[show abstract][hide abstract] ABSTRACT: Prevalence of human immunodeficiency virus (HIV) infection has reached 16% among non-injecting drug users (NIDU) in New York City, an unusually high prevalence for a predominantly heterosexual population that does not inject drugs. Using a long-term study (1983-2011, >7,000 subjects) among persons entering the Beth Israel drug-treatment programs in New York City, we identified factors that contributed to this high prevalence: a preexisting HIV epidemic among injectors, a crack cocaine epidemic, mixing between injectors and crack users, policy responses not centered on public health, and herpes-simplex virus 2 facilitating HIV transmission. Implications for avoiding high prevalence among NIDU in other areas are discussed.
Substance Use & Misuse 02/2014; · 1.11 Impact Factor
[show abstract][hide abstract] ABSTRACT: To examine herpes simplex virus 2 (HSV-2)/HIV co-infection as a contributing factor in the increase in HIV infection among non-injecting heroin and cocaine users in New York City.
Subjects were recruited from the Beth Israel Medical Center drug detoxification and methadone maintenance programs in New York City in 1995-1999 and 2005-2011. All reported current heroin and/or cocaine use and no injection drug use. A structured questionnaire was administered and serum samples collected for HIV and HSV-2 testing. Population-attributable risk percentages (PAR%s) were estimated for associations between HSV-2 and increased susceptibility to and increased transmissibility of HIV among female NIDUs.
785 subjects were recruited from 1995-1999, and 1764 subjects from 2005-2011. HIV prevalence increased from 7% to 13%, with nearly uniform increases among all demographic subgroups. HSV-2/HIV co-infection was common in both time periods, with an average (over the two time periods) of 80% of HIV negative females infected with HSV-2, an average of 43% of HIV negative males infected with HSV-2; an average of 97% of HIV positive females also infected with HSV-2 and an average of 67% of HIV positive males also infected with HSV-2. The increase in HIV prevalence was predominantly an increase in HSV-2/HIV co-infection, with relatively little HIV mono-infection in either time period. The estimated PAR%s indicate that approximately half of HIV acquisition among females was caused by HSV-2 infection and approximately 60% of HIV transmission from females was due to HSV-2 co-infection.
The increase in HIV infection among these non-injecting drug users is better considered as an increase in HSV-2/HIV co-infection rather than simply an increase in HIV prevalence. Additional interventions (such as treatment as prevention and suppressing the effects of HSV-2 on HIV transmission) are needed to reduce further HIV transmission from HSV-2/HIV co-infected non-injecting drug users.
PLoS ONE 01/2014; 9(1):e87993. · 3.73 Impact Factor
[show abstract][hide abstract] ABSTRACT: Background
Men who have sex with men (MSM), particularly young black MSM, are disproportionately affected in the United States’ HIV epidemic. Drug use may contribute to these disparities, yet previous studies have failed to provide evidence of elevated use among black MSM, relying exclusively on self-reported usage. This study uses biological assays to validate self-reports of drug use and explore the potential for misclassification to distort findings on racial patterns of use in this population.
From an Atlanta-based cohort study of 454 black and 349 white MSM from 2010 to 2012, participants’ self-reported drug use was compared to urine drug screening findings. The sensitivity of self-report was calculated as the proportion reporting recent usage among those who screened positive. Multivariable regression models were constructed to examine racial patterns in self-report, urine-detection, and self-report sensitivity of marijuana and cocaine usage, adjusted for socio-demographic factors.
In analyses that adjusted for age, education, income, sexual orientation, and history of arrest, black MSM were less likely to report recent use of marijuana (P < 0.001) and cocaine (P = 0.02), but equally likely to screen positive for either drug. This discrepancy between self-reported and urine-detected drug use was explained by significantly lower sensitivity of self-report for black participants (P < 0.001 for marijuana, P < 0.05 for cocaine).
The contribution of individual drug-related risk behaviors to the HIV disparities between black and white MSM should be revisited with methods that validate self-reports of illegal drug use.
