Search

ObjectivesWe examined the association between comorbidity and long-term mortality from breast cancer and other causes among African-American and white women with breast cancer. MethodsA total of 170 African-American and 829 white women aged 40-84. years were followed for up to 28. years with median follow-up of 11.3 years in the Health and Functioning in Women (HFW) study. The impact of the Charlson Comorbidity Score (CCS) in the first few months following breast cancer diagnosis on the risk of mortality from breast cancer and other causes was examined using extended Cox models. ResultsMedian follow-up was significantly shorter for African-American women than their white counterparts (median 8.5 years vs. 12.3 years). Compared to white women, African-American women had significantly fewer years of education, greater body mass index, were more likely to have functional limitations and later stage at breast cancer diagnosis, and fewer had adequate financial resources (all P < 0.05). Proportionately more African-American women died of breast cancer than white women (37.1% vs. 31.4%, P = 0.15). A positive and statistically significant time-varying effect of the Charlson Comorbidity Score (CCS) on other-cause mortality persisted throughout the first 5. years of follow-up (P < 0.001) but not for its remainder. Conclusions Higher CCS was associated with increased risk of other-cause mortality, but not breast cancer specific mortality; the association did not differ among African-American and white women. © 2014 Elsevier Inc.

Objectives: The primary objective of this exploratory analysis was to assess the prevalence of caregiving among older (60+) newly diagnosed female breast cancer patients and to examine the risk of depression associated with breast cancer, caregiving, and age, at 3 months and 12 months after diagnosis. Methods: Data from interviews conducted for the case-control study, Health and Functioning in Women with Breast Cancer (HFW), were used for this analysis. Interviews were conducted at 3 months and 12 months post-diagnosis. Participants for this analysis were restricted to those who completed both interviews (cases n = 904; controls n = 966). Risk of depression was assessed using a self-reported depression question from the HFW instrument. Results: The multivariate analysis showed that stage of breast cancer was significantly related to depression among older women with breast cancer while controlling for various socio-demographic factors; however, caregiving did not significantly increase the risk for depression for this population. Discussion: A breast cancer diagnosis for women, regardless of age or caregiving status, presented an increased risk of depression at 3 and 12 months post-diagnosis. These and other findings and their implications for social work practice are discussed. [ABSTRACT FROM AUTHOR]

Purpose: To test the hypothesis that high unemployment predicts reduced detection of local breast tumors among African American and non-Hispanic white women in the Detroit, Michigan and Atlanta, Georgia SEER catchment areas.Methods: We test the hypothesis with data for the 156 months from January 1985 through December 1997.Results: In situ and local breast tumors in African American and non-Hispanic white women were less likely to be detected during periods of high unemployment.Conclusions: Contracting labor markets may impede women with symptoms from getting proper medical attention or distract women from discovering symptoms they would otherwise detect. African American women appear at greatest risk of having a tumor going undetected by virtue of labor market performance. [ABSTRACT FROM AUTHOR]

OBJECTIVE. This is an examination of factors associated with returning to work after the diagnosis of breast cancer. METHODS. Three months after being diagnosed with breast cancer, 296 employed women from the Detroit metropolitan area (52 black and 244 white women) were interviewed. These women were part of a larger cohort of 1,011 breast cancer patients ages 40 to 84 interviewed for the study 'Health and Functioning in Women with Breast Cancer'. RESULTS. Although most employed women returned to work within three months of the diagnosis of breast cancer, black women were twice as likely as white women to be on medical leave three months after diagnosis (OR = 1.94; 95% CI 1.04 to 3.62). Being on leave was found to be associated with the need for assistance with transportation, limitations in upper-body strength, and employment in jobs requiring physical activity. After adjusting for these factors, the racial difference was reduced and no longer statistically significant (OR = 1.34; 95% CI 0.67, 2.70). CONCLUSION. Breast cancer rehabilitation programs should not only address the patient's physical capacity but also the daily demands she is likely to face once she leaves the hospital and returns to work. [ABSTRACT FROM AUTHOR]

It has become increasingly clear that the influences on walking as well as other forms of regular physical activity are complex and require an increased understanding of factors across multiple levels of influence. Ecological frameworks have provided the field with a heuristic means of capturing potential impacts on behavior across diverse domains, including personal, behavioral, social or cultural, and environmental. We discuss advances in both understanding and applying this framework through the inclusion of previously ignored dimensions of impact (e.g., time), the application of state-of-the-art statistical methods for understanding interactions among multiple domains (e.g., signal detection), and the development of computer technologies (e.g., agent-based modeling) aimed at simulating the complex relationships between multiple levels of impact and walking behavior. We conclude with suggestions for future research in this emerging field. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This report examines the role of (a) disease processes affecting vision, (b) reported troubles with vision, (c) physical symptoms affecting the eyes, and (d) objective measures in reported driving limitation due to problems with eyesight among older drivers. METHODS: Data for this study (N = 1,840) were obtained from participants in a community-based study of aging and physical performance in people age 55 or older in the city of Sonoma, California. Each of 16 visual conditions was assessed for impact on reported driving limitation due to eyesight by calculating a 'risk' ratio. Then, prevalence of the condition was combined with the ratio to generate an attributable risk for that condition for vision-related limitations in driving. RESULTS: Each condition was significantly associated with reported limitations in driving due to eyesight. 'Avoiding physical activity due to vision' (ratio = 3.4) and 'trouble seeing steps up/down stairs' (ratio = 2.9) had the strongest association. However, 'glasses/contacts required for driving' and 'trouble with glare from sun/lights' had the highest attributable risks (35.8 and 29.4). DISCUSSION: The risk ratio is relevant for evaluating individuals; the attributable risk is relevant to planning countermeasures in populations. Addressing specific problems related to vision should substantially reduce driving limitations due to eyesight. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to obtain information concerning the health status of the theoretically advantaged elderly population of Marin County, California, and to compare these data with those from other populations with different levels of socioeconomic status.Methods: An age-stratified sample of 2,018 community-dwelling elderly residents of Marin was selected, and these participants were interviewed between 1989 and 1991. Interview items included medical history of life-threatening diseases and chronic conditions, reported and observed disabilities, and life-style characteristics.Results: While the residents of Marin had lower mortality rates than the total U.S. population, there were few meaningful differences in measures of health and function in comparison to other elderly populations with substantially lower levels of socioeconomic status. The main exceptions were better memory performance and lower depressive symptomatology in Marin. Because of the many methodological differences, these comparisons must be viewed with caution.Conclusion: The general pattern of findings in this study indicates that while death has been postponed in this socioeconomically advantaged population, the prevalence of disease and disability has not. If true, this implies that residents of an affluent community can spend a longer rather than shorter period of their late life in a state of infirmity and in need of medical care. This appears to be especially true for women. [ABSTRACT FROM AUTHOR]

