Carolyn C. Cannuscio

Cardiovascular Morbidity and Mortality in Women Diagnosed With Rheumatoid Arthritis

Background—Rheumatoid arthritis may be associated with an increased risk of cardiovascular disease. We compared the incidence rates of myocardial infarction and stroke in subjects with and without rheumatoid arthritis. Methods and Results—A prospective cohort study was conducted among the 114 342 women participating in the Nurses’ Health Study who were free of cardiovascular disease and rheumatoid arthritis at baseline in 1976. All self-reported cases of rheumatoid arthritis were confirmed by medical record review. Fatal and nonfatal myocardial infarctions and strokes were similarly confirmed. Multivariate pooled logistic regression was used to adjust for potential cardiovascular risk factors. Five hundred twenty-seven incident cases of rheumatoid arthritis and 3622 myocardial infarctions and strokes were confirmed during 2.4 million person-years of follow-up. The adjusted relative risk of myocardial infarction in women with rheumatoid arthritis compared with those without was 2.0 (95% confidence interval [CI], 1.23 to 3.29). For stroke, the adjusted relative risk was 1.48 (95% CI, 0.70 to 3.12). Women who had rheumatoid arthritis for at least 10 years had a risk for myocardial infarction of 3.10 (95% CI, 1.64 to 5.87). Conclusion—In this large prospective cohort of women, participants with rheumatoid arthritis had a significantly increased risk of myocardial infarction but not stroke compared with those without rheumatoid arthritis. If these data are confirmed, aggressive coronary heart disease prevention strategies should be tested for persons with rheumatoid arthritis.

Physical activity and reduced risk of colon cancer: implications for prevention

This paper reviews the consistency of the relation between increasedphysical activity and reduced risk of colon cancer, estimates the potentialprevention benefit from increasing population levels of physical activity,and considers social strategies to increase activity levels. The publishedliterature was reviewed systematically and supplemented by MEDLINE searchesthrough March 1997. Studies that reported a measure of physical activity andoutcomes of colon cancer or colorectal cancer were included. We excluded thefirst report of a study that was expanded subsequently by extended follow-up,and any study that did not report the methods for measurement of physicalactivity. Data were extracted including details on study size, methods ofclassifying physical activity, and outcomes. A consistent inverse relationwas observed such that increased physical activity was associated withreduced risk of colon cancer. About a 50 percent reduction in incidence wasobserved among thos e with the highest level of activity across numerousstudies that used different measures of activity (occupational orleisure-time activity). This association persisted in studies usingmultivariate analyses to control for diet and other known or suspected riskfactors for colon cancer. Risk reduction was attenuated in those studies thatcombined colon and rectal cancer. This review indicates that greaterattention should be placed on social strategies to increase physical activityas a means of preventing colon cancer.

How Far Do Low-Income Parents Travel to Shop for Food? Empirical Evidence from Two Urban Neighborhoods

Research on the impact of the built environment on obesity and access to healthful foods often fails to incorporate information about how individuals interact with their environment. A sample of 198 low-income WIC recipients from two urban neighborhoods were interviewed about where they do their food shopping and surveys were conducted of food stores in their neighborhoods to assess the availability of healthful foods. Results indicate that participants rarely shop at the closest supermarket, traveling on average 1.58 miles for non-WIC food shopping and 1.07 miles for WIC shopping. Findings suggest that access to healthful foods is not synonymous with geographic proximity.