[show abstract][hide abstract] ABSTRACT: The reasons for black/white disparities in HIV epidemics among men who have sex with men have puzzled researchers for decades. Understanding reasons for these disparities requires looking beyond individual-level behavioral risk to a more comprehensive framework.
From July 2010-Decemeber 2012, 803 men (454 black, 349 white) were recruited through venue-based and online sampling; consenting men were provided HIV and STI testing, completed a behavioral survey and a sex partner inventory, and provided place of residence for geocoding. HIV prevalence was higher among black (43%) versus white (13% MSM (prevalence ratio (PR) 3.3, 95% confidence interval (CI): 2.5-4.4). Among HIV-positive men, the median CD4 count was significantly lower for black (490 cells/µL) than white (577 cells/µL) MSM; there was no difference in the HIV RNA viral load by race. Black men were younger, more likely to be bisexual and unemployed, had less educational attainment, and reported fewer male sex partners, fewer unprotected anal sex partners, and less non-injection drug use. Black MSM were significantly more likely than white MSM to have rectal chlamydia and gonorrhea, were more likely to have racially concordant partnerships, more likely to have casual (one-time) partners, and less likely to discuss serostatus with partners. The census tracts where black MSM lived had higher rates of poverty and unemployment, and lower median income. They also had lower proportions of male-male households, lower male to female sex ratios, and lower HIV diagnosis rates.
Among black and white MSM in Atlanta, disparities in HIV and STI prevalence by race are comparable to those observed nationally. We identified differences between black and white MSM at the individual, dyadic/sexual network, and community levels. The reasons for black/white disparities in HIV prevalence in Atlanta are complex, and will likely require a multilevel framework to understand comprehensively.
PLoS ONE 01/2014; 9(3):e90514. · 3.73 Impact Factor
[show abstract][hide abstract] ABSTRACT: USA is experiencing a paradigm shift in public housing policy: while policies used to place people who qualified for housing assistance into spatially concentrated housing complexes, they now seek to geographically disperse them, often to voucher-subsidized rental units in the private market. Programs that relocate residents from public housing complexes tend to move them to neighborhoods that are less impoverished and less violent. To date, studies have reached conflicting findings about the relationship between public housing relocations and depression among adult relocaters. The present longitudinal multilevel analysis tests the hypothesis that pre-/postrelocation improvements in local economic conditions, social disorder, and perceived community violence are associated with declines in depressive symptoms in a cohort of African-American adults; active substance misusers were oversampled. We tested this hypothesis in a cohort of 172 adults who were living in one of seven public housing complexes scheduled for relocation and demolition in Atlanta, GA; by design, 20 % were dependent on substances and 50 % misused substances but were not dependent. Baseline data captured prerelocation characteristics of participants; of the seven census tracts where they lived, three waves of postrelocation data were gathered approximately every 9 months thereafter. Surveys were administered at each wave to assess depressive symptoms measured using the Center for Epidemiologic Studies Depression Scale (CES-D), perceived community violence, and other individual-level covariates. Participants' home addresses were geocoded to census tracts at each wave, and administrative data sources were used to characterize tract-level economic disadvantage and social disorder. Hypotheses were tested using multilevel models. Between waves 1 and 2, participants experienced significant improvements in reported depressive symptoms and perceived community violence and in tract-level economic disadvantage and social disorder; these reductions were sustained across waves 2-4. A 1 standard deviation improvement in economic conditions was associated with a 1-unit reduction in CES-D scores; the magnitude of this relationship did not vary by baseline substance misuse or gender. Reduced perceived community violence also predicted lower CES-D scores. Our objective measure of social disorder was unrelated to depressive symptoms. We found that relocaters who experienced greater pre-/postrelocation improvements in economic conditions or in perceived community violence experienced fewer depressive symptoms. Combined with past research, these findings suggest that relocation initiatives should focus on the quality of the places to which relocaters move; future research should also identify pathways linking pre-/postrelocation changes in place characteristics to changes in mental health.
