Preventive Medicine

Information for CME Credit—Mortality Risk Reductions for Replacing Sedentary Time With Physical Activities Publication date: May 2019 Source: American Journal of Preventive Medicine, Volume 56, Issue 5 Author(s):

Pathways From Food Insecurity to Intimate Partner Violence Perpetration Among Peri-Urban Men in South Africa Publication date: May 2019 Source: American Journal of Preventive Medicine, Volume 56, Issue 5 Author(s): Abigail M. Hatcher, Heidi Stöckl, Ruari-Santiago McBride, Mzwakhe Khumalo, Nicola Christofides Introduction Although poverty is sometimes seen as a driver of intimate partner violence victimization, less is known about how it intersects with men's violence perpetration. Food insecurity is a sensitive marker of poverty that may have unique mechanisms leading to men's intimate partner violence perpetration given its association with gender roles and men "providing for the family." Methods Using cluster-based sampling, the team conducted an audio-assisted questionnaire in 2016 among men living in a peri-urban settlement near Johannesburg, South Africa. The aim was to examine the relationship between men's food insecurity and their use of past-year intimate partner violence, and to explore the pathways linking these two conditions. Results Among 2,006 currently partnered men, nearly half (48.4%) perpetrated intimate partner violence and more than half (61.4%) were food insecure. Food insecurity was associated with doubled odds of intimate partner violence (OR=2.15, 95% CI=1.73, 2.66). This association persisted after controlling for sociodemographics, relationship characteristics, and neighborhood clustering. In a structural equation model, food insecurity retained a direct relationship with men's violence perpetration and worked through indirect pathways of mental health and relationship quality. Conclusions Addressing men's perpetration of intimate partner violence may require examination of broader structural challenges, such as food insecurity. Future interventions should consider livelihood strategies alongside relationship and mental health approaches.

Fall Prevention Self-Management Among Older Adults: A Systematic Review Publication date: May 2019 Source: American Journal of Preventive Medicine, Volume 56, Issue 5 Author(s): Kumiko O. Schnock, Elizabeth P. Howard, Patricia C. Dykes Context Adequate self-management could minimize the impact of falls in older adults. The efficacy of fall prevention self-management interventions has been widely studied, yet little is known about why some older adults engage in fall prevention self-management actions and behaviors, whereas others do not. Through a systematic review of fall prevention self-management studies, this study identified characteristics and the personal, social, and environmental factors of older adults who engage in self-management actions and behaviors. Evidence acquisition Medical and nursing literature related to fall prevention self-management was searched in PubMed, Embase, and CINAHL (1997–2017), and relevant publications were selected by three researchers to assess whether the papers included subject characteristics and their fall prevention self-management actions and behaviors. GRADE (Grading of Recommendations, Assessment, Development and Evaluations) was used by the researchers to assess the quality of the included studies and to determine the significance of the extracted characteristics. Evidence synthesis Searching literature through 2017, a total of 972 papers were identified, and 28 papers remained after removing those that did not meet inclusion criteria. Nine papers that addressed subject characteristics in relation to the study outcomes were included in a sub-analysis. The authors identified the following characteristics of older adults who participated in fall prevention self-management actions and behaviors: younger males, not living alone and with self-reported good health, having greater fear of falling and high fall prevention self-efficacy, and possessing high motivation for engagement with self-management activities. Conclusions The systematic literature review revealed the personal characteristics of older adults who engage in fall prevention self-management actions and behaviors.

