David J. Klein

Racial and Ethnic Health Disparities among Fifth-Graders in Three Cities

BACKGROUNDnFor many health-related behaviors and outcomes, racial and ethnic disparities among adolescents are well documented, but less is known about health-related disparities during preadolescence.nnnMETHODSnWe studied 5119 randomly selected public-school fifth-graders and their parents in three metropolitan areas in the United States. We examined differences among black, Latino, and white children on 16 measures, including witnessing of violence, peer victimization, perpetration of aggression, seat-belt use, bike-helmet use, substance use, discrimination, terrorism worries, vigorous exercise, obesity, and self-rated health status and psychological and physical quality of life. We tested potential mediators of racial and ethnic disparities (i.e., sociodemographic characteristics and the childs school) using partially adjusted models.nnnRESULTSnThere were significant differences between black children and white children for all 16 measures and between Latino children and white children for 12 of 16 measures, although adjusted analyses reduced many of these disparities. For example, in unadjusted analysis, the rate of witnessing a threat or injury with a gun was higher among blacks (20%) and Latinos (11%) than among whites (5%), and the number of days per week on which the student performed vigorous exercise was lower among blacks (3.56 days) and Latinos (3.77 days) than among whites (4.33 days) (P<0.001 for all comparisons). After statistical adjustment, these differences were reduced by about half between blacks and whites and were eliminated between Latinos and whites. Household income, household highest education level, and the childs school were the most substantial mediators of racial and ethnic disparities.nnnCONCLUSIONSnWe found that harmful health behaviors, experiences, and outcomes were more common among black children and Latino children than among white children. Adjustment for socioeconomic status and the childs school substantially reduced most of these differences. Interventions that address potentially detrimental consequences of low socioeconomic status and adverse school environments may help reduce racial and ethnic differences in child health. (Funded by the Centers for Disease Control and Prevention.).

Longitudinal Relationships Between Antiretroviral Treatment Adherence and Discrimination Due to HIV-serostatus, Race, and Sexual Orientation Among African-American Men with HIV

African–Americans show worse HIV disease outcomes compared to Whites. Health disparities may be aggravated by discrimination, which is associated with worse health and maladaptive health behaviors. We examined longitudinal effects of discrimination on antiretroviral treatment adherence among 152 HIV-positive Black men who have sex with men. We measured adherence and discrimination due to HIV-serostatus, race/ethnicity, and sexual orientation at baseline and monthly for 6xa0months. Hierarchical repeated-measures models tested longitudinal effects of each discrimination type on adherence. Over 6xa0months, participants took 60% of prescribed medications on average; substantial percentages experienced discrimination (HIV-serostatus, 38%; race/ethnicity, 40%; and sexual orientation, 33%). Greater discrimination due to all three characteristics was significantly bivariately associated with lower adherence (all p’su2009<u20090.05). In the multivariate model, only racial discrimination was significant (pu2009<u20090.05). Efforts to improve HIV treatment adherence should consider the context of multiple stigmas, especially racism.

Perceived discrimination and mental health symptoms among Black men with HIV.

People living with HIV (PLWH) exhibit more severe mental health symptoms, including depression and posttraumatic stress disorder (PTSD) symptoms, than do members of the general public. We examined whether perceived discrimination, which has been associated with poor mental health in prior research, contributes to greater depression and PTSD symptoms among HIV-positive Black men who have sex with men (MSM), who are at high risk for discrimination from multiple stigmatized characteristics (HIV-serostatus, race/ethnicity, sexual orientation). A total of 181 Black MSM living with HIV completed audio computer-assisted self-interviews (ACASI) that included measures of mental health symptoms (depression, PTSD) and scales assessing perceived discrimination due to HIV-serostatus, race/ethnicity, and sexual orientation. In bivariate tests, all three perceived discrimination scales were significantly associated with greater symptoms of depression and PTSD (i.e., reexperiencing, avoidance, and arousal subscales; all p values < .05). The multivariate model for depression yielded a three-way interaction among all three discrimination types (p < .01), indicating that perceived racial discrimination was negatively associated with depression symptoms when considered in isolation from other forms of discrimination, but positively associated when all three types of discrimination were present. In multivariate tests, only perceived HIV-related discrimination was associated with PTSD symptoms (p < .05). Findings suggest that some types of perceived discrimination contribute to poor mental health among PLWH. Researchers need to take into account intersecting stigmata when developing interventions to improve mental health among PLWH.