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) is neurotoxic in animals but few studies have investigated its effects on the human brain. Related dioxin-like compounds have been linked to poorer cognitive and motor function in older adults, with effects more pronounced in women, perhaps due to the loss of neuro-protective estrogen in menopause. On 10 July 1976, a chemical explosion in Seveso, Italy, resulted in one of the highest known residential exposures to TCDD. In 1996, we initiated the Seveso Women's Health Study, a retrospective cohort study of the health of the women who were newborn to 40 years old in 1976. Here, we investigate whether TCDD exposure is associated with physical functioning and working memory more than 20 years later. Individual TCDD concentration (ppt) was measured in archived serum collected soon after the explosion. In 1996 and 2008, we measured physical functioning (n=154) and working memory (n=459), respectively. We examined associations between serum TCDD and motor and cognitive outcomes with multivariate linear regression and semi-parametric estimators. A 10-fold increase in serum TCDD was not associated with walking speed (adjusted β=0.0006ft/s, 95% Confidence Interval (CI): -0.13, 0.13), upper body mobility (adjusted β=-0.06, 95% CI: -0.36, 0.23), or manual dexterity (adjusted β=0.34, 95% CI: -0.65, 1.33). We observed an inverted U-shaped association in grip strength, with poorer strength in the lowest and highest TCDD exposure levels. There was no association between TCDD and the Wechsler digit and spatial span tests. Neither menopause status at assessment nor developmental timing of exposure modified associations between TCDD and working memory. Our findings, in one of the only studies of TCDD's effects on neuropsychological and physical functioning in women, do not indicate an adverse effect on these domains, with the exception of a U-shaped relationship with grip strength. Given the limited assessment and relative youth of the women at this follow-up, future work examining additional neuropsychological outcomes is warranted., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Addressing drinking and driving remains a challenge in the United States. The present study aims to provide feedback on driving under the influence (DUI) in California by assessing whether drinking and driving behavior is associated with the DUI arrest rates in the city in which the driver lives; whether this is due to perceptions that one can get arrested for this behavior; and whether this differed by those drivers who would be most affected by deterrence efforts (those most likely to drink outside the home)., Methods: This study consisted of a 2012 roadside survey of 1,147 weekend nighttime drivers in California. City DUI arrest rates for 2009-2011 were used as an indicator of local enforcement efforts. Population average logistic modeling was conducted modeling the odds of perceived high arrest likelihood for DUI and drinking and driving behavior within the past year., Results: As the DUI arrest rates for the city in which the driver lives increased, perceived high risk of DUI arrest increased. There was no significant relationship between either city DUI arrest rates or perceived high risk of DUI arrest with self-reported drinking and driving behavior in the full sample. Among a much smaller sample of those most likely to drink outside the home, self-reported drinking and driving behavior was negatively associated with DUI arrests rates in their city of residence but this was not mediated by perceptions., Conclusion: The results of the present study suggest that perceptions are correlated with one aspect of DUI efforts in one's community. Those who were more likely to drink outside the home could be behaviorally influenced by these efforts.

Objective: To address whether neighborhood factors, together with older adults' levels of health and functioning, suggest new combinations of risk factors for falls and new directions for prevention. To explore the utility of Grade-of-Membership (GoM) analysis to conduct this descriptive analysis., Method: This is a cross-sectional, descriptive study of 884 people aged ≥65 years from Alameda County, CA, Cook County, IL, Allegheny County, PA, and Wake and Durham counties, NC. Interviews focused on neighborhood characteristics, physical and cognitive function, walking, and falls and injuries. Four risk profiles (higher order interactions of individual and neighborhood factors) were derived from GoM analysis., Results: Profiles 1 and 2 reflect previous results showing that frail older adults are likely to fall indoors (Profile 1); healthy older adults are likely to fall outdoors (Profile 2). Profile 3 identifies the falls risk for older with mild cognitive impairment living in moderately walkable neighborhoods. Profile 4 identifies the risk found for healthy older adults living in neighborhoods with low walkability., Discussion: Neighborhood walkability, in combination with levels of health and functioning, is associated with both indoor and outdoor falls. Descriptive results suggest possible research hypotheses and new directions for prevention, based on individual and neighborhood factors.

Background : Older adults in rural areas have unique transportation barriers to accessing medical care, which include a lack of mass transit options and considerable distances to health-related services. This study contrasts non-emergency medical transportation (NEMT) service utilization patterns and associated costs for Medicaid middle-aged and older adults in rural versus urban areas. Methods : Data were analyzed from 39,194 NEMT users of LogistiCare-brokered services in Delaware residing in rural (68.3%) and urban (30.9%) areas. Multivariable logistic analyses compared trip characteristics by rurality designation. Results : Rural (37.2%) and urban (41.2%) participants used services more frequently for dialysis than for any other medical concern. Older age and personal accompaniment were more common and wheel chair use was less common for rural trips. The mean cost per trip was greater for rural users (difference of $2910 per trip), which was attributed to the greater distance per trip in rural areas. Conclusions : Among a sample who were eligible for subsidized NEMT and who utilized this service, rural trips tended to be longer and, therefore, higher in cost. Over 50% of trips were made for dialysis highlighting the need to address prevention and, potentially, health service improvements for rural dialysis patients.

