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BackgroundDiabetes prevalence continues to increase in urban areas of low-income and middle-income countries (LMIC). Evidence from high-income countries suggests an inverse association between educational attainment and diabetes, but research in LMIC is limited. We investigated educational differences in diabetes prevalence across 232 Latin American (LA) cities, and the extent to which these inequities vary across countries/cities and are modified by city socioeconomic factors.MethodsUsing harmonised health survey and census data for 110 498 city dwellers from eight LA countries, we estimated the association between education and diabetes. We considered effect modification by city Social Environment Index (SEI) as a proxy for city-level development using multilevel models, considering heterogeneity by sex and country.ResultsIn women, there was an inverse dose–response relationship between education and diabetes (OR: 0.80 per level increase in education, 95% CI 0.75 to 0.85), consistent across countries and not modified by SEI. In men, Argentina, Brazil, Colombia, Chile and Mexico showed an inverse association (pooled OR: 0.92; 95% CI 0.86 to 0.99). Peru, Panama and El Salvador showed a positive relationship (pooled OR 1.24; 95% CI 1.04 to 1.49). For men, these associations were further modified by city-SEI: in countries with an inverse association, it became stronger as city-SEI increased. In countries where the association was positive, it became weaker as city-SEI increased.ConclusionSocial inequities in diabetes inequalities increase as cities develop. To achieve non-communicable disease-related sustainable development goals in LMIC, there is an urgent need to develop policies aimed at reducing these educational inequities.

BackgroundDisparities in access to care persist for Latino youth born in the United States (US). The association of maternal characteristics, such as maternal citizenship status and insurance coverage, on youth health insurance coverage is unclear and is important to examine given the recent sociopolitical shifts occurring in the US.MethodsWe analyzed pooled cross-sectional data from the 2010–2018 National Health Interview Survey to examine the association of Latina maternal citizenship status on maternal insurance coverage status and youth uninsurance among US-born Latino youth. Our study sample consisted of 15,912 US-born Latino youth (ages ResultsOverall, 7% of US-born Latino youth were uninsured. Just 6% of youth with US-born mothers were uninsured compared to almost 10% of those with noncitizen mothers. Over 18% of youth with uninsured mothers were uninsured compared to 2.2% among youth with mothers who had private insurance coverage. Compared to both US-born and naturalized citizen Latina mothers, noncitizen Latina mothers had 4.75 times the odds of reporting being uninsured. Once adjusted for predisposing, enabling, and need factors, maternal uninsurance was strongly associated with youth uninsurance and maternal citizenship was weakly associated with youth uninsurance among US-born Latino youth.ConclusionMaternal citizenship was associated with both maternal uninsurance and youth uninsurance among US-born Latino youth. Federal- and state-level health policymaking should apply a two-generational approach to ensure that mothers of children are offered affordable health insurance coverage, regardless of their citizenship status, thus reducing uninsurance among US-born Latino youth.

Background Studies have observed that recent Latino immigrants tend to have a physical health advantage compared to immigrants who have been in the US for many years or Latinos who are born in the United States. An explanation of this phenomenon is that recent immigrants have positive health behaviors that protect them from chronic disease risk. This study aims to determine if trends in positive cardiovascular disease (CVD) risk behaviors extend to Latino immigrants in California according to citizenship and documentation status. Methods We examined CVD behavioral risk factors by citizenship/documentation statuses among Latinos and non-Latino US-born whites in the 2011–2015 waves of the California Health Interview Survey. Adjusted multivariable logistic regressions estimated the odds for CVD behavioral risk factors, and analyses were stratified by sex. Results In adjusted analyses, using US-born Latinos as the reference group, undocumented Latino immigrants had the lowest odds of current smoking, binge drinking, and frequency of fast food consumption. There were no differences across the groups for fruit/vegetable intake and walking for leisure. Among those with high blood pressure, undocumented immigrants were least likely to be on medication. Undocumented immigrant women had better patterns of CVD behavioral risk factors on some measures compared with other Latino citizenship and documentation groups. Conclusions This study observes that the healthy Latino immigrant advantage seems to apply to undocumented female immigrants, but it does not necessarily extend to undocumented male immigrants who had similar behavioral risk profiles to US-born Latinos.

Health insurance literacy helps individuals make informed choices. However, evidence suggests that Medicare beneficiaries experience low health insurance literacy, leading to high-cost or poor-quality coverage choices.To examine how health insurance literacy was associated with coverage choices between traditional Medicare (TM) and Medicare Advantage (MA), as well as within MA.This cross-sectional study included 6627 TM and MA enrollees, using data from the 2015-2016 Medicare Current Beneficiary Survey. Data analyses were conducted between May 1 and June 30, 2021.Three self-reported measures of health insurance literacy (presence of information to make an informed comparison, ease in reviewing and comparing coverage options, and annual review and comparison of coverage options).Enrollment in TM vs MA and enrollment in an MA plan with different characteristics (star rating, monthly plan premium, in-network maximum out-of-pocket limit, plan type, and provision of supplemental benefits).We included 6627 Medicare beneficiaries (3578 women [54.0%]; mean [SD] age, 75.13 [7.12] years). A total of 77 individuals were Asian (1.2%), 696 were Black (10.5%), 488 were Hispanic (7.4%), 5277 were non-Hispanic White (79.6%), and 225 (3.4%) were single races not of Hispanic origin (including American Indian or Alaska Native and Native Hawaiian) or were 2 or more races. Medicare Advantage enrollment was higher among individuals with higher health insurance literacy than those with lower health insurance literacy, especially for those who reviewed or compared coverage options annually than among those who did not (38.0%; 95% CI, 36.0%-40.1% vs 27.8%; 95% CI, 25.8%-29.7%). Among MA beneficiaries, those who reviewed or compared coverage options annually were more likely to enroll in plans with 4 to 4.5 stars and plans with monthly premiums of $1 to $50 by 4.6 percentage points (95% CI, 0.1-9.2 percentage points) and 4.8 percentage points (95% CI, 0.6-9.0 percentage points), respectively. However, enrollment in plans with 5 stars was 3.8 percentage points lower (95% CI, -5.8 to -1.9 percentage points) among individuals who reviewed or compared coverage options annually than among those who did not. Among individuals with low socioeconomic status, the likelihood of reviewing or comparing coverage options annually was lower for those with Medicare and Medicaid dual eligibility than for those without it (odds ratio, 0.79; 95% CI, 0.63-0.99).Results of this study suggest that higher health insurance literacy-particularly, annual review and comparison of coverage choices-is associated with higher MA enrollment and choice of a particular MA plan. Policy makers should develop programs to encourage frequent review and comparison of coverage options for informed decision making.

