Expansion of HIV care and treatment in Yunnan Province, China: treatment outcomes with scale up of combination antiretroviral therapy.

Effective health care models to scale up combination antiretroviral therapy (ART) are needed in rural southwestern China. We aimed to evaluate the ART treatment outcomes and their associations with patients' demographic characteristics and pre-treatment clinical features in a scaled-up provincial ART program serving eight heavily HIV-affected prefectures in Yunnan Province. We abstracted information from a computerized database for adults initiating ART between July 2007 and September 2008. Survival functions of mortality and treatment failure were calculated by age group, gender, transmission mode, and baseline CD4 count. Multivariable Cox regression analyses were conducted to find independent associations of various demographic and baseline clinical features with outcome variables. Of the 1967 patients in the mortality analysis, there were 110 deaths, of which 16 were coded as accidents or suicides. Adjusted hazard ratios (AHR) associated with mortality were greater for patients with baseline CD4 counts <100 cells/µl vs. patients with CD4 counts ≥200 cells/µl, for male vs. female, for single vs. married, and for those acquired HIV through injection drug use (IDU) vs. other modes of transmission. Successful treatment was 81.3% at six months after treatment started. Immunologic treatment failure was associated with baseline CD4 counts but not with demographic characteristics. Overall loss to follow-up rate was 2.1%. Collaboration between clinics and community networks are distinctive features of Yunnan's model for scaling up ART across a diverse, poor, and rural population. This study finds that the strategy can succeed even if 40% of the patients have a history of IDU.

The utilization of antenatal care among rural-to-urban migrant women in Shanghai: a hospital-based cross-sectional study.

BACKGROUND: Improving utilization of antenatal care is a critical strategy for achieving China's Millennium Development Goal of decreasing the maternal mortality ratio (MMR). While overall utilization has increased recently in China, an urban vs. rural disparity in access remains. Here we aim to assess utilization of antenatal care in rural-to-urban migrant women and identify its risk and protective factors. METHODS: Migrant women who had been living in Shanghai for more than six months, delivered in one of the two study hospitals between August 2009 and February 2010, and provided written consent were interviewed using a structured questionnaire. RESULTS: Of 767 women, 90.1% (691) made at least one antenatal care visit, while 49.7% (381) had adequately utilized antenatal care (i.e., made five or more antenatal care visits). Only 19.7% of women visited an antenatal care center during the first trimester (12 weeks). Women between the ages of 25 and 30 and women older than 30 were more likely than younger women to have adequately utilized antenatal care (AOR=2.2 and 1.9, 95%CI=1.4-3.5 and 1.1-3.2, respectively). Women whose husbands held Shanghai residency status (AOR=4.9, 95%CI=2.2-10.9) or who had more than 10 years of education (AOR=1.8, 95%CI=1.2-2.9), previously experienced a miscarriage or abortion (AOR=2.2, 95%CI=1.3-3.8), had higher household income (AOR=1.6, 95%CI=1.0-2.5) were more likely to have adequately utilized antenatal care. Women from high-income households were also more likely to receive antenatal care during the first 12 weeks (AOR=3.5, 95%CI=1.7-5.5). CONCLUSIONS: Many migrant women in Shanghai did not receive adequate antenatal care and initiated antenatal care later than the optimal first 12 weeks of pregnancy. Poor antenatal care utilization was associated with low socioeconomic status, education, and certain demographic factors. Tailored health education for both migrant women and their husbands should be strengthened to improve maternal health. Financing supports should be provided to improve the utilization of antenatal care.

Variations in the relationship between maternal depression, maternal sensitivity, and child attachment by race/ethnicity and nativity: findings from a nationally representative cohort study.

This study uses data from the nationally representative Early Childhood Longitudinal Study-Birth Cohort to examine the relationship between maternal depression, maternal sensitivity, and child attachment, specifically among Hispanic and Asian American mothers and their young children, and to explore the role of cultural variation and nativity in the associations between these variables. Data used in this study were collected from biological mothers on two occasions, when their children were approximately 9 and 24 months of age. Trained observers completed a direct assessment of child attachment security and an observational measure of maternal sensitivity, data on maternal depression was obtained via maternal report. Hierarchical logistic regression models were used to predict odds of child insecure attachment. The risk of child insecure attachment associated with chronic maternal depression was found to be much higher for Hispanic mothers than for Asians. In contrast, mothers' foreign-born status was a stronger risk factor than depression for insecure child attachment among Asian Americans. Maternal sensitivity significantly reduced the odds of Asian American children being insecurely attached by more than half. Among the full sample of mothers, which included U.S.-born non-Hispanic White mothers and U.S.-born non-Hispanic Black mothers, decreased maternal sensitivity mediated the association between chronic depression and child insecure attachment. However, this mediation was not found in stratified analyses of Hispanic and Asian mothers. Finally, mothers' nativity did not influence the extent to which maternal depression or sensitivity was associated with child attachment. These findings suggest that the associations between maternal depression, sensitivity, and child attachment are culturally specific, and that mothers' immigrant status may be a risk factor in some racial/ethnic groups but protective in others.

