Co-occurring Health Risks Research Articles

Understanding the risks of co-exposures in a changing world: a case study of dual monitoring of the biotoxin domoic acid and Vibrio spp. in Pacific oyster.

Assessing the co-occurrence of multiple health risk factors in coastal ecosystems is challenging due to the complexity of multi-factor interactions and limited availability of simultaneously collected data. Understanding co-occurrence is particularly important for risk factors that may be associated with, or occur in similar environmental conditions. In marine ecosystems, the co-occurrence of harmful algal bloom toxins and bacterial pathogens within the genus Vibrio may impact both ecosystem and human health. This study examined the co-occurrence of Vibrio spp. and domoic acid (DA) produced by the harmful algae Pseudo-nitzschia by (1) analyzing existing California Department of Public Health monitoring data for V. parahaemolyticus and DA in oysters; and (2) conducting a 1-year seasonal monitoring of these risk factors across two Southern California embayments. Existing public health monitoring efforts in the state were robust for individual risk factors; however, it was difficult to evaluate the co-occurrence of these risk factors in oysters due to low number of co-monitoring instances between 2015 and 2020. Seasonal co-monitoring of DA and Vibrio spp. (V. vulnificus or V. parahaemolyticus) at two embayments revealed the co-occurrence of these health risk factors in 35% of sampled oysters in most seasons. Interestingly, both the overall detection frequency and co-occurrence of these risk factors were considerably less frequent in water samples. These findings may in part suggest the slow depuration of Vibrio spp. and DA in oysters as residual levels may be retained. This study expanded our understanding of the simultaneous presence of DA and Vibrio spp. in bivalves and demonstrates the feasibility of co-monitoring different risk factors from the same sample. Individual programs monitoring for different risk factors from the same sample matrix may consider combining efforts to reduce cost, streamline the process, and better understand the prevalence of co-occurring health risk factors.

A latent class analysis of young women’s co-occurring health risks in urban informal settlements in Durban, South Africa

In South Africa, substance use, violence, and HIV risk disproportionately affect young poor Black women. Few studies have explicitly measured the co-occurrence of these health risks or the impact on mental health and wellbeing for this population. To this aim, we use a person-centred approach to explore the clustering of health risks among young Black women from urban informal settlements in Durban, South Africa, enrolled in an intervention trial. Latent class analysis identified three health risk subgroups with increasing levels of health risk co-occurrence: while all three subgroups had high rates of emotional/economic intimate partner violence, they differed in their levels of the other health risks, with one (“lower-risk”) subgroup defined by experiencing violence against women (VAW), another by the co-occurrence of VAW with problematic alcohol use (i.e. “mid-risk”), and the last (“high-risk”) subgroup by the co-occurrence of VAW, problematic alcohol use and sexual risk behaviour. Descriptive analyses showed that lower education and food insecurity were associated with greater health risk co-occurrence and that this in turn was associated with increased chances of depression and suicidal ideation. Between subgroup differences persisted over time - after two years, the chances of experiencing violence, problematic alcohol use, transactional sex and depression remained elevated for the women who initially experienced more health risks. Persistent yet differing levels of risk suggest the need for urgent structural interventions that address these health risks synergistically while taking account of individual differing primary and secondary prevention needs. Our analyses highlight that social epidemics such as poverty, racism and gender inequality play into the production of poor health outcomes, including poor mental health. These are the underlying structural issues that need to be addressed in order to protect women’s health and reduce harm.

The prevalence and clustering of alcohol consumption, gambling, smoking, and excess weight in an English adult population