Purpose: In recent years, cancer case counts in the U.S. underwent a large, rapid decline-an unexpected change given population growth for older persons at highest cancer risk. As these declines coincided with the Great Recession, we examined whether they were related to economic conditions., Methods: Using California Cancer Registry data from California's 30 most populous counties, we analyzed trends in cancer incidence during pre-recession (1996-2007) and recession/recovery (2008-2012) periods for all cancers combined and the ten most common sites. We evaluated the recession's association with rates using a multifactorial index that measured recession impact, and modeled associations between case counts and county-level unemployment rates using Poisson regression., Results: Yearly cancer incidence rate declines were greater during the recession/recovery (3.3% among males, 1.4% among females) than before (0.7 and 0.5%, respectively), particularly for prostate, lung, and colorectal cancers. Lower case counts, especially for prostate and liver cancer among males and breast cancer, melanoma, and ovarian cancer among females, were associated with higher unemployment rates, irrespective of time period, but independent of secular effects. The associations for melanoma translated up to a 3.6% decrease in cases with each 1% increase in unemployment. Incidence declines were not greater in counties with higher recession impact index., Conclusions: Although recent declines in incidence of certain cancers are not differentially impacted by economic conditions related to the Great Recession relative to pre-recession conditions, the large recent absolute declines in the case counts of some cancer may be attributable to the large declines in unemployment in the recessionary period. This may occur through decreased engagement in preventive health behaviors, particularly for clinically less urgent cancers. Continued monitoring of trends is important to detect any rises in incidence rates as deferred diagnoses come to clinical attention.

Objective: To determine the association of prediagnostic alcohol consumption with long-term mortality from breast cancer and other causes in a cohort of women with breast cancer., Methods: We studied a Michigan-based cohort of 939 women aged 40-84 years, who provided complete information about the type, amount and intensity of prediagnostic alcohol consumption. Associations of alcohol consumption, based on weekly volume of alcohol consumption during the year prior to breast cancer diagnosis, with mortality were evaluated in Cox proportional hazards models, with adjustment for sociodemographic factors, body mass index, smoking, comorbidity, tumor characteristics, and treatment. Differences among covariates were assessed with Pearson χ2 , Student t -tests and Wilcoxon Rank Sum tests. All statistical tests were two-sided., Results: During a median follow-up of 11 years, 724 deaths occurred overall, with 303 from breast cancer. Fifty-five percent of the women were categorized as drinkers with volume of alcohol consumption ranging from 0.75 to 36.00 drinks/week. In multivariable models, a decreased risk of other-cause mortality was associated with low alcohol drinking (0.75-3.75 drinks/week; HR = 0.61, 95% CI = 0.47-0.78), moderate volume alcohol drinking (4.00-9.75 drinks/week; HR = 0.57, 95% CI = 0.39-0.85) and low frequency (0.75-3.75 drinks/week) beer and wine intake (HR = 0.69, 95% CI = 0.50-0.96 and HR = 0.68, 95% CI = 0.52-0.88 respectively). Although the risk of breast cancer-specific mortality was not statistically significantly associated with moderate (4.00-9.75 drinks/week) and high volume (10.00-36.00 drinks/week) alcohol drinking in the overall cohort (HR = 1.43, 95% CI = 95% 0.97-2.12 and HR = 1.53, 95% CI = 0.87-2.70 respectively), there was a positive association of alcohol consumption with breast cancer-specific mortality among current smokers (HR = 1.92, 95% CI = 1.03-3.57; Pinteraction = 0.04)., Conclusion: In this prospective cohort study, regular consumption of 0.75-36.00 alcoholic drinks per week during the year prior to breast cancer diagnosis was associated with a reduction in other-cause mortality and with an increase in breast cancer-specific mortality among current smokers, after taking into account clinical and sociodemographic factors.

Purpose: Mobility disability is associated with poor lower body function among older adults. This study examines whether specific types of neighborhood characteristics moderate that association., Design and Methods: This study is based on a cross-sectional sample of 884 people aged ≥ 65 years identified through service organizations in Alameda County, CA; Cook County, IL; Allegheny County, PA; and Wake and Durham counties, NC. In-person interviews focus on neighborhood characteristics, physical and cognitive function, depression, and walking. Functional capacity is tested using objective measures of lower body strength, balance, and walking speed. Mobility disability, the main study outcome, is measured as self-reported level of difficulty in walking 2-3 neighborhood blocks. Estimates of main and interactive effects are derived from logistic regression models., Results: Among older adults with poor lower body function, those who report less proximity to goods and services and barriers to walking report more mobility disability than other older adults. In contrast, among older adults with good lower body function, there is a low prevalence of mobility disability and little association between perceptions of the neighborhood and mobility disability., Implications: In addition to more refined longitudinal studies, this research provides a foundation for innovative place-based rehabilitation and hospital discharge programs for older adults newly diagnosed and treated for chronic health conditions., (© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Research on walking and walkability has yet to focus on wayfinding, the interactive, problem-solving process by which people use environmental information to locate themselves and navigate through various settings., Methods: We reviewed the literature on outdoor pedestrian-oriented wayfinding to examine its relationship to walking and walkability, 2 areas of importance to physical activity promotion., Results: Our findings document that wayfinding is cognitively demanding and can compete with other functions, including walking itself. Moreover, features of the environment can either facilitate or impede wayfinding, just as environmental features can influence walking., Conclusions: Although there is still much to be learned about wayfinding and walking behaviors, our review helps frame the issues and lays out the importance of this area of research and practice.

