Allison Diamant

Improving the nutritional resource environment for healthy living through community-based participatory research.

OBJECTIVES: To build health promotion capacity among community residents through a community-based participatory model, and to apply this model to study the nutritional environment of an urban area to better understand the role of such resources in residents’ efforts to live a healthy life.DESIGN: A multiphase collaborative study that inventoried selected markets in targeted areas of high African-American concentration in comparison with markets in a contrasting wealthier area with fewer African Americans.SETTING: A community study set in the Los Angeles metropolitan area.PARTICIPANTS: African-American community organizations and community residents in the target areas.INTERVENTIONS: Two surveys of market inventories were conducted. The first was a single-sheet form profiling store conditions and the availability of a small selection of healthy foods. The second provided detailed information on whether the store offered fruit, vegetables, low-fat dairy products, dried goods and other items necessary for residents to consume a nutritious diet.RESULTS: The targeted areas were significantly less likely to have important items for living a healthier life. The variety and quality of fresh fruit and vegetable produce was significantly lower in the target areas. Such products as 1% milk, skim milk, low-fat and nonfat cheese, soy milk, tofu, whole grain pasta and breads, and low-fat meat and poultry items were significantly less available.CONCLUSIONS: Healthy food products were significantly less available in the target areas. The authors conclude from these results that the health disparities experienced by African-American communities have origins that extend beyond the health delivery system and individual behaviors inasmuch as adherence to the healthy lifestyle associated with low chronic disease risk is more difficult in resource-poor neighborhoods than in resource-rich ones.

Sexual Orientation and Variation in Physical and Mental Health Status among Women

OBJECTIVE To assess and compare the physical and mental health status of women of differing sexual orientation within a population-based sample. METHODS We used a population-based telephone survey performed using random digit dialing techniques. Our study population was drawn from the 1999 Los Angeles County Health Survey and included women age 18-64 years who reported their sexual orientation (98%, n = 4135). These analyses include 4023 heterosexuals, 69 bisexuals, and 43 lesbians. RESULTS We assessed the unique association of sexual orientation with physical and mental health status using bivariate and multivariate analyses. Both lesbians and bisexuals were more likely than heterosexual women to report a diagnosis of heart disease. Among women with a depressive disorder, lesbians were more likely than heterosexuals to be using an antidepressant medication. Compared with heterosexuals within the preceding 30 days, lesbians reported significantly more days of poor mental health, and bisexuals reported significantly more days of poor physical health. However, there were no significant differences by sexual orientation in impaired ability to perform daily activities due to physical or mental health. CONCLUSIONS In this rare opportunity to use population-based data to study lesbian and bisexual health, we found that sexual orientation as a nonheterosexual woman was associated with increased rates of poor physical and mental health. We believe these findings support the need for the increased systematic study of the relationship between sexual orientation and health.

Delays and Unmet Need for Health Care Among Adult Primary Care Patients in a Restructured Urban Public Health System

OBJECTIVES We estimated the prevalence and determinants of delayed and unmet needs for medical care among patients in a restructured public health system. METHODS We conducted a stratified cross-sectional probability sample of primary care patients in the Los Angeles County Department of Health Services. Face-to-face interviews were conducted with 1819 adult patients in 6 languages. The response rate was 80%. The study sample was racially/ethnically diverse. RESULTS Thirty-three percent reported delaying needed medical care during the preceding 12 months; 25% reported an unmet need for care because of competing priorities; and 46% had either delayed or gone without care. CONCLUSIONS Barriers to needed health care continue to exist among patients receiving care through a large safety net system. Competing priorities for basic necessities and lack of insurance contribute importantly to unmet health care needs.

