APHA 2014 - New Orleans, LA

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Student Presentation Schedule

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Student Presentation Abstracts

Listed in order of student last name

Decomposing rural urban differences in use of skilled birth attendants: Does quality of antenatal care matter?

Patience A. Afulani, MBChB, MPH, PhD Candidate

Use of skilled birth attendants (SBAs) is critical to reducing maternal mortality. Although place of residence (rural/urban) is recognized as a contextual factor that affects use of SBAs, the intervening pathways by which this occurs has received less attention. Also, many qualitative studies suggest quality of  health services influences women’s use of SBAs, but few quantitative studies have examined this; and even fewer have examined the factors that influence the quality of maternal health care women in sub-Sahara Africa receive. Aim: The purpose of this study is to examine the factors that influence quality of antenatal care (ANC) and use of SBAs; and whether quality of ANC explains some of the effects of place of residence on use of SBAs. Methods: The World Health Survey data for Ghana and Burkina Faso are used (N=2,049). Analytic techniques include linear and logistic regressions with mediation and moderation analysis. Results: Net of other factors, urban residence and higher education are positively associated with better quality of ANC; but the effect of education is conditional on country. Urban residence, higher education, greater wealth, quality of ANC and perceived accessibility of health facilities are also positively associated with use of SBAs. Quality of ANC and perceived accessibility of health facilities explain some of the effect of place of residence on use of SBAs, but this is also conditional on country. Implications: Improving quality of ANC provided to rural women is a potential approach to bridging rural urban differences in use of SBAs.  

Does quality of antenatal care explain rural-urban differentials in use of skilled birth attendants?

Patience A. Afulani, MBChB, MPH, PhD Candidate

About 800 maternal deaths occur each day, with over half in Sub-Sahara-Africa (SSA) alone. Delivery by Skilled-Birth-Attendants (SBAs) is critical to reducing maternal mortality.  Yet, less than half of births in rural SSA are assisted by a SBA. This is usually attributed to poor health service accessibility, but few studies have actually examined the intervening factors. Qualitative studies suggest quality of maternal health services influences use of SBAs, but few quantitative studies have examined this; and fewer have examined the factors that influence the quality of maternal health care women in SSA receive. Aim: The purpose of this study is to examine the factors that influence quality of antenatal care (ANC) and use of SBAs in SSA; and whether quality of ANC partially mediates the effect of place of residence on use of SBAs. Methods: The World Health Survey data for Ghana and Burkina Faso are used (N=2,049). The analysis includes logistic regression with mediation and moderation analysis. Results: Net of other factors, urban residence is positively associated with better ANC quality. Urban residence and ANC quality are both positively associated with use of SBAs – controlling for socioeconomic and other factors. Quality of ANC care explains a significant amount of the rural/urban differential in use of SBAs. Implications: Improving basic quality of ANC provided to rural women is a potential approach to bridging the rural/urban difference in use of SBAs in SSA. This may be more feasible in the short term in many SSA countries than improving access. 

Differential Rates in Acute HIV Infection Diagnosis in Men who Have Sex with Men at a Community-based Organization in Los Angeles, California

Matthew Beymer, MPH, PhD Student/L.A. Gay & Lesbian Center
Robert K. Bolan, L.A. Gay & Lesbian Center

Background: Over 22% of all HIV infections in the United States are diagnosed in African-American MSM. African-American MSM bear the largest disparity in HIV infection compared to other groups at risk with over six times the rate experienced by White MSM. The objective of this study was to determine if there were disparities in diagnosis of acute HIV infection, and thus early HIV detection, among MSM by race.

Methods: Data were analyzed for all HIV positive diagnoses given to MSM at the L.A. Gay & Lesbian Center between January 2011 and January 2014 (n=618). Acute HIV infections were defined as a negative result for an HIV antibody test paired with a positive result for a HIV nucleic acid amplification test (NAAT). Acute HIV infections were compared to non-acute HIV infections in a multivariate logistic regression by race, age group and education level.