Objectives:To develop a simulation framework for assessing how combinations of taxes, nutrition warning labels and advertising levels could affect purchasing of ultra-processed foods (UPF) in Latin American countries and to understand whether policies reinforce or reduce pre-existing social disparities in UPF consumption.Design:We developed an agent-based simulation model using international evidence regarding the effect of price, nutrition warning labels and advertising on UPF purchasing.Setting:We estimated policy effects in scenarios representing two stages of the ‘social transition’ in UPF purchasing: (1) a pre-transition scenario, where UPF purchasing is higher among high-income households, similar to patterns in Mexico; and (2) a post-transition scenario where UPF purchasing is highest among low-income households, similar to patterns in Chile.Participants:A population of 1000 individual agents with levels of age, income, educational attainment and UPF purchasing similar to adult women in Mexico.Results:A 20 % tax would decrease purchasing by 24 % relative to baseline in both the pre- and post-transition scenarios, an effect that is similar in magnitude to that of a nutrition warning label policy. A 50 % advertising increase or decrease had a comparatively small effect. Nutrition warning labels were most effective among those with higher levels of educational attainment. Labelling reduced inequities in the pre-transition scenario (i.e. highest UPF purchasing among the highest socio-economic group) but widened inequities in the post-transition scenario.Conclusions:Effective policy levers are available to reduce UPF purchasing, but policymakers should anticipate that equity impacts will differ depending on existing social patterns in UPF purchasing.

BACKGROUND: The aim of the study was to assess the relationship between educational attainment and health care access and use among Mexican-origin populations. METHODS: Data from the 2012 Mexican National Health and Nutrition Study, the 2013 Project Migrante Health Care Access and Utilization Survey, and the 2013–2014 California Health Interview Survey were used to examine educational gradients in health insurance, medical home, and hospitalization among Mexicans in Mexico, northbound, southbound, and deported migrants, and U.S.-and foreign-born Mexican Americans. RESULTS: College graduates had greater odds of being insured relative to those with less than a high school degree among Mexicans (AOR=1.48, p

Introduction Time spent eating is associated with obesity and diet-related diseases. We examined the association between time adults spent eating, immigrant status, race/ethnicity, and race/ethnicity among adults in the United States. Methods We used multivariate linear regression to analyze a cross-sectional, nationally representative sample of respondents aged 19 years or older (N = 192,486) from the 2016 American Time Use Survey. The outcome measures were time spent per day on primary eating and drinking and secondary eating. The predictors were immigrant status, race/ethnicity, and years spent living in the United States. Results Multivariate adjusted minutes per day spent on primary eating and drinking were 66.4 for noncitizens, 66.5 for naturalized citizens, and 60.1 for US-born individuals. Multivariate adjusted minutes per day spent on secondary eating were 11.1 for noncitizens, 12.2 for naturalized citizens, and 12.9 for US-born individuals. Minutes per day spent on primary eating and drinking for immigrants by length of residence in the United States was 69.7 minutes for 5 years or less of residence, 67.9 minutes for 6 to 10 years of residence, 63.6 minutes for 11 to 15 years of residence, and 63.6 minutes for more than 15 years of residence. Minutes per day spent on secondary eating for immigrants by length of residence was 5.5 minutes for 5 years or less of residence, 9.7 minutes for 6 to 10 years of residence, 8.4 minutes for 11 to 15 years of residence, and 12.6 minutes for more than 15 years of residence. Conclusion Time spent eating varied by immigrant status and length of residence in the United States.

Introduction The objective of this study is to examine how allostatic load, a multidimensional measure of the body's cumulative response to stressors experienced throughout the life course, has changed over time and by age among U.S.- and foreign-born Whites, Blacks, and Latinx. Methods Data were from 26,818 adult participants in the 2005–2018 National Health and Nutrition Examination Survey, a national repeated cross-sectional study. Allostatic load was measured based on 10 indicators of cardiovascular, metabolic, and immunologic risk. The analyses were conducted in March 2020. Results Allostatic load increased over time across all groups. The difference between the first and last survey cycle was greatest among U.S.-born Black women (from 2.74 in 2005–2006 to 3.02 in 2017–2018), U.S.-born Latino men (from 2.69 to 3.09) and foreign-born Latino men (from 2.58 to 2.87). Aging gradients in allostatic load were steepest among foreign-born Blacks of both genders and foreign-born Latina women and flattest among U.S.-born and foreign-born Whites. Conclusions Chronic exposure to stressors leads to an erosion of health that is particularly severe among foreign-born Blacks and Latinx. Policies should seek to reduce exposure to structural and environmental risks and to ensure equitable opportunities to achieve optimal health among racial/ethnic minorities and immigrants.

Background: This paper provides statewide estimates on health care access and utilization patterns and physical and behavioral health by citizenship and documentation status among Latinos in California. Methods: This study used data from the 2011–2015 California Health Interview Survey to examine health care access and utilization and physical and behavioral health among a representative sample of all nonelderly Latino and US-born non-Latino white adults (N=51,386). Multivariable regressions estimated the associations between the dependent measures and citizenship/documentation status among Latinos (US-born, naturalized citizen, green card holder, and undocumented). Results: Adjusted results from multivariable analyses observed worse access and utilization patterns among immigrant Latinos compared with US-born Latinos, with undocumented immigrants using significantly less health care. Undocumented Latinos had lower odds of self-reporting excellent/very good health status compared with US-born Latinos, despite them having lower odds of having several physical and behavioral health outcomes (overweight/obesity, physician-diagnosed hypertension, asthma, self-reported psychological distress, and need for behavioral health services). Among those reporting a need for behavioral health services, access was also worse for undocumented Latinos when compared with US-born Latinos. Conclusions: Patterns of poor health care access and utilization and better physical and behavioral health are observed across the continuum of documentation status, with undocumented immigrants having the worst access and utilization patterns and less disease. Despite fewer reported diagnoses and better mental health, undocumented Latinos reported poorer health status than their US-born counterparts.

