Behavioral and Environmental Explanations of Elevated Blood Lead Levels in Immigrant Children and Children of Immigrants.

Immigrant/refugee children sometimes have substantially higher blood lead levels (BLLs) than US-born children in similar environments. We try to understand why, by exploring the relationship between immigration status of mother and the BLLs of US-born children. We compared BLLs of children born in Michigan to immigrant and non-immigrant parents, using the Michigan database of BLL tests for 2002-2005, which includes the child's race, Medicaid eligibility and address. We added census data on socio-demographic/housing characteristics of the child's block group, and information about parents. Low parental education, single parent households, mothers' smoking and drinking, all increase the child's BLL. However, immigrant parents had fewer characteristics associated with high BLL than US born parents, and their children had lower BLLs than children of US-born mothers. Our findings suggest that prior findings of higher BLLs among immigrant/refugee children probably result from them starting life in high-lead environments.

Acculturation and glycemic control of Asian Indian adults with type 2 diabetes.

The prevalence of type 2 diabetes is disproportionately high among Asian Indians (AI), one of the fastest growing immigrant groups in the United States (US). Poorly controlled diabetes associated with inadequate self-management increases complications and thus medical costs. Acculturation may be an important determinant of diabetes self-management and hence control. This study examined the association between the degree of acculturation and glycemic control as measured by Hemoglobin A1c in AI adults with type 2 diabetes. A mixed method (quantitative and qualitative) study was conducted among 30 AI adults with type 2 diabetes. Acculturation assessment using the Suinn-Lew Asian Self-identity Instrument was followed by socio-demographic questions, self-reported anthropometric measures, and open ended diabetes self-care questions. A two-step multiple regression analysis and content analysis of verbatim interview transcriptions were conducted. Interactions of acculturation with body mass index (interaction b = 1.11; p = 0.01), annual household income (interaction b = 7.19; p = .01), and diabetes duration (interaction b = .30; p = .02) significantly predicted higher HbA1c levels (R(2) change = .368; F change = 4.21; p = .02). From the qualitative interviews, the following were regarded as US specific facilitators for glycemic control: excellent health care system and facilities, availability of healthy food choices and self-monitoring devices, medical insurance benefits, good quality medications, and improved health awareness. Cultural orientation might be important for patient tailored interventions targeting AI with type 2 diabetes. Therefore, interventions targeted at Asian Indians with diabetes should include culture specific adaptations to nutrition education and support.

The predictive value of self-report questions in a clinical decision rule for pediatric lead poisoning screening.

OBJECTIVE: We derived a clinical decision rule for determining which young children need testing for lead poisoning. We developed an equation that combines lead exposure self-report questions with the child's census-block housing and socioeconomic characteristics, personal demographic characteristics, and Medicaid status. This equation better predicts elevated blood lead level (EBLL) than one using ZIP code and Medicaid status. METHODS: A survey regarding potential lead exposure was administered from October 2001 to January 2003 to Michigan parents at pediatric clinics (n=3,396). These self-report survey data were linked to a statewide clinical registry of blood lead level (BLL) tests. Sensitivity and specificity were calculated and then used to estimate the cost-effectiveness of the equation. RESULTS: The census-block group prediction equation explained 18.1% of the variance in BLLs. Replacing block group characteristics with the self-report questions and dichotomized ZIP code risk explained only 12.6% of the variance. Adding three self-report questions to the census-block group model increased the variance explained to 19.9% and increased specificity with no loss in sensitivity in detecting EBLLs of ≥ 10 micrograms per deciliter. CONCLUSIONS: Relying solely on self-reports of lead exposure predicted BLL less effectively than the block group model. However, adding three of 13 self-report questions to our clinical decision rule significantly improved prediction of which children require a BLL test. Using the equation as the clinical decision rule would annually eliminate more than 7,200 unnecessary tests in Michigan and save more than $220,000.

Feeding behaviors of low-income mothers: directive control relates to a lower BMI in children, and a nondirective control relates to a healthier diet in preschoolers.

BACKGROUND: A topic of interest in the etiology of child obesity is whether and how parental feeding behaviors are associated with the food intake and weight status of children. OBJECTIVE: The objective was to explore whether and how directive (overt) and nondirective (covert and food environmental structure) types of parental feeding control were associated with children's food intake and weight status. DESIGN: This was a cross-sectional exploratory study using structural equation modeling to determine directional associations between maternal feeding practices and children's food intake and weight status. Researchers collected data from 330 dyads of children aged 3-5 y and mothers participating in a federal preschool program for low-income families (Head Start) in Michigan. The mothers' feeding practices (directive and nondirective control), the children's food intakes, and the height and weight of both the mothers and children were measured. Structural equation models tested the relations between maternal feeding practices, the children's food intake, and weight status. RESULTS: The structural equation model confirmed that children's weight status was inversely associated with mothers' directive control, and mothers' nondirective control was associated with children's intakes of more nutrient-dense foods and less energy-dense foods. No association was found between the mothers' directive control and the children's food intakes. CONCLUSIONS: Mothers' use of nondirective feeding practices was associated with children's intakes of more nutrient-dense foods. However, use of more directive feeding control was associated with lower weight status in preschoolers of low-income mothers. These findings need to be examined in longitudinal studies. This trial was registered at clinicaltrials.gov as NCT01525186.

