Disparities in Compliance with Colorectal Cancer Screening: Evidence from Two US National Surveys

OBJECTIVE

Colorectal cancer (CRC) is the most preventable cancer if adherence to its screening guidelines through compliance with physician recommendations are met. Lack of access to care is the most significant barrier which was decreased by the Affordable Care Act (ACA), that may influence healthcare behaviors/practices. The aim of this study was to determine the factors affecting compliance with recommendations for CRC screening between two US National Health Interview Surveys (NHIS) in 2010 and 2015.

METHODS

We used individual data of adults aged ≥50 years from the Cancer Module of NHIS that repeats every-5-years. Multiple logistic regression analyses were employed to identify the compliance associated factors and their changes after five years.

RESULTS

We included final data of 1,553 and 2259 and individual from 2010 and 2015, respectively. Overall, compliance to physician recommendations for colorectal cancer was 85.70% in 2010 and 81.54%. Men compiled more in 2010 than women which was reversed in 2015. The multivariable-adjusted odds of compliance were increased with age; lower for female [Odds ratio (OR)= 0.45 Confidence Interval (CI 95% 0.27, 0.75), having a family history of CRC [OR=3.05 CI:1.02, 9.05], having insurance [OR 3.58 CI:1.4, 9.12], and Odds increased with the number of doctor visit in 2010. However, in 2015 the odds were substantially increased with the increasing age, reversed odds for female [OR= 3.49 CI: 1.67, 7.29)], increased for non-Hispanic Blacks [OR= 4.87 CI: 2.05, 11.55] and lower for Asian [OR=0.33 CI:0.15, 0.74], higher for family history of colorectal cancer [OR=3.31 CI:1.92, 5.69]. Although insurance coverage and the number of doctor visits were significant predictors of compliance in 2010, those became non-significant in 2015.

CONCLUSIONS

Compliance disparities by gender and access to healthcare either reduced in strength or reversed between 2010 and 2015. The non-Hispanic Black significantly higher in compliance than other race-ethnicities in 2015.

The availability of essential medicines for diabetes at health facilities in Bangladesh: evidence from 2014 and 2017 national surveys

Background

Bangladesh ranks among the world’s top ten countries in the number of diabetic patients. The prevention of this disease requires treating patients with essential medicines, and the first crucial step in the uptake of these medicines is availability. We aimed to assess the availability of essential medicines for diabetes (EM-Diabetes) and to explore health facility characteristics associated with the availability of those medicines.

Methods

We performed the analysis using nationally representative data from the two waves of the cross-sectional Bangladesh Health Facility Survey (BHFS) in 2014 and 2017. Data are available for 1548 and 1524 health facilities in the 2014 and 2017 BHFS. Study samples of this study were 217 facilities (73 from 2014 and 144 from 2017) that offer diabetes diagnosis and treatment services. The outcome variable ‘EM-Diabetes availability’ was calculated as a counting score of the tracer medicines: metformin, glibenclamide, injectable insulin, and injectable glucose solution. A multivariable Poisson regression model was used to identify the health facility characteristics (such as, managing authority, location, external supervision, regular quality assurance activities, national guidelines for diagnosis and management of diabetes, etc.) associated with EM-Diabetes availability.

Results

Since 2014, there have been minimal increases in Bangladeshi health facilities that provide diabetes screening and treatment services (from 4.7% to 9.4%). Among facilities offering diabetes services, 64.5% (BHFS 2014) and 55.7% (BHFS 2017) facilities had no EM-Diabetes on-site at all. Between 2014 and 2017, the availability of metformin increased (from 27.5% to 40.1%), but there was a decrease in the availability of glibenclamide (from 16.5% to 9.1%), injectable insulin (from 20.4% to 11.4%), and injectable glucose solution (from 20.4% to 19.2%). Furthermore, publicly owned facilities [relative risk (RR) = 0.44, 95% confidence interval (CI): 0.25–0.78 for 2014 and RR= 0.54, 95% CI: 0.41–0.71 for 2017] and facilities in rural settings [RR= 0.26, 95% CI: 0.12–0.55 for 2014 and RR= 0.60, 95% CI: 0.44–0.81 for 2017] were significantly associated with decreased availability of EM-Diabetes in both survey years. Moreover, routine user fees [RR=3.70, 95% CI: 1.86–7.38] and regular quality assurance activities [RR= 1.62, 95% CI: 1.12–2.34] were also significantly associated with increased EM-Diabetes availability in 2017 only.

Conclusions

Overall, the health facilities in Bangladesh had insufficient essential medicines for treating diabetes. In general, the availability of EM-Diabetes declined from 2014 to 2017, except for metformin. Policymakers should consider a wide range of policy implications, focusing on the management of public facilities, rural facilities, routine user fees, and quality assurance activities to improve the availability of EM-Diabetes at health facilities in Bangladesh.

The availability of essential medicines for cardiovascular diseases at healthcare facilities in low- and middle-income countries: The case of Bangladesh

Long-term, often lifelong care for cardiovascular disease (CVD) patients requires consistent use of medicine; hence, the availability of essential medicine for CVD (EM-CVD) is vital for treatment, quality of life, and survival. We aimed to assess the availability of EM-CVD and explore healthcare facility (HCF) characteristics associated with the availability of those medicines in Bangladesh. This study utilized publicly available cross-sectional data from the 2014 and 2017 waves of the Bangladesh Health Facilities Survey (BHFS). The analysis included 204 facilities (84 from the 2014 BHFS and 120 from the 2017 BHFS) that provide CVD diagnosis and treatment services. The outcome variable "EM-CVD availability" was calculated as a counting score of the following tracer medicines: angiotensin-converting enzyme (ACE) inhibitors (enalapril), thiazide, beta-blockers (atenolol), calcium channel blockers (amlodipine and nifedipine), aspirin, and simvastatin/atorvastatin. A multivariable Poisson regression model was used to identify the HCF characteristics associated with EM-CVD availability. The number of Bangladeshi HCFs that provide CVD screening and treatment services increased just a little between 2014 and 2017 (from 5.4% to 7.9%). Since 2014, there has been an increase in the availability of calcium channel blockers (from 37.5% to 38.5%), aspirin (from 25.3% to 27.9%), and simvastatin/atorvastatin (from 8.0% to 30.7%), whereas there has been a decrease in the availability of ACE inhibitors (enalapril) (from 12.5% to 6.5%), thiazide (from 15.7% to 11.1%), and beta-blockers (from 42.5% to 32.5%). The likelihood of EM-CVD being available was higher among private and urban facilities than among public and rural facilities. Furthermore, facilities that had 24-hour staff coverage and performed quality assurance activities had a higher chance of having EM-CVD available than those that did not have 24-hour staff coverage and did not undertake quality assurance activities. Government authorities should think about a wide range of policy implications, such as putting more emphasis on public and rural facilities, making sure staff is available 24 hours a day, and performing quality assurance activities at facilities to make EM-CVD more available.

A novel index-based decision support toolkit for safe reopening following a generalized lockdown in low and middle-income countries

While the effectiveness of lockdowns to reduce Coronavirus Disease-2019 (COVID-19) transmission is well established, uncertainties remain on the lifting principles of these restrictive interventions. World Health Organization recommends case positive rate of 5% or lower as a threshold for safe reopening. However, inadequate testing capacity limits the applicability of this recommendation, especially in the low-income and middle-income countries (LMICs). To develop a practical reopening strategy for LMICs, in this study, we first identify the optimal timing of safe reopening by exploring accessible epidemiological data of 24 countries during the initial COVID-19 surge. We find that a safe opening can occur two weeks after the crossover of daily infection and recovery rates while maintaining a negative trend in daily new cases. Epidemiologic SIRM model-based example simulation supports our findings. Finally, we develop an easily interpretable large-scale reopening (LSR) index, which is an evidence-based toolkit-to guide/inform reopening decision for LMICs.

Changes in prevalence, and factors associated with tobacco use among Bangladeshi school students: evidence from two nationally representative surveys

Background

Globally, tobacco kills more than nine million people per year. Annually in Bangladesh, smoking accounts for 1.2 million illnesses and over one hundred fifty thousand deaths. Worldwide, about one out of five school students smoke tobacco, and this problem is also growing significantly in Bangladesh. There is a need to address this problem. However, to the best of knowledge, no published study has been evaluated the changes in factors associated with tobacco use over time among Bangladeshi adolescent students using large, nationally representative comparable surveys. Our objective was to identify the factors associated with tobacco use among school going students, examine any changes in them over time, and explore policy options based on national surveys.

