BACKGROUND: Refugees are at an increased risk of chronic Hepatitis B virus (HBV) infection because many of their countries of origin, as well as host countries, have intermediate-to-high prevalence rates. Refugees arriving to the US are also at risk of serious sequelae from chronic HBV infection because they are not routinely screened for the virus overseas or in domestic post-arrival exams, and may live in the US for years without awareness of their infection status. METHODS: A cohort of 26,548 refugees who arrived in Minnesota and Georgia during 2005-2010 was evaluated to determine the prevalence of chronic HBV infection. This prevalence information was then used in a cost-benefit analysis comparing two variations of a proposed overseas program to prevent or ameliorate the effects of HBV infection, titled 'Screen, then vaccinate or initiate management' (SVIM) and 'Vaccinate only' (VO). The analyses were performed in 2013. All values were converted to US 2012 dollars. RESULTS: The estimated six year period-prevalence of chronic HBV infection was 6.8% in the overall refugee population arriving to Minnesota and Georgia and 7.1% in those ≥6 years of age. The SVIM program variation was more cost beneficial than VO. While the up-front costs of SVIM were higher than VO ($154,084 vs. $73,758; n=58,538 refugees), the SVIM proposal displayed a positive net benefit, ranging from $24 million to $130 million after only 5 years since program initiation, depending on domestic post-arrival screening rates in the VO proposal. CONCLUSIONS: Chronic HBV infection remains an important health problem in refugees resettling to the United States. An overseas screening policy for chronic HBV infection is more cost-beneficial than a 'Vaccination only' policy. The major benefit drivers for the screening policy are earlier medical management of chronic HBV infection and averted lost societal contributions from premature death.
Background
Text4baby provides educational text messages to pregnant and postpartum women and targets underserved women. The primary purpose of this study is to examine the health behaviors and cell phone usage patterns of a text4baby target population and the associations with health literacy.
Methods
Pregnant and postpartum women were recruited from two Women, Infant and Children clinics in Atlanta. Women were asked about their demographics, selected pregnancy or postpartum health behaviors, and cell phone usage patterns. Health literacy skills were measured with the English version of the Newest Vital Sign. Multivariable logistic regression was used to examine health behaviors and cell usage patterns by health literacy classification, controlling for commonly accepted confounders.
Results
Four hundred sixty-eight women were recruited, and 445 completed the Newest Vital Sign. Of these, 22% had inadequate health literacy, 50% had intermediate health literacy, and 28% had adequate health literacy skills. Compared to adequate health literacy, limited literacy was independently associated with not taking a daily vitamin during pregnancy (OR 3.6, 95% CI: 1.6, 8.5) and never breastfeeding their infant (OR 1.4, 95% CI: 1.1, 1.8). The majority (69.4%) of respondents received nine or more text messages a day prior to enrollment, one in four participants (24.6%) had changed their number within the last six months, and 7.0% of study participants shared a cell phone. Controlling for potentially confounding factors, those with limited health literacy were more likely to share a cell phone than those with adequate health literacy (OR 2.57, 95% CI: 1.79, 3.69).
Conclusions
Text4baby messages should be appropriate for low health literacy levels, especially as this population may have higher prevalence of targeted unhealthy behaviors. Text4baby and other mhealth programs targetting low health literacy populations should also be aware of the different ways that these populations use their cell phones, including: sharing cell phones, which may mean participants will not receive messages or have special privacy concerns; frequently changing cell phone numbers which could lead to higher drop-off rates; and the penetrance of text messages in a population that receives many messages daily.
Background
Over the past 30 years, obesity in the United States has increased twofold in children and threefold in adolescents. In Georgia, nearly 17% of children aged 10 – 17 are obese. In response to the high prevalence of child obesity in Georgia and the potential deleterious consequences that this can have, HealthMPowers was founded in 1999 with the goal of preventing childhood obesity by improving health-enhancing behaviors in elementary schools, utilizing a holistic three-year program. This study measures the effectiveness of the HealthMPowers program in improving the school environment, student knowledge, behavior, cardiovascular fitness levels, and Body Mass Index (BMI).
Methods
The present analysis utilizes data from 40 schools that worked with HealthMPowers over the course of the 2012 – 2013 school year (including schools at each of the three years of the intervention period) and provided information on demographics, student knowledge and behaviors, BMI, performance on the PACER test of aerobic capacity, and school practices and policies (measured via school self-assessment with the HealthMPowers-developed instrument “Continuous Improvement Tracking Tool” or CITT), measured at the beginning and end of each school year. Paired two-sample T tests were used to compare continuous variables (e.g., student knowledge scores, BMI-for-age Z scores), while chi-squared tests were used to assess categorical variables (e.g., trichotomized PACER performance).
Results
Students across all grades and cohorts demonstrated improvements in knowledge and self-reported behaviors, with particularly significant improvements for third-graders in schools in the second year of the HealthMPowers program (p < 0.0001). Similarly, decreases were observed in BMI-for-Age Z scores for this cohort (and others) across grades and gender, with the most significant decreases for students overweight or obese at baseline (p < 0.0005). Students also showed significant increases in performance on the PACER test across grades and cohorts (p < 0.0001). Lastly, schools tended to improve their practices over time, as measured via the CITT instrument.
