1.35; 95% CI, 1.17-1.56).

CONCLUSIONS

Nationally representative data show that one-third of school-age children have inadequate sleep. Inadequate sleep is associated with decreased flourishing. These data will help inform sleep policies and optimize child development.

Transfusion, mortality and hemoglobin level: Associations among emergency department patients in Kigali, Rwanda

BACKGROUND

Studies from high-income countries (HIC) support restrictive blood transfusion thresholds in medical patients. In low- and middle-income countries (LMIC), the etiologies of anemia and baseline health states differ greatly; optimal transfusion thresholds are unknown. This study evaluated the association of packed red blood cell (PRBC) transfusion with mortality outcomes across hemoglobin levels amongst emergency center (EC) patients presenting with medical pathology in Kigali, Rwanda.

METHODS

This retrospective cohort study was performed using a random sample of patients presenting to the EC at the University Teaching Hospital of Kigali. Patients ≥15 years of age, treated for medical emergencies during 2013-16, with EC hemoglobin measurements were included. The relationship between EC PRBC transfusion and patient mortality was evaluated using logistic regression, with stratified analyses performed at hemoglobin levels of 7 mg/dL and 5 mg/dL.

RESULTS

Of 3609 cases sampled, 1116 met inclusion. The median age was 42 years (IQR 29, 60) and 45.2% were female. Transfusion occurred in 12.1% of patients. Hematologic (24.4%) and gastrointestinal pathologies (20.7%) were the primary diagnoses of those transfused. Proportional mortality was higher amongst those receiving transfusions, although not statistically significant (23.7% vs 17.0%, p = 0.06). No significant difference in adjusted odds of overall mortality by PRBC transfusion was found. In stratified analysis, patients receiving EC transfusions with a hemoglobin >5.0 mg/dL, had 2.21 times the odds of mortality (95% CI 1.51-3.21) as compared to those ≤5.0 mg/dL.

CONCLUSIONS

No association between PRBC transfusion and odds of mortality was observed amongst EC patients in this LMIC setting. An increased mortality association was found for patients receiving PRBC transfusions with an initial hemoglobin >5 mg/dL. Results suggest benefits from PRBC transfusion are limited as compared to HIC. Further research evaluating emergent transfusion thresholds for medical pathologies should be performed in LMICs to guide practice.

Higher education associated with better national tetanus vaccination coverage: A population-based assessment

Vaccination coverage among United States (U.S.) adults for tetanus continues to be lower than the national goals. Education has demonstrated a positive impact on vaccination coverage. However, recently there have been outbreaks of vaccine preventable conditions in areas with high college completion rates. This study assessed the relationship between education and tetanus vaccination. Data from the 2016 Behavioral Risk Factor Surveillance System (BRFSS), a self-reported annual survey for non-institutionalized adults in the US from the Centers for Disease Control, was analyzed in 2019. The outcome was up-to-date tetanus vaccination if received within the last 10 years. Education was categorized into 1) grade 11 or less, 2) grade 12/GED, 3) college 1-3 years, and 4) college 4 or more years. Bivariate analyses and multivariable logistic regression were conducted on the analytic sample (n = 417,473) using Stata 15, accounting for weighting and the complex survey design. In 2016, 59.9% of U.S. adults had up-to-date tetanus vaccination. Higher education level was associated with increased odds of up-to-date tetanus vaccination. The highest odds were for those with 4 or more years of college education [aOR = 1.31; 95% (CI: 1.26-1.35)]. Female sex, Black (non-Hispanic), unemployed, not being married, not having insurance or a personal health care provider, and above 45 years of age had lower odds of up-to-date tetanus vaccination. Targeted community specific vaccination education programs for those without tertiary education may help enhance the knowledge and thus the overall vaccination status in the U.S.

Assessing the Association Between Maternal Education and Access to Pediatric Specialty Care

Background. Timely access to pediatric specialty care continues to be a pervasive issue. We aimed to identify factors associated with unmet pediatric specialty care needs by assessing the association with maternal level of education. Methods. A sample was extracted from the 2011-2012 National Survey of Children's Health, which identified a subset of patients with unmet specialty care needs. Logistic regression models determined the strength of association between our sample and maternal level of education. Results. An estimated 12.5% of US children had unmet specialty care needs. Independent of confounding variables, children with mothers educated at a level of high school or less were 41% more likely to have unmet specialty care needs compared to those with mothers who were educated at a level greater than high school. Conclusions. Maternal level of education can be used as a risk factor to assess whether a child will have unmet specialty care needs.

1646. Education Level is Associated with Tetanus Vaccine Coverage: Results from the 2016 BRFSS

Background

Vaccination coverage among US adults for tetanus, a potentially fatal disease, continues to be lower than the national goals. Education has been considered to have positive impact on vaccination coverage. However, recently there have been outbreaks of vaccine preventable conditions in areas with high college completion rates. This study aims to assess the relationship between education and vaccination coverage. Specifically, we looked at the association between education level and tetanus vaccination status of the US adults.