The Contribution of Urban Foodways to Health Disparities

How do urban food environments produce health disparities? The literature currently emphasizes the etiologic relevance of urban food deserts and their nutritional shortcomings. This paper instead examines the health relevance of foodways—the social dynamics surrounding the production, purchase, and consumption of food. We report on data from 32 photo-elicitation interviews conducted with adult residents of Philadelphia, examining distinct foodways and health concerns that play out in the most commonly discussed retail establishments: corner stores, “Stop and Go’s” (delis that also sell beer), and Chinese takeout restaurants. Corner store visits, described as a routinized element of children’s school day, were implicated in early life patterning of unsound nutritional choices. Stop and Go’s were described as a health threat because of their alcohol sales and tacit promotion of public drunkenness, coupled with accessibility to youth. Stop and Go’s and Chinese takeouts both were perceived as generators of violence in part because of on-site sales of alcohol, drug paraphernalia, and illicit drugs. Chinese takeouts also were described as symbolic reminders of African Americans’ economic exclusion and as places infused with race/ethnic tension and hostile merchant–customer interactions. Instead of viewing the food environment simply as a source of calories and nutrients, participants discussed the complex social dynamics that play out therein, raising a range of important considerations for (especially disadvantaged) urban residents’ safety, physical well-being, and mental health.

Mortgage Delinquency and Changes in Access to Health Resources and Depressive Symptoms in a Nationally Representative Cohort of Americans Older Than 50 Years

OBJECTIVES We evaluated associations between mortgage delinquency and changes in health and health-relevant resources over 2 years, with data from the Health and Retirement Study, a longitudinal survey representative of US adults older than 50 years. METHODS In 2008, participants reported whether they had fallen behind on mortgage payments since 2006 (n = 2474). We used logistic regression to compare changes in health (incidence of elevated depressive symptoms, major declines in self-rated health) and access to health-relevant resources (food, prescription medications) between participants who fell behind on their mortgage payments and those who did not. RESULTS Compared with nondelinquent participants, the mortgage-delinquent group had worse health status and less access to health-relevant resources at baseline. They were also significantly more likely to develop incident depressive symptoms (odds ratio [OR] = 8.60; 95% confidence interval [CI] = 3.38, 21.85), food insecurity (OR = 7.53; 95% CI = 3.01, 18.84), and cost-related medication nonadherence (OR = 8.66; 95% CI = 3.72, 20.16) during follow-up. CONCLUSIONS Mortgage delinquency was associated with significant elevations in the incidence of mental health impairments and health-relevant material disadvantage. Widespread mortgage default may have important public health implications.

The Impact of WIC Food Package Changes on Access to Healthful Food in 2 Low-Income Urban Neighborhoods

OBJECTIVE To evaluate the impact of the 2009 food package changes for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on the availability of healthful food. DESIGN Survey of all food stores in the study area before and after the changes were implemented. SETTING Two low-income neighborhoods in Philadelphia, 1 predominantly African-American, the other predominantly Hispanic. PARTICIPANTS One hundred forty one supermarkets, grocery stores, and non-chain corner stores identified through field enumeration. MAIN OUTCOME MEASURES Nutrition Environment Measure Survey for Stores (NEMS-S) to determine availability, price, and quality of fruit, vegetables, milk, cereal, beans, canned fish, meat, whole grains, and juice. ANALYSIS Comparison of NEMS-S scores before and after food package changes using t tests and ordinary least squares regression to understand the role of supermarket status, WIC participation, and racial and income composition in predicting NEMS-S scores; geographic information systems to calculate proximity of residents to food stores. RESULTS The availability of healthful food increased significantly in stores, overall, with more substantial increases in WIC-authorized stores. Supermarket status, WIC retail status, and NEMS-S scores at baseline were significant predictors of NEMS-S scores after the food package changes. CONCLUSIONS AND IMPLICATIONS Changes in the WIC food package were associated with increased availability of healthful food in 2 low-income neighborhoods.