Purpose of the Study: This study identified factors associated with canceling nonemergency medical transportation appointments among older adult Medicaid patients., Design and Methods: Data from 125,913 trips for 2,913 Delaware clients were examined. Mediation analyses, as well as, multivariate logistic regressions were conducted., Results: Over half of canceled trips were attributed to client reasons (e.g., no show, refusal). Client characteristics (e.g., race, sex, functional status) were associated with cancelations; however, these differed based on the cancelation reason. Regularly scheduled trips were less likely to be canceled., Implications: The evolving American health care system may increase service availability. Additional policies can improve service accessibility and overcome utilization barriers., (© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Alcohol-impaired driving accounts for substantial proportion of traffic-related fatalities in the U.S. Risk perceptions for drinking and driving have been associated with various measures of drinking and driving behavior. In an effort to understand how to intervene and to better understand how risk perceptions may be shaped, this study explored whether an objective environmental-level measure (proportion of alcohol-involved driving crashes in one's residential city) were related to individual-level perceptions and behavior., Methods: Using data from a 2012 cross-sectional roadside survey of 1147 weekend nighttime drivers in California, individual-level self-reported acceptance of drinking and driving and past-year drinking and driving were merged with traffic crash data using respondent ZIP codes. Population average logistic regression modeling was conducted for the odds of acceptance of drinking and driving and self-reported, past-year drinking and driving., Results: A non-linear relationship between city-level alcohol-involved traffic crashes and individual-level acceptance of drinking and driving was found. Acceptance of drinking and driving did not mediate the relationship between the proportion of alcohol-involved traffic crashes and self-reported drinking and driving behavior. However, it was directly related to behavior among those most likely to drink outside the home., Discussion: The present study surveys a particularly relevant population and is one of few drinking and driving studies to evaluate the relationship between an objective environmental-level crash risk measure and individual-level risk perceptions. In communities with both low and high proportions of alcohol-involved traffic crashes there was low acceptance of drinking and driving. This may mean that in communities with low proportions of crashes, citizens have less permissive norms around drinking and driving, whereas in communities with a high proportion of crashes, the incidence of these crashes may serve as an environmental cue which informs drinking and driving perceptions. Perceptual information on traffic safety can be used to identify places where people may be at greater risk for drinking and driving. Community-level traffic fatalities may be a salient cue for tailoring risk communication., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Neighborhood social and built environments have been recognized as important contexts in which health is shaped. The authors reviewed the extent to which these neighborhood factors have been addressed in population-level cancer research by scanning the literature for research focused on specific social and/or built environment characteristics and their association with outcomes across the cancer continuum, including incidence, diagnosis, treatment, survivorship, and survival. The commonalities and differences in methodologies across studies, the current challenges in research methodology, and future directions in this research also were addressed. The assessment of social and built environment factors in relation to cancer is a relatively new field, with 82% of the 34 reviewed articles published since 2010. Across the wide range of social and built environment exposures and cancer outcomes considered by the studies, numerous associations were reported. However, the directions and magnitudes of associations varied, in large part because of the variation in cancer sites and outcomes studied, but also likely because of differences in study populations, geographic regions, and, importantly, choice of neighborhood measures and geographic scales. The authors recommend that future studies consider the life-course implications of cancer incidence and survival, integrate secondary and self-report data, consider work neighborhood environments, and further develop analytical and statistical approaches appropriate to the geospatial and multilevel nature of the data. Incorporating social and built environment factors into research on cancer etiology and outcomes can provide insights into disease processes, identify vulnerable populations, and generate results with translational impact of relevance for interventionists and policy makers., (© 2015 American Cancer Society.)

Purpose: Given that emotional health is a critical component of healthy aging, we undertook a systematic literature review to assess whether current interventions can positively affect older adults' emotional health., Methods: A national panel of health services and mental health researchers guided the review. Eligibility criteria included community-dwelling older adult (aged ≥ 50 years) samples, reproducible interventions, and emotional health outcomes, which included multiple domains and both positive (well-being) and illness-related (anxiety) dimensions. This review focused on three types of interventions - physical activity, social support, and skills training - given their public health significance and large number of studies identified. Panel members evaluated the strength of evidence (quality and effectiveness)., Results: In all, 292 articles met inclusion criteria. These included 83 exercise/physical activity, 25 social support, and 40 skills training interventions. For evidence rating, these 148 interventions were categorized into 64 pairings by intervention type and emotional health outcome, e.g., strength training targeting loneliness or social support to address mood. 83% of these pairings were rated at least fair quality. Expert panelists found sufficient evidence of effectiveness only for skills training interventions with health outcomes of decreasing anxiety and improving quality of life and self-efficacy. Due to limitations in reviewed studies, many intervention-outcome pairings yielded insufficient evidence., Conclusion: Skills training interventions improved several aspects of emotional health in community-dwelling older adults, while the effects for other outcomes and interventions lacked clear evidence. We discuss the implications and challenges in moving forward in this important area.

We examined the effect of smoking on long-term mortality from breast cancer and other causes among a cohort of women with breast cancer. A total of 975 women diagnosed with breast cancer and aged 40-84 years were followed for a median follow-up of 11 years in the U.S. Health and Functioning in Women (HFW) study. The impact of the individual smoking status and smoking intensity reported in the first few months following breast cancer diagnosis on the risk of mortality from breast cancer and other causes was examined using Cox proportional hazards models. In this study, former smoking was associated with increased risk of other-cause mortality (hazard ratio [HR] = 1.47, 95% confidence interval [CI]: 1.13-1.90), and the risk doubled with increased intensity (HR for <50 pack-years [py]: 1.36, 95% CI: 1.03-1.79; HR for ≥50 py: 2.45, 95% CI: 1.41-4.23). Current smoking (HR = 2.45, 95% CI: 1.81-3.32) and each additional 10 py smoked (HR = 1.16, 95% CI: 1.11-1.22) were associated with statistically significant increases in the risk of other-cause mortality. The effect of current smoking on other-cause mortality decreased with advancing stage and increasing body mass index (BMI). Breast cancer-specific mortality was associated with current smoking of ≥50 py (HR = 2.36, 95% CI: 1.26-4.44), and each additional 10 py smoked (HR = 1.07, 95% CI: 1.01-1. 14). Current smoking, but not former smoking, was associated with increased risk of breast cancer-specific mortality in women with local disease (HR = 2.32, 95% CI: 1.32-4.09), but not in those with regional and distant disease (HR = 1.10, 95% CI: 0.73-1.68). Our findings suggest that current smoking at the time of breast cancer diagnosis may be associated with increased risk of breast-cancer specific and other-cause mortality, whereas former smoking is associated with increased risk of other-cause mortality. Smoking cessation at the time of diagnosis may lead to better prognosis among women with breast cancer., (© 2014 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Problem: Rules for protecting human subjects, in place federally since 1974, have focused primarily on guarding against placing research subjects at social, physical, or psychological risk or violating their privacy and confidentiality. Nevertheless, high-risk communities are routinely subjected to "sins of omission," which limit access to potentially significant research opportunities and result in the absence of studies that could confer high degree of community beneficence., Purpose of Article: To describe "sins of omission" and provide examples from the Community Networks Program Centers (CNPC) to illustrate how community-based participatory research (CBPR) can prevent them., Key Points: CBPR is an effective antidote to sins of omission. Activities undertaken by the CNPCs illustrate how adherence to CBPR principles can improve research access and outcomes., Conclusions: By working with community members as partners, we expand the concept of beneficence to include "community beneficence," thus reducing the probability of "sins of omission."