Methods

Data from the 2016 Behavioral Risk Factor Surveillance System, a self-reported annual survey for non-institutionalized adults in the United States from the Centers for Disease Control, were analyzed. The outcome was up-to-date tetanus coverage (within the last 10 years) defined by the response to: have you received tetanus vaccine since 2005? Education was stratified into four categories: (1) grade 11 or less, (2) grade 12/GED, 3) college 1–3 years, and (4) college 4 or more years. Bivariate analyses and multivariable logistic regression were conducted on the analytic sample (n = 417,473) using Stata 15, accounting for weighting and the complex survey design of the BRFSS.

Results

This study identified that 59.9% of US adults are up-to-date on the tetanus vaccine status (Table 1). Higher education level was found to be associated with increased odds of up to date tetanus vaccination. The highest odds were for those with 4 or more years of college education [aOR = 1.31; 95% CI: 1.26–1.35)] while the lowest odds were for those less than grade 11 education, when compared with those with a high school degree [aOR = 0.93; 95% CI: 0.88–0.98] (Figure 1). Other covariates identified as negatively associated with up-to-date tetanus status were race/ethnicity, female sex, unemployment, not being married, not having insurance or a personal healthcare provider, and being above 45 years of age (Figure 1).

Conclusion

This study identified a positive association between up-to-date tetanus status and higher education level. Introducing community-specific vaccination education programs for those without tertiary education, especially for those above age 45 and without insurance, may help increase the overall vaccination status in the United States.

Disclosures

All authors: No reported disclosures.

Adolescent Access to Patient-Centered Medical Homes

OBJECTIVES

To analyze the distribution of patient-centered medical homes (PCMHs) among US adolescents, and to examine whether disparities exist among subgroups.

STUDY DESIGN

Data on adolescents ages 12-17 years (n = 34 601) from the 2011-2012 National Survey of Children's Health were used in this cross-sectional study to determine what proportion had access to a PCMH. Multivariable logistic regression was used to calculate the odds of having a PCMH, adjusting for sociodemographic characteristics and special health care needs. Comparisons were made to distribution of PCMH in 2007.

RESULTS

Although most US adolescents had a usual source of care (91%), only about one-half (51%) had access to a PCMH. Disparities in the prevalence of PCMHs were seen by race/ethnicity, poverty, and having special health care needs. There were lower adjusted odds in having a PCMH for Hispanic (aOR, 0.56; 95% CI, 0.45-0.68) and black adolescents (aOR, 0.55; 95% CI, 0.46-0.66) compared with white adolescents. Those living below 4 times the poverty level had lower adjusted odds of PCMH access. Adolescents with 3-5 special health care needs had lower adjusted odds (aOR, 0.43; 95% CI, 0.35-0.52) of having a PCMH compared with adolescents without any special health care needs. Other than receiving family centered care, every component of PCMH was slightly lower in 2011-2012 compared with 2007.

CONCLUSIONS

PCMH access was lower among minorities, those living in poverty, and those with multiple special health care needs. These disparities in PCMH access among these typically underserved groups call for further study and interventions that would make PCMHs more accessible to all adolescents.

Adverse Childhood Experiences and Protective Factors With School Engagement

OBJECTIVES

To determine the associations of adverse childhood experiences (ACEs) and protective familial and community factors with school performance and attitudes in children ages 6 to 17.

METHODS

A cross-sectional analysis of the 2011-2012 National Survey of Children's Health was performed. All data were demographically weighted and included 65 680 children ages 6 to 17. The survey identified up to 9 ACEs in each child. ACE scores were categorized as 0, 1, 2, 3, and ≥4 ACEs. Children's protective factors (PFs) included the following: safe neighborhood, supportive neighbors, 4 neighborhood amenities, well-kept neighborhood, no household smoking, ≥5 family meals per week, and a parent who can talk to the child. PFs were categorized into ≤3, 4, 5, 6, and 7 PFs. School outcomes included the following: child repeated ≥1 grade; never, rarely, or sometimes completes homework; and never, rarely, or sometimes cares about school. χ² tests and logistic regressions assessed the relationships between ACEs and school outcomes, PFs and school outcomes, and both ACEs and PFs and school outcomes, adjusting for sex, age, race, ethnicity, and maternal education.

RESULTS

Each negative school outcome is associated with higher ACE scores and lower PF scores. After adding PFs into the same model as ACEs, the negative outcomes are reduced. The strongest PF is a parent who can talk to the child about things that matter and share ideas.

CONCLUSIONS

As children's ACE scores increase, their school performance and attitudes decline. Conversely, as children's PF scores increase, school outcomes improve. Pediatric providers should consider screening for both ACEs and PFs to identify risks and strengths to guide treatment, referral, and advocacy.