Peer Victimization in Fifth Grade and Health in Tenth Grade

BACKGROUND AND OBJECTIVES: Children who experience bullying, a type of peer victimization, show worse mental and physical health cross-sectionally. Few studies have assessed these relationships longitudinally. We examined longitudinal associations of bullying with mental and physical health from elementary to high school, comparing effects of different bullying histories. METHODS: We analyzed data from 4297 children surveyed at 3 time points (fifth, seventh, and tenth grades) in 3 cities. We used multivariable regressions to test longitudinal associations of bullying with mental and physical health by comparing youth who experienced bullying in both the past and present, experienced bullying in the present only, experienced bullying in the past only, or did not experience bullying. RESULTS: Bullying was associated with worse mental and physical health, greater depression symptoms, and lower self-worth over time. Health was significantly worse for children with both past and present bullying experiences, followed by children with present-only experiences, children with past-only experiences, and children with no experiences. For example, 44.6% of children bullied in both the past and present were at the lowest decile of psychosocial health, compared with 30.7% of those bullied in the present only (P = .005), 12.1% of those bullied in the past only (P < .001), and 6.5% of those who had not been bullied (P < .001). CONCLUSIONS: Both chronic and current bullying are associated with substantially worse health. Clinicians who recognize bullying when it first starts could intervene to reverse the downward health trajectory experienced by youth who are repeated targets.

Perceived Discrimination and Physical Health Among HIV-Positive Black and Latino Men Who Have Sex with Men

We conducted the first study to examine health correlates of discrimination due to race/ethnicity, HIV-status, and sexual orientation among 348 HIV-positive Black (nxa0=xa0181) and Latino (nxa0=xa0167) men who have sex with men. Participants completed audio computer-assisted self-interviews. In multivariate analyses, Black participants who experienced greater racial discrimination were less likely to have a high CD4 cell count [ORxa0=xa00.7, 95xa0% CIxa0=xa0(0.5, 0.9), pxa0=xa00.02], and an undetectable viral load [ORxa0=xa00.8, 95xa0% CIxa0=xa0(0.6, 1.0), pxa0=xa00.03], and were more likely to visit the emergency department [ORxa0=xa01.3, 95xa0% CIxa0=xa0(1.0, 1.7), pxa0=xa00.04]; the combined three types of discrimination predicted greater AIDS symptoms [F (3,176)xa0=xa03.8, pxa0<xa00.01]. Among Latinos, the combined three types of discrimination predicted greater medication side effect severity [F (3,163)xa0=xa04.6, pxa0<xa00.01] and AIDS symptoms [F (3,163)xa0=xa03.1, pxa0<xa00.05]. Findings suggest that the stress of multiple types of discrimination plays a role in health outcomes.ResumenHemos realizado el primer estudio que examina los factores de la salud correlacionados con la discriminación por motivos de raza/origen étnico, estado del VIH, y la orientación sexual entre 348 hombres VIH-positivos Afro-Americanos (nxa0=xa0181) y Latinos (nxa0=xa0167) que tienen sexo con hombres. Los participantes completaron una auto-entrevista auditiva con ayuda de una computadora. En los análisis multivariantes, participantes Afro-Americanos que experimentaron mayor discriminación racial tenían menos probabilidades de tener un alto recuento de células CD4 [razón de momios (RM)xa0=xa00.7, ICxa0=xa0(0.5, 0.9), pxa0=xa00.02], y una carga viral indetectable [RMxa0=xa00.8, ICxa0=xa0(0.6,1.0), pxa0=xa00.03], y eran más propensos a visitar la sala de emergencia [RMxa0=xa01.3, ICxa0=xa0(1.0,1.7), pxa0=xa00.04]; el combinado de los tres tipos de discriminación predijo mayores síntomas del SIDA [F (3,176)xa0=xa03.8, pxa0<xa00.01]. Entre los Latinos, el combinado de los tres tipos de discriminación predijo mayor severidad en los efectos de los medicamentos [F (3,163)xa0=xa04.6, pxa0<xa00.01] y mayores síntomas del SIDA [F (3,163)xa0=xa03.1, pxa0<xa00.05]. Los resultados sugieren que el estrés debido a múltiples tipos de discriminación juega un papel en los resultados de salud.

