Faculty Bibliography

OBJECTIVE: The authors evaluated Project TEACH (PT), a statewide training and consultation program for pediatric primary care providers (PCPs) on identification and treatment of mental health conditions. METHODS: An intervention group of 176 PCPs who volunteered for PT training was compared with a stratified random sample of 200 PCPs who did not receive PT training. Data on prescription practices, diagnoses, and follow-up care were from New York State Medicaid files (2009-2013) for youths seen by the trained (N=21,784) and untrained (N=46,607) PCPs. RESULTS: The percentage of children prescribed psychotropic medication increased after PT training (9% to 12%, p<.001), a larger increase than in the untrained group (4% to 5%, p<.001) (comparison, p<.001). Fewer differences were noted in diagnoses and in medication use and follow-up care among children with depression. CONCLUSIONS: This intervention may have an impact on providers' behaviors, but further research is needed to clarify its effectiveness.

Objectives. We estimated sodium intake, which is associated with elevated blood pressure, a major risk factor for cardiovascular disease, and assessed its association with related variables among New York City adults. Methods. In 2010 we conducted a cross-sectional, population-based survey of 1656 adults, the Heart Follow-Up Study, that collected self-reported health information, measured blood pressure, and obtained sodium, potassium, and creatinine values from 24-hour urine collections. Results. Mean daily sodium intake was 3239 milligrams per day; 81% of participants exceeded their recommended limit. Sodium intake was higher in non-Hispanic Blacks (3477 mg/d) and Hispanics (3395 mg/d) than in non-Hispanic Whites (3066 mg/d; both P < .05). Higher sodium intake was associated with higher blood pressure in adjusted models, and this association varied by race/ethnicity. Conclusions. Higher sodium intake among non-Hispanic Blacks and Hispanics than among Whites was not previously documented in population surveys relying on self-report. These results demonstrate the feasibility of 24-hour urine collection for the purposes of research, surveillance, and program evaluation. (Am J Public Health. Published online ahead of print January 16, 2014: e1-e8. doi:10.2105/AJPH.2013.301542).

BACKGROUND: Characterization of health conditions in recent immigrant subgroups, including foreign-born whites and Asians, is limited but important for identifying emerging health disparities. Hypertension, a major modifiable risk factor for cardiovascular disease, has been shown to be associated with acculturation, but the acculturative experience varies for different racial/ethnic groups. Assessing the impact of race/ethnicity on the relationship between acculturation-related factors and hypertension is therefore of interest. METHODS: Data from the 2005-2008 waves (n = 36,550) of the NYC Community Health Survey were combined to estimate self-reported hypertension prevalence by nativity, language spoken at home, and time spent in the United States. Multivariable analyses were used to assess (i) the independent associations of acculturation-related factors and hypertension and (ii) potential effect modification by race/ethnicity. Sensitivity analysis recalibrating self-reported hypertension using measured blood pressures from a prior NYC population-based survey was performed. Prevalence was also explored by country of origin. RESULTS: Being foreign vs. US born was associated with higher self-reported hypertension in whites only. Speaking Russian vs. English at home was associated with a 2-fold adjusted odds of self-reported hypertension. Living in the United States for >/=10 years vs. less time was associated with higher self-reported hypertension prevalence in blacks and Hispanics. Hypertension prevalence in Hispanics was slightly lower when using a recalibrated definition, but other results did not change substantively. CONCLUSIONS: Race/ethnicity modifies the relationship between acculturation-related factors and hypertension. Consideration of disease prevalence in origin countries is critical to understanding health patterns in immigrant populations. Validation of self-reported hypertension in Hispanic populations is indicated.

