California Health Interview Survey Research Articles

Disparities in Screening for Adverse Childhood Experiences.

Screening for adverse childhood experiences (ACEs) in the clinical setting is set to become more commonplace with continued efforts to reimburse clinicians for screening. However, an examination of disparities in ACEs screening and related attitudes and beliefs is needed. Using the 2021 California Health Interview Survey (CHIS), this study examined if several measures of socioeconomic status, access to care and identities were associated with 3 outcomes: 1) getting screened for ACEs by a clinician; 2) beliefs about the importance of screening and 3) satisfaction with efforts to address the impacts of ACEs. Logistic regressions were used to estimate odds of the outcomes. Black, Latinx, and Asian individuals had lower odds of being screened for ACEs than non-Hispanic Whites. A recent doctor's visit, higher burden of ACEs, and serious psychological distress were associated with higher odds of being screened. Latinx individuals, women, bisexual individuals, those with a recent doctor's visit and those with serious psychological distress had higher odds of believing clinicians asking about ACEs was very important, relative to their counterparts. Latinx individuals, American Indian or Alaska native individuals, Asian individuals, those with higher educational attainment and those with serious psychological distress had lower odds of being very satisfied with providers' efforts to address the impact of ACEs, relative to their counterparts. Efforts to expand ACEs screening should consider the disparities in screening that currently exist. Given the wide-ranging impacts that ACEs have on health, an equitable approach to screening is necessary.

RACE/ETHNICITY DISPARITY FOR PEOPLE WITH LTSS NEEDS IN CALIFORNIA: DISABILITY, FINANCE, AND HEALTH AND WELL-BEING

Abstract Older adults and people with disabilities have high needs for Long-Term Services and Supports (LTSS). Disability status, financial difficulties, and health and well-being are likely not uniformly experienced by all people with LTSS needs. Subgroups of older adults and people with disabilities, such as racial/ethnic minorities, may be at significant risk of experiencing financial difficulties and stress about making ends meet. This study used the first cycle of data (2019-2020) from the California Long-Term Services and Supports (CA-LTSS) survey, merged with select data from the California Health Interview Survey (CHIS) (N = 2,030). Multivariate Regressions and Conditional Process Analysis (CPA) were applied to test the hypothesized relationships. Findings show that black/African American and Asian participants with LTSS needs were more likely to have cognitive impairments. Black/African American participants with LTSS needs were more likely to report difficulties in activities of daily living. Racial/ethnic minorities with LTSS needs experienced diverse and more financial difficulties on average than their white counterparts. Asian participants with LTSS needs reported worse psychological distress than other racial/ethnic groups. American Indians and Alaska Natives with cognitive impairments were more likely to have more financial difficulties, and those with difficulty in instrumental activities of daily living were more likely to report worse self-rated health. This study moves beyond the typical white/black disparities analyses and focuses on diverse racial/ethnic groups. We need to address the financial needs of various racial/ethnic groups of people with LTSS needs and target policies and service programs to meet their mental health needs.

EXTREME WEATHER AND HEALTH AMONG OLDER POPULATIONS: INDIVIDUAL AND CONTEXTUAL-LEVEL VULNERABILITY AND RESILIENCE

Abstract Intense, frequent extreme weather events pose a significant public health threat, particularly for middle-aged and older adults who may be at elevated health risk. Yet, the social and environmental factors that determine their vulnerability and resilience remain largely unexplored. This study investigates individual and contextual determinants associated with exposure to and the health effects of extreme weather. Data were from the 2021 California Health Interview Survey of adults aged 50+ (N=14,726). Respondents were asked whether they had experienced any hazardous weather events such as heat waves, floods, and wildfires in the past two years and whether mental or physical health was harmed by these events. About 53% were exposed to extreme weather events. Among the exposed group, 18% and 17% reported harm to mental and physical health, respectively. Logistic regression analysis revealed increased exposure risk among middle-aged adults (age 50-64), those with chronic conditions, people living alone, and residents of rural and unsafe neighborhoods. Similarly, mental and physical health harms were more prevalent among these groups, along with females and those with unstable housing conditions. Conversely, living in cohesive neighborhoods was identified as a resilient factor, associated with reduced mental (OR=0.78, p< 0.05) and physical health risks (OR=0.70, p< 0.01). This study reveals pronounced vulnerabilities to climate change risks among populations identified as socioeconomically disadvantaged. Moreover, the findings emphasize the role of contextual conditions in shaping vulnerability and resilience. Our study contributes valuable insights to develop targeted climate change mitigation strategies, fostering resilience among older populations and supportive communities.

