Indiana University

IU researchers discuss cervical cancer screenings, opioid abuse, food deserts, condom-use kits and STIs at APHA

  • Nov. 6, 2013

FOR IMMEDIATE RELEASE

Indiana University researchers, including graduate students and faculty members of the IU School of Public Health-Bloomington and the Richard M. Fairbanks School of Public Health at Indiana University-Purdue University Indianapolis, are participating in the 141st American Public Health Association annual meeting this week in Boston.  

Here is a sampling of their studies:

Leadership void, not lack of money, slows efforts to address cervical cancer
Higher rates of diabetes, hypertension, heart disease and stroke found in food desert
Access to health care increases prescription opioid availability, associated abuse
Ditty bag of condoms, home-use instructions lead to improved comfort and consistency with condom use
Conversations between lovers about STIs are important in theory but difficult in bed 
Considerable gender, racial and sexuality differences exist in attitudes toward bisexuality

Leadership void, not lack of money, slows efforts to address cervical cancer
Beth Meyerson

Beth Meyerson

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A study by Indiana University public health researchers found that the opportunity for significant progress in addressing cervical cancer across the country is being squandered -- not because of a lack of money, but because of a void of leadership and organization at the state levels.

"We focus on cervical cancer because it is likely the 'low-hanging fruit' opportunity to beat a cancer in this generation," said Beth Meyerson, a health policy expert at the IU School of Public Health-Bloomington. "We have the tools of HPV vaccination, screening and treatment; but uninsured women and women of color experience huge health disparities. This is the signal that we have a health system problem."

Meyerson and her research colleagues conducted interviews with 15 professionals working in programs involving cervical cancer. These included federal and state government breast and cervical cancer programs; women's health and cancer control; national advocacy organizations engaged in sexual health and cancer; legislative affairs; researchers working in cervical cancer intervention and evaluation; state coalitions engaged in cervical cancer efforts; and partners from industry working on diagnostics, therapeutics or vaccines.

The researchers identified numerous obstacles, including "paucity of state-level coordination exacerbated by a lack of cervical cancer inter-agency/program influence" that prevented comprehensive, streamlined systems of care.

A possible solution would establish state-level coordinated efforts across agencies, as done in Kentucky. Those involved would meet to set strategic goals that would align policies and programs. This would include agencies such as the state departments of health and state Medicaid programs. Addressing this likely would cost very little, Meyerson said, but the benefits would be substantial.

"The challenge is to help separately funded programs work together -- a very tall charge and one that public health administration grapples with perennially," she said.

Meyerson, assistant professor in the Department of Applied Health Science and co-director of the Rural Center for AIDS/STD Prevention, discussed "Identifying and exploring state policy issues in cervical cancer" during an oral poster session focused on women’s health Nov. 3.

Co-authors are Carrie Lawrence, IU School of Public Health-Bloomington; and Jennifer S. Smith, University of North Carolina.

Meyerson can be reached at 812-855-0585 or bmeyerson@indiana.edu. For additional assistance, contact Tracy James at 812-855-0084 or traljame@iu.edu. Top

Higher rates of diabetes, hypertension, heart disease and stroke found in food desert
Cynthia Stone

Cynthia Stone

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There is more to the cost of living in a food desert than higher prices for the few fruits and vegetables sold nearby, according to a study by an Indiana University-Purdue University Indianapolis researcher and the Marion County Public Health Department.

The study, discussed Nov. 5, examined the health impact of developing a grocery store in a low-income urban neighborhood on the east side of Indianapolis. Researchers found that residents of the community have much higher rates of diabetes, hypertension, heart disease and stroke than in other areas of Marion County.

“We looked at those particular diagnoses because they are ones that are influenced by eating a healthy diet and being more physically active,” said Cynthia Stone, clinical associate professor in the Richard M. Fairbanks School of Public Health at IUPUI. Stone led the research project.

The neighborhood, which has no full-service grocery store, is on the east side of the Indiana State Fairgrounds, bounded by 38th and 42nd Streets and Fall Creek Parkway and Sherman Drive. The nearest grocery stores are two to five miles away, falling within the U.S. Department of Agriculture’s federal designation of a food desert, Stone said. The federal agency defines a food desert as a census tract with a substantial share of residents who live in low-income areas that have low levels of access to a grocery store or healthy, affordable food retail outlet.

The USDA’s Economic Research Service estimates that 23.5 million people in the U.S. live in food deserts in urban neighborhoods and rural towns without ready access to fresh, healthy and affordable food. This lack of access contributes to a poor diet and can lead to higher levels of obesity and other diet-related illness, such as diabetes and heart disease. In the eastside neighborhood, many residents depend upon public transportation. Traveling to the closest grocery stores takes 30 to 45 minutes each way. Some residents had cars or were able to arrange for a ride in a car to the grocery store.