Intoxication and Flame Burn Injuries in Young Adults in the United States

Flame injuries are the primary cause of burns in young adults. Although drug and alcohol intoxication has been associated with other types of trauma, its role in burn injury has not been well described in this population. The purpose of this study was to investigate the association of intoxication and flame burn injuries in young adults in the United States. The 2014 Nationwide Emergency Department Sample was queried for burn injury visits of young adult patients, 13-25 years old. This data is weighted to allow for national estimates. Burn mechanism and intoxication status were determined by International Classification of Diseases, Ninth Revision codes. Multivariable logistic regression analysis was used to assess the association of intoxication and emergency department (ED) visits due to flame burns, adjusting for patient age, gender, zip code median income, zip code rural-urban designation, timing of visit, and hospital region. Further analyses assessed the odds of admission or transfer, as a possible proxy of injury severity, in patients with flame or other burns, with and without intoxication adjusting for patient age, gender, primary insurance, and hospital trauma designation. There were 20,787 visits for patients 13-25 years old with burn injuries and 12.9% (n = 2678) had a codiagnosis of intoxication. There was an increasing proportion of intoxication by age (5.8% 13-17 years old, 25% 18-20 years old, 69% 21-25 years old, P < .001). ED visits for burns with a codiagnosis of intoxication had 1.34 times ([95% confidence interval (CI): 1.18, 1.52], P < .01) higher odds of having flame burns compared to other burn mechanisms. Those with flame burns and intoxication were most likely to be admitted or transferred when compared to nonflame, nonintoxication visits in the adjusted model (odds ratio [OR] 5.49, [95% CI: 4.29, 7.02], P < .01). Furthermore, the odds of admission or transfer in visits with the combined exposure of intoxication and flame mechanism were significantly higher than visits due to nonflame burns and intoxication (OR 2.75, [2.25, 3.36], P < .01) or flame burns without intoxication (OR 3.00, [95% CI: 2.61, 3.42], P < .01). This study identified a significant association between flame-burn-related ED visits and intoxication in the young adult population in the United States. In addition, the combination of flame mechanism and intoxication appears to result in more substantial injury compared with either exposure alone. The relationship seen between intoxication and flame burn injury underscores a major target for burn prevention efforts in the young adult population.

Neighborhood Risk and Hospital Use for Pediatric Asthma, Rhode Island, 2005-2014

Introduction

Studies consistently show that children living in poor neighborhoods have worse asthma outcomes. The objective of our study was to assess the association between negative neighborhood factors (ie, neighborhood risk) and pediatric asthma hospital use.

Methods

This retrospective study used data from children aged 2 to 17 years in a statewide (Rhode Island) hospital network administrative database linked to US Census Bureau data. We defined an asthma visit as an International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code of 493 in any diagnosis field. We used 8 highly correlated measures for each census-block group to construct an index of neighborhood risk. We used maps and linear regression to assess the association of neighborhood risk with average annual census-block–group rates of asthma emergency department visits and hospitalizations. We used multivariable analyses to identify child characteristics and neighborhood risk associated with an asthma revisit, accounting for the child’s sociodemographic information, season, and multiple measurements per child.

Results

From 2005 through 2014, we counted 359,195 visits for 146,889 children. Of these, 12,699 children (8.6%) had one or more asthma visits. Linear regression results showed 1.18 (95% confidence interval, 1.06–1.30) more average annual emergency departments visits per 100 children and 0.41 (95% confidence interval, 0.34–0.47) more average annual hospitalizations per 100 children in neighborhoods in the highest-risk index quintile than in neighborhoods in the lowest-risk index quintile.

Conclusion

Interventions to improve asthma outcomes among children should move beyond primary care or clinic settings and involve a careful evaluation of social context and environmental triggers.

The influence of depression status on weekly exercise in children ages 6 to 17 years

Exercise has been found to be an effective treatment for mild to moderate depression. The purpose of this study is to explore the relationship between depression status and weekly exercise in children ages 6 to 17 years stratifying by age and sex using a large nationally representative sample. The study data (n = 65,059) came from the 2011-12 National Survey of Children's Health. Depression categories were current, former, and no history of diagnosed depression. Exercise categories were exercising ≤6 days a week and 7 days a week. Multivariable regression stratified by age and by sex was conducted on the weighted survey data. Among children age 6 to 17, 95.2% were never depressed, 2.1% were formerly depressed, and 2.8% were currently depressed and 28.0% exercised daily. Currently depressed children had 0.75 (95% CI 0.56, 1.00) times and formerly depressed children had 1.09 (95% CI 0.76, 1.57) times the adjusted odds of exercising daily compared to never depressed children. Stratified separately by sex and by age, females and children age 12 to 17 with current depression had 0.63 (95% CI 0.42, 0.94) and 0.48 (95% CI 0.35, 0.66) times the adjusted odds of exercising daily compared to their counterparts with no depression. This study indicates a significant difference in daily exercise habits between currently depressed children age 12 to 17 and females compared to their never depressed counterparts. Healthcare workers should be aware of the possible heightened risk of physical inactivity for depressed female children and children age 12 to 17.

