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Background: In the United States, worksite wellness programs are more often offered by larger employers. The Massachusetts Working on Wellness (WoW) program is an innovative, statewide capacity-building model designed to increase the number of smaller employers (200 or fewer workers) adopting health promotion initiatives. This article describes the WoW program design and approaches to recruitment, implementation, and evaluation.Methods/design: WoW provides employer training, technical assistance and seed funding, utilizing a Wellness Program Development framework based on recognized good practices. For-profit employers with 200 employees or fewer are eligible for and encouraged to apply for a Massachusetts Small Business Wellness Tax Credit. During the phase described in this paper, employer organizations applied to the program and committed to designating a champion responsible for program implementation. Interventions were to include policy and environmental supports, as well as those targeting individual behavior change through raising awareness and education. Supports provided to employers included seed grants for qualifying activities (up to $10,000 with matching required), community linkages, data collection and organization-specific feedback tools, an on-line curriculum supplemented with technical assistance, and an expert webinar series. Data collection at multiple time points, from the initial application through program completion, provides information for evaluation of recruitment, planned and completed activities.Discussion: This model is grounded in literature on good practices as well as in local knowledge about Massachusetts employers. It does not directly address the influence of working conditions, which can affect both worker participation and health behaviors. Implementation may be less successful with some organizations, such as those with many workers who are part-time or geographically distributed rather than in a centralized physical location. Program evaluation will assess the extent to which WoW achieves its goals. The data are expected to increase understanding of the needs of smaller employers and industries not traditionally implementing employee wellness programs. [ABSTRACT FROM AUTHOR]

Background: Fatal opioid-involved overdose rates increased precipitously from 5.0 per 100,000 population to 33.5 in Massachusetts between 1999 and 2022. Methods: We used spatial rate smoothing techniques to identify persistent opioid overdose-involved fatality clusters at the ZIP Code Tabulation Area (ZCTA) level. Rate smoothing techniques were employed to identify locations of high fatal opioid overdose rates where population counts were low. In Massachusetts, this included areas with both sparse data and low population density. We used Local Indicators of Spatial Association (LISA) cluster analyses with the raw incidence rates, and the Empirical Bayes smoothed rates to identify clusters from 2011 to 2021. We also estimated Empirical Bayes LISA cluster estimates to identify clusters during the same period. We constructed measures of the socio-built environment and potentially inappropriate prescribing using principal components analysis. The resulting measures were used as covariates in Conditional Autoregressive Bayesian models that acknowledge spatial autocorrelation to predict both, if a ZCTA was part of an opioid-involved cluster for fatal overdose rates, as well as the number of times that it was part of a cluster of high incidence rates. Results: LISA clusters for smoothed data were able to identify whether a ZCTA was part of a opioid involved fatality incidence cluster earlier in the study period, when compared to LISA clusters based on raw rates. PCA helped in identifying unique socio-environmental factors, such as minoritized populations and poverty, potentially inappropriate prescribing, access to amenities, and rurality by combining socioeconomic, built environment and prescription variables that were highly correlated with each other. In all models except for those that used raw rates to estimate whether a ZCTA was part of a high fatality cluster, opioid overdose fatality clusters in Massachusetts had high percentages of Black and Hispanic residents, and households experiencing poverty. The models that were fitted on Empirical Bayes LISA identified this phenomenon earlier in the study period than the raw rate LISA. However, all the models identified minoritized populations and poverty as significant factors in predicting the persistence of a ZCTA being part of a high opioid overdose cluster during this time period. Conclusion: Conducting spatially robust analyses may help inform policies to identify community-level risks for opioid-involved overdose deaths sooner than depending on raw incidence rates alone. The results can help inform policy makers and planners about locations of persistent risk. [ABSTRACT FROM AUTHOR]

Background: Overweight and obesity are prevalent among young women and are greater among minority and low-income women. The postpartum period is critical in women's weight trajectories as many women do not lose their pregnancy weight, and others lose some and then plateau or experience weight gain. Excess weight puts women at greater risk of chronic disease and thus weight loss in the postpartum period may be key to the long-term health of young women. This paper describes the design and methods of a randomized clinical trial of Fresh Start, an innovative narrative-based group intervention aimed at promoting postpartum weight loss among low-income, diverse women.Methods/design: Study participants were recruited from the five sites of the Women, Infants and Children (WIC) program in central Massachusetts. Participants were English-speaking, age ≥ 18 years, 6 weeks to 6 months postpartum, with a body mass index (BMI) ≥ 27 kg/m(2). The Fresh Start postpartum weight loss intervention, adapted from the Diabetes Prevention Program (DPP) in collaboration with WIC staff and clients, consisted of an 8-week group-based curriculum followed by nine monthly telephone calls. It included a narrative component (i.e., storytelling), group discussions, print materials and access to exercise facilities. The study is a two-arm randomized controlled trial. The control condition included print materials and access to exercise facilities. In-person assessments were conducted at baseline and at 6 and 12 months following the eight-week intervention phase.Discussion: The Fresh Start intervention translated key elements of an evidence-based weight loss protocol into a format that is hypothesized to be relevant, acceptable and effective for the target audience of low-SES postpartum women. This novel intervention was developed in collaboration with WIC to be sustainable within the context of its clinics, which reach approximately 9 million individuals per year across the U.S. via 10,000 clinics.Trial Registration: clinicaltrials.gov NCT02176915 . Registered 25 June 2014. [ABSTRACT FROM AUTHOR]