Methods

We analysed the data from the 2007 and the 2013 Global Youth Tobacco Survey (GYTS), a school-based survey targeting adolescents age 13–15 years (7th–9th grade), developed by the World Health Organization (WHO) and the Centres for Disease Control and Prevention (CDC). The samples were selected based on a two-stage cluster sample design. The data were collected in school classes using a self-administered anonymous survey. We applied chi-square tests and survey logistic regression models for analysing the data.

Results

Overall tobacco usage significantly declined from 8.4 to 6.9% over six years. The prevalence of tobacco use decreased among females (5.22 to 2.84%), those who received anti-tobacco messages (8.93 to 7.24%) and because of age restriction could not buy tobacco products (18.86 to 15.78%). Compared with the female, the odds of overall tobacco smoking among male students was 1.97 (CI: 0.99–3.92) in the year 2007 and it increased (OR = 3.07; CI: 1.56–6.04) in the year 2013. Moreover, the odds of smoking among those exposed to tobacco smoke had increased (OR = 3.26; CI: 1.46–7.29 vs 5.43; CI: 1.63–18.07) from 2007 to 2013.

Conclusion

There was a decline in tobacco use, especially among female students. Male students were higher tobacco user. It appeared anti-smoking campaign and age restriction policies were working.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10623-0.

Low Cardiac Output Syndrome: Incidence after Mitral Valve Replacement with or without Preservation of Mitral Valve Apparatus

Standard mitral valve replacement in patients with chronic mitral valve regurgitation and mitral valve stenosis consistently results in a decrease in early postoperative left ventricular ejection performance. Some studies showed that preservation of mitral valve leaflet and subvalvular apparatus can reduce postoperative left ventricular dysfunction. On the basis of the concept, this randomized clinical trial comparing mitral valve replacement with preservation of mitral subvalvular apparatus and conventional mitral valve replacement performed in National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh, in the period of July 2010 to December 2011. We included 60 patients of mitral regurgitation and mitral stenosis, among them 30 patients underwent mitral valve replacement with preservation of mitral subvalvular apparatus (Group A) and 30 patients underwent conventional mitral valve replacement (Group B). There was no significant difference between two groups in terms of peri-operative variables. But there was significant higher incidence of Low cardiac output (LOS) syndrome [36.7% vs. 6.9% (p<0.05)] and congestive heart failure in Group B than Group A. The duration of ICU stay was also significantly higher in conventional mitral valve replacement group [113.23±11.30 hours vs. 96.23±20.02 (p=0.001)]. Additionally, there was significantly less fall of left ventricular ejection fraction in preservation of mitral subvalvular apparatus group [preop 65.27±5.45, at discharge 54.31±3.78, after 3 months 58.28±5.20 (p<0.0001)] than conventional group [preop 66.43±4.58, at discharge 46.43±3.87, after 3 months 46.55±3.63 (p<0.0001)]. In this study left ventricular ejection fraction was used as measure of left ventricular function. We postulate that, this relative preservation of left ventricular ejection fraction was likely the result of preservation of mitral subvalvular apparatus.

The Devastating Cost of Racial and Ethnic Health Inequity in the COVID-19 Pandemic

The COVID-19 pandemic has laid bare the devastating truth about pervasive health inequity in the United States. As the virus swept through the country, underserved racial and ethnic minority populations disproportionately bore the brunt of the hospitalizations, severe illness, and fatalities. The devastation among these groups far outstripped their privileged counterparts due to convergence of disadvantages that created a perfect storm of exposures. We used empirical evidence incorporated into a theoretical framework analyzing vulnerabilities that have long plagued these communities. These exposures were further exacerbated by the rapid transmission of this virus and impaired the capability of these communities to escape illness and death due to a lack of adequate public health and medical responses. Will the aftermath of this coronavirus prove to be a reckoning for how American society addresses the conditions of most vulnerable populations or another ignored data-point? We suggest some policy steps to address the problem.

Cesarean delivery and early childhood diseases in Bangladesh: An analysis of Demographic and Health Survey (BDHS) and Multiple Indicator Cluster Survey (MICS)

Introduction

The rate of cesarean delivery (C-section) has been increasing worldwide, including Bangladesh, and it has a negative impact on the mother and child's health. Our aim was to examine the association between C-section and childhood diseases and to identify the key factors associated with childhood diseases.

Methods

We used four nationally representative data sets from multiple indicator cluster survey (MICS, 2012 and 2019) and Bangladesh Demographic and Health Survey (BDHS, 2011and 2014) and analyzed 25,270 mother-child pairs. We used the frequency of common childhood diseases (fever, short or rapid breaths, cough, blood in stools, and diarrhea) as our outcome variable and C-section as exposure variable. We included mother’s age, place of residence, division, mother’s education, wealth index, child age, child sex, and child size at birth as confounding variables. Negative binomial regression model was used to analyze the data.

Results

In the BDHS data, the prevalence of C-section increased from 17.95% in 2011 to 23.33% in 2014. Also, in MICS, the prevalence almost doubled over an eight-year period (17.74% in 2012 to 35.41% in 2019). We did not observe any significant effect of C-section on childhood diseases in both surveys. Only in 2014 BDHS, we found that C-section increases the risk of childhood disease by 5% [Risk Ratio (RR): 1.05, 95% CI: 0.95, 1.17, p = 0.33]. However, the risk of childhood disease differed significantly in all survey years by division, child's age, and child’s size at birth after adjusting for important confounding variables. For example, children living in Chittagong division had a higher risk [(2011 BDHS RR: 1.22, 95% CI: 1.08, 1.38) and (2019 MICS RR: 1.21, 95% CI: 1.08, 1.35)] of having disease compared to Dhaka division. Maternal age, education, and wealth status showed significant differences with the outcome in some survey years.

Conclusion

Our study shows that C-section in Bangladesh continued to increase over time, and we did not find significant association between C-section and early childhood diseases. High C-section rate has a greater impact on maternal and child health as well as the burden on the health care system. We recommend raising public awareness of the negative impact of unnecessary C-section in Bangladesh.

Knowledge of Cervical Cancer and Adherence to Pap Smear Screening Test Among Female University Students in a Multiethnic Institution, USA

BACKGROUND/PURPOSE

This study assessed cervical cancer knowledge and examined its correlation with adherence to Pap smear guidelines.

METHODS

We carried out a cross-sectional survey in 141 undergraduate female college students. The response rate of the survey was 91.5%. Knowledge scores (0 - 4) were calculated based on students' answers to four items.

RESULTS

About 61.7% of the participants did not have annual checkups within a year, and 69% have never received Pap-test. Students who never received Pap-test mentioned procrastination (82%), lack of interest and fear as reasons for not practicing the behavior. About 92.9% of the students were not aware that the university student health service provides free Pap tests. More than double of annual checkup recipients undergone Pap test (33%) compared with those who did not have annual checkups (14.3%). Students who knew multi-partners sexual activity as a risk factor for cervical cancer had higher odds of receiving Pap test than those who didn't know the correlation between the number of sexual partner and the risk of cervical cancer [aOR= 2.87; 95% CI 1.07- 8.90]. Students with knowledge scores about cervical cancer risk factors and prevention methods at least a median had higher odds of receiving Pap test than those with knowledge scores lower than the median [aOR=6.49; 95% CI 2.8 - 14.7]. The increase in receipt of Pap test was associated with an increase in the level of knowledge about risk factors of cervical cancer.

CONCLUSIONS

This study confirmed a correlation of the receipt of Pap test with knowing the causes and prevention mechanisms of cervical cancer. Adequate knowledge about cervical cancer causes, and prevention/control strategies may help to improve adherence to Pap smear testing in college students.