Depression among Women Released from Prison or Jail in the United States

Risk factors for depression among 179 women recently released from prison or jail in a state correctional facility in the northeastern United States were examined in this study. The Center for Epidemiologic Studies Depression Scale (CESD-10) was used to measure longitudinal, self-reported depression data. In addition, potential risk factors for depression among women recently released from prison and jail were analyzed. Findings of this study indicated that approximately 83% of the women suffered depression throughout baseline and/or at least one follow up period after release. Significant risk factors for depression among these women included drug use, alcohol use, physical partner abuse, number of living children, and emotional abuse during childhood. Women who used drugs other than marijuana were eight times as likely to suffer from depression compared with women who had never used such drugs.

Having a Regular Primary Care Provider Is Associated With Improved Markers of Well-Being Among Children With Attention-Deficit Hyperactivity Disorder

We examined the association between having a regular primary care physician (PCP) and measures of flourishing and academic success in children with attention-deficit hyperactivity disorder (ADHD). We performed a cross-sectional study using data from the 2011-2012 National Survey of Children's Health. Children aged 6 to 17 years with a diagnosis of ADHD were included in the study (n = 8173). The exposure was whether the guardian identified a regular PCP for their child. The outcomes were parental-reported measures of child well-being and academic performance. Among the study population, 8.9% reported no regular PCP. These children were found to be significantly less likely to finish assigned tasks (adjusted odds ratio [OR] = 0.52, 95% confidence interval [CI] = 0.35-0.79), care about school (adjusted OR = 0.62, 95% CI = 0.38-0.92), and finish homework (adjusted OR = 0.58, 95% CI = 0.36-0.88). There were no differences in other examined outcomes. Enhancing longitudinal care for this population may optimize their academic performance.

Prenatal Exposure to Stressful Life Events and Infant Breastfeeding

BACKGROUND

Of the various barriers to breastfeeding, limited information is available on the relationship between prenatal stress and breastfeeding. This study investigates the association between prenatal stressful life event (SLE) exposure and breastfeeding initiation postpartum.

MATERIALS AND METHODS

Using Rhode Island Pregnancy Risk Assessment Monitoring System data from 2012 to 2014, SLE was defined as self-report of prenatal exposure to 14 predefined life events such as job loss or illness. Exposure to SLE was categorized by number and type of events. Multivariable logistic regression was performed to assess the relationship between SLE and breastfeeding initiation. Results accounted for complex survey design and were adjusted for maternal and infant characteristics (age, race, ethnicity, insurance, delivery type, parity, gestational age, birth weight for gestational age, and neonatal intensive care unit admission).

RESULTS

Among 3,353 respondents, 86% reported breastfeeding initiation, 74% reported exposure to ≥1 SLE, and 17% reported exposure to ≥4 SLE. Decreased odds of breastfeeding initiation were associated with prenatal exposure to ≥4 SLE (adjusted odds ratio [aOR] 0.67; 95% confidence interval [CI]: 0.48-0.95), emotional stressors (aOR 0.77; 95% CI: 0.61-0.98), and traumatic stressors (aOR 0.68; 95% CI: 0.50-0.91).

CONCLUSION

This study underscores the impact of exposure to prenatal SLE on breastfeeding initiation among postpartum women. Findings may assist providers in identifying at-risk women for anticipatory guidance to improve breastfeeding rates.

Pediatric Emergency Department Utilization and Reliance by Insurance Coverage in the United States

OBJECTIVES

For many children, the emergency department (ED) serves as the main destination for health care, whether it be for emergent or nonurgent reasons. Through examination of repeat utilization and ED reliance (EDR), in addition to overall ED utilization, we can identify subpopulations dependent on the ED as their primary source of health care.

METHODS

Nationally representative data from the 2010 to 2014 Medical Expenditure Panel Survey were used to examine the annual ED utilization of children age 0 to 17 years by insurance coverage. Overall utilization, repeat utilization (two or more ED visits), and EDR (percentage of all health care visits that occur in the ED) were examined using multivariate models, accounting for weighting and the complex survey design. High EDR was defined as having > 33% of outpatient visits in a year being ED visits.