Background: Neighborhood safety may be an important social environmental determinant of overweight. We examined the relationship between perceived neighborhood safety and overweight status, and assessed the validity of reported neighborhood safety among a representative community sample of urban adolescents (who were racially and ethnically diverse). Methods: Data come from the 2006 Boston Youth Survey, a cross-sectional study in which public high school students in Boston, MA completed a pencil-and-paper survey. The study used a two-stage, stratified sampling design whereby schools and then 9th-12th grade classrooms within schools were selected (the analytic sample included 1,140 students). Students reported their perceptions of neighborhood safety and several associated dimensions. With self-reported height and weight data, we computed body mass index (BMI, kg/m²) for the adolescents based on CDC growth charts. Chi-square statistics and corresponding p-values were computed to compare perceived neighborhood safety by the several associated dimensions. Prevalence ratios (PRs) and 95% confidence intervals (CI) were calculated to examine the association between perceived neighborhood safety and the prevalence of overweight status controlling for relevant covariates and school site. Results: More than one-third (35.6%) of students said they always felt safe in their neighborhood, 43.9% said they sometimes felt safe, 11.6% rarely felt safe, and 8.9% never felt safe. Those students who reported that they rarely or never feel safe in their neighborhoods were more likely than those who said they always or sometimes feel safe to believe that gang violence was a serious problem in their neighborhood or school (68.0% vs. 44.1%, p < 0.001), and to have seen someone in their neighborhood assaulted with a weapon (other than a firearm) in the past 12 months (17.8% vs. 11.3%, p = 0.025). In the fully adjusted model (including grade and school) stratified by race/ethnicity, we found a statistically significant association between feeling unsafe in one's own neighborhood and overweight status among those in the Other race/ ethnicity group [(PR = 1.56, (95% CI: 1.02, 2.40)]. Conclusion: Data suggest that perception of neighborhood safety may be associated with overweight status among urban adolescents in certain racial/ethnic groups. Policies and programs to address neighborhood safety may also be preventive for adolescent overweight. [ABSTRACT FROM AUTHOR]

Background: Growing research points to potential long-term developmental implications of prenatal opioid exposure for children. Yet, polysubstance use and adverse childhood experiences are raised as potential confounders. Further, there is a lack of data on school-age children and the children's strengths. Methods: Parents and caregivers of children with prenatal opioid exposure worked with the study team to design, collect, and descriptively analyze mixed method data. Data were collected through survey (n = 148) and two focus groups (n = 15) from a convenience sample in mostly West Virginia and Massachusetts. Results: Nearly half of the children in the sample were diagnosed with multiple developmental delays, behavioral health conditions, and specific learning disorders. Roughly 85% of children have behavioral challenges. Associations between prenatal opioid exposure and negative developmental outcomes did not vary by type of opioid nor by polysubstance use, while controlling for adverse childhood experiences. Importantly, over 80% of families also reported their child's strengths, including empathy, social magnetism, and their resilience. Conclusions: The challenges for children born with prenatal opioid exposure may extend into school-age. The results are consistent with prior research on younger children, suggesting a need for best practices for caring for these children beyond the neonatal stage. [ABSTRACT FROM AUTHOR]

Background: HIV incidence has recently increased among people who inject drugs (PWID) across the United States, with outbreaks occurring in states with long-standing syringe service programs (SSPs) including Massachusetts (MA). Antiretroviral pre-exposure prophylaxis (PrEP) is an evidence-based HIV prevention strategy recommended for PWID, but uptake in this marginalized population is extraordinarily low. Methods: We describe the design and procedures for a National Institute on Drug Abuse (NIDA)-funded (R01) randomized controlled trial (RCT) testing the efficacy of "PrEP for Health," a multicomponent behavioral intervention to increase PrEP uptake, adherence, and persistence among HIV-negative PWID attending SSPs in two areas of the U.S. Northeast that are heavily affected by injection-related HIV transmission. Participants are equally randomized to receive the "PrEP for Health" intervention (involving individually tailored HIV and PrEP education, motivational interviewing, problem-solving skills and planning, and ongoing navigation support) or an enhanced standard of care (eSOC) control condition involving a brief educational video on the utility of PrEP for HIV prevention. Co-primary outcomes are PrEP uptake (using medical/pharmacy records) and adherence (using tenofovir quantification in hair samples); a secondary outcome is PrEP persistence (using medical/pharmacy records) over 12 months. Major assessments occur at baseline, 1-, 3-, 6-, and 12-month follow-up visits. Planned analyses will examine intervention efficacy, specific hypothesized conceptual mediators of the intervention effect (e.g., self-perceived HIV risk; PrEP knowledge, interest in use, motivation, and behavioral skills) and epidemiologically linked moderators (e.g., age; gender; condomless vaginal or anal sex). Discussion: Findings from our extensive preliminary research with the study population revealed that a multicomponent, theory-based intervention targeting PrEP knowledge, motivation, self-efficacy, behavioral skills, and structural barriers to PrEP access is urgently needed for PWID who are at risk of HIV acquisition. We also learned that SSPs represent a highly acceptable service setting for delivering such interventions. In this study, we are evaluating the efficacy of the "PrEP for Health" intervention. If efficacious, findings from our implementation evaluation could help guide its dissemination to diverse SSPs and possibly other community-based settings accessed by this population. Trial registration: ClinicalTrials.gov number NCT04430257, registered June 12, 2020. [ABSTRACT FROM AUTHOR]

