Natalie D. Crawford

Subpopulations of Illicit Drug Users Reached by Targeted Street Outreach and Respondent-Driven Sampling Strategies: Implications for Research and Public Health Practice

PURPOSE To determine whether illicit drug users recruited through respondent-driven sampling (RDS) and targeted street outreach (TSO) differ by comparing two samples recruited concurrently with respect to sample selection and potential recruitment biases. METHODS Two hundred seventeen (217) heroin, crack, and cocaine users aged 18-40 years were recruited through TSO in New York City (2006-2009). Forty-six RDS seeds were recruited similarly and concurrently, yielding a maximum of 14 recruitment waves and 357 peer recruits. Baseline questionnaires ascertained sociodemographic, drug use, and drug network characteristics. Descriptive statistics and log-binomial regression were used to compare RDS and TSO samples. RESULTS RDS recruits were more likely to be male (prevalence ratio [PR]:1.28), Hispanic (PR:1.45), black (PR: 1.58), older (PR: 1.02), homeless (PR: 1.19), and crack users (PR: 1.37). RDS recruited fewer injectors (PR:0.35) and heroin users (PR:0.74). Among injectors, RDS recruits injected less frequently (PR:0.77) and were less likely to use Needle Exchange Programs (PR:0.35). CONCLUSION These data suggest that RDS and TSO strategies reach different subgroups of drug users. Understanding the differing capabilities of each recruitment strategy will enable researchers and public health practitioners to select an appropriate recruitment tool for future research and public health practice.

Socioeconomic position indicators and periodontitis: examining the evidence

Disparities in the prevalence and severity of periodontal disease are associated with socioeconomic factors, such as education and income, and have been recognized since the1960s. Epidemiologic reports have consistently shown that i) periodontal disease is inversely related to education and income after controlling for age and gender, and ii) differences in education and income explain mode if not all of the observed disparities in periodontal disease between blacks and whites. Although race/ethnicity has been the main focus of differences in periodontal diseases in the U.S., disparities in socioeconomic position (SEP) indicators (i.e., education, income, poverty-income ratio) have remained pervasive in the U.S. over the years. SEP indicators, as used in the epidemiologic literature, allocate assignment of socioeconomic measures as a proxy for ones place, position and power in society. Thus, understanding these disparities in periodontal health status may provide insight and context more generally into why racial/ethnic disparities persist. In this paper, we review recent prevalence estimates of periodontitis, according to SEP indicators, and critically assess the importance of SEP factors in periodontal epidemiolgy. The majority of the data available for review comes from the U.S. However, data from other countries is included where available. Specifically, we aim to identify the advantages and disadvantages of the most commonly used SEP indicators in studying periodontal disease; summarize existing evidence on the association between SEP indicators and periodontitis; discuss the analytical issues associated with SEP indicators; and finally, discuss and present, future and alternative research directions on examining the association between SEP indicators and periodontitis.

All-Cause Mortality Among Hispanics in the United States: Exploring Heterogeneity by Nativity Status, Country of Origin, and Race in the National Health Interview Survey-Linked Mortality Files

PURPOSE To investigate the association of nativity status, country of origin, and race with all-cause mortality in Hispanic adults relative to non-Hispanic adults in the United States, we used 565,352 records of participants 25 years and older from years 1990 to 2000 of the National Health Interview Survey linked to the National Death Index. METHODS All-cause mortality was coded for underlying cause of death according to the Ninth and Tenth Revision of the International Statistical Classification of Diseases, Injuries, and Causes of Deaths. Time to death was considered from each survey year through December 31, 2002. Cox proportional hazard models were used to estimate all-cause mortality death rates for Hispanics and non-Hispanic blacks relative to non-Hispanic whites. RESULTS In the adjusted analysis, we found that Hispanics ages 25-44 had greater death rates than non-Hispanic-white adults regardless of sex and nativity. However, it appears that this finding is driven by island/foreign-born men and women. Compared with non-Hispanic white adults, younger Puerto Rican women and Mexican American men and women had a 61% (95% confidence interval [CI], 1.15-2.24), 44% (95% CI, 1.22-1.26), and 36% (95% CI, 1.17-1.59) greater all-cause death rate, respectively. Hispanics who identify as white, regardless of sex, had greater death rates than non-Hispanic white adults. CONCLUSIONS These findings highlight important differences in Hispanics by nativity status, country of origin and race. Studies assessing disparities in health among Hispanics should closely examine the heterogeneity of this population usually lost under a homogeneous classification. This examination would lead to a better understanding of health outcomes within Hispanics.