Stone said interviews were conducted with neighborhood association members and officials, as well as representatives of other agencies working in the community. Residents were given a written survey with questions about food shopping, including a question that asked how their food purchases might change if their community had a grocery store.

Researchers gathered data on the current health of the community, looking at hospital and emergency room data, Stone said. The study also found that the residents have a higher hospitalization rate and more frequent visits to the emergency room, compared to other county residents.

The community has 11 convenience stores. Ten of the stores allowed researchers to come inside and look at the kinds of foods they provided, Stone said. One of the stores sold fresh fruits and vegetables, while another one had a basket with a few apples and oranges, Stone said. Selections of healthier foods were limited, and what was available was more expensive than at a grocery store.

The survey showed neighborhood residents would be very supportive of a grocery store in their neighborhood and would change what foods they purchased if a grocery store were located nearby, Stone said. Residents also indicted a need not only for a grocery store but for nutritional education about healthy food, particularly for men who tended to purchase fewer healthy foods than women.

To speak with Stone, contact Rich Schneider at 317-278-4564 or scschnei@iu.edu. Top

Access to health care increases prescription opioid availability, associated abuse

Researchers at Indiana University-Purdue University Indianapolis say one way to gauge the extent of prescription opioid pain reliever abuse in any Indiana county is to count the number of health care providers, particularly dentists and pharmacists.

In a study of opioid use and abuse, the researchers said they found that access to health care increases the availability of prescription opioids, which, in turn, is associated with higher rates of opioid abuse and associated consequences.

The study concludes the structure of local health care systems at the county level is a major determinant of community-level access to opioids.

"Our study clearly underscores that the broader problem of prescription opioid abuse in Indiana is, in part, an 'iatrogenic epidemic,' or an unintended and unfortunate byproduct of the evolution of our health care system, medical science and the growth of the pharmaceutical industry," said Eric Wright, who led the study. Wright is a professor and chair of the Department of Health Policy and Management in the Richard M. Fairbanks School of Public Health at IUPUI. He also is director of the Center for Health Policy at IUPUI.

Prescription opioid abuse is a public health problem in the United States, with the number of prescriptions for opioid pain relievers dispensed in the U.S. climbing dramatically over the past decade. The Food and Drug Administration estimates retail pharmacies filled about 174.1 million prescriptions for immediate- and extended-release opioid pain relievers in 2002. By 2009, this number had risen to 256.9 million.

In Indiana, counties with higher rates of dentists and pharmacists had more per-capita opioid prescriptions. Prior research has shown that dentists are a significant source of opioid prescriptions, which are dispensed by pharmacists, along with prescriptions from other health care providers.

The study focuses on counties within Indiana because of the unique availability of detailed dispensation data from Indiana's prescription drug monitoring program.

The most widely prescribed opioid is hydrocodone (Vicodin), accounting for 68.93 percent of all opioid prescriptions, followed by oxycodone at 11.74 percent, codeine-containing products at 8.52 percent and fentanyl at 2.62 percent.

Prior research has shown that most abusers report they obtained prescriptions on their own or from friends and relatives who had been prescribed opioids.

The researchers cautioned against temptations to use countywide data to generalize results and "blame" individual providers and inappropriate prescribing practices.

"We must be cautious and work with public health and health care leaders to avoid 'overcorrecting,' unnecessarily restricting the supply of opioids, or inadvertently vilifying or punishing providers who are struggling to meet patients' legitimate clinical needs," Wright said.

Nevertheless, the study points to the importance of working with healthcare provider groups to help them dispense needed medication in ways that meet needs while avoiding potential diversion or misuse, Wright said. The findings were discussed Nov. 5.

To speak with Wright, contact Rich Schneider at 317-278-4564 or scschnei@iu.eduTop

Ditty bag of condoms, home-use instructions lead to improved comfort and consistency with condom use
Roberta Emetu

Roberta Emetu

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A new and successful strategy for combating the spread of sexually transmitted diseases such as HIV draws from an old idea: Practice is fundamental to learning, even when it involves using condoms correctly.

The Kinsey Institute Homework Intervention Strategy gives men a "ditty bag" full of condoms and lubricants, makes sure the men understand how to apply condoms correctly, and then assigns homework. The men are expected to try out at least six condoms solo, paying particular attention to their own pleasure and which condoms they like best.