Urban planners have suggested that built environment characteristics can support active travel (walking and cycling) and reduce sedentary behavior. This study assessed whether engagement in active travel is associated with neighborhood walkability measured for zip codes in New York City. Data were analyzed on engagement in active travel and the frequency of walking or biking ten blocks or more in the past month, from 8,064 respondents to the New York City 2003 Community Health Survey (CHS). A neighborhood walkability scale that measures: residential, intersection, and subway stop density; land use mix; and the ratio of retail building floor area to retail land area was calculated for each zip code. Data were analyzed using zero-inflated negative binomial regression incorporating survey sample weights and adjusting for respondents' sociodemographic characteristics. Overall, 44 % of respondents reported no episodes of active travel and among those who reported any episode, the mean number was 43.2 episodes per month. Comparing the 75th to the 25th percentile of zip code walkability, the odds ratio for reporting zero episodes of active travel was 0.71 (95 % CI 0.61, 0.83) and the exponentiated beta coefficient for the count of episodes of active travel was 1.13 (95 % CI 1.06, 1.21). Associations between lower walkability and reporting zero episodes of active travel were significantly stronger for non-Hispanic Whites as compared to non-Hispanic Blacks and to Hispanics and for those living in higher income zip codes. The results suggest that neighborhood walkability is associated with higher engagement in active travel.

OBJECTIVE: Recommendations for fruit and vegetable consumption are largely unmet. Lower socio-economic status (SES), neighbourhood poverty and poor access to retail outlets selling healthy foods are thought to predict lower consumption. The objective of the present study was to assess the interrelationships between these risk factors as predictors of fruit and vegetable consumption. DESIGN: Cross-sectional multilevel analyses of data on fruit and vegetable consumption, socio-demographic characteristics, neighbourhood poverty and access to healthy retail food outlets. SETTING: Survey data from the 2002 and 2004 New York City Community Health Survey, linked by residential zip code to neighbourhood data. SUBJECTS: Adult survey respondents (n 15 634). RESULTS: Overall 9.9 % of respondents reported eating >/=5 servings of fruits or vegetables in the day prior to the survey. The odds of eating >/=5 servings increased with higher income among women and with higher educational attainment among men and women. Compared with women having less than a high-school education, the OR was 1.12 (95 % CI 0.82, 1.55) for high-school graduates, 1.95 (95 % CI 1.43, 2.66) for those with some college education and 2.13 (95 % CI 1.56, 2.91) for college graduates. The association between education and fruit and vegetable consumption was significantly stronger for women living in lower- v. higher-poverty zip codes (P for interaction < 0.05). The density of healthy food outlets did not predict consumption of fruits or vegetables. CONCLUSIONS: Higher SES is associated with higher consumption of produce, an association that, in women, is stronger for those residing in lower-poverty neighbourhoods.

BACKGROUND: One strategy to address health problems related to insufficient physical activity is to examine modifiable neighborhood characteristics associated with active transportation. PURPOSE: The aim of this study is to evaluate whether neighborhoods with more aesthetic amenities (sidewalk cafes, street trees, and clean sidewalks) and fewer safety hazards (pedestrian-auto fatalities and homicides) are associated with active transportation. METHODS: The 2003 Community Health Survey in New York City, which asked about active transportation (walking or bicycling >10 blocks) in the past 30 days, was linked to ZIP-code population census and built environment characteristics. Adjusted associations were estimated for dichotomous (any active transportation versus none) and continuous (trip frequency) active transportation outcomes. RESULTS: Among 8,034 adults, those living near sidewalk cafes were 10 % more likely to report active transportation (p = 0.01). Homicide rate was associated with less frequent active transportation among those reporting any active transportation (p = 0.002). CONCLUSIONS: Investments in aesthetic amenities or homicide prevention may help to promote active transportation.