CONDUCTING A COUNTYWIDE ALZHEIMER’S DISEASE AND RELATED DEMENTIAS CAREGIVER LANDSCAPE ANALYSIS

Abstract In Los Angeles County (LAC), approximately 1 in 5 caregivers provide care to older adults with dementia and cognitive impairment. By 2040, a projected 1.5 million Californians will be living with Alzheimer’s disease and related dementias, foreshadowing an unprecedented need for family caregivers across the state. In 2021, the LAC Department of Public Health launched the Centers for Disease Control and Prevention-funded LA BOLD initiative with the intent of developing a strategic plan to address dementia awareness and care in LAC, including improving local infrastructure for supporting unpaid family caregivers. To support this effort, LA BOLD commissioned the University of Southern California Family Caregiver Support Center to conduct a landscape analysis of the caregiver population in LAC. The analysis used a multi-method approach that included: primary analysis of community-based organization surveys, stakeholder interviews, focus groups with family caregivers, and secondary analyses of California Health Interview Survey and California Caregiver Resource Center System CareNav™ data and an environmental scan of best-practice caregiving models in use in other states. Results informed the development of three functional recommendations specific to LAC caregivers: 1) Leverage existing infrastructure to strengthen and build family caregiver services and supports; 2) Promote health care payer, provider, and system recognition of and support for family caregivers; and 3) Increase respite services for caregivers. This presentation highlights the methods and the findings from the landscape analysis, providing insights into the barriers and opportunities that a growing caregiver population of persons with dementia may pose to LAC.

Exploring the characteristics and health outcomes of working from home: Analysis of 2021 California Health Interview Survey data.

Working from home (WFH) may affect health behaviors and mental health. The coronavirus disease-2019 (COVID-19) pandemic saw many USemployees transition to WFH, which has persisted in various job sectors and significantly impacted employees. However, its effects on health outcomes have remained unclear. We aimed to explore the characteristics and health outcomes of, and health-related differences between, WFH and not-WFH groups. Using the 2021 California Health Interview Survey data, we analyzed health behaviors (smoking, alcohol consumption, and fruit-related nutrition) and the mental health status of 12,438 individuals using descriptive statistics, Pearson's χ2 test, and regressions. A total of 39% were WFH and 61% were not-WFH. Overall, the WFH group had worse health behaviors and mental health than the not-WFH group. Age was associated with smoking in both groups (WFH: b = 0.37; not-WFH: b = 0.35), but with fruit-related nutrition only in the WFH group. Household income and occupation were associated with alcohol consumption in both groups. Age (WFH: b = -1.58; not-WFH: b = -1.39), household income (WFH: b = -0.75; not-WFH: b = -0.34), and job duration (WFH: b = -0.34; not-WFH: b = -0.40) were associated with mental health in both groups; those who were younger and had lower household incomes and job durations had worse mental health. Health management is a clear necessity for the WFH group. Irrespective of WFH status, young workers with shorter than 5 years'job duration reported mental distress, highlighting a need for distress assessment and management for the young workforce.