Objectives: We explored relationships between depressive symptoms and neighborhood environment measures including traffic safety, crime, social capital, and density of businesses in community-dwelling older adults from four different regions of the United States., Method: The Healthy Aging Research Network walking study is a cross-sectional study of 884 adults aged 65+, which included a 10-item Center for Epidemiologic Studies Depression scale of depressive symptoms, demographics, self-reported neighborhood perceptions, and objective neighborhood data., Results: After adjusting for individual covariates, reports of neighborhood crime, unsafe traffic, and unwillingness of neighbors to help each other were significantly positively associated with depressive symptoms among participants., Conclusion: This research suggests an association between self-reported depressive symptoms and the social and built environment; examining causal association requires additional longitudinal research in diverse populations of older adults.

Objective: To review the range of promising technologies (e.g., smart phones, remote monitoring devices) designed to enhance aging in place; identify challenges for implementation of those technologies; and recommend ways to improve access to technologies in older populations., Method: A narrative review of research, practice, and policies from multiple fields, including information science, gerontology, engineering, housing and social services, health care and public health., Results: Despite a wide range of emerging and current technologies, there are significant challenges for implementation, including an uneven evidence base, economic barriers, and educational and ergonomic issues that adversely affect many older adults., Discussion: Recommendations for future development and adoption include improving the evidence base through field-testing of "packages" of devices in diverse populations of older adults; development of innovative funding mechanisms involving multidisciplinary teams, older adults, and caregivers; and promotion of safety and security in the use of these technologies in older populations., (© The Author(s) 2014.)

The Asian American, Native Hawaiian, and Pacific Islander population is large, growing, and extremely heterogeneous. Not only do they bear unique burdens of incidence and outcomes for certain cancer types, they exhibit substantial variability in cancer incidence and survival patterns across the ethnic groups. By acknowledging and leveraging this heterogeneity through investing in cancer research within these populations, we have a unique opportunity to accelerate the availability of useful and impactful cancer knowledge. See all the articles in this CEBP Focus section, "Cancer in Asian and Pacific Islander Populations.", (©2014 American Association for Cancer Research.)

Mobility, broadly defined as movement in all of its forms from ambulation to transportation, is critical to supporting optimal aging. This article describes two projects to develop a framework and a set of priority actions designed to promote mobility among community-dwelling older adults. Project 1 involved a concept-mapping process to solicit and organize action items into domains from a broad group of stakeholders to create the framework. Concept mapping uses qualitative group processes with multivariate statistical analysis to represent the ideas visually through maps. A snowball technique was used to identify stakeholders (n = 211). A 12-member steering committee developed a focus prompt, "One specific action that can lead to positive change in mobility for older adults in the United States is..." Project 2 included a Delphi technique (n = 43) with three iterations to prioritize four to six items using results from the concept mapping rating process. Project 1 resulted in 102 items across nine domains (Research to Practice, Independence and Engagement, Built Environment and Safety, Transportation, Policy, Housing and Accessibility, Community Supports, Training, and Coordinated Action). The number of items ranged from 6 to 18 per domain. Project 2 resulted in agreement on four items that reflect the importance of promoting environmental strategies through collaborative initiatives aimed at planning and best practices focusing on environmental enhancements or transit, training of professionals, and integration of mobility into state and local public health plans. These findings can be applied to support coordinated, multidisciplinary research and practice to promote mobility among older adults., (© 2014 Society for Public Health Education.)

Objective: This study assesses the impact of health problems on driving status (current driver vs. ex-driver) among older adults to identify which of those health problems have the greatest individual and population impact on driving cessation., Methods: Data were from baseline and 5 year follow-up waves of a longitudinal survey of adults age 55 years and older (N=1,279). The impact of several health problems on driving status was assessed using a relative risk ratio and a population attributable risk percent. Analyses controlled for age, gender, and the presence of additional baseline health problems., Results: Many health conditions were not associated with driving cessation. Functional limitations, cognitive function, and measures of vision were significant predictors of driving cessation. Self-care functional limitations were associated with the highest risk for driving cessation, while visual function was associated with the highest attributable risks., Discussion: In order to effectively address healthy aging and mobility transitions, it is important to consider the implications of targeting individuals or populations who are most at risk for driving cessation. The risk ratio is relevant for evaluating individuals; the attributable risk is relevant for developing interventions in populations.

Background: Research is limited on the independent and joint effects of individual- and neighborhood-level socioeconomic status (SES) on breast cancer survival across different racial/ethnic groups., Methods: We studied individual-level SES, measured by self-reported education, and a composite neighborhood SES (nSES) measure in females (1,068 non-Hispanic whites, 1,670 Hispanics, 993 African-Americans, and 674 Asian-Americans), ages 18 to 79 years and diagnosed 1995 to 2008, in the San Francisco Bay Area. We evaluated all-cause and breast cancer-specific survival using stage-stratified Cox proportional hazards models with cluster adjustment for census block groups., Results: In models adjusting for education and nSES, lower nSES was associated with worse all-cause survival among African-Americans (P trend = 0.03), Hispanics (P trend = 0.01), and Asian-Americans (P trend = 0.01). Education was not associated with all-cause survival. For breast cancer-specific survival, lower nSES was associated with poorer survival only among Asian-Americans (P trend = 0.01). When nSES and education were jointly considered, women with low education and low nSES had 1.4 to 2.7 times worse all-cause survival than women with high education and high nSES across all races/ethnicities. Among African-Americans and Asian-Americans, women with high education and low nSES had 1.6 to 1.9 times worse survival, respectively. For breast cancer-specific survival, joint associations were found only among Asian-Americans with worse survival for those with low nSES regardless of education., Conclusions: Both neighborhood and individual SES are associated with survival after breast cancer diagnosis, but these relationships vary by race/ethnicity., Impact: A better understanding of the relative contributions and interactions of SES with other factors will inform targeted interventions toward reducing long-standing disparities in breast cancer survival., (©2014 AACR.)