Racial/Ethnic Disparities in Obesity Among US-born and Foreign-born Adults by Sex and Education

This study examines sex and education variations in obesity among US‐ and foreign‐born whites, blacks, and Hispanics utilizing 1997–2005 data from the National Health Interview Survey on 267,585 adults aged ≥18 years. After adjusting for various demographic, health, and socioeconomic factors via logistic regression, foreign‐born black men had the lowest odds for obesity relative to US‐born white men. The largest racial/ethnic disparity in obesity was between US‐born black and white women. High educational attainment diminished the US‐born black–white and Hispanic–white disparities among women, increased these disparities among men, and had minimal effect on foreign‐born Hispanic–white disparities among women and men. Comprehension of these relationships is vital for conducting effective obesity research and interventions within an increasingly diverse United States.

Progress in HIV reduction and prevention among injection and noninjection drug users.

Substantial progress has been made in reducing HIV among injection drug users (IDUs) in the United States, despite political and social resistance that reduced resources and restricted access to services. The record for HIV prevention among noninjecting drug users is less developed, although they are more numerous than IDUs. Newer treatments for opiate and alcohol abuse can now be integrated into primary HIV care; treatment for stimulant abuse is less developed. All drug users present challenges for newer HIV prevention strategies (eg, “test and treat,” nonoccupational postexposure prophylaxis and preexposure prophylaxis, contingency management, and conditional cash transfer). A comprehensive HIV prevention program that includes multicomponent multilevel approaches (ie, individual, network, structural) has been effective in HIV prevention among IDUs. Expanding these approaches to noninjecting drug users, especially those at highest risk (eg, minority men who have sex with men) and incorporating these newer approaches is a public health priority.

Individual- and Neighborhood-Level Characteristics Associated with Support of In-Pharmacy Vaccination among ESAP-Registered Pharmacies: Pharmacists’ Role in Reducing Racial/Ethnic Disparities in Influenza Vaccinations in New York City

New York State (NYS) passed legislation authorizing pharmacists to administer immunizations in 2008. Racial/socioeconomic disparities persist in vaccination rates and vaccine-preventable diseases such as influenza. Many NYS pharmacies participate in the Expanded Syringe Access Program (ESAP), which allows provision of non-prescription syringes to help prevent transmission of HIV, and are uniquely positioned to offer vaccination services to low-income communities. To understand individual and neighborhood characteristics of pharmacy staff support for in-pharmacy vaccination, we combined census tract data with baseline pharmacy data from the Pharmacies as Resources Making Links to Community Services (PHARM-Link) study among ESAP-registered pharmacies. The sample consists of 437 pharmacists, non-pharmacist owners, and technicians enrolled from 103 eligible New York City pharmacies. Using multilevel analysis, pharmacy staff who expressed support of in-pharmacy vaccination services were 69% more likely to support in-pharmacy HIV testing services (OR, 1.69; 95% CI 1.39–2.04). While pharmacy staff who worked in neighborhoods with a high percent of minority residents were less likely to express support of in-pharmacy vaccination, those in neighborhoods with a high percent of foreign-born residents were marginally more likely to express support of in-pharmacy vaccination. While educational campaigns around the importance of vaccination access may be needed among some pharmacy staff and minority community residents, we have provided evidence supporting scale-up of vaccination efforts in pharmacies located in foreign-born/immigrant communities which has potential to reduce disparities in vaccination rates and preventable influenza-related mortality.

Self-reported diabetes in Hispanic subgroup, non-Hispanic black, and non-Hispanic white populations: National Health Interview Survey, 1997-2005.