Abstract A090: Association between breast cancer screening adherence and food insecurity in women with low income from California

Abstract Background: Food insecurity has been associated with delayed breast cancer screening among low-income individuals and communities in the United States (US). However, it is unclear if this association is due to poverty and related factors more generally (e.g., education, access to health care) or food insecurity specifically. Hence, we tested the association of food insecurity with being up-to-date with breast cancer screening recommendations in women with low-income from California. Methods: Individual-level information on breast cancer screening and food security status from females ages 50-74 years with an annual household income below 200% of the federal poverty level (FPL) was obtained from 2015-2016 California Health Interview Survey publicly available data. Bivariate and multivariate weighted logistic regression models were employed to test the association between breast cancer screening adherence and food insecurity, factoring in sociodemographic covariates including age, race/ethnicity, English use and proficiency, poverty level (dichotomized as 0-99% vs. 100-199% FPL), educational attainment, marital status, health insurance status, usual source of care, working status, and rurality. Results: The total sample included 3598 women with low-income from California, the majority of whom reported to be ages 50-59 years old (46.6%), Hispanic (50.5%), have health insurance (89.0%) and a usual source of health care (84.5%), live in an urban area (91.6%), and identify as food secure (51.1%). Most women reported being up-to-date with breast cancer screening (78.3%), of which 52.8% had food security and 47.2% experienced food insecurity. In comparison, among women not up-to-date with screening (21.7%), only 44.9% had food security while a majority of 55.1% experienced food insecurity. In the multivariable model, food insecurity was associated with lower odds of being up-to-date with breast cancer screening (odds ratio [OR]: 0.69; 95% confidence interval [CI]: 0.44–1.07) at a suggestive level of statistical significance. This observed difference may be explained by the correlation between food insecurity and other important factors known to be associated with screening behavior, including history of cancer and other socioeconomic metrics such as income amount, financial security, and housing instability. Conclusions: Food insecurity was inversely associated with being up-to-date with breast cancer screening. There is an imperative need to address breast cancer screening among low-income women in California, especially those who experience food insecurity. Impact: Future studies should combine food insecurity and breast cancer screening interventions to improve screening rates. Citation Format: Charlotte L. Bergheimer, Laura Fejerman. Association between breast cancer screening adherence and food insecurity in women with low income from California [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A090.

Dietary Factors Affecting Asthma Outcomes among Asthmatic Children in California

Asthma is one of the principal causes of absenteeism from school and the leading cause of emergency department visits for children in the United States. Some dietary habits are associated with asthma prevalence and play a role in the pathogenesis and control of symptoms. The objective of this study was to characterize dietary factors that may affect asthma outcomes among children with asthma in California. The California Health Interview Survey (CHIS) is the largest state health survey in the nation. This cross-sectional study included 7687 surveys, representing an estimated annual 710,534 children (ages 2–11) reported to have asthma between 2001 and 2015. Analysis was survey-weighted. We used multivariable regression, adjusting for covariates, to examine the association between dietary factors and asthma outcomes. Asthmatic children consuming two or more servings of sodas per day had more symptoms of asthma than those who did not consume soda daily (OR = 1.50, 95% CI: 1.04, 2.15). Moreover, those consuming two servings of fruits per day had lower odds of missing school due to asthma. Children with asthma may be affected by certain pro-inflammatory foods that are energy dense. This study provided an additional reason to discourage the consumption of sodas and sugary drinks due to the negative respiratory impact, in addition to their effect on childhood obesity, oral health problems, and future chronic diseases.

Real-World Adoption of Mental Health Support Among Adolescents: Cross-Sectional Analysis of the California Health Interview Survey