BackgroundThe aim of this study was to examine the prevalence and clustering of four health risks (increasing−/higher-risk drinking, current smoking, overweight/obesity, and at-risk gambling), and to examine variation across sociodemographic groups in the English adult population. MethodsWe analysed data from the 2012, 2015, 2016, and 2018 Health Survey for England (n = 20,698). Prevalence odds ratios (POR) were calculated to examine the clustering of risks. We undertook a multinomial multilevel regression model to examine sociodemographic variation in the clustering of health risks. ResultsOverall, 23.8% of the adult English population had two or more co-occurring health risks. The most prevalent was increasing−/higher-risk drinking and overweight/obesity (17.2%). Alcohol consumption and smoking were strongly clustered, particularly higher-risk drinking and smoking (POR = 2.68; 95% CI = 2.31, 3.11; prevalence = 1.7%). Higher-risk drinking and at-risk gambling were also clustered (POR = 2.66; 95% CI = 1.76, 4.01), albeit with a very low prevalence (0.2%). Prevalence of multiple risks was higher among men for all risk combinations except smoking and obesity. The odds of multiple risks were highest for men and women aged 35–64 years. Unemployed men and women with lower educational qualifications had a higher odds of multiple risks. The relationship between deprivation and multiple risks depended on the definition of multiple risks, with the clearest socioeconomic gradients seen for the highest risk health behaviours. ConclusionAn understanding of the prevalence, clustering, and risk factors for multiple health risks can help inform effective prevention and treatment approaches and may support the design and use of multiple behaviour change interventions.

Patient motivation and preferences in changing co-occurring health risk behaviors in general hospital patients

ObjectivesMore than 60% of general hospital patients report ≥ 2 health risk behaviors (HRBs), i.e. tobacco smoking, at-risk alcohol use, unhealthy diet, and/or insufficient physical activity. This study investigates a) the association between numbers of HRBs and motivation to change, b) patient preferences for receiving feedback on HRBs, and c) patients’ expected gain in quality of life if behavior change made. MethodsIn 2020/2021, 256 18–64-year-old general hospital patients (72.1% of eligibles) reported on their motivation to change each of their HRBs. Associations between HRB number and motivation were assessed using multivariate linear regressions. Participants ranked HRBs concerning their interest in receiving feedback and concerning their expected gain in quality of life if behavior change occurred. ResultsHigher HRB number was negatively related to motivation among at-risk alcohol users (p = 0.034); 24.6% expected gain in their quality of life from behavior change. Participants overall appeared more favorable to feedback about vegetable/fruit intake and physical activity. ConclusionsUnhealthier lifestyle may be accompanied by decreased motivation to change in at-risk alcohol users. In case of co-occurring HRBs, asking patients for expected gain in quality of life may help guiding intervention target. Practice implicationsRelying on patient selection only, may often leave substance-use unaddressed.

Correction to Jackson et al. (2022).

Reports an error in "A pilot test of a treatment to address intersectional stigma, mental health, and HIV risk among gay and bisexual men of color" by Skyler D. Jackson, Krystn R. Wagner, Mike Yepes, Tyler D. Harvey, Jackson Higginbottom and John E. Pachankis (Psychotherapy, 2022[Mar], Vol 59[1], 96-112). In the article, text changes have been made to point (c) in the abstract and in the first and fifth paragraphs of the introduction, an em dash has been added in the block quote that appears in the Treatment Structure Was Deemed Appropriate and Supported Participation section, the year of publication has been updated to 2021 for the Braun and Clarke source, the coloration of the arrows for Exacerbating in Figure 1 has been corrected, and the supplemental materials have been revised. The online version of this article has been corrected. (The following abstract of the original article appeared in record 2022-19900-001.) We tested the feasibility and acceptability of a group therapy treatment that addresses the intersecting stigma-related stressors theorized to drive elevated mental health risk, sexual health risk, and their co-occurrence among Black and Latino gay, bisexual, and other men who have sex with men (GBM). First, we modified an existing 10-week, one-on-one, cognitive-behavioral treatment addressing co-occurring health risks among GBM to develop a group-based, intersectionally informed treatment for GBM of color. Then, an open pilot was conducted (n = 21, across two cohorts) with young Black and Latino GBM. An evaluation of feasibility metrics (e.g., eligibility-enrollment ratio, session attendance, rate of retention) supported overall treatment feasibility. Qualitative data suggest high acceptability of the treatment length, format, and content-and revealed a powerful theme: The treatment and group composition led participants to feel less alone as GBM of color. To further evaluate acceptability, baseline and 3-month posttreatment assessments and exit interviews were used to examine the treatment's impact on stigma coping, mental health, and sexual health. Expected changes were found for: (a) stigma coping, as demonstrated by decreases in perceived sexual minority stress, racial minority stress, and intersectional stress; (b) mental health, including depression, anxiety, stress, and suicidality, but not alcohol use; and (c) sexual health, including condom use efficacy, sexual compulsivity, and preexposure prophylaxis uptake; with partial support for decreased in human immunodeficiency virus; HIV-transmission risk acts. This study lays the groundwork for a group treatment to address intersectional stigma, mental health, and HIV risk among young Black and Latino GBM in the U.S. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A latent class analysis of health risk behaviours in the UK Police Service and their associations with mental health and job strain

