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issn:0277-95.6
1.  Provider and Patient Influences on the Formation of Socioeconomic Health Behavior Disparities Among Pregnant Women 
Socially advantaged individuals are better positioned to benefit from advances in biomedicine, which frequently results in the emergence of social inequalities in health. I use survey and in-depth interviews with pregnant women and their health care providers from four Midwestern clinics in the United States, conducted in 2009 and 2010. I compare socioeconomic differences in intake of two new prenatal supplements: Vitamin D and omega-3 fatty acid. Although socioeconomic differences in omega-3 fatty acid supplementation emerged, there were no differences in the use of vitamin D. I argue that providers may have contributed to the prevention of a health disparity in vitamin D supplementation by implementing an aggressive uniform protocol. These results suggest that providers not only serve as a conduit for the dissemination of new biomedical information, the strength and uniformity of their recommendations have the potential to prevent or exacerbate socioeconomic differences in health behaviors.
doi:10.1016/j.socscimed.2013.01.018
PMCID: PMC3587969  PMID: 23453315
health disparities; health care providers; health knowledge; provider-patient interaction; United States
2.  Revisiting the Hispanic Paradox in the United States: the role of smoking 
More than three decades of health disparities research in the United States has consistently found lower adult mortality risks among Hispanics than their non-Hispanic white counterparts, despite lower socioeconomic status among Hispanics. Explanations for the “Hispanic Paradox” include selective migration and cultural factors, though neither has received convincing support. This paper uses a large nationally representative survey of health and smoking behavior to examine whether smoking can explain life expectancy advantage of Hispanics over US-born non-Hispanics whites, with special attention to individuals of Mexican origin. It tests the selective migration hypothesis using data on smoking among Mexico-to-US migrants in Mexico and the United States. Both US-born and foreign-born Mexican-Americans exhibit a life expectancy advantage vis-à-vis whites. All other Hispanics only show a longevity advantage among the foreign-born, while those born in the United States are disadvantaged relative to whites. Smoking-attributable mortality explains the majority of the advantage for Mexican-Americans, with more than 60% of the gap deriving from lower rates of smoking among Mexican-Americans. There is no evidence of selective migration with respect to smoking; Mexicans who migrate to the US smoke at similar rates to Mexicans who remain in Mexico, with both groups smoking substantially less than non-Hispanic whites in the US. The results suggest that more research is needed to effectively explain the low burden of smoking among Mexican-Americans in the United States.
doi:10.1016/j.socscimed.2012.12.028
PMCID: PMC3588600  PMID: 23453311
U.S.A; Hispanic paradox; cigarette smoking; life expectancy; migration; Mexican; selection
3.  Does incentivising pill-taking ‘crowd out’ risk-information processing? Evidence from a web-based experiment☆ 
Social Science & Medicine (1982)  2014;106(100):75-82.
The use of financial incentives for changing health-related behaviours raises concerns regarding their potential to undermine the processing of risks associated with incentivised behaviours. Uncertainty remains about the validity of such concerns. This web-based experiment assessed the impact of financial incentives on i) willingness to take a pill with side-effects; ii) the time spent viewing risk-information and iii) risk-information processing, assessed by perceived-risk of taking the pill and knowledge of its side-effects. It further assesses whether effects are moderated by limiting cognitive capacity. Two-hundred and seventy-five UK-based university staff and students were recruited online under the pretext of being screened for a fictitious drug-trial. Participants were randomised to the offer of different compensation levels for taking a fictitious pill (£0; £25; £1000) and the presence or absence of a cognitive load task (presentation of five digits for later recall). Willingness to take the pill increased with the offer of £1000 (84% vs. 67%; OR 3.66, CI 95% 1.27–10.6), but not with the offer of £25 (79% vs. 67%; OR 1.68, CI 95% 0.71–4.01). Risk-information processing was unaffected by the offer of incentives. The time spent viewing the risk-information was affected by the offer of incentives, an effect moderated by cognitive load: Without load, time increased with the value of incentives (£1000: M = 304.4sec vs. £0: M = 37.8sec, p < 0.001; £25: M = 66.6sec vs. £0: M = 37.8sec, p < 0.001). Under load, time decreased with the offer of incentives (£1000: M = 48.9sec vs. £0: M = 132.7sec, p < 0.001; £25: M = 60.9sec vs. £0: M = 132.7sec, p < 0.001), but did not differ between the two incentivised groups (p = 1.00). This study finds no evidence to suggest incentives “crowd out” risk-information processing. On the contrary, incentives appear to signal risk, an effect, however, which disappears under cognitive load. Although these findings require replication, they highlight the need to maximise cognitive capacity when presenting information about incentivised health-related behaviours.