Comparative Effectiveness of Pharmacologic Treatments to Prevent Fractures: An Updated Systematic Review

Osteoporosis is a skeletal disorder characterized by compromised bone strength, increasing the risk for fracture (1). Risk factors include, but are not limited to, increasing age, female sex, postmenopause for women, low body weight, parental history of a hip fracture, cigarette smoking, race, hypogonadism, certain medical conditions (particularly rheumatoid arthritis), and certain medications for chronic diseases (such as glucocorticoids). During ones expected remaining life, 1 in 2 postmenopausal women and 1 in 5 older men are at risk for an osteoporosis-related fracture (2). The increasing prevalence and cost of osteoporosis have heightened interest in the effectiveness and safety of the many interventions currently available to prevent osteoporotic fracture. In 2007, we conducted a systematic review of the comparative effectiveness of treatments to prevent fractures in men and women with low bone density or osteoporosis (3, 4). Since that time, new drugs have been approved for treatment, and new studies have been published about existing drugs. Additional issues about pharmacologic treatments for osteoporosis that have become particularly salient include the optimal duration of therapy; the safety of long-term therapy; and the role of bone mineral density (BMD) measurement, both for screening and for monitoring treatment. Therefore, we updated our original systematic review. Methods This article is a condensed and further updated version of an evidence review conducted for the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Centers program (5). This article focuses on the comparative benefits and risks of short- and long-term pharmacologic treatments for low bone density. In addition, we address issues regarding monitoring and duration of therapy. For this updated review, we followed the same methods as our 2007 review, with a few exceptions. A protocol for this review was developed and posted on the Effective Health Care Program Web site (6). Data Sources and Searches We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the ACP Journal Club database, the National Institute for Clinical Excellence, the Food and Drug Administrations (FDA) MedWatch database, and relevant pharmacologic databases from 2 January 2005 to 3 June 2011. The search strategy followed that of the original report, with the addition of terms for new FDA-approved drugs (such as denosumab) and newly reported adverse events. The full search strategies are in our evidence report (5). We later updated this search to 21 January 2013 and used a machine learning method that a previous study showed had high sensitivity for detecting relevant evidence for updating a search of the literature on osteoporosis treatments (7) and then updated the searches to 4 March 2014 using the full search strategy. Study Selection Eligible studies were systematic reviews and randomized, controlled trials (RCTs) that studied FDA-approved pharmacotherapy (excluding calcitonin and etidronate) for women or men with osteoporosis that was not due to a secondary cause (such as glucocorticoid therapy and androgen-deprivation therapy) and also measured fractures as an outcome at a minimum follow-up of 6 months. In addition, we included observational studies with more than 1000 participants for adverse events and case reports for rare events. As in our original review, only English-language studies were included. Data Extraction and Quality Assessment Reviews were done in duplicate by pairs of reviewers. Study characteristics were extracted in duplicate, and outcomes data (both benefits and harms) were extracted by the study statistician. Study quality was assessed as it was in the 2007 report using the Jadad scale for clinical trials (with several questions added to assess allocation concealment and other factors) and the NewcastleOttawa Scale for observational studies (8, 9). Systematic reviews were assessed using a modified version of the 11 AMSTAR (A Measurement Tool to Assess Systematic Reviews) criteria (the modifications included eliminating the requirements to list all of the excluded studies and assess the conflicts of interest for all of the included studies) (10). The assessments of efficacy and effectiveness used reduction in fracture (all, vertebral, nonvertebral, spine, hip, wrist, or other) as the outcome (studies reporting changes in BMD but not fracture were excluded). Data Synthesis and Analysis Evidence on efficacy and effectiveness was synthesized narratively. For adverse events, we pooled data as in the 2007 report: We compared agent versus placebo and agent versus agent for agents within the same class and across classes. For groups of events that occurred in 3 or more trials, we estimated the pooled odds ratio (OR) and its associated 95% CI. Because many events were rare, we used exact conditional inference to perform the