Regular Sunscreen Use and Risk of Mortality: Long-Term Follow-up of a Skin Cancer Prevention Trial Publication date: May 2019 Source: American Journal of Preventive Medicine, Volume 56, Issue 5 Author(s): Akiaja R. Lindstrom, Lena A. von Schuckmann, Maria Celia B. Hughes, Gail M. Williams, Adele C. Green, Jolieke C. van der Pols Introduction Sunscreen is widely used to protect the skin from harmful effects of sun exposure. However, there are concerns that sunscreens may negatively affect overall health. Evidence of the general safety of long-term regular sunscreen use is therefore needed. Methods The effect of long-term sunscreen use on mortality was assessed over a 21-year period (1993–2014) among 1,621 Australian adults who had participated in a randomized skin cancer prevention trial of regular versus discretionary sunscreen use (1992–1996). In 2018, an intention-to-treat analysis was conducted using Cox proportional hazards regression to compare death rates in people who were randomized to apply sunscreen daily for 4.5years, versus randomized to use sunscreen at their usual, discretionary level. All-cause mortality and deaths resulting from cardiovascular disease, cancer, and other causes were considered. Results In total, 160 deaths occurred in the daily sunscreen group compared with 170 deaths in the discretionary sunscreen group (hazard ratio=0.94, 95% CI=0.76, 1.17); 59vs 76 cardiovascular disease deaths (hazard ratio=0.77, 95% CI=0.55, 1.08), 63vs 58 cancer deaths (hazard ratio=1.09, 95% CI=0.76, 1.57), and 45vs 44 deaths resulting from other causes (hazard ratio=1.02, 95% CI=0.67, 1.54) occurred respectively. Conclusions Regular use of a sun protection factor 16 sunscreen on head, neck, arms, and hands for 4.5years did not increase mortality.

Characteristics of Veteran and Civilian Suicide Decedents: A Sex-Stratified Analysis Publication date: May 2019 Source: American Journal of Preventive Medicine, Volume 56, Issue 5 Author(s): Adam G. Horwitz, Dale L. Smith, Philip Held, Alyson K. Zalta Introduction Few studies have examined characteristics distinguishing Veteran and civilian suicide decedents. An understanding of unique risk factors for Veteran suicide is critical to develop effective preventive interventions. This is particularly imperative for female Veterans, who have near double the suicide mortality rate of same-aged female civilians. The objectives of this study were to examine whether Veteran and civilian suicide decedents differed on risk factors and suicide-event characteristics, and to determine whether predictors changed based on sex. Methods Data from 116,515 suicides collected by the National Violent Death Reporting System in 27 states between 2003 and 2015 were analyzed in 2018 in sex-stratified analyses. Logistic regression models examined population differences in risk factors and suicide-event characteristics. Results Relative to male civilians, male Veterans were more likely to have a contributing physical health problem (AOR=1.10, 95% CI=1.06, 1.14) and to use a firearm for their suicide (AOR=1.41, 95% CI=1.36, 1.47); they were less likely to have substance use problems (AOR=0.70, 95% CI=0.66, 0.75), depressed mood (AOR=0.93, 95% CI=0.90, 0.97), or financial problems (AOR=0.91, 95% CI=0.86, 0.97). Female Veterans were more likely to use a firearm for their suicide (AOR=1.39, 95% CI=1.19, 1.63) relative to female civilians. Conclusions Firearm use as a suicide method was a key distinguishing feature of Veteran suicide. Means restriction and firearm safety are pertinent to preventing Veteran suicide. Given low utilization of mental health care and frequent presence of physical health problems in this population, safe storage messages may have a greater preventive impact if delivered in primary care or other nonpsychiatric settings.

Mortality Risk Reductions for Replacing Sedentary Time With Physical Activities Publication date: May 2019 Source: American Journal of Preventive Medicine, Volume 56, Issue 5 Author(s): Erika Rees-Punia, Ellen M. Evans, Michael D. Schmidt, Jennifer L. Gay, Charles E. Matthews, Susan M. Gapstur, Alpa V. Patel Introduction Excess sitting is a risk factor for early mortality. This may be resulting, at least in part, from the displacement of physical activity with sedentary behaviors. The purpose of this observational study was to examine the mortality risk reductions associated with replacing 30minutes/day sitting for an equivalent duration of light or moderate to vigorous physical activity (MVPA). Methods Participants included 37,924 men and 54,617 women in the Cancer Prevention Study-II Nutrition Cohort, of which 14,415 men and 13,358 women died during follow-up (1999–2014). An isotemporal substitution approach to the Cox proportional hazards regression model was used to estimate adjusted hazard ratios and 95% CIs for mortality associated with the substitution of 30minutes/day self-reported sitting for light physical activity or MVPA. Analyses were conducted in 2018. Results Among the least active participants (≤17minutes/day MVPA), the replacement of 30minutes/day sitting with light physical activity was associated with a 14% mortality risk reduction (hazard ratio=0.86, 95% CI=0.81, 0.89) and replacement with MVPA was associated with a 45% mortality risk reduction (hazard ratio=0.55, 95% CI=0.47, 0.62). Similar associations were seen among moderately active participants (light physical activity replacement, hazard ratio=0.94, 95% CI=0.91, 0.97; MVPA replacement, hazard ratio=0.83, 95% CI=0.76, 0.88). However, for the most active (MVPA >38 minutes/day), substitution of sitting time with light physical activity or MVPA was not associated with a reduction in mortality risk (hazard ratio=1.00, 95% CI=0.97, 1.03, and hazard ratio=0.99, 95% CI=0.95, 1.02, respectively). Conclusions These findings suggest that the replacement of modest amounts of sitting time with even light physical activity may have the potential to reduce the risk of premature death among less active adults.