Health status and health services access and utilization among Chinese, Filipino, Japanese, Korean, South Asian, and Vietnamese children in California.

OBJECTIVES: We examined health status and health services access and utilization of Chinese, Filipino, Japanese, Korean, South Asian, Vietnamese, and non-Hispanic White children in California. METHODS: We analyzed aggregated data from the 2003 and 2005 California Health Interview Survey (648 Chinese, 523 Filipino, 235 Japanese, 308 Korean, 314 South Asian, 264 Vietnamese, and 8468 non-Hispanic White children aged younger than 12 years), examining the relationship between Asian ethnicities and outcomes. RESULTS: Compared with non-Hispanic White children, Korean children were 4 times more likely to lack health insurance; Filipino children were twice as likely to not have had recent contact with a doctor; Chinese, Korean, and Vietnamese children were less likely to have visited an emergency room in the past year; and Chinese, Korean, and Vietnamese children were more likely to be in fair or poor health. Age, gender, poverty, citizenship-nativity status, health insurance, and parental marital and child health statuses were related to most outcomes. CONCLUSIONS: Asian ethnicities have heterogeneous health care access and utilization patterns, suggesting the need for targeted outreach to different Asian ethnic groups.

Self-reported HIV testing behaviors among a sample of southeast Asians in an urban setting in the United States.

In light of the abruptness and severity of the HIV/AIDS epidemic in Asia, there has been growing concern in recent years about the HIV/AIDS risks with the steady rate of Asian and Pacific Islander (AAPI) migration to the United States. Little is known, however, about existing HIV risks among non-MSM (men who have sex with men) AAPIs. The purpose of this study was to examine self-reported HIV testing behaviors and their correlates among a sample of 604 Southeast Asians living in a U.S. urban setting. The HIV testing rate among our sample adults is 30.8%, lower than the median HIV testing rate in the U.S. adult population by state, lower than that of the general adult testing rate in the study city, and lower than that of the AAPI MSM population. A low sexually transmitted infection (STI) testing rate as a proxy for low perceived sexual risks and a dearth of HIV knowledge were associated with the low HIV testing rate. Traditional health care access measures, such as availability of medical insurance and a personal doctor, cannot explain the low HIV testing rate in this predominantly immigrant population. Culturally and linguistically appropriate HIV prevention campaigns could increase the awareness of HIV/STI risk in this AAPI population.

Substance use among Asian Americans and Pacific Islanders sexual minority adolescents: findings from the National Longitudinal Study of Adolescent Health.

PURPOSE: We assessed the prevalence, incidence, and correlates of substance use among Asian American individuals transitioning from adolescence to young adulthood. METHODS: Data were obtained from the National Longitudinal Study of Adolescent Health, Wave II (1996) and Wave III (2001). Information on substance use was abstracted from a nationally representative sample of 1108 Asian Americans and Pacific Islanders (AAPIs) from both Waves. Weighted prevalence, incidence, and patterns of smoking, binge drinking, marijuana use, and other drug use were analyzed by sexual orientation and gender. Multiple logistic regression analyses were conducted to investigate the unique contribution of being a sexual minority in relation to four types of substance use by gender. RESULTS: A link between sexual orientation and substance use behaviors among AAPIs did not emerge until young adulthood. Significant increases in the incidence and prevalence of all four types of substance use (tobacco, binge drinking, marijuana, and other drugs) were found among sexual minority AAPIs. Specifically being an AAPI sexual minority young woman, compared with being a heterosexual young woman, a heterosexual young man, or a sexual minority young man, was significantly associated with substance use after controlling for demographic characteristics, problem behaviors, and substance use during adolescence. Also the highest prevalence of substance use was found among AAPI sexual minority women. CONCLUSIONS: These findings add greater urgency to addressing the role of sexual orientation in designing substance abuse programs.

Substance use among a sample of foreign- and U.S.-born southeast Asians in an urban setting.

Asian Americans (AA) are thought to have the lowest rates of substance use. This study examined substance use prevalence among 494 urban-dwelling Southeast Asians using snowball techniques. Prevalence estimates were age-adjusted proportionate to the U.S. Asian population. Findings show beer and alcohol consumption approximated the national percentage among 25-44 year olds. U.S.-born were about three times likelier to have past month substance use. Foreign-born Vietnamese were likelier than U.S.-born to use all substances except for beer. U.S.- and foreign-born beer consumption rates were similar. Future research is needed to delineate substance use determinants and patterns in foreign and U.S.-born AA sub-groups.

The diagnosis and treatment of HIV-infected children in China: challenges and opportunities.