Abstract Objective We aim to examine: (a) the extent to which patterns of adoption of counseling services and digital mental health interventions (DMHIs) shifted in recent years (2019–2021); (b) the impact of distress on adoption of mental health support; and (c) reasons related to adolescents’ low adoption of DMHIs when experiencing distress. Methods Data were from three cohorts of adolescents aged 12–17 years (n = 847 in 2019; n = 1,365 in 2020; n = 1,169 in 2021) recruited as part of the California Health Interview Survey. We estimated logistic regression models to examine the likelihood of using mental health support as a function of psychological distress, sociodemographic characteristics, and cohorts. We also analyzed adolescents’ self-reported reasons for not trying DMHIs as a function of distress. Results The proportion of adolescents reporting elevated psychological distress (∼50%) was higher than those adopting counseling services (<20%) or DMHIs (<10%). A higher level of distress was associated with a greater likelihood of receiving counseling (OR = 1.15), and using DMHIs to connect with a professional (Odds ratio (OR) = 1.11) and for self-help (OR = 1.17). Among those experiencing high distress, adolescents’ top reason for not adopting an online tool was a lack of perceived need (19.2%). Conclusion Adolescents’ main barriers to DMHI adoption included a lack of perceived need, which may be explained by a lack of mental health literacy. Thoughtful marketing and dissemination efforts are needed to increase mental health awareness and normalize adoption of counseling services and DMHIs.

Asthma heterogeneity among Asian American children: The California Health Interview Survey

BackgroundThe Asian American (AsA) population is heterogenous and rapidly growing; however, little is known regarding childhood asthma burden among AsA ethnic groups. The relation between obesity and asthma in AsA ethnic groups also remains unclear. ObjectiveTo evaluate asthma prevalence and the relation of obesity to asthma risk among children in 7 AsA ethnic groups. MethodsWe analyzed data from the California Health Interview Survey from 2011 to 2020. AsA ethnicities were self-reported. Body mass index z-scores, calculated from self-reported height/weight, were used to categorize children by obesity status, based on body mass index-for-age growth charts. Prevalence of self-reported lifetime doctor-diagnosed asthma and asthma attack in the last 12 months was calculated. We performed multivariable logistic regressions adjusting for age and sex. ResultsOf 34,146 survey respondents, 12.2% non-Hispanic White and 12.5% AsA children reported lifetime asthma. Among AsA ethnic groups, however, lifetime asthma ranged from 5.1% (Korean American) to 21.5% (Filipino American). Non-Hispanic White children and AsA children had a similar lifetime asthma prevalence (adjusted odds ratio [aOR], 1.05; 95% CI, 0.71-1.55; P = .81), but prevalence was lower in Korean American children (aOR, 0.37; 95% CI, 0.19-0.73; P = .004) and higher in Filipino American children (aOR, 1.97; 95% CI, 1.22-3.17; P = .006). The lifetime asthma prevalence of different AsA ethnic groups persisted even when stratified by obesity status. ConclusionChildhood lifetime asthma prevalence varied among AsA ethnic groups, with lowest prevalence in Korean American children and highest prevalence in Filipino American. Further characterization of asthma burden among AsA ethnic groups may help guide asthma screening and prevention measures and offer new insights into asthma pathogenesis.

Social isolation, social media use, and poor mental health among older adults, California Health Interview Survey 2019–2020

BackgroundOlder adults’ engagement on social media may be a resource to reduce loneliness and improve mental health. Purpose: This study aimed to examine loneliness and social media use and its association with severe psychological distress among older adults and whether social media use moderated the association of loneliness on severe psychological distress among older adults.MethodsThis study is a secondary analysis of the 2019–2020 California Health Interview Survey. The Kessler 6-item Psychological Distress Scale (K6) assessed symptoms of psychological distress, with a K6 score ≥ 13 associated with severe mental illness. Loneliness was measured using a revised Three Item Loneliness Scale (TILS) score. Multiple regression analyses were conducted to examine associations between loneliness and severe psychological distress.ResultsLoneliness, health status, and identification as Asian, remained strong predictors of severe psychological distress among older adults when adjusting for other factors. In bivariate analysis, high-frequent social media users, but did not remain significant when accounting for covariates. Social media use did not moderate the association between loneliness and severe psychological distress.ConclusionThis study underscores the significant impact of loneliness on poor mental health among older adults, emphasizing that while frequent social media use correlates with severe psychological distress, it may not alleviate the association of loneliness on poor mental health, thus highlighting the urgent need to address social isolation and promote genuine social connectedness, particularly among Asian older adults.