RESULTS

A total of 47,926 children were included in the study. Approximately 12% of children visited an ED within a 1-year period. A greater number of children with public insurance (15.2%) visited an ED at least once, compared to privately insured (10.1%) and uninsured (6.4%) children. Controlling for covariates, children with public insurance were more likely to visit the ED (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI] = 1.40-1.73) than children with private insurance, whereas uninsured children were less likely (aOR = 0.64, 95% CI = 0.51-0.81). Children age 3 and under were significantly more likely to visit the ED than children age 15 to 17, whereas female children and Hispanic and non-Hispanic other race children were significantly less likely to visit the ED than male children and non-Hispanic white children. Among children with ED visits, 21% had two or more visits to the ED in a 1-year period. Children with public insurance were more likely to have two or more visits to the ED (aOR = 1.53, 95% CI = 1.19-1.98) than children with private insurance whereas there was no significant difference in repeat ED utilization for uninsured children. Publicly insured (aOR = 1.70, 95% CI = 1.47-1.97) and uninsured children (aOR = 1.90, 95% CI = 1.49-2.42) were more likely to be reliant on the ED than children with private insurance.

CONCLUSIONS

Health insurance coverage was associated with overall ED utilization, repeat ED utilization, and EDR. Demographic characteristics, including sex, age, income, and race/ethnicity were important predictors of ED utilization and reliance.

Prospective Association of Physical Activity and Heart Failure Hospitalizations Among Black Adults With Normal Ejection Fraction: The Jackson Heart Study

BACKGROUND

Given high rates of obesity, hypertension, and diabetes mellitus, black persons are at risk to develop heart failure. The association of moderate to vigorous physical activity (MVPA) and heart failure in black adults is underresearched. The purpose of this study was to explore whether greater MVPA was associated with lower risk of heart failure hospitalizations (HFHs) among black adults with normal ejection fractions.

METHODS AND RESULTS

We performed a prospective analysis of 4066 black adults who participated in the Jackson Heart Study and who had physical activity measured, had normal ejection fraction on 2-dimensional echocardiograms, and were followed for 7 years for incident HFH. We used Cox proportional regression analyses adjusted for age, sex, body mass index, smoking status, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, coronary heart disease, atrial fibrillation, and chronic kidney disease and examined effect modification by sex and body mass index. Of the eligible population, 1925 participants, according to the duration of MVPA, had poor health (0 minutes/week), 1332 had intermediate health (1-149 minutes/week), and 809 had ideal health (≥150 minutes/week). There were 168 incident HFHs. MVPA for intermediate and ideal health was associated with decreasing risk of incident HFH (hazard ratio: 0.70 [95% confidence interval, 49-1.00] and 0.35 [95% confidence interval, 0.19-0.64], respectively; P_trend=0.003). The full model revealed hazard ratios of 0.74 [95% confidence interval, 0.52-1.07] and 0.41 [95% confidence interval, 0.22-0.74], respectively. There was no effect modification between MVPA and body mass index or sex on incident HFH.

CONCLUSIONS

A dose-response relationship between increasing levels of MVPA and protection from incident HFH was found in black men and women with normal ejection fractions.

The State of Prescreening Discussions About Prostate-specific Antigen Testing Following Implementation of the 2012 United States Preventive Services Task Force Statement

OBJECTIVE

To determine if the quality of prescreening discussions has changed following release of the United States Preventive Services Task Force statement against prostate cancer screening.

METHODS

This cross-sectional study used the 2012 and 2014 Behavioral Risk Factor Surveillance System surveys. Respondents were categorized based on the year in which they responded to the Behavioral Risk Factor Surveillance System Survey. Quality of prescreening discussion was operationalized as having discussed only advantages, only disadvantages, both advantages and disadvantages, or neither. Race/ethnicity, education level, income, insurance status, and having a prostate-specific antigen (PSA) level actually drawn after prescreening counseling served as confounders in our multivariate analysis.

RESULTS

Among 217,053 men in the analytic sample, 37% were told about only advantages of PSA screening compared to 30% of men who were advised about both advantages and disadvantages. Men who were told about neither advantages nor disadvantages were more likely to be Hispanic, not graduate high school, have low income, and not have insurance. Controlling for covariates, men in 2014 were significantly more likely to have undergone PSA testing without having discussed either advantages or disadvantages than men in 2012.

CONCLUSION

Comprehensive prescreening discussions about advantages and disadvantages of PSA testing are critical to informed decision making about prostate cancer screening. Disparities not only exist with regard to the quality of prescreening discussions that patients receive from their providers prior to PSA testing across categories of race/ethnicity, education, income, and insurance status, but these disparities became more substantial between 2012 and 2014. Further investigation is warranted to elicit more specific reasons behind these variations.

Association of Sickle Cell Trait With Hemoglobin A1c in African Americans

Importance

Hemoglobin A1c (HbA1c) reflects past glucose concentrations, but this relationship may differ between those with sickle cell trait (SCT) and those without it.

Objective

To evaluate the association between SCT and HbA1c for given levels of fasting or 2-hour glucose levels among African Americans.

