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1.  School Readiness Among Children Insured by Medicaid, South Carolina 
The American Academy of Pediatrics recommends a schedule of age-specific well-child visits through age 21 years. For children insured by Medicaid, these visits are called Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). These visits are designed to promote physical, emotional, and cognitive health. Six visits are recommended for the first year of life, 3 for the second year. We hypothesized that children with the recommended visits in the first 2 years of life would be more likely than others to be ready for school when they finish kindergarten.
We studied children insured by Medicaid in South Carolina, born during 2000 through 2002 (n = 21,998). Measures included the number of EPSDT visits in the first 2 years of life and an assessment of school readiness conducted at the end of kindergarten. We used logistic regression to examine the adjusted association between having the recommended visits and school readiness, controlling for characteristics of mothers, infants, prenatal care and delivery, and residence area.
Children with the recommended visits had 23% higher adjusted odds of being ready for school than those with fewer visits.
EPSDT may contribute to school readiness for children insured by Medicaid. Children having fewer than the recommended EPSDT visits may benefit from school readiness programs.
PMCID: PMC3457755  PMID: 22677161
2.  More May Be Better: Evidence of a Negative Relationship between Physician Supply and Hospitalization for Ambulatory Care Sensitive Conditions 
Health Services Research  2005;40(4):1148-1166.
To conduct an empirical test of the relationship between physician supply and hospitalization for ambulatory care sensitive conditions (ACSH).
Data Sources/Study Setting
A data set of county ACSH rates compiled by the Safety Net Monitoring Initiative of the Agency for Healthcare Research and Quality (AHRQ). The analytical data set consists of 642 urban counties and 306 rural counties. We supplemented the AHRQ data with data from the Area Resource File and the Environmental Protection Agency.
Study Design
Ordinary least squares regression estimated ACSH predictors. Physician supply, the independent variable of interest in this analysis, was measured as a continuous variable (MDs/100,000). Urban and rural areas were modeled separately. Separate models were estimated for ages 0–17, 18–39, and 40–64.
Data Extraction Methods
Data were limited to 20 states having more than 50 percent of counties with nonmissing data.
Principal Findings
In the urban models for ages 0–17, standardized estimates indicate that, among the measured covariates in our model, physician supply has the largest negative adjusted relationship with ACSH (p<.0001). For ages 18–39 and 40–64, physician supply has the second largest negative adjusted relationship with ACSH (p<.0001, both age groups). Physician supply was not associated with ACSH in rural areas.
Physician supply is positively associated with the overall performance of the primary health care system in a large sample of urban counties of the United States.
PMCID: PMC1361189  PMID: 16033497
Physician supply; ambulatory care sensitive conditions; primary care access
3.  Farming Activities and Carrying and Lifting: The Agricultural Health Study 
Heavy carrying and lifting (HCL) is a common activity among farmers that may be related to health. The aim of this study was to examine HCL as a proxy for occupational physical activity (PA) among farm residents. The secondary objective was to evaluate PA based on HCL.
Data from 21,296 farmers and 30,951 spouses in the Agricultural Health Study examined the relationship between HCL and farm activities and individual/farm characteristics. HCL was categorized as ≥1 or <1 hours per day. The association between HCL and farm activities (15 for farmers; 16 for spouses) and individual/farm characteristics was examined using adjusted logistic regression. To evaluate PA, we created a PA activity index using metabolic equivalents for HCL, and compared PA weekly averages with national guidelines.
In adjusted results, most farm activities were significantly associated with HCL. Based on HCL, farmers had a median of 1.5 hours and spouses 0.5 hours of vigorous or muscle-strengthening PA per day. Most farmers (94%) and about 60% of spouses meet or exceed 2008 national guidelines for vigorous or muscle-strengthening PA.
Findings suggest the HCL measure may be useful as a PA metric in future studies of occupational PA among farm residents.
PMCID: PMC3257835  PMID: 22232503
Occupational Physical Activity; Muscle Strengthening; Resistance Exercise
Despite the increase in breastfeeding initiation and duration in the United States, only five states have met the three Healthy People 2010 breastfeeding objectives. Our objectives are to study women’s self-reported reasons for not initiating breastfeeding and to determine whether these reasons vary by race/ethnicity, and other maternal and hospital support characteristics.
