Racial/ethnic and income disparities in neighborhood-level broadband access in 905 US cities, 2017-2021

OBJECTIVES

Broadband access is an essential social determinant of health, the importance of which was made apparent during the COVID-19 pandemic. We sought to understand disparities in broadband access within cities and identify potential solutions to increase urban access.

STUDY DESIGN

This was a descriptive secondary analysis using multi-year cross-sectional survey data.

METHODS

Data were obtained from the City Health Dashboard and American Community Survey. We studied broadband access in 905 large US cities, stratifying neighborhood broadband access by neighborhood median household income and racial/ethnic composition.

RESULTS

In 2017, 30% of urban households across 905 large US cities did not have access to high-speed broadband internet. After controlling for median household income, broadband access in majority Black and Hispanic neighborhoods was 10-15% lower than in majority White or Asian neighborhoods. Over time, lack of broadband access in urban households decreased from 30% in 2017 to 24% in 2021, but racial and income disparities persisted.

CONCLUSIONS

As an emerging social determinant, broadband access impacts health across the life course, affecting students' ability to learn and adults' ability to find and retain jobs. Resolving lack of broadband access remains an urban priority. City policymakers can harness recent infrastructure funding opportunities to reduce broadband access disparities.

Hypertension Prevalence Jointly Influenced by Acculturation and Gender in US Immigrant Groups

BACKGROUND

Latinos and Asians in the United States are disproportionately burdened by hypertension, a leading risk factor for cardiovascular disease. Few studies have used multicomponent measures of acculturation to compare cardiovascular risk factors across immigrant-origin groups. Additionally, little is known about how acculturation and gender shape hypertension risk among immigrants.

METHODS

We created an acculturation score composed of language use, nativity, and years in the United States and fit separate race/ethnicity log-binomial models examining associations with hypertension prevalence (≥130/80 mm Hg) among Latino (n = 4,267) and Asian (n = 2,142) National Health and Nutrition Examination Survey 2011-2016 participants aged 18+. Joint effect models tested the concept of "intersectionality" between acculturation and gender.

RESULTS

Adjusting for age, gender, and socioeconomic position, Latinos and Asians with high acculturation were 25% and 27% more likely to have hypertension, respectively, compared with low acculturation groups. Latino and Asian American men with high levels of acculturation were 74-79% more likely to have hypertension compared with women with low acculturation (adjusted prevalence ratios (aPR) for Latinos = 1.74, 95% confidence interval (CI): 1.49-2.03; aPR for Asians = 1.79, 95% CI: 1.42-2.25). The gradient of increasing hypertension with increasing acculturation was most apparent among Latino men (adjusted risk differences (aRD) = 12.0%, P < 0.001) and Asian women (aRD = 14.0%, P = 0.003) and nonsignificant among Latino women and Asian men when comparing high vs. low acculturation categories.

CONCLUSIONS

Our results correspond with prior literature demonstrating increased morbidity among immigrants with increasing acculturation but also suggest differing patterns by race/ethnicity and gender. Future research should explore how migration processes differentially influence hypertension among men and women.

Speaking the same language: treatment outcome definitions for multidrug-resistant tuberculosis

SETTING

Globally it is estimated that 273000 new cases of multidrug-resistant tuberculosis (MDR-TB, resistance to isoniazid and rifampicin) occurred in 2000. To address MDR-TB management in the context of the DOTS strategy, the World Health Organization and partners have been promoting an expanded treatment strategy called DOTS-Plus. However, standard definitions for MDR-TB patient registration and treatment outcomes do not exist.

OBJECTIVE

To propose a standardized set of case registration groups and treatment outcome definitions for MDR-TB and procedures for conducting cohort analyses under the DOTS-Plus strategy.

DESIGN

Using published definitions for drug-susceptible TB as a guide, a 2-year-long series of meetings, conferences, and correspondence was undertaken to review published literature and country-specific program experience, and to develop international agreement.

RESULTS

Definitions were designed for MDR-TB patient categorization, smear and culture conversion, and treatment outcomes (cure, treatment completion, death, default, failure, transfer out). Standards for conducting outcome analyses were developed to ensure comparability between programs.

CONCLUSION

Optimal management strategies for MDR-TB have not been evaluated in controlled clinical trials. Standardized definitions and cohort analyses will facilitate assessment and comparison of program performance. These data will contribute to the evidence base to inform decision makers on approaches to MDR-TB control.

Capacity building for international tuberculosis control through operations research training

SETTING

In resource-poor countries, few tuberculosis (TB) program staff at the national, provincial, and even district levels have the basic analytical and epidemiological skills necessary for collecting and analyzing quality data pertaining to national TB control program (NTP) improvements. This includes setting program priorities, operations planning, and implementing and evaluating program activities.

OBJECTIVES

To present a model course for building capacity in basic epidemiology and operations research (OR).

DESIGN

A combination of didactic lectures and applied field exercises were used to achieve the main objectives of the 6-day OR course. These were to increase the understanding of quantitative and qualitative research concepts, study design, and analytic methods, and to increase awareness of how these methods apply to the epidemiology and control of TB; and to demonstrate the potential uses of OR in answering practical questions on NTP effectiveness. As a final outcome, course participants develop OR proposals that are funded and later implemented.