Journal of Urban Health 12/2013; · 1.89 Impact Factor
[show abstract][hide abstract] ABSTRACT: We assessed awareness and use of the "NYC Condom" among persons who use heroin and cocaine in New York City. The NYC Condom distribution program is the largest free condom distribution program in the USA, with over 30 million condoms distributed per year. It includes a condom social marketing program for a specific brand, the NYC Condom with its own packaging and advertising. People who use heroin and cocaine are at relatively high risk for HIV infection and are an important target population for the program. In order to assess awareness of the NYC Condom, structured interviews and blood testing for HIV, HSV-2, and sexually transmitted infections (STI) were conducted among entrants to the Beth Israel Medical Center drug detoxification and methadone treatment programs. Participants were asked about drug use, sexual risk behaviors, and awareness and use of the NYC Condom. Univariate and multivariable regression analyses were conducted to examine the associations between use of NYC Condoms and consistent condom use with primary and casual sexual partners. A total of 970 subjects were recruited between February 2011 and December 2012. Subjects were primarily African-American and Hispanic, with a mean age of 43. Fifty-five percent of subjects reported being sexually active with primary sexual partners, and 25 % reported being sexually active with a casual partner for the 6 months prior to the interview. Sixty-five percent of subjects had heard of the NYC Condom, 48 % of those who had heard of the condom had used it, and 58 % of those who had ever used it were currently using it (in the previous 6 months). In multivariable regression analyses, current use of NYC Condoms was strongly associated with consistent condom use with primary sexual partners (adjusted odds ratio (AOR) = 3.99, 95 % confidence interval (CI) 1.85-8.58) and consistent condom use with casual sexual partners (AOR = 4.48, 95 % CI 1.49-13.42). In terms of market share, 38 % of subjects consistently using condoms with primary partners were using the NYC Condom, and 47 % of those consistently using condoms with casual partners were using the NYC Condom. The NYC Condom is an important tool for reducing sexual transmission of HIV and STI among persons who use drugs in the city. Given the strong relationship between using the NYC Condom and consistent condom use, further efforts to promote the NYC Condom brand would be easily justified.
Journal of Urban Health 12/2013; · 1.89 Impact Factor
[show abstract][hide abstract] ABSTRACT: Examine long term sexual risk behaviors among persons who inject drugs (PWID) in New York City following implementation of "combined" prevention programming, including condom social marketing. Quantitative interviews and human immunodeficiency virus (HIV) testing were conducted among PWID entering Beth Israel Medical Center drug treatment programs 1990-2012. Data were analyzed by four time periods corresponding to the cumulative implementation of HIV prevention interventions. 7,132 subjects were recruited from 1990 to 2012; little change in sexual behavior occurred among HIV seronegative subjects, while HIV seropositive subjects reported significant decreases in being sexually active and significant increases in consistent condom use. HIV transmission risk (being HIV positive and engaging in unprotected sex) declined from 14 % in 1990-1995 to 2 % in 2007-2012 for primary sexual partners and from 6 to 1 % for casual partners. Cumulative implementation of combined prevention programming for PWID was associated with substantial decreases in sexual risk behavior among HIV seropositives.
[show abstract][hide abstract] ABSTRACT: Transitions from injecting to non-injecting drug use have been reported from many different areas, particularly in areas with large human immunodeficiency virus (HIV) epidemics. The extent to which such transitions actually protect against HIV and HCV has not been determined. A cross-sectional survey with HIV and hepatitis C (HCV) testing was conducted with 322 former injectors (persons who had injected illicit drugs but permanently transitioned to non-injecting use) and 801 current injectors recruited in New York City between 2007 and 2012. There were no differences in HIV prevalence, while HCV prevalence was significantly lower among former injectors compared to current injectors. Years injecting functioned as a mediating variable linking former injector status to lower HCV prevalence. Transitions have continued well beyond the reduction in the threat of AIDS to injectors in the city. New interventions to support transitions to non-injecting drug use should be developed and supported by both drug treatment and syringe exchange programs.