Background: Electronic Health Record (EHR) data are increasingly being used to monitor population health on account of their timeliness, granularity, and large sample sizes. While EHR data are often sufficient to estimate disease prevalence and trends for large geographic areas, the same accuracy and precision may not carry over for smaller areas that are sparsely represented by non-random samples.Methods: We developed small-area estimation models using a combination of EHR data drawn from MDPHnet, an EHR-based public health surveillance network in Massachusetts, the American Community Survey, and state hospitalization data. We estimated municipality-specific prevalence rates of asthma, diabetes, hypertension, obesity, and smoking in each of the 351 municipalities in Massachusetts in 2016. Models were compared against Behavioral Risk Factor Surveillance System (BRFSS) state and small area estimates for 2016.Results: Integrating progressively more variables into prediction models generally reduced mean absolute error (MAE) relative to municipality-level BRFSS small area estimates: asthma (2.24% MAE crude, 1.02% MAE modeled), diabetes (3.13% MAE crude, 3.48% MAE modeled), hypertension (2.60% MAE crude, 1.48% MAE modeled), obesity (4.92% MAE crude, 4.07% MAE modeled), and smoking (5.33% MAE crude, 2.99% MAE modeled). Correlation between modeled estimates and BRFSS estimates for the 13 municipalities in Massachusetts covered by BRFSS's 500 Cities ranged from 81.9% (obesity) to 96.7% (diabetes).Conclusions: Small-area estimation using EHR data is feasible and generates estimates comparable to BRFSS state and small-area estimates. Integrating EHR data with survey data can provide timely and accurate disease monitoring tools for areas with sparse data coverage. [ABSTRACT FROM AUTHOR]

Background: We conducted a medical record review for healthcare utilization, risk factors, and clinical data among people who inject drugs (PWID) in Massachusetts to aid HIV outbreak response decision-making and strengthen public health practice. Setting: Two large community health centers (CHCs) that provide HIV and related services in northeastern Massachusetts. Methods: Between May and July 2018, we reviewed medical records for 88 people with HIV (PWH) connected to the outbreak. The review period included care received from May 1, 2016, through the date of review. Surveillance data were used to establish date of HIV diagnosis and assess viral suppression. Results: Sixty-nine (78%) people had HIV infection diagnosed during the review period, including 10 acute infections. Persons had a median of 3 primary care visits after HIV diagnosis and zero before diagnosis. During the review period, 72% reported active drug or alcohol use, 62% were prescribed medication assisted treatment, and 41% were prescribed antidepressants. The majority (68, 77%) had a documented ART prescription. HIV viral suppression at < 200 copies/mL was more frequent (73%) than the overall across the State (65%); it did not correlate with any of the sociodemographic characteristics studied in our population. Over half (57%) had been hospitalized at least once during the review period, and 36% had a bacterial infection at hospitalization. Conclusions: Medical record review with a field investigation of an outbreak provided data about patterns of health care utilization and comorbidities not available from routine HIV surveillance or case interviews. Integration of HIV screening with treatment for HIV and SUD can strengthen prevention and care services for PWID in northeastern Massachusetts. [ABSTRACT FROM AUTHOR]

Background: Public drinking water can be an important source exposure to lead, which can affect children's cognitive development and academic performance. Few studies have looked at the impact of lead exposures from community water supplies or their impact on school achievements. We examined the association between annual community water lead levels (WLLs) and children's academic performances at the school district level.Methods: We matched the 90th percentile WLLs with the grade 3-8 standardized test scores from the Stanford Education Data Archive on Geographic School Districts by geographic location and year. We used multivariate linear regression and adjusted for urbanicity, race, socioeconomic characteristics, school district, grade, and year. We also explored potential effect measure modifications and lag effects.Results: After adjusting for potential confounders, a 5 μg/L increase in 90th percentile WLLs in a GSD was associated with a 0.00684 [0.00021, 0.01348] standard deviation decrease in the average math test score in the same year. No association was found for English Language Arts.Conclusions: We found an association between the annual fluctuation of WLLs and math test scores in Massachusetts school districts, after adjusting for confounding by urbanicity, race, socioeconomic factors, school district, grade, and year. The implications of a detectable effect of WLLs on academic performance even at the modest levels evident in MA are significant and timely. Persistent efforts should be made to further reduce lead in drinking water. [ABSTRACT FROM AUTHOR]