Results: The proportion of acute HIV diagnoses was 16.3% in White MSM but only 4.6% in African-American MSM. A multivariate logistic regression showed that African-American MSM had 74% lower odds of acute HIV infection diagnosis when compared to White MSM (p=0.04, OR: 0.26; CI: 0.11-0.66), controlling for age group and education level.

Discussion: African-American MSM in this study accounted for a significantly lower proportion of acute HIV infections than other racial groups. This study demonstrates that African-American MSM have lower rates of early HIV detection, potentially contributing to increased HIV transmission. NAAT testing should be more actively promoted in the African-American MSM community of Los Angeles as a tool for early HIV detection.

Community as a Construct

Alexis Cooke, MPH, PhD Student

Background: The idea of community is central in public health. We intervene on ‘communities’ conduct ‘community’ based research, work with ‘communities’, compare ‘communities’, etc. Yet how community is defined, constructed or operationalized is not often discussed. Anecdotally if you ask people to define their communities you will get a range of answers and perspectives. This suggests that community has a subjective definition making it difficult to develop a construct that would be inclusive and exhaustive. Much of health disparities work is focused on comparing communities, i.e comparing affluent communities with resource deprived ones or communities of color with white communities. It becomes difficult to compare studies or look at the broader body of work if there are not commonalities or an understanding of community as a construct.

Objectives: There has been limited conceptualization and varying understanding of the role of community in public health intervention. It is especially important to develop a clear definition of community to anchor community based evaluation research. For this reason it is important to understand the construct of community and identify appropriate ways in which are amenable to intervention.

Methods: A literature review was conducted in an iterative manner to locate articles related to community. Search terms will seek out research that focuses on community-based evaluation, community interventions and the operationalization of community in public health. An analysis was done to identify key themes and components that go into defining and understating community as a construct.

Child Maltreatment and Inflammation in Young Adults: The Role of Resilience Protective Factors

Elinam Dellor, MPH, PhD Candidate

Epidemiologic studies show maltreatment in childhood is a strong predictor of cardiovascular disease in later life with effects observed even after controlling for traditional risk factors such as smoking, hypertension and physical inactivity. In recent years, inflammation has emerged as an important pathway through which maltreatment confers vulnerability cardiovascular disease because it is implicated in the development and progression of atherosclerosis, the condition underlying cardiovascular disease. Most of the existing literature linking maltreatment to high inflammation however comes from middle aged and older adult populations. Moreover, little is understood about how and why some adults avoid the chronic disease costs of childhood maltreatment while others do not.

This study uses restricted data from the National Longitudinal Study of Adolescent Health (Add Health) to test the association between maltreatment and c-reactive protein--a biological marker of inflammation--in a US population of young adults (mean age 28). Further, we analyze the potential moderating role of two resilience protective factors: family connectedness and school connectedness. Preliminary results show that the number of maltreatment events is associated with higher levels of C-reactive protein.

Determinants of consistent condom use among sex workers in India: Testing competing hypotheses of perceived risk, empowerment, and financial security

Anne Fehrenbacher, MPH, PhD Candidate
Dallas Swendeman, PhD, MPH , Department of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine, UCLA Center for HIV Identification, Prevention & Treatment Services (CHITPS), Los Angeles, CA
Toorjo Ghose, PhD , School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA

Objective: To test three competing hypotheses for predicting consistent condom use among sex workers: 1) Sex workers use condoms if they feel at risk for contracting a sexually transmitted infection (risk perception hypothesis), 2) Sex workers use condoms if they have a high level of knowledge, influence, and autonomy (empowerment hypothesis), and 3) Sex workers use condoms if they are financially secure (economic hypothesis).

Methods: A household survey was conducted with a random sample of sex workers (n=200) in two red light districts in Kolkata, India. Logistic regression was used to assess predictors of condom use with occasional clients, regular clients, intimate live-in partners, husbands, and all partners combined.