Low-Income Asian Americans: High Levels Of Food Insecurity And Low Participation In The CalFresh Nutrition Program.

Little is known about food insecurity and the extent of Supplemental Nutrition Assistance Program (SNAP) participation in the heterogeneous Asian American population. Using California Health Interview Survey data from the period 2011-20, we examined both issues among low-income Asian American adults from six origin groups: Chinese, Filipino, Japanese, Korean, South Asian, and Vietnamese. We found high and varied levels of overall food insecurity, with the highest burden among Filipino adults (40percent). Food insecurity by severity was also heterogenous; very low food security affected 2percent of Chinese adults but 9percent and 10percent of Filipino and Japanese adults, respectively. Participation in CalFresh (California-implemented SNAP) ranged from 11percent and 12percent among Korean and Chinese adults, respectively, to 20percent among Vietnamese adults. Compared with English-proficient low-income Asian American adults, those with limited English proficiency were no less likely to participate in CalFresh, possibly reflecting language assistance required by California law and provided by community-based organizations. These results underscore the importance of collecting and reporting disaggregated data by Asian origin group that could inform targeted outreach and interventions.

A cross-sectional study on social determinants of mental health during COVID-19 among adults in California.

To explore the impact of structural and intermediary social determinants of health (SDoH) on Californian adults' mental health during the early phase of the COVID-19 pandemic. This cross-sectional study used data from the 2020 cycle of the California Health Interview Survey, the largest US state-level population health survey. Descriptive statistics and logistic regression were used to analyse the data. Using a general social determinant of health framework, we operationalized different survey questions to measure structural and intermediary determinants of mental health. Mental health during the early phase of COVID-19 among adults in California was associated with age, gender, health conditions, delayed care, employment status (loss of job or reduced income) and discrimination. People in higher social strata were more likely to have better mental health for many of these factors. This study supports the assertion that material circumstances (such as employment status) and discrimination are associated with experiencing mental health issues among adults in California during COVID-19. Racism is a public health issue, and as nurses, addressing racism is critical. In addition, much work is needed to address SDoH to improve health outcomes, especially among marginalized populations. This study addressed the knowledge gap concerning the social determinants of mental health among Californian adults during the early phase of the COVID-19 pandemic. Those who had reduced income and those who lost their jobs during the COVID-19 pandemic were 46% and 56%, respectively, more likely to report mental health problems. Those who experienced discrimination in healthcare were 304% more likely to report mental health issues. This research will increase the understanding of the social determinants of health, particularly for those with chronic illnesses and mental health issues during the COVID-19 pandemic. No patient or public contribution, as we used an existing US state dataset. However, California Health Interview Survey is the largest state health survey in the United States and interviews more than 20,000 households each year representing the health care needs of Californians.

Disparities in unmet needed paid leave across race, ethnicity and citizenship status among employed Californians: a cross-sectional study