As part of setting the stage for this supplement to the American Journal of Preventive Medicine, a life-course perspective is presented to assist in understanding the importance of cancer prevention for adults in midlife, a period roughly spanning 20 years between ages 45 and 64 years. Drawing on disciplinary perspectives from the social sciences and public health, several life-course themes are delineated in this article: how specific life transitions present unique opportunities for interventions to inform policy and practice that can improve population health outcomes; how interventions can be focused on those at particular life stages or on the entire life course; and how the onset and progression of chronic conditions such as cancer are dependent on a complex interplay of critical and sensitive periods, and trajectory and accumulation processes. A translational research framework is applied to help promote the movement of applied public health interventions for cancer prevention into practice. Also explored are differences that can affect people at midlife relative to other age cohorts. Specifically, cancer-related risks and care networks are examined, with examples of public health strategies that can be applied to cancer prevention and control. As a conclusion, select methodologic issues and next steps for advancing research and practice are identified., (Copyright © 2014. Published by Elsevier Inc.)

Objectives: We examined the impact of functional limitations and functional decline during the first year following breast cancer diagnosis on the risk of mortality from breast cancer and other causes among African-American and white women, respectively., Design: The Health and Functioning in Women (HFW) cohort study., Setting: Detroit, Michigan, USA., Participants: A total of 162 African-American and 813 white women aged 40-84 years with newly diagnosed breast cancer identified through the Metropolitan Detroit Cancer Surveillance System over a 7-month period between 1984 and 1985 and followed for up to 28 years (median 11 years)., Outcome Measures: Risk of mortality from breast cancer and other causes., Results: Statistically significant increases in the risk of other-cause mortality were found for each unit increase in the number of self-reported functional limitations (HR=1.08, 95% CI 1.03 to 1.14), 0 vs ≥1 functional limitations (HR=1.47, 95% CI 1.13 to 1.91), difficulty in pushing or pulling large objects (HR=1.34, 95% CI 1.04 to 1.73), writing or handling small objects (HR=1.56, 95% CI 1.00 to 2.44), and walking half a mile (HR=1.60, 95% CI 1.19 to 2.14). Functional limitations and functional decline did not explain racial disparities in the survival of this cohort. Functional decline was associated with increased risk of other-cause mortality in women with regional and remote disease but not in women with localised disease. Whereas measures of functional limitation were not associated with breast cancer-specific mortality, each unit of functional decline (HR=1.17, 95% CI 1.05 to 1.31) and decline in the ability to sit ≥1 h (HR=2.06, 95% CI 1.13 to 3.76) were associated with increased risk of breast cancer-specific mortality. Measures of functional decline were associated with increased risk of breast cancer mortality in overweight and obese women, but not in women of normal weight., Conclusions: Whereas functional limitations were associated with increased risk of other-cause mortality, functional decline was associated with increased risk of breast cancer mortality.

There is an urgent need to translate science into practice and help enhance the capacity of professionals to deliver evidence-based programming. We describe contributions of the Healthy Aging Research Network in building professional capacity through online modules, issue briefs, monographs, and tools focused on health promotion practice, physical activity, mental health, and environment and policy. We also describe practice partnerships and research activities that helped inform product development and ways these products have been incorporated into real-world practice to illustrate possibilities for future applications. Our work aims to bridge the research-to-practice gap to meet the demands of an aging population.

Safe and well-designed community environments support healthful behaviors that help prevent chronic conditions and unintentional injuries and enable older adults to be active and engaged in community life for as long as possible. We describe the work of the Healthy Aging Research Network (HAN) and partners over the past decade to better understand place-based determinants of health and translate that knowledge to real-world practice, with a focus on environmental strategies. Using key components of the Knowledge to Action framework, we document the importance of a sustained, multidisciplinary, collaborative approach and ongoing interaction between researchers and communities. We share examples of practical tools and strategies designed to engage and support critical sectors with the potential to enhance the health and well-being of older adults and their communities. We conclude with a description of lessons learned in facilitating the translation of prevention research into practice.

Optimal mobility, defined as relative ease and freedom of movement in all of its forms, is central to healthy aging. Mobility is a significant consideration for research, practice, and policy in aging and public health. We examined the public health burdens of mobility disability, with a particular focus on leading public health interventions to enhance walking and driving, and the challenges and opportunities for public health action. We propose an integrated mobility agenda, which draws on the lived experience of older adults. New strategies for research, practice, and policy are needed to move beyond categorical promotion programs in walking and driving to establish a comprehensive program to enhance safe mobility in all its forms.

Background: Little is known about the long-term impact of comorbidity among women with breast cancer., Methods: We studied a prospective cohort of 2,272 women with breast cancer, who were recruited following initial breast cancer treatment. Associations of the Charlson comorbidity index (CCI) and hypertension with survival were evaluated in delayed entry Cox proportional hazards models., Results: During a median follow-up of nine years, higher CCI scores were independently associated with an increased risk of death from all causes [HR, 1.32; 95% confidence interval (CI), 1.13-1.54] and from nonbreast cancer causes (HR, 1.55; 95% CI, 1.19-2.02), but not from breast cancer (HR, 1.14; 95% CI, 0.93-1.41). Hypertension was independently associated with an increased risk of death from all causes (HR, 1.55; 95% CI, 1.20-1.99), from nonbreast cancer causes (HR, 1.67; 95% CI, 1.10-2.54), and from breast cancer (HR, 1.47; 95% CI, 1.03-2.09), but these associations were no longer significant after adjustment for antihypertensive medication. The relationship between the CCI and overall survival was the strongest among women with stage I disease (stage I, HR, 1.65; 95% CI, 1.26-2.16 vs. stage III, HR, 0.53; 95% CI, 0.23-1.25)., Conclusion: The CCI was independently associated with lower overall and nonbreast cancer survival, but not with breast cancer-specific survival., Impact: Comorbidity may play an important role in breast cancer outcomes., (©2012 AACR)

Objectives: Data from the Healthy Aging Network (HAN) study (Prohaska, T., Eisenstein, A., Satariano, W., Hunter, R., Bayles, C., Kurtovich, E., … Ivey, S. [2009]. Walking and the preservation of cognitive function in older populations. The Gerontologist, 49[Suppl. 1], S86-S93; and Satariano, W., Ivey, S., Kurtovich, E., Kealey, M., Hubbard, A., Bayles, C., … Prohaska, T. [2010]. Lower-body function, neighborhoods, and walking in an older population. American Journal of Preventive Medicine, 38, 419-428.) were used to examine the relationships among physical activity, self-efficacy, functional performance, and limitations., Method: Interviews were conducted within homes and senior centers in 4 geographic regions across the United States. Participants were 884 older adults (M age = 74.8; 77% female; 35% minority status) who completed measures of walking behavior, way-finding self-efficacy, walking self-efficacy, functional performance, functional limitations, and demographic characteristics., Results: Path analysis within a covariance modeling framework revealed significant direct effects of walking on self-efficacy constructs, functional performance on functional limitations, and efficacy on limitations. Additionally, significant indirect effects were also found, including walking on limitations via walking self-efficacy and performance and walking self-efficacy on limitations via performance. Furthermore, we found support for invariance of the model across geographical grouping., Discussion: Our findings provide further validation for an efficacy-based model of functional limitations. Walking-related efficacy may help reduce or possibly delay the onset of functional limitations.