Home Based Pulmonary Rehabilitation on Oxygenation Status, Dyspnea and Fatigue in Stable Patients with COPD

Pulmonary rehabilitation (PR) program of a sufficient duration has impact on consequence of COPD. To evaluate the effects of combination of pursed lip breathing (PLB), diaphragmatic breathing (DB) and lower extremity endurance training (LEET) as part of PR program in stable patients with COPD on oxygenation status, dyspnea and fatigue. This prospective interventional study was performed in the Department of Physiology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from July 2010 to June 2011 and was performed on 116 male stable moderate COPD patients aged 50 to 65 years. Among them, 56 patients were without PR (control group) and 60 patients were intervened with PR (experimental group). The experimental patients were advised to perform the home based PR program (PLB, DB and LEET) for 30 minutes duration per session at home twice per day, along with standard drug treatment of COPD for uninterrupted 60 days. The control patients continued their treatment of COPD with standard drug for successive 60 days were advised. To evaluate the effects of PR, Peripheral capillary oxygen saturation (SpO₂, by pulse Oximeter), level of dyspnea and level of fatigue by Modified Borg Scale from baseline to end of six minute walk test (6MWT) of all subjects were recorded on day 0 and day 60 for both the groups. Independent sample 't' test and paired Student's 't' test were done with SPSS software. In the interpretation of results, p value of <0.05 was considered as statistically significant. In the present study, we found less decrement of SpO₂ and less increment of level of dyspnea as well as level of fatigue after 6MWT in the COPD patients with PR on 60th day of follow up. The study reveals that oxygenation status, dyspnea and fatigue improve after execution of regular home based PR program in patients with moderate stable COPD.

Pattern of Casualties Attending in the Casualty Department of Mymensingh Medical College Hospital, Mymensingh, Bangladesh

Casualty, in relation to personnel, any person who is lost to his organization; by reason of being declared dead, wounded, diseased, detained, captured or missing. Casualty service or department is not well organized in the hospitals of our country. We have recently started functioning casualty department to manage casualties properly in spite of the increasing workload and emerging needs of this department. This study was conducted in the Casualty department, Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh to analyze the number of patients and pattern of casualties. A total number of 17435 patients were enrolled in this retrospective observational study. Data was collected from hospital records of all patients attending in the Casualty Department, MMCH between November 19, 2017 and May 18, 2018 and patients were categorized on the basis of their mode of injury. The demographic characteristics of patients with mode of Casualty were analyzed. Male were 75% and female 25%. Avergae per day patient attended in the Casualty department was 96, maximum was 176 and minimum 33. According to age sub-division, 11-20 years age group attended maxiumum was 48. One day attended Road traffic accident (RTA) maximum was 65 and minimum was 3, Non-RTA maximum was 83 and minimum 25, physical assaults maximum was 48 and minimum 1. Injury due to fall and RTA were the common mode of casualty especially in the young population in the study area. Study showed that injury caused by fall was 44% among the all patients. Patients due to fall from tree was highest (35%) in April-May. Incidents of fall were followed by RTA which was 25%. Physical assaults (17%), machinery injury (9%) and others were 5%.

Assessment of the Impact of a Hygiene on Environmental Sanitation, Childhood Diarrhoea, and the Growth of Children in Rural Bangladesh

A community-based hygiene intervention was developed and implemented in five villages of lowland Bangladesh with the active participation of members of the target group, with the objective of reducing childhood diarrhoea by altering ground sanitation and personal and food hygiene practices such as the washing of hands with ash before handling food and after defecation-related activities, cutting fingernails, removing faeces from the child's body and from the yard, using tube-well water for preparing baby food, and reducing supplementary feeding contamination by proper cleaning of bottles or avoiding bottle-feeding.

The project area, typical of Bangladesh, was selected because of its pour hygiene and sanitation conditions and its high rates of diarrhoea and malnutrition. Households with children 0–18 months old in five contiguous villages were targeted for the intervention. Households with children in the same age range in a comparison (control) site selected for observational study without intervention were exposed to about the same amount of contact with the researchers.

Baseline surveys of the subset of households with children 9–18 months old were conducted at the control site in July 1985 and at the intervention site in September. The intervention activities were carried out from January to July 1986. A final survey was conducted at both sites in August 1986, using the same questionnaire as for the baseline survey and the children who were then in the same age range, 9–18 months.

Both sites had higher cleanliness scores, lower diarrhoeal morbidity, and better growth status at the end of the study period, but the improvement was greater at the intervention site. The effect at the control site may be attributed to the intensive observation exposures, mothers’ education, and socio-economic conditions of the households, whereas the intervention site effects were most likely due to the intervention activities.

For evaluation of the effect of interventions, the repeat cross-sectional survey may be adequate for measuring relatively stable outcomes such as knowledge and practices, as well as cumulative growth status, but inadequate for fluctuating morbidity.

A Review: Associations Between Attention-deficit/hyperactivity Disorder, Physical Activity, Medication Use, Eating Behaviors and Obesity in Children and Adolescents

In the past few years we have become increasingly aware of strong associations between obesity and ADHD. Both conditions are major public health issues, affecting children, adolescents and adults alike.

OBJECTIVE

This review seeks to (1) examine prior research on the association between ADHD and obesity in children and adolescents; (2) discuss mechanisms and consequent behavioral attributes to gain understanding of the path association between ADHD and obesity, (3) review studies examining the role of physical activity, medication, eating behavior and gender on the relationship between ADHD and obesity in children and adolescents.

METHOD

PubMed, CINAHL and PsycINFO databases were used to search for studies whose subjects were children and adolescents, ages 0-17 years and whose publication years were from 2000 to 2016. After screening 31 studies were included in the review.

RESULTS

The literature suggests that there is a significant association between ADHD and obesity. Further, the inattentive and impulsive behaviors that characterize ADHD could contribute to dis-regulated eating behaviors and a lack of motivation to engage in physical activity. In addition, it is proposed that medication, gender and physical activity play a role in mediating and moderating the relationship between ADHD and obesity.

The Role of HIV in the Progression through the Stages of the Human Papillomavirus to Cervical Cancer Pathway

Globally, an estimated 36.9 million persons are living with HIV/AIDS, and approximately 291 million women worldwide are carriers of human papillomavirus (HPV). A large number of women currently infected with either or both viruses constitute a large burden on the national health care system. Women with HIV have significantly higher rates of HPV infections than women without HIV. Approximately 77% of women with HIV are carriers of HPV. While research has established a linkage between HIV and progression to cervical cancer in general, there are currently no review articles exploring the role HIV has in the progression from HPV to each stage of carcinogenesis that leads to cervical cancer. The objective of this review is to examine the relationship between HIV and progression from HPV to each stage of carcinogenesis related to cervical cancer. The findings of the review support the conclusion that HIV infection increases the likelihood of progression to each stage of the HPV to cervical cancer pathway.

State-Mandated Nutrition, Physical Activity, and Screen Time Policies in Child Care Centers

BACKGROUND

The child care center (CCC) environment presents opportunities for healthy weight promotion in preschoolers. Our study examined the current state of CCC adherence to nutrition, physical activity, and screen time legislative regulations and the differences in their adherence by center socioeconomic position (SEP: low, middle, high) in Miami-Dade County.

METHOD

In 34 CCC, we used the Environment and Policy Assessment and Observation tool to evaluate nutrition, physical activity, and screen time practices during 1-school day.

RESULTS

Twenty-five of the centers (73.5%) were participants of the Child and Adult Care Food Program. Almost 80% of the centers adhered to serving low-fat/fat-free milk to children older than 2 years. Only 34.5% served vegetables and 75.9% served whole fruits during meals/snacks. Ninety-four percent of the centers had quiet and active play incorporated into their daily routines. All centers adhered to the 2-hour screen time limit for children older than 2 years. Low- and middle-SEP centers fared better in the serving of fruits, vegetables, and low-fat/fat-free milk. The centers averaged 1 hour in outdoor play regardless of SEP. High-SEP centers had no TV or screen time during day of observation.

CONCLUSION

CCC practices highlight opportunities for improvement in nutrition, physical activity, and screen time practices in the prevention of overweight in early childhood.

Community-Based Trial and Ethnographic Techniques for the Development of Hygiene Intervention in Rural Bangladesh

Community-based three-stage iterative trials were performed to develop interventions for improving hygiene practices to reduce childhood diarrhea in rural Bangladesh. Ethnographic techniques were used to identify practices associated with diarrhea, to understand cultural beliefs and reasoning related to causes of diarrhea, and to tap community resources. Hygiene behaviors and products designed through in-home problem diagnosis went through trials sequentially at three socio-economic levels consisting of ten educated project workers, twenty-five volunteer mothers and twenty-five very low- income mothers. These levels, chosen in order to meet the needs of all including the poorest, permitted new practices which proved feasible in the workers' trial to be then tried by the volunteers. The results were synthesized, with successful behavioral advice translated into simple verbal messages created to resemble locally popular proverbs, poems and folk songs. The messages and products were finalized after pretesting and revision among the very low-income group of mothers. Evaluation of the community-wide campaign showed very high rates of adoption (85%–95%) of the interventions. The involvement of target groups and their opinion leaders in the intervention development process contributed to the sense of ownership reflected in the high rate of adoption. Program organizers' comprehensive understanding of practices associated with diarrhea and its cultural context, and the community's empowerment to find local solutions are both critical to the success of such interventions.