BackgroundHealth risk behaviours (e.g., harmful drinking and smoking) often cluster together and can be associated with poor mental health and stress. This study examined how health risk behaviours cluster together in individuals in a high stress occupation (UK Police Service), and the associations with mental health and job strain.MethodsData was obtained from the Airwave Health Monitoring Study (25,234 male and 14,989 female police employees), which included measures of health risk behaviours (alcohol use, diet, smoking status, physical activity), poor mental health (depression, anxiety, post-traumatic stress disorder [PTSD]), and job strain (low, high, active, passive). Classes of health risk behaviours were identified using Latent Class Analysis (LCA) and the associations with mental health and job strain were analysed through multinomial logistic regressions.ResultsFor men and women, a 5-class solution was the best fit. Men and women with depression, anxiety, and/or PTSD (analysed as separate variables) had at least double the odds of being assigned to the “high health risk behaviours” class, compared to those with no mental health problem. Compared to those reporting low strain, men and women reporting high strain had increased odds of being assigned to the “low risk drinkers with other health risk behaviours” classes.ConclusionsThese finding highlight the importance of holistic interventions which target co-occurring health risk behaviours, to prevent more adverse physical health consequences. Police employees with poor mental health are more likely to engage in multiple health risk behaviours, which suggests they may need additional support. However, as the data was cross-sectional, the temporal associations between the classes and mental health or job strain could not be determined.

The Relationship of School Connectedness to Adolescents' Engagement in Co-Occurring Health Risks: A Meta-Analytic Review.

School connectedness is an important factor in the lives of youth and are a leverage point for optimizing youth's social, emotional, and physical health. This study presents a meta-analysis examining the relationship between school connectedness and four health domains that are prevalent in adolescence, have implications for adult health, and often co-occur: mental health, sexual health, violence, and high-risk substance use. Ninety articles published between 2009 and 2019 were included in the analysis. The study found that school connectedness had a protective average effect size across all health domains (Hedges' g = -0.345, p-value<0.001). When examined separately, school connectedness had a significant protective relationship with substance use (g = -0.379, p < 0.001), mental health (Hedges' g = -0.358, p < 0.001), violence (Hedges' g = -0.318, p < 0.001), sexual health (Hedges' g = -0.145, p < 0.001), and with co-occurring risks (Hedges' g = -0.331, p < 0.001). These results provide strong evidence that school connectedness has the potential to prevent and mitigate multiple health risks during adolescence.

Associations between Impulsivity and Exercise Addiction, Disordered Eating, and Alcohol Use Behaviors: A Latent Profile Analysis

BackgroundDespite the known negative consequences of exercise addiction and preliminary evidence suggesting that it may co-occur with other health risk behaviors, no studies to date have examined exercise addiction among college students in conjunction with disordered eating behaviors and alcohol use. The aim of this study was to describe which college students are most at-risk for co-occurring health risk behaviors to enhance the efficiency of health risk prevention efforts. Method: Guided by multidimensional theories of impulsivity and substance use models of comorbidity, this study used latent profile analysis to examine whether separate, conceptually meaningful profiles of risk for exercise addiction, disordered eating behaviors, and alcohol use would emerge among 503 college students from a large public university. Results: The best-fitting model supported three profiles. MANOVA results revealed significant profile differences based on exercise addiction, binge eating, purging, laxative/pill/diuretic use, exercising longer than 60 minutes, negative urgency, and problematic alcohol use. Profile 3 students (n = 29), labeled the Affect Driven Health Risk-Takers, demonstrated the highest levels of impulsivity (i.e., negative urgency, lack of premeditation, lack of perseverance, and sensation seeking) and the most risk behaviors compared to the other two profiles. Profile membership was associated with distinct levels of negative urgency, exercise addiction, disordered eating behaviors, and problematic alcohol use. A small proportion of undergraduates demonstrated co-occurring exercise addiction, disordered eating behaviors, and problematic alcohol use. Profile membership also predicted the health outcomes of clinically significant exercise addiction and hazardous alcohol use. Conclusions: Findings illuminated how patterns of risk behavior engagement were associated with clinically significant exercise addiction and hazardous alcohol use and will inform prevention efforts and clinical interventions with at-risk college students.