Objective To examine whether there have been changes in insurance coverage and health care utilization for youth before and after the national implementation of the Patient Protection and Affordable Care Act (ACA) and to assess whether racial and ethnic inequities have improved. Methods Data are from 64,565 youth (ages 0–17 years) participants in the 2011 to 2015 National Health Interview Survey. We conducted multivariate logistic regression analyses to determine how the period after national implementation of the ACA (years 2011–2013 vs years 2014–2015) was associated with health insurance coverage and utilization of health care services (well-child visits, having visited an emergency department, and having visited a physician, all in the past 12 months), and whether changes over the pre- and post-ACA periods varied according to race and Latino ethnicity. Results The post-ACA period was associated with improvements in insurance coverage and well-child visits for all youth. Latino youth had the largest absolute gain in insurance coverage; however, they continued to have the highest proportion of uninsurance post national ACA implementation. With regard to health care equity, non-Latino black youth were less likely to be uninsured and Latino youth had no significant improvements in insurance coverage relative to non-Latino white youth after national ACA implementation. Inequities in health care utilization for non-Latino black and Latino youth relative to non-Latino white youth did not improve. Conclusions Insurance coverage and well-child visits have significantly improved for all youth since passage of the ACA, but inequities persist, especially for Latino youth.

This cross-sectional study examines the association between quality of care for Latinx youths and the ethnic concordance of the mothers and clinicians., Key Points Question Is maternal-clinician ethnic concordance associated with youth receipt of family-centered care? Findings In this cross-sectional study including 2515 Latinx youths, maternal-clinician Latinx ethnic concordance was found to have had a positive average association with maternal reports of their youths receiving family-centered care, after adjusting for maternal characteristics. Meaning The findings of this study suggest that clinicians from underrepresented minority backgrounds contribute to the attenuation of medical home provision disparities among Latinx youths in the US., Importance Disparities in medical home provisions, including receipt of family-centered care (FCC), have persisted for Latinx youths in the US. Objective To examine the association between maternal-clinician ethnic concordance and receipt of FCC among US-born Latinx youths. Design, Setting, and Participants A cross-sectional secondary analysis of data from the Medical Expenditure Panel Survey from January 1, 2010, to December 31, 2017, was conducted. Data analysis was performed from January 6 to February 3, 2020. Latinx youths (age, ≤17 years) born in the US who had a usual source of care and used care in the past year, their Latina mothers (age, 18-64 years), and youths’ health care clinician characteristics (eg, race, ethnicity, and sex) were evaluated using χ2 tests and propensity-score matching methods. Main Outcomes and Measures Maternal reports on whether their youths’ clinician listened carefully to the parent, explained things in a way the parent could understand, showed respect, and spent enough time with the patient. Results There were 2515 US-born Latinx youths with linked maternal characteristics during the study period; 51.67% (95% CI, 48.87%-54.45%) of the youths were male, mean (SD) age was 8.48 (0.17) years (30.86% [95% CI, 28.39%-33.44%] were between ages 5 and 9 years), 61.53% (95% CI, 57.15%-65.74%) had public insurance coverage, and 39.89% (95% CI, 32.33%-47.89%) had mothers who were ethnically concordant with the youths’ medical care clinician. We found that for youths with maternal-clinician ethnic concordance, the probabilities of reporting FCC were significantly higher than they would have been in the absence of concordance: that the medical care clinician listened carefully to the parent (average treatment effect on the treated [ATET], 5.44%; 95% CI, 2.14%-8.74%), explained things in a way the parent could understand (ATET, 4.82%; 95% CI, 1.60%-8.03%), showed respect for what the parent had to say (ATET, 5.51%; 95% CI, 2.58%-8.45%), and spent enough time with the patient (ATET, 5.28%; 95% CI, 1.68%-8.88%). Conclusions and Relevance Given the increase of Latinx populations and the simultaneous shortage of underrepresented minority health care clinicians, the findings of this study suggest that increasing the number of clinicians from underrepresented minority backgrounds and ethnic-concordant parental-clinician relationships may help reduce disparities in receipt of medical home provision among US-born Latinx youths.

In January 2017, Philadelphia (Pennsylvania) implemented an excise tax ($ 0.015/ounce) on sugar-sweetened and diet beverages. This study is a general population-based study to report on the longer-term impacts of the tax on within-person changes in consumption 12 months after implementation. A quasi-experimental difference-in-difference design was used to contrast Philadelphia vs. nearby comparison cities (Trenton, New Jersey, Camden, New Jersey, and Wilmington, Delaware) at baseline (December 2016&ndash, January 2017) vs. 12-month follow-up (December 2017&ndash, February 2018). A random-digit-dialing phone survey was administered to a population-based cohort. Analyses assessed changes in 30-day consumption frequency and ounces of sugar-sweetened and diet beverages (and a substitution beverage, bottled water) in the analytic sample (N = 515). After 12 months, relative to the comparison group, Philadelphians were slightly more likely to decrease their frequency of sugar-sweetened beverage consumption (39.2% vs. 33.5%), and slightly less likely to increase their frequency of sugar-sweetened beverage consumption (38.9% vs. 43.0%). The effects of the tax estimated in the adjusted difference-in-difference analysis were very small (for example, changes in monthly sugar-sweetened beverage consumption in Philadelphia relative to comparison cities was &minus, 3.03 times or &minus, 51.65 ounces) and confidence intervals were very wide. Results suggested that, one year after implementation, there was no major overall impact of the tax on general population-level consumption of sugar-sweetened or diet beverages, or bottled water. Future studies should test whether the tax&rsquo, s effect differs in vulnerable sub-populations.