Provider communication and patient participation in diabetes self-care.

OBJECTIVE: To determine the effect size of provider communication about self-care and the provider's following treatment guidelines on the self-care behaviors of people with Type 2 diabetes (T2DM). METHODS: Data were from the TRIAD telephone surveys of Michigan patients in managed care with T2DM (n=1438). The survey asked about the patients' self-care and provider communication about blood glucose monitoring, exercise, foot care, flu vaccination and annual retina screening. RESULTS: After controlling for patient socio-demographics and disease severity, remembering having received provider information on these activities more than doubled the odds of performing blood glucose monitoring, and performing foot examinations. It also significantly increased the amount of exercise the patient performed. Provider modeling had a strong association with foot care. Counseling by a diabetes educator was positively and significantly associated with having an annual retina examination and receiving an influenza vaccination. CONCLUSIONS: Remembering self-care information is associated with increased home based self-care by patients and their families. Consulting with a diabetes educator can substantially improve patient self-care. PRACTICE IMPLICATIONS: Health care providers should encourage patient education. However, physician time is costly and most nurses do not specialize in patient education; one solution is to refer patients to a diabetes educator.

Comparing lead poisoning risk assessment methods: census block group characteristics vs. zip codes as predictors.

OBJECTIVE: We determined which children should be tested for elevated blood lead levels (BLLs) in the face of financial and practical barriers to universal screening efforts and within 2009 Centers for Disease Control and Prevention recommendations allowing health departments to develop BLL screening strategies. METHODS: We used the Michigan database of BLL tests from 1998 through 2005, which contains address, Medicaid eligibility, and race data. Linking addresses to U.S. Census 2000 data by block group provided neighborhood sociodemographic and housing characteristics. To derive an equation predicting BLL, we treated BLL as a continuous variable and used Hierarchical Linear Modeling to estimate the prediction equation. RESULTS: Census block groups explained more variance in BLL than tracts and much more than dichotomized zip code risk (which is current pediatric practice). Housing built before 1940, socioeconomic status and racial/ethnic characteristics of the block group, child characteristics, and empirical Bayesian residuals explained more than 41% of the variance in BLL during 1998-2001. By contrast, zip code risk and Medicaid status only explained 15% of the BLL variance. An equation using 1998-2001 BLL data predicted well for BLL tests performed in 2002-2005. While those who received BLL tests had above-average risk, this method produced minimal bias in using the prediction equation for all children. CONCLUSIONS: Our equation offers better specificity and sensitivity than using dichotomized zip codes and Medicaid status, thereby identifying more high-risk children while also offering substantial cost savings. Our prediction equation can be used with a simple Internet-based program that allows health-care providers to enter minimal information and determine whether a BLL test is recommended.

Cancer patients' desires for communication of prognosis information.

A mail survey was sent to cancer patients to determine how often they want, request, and receive a qualitativeprognosis (i.e., will they die from the disease?) and a quantitative estimate (how long they will survive). The survey included measures of social and psychological characteristics that were hypothesized to be associated with their desire for and willingness to request prognosis information (N = 352). Major findings are as follows: (a) Whereas about 80% of patients wanted a qualitative prognosis, only about one half wanted a quantitative one; (b) over 90% of those who wanted a qualitative prognosis were given one, but only about one half of those who wanted a quantitative prognosis were given one; and (c) about 15% ofthose who wanted a qualitative prognosis failed to ask for it, and over one third of those who wanted a quantitative prognosis failed to ask for it. Multivariate analyses indicate that the effects of education on wanting, asking for, and receiving prognosis information are slight, and the effects of sex are essentially nil. Older people were significantly less likely to request and to be given prognosis information. Those who had greater anxiety and who needed to avoid thinking about death wanted, requested, and received significantly less information. Fear had significant nonlinear effects on desire, request, and receipt of quantitative information. Those whose prognosis was worse were less likely to want, ask for, and receive quantitative information. Those least likely to want, request, and be given qualitative information were those who combined a bad prognosis with a need to avoid thinking about death.