PURPOSE: Single motherhood is a well-established risk factor for depression in women. The goal of this study is to analyze the relationships among partner status, having children, and depression among women of White, Black, and Hispanic race/ethnicity. METHODS: Stratified analyses were conducted on 2002, 2003, 2005, 2006, and 2008 cross-sectional survey data from 10,520 White women, 7,655 Black women, and 7,343 Hispanic women aged at least 18 years and residing in New York City. Depression was evaluated using Kessler's K6 scale. Race/ethnicity-specific logistic regression analysis assessed the association between partner status and depression among women with and without children. RESULTS: Partner status was significantly associated with depression among White (p < .0001) and Hispanic (p = .0001) women, but not among Black women (p = .82), after adjusting for age, nativity, employment, education, poverty level, general health, and health insurance. Among White women, the conditional odds of depression were elevated for single relative to partnered women both with (odds ratio [OR], 2.10; 95% confidence interval [CI], 1.57-2.81; p < .0001) and without (OR, 1.29; 95% CI, 1.06-1.56; p = .01) children, but the size of the effect was significantly larger for those with children than for those without children (p = .006). Among Hispanic women, the conditional odds of depression were elevated for single relative to partnered women with children (OR, 1.58; 95% CI, 1.29-1.95; p < .0001), but not for single versus partnered women without children (OR, 1.09; 95% CI, 0.82-1.46; p = .54). Among Black women, there was no evidence of elevated depression in single relative to partnered women, either overall or conditional on the presence of children (with children: OR, 1.21 [95% CI, 0.95-1.54; p = .13]; without children: OR, 0.75 [95% CI, 0.56-1.02; p = .06]). CONCLUSION: Past focus on single mothers as a high-risk group has oversimplified the relationship between partner status and depression, obscuring important distinctions between women of different racial backgrounds.

The New York City (NYC) Health Department has implemented a comprehensive tobacco control plan since 2002, and there was a 27% decline in adult smoking prevalence in NYC from 2002 to 2008. There are conflicting reports in the literature on whether residual smoker populations have a larger or smaller share of "hardcore" smokers. Changes in daily consumption and daily and nondaily smoking prevalence, common components used to define hardcore smokers, were evaluated in the context of the smoking prevalence decline. Using the NYC Community Health Survey, an annual random digit dial, cross-sectional survey that samples approximately 10,000 adults, the prevalence of current heavy daily, light daily, and nondaily smokers among NYC adults was compared between 2002 and 2008. A five-level categorical cigarettes per day (CPD) variable was also used to compare the population of smokers between the 2 years. From 2002 to 2008, significant declines were seen in the prevalence of daily smoking, heavy daily smoking, and nondaily smoking. Among daily smokers, there is also evidence of population declines in all but the lowest smoking category (one to five CPD). The mean CPD among daily smokers declined significantly, from 14.6 to 12.5. After an overall decline in smoking since 2002, the remaining smokers may be less nicotine dependent, based on changes in daily consumption and daily and nondaily smoking prevalence. These findings suggest the need to increase media and cessation efforts targeted towards lighter smokers.

The authors assessed the risks of drug-related death, suicide, and homicide after release from New York City jails in 155,272 people who were incarcerated anytime from 2001 through 2005 and examined whether the mortality rate was associated with homelessness. Using jail records matched with death and single-adult homeless registries in New York City, they calculated standardized mortality ratios (SMRs) and relative risks. After adjustment for age, sex, race, and neighborhood, the risks of drug-related death and homicide in formerly incarcerated persons were 2 times higher than those of New York City residents who had not been incarcerated in New York City jails during the study period. These relative risks were greatly elevated during the first 2 weeks after release (for drug-related causes, SMR = 8.0, 95% confidence interval (CI): 5.2, 11.8; for homicide, SMR = 5.1, 95% CI: 3.2, 7.8). Formerly incarcerated people with histories of homelessness had higher rates of drug-related death (RR = 3.4, 95% CI: 2.1, 5.5) and suicide (RR = 2.1, 95% CI: 1.2, 3.4) than did persons without such histories. For individuals who died of drug-related causes, longer jail stays were associated with a shorter time until death after release. These results suggest that jail- and community-based interventions are needed to reduce the excess mortality risk among formerly incarcerated people.