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Objectives. Despite decreasing infant mortality in North Carolina, the gap between African Americans and Whites persists. This study examined how racial differences in infant mortality vary by maternal education. Methods. Data came from Linked Birth and Infant Death files for 1988 through 1993. Multiple logistic regression models adjusted for confounders. Results. Infant mortality risk ratios comparing African Americans and Whites increased with higher levels of maternal education. Education beyond high school reduced risk of infant mortality by 20% among Whites but had little effect among African Americans. Conclusions. Higher education magnifies racial differences in infant mortality on a multiplicative scale. Possible reasons include greater stress, fewer economic resources, and poorer quality of prenatal care among African Americans. (Am J Public Health. 1998;88:651-656)

Abstract Background Compared with whites, sleep disturbance and sleep deprivation appear more prevalent in African Americans (AA). Long-term sleep deprivation may increase the risk of obesity through multiple metabolic and endocrine alterations. Previous studies have reported contradictory results on the association between habitual sleep duration and obesity. Accordingly, we aimed to assess whether sleep quality and duration are inversely associated with body mass index (BMI) and obesity and test whether these associations are modified by psychosocial stress, known to influence sleep quality. Methods A sample of 1,515 AA residents of metropolitan Atlanta, aged 30-65 years, was recruited by a random-digit-dialing method in 2007-08. The outcome obesity was defined by BMI (kg/m2) continuously and categorically (BMI ≥ 30 versus BMI < 30). Global sleep quality (GSQ) score was computed as the sum of response values for the seven components of the Pittsburgh Sleep Quality Index (PSQI) scale. GSQ score was defined as a continuous variable (range 0-21) and as tertiles. The general perceived stress (GPS), derived from the validated Cohen scale, was categorized into tertiles to test the interaction. Chi-square tests, correlation coefficients and weighted multiple linear and logistic regression were used to assess the associations of GSQ, GPS and obesity. Results The mean (standard deviation) age was 47.5 (17.0) years, and 1,096 (72%) were women. GSQ score categorized into tertiles was associated with BMI. Among women, after multivariable adjustment that included age, gender, physical activity, smoking status, education, total family income, financial stress and history of hypertension, hypercholesterolemia, diabetes and myocardial infarction, obesity was associated with sleep quality as assessed by GSQ continuous score, [odds ratio, OR (95% C.I.): 1.08 (1.03 - 1.12)], and with a worse sleep disturbance subcomponent score [OR (95% C.I.): 1.48 (1.16 - 1.89)]. Among all participants, stress modified the association between obesity and sleep quality; there was an increased likelihood of obesity in the medium stress category, OR (95% C.I.): 1.09 (1.02 - 1.17). Conclusion Sleep quality was associated with obesity in women. The association of sleep quality with obesity was modified by perceived stress. Our results indicate the need for simultaneous assessment of sleep and stress.

A continuous quality care improvement program (CQIP) was built into Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together) to improve providers' patterns of diabetes care and patients' glycemic control. Project DIRECT consisted of a comprehensive program aimed at reducing the burden of diabetes in the vulnerable high-risk African-American population of southeast Raleigh, NC. Forty-seven providers caring for this target population of adult diabetes patients were included in this quasi-experimental study. At the initial session, providers learned about the CQIP components, completed a planning worksheet, and chose a CQIP coordinator. Educational events included continuing education in practices and through conferences by experts, and guideline distribution. Follow-up was accomplished through phone calls and visits. Effectiveness was measured by a change in prevalence of selected patterns of care abstracted from 1,006 medical charts. Appropriate statistical methods were used to account for the cluster design and repeated measures. At the fourth follow-up year, approximately 40% of providers still participated in the program. Among the providers who stayed in the program for the whole study period, most selected quality care patterns showed significant upward trends. Glycemic control indicators did not change, however, despite an increased number of hemoglobin A1c tests per year. A diabetes CQI program can be effectively implemented in a community setting. Improved performance measures were not associated with improved outcomes. These results suggest that a patient-centered component should reinforce the provider-centered component.