Journal of substance abuse treatment 10/2013; · 2.90 Impact Factor
[show abstract][hide abstract] ABSTRACT: Among the largest US metropolitan areas, trends in mortality rates for injection drug users (IDUs) with AIDS vary substantially. Ecosocial, risk environment and dialectical theories suggest many metropolitan areas characteristics that might drive this variation. We assess metropolitan area characteristics associated with decline in mortality rates among IDUs living with AIDS (per 10,000 adult MSA residents) after highly active antiretroviral therapy (HAART) was developed.
This is an ecological cohort study of 86 large US metropolitan areas from 1993-2006. The proportional rate of decline in mortality among IDUs diagnosed with AIDS (as a proportion of adult residents) from 1993-1995 to 2004-2006 was the outcome of interest. This rate of decline was modeled as a function of MSA-level variables suggested by ecosocial, risk environment and dialectical theories. In multiple regression analyses, we used 1993-1995 mortality rates to (partially) control for pre-HAART epidemic history and study how other independent variables affected the outcomes.
In multivariable models, pre-HAART to HAART era increases in 'hard drug' arrest rates and higher pre-HAART income inequality were associated with lower relative declines in mortality rates. Pre-HAART per capita health expenditure and drug abuse treatment rates, and pre- to HAART-era increases in HIV counseling and testing rates, were weakly associated with greater decline in AIDS mortality.
Mortality among IDUs living with AIDS might be decreased by reducing metropolitan income inequality, increasing public health expenditures, and perhaps increasing drug abuse treatment and HIV testing services. Given prior evidence that drug-related arrest rates are associated with higher HIV prevalence rates among IDUs and do not seem to decrease IDU population prevalence, changes in laws and policing practices to reduce such arrests while still protecting public order should be considered.
PLoS ONE 01/2013; 8(2):e57201. · 3.73 Impact Factor
[show abstract][hide abstract] ABSTRACT: To examine the potential contribution of herpes simplex virus 2 (HSV-2) infection to female/male and racial/ethnic disparities in HIV among non-injecting heroin and cocaine drug users. HSV-2 infection increases susceptibility to HIV infection by a factor of two to three.
Subjects were recruited from entrants to the Beth Israel drug detoxification program in New York City 2005-11. All subjects reported current use of heroin and/or cocaine and no lifetime injection drug use. A structured questionnaire was administered and serum samples collected for HIV and HSV-2 testing. Population-attributable risk percentages (PAR%s) were calculated for associations between HSV-2 infection and increased susceptibility to HIV.
1745 subjects were recruited from 2005-11. Overall HIV prevalence was 14%. Females had higher prevalence than males (22% vs. 12%) (p<0.001), African-Americans had the highest prevalence (15%), Hispanics an intermediate prevalence (12%), and Whites the lowest prevalence (3%) (p<.001). There were parallel variations in HSV-2 prevalence (females 86%, males 51%, African-Americans 66%, Hispanics 47%, Whites 36%), HSV-2 prevalence was strongly associated with HIV prevalence (OR = 3.12 95% CI 2.24 to 4.32). PAR%s for HSV-2 as a cause of HIV ranged from 21% for Whites to 50% for females. Adjusting for the effect of increased susceptibility to HIV due to HSV-2 infection greatly reduced all disparities (adjusted prevalence = males 8%, females 11%; Whites 3%, African-Americans 10%, Hispanics 9%).
Female/male and racial/ethnic variations in HSV-2 infection provide a biological mechanism that may generate female/male and racial/ethnic disparities in HIV infection among non-injecting heroin and cocaine users in New York City. HSV-2 infection should be assessed as a potential contributing factor to disparities in sexually transmitted HIV throughout the US.
PLoS ONE 01/2013; 8(6):e66874. · 3.73 Impact Factor
[show abstract][hide abstract] ABSTRACT: People who inject drugs (PWID) have increased risk of morbidity and mortality. We update and present estimates and trends of the prevalence of current PWID and PWID subpopulations in 96 US metropolitan statistical areas (MSAs) for 1992-2007. Current estimates of PWID and PWID subpopulations will help target services and help to understand long-term health trends among PWID populations.