Trends and disparities in the prevalence of physicians' counseling on diet and nutrition among the U.S. adult population, 2000-2011

BACKGROUND

Although healthy eating plays a crucial role in addressing the obesity and chronic disease epidemics, a few Americans have diets that meet dietary guidelines. Because physicians-delivered counseling is a strong predictor for behavioral modification among patients, the Healthy People Objectives have emphasized diet counseling since 2000. However, research on impact of physicians' counseling over time on a national level has been limited.

METHODS

We used data from the 2000 and 2011 National Health Interview Surveys to apply a logistic regression model to identify predictors of physicians' counseling and examine any changes in disparities over a decade.

RESULTS

In 2000, only 23.7% of our national sample had received dietary counseling, it increased to 32.6% in 2011. Hispanics were less likely than Whites to receive advice on diet in 2000 (adjusted odds ratio [AOR]=0.74, 95% confidence interval [CI]=0.62-0.88). By 2011, Hispanics 18% (AOR=1.18, CI=1.09-1.28) and Blacks were 42% (AOR=1.42, CI=1.32-1.54) more likely to receive advice from their physicians on diet than Whites. In both years, men were significantly less likely than women to receive counseling. The uninsured patients were increasingly less likely than insured patients in receiving diet counseling, being 60% less likely in 2011 (AOR=0.40, CI=0.37-0.40). Obese patients were substantially (88% in 2000 to 290% in 2011) more likely to receive counseling than normal-weight patients.

CONCLUSIONS

The overall prevalence of physicians' counseling on diet increased moderately between 2000 and 2011. However, substantial disparities in dietary counseling related to access to care and gender continue to exist.

Prevalence of Smokeless Tobacco among Low Socioeconomic Populations: A Cross-Sectional Analysis

Background

Cost, social acceptability and non-stringent regulations pertaining to smokeless tobacco (SLT) product sales have made people choose and continue using SLT. If disaggregated data on smokeless forms and smoked practices of tobacco are reviewed, the incidence of SLT remains static. There is a strong positive correlation of SLT intake with the occurrence of adverse cardiovascular disease, particularly in the low socioeconomic populations.

Aims

To investigate the prevalence of smokeless tobacco, its initiation influence and risk factors associated with the practice among lower socioeconomic populations of Bangladesh.

In this study, we explore the utilization of SLT among lower socioeconomic populations in industrialized zone of Bangladesh.

Methods

A cross-sectional analysis using both quantitative and categorical approaches was employed. Using systematic random sampling method, four focus group discussions (FGDs) were conducted and 459 participants were interviewed. Multiple logistic regression model was applied to distinguish the significant factors among the SLT users.

Results

Almost fifty percent of the respondents initiated SLT usage at the age of 15–24 years and another 22 percent respondents were smoking and using SLT concurrently. The bulk of the women respondents used SLT during their pregnancy. Nearly twenty five percent of the respondents tried to quit the practice of SLT and one-quarter had a plan to quit SLT in the future. More than twenty percent respondents were suffering from dental decay. A noteworthy correlation was found by gender (p<0.01), sufferings from SLT related disease (p<0.05). The multiple logistic regression analysis suggested that, males were 2.7 times more knowledgeable than that of females (p<0.01) about the adversative health condition of SLT usage. The respondents suffering from SLT related diseases were 3.7 times as more knowledgeable about the effect of the practice of SLT than the respondents without diseases (p<0.01). Regarding the knowledge about the health consequences of the practice of SLT, one participant in the FGD session commented that “although the mouth is the gateway to health, we infected our mouth by using Zarda and Gul”. Again, informants opined that peer, family, curiosity and hospitality, culture are influencing factors for SLT initiation.

Conclusion

counselling on tobacco, including SLT, health hazards have to be emphasized through mass media and it is essential for development of relevant policies and communication messages to make people aware of serious health consequences of SLT usages.

The Impact of Red Light Cameras on Crashes Within Miami-Dade County, Florida

OBJECTIVE

To determine the safety effect of red light camera (RLC) programs, this study attempted to estimate its impact on collisions within Miami-Dade County, Florida Methods: A before-after evaluation using a comparison group along with traffic control correction was employed. Twenty signalized intersections with RLCs that began enforcement on January 1, 2011, were matched to 2 comparison sites located at least 2 miles from camera sites to minimize spillover effect. An empirical Bayes analysis was used to account for potential regression to the mean effects. An index of effectiveness along with 95% confidence intervals were calculated based on the comparison between the estimated and actual number of crashes in the after period.

RESULTS

During the first year, RLC sites experienced a marginal decrease in right angle/turn collisions (-3%), a significant increase in rear-end collisions (+40%), and significant decreases in all injury (-19%) and RLR-related injury collisions (-24%). An increase in right angle/turning (+14%) and rear-end (+51%) collisions at the RLC sites was observed after 2 years despite camera enforcement. A significant reduction in RLR-related injury crashes (-17%), however, was still observed after 2 years. A nonsignificant decline in all injury collisions (-12%) was also noted.

CONCLUSIONS

RLCs showed a benefit in reducing RLR-related injury collisions at camera sites after enforcement commenced, yet its tradeoff was a large increase in rear-end collisions. There was inconclusive evidence whether RLCs affected right angle/turning and all injury collisions. Statutory changes in crash reporting during the second year of camera enforcement affected the incidence of right angle and rear-end collisions; nevertheless, a "novelty effect" could not be ruled out. Future research should consider events such as low frequencies of severe injury/fatal collisions and changes in crash reporting requirements when conducting RLC analyses.

The effectiveness of red light cameras in the United States-a literature review

OBJECTIVE

To examine the available scientific evidence based on peer-reviewed publications concerning the effectiveness of red light cameras (RLCs) within the U.S. traffic system.

METHODS

Relevant literature published prior to December 2012 was retrieved from the PubMed, Medline, and Engineering Index databases using free-text term queries. Jurisdictions with either a fixed number of RLCs studied or area wide programs within the United States were included. RLC studies with additional interventions were excluded. Nine RLC studies were extracted and grouped into 3 categories based on outcome measures: violations, crashes, and injuries/fatalities.

RESULTS

All 9 studies reviewed showed significant reductions in the frequency/rate of violations, crashes, and injuries at intersections after RLC implementation. RLC interventions appear to decrease violations, crashes, and injuries at intersections.

CONCLUSIONS

Despite limited peer-reviewed publications available in the literature, it appears that RLCs decrease violations, crashes, and injuries at intersections. Some studies, however, contained methodological shortcomings. Therefore, the apparent effectiveness should be confirmed with stronger methodological approaches. Although spillover effects appeared to be evident, many of the jurisdictions examined were small in area. Thus, it is unknown whether spillover resulting from RLCs would have similar effects in large metropolitan areas. To determine the full public health impact of RLC programs, crashes, injuries, and fatalities should be considered as primary outcomes of interest. To accomplish this requires a clear definition of which types of crashes will be included for RLC studies. Lastly, it is unknown whether RLCs would be effective in reducing crashes resulting from distracted or alcohol-impaired drivers. Future studies should examine the effects of RLCs by exclusively analyzing these crash types.

Factors explaining racial/ethnic disparities in rates of physician recommendation for colorectal cancer screening

OBJECTIVES

Physician recommendation plays a crucial role in receiving endoscopic screening for colorectal cancer (CRC). This study explored factors associated with racial/ethnic differences in rates of screening recommendation.

METHODS

Data on 5900 adults eligible for endoscopic screening were obtained from the National Health Interview Survey. Odds ratios of receiving an endoscopy recommendation were calculated for selected variables. Planned, sequenced logistic regressions were conducted to examine the extent to which socioeconomic and health care variables account for racial/ethnic disparities in recommendation rates.

RESULTS

Differential rates were observed for CRC screening and screening recommendations among racial/ethnic groups. Compared with Whites, Hispanics were 34% less likely (P < .01) and Blacks were 26% less likely (P < .05) to receive this recommendation. The main predictors that emerged in sequenced analysis were education for Hispanics and Blacks and income for Blacks. After accounting for the effects of usual source of care, insurance coverage, and education, the disparity reduced and became statistically insignificant.