More Than Just An Eyesore: Local Insights And Solutions on Vacant Land And Urban Health

Vacant land is a significant economic problem for many cities, but also may affect the health and safety of residents. In order for community-based solutions to vacant land to be accepted by target populations, community members should be engaged in identifying local health impacts and generating solutions. We conducted 50 in-depth semi-structured interviews with people living in Philadelphia, Pennsylvania, a city with high vacancy, about the impact of vacant land on community and individual health and safety, as well as ideas for solutions to vacant land. Participants described a neighborhood physical environment dominated by decaying abandoned homes and overgrown vacant lots which affected community well-being, physical health, and mental health. Vacant land was thought to affect community well-being by overshadowing positive aspects of the community, contributing to fractures between neighbors, attracting crime, and making residents fearful. Vacant land was described as impacting physical health through injury, the buildup of trash, and attraction of rodents, as well as mental health through anxiety and stigma. Participants had several ideas for solutions to vacant land in their community, including transformation of vacant lots into small park spaces for the elderly and playgrounds for youth, and the use of abandoned homes for subsidized housing and homeless shelters. A few participants took pride in maintaining vacant lots on their block, and others expressed interest in performing maintenance but lacked the resources to do so. Public health researchers and practitioners, and urban planners should engage local residents in the design and implementation of vacant land strategies. Furthermore, municipalities should ensure that the health and safety impact of vacant land helps drive policy decisions around vacant land.

Housing strain, mortgage foreclosure, and health.

BACKGROUND Foreclosure rates have risen rapidly since 2005, reaching historically high levels. The purpose of this study was to examine the health implications of the current housing crisis. METHODS We conducted a cross-sectional online consumer panel survey including residents of California, Arizona, Nevada, and Florida (n = 798) to determine the feasibility of contacting distressed homeowners via the Internet and to assess mental and physical health among respondents across the spectrum from those having no housing strain to those in loan default or home foreclosure. RESULTS Homeowners in default or foreclosure exhibited poorer mental health and more physical symptoms than renters, homeowners with moderate strain, and homeowners with no strainöfollowing a gradient that was consistent across multiple health indicators. CONCLUSIONS Internet panel sampling was an efficient method of contacting distressed homeowners. Record-high foreclosure rates may have broad implications for nursing and public health. Homeowners in default or foreclosure represent an identifiable high-risk group that may benefit from coordinated, affordable health and social services.

Material resources and population health: disadvantages in health care, housing, and food among adults over 50 years of age.

OBJECTIVES We examined associations between material resources and late-life declines in health. METHODS We used logistic regression to estimate the odds of declines in self-rated health and incident walking limitations associated with material disadvantages in a prospective panel representative of US adults aged 51 years and older (N = 15,441). RESULTS Disadvantages in health care (odds ratio [OR] = 1.39; 95% confidence interval [CI] = 1.23, 1.58), food (OR = 1.69; 95% CI = 1.29, 2.22), and housing (OR = 1.20; 95% CI = 1.07, 1.35) were independently associated with declines in self-rated health, whereas only health care (OR = 1.43; 95% CI = 1.29, 1.58) and food (OR = 1.64; 95% CI = 1.31, 2.05) disadvantage predicted incident walking limitations. Participants experiencing multiple material disadvantages were particularly susceptible to worsening health and functional decline. These effects were sustained after we controlled for numerous covariates, including baseline health status and comorbidities. The relations between health declines and non-Hispanic Black race/ethnicity, poverty, marital status, and education were attenuated or eliminated after we controlled for material disadvantage. CONCLUSIONS Material disadvantages, which are highly policy relevant, appear related to health in ways not captured by education and poverty. Policies to improve health should address a range of basic human needs, rather than health care alone.

Practical Guidance and Ethical Considerations for Studies Using Photo-Elicitation Interviews

Photo-elicitation is a qualitative interviewing technique that has gained popularity in recent years. It is the foundation for photovoice projects and is a tool well-suited for community-based participatory research. Photo-elicitation yields rich data, and interview participants say these interviews encourage community awareness and engagement. This article draws on 9 studies, conducted by researchers at 3 institutions (the University of Pennsylvania, the Philadelphia Veterans Affairs Medical Center, and the Geisel School of Medicine at Dartmouth) in partnership with community-based organizations and students, in which 303 participants completed photo-elicitation interviews. We offer 8 practical suggestions for overcoming challenges encountered during photo-elicitation research and for managing ethical concerns about the use of visual data in public health research. Our guidelines can inform study design, protocol development, and institutional review board approval.