We calculated the number of PWID in the US annually from 1992-2007 and apportioned estimates to MSAs using multiplier methods. We used four types of data indicating drug injection to allocate national annual totals to MSAs, creating four distinct series of component estimates of PWID in each MSA and year. The four component estimates are averaged to create the best estimate of PWID for each MSA and year. We estimated PWID prevalence rates for three subpopulations defined by gender, age, and race/ethnicity. We evaluated trends using multi-level polynomial models.
PWID per 10,000 persons aged 15-64 years varied across MSAs from 31 to 345 in 1992 (median 104.4) to 34 to 324 in 2007 (median 91.5). Trend analysis indicates that this rate declined during the early period and then was relatively stable in 2002-2007. Overall prevalence rates for non-Hispanic black PWID increased in 2005 as compared to other racial/ethnic groups. Hispanic prevalence, in contrast, declined across time. Importantly, results show a worrisome trend in young PWID prevalence since HAART was initiated - the mean prevalence was 90 to 100 per 10,000 youth in 1992-1996, but increased to >120 PWID per 10,000 youth in 2006-2007.
Overall, PWID rates remained constant since 2002, but increased for two subpopulations: non-Hispanic black PWID and young PWID. Estimates of PWID are important for planning and evaluating public health programs to reduce harm among PWID and for understanding related trends in social and health outcomes.
PLoS ONE 01/2013; 8(6):e64789. · 3.73 Impact Factor
[show abstract][hide abstract] ABSTRACT: There are significant relationships between racial residential segregation (RRS) and a range of health outcomes, including cancer-related outcomes. This study explores the contribution of metropolitan area RRS, census tract racial composition and breast cancer and all-cause mortality among black and white breast cancer patients.
This study has three units of analysis: women diagnosed with breast cancer (n = 22,088), census tracts where they lived at diagnosis (n = 1,373), and the metropolitan statistical area (MSA)/micropolitan statistical area (MiSA) where they lived at diagnosis (n = 37). Neighborhood racial composition was measured as the percent of black residents in the census tract. Metropolitan area RRS was measured using the Information Theory Index. Multilevel Cox proportional hazards models examined the association of metropolitan area RRS and census tract racial composition with breast cancer and all-cause mortality. Survival analysis explored and compared the risk of death in women exposed to environments where a higher and lower proportion of residents were black.
Breast cancer mortality disparities were largest in racially mixed tracts located in high MSA/MiSA segregation areas (RR = 2.06, 95 % CI 1.70, 2.50). For black but not white women, as MSA/MiSA RRS increased, there was an increased risk for breast cancer mortality (HR = 2.20, 95 % CI 1.09, 4.45). For all-cause mortality, MSA/MiSA segregation was not a significant predictor, but increasing tract percent black was associated with increased risk for white but not black women (HR 1.29, 95 % CI 1.05, 1.58).
Racial residential segregation may influence health for blacks and whites differently. Pathways through which RRS patterns impact health should be further explored.
Cancer Causes and Control 07/2012; 23(9):1519-27. · 3.20 Impact Factor
[show abstract][hide abstract] ABSTRACT: There are now an estimated 16 million people who inject drugs (PWID) throughout the world, 3 million of whom are estimated to be infected with HIV. In many countries, substantial proportions of PWID belong to racial/ethnic/nationality minority groups, and are at increased likelihood of being infected with HIV. This article reviews current evidence on ethnic disparities in HIV infection among PWID and assesses the issues that would need to be addressed to reduce these disparities.
An ongoing systematic review of ethnic disparities has found that, in a pooled weighted odds ratio, ethnic minority PWID are twice as likely to be HIV seropositive than ethnic majority, PWID from the same geographic area. If implemented with sufficient quality and coverage, current HIV prevention programs probably have the capability of ending HIV transmission among both ethnic majority and minority PWID. Large-scale, evidence-based prevention programs need to be implemented in the contexts of patterns of injecting drug use that continue to evolve-with injecting practices spreading to new areas, changes in drugs injected, and some transitions from injecting to noninjecting drug use. Lack of financial resources and policies against evidence-based programming are increasingly important problems that are likely to have particularly adverse effects on ethnic minority PWID.
