RESUMO
OBJECTIVE: To estimate racial and ethnic disparities in type 2 diabetes mellitus after gestational diabetes mellitus (GDM) and to investigate baseline pregnancy clinical and social or structural characteristics as mediators. METHODS: We conducted a retrospective cohort of individuals with GDM using linked 2009-2011 New York City birth and hospital data and 2009-2017 New York City A1c Registry data. We ascertained GDM and pregnancy characteristics from birth and hospital records. We classified type 2 diabetes as two hemoglobin A 1c test results of 6.5% or higher. We grouped pregnancy characteristics into clinical (body mass index [BMI], chronic hypertension, gestational hypertension, preeclampsia, preterm delivery, caesarean, breastfeeding, macrosomia, shoulder dystocia) and social or structural (education, Medicaid insurance, prenatal care, and WIC [Special Supplemental Nutrition Program for Women, Infants, and Children] participation). We used Cox proportional hazards models to estimate associations between race and ethnicity and 8-year type 2 diabetes incidence, and we tested mediation of pregnancy characteristics, additionally adjusting for age and nativity (U.S.-born vs foreign-born). RESULTS: The analytic data set included 22,338 patients with GDM. The 8-year type 2 diabetes incidence was 11.7% overall and 18.5% in Black, 16.8% in South and Southeast Asian, 14.6% in Hispanic, 5.5% in East and Central Asian, and 5.4% in White individuals with adjusted hazard ratios of 4.0 (95% CI 2.4-3.9), 2.9 (95% CI 2.4-3.3), 3.3 (95% CI 2.7-4.2), and 1.0 (95% CI 0.9-1.4) for each group compared with White individuals. Clinical and social or structural pregnancy characteristics explained 9.3% and 23.8% of Black, 31.2% and 24.7% of Hispanic, and 7.6% and 16.3% of South and Southeast Asian compared with White disparities. Associations between education, Medicaid insurance, WIC participation, and BMI and type 2 diabetes incidence were more pronounced among White than Black, Hispanic, and South and Southeast Asian individuals. CONCLUSION: Population-based racial and ethnic inequities are substantial in type 2 diabetes after GDM. Characteristics at the time of delivery partially explain disparities, creating an opportunity to intervene on life-course cardiometabolic inequities, whereas weak associations of common social or structural measures and BMI in Black, Hispanic and South and Southeast Asian individuals demonstrate the need for greater understanding of how structural racism influences postpartum cardiometabolic risk in these groups.
Assuntos
Diabetes Mellitus Tipo 2 , Diabetes Gestacional , Hipertensão Induzida pela Gravidez , Gravidez , Criança , Lactente , Estados Unidos , Recém-Nascido , Humanos , Feminino , Diabetes Gestacional/epidemiologia , Diabetes Mellitus Tipo 2/epidemiologia , Diabetes Mellitus Tipo 2/etiologia , Estudos Retrospectivos , Macrossomia FetalRESUMO
BACKGROUND: The majority of births in Mexico take place in a health facility and are attended by a skilled birth attendant, yet maternal mortality has not declined to anticipated levels. Coverage estimates of skilled attendance and other maternal and newborn interventions often rely on women's self-report through a population-based survey, the accuracy of which is not well established. METHODS: We used a facility-based design to validate women's report of skilled birth attendance, as well as other key elements of maternal, newborn intrapartum, and immediate postnatal care. Women's reports of labor and delivery care were collected by exit interview prior to hospital discharge and were compared against direct observation by a trained third party in a Mexican public hospital (n = 597). For each indicator, validity was assessed at the individual level using the area under the receiver operating curve (AUC) and at the population level using the inflation factor (IF). RESULTS: Five of 47 indicators met both validation criteria (AUC > 0.60 and 0.75 < IF < 1.25): urine sample screen, injection or IV medication received during labor, before the birth of the baby (i.e., uterotonic for either induction or augmentation of labor), episiotomy, excessive bleeding, and receipt of blood products. An additional 9 indicators met criteria for the AUC and 18 met criteria for the IF. A skilled attendant indicator had high sensitivity (90.1 %: 95 % CI: 87.1-92.5 %), low specificity (14.0 %: 95 % CI: 5.8-26.7 %) and was suitable for population-level estimation only. CONCLUSION: Women are able to give valid reports on some aspects of the content of care, although questions regarding the indication for interventions are less likely to be known. Questions that include technical terms or refer to specific time periods tended to have lower response levels. A key aspect of efforts to improve maternal and newborn health requires valid measurement of women's access to maternal and newborn health interventions and the quality of such services. Additional work on improving measurement of population coverage indicators is warranted.