Public Health Workforce Development Needs: A National Assessment of Executives' Perspectives Publication date: May 2019 Source: American Journal of Preventive Medicine, Volume 56, Issue 5 Author(s): Jonathon P. Leider, Fatima Coronado, Kyle Bogaert, Elizabeth Gould Introduction Workforce development is one of the ten essential public health services. Recent studies have better characterized individual worker perceptions regarding workforce interests and needs, but gaps remain around workforce needs from program managers' perspectives. This study characterized management perspectives regarding subordinate's abilities and training needs and perceived challenges to recruitment and retention. Methods In 2017, the Directors Assessment of Workforce Needs Survey was sent to 574 managers at state health agencies across the U.S. Respondents were invited based on the positions they held (i.e., to be included, respondents had to be employed as managers and oversee specific program areas). In 2018, descriptive statistics were calculated, including Fisher's exact for inferential comparisons and Tukey's test for multiple comparisons, as appropriate. Results Response rate was 49% after accounting for undeliverable e-mails; 226 respondents met the inclusion criteria. The largest perceived barriers to staff recruitment were wages or salaries (74%) and private sector competition (56%). Similarly, wages or salaries were identified as the main cause of turnover by 70% of respondents, followed by lack of opportunities for advancement (68%), and opportunities outside the agency (67%). Conclusions The Directors Assessment of Workforce Needs Survey fills important knowledge gaps and complements previously identified evidence to guide refinement of workforce development efforts. Although competition from the private sector remains challenging, these findings indicate that recruitment and retention must be top priorities in state health agencies nationwide. Prioritizing individual state health agency workforce gaps and committing to provide specific local-level interventions to those priorities is crucial for individual health agencies.

Administrative Military Discharge and Suicidal Ideation Among Post–9/11 Veterans Publication date: May 2019 Source: American Journal of Preventive Medicine, Volume 56, Issue 5 Author(s): Claire A. Hoffmire, Lindsey L. Monteith, Ryan Holliday, Crystal L. Park, Lisa A. Brenner, Rani A. Hoff Introduction From 2005 to 2016, the Veteran suicide rate increased 25.9%. Reducing this rate is a top priority for the Department of Veterans Affairs. In 2017, a policy change expanded emergent mental health services to include previously ineligible Veterans discharged under other than honorable conditions. To date, research examining the relationship between military discharge type and suicide risk has been limited. Methods This study aimed to examine the association between discharge type (honorable versus administrative) and active suicide ideation among Veterans participating in the Survey of Experiences of Returning Veterans (N=850, data collection 2012–2015 and data analysis 2017–2018) using logistic regression. Stratified analyses explored whether gender, time since military separation, or recent mental health service use moderated this relationship. Results The prevalence of suicide ideation was significantly higher (p<0.01) among Veterans reporting administrative discharge (23.1%, 95% CI=12.8, 33.3 vs 10.6%, 95% CI=8.4, 12.8). However, after accounting for lifetime suicide attempt history, combat experiences, posttraumatic stress disorder symptoms, depression, and drug dependence, discharge was no longer associated with suicide ideation. Recent mental health service use and time since separation significantly modified this relationship. The relationship was only significant among Veterans not using mental health services (OR=4.8, 95% CI=1.3, 18.2) and among transitioning Veterans <2years from separation (OR=3.6, 95% CI=1.4, 9.2). Conclusions These findings suggest that recognized risk factors for suicide, such as a history of mental health conditions, account for the increased prevalence of suicide ideation among Veterans with administrative discharges and that mental health services may have the potential to mitigate such risk in this high-risk Veteran population.