Racial/ethnic/nationality disparities in HIV infection are quite common among PWID. Addressing these disparities will be a fundamental challenge within a human rights approach to public health.
Current opinion in HIV and AIDS 04/2012; 7(4):354-61. · 4.75 Impact Factor
[show abstract][hide abstract] ABSTRACT: Health education and behavior change interventions typically pay little attention to the intervention's instructional foundation. Combining the fields of health literacy, cognitive psychology, and adult learning theory, this article provides an integrative scientific approach, called the BEAN (Better Education and iNnovation) model, to creating an instructional foundation based on how individuals acquire knowledge and skills. The article uses a case study example from an adult literacy center's health literacy class to explore how environmental factors and instructional strategies can be applied to health education and behavior change interventions. Data for this case study were derived through 20 hours of classroom observation and qualitative interviews with 21 adult education students and 3 instructors. Results provide practical examples of environmental factors and instructional strategies designed to facilitate learning, such as fostering autonomy, activating prior knowledge, and fostering perspective change. Results also describe the resulting health behavior changes of students attending the health literacy class, such as increased medication adherence and physical activity, improved nutritional habits, and increased question asking of health practitioners. This article serves as a first step to encouraging researchers and educators to consider the importance of drawing on cognitive psychology and theories of adult learning to create a scientifically based instructional foundation for health behavior change programs. Additionally, by drawing on the expertise of adult educators well versed in the science of instructional design, this article also demonstrates that the adult education classroom is an excellent setting for conducting health education and behavior change interventions.
[show abstract][hide abstract] ABSTRACT: Little information exists on the population prevalence or geographic distribution of injection drug users (IDUs) who are Hispanic in the USA. Here, we present yearly estimates of IDU population prevalence among Hispanic residents of the 96 most populated US metropolitan statistical areas (MSAs) for 1992-2002. First, yearly estimates of the proportion of IDUs who were Hispanic in each MSA were created by combining data on (1) IDUs receiving drug treatment services in Substance Abuse and Mental Health Services Administration (SAMHSA)'s Treatment Entry Data System, (2) IDUs being tested in the Centers for Disease Control and Prevention (CDC) HIV-Counseling and Testing System, and (3) incident AIDS diagnoses among IDUs, supplemented by (4) data on IDUs who were living with AIDS. Then, the resulting proportions were multiplied by published yearly estimates of the number of IDUs of all racial/ethnic groups in each MSA to produce Hispanic IDU population estimates. These were divided by Hispanic population data to produce population prevalence rates. Time trends were tested using mixed-effects regression models. Hispanic IDU prevalence declined significantly on average (1992 mean = 192, median = 133; 2002 mean = 144, median = 93; units are per 10,000 Hispanics aged 15-64). The highest prevalence rates across time tended to be in smaller northeastern MSAs. Comparing the last three study years to the first three, prevalence decreased in 82% of MSAs and increased in 18%. Comparisons with data on drug-related mortality and hepatitis C mortality supported the validity of the estimates. Generally, estimates of Hispanic IDU population prevalence were higher than published estimates for non-Hispanic White residents and lower than published estimates for non-Hispanic Black residents. Further analysis indicated that the proportion of IDUs that was Hispanic decreased in 52% and increased in 48% of MSAs between 2002 and 2007. The estimates resulting from this study can be used to investigate MSA-level social and economic factors that may have contributed to variations across MSAs and to help guide prevention program planning for Hispanic IDUs within MSAs. Future research should attempt to determine to what extent these trends are applicable to Hispanic national origin subgroups.
Journal of Urban Health 03/2012; 89(3):527-64. · 1.89 Impact Factor
[show abstract][hide abstract] ABSTRACT: High incidence and prevalence of sexually transmitted infection (STI) in blacks have been attributed to multiple factors. However, few articles have discussed spatial access to healthcare as a driver of disparities. The objective of this analysis was to evaluate the relationship between travel time to a healthcare provider and the likelihood of testing positive for 1 of 3 STIs in a sample of adults living in public housing.