Results: Financial security significantly increases the odds of using a condom with all partner types. Feeling susceptible to HIV (perceived risk), serving as a peer educator (empowerment), and participating in a door-to-door campaign to teach other sex workers about condoms (empowerment) significantly increases odds of using a condom with regular clients, intimate partners, and husbands but not with occasional clients.

Conclusions: The findings demonstrate the importance of financial security for predicting consistent condom use between sex workers and all partner types. Risk perceptions and empowerment become more important predictors of condom use as the level of intimacy and regularity of interaction between sex worker and partner increases. Interventions to improve consistent condom use among sex workers should utilize strategies specific to each type of partner rather than employing a one-size-fits-all approach.

Job insecurity and quality of life: A longitudinal study of job stress proliferation

Anne Fehrenbacher, MPH, PhD Candidate

Background and Objectives: More than 60% of workers in the United States report anxiety about losing their jobs within the next two years. The objectives of this study are to examine causal pathways linking job insecurity with quality of life and group differences in the effect of job insecurity on quality of life. The theoretical framework for this study is Leonard Pearlin’s stress process model, which suggests that differential exposure to stressors (e.g., job insecurity) and unequal access to coping resources (e.g., social support) create and sustain health disparities.

Methods: The relationship between job insecurity and quality of life is tested among a longitudinal sample of working adults in two waves (1995 and 2005) of the National Survey of Midlife Development in the United States (N=2,184). Cross-lagged structural equation models are used to test mediation and moderation effects.

Results: Job insecurity is negatively associated with quality of life net of controls for personality, demographic, job, and health characteristics. Work-to-family spillover of stress significantly mediates the relationship between job insecurity and quality of life. Having at least a bachelor's degree and being white buffers the negative effect of job insecurity on quality of life.

Conclusions: Structural inequality predisposes certain groups to work in insecure jobs but also to have fewer resources for dealing with the consequences of job insecurity. As a result, policy and intervention strategies to address job insecurity must act on underlying causes of disparities such as educational and racial stratification in the workforce.

Alcohol Use, Sexual Risk Behavior, and HIV among People Living in Russia: A Systematic Review

Chiao-Wen Lan, MPH, PhD Student

Alcohol consumption in Russia is among the highest per capita in the world and HIV in Russia has increased dramatically over the past three decades, accounting for nearly 70% of the known infections in Eastern Europe and Central Asia. The purpose of this systematic review was to examine the prevalence of alcohol use, sexual risk behaviors, and HIV among Russians. Comprehensive electronic searches were conducted to locate studies that sampled Russians, assessed alcohol use and either a behavioral measure of risk (e.g., unprotected sex) or a biological measure of HIV incidence, and reported sufficient statistical information. Of the 618 studies identified through database searches, 19 met inclusion criteria. Study samples included 22,912 participants living in Russia (M = 30 years of age; 37% women; 13% MSM). Participants were recruited via clinical contact (47%; e.g., sexually transmitted infection clinic, drug treatment); 21% recruited participants from high-risk settings (e.g., sexual or drug networks), and a single study recruited participants from schools. Findings indicate that a substantial proportion of the participants used substances: alcohol (72%; 63% heavy drinking) and drugs (42%; 39% injecting drugs). Most participants (90%) were sexually active and many of them engage in sexual risk behaviors (57% unprotected sex; 53% multiple sexual partners). Nearly half (48%) of all participants reported using alcohol before sex. Of the five studies testing participants for HIV, 11% of participants tested positive. These findings support the need and potential benefit of integrating alcohol use as a risk factor in programs to prevent HIV among Russians.