Background: Sugar-sweetened beverage (SSB) consumption is an important behavior that can influence individuals' risk for diabetes, obesity, and other chronic diseases. Nonetheless, there is a lack of valid measures to assess SSB-related constructs. Reliable and valid measures can help evaluate the efficacy of interventions designed to curb SSB consumption. Our aim was to develop a valid and reliable instrument to measure constructs related to SSB consumption in English and Spanish.Methods: A cross-sectional survey was conducted among a convenience sample of 150 adult residents of public housing developments in Boston, Massachusetts between July of 2016 and January of 2017. All households from two public housing developments were approached by study staff to solicit participation via door-to-door knocking and posted flyers. We developed questions to measure three SSB-related constructs informed by the Social Cognitive Theory: SSB knowledge, and self-efficacy and intention to act on SSB consumption. The questions were pilot tested in the population, and then administered in-person by bilingual study staff in either English or Spanish. Interviews were conducted most often in the participant's home and less frequently within a community space. Item normality was assessed with descriptive statistics. Difficulty of knowledge items was assessed with percent correct. Construct validity of self-efficacy items was assessed using confirmatory factor analysis (CFA). A model was considered a good fit if confirmatory factor index (CFI) > 0.95, root mean square error of approximation (RMSEA) < 0.05, and standardized root mean square residual (RMSR) < 0.05. Pearson correlations with consumption scores assessed criterion validity, and intraclass correlation coefficients (ICC) assessed test-retest reliability.Results: Of the eight knowledge items tested, only four items resulted in correct answers less than half of the time. CFA resulted in a 5-item scale with excellent fit indices (CFI = .99; RMSEA = .025: SRMR = .02) and Cronbach's (0.79), test-retest (ICC = 0.68), and significant correlation with intention and SSB consumption. Of the four intention items, one was significantly correlated with SSB consumption.Conclusions: This study provides evidence for the validity of key constructs related to SSB consumption for use in adults, which could provide important theory-based markers for program evaluations of SSB-related interventions. [ABSTRACT FROM AUTHOR]

Background: Increasing children's physical activity (PA) at school is critical to obesity prevention and health promotion. Implementing novel, low-cost PA programs offers potential to contribute to children's in-school PA, particularly in resource-constrained schools. This evaluation describes implementation fidelity, reach, and dose of two PA programs in the Fueling Learning through Exercise (FLEX) Study.Methods: Thirteen diverse, low-income Massachusetts elementary schools were recruited and randomized to the 100 Mile Club walking/running program (n = 7) or CHALK/Just Move classroom activity break PA program (n = 6). Intervention programs were delivered across two school years. Surveys with program champions/teachers and children, in-session measurement of children's PA by accelerometry (Actigraph GT3X) in a subset of schools, and key informant interviews were used to collect information on implementation, including fidelity, dose, reach, and sustainability, and to calculate an implementation score.Results: Six CHALK/Just Move schools implemented the program in both years. Two schools randomized to 100 Mile Club did not implement at all, and only three schools implemented both years. Implementing schools had similar implementation scores (range = 0-3; 100 Mile Club = 2.0 vs. CHALK/Just Move = 1.9) but fidelity to core and enhanced elements differed between programs. In 100 Mile Club schools, dose of program delivered was greater than in CHALK/Just Move schools (34.9 vs. 19.7 min per week). Dose of PA received per session was also greater in 100 Mile Club schools (n = 55, 2 schools) compared with CHALK/Just Move schools (n = 160, 2 schools) (13.6 min vs. 2.7 min per session). A slightly higher proportion of eligible children participated in CHALK/Just Move compared to 100 Mile Club (54.0% vs. 31.2%). Both programs were well received by champions/teachers and students.Conclusions: Program implementation varied across programs and schools, and erosion in delivery was seen over the two years. However, among implementing schools, additional PA was delivered and received, and the programs were generally well-received. Although school resource issues remain barriers to implemention, this evaluation demonstrates that low-cost programs may enhance PA opportunities. Future research should evaluate how multiple programs can be implemented to increase children's PA at school.Trial Registration: ClinicalTrials.gov Identifier: NCT02810834 . Registered May 11, 2015. [ABSTRACT FROM AUTHOR]

Background: Nutrition clubs (NC) operate in community settings and provide members with nutrition education and meal replacements for weight management. NC are owned and operated by distributors of Herbalife products. There are over 6200 NC in the US, but there has been no independent assessment of the association of these NC with biomarkers of health.Methods: We conducted a cross-sectional pilot study to compare the health status of 100 NC members to 100 community-matched controls (CC) in the greater Boston area. Each CC was matched to a NC member for community of residence (zip code), age category, gender, BMI category, race/ethnicity, education level (category), and readiness to make health changes. Measures obtained included cardio-metabolic risk factors, body composition, markers of nutritional status, reported health status, dietary intake, physical activity, sleep and depression.Results: Participants were predominantly female (64%) and Hispanic (73%). NC members had significantly lower fasting insulin (P < 0.001) and lower HbA1c (P = 0.008), higher levels of 25 hydroxy-vitamin D (P = 0.001), and vitamin E:cholesterol ratio (P < 0.001), and lower prevalence of metabolic syndrome (P = 0.02) compared to CC. In addition, most of the NC members (99%) were satisfied with Herbalife NC membership for themselves and their families. A higher percentage of NC members (86%) compared to CC (32%) reported being in much better or somewhat better health compared to a year ago (P < 0.001); and they reported significantly better physical health (P = 0.03), and fewer sleep problems (P = 0.03).Conclusion: Herbalife NC membership was positively associated with perceived health and measured cardiometabolic benefits. However, causality cannot be inferred from these findings. [ABSTRACT FROM AUTHOR]