One hundred and eight black adults in Atlanta, GA from November 2008 to June 2009, completed a survey that queried sexual behavior and healthcare use and had urine tested for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis by molecular methods. Travel time was a continuous variable capturing the number of minutes it took to reach the place where participants received most of their care. Multivariate analyses tested the hypothesis that individuals reporting longer travel times would be more likely to test positive for an STI. Travel time was squared to linearize its relationship to the outcome.
Thirty-six residents (37.5%) tested positive for ≥1 STI. A curvilinear relationship existed between travel time and STI status. When travel time was <48 minutes, a positive relationship existed between travel time and the odds of testing positive for an STI. An inverse relationship existed when travel time was ≥48 minutes.
Residents of impoverished communities experience a curvilinear relationship between travel time and STI status. We discuss possible factors that might have created this curvilinear relationship, including voluntary social isolation.
[show abstract][hide abstract] ABSTRACT: Over the next decade, as literacy rates are predicted to decline, the health care sector faces increasing challenges to effective communication with low-literate groups. Considering the rising costs of health care and the forthcoming changes in the American health care system, it is imperative to find nontraditional avenues through which to impart health knowledge and functional skills. This article draws on classroom observations and qualitative interviews with 21 students and 3 teachers in an adult education health literacy class to explore the efficacy of using adult education courses to teach functional health literacy skills to low-literate populations. Data were analyzed using a combination of thematic and content analyses. Results describe the motivation of students to share information within the classroom and with friends and family outside the classroom. This article also provides several recommendations to help ensure accuracy of diffused information both within and outside of the classroom. Ultimately, this study suggests that the adult education system is in a prime position to impart functional health literacy skills to low-literate populations in the classroom. Significantly, this study demonstrates that adult education students themselves may be a powerful vehicle for health communication beyond the walls of the classroom.
Journal of Health Communication 09/2011; 16 Suppl 3:119-33. · 1.61 Impact Factor
[show abstract][hide abstract] ABSTRACT: We explored the association between neighborhood residential racial composition and breast cancer mortality among Black and White breast cancer patients in Georgia and whether spatial access to cancer care mediates this association. Participants included 15,256 women living in 15 metropolitan statistical areas in Georgia who were diagnosed with breast cancer between 1999 and 2003. Residential racial composition was operationalized as the percent of Black residents in the census tract. We used gravity-based modeling methods to ascertain spatial access to oncology care. Multilevel Cox proportional hazards models and mediation analyses were used to test associations. Black women were 1.5 times more likely to die from breast cancer than White women. Residential racial composition had a small but significant association with breast cancer mortality (hazard ratios [HRs] = 1.04-1.08 per 10% increase in the percent of Black tract residents). Individual race did not moderate this relationship, and spatial access to care did not mediate it. Residential racial composition may be part of the socioenvironmental milieu that produces increased breast cancer mortality among Black women. However, there is a lack of evidence that spatial access to oncology care mediates these processes.
Journal of Urban Health 08/2011; 88(6):1117-29. · 1.89 Impact Factor
[show abstract][hide abstract] ABSTRACT: Young injection drug users (IDUs) are at risk for acquiring blood-borne diseases like HIV and Hepatitis C. Little is known about the population prevalence of young IDUs. We (1) estimate annual population prevalence rates of young IDUs (aged 15-29) per 10,000 in 95 large U.S. metropolitan statistical areas (MSAs) from 1992 to 2002; (2) assess the validity of these estimates; and (3) explore whether injection drug use among youth in these MSAs began to rise after HAART was discovered. A linear mixed model (LMM) estimated the annual population prevalence of young IDUs in each MSA and described trends therein. The population prevalence of IDUs among youths across 95 MSAs increased from 1996 (mean = 95.64) to 2002 (mean = 115.59). Additional analyses of the proportion of young IDUs using health services suggest this increase may have continued after 2002. Harm reduction and prevention research and programs for young IDUs are needed.
AIDS and Behavior 07/2011; 15(7):1570-8. · 3.49 Impact Factor