Collaborative International Research: An Example of Partnership for Genetic Studies of Orofacial Clefts

Stephanie Ly, MPH, PhD Student
Haley Marie Raimondi, MA, Kathleen Magee, MEd, MSW, Pedro Sanchez, MD, William Magee III, MD, DDS, Jane Figueiredo, PhD

International collaboration faces ethical challenges in the design, approval and conduct of research. Some of these challenges include differences in research ethics capacity, cultural differences in interpretation and application of ethical principles, and cooperation between ethics review boards at collaborating institutions. In partnership with the University of Southern California (USC) and the Children’s Hospital Los Angeles, Operation Smile, Inc. is investigating genetic and environmental factors in the etiology of clefts through the collection of self-reported questionnaire data and saliva samples during Operation Smile surgical missions and at local maternity wards in 4 countries: Democratic Republic of Congo (DRC), Vietnam, Honduras and the Philippines. In order to uphold the highest ethical standards when conducting research, the partners have established a multi-country Institution Review Board (IRB) protocol. The research proposal, questionnaires, information sheet and informed consent are translated into local languages and then reviewed by in-country institutions, including government entities and nonprofit organizations, and partnering hospitals. Research experience and methodology including developing focus groups to facilitate discussion at each institution to increase understanding and respect for the other's culture are outlined. Final ethical approval is obtained by USC’s IRB, which oversees the international study. Overall we found that the participants at each location agreed on the major principles and issues in research ethics and on the importance attributed to them; however, practical issues with the conduct of research need to be continually addressed. 

Maternal risk factors in the development of and risk of orofacial clefts in the Philippines

Stephanie Ly, MPH, PhD Student
Caroline Yao, MD, Stephanie Ly, MPH (presenter), Haley Marie Raimondi, MA, William Magee III, MD, DDS, Jane Figueiredo, PhD, Kathleen Magee, MEd, MSW 

BACKGROUND: Orofacial clefts are among the most common birth defects in the world, but their etiology have not been extensively studied in non-Caucasian populations. While prior studies agree that the etiology of cleft lip +/- cleft palate is multifactorial in terms of genetics and exposures, consistent maternal risk factors have not been documented.

METHODS: As part of an epidemiologic-genetic study between Operation Smile, University of Southern California and Children’s Hospital Los Angeles, maternal and paternal history and exposures during pregnancy were collected in 2012 using interviewer-administrated questionnaires. Cases were children under age three during an Operation Smile mission in the Philippines and controls were non-cleft newborns at a local hospital. Both groups were matched for socio-economic status and education level. Univariate and multivariate logistic regression were used to compare cases and controls.

49 cases and 97 controls were obtained. Industrial chemical exposure and rural residence showed in increased risk of orofacial clefting, with odds ratios of 1.6 (95% CI 0.41-6.5 p=0.04) and 3.4 (95% CI 1.6-7.3, p=0.001), respectively. Adjustments were made for maternal/paternal age, tobacco exposure and public water consumption.

Comparative analysis of environmental exposures and orofacial clefts in the Democratic Republic of Congo and the Philippines

Stephanie Ly, MPH, PhD Student
Caroline Yao, MD, Stephanie Ly, MPH (presenter), Haley Marie Raimondi, MA, William Magee III, MD, DDS, Jane Figueiredo, PhD, Kathleen Magee, MEd, MSW

BACKGROUND: Literature suggests that chemical exposures may be potential risk factors for orofacial clefts. While prior studies agree that the etiology of cleft lip with or without cleft palate is multifactorial in terms of genetics and exposures, there is wide variability in the estimate of risk associated with several environmental exposures. In particular, risk factor data in underserved minority populations are scarce and merit further investigation.

METHODS: As part of an epidemiologic-genetic study between Operation Smile, University of Southern California and Children’s Hospital Los Angeles, maternal and paternal exposure data during pregnancy were collected from 2011 to 2013 using interviewer-administrated questionnaires in the Democratic Republic of Congo (DRC) and the Philippines. Chi-squared, Student t and Fischer’s exact tests were used to compare groups.

