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Aims To examine the effects of psychographically targeted e-cigarette advertisements on young adults. Methods A total of 2100 young adults (18–29 years old) representing five peer crowds (groups with shared values, interests, and lifestyle: Mainstream, Young Professional, Hip Hop, Hipster, and Partier) were recruited from a nationwide opt-in online panel. Participants were randomly assigned to view e-cigarette advertisements featuring characters that either did or did not match their own peer crowd affiliation and evaluated advertising effectiveness using Likert-type and semantic differential scales. Participants also reported their attitudes toward using e-cigarettes. Results No significant overall effect of peer crowd matching was observed. However, significant two-way interaction effects emerged where matching advertisements yielded higher evaluations than mismatching advertisements among those who currently do not use tobacco and nicotine products and among Mainstream participants. Advertisements featuring Mainstream characters were in general rated more highly than other advertisements. Additional analyses found significant effects of peer crowd matching among those who viewed advertisements featuring non-Mainstream characters. Conclusions Peer crowd-based targeting can increase the effectiveness of e-cigarette advertisements which may impact initiation among current nonusers, requiring stricter marketing regulations. More research is needed to determine if anti-tobacco messaging tailored by peer crowds may effectively counteract targeted e-cigarette marketing. Implications E-cigarette advertisements often use psychographic targeting strategies, using lifestyles, attitudes, and values. Low-risk young adults (eg, those who currently do not use tobacco and nicotine products) are susceptible to psychographically targeted e-cigarette advertisements. This may result in the initiation of e-cigarette use among young adults who would otherwise be less likely to use tobacco and nicotine products. Stricter marketing regulations for emerging tobacco and nicotine products are required to reduce marketing exposure.

To improve language-concordant, equitable healthcare for Spanish speakers, many United States medical schools offer medical Spanish education. However, there is no clinically contextualized, standardized approach to medical student language assessment. This article reports on the development and effectiveness of a training curriculum to prepare raters to use a new rubric, the Physician Oral Language Observation Matrix (POLOM), to reliably rate medical student Spanish oral proficiency after observing videorecorded encounters between students and standardized patients. Curriculum effectiveness was primarily evaluated by examining each rater trainee’s level of agreement with expert consensus POLOM ratings (i.e., inter-rater reliability as measured by the generalizability theory dependability coefficient). Out of the study’s nine rater trainees, who were from either medical or linguistic professional backgrounds, five proceeded to the calibration phase, and four attained the reliability threshold required for calibration. The paper concludes that this rater training curriculum can successfully train raters to use the POLOM reliably when evaluating medical student Spanish oral proficiency during videorecorded healthcare encounters. To allow for improved assessment of student language skills prior to use in patient care, future efforts should focus on POLOM validity assessment and larger scale rater recruitment, training, calibration, and maintenance.

To communicate with linguistically diverse patients, medical students and physicians often use their non-English language skills. However, there is no standard protocol to determine whether those skills are adequate prior to patient care. This causes many physicians, institutions, educators, and learners to forgo non-English language proficiency assessment altogether. The purpose of this study is to report on the development, refinement, and interrater reliability of the Physician Oral Language Observation Matrix (POLOM), a rater-based tool assessing 6 language skill categories observed during clinical interactions: comprehension, fluency/fluidity, vocabulary, pronunciation, grammar, and communication. This study focused on the use of the POLOM in Spanish interactions.The authors adapted an existing language observation tool for use in clinical settings, creating the preliminary POLOM. Next, they iteratively refined the tool from April to July 2021 using videorecorded medical student-standardized patient encounters from a U.S.-based medical Spanish program. In each refinement iteration, 4 bilingual raters (2 physicians and 2 linguists) independently rated 3 to 6 encounters and convened to discuss ratings with the goals of improving instrument instructions, descriptors, and subsequent rater agreement. Using the final POLOM, raters independently rated 50 videos in rotating interdisciplinary pairs. Generalizability theory was applied to estimate reliability via interrater agreement (dependability) coefficients (range 0-1) for each POLOM category and the total score.POLOM total score dependability equaled 0.927 (single rater) and 0.962 (averaged across 2 raters). The highest mean score was observed for the comprehension category (4.15; range: 1-5) while the lowest was for communication (3.01; range 1-5).Raters achieved a high level of agreement on POLOM assessments of students' medical oral Spanish proficiency. The POLOM is the first such assessment tool that provides examinees and instructors with both a holistic and detailed review of clinician non-English oral language skills as contextualized for patient care.

Purpose: Asian and Latinx individuals have a high burden of untreated depression. Under-recognition of depressive symptoms may contribute to existing disparities in depression treatment. The objective of this cross-sectional study was to determine whether physicians recognize and treat depressive symptoms for Chinese and Latinx patients during routine primary care visits. Methods: We analyzed data from 1171 Chinese and Latinx patients who were interviewed within 1 week after a primary care visit in a large academic practice, which had not yet implemented universal depression screening. We included participants with depressive symptoms (defined as a Patient Health Questionaire-2 score ≥3) and no prior history of depression (N=118). We investigated whether patients perceived having a mental health need in the prior year and conducted chart reviews to assess provider recognition of depressive symptoms, defined as documentation of symptoms, antidepressant initiation, or mental health referral within 30 days of the visit. We further examined differences by race/ethnicity and language preference. Results: Among the 118 patients with depressive symptoms and no prior depression diagnosis (mean age 68), 71 (61%) reported a mental health need in the prior 12 months; however, providers recognized depressive symptoms in only 8/118 patients (7%). The number of patients with recognized symptoms was small across race/ethnicity and language preference groups and we found no significant differences. Conclusion: Physicians recognized and documented depressive symptoms for 1 in 10 Chinese and Latinx patients during routine primary care visits. Targeted efforts are needed to address under-recognition of symptoms and improve depression care for these populations.

PurposeThe purpose of the current study, The National Institute of Child Health and Human Development (NICHD) Study of Health in Early and Adult Life (SHINE), was to build on the landmark Study of Early Child Care and Youth Development (SECCYD), a longitudinal birth cohort initiated in 1991, by conducting a health-focused follow-up of the now adult participants. This effort has produced an invaluable resource for the pursuit of life course research examining links between early life risk and resilience factors and adulthood health and disease risk.ParticipantsOf the 927 NICHD SECCYD participants available for recruitment in the current study, 705 (76.1%) participated in the study. Participants were between 26 and 31 years and living in diverse geographic locations throughout the USA.Findings to dateIn descriptive analyses, the sample exhibited risk on health status indicators, especially related to obesity, hypertension and diabetes. Of particular concern, the prevalence of hypertension (29.4%) and diabetes (25.8%) exceeded national estimates in similar-age individuals. Health behaviour indicators generally tracked with the parameters of poor health status, showing a pattern of poor diet, low activity and disrupted sleep. The juxtaposition of the sample’s relatively young age (mean=28.6 years) and high educational status (55.6% college educated or greater) with its poor health status is noteworthy, suggesting a dissociation between health and factors that are typically health protective. This is consistent with observed population health trends, which show a worsening of cardiometabolic health status in younger generations of Americans.Future plansThe current study, SHINE, lays the groundwork for future analyses in which the uniquely robust measures collected as a part of the original NICHD SECCYD will be leveraged to pinpoint specific early life risk and resilience factors as well as the correlates and potential mechanisms accounting for variability in health and disease risk indicators in young adulthood.

