Dental caries is influenced by a complex interplay of genetic and environmental factors including dietary habits. Previous reports have characterized the influence of genetic variation on taste preferences and dietary habits. We therefore hypothesized that genetic variation in taste pathway genes (TAS2R38, TAS1R2, GNAT3) may be associated with dental caries risk and/or protection. Families were recruited by the Center for Oral Health Research in Appalachia (COHRA) for collection of biological samples, demographic data and clinical assessment of oral health including caries scores. Multiple single nucleotide polymorphism (SNP) assays for each gene were performed and analyzed using transmission disequilibrium test (TDT) analysis (FBAT software) for three dentition groups: primary, mixed, and permanent. Statistically significant associations were seen in TAS2R38 and TAS1R2 for caries risk and/or protection.
Dental Caries; Genetics; Taste Genes; Taste Preference; Association Analysis
Dental caries is influenced by a complex interplay of genetic and environmental factors, including dietary habits. Previous reports have characterized the influence of genetic variation on taste preferences and dietary habits. We therefore hypothesized that genetic variation in taste pathway genes (TAS2R38, TAS1R2, GNAT3) may be associated with dental caries risk and/or protection. Families were recruited by the Center for Oral Health Research in Appalachia (COHRA) for collection of biological samples, demographic data, and clinical assessment of oral health, including caries scores. Multiple single-nucleotide polymorphism (SNP) assays for each gene were performed and analyzed by transmission disequilibrium test (TDT) analysis (FBAT software) for three dentition groups: primary, mixed, and permanent. Statistically significant associations were seen in TAS2R38 and TAS1R2 for caries risk and/or protection.
dental caries; taste preference; genetic association; taste pathway genes
Social, cultural, and economic environments are associated with high rates of disease incidence and mortality in poor Appalachian regions of the United States. Although many historical studies suggest that aspects of Appalachian culture (e.g., fatalism, patriarchy) include values and beliefs that may put Appalachians at risk for poor health, other cultural aspects may be protective (e.g., strong social ties). Few recent studies have explored regional cultural issues qualitatively. The purpose of this study was to examine social and cultural factors that may be associated with health and illness in an Appalachian region.
Ten focus groups were conducted in southern West Virginia and included five groups of men and five groups of women. Cultural norms associated with residents of rural Appalachia, such as faith, family values, and patriarchy, were examined.
Both men and women in the focus groups have a sense of place, strong family ties, and a strong spiritual belief or faith in God. Patriarchy as a cultural value was not a strong factor.
There are limits to how qualitative data may be used, but findings from this study help increase understanding of the social and cultural environments of people living in rural Appalachia and how these environments may affect health.
The objective of our study of oral health disparities in Appalachia was to use existing data sources to geographically analyze suspected disparities in oral health status in the 420 counties of Appalachia, and to make sub-state comparisons within Appalachia and to the rest of the nation. The purpose of this manuscript is to describe the methods used to overcome challenges associated with using limited oral health data to make inferences about oral health status.
Oral health data were obtained from the Behavioral Risk Factor Surveillance System (BRFSS). Because the BRFSS was designed for state-level analysis, there were inadequate numbers of responses to study Appalachia by county. We set out to determine the smallest possible unit we could use, aggregating data to satisfy CDC minimum requirements for spatially identified responses. For sub-state comparisons, data were first aggregated to Appalachian and non-Appalachian regions within Appalachian states. Next, urban versus rural areas within Appalachian and non-Appalachian regions were examined. Beale codes were used to define metropolitan and non-metropolitan statistical regions for the United States.
Aggregating the data as described proved useful for smoothing the data used to analyze oral health disparities, while still revealing important sub-state differences. Using geographic information systems to map data throughout the process was very useful for determining an effective approach for our analysis.
Studying oral health disparities on a regional or national level is difficult given a lack of appropriate data. The BRFSS can be adapted for this purpose; however, there is a limited number of oral health questions and because they are also optional, they are not routinely asked by all states. Expanding the BRFSS to include a larger sampling frame would be very helpful for studying oral health disparities.
Novel techniques were introduced to use BRFSS data to study oral health disparities in Appalachia, which provided informative sub-state results, useful to health planners for targeting intervention strategies.