RESULTS: In the DRC and Philippines, exposure to industrial chemicals (p<0.01), rural residence (p<0.01) and public or well-water consumption (p<0.05), were more frequent among mothers of cases compared to mothers of controls. When comparing exposure trends for the Congolese and Filipino populations, significantly more cases in the DRC had exposures to industrial chemicals (13.5% vs. 8.5%, p<0.01), rural residence (9.5% vs. 53.2%, p<0.01), well-water consumption (10.2% vs. 40.0% P<0.01) and public water consumption (76.5% vs. 8%, p<0.01).
CONCLUSION: With considerable lifestyle and cultural differences in the DRC and Philippines, both populations have similar exposure risks for cleft disease while having significantly different incidences of exposure. The nuances of these relationships are key to deciphering the full picture of cleft risk around the world. 

A controlled education intervention on proper mosquito net usage in Tanzania

Stephanie Ly, MPH, PhD Student
Caroline Yao, MD, Melody Serra, MPH, DDS, John Dennis Mull, MD, William Magee, III, MD 

Mass distribution campaigns have effectively dispersed 26.9 million long lasting insecticidal nets (LLINs) covering 89.6% of surveyed Tanzanians in 2012. Although net ownership is no longer a hurdle in malaria prevention, correct usage of nets remains an issue. Studies have suggested improper use behaviors such as leaving unrepaired holes, overwashing, seasonal use or neglecting vulnerable household members. In our study, households were randomized to an intervention and control group. Intervention participants (n=60) received an education consisting of a diagram, verbal explanation and physical demonstration of proper net use practices prior to a baseline questionnaire. Control participants (n=57) received the education after the two-week evaluation questionnaire. Paired t-tests were used to compare baseline and evaluation responses in both groups. Significant differences were found in the intervention group between pre- and post- test in: knowledge of using nets in protection from mosquitoes (p<0.0001), having no holes in net (p=0.002), daylong net use (p=0.002), not leaving net in the sun (p<0.0001) and less frequent washing of nets (p<0.0001). Differences were also found in the control group for: knowledge of nets in protection from mosquitoes (p<0.001), no holes in net (p<0.0001) and not leaving nets in the sun (p=0.016). Our findings suggest a crossover effect of the intervention with significant differences in the control group; this may be due to ineffective randomization. The study reinforces the lack of knowledge of free net recipients in proper net care and usage. Multi-faceted education demonstrating proper net use would be essential in accompanying free net distribution campaigns.

Barriers to Contraception: The Effect of Obesity Bias on Women's Contraceptive Practices

Lauren Lessard, MPH, PhD Candidate

Preventing unplanned pregnancies for women who are obese is especially important given the likelihood of co-morbidities that would endanger both the woman and fetus should an unintended pregnancy occur.  This study addresses the following question: Does obesity impact contraception use and women’s choice in contraception type and if so, how does health care provider bias toward obese individuals contribute to this impact?    Given that the most effective contraception methods are available by prescription only, it is important to evaluate the possible effect of health care provider bias on obese women’s use of contraception.  

Impact of stress on adolescent obesity: Findings from the NGHS study

Tabashir Z. Nobari MPH, PhD Student
May C. Wang, DrPH , Community Health Sciences, UCLA Fielding School of Public Health, Los Angeles, CA
Patricia B. Crawford, DrPH, RD , Dr. Robert C. and Veronica Atkins Center for Weight and Health, University of California, Berkeley, Berkeley, CA

Child obesity is a major public health problem. While research has found that chronic psychosocial stress is associated with obesity in adults, relatively little is known about how it affects the risk of childhood obesity. Understanding its impact during adolescence is especially important as this period is characterized by rapid physical and social changes. Methods: To determine if stressful life events during adolescence (“life stress”) are associated with increased Body Mass Index (BMI), we conducted linear regression analyses on adolescent girls (n=1,850) who participated in the NHLBI Growth and Health Study (NGHS). NGHS is a longitudinal cardiovascular disease study that followed black and white 9-10 year old girls for ten years. More than forty primarily negative life events were asked of the girls when they were 16-19 years old. These negative life events occurred to the respondent or a family or friend, and included illness, incarceration, death, unwanted pregnancy, crime, homelessness, parents’ divorce, and academic failure. BMI was obtained from measured height and weight data. Results: The girls experienced a mean (SD) number of life events of 7.3 (4.8) and had a mean (SD) BMI of 25.1 (6.5) kg/m2. Adjusting for age, race, and household income, the number of negative life events was positively and significantly associated with BMI [b(SE) = .08 (.02), p=.0006]. Conclusions: Life stress during adolescence is associated with increased obesity risk. Effective interventions to reduce the risk of developing obesity during adolescence should consider the psychosocial stresses that adolescents may experience from negative life events.