Objectives To explore consequences of interpreter mediation of visit communication on patient centered dialogue and patient satisfaction with interpreter listening. Methods Fifty-five professionally interpreted primary care visits were coded using the Roter Interaction Analysis System (RIAS). Two corresponding quantitative measures of patient-centered dialogue were calculated as ratios of psycho-emotional to biomedical statements based on (1) patient and clinician expressed codes and (2) interpreter conveyed codes. Multilevel models examined consequences of interpreter mediation on patient-centered dialogue and patient ratings of interpreter listening. Results Study participants included 27 Cantonese, 17 Mandarin and 11 Spanish-speaking primary care patients and 31 of their clinicians. Overall, clinicians expressed 2.26 times more statements and patients expressed 1.74 times more statements than interpreters conveyed. Interpreters conveyed significantly less patient-centered dialogue than expressed by patients and clinicians. All differences were evident within each study language. Interpreter conveyed patient centered dialogue positively predicted patient ratings of interpreter listening (B = 0.817; p Conclusions The level of interpreter-conveyed patient-centered dialogue was both substantially lower than that expressed by patients and clinicians and a positive predictor of patient satisfaction with interpreter listening. Practice implications Fuller interpretation of patient-centered dialogue may enhance patient experience with interpreters and thereby increase care quality.

Background Black individuals with muscle‐invasive bladder cancer (MIBC) experienced 21% lower odds of guideline‐based treatment (GBT) and differences in treatment explain 35% of observed Black‐White differences in survival. Yet little is known of how interactions between race/ethnicity and receipt of GBT drive within‐ and between‐race survival differences. Methods Black, White, and Latino individuals diagnosed with nonmetastatic, locally advanced MIBC from 2004 to 2013 within the National Cancer Database were included. Guideline‐based treatment was defined as the receipt including one or more of the following treatment modalities: radical cystectomy (RC), neoadjuvant chemotherapy with RC, RC with adjuvant chemotherapy, and/or chemoradiation based on American Urological Association guidelines. Cox proportional hazards model of mortality estimated effects of GBT status, race/ethnicity, and the GBT‐by‐race/ethnicity interaction, adjusting for covariates. Results Of the 54 910 MIBC individuals with 125 821 person‐years of posttreatment observation (max = 11 years), 6.9% were Black, and 3.0% were Latino. Overall, 51.4%, 45.3%, and 48.5% of White, Black, and Latino individuals received GBT. Latino individuals had lower hazard of death compared to Black (HR 0.81, 95% CI 0.75‐0.87) and White individuals (HR 0.92, 95% 0.86‐0.98). With GBT, Latino and White individuals had similar outcomes (HR = 1.00, 95% 0.91‐1.10) and both fared better than Black individuals (HR = 0.88, 95% 0.79‐0.99 and HR = 0.88, 95% 0.83‐0.94, respectively). Without GBT, Latino individuals fared better than White (HR = 0.85, 95% 0.77‐0.93) and Black individuals (HR = 0.74, 95% 0.67‐0.82) while White individuals fared better than Black individuals (HR = 0.87, 95% 0.83‐0.92). Black individuals with GBT fared worse than Latinos without GBT (HR = 1.02, 95% 0.92‐1.14), although not statistically significant. Conclusion Low GBT levels demonstrated an “under‐allocation” of GBT to those who needed it most—Black individuals. Interventions to improve GBT allocation may mitigate race‐based survival differences observed in MIBC., Receipt of guideline‐based treatment nearly eliminated survival disparities between Latino and white individuals with bladder cancer but the benefit was not the same for black individuals, highlighting several potential targets for intervention.

It is unknown whether the HPV vaccine is effective in immunocompromised women during catch-up ages. We performed a case-control study of 4,357 women with incident CIN2+ (cases) and 5:1 age-matched, incidence-density selected controls (N=21,773) enrolled in an integrated health care system from 2006 to 2014. Vaccine effectiveness was estimated from multivariable conditional logistic regression models, with results stratified by immunosuppression history, defined as prior HIV infection, solid organ transplant history, or recently prescribed immunosuppressive medications. HPV vaccination resulted in a 19% reduction in CIN2+rates for women without an immunosuppression history but a nonsignificant 4% reduction for women with an immunosuppression history. Further research is needed to evaluate whether catch-up HPV vaccine effectiveness varies by immunosuppression status, especially given the recent approval of the HPV vaccine for adults up to 45years of age.

Purpose We examined prostate cancer patients’ participation in research and associated factors by race/ethnicity in a multiethnic sample. Methods Men with a new diagnosis of prostate cancer were identified through the California Cancer Registry. Patients completed a cross-sectional telephone interview in English, Spanish, Cantonese or Mandarin. Multivariable logistic regression models, stratified by race/ethnicity, estimated the associations of patient demographic and health characteristics with participation in (1) any research, (2) behavioral research, and (3) biological/clinical research. Results We included 855 prostate cancer patients: African American (19%), Asian American (15%), Latino (24%), and White (42%). In the overall model of participation in any research, African American men (Odds Ratio (OR) = 2.54, 95% CI 1.63–3.94), and those with two or more comorbidities (OR = 2.20, 95% CI 1.27–3.80) were more likely to report participation. Men 65 years old and older (OR = 0.65, 95% CI 0.47–0.91), those who were married or living with a partner (OR = 0.67, 95% CI 0.45–0.98), and those who completed the interview in Spanish (OR = 0.36, 95% CI 0.15–0.85) were less likely to report participating in any research. Stratified analyses identified racial/ethnic-specific sociodemographic characteristics associated with lower research participation, including Spanish or Chinese language, older age, and lower education. Conclusion African American prostate cancer patients reported higher research participation than all other groups. However, recruitment efforts are still needed to overcome barriers to participation for Spanish and Chinese speakers, and barriers among older adults and those with lower education levels.

Context Prepubertal obesity is a well-established predictor of earlier pubertal onset, which is itself a risk factor for poor health and well-being. Identifying specific patterns of weight gain in early life may help explain differential risk for earlier pubertal onset. Objective The objective of the study was to examine patterns of weight gain across infancy and early childhood in relation to pubertal onset outcomes. Design, Setting, and Participants Participants were 426 girls in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development, a longitudinal birth cohort of children and their families followed between birth and adolescence. Main Outcome Measures Three pubertal onset outcomes were examined, including age at menarche and ages at Tanner stage II for dimensions of breast and pubic hair development. Results In infancy (birth to 15 months), greater percent weight gain and higher birthweight predicted earlier pubertal onset for all outcomes (Ps < 0.05). In early childhood (24 months to grade 1), body mass index (BMI) trajectories reflecting BMI values that were persistently high or changed from low to high over time (vs BMI values that were stable at median or low levels), predicted younger ages at menarche and the onset of breast (Ps < 0.05), but not pubic hair (Ps > 0.05), development. All associations were independent of breastfeeding, maternal menarcheal age, and race/ethnicity. Conclusions Distinct patterns of early life weight gain predict differential risk for earlier onset puberty. Focusing on these patterns for earlier and more targeted intervention may help lessen life course linkages between prepubertal obesity, accelerated pubertal development, and negative postpubertal outcomes.