A pilot test of a treatment to address intersectional stigma, mental health, and HIV risk among gay and bisexual men of color.

We tested the feasibility and acceptability of a group therapy treatment that addresses the intersecting stigma-related stressors theorized to drive elevated mental health risk, sexual health risk, and their co-occurrence among Black and Latino gay, bisexual, and other men who have sex with men (GBM). First, we modified an existing 10-week, one-on-one, cognitive-behavioral treatment addressing co-occurring health risks among GBM to develop a group-based, intersectionally informed treatment for GBM of color. Then, an open pilot was conducted (n = 21, across two cohorts) with young Black and Latino GBM. An evaluation of feasibility metrics (e.g., eligibility-enrollment ratio, session attendance, rate of retention) supported overall treatment feasibility. Qualitative data suggest high acceptability of the treatment length, format, and content-and revealed a powerful theme: The treatment and group composition led participants to feel less alone as GBM of color. To further evaluate acceptability, baseline and 3-month posttreatment assessments and exit interviews were used to examine the treatment's impact on stigma coping, mental health, and sexual health. Expected changes were found for: (a) stigma coping, as demonstrated by decreases in perceived sexual minority stress, racial minority stress, and intersectional stress; (b) mental health, including depression, anxiety, stress, and suicidality, but not alcohol use; and (c) sexual health, including condom use efficacy, sexual compulsivity, and preexposure prophylaxis uptake; with partial support for decreased in human immunodeficiency virus; HIV-transmission risk acts. This study lays the groundwork for a group treatment to address intersectional stigma, mental health, and HIV risk among young Black and Latino GBM in the U.S. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Gender and Sexual Identities Predicting Patterns of Co-occurring Health Risks Among Sexual Minority Youth: a Latent Class Analysis Approach.

Behavioral health disparities (e.g., substance use, mental health) exist for gender nonconforming (GNC) and sexual minority youth; however, there is limited knowledge on disparities that may be unique among youth who identify as both a sexual and gender minority. This study utilized a diverse sample of GNC and cisgender sexual minority youth seeking crisis services to examine co-occurrence of behavioral health outcomes. Surveys were administered with youth (aged 12-24, N = 592), and latent class analyses were applied. Two latent class regression models were conducted to examine how gender and sexual identity separately (independent effect; Model 1) and configurations of gender and sexual identity (Model 2) predicted class membership. Analyses resulted in a four-class solution: High All (17.6%), High Substance Use and Moderate Mental Health (10.6%), Low All (20.1%), and High Suicide and High Mental Health (51.7%). In our first model, youth who identified as GNC had 2.11 higher odds of being in the High Suicide and High Mental Health class compared to the Low All class; however, sexual identity was not a significant predictor. In the second model, individuals identifying as GNC gay or lesbian or GNC pansexual had 1.95 and 2.57 higher odds, respectively, of being in the High Suicide and High Mental Health class compared to the Low All class. Our study suggests the information on gender and sexual identities together are more helpful in identifying youth at risk for co-occurring negative health outcomes. Implications for prevention approaches are described.