Behavioral Risk Factor Surveillance System (BRFSS); Beale codes; oral health; disparities; Geographic Information Systems (GIS)
This study investigated whether oral hygiene self-care behavior differs between genders in older adults in Appalachia, a geographic area with significant oral health concerns. Identifying the practices of older adults may provide valuable information for designing interventions, and improving overall oral health outcomes.
As part of a larger, on-going study on cognition and oral health in later life in Appalachia, a sample of dentate, older adults without dementia aged 70 and above (n =245, 86 men and 159 women) received an oral assessment by either a dentist or dental hygienist. Psychometricians assessed cognition using a standardized battery of neuropsychological tests. They also administered the General Oral Health Assessment Index and conducted structured interviews concerning diet, oral hygiene practices, oral health, social support, income, and years of education.
Over 80% of women (n = 128) and 52.3% of men (n = 45) reported brushing their teeth twice daily. Multivariate logistic regression analysis was conducted, controlling for socioeconomic status, social support (i.e., frequency of contacting friends and relatives), general oral health assessment items, number of decayed, missing, and filled surfaces, plaque index, and having regular dental visits. The results showed that women reported more frequent toothbrushing than their male counterparts (OR=4.04, 95% CI:1.93,8.42).
Older women in West Virginia had significantly better oral hygiene practices than older men, particularly regarding toothbrushing. Interventions are needed to improve older men’s dental hygiene behaviors to improve overall oral health outcomes.
aged; self-care; gender differences; preventive behavior; Appalachia; oral hygiene
The study's objectives were to characterize initiation of injection drug use, examine the independent association of specific substance use with injection drug use, and determine factors associated with rates of transition from first illicit drug use to first injection among a sample of rural Appalachian drug users.
Interview-administered questionnaires were administered to a sample of drug users recruited via respondent-driven sampling.
Injection drug users (IDUs) (n=394) and non-IDUs (n=109)
Data were collected on substance use and years from age at initiation of illicit substance use to ‘event’ (initiation of injection or date of baseline interview for non-IDUs). Logistic regression and Cox regression were used to identify factors associated with lifetime injection drug use and transition time to injection, respectively.
OxyContin® was involved in nearly as many initiations to injection (48%) as were stimulants, other prescription opioids, and heroin combined; for participants who initiated with OxyContin®, the median time from which they began OxyContin® use to their first injection of OxyContin® was 3 years. Adjusting for demographics, five prescription drugs (benzodiazepines, illicit methadone, oxycodone, OxyContin® and other opiates) were associated with an increased hazard for transitioning from first illicit drug use to first injection drug use (each at p<.01).
In Appalachia, in the US, the prescription opioid, OxyContin®, is widely used nonmedically and appears to show a particularly high risk of rapid transition to injection compared with the use of other illicit drugs.
Appalachian counties have historically had elevated infant mortality rates. Changes in infant mortality disparities over time in Appalachia are not well-understood. This study explores spatial inequalities in white infant mortality rates over time in the 13 Appalachian states, comparing counties in Appalachia with non-Appalachian counties.
Data are analyzed for 1,100 counties in 13 Appalachian states that include 420 counties designated as Appalachian by the Appalachian Regional Commission. Area Resource File data for 1976-1980 and 1996-2000 provide county- and city-level infant mortality rates, poverty rates, rural-urban continuum codes, and numbers of physicians per 1,000 residents. Multiple regression analyses evaluate whether Appalachian counties are significantly associated with elevated white infant mortality in each time period, accounting for covariates.
White infant mortality rates decreased substantially in all sub-regions over the last 2 decades; however, disparities in infant mortality did not diminish in Appalachian counties compared to non-Appalachian counties. After accounting for poverty, rural/urban status, and health care resources, Appalachian counties were significantly associated with comparatively higher infant mortality during the late 1970s but not in the late 1990s. At the more recent time point, higher poverty rates, residence in more rural areas, and lower physician density were associated with greater infant mortality risk.
Appalachian counties continue to experience relatively elevated infant mortality rates. Poverty and rurality remain important dimensions of health service need in Appalachia.