Design, Setting, and Participants

Retrospective cohort study using data collected from 7938 participants in 2 community-based cohorts, the Coronary Artery Risk Development in Young Adults (CARDIA) study and the Jackson Heart Study (JHS). From the CARDIA study, 2637 patients contributed a maximum of 2 visits (2005-2011); from the JHS, 5301 participants contributed a maximum of 3 visits (2000-2013). All visits were scheduled at approximately 5-year intervals. Participants without SCT data, those without any concurrent HbA1c and glucose measurements, and those with hemoglobin variants HbSS, HbCC, or HbAC were excluded. Analysis of the primary outcome was conducted using generalized estimating equations (GEE) to examine the association of SCT with HbA1c levels, controlling for fasting or 2-hour glucose measures.

Exposures

Presence of SCT.

Main Outcomes and Measures

Hemoglobin A1c stratified by the presence or absence of SCT was the primary outcome measure.

Results

The analytic sample included 4620 participants (mean age, 52.3 [SD, 11.8] years; 2835 women [61.3%]; 367 [7.9%] with SCT) with 9062 concurrent measures of fasting glucose and HbA1c levels. In unadjusted GEE analyses, for a given fasting glucose, HbA1c values were statistically significantly lower in those with (5.72%) vs those without (6.01%) SCT (mean HbA1c difference, -0.29%; 95% CI, -0.35% to -0.23%). Findings were similar in models adjusted for key risk factors and in analyses using 2001 concurrent measures of 2-hour glucose and HbA1c concentration for those with SCT (mean, 5.35%) vs those without SCT (mean, 5.65%) for a mean HbA1c difference of -0.30% (95% CI, -0.39% to -0.21%). The HbA1c difference by SCT was greater at higher fasting (P = .02 for interaction) and 2-hour (P = .03) glucose concentrations. The prevalence of prediabetes and diabetes was statistically significantly lower among participants with SCT when defined using HbA1c values (29.2% vs 48.6% for prediabetes and 3.8% vs 7.3% for diabetes in 572 observations from participants with SCT and 6877 observations from participants without SCT; P<.001 for both comparisons).

Conclusions and Relevance

Among African Americans from 2 large, well-established cohorts, participants with SCT had lower levels of HbA1c at any given concentration of fasting or 2-hour glucose compared with participants without SCT. These findings suggest that HbA1c may systematically underestimate past glycemia in black patients with SCT and may require further evaluation.

Residential Proximity to Traffic-Related Pollution and Atherosclerosis in 4 Vascular Beds Among African-American Adults: Results From the Jackson Heart Study

To our knowledge, no study has investigated the association of long-term exposure to traffic pollution with markers of atherosclerosis in 4 vascular beds simultaneously in an all-African-American cohort. Among participants in the Jackson Heart Study (Jackson, Mississippi; baseline mean age = 55.5 (standard deviation, 12.7) years), we used linear regression to estimate percent differences in carotid intima-media thickness (CIMT) at baseline (2004) and used modified Poisson regression (robust error variance) to estimate prevalence ratios for peripheral artery disease (PAD), coronary artery calcification (CAC), and abdominal aortic calcification (AAC) at the first follow-up visit (2005-2008) for persons living less than 150 m (versus more than 300 m) from major roadways, adjusting for confounders. Living less than 150 m from such roadways was associated with a significant 6.67% (95% confidence interval: 1.28, 12.35) increase in CIMT (4,800 participants). PAD prevalence among persons living less than 150 m from a major roadway was 1.17 (95% confidence interval: 0.73, 1.86) times that of persons living more than 300 m away (4,443 participants), but this result was not statistically significant. There was no association for CAC or AAC. The association with CIMT was stronger in participants with a cardiovascular disease history than in those without one (P = 0.04). We observed an association in the carotid vascular beds but not the coronary, abdominal, or peripheral vascular beds. Our results highlight the need to consider residential proximity to roadways as a potential cardiovascular disease risk factor for blacks.

Adverse childhood events: incarceration of household members and health-related quality of life in adulthood

BACKGROUND

Incarceration of a household member has been associated with adverse outcomes for child well-being.

METHODS

We assessed the association between childhood exposure to the incarceration of a household member and adult health-related quality of life (HRQOL) in the 2009/2010 Behavioral Risk Factor Surveillance System controlling for age, race/ethnicity, education, and additional adverse childhood experiences.

RESULTS

Adults who lived in childhood with an incarcerated household member had higher risk of poor HRQOL compared with adults who had not (adjusted relative risk [ARR] 1.18; 95% CI 1.07, 1.31). Among Black adults the association was strongest with the physical health component of HRQOL (ARR 1.58 [95% CI 1.18, 2.12]); among White adults, the association was strongest with the mental health component of HRQOL (ARR 1.29, [95% CI 1.07-1.54]).

CONCLUSIONS

Living with an incarcerated household member during childhood is associated with higher risk of poor HRQOL during adulthood, suggesting that the collateral damages of incarceration for children are long-term.