ObjectivesPaid leave is essential for public health in order to prevent presenteeism (i.e., working while sick), provide an economic safety net for workers when ill, and promote family well-being through parental leave. While racial and ethnic disparities in unmet paid leave (or needing but not being able to take paid leave) are well documented, little evidence of the intersecting role of citizenship status exists. This study examined disparities in unmet paid leave across race, ethnicity and citizenship status. Study designThis was a cross-sectional study of employed adults in California, USA. MethodsWeighted, multivariable logistic regressions were used to assess disparities in unmet needed paid leave across race, ethnicity and citizenship status categories, including non-citizen, naturalised, and citizen Latinx and Asian respondents, and naturalised and non-citizen White respondents, relative to US-born White respondents, controlling for demographic, familial, health-related and work-related covariates. This study examined a representative sample of Californian adults using the 2021 California Health Interview Survey (CHIS). A total of 24,453 people completed the CHIS from March to October 2021. This analysis was restricted to individuals who had complete data, were employed at the time of the survey and were part of the study race and ethnic groups of interest, leading to an analytical sample of 12,485 respondents. ResultsWhile 16.9% of employed Californians reported forgoing needed paid leave, disparities across race, ethnicity and citizenship status were evident. Specifically, 31.8% of non-citizen Latinx respondents, compared to 11% of US-born White respondents, did not use paid leave when they needed it due to fear of job loss, fear of negative impacts on job advancement, employers denying it, lack of information or knowledge regarding the process or ineligibility. In the fully adjusted analyses, respondents identifying as non-citizen Latinx (adjusted odds ratio [aOR] = 2.57, 95% confidence interval [CI] = 1.94–3.40), naturalised Latinx (aOR = 1.90, 95% CI = 1.46–2.48), US-born Latinx (OR = 1.30, 95% CI = 1.06–1.60), non-citizen Asian (aOR = 2.34, 95% CI = 1.69–3.23) and naturalised Asian (aOR = 1.78, 95% CI = 1.35–2.34) had a statistically significantly higher likelihood of experiencing unmet needed paid leave compared to US-born White respondents. ConclusionsDespite its importance for health, disparities across race, ethnicity and citizenship status exist in those who experience unmet paid leave. It is recommended that the administrative and enforcement agencies in California further communicate eligibility, facilitate the application process and enforce equitable access to paid leave for all workers.

Predictors of psychological distress among healthcare workers during the COVID-19 pandemic in California

ABSTRACT This study explores factors contributing to California healthcare workers’ stress during the COVID-19 pandemic. A retrospective data from the 2021 UCLA California Health Interview Survey was retrieved to analyze responses from 918 healthcare workers. Results showed that healthcare workers with single parents had the highest stress, followed by Hispanics, single persons without children, and women. Healthcare workers experiencing racial discrimination and difficulty paying for basic needs during COVID-19 had the highest average stress. Being women, having COVID-19 difficulties, being younger, and being married explained 12.4% of the variance in the psychological distress of healthcare workers from California when linear regression was run. Implications on the necessity for Employee Assistance Programs (EAP) and creating policies that support the mental health of healthcare workers are elaborated.

Short-Term total and wildfire fine particulate matter exposure and work loss in California

BackgroundFew studies investigated the impact of particulate matter (PM2.5) on some symptom exacerbations that are not perceived as severe enough to search for medical assistance. We aimed to study the association of short-term daily total PM2.5 exposure with work loss due to sickness among adults living in California. MethodsWe included 44,544 adult respondents in the workforce from 2015 to 2018 California Health Interview Survey data. Daily total PM2.5 concentrations were linked to respondents’ home addresses from continuous spatial surfaces of PM2.5 generated by a geostatistical surfacing algorithm. We estimated the effect of a 2-week average of daily total PM2.5 exposure on work loss using logistic regression models. ResultsAbout 1.69% (weighted percentage) of adult respondents reported work loss in the week before the survey interview. The odds ratio of work loss was 1.45 (odds ratio [OR] = 1.45, 95% confidence interval [CI]: 1.03, 2.03) when a 2-week average of daily total PM2.5 exposure was higher than 12 µg/m3. The OR for work loss was 1.05 (95% CI: 0.98, 1.13) for each 2.56ug/m3 increase in the 2-week average of daily total PM2.5 exposure, and became stronger among those who were highly exposed to wildfire smoke (OR = 1.06, 95% CI: 1.00, 1.13), compared to those with lower wildfire smoke exposure (OR = 1.04, 95% CI: 0.79, 1.39). ConclusionsOur findings suggest that short-term ambient PM2.5 exposure is positively associated with work loss due to sickness and the association was stronger among those with higher wildfire smoke exposure. It also indicated that the current federal and state PM2.5 standards (annual average of 12 µg/m3) could be further strengthened to protect the health of the citizens of California.