To examine differences in health information seeking between U.S.-born and foreign-born populations in the U.S.Data from 2008 to 2014 from the Health Information National Trends Survey were used in this study (n = 15,249). Bivariate analyses, logistic regression, and predicted probabilities were used to examine health information seeking and sources of health information.Findings demonstrate that 59.3% of the Hispanic foreign-born population reported looking for health information, fewer than other racial/ethnic groups in the sample. Compared with non-Hispanic White, non-Hispanic Black (OR = 0.62) and Hispanic foreign-born individuals (OR = 0.31) were the least likely to use the internet as a first source for health information. Adjustment for language preference explains much of the disparity in health information seeking between the Hispanic foreign-born population and Whites; controlling for nativity, respondents who prefer Spanish have 0.25 the odds of using the internet as a first source of health information compared to those who prefer English.Foreign-born nativity and language preference are significant determinants of health information seeking. Further research is needed to better understand how information seeking patterns can influence health care use, and ultimately health outcomes. To best serve diverse racial and ethnic minority populations, health care systems, health care providers, and public health professionals must provide culturally competent health information resources to strengthen access and use by vulnerable populations, and to ensure that all populations are able to benefit from evolving health information sources in the digital age.

This cross-sectional study uses data from the American Community Survey to examine the association of state-level immigrant integration and criminalization policies and maternal citizenship status with health insurance coverage among US-born Latino youths., Key Points Question Are state-level policies that integrate or criminalize immigrants associated with disparities in youth health insurance coverage by maternal citizenship status? Findings In this cross-sectional study of 226 691 US-born Latino youths, residing in a state with a lower level of immigrant integration policies and a higher level of immigrant criminalization policies was associated with higher uninsurance rates. Uninsurance rates for youths with non–US citizen mothers were higher for those who resided in states with low integration and high criminalization immigrant policies. Meaning State-level immigrant policies may be associated with health care access among US-born Latino youths based on maternal citizenship status, and awareness of these disparities appears to be needed to inform advocacy efforts., Importance The association of state-level immigrant policies with uninsurance among Latino youths remains unknown. Objective To assess the association of state-level immigrant integration and criminalization policies with health insurance coverage among US-born Latino youths by maternal citizenship. Design, Setting, and Participants This cross-sectional study analyzed secondary data from the American Community Survey, January 1, 2016, to December 31, 2018, for US-born Latino youths (age, ≤17 years) and their mothers (age, 18-64 years) as well as state-level indicators of immigrant integration and criminalization policies (in all 50 states and the District of Columbia). Exposures Immigrant integration and criminalization policies. Main Outcomes and Measures The main outcome was maternal reports of youth uninsurance status at the time of the American Community Survey interview. Variation in youth uninsurance by maternal citizenship, state immigrant integration policy context, and state immigrant criminalization policy context were examined. All analyses were conducted with weighted survey data. Results Of the 226 691 US-born Latino youths (115 431 [50.92%] male; mean [SD] age, 7.66 [4.92] years) included in the study, 36.64% (95% CI, 36.21%-36.92%) had noncitizen mothers. Overall, 7.09% (95% CI, 6.78%-7.41%) of noncitizen mothers reported that their youths were uninsured compared with 4.68% (95% CI, 4.49%-4.88%) of citizen mothers. Of uninsured youths who resided in states with a low level of immigrant integration policies, 9.10% (8.22%-10.06%) had noncitizen mothers and 4.75% (95% CI, 4.19%-5.37%) had citizen mothers; of uninsured youths who resided in states with high criminalization policies, 9.37% (95% CI, 8.90%-9.87%) had noncitizen mothers and 5.91% (95% CI, 5.64%-6.20%) had citizen mothers. In states with few immigrant integration policies, the probability of uninsurance among youths with noncitizen mothers was 3.3% (95% CI, 2.3%-4.4%) higher than that among youths with citizen mothers. Among youths with noncitizen mothers, the difference in the probability of uninsurance between those residing in states with a low level vs a high level of immigrant integration policies was 2.1% (95% CI, 0.6%-3.6%). Among youths residing in states with high levels of immigrant criminalization policies, those with noncitizen mothers had a 2.6% (95% CI, 1.9%-3.0%) higher probability of being uninsured compared with those whose mothers were citizens. Among youths with noncitizen mothers, the difference in the probability of uninsurance between those who resided in a state with a low level vs a state with a high level of immigrant criminalization policies was 1.7% (95% CI, 0.7%-2.7%). Conclusions and Relevance The findings of this cross-sectional study suggest that among US-born Latino youths, disparities in uninsurance by maternal citizenship are associated with state-level immigrant integration and criminalization policies and that anti-immigrant policies may be associated with disparities in health care access for US-born Latino youths.

Refereed/Peer-reviewed Purpose: To: (1) explore how multi-level factors impact the longitudinal prevalence of depression and alcohol misuse among urban older adults (≥ 65 years), and (2) simulate the impact of alcohol taxation policies and targeted interventions that increase social connectedness among excessive drinkers, socially isolated and depressed older adults; both alone and in combination. Methods: An agent-based model was developed to explore the temporal co-evolution of depression and alcohol misuse prevalence among older adults nested in a spatial network. The model was based on Los Angeles and calibrated longitudinally using data from the Multi-Ethnic Study of Atherosclerosis. Results: Interventions with a social component targeting depressed and socially isolated older adults appeared more effective in curbing depression prevalence than those focused on excessive drinkers. Targeting had similar impacts on alcohol misuse, though the effects were marginal compared to those on depression. Alcohol taxation alone had little impact on either depression or alcohol misuse trajectories. Conclusions: Interventions that improve social connectedness may reduce the prevalence of depression among older adults. Targeting considerations could play an important role in determining the success of such efforts.