Background The COVID-19 pandemic is a crisis unprecedented in its size and scope. Yet studies of resilience suggest most individuals will successfully negotiate this challenge and some may even experience growth and positive change. Some evidence suggests that the capacity to enact positive change in the face of adversity may be shaped by early life experiences. Methods In a subset of 374 participants (57% female, mean age = 29 years) in the Study of Early Child Care and Youth Development (SECCYD), a longitudinal, birth cohort, prospective models were tested to determine whether early life adversities in family and neighborhood contexts predict positive change events in response to the COVID-19 pandemic. Childhood family and neighborhood contexts were assessed using a combination of self-report questionnaires and US Census data. Adulthood positive change events (e.g., becoming more appreciative of things usually taken for granted) were assessed using the Epidemic-Pandemic Impacts Inventory (EPII). Results In regression analyses, neighborhood disadvantage in childhood, measured both by objective and subjective assessments, predicted a higher number of positive change events in response to the COVID-19 pandemic (β = .18, p = .004 and β = .15, p = .006, respectively). Examination of the positive change event subscales showed neighborhood disadvantage in childhood predicted increases in events related to ‘perspective taking and charitable giving’ (β = .20, p = .022 and β = .17, p = .002, respectively) and improved ‘social relationships’ (β = .18, p = .004 and β = .13, p = .020, respectively), but not to positive ‘health behaviors’ (ps > .05). All associations were independent of sociodemographic factors and childhood family dysfunction. Conclusions Findings suggest that neighborhood disadvantage in childhood may shape prosocial responses to stress in adulthood, potentially through early life adaptions to stress that are protective when facing adversity. There are several notable implications of the study findings. Although adversity in early life has clear negative impacts, it is possible that adversity experiences may also provide opportunities to develop adaptive strategies that foster resilience and growth when facing stress. Intervention efforts should consider leveraging such stress-adapted strengths to reduce the many negative impacts of early life adversity.

BACKGROUND: Ethnic minorities who present with mental health symptoms in primary care are less likely to receive treatment than non-Hispanic whites; language barriers may magnify this disparity. OBJECTIVE: We examined the contributions of ethnicity, gender, and English proficiency to unmet mental health need. DESIGN: Cross-sectional study. PARTICIPANTS: Chinese and Latino primary care patients with a preferred language of English, Cantonese, Mandarin, or Spanish. MAIN MEASURES: Participants were interviewed within 1 week of a primary care visit and asked whether in the prior year they (1) needed help with emotional or mental health symptoms and (2) had seen a primary care physician or a mental health professional for these symptoms. Among those who reported “mental health need,” we defined “unmet mental health need” as no reported use of services for these symptoms. Regression models explored independent and interaction effects among ethnicity, gender, and English proficiency, on the two outcomes. KEY RESULTS: Among 1149 participants (62% women; 262 Chinese, with English proficiency [EP], 532 Chinese, with limited English proficiency [LEP], 172 Latino with EP; and 183 Latino with LEP), 33% reported mental health need. Among Chinese, but not Latino, participants, those with LEP were more likely than those with EP to report mental health need (AOR 2.55, 95% CI 1.73–3.76). Women were more likely to report mental health need than men (AOR 1.35, 1.03–1.79) regardless of ethnicity or English proficiency. Among participants reporting mental health need, 41% had unmet mental health need. Men with LEP, compared with those with EP, were more likely to have unmet mental health need regardless of ethnicity (AOR 2.53, 1.06–6.04). CONCLUSIONS: We found high levels of mental health symptoms and unmet mental health need in both Chinese and Latino primary care patients. These results affirm the need to implement depression screening and targeted treatment interventions for patient subgroups at highest risk of untreated symptoms, such as men with LEP.

BACKGROUND: Although the family caregiver workforce is increasingly diverse, little is known about culturally and linguistically diverse caregivers and patients for whom they care. Caregiver roles include communicating with health care teams on behalf of patients with language barriers. OBJECTIVE: Our objective is to describe characteristics and experiences of caregivers for patients with limited English proficiency (LEP) immediately following hospital discharge. DESIGN: Cross-sectional. PARTICIPANTS: Primary informal caregivers for Chinese- and Spanish-speaking patients with LEP discharged from a large academic medical center’s orthopedic surgery, general surgery, and cardiovascular inpatient floors from June 2012 to August 2013. MAIN MEASURES: Bilingual-bicultural research assistants conducted baseline structured interviews with patients or surrogates in the hospital, and 3 weeks after discharge, gathering demographic and health information. They then interviewed by phone informal caregivers, identified by patients, to determine caregiving experiences. KEY RESULTS: One hundred fifty-eight caregivers were interviewed post-discharge. Two-thirds (69.0%) were adults caring for parents or grandparents, and 20.9% were spouses or partners. Sixty-nine (43.7%) caregivers had LEP themselves, yet only 12% of patients reported having access to professional interpreters at the time discharge instructions were provided. Ninety percent reported performing three or more caregiving roles for the patient (helping at home, helping with medical decisions, helping with medical forms, helping communicate with medical staff, and talking with doctors about medical care). Forty percent reported moderate/high levels of perceived stress (some, most, or all of the time) caring for the patient. Multivariate regression revealed caregivers for Chinese-speaking patients, and those for patients discharged to another hospital were most likely to report moderate/high levels of perceived stress. CONCLUSION: Culturally and linguistically diverse caregivers perform multiple roles caring for patients with LEP, often have LEP themselves, and experience notable levels of stress. These results also demonstrate an opportunity to expand the use of professional interpreters at hospital discharge to avoid communication errors.

Purpose: Low-income Latino immigrants lack access to mental health providers. We explored the feasibility of training promotores to deliver a stress management program in community settings. Methods: We trained promotores to deliver an 8-week intervention program comprising evidence-based cognitive-behavioral stress management techniques. Trained promotores then delivered the program to Spanish-speaking Latino immigrants. Results: Promotores (n=10) improved their knowledge significantly after the training (p

Introduction: Electronic health record (EHR) systems provide investigators with rich data from which to examine actual impacts of care delivery in real-world settings. However, confounding is a major concern when comparison groups are not randomized. Objectives: This article introduced a step-by-step strategy to construct comparable matched groups in a dental study based on the EHR of the Willamette Dental Group. This strategy was employed in preparation for a longitudinal study evaluating the impact of a standardized risk-based caries prevention and management program across patients with public versus private dental insurance in Oregon. Methods: This study constructed comparable dental patient groups through a process of 1) evaluating the need for and feasibility of matching, 2) considering different matching methods, and 3) evaluating matching quality. The matched groups were then compared for their average ratio in the number of decayed, missing, and filled tooth surfaces (DMFS + dmfs) at baseline. Results: This systematic process resulted in comparably matched groups in baseline covariates but with a clear baseline disparity in caries experience between them. The weighted average ratio in our study showed that, at baseline, publicly insured patients had 1.21-times (95% CI: 1.08 to 1.32) and 1.21-times (95% CI: 1.08 to 1.37) greater number of DMFS + dmfs and number of decayed tooth surfaces (DS + ds) than privately insured patients, respectively. Conclusion: Matching is a useful tool to create comparable groups with EHR data to resemble randomized studies, as demonstrated by our study where even with similar demographics, neighborhood and clinic characteristics, publicly insured pediatric patients had greater numbers of DMFS + dmfs and DS + ds than privately insured pediatric patients. Knowledge Transfer Statement: This article provides a systematic, step-by-step strategy for investigators to follow when matching groups in a study—in this case, a study based on electronic health record data. The results from this study will provide patients, clinicians, and policy makers with information to better understand the disparities in oral health between comparable publicly and privately insured pediatric patients who have similar values in individual, clinic, and community covariates. Such understanding will help clinicians and policy makers modify oral health care and relevant policies to improve oral health and reduce disparities between publicly and privately insured patients.