Long-term air pollution exposures on type 2 diabetes prevalence and medication use

BackgroundType 2 diabetes has raised great public health concerns due to its association with the increased risk of several adverse health outcomes. We aimed to investigate the association of criteria air pollutants and traffic density with the prevalence of type 2 diabetes and antidiabetic medication use in California. MethodsA cross-sectional study was conducted using 2005 California Health Interview Survey (CHIS) data, linked with criteria air pollutant exposure measures, including government-monitored ozone (O3), particulate matter (PM10, PM2.5) and nitrogen dioxide (NO2), residential traffic density, and land use regression modeled NOX, NO, and NO2 estimates for Los Angeles County only based on the respondents’ geocoded residential addresses. Weighted logistic regression models were used to examine the influences of 36-month average exposures to each air pollutant and traffic density on diabetes prevalence and medication use. ResultsAmong 31,483 CHIS 2005 state-wide respondents, 6.7% of adults reported having been diagnosed with type 2 diabetes. We observed type 2 diabetes prevalence was positively associated with exposures to O3, PM10, and PM2.5, and with NO, NO2, and NOx only in Los Angeles County. For each 10ppb increase in O3 or 10ug/m3 increase in PM10 or PM2.5, the odds of taking any medication increased by 40%, 56%, and 50%; taking pills increased by 33%, 31%, and 41%; taking insulin increased by 43%, 53%, and 46%; and taking both insulin and pills increased by 70%, 60%, and 88%, respectively. When traffic density within 750 feet of a respondent's home increased by one interquartile, 7% increase in odds of using any medication and taking pills was also observed. ConclusionThis study adds to evidence indicating greater air pollution exposure is associated with increased diabetes prevalence. It also provides new evidence demonstrating a strong association between pollutant exposure and antidiabetic medication use in adult Californians.

Variation in adults' use of flavored tobacco products by sales restrictions in California jurisdictions.

State and local policies prohibiting the sales of flavored tobacco have been effective in curtailing retail availability and sales of products across the United States. Less is known about the use of flavored tobacco which could vary as a function of type of ordinance, product category, policy implementation, and other factors. The 2019-2020 California Health Interview Surveys were used to estimate flavored and non-flavored tobacco use among adults (n=43,681) residing in a California jurisdiction with a comprehensive (n=48), partial (n=35), or no flavored tobacco sales restriction (FTSR) (n=427). Multinomial logistic regression models, which accounted for clustering within jurisdictions (n=510), were separately developed for outcomes corresponding to use of any tobacco, non-cigarette tobacco products (NCTPs), electronic nicotine delivery systems, and conventional cigarettes. Individual-level effects of policy on tobacco use were estimated due to the overlap between the survey periods and effective policy dates. Approximately 22% of Californians were subject to a partial or comprehensive FTSR by December 31, 2020. Accounting for potential confounders, residents of jurisdictions with a comprehensive FTSR (vs. no ban) had 30% lower odds of using any flavored tobacco. The strongest and only statistically significant association by product category was exposure to a comprehensive FTSR and use of a flavored NCTP (aOR=0.4 (0.2, 0.8); p=0.008). Null or positive associations were primarily observed between a partial FTSR and flavored tobacco use, as well as associations between any FTSR and non-flavored tobacco use. Recent passage of a statewide ban in California will close gaps from the patchwork of local policies and eliminate most partial FTSR exemptions. However, state law still exempts the sales of some flavored tobacco products (e.g., hookah), leaving jurisdictions the option of enacting comprehensive FTSRs that may be more effective than partial FTSRs in reducing use of flavored tobacco.

The Relationship Between Homeownership and Health by Race/Ethnicity Since the Foreclosure Crisis: California Health Interview Survey 2011-2018.