Background: The U.S. Food and Drug Administration can set standards for cigarettes that could include reducing their nicotine content. Such a standard should improve public health without causing unintended serious consequences for sub-populations. This study evaluates the effect of progressive nicotine reduction in cigarettes on smoking behavior, toxicant exposure, and psychiatric symptoms in smokers with comorbid mood and/or anxiety disorders using a two-site, two-arm, double-blind, parallel group, randomized controlled trial (RCT) in four phases over 34 weeks.Methods: Adult smokers (N = 200) of 5 or more cigarettes per day will be randomized across two sites (Penn State and Massachusetts General). Participants must have not had a quit attempt in the prior month, nor be planning to quit in the next 6 months, meet criteria for a current or lifetime unipolar mood and/or anxiety disorder based on the structured Mini-International Neuropsychiatric Interview, and must not have an unstable medical or psychiatric condition. After a week of smoking their own cigarettes, participants receive two weeks of Spectrum research cigarettes with usual nicotine content (11.6 mg). After this baseline period, participants will be randomly assigned to continue smoking Spectrum research cigarettes that contain either (a) Usual Nicotine Content (11.6 mg); or (b) Reduced Nicotine Content: the nicotine content per cigarette is progressively reduced from approximately 11.6 mg to 0.2 mg in five steps over 18 weeks. At the end of the randomization phase, participants will be offered the choice to either (a) quit smoking with assistance, (b) continue smoking free research cigarettes, or (c) return to purchasing their own cigarettes, for the final 12 weeks of the study. The primary outcome measure is blood cotinine; key secondary outcomes are: exhaled carbon monoxide, urinary total NNAL- 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol and 1-hydroxypyrene, oxidative stress biomarkers including 8-isoprostanes, measures of psychiatric symptoms (e.g., depression, anxiety), smoking behavior and dependence (e.g., cigarette consumption, quit attempts), and health effects (e.g., blood pressure, respiratory symptoms).Discussion: Results from this study will inform FDA on the potential effects of regulating the nicotine content of cigarettes and help determine whether smokers with mood and/or anxiety disorders can safely transition to significantly reduced nicotine content cigarettes.Trial Registration: TRN: NCT01928758 , registered August 21, 2013. [ABSTRACT FROM AUTHOR]

Background: Obesity and hypertension and their associated health complications disproportionately affect communities of color and people of lower socioeconomic status. Recruitment and retention of these populations in research trials, and retention in weight loss trials has been an ongoing challenge. Methods: Be Fit, Be Well was a pragmatic randomized weight loss and hypertension management trial of patients attending one of three community health centers in Boston, Massachusetts. Participants were asked to complete follow-up assessments every 6-months for two years. We describe challenges encountered and strategies implemented to recruit and retain trial participants over the 24-month intervention. We also identify baseline participant characteristics associated with retention status. Retention strategies included financial incentives, contact between assessment visits, building relationships with health center primary care providers (PCPs) and staff, and putting participant convenience first. Results: Active refusal rates were low with 130 of 2,631 patients refusing participation (4.9%). Of 474 eligible persons completing telephone screening, 365 (77.0%) completed their baseline visit and were randomized into the study. The study population was predominantly non-Hispanic Black (71.2%), female (68.5%) and reported annual household income of less than $35,000 (70.1%). Recruitment strategies included use of passive approval of potential participants by PCPs, use of part-time staff, and outsourcing calls to a call center. A total of 314 (86.0%) people completed the 24-month visit. Retention levels varied across study visits and intervention condition. Most participants completed three or more visits (69.6%), with 205 (56.2%) completing all four. At 24-months, lower retention was observed for males and the intervention condition. Retention strategies included building strong relationships with clinic staff, flexibility in overcoming participant barriers through use of taxi vouchers, night and weekend appointments, and keeping participants engaged via newsletters and social gatherings. Conclusion: We were able to retain 86.0% of participants at 24-months. Recruitment and retention of high percentages of racial/ethnic minorities and lower income samples is possible with planning, coordination with a trusted community setting and staff (e.g. community health centers and RAs), adaptability and building strong relationships. [ABSTRACT FROM AUTHOR]