Highlights
•Concerns exist that health incentives undermine risk-information processing.•We assessed these concerns in the context of taking a pill with side-effects.•Financial incentives did not undermine the processing of risk-information.•Incentives increased risk-information viewing time, implying a cautionary effect.•This cautionary effect disappeared under cognitive load.
doi:10.1016/j.socscimed.2014.01.020
PMCID: PMC3969102  PMID: 24534735
Financial incentives; Risk-information; Side-effects; Risks; Pill-taking; Health incentives; Medication adherence
4.  Marginalized identities, discrimination burden, and mental health: Empirical exploration of an interpersonal-level approach to modeling intersectionality 
Social science & medicine (1982)  2012;75(12):2437-2445.
Intersectionality is a term used to describe the intersecting effects of race, class, gender, and other marginalizing characteristics that contribute to social identity and affect health. Adverse health effects are thought to occur via social processes including discrimination and structural inequalities (i.e., reduced opportunities for education and income). Although intersectionality has been well-described conceptually, approaches to modeling it in quantitative studies of health outcomes are still emerging. Strategies to date have focused on modeling demographic characteristics as proxies for structural inequality. Our objective was to extend these methodological efforts by modeling intersectionality across three levels: structural, contextual, and interpersonal, consistent with a social-ecological framework. We conducted a secondary analysis of a database that included two components of a widely used survey instrument, the Everyday Discrimination Scale. We operationalized a meso- or interpersonal-level of intersectionality using two variables, the frequency score of discrimination experiences and the sum of characteristics listed as reasons for these (i.e., the person’s race, ethnicity, gender, sexual orientation, nationality, religion, disability or pregnancy status, or physical appearance). We controlled for two structural inequality factors (low education, poverty) and three contextual factors (high crime neighborhood, racial minority status, and trauma exposures). The outcome variables we modeled were posttraumatic stress disorder symptoms and a quality of life index score. We used data from 619 women who completed the Everyday Discrimination Scale for a perinatal study in the U.S. state of Michigan. Statistical results indicated that the two interpersonal-level variables (i.e., number of marginalized identities, frequency of discrimination) explained 15% of variance in posttraumatic stress symptoms and 13% of variance in quality of life scores, improving the predictive value of the models over those using structural inequality and contextual factors alone. This study’s results point to instrument development ideas to improve the statistical modeling of intersectionality in health and social science research.
doi:10.1016/j.socscimed.2012.09.023
PMCID: PMC3962770  PMID: 23089613
Health disparities; discrimination; intersectionality; methods; mental health; posttraumatic stress disorder; quality of life; United States
5.  Dynamics of change in the practice of female genital cutting in Senegambia: Testing predictions of social convention theory 
Social science & medicine (1982)  2011;73(8):1275-1283.