Racial Differences in the Performance of Existing Risk Prediction Models for Incident Type 2 Diabetes: The CARDIA Study

OBJECTIVE

In 2010, the American Diabetes Association (ADA) added hemoglobin A1c (A1C) to the guidelines for diagnosing type 2 diabetes. However, existing models for predicting diabetes risk were developed prior to the widespread adoption of A1C. Thus, it remains unknown how well existing diabetes risk prediction models predict incident diabetes defined according to the ADA 2010 guidelines. Accordingly, we examined the performance of an existing diabetes prediction model applied to a cohort of African American (AA) and white adults from the Coronary Artery Risk Development Study in Young Adults (CARDIA).

RESEARCH DESIGN AND METHODS

We evaluated the performance of the Atherosclerosis Risk in Communities (ARIC) diabetes risk prediction model among 2,456 participants in CARDIA free of diabetes at the 2005-2006 exam and followed for 5 years. We evaluated model discrimination, calibration, and integrated discrimination improvement with incident diabetes defined by ADA 2010 guidelines before and after adding baseline A1C to the prediction model.

RESULTS

In the overall cohort, re-estimating the ARIC model in the CARDIA cohort resulted in good discrimination for the prediction of 5-year diabetes risk (area under the curve [AUC] 0.841). Adding baseline A1C as a predictor improved discrimination (AUC 0.841 vs. 0.863, P = 0.03). In race-stratified analyses, model discrimination was significantly higher in whites than AA (AUC AA 0.816 vs. whites 0.902; P = 0.008).

CONCLUSIONS

Addition of A1C to the ARIC diabetes risk prediction model improved performance overall and in racial subgroups. However, for all models examined, discrimination was better in whites than AA. Additional studies are needed to further improve diabetes risk prediction among AA.

HIV Incidence Prior to, during, and after Violent Conflict in 36 Sub-Saharan African Nations, 1990-2012: An Ecological Study

Objectives

The aim of this study was to determine the association between violent conflict and HIV incidence within and across 36 sub-Saharan Africa countries between 1990 and 2012.

Methods

We used generalized linear mixed effect modeling to estimate the effect of conflict periods on country-level HIV incidence. We specified random intercepts and slopes to account for across and within country variation over time. We also conducted a sub-analysis of countries who experienced conflict to assess the effect of conflict intensity on country-level HIV incidence. All models controlled for level of economic development, number of refugees present in the country, and year.

Results

We found that, compared to times of peace, the HIV incidence rate increased by 2.1 per 1000 infections per year (95%CI: 0.39, 3.87) in the 5 years prior to conflict. Additionally, we found a decrease of 0.7 new infections per 1000 people per year (95%CI: -1.44, -0.01) in conflicts with 25 to 1000 battle-related deaths and a decrease of 1.5 new infections per 1000 people per year (95%CI:-2.50, -0.52) for conflict with more than 1000 battle-related deaths, compared to conflicts with less than 25 battle-related deaths

Conclusions

Our results demonstrate that HIV infection rates increase in the years immediately prior to times of conflict; however, we did not identify a significant increase during and immediately following periods of violent conflict. Further investigation, including more rigorous data collection, is needed, as is increased aid to nations at risk of violent conflict to help in the fight against HIV/AIDS in sub-Saharan Africa.

Evaluating the Effects of Coping Style on Allostatic Load, by Sex: The Jackson Heart Study, 2000-2004

The objective of this study was to examine the cross-sectional association between coping styles and allostatic load among African American adults in the Jackson Heart Study (2000–2004). Coping styles were assessed using the Coping Strategies Inventory-Short Form; allostatic load was measured by using 9 biomarkers standardized into z-scores. Sex-stratified multivariable linear regressions indicated that females who used disengagement coping styles had significantly higher allostatic load scores (β = 0.016; 95% CI, 0.001–0.032); no such associations were found in males. Future longitudinal investigations should examine why disengagement coping style is linked to increased allostatic load to better inform effective interventions and reduce health disparities among African American women.

Extracurricular Activities and Bullying Perpetration: Results From a Nationally Representative Sample

BACKGROUND

Bullying is a widespread problem for school-aged children and adolescents. Interventions to reduce bullying are not well disseminated. Extracurricular involvement is, however, common. This study aims to examine the relationship between parent-reported participation in extracurricular activities and bullying perpetration.

METHODS

Using the 2011 National Survey of Children's Health, 62,215 interviews with parents of children 6 to 17 were analyzed. Extracurricular categories of sports only, sports + nonsport, nonsport only, and no activities were based on parental response to questions regarding sport teams/lessons, clubs, and organizations. Bullying was derived from report of the child "bullying or being cruel/mean to others." Weighted bivariate analyses, logistic regression, and sex/race/ethnicity/age stratified analyses were conducted.

RESULTS

Eighty percent of children participated in extracurricular activities: 8% sports, 48% sports + nonsports, and 24% nonsports. Bullying perpetration was reported in 15% of the sample. Compared with those not participating in extracurricular activities, the odds of bullying were significantly lower for children who participated in sports + nonsports (Adjusted odds ratio (AOR) 0.67, 95% confidence interval [CI] 0.57-0.79) and nonsport only (AOR 0.82, 95% CI 0.70-0.97). Stratified analyses showed attenuated effects of extracurricular activities for boys and for Hispanics.