CONCLUSIONS

Socioeconomic status and access to health care may explain major racial/ethnic disparities in CRC screening recommendation rates.

Family history of cancer and its association with breast cancer risk perception and repeat mammography

OBJECTIVES

We examined the strength of association between family history of breast cancer and family history of other cancers with breast cancer risk perception and repeat mammography.

METHODS

The sample included 6706 women, aged 46 to 74 years, with no breast cancer history. Multinomial logistic regression assessed the association between family history of cancer and breast cancer risk perception. Structural equation modeling estimated the relationship between family history of cancer and repeat mammography.

RESULTS

Breast cancer risk perception was strongly associated with family history of breast cancer in the mother or mother and sister (odds ratio [OR] = 32.15; P < .001); family history of breast cancer in the sister, daughter, or male first-degree relative (OR = 6.6-8.4; P < .001); and maternal history of other cancers (OR = 1.38-2.73; P < .001). For repeat mammography, women with maternal history of breast cancer had a mean increase of 0.50 more mammograms in the past 6 years compared with women without maternal history of breast cancer (P < .001).

CONCLUSIONS

Breast cancer risk perception was associated with the type of cancer found in first-degree relatives and with the person's relationship to the family member with cancer. Family history of breast cancer affected repeat mammography behavior.

Assessment of the effects of teaching germ theory on changes in hygiene behaviors, cleanliness, and diarrheal incidence in rural bangladesh

Germ theory was taught as part of a hygiene intervention in five villages in Bangladesh in which 87 percent of mothers were illiterate. Volunteer mothers taught other community mothers interactively in small groups using demonstration and teaching aids developed by a community working group. At final measurement 91 percent of mothers could explain five simple messages defining germ theory. Using germ theory in groups they identified forty high risk day-to-day practices and modified them to reduce diarrheal transmission. They adopted these new hygiene practices at rates ranging from 65 percent to 100 percent. Regression analysis suggests that understanding of germ theory was an important determinant of hygiene practices, cleanliness, and reduction in diarrheal incidence. Understanding of germ theory appeared to reduce diarrheal incidence not only through the interventions designed by the project but also changing perceptions of risk in the environment which led to spontaneous improvement in hygiene behaviors. We believe that accurate understanding of causes, transmission, and prevention of disease can 1) empower community and individual actions; and 2) contribute significantly to the impact of hygiene interventions. Therefore, it may be imperative to integrate teaching germ theory into community health education.

Breastfeeding and cognitive development of children: assessment at one year of age

Breastfeeding is the fundamental component of child survival strategy. It significantly influences neurological development of children. The study was conducted to assess whether exclusive and prolonged breastfeeding improves children's cognitive development, including low birth weight (LBW) babies, in a developing country setting like Bangladesh. This observational study was done on a cohort of newborn infants who were discharged from the special care baby unit of Dhaka Shishu Hospital during January 2006 to December 2008 with proper counseling about exclusive and prolonged breastfeeding. Their neuro-developmental follow-up was started at 4 weeks postnatal age and continued at 3-monthly intervals up to 1 year of age. At each visit, cognitive development was assessed using the Bayley Scales of Infant Development (BSID II). Cognitive development was compared between the babies of exclusive vs. non exclusive breastfeeding, normal weight vs. low birth weight and male vs. female babies. A total of 105 cases were successfully followed-up during this period. Out of these 47(44.8%) babies were exclusively breastfed up to 6 month of age and 58(55.2%) were in nonexclusive group. Overall Psychomotor Development Index (PDI) was slightly more (108.40 ± 23.06 vs. 103.23 ± 19.87) in the exclusive breast fed babies in comparison to nonexclusive breast fed babies, but was significantly more in babies having birth weight >2.5 kg in comparison to those having birth weight of <2.5 kg. Other parameters of cognitive development were more or less same in both normal and LBW groups. Mental and motor development was same in both boys and girls. In behavior ratings, cooperation was significantly high (5.89 ± 2.54 vs. 4.71 ± 3.13, p=0.05) and vocalization (5.89 ± 1.07 vs. 4.58 ± 1.16) was also high, though not significant, in girls than boys.

Clustering very low-income, insured women's mammography screening barriers into potentially functional subgroups

BACKGROUND

Mammography screening is essential for early detection of breast cancer and increased survival rates. Women, particularly those of low socioeconomic status, face barriers that impede their screening adherence. Although many studies have sought to identify these barriers, more research is needed on to address these obstacles in practice. The objective of this study is to divide mammography screening barriers into functional clusters using empirical evidence, which may guide the development of effective mammography screening promotion messages.

METHODS

A sample of 173 low-income White and Black women randomly selected from a managed care organization rated each of 21 potential mammography barriers on a scale ranging from "strongly agree" to "strongly disagree." A maximum clustering similarity method was used to identify relevant clusters of screening barriers.

RESULTS

Five clusters were derived, with a high similarity index (0.881). Each cluster was named to reflect the shared theme of the barriers within it: Perceived Lack of Value in Health Care, Lack of Information, Mistrust/Skepticism, Medical Delay Behavior, and Anxiety/No Control. A dominant barrier within each cluster was identified, and bivariate correlation coefficients were reported.

CONCLUSION

Cluster analysis yielded five distinct subgroups of mammography screening barriers.

Randomized controlled trial of mammography intervention in insured very low-income women

BACKGROUND

The expectation that insurance coverage mitigates health disparities and equalizes use of healthcare assumes that services are equally accessed; however, the insured low-income target population in this research had a mammography rate of 23.4%, well below the general population. Our objective was to determine the most effective intervention to improve mammography use in low-income women insured by a managed care organization (MCO).

METHODS

The study was a randomized controlled trial. Participants were 2,357 women noncompliant with screening mammography randomly assigned to one of three groups: control (n = 786) received usual care; simple intervention (n = 785) received prompt letter from the MCO medical director; and stepwise intervention (n = 786) received the same prompt letter from the MCO; if noncompliant, a second prompt letter from their primary care physician and, if still noncompliant, counseling from lay health workers. Outcome was completion of screening mammography extracted from medical records.

RESULTS

Screening rates were 13.4% for the control, 16.1% for the simple intervention, and 27.1% for the stepwise intervention. Compared with the control, the primary care physician letter in the stepwise intervention increased the likelihood of screening by 80% [Relative Risk (RR) = 1.80; P < 0.001], and counseling tripled the likelihood of screening (RR = 3.11; P < 0.001).

CONCLUSIONS

Compared with the control and simple intervention, a stepwise intervention to increase mammography is effective in a target population of hard-to-reach, low-income, insured women.

IMPACT

The research provides evidence for the impact of stepwise interventions to improve cancer screening in low-income insured populations, although the screening rates remain well below those of the general population.

Breast cancer knowledge and barriers to mammography in a low-income managed care population

BACKGROUND

Low-income women experience multiple barriers to screening mammography. This study explored cancer knowledge as a point of intervention to reduce overall barriers.

METHODS

A survey of breast cancer knowledge and barriers was obtained from 173 low-income female residents of Middle Tennessee, > or =40 years, enrolled in the state managed care organization and nonadherent to mammography. Multiple regression models examined the effect of breast cancer knowledge on mammography screening barriers.

RESULTS

Comprehensive breast cancer knowledge, not mere screening awareness, was the strongest contributor towards lower barrier scores.

CONCLUSIONS

Strategies to overcome mammography barriers should include comprehensive breast cancer education.

Comparison of haematological values among different groups of low birth weight babies and normal birth weight babies

This prospective cross sectional study was carried out in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka. This study was undertaken to compare the haematological value (reference range) among Small for gestational age-low birth weight (SGA-LBW), Appropriate for gestational age-low birth weight (AGA-LBW) and Normal birth weight (NBW) babies. Total 90 (ninety) newborn babies were enrolled in this study. They were ultimately divided into three groups as a) Group I (SGA-LBW), b) Group II (AGA-LBW), c) Group III (NBW). Study period was one year (December 2003 to December 2004), Relevant informations were collected from the guardian of the babies before inclusion in the study. In group I, 19(63.3%) were preterm and 11(36.7%) were term. In group II, 30(100%) were preterm and in group III, 30(100%) were term. Mean Hb, and HCT levels were highest in group I (SGA-LBW) and the value was 17.14+/-1.41 gm/dl (Hb) and 0.51+/-0.04 (HCT) respectively. Mean Hb and HCT value were lowest in group II (AGA-LBW) and the value was 14.57+/-1.78 gm/dl (Hb) and 0.43+/-0.05 (HCT) respectively. In between value was found in group III (NBW) and the value was 16.14+/-1.09 gm/dl (Hb) and 0.48+/-0.04 (HCT) respectively. Differences were statistically significant. On the contrary, MCV Values were highest in group II (AGA-LBW) and the value was 103.23+/-4.99 (fl). Lowest MCV value was in group III (NBW) and the value was 98.13+/-3.93 (fl). In between result of MCV value was found in group I (SGA-LBW) and the value was 99.27+/-10.73 (fl). Differences were also statistically significant. MCH and MCHC level was also highest in group I (SGA-LBW). Difference was also statistically significant. No significant differences of TC of WBC and platelet counts were not found among different groups. Hb and HCT level had significant positive correlation with gestational age. Other parameters had no Positive correlation with gestational age.