Objectives We examined the association between three inflammatory markers (Interleukin (IL)-6, C-reactive protein (CRP), tumor necrosis factor (TNF)-α) and incident lung cancer using baseline, updated, and averaged inflammatory measures in older adults. Methods We fitted multivariable Cox models to assess whether circulating levels of inflammation markers were associated with incident lung cancers in the Health Aging, Body and Composition (HealthABC) prospective cohort of 3075 older adults aged 70–79 years at baseline. IL-6 and CRP were measured biennially, whereas TNF-α was measured at baseline. Results Baseline levels of IL-6 were significantly associated with incident lung cancer risk in a model that adjusted for age, gender, race, and site (Model 1) (Hazard RatioT3 vs. T1: 3.34, 95% Confidence Interval: 1.91, 5.85) and in a model adjusted for health factors linked to chronic inflammation (Model 2) (HR T3 vs. T1: 2.57, 95% CI: 1.41, 4.65). The associations observed in time-updated IL-6 (HR T3 vs. T1: 2.47, 95% CI: 1.43, 4.28), cumulatively averaged IL-6 (HR T3 vs. T1: 2.47, 95% CI: 1.43, 4.35), and baseline CRP levels (HR T3 vs. T1: 1.85, 95% CI: 1.11, 3.08) with incident lung cancer in Model 1 were not statistically significant in Model 2. Conclusions Baseline CRP and IL-6 levels were associated with increased risk of lung cancer in Model 1 and both models, respectively. Chronic IL-6 inflammation, as quantified by repeated measures was associated with incident lung cancer in Model 1, but not Model 2. Further research is needed to understand the role of CRP and IL-6 in lung carcinogenesis.

Understanding health disparity causes is an important first step toward developing policies or interventions to eliminate disparities, but their nature makes identifying and addressing their causes challenging. Potential causal factors are often correlated, making it difficult to distinguish their effects. These factors may exist at different organizational levels (e.g., individual, family, neighborhood), each of which needs to be appropriately conceptualized and measured. The processes that generate health disparities may include complex relationships with feedback loops and dynamic properties that traditional statistical models represent poorly. Because of this complexity, identifying disparities’ causes and remedies requires integrating findings from multiple methodologies. We highlight analytic methods and designs, multilevel approaches, complex systems modeling techniques, and qualitative methods that should be more broadly employed and adapted to advance health disparities research and identify approaches to mitigate them.

ObjectiveIt is unclear why Black smokers in the United States have elevated risk of some tobacco-related diseases compared to White smokers. One possible causal mechanism is differential intake of tobacco toxicants, but results across studies are inconsistent. Thus, we examined racial differences in biomarkers of toxic volatile organic compounds (VOCs) present in tobacco smoke.MethodWe analyzed baseline data collected from 182 Black and 184 White adult smokers who participated in a randomized clinical trial in 2013-2014 at 10 sites across the United States. We examined differences in urinary levels of ten VOC metabolites, total nicotine equivalents (TNE), and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), controlling for covariates such as cigarettes per day (CPD), as well as differences in VOCs per TNE to assess the extent to which tobacco exposure, and not metabolic factors, accounted for racial differences.ResultsConcentration of metabolites of acrolein, acrylonitrile, ethylene oxide, and methylating agents were significantly higher in Blacks compared to Whites when controlled for covariates. Other than the metabolite of methylating agents, VOCs per TNE did not differ between Blacks and Whites. Concentrations of TNE/CPD and VOCs/CPD were significantly higher in Blacks. Menthol did not contribute to racial differences in VOC levels.ConclusionsFor a given level of CPD, Black smokers likely take in higher levels of acrolein, acrylonitrile, and ethylene oxide than White smokers. Our findings are consistent with Blacks taking in more nicotine and toxicants per cigarette smoked, which may explain their elevated disease risk relative to other racial groups.

Cognitive theories suggest the manner in which individuals process trauma-related information influences posttraumatic sequelae. Interpretations about trauma can be maladaptive and lead to cognitive distortions implicated in the development of posttraumatic stress disorder (PTSD) through the processes of overaccommodation and assimilation. Alternatively, adaptive interpretations about trauma through the process of accommodation can lead to post-trauma resilience and recovery. The Trauma-Related Cognitions Scale (TRCS) provides a measure of beliefs associated with these cognitive processes. The TRCS was developed over the course of four phases. During Phase 1, 94 items derived from previously validated trauma cognition/beliefs measures were aggregated with 40 items developed by the authors. Phase 2 investigated the TRCS factor structure by fitting exploratory factor analysis (EFA) models to data from a non-clinical sample, resulting in a reduced 69-item TRCS representing four factors: the three theoretical cognitive processes of overaccommodation, assimilation, and accommodation, and an additional optimism factor. Phases 3 and 4 fit confirmatory factor analysis (CFA) models of the 69-item TRCS in a new non-clinical and a clinical sample, respectively, and further validation analyses were conducted. Initial evidence suggests the TRCS is a valid and reliable measure of trauma beliefs. Continued validation can determine its utility in both research and clinical contexts.

The after-visit summary (AVS), a document generated from the electronic health record that summarizes patients' encounters with the healthcare system, is a widely used communication tool. Its use by and usefulness for populations with limited English proficiency (LEP) and limited health literacy (LHL) is poorly understood. In this cross-sectional study, we assessed use and usefulness of the AVS among English-, Spanish-, Cantonese-, or Mandarin-speaking Latinx and Chinese primary-care patients. Outcome measures were self-reported AVS use (did not use/looked-at only/shared only/looked-at and shared) and usefulness (useful/not useful). Among 993 participants, 57% were ≥65years old, 61% had LEP, 21% had LHL, 30.2% were Latinx, 69.8% were Chinese. The majority used the AVS (86%) and found it useful (65%). In adjusted models, participants with LEP were more likely to "look at" (OR 1.68, 95% CI 1.07-2.62) and "look at and share" (OR 1.65, 1.02-2.66) the AVS, but less likely to find it useful (OR 0.68, 0.47-0.98) compared to English speakers. Those with LHL were less likely to "look at" (OR 0.60, 0.39-0.93) and less likely to find the AVS useful (OR 0.67, 0.46-0.99) compared to those with adequate health literacy. Our results emphasize the need for easy-to-understand and fully language-concordant AVS.

Background: While guidelines recommend focusing primarily on stroke risk when considering anticoagulants in atrial fibrillation (AF), physicians report that geriatric syndromes (e.g., falls, disability) are important when considering anticoagulants. However, little is known about the prevalence of geriatric syndromes in older adults with AF or the association with anticoagulant use. Methods: We performed a cross-sectional analysis of the 2014 Health and Retirement Study, a nationally representative study of older adults. We included patients ≥67 years with 2 years of continuous Medicare fee-for-service enrollment and 1 inpatient or 2 outpatient AF diagnosis claims. We evaluated five geriatric syndromes: falls, activities of daily living impairment (ADL), instrumental activities of daily living impairment (IADL), cognitive impairment, and incontinence. We measured their prevalence and associations with anticoagulant use via log-binomial regression models adjusting for CHA2DS2-VASc score. Results: In this study of 779 patients with AF (median age 80 years, median CHA2DS2-VASc score 4), 83% (CI 79-86%) had ≥1 geriatric syndrome. Adjusting for stroke risk, lower rates of anticoagulant use were reported in those with ADL dependency (RR 0.87, CI 0.79-99), IADL dependency (RR 0.86, CI 0.77-0.98), and dementia (RR 0.72, CI 0.60-0.86). Conclusion: Most older patients with AF have at least one geriatric syndrome, and geriatrics syndromes are associated with less anticoagulant use. The high prevalence of geriatric syndromes may explain the lower than expected anticoagulants use in older adults. Since the benefits and harms of anticoagulants in this group are ill-defined, it is unclear if lower anticoagulant use is appropriate.