Longitudinal association of HIV conspiracy beliefs with sexual risk among black males living with HIV.

Research is needed to identify culturally relevant factors that may contribute to sexual risk among African Americans. We investigated HIV-specific medical mistrust as one such cultural factor, often exhibited as conspiracy beliefs about HIV (e.g., “AIDS was produced in a government laboratory”), which may be indicative of general suspicion of HIV treatment and prevention messages. Over a 6-month time-period, we measured endorsement of HIV conspiracy beliefs three times and frequency of condom use monthly among 181 HIV-positive African American males. A hierarchical multivariate repeated-measures logistic random effects model indicated that greater belief in HIV conspiracies was associated with a higher likelihood of reporting unprotected intercourse across all time-points. An average of 54% of participants who endorsed conspiracies reported unprotected intercourse, versus 39% who did not endorse conspiracies. Secondary prevention interventions may need to address medical mistrust as a contributor to sexual risk among African Americans living with HIV.

Understanding Nonresponse to the 2007 Medicare CAHPS Survey

PURPOSEnThe Medicare Consumer Assessments of Healthcare Providers and Systems (MCAHPS) survey, a primarily English-language mail survey with English and Spanish telephone follow-up, is the primary means of assessing the health care experiences of American seniors. We examine unit (whole survey) and item nonresponse for this survey to explore issues regarding surveying seniors about their health care.nnnDESIGN AND METHODSnWe describe overall rates and analyze predictors of unit and item nonresponse for the 695,197 Medicare beneficiaries selected for the 2007 MCAHPS survey (335,249 unit respondents, 49% overall response rate).nnnRESULTSnAsians, African Americans, and Hispanics responded at adjusted response rates 7-17 percentage points lower than non-Hispanic Whites (p < .001 for each). Among seniors, response rates dropped beyond age 75. Asians and older beneficiaries were especially likely to respond by mail, and African Americans and Hispanics by phone. Breakoff from telephone surveys was most common among African Americans and older respondents. Among respondents, older age was the strongest predictor of item missingness (e.g., those 85 years and older failed to answer items at twice the rate of those aged 65-74 years, p < .001). Non-Hispanic Whites had lower rates of item missingness than other racial/ethnic groups (p < .001 for each; one-third lower than African Americans).nnnIMPLICATIONSnSurvey research on older adults, especially regarding racial/ethnic disparities in health care, could benefit from improved response rates. These results suggest that targeted prenotification materials and campaigns, tailored follow-up, targeted Spanish mailings, Chinese translations/calls, and adjustments to telephone protocols may improve representation and response.

The Development of a Pediatric Inpatient Experience of Care Measure: Child HCAHPS®

The Centers for Medicare and Medicaid Services (CMS) uses Adult Hospital Consumer Assessment of Healthcare Providers and Systems (Adult HCAHPS®) scores for public reporting and pay-for-performance for most US hospitals, but no publicly available standardized survey of inpatient experience of care exists for pediatrics. To fill the gap, CMS and the Agency for Healthcare Research and Quality commissioned the development of a pediatric version (Child HCAHPS), a survey of parents/guardians of pediatric patients (<18 years old) who were recently hospitalized. This article describes the development of Child HCAHPS, which included an extensive review of the literature and quality measures, expert interviews, focus groups, cognitive testing, pilot testing of the draft survey, a national field test with 69 hospitals in 34 states, psychometric analysis, and end-user testing of the final survey. We conducted extensive validity and reliability testing to determine which items would be included in the final survey instrument and develop composite measures. We analyzed national field test data of 17u2009727 surveys collected in November 2012 to January 2014 from parents of recently hospitalized children. The final Child HCAHPS instrument has 62 items, including 39 patient experience items, 10 screeners, 12 demographic/descriptive items, and 1 open-ended item. The 39 experience items are categorized based on testing into 18 composite and single-item measures. Our composite and single-item measures demonstrated good to excellent hospital-level reliability at 300 responses per hospital. Child HCAHPS was developed to be a publicly available standardized survey of pediatric inpatient experience of care. It can be used to benchmark pediatric inpatient experience across hospitals and assist in efforts to improve the quality of inpatient care.