Colorectal cancer prevention: adherence patterns and correlates of tests done for screening purposes within United States populations

BACKGROUND

Studies exploring CRC testing prevalence and correlates within US populations have provided limited and sometimes conflicting information. The most recent national-level reports have described US usage of CRC tests but none have considered only those tests done specifically for screening reasons as an outcome variable.

METHODS

Using the NHIS 2000 sample of >or=50 year-old, we assessed screening behavior using an outcome variable accounting for (1) any combination of recommended tests (2) done within their respective time guidelines, and (3) specifically for screening purposes.

RESULTS

Only 25.8% (95% CI: 24.9-26.7%) of the population reported getting a test done for screening purposes within the recommended time. Most (>85%) of the FOBTs and only about 60% of endoscopies were done for screening. Among those who had an endoscopy within the recommended time, Blacks were more likely than Whites to report screening as the purpose of the test. Hispanics had the lowest test usage irrespective of test time, reason or type. Hispanics were 50% (p<0.001) less likely to be adherent, and Blacks approximately 22% (p<0.01) less likely to be adherent, than Whites. After multivariate adjustment, differences between Whites and Blacks disappeared; Hispanics remained less likely. Increasing education predicted higher adherence among Whites but only undergraduate completion did so among Blacks. Male gender predicted adherence only among Blacks and insurance only among Hispanics.

CONCLUSIONS

Preventive screening for CRC is lower than estimates from previous studies. Future studies should consider accounting for test purpose. Our findings need confirmation through studies based on objective data.

Changes Needed in the Healthcare System

Lay health workers can play a crucial role in connecting the community-in-need to the healthcare system. This article provides insights into how lay health workers, selected from underserved communities, view the issues faced in accessing the healthcare system. A sample of lay health workers responded to a questionnaire used to identify barriers they, themselves, experienced as well as get their perspectives on obstacles faced by their clients. The results demonstrated that lay health workers perceived themselves less affected by barriers as compared with their clients in regard to their provider relationship, getting health information, and their own personal attitudes and beliefs about healthcare. In addition, focus group discussions yielded recommendations and potential solutions to reduce barriers and improve the healthcare system, which included improved access to the facilities, management, scope of services offered, and provider behaviors. These results may benefit the efforts of healthcare professionals and researchers by enhancing their knowledge of, and facility to utilize and deploy, community resources, and, in turn, will assist underserved populations to better negotiate the system and obtain the services they need the most.

Impact of a two-city community cancer prevention intervention on African Americans

We report the first multisite, multicomponent community intervention trial to focus on cancer prevention in African Americans. The project explored the potential of historically black medical schools to deliver health information to their local communities and used a community-based participatory research approach. The intervention consisted of culturally sensitive messages at appropriate educational levels delivered over an 18-month period and tested in predominantly black census tracts in Nashville, TN and Atlanta, GA. Chattanooga, TN and Decatur, GA served as comparison cities. Results were evaluated by pre- and postintervention random-digit dial telephone surveys. The intervention cities showed an increase in reported contact with or knowledge of the project. There was little or no effect on knowledge or attitudes in the intervention cities. Compared to Chattanooga, Nashville showed an increase in percentage of women receiving Pap smears. Compared to Decatur, Atlanta showed an increase in percentage of age-appropriate populations receiving digital rectal exams, colorectal cancer screenings and mammograms. The results of this community intervention trial demonstrated modest success and are encouraging for future efforts of longer duration.

Effect of race on long-term survival of breast cancer patients: transinstitutional analysis from an inner city hospital and university medical center

Black women have the highest mortality for breast cancer. Our hypothesis is that racial disparities in breast cancer survival persist after controlling for stage of disease and treatment at both a city hospital as well as at a university hospital. Data from tumor registries of breast cancer patients at a city hospital and a university center were analyzed for overall and disease-specific survival, controlling for stage and treatment. Black patients presented with more advanced stages and had significantly worse survival compared with whites. After controlling for stage of disease and treatment, a difference in survival persisted for stage II patients, with blacks doing worse than whites at both institutions. Although there were socioeconomic differences, race was an independent prognostic factor, with black patients having the worse prognosis. The lower survival of black women with breast cancer is only partially explained by their advanced stage at diagnosis. Black women with potentially curable stage II cancer had a lower survival that is not explained by the variables measured.

Effect of Race on Long-Term Survival of Breast Cancer Patients: Transinstitutional Analysis from an Inner City Hospital and University Medical Center

Black women have the highest mortality for breast cancer. Our hypothesis is that racial disparities in breast cancer survival persist after controlling for stage of disease and treatment at both a city hospital as well as at a university hospital. Data from tumor registries of breast cancer patients at a city hospital and a university center were analyzed for overall and disease-specific survival, controlling for stage and treatment. Black patients presented with more advanced stages and had significantly worse survival compared with whites. After controlling for stage of disease and treatment, a difference in survival persisted for stage II patients, with blacks doing worse than whites at both institutions. Although there were socioeconomic differences, race was an independent prognostic factor, with black patients having the worse prognosis. The lower survival of black women with breast cancer is only partially explained by their advanced stage at diagnosis. Black women with potentially curable stage II cancer had a lower survival that is not explained by the variables measured.

Empowering factors for regular mammography screening in under-served populations: pilot survey results in Tennessee

BACKGROUND

Mammography screening can reduce breast cancer burden, however it continues to be underutilized by low-income women even though their health insurance provides free mammograms. While a vast majority of eligible women in Tennessee do not receive the free mammograms available to them, 25% of women with comparable backgrounds do.

OBJECTIVE

To describe the influences that may have led these women to adhere to mammography screening guidelines in order to develop a case-control study for further research.

DESIGN

Healthcare workers conducted personal interviews on mammography knowledge, attitudes, and behaviors.

SETTING

In-home.

PARTICIPANTS

All were members of the Managed Care Organization Access MedPlus with incomes <200% above poverty. All were adherent to mammography guidelines per medical records. Fifty-eight respondents were Black, 27 were White, and all were at least 40 years old.

RESULTS

Participants recognized breast cancer risk factors, warning signs, and the importance of early detection to survival. 75% reported a family history of any cancer type, 77% knew someone who had breast cancer, and 52% knew someone who had died from it. These women expressed that screening strongly reassured them. Willing to work with their doctors, they trust the health system's ability to treat breast cancer and are generally satisfied with their health care.

CONCLUSIONS

Repeat regular mammography screening is positively associated with higher knowledge about risk factors, warning signs, screening, and treatment. Trust in the healthcare system, ability to work with physicians, and support by family and friends lead low-income, adhering women to be proactive in seeking mammography screenings.

Racial/ethnic disparity and predictors of leisure-time physical activity among U.S. men

OBJECTIVES

To examine racial/ethnic disparity in and predictors of leisure-time physical activity (LTPA) among men.

METHODS

We used the National Health Interview Surveys (NHIS) 1999-2000 data, a multistage probability sampling design producing a U.S. representative sample of 23,459 adult males. Data were analyzed using multinomial logistic regression.

RESULTS

The likelihood of engaging in irregular or regular LTPA was associated with younger age, being unmarried, lower household sizes, higher levels of education and income, home ownership, U.S. citizenship, perceived better health status, contact with a health professional within a year, being a non-smoker, living in the West, and residing in a midsize metropolitan statistical area. Hispanics were significantly less likely to engage in regular LTPA than Whites and higher percentages of Hispanics were physically inactive in almost all age and education groups when compared to other races. Disparity between Whites and Blacks was less pronounced. Non-citizen Hispanics were twice as likely to be inactive than citizens and White non-citizens were 40% more likely to be inactive than citizens. Conversely, Black citizens were 20% more likely to be inactive than non-citizens.