BACKGROUND: Older adults with atrial fibrillation (AF) have multiple risk factors for disablement. Long-term function and the contribution of strokes to disability has not been previously characterized. METHODS: We performed a longitudinal, observational study in the nationally representative Health and Retirement Study (1992-2014). We included participants ≥65 years with Medicare claims who met incident AF diagnosis claims criteria. We examined the association of incident stroke with three functional outcomes: independence with activities of daily living (ADL) and instrumental activities of daily living (IADL) and community-dwelling. We fit separate logistic regression models with repeated measures adjusting for comorbidities and demographics to estimate the effect of stroke on function. We estimate the contribution of strokes to the overall population burden of functional impairment using the method of recycled predictions. RESULTS: Among 3530 participants (median age 79 years, 53% women, median CHA (2) DS (2) -VASc 5), 262 had a stroke over 17,396 person-years. Independent of stroke and accounting for population comorbidities, annually, ADL dependence increased by 4.4%, IADL dependence increased by 3.9%, and nursing home residence increased by 1.2% (p

Background The use of professional interpretation is associated with improvements in overall healthcare of patients with limited English proficiency (LEP). For these patients, it is important to understand whether quality of professional interpretation in-person is preserved using remote interpretation modalities (video-conferencing, telephone). Objective To compare patient perceptions of professional interpretation quality delivered in-person, via video-conferencing, or via telephone during in-person primary care clinical visits. Design Secondary analysis of a telephone survey conducted within 1 week after a primary care visit Participants The 326 Chinese and Latino survey participants with LEP who reported using a professional interpreter—in-person, video medical conferencing (VMI), or telephone—during their visit Main Measures Six items about the quality of interpretation: five detailed items scored as a scale, and a sixth overall quality item (range 1 = poor to 5 = excellent) Key Results While there was a range for all modalities, most patients reported “very good” or “excellent” quality on both the scale and the overall single quality measure. In adjusted analysis, patients rated VMI quality the highest, followed by in-person and then telephone on both the 5-item scale (adjusted means: VMI 3.91, in-person 3.86, telephone 3.73) and the overall single quality item (adjusted means: VMI 3.94, in-person 3.85, telephone 3.83); however, no two-way comparisons were statistically significant (p values ranged 0.15–0.95). Conclusions Our results highlight that, overall, the interpretation experience among patients who used any type of professional interpretation was positive, and that the quality found with in-person interpretation is preserved for remote modalities. Health systems should consider a multimodality approach to interpreter service provision including options for accessing professional interpreters via all three modalities based on communication and access needs.

ObjectivesTo test effects of the Community of Voices choir intervention on the health, well-being, and health care costs of racial/ethnically diverse older adults.MethodTwelve Administration-on-Aging-supported senior centers were cluster randomized into two groups: the intervention group started the choir immediately and a wait-list control group began the choir 6 months later. The choir program was designed for community-dwelling adults aged 60 years and older. The multimodal intervention comprises activities that engage participants cognitively, physically, and socially. Outcome measures assessed these three domains as well as health care utilization and costs. The intention-to-treat comparison was at 6 months.ResultsThe sample (N = 390) had a mean age of 71.3 years (SD = 7.2); 65% were nonwhite. Six-month retention was 92%. Compared to controls, intervention group members experienced significantly greater improvements in loneliness (p = .02; standardized effect size [ES = 0.34] and interest in life (p = .008, ES = 0.39). No significant group differences were observed for cognitive or physical outcomes or for health care costs.DiscussionFindings support adoption of community choirs for reducing loneliness and increasing interest in life among diverse older adults. Further efforts need to examine the mechanisms by which engagement in choirs improves aspects of well-being and reduces health disparities among older adults, including potential longer-term effects.ClinicalTrials.gov RegistrationNCT01869179 registered January 9, 2013.

Background: Cultivation of tobacco raises concerns about detrimental health and social consequences for youth, but tobacco producing countries only highlight economic benefits. We compared sociodemographic and health-related characteristics of school-age youth who worked and did not work in tobacco farming and assessed the effects on smoking behavior and health at 1 year. Methods: We used existing data collected in the province of Jujuy, Argentina where 3188 youth 13 to 17 years of age from a random middle school sample responded to longitudinal questionnaires in 2005 and 2006. Multivariate logistic regression models predicted association of tobacco farming work with health status and smoking behavior at 1 year. Results: 22.8% of youth in the tobacco growing areas of the province were involved in tobacco farming. The mean age of initiation to tobacco farming was 12.6 years. Youth working in farming had higher rates of fair or poor versus good or excellent self-perceived health (30.3% vs. 19.0%), having a serious injury (48.5% vs. 38.5%), being injured accidentally by someone else (7.5% vs. 4.6%), being assaulted (5.5% vs. 2.6%), and being poisoned by exposure to chemicals (2.5% vs. 0.7%). Youth working in tobacco farming also had higher prevalence of ever (67.9% vs. 55.2%), current (48.0% vs. 32.6%) and established smoking (17.8% vs. 9.9%). In multivariate logistic regression models tobacco farming in 2005 was associated with significant increased reporting of serious injury (OR = 1.4; 95%CI 1.1-2.0), accidental injury by someone else (OR = 1.5; 95% 1.0-2.1), assault (OR = 2.2; 95% CI 1.3-3.8), and poisoning by exposure to chemicals (OR = 2.5; 95% CI 1.2-5.4). Tobacco farming in 2005 predicted established smoking 1 year later (OR = 1.5; 95% CI 1.1-2.0). Conclusion: Youth who work in tobacco faming face a challenging burden of adversities that increase their vulnerability. Risk assessments should guide public policies to protect underage youth working in tobacco farming. (298 words). Fil: Alderete, Ethel del Carmen. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Salta. Unidad Ejecutora en Ciencias Sociales Regionales y Humanidades. Universidad Nacional de Jujuy. Unidad Ejecutora en Ciencias Sociales Regionales y Humanidades; Argentina Fil: Livaudais Toman, Jennifer. University of California; Estados Unidos Fil: Kaplan, Celia. University of California; Estados Unidos Fil: Gregorich, Steven E.. University of California; Estados Unidos Fil: Mejía, Raúl. Centro de Estudios de Estado y Sociedad; Argentina Fil: Pérez Stable, Eliseo J.. National Institutes of Health; Estados Unidos

Introduction: Caries experience among preschool-age children has remained relatively unchanged for the past 2 decades, despite recently documented decreases in untreated decay. Objectives: In a community-based cluster-randomized controlled trial, a motivational interviewing (MI) intervention administered to primary caregivers was hypothesized to reduce caries increment over 2 y as compared with controls, among children aged 0 to 5 y at baseline living in public housing. Methods: Public housing residents, who served as interventionists, were trained in MI with a focus on early childhood caries prevention. All 26 eligible public housing developments were randomized to either control (quarterly clinical examinations, fluoride varnish applications, toothbrush/toothpaste, and educational brochures) or intervention (same procedures as control plus MI counseling). Quarterly MI sessions were delivered in English or Spanish over 2 y, audio recorded, and assessed for treatment fidelity. The primary outcome was the increment in dmfs (decayed, missing, and filled tooth surfaces) as assessed by clinical examination at baseline, 12 mo, and 24 mo. Secondary outcomes included caregiver oral health knowledge and child oral health behaviors (child toothbrushing and sugar-sweetened beverage intake). Baseline characteristics were compared between groups and adjusted for housing-site clusters. Longitudinal outcomes were analyzed with mixed models. Results: A total of 1,065 children (49% female, 55% non-White, 61% Hispanic, 89% below poverty level, n = 686 control) and their caregivers were enrolled. During 2 y of follow-up, the mean dmfs increment increased in both groups; however, there were no statistically significant group differences at 24 mo or group × time interactions. The mean increase in intervention caregivers’ knowledge was significantly greater than that of control, F(2, 1,593) = 3.48, P = 0.0310, but there were no significant intervention effects on caregiver-reported child sugar-sweetened beverage intake or child toothbrushing. Conclusion: MI counseling plus intensive caries prevention activities resulted in knowledge increases but did not improve oral health behaviors or caries increment (ClinicalTrials.gov NCT01205971). Knowledge Transfer Statement: When viewed in light of the findings from the companion Pine Ridge study and other recent MI studies, the results of this study suggest that when the complex disease of early childhood caries is addressed in high-risk populations, MI is not effective, and alternative approaches are warranted.