pooling rather than applying the usual asymptotic methods that assume normality. StatXact PROCs software was used for the analysis (11, 12). Large cohort and casecontrol studies were included to assess adverse events. Strength of evidence was assessed using the criteria of the Agency for Healthcare Research and Quality Evidence-based Practice Centers program, which are similar to those proposed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group (13). Role of the Funding Source The update that included studies identified in the 3 June 2011 search was funded by AHRQ. Subsequent updating received no external funding. Although AHRQ formulated the initial study questions for the original report, it did not participate in the literature search, determination of study eligibility criteria, data analysis, or interpretation of the data. Staff from AHRQ reviewed and provided comments on the report. Results The first search yielded 26366 titles, 2440 of which were considered potentially relevant (Figure). Of these, 661 full-text articles were reviewed, resulting in 255 articles that were included in the update report. Of these, 174 articles were relevant to this article. The second update search plus hand searching initially yielded 16589 titles, and machine learning and full-text review identified 107 as relevant. The third update yielded 12131 titles. After title, abstract, and full-text screening, 34 were relevant. Thus, 55086 titles were screened and 315 articles met eligibility criteria for inclusion. Not every eligible study is cited in this article. A complete list of studies that met eligibility criteria is available at www.rand.org/health/centers/epc. Figure. Summary of evidence search and selection. FRAX = Fracture Risk Assessment Tool; HRT = hormone replacement therapy; LBD = low bone density. *Original LBD report (4). Fracture Prevention Our previous review (3) identified 76 randomized trials and 24 meta-analyses and concluded that there was good-quality evidence that alendronate, etidronate, ibandronate, risedronate, zoledronic acid, estrogen, parathyroid hormone, and raloxifene prevented osteoporotic fractures, although not all of these agents prevented hip fractures. The principal new efficacy findings since that time are additional data about zoledronic acid and data about a new agent, denosumab (Tables 1 and 2). The data for zoledronic acid came from 6 placebo-controlled studies of various doses in postmenopausal women (1419), the 2 largest of which enrolled 7230 women (15) and 2127 women (14). Both studies showed statistically significant reductions in nearly all types of fractures assessed, with relative risk reductions ranging from 0.23 to 0.73 at time points from 24 to 36 months after initiation of treatment. The data for denosumab came from 2 placebo-controlled trials in postmenopausal women, one small (332 enrolled women) (20) and one much larger that followed 7521 women for 36 months (21). This latter study found statistically significant reductions in each anatomical fracture type measured (hip, nonvertebral, vertebral, and new clinical vertebral), with hazard ratios of 0.31 to 0.80. Many secondary analyses and open-label extension results of this trial report the effectiveness of denosumab in various subpopulations and other circumstances (2228). Table 1. Principal Conclusions About Drug Efficacy/Effectiveness and Adverse Events Table 2. Principal Conclusions About Monitoring and Treatment Duration Despite some difficulties in comparing results across trials because of differences in the outcomes reported, high-strength evidence shows that bisphosphonates (alendronate, ibandronate, risedronate, and zoledronic acid), denosumab, and teriparatide (the 1,34 amino acid fragment of the parathyroid hormone) reduce fractures compared with placebo in postmenopausal women with osteoporosis, with relative risks for fractures generally in the range of 0.40 to 0.60 for vertebral fractures and 0.60 to 0.80 for nonvertebral fractures. This range translates into a number needed to treat of 60 to 89 to prevent 1 vertebral fracture and 50 to 67 to prevent 1 hip fracture over 1 to 3 years of treatment, using a pooled average of the incidence of these fractures in the placebo groups from included studies. The effect of ibandronate on hip fracture risk reduction is unclear because hip fracture was not a separately reported outcome in placebo-controlled trials of this agent. The selective estrogen receptor modulator raloxifene has been shown in placebo-controlled trials to reduce only vertebral fractures; reduction in the risk for hip or nonvertebral fractures was not statistically significant. There is only one randomized, controlled trial of men with osteoporosis that was designed with a primary fracture reduction outcome. Nearly 1200 men with osteoporosis were randomly assigned to placebo or zoledronic acid intravenously once per year for 2 years. At follow-up, 1.6% of treated men had new radio