Recent reviews of intervention efforts aimed at ending female genital cutting (FGC) have concluded that progress to date has been slow, and call for more efficient programs informed by theories on behavior change. Social convention theory, first proposed by Mackie (1996), posits that in the context of extreme resource inequality, FGC emerged as a means of securing a better marriage by signaling fidelity, and subsequently spread to become a prerequisite for marriage for all women. Change is predicted to result from coordinated abandonment in intermarrying groups so as to preserve a marriage market for uncircumcised girls. While this theory fits well with many general observations of FGC, there have been few attempts to systematically test the theory. We use data from a three year mixed-method study of behavior change that began in 2004 in Senegal and The Gambia to explicitly test predictions generated by social convention theory. Analyses of 300 in-depth interviews, 28 focus group discussions, and survey data from 1220 women show that FGC is most often only indirectly related to marriageability via concerns over preserving virginity. Instead we find strong evidence for an alternative convention, namely a peer convention. We propose that being circumcised serves as a signal to other circumcised women that a girl or woman has been trained to respect the authority of her circumcised elders and is worthy of inclusion in their social network. In this manner, FGC facilitates the accumulation of social capital by younger women and of power and prestige by elder women. Based on this new evidence and reinterpretation of social convention theory, we suggest that interventions aimed at eliminating FGC should target women’s social networks, which are intergenerational, and include both men and women. Our findings support Mackie’s assertion that expectations regarding FGC are interdependent; change must therefore be coordinated among interconnected members of social networks.
doi:10.1016/j.socscimed.2011.07.022
PMCID: PMC3962676  PMID: 21920652
Senegal; The Gambia; Female genital cutting; Behavior change; Social convention theory; Social capital
6.  A randomized controlled trial to improve health among women receiving welfare in the U.S.: the relationship between employment outcomes and the economic recession 
The high prevalence of health conditions among U.S. women receiving Temporary Assistance for Needy Families (TANF, or `welfare') impedes the ability of many in this group to move from `welfare-to-work', and the economic recession has likely exacerbated this problem. Despite this, few interventions have been developed to improve employment outcomes by addressing the health needs of women receiving TANF, and little is known about the impact of economic downturns on the employment trajectory of this group. Using data from a recent randomized controlled trial (RCT) that tested the efficacy of a public health nursing (PHN) intervention to address the chronic health condition needs of 432 American women receiving TANF, we examine the effect of the intervention and of recession exposure on employment. We further explore whether intervention effects were modified by select sociodemographic and health characteristics. Both marginal and more robust intervention effects were noted for employment-entry outcomes (any employment, p=0.05 and time-to-employment, p=0.01). There were significant effects for recession exposure on employment-entry (any employment, p=0.002 and time-to-employment, p<0.001). Neither the intervention nor recession exposure influenced longer-term employment outcomes (employment rate or maximum continuous employment). Intervention effects were not modified by age, education, prior TANF receipt, functional status, or recession exposure, suggesting the intervention was equally effective in improving employment-entry across a fairly heterogeneous group both before and after the recession onset. These findings advance our understanding of the health and employment dynamics among this group of disadvantaged women under variable macroeconomic conditions, and have implications for guiding health and TANF-related policy.
doi:10.1016/j.socscimed.2012.08.011
PMCID: PMC3577993  PMID: 22963921
health disparities; welfare policy; Temporary Assistance for Needy Families (TANF); women's health; public health nursing; economic recession; U.S.A.
7.  Cross-border ties and self-rated health status for young Latino adults in Southern California 
At the same time that health researchers have mostly ignored the cross-border nature of immigrant social networks, scholars of immigrant “transnationalism” have left health largely unexamined. This paper addresses this gap by analyzing the relationship between cross-border ties and self-rated health status for young Latino adults living in the greater Los Angeles area (n=1268). Findings based on an ordered logistic regression analysis suggest that cross-border relationships may have both protective and adverse effects on overall health status. Specifically, those reporting a period of extended parental cross-border separation during childhood have lower odds of reporting better categories of self-rated health, all else equal. Conversely, a significant positive association was found between having a close relative living abroad and self-rated health status for foreign-born respondents when interacted with immigrant generation (foreign versus U.S.-born). Given the findings of significant negative and positive relationships between cross-border ties and self-rated general health status, I discuss the implications for future research on the social determinants of immigrant health.