BACKGROUND: HIV-infected children in China have not been well studied. This national survey describes the demographic characteristics and the associated diagnostic and antiretroviral treatment (ART) efforts directed toward surviving HIV-infected children. METHODS: A cross-sectional study was conducted in the 6 provinces with the highest HIV prevalence: 4 former plasma donation (FPD) provinces and 2 intravenous drug use (IDU) provinces. A survey on demographics and treatment-related issues was distributed to the parents or guardians of all living HIV-infected children identified through the national case reporting system. Descriptive and bivariate analyses were performed on completed surveys. RESULTS: Six hundred ninety-two (62.4%) of the total 1108 surveys were returned, and 650 were eligible for analysis. The average age in FPD provinces (mean +/- SD: 8.1 +/- 3.2 years) was significantly older than in IDU provinces (mean +/- SD: 5.4 +/- 2.2 years; P < 0.001). The average lag time from the probable date of transmission to a diagnosis for patients with mother-to-child transmission (MTCT) was 6.7 +/- 3.1 years in the FPD provinces and 4.7 +/- 1.9 years in the IDU provinces (P < 0.001). On the basis of the CD4 cell count or World Health Organization staging, 29.8% (144 of 484) of children from all 6 provinces who were not on ART needed it. CONCLUSIONS: This first national pediatric survey indicates that the age and time required for diagnosis were greater in HIV-infected children from FPD provinces compared with those from IDU provinces. In addition, this survey highlights the prolonged delay in the diagnosis and initiation of ART for children in China. Aggressive efforts to identify HIV-positive pregnant women, scale up prevention of MTCT activities, and expand early diagnosis and treatment are urgently needed.

Depressive symptomatology and mental health help-seeking patterns of U.S.- and foreign-born mothers.

OBJECTIVES: This report presents the national estimates of maternal depressive symptomatology prevalence and its socio-demographic correlates among major racial/ethnic-nativity groups in the United States. We also examined the relationship of mental health-seeking patterns by race/ethnicity and nativity. METHODS: Using the Early Childhood Longitudinal Survey-Birth Cohort Nine-month data, we present the distribution of Center for Epidemiological Study-Depression (CES-D) score by new mothers' nativity and race/ethnicity. The mental health-seeking pattern study was limited to mothers with moderate to severe symptoms. Weighted prevalence and 95% confidence intervals for depression score categories were presented by race/ethnic groups and nativity. Multi-variable logistic regression was used to obtain the adjusted odds ratios of help-seeking patterns by race/ethnicity and nativity in mothers with moderate to severe symptoms. RESULTS: Compared to foreign-born mothers, mothers born in the U.S. were more likely to have moderate to severe depressive symptoms in every racial/ethnic group except for Asian/Pacific Islanders. These US-born mothers were also more likely to be teenagers, lack a partner at home, and live in rural areas. Among Asians, Filipina mothers had the highest rate of severe depressive symptoms (9.6%), similar to those of US-born black mothers (10.2%). Racial/ethnic minorities and foreign-born mothers were less likely to consult doctors (OR: 2.2 to 2.5) or think they needed consultation (OR: 1.9 to 2.2) for their emotional problems compare to non-Hispanic White mothers. CONCLUSION: Our research suggests that previous "global estimates" on Asian American mental health underestimated sub-ethnic group differences. More efforts are needed to overcome the barriers in mental health services access and utilizations, especially in minority and foreign-born populations.

A cross-cultural pediatric residency program merger.

Academic health centers, health systems, and, to a lesser degree, medical schools and residency programs have merged, consolidated, or formed strategic alliances. There are few published reports of residency program mergers, and only one involving a merger between a historically black college and university (HBCU) and a predominantly white institution.This case study describes a merger between two dissimilar urban pediatric residency programs. The Howard University Hospital (HUH) pediatric residency program is affiliated with a HBCU, and the Children's National Medical Center (CNMC) pediatric residency program, is affiliated with a leading children's hospital which had relatively few underrepresented minority physicians or residents. The pediatric residency program merger between HUH and CNMC occurred in 2003 and presented organizational, cultural, and programmatic challenges and opportunities for both institutions. However, there was a sharp contrast between the opinions of the HUH and CNMC residents with respect to the perceived effect of the merger on residency training, patient care, and the individual institutions. Increasing the size and diversity of CNMC's resident pool and the granting of accreditation for the community health track were positive outcomes, but the magnitude of the institutional change process and the disruption to residents' routines and schedules were significant challenges. The merger served as an impetus to embed cultural competency guiding principles and expectations into the organizational fabric of the combined residency program.

Health status and health service access and use among children in U.S. immigrant families.

OBJECTIVES: We examined the health status and patterns of health care use of children in US immigrant families. METHODS: Data from the 1999 National Survey of America's Families were used to create 3 subgroups of immigrant children: US-born children with noncitizen parents, foreign-born children who were naturalized US citizens, and foreign-born children with noncitizen parents. Chi-square and logistic regression analyses were used to examine relationships between immigrant status and health access variables. Subgroup analyses were conducted with low-income families. RESULTS: Foreign-born noncitizen children were 4 times more likely than children from native families to lack health insurance coverage and to have not visited a mental health specialist in the preceding year. They were 40% and 80% more likely to have not visited a doctor or dentist in the previous year and twice as likely to lack a usual source of care. US-born children with noncitizen parents were also at a disadvantage in many of these aspects of care. CONCLUSIONS: We found that, overall, children from immigrant families were in worse physical health than children from non-immigrant families and used health care services at a significantly lower frequency.