"It's such a simple idea, but nobody has every structured an approach like this," said William L. Yarber, professor in the Indiana University School of Public-Health-Bloomington. Yarber is co-author of the study, "A novel, self-guided, home-based intervention to improve condom use among young men who have sex with men," which were discussed Nov. 6. "These are pilot studies. But even with small samples, the results are really good. Men become more motivated to use condoms; they use them more correctly and consistently. They also appreciate learning that there are different condoms available."

The first pilot study, published in the Journal of Men’s Health in 2011, focused on heterosexual men. The APHA study, which will be published in the Journal of American College Health, focuses on young men who have sex with men, or MSM. This is an important group of men to reach, said Roberta Emetu, who coordinated the research project. MSM ages 18 to 29 are disproportionately diagnosed with HIV, according to the Centers for Disease Control and Prevention.

"The men who experienced this intervention became better in their condom use," said Emetu, a doctoral student at the IU School of Public Health-Bloomington. "They not only used them more often but used them correctly. We saw an increase in motivation to use them."

Yarber and his colleague Stephanie A. Sanders, along with the rest of the Kinsey Institute Condom Use Research Team have documented for more than 10 years how merely wearing a condom is not enough to provide effective protection against STDs and unwanted pregnancies. Condoms need to be used correctly, yet fit-and-feel issues can result in erection difficulty, loss of sensation, removal of condoms before the intercourse episode ends, and other problems that can interfere with their correct use.

"This homework strategy combines common sense, in that practice is important; the science of how the fit and feel of condoms may affect sexual arousal, and advances in technology -- the new shapes, sizes and textures of condoms coming into the marketplace," said Sanders, associate director of The Kinsey Institute.

Not all condoms fit the same, and the use of lubricant also can be helpful.

"Most men do not experiment with different kinds of condoms," Yarber said. "They get what's available or what the other guys talk about. The kits for this study included eight different kinds of condoms and five kinds of lubricant."

Emetu discussed the findings Nov. 6. Co-authors include Yarber, senior director of the Rural Center for AIDS/STD Prevention, professor at the IU School of Public Health-Bloomington and senior research fellow at The Kinsey Institute; Alex Marshall, Department of Health Sciences, University of Central Arkansas; Sanders, professor in the Department of Gender Studies in the College of Arts and Sciences at IU Bloomington; Richard A. Crosby, College of Public Health, University of Kentucky; Cynthia A. Graham, Department of Psychology, Brunel University, England; and Robin R. Milhausen, Department of Family Relations and Applied Nutrition, University of Guelph, Canada.

The research was supported by The Kinsey Institute and the Rural Center for AIDS/STD Prevention at Indiana University. No federal funding was involved.

Yarber can be reached at 812-855-7974 or yarber@indiana.edu. For additional assistance, contact Tracy James at 812-855-0084 or traljame@iu.edu. Top

Conversations between lovers about STIs are important in theory but difficult in bed
Margo Mullinax

Margo Mullinax

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Having sex can be fun; and talking about sex can be fun. Talking about sexually transmitted infections with a sexual interest, however, is a totally different matter, according to new research from Indiana University's Center for Sexual Health Promotion.

The study found a disconnect between the public health messages that promote STI testing as a way to prevent STIs such as HIV and chlamydia and the conversations -- or lack of them -- occurring in bedrooms.

"Talking to partners about STIs is an important conversation to have," said Margo Mullinax, lead researcher for "Talk about testing: What sexual partners discuss in relation to STI status and why." "However, findings from this study suggest public health campaigns need to promote specific messages, concrete tips and tools around sexual health conversations stratified by relationship status. Campaigns should also address STI stigma and promote messages of normalcy with regard to talking about STIs."

STIs, if untreated, can lead to a range of health problems including infertility, so a growing public health emphasis has been on preventing STIs through testing. Mullinax said little was known, however, about how STI testing figured into actual conversations between lovers, particularly among the college-age crowd that accounts for a disproportionate number of new STI cases nationwide.

She recruited 181 sexually active men and women, average age 26, to take an anonymous online questionnaire that probed the issue, looking for insights into how conversations about STIs might influence behavior and decision-making.

She described the sample as highly educated, with many participants who commented on their own work in sexual health education. More than half were in monogamous relationships. Most of the participants were white and identified themselves as heterosexual or straight.

Mullinax said she was surprised to learn that about the same percentage of study participants engaged in sex without a condom regardless of whether they talked about STIs with their partners.

"Participants who reported talking to their partners about STIs say it affected their decision to engage in certain behaviors in that it made them feel more comfortable and led them to stop using condoms," she said. "But this finding concerns me given that many participants did not also report routinely getting tested nor having detailed conversations with partners about STIs."