Introduction: In a randomized controlled trial, the effectiveness of motivational interviewing (MI) combined with enhanced community services (MI + ECS) was compared with ECS alone for reducing dental caries in American Indian children on the Pine Ridge Reservation. The intervention was developed and delivered with extensive tribal collaboration. Methods: A total 579 mother-newborn dyads were enrolled and randomized to the MI + ECS and ECS groups. They were followed for 36 mo. Four MI sessions were provided, the first shortly after childbirth and then 6, 12, and 18 mo later. Both groups were exposed to ECS, which included public service announcements through billboards and tribal radio, as well as broad distribution of brochures on behavioral risk factors for early childhood caries (ECC), toothbrushes, and toothpaste. MI impact was measured as decayed, missing, and filled tooth surfaces (dmfs). Secondary outcomes included decayed surfaces, caries prevalence, and maternal oral health knowledge and behaviors. Modified intention-to-treat analyses were conducted. Eighty-eight percent of mothers completed at least 3 of 4 MI sessions offered. Results: After 3 y, dmfs was not significantly different for the 2 groups (MI + ECS = 10, ECS = 10.38, P = 0.68). In both groups, prevalence of caries experience was 7% to 9% after 1 y, 35% to 36% at 2 y, and 55% to 56% at 3 y. Mean knowledge scores increased by 5.0, 5.3, and 5.9 percentage points at years 1, 2, and 3 in the MI + ECS group and by 1.9, 3.3, and 5.0 percentage points in the ECS group (P = 0.03), respectively. Mean maternal oral health behavior scores were not statistically significantly different between the treatment arms. Conclusion: In summary, the MI intervention appeared to improve maternal knowledge but had no effect on oral health behaviors or on the progression of ECC (ClinicalTrials.gov NCT01116726). Knowledge Transfer Statement: The findings of this study suggest that motivational interviewing focusing on parental behaviors may not be as effective as previously hoped for slowing the development of childhood caries in some high-risk groups. Furthermore, social factors may be even more salient determinants of oral health than what we previously supposed, perhaps interfering with the capacity to benefit from behavioral strategies that have been useful elsewhere. The improvement of children’s oral health in high-risk populations characterized by poverty and multiple related life stresses may require more holistic approaches that address these formidable barriers.

Objective Effective treatments for rheumatoid arthritis (RA) fatigue are limited. We tested the effect of a pedometer-based intervention on increasing physical activity and decreasing fatigue among individuals with RA. Methods Participants completed baseline questionnaires; had 1 week of activity monitoring; were randomized to control (education [EDUC]), pedometer and step-monitoring diary (PED), or pedometer and diary plus step targets (PED+) groups, and were followed for 21 weeks. At week 10, questionnaires were administered by phone to all participants. During the final week, all participants again had 1 week of activity monitoring. Primary outcomes were changes in average weekly steps and fatigue (Patient-Reported Outcomes Measurement Information System 7-item questionnaire) from baseline to week 21. Secondary outcomes were self-reported disease activity, physical function, pain interference, and depressive symptoms. Changes in steps were tested using a linear mixed model. Changes in fatigue were tested with repeated-measures models, including baseline, week-10, and week-21 scores. Results A total of 96 individuals participated. Eight did not complete the 21-week assessments. Both intervention groups significantly increased steps (+1,441 [P = 0.004] for PED and +1,656 [P = 0.001] for PED+), and the EDUC group decreased steps (-747 [P = 0.14]) (group-by-time interaction P = 0.0025). Between-group changes in fatigue were not significantly different (interaction P = 0.21). Mean changes in fatigue scores from baseline to week 21 were -1.6 (with-group P = 0.26), -3.2 (P = 0.02), and -4.8 (P = 0.0002) for EDUC, PED, and PED+ groups, respectively. Function and self-reported disease activity also improved in the PED and PED+ groups. Conclusion Provision of pedometers, with and without providing step targets, was successful in increasing activity levels and decreasing fatigue in this sample of individuals with RA.

Introduction National and professional organizations recommend oral health promotion in prenatal care to improve women's oral health. However, few prenatal programs include education about oral health promotion. The objective of this study was to determine if women receiving a brief, low-cost, and sustainable educational intervention entitled CenteringPregnancy Oral Health Promotion had clinically improved oral health compared to women receiving standard CenteringPregnancy care. Methods Women attending CenteringPregnancy, a group prenatal care model, at 4 health centers in the San Francisco Bay Area, participated in this nonrandomized controlled pilot study in 2010 to 2011. The intervention arm received the CenteringPregnancy Oral Health Promotion intervention consisting of two 15-minute skills-based educational modules addressing maternal and infant oral health, each module presented in a separate CenteringPregnancy prenatal care session. The present analysis focused on the maternal module that included facilitated discussions and skills-building activities including proper tooth brushing. The control arm received standard CenteringPregnancy prenatal care. Dental examinations and questionnaires were administered prior to and approximately 9 weeks postintervention. Primary outcomes included the Plaque Index, percent bleeding on probing, and percent of gingival pocket depths 4 mm or greater. Secondary outcomes were self-reported oral health knowledge, attitudes (importance and self-efficacy), and behaviors (tooth brushing and flossing). Regression models tested whether pre to post changes in outcomes differed between the intervention versus the control arms. Results One hundred and one women participated in the study; 49 were in the intervention arm, and 52 were in the control arm. The control and intervention arms did not vary significantly at baseline. Significant pre to post differences were noted between the arms with significant improvements in the intervention arm for the Plaque Index, bleeding on probing, and pocket depths 4 mm or greater. Discussion Providing brief oral health education and skills-building activities within prenatal care may be effective in improving women's oral health during pregnancy. These findings provide support for developing a full-scale randomized clinical trial of the CenteringPregnancy Oral Health Promotion intervention.

Clinical practice guidelines recommend that clinicians implement the 5As (Ask, Advise, Assess, Assist, and Arrange) for smoking cessation at every clinical encounter. We sought to examine the prevalence of patient- and clinician-reported 5As in two primary care and one HIV care clinics in San Francisco, California between August 2013 and March 2014 (n = 462 patients and n = 61 clinicians). We used multivariable logistic regression analysis to identify factors associated with receipt of the 5As, adjusting for patient demographics, patient insurance, clinic site, patient tobacco use, and patient comorbidities. The patient-reported prevalence of 5As receipt was as follows: Ask, 49.9%; Advise, 47.2%; Assess, 40.6%; any Assist, 44.9%; and Arrange, 22.4%. In multivariable analysis, receipt of Advise, Assess, and Assist were associated with older patient age. Whereas patients with HIV had a lower odds of reporting being advised (AOR 0.5, 95% CI 0.3–0.8) or assessed for readiness to quit (AOR 0.6, 95% CI 0.4–0.9), patients with pulmonary diseases had higher odds of reporting being assisted (AOR 1.6, 95% 1.0–2.6) than patients without these diagnoses. Although the majority of clinicians reported asking (91.8%), advising (91.8%), and assessing (93.4%) tobacco use ‘most of the time’ or ‘always’ during a clinical encounter, fewer reported assisting (65.7%) or arranging (19.7%) follow-up. Only half of patients reported being screened for tobacco use and fewer reported receipt of the other 5As, with significant disparities in receipt of the 5As among patients with HIV. Our findings confirm the need for interventions to increase clinician-delivered cessation treatment in primary and HIV care., Highlights • Clinical practice guidelines recommend the use of 5As for smoking cessation. • Patient reports of Assist and Arrange were low in primary care and HIV care. • There were significant disparities in the receipt of 5As among patients with HIV. • Digital interventions could facilitate clinician-delivered 5As for patients.