RESULTS

Since 1997, this OR course has been conducted nine times in five countries; 149 key NTP and laboratory staff have been trained in OR methods, and 44 OR protocols have been completed or are underway.

CONCLUSION

This low-cost model course can be adapted to a wide range of public health issues.

Encouraging outcomes in the first year of a TB control demonstration program: Orel Oblast, Russia

SETTING

Orel, Russia.

OBJECTIVE

To evaluate outcomes of tuberculosis (TB) patients treated in the first year of a TB control demonstration project using a revised strategy of directly observed treatment, short-course (DOTS). Standard methods recommended by World Health Organization (WHO) were adapted to include mycobacterial cultures.

DESIGN

Retrospective cohort analysis of TB patients diagnosed between October 1999 and September 2000.

RESULTS

Among 749 TB patients, 65% had bacteriologic confirmation of pulmonary TB, 31% were diagnosed clinically, and 4% had extra-pulmonary TB. Most (92%) had no previous TB treatment, but 8% were identified as retreatment cases. Of all patients, 41% had new sputum smear-positive TB. No patients were HIV-infected. Multidrug-resistant (MDR) TB levels were 3% among new and 17% among retreatment patients. Among new smear-positive patients, treatment success was 79% (72% cure, 7% completion); remaining outcomes were 8% failure, 3% default, 8% death, and 1% transfer. Success rates for new culture-positive and clinically diagnosed patients were 81% and 91%, respectively.

CONCLUSION

Despite historical differences, successful implementation of the revised TB strategy in Russia is possible. Treatment success rates were high, suggesting WHO targets of 85% cure for smear-positive patients is attainable. Obstacles include drug resistance and elevated death rates among smear-positive patients.

Injection-related risk behaviors in young urban and suburban injection drug users in Chicago (1997-1999)

We compared injection-related risk practices between urban and suburban injection drug users (IDUs) in a large cross-sectional sample of young IDUs. From 1997 to 1999, we recruited 700 active IDUs aged 18 to 30 years in Chicago and its suburbs. A suburban residence was reported by 38% of participants. Participants were interviewed at four urban locations and screened for HIV and hepatitis C virus antibodies. Receptive sharing of syringes and other paraphernalia by urban and suburban IDUs in the preceding 6 months was compared using univariable and multivariable models. Sharing injection paraphernalia in the total sample was high, with 50% of participants reporting receptive syringe sharing and 70% reporting sharing cotton, cookers, and/or rinse water. After adjusting for demographic characteristics, injection settings, frequency, and duration of injection as well as ease of acquiring new syringes, suburban IDUs were significantly more likely than urban IDUs to share syringes (adjusted odds ratio = 1.7; 95% confidence interval: 1.1-2.5); however, the likelihood of sharing cotton, cookers, or rinse water was roughly equal. Despite overall higher risk profiles among suburban IDUs, HIV and hepatitis C prevalence levels were significantly lower than among urban participants. Current high levels of injection risk behaviors in suburban groups represent a potential for rapid dissemination of infection.

Prevalence and incidence of HIV among out-of-treatment injecting drug users, Chicago 1994-1996

OBJECTIVES

To assess HIV prevalence, incidence, and associated risk factors among IDUs in Chicago.

METHODS

Seven hundred ninety-four street-recruited IDUs ranging in age from 18 to 50 years, who were not in drug treatment at study enrollment, were interviewed and tested for HIV at baseline and at two follow-ups scheduled 6 and 12 months after baseline. Questionnaires assessed respondents' demographic characteristics, medical and drug treatment histories, drug use, and sexual practices.

RESULTS

HIV seroprevalence at baseline was 18%. Logistic regression identified the following determinants of prevalent HIV infection: Puerto Rican ethnicity, homosexual or bisexual self-identification, injecting for 4 or more years, and having smoked crack cocaine in the past 6 months. Follow-up data were collected from 584 (73.6%) participants. Mean duration of follow-up was 16.5 months, indicating that most subjects had follow-up intervals longer than the scheduled 6 and 12 months. Seven HIV seroconversions were observed in 632 person years of risk, yielding an incidence rate of 1.1 per 100 person years of risk. Injection for 3 or less years was positively associated with HIV seroconversion.

CONCLUSIONS

The findings provide evidence of a decline in HIV incidence among IDUs, though newer injectors remain at elevated risk for infection.

Hepatitis C virus infection: prevalence, risk factors, and prevention opportunities among young injection drug users in Chicago, 1997-1999

The prevalence, risk factors, and prevention opportunities of hepatitis C virus (HCV) infection were studied in a large sample of 698 young adult injection drug users (IDUs) in Chicago, 18-30 years old. Participants were recruited between 1997 and 1999 by using street outreach, targeted advertising, and chain-referral methods. HCV infection prevalence was 27% and was strongly associated with both age and duration of injecting (P<.001). In multivariable analysis, sexual behaviors were unrelated to seropositivity. Independent drug-related risk factors included frequent injection, heavy crack smoking, injecting in a shooting gallery, and syringe-mediated sharing. Urban residents were more likely than suburban residents to be infected. Most research on hepatitis C has shown rapid spread of infection among IDUs, but these findings underscore that opportunities to identify IDUs uninfected with HCV may be greater than assumed and emphasize the need to target younger, newer IDUs.