Objectives. We estimated the prevalence of self-reported diabetes in Hispanic subgroup (Puerto Rican, Mexican, Mexican American, Cuban, Dominican, Central and South American, and other Hispanic), non-Hispanic black, and non-Hispanic white populations aged 20 years and older. Methods. Using the National Health Interview Survey 1997–2005, we limited these analyses to 272,041 records of adults aged 20 years and older, including 46,749 records for Hispanic respondents. We used logistic regression to assess the strength of the association between race/ethnicity and self-reported diabetes before and after adjusting for selected characteristics. Results. Compared with non-Hispanic white respondents, Mexican American (odds ratio [OR] = 2.02; 95% confidence interval [CI] 1.75, 2.34), Mexican (OR=1.52; 95% CI 1.31, 1.91), Puerto Rican (OR=1.53; 95% CI 1.23, 1.91), other Hispanic (OR=2.08; 95% CI 1.68, 2.58), and non-Hispanic black (OR=1.47; 95% CI 1.35, 1.61) respondents had greater odds of reporting diabetes. When compared with non-Hispanic white respondents, Mexican American respondents with less than a high school diploma had the lowest odds of reporting diabetes, while those with at least a college degree had greater odds of reporting diabetes. However, Puerto Rican respondents with less than a high school education, Mexican respondents with at least some college education, and other Hispanic respondents with at least a high school diploma/general equivalency diploma had greater odds of reporting diabetes. Conclusions. Although Hispanic respondents bear a greater burden of diabetes than non-Hispanic white respondents, this burden is unevenly distributed across subgroups. These findings call attention to data disaggregation whenever possible for U.S. racial/ethnic populations classified under categories considered homogeneous.

A Community-Based Approach to Linking Injection Drug Users with Needed Services Through Pharmacies: An Evaluation of a Pilot Intervention in New York City

Studies suggest that community-based approaches could help pharmacies expand their public health role, particularly pertaining to HIV prevention. Thirteen pharmacies participating in New Yorks Expanded Syringe Access Program, which permits nonprescription syringe sales to reduce syringe-sharing among injection drug users (IDUs), were enrolled in an intervention to link IDU syringe customers to medical/social services. Sociodemographics, injection practices, beliefs about and experiences with pharmacy use, and medical/social service utilization were compared among 29 IDUs purchasing syringes from intervention pharmacies and 66 IDUs purchasing syringes from control pharmacies using chi-square tests. Intervention IDUs reported more positive experiences in pharmacies than controls; both groups were receptive to a greater public health pharmacist role. These data provide evidence that community-based participatory research aided in the implementation of a pilot structural intervention to promote understanding of drug use and HIV prevention among pharmacy staff, and facilitated expansion of pharmacy services beyond syringe sales in marginalized drug-using communities.

Race, Ethnicity, and Self-Rated Health Status in the Behavioral Risk Factor Surveillance System Survey

This study examines the association between race and self-rated health status among Hispanic and non-Hispanic adults in the 2003 Behavioral Risk Factor Surveillance System survey (N = 241,038). Logistic regression was used to estimate the odds of self-rated health as fair/poor for Hispanic Blacks, Hispanic Whites, and non-Hispanic Blacks as compared with non-Hispanic Whites. This study found that, first, Hispanic Blacks were more likely to rate their health as fair/poor than Hispanic and non-Hispanic Whites, and second, there was no difference between Hispanic and non-Hispanic Blacks. Specifically, when compared with non-Hispanic Whites, Hispanic Blacks and Whites were more likely to report their health as fair/poor. However, this association was stronger for Hispanic Blacks. More careful examination of race among Hispanics is imperative to unmask important health variations.

Pharmacy staff characteristics associated with support for pharmacy-based HIV testing

OBJECTIVES To determine support of in-pharmacy human immunodeficiency virus (HIV) testing among pharmacy staff and the individual-level characteristics associated with in-pharmacy HIV testing support. DESIGN Descriptive, nonexperimental, cross-sectional study. SETTING New York City (NYC) from January 2008 to March 2009. PARTICIPANTS 480 pharmacy staff, including pharmacists, owners/managers, and technicians/clerks. INTERVENTION 131 pharmacies registered in the Expanded Syringe Access Program (ESAP) completed a survey. MAIN OUTCOME MEASURE Support of in-pharmacy HIV testing. RESULTS Support of in-pharmacy HIV testing is high among pharmacy staff (79.4%). Pharmacy staff who supported in-pharmacy vaccinations were significantly more likely to support in-pharmacy HIV testing. Pharmacy staff who thought that selling syringes to injection drug users (IDUs) caused the community to be littered with dirty syringes were significantly less likely to support in-pharmacy HIV testing. CONCLUSION Support for in-pharmacy HIV testing was high among our sample of ESAP pharmacy staff actively involved in nonprescription syringe sales. These findings suggest that active ESAP pharmacy staff may be amenable to providing HIV counseling and testing to IDUs and warrants further investigation.