A Randomized Controlled Trial of Students for Nutrition and eXercise: A Community-Based Participatory Research Study

PURPOSEnTo conduct a randomized controlled trial of Students for Nutrition and eXercise, a 5-week middle school-based obesity-prevention intervention combining school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education.nnnMETHODSnWe randomly selected schools (five intervention, five waitlist control) from the Los Angeles Unified School District. School records were obtained for number of fruits and vegetables served, students served lunch, and snacks sold per attending student, representing an average of 1,515 students (SD = 323) per intervention school and 1,524 students (SD = 266) per control school. A total of 2,997 seventh-graders (75% of seventh-graders across schools) completed pre- and postintervention surveys assessing psychosocial variables. Consistent with community-based participatory research principles, the school district was an equal partner, and a community advisory board provided critical input.nnnRESULTSnRelative to control schools, intervention schools showed significant increases in the proportion of students served fruit and lunch and a significant decrease in the proportion of students buying snacks at school. Specifically, the intervention was associated with relative increases of 15.3% more fruits served (p = .006), 10.4% more lunches served (p < .001), and 11.9% fewer snacks sold (p < .001) than would have been expected in its absence. Pre-to-post intervention, intervention school students reported more positive attitudes about cafeteria food (p = .02) and tap water (p = .03), greater obesity-prevention knowledge (p = .006), increased intentions to drink water from the tap (p = .04) or a refillable bottle (p = .02), and greater tap water consumption (p = .04) compared with control school students.nnnCONCLUSIONSnMultilevel school-based interventions may promote healthy adolescent dietary behaviors.

Preliminary Healthy Eating Outcomes of SNaX, a Pilot Community-Based Intervention for Adolescents

PURPOSEnWe used principles of community-based participatory research to develop and pilot test a 5-week intervention for middle school students, Students for Nutrition and eXercise (SNaX). SNaX aimed to translate school obesity-prevention policies into practice with peer advocacy of healthy eating and school cafeteria changes.nnnMETHODSnA total 425 seventh graders (63% of all seventh graders) in the intervention school were surveyed at baseline regarding cafeteria attitudes and sugar-sweetened beverage consumption; of the 425 students, 399 (94%) were surveyed again at 1-month post-intervention. School cafeteria records were obtained from two schools: the intervention school and a nonrandomized selected comparison school with similar student socio-demographic characteristics.nnnRESULTSnA total of 140 students in the intervention school were trained as peer advocates. In the intervention school, cafeteria attitudes among peer advocates significantly improved over time (approximately one-third of a standard deviation), whereas cafeteria attitudes of non-peer advocates remained stable; the improvement among peer advocates was significantly greater than the pre-post-change for non-peer advocates (b = .71, p < .001). Peer advocates significantly reduced their sugar-sweetened beverage intake (sports and fruit drinks), from 33% before intervention to 21% after intervention (p = .03). Cafeteria records indicated that servings of fruit and healthier entrées (salads, sandwiches, and yogurt parfaits) significantly decreased in the comparison school and significantly increased in the intervention school; the magnitude of changes differed significantly between the schools (p < .001).nnnCONCLUSIONSnAs compared with the non-peer advocates, peer advocates appeared to benefit more from the intervention. Future research should consider engaging parents, students, and other key community stakeholders to determine acceptable and sustainable cafeteria changes.