Background: Education is inversely associated with cardiovascular disease incidence in developed countries. Blood pressure may be an explanatory biological mechanism. However few studies have investigated educational gradients in longitudinal blood pressure trajectories, particularly over substantial proportions of the life course. Study objectives were to determine whether low education was associated with increased blood pressure from multiple longitudinal assessments over 30 years. Furthermore, we aimed to separate antecedent effects of education, and other related factors, that might have caused baseline differences in blood pressure, from potential long-term effects of education on post-baseline blood pressure changes. Methods: The study examined 3890 participants of the Framingham Offspring Study (mean age 36.7 years, 52.0% females at baseline) from 1971 through 2001 at up to 7 separate examinations using multivariable mixed linear models. Results: Mixed linear models demonstrated that mean systolic blood pressure (SBP) over 30 years was higher for participants with ≤12 vs. ≥17 years education after adjusting for age (3.26 mmHg, 95% CI: 1.46, 5.05 in females, 2.26 mmHg, 95% CI: 0.87, 3.66 in males). Further adjustment for conventional covariates (antihypertensive medication, smoking, body mass index and alcohol) reduced differences in females and males (2.86, 95% CI: 1.13, 4.59, and 1.25, 95% CI: -0.16, 2.66 mmHg, respectively). Additional analyses adjusted for baseline SBP, to evaluate if there may be educational contributions to post-baseline SBP. In analyses adjusted for age and baseline SBP, females with ≤12 years education had 2.69 (95% CI: 1.09, 4.30) mmHg higher SBP over follow-up compared with ≥17 years education. Further adjustment for aforementioned covariates slightly reduced effect strength (2.53 mmHg, 95% CI: 0.93, 4.14). Associations were weaker in males, where those with ≤12 years education had 1.20 (95% CI: -0.07, 2.46) mmHg higher SBP over follow-up compared to males with ≥17 years of education, after adjustment for age and baseline blood pressure; effects were substantially reduced after adjusting for aforementioned covariates (0.34 mmHg, 95% CI: -0.90, 1.68). Sex-by-education interaction was marginally significant (p = 0.046). Conclusion: Education was inversely associated with higher systolic blood pressure throughout a 30-year life course span, and associations may be stronger in females than males. [ABSTRACT FROM AUTHOR]

Background: Modifying transport infrastructure to support active travel (walking and cycling) could help to increase population levels of physical activity. However, there is limited evidence for the effects of interventions in this field, and to the best of our knowledge no study has convincingly demonstrated an increase in physical activity directly attributable to this type of intervention. We have therefore taken the opportunity presented by a 'natural experiment' in Cambridgeshire, UK to establish a quasi-experimental study of the effects of a major transport infrastructural intervention on travel behaviour, physical activity and related wider health impacts. Design and methods: The Commuting and Health in Cambridge study comprises three main elements: a cohort study of adults who travel to work in Cambridge, using repeated postal questionnaires and basic objective measurement of physical activity using accelerometers; in-depth quantitative studies of physical activity energy expenditure, travel and movement patterns and estimated carbon emissions using household travel diaries, combined heart rate and movement sensors and global positioning system (GPS) receivers; and a longitudinal qualitative interview study to elucidate participants' attitudes, experiences and practices and to understand how environmental and social factors interact to influence travel behaviour, for whom and in what circumstances. The impacts of a specific intervention - the opening of the Cambridgeshire Guided Busway - and of other changes in the physical environment will be examined using a controlled quasi-experimental design within the overall cohort dataset. Discussion: Addressing the unresolved research and policy questions in this area is not straightforward. The challenges include those of effectively combining different disciplinary perspectives on the research problems, developing common methodological ground in measurement and evaluation, implementing robust quantitative measurement of travel and physical activity behaviour in an unpredictable 'natural experiment' setting, defining exposure to the intervention, defining controls, and conceptualising an appropriate longitudinal analytical strategy. [ABSTRACT FROM AUTHOR]

Background: Despite endorsement by national organizations, the impact of screening for intimate partner violence (IPV) is understudied, particularly as it occurs in different clinical settings. We analyzed interviews of IPV survivors to understand the risks and benefits of disclosing IPV to clinicians across specialties. Methods: Participants were English-speaking female IPV survivors recruited through IPV programs in Massachusetts. In-depth interviews describing medical encounters related to abuse were analyzed for common themes using Grounded Theory qualitative research methods. Encounters with health care clinicians were categorized by outcome (IPV disclosure by patient, discovery evidenced by discussion of IPV by clinician without patient disclosure, or non-disclosure), attribute (beneficial, unhelpful, harmful), and specialty (emergency department (ED), primary care (PC), obstetrics/gynecology (OB/GYN)). Results: Of 27 participants aged 18-56, 5 were white, 10 Latina, and 12 black. Of 59 relevant health care encounters, 23 were in ED, 17 in OB/GYN, and 19 in PC. Seven of 9 ED disclosures were characterized as unhelpful; the majority of disclosures in PC and OB/GYN were characterized as beneficial. There were no harmful disclosures in any setting. Unhelpful disclosures resulted in emotional distress and alienation from health care. Regardless of whether disclosure occurred, beneficial encounters were characterized by familiarity with the clinician, acknowledgement of the abuse, respect and relevant referrals. Conclusion: While no harms resulted from IPV disclosure, survivor satisfaction with disclosure is shaped by the setting of the encounter. Clinicians should aim to build a therapeutic relationship with IPV survivors that empowers and educates patients and does not demand disclosure. [ABSTRACT FROM AUTHOR]