Given the growing evidence of the influence of the environment on older adult health, the need to design and implement effective environmental policy around healthy and vital aging is urgent. This article describes issues amenable to improvement through policy change, evidence supporting specific policy approaches and outcomes, and promising strategies for implementing those approaches. Key areas of focus are neighborhood design and safety, housing, transportation, and mobility. Strategies to build capacity for policy change are also addressed. Our goals are to foster greater attention to environmental change in support of healthy aging and to illuminate directions for policy change.

Objective: This study examines the role of environmental correlates of overweight and obesity among older adults independent of walking activity and lower body function., Methods: In-person interviews were conducted with 789 adults aged 65 and older, residing in four areas in the U.S. Demographic information, general health, lower body function, walking behavior, and awareness of environmental infrastructure features using the modified Neighborhood Environment Walking Survey (NEWS) were obtained. Regression analyses examined the association between Body Mass Index (BMI) and environmental infrastructure features, adjusting for demographics and lower body function., Results: Older adults who perceived their neighborhood as less safe from crime and had reduced access to services were more likely to have higher BMI. Controlling for demographic and functional characteristics, access to services remained significant. This association remained significant for those with lower functional status., Discussion: This research suggests that neighborhood environment may have an influence on BMI above and beyond walking activity.

Background: There is a paucity of literature comparing Bayesian analytic techniques with traditional approaches for analyzing clinical trials using real trial data., Methods: We compared Bayesian and frequentist group sequential methods using data from two published clinical trials. We chose two widely accepted frequentist rules, O'Brien-Fleming and Lan-DeMets, and conjugate Bayesian priors. Using the nonparametric bootstrap, we estimated a sampling distribution of stopping times for each method. Because current practice dictates the preservation of an experiment-wise false positive rate (Type I error), we approximated these error rates for our Bayesian and frequentist analyses with the posterior probability of detecting an effect in a simulated null sample. Thus for the data-generated distribution represented by these trials, we were able to compare the relative performance of these techniques., Results: No final outcomes differed from those of the original trials. However, the timing of trial termination differed substantially by method and varied by trial. For one trial, group sequential designs of either type dictated early stopping of the study. In the other, stopping times were dependent upon the choice of spending function and prior distribution., Conclusions: Results indicate that trialists ought to consider Bayesian methods in addition to traditional approaches for analysis of clinical trials. Though findings from this small sample did not demonstrate either method to consistently outperform the other, they did suggest the need to replicate these comparisons using data from varied clinical trials in order to determine the conditions under which the different methods would be most efficient., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Research on neighborhoods and health has been growing. However, studies have not investigated the association of specific neighborhood measures, including socioeconomic and built environments, with cancer incidence or outcomes. We developed the California Neighborhoods Data System (CNDS), an integrated system of small area-level measures of socioeconomic and built environments for California, which can be readily linked to individual-level geocoded records. The CNDS includes measures such as socioeconomic status, population density, racial residential segregation, ethnic enclaves, distance to hospitals, walkable destinations, and street connectivity. Linking the CNDS to geocoded cancer patient information from the California Cancer Registry, we demonstrate the variability of CNDS measures by neighborhood socioeconomic status and predominant race/ethnicity for the 7,049 California census tracts, as well as by patient race/ethnicity. The CNDS represents an efficient and cost-effective resource for cancer epidemiology and control. It expands our ability to understand the role of neighborhoods with regard to cancer incidence and outcomes. Used in conjunction with cancer registry data, these additional contextual measures enable the type of transdisciplinary, "cells-to-society" research that is now being recognized as necessary for addressing population disparities in cancer incidence and outcomes.

Background: The long-term prognostic role of functional limitations among women with breast cancer is poorly understood., Methods: We studied a cohort of 2202 women with breast cancer at two sites in the United States, who provided complete information on body functions involving endurance, strength, muscular range of motion, and small muscle dexterity following initial adjuvant treatment. Associations of baseline functional limitations with survival were evaluated in delayed entry Cox proportional hazards models, with adjustment for baseline sociodemographic factors, body mass index, smoking, physical activity, comorbidity, tumor characteristics, and treatment. Difference in covariates between women with and without limitations was assessed with Pearson χ(2) and Student t tests. All statistical tests were two-sided., Results: During the median follow-up of 9 years, 112 deaths were attributable to competing causes (5% of the cohort) and 157 were attributable to breast cancer causes (7% of the cohort). At least one functional limitation was present in 39% of study participants. Proportionately, more breast cancer patients with functional limitations after initial adjuvant treatment were older, less educated, and obese (P < .001). In multivariable models, functional limitations were associated with a statistically significantly increased risk of death from all causes (hazard ratio [HR] = 1.40, 95% confidence interval [CI] = 1.03 to 1.92) and from competing causes (HR = 2.60, 95% CI = 1.69 to 3.98) but not from breast cancer (HR = 0.90, 95% CI = 0.64 to 1.26). The relationship between functional limitations and overall survival differed by tumor stage (among women with stage I and stage III breast cancer, HR = 2.02, 95% CI = 1.23 to 3.32 and HR = 0.74, 95% CI = 0.42 to 1.30, respectively)., Conclusion: In this prospective cohort study, functional limitations following initial breast cancer treatment were associated with an important reduction in all-cause and competing-cause survival, irrespective of clinical, lifestyle, and sociodemographic factors.