BackgroundTwenty-five million people in the United States have limited English proficiency (LEP); this growing and aging population experiences worse outcomes when hospitalized. Federal requirements that hospitals provide language access services are very challenging to implement in the fast-paced, 24-hour hospital environment.ObjectiveTo determine if increasing access to professional interpreters improves hospital outcomes for older patients with LEP.DesignNatural experiment on a medicine floor of an academic hospital.ParticipantsPatients age 50 years or above discharged between January 15, 2007 and January 15, 2010.ExposureDual-handset interpreter telephone at every bedside July 15, 2008 to Mar 14, 2009.Outcome measuresThirty-day readmission, length of stay, estimated hospital expenditures.ResultsOf 8077 discharges, 1963 were for LEP, and 6114 for English proficient patients. There was a significant decrease in observed 30-day readmission rates for the LEP group during the 8-month intervention period compared with 18 months preintervention (17.8% vs. 13.4%); at the same time English proficient readmission rates increased (16.7% vs. 19.7%); results remained significant in adjusted analyses. This improved readmission outcome for the LEP group was not maintained during the subsequent postintervention period when the telephones became less accessible. There was no significant intervention impact on length of stay in either unadjusted or adjusted analyses. After accounting for interpreter services costs, the estimated 119 readmissions averted during the intervention period were associated with estimated monthly hospital expenditure savings of $161,404.ConclusionsComprehensive language access represents an important, high value service that all medical centers should provide to achieve equitable, quality healthcare for vulnerable LEP populations.

Different conventional and causal approaches have been proposed for mediation analysis to better understand the mechanism of a treatment. Count and zero-inflated count data occur in biomedicine, economics, and social sciences. This paper considers mediation analysis for count and zero-inflated count data under the potential outcome framework with nonlinear models. When there are post-treatment confounders which are independent of, or affected by, the treatment, we first define the direct, indirect, and total effects of our interest and then discuss various conditions under which the effects of interest can be identified. Proofs are provided for the sensitivity analysis proposed in the paper. Simulation studies show that the methods work well. We apply the methods to the Detroit Dental Health Project’s Motivational Interviewing DVD trial for the direct and indirect effects of motivational interviewing on count and zero-inflated count dental caries outcomes.

Background Cultivation of tobacco leaf raises concerns about detrimental occupational health and social consequences especially for youth, but tobacco producing countries only highlight economic benefits. We examined sociodemographic and health-related characteristics of underage youth working in tobacco farming and assessed the effects of tobacco farming on smoking behavior and health at one year.Methods We used existing data collected in the province of Jujuy, Argentina where 3188 youth 13 to 17 years of age from a random middle school sample responded to longitudinal questionnaires in 2005 and 2006. Multivariate logistic regression models predicted association of tobacco farming work with smoking behavior and health status at one year.Results 22.8% of youth in the tobacco growing areas of the province were involved in tobacco farming. The mean age of initiation was 12.6 years. Tobacco farming was associated with higher rates of fair or poor versus good or excellent self-perceived health (30.3% vs. 19.0%), having a serious injury (48.5% vs. 38.5%), being injured accidentally by someone else (7.5% vs. 4.6%), being assaulted (5.5% vs. 2.6%), and being poisoned by exposure to chemicals (2.5% vs. 0.7%). Youth working in tobacco farming had higher prevalence of ever (67.9% vs. 55.2%), current (48.0% vs. 32.6%) and established smoking (17.8% vs. 9.9%). In multivariate logistic regression (MLR) models tobacco farming in 2005 significantly increased the likelihood of serious injury (OR=1.4; 95%CI 1.1-2.0), accidental injury by someone else (OR=1.5; 95% 1.0-2.1), assault (OR=2.2; 95% CI 1.3-3.8), poisoning by exposure to chemicals (OR=2.5; 95% CI 1.2-5.4), in the same year. Tobacco farming in 2005 predicted established smoking one year later (OR=1.5; 95% CI 1.1-2.0).Conclusion Youth who work in tobacco faming face a challenging burden of adversities that increase their vulnerability. Risk assessments should guide public policies to protect underage youth working in tobacco farming. (297 words)

Objective: To assess whether unhealthy behaviors moderated the relationship between allostatic load (AL) and future significant depressive symptoms (SDSs) among 1,789 older Latinos. Method: Longitudinal data included baseline AL, three unhealthy behaviors (UBs), and 2-year follow-up SDS. Multivariable logistic regression analyses, stratified by birthplace (U.S. vs. foreign born), modeled the effects of AL, UB count (range = 0-3), and their interaction on follow-up SDS. Results: Compared with U.S.-born, foreign-born participants engaged in fewer UBs (0.52 vs. 0.60 behaviors, p = .01) and had higher baseline SDS (31% vs. 20%, p < .001). Among foreign-born participants, the effect of AL on future SDS (adjusted odds ratios [aORs]; 95% confidence interval [CI]) significantly increased across UB counts of 0 to 3: 1.06 [0.83, 1.35], 1.46 [1.14, 1.87], 2.00 [1.18, 3.41], and 2.75 [1.18, 6.44], respectively. Discussion: Among foreign-born Latinos, these results were most pronounced for women and adults above age 80, which may represent higher risk groups requiring more intensive screening for depression.

Importance Many cervical cancer screening strategies are now recommended in the United States, but the benefits, harms, and costs of each option are unclear. Objective To estimate the cost-effectiveness of 12 cervical cancer screening strategies. Design, Setting, and Participants The cross-sectional portion of this study enrolled a convenience sample of 451 English-speaking or Spanish-speaking women aged 21 to 65 years from September 22, 2014, to June 16, 2016, identified at women's health clinics in San Francisco. In this group, utilities (preferences) were measured for 23 cervical cancer screening–associated health states and were applied to a decision model of type-specific high-risk human papillomavirus (hrHPV)–induced cervical carcinogenesis. Test accuracy estimates were abstracted from systematic reviews. The evaluated strategies were cytologic testing every 3 years for women aged 21 to 65 years with either repeat cytologic testing in 1 year or immediate hrHPV triage for atypical squamous cells of undetermined significance (ASC-US), cytologic testing every 3 years for women age 21 to 29 years followed by cytologic testing plus hrHPV testing (cotesting), or primary hrHPV testing alone for women aged 30 to 65 years. Screening frequency, abnormal test result management, and the age to switch from cytologic testing to hrHPV testing (25 or 30 years) were varied. Analyses were conducted from both the societal and health care sector perspectives. Main Outcomes and Measures Utilities for 23 cervical cancer screening–associated health states (cross-sectional study) and quality-adjusted life-years (QALYs) and total costs for each strategy. Results Utilities were measured in a sociodemographically diverse group of 451 women (mean [SD] age, 38.2 [10.7] years; 258 nonwhite [57.2%]). Cytologic testing every 3 years with repeat cytologic testing for ASC-US yielded the most lifetime QALYs and conferred more QALYs at higher costs ($2166 per QALY) than the lowest-cost strategy (cytologic testing every 3 years with hrHPV triage of ASC-US). All cytologic testing plus hrHPV testing (cotesting) and primary hrHPV testing strategies provided fewer QALYs at higher costs. Adding indirect costs did not change the conclusions. In sensitivity analyses, hrHPV testing every 5 years with genotyping triage beginning at age 30 years was the lowest-cost strategy when hrHPV test sensitivity was markedly higher than cytologic test sensitivity or when hrHPV test cost was equated to the lowest reported cytologic test cost ($14). Conclusions and Relevance Cytologic testing every 3 years for women aged 21 to 29 years with either continued cytologic testing every 3 years or switching to a low-cost hrHPV test every 5 years confers a reasonable balance of benefits, harms, and costs. Comparative modeling is needed to confirm the association of these novel utilities with cost-effectiveness.