Background: Safety belt use is 80% nationally, yet only 63% in Massachusetts. Safety belt use among potentially at-risk groups in Boston is unknown. We sought to assess the prevalence and correlates of belt non-use among emergency department (ED) patients in Boston. Methods: A cross-sectional survey with systematic sampling was conducted on non-urgent ED patients age ≥18. A closed-ended survey was administered by interview. Safety belt use was defined via two methods: a single-item and a multiple-item measure of safety belt use. Each was scored using a 5-point frequency scale. Responses were used to categorize safety belt use as 'always' or less than 'always'. Outcome for multivariate logistic regression analysis was safety belt use less than 'always'. Results: Of 478 patients approached, 381 (80%) participated. Participants were 48% female, 48% African-American, 40% White, median age 39. Among participants, 250 (66%) had been in a car crash; 234 (61%) had a valid driver's license, and 42 (11%) had been ticketed for belt non-use. Using two different survey measures, a single-item and a multiple-item measure, safety belt use 'always' was 51% and 36% respectively. According to separate regression models, factors associated with belt non-use included male gender, alcohol consumption >5 drinks in one episode, riding with others that drink and drive, ever receiving a citation for belt non-use, believing that safety belt use is 'uncomfortable', and that 'I just forget', while 'It's my usual habit' was protective. Conclusion: ED patients at an urban hospital in Boston have considerably lower self-reported safety belt use than state or national estimates. An ED-based intervention to increase safety belt use among this hard-to-reach population warrants consideration. [ABSTRACT FROM AUTHOR]

Background: The authors sought to monitor the impact of widespread varicella vaccination on the epidemiology of varicella and herpes zoster. While varicella incidence would be expected to decrease, mathematical models predict an initial increase in herpes zoster incidence if re-exposure to varicella protects against reactivation of the varicella zoster virus. Methods: In 1998-2003, as varicella vaccine uptake increased, incidence of varicella and herpes zoster in Massachusetts was monitored using the random-digit-dial Behavioral Risk Factor Surveillance System. Results: Between 1998 and 2003, varicella incidence declined from 16.5/1,000 to 3.5/1,000 (79%) overall with =66% decreases for all age groups except adults (27% decrease). Age-standardized estimates of overall herpes zoster occurrence increased from 2.77/1,000 to 5.25/1,000 (90%) in the period 1999-2003, and the trend in both crude and adjusted rates was highly significant (p < 0.001). Annual age-specific rates were somewhat unstable, but all increased, and the trend was significant for the 25-44 year and 65+ year age groups. Conclusion: As varicella vaccine coverage in children increased, the incidence of varicella decreased and the occurrence of herpes zoster increased. If the observed increase in herpes zoster incidence is real, widespread vaccination of children is only one of several possible explanations. Further studies are needed to understand secular trends in herpes zoster before and after use of varicella vaccine in the United States and other countries. [ABSTRACT FROM AUTHOR]

Background: The Boston Puerto Rican Health Study is an ongoing longitudinal cohort study designed to examine the role of psychosocial stress on presence and development of allostatic load and health outcomes in Puerto Ricans, and potential modification by nutritional status, genetic variation, and social support.Methods: Self-identified Puerto Ricans, aged 45-75 years and residing in the Boston, MA metro area, were recruited through door-to-door enumeration and community approaches. Participants completed a comprehensive set of questionnaires and tests. Blood, urine and salivary samples were extracted for biomarker and genetic analysis. Measurements are repeated at a two-year follow-up.Results: A total of 1500 eligible participants completed baseline measurements, with nearly 80% two-year follow-up retention. The majority of the cohort is female (70%), and many have less than 8th grade education (48%), and fall below the poverty level (59%). Baseline prevalence of health conditions is high for this age range: considerable physical (26%) and cognitive (7%) impairment, obesity (57%), type 2 diabetes (40%), hypertension (69%), arthritis (50%) and depressive symptomatology (60%).Conclusions: The enrollment of minority groups presents unique challenges. This report highlights approaches to working with difficult to reach populations, and describes some of the health issues and needs of Puerto Rican older adults. These results may inform future studies and interventions aiming to improve the health of this and similar communities. [ABSTRACT FROM AUTHOR]

Background: Gaps in disease surveillance capacity, particularly for emerging infections and bioterrorist attack, highlight a need for efficient, real time identification of diseases.Methods: We studied automated records from 1996 through 1999 of approximately 250,000 health plan members in greater Boston.Results: We identified 152,435 lower respiratory infection illness visits, comprising 106,670 episodes during 1,143,208 person-years. Three diagnoses, cough (ICD9CM 786.2), pneumonia not otherwise specified (ICD9CM 486) and acute bronchitis (ICD9CM 466.0) accounted for 91% of these visits, with expected age and sex distributions. Variation of weekly occurrences corresponded closely to national pneumonia and influenza mortality data. There was substantial variation in geographic location of the cases.Conclusion: This information complements existing surveillance programs by assessing the large majority of episodes of illness for which no etiologic agents are identified. Additional advantages include: a) sensitivity, uniformity and efficiency, since detection of events does not depend on clinicians' to actively report diagnoses, b) timeliness, the data are available within a day of the clinical event; and c) ease of integration into automated surveillance systems. These features facilitate early detection of conditions of public health importance, including regularly occurring events like seasonal respiratory illness, as well as unusual occurrences, such as a bioterrorist attack that first manifests as respiratory symptoms. These methods should also be applicable to other infectious and non-infectious conditions. Knowledge of disease patterns in real time may also help clinicians to manage patients, and assist health plan administrators in allocating resources efficiently. [ABSTRACT FROM AUTHOR]