Data are from the 2000–2003 Arkansas Pregnancy Risk Assessment Monitoring System, restricting the sample to women who did not initiate breastfeeding (unweighted n = 2,917). Reasons for not initiating breastfeeding are characterized as individual reasons, household responsibilities, and circumstances. Analyses include the χ2 test and multiple logistic regression.
About 38% of Arkansas mothers of live singletons did not initiate breastfeeding. There was a greater representation of non-Hispanic Blacks among those who did not initiate breastfeeding (32%) than among those who initiated breastfeeding (9.9%). Among those who never breastfed, individual reasons were most frequently cited for noninitiation (63.0%). After adjusting for covariates, Hispanics had three times the odds of citing circumstances than Whites (odds ratio [OR], 3.07; 95% confidence interval [CI], 1.31–7.18). Women who indicated that the hospital staff did not teach them how to breastfeed had more than two times greater odds of citing individual reasons (OR, 2.25; 95% CI, 1.30–3.91) or reasons related to household responsibilities (OR, 2.27; 95% CI, 1.19–4.36) as compared with women who indicated they were taught.
Findings suggest the need for targeting breastfeeding interventions to different subgroups of women. In addition, there are implications for policy particularly regarding breastfeeding support in hospitals.
PMCID: PMC2865685  PMID: 19589476
5.  Cognitive Health Messages in Popular Women’s and Men’s Magazines, 2006-2007 
Preventing Chronic Disease  2010;7(2):A32.
Growing evidence suggests that physical activity, healthy diets, and social engagement may promote cognitive health. Popular media helps establish the public health agenda. In this study, we describe articles about cognitive health in top-circulating women's and men's magazines.
To identify articles on cognitive health, we manually searched all pages of 4 top-circulating women's magazines and 4 top-circulating men's magazines published in 2006 and 2007 to identify articles on cognitive health. We examined article volume, narrative and illustrative content, information sources, and contact resources.
Women's magazines had 27 cognitive health articles (5.32/1,000 pages), and men's magazines had 26 (5.26/1,000 pages). Diet was the primary focus (>75% of content) in 30% of articles in women's magazines and 27% of men's magazines. Vitamins/supplements were the focus of 15% of articles in men's magazines and 11% in women's magazines. Articles mentioned physical activity, cognitive activity, and social interaction, although these subjects were rarely the focus. Articles focused more on prevention than treatment. Topics were primarily "staying sharp," memory, and Alzheimer's disease. Colleges/universities were most often cited as sources; contacts for further information were rare. Most articles were illustrated.
Although the volume of cognitive health articles was similar in the magazines, content differed. More articles in men's magazines discussed multiple chronic conditions (eg, Alzheimer's disease), whereas more in women's magazines discussed memory. Including more articles that focus on physical activity and direct readers to credible resources could enhance the quality of cognitive health communication in the popular media.
PMCID: PMC2831786  PMID: 20158960
6.  Attitudes on Aging Well Among Older African Americans and Whites in South Carolina 
Preventing Chronic Disease  2009;6(4):A113.
Cognitive impairment in older adults is a major cause of functional disability. Interest in protecting brain health is likely to grow as the US population ages and more people have experiences with cognitive decline. Recent scientific evidence suggests that physical activity, heart-healthy diets, and social involvement may help to maintain brain health. We investigated attitudes about aging well among older African Americans and whites to inform the development of interventions to promote cognitive health.
We used a purposive sample to conduct 5 focus groups with African Americans (n = 42) and 4 with whites (n = 41). Participants also completed a brief survey. In discussions centered on brain health, participants were asked to describe someone they know who is aging well. We used a grounded theory approach to guide the analysis and interpretation of the data.
Both African Americans and whites said that components of aging well include social activity, a strong spiritual life, not taking medications, and traveling. African Americans said aging well means being cognitively intact, free of serious mobility impairment or other health problems, and independent. Whites described aging well as living a long time, staying physically active, maintaining a positive outlook, and having good genes.