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Hospitais Públicos/normas , Serviços de Saúde Materno-Infantil/normas , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Adolescente , Adulto , Área Sob a Curva , Feminino , Humanos , Recém-Nascido , México , Gravidez , Adulto JovemRESUMO
Migration and population movement are increasingly viewed as important factors associated with HIV transmission risk. With growing awareness of the potential impact of migration on HIV transmission, several perspectives have emerged that posit differing dynamics of risk. We considered available data on the role of migration on HIV transmission among Mexican migrants in New York City and Puebla, Mexico. Specifically, we examined 3 distinct models of migratory dynamics of HIV transmission-namely, the structural model, the local contextual model, and the interplay model. In doing so, we reframed current public health perspectives on the role of migration on HIV transmission.
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Infecções por HIV/transmissão , Migrantes/estatística & dados numéricos , Feminino , Humanos , Masculino , México/epidemiologia , México/etnologia , Modelos Teóricos , Cidade de Nova Iorque/epidemiologia , Fatores de Risco , Comportamento Sexual/etnologia , Comportamento Sexual/estatística & dados numéricosRESUMO
BACKGROUND: Tourism areas represent ecologies of heightened HIV vulnerability characterized by a disproportionate concentration of alcohol venues. Limited research has explored how alcohol venues facilitate HIV transmission. METHODS: We spatially mapped locations of alcohol venues in a Dominican tourism town and conducted a venue-based survey of key informants (n=135) focused on three facets of alcohol venues: structural features, type of patrons, and HIV risk behaviors. Using latent class analysis, we identified evidence-based typologies of alcohol venues for each of the three facets. Focused contrasts identified the co-occurrence of classes of structural features, classes of types of patrons, and classes of HIV risk behavior, thus elaborating the nature of high risk venues. RESULTS: We identified three categories of venue structural features, three for venue patrons, and five for HIV risk behaviors. Analysis revealed that alcohol venues with the greatest structural risks (e.g. sex work on-site with lack of HIV prevention services) were most likely frequented by the venue patron category characterized by high population-mixing between locals and foreign tourists, who were in turn most likely to engage in the riskiest behaviors. CONCLUSION: Our results highlight the stratification of venue patrons into groups who engage in behaviors of varying risk in structural settings that vary in risk. The convergence of high-risk patron groups in alcohol venues with the greatest structural risk suggests these locations have potential for HIV transmission. Policymakers and prevention scientists can use these methods and data to target HIV prevention resources to identified priority areas.
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Consumo de Bebidas Alcoólicas/epidemiologia , Infecções por HIV/transmissão , Viagem/classificação , Adulto , Bebidas Alcoólicas/estatística & dados numéricos , Região do Caribe/epidemiologia , Análise por Conglomerados , Preservativos , Interpretação Estatística de Dados , República Dominicana/epidemiologia , Feminino , Infecções por HIV/epidemiologia , Homossexualidade Masculina/estatística & dados numéricos , Humanos , Masculino , Assunção de Riscos , Trabalho Sexual/estatística & dados numéricos , Profissionais do Sexo/estatística & dados numéricos , Transexualidade , Viagem/estatística & dados numéricosRESUMO
Existing literature related to HIV in the Dominican Republic has tended to neglect the unique role of tourism areas as distinct ecologies facilitative of sexual risk behavior, particularly HIV vulnerability and transmission. Furthermore, limited attention has focused on Dominican adolescents living in close proximity to tourism areas who have become increasingly exposed to alcohol due to the expanding tourism industry in the Dominican Republic. While most previous analyses of the effects of alcohol on adolescent sexual risk behavior have focused on the transient effects of alcohol on judgment and decision making, the effects of chronic alcohol use on sexual behavior has been a neglected area of research. Our study explores the relationship between chronic alcohol use, the parent-adolescent relationship, affective factors such as self-esteem, and intentions to engage in sex. We examine the above factors within the context of tourism areas which represent a unique ecology of alcohol availability and consumption and HIV risk. We discuss implications for developing applied family-based programs to target Dominican adolescent alcohol use and sexual risk behavior in tourism areas of high alcohol exposure.