Background: This paper explores strategies to engage community stakeholders in efforts to address the effects of traffic-related air pollution (TRAP). Communities of color and low-income communities are disproportionately impacted by environmental threats including emissions generated by major roadways., Methods: Qualitative instrumental case study design was employed to examine how community-level factors in two Massachusetts communities, the City of Somerville and Boston's Chinatown neighborhood, influence the translation of research into practice to address TRAP exposure. Guided by the Interactive Systems Framework (ISF), we drew on three data sources: key informant interviews, observations and document reviews. Thematic analysis was used., Results: Findings indicate political history plays a significant role in shaping community action. In Somerville, community organizers worked with city and state officials, and embraced community development strategies to engage residents. In contrast, Chinatown community activists focused on immediate resident concerns including housing and resident displacement resulting in more opposition to local municipal leadership., Conclusions: The ISF was helpful in informing the team's thinking related to systems and structures needed to translate research to practice. However, although municipal stakeholders are increasingly sympathetic to and aware of the health impacts of TRAP, there was not a local legislative or regulatory precedent on how to move some of the proposed TRAP-related policies into practice. As such, we found that pairing the ISF with a community organizing framework may serve as a useful approach for examining the dynamic relationship between science, community engagement and environmental research translation. Social workers and public health professionals can advance TRAP exposure mitigation by exploring the political and social context of communities and working to bridge research and community action.

Background: Smoking cessation interventions for hospitalized smokers are effective in promoting smoking cessation, but only if the tobacco dependence treatment continues after the patient leaves the hospital. Sustaining tobacco dependence treatment after hospital discharge is a challenge for health care systems. Our previous single-site randomized controlled trial demonstrated the effectiveness of an intervention that facilitated the delivery of comprehensive tobacco cessation treatment, including both medication and counseling, after hospital discharge. We subsequently streamlined the intervention model to increase its potential for dissemination. This new model is being tested in a larger multi-site trial with broader eligibility criteria in order to enroll a more representative sample of hospitalized smokers. This paper describes the trial design and contrasts it with the earlier study., Methods/design: A 2-arm, 3-site randomized controlled trial is testing the hypothesis that a multi-component Sustained Care intervention is more effective than Standard Care in helping hospitalized cigarette smokers stop smoking after hospital discharge. The trial enrolls adult daily cigarette smokers who are admitted to 1 of 3 participating hospitals in Massachusetts or Pennsylvania. Participants receive the same smoking cessation intervention in the hospital. They are randomly assigned to receive either Standard Care or Sustained Care after hospital discharge. Participants in the Sustained Care arm receive a free 3-month supply of FDA-approved smoking cessation medication and 5 interactive voice response calls that provide tailored motivational messages, medication refills, and access to a live tobacco treatment counselor. Participants in the Standard Care arm receive a smoking cessation medication recommendation and information about community resources. Outcomes are assessed at 1, 3, and 6 months after discharge. The primary outcome is biochemically-validated tobacco abstinence for the past 7 days at 6-month follow-up. Other outcome measures include self-reported tobacco abstinence measures, use of medication and counseling after discharge, hospital readmissions, and program cost-effectiveness., Discussion: We adapted a proven intervention for hospitalized smokers to enhance its potential for dissemination and are testing it in a multi-site trial. Study enrollment data suggests that the trial achieved the goal of recruiting a broader sample of hospitalized smokers., Trial Registration: Comparative Effectiveness of Post-Discharge Strategies for Hospitalized Smokers (Helping HAND2) NCT01714323. Registered October 22, 2012.

Background: Although daily emergency department (ED) data is a source of information that often includes residence, its potential for space-time analyses at the individual level has not been fully explored. We propose that ED data collected for surveillance purposes can also be used to inform spatial and temporal patterns of disease using generalized additive models (GAMs). This paper describes the methods for adapting GAMs so they can be applied to ED data., Methods: GAMs are an effective approach for modeling spatial and temporal distributions of point-wise data, producing smoothed surfaces of continuous risk while adjusting for confounders. In addition to disease mapping, the method allows for global and pointwise hypothesis testing and selection of statistically optimum degree of smoothing using standard statistical software. We applied a two-dimensional GAM for location to ED data of overlapping calendar time using a locally-weighted regression smoother. To illustrate our methods, we investigated the association between participants' address and the risk of gastrointestinal illness in Cape Cod, Massachusetts over time., Results: The GAM space-time analyses simultaneously smooth in units of distance and time by using the optimum degree of smoothing to create data frames of overlapping time periods and then spatially analyzing each data frame. When resulting maps are viewed in series, each data frame contributes a movie frame, allowing us to visualize changes in magnitude, geographic size, and location of elevated risk smoothed over space and time. In our example data, we observed an underlying geographic pattern of gastrointestinal illness with risks consistently higher in the eastern part of our study area over time and intermittent variations of increased risk during brief periods., Conclusions: Spatial-temporal analysis of emergency department data with GAMs can be used to map underlying disease risk at the individual-level and view changes in geographic patterns of disease over time while accounting for multiple confounders. Despite the advantages of GAMs, analyses should be considered exploratory in nature. It is possible that even with a conservative cutoff for statistical significance, results of hypothesis testing may be due to chance. This paper illustrates that GAMs can be adapted to measure geographic trends in public health over time using ED data.