Two modeling approaches are commonly used to estimate the associations between neighborhood characteristics and individual-level health outcomes in multilevel studies (subjects within neighborhoods). Random effects models (or mixed models) use maximum likelihood estimation. Population average models typically use a generalized estimating equation (GEE) approach. These methods are used in place of basic regression approaches because the health of residents in the same neighborhood may be correlated, thus violating independence assumptions made by traditional regression procedures. This violation is particularly relevant to estimates of the variability of estimates. Though the literature appears to favor the mixed-model approach, little theoretical guidance has been offered to justify this choice. In this paper, we review the assumptions behind the estimates and inference provided by these 2 approaches. We propose a perspective that treats regression models for what they are in most circumstances: reasonable approximations of some true underlying relationship. We argue in general that mixed models involve unverifiable assumptions on the data-generating distribution, which lead to potentially misleading estimates and biased inference. We conclude that the estimation-equation approach of population average models provides a more useful approximation of the truth.

Background: Poor lower-body capacity is associated with reduced mobility in older populations., Purpose: This study sought to determine whether neighborhood environments (e.g., land-use patterns and safety) moderate that association., Methods: The study is based on a cross-sectional sample of 884 people aged > or =65 years identified through service organizations in Alameda County CA, Cook County IL, Allegheny County PA, and Wake and Durham counties NC. In-person interviews focused on neighborhood characteristics, physical and cognitive function, and physical activity and walking. Functional capacity was tested using measures of lower-body strength, balance, and walking speed. The main outcome was time spent walking in a typical week (<150 vs > or =150 minutes per week). Objective environmental measures were also included. Estimates of main and interaction effects were derived from regression models., Results: Living in a residential area, compared to a mixed-use or commercial area, was associated with less time spent walking (<150 minutes per week; OR=1.57, 95% CI=1.04, 2.38). Living in a less-compact area (greater median block length) is also significantly associated with less walking for seniors, but only among those with excellent lower-body strength., Conclusions: Neighborhood type is associated with walking among older people, as it is among the general adult population. In individuals with poor lower-body function, no association was found between residence in a less-compact area and walking. For those people, the relationship between neighborhood characteristics and walking requires further study., (2010 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To examine the prevalence of self-reported functional limitations in a breast cancer population, identify whether these reported limitations are attributed to breast cancer versus other coexisting illnesses, and examine how this attribution changes over time from early in treatment to 9 months later., Design: Longitudinal, observational study., Setting: Community dwelling adults in Detroit metropolitan area., Participants: 2033 participants (1011 breast cancer patients, 1022 controls) aged 40-84 years., Measurements: Participants were asked about each of 23 possible coexisting illnesses in addition to breast cancer and whether or not each illness, including breast cancer, caused any activity limitation., Results: Of the 933 cancer patients who completed both baseline and follow-up evaluations, 45% were aged 65 years and older. At baseline, 56% of patients 65 years and older reported functional limitation compared with 50% of patients younger than 65 years (p=0.005). Of those patients who reported limitation at baseline, 59% of older patients and 78% of younger patients attributed their limitation to breast cancer (p<0.001). At follow-up, 53% of older and 37% of younger patients reported functional limitation (p<0.001), with 27% of older patients compared with 57% of younger patients (p<0.001) attributing limitation to breast cancer., Conclusion: Self-reported functional limitations are common 3 months after breast cancer diagnosis, being attributed primarily to breast cancer. By 1 year after diagnosis, much of the limitation due to breast cancer resolves. Older women are less likely to have resolution of their limitations, which are most commonly due to other coexisting illnesses.

Purpose: This cross-sectional study takes a unique look at the association between patterns of walking and cognitive functioning by examining whether older adults with mild cognitive impairment differ in terms of the community settings where they walk and the frequency, intensity, or duration of walking., Design and Methods: The sample was based on interviews with 884 adults aged 65 years and older, residing in 4 locations across the United States: Alameda County, California; Cook County, Illinois; Allegheny County, Pennsylvania; and Durham/Wake Counties, North Carolina. Cognitive function was assessed using a modified Mini-Mental State Examination (MMSE) and the Mental Alternation Test (MAT). Multiple linear regressions were conducted between self-reported walking activities and cognitive measures, controlling for psychosocial, demographic, health status, functional performance, and neighborhood characteristics., Results: The community setting where people walk and the intensity of walking in their neighborhood were significantly associated with cognitive status. After controlling for individual and neighborhood characteristics, better MAT scores were significantly associated with brisk walking and walking fewer times per week. Compared with the MMSE, the MAT was more likely to be associated with patterns of walking among older adults. Older adults with lower MAT scores were more likely to walk in indoor shopping malls and less in parks, whereas those with higher cognitive function scores on the MMSE were less likely to walk in indoor gyms., Implications: This investigation provides insight into the extent to which walking is associated with preservation of cognitive health, setting the stage for future longitudinal studies and community-based interventions.

The objective of this study was to determine whether comorbidity, or pre-existing conditions, can account for some of the disparity in survival between African-American and white breast cancer patients. A historical cohort study was conducted of 416 African-American and 838 white women diagnosed with breast cancer between 1973 and 1986, and followed through 1999 in the Kaiser Permanente Northern California Medical Care Program. Information on comorbidity, tumor characteristics and breast cancer treatment was obtained from medical records, and Surveillance, Epidemiology and End Results, Northern California Cancer Center Registry. Associations between comorbidity and survival were analyzed with multiple Cox proportional hazards regression. Over a mean follow-up of 9 years, African Americans had higher overall crude mortality than whites: 165 (39.7%) versus 279 (33.3%), respectively. When age, race, tumor characteristics and breast cancer treatment were controlled, the presence of hypertension was associated with all cause survival [hazard ratio (HR) = 1.33, 95% confidence intervals (CI) 1.07-1.67] and it accounted for 30% of racial disparity in this outcome. Hypertension-augmented Charlson Comorbidity Index was a significant predictor of survival from all causes (HR = 1.32, 95%CI 1.18-1.49), competing causes (HR = 1.52, 95%CI 1.32-1.76) and breast cancer specific causes (HR = 1.18, 95%CI 1.03-1.35). In conclusion, hypertension has prognostic significance in relation to survival disparity between African-American and white breast cancer patients. If our findings are replicated in contemporary cohorts, it may be necessary to include hypertension in the Charlson Comorbidity Index and other comorbidity measures.