doi:10.1016/j.socscimed.2012.12.012
PMCID: PMC3578071  PMID: 23312794
U.S.A.; Latino immigrant health; cross-border social ties; self-rated health
8.  The social environment and walking behavior among low-income housing residents 
Walking, both for leisure and for travel/errands, counts towards meeting physical activity recommendations. Both social and physical neighborhood environmental features may encourage or inhibit walking. This study examined social capital, perceived safety, and disorder in relation to walking behavior among a population of low-income housing residents. Social and physical disorder were assessed by systematic social observation in the area surrounding 20 low-income housing sites in greater-Boston. A cross-sectional survey of 828 residents of these housing sites provided data on walking behavior, socio-demographics, and individual-level social capital and perceived safety of the areas in and around the housing site. Community social capital and safety were calculated by aggregating individual scores to the level of the housing site. Generalized estimating equations were used to estimate prevalence rate ratios for walking less than 10 minutes per day for a) travel/errands, b) leisure and c) both travel/errands and leisure. 21.8% of participants walked for travel/ errands less than 10 minutes per day, 34.8% for leisure, and 16.8% for both kinds of walking. In fully adjusted models, those who reported low individual-level social capital and safety also reported less overall walking and less walking for travel/errands. Unexpectedly, those who reported low social disorder also reported less walking for leisure, and those who reported high community social capital also walked less for all outcomes. Physical disorder and community safety were not associated with walking behavior. For low-income housing residents, neighborhood social environmental variables are unlikely the most important factors in determining walking behavior. Researchers should carefully weigh the respective limitations of subjective and objective measures of the social environment when linking them to health outcomes.
doi:10.1016/j.socscimed.2012.11.030
PMCID: PMC3578154  PMID: 23312303
USA; Environment; Social capital; Safety; Social disorder; Physical activity; Low-income housing
9.  The effect of Hurricane Katrina on the prevalence of health impairments and disability among adults in New Orleans: Differences by age, race, and sex 
We examined the effects of Hurricane Katrina on disability-related measures of health among adults from New Orleans, U.S.A., in the year after the hurricane, with a focus on differences by age, race, and sex. Our analysis used data from the American Community Survey to compare disability rates between the pre-Katrina population of New Orleans with the same population in the year after Katrina (individuals were interviewed for the study even if they relocated away from the city). The comparability between the pre-and post-Katrina samples was enhanced by using propensity weights. We found a significant decline in health for the adult population from New Orleans in the year after the hurricane, with the disability rate rising from 20.6% to 24.6%. This increase in disability reflected a large rise in mental impairments and, to a lesser extent, in physical impairments. These increases were, in turn, concentrated among young and middle-aged black females. Stress-related factors likely explain why young and middle-aged black women experienced worse health outcomes, including living in dwellings and communities that suffered the most damage from the hurricane, household breakup, adverse outcomes for their children, and higher susceptibility.
doi:10.1016/j.socscimed.2012.12.009
PMCID: PMC3640812  PMID: 23321678
U.S.A; Disability; Demographic disparities; Hurricane Katrina; New Orleans; Natural disasters and health
10.  Childhood adversities and subsequent risk of one or multiple abortions 
Although many studies have found an association between childhood adversities and mental health disorders, few have examined whether childhood adversities are linked to having abortions. This research investigates the association between a range of childhood adversities and risk of abortion in part to identify which adversities should be considered when examining the association between abortion and subsequent mental health. Using the U.S. National Comorbidity Survey-Replication (NCS-R), we tested the association between 10 childhood adversities and risk of 0,1, or multiple abortions among 1511 women ages 18–41. We employed multinomial logistic regression to examine the independent association between each childhood adversity and number of subsequent abortions, controlling for sociodemographic factors, total number of pregnancies, and each adversity. Women who had experienced two or more personal safety threats, one parental mental illness, or two or more parental mental illnesses while growing up were more likely subsequently to have multiple versus no abortions [Relative Risk Ratio (RRR) = 9.87, 95% CI: 2.45–39.72; OR = 2.81, 95% CI: 1.27–6.21; RRR = 5.28, 95% CI: 1.60–17.38, respectively], and multiple versus one abortion [RRR = 13.33, 95% CI: 2.48–71.68; RRR = 2.17, 95% CI: 1.03–4.56; RRR = 3.67, 95% CI: 1.15–11.76, respectively]. Women who had experienced childhood physical abuse were more likely to have one compared to no abortions [RRR = 2.00; 1.19–3.34]. These results suggest that some childhood adversities may partially explain the association between abortion and mental health. Accordingly, they should be considered in future research examining the link between abortion and mental health.