Here are some of the other findings:

  • Many participants reported that they occasionally, rarely or never got tested before having sex with partners who were casual (50.3 percent) or long-term (38.7 percent).
  • Of the people who did discuss STI testing, very few discussed concurrent sexual partners or when partners' testing occurred in relation to their last sex act, and only half clarified what types of STIs their partner had been tested for. These issues are important components of assessing STI risk.
  • About a third of participants said they told a partner they didn't have an STI even though they hadn't been tested since their last sexual partner.

Mullinax said just a little more than half of study participants reported feeling "very comfortable" talking to partners about how to prevent STIs. Less than half felt "very comfortable" talking with a partner about sexual histories. Comfort levels improved -- and conversations became easier -- when people felt better informed about STIs and had practice talking about STIs with partners

"Take time to get informed," she said. "It will only make your conversation more comfortable and ensure that you are really protecting your health."

Mullinax discussed her study Nov. 6. The co-author is Michael Reece, co-director of the Center for Sexual Health Promotion at IU Bloomington and associate dean of the IU School of Public Health-Bloomington.

Mullinax can be reached at marbmull@indiana.edu. For additional assistance, contact Tracy James at 812-855-0084 or traljame@iu.edu. Top

Considerable gender, racial and sexuality differences exist in attitudes toward bisexuality

Men who identify themselves as heterosexual are three times more likely to categorize bisexuality as "not a legitimate sexual orientation," an attitude that can encourage negative health outcomes in people who identify as bisexual, according to a study by researchers at the University of Pittsburgh Graduate School of Public Health and the Indiana University School of Public Health-Bloomington.

"Bisexual men and women face prejudice, stigma and discrimination from both heterosexual and homosexual people," said Mackey Friedman, director of Project Silk, an HIV prevention initiative. Friedman is a researcher at the University of Pittsburgh Graduate School of Public Health and led the analysis for the study. "This can cause feelings of isolation and marginalization, which prior research has shown leads to higher substance use, depression and risky sexual behavior. It also can result in lower rates of HIV testing and treatment."

The results of the survey, sponsored by the Center for Sexual Health Promotion at the IU School of Public Health-Bloomington and the National Institutes of Health, were discussed Tuesday. Additional collaborators are Brian Dodge, Vanessa Schick, Gabriel Goncalves, Debby Herbenick, Randolph D. Hubach and Michael Reece, all of the Center for Sexual Health Promotion. 

"The results from these analyses confirm what we have long suspected, that bisexual men and women experience unique and significant psychosocial stressors in comparison to our exclusively heterosexual and homosexual counterparts," said Dodge, principal investigator and associate director of the Center for Sexual Health Promotion. "Our IU team is thrilled that our research collaboration with Dr. Friedman, who I crossed paths with just last year at the 2012 APHA annual meeting, has helped to bring these findings to light. APHA truly connects great people doing great work to do even greater things together

Building on previous work assessing attitudes toward bisexual men and women, Friedman and his colleagues surveyed hundreds of adult college students for words that come to mind in relation to bisexual people, such as "confused," "different" and "experimental." The researchers then developed a 33-question survey and administered it to an online sample of 1,500 adults.

Overall, respondents were generally negative in terms of their attitudes toward bisexual men and women, with almost 15 percent of the sample in disagreement that bisexuality is a legitimate sexual orientation. However, women, white people and people who identified themselves as lesbian, gay or bisexual had less bias and prejudice against bisexual people. Of note, respondents who identified as gay or lesbian responded significantly less positively toward bisexuality than those identifying as bisexual, indicating that even within the sexual minority community, bisexuals face profound stigma. In addition, these findings indicate that male bisexuals likely suffer more stigma than female bisexuals.

When a bisexual person perceives that his or her sexual orientation is not recognized by peers, it can cause the person to feel socially isolated and unable to talk openly with friends, family and school mates.

"Having hard data to back up why a bisexual person might feel the need to be secretive about sexual orientation, something that can lead to higher depression and many other negative health outcomes, is very useful to people trying to fight stigma and marginalization," Friedman said. "For example, this information can guide social marketing interventions and outreach to reduce that stigma, and improve rates of HIV prevention, testing and treatment within the bisexual community."

To speak with Friedman, contact Allison Hydzik, 412-647-9975 or hydzikam@upmc.edu; Cyndy McGrath, 412-647-9975 or McGrathC3@upmc.edu; or Wendy Zellner, 412-586-9777 or zellnerwl@upmc.edu. To speak with researchers from the Center for Sexual Health Promotion, contact Tracy James, 812-855-0084 or traljame@iu.edu.  Top

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