Dinnertime Routine Among Low-Income Latino Families: Work Schedules and Parenting Within the Context of Migration

Mirna Troncoso Sawyer, MPH, PhD Candidate

1) Introduction- With the growing obesity epidemic, and with Latinos being overburdened, food behaviors at the family level are of particular interest. Many analysts have focused on the demise of the dinnertime routine as an important factor that influences overweight and obesity.

2) Approach- This qualitative study explored the factors that influence family dinnertime routines among 23 families via participant observation and interviews over the course of one year.

3) Results- This study found that among families in which both parents work or one parent works a late-night or graveyard shift that some families stop eating dinner together. Families that do not eat dinner together or who eat together but who serve one meal to children and a different one to parents appear to follow a “path of least resistance” food behavior pattern.  Families that follow a “one-dinner for everyone” schema do not necessarily eat healthier meals as some choose fast food for dinner on a regular basis. Children in families with a “one-dinner for everyone schema” however do appear to have a taste for the food that their parents emphasize. Issues related to migration also emerged such as the intergenerational transmission of cooking practices and the relationship of various food behaviors and practices with children’s food preferences for traditional Latino food and non-traditional food.

4) Discussion- It is unclear whether parents shape their children’s’ food preferences through the implementation of a “one-dinner-for everyone” schema or if parents uphold a “one-dinner for everyone” schema because of their children’s’ food preferences.

Schools, Work, and the Nutrition Environment: Low-Income Latino Family Food Behaviors

Mirna Troncoso Sawyer, MPH, PhD Candidate

1) Introduction- With the growing obesity epidemic, especially among low-income Latinos, food behaviors at the family level are of particular interest.

2) Approach- This qualitative study explored how schools and jobs shape family food behaviors in 23 low-income Latino families, whose children attend schools with the National School Lunch Program and/or a charter school that makes lunch from scratch.  Data was collected via participant observation and interviews over the course of one year. 3) Results- Many of the children who participate in the National School Lunch Program (NSLP) have a taste for “fast food” although children’s food preferences are also influenced by food prepared at home and family dinner routines. Work schedules of parents, especially late night shifts, shape the dinnertime routine and other food behaviors such as types of snacks made available and cooking behaviors. These routines play an interacting deterministic relationship with food preferences and behaviors.

3) Discussion- Low-income, immigrant Latino children are socialized into American “fast food” through the NSLP while simultaneously being socialized to traditional food at home. Traditional Latino food can range from minimally processed to heavily fried. As many low-income Latino children participate in NSLP many systematically attain a preference for “fast food;” while parents simultaneously struggle to reproduce a taste for traditional foods among their children. Parents who also must work a late night shift may lead to the demise of a dinnertime routine, which may also be related to the socialization of children’s food preferences.

Investigating pathways linking women's status and empowerment to the use of skilled birth attendant at childbirth in Tanzania: Structural Equation Modeling approaches

Kyoko Shimamoto, MPH, PhD Candidate
Jessica D. Gipson, MPH, PhD , Department of Community Health Sciences, School of Public Health, University of California, Los Angeles, Los Angeles, CA

Objective. Skilled birth attendance and women’s empowerment are considered to be critical factors in reducing maternal mortality in sub-Saharan Africa. Yet few studies have assessed the complex pathways linking women’s status and empowerment to Skilled Birth Attendant (SBA) use. This study examines these pathways and linkages using SEM.