Co-Occurring Health Risk Behaviors and Their Association with Self-Rated Health among Female College Students

ABSTRACT Background Existing research focuses on the co-occurrence of lifestyle-related health risk behaviors among college students. Although students’ self-reported health risk behaviors have been examined, students’ self-rated health and its association with these co-occurring health risk behaviors have been overlooked. Purpose: The goals of the current study were to identify levels of co-occurrence of health risk behaviors among female college students and to test the prediction that students with multiple co-occurring health risk behaviors would report poorer self-rated health. Methods: Data from an online survey that assessed the five selected health risk behaviors and self-rated health of undergraduate students at a liberal arts university in the northeast of the USA were analyzed. Results: High prevalence rates were found on all five risk behaviors and the majority of participants reported engaging in two or more co-occurring health behaviors. The inverse association between perceived health and level of co-occurrence of health risk behaviors was consistent with what was predicted. Discussion: Students’ perceived health should be considered in the examination of health risk behaviors among college students. Translation to Health Education Practice: These findings can inform efforts to provide Health Education and prevention programming on college campuses that incorporates multiple health behaviors. A AJHE Self-Study quiz is online for this article via the SHAPE America Online Institute (SAOI) http://portal.shapeamerica.org/trn-Webinars

Project ESTEEM protocol: a randomized controlled trial of an LGBTQ-affirmative treatment for young adult sexual minority men\u2019s mental and sexual health

BackgroundYoung gay and bisexual men disproportionately experience depression, anxiety, and substance use problems and are among the highest risk group for HIV infection in the U.S. Diverse methods locate the source of these health disparities in young gay and bisexual men’s exposure to minority stress. In fact, minority stress, psychiatric morbidity, substance use, and HIV risk fuel each other, forming a synergistic threat to young gay and bisexual men’s health. Yet no known intervention addresses minority stress to improve mental health, substance use problems, or their joint impact on HIV risk in this population. This paper describes the design of a study to test the efficacy of such an intervention, called ESTEEM (Effective Skills to Empower Effective Men), a 10-session skills-building intervention designed to reduce young gay and bisexual men’s co-occurring health risks by addressing the underlying cognitive, affective, and behavioral pathways through which minority stress impairs health.MethodsThis study, funded by the National Institute of Mental Health, is a three-arm randomized controlled trial to examine (1) the efficacy of ESTEEM compared to community mental health treatment and HIV counseling and testing and (2) whether ESTEEM works through its hypothesized cognitive, affective, and behavioral minority stress processes. Our primary outcome, measured 8 months after baseline, is condomless anal sex in the absence of PrEP or known undetectable viral load of HIV+ primary partners. Secondary outcomes include depression, anxiety, substance use, sexual compulsivity, and PrEP uptake, also measured 8 months after baseline.DiscussionDelivering specific stand-alone treatments for specific mental, behavioral, and sexual health problems represents the current state of evidence-based practice. However, dissemination and implementation of this one treatment-one problem approach has not been ideal. A single intervention that reduces young gay and bisexual men’s depression, anxiety, substance use, and HIV risk by reducing the common minority stress pathways across these problems would represent an efficient, cost-effective alternative to currently isolated approaches, and holds great promise for reducing sexual orientation health disparities among young men.Trial registrationRegistered October 10, 2016 to ClinicalTrials.gov Identifier: NCT02929069.

Adelante Ambassadors: Using Digital Media to Facilitate Community Engagement and Risk-Prevention for Latino Youth

Digital and social media are now widely used to promote engagement in health programs and improve health behaviors across a variety of age groups and domains. However, limited research exists on applying culturally relevant, new media interventions specific to Latino immigrant youth. This paper describes the pilot Adelante Youth Ambassador program for Latino immigrant youth, which used digital media and community-based participatory research to build positive youth development (PYD) assets as a prevention mechanism to reduce co-occurring health risks of substance use, sexual risk, and interpersonal violence. We worked collaboratively with adolescents to create video content as a conduit for Adelante-branded messages to be disseminated on the program’s social media platforms. Using an active audience engagement methodology, youth participants informed the development of prevention messages, scripts for the videos, and acted in videos. Participants disseminated content to their social media networks and engaged peers in dialogue about topics addressed in the videos. Using pre and post tests, we evaluated changes in PYD assets (Civic Action Competence, Confidence, Connection to Community, and Connection to Peers) and skills related to digital media use, communication, and advocacy. The program used innovative branding and social media strategies to engage Latino youth in health risk prevention.