US housing policy places a high priority on homeownership, providing large homeowner subsidies that are justified in part by homeownership's purported health benefits. However, studies conducted before, during, and immediately after the 2007-2010 foreclosure crisis found that while homeownership is associated with better health-related outcomes for White households, that association is weaker or non-existent for African-American and Latinx households. It is not known whether those associations persist in the period since the foreclosure crisis changed the US homeownership landscape. To examine the relationship between homeownership and health and whether that relationship differs by race/ethnicity in the period since the foreclosure crisis. We conducted a cross-sectional analysis of 8 waves (2011-2018) of the California Health Interview Survey (n = 143,854, response rate 42.3 to 47.5%). We included all US citizen respondents ages 18 and older. The primary predictor variable was housing tenure (homeownership or renting). The primary outcomes were self-rated health, psychological distress, number of health conditions, and delays in receiving necessary medical care and/or medications. Compared to renting, homeownership is associated with lower rates of reporting fair or poor health (OR = 0.86, P < 0.001), fewer health conditions (incidence rate ratio = 0.95, P = 0.03), and fewer delays in receiving medical care (OR = 0.81, P < 0.001) and medication (OR = 0.78, P < 0.001) for the overall study population. Overall, race/ethnicity was not a significant moderator of these associations in the post-crisis period. Homeownership has the potential to provide significant health-related benefits to minoritized communities, but this potential may be threatened by practices of racial exclusion and predatory inclusion. Further study is needed to elucidate health-promoting mechanisms within homeownership as well as potential harms of specific homeownership-promoting policies to develop healthier, more equitable housing policy.

A complex systems model of breast cancer etiology: The Paradigm II Model.

Complex systems models of breast cancer have previously focused on prediction of prognosis and clinical events for individual women. There is a need for understanding breast cancer at the population level for public health decision-making, for identifying gaps in epidemiologic knowledge and for the education of the public as to the complexity of this most common of cancers. We developed an agent-based model of breast cancer for the women of the state of California using data from the U.S. Census, the California Health Interview Survey, the California Cancer Registry, the National Health and Nutrition Examination Survey and the literature. The model was implemented in the Julia programming language and R computing environment. The Paradigm II model development followed a transdisciplinary process with expertise from multiple relevant disciplinary experts from genetics to epidemiology and sociology with the goal of exploring both upstream determinants at the population level and pathophysiologic etiologic factors at the biologic level. The resulting model reproduces in a reasonable manner the overall age-specific incidence curve for the years 2008-2012 and incidence and relative risks due to specific risk factors such as BRCA1, polygenic risk, alcohol consumption, hormone therapy, breastfeeding, oral contraceptive use and scenarios for environmental toxin exposures. The Paradigm II model illustrates the role of multiple etiologic factors in breast cancer from domains of biology, behavior and the environment. The value of the model is in providing a virtual laboratory to evaluate a wide range of potential interventions into the social, environmental and behavioral determinants of breast cancer at the population level.

Loneliness and Psychological Distress Among Older Californians: The Moderating Roles of Citizenship Status and English Proficiency.

Guided by the theory of stress proliferation, our study examined whether loneliness, citizenship status, and English proficiency were associated with psychological distress among older adults, and if citizenship status and English proficiency moderated these relationships. Using the older adult subsample (65+ years) of the 2019-2020 California Health Interview Survey (N = 15,210), we assessed cross-sectional associations between loneliness, citizenship status, and English proficiency on psychological distress by conducting multivariable linear regression models. Interaction terms were included in subsequent models to determine if citizenship status and English proficiency moderated the relationship between loneliness and psychological distress. In unadjusted models, greater loneliness was associated with higher distress. Both naturalized citizens and noncitizens, and those with limited English proficiency (LEP) exhibited greater distress than US born citizens and those who speak English only (EO). After adjusting for sociodemographic and health covariables, loneliness remained significant for distress although the relationships between citizenship status and English proficiency became attenuated. With the inclusion of interactions, the magnitude of the relationship between loneliness and distress was stronger for naturalized citizens and those with LEP than native-born citizens and those who speak EO, respectively. Loneliness was the most consistent stressor affecting multiple life domains. However, our findings demonstrate that stress proliferation is occurring among older immigrant adults and the interplay between loneliness, citizenship status, and English proficiency is contributing to heightened distress. Further attention is needed in understanding the role of multiple stressors influencing mental health among immigrant older adults.