Latino youth experience worse access to and utilization of health care compared with non-Latino "white" youth, with inequities persisting following the implementation of the Affordable Care Act (ACA). To better understand these disparities, we examine changes in youth's access and utilization associated with the ACA for different Latino heritage groups relative to whites.We use 6 years (2011-2016) of National Health Interview Survey data to examine Latino youth's insurance coverage and health care utilization by heritage group, nativity, and parental language. The dependent measures of utilization included well-child, emergency department, and physician visits. We used multivariable logistic regression models to estimate the odds of each dependent measure and interacted heritage group and time period [2011-2013 (pre-ACA) versus 2014-2016 (post-ACA)] to examine how changes associated with the ACA varied by group.Insurance coverage and well-child visits improved among youth overall following implementation of the ACA. Although Mexican and Central or South American youth experienced the largest absolute increase in coverage, they still had high levels of uninsurance post-ACA (9.9% and 9.1%, respectively). Disparities in coverage between Puerto Rican and white youth improved, while disparities in well-child visits between Mexican and white youth worsened. Little to no movement was observed in disparities by nativity and parental language.Most disparities in insurance and utilization across Latino heritage groups and white youth persisted post-ACA despite significant gains within groups. Although disparities for Puerto Rican youth have improved, Mexican and Central or South American youth continue to experience disparities.

ObjectiveInvestments have been made to alter the food environment of neighbourhoods that have a disproportionate number of unhealthy food venues. Corner store conversions are one strategy to increase access to fruits and vegetables (F&V). Although the literature shows modest success, the effectiveness of these interventions remains equivocal. The present paper reports on the evaluation of Proyecto MercadoFRESCO, a corner store conversion intervention in two Latino communities.DesignA repeated cross-sectional design was employed. Data were stratified by intervention arm and bivariate tests assessed changes over time. Logistic and multiple regression models with intervention arm, time and the interaction of intervention and time were conducted. Supplementary analyses account for clustering of patrons within stores and staggering of store conversions.SettingThree stores were converted and five stores served as comparisons in East Los Angeles and Boyle Heights, California, USA.SubjectsStore patrons were interviewed before (n550) and after (n407) the intervention.ResultsRelative to patrons of comparison stores, patrons of intervention stores demonstrated more favourable perceptions of corner stores and increased purchasing of F&V during that store visit. Changes were not detected in store patronage, percentage of weekly dollars spent on food for F&V or daily consumption of F&V.ConclusionsConsistent with some extant food environment literature, findings demonstrate limited effects. Investments should be made in multilevel, comprehensive interventions that target a variety retail food outlets rather than focusing on corner stores exclusively. Complementary policies limiting the availability, affordability and marketing of energy-dense, nutrient-poor foods should also be pursued.

Objectives. We assessed the effect of the new Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package, implemented in October 2009, on breastfeeding outcomes among a predominately Latina sample of WIC participants in Los Angeles County, California. Methods. We used data from 5020 WIC participants who were interviewed in a series of repeated cross-sectional surveys conducted in 2005, 2008, and 2011. Participants were randomly selected from Los Angeles County residents who received WIC services during those years. Results. Consistent with the WIC population in Los Angeles, participants were mostly Latina and had low levels of income and education; more than half were foreign-born. We found small but significant increases from pre- to postimplementation of the new WIC food package in prevalence of prenatal intention to breastfeed and breastfeeding initiation, but no changes in any breastfeeding at 3 and 6 months. The prevalence of exclusive breastfeeding at 3 and 6 months roughly doubled, an increase that remained large and significant after adjustment for other factors. Conclusions. The new food package can improve breastfeeding outcomes in a population at high risk for negative breastfeeding outcomes.

Objective To assess differences in health care access, utilization, and experiences among Latino children in California according to parental citizenship status and language use. Methods Data are from the 2011 and 2012 California Health Interview Survey public use child files. A total of 2841 interviews of parents of Latino children younger than the age of 12 years were conducted. Analyses were conducted to determine the associations between access (usual of source of care, delay in receiving needed care, health insurance), utilization (physician visits in past year, emergency department visits), and experiences (doctor listens, doctor explains instructions clearly, communication via telephone or e-mail) according to parental citizenship status and household language use after adjusting for confounders. Results In multivariate analyses, there were no significant differences in access to care according to parental citizenship status. Children with 2 noncitizen parents had fewer doctor visits and were less likely to go to the emergency department in the past year than those with 2 citizen parents. Among children with 1 or 2 noncitizen parents, their parents reported worse experiences in care than those with 2 citizen parents. Similar results were observed for language use. Parents of children in bilingual and Spanish-only households were less likely to report that their children's doctors explained things clearly, and parents in Spanish-only households were less likely to communicate via telephone or e-mail than those in English-only households. Conclusions Health policy should focus on provider-parent communication to ensure health care equity for Latino children whose parents are not citizens or do not speak English.

Introduction: In the United States, Latinos have poorer access to and utilization of health care than non-Latino whites. The Patient Protection and Affordable Care Act (ACA) may reduce these disparities. The ACA9s impact among Latino subgroups is unknown. Methods: Using the 2011 to 2015 National Health Interview Survey, we examined access to and utilization of health care by Latino subgroups (18–64 years old). Subgroups were defined by Latino heritage group, citizenship status, and language use. Measures of access and utilization included insurance status, delaying medical care, forgoing medical care, visiting the emergency department, and visiting a physician. Logistic regression models were used to estimate the odds of the outcomes. Time period and subgroup interaction terms were used to test the effects of the ACA. Results: Mexicans and Central Americans had lower odds of being insured than did non-Latino whites. After ACA implementation, most reductions in disparities occurred between Puerto Ricans and non-Latino whites. Limited impact of the ACA was observed by language and citizenship status. Conclusions: The ACA has reduced gaps in access to and utilization of health care for some Latino population subgroups. Remaining disparities necessitate policy solutions that move beyond the ACA, particularly for groups excluded from coverage options, such as noncitizens.