Electronic Nicotine Delivery Systems (E-cigarette/Vape) use and Co-Occurring Health-Risk Behaviors Among an Ethnically Diverse Sample of Young Adults

ABSTRACTBackground: Prevalence rates of electronic nicotine delivery systems (ENDS; i.e., e-cigarette/vape) use has grown exponentially in the past few years. College students present a particularly vulnerable group for ENDS use. The current study sought to expand the literature by examining the context in which college students use ENDS, co-occurring health risks beyond traditional tobacco use, and the role of ethnicity in ENDS use. Methods: Health-risk behavior survey data was collected from 452 undergraduates attending a large, public urban university during the 2015–2016 academic year. Ever ENDS users vs. non-ENDS users were compared across potential demographic, health-risk, and other health-related correlates. Results: Almost 40% of participants reported lifetime use of ENDS. No ethnic or sex differences were found. The primary source for obtaining ENDS was friends and ENDS were most often used with friends vs. alone or with others not considered friends. Participants engaging in risky alcohol use and cigarette smoking had a higher likelihood of endorsing ENDS use. Conclusions/Importance: The current study indicated that a large proportion of college students have tried ENDS irrespective of ethnicity or sex. An increasingly normative social context may inform the popularity of ENDS use across ethnicity and sex, but additional research using ethnically diverse samples is warranted. Risky alcohol use appears to be a significant correlate of ENDS use, even after accounting for the robust relationship between ENDS use and cigarette smoking. The robust relationship between alcohol and tobacco use likely extends to ENDS use.

Depression, Self-Esteem, and Childhood Abuse Among Hispanic Men Residing in the U.S.–Mexico Border Region

Hispanics experience health disparities in mental health and HIV infection when compared to non-Hispanic Whites, which may be related to childhood abuse. The purpose of our cross-sectional study was to examine the relationship between childhood abuse and depressive symptoms in a sample of Hispanic men (N=103) living in a metropolitan U.S.-Mexico border area. Secondarily, we examined the role of self-esteem in mediating this relationship, and the moderating role of sexual orientation. Gay/bisexual men (n=53) were more likely to report childhood abuse than heterosexual (n=50) counterparts (47.2% vs. 32%). Self-esteem mediated the relationship between childhood abuse and depression for men who have sex with men, but not heterosexual men. Nurses should increase knowledge of mental health disparities that impact Hispanic men to ensure that appropriate treatment can be provided to reduce the risk of co-occurring health risks to these men, including risk for HIV infection.

LGB-affirmative cognitive-behavioral therapy for young adult gay and bisexual men: A randomized controlled trial of a transdiagnostic minority stress approach.

We tested the preliminary efficacy of a transdiagnostic cognitive-behavioral treatment adapted to improve depression, anxiety, and co-occurring health risks (i.e., alcohol use, sexual compulsivity, condomless sex) among young adult gay and bisexual men. Treatment adaptations focused on reducing minority stress processes that underlie sexual orientation-related mental health disparities. Young gay and bisexual men (n = 63; M age = 25.94) were randomized to immediate treatment or a 3-month waitlist. At baseline, 3-month, and 6-month assessments, participants completed self-reports of mental health and minority stress and an interview of past-90-day risk behavior. Compared to waitlist, treatment significantly reduced depressive symptoms (b = -2.43, 95% CI: -4.90, 0.35, p < .001), alcohol use problems (b = -3.79, 95% CI: -5.94, -1.64, p < .001), sexual compulsivity (b = -5.09, 95% CI: -8.78, -1.40, p < .001), and past-90-day condomless sex with casual partners (b = -1.09, 95% CI: -1.80, -0.37, p < .001), and improved condom use self-efficacy (b = 10.08, 95% CI: 3.86, 16.30, p < .001). The treatment yielded moderate and marginally significant greater improvements than waitlist in anxiety symptoms (b = -2.14, 95% CI: -4.61, 0.34, p = .09) and past-90-day heavy drinking (b = -0.32, 95% CI: -0.71, 0.07, p = .09). Effects were generally maintained at follow-up. Minority stress processes showed small improvements in the expected direction. This study demonstrated preliminary support for the first intervention adapted to address gay and bisexual men's co-occurring health problems at their source in minority stress. If found to be efficacious compared to standard evidence-based treatments, the treatment will possess substantial potential for helping clinicians translate LGB-affirmative treatment guidelines into evidence-based practice. (PsycINFO Database Record