CONCLUSIONS

Racial/ethnic disparities exist after accounting for socio-demographic characteristics. Not being a citizen exacerbates the disparity between Hispanic and White men. While disparity did exist between Black and White men, this gap was not as large as between Hispanic and White men. Health-seeking behaviors, such as contact with a health professional and non-smoking status are modifiable and influence men of all racial and ethnic backgrounds to engage in LTPA.

Empowering factors in repeat mammography: insights from the stories of underserved women

Screening mammography can reduce breast cancer mortality. Although a significant percentage of underserved women obtain low income, minority mammograms regularly women underutilize mammography and rates of regular screening are also very low in the general population. By structuring focus groups around constructs from the Precede-Proceed Model, our study explored how these underserved women overcame barriers to be screened on a regular basis. Twenty-eight items were categorized as personal factors that helped them overcome the barriers: awareness and knowledge of risk factors (age and family history); knowledge and trust in early detection and treatment processes; personal responsibility about own health and well-being; and pride in self and satisfaction with one's own actions.

Amniotic fluid concentrations of collagenase-1 and collagenase-3 are increased in polyhydramnios

OBJECTIVE

Polyhydramnios places increased tension on the fetal membranes and should conceptually be associated with an increased need for tissue remodeling to prevent premature rupture of membranes (PROM). Herein we use polyhydramnios as a model to study the association of the collagenase class of matrix metalloproteinases (MMPs) with tissue remodeling during pregnancy.

METHODS

Amniotic fluids were collected by transabdominal amniocentesis from women with polyhydramnios and from women with normal amniotic fluid volume at second trimester, third trimester and at term. Fluids were assayed for MMP-1 and MMP-13 (collagenase-1 and 3) using ELISA. The concentrations in polyhydramnios were compared with subjects undergoing amniocentesis with normal amniotic fluid volume. Statistical comparisons were made using Scheffe's method for correction in multiple means comparison. P of <0.05 was considered statistically significant.

RESULTS

MMP-1 and MMP-13 are present in the amniotic fluid at all stages of pregnancy. The concentrations of these MMPs were significantly elevated in the polyhydramnios samples independent of gestational age.

CONCLUSION

Polyhydramnios is associated with increased amniotic fluid concentrations of MMP-1 and MMP-13 suggesting their role in tissue remodeling.

Prevalence and correlates of initiation of smoking behavior among preteen black and white children

This study estimated smoking prevalence and identified factors associated with initiation among preteens in Nashville, TN. An anonymous, self-administrated questionnaire was given to 238 fifth- and sixth-graders in a middle-class neighborhood school. The mean age at initiation was 8.5 years (range 6-11 years). Overall, 10.5% of students had ever smoked; 16.1% of blacks and 9.3% of whites. Eighty-six percent continued to smoke. Black sixth-graders smoked (26.9%) four times the rate of black fifth-graders and 2.5 times that of white sixth-graders. Relatives initiated 78% of blacks while friends initiated 68% of whites. One-quarter of smokers got their cigarettes at home. Regular attendees of religious services had a lower smoking rate (6.9% versus 16.4%; p=0.01). Smoking rates decreased with increased knowledge of risks (p=0.00001). Among smokers, none believed that smoking is a risk factor for heart disease, 96% did not believe that smoking has any short-term health effects or is a risk factor for stroke. Few ever-smokers had a complete understanding of the health risks. Targeted messages and curriculum should be developed to teach preteens about the short- and long-term dangers of smoking. Clinicians can play a major role in educating their clients about the risks of smoking.

Using focus groups to understand health-related practices and perceptions of African Americans: Nashville REACH 2010 preliminary findings

To gain an understanding of health-related practices and perceptions, Nashville REACH 2010 conducted focus studies among 5 community groups. Attitudes about health, personal risk behaviors, quality of health care, and models of personal behavior change were assessed. All focus-group sessions were transcribed and analyzed using a consensus panel methodology. A combined analysis of the focus groups revealed 3 categories of barriers to healthier living: 1) personal, 2) environmental, and 3) systemic. Personal barriers included lack of adequate finances, physical limitations, lack of knowledge, and stress. Environmental barriers were related to the unavailability of healthy food choices and adequate places to exercise in the community. The accessibility and quality of health care were the most pervasive systemic barriers identified. Though these findings are not novel to urban African-American communities, they will serve as the framework by which Nashville REACH 2010 will implement strategies to reduce and, ultimately, eliminate cardiovascular disease and diabetes disparities.

Impact of a Drug Abuse Resistance Education (D.A.R.E) program in preventing the initiation of cigarette smoking in fifth- and sixth-grade students

An alarmingly high number of children become addicted to tobacco use. To teach children the skills to resist the influences surrounding the initiation of tobacco and other drug use, a Drug Abuse Resistance Education (D.A.R.E.) program is being implemented in three fourths of the schools in the United States. The purpose of this study is to examine the impact of this program in preventing smoking. A survey was conducted among 236 fifth and sixth graders in Nashville, Tennessee. Of the students included in the survey, 88% graduated from D.A.R.E. Approximately 11.6% of respondents had ever smoked cigarettes; 86% of them continued to smoke. The D.A.R.E. group had a significantly lower rate of smoking compared with their non-D.A.R.E. counterparts (8.7% vs. 28.0%; p = 0.0001). Logistic regression analysis shows that the D.A.R.E. group was five times (odds 4.9; p = 0.003; 95% CI: 1.7, 14.0) less likely to initiate smoking compared with the non-D.A.R.E. group. The D.A.R.E. group had a significantly (p = 0.002) higher knowledge score on the risk of smoking. The knowledge score has strong opposite correlation to smoking behavior (p = 0.00001). Students with top-quartile knowledge scores had a substantially lower rates of smoking (1.4% vs. 14.4%; p = 0.001). This finding is consistent for both African-American (0% vs. 19.6%; p = 0.001) and white children (1.9% vs. 13%; p = 0.001). The D.A.R.E. program may have an impact in preventing the initiation of smoking behavior.

How the health care system can improve mammography-screening rates for underserved women: a closer look at the health care delivery system

The way care is delivered has dramatic impact on the patient-provider interaction and the outcomes experienced by the patient. This article explores a deceptively simple but very powerful method for evaluating and improving care delivery. Mammography is a routine screening procedure. However, many factors can influence how frequently women seek and obtain mammograms. Twenty-five low-income women identified empowering factors and barriers they experienced when trying to obtain a mammogram.

Aberrant expression of MSG1 transcriptional activator in human malignant melanoma in vivo

MSG1 was originally isolated as a candidate pigmentation-related gene. MSG1 mRNA transcripts were expressed strongly in cultured human and mouse normal epidermal melanocytes, and in highly pigmented mouse melanoma cells, while its expression was very weak in cultured non-pigmented human melanoma cells. Thus, MSG1 was initially proposed to be a melanocyte-specific gene, and its possible role in pigmentation has been speculated. It was found recently that the MSG1 protein interacts functionally with Smad4, which plays a pivotal role in signal transduction of transforming growth factor-beta. In this study, we analyzed MSG1 protein expression by immunohistochemistry using human tumor samples from nevus and malignant melanoma to reveal its role in pigmentation and melanoma development in vivo. A relatively strong but heterogeneous expression of MSG1 protein was seen in melanomas compared with weak expression in nevi. In nevi, MSG1 expression was mostly confined to the pigmented region, while it was expressed in both pigmented and non-pigmented regions in melanoma. Intracellularly, MSG1 protein was localized in the cytoplasm of nevus cells, but was seen in both nuclei and cytoplasm of melanoma cells. These results support a hypothesis that MSG1 plays a role in pigmentation. It is also suggested that MSG1 may be involved in malignant transformation of pigment cells. Alternatively, the aberrant expression of MSG1 in melanoma cells might be due to the abnormal environment, including aberrant cytokine or growth factor expression, associated with melanoma formation.