ObjectiveTo introduce the concept ‘nutrition activation’ (the use of health and nutrition information when making food and diet decisions) and to assess the extent to which nutrition activation varies across racial/ethnic groups and explains dietary disparities.DesignCross-sectional sample representative of adults in the USA. Primary outcome measures include daily energy intake and consumption of sugar-sweetened beverages (SSB), fast foods and sit-down restaurant foods as determined by two 24 h dietary recalls. We use bivariate statistics and multiple logistic and linear regression analyses to assess racial/ethnic disparities in nutrition activation and food behaviour outcomes.SettingUSA.SubjectsAdult participants (n 7825) in the 2007–2010 National Health and Nutrition Examination Survey.ResultsNutrition activation varies across racial/ethnic groups and is a statistically significant predictor of SSB, fast-food and restaurant-food consumption and daily energy intake. Based on the sample distribution, an increase from the 25th to 75th percentile in nutrition activation is associated with a decline of about 377 kJ (90 kcal)/d. Increased nutrition activation is associated with a larger decline in SSB consumption among whites than among blacks and foreign-born Latinos. Fast-food consumption is associated with a larger ‘spike’ in daily energy intake among blacks (+1582 kJ (+378 kcal)/d) than among whites (+678 kJ (+162 kcal)/d).ConclusionsNutrition activation is an important but understudied determinant of energy intake and should be explicitly incorporated into obesity prevention interventions, particularly among racial/ethnic minorities.

Background The effectiveness of food retail interventions is largely undetermined, yet substantial investments have been made to improve access to healthy foods in food deserts and swamps via grocery and corner store interventions. This study evaluated the effects of corner store conversions in East Los Angeles and Boyle Heights, California on perceived accessibility of healthy foods, perceptions of corner stores, store patronage, food purchasing, and eating behaviors. Methods Household data (n = 1686) were collected at baseline and 12- to 24-months post-intervention among residents surrounding eight stores, three of which implemented a multi-faceted intervention and five of which were comparisons. Bivariate analyses and logistic and linear regressions were employed to assess differences in time, treatment, and the interaction between time and treatment to determine the effectiveness of this intervention. Results Improvements were found in perceived healthy food accessibility and perceptions of corner stores. No changes were found, however, in store patronage, purchasing, or consumption of fruits and vegetables. Conclusions Results suggest limited effectiveness of food retail interventions on improving health behaviors. Future research should focus on other strategies to reduce community-level obesity. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3074-1) contains supplementary material, which is available to authorized users.

Background. Few population-based studies have assessed health outcomes and health care access and use among youth in the US Commonwealth of Puerto Rico. Methods. Data are from an island population–based sample of 337 youth, 10 to 17 years old, who participated in the Asthma, Depression, and Anxiety in Puerto Rican Youth Study. In-person interviews with youth and caregivers assessed self-rated physical and mental health, weight status, diagnosed health conditions, and health care access and use. Results. Island Puerto Rican youth report slightly worse physical and mental health than mainland youth. Puerto Rican youth have high rates of asthma, headaches, and stomachaches. Also, 6 in 10 island youth use public health insurance, and 1 in 3 regularly receive care at the emergency department. Conclusions. Island Puerto Rican youth are at a health disadvantage compared with mainland youth. Public health research is needed to fully understand and combat health challenges among Puerto Rican youth.

Hospital practices and early maternal return to work are associated with breastfeeding duration; however, research has not documented the long-term effects of many hospital policies or the effect of early return to work on breastfeeding outcomes of WIC participants. This study investigated the impact of in-hospital breastfeeding, receipt of a formula discharge pack, and maternal return to work on the long-term breastfeeding outcomes of 4,725 WIC participants in Los Angeles County, California. Multivariate logistic regression analyses were used to assess determinants of exclusive breastfeeding at 6 months and breastfeeding at 6, 12, and 24 months. In-hospital initiation of breastfeeding, exclusive breastfeeding in the hospital, receipt of a formula discharge pack, and maternal return to work before 3 months were all significantly associated with breastfeeding outcomes after controlling for known confounders. Mothers who exclusively breastfed in the hospital were eight times as likely as mothers who did not breastfeed in the hospital to reach the AAP recommendation of breastfeeding for 12 months or longer (P < .01). Only 6.9% of the sample reported exclusively breastfeeding for 6 months or more, and just one-third reported any breastfeeding at 12 months. Nine in ten respondents received a formula discharge pack in the hospital. Mothers who received a discharge pack were half as likely to exclusively breastfeed at 6 months as those who did not receive one (P < .01). Medical providers should educate, encourage, and support WIC mothers to breastfeed in the hospital and refrain from giving formula discharge packs.

Childhood obesity is a growing problem in the United States. Parental perception of their children's weight status is a key factor that needs to be considered when developing prevention programs for preschool children. Using a randomly selected sample of participants of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Los Angeles County, we assessed accuracy of maternal perceptions of their children's weight status by comparing children's weight classification to the mothers' response to the question "Do you consider your child to be overweight, underweight or about right weight for (his) (her) height?" Additionally, we identified possible predictors of accurate maternal perception of their children's weight status by conducting a logistic regression model with child's gender, child's birth weight, maternal age, maternal BMI, maternal education, maternal acculturation level, and maternal language preference as potential predictors. Almost all mothers in the study classified their overweight or obese child as being about the right weight (93.6% and 77.5% of mothers, respectively). Maternal BMI and child's birth weight were the only predictors of maternal perception of their child's weight. Both were negatively associated with accuracy, with higher maternal BMI and higher infant birthweight associated with less accurate maternal perception of child weight. Parents need to be educated on the importance of childhood obesity and how to identify if their children are overweight or obese. If parents fail to recognize that their overweight child is overweight, then it is unlikely that they will recognize that interventions targeting obesity are relevant to their families.