CONCLUSIONS

Children who participate in a variety of extracurricular activities exhibit the least frequent bullying perpetration.

Association between sexual behaviors, bullying victimization and suicidal ideation in a national sample of high school students: implications of a sexual double standard

PURPOSE

The sexual double standard is the notion that women are more harshly judged for their sexual behaviors than men. The purpose of this study was to investigate if the sexual double standard could explain gender differences in bullying victimization among adolescents and the extent to which that relationship correlated with depression and suicidal ideation.

METHODS

Analyses were conducted using a sample of high school students (n = 13,065) from the 2011 Youth Risk Behavior Survey, a cross-sectional and national school-based survey conducted by the Centers for Disease Control and Prevention. Data were assessed using multiple logistic regression, gender-stratified analyses, and interaction terms.

FINDINGS

Students who engaged in sexual intercourse (sexually active) had higher odds of being bullied. When this association was stratified by gender, odds of being bullying increased for girls (odds ratio [OR], 1.83; 95% CI, 1.58-2.13) and decreased for boys (OR, 0.94; 95% CI, 0.77-1.16). Sexually active students who were bullied also displayed more than five times (OR, 5.65; 95% CI, 4.71-6.78) the adjusted odds of depression and three times (adjusted OR, 3.38; 95% CI, 2.65-4.32) the adjusted odds of suicidal ideation compared with students who reported neither of those behavioral characteristics. When stratified by gender, girls had slightly higher odds of depression and suicidal ideation but overall, the odds remained strong for both genders.

CONCLUSIONS

Results provide some evidence that a sexual double standard exists and may play a prominent role in bullying victimization among girls. Therefore, addressing the sexual double may be important to consider when tailoring school bullying intervention programs.

Association between adverse childhood experiences in the home and pediatric asthma

BACKGROUND

Numerous studies suggest that psychosocial factors could contribute to pediatric asthma.

OBJECTIVE

To examine the relation between single and cumulative adverse childhood experiences (ACEs), a measurement of household dysfunction, on parent report of lifetime asthma in children.

METHODS

This cross-sectional study used data from the 2011 to 2012 National Survey of Children's Health, a nationally representative sample of children 0 to 17 years old (n = 92,472). The main exposure was parent or guardian report of 6 ACE exposures (eg, witnessing domestic violence). The relation between ACE exposures and parent-reported diagnosis of childhood asthma was examined using multivariable logistic regression after controlling for demographic, socioeconomic, and behavioral covariates.

RESULTS

Overall asthma prevalence was 14.6%. Exposure prevalence to any ACE was 29.2%. Increased number of ACE exposures was associated with increased odds of asthma. In the adjusted model, the odds of reporting asthma were 1.28 (95% confidence interval [CI] 1.14-1.43) for those reporting 1 ACE, 1.73 (95% CI 1.27-2.36) for those with 4 ACEs, and 1.61 (95% CI 1.15-2.26) for those with 5 or 6 ACEs compared with those with no ACE exposures. Effects were moderated by Hispanic ethnicity. Hispanic children exposed to 4 ACEs had a 4.46 times increase in lifetime asthma (95% CI 2.46-8.08); white children had a 1.19 times increase (95% CI 0.80-1.79) compared with those exposed to 0 ACE.

CONCLUSION

This study supports the growing evidence for the biopsychosocial model of asthma onset. Future studies should examine the association between ACEs and specific asthma-related health outcomes.

Mental health and bullying in the United States among children aged 6 to 17 years

This article examines the association between mental health disorders and being identified as a bully among children between the ages of 6 and 17 years. Data from the 2007 National Survey of Children's Health were examined. A total of 63,997 children had data for both parental reported mental health and bullying status. Bivariate analysis and logistic regression was performed to assess the association between mental health status and being identified as a bully with an age-stratified analysis and sub-analysis by type of mental health disorder. In 2007, 15.2% of U.S. children ages 6 to 17 years were identified as bullies by their parent or guardian. Children with a diagnosis of depression, anxiety, or depression had a threefold increased odds of being a bully. The diagnosis of depression is associated with a 3.31 increased odds (95% CI = [2.7, 4.07]) of being identified as a bully. Children with anxiety and attention deficit and hyperactivity disorder (ADHD) had similar odds. The diagnosis of a mental health disorder is strongly associated with being identified as a bully. In particular, depression, anxiety, and ADHD are strongly associated with being identified as a bully. These findings emphasize the importance of providing psychological support to not only victims of bullying but bullies as well. Understanding the risk profile of childhood bullies is essential in gaining a better grasp of this public health problem and in creating useful and appropriate resources and interventions to decrease bullying.