Appalachia; disparity; infant mortality; rural
Appalachia is a region of the United States noted for the poverty and poor health outcomes of its residents. Residents of the poorest Appalachian counties have a high prevalence of diabetes and risk factors (obesity, low income, low education, etc.) for type 2 diabetes. However, diabetes prevalence exceeds what these risk factors alone explain. Based on this, the history of poor health outcomes in Appalachia, and personally observed high rates of childhood obesity and lack of concern about prediabetes, we speculated that people in Appalachia with diagnosed diabetes might tend to be diagnosed younger than their non-Appalachian counterparts.
We used data from the Behavioral Risk Factor Surveillance System (2006-2008). We compared age at diagnosis among counties by Appalachian Regional Commission-defined level of economic development. To account for risk differences, we constructed a model for average age at diagnosis of diabetes, adjusting for county economic development, obesity, income, sedentary lifestyle, and other covariates.
After adjustment for risk factors for diabetes, people in distressed or at-risk counties (the least economically developed) had their diabetes diagnosed two to three years younger than comparable people in non-Appalachian counties. No significant differences between non-Appalachian counties and Appalachian counties at higher levels of economic development remained after adjusting.
People in distressed and at-risk counties have poor access to care, and are unlikely to develop diabetes at the same age as their non-Appalachian counterparts but be diagnosed sooner. Therefore, people in distressed and at-risk counties are likely developing diabetes at younger ages. We recommend that steps to reduce health disparities between the poorest Appalachian counties and non-Appalachian counties be considered.
Appalachia; Diabetes: Disparities; Geography
Breast cancer death rates in the U.S. have decreased in recent decades, however areas such as Appalachia with fewer cancer care resources may not have experienced comparable mortality declines. This study examines trends in breast cancer mortality rate disparities in Appalachian states and the continental U.S. using data from SEER mortality files 1969–2007 and the Area Resource File. Overall breast cancer mortality rates decreased significantly, with a smaller decline in Appalachian counties (17.5%) compared with non-Appalachian counties in Appalachian states (30.5%), and compared with non-Appalachia U.S. counties (28.3%). After accounting for poverty, rural/urban status, education, health care resources, and proportion White in the population, residence in Appalachian counties except for those in the Northern subregion was significantly associated with smaller reduction in breast cancer mortality rates. Lower levels of education, physician density, and percent White in the population were also associated with smaller reductions in breast cancer mortality.
Breast cancer; mortality; Appalachia; disparity
Despite evidence of the importance of cervical cancer screening, screening rates in the United States remain below national prevention goals. Women in the Appalachia Ohio region have higher cervical cancer incidence and mortality rates along with lower cancer screening rates. This study explored Appalachian Ohio women’s expectations about Pap test cost and perceptions of cost as a barrier to screening.
Face-to-face interviews were conducted with 571 women who were part of a multilevel observational community-based research program in Appalachia Ohio. Eligible women were identified through 14 participating health clinics and asked questions about Pap test cost and perceptions of cost as a barrier to screening. Estimates of medical costs were compared to actual costs reported by clinics.
When asked about how much a Pap test would cost, 80% of the women reported they did not know. Among women who reportedly believed they knew the cost, 40% overestimated test cost. Women who noted cost as a barrier were twice as likely to not receive a test within screening guidelines as those who did not perceive a cost barrier. Further, uninsured women were more than 8.5 times as likely to note cost as a barrier than women with private insurance.
While underserved women in need of cancer screening commonly report cost as a barrier, these findings suggest that women may have a very limited and often inaccurate understanding about Pap test cost. Providing women with this information may help reduce the impact of this barrier to screening.
Pap test; disparities; perception of cost; access; cost barriers; underserved populations; Appalachia; cancer screening
We compared health-related quality of life (HRQOL) in mining and non-mining counties in and out of Appalachia using the 2006 Behavioral Risk Factor Surveillance System (BRFSS) survey.
Dependent variables included self-rated health, the number of poor physical and mental health days, the number of activity limitation days (in the last 30 days), and the Centers for Disease Control and Prevention Healthy Days Index. Independent variables included the presence of coal mining, Appalachian region residence, metropolitan status, primary care physician supply, and BRFSS behavioral (e.g., smoking, body mass index, and alcohol consumption) and demographic (e.g., age, gender, race, and income) variables. We compared dependent variables across a four-category variable: Appalachia (yes/no) and coal mining (yes/no). We used SUDAAN® Multilog and multiple linear regression models with post-hoc least-squares means to test for Appalachian coal-mining effects after adjusting for covariates.