Does the return to work have a negative impact on the lifestyle of cardiovascular patients? Comments on the ICAROS results

Dear Editor,Although cardiovascular disease (CVD) is most prevalent in theelderly, it often affects patients in their productive years prior toretirement age (65–70 years) [1]. In this case, almost always,medical and rehabilitative support has the objective to promotethe return to work (RTW) [2]. Previous studies have focused onvariables that can affect a more rapid and satisfactory RTW, andthese studies concluded that the RTW after CVD is a complex andmultidimensional process that is more influenced by psychosocialfactors (e.g., depression, work strain, job satisfaction, and workplacejustice) than by the patient's clinical status (e.g., left ventricularejection fraction) [3,4]. The RTW after a cardiovascular event is noteasy [5], and observational studies have reported that workers withCVD show increased rates of absenteeism and disability periodscompared with workers without CVD [6]. There is an abundance ofscientific literature demonstrating that lifestyle interventions inpatients with CAD can reduce the risk of new events, improve thesurvival and the quality of life [7,8]. Nevertheless, the influence ofwork on healthy lifestyle is relatively unknown and adverse jobconditions, characterized by high job strain, might increase thelikelihood of co-occurring health risk behaviors [9].Wethusanalyzed the data collected with the Italian survey on CardiacRehabilitation and Secondary prevention after cardiac revascular-ization (ICAROS) to verify patient adherence to a healthy lifestyle.ICAROS has already been described elsewhere [8,10].Inbrief,itisaprospective, longitudinal, multicenter registry with on-line datacollection that evaluates the achievement and maintenance ofrecommended lifestyle targets and risk control after completing acomprehensive inpatient or outpatient cardiac rehabilitation pro-gram aftercardiac revascularization. The lifestyle data collectionwasperformed by trained investigators at discharge from the CardiacRehabilitation program, as well as 6 months and 1 year later, using abrief questionnaire that analyzed smoking habits (smoking vs. nosmoking), diet (the consumption frequency of vegetables, fruit, fish,olive oil and cheese/butter was evaluated to obtain a Mediterraneandiet score, which was then categorized into good or bad diet), andphysical activity (never/rarely vs. ≥30 min/session of moderateintensity exercise per 3 times/week) [8,10]. The ethical committeefor each center approved the protocol, and informed consent wasobtained from each patient. To obtain a balanced sample for thisresearch,accordingtothecurrentincreasein meanretirementageinItaly, we extracted only working age patients (b70) from the ICAROSdatabase, and we divided them into two groups: workers and non-workers before CVD. Using these categories, we selected 789 of 1272patients; demographic and lifestyle profiles of the study populationsare reported in Table 1.Inoursample,thenumberofworkingpeopledecreasedovertime.Atthe moment of the index event workers were 51.5% of the studypopulation:6and12 monthsaftertheendofthesupervisedCRprogrampatient with a profitable work were 47 and 38.9%, respectively. Thus,9.6% of those that were working before CVD did not return to work6 months after discharge, and 17.3% of those that returned to work lefttheir jobs within the first 12 months after discharge.We performed 3 logistic regressions to assess the influence ofwork on smoking behavior, dietary habits and physical activity,controlling for the effects of time after discharge, other lifestylehabits, intervention type, age and sex (Table 2 ).The logistic regressionused to predict smoking behavior revealedthat the odds for smoking was 1.84 (95% CI = 1.13–2.99) timesgreater for workers compared with non-workers. Nevertheless, sex(male odds ratio (OR) = 2.75; 95% CI = 1.25–6.03) and, weakly, age(OR = 0.97; 95% CI = 0.94–0.99) also affected smoking behavior.The return to work did not have an effect on dietary habits andphysical activity. However, our data suggested that these lifestylebehaviors were linked. Indeed, bad dietary habits increased theprobability of smoking (OR = 1.81; 95% CI = 1.23–2.66), smokingbehavior decreased the probability of adopting a healthy diet(OR = 0.62; 95% CI = 0.39–1.00) and adopting a healthy dietincreased the probability of being physically active (≥3times/week), with an odds ratio of 1.98 (95% CI = 1.56–2.40).Our data highlighted three important aspects related to thereturn to work and lifestyle modification that, to the best of ourknowledge, were previously unexplored. First, a considerable groupof CVD patients returned to work but then, within the first yeardecided to retire; second, patients that returned to work had anincreased risk of not quitting. Finally patients with a defectivecontrol of one lifestyle risk factors are at higher risk for adoption ofan additional unhealthy lifestyle. Because the return to work for CVDpatients is psychologically stressful [4,6], it might be postulated thatsome patients decide to retire and that other patients resumesmoking after the RTW as a result of maladaptive coping strategies.In conclusion, this ancillary analysis of ICAROS highlights theimportance of considering in patients with CAD not only the RTWbut also their level of functioning once they are back at work [10].Inparticular, one question raised here is whether it is possible tobalance work life with a healthy lifestyle or if the RTW leads tosmoking and other unhealthy behaviors. From this perspective, wethink that our data open an interesting field of research and a newrole for cardiac rehabilitation.