Conclusions
The present report demonstrates the effectiveness of the HealthMPowers program in producing positive change in school policies and practices, student knowledge and behaviors, and student fitness and BMI, supporting the use of holistic interventions to address childhood obesity.
Background
Tuberculosis (TB) in developed countries has historically been associated with poverty and low socioeconomic status (SES). In the past quarter century, TB in the United States has changed from primarily a disease of native-born to primarily a disease of foreign-born persons, who accounted for more than 60% of newly-diagnosed TB cases in 2010. The purpose of this study was to assess the association of SES with rates of TB in U.S.-born and foreign-born persons in the United States, overall and for the five most common foreign countries of origin.
Methods
National TB surveillance data for 1996–2005 was linked with ZIP Code-level measures of SES (crowding, unemployment, education, and income) from U.S. Census 2000. ZIP Codes were grouped into quartiles from low SES to high SES and TB rates were calculated for foreign-born and U.S.-born populations in each quartile.
Results
TB rates were highest in the quartiles with low SES for both U.S.-born and foreign-born populations. However, while TB rates increased five-fold or more from the two highest to the two lowest SES quartiles among the U.S.-born, they increased only by a factor of 1.3 among the foreign-born.
Conclusions
Low SES is only weakly associated with TB among foreign-born persons in the United States. The traditional associations of TB with poverty are not sufficient to explain the epidemiology of TB among foreign-born persons in this country and perhaps in other developed countries. TB outreach and research efforts that focus only on low SES will miss an important segment of the foreign-born population.
Childhood obesity is a recognized public health crisis. This paper reviews the lessons learned from a voluntary initiative to expand insurance coverage for childhood obesity prevention and treatment services in the United States. In-depth telephone interviews were conducted with key informants from 16 participating health plans and employers in 2010-11. Key informants reported difficulty ensuring that both providers and families were aware of the available services. Participating health plans and employers are beginning new tactics including removing enrollment requirements, piloting enhanced outreach to selected physician practices, and educating providers on effective care coordination and use of obesity-specific billing codes through professional organizations. The voluntary initiative successfully increased private health insurance coverage for obesity services, but the interviews described variability in implementation with both best practices and barriers identified. Increasing utilization of obesity-related health services in the long term will require both family- and provider-focused interventions in partnership with improved health insurance coverage.
The Physical Activity Guidelines for Americans recommend adolescents engaging in 60 min of physical activity (PA) every day. Students should spend at least 30 min being active while at school. However, schools rarely provide that much PA time for students. This paper describes the planned analyses for a study evaluating the relationships between PA (measured as average daily minutes of Moderate to Vigorous Physical Activity [MVPA]) and educational outcomes of standardized test scores and classroom grades cross-sectionally in 4 th grade and longitudinally from 4 th to 5 th grade. Investigations of moderators (both student- and school-level), mediators, and potential dosage of average MVPA thresholds are outlined. To ensure a high level of variability in student PA, the Health Empowers You! program is implemented in a random sample of half of the participating schools. The intervention is designed to affect students’ PA behaviors and health outcomes (cardiorespiratory fitness, body mass index). Utilizing accelerometer data from students in participating schools, the relationship between PA and health and academic outcomes (academic achievement test scores, reading lexile, grades, attendance, and tardiness) is evaluated. A total of 4968 grade 4 students across 40 schools (20 receiving intervention) participated (75% participation rate), and this cohort is being tracked from grade 4 through grade 5. In addition, implementation process and fidelity data are gathered. Given that school closures in response to COVID-19 pre-maturely terminated Spring 5 th grade data collection, modifications to the original analysis plan are discussed throughout.
Objective. To examine costs associated with obesity in an employee population and factors associated with increased costs. Methods. We used data from the Physical Activity and Life Style (PALS) study, a randomized prospective design evaluating three interventions to increase physical activity among physically inactive nonfaculty university employees (). The primary exposure variable, obesity (measured by body mass index), was obtained from the in-person baseline survey. Covariates were obtained from the baseline survey and included demographic characteristics and health status. Data from the baseline survey was linked with administrative data to determine pharmaceutical, inpatient, outpatient, and total health care costs for three years. Average monthly expenditures for obese and nonobese individuals were compared using t-tests and a two-part multivariate regression model adjusted for demographic and socioeconomic characteristics and health behaviors. Results. Although in-patient and outpatient expenses were not associated with obesity, pharmaceutical expenditures were $408 or 87.2% higher per year ($468 versus $876) for obese individuals than for nonobese individuals, which reflected poorer health behaviors and health status of obese adults. Conclusion. Awareness of the costs associated with obesity among employees can stimulate employers to make the investment in providing employer-sponsored wellness and health improvement programs to address obesity.