Residents of coal-mining counties inside and outside of Appalachia reported significantly fewer healthy days for both physical and mental health, and poorer self-rated health (p<0.0005) when compared with referent U.S. non-coal-mining counties, but disparities were greatest for people residing in Appalachian coal-mining areas. Furthermore, results remained consistent in separate analyses by gender and age.
Coal-mining areas are characterized by greater socioeconomic disadvantage, riskier health behaviors, and environmental degradation that are associated with reduced HRQOL.
Meeting the health care needs of rural residents is complicated by their substantial medical burdens that frequently outstrip patient and community resources. Nowhere is this more evident than in central Appalachia. Preventive procedures are often sacrificed as patients and providers attend to more pressing medical issues. We report the results of a pilot study designed to explore the need for and appropriateness of a potential intervention placed in an emergency department (ED), with the eventual goal of using the ED to link traditionally underserved patients to preventive services. We used a convenience sample of 49 ED patients to explore their characteristics and health needs and compare them with a sample of 120 case management clients participating in the Kentucky Homeplace Program (KHP), and a general sample of 3,165 Appalachian Kentuckians. The recruited ED patients had low socio-economic status, numerous health conditions, and several unmet health needs, including need for colorectal, cervical, and breast cancer screening. Compared to their KHP counterparts, more ED patients were uninsured. Participants in the ED and KHP groups had particularly low income, were less educated, and had less insurance coverage than an average Appalachian resident. Although case management services, including the KHP, have been successful in increasing access to health care by those in need, certain segments of the population remain underserved and continued to be missed by such programs. Our study suggests the need for and appropriateness of reaching out to such underserved populations in the ED and involving them into potential interventions designed to enhance preventive health services.
prevention; community health; emergency department; rural population; Appalachia
Appalachia has high rates of tobacco use and related health problems, and despite significant impediments to alcohol use, alcohol abuse is common. Adolescents are exposed to sophisticated tobacco and alcohol advertising. Prevention messages, therefore, should reflect research concerning culturally influenced attitudes toward tobacco and alcohol use.
With 4 grants from the National Institutes of Health, 34 focus groups occurred between 1999 and 2003 in 17 rural Appalachian jurisdictions in 7 states. These jurisdictions ranged between 4 and 8 on the Rural-Urban Continuum Codes of the Economic Research Service of the US Department of Agriculture. Of the focus groups, 25 sought the perspectives of women in Appalachia, and 9, opinions of adolescents.
The family represented the key context where residents of Appalachia learn about tobacco and alcohol use. Experimentation with tobacco and alcohol frequently commenced by early adolescence and initially occurred in the context of the family home. Reasons to abstain from tobacco and alcohol included a variety of reasons related to family circumstances. Adults generally displayed a greater degree of tolerance for adolescent alcohol use than tobacco use. Tobacco growing represents an economic mainstay in many communities, a fact that contributes to the acceptance of its use, and many coal miners use smokeless tobacco since they cannot light up in the mines. The production and distribution of homemade alcohol was not a significant issue in alcohol use in the mountains even though it appeared not to have entirely disappeared.
Though cultural factors support tobacco and alcohol use in Appalachia, risk awareness is common. Messages tailored to cultural themes may decrease prevalence.
To assess HPV vaccine acceptability, focus groups of women (18–26 years), parents, community leaders, and healthcare providers were conducted throughout Ohio Appalachia. Themes that emerged among the 23 focus groups (n=114) about the HPV vaccine were: barriers (general health and vaccine specific), lack of knowledge (cervical cancer and HPV), cultural attitudes, and suggestions for educational materials and programs. Important Appalachian attitudes included strong family ties, privacy, conservative views, and lack of trust of outsiders to the region. There are differences in HPV vaccine acceptability among different types of community members highlighting the need for a range of HPV vaccine educational materials/programs to be developed that are inclusive of the Appalachian culture.
HPV vaccine; cervical cancer; health disparities
Screen for Life: National Colorectal Cancer Action Campaign is a multimedia campaign that informs men and women aged 50 and older about the importance of colorectal cancer screening. The Appalachia Cancer Network undertook a qualitative research study to help determine whether Screen for Life materials are being used and distributed by organizations serving Appalachian residents and to help assess key informants' perceived acceptability of the materials.