Health-Related Outcomes Associated with Patterns of Risk Factors in Primary Care Patients

It is important to find ways to identify prevalent co-occurring health risk factors to help facilitate treatment programming. One method is to use electronic medical record (EMR) data. Funderburk et al. (J Behav Med 31:525-535, 2008) used such data and latent class analysis to identify three classes of individuals based on standard health screens administered in Veterans Affairs primary care clinics. The present study extended these results by examining the health-related outcomes for each of these identified classes. Follow-up data were collected from a subgroup of the original sample (N=4,132). Analyses showed that class assignment predicted number of diagnoses associated with the diseases that the health screens target and number of primary care behavioral health, and emergency room encounters. The findings illustrate one way an EMR can be used to identify clusters of individuals presenting with multiple health risk factors and where the healthcare system comes in contact with them.

School Difficulties and Co‐Occurring Health Risk Factors: Substance Use, Aggression, Depression, and Suicidal Behaviors

Effective prevention requires understanding vulnerable populations, early signs of health risks, and the impact of social contexts. We tested a model of co-occurring mental health risks among at-risk youth experiencing school difficulties. We analyzed data from a random sample of 336 at-risk youth, grades 9-12, who completed a comprehensive risk/protective factors assessment. Simultaneously controlling for correlations among health risks, we observed systematic associations among risk factors, with generally consistent patterns for males and females. The findings underscore the importance of developing interventions that incorporate contextual influences and of identifying common adaptable strategies for attenuating co-occurring health risks for at-risk youth.

The relation between adolescent self assessment of health and risk behaviours

Objective: Self-rated health (SRH) has become a key organizing construct for assessing multiple dimensions of populations’ physical and psychosocial health functioning. However, it is unclear how adolescents’ subjective self assessment of health reflects health risk exposures, co-occurring health risks (problem behaviours) and other pre-existing health conditions. It is unknown whether adolescents place more emphasis on mental or physical health functioning in determining overall health. Methods: We evaluated the association between SRH and a set of behavioural and other psychosocial health risks including pre-existing medical conditions using Colorado Youth Risk Behavioural Survey (2005). We analyzed the data using descriptive statistics and logistic regression models. Results: Adolescents with behavioural problems were at increased risk of poor health, and in particular females were at a higher risk of poor health compared with boys. However, in sub-group analyses boys with risks of sexual abuses were more likely to report worse health. Current smoking status, perception of body image as overweight and suicidal attempts were the most consistent predictors of poor health among this sampled population. Conclusions: SRH could be an indicator of health risk in situations where other biomedical information about an adolescent is unavailable. It appears that mental health functioning might be one of the most important factors used to determine the overall health in this population of adolescents. The role of parents and other adult mentors might be crucial in assisting adolescents to make appropriate choices regarding underlying health risks related to overall health functioning.