African Americans did not commonly associate physical activity with aging well, which suggests that tailored intervention strategies for promoting brain health should emphasize physical activity. African Americans and whites did not commonly associate nutrition with aging well, which also suggests a useful focus for public health interventions.
PMCID: PMC2774627  PMID: 19754989
7.  Association between community health center and rural health clinic presence and county-level hospitalization rates for ambulatory care sensitive conditions: an analysis across eight US states 
Federally qualified community health centers (CHCs) and rural health clinics (RHCs) are intended to provide access to care for vulnerable populations. While some research has explored the effects of CHCs on population health, little information exists regarding RHC effects. We sought to clarify the contribution that CHCs and RHCs may make to the accessibility of primary health care, as measured by county-level rates of hospitalization for ambulatory care sensitive (ACS) conditions.
We conducted an ecologic analysis of the relationship between facility presence and county-level hospitalization rates, using 2002 discharge data from eight states within the US (579 counties). Counties were categorized by facility availability: CHC(s) only, RHC(s) only, both (CHC and RHC), and neither. US Agency for Healthcare Research and Quality definitions were used to identify ACS diagnoses. Discharge rates were based on the individual's county of residence and were obtained by dividing ACS hospitalizations by the relevant county population. We calculated ACS rates separately for children, working age adults, and older individuals, and for uninsured children and working age adults. To ensure stable rates, we excluded counties having fewer than 1,000 residents in the child or working age adult categories, or 500 residents among those 65 and older. Multivariate Poisson analysis was used to calculate adjusted rate ratios.
Among working age adults, rate ratio (RR) comparing ACS hospitalization rates for CHC-only counties to those of counties with neither facility was 0.86 (95% Confidence Interval, CI, 0.78–0.95). Among older adults, the rate ratio for CHC-only counties compared to counties with neither facility was 0.84 (CI 0.81–0.87); for counties with both CHC and RHC present, the RR was 0.88 (CI 0.84–0.92). No CHC/RHC effects were found for children. No effects were found on estimated hospitalization rates among uninsured populations.
Our results suggest that CHCs and RHCs may play a useful role in providing access to primary health care. Their presence in a county may help to limit the county's rate of hospitalization for ACS diagnoses, particularly among older people.
PMCID: PMC2727502  PMID: 19646234
8.  Effects of residence and race on burden of travel for care: cross sectional analysis of the 2001 US National Household Travel Survey 
Travel burden is a key element in conceptualizing geographic access to health care. Prior research has shown that both rural and minority populations bear disproportionate travel burdens. However, many studies are limited to specific types of patient or specific locales. The purpose of our study was to quantify geographic and race-based differences in distance traveled and time spent in travel for medical/dental care using representative national data.
Data were drawn from 2001 National Household Travel Survey (NHTS), a nationally representative, cross-sectional household survey conducted by the US Department of Transportation. Participants recorded all travel on a designated day; the overall response rate was 41%. Analyses were restricted to households reporting at least one trip for medical and/or dental care; 3,914 trips made by 2,432 households. Dependent variables in the analysis were road miles traveled, minutes spent traveling, and high travel burden, defined as more than 30 miles or 30 minutes per trip. Independent variables of interest were rural residence and race. Characteristics of the individual, the trip, and the community were controlled in multivariate analyses.
The average trip for care in the US in 2001 entailed 10.2 road miles (16.4 kilometers) and 22.0 minutes of travel. Rural residents traveled further than urban residents in unadjusted analysis (17.5 versus 8.3 miles; 28.2 versus 13.4 km). Rural trips took 31.4% longer than urban trips (27.2 versus 20.7 minutes). Distance traveled did not vary by race. African Americans spent more time in travel than whites (29.1 versus 20.6 minutes); other minorities did not differ. In adjusted analyses, rural residence (odds ratio, OR, 2.67, 95% confidence interval, CI 1.39 5.1.5) was associated with a trip of 30 road miles or more; rural residence (OR, 1.80, CI 1.09 2.99) and African American race/ethnicity (OR 3.04. 95% CI 2.0 4.62) were associated with a trip lasting 30 minutes or longer.
Rural residents and African Americans experience higher travel burdens than urban residents or whites when seeking medical/dental care.
PMCID: PMC1851736  PMID: 17349050

Results 1-8 (8)