Semistructured telephone interviews were conducted with 13 state and local informants in three Appalachian states to assess the diversity of community organizations that received the materials, the level of material use, and receptivity to Screen for Life.
Regional cancer control programs were more active in promoting Screen for Life at local levels than state health departments. Although state health departments are the primary route for distributing Screen for Life materials, they did not report the breadth of activities noted by regional cancer control programs. Several local interview respondents were unfamiliar with Screen for Life, and respondents who were familiar with Screen for Life used the materials in a general, unplanned way. Although some respondents were unfamiliar with the campaign materials, they were interested in Screen for Life. No formal evaluations on the effectiveness of the materials were reported.
More guidance on how to implement the Screen for Life campaign as a targeted health communication media campaign would be helpful.
Challenges to the identification of hereditary cancer in primary care may be more pronounced in rural Appalachia, a medically underserved region.
To examine primary care physicians’ identification of hereditary cancers.
A cross-sectional survey was mailed to family physicians in the midwestern and southeastern United States, stratified by rural/non-rural and Appalachian/non-Appalachian practice location (N=176). Identification of hereditary breast-ovarian cancer (BRCA1/2), hereditary non-polyposis colon cancer (HNPCC), and other hereditary cancers was assessed.
Less than half of physicians (45%) reported having patients with cancer genetic testing. Most (70%) correctly identified the BRCA1/2-relevant scenario; 49% correctly identified the HNPCC-relevant scenario. Factor analysis of psychosocial variables revealed 2 factors: Confidence (knowledge, comfort, confidence) and Importance (responsible, important, effective, need) of identifying hereditary cancer. Greater confidence was associated with use of 3 generation pedigree in taking family history. Greater knowledge and access to genetic services were associated with use of genetic testing. More recent graduation year, greater knowledge, and greater confidence were associated with identifying the BRCA1/2-relevant scenario. Greater knowledge and confidence were associated with identifying the HNPCC-relevant scenario.
Although rural Appalachian physicians do not differ in ability to identify high risk individuals, access barriers may exist for genetic testing. Interventions are needed to boost physician confidence in identifying hereditary cancer and to improve availability and awareness of availability of genetic services.
hereditary cancer; physicians; primary care; psychosocial factors; Appalachian region
The incidence of colorectal cancer in portions of rural Appalachia is higher than in much of the United States. To reduce this disparity, cancer-control strategies could be adapted to and implemented in rural Appalachian communities. The objectives of this pilot study were to develop and test community-based participatory research methods to examine whether cancer coalitions in Appalachia could effectively disseminate print materials from a national media campaign intended to promote colorectal cancer awareness to their rural communities.
This pilot study used a two-arm intervention design with random selection of 450 community organizations from nine counties with cancer coalitions (the coalition arm) and 450 organizations from nine matched counties without a cancer coalition (the noncoalition arm) in northern Appalachia. The primary outcome measures were participation by and interest of community organizations in dissemination of materials from Screen for Life:
National Colorectal Cancer Action Campaign, a national campaign to promote colorectal cancer education and screening. The data were collected with prestudy and poststudy surveys.
One-hundred thirty (29%) organizations participated in the coalition arm, and 38 (8%) participated in the noncoalition arm (P < .001). Within the coalition arm, 86 of the 119 (66%) organizations that responded to the question about influence reported being influenced to participate by the local coalition. Initial interest in dissemination was high in each of the study arms but remained higher throughout the study in the coalition arm than the noncoalition arm.
Community cancer coalitions can increase the local dissemination of material from a national media campaign in rural Appalachia. Continued development and study of methods for coalitions to translate and implement cancer-control strategies at a local level in Appalachia is warranted.
The incidence of cervical cancer in Appalachia exceeds the national rate; rural Appalachian women are at especially high risk. We assessed the attitudes and practices related to human papillomavirus vaccination among providers in primary care practices in a contiguous 5-county area of Appalachian Pennsylvania.
In December 2006 and May 2007, all family medicine, pediatric, and gynecology practices (n = 65) in the study area were surveyed by 2 faxed survey instruments.