From the Schools and Programs of Public Health MOBILIZING YOUNG PEOPLE IN COMMUNITY EFFORTS TO IMPROVE THE FOOD ENVIRONMENT: CORNER STORE CONVERSIONS IN EAST LOS ANGELES Mienah Z. Sharif, MPH Jeremiah R. Garza, MA, MPH Brent A. Langellier, MA, PhD Alice A. Kuo, MD, PhD Deborah C. Glik, ScD Michael L. Prelip, DPA Alexander N. Ortega, PhD Latino young people are significantly more likely to be obese than their non-Latino white peers. 1–3 Higher obesity rates place Latino young people—one of the largest, fastest-growing ethnic groups in the United States—at a heightened risk for developing a range of chronic diseases, including obesity, cardiovascu- lar disease (CVD), and type 2 diabetes. 4–8 Moreover, Latinos are far from meeting the recommended daily intake of fruit and vegetables, 9–12 which is a critical public health concern considering that maintaining a healthful diet, including fruit and vegetables, is a key strategy for preventing chronic disease. 13–21 The food environment influences dietary behavior. However, social and economic factors lead to stark variations in the composition and quality of food among communities that help explain disparities in dietary practices and health outcomes. 22–28 Specifically, low-income communities of color have less access to fresh, affordable fruit and vegetables than more afflu- ent communities. 25,26,29–31 Furthermore, low-income, racial/ethnic minority families often find it easier to purchase energy-dense foods (characterized as high in fat, calories, and sugar) than healthier options, such as fresh fruit and vegetables. 25,29,32–34 One such example is East Los Angeles (East LA), an urban, predominantly Mexican-American community that has limited access to affordable, healthful food, but an abundance of fast-food restaurants and other sources of unhealthful food. 35,36 The food environment is one factor that helps explain why East LA residents experience higher rates of heart disease, diabetes, hypertension, and stroke than residents of more affluent LA neighborhoods. 37 Converting corner stores to improve access to affordable, healthful foods is one potential strategy to improve the food environment. 28,34,38–44 There is no one definition, or approach, for conducting corner store conversions. However, common strategies include improving the store’s facade and installing refrigera- tion units to store the newly available fresh produce. 44 The University of California, Los Angeles (UCLA) Center for Population Health and Health Disparities (CPHHD) implemented a community-engaged corner store conversion project called Proyecto Mercado- FRESCO (Fresh Market Project) in East LA and the neighboring community of Boyle Heights. This inter- vention converted four locally owned corner stores with the goal of increasing access to healthful food and reducing CVD risk. The CPHHD approach emphasized collaboration among community residents and orga- nizations, public health agencies, local public schools, and store owners. 44–47 The process included moving less healthful food items (i.e., chips, soda, and candy) to the back of the store, installing a fresh produce section at the front, improving the interior and exterior store facade, replacing alcohol and tobacco advertisements with healthful food messages, and providing business skills training to store owners. A major supplement to the conversion was a youth- driven campaign of community nutrition education and social marketing to promote the converted stores and increase the purchase of fruit and vegetables. 45–47 An elective course was implemented at two public high schools, one in East LA and one in Boyle Heights, to build the capacity of local students to lead the com- munity social marketing campaign. Students received classroom and field training in nutrition, food justice, media production, and social marketing. The campaign consisted of the following activities: performances at schools, community centers, and parks; short videos on buses; the design and dissemination of posters at bus shelters and marketing materials in neighborhoods surrounding converted stores; and cooking demonstra- tions at the stores (Photos 1 and 2). In addition to lead- ing the social marketing campaign, young people were actively involved in the stores’ physical transformation. The importance of youth perspectives in imple- menting policy advocacy, social marketing, and health projects has been well established in tobacco and substance use prevention. 48–54 While some reports document the engagement of low-income, minority young people in advocating for improvements in their access to healthful food, few reports focus on corner store interventions, and none use qualitative Public Health Reports / July–August 2015 / Volume 130

We use data from the 2011-2016 National Health Interview Survey to examine how the Patient Protection and Affordable Care Act (ACA) has influenced disparities in health care–related financial strain, access to care, and utilization of services by categories of the Federal Poverty Level (FPL). We use multivariable regression analyses to determine the ACA’s effects on these outcome measures, as well as to determine how changes in these measures varied across different FPL levels. We find that the national implementation of the ACA’s insurance expansion provisions in 2014 was associated with improvements in health care–related financial strain, access, and utilization. Relative to adults earning more than 400% of the FPL, the largest effects were observed among those earning between 0% to 124% and 125% to 199% of the FPL after the implementation of the ACA. Both groups experienced reductions in disparities in financial strain and uninsurance relative to the highest FPL group. Overall, the ACA has attenuated health care–related financial strain and improved access to and the utilization of health services for low- and middle-income adults who have traditionally not met income eligibility requirements for public insurance programs. Policy changes that would replace the ACA with less generous age-based tax subsidies and reductions in Medicaid funding could reverse these gains.

ObjectivePrevious studies have established that acculturation is associated with dietary intake among Mexican immigrants and their offspring, but few studies have investigated whether food purchasing, food preparation or food-related values act as mechanisms of dietary acculturation. We examine the relationship between language use and a wide range of food behaviours and food-related values among Mexican-American adults.DesignNationally representative probability sample of the US population.Setting2005–2010 National Health and Nutrition Examination Survey.SubjectsMexican-American adults (n 2792) at least 20 years of age.ResultsMexican Americans who speak only or mostly English consume more energy from fast-food and sit-down restaurants and report increased consumption of non-homemade meals, fast-food and pizza meals, frozen meals and ready-to-eat meals relative to Spanish speakers. English speakers prepare one fewer homemade dinner per week and spend less time on meal preparation. English speakers are more likely than Spanish speakers to cite convenience as an important reason why they prefer fast food over cooking at home. There is no relationship between language use and the perceived importance of the nutritional quality, price or taste of fast food.ConclusionsOur results provide evidence that the well-documented relationship between acculturation and diet among Mexican Americans may be just one indicator of a broader pattern characterized by decreased home meal preparation and increased reliance on convenience foods.