Objective The study objective was to identify biobehavioral variables associated with greater intake of nicotine and a tobacco carcinogen among Black light smokers who smoke 1 to 10 cigarettes per day (CPD). Methods We analyzed baseline data collected from 426 Black light smokers enrolled in Kick It at Swope III (KIS III), a smoking cessation trial for Black smokers. We examined differences in concentrations of tobacco biomarkers, including urinary total nicotine equivalents (TNE) and total 4-(methylnitrosamino)-1-(3)pyridyl-1-butanonol (NNAL; a human carcinogen), across gender, age, plasma nicotine metabolite ratio (NMR), CPD, and measures of tobacco dependence, including time to first cigarette (TFC), using ANOVA. Results Tobacco biomarker levels were significantly higher among those who smoked more CPD (6–10 vs 1–5 CPD) and those with greater reported physical dependence on tobacco. Concurrently, those who smoked 1–5 CPD smoked each cigarette more intensely than those who smoked 6–10 CPD. While we found no gender differences overall, among those who smoked 1–5 CPD, women had higher NNAL levels compared to men. The rate of nicotine metabolism, measured by the nicotine metabolite ratio, was not significantly related to TNE or NNAL levels. Conclusion Among Black Light smokers, higher cigarette consumption and greater physical dependence—but not rate of nicotine metabolism, menthol use, or socioeconomic status—were associated with greater toxicant exposure and thus a likely increased risk of tobacco-related diseases. The lack of data on light smokers, and specifically on Blacks, make this observation important given the disproportionate burden of lung cancer in this population.

Rationale: Although lung transplantation aims to improve health-related quality of life (HRQL), existing instruments fail to include health domains considered important in this population. Objectives: We aimed to develop a comprehensive lung transplant–specific instrument to address this shortcoming. Methods: We developed a pool of 126 candidate items addressing domains previously identified as important by lung transplant recipients. Through cognitive interviews conducted in 43 transplant recipients, items deemed irrelevant or redundant were dropped. The 84 remaining items were field tested in lung transplant recipients. Exploratory and confirmatory factor analyses were used to evaluate the factor structure, and scales were evaluated for internal consistency and construct validity. Measurements and Main Results: The 84-item preliminary survey was administered to 201 lung transplant recipients with a mean age of 57.9 (±12.7) years; 46% were female. After factor analyses and internal consistency evaluation, we retained 60 items comprising the Lung Transplant Quality of Life (LT-QOL) Survey. The LT-QOL contains 10 scales that measure symptoms, health perceptions, functioning, and well-being. The confirmatory factor analysis model had good approximate fit (comparative fit index = 0.990; standardized root-mean-square residual = 0.062). Cronbach αs for the 10 scales ranged from 0.75 to 0.95. Interscale correlations were consistent with hypothesized relationships. Subjects with severe chronic lung allograft dysfunction (n = 13) reported significantly worse HRQL than subjects without chronic lung allograft dysfunction (n = 168) on 6 of the 10 LT-QOL scales. Conclusions: The LT-QOL is a new, multidimensional instrument that characterizes and quantifies HRQL in lung transplant recipients.

OBJECTIVE: This study aimed to examine the relationship between circadian sleep and activity behaviors (sedentary time [SED], light-intensity physical activity [LPA], and moderate- to vigorous-intensity physical activity [MVPA]) across three consecutive days. METHODS: This study included 308 Mexican American children aged 8-10 years from the San Francisco Bay Area. Minutes of sleep duration, SED, LPA, and MVPA were estimated using hip-worn accelerometers from Wednesday night to Saturday night. A cross-lagged panel model was used to estimate paths between sleep duration the prior night and subsequent behaviors, and paths between behaviors to subsequent sleep duration across the three days. We adjusted for child age, sex, BMI, and household income. RESULTS: Overall, children were 8.9 (s.d. 0.8) years old; the weighted average for weekday and weekend combined was 9.6 (s.d. 0.7) hours/night in sleep duration, 483 (s.d. 74) minutes/day SED, 288 (s.d. 61) minutes/day LPA, and 63 (s.d. 38) minutes/day MVPA. Cross-lagged panel analyses showed that, over three days, for every one-hour increase in sleep duration there was an expected 0.66 hour (40-minute) decrease in SED, 0.37 hour (22-minute) decrease in LPA, and 0.06 hour (4-minute) decrease in MVPA. For every one-hour increase in LPA there was an expected 0.25 hour (15-minute) decrease in sleep duration. CONCLUSION: An additional hour of sleep the night before corresponded to an hour decrease in combined SED and LPA the next day in Mexican American children. For every hour of LPA there was an associated 15-minute decrease in sleep. Encouraging longer sleep may help to reduce SED and LPA, and help offset LPA’s negative predictive effect on sleep.

OBJECTIVE: We examined prostate cancer patients’ perceived engagement in treatment decision-making and associated factors by race/ethnicity in a multiethnic sample. METHODS: We identified patients through the California Cancer Registry. Patients completed a cross-sectional telephone interview in English, Spanish, Cantonese or Mandarin. Multivariable logistic regression models, stratified by race/ethnicity, estimated the associations of patient demographic and health status characteristics on (1) doctor asked patient to help decide treatment plan and (2) patient and doctor worked out a treatment plan together. RESULTS: We included 855 prostate cancer patients: African American (19%), Asian American (15%), Latino (24%), and White (42%). Asian American patients were less likely than White patients to report that their doctors asked them to help decide a treatment plan (OR=0.31; 95% CI=0.18–0.53), and that they worked out a treatment plan with their doctors (OR=0.54; 95% CI=0.33–0.90). Language of interview was a significant contributing factor in stratified analysis for both outcomes. CONCLUSION: Asian American prostate cancer patients reported less engagement in treatment decision-making, with Chinese language being a significant contributing factor. Future research should identify patient-centered strategies that effectively engage underserved patients and support healthcare providers in shared decision-making with multiethnic and multilingual patients.

Objectives: To report intention-to-treat results of a pragmatic, cluster-randomized trial to examine the effect of Community of Voices, a multi-modal community choir intervention, on the health and well-being of racial/ethnically and socioeconomically diverse older adults. Method: Twelve Administration-on-Aging-supported senior centers were randomized to receive the choir intervention immediately or after a six-month delay. We recruited community-dwelling adults aged 60 and over. The choir intervention was culturally tailored around three engagement components (cognitive, physical, and psychosocial) and delivered at senior centers by community-based music professionals. The main randomized comparison was at 6 months (after 23 choir sessions). Results: The sample (N=390) had a mean age of 71.3 (SD=7.2); 65% were from non-white racial/ethnic backgrounds. Study retention was 92%. Intention-to-treat analyses found a significant group-by-time interaction effect for two of six psychosocial outcomes: participants in the choir intervention experienced significant improvements in loneliness and interest in life compared to the wait-list controls. No significant group differences were observed for cognitive or physical outcomes. Discussion: The finding that singing in a choir can reduce loneliness and increase interest in life in diverse older adults are important because of the relatively low-cost and cultural salience of the intervention. This supports further efforts to examine how engagement in the arts may improve health and well-being and reduce health disparities in diverse older adults.