Of the 65 practices, 55 completed the first survey instrument. Of these 55, 44 offered the vaccine to their patients. Forty of the 44 practices offered it to girls and women aged 9 to 26 years, and 11 were willing to accept referrals from other practices for vaccination. The average reported charge for each of the 3 required injections was $150. Of the 55 practices that responded to the first survey instrument, 49 responded to the second survey instrument, 46 of which recommended the vaccine to their patients.
The prevalence of offering the vaccine against human papillomavirus was high in this area of Appalachian Pennsylvania. Future interventions may focus on community education because the vaccine is available from most providers.
The Appalachian region of the United States has disproportionately high colorectal cancer (CRC) death rates and low screening rates. The purpose of this pilot study was to assess acceptability of a take-home fecal immunochemical test (FIT) and the effect of follow-up telephone counseling for increasing CRC screening in rural Appalachia.
We used a prospective, single-group, multiple-site design, with centralized laboratory reports of screening adherence and baseline and 3-month questionnaires. Successive patients, aged 50 or older, at average CRC risk and due for screening were enrolled during a routine visit to 3 primary care practices in rural Appalachian Pennsylvania and received a free take-home FIT and educational brochure. Those who had not returned the test 2 weeks later were referred for telephone counseling.
Of 232 patients approached, 200 (86.2%) agreed to participate. Of these, 145 (72.5%) completed the FIT as recommended (adherent) and 55 (27.5%) were referred for telephone counseling (nonadherent), of whom 23 (41.8%) became adherent after 1 to 2 counseling sessions, an 11.5 percentage-point increase in screening after telephone counseling and 84% FIT adherence overall. Lack of CRC-related knowledge and perceived CRC risk were the screening barriers most highly associated with nonadherence. Although not statistically significant, the rate of conversion to screening adherence was higher among participants who received telephone counseling compared to an answering machine reminder.
If confirmed in future randomized trials, provider-recommended take-home FIT and follow-up telephone counseling may be methods to increase CRC screening in Appalachia.
Qualitative research on knowledge and perceptions of diabetes is limited in the Appalachian region, where social, economic, and behavioral risk factors put many individuals at high risk for diabetes. The aim of this study was to gain a culturally informed understanding of diabetes in the Appalachian region by 1) determining cultural knowledge, beliefs, and attitudes of diabetes among those who live in the region; 2) identifying concerns and barriers to care for those with diabetes; and 3) determining the barriers and facilitators to developing interventions for the prevention and early detection of diabetes in Appalachia.
Thirteen focus groups were conducted in 16 counties in West Virginia in 1999. Seven of the groups were composed of persons with diabetes (n = 61), and six were composed of community members without diabetes (n = 40). Participants included 73 women and 28 men (n = 101).
Findings show that among this population there is lack of knowledge about diabetes before and after diagnosis and little perception that a risk of diabetes exists (unless there is a family history of diabetes). Social interactions are negatively affected by having diabetes, and cultural and economic barriers to early detection and care create obstacles to the early detection of diabetes and education of those diagnosed.
Public health education and community-level interventions for primary prevention of diabetes in addition to behavior change to improve the management of diabetes are needed to reduce the health disparities related to diabetes in West Virginia.
West Virginia is the only state that lies entirely within Appalachia. West Virginians tend to be poorer and more likely to lack health insurance than the general U.S. population. The purpose of this qualitative study was to 1) obtain an understanding of attitudes about breast and cervical cancer screening among women aged 25 to 64 years; 2) determine factors that motivate women to be screened for breast and cervical cancer; and 3) evaluate educational materials about breast and cervical cancer screening for use in this population.
The West Virginia Breast and Cervical Cancer Screening Program (WVBCCSP) is a comprehensive public health program, funded by the Centers for Disease Control and Prevention, dedicated to removing barriers to breast and cervical cancer screening and providing screenings to underserved women aged 25 to 64 years. The program partnered with RMS Strategies, Inc, to conduct six focus groups in three communities in West Virginia. Women were recruited by telephone based on program eligibility guidelines.
Results indicated that women were concerned about health care costs and lack of health insurance. Cost, fear, and embarrassment were identified as the top barriers to breast and cervical cancer screening. Participants believed that community-based educational campaigns would increase screening and promote use of the WVBCCSP.