Time to Follow-up After Colorectal Cancer Screening by Health Insurance Type Publication date: May 2019 Source: American Journal of Preventive Medicine, Volume 56, Issue 5 Author(s): Nancy Breen, Celette Sugg Skinner, Yingye Zheng, Stephen Inrig, Douglas A. Corley, Elisabeth F. Beaber, Mike Garcia, Jessica Chubak, Chyke Doubeni, Virginia P. Quinn, Jennifer S. Haas, Christopher I. Li, Karen J. Wernli, Carrie N. Klabunde, PROSPR consortium Introduction The purpose of this study was to test the hypothesis that patients with Medicaid insurance or Medicaid-like coverage would have longer times to follow-up and be less likely to complete colonoscopy compared with patients with commercial insurance within the same healthcare systems. Methods A total of 35,009 patients aged 50–64years with a positive fecal immunochemical test were evaluated in Northern and Southern California Kaiser Permanente systems and in a North Texas safety-net system between 2011 and 2012. Kaplan–Meier estimation was used between 2016 and 2017 to calculate the probability of having follow-up colonoscopy by coverage type. Among Kaiser Permanente patients, Cox regression was used to estimate hazard ratios and 95% CIs for the association between coverage type and receipt of follow-up, adjusting for sociodemographics and health status. Results Even within the same integrated system with organized follow-up, patients with Medicaid were 24% less likely to complete follow-up as those with commercial insurance. Percentage receiving colonoscopy within 3 months after a positive fecal immunochemical test was 74.6% for commercial insurance, 63.10% for Medicaid only, and 37.5% for patients served by the integrated safety-net system. Conclusions This study found that patients with Medicaid were less likely than those with commercial insurance to complete follow-up colonoscopy after a positive fecal immunochemical test and had longer average times to follow-up. With the future of coverage mechanisms uncertain, it is important and timely to assess influences of health insurance coverage on likelihood of follow-up colonoscopy and identify potential disparities in screening completion.

Impacts of the Affordable Care Act Dependent Coverage Provision on Young Adults With Cancer Publication date: May 2019 Source: American Journal of Preventive Medicine, Volume 56, Issue 5 Author(s): Justin M. Barnes, Jenine K. Harris, Derek S. Brown, Allison King, Kimberly J. Johnson Introduction Evidence through 2012 suggests that the 2010 Affordable Care Act Dependent Coverage Provision, extending dependent insurance coverage eligibility to age 26years, increased young adult insurance coverage and decreased cancer diagnosis stage in young adult cancer patients. This study examines Dependent Coverage Provision–associated changes in insurance coverage and diagnosis stage through 2014 in young adult cancer patients. Methods Using a quasi-experimental study design, analyses were conducted in 2017–2018 using 2007 to 2014 data from the Surveillance, Epidemiology, and End Results (SEER) 18 and the National Cancer Database (NCDB). Using difference-in-differences analyses applied to linear probability models, changes in the percentage of policy-eligible individuals aged 19–25years versus ineligible individuals aged 27–29years who were insured (excluding Medicaid) and diagnosed at early (Stages 0 and 1) or late (Stage 4) stages following Dependent Coverage Provision enactment were estimated. Results A total of 36,901 and 92,358 young adults were included from SEER and NCDB. Consistent increases in the percentage insured (SEER: 3.45 percentage points, 95% CI=2.04, 4.87; NCDB: 3.72 percentage points, 95% CI=2.80, 4.64); variable increases in early-stage diagnoses (2.25 percentage points, 95% CI=0.40, 4.10; 0.69 percentage points, 95% CI= –0.65, 2.02); and decreases in late-stage diagnoses (–1.74 percentage points, 95% CI= –3.10, –0.38; –0.58 percentage points, 95% CI= –1.46, 0.30) were observed in young adults aged 19–25 versus 27–29years. Conclusions These results provide clear evidence for a Dependent Coverage Provision–associated impact on insurance coverage in young adult cancer patients; however, clear impacts on diagnosis stage are less evident.