BACKGROUND: It is recommended that school-aged children accrue 30 minutes of daily moderate-to-vigorous physical activity (MVPA) in school. Current literature is inconclusive about the long-term associations between school-based physical activity and academic achievement. In this study, we use a large sample and longitudinal design to rigorously evaluate whether school-day MVPA is associated with academic achievement. METHODS: In a diverse suburban public school district, 4936 Grade 4 students were recruited in 40 elementary schools. Students wore accelerometers to measure school-day MVPA for 15 days across three semesters. Academic performance data was collected across Grade 3 fall to Grade 5 spring, including teacher-assigned grades and standardized test scores. Multilevel modeling was conducted controlling for student demographics and school characteristics. RESULTS: Cross-sectional analyses found small negative associations in Grade 4. Grade 4 full-year mean daily school-day MVPA had β = --0.066, β = --0.063, β = --0.066, and β = --0.058 associations (p < 0.001) with Grade 4 math, reading, spelling, and writing grades respectively, and Grade 4 full-year mean daily school-day MVPA had β = --0.206 and β = --0.283 (p < 0.001) associations with Grade 4 math and English Language Arts (ELA) standardized test scores respectively out of approximately 500 points. Longitudinal analyses found no significant associations between Grade 4 full-year mean daily school-day MVPA and Grade 5 Fall course grades. Results also indicated small negative associations for students attaining 30+ minutes of daily school-day MVPA compared to those attaining less than 15 minutes, but only in Grade 4 Fall cross-sectional analyses where teacher-assigned reading, spelling, and writing grades were - 1.666, - 1.638, and - 1.993 points lower respectively (p < 0.001). CONCLUSION: The cross-sectional findings, while statistically significant in a negative direction, have a negligible association when translated practically. For example, even if students attained twice the recommended amount of school-day MVPA - which would constitute an approximately 300% increase from current levels - results suggest that grades would only decrease by 2 points on a 100-point scale. Furthermore, longitudinal analyses suggest school-day MVPA does not have a predictive association with course grades or standardized test scores. Findings suggest school-based MVPA implemented in accordance with recommendations does not meaningfully detract from academic progress. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03765047. Registered 05 December 2018 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03765047.
Background: Atherosclerotic changes associated with dyslipidemia and increased cardiovascular disease risk are believed to begin in childhood. While previous studies have linked added sugars consumption to low high-density lipoprotein (HDL), little is known about the long-term impact of this consumption. This study aims to assess the association between added sugars intake and HDL cholesterol levels during adolescence, and whether this association is modified by obesity. Methods and Results: We used data from the National Heart Lung and Blood Institute's Growth and Health Study, a 10-year cohort study of non-Hispanic Caucasian and African-American girls (N=2379) aged 9 and 10 years at baseline recruited from 3 sites in 1987-1988 with biennial plasma lipid measurement and annual assessment of diet using a 3-day food record. Added sugars consumption was dichotomized into low (0% to <10% of total energy) and high (≥10% of total energy). In a mixed model controlling for obesity, race, physical activity, smoking, maturation stage, age, and nutritional factors, low compared with high added sugar consumption was associated with a 0.26 mg/dL greater annual increase in HDL levels (95% CI 0.48 to 0.04; P=0.02). Over the 10-year study period, the model predicted a mean increase of 2.2 mg/dL (95% CI 0.09 to 4.32; P=0.04) among low consumers, and a 0.4 mg/dL decrease (95% CI-1.32 to 0.52; P=0.4) among high consumers. Weight category did not modify this association (P=0.45). Conclusion: Low added sugars consumption is associated with increasing HDL cholesterol levels throughout adolescence.
Purpose: This study aimed to characterize physical activity (PA) environments in Georgia public elementary schools and to identify socioeconomic status (SES) and racial/ethnic disparities in PA environments. Design: A school setting PA survey was launched in 2013 to 2014 as a cross-sectional online survey assessing PA environment factors, including facility access and school PA practices, staff PA opportunities, parental involvement in school PA, and out-of-school PA opportunities. Setting: All 1333 Georgia public elementary schools were recruited. Participants: A total of 1083 schools (81.2%) responded. Survey respondents included school administrators, physical education (PE) teachers, and grade-level chairs. Measures: Physical activity environment factors were assessed via an online questionnaire adapted from school PA surveys and articles. Analysis: The chi-square and Fisher exact analyses were conducted to examine the reporting of PA environment factors overall and by school SES, as measured by free/reduced lunch rate, and/or racial/ethnic composition. Results: Overall, many PA environment factors were widely prevalent (ie, gym [99%] or field [79%] access), although some factors such as some PA-related programs (ie, a structured walk/bike program [11%]) were less widely reported. Disparities in school PA environment factors were largely patterned by SES, though they varied for some factors by racial/ethnic composition and across SES within racial/ethnic composition categories. For example, lower SES schools were less likely to report access to blacktops and tracks (p-value <.0001), and higher SES schools were less likely to report access to playgrounds (p-value =.0076). Lower SES schools were also less likely to report “always/often” giving access to PE/PA equipment during recess (p-value <.01). Lower SES and majority nonwhite schools were less likely to report having joint use agreements with community agencies (p-value <.0001). Conclusion: This study highlights SES and racial/ethnic disparities in PA environments in Georgia public elementary schools.