ObjectiveWeight self-perceptions, or how a person perceives his/her weight status, may affect weight outcomes. We use nationally representative data from 1988–1994 and 1999–2008 to examine racial/ethnic disparities in weight self-perceptions and understand how disparities have changed over time.DesignUsing data from two time periods, 1988–1994 and 1999–2008, we calculated descriptive statistics, multivariate logistic regression models and predicted probabilities to examine trends in weight self-perceptions among Whites, Blacks, US-born Mexican Americans and Mexican immigrants to the USA.SettingNational Health and Nutrition Examination Survey (NHANES) III (1988–1994) and continuous NHANES (1999–2008).SubjectsAdult NHANES participants aged 18 years and older (n 37 050).ResultsThe likelihood of self-classifying as overweight declined between 1988–1994 and 1999–2008 among all US adults, despite significant increases in mean BMI and overweight prevalence. Trends in weight self-perceptions varied by gender and between racial/ethnic groups. Whites in both time periods were more likely than racial/ethnic minorities to perceive themselves as overweight. After adjustment for other factors, disparities in weight self-perceptions between Whites and Blacks of both genders grew between survey periods (PPConclusionsWeight self-perceptions have changed during the obesity epidemic in the USA, but changes have not been consistent across racial/ethnic groups. Secular declines in the likelihood of self-classifying as overweight, particularly among Blacks, are troubling because weight self-perceptions may affect weight-loss efforts and obesity outcomes.

It is important to understand the source of health-care disparities between Latinos and other children in the United States. We examine parent-reported health-care access and utilization among Latino, White, and Black children (≤17 years old) in the United States in the 2006–2011 National Health Interview Survey. Using Blinder-Oaxaca decomposition, we portion health-care disparities into two parts (1) those attributable to differences in the levels of sociodemographic characteristics (e.g., income) and (2) those attributable to differences in group-specific regression coefficients that measure the health-care ‘return’ Latino, White, and Black children receive on these characteristics. In the United States, Latino children are less likely than Whites to have a usual source of care, receive at least one preventive care visit, and visit a doctor, and are more likely to have delayed care. The return on sociodemographic characteristics explains 20–30% of the disparity between Latino and White children in the usual source of care, delayed care, and doctor visits and 40–50% of the disparity between Latinos and Blacks in emergency department use and preventive care. Much of the health-care disadvantage experienced by Latino children would persist if Latinos had the sociodemographic characteristics as Whites and Blacks.

Exposure to US culture is negatively associated with fruits and vegetables (F&V) intake. Our goal was to investigate how parent's nativity and length of stay in the US influences preschoolers' F&V intake. We analyzed survey data from 2,352 children, aged 36-60 months, who participate in the Supplemental Nutrition Program for Women, Infants and Children (WIC) in Los Angeles County. Using multiple linear regression, we examined children's F&V intake by parent's nativity and years in the US, adjusting for possible confounders. Children of foreign born parents who had lived in the US for

Objectives. We investigated whether access to and use of health care services increased among residents of a low-income, predominantly Mexican American border community affected by the expansion of Arizona’s Medicaid program in 2001 and multiple community-level programs and policies. Methods. We used data from a probability sample of 1623 adult residents of Douglas, Arizona, who participated in cross-sectional health surveys in 1998 and 2010. Response rates were 83% and 86%, respectively. Results. In 2010, participants were more likely to have a usual source of care, to have visited a provider in the previous year, and to have been screened for diabetes and hypertension and less likely to have delayed needed care or to have seen a regular provider in Mexico (P Conclusions. Expansion of public insurance programs can effectively reduce health care disparities when paired with other community-level policies and programs that target medically underserved populations.

Refereed/Peer-reviewed Objectives: Daily transport may impact depression risk among older adults through several pathways including facilitating the ability to meet basic needs, enabling and promoting contact with other people and nature, and promoting physical activity (e.g. through active transportation such as walking or walking to public transit). Both daily transport and depression are influenced by the neighborhood environment. To provide insights into how transport interventions may affect depression in older adults, we developed a pilot agent-based model to explore the contribution of daily transport and neighborhood environment to older adults’ depression in urban areas. Method: The model includes about 18,500 older adults (i.e. agents) between the ages of 65 and 85 years old, living in a hypothetical city. The city has a grid space with a number of neighborhoods and locations. Key dynamic processes in the model include aging, daily transport use and feedbacks, and the development of depression. Key parameters were derived from US data sources. The model was validated using empirical studies. Results: An intervention that combines a decrease in bus fares, shorter bus waiting times, and more bus lines and stations is most effective at reducing depression. Lower income groups are likely to be more sensitive to the public transit-oriented intervention. Conclusion: Preliminary results suggest that promoting public transit use may be a promising strategy to increase daily transport and decrease depression. Our results may have implications for transportation policies and interventions to prevent depression in older adults.

Background: The Nutrition Facts label can facilitate healthy dietary practices. There is a dearth of research on Latinos' utilization and comprehension of the Nutrition Facts label. Objective: To measure use and comprehension of the Nutrition Facts label and to identify correlates among Latinos in East Los Angeles, CA. Design: Cross-sectional interviewer-administered survey using computer-assisted personal interview software, conducted in either English or Spanish in the participant's home. Participants/setting: Eligibility criteria were: living in a household within the block clusters identified, being age 18 years or older, speaking English or Spanish, identifying as Latino and as the household's main food purchaser and preparer. Analyses were based on 269 eligible respondents. Statistical analyses performed: χ2 test and multivariate logistic regression analysis assessed the associations among the main outcomes and demographics. Multiple imputations addressed missing data. Results: Sixty percent reported using the label; only 13% showed adequate comprehension of the label. Utilization was associated with being female, speaking Spanish, and being below the poverty line. Comprehension was associated with younger age, not being married, and higher education. Utilization was not associated with comprehension. Conclusions: Latinos who are using the Nutrition Facts label are not correctly interpreting the available information. Targeted education is needed to improve use and comprehension of the Nutrition Facts label to directly improve diet, particularly among males, older Latinos, and those with less than a high school education. © 2014 Academy of Nutrition and Dietetics.