Understanding why low-income Appalachian women do not get screened for breast and cervical cancer and determining motivational factors that encourage screening are important to increase screening rates among this population. Breast and cervical cancer efforts that use the words, knowledge, and suggestions of the women they serve are more likely to be effective and have a larger impact.
Using data from the Center for Oral Health Research in Appalachia Study, we examined variability in susceptibility to dental caries among children and adolescents in rural Appalachia. Among 210 participants who were caries-free at the initial visit, age at the baseline visit can be used as a proxy for the degree of caries resistance; probability of caries development at the tooth level decreased as age at the baseline visit increased. Participants who stayed caries-free for a longer period during childhood and adolescence experienced less extensive caries, as measured by the number of carious teeth. However, the probability of becoming caries-positive did not correlate with age at the baseline visit. For children between 1 and 18 years of age, there was not a “threshold age” after which a caries-free child’s risk of caries onset is significantly reduced.
caries resistance; age; caries-free; Bayesian analysis; epidemiology; dental public health
A recursive system of ordered self assessed health together with BRFSS data were used to investigate health and obesity in the Appalachian state of West Virginia. Implications of unobserved heterogeneity and endogeneity of lifestyle outcomes on health were investigated. Obesity was found to be an endogenous lifestyle outcome associated with impaired health status. Risk of obesity is found to increase at a decreasing rate with per capita income and age. Intervention measures which stimulate human capital development, diet-disease knowledge and careful land use planning may improve health and obesity outcomes in Appalachia in particular and rural America in general.
health; obesity; endogeneity; human capital; land use; Appalachia
PURPOSE: The present study was designed to examine the underlying factorial structure of various problem behaviors among diverse populations using data from multiple cohorts of community-based samples of low-income urban African-American and rural Caucasian children and adolescents over multiple years. In this study, we tested the model of a single underlying problem behavior factor against competing models with multiple (and second-order) problem behavior factors. METHOD: The current study employed five data sets, four of which were collected in four consecutive community-based risk assessment or risk-reduction studies among urban low-income African-American children and adolescents in an eastern city in the United States from 1992-1996. The fifth was collected among rural primarily Caucasian adolescents living in Appalachia in 2000. Exploratory factor analysis with oblique rotation was performed to generate the factors underlying various adolescent problem behaviors. Confirmatory factor analysis was conducted based on the initial factors generated through the exploratory factor analysis to compare three competing models: single-factor model, multiple-factor model and one-factor second-order model. RESULTS: The data in the current study support the multiple-factor structure of adolescent problem behaviors. At the same time, the data also support the notion of a one-factor-second-order structure underlying various adolescent problem behaviors. The findings were robust across five data sets despite variations in: 1 samples (different cohorts with different demographics and different problem behavior profiles), 2) the types of problem behaviors examined, 3) the methods of data collection (e.g., computer assisted and paper and pencil), and 4) the number of problem behaviors and first-order factors involved. In addition, the results were also robust across gender and age groups. CONCLUSIONS: Compared with the single-factor model, the alternative models (i.e., multifactor model and one-factor second-order model) better explained the relationships among various measures of adolescent problem behaviors. The findings in the current study will help us for a better understanding of adolescent risk behaviors and contribute to more effective assessment and prevention intervention efforts.
To empirically test a multilevel conceptual model of children’s oral health incorporating 22 domains of children’s oral health across four levels: child, family, neighborhood and state.
The 2003 National Survey of Children’s Health, a module of the State and Local Area Integrated Telephone Survey conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics, is a nationally representative telephone survey of caregivers of children.
We examined child-, family-, neighborhood-, and state-level factors influencing parent’s report of children’s oral health using a multilevel logistic regression model, estimated for 26 736 children ages 1–5 years.
Factors operating at all four levels were associated with the likelihood that parents rated their children’s oral health as fair or poor, although most significant correlates are represented at the child or family level. Of 22 domains identified in our conceptual model, 15 domains contained factors significantly associated with young children’s oral health. At the state level, access to fluoridated water was significantly associated with favorable oral health for children.
Our results suggest that efforts to understand or improve children’s oral health should consider a multilevel approach that goes beyond solely child-level factors.
children’s oral health; multilevel modeling; multiple imputation