Determinants of Breast Cancer Knowledge Among Newly Diagnosed, Low-income, Medically Underserved Women With Breast Cancer

Among women with breast cancer (BC), greater BC knowledge has been associated with greater participation in treatment decision‐making, patient satisfaction, and survival. The objective of this study was to identify modifiable determinants associated with BC knowledge.

Is Incarceration a Contributor to Health Disparities? Access to Care of Formerly Incarcerated Adults

Despite the disproportionate prevalence of incarceration in communities of color, few studies have examined its contribution to health disparities. We examined whether a lifetime history of incarceration is associated with recent access to medical and dental care. We performed a secondary data analysis of the 2007 Los Angeles County Health Survey, a population-based random-digit-dialing telephone survey of county households. Any history of incarceration in a prison/jail/detention center as an adult was assessed for a random subsample. Bivariate and multivariate logistic regression analyses examined whether incarceration history was associated with access to care, controlling for other characteristics. Ten percent of our study population reported a history of incarceration. While persons with an incarceration history were similar to their peers with regard to health and insurance status, their access to medical and dental care was worse. Incarceration history was independently associated with disparities in access to care. Interventions to improve the health of communities affected by high rates of incarceration could include efforts that enable access to care for formerly incarcerated adults.

Income Disparities in Obesity Trends Among California Adolescents

OBJECTIVES We assessed income-specific trends in obesity rates among a diverse population of California adolescents. METHODS We used data from 17,535 adolescents who responded to the California Health Interview Survey between 2001 and 2007 to examine disparities in obesity prevalence by family income and gender. RESULTS Between 2001 and 2007, obesity prevalence significantly increased among lower-income adolescents but showed no statistically significant differences among higher-income adolescents after adjustment for age, gender, and race/ethnicity. Although the overall disparity in obesity by family income doubled in this time period, trends were more consistent among male adolescents than among female adolescents. CONCLUSIONS The magnitude of the income disparity in obesity prevalence among California adolescents more than doubled between 2001-2007. The overall leveling off of adolescent obesity prevalence rates could indicate that efforts to decrease childhood obesity are having an impact; however, our results suggest that efforts to prevent childhood obesity may be failing to help adolescents from lower-income families, particularly male adolescents.

Lesbians' Sexual Activities and Efforts to Reduce Risks for Sexually Transmitted Diseases

Introduction: Little information is available regarding the specific sexual practices of lesbians, and whether these activities may carry an associated health risk. Methods: Self-identified lesbians from all U.S. states (N = 6935) responded to a questionnaire that was printed in a national biweekly gay, lesbian and bisexual news magazine. Items included sexual practices engaged in with women during the past 1 and 5 years, past history of a sexually transmitted disease (STD), number and gender of lifetime and recent sexual partners, concerns regarding STDs, and risk reduction behaviors. Results: Lesbians engaged in a variety of sexual activities with female partners including orogenital sex, use of a dildo, and anilingus. Seventeen percent reported a lifetime diagnosis of an STD. Women with a history of an STD were more likely to be concerned about STDs, to ask questions of their new female sexual partners, and to have had an HIV test. Conclusions: Lesbians participate in a variety of sexual activities with their female partners that involve the exchange of body fluids, potential exposure to blood, and genital and anal stimulation that may put them at risk for STDs.

Return to work in low-income Latina and non-Latina white breast cancer survivors: a 3-year longitudinal study.

Previous research has found an 80% return‐to‐work rate in mid‐income white breast cancer survivors, but little is known about the employment trajectory of low‐income minorities or whites. We set out to compare the trajectories of low‐income Latina and non‐Latina white survivors and to identify correlates of employment status.

The Impact of Acculturation on Utilization of HIV Prevention Services and Access to Care Among an At-Risk Hispanic Population

Introduction. HIV/AIDS disproportionately affects Hispanics in the United States, a diverse and heterogeneous population. The purpose of this study was to evaluate the relationship of acculturation with HIV and hepatitis C testing, and access to care among Hispanics at risk for HIV. Methods. We recruited 600 Hispanics from STD clinics, community-based organizations, and needle exchange programs in Los Angeles County. Results. Low levels of acculturation were significantly associated with having fewer HIV tests (OR 1.98, 95% CI 1.24, 3.15), no hepatitis C tests (OR 2.61, 95% CI 1.77, 3.84), testing positive for HIV (OR 2.67, 95% CI 1.04, 6.83), and low levels of access to care (β=0.06; p<.05). Conclusions. Low levels of acculturation are an important barrier to the use of HIV-related health care services. Our findings may inform the development of effective interventions that address the cultural and behavioral differences among Hispanic subgroups.