Protective effect of topically applied olive oil against photocarcinogenesis following UVB exposure of mice

Reactive oxygen species have been shown to play a role in ultraviolet light (UV)-induced skin carcinogenesis. Vitamin E and green tea polyphenols reduce experimental skin cancers in mice mainly because of their antioxidant properties. Since olive oil has also been reported to be a potent antioxidant, we examined its effect on UVB-induced skin carcinogenesis in hairless mice. Extra-virgin olive oil was applied topically before or after repeated exposure of mice to UVB. The onset of UVB-induced skin tumors was delayed in mice painted with olive oil compared with UVB control mice. However, with increasing numbers of UVB exposures, differences in the mean number of tumors between UVB control mice and mice pretreated with olive oil before UVB exposure (pre-UVB group) were lost. In contrast, mice that received olive oil after UVB exposure (post-UVB group) showed significantly lower numbers of tumors per mouse than those in the UVB control group throughout the experimental period. The mean number of tumors per mouse in the UVB control, pre-UVB and post-UVB groups was 7.33, 6.69 and 2.64, respectively, in the first experiment, and 8.53, 9.53 and 3.36 in the second experiment. Camellia oil was also applied, using the same experimental protocol, but did not have a suppressive effect. Immunohistochemical analysis of DNA damage in the form of cyclobutane pyrimidine dimers (CPD), (6-4) photoproducts and 8-hydroxy-2'-deoxyguanosine (8-OHdG) in samples taken 30 min after a single exposure of UVB showed no significant difference between UVB-irradiated control mice and the pre-UVB group. In the post-UVB group, there were lower levels of 8-OHdG in epidermal nuclei, but the formation of CPD and (6-4) photoproducts did not differ. Exposure of olive oil to UVB before application abrogated the protective effect on 8-OHdG formation. These results indicate that olive oil topically applied after UVB exposure can effectively reduce UVB-induced murine skin tumors, possibly via its antioxidant effects in reducing DNA damage by reactive oxygen species, and that the effective component may be labile to UVB.

Preventive effect of antioxidant on ultraviolet-induced skin cancer in mice

Reactive oxygen species (ROS) have been shown to be responsible for inducing DNA damage after ultraviolet radiation (UV). Antioxidant, vitamin E and epigallocatechin gallate extracted from green tea, applied topically to the skin, delayed the onset of UV-induced skin cancer in mice. Since olive oil is reported to have a potent antioxidative effect in in vitro system, we asked whether, topical use of olive oil reduces the number and delays the onset of UV-induced skin cancer in mice. We found that super virgin olive oil painted immediately after UVB radiation significantly delayed the onset and reduced the number of skin cancer, but pretreatment of super virgin olive oil and pre- and/or post treatment by regular olive oil neither retarded nor reduced skin cancer formation in UV-irradiated mice. Further, 8-hydroxy-deoxyguanosine (8-OHdG) formation in mice epidermis was apparently reduced by super virgin olive oil painted immediately after UV radiation, although cyclobutane pyrimidine dimers and (6-4) photoproducts were not reduced by olive oil treatment. Our results suggest that daily topical use of super virgin olive oil after sun bathing may delay and reduce UV-induced skin cancer development in human skin, possibly by decreasing ROS-induced 8-OHdG which is responsible for gene mutation.

Difficulty in reaching low-income women for screening mammography

Low-income women have a high mortality from breast cancer. Yet, they participate in breast cancer early detection screening programs less than women in the general population. An intervention study to improve screening mammography rates of low-income women participating in Tennessee's TennCare program (state Medicaid and Medicare program) revealed significant barriers to reaching these women. Intervention methods included mail, telephone calls, and home visits. Results indicate that only 38 percent of the women could be contacted for a baseline survey. Reasons for noncontact included absence from home (39 percent), having moved (22 percent), refusal to participate (17 percent), having no physical domicile (15 percent), language barriers (4 percent), and miscellaneous other factors (4 percent). Women with telephones tended to have a relatively higher economic status and were more successfully reached than women without telephones. These findings provide useful insights for future program planning and research design.

The inhibitory effect of DL-alpha-tocopheryl ferulate in lecithin on melanogenesis

Oral vitamin E (alpha-tocopherol) supplementation has been reported to improve facial hyperpigmentation. The compound of alpha-tocopherol and ferulic acid, also an antioxidant connected with an ester bond, alpha-tocopheryl ferulate (alpha-TF) can absorb ultraviolet (UV) radiation and thus maintain tocopherol in a stable state. Our aim was to determine whether alpha-TF can be applied to improve and prevent facial hyperpigmentation induced by UV as a whitening agent as well as an antioxidant. In this study, the effects of alpha-TF on melanogenesis were examined using cultured human melanoma cells and normal human melanocytes in vitro. alpha-TF solubilized in 0.5% lecithin inhibited melanization significantly at the concentration of 30 micrograms/ml compared with arbutin (100 micrograms/ml), kojic acid (100 micrograms/ml), ascorbic acid (600 micrograms/ml), and tranexamic acid (600 micrograms/ml). alpha-TF had no effect on the protein amounts of tyrosinase, TRP (tyrosinase related protein)-1, and TRP-2 of human melanoma cells exposed to UV radiation, but inhibited tyrosine hydroxylase activity. alpha-TF neither directly inhibited tyrosinase activity of the large granule fraction extracted from melanoma cells, nor modulated glycosylation of tyrosinase. These results suggest that alpha-TF may be a candidate for whitening agent which suppresses melanogenesis, possibly by inhibiting tyrosine hydroxylase activity in an indirect manner. Further, alpha-TF decreased the amount of 8-hydroxydeoxyguanosine produced indirectly through active oxygen species (AOS) in guinea pig skin exposed to 2 times the minimal erythema dose of UVB radiation, but did not suppress the direct formation of cyclobutane pyrimidine dimers and (6-4) photoproducts. Thus alpha-TF may reduce AOS-induced DNA damage and thereby contribute at least in part to suppressing or retarding skin cancer development.

Induced expression of p16 and p21 proteins in UVB-irradiated human epidermis and cultured keratinocytes

It has been suggested that p16INK4a, the product of the cyclin-dependent kinase inhibitor 2 or multiple tumor suppressor 1 gene, prevents phosphorylation of the retinoblastoma gene product, and thus acts as a negative cell cycle regulator. To elucidate an effect of ultraviolet B (UVB) radiation on p16 expression and its relation to p21, and proliferating cell nuclear antigen (PCNA), immunohistochemical and western blot analyses were performed on UVB-irradiated normal human epidermis and cultured keratinocytes, respectively. Little p16 protein was seen in the control epidermis or keratinocytes. Increases in the levels of p16 protein in both UVB-irradiated epidermis and keratinocytes occurred in a similar manner, in which p16 was induced at 24-48 h and peaked at 72-120 h after irradiation. The induced expression of p21 was observed relatively earlier than that of p16, with peaked expression at 24-48 h and a return to control level by 168 h. PCNA expression was increased slightly until 48 h but significantly increased during 48-168 h of post-irradiation with peak expression at 72 h. These results indicate that together with p21, p16 protein may play an important role for protective or adaptive response to UVB exposure of human skin.

High levels of 8-hydroxy-2'-deoxyguanosine appear in normal human epidermis after a single dose of ultraviolet radiation

Major photoproducts induced by carcinogenic ultraviolet (UV) radiation are the cylobutane pyrimidine dimers (CPDs) and pyrimidine-pyrimidone (6-4) photoproducts (6-4 PPs). 8-Hydroxy-2 -deoxyguanosine (8-OHdG) is also a DNA base-modified product generated by reactive oxygen species in conditions of ultraviolet stress, Although UVB-induced CPDs and 6-4 PPs have been investigated in animal and human skin, little is known about the role of 8-OHdG in UVB-induced human skin damage or carcinogenesis. Normal human skin from three volunteers was exposed to UV radiation, and the time course of induction and removal of 8-OHdG was examined by immunohistochemical analysis with catalysed signal amplification on formalin-fixed paraffin sections. Formation of CPDs and 6-4 PPs was also examined by immunostaining on the same skin specimens. Control epidermis with no exposure to UV radiation showed little nuclear staining of 8-OHdG, but an increased level of 8-OHdG was clearly observed in epidermis biopsied after irradiation. Induced 8-OHdG can rapidly be removed from nucleus during the first 24-48 h, as the staining intensity diminished gradually, almost reaching the control level by 72-96 h after irradiation. Staining for CPDs or 6-4 PPs revealed induction of these photoproducts in human skin, although 6-4 PP-positive cells disappeared more rapidly than those that stained for CPDs or 8-OHdG. Together with protective effect of antioxidants, our results indicate that not only CPDs and 6-4 PPs but also 8-OHdG may play a significant part in UV carcinogenesis.