Data and Methods. Data from married women participating in the 2010 Tanzania Demographic and Health Survey (weighted n=4,445) were analyzed. An SEM tested four equations simultaneously, using probit regression with the weighted least squares estimator. The analysis controlled for sociodemographic characteristics and perceived difficulties in accessing health care, and the path coefficients were standardized.

Results. Women with more education (standardized b=0.095, p<0.001) and higher decision-making power (b=0.067, p<0.01) are more likely to use SBA. However, the age at first marriage (b=0.005, p=0.84) and progressive perceptions of gender norms (b=0.020, p=0.36) are not significant predictors. The relationship between women’s education status and SBA use is significantly mediated by age at first marriage, power, and gender norms in the partially adjusted model (p<0.001). In the fully adjusted model, only the mediation effect of power remains significant (b=0.006, p<0.05), yet the other mediation effects have become not significant.

Conclusion. There is evidence that high women’s status positively affects empowerment, especially decision-making power, which in turn positively affects SBA use. Most of the sociodemographic characteristics are shown to be significant predictors for women’s power and SBA use. In an effort to accelerate maternal health and empowerment, it is essential to address women’s decision-making power and underlying sociodemographic status.

Relationship between citizenship and legal status and BMI and hypertension among individuals of Mexican descent in Los Angeles

Maria-Elena Young, MPH, PhD Student

Background: In literature on Latino health disparities, few studies examine differences between Latino sub-groups.  Research is needed to understand the impact of citizenship and legal status on Latino health, either directly or through effects on socio-economic position and health care access.  

Objective: I examine the associations of citizenship or legal status with BMI and hypertension and test for mediation and moderation by socio-demographic and health care characteristics.  

Methods:  The sample included Mexican and Mexican-Americans in the Los Angeles Family and Neighborhood Survey.  The independent variable was based on self-identified citizenship or legal status.  The dependent variables included two measures each of BMI and hypertension. Socio-demographic and health care access measures were included. I tested hierarchical regression models of associations between each dependent variable and socio-demographic and health care measures and the independent variable.  I then tested for moderation and mediation by gender, employment, and health care access.  

Results:  BMI and hypertension are high across all status groups.  There are significant differences in education, income, and employment; with the highest levels of disadvantage among the undocumented and visa and green card holders.  Preliminary findings indicate that US-born citizenship is associated with a 7% greater BMI (ß, 0.07; CI 0.3-1.84).  Having a place to receive health care is the strongest predictor of hypertension diagnosis (OR, 1.72; CI 1.24-2.39).  

Conclusion: This study illuminates the complex relationships between citizenship and legal status and health.  It demonstrates significant disparities in socio-economic position and access to health care, key determinants of health outcomes, across these groups.

Undocumented status: Measurement and definition in public health research

Maria-Elena Young, MPH, PhD Student
Daniel Madrigal, MPH , Center for Environmental Research and Children's Health (CERCH), University of California, Berkeley, Berkeley, CA

BACKGROUND  Undocumented immigrants in the United States face a complex web of legal, political, and economic factors that shape their health environments. Data on this population is critical; however, given their vulnerability measurement of undocumented status must be thoughtful.  Research must be based on a clear methodology for measuring undocumented status in community populations. Yet, no systematic review has examined how undocumented status is measured and defined in health research.  Improved understanding of the health of undocumented individuals allows health professionals to provide health care and promote healthy environments. Therefore, this study reviews how public health research defines and measures undocumented status through a systematic review of recent studies.

METHODS  For our systematic review, we compiled recent public health articles on undocumented immigrants and coded each on its classifications of undocumented status.

RESULTS  Four measurement methodologies were identified: explicit, where status was asked directly; deductive, where status was determined by process of elimination; and proxy, where status was estimated via respondent characteristics.  Assumptions underlying the definitions of undocumented include: status is legally and socially determined; status is a fixed social position; and status results in mechanisms affecting health.  

CONCLUSION  Public health interventions and policies require a better understanding of the factors that affect the health of undocumented immigrants. This study identifies approaches that are currently being used and that can adapted to future public health research to expand the base of knowledge on this vulnerable population.