doi:10.1016/j.socscimed.2012.11.011
PMCID: PMC3699177  PMID: 23312795
U.S.A.; Childhood adversities; Abortion; Mental health
11.  Violence as a public health problem: An ecological study of 169 countries☆ 
Social Science & Medicine (1982)  2014;104(100):220-227.
Individual level risk factors for violence have been widely studied, but little is known about country-level determinants, particularly in low and middle-income countries. We hypothesized that income inequality, through its detrimental effects on social cohesion, would be related to an increase in violence worldwide, and in low and middle-income countries in particular. We examined country-level associations of violence with socio-economic and health-related factors, using crime statistics from the United Nations Office on Drugs and Crime, and indicators from the Human Development Report published by the United Nations Development Programme. Using regression models, we measured relationships between country-level factors (age, education, measures of income, health expenditure, and alcohol consumption) and four violent outcomes (including measures of violence-related mortality and morbidity) in up to 169 countries. We stratified our analyses comparing high with low and middle-income countries, and analysed longitudinal data on homicide and income inequality in high-income countries. In low and middle-income countries, income inequality was related to homicide, robbery, and self-reported assault (all p's < 0.05). In high-income countries, urbanicity was significantly associated with official assault (p = 0.002, β = 0.716) and robbery (p = 0.011, β = 0.587) rates; income inequality was related to homicide (p = 0.006, β = 0.670) and self-reported assault (p = 0.020, β = 0.563), and longitudinally with homicide (p = 0.021). Worldwide, alcohol consumption was associated with self-reported assault rates (p < 0.001, β = 0.369) suggesting public policy interventions reducing alcohol consumption may contribute to reducing violence rates. Our main finding was that income inequality was related to violence in low and middle-income countries. Public health should advocate for global action to moderate income inequality to reduce the global health burden of violence.
Highlights
•In low and middle-income countries, income inequality is related to rates of homicide and assault.•In high-income countries, urbanicity is associated with assault and robbery rates.•In high-income countries, income inequality is related to homicide and self-reported assault rates.•Worldwide, alcohol consumption is associated with self-reported assault rates.
doi:10.1016/j.socscimed.2013.12.006
PMCID: PMC3969091  PMID: 24581081
Crime; Violence; Public health; Income inequality; Alcohol
12.  The effect of financial incentives on chlamydia testing rates: Evidence from a randomized experiment☆ 
Social Science & Medicine (1982)  2014;105(100):140-148.
Financial incentives have been used in a variety of settings to motivate behaviors that might not otherwise be undertaken. They have been highlighted as particularly useful in settings that require a single behavior, such as appointment attendance or vaccination. They also have differential effects based on socioeconomic status in some applications (e.g. smoking). To further investigate these claims, we tested the effect of providing different types of non-cash financial incentives on the return rates of chlamydia specimen samples amongst 16–24 year-olds in England. In 2011 and 2012, we ran a two-stage randomized experiment involving 2988 young people (1489 in Round 1 and 1499 in Round 2) who requested a chlamydia screening kit from Freetest.me, an online and text screening service run by Preventx Limited. Participants were randomized to control, or one of five types of financial incentives in Round 1 or one of four financial incentives in Round 2. We tested the effect of five types of incentives on specimen sample return; reward vouchers of differing values, charity donation, participation in a lottery, choices between a lottery and a voucher and including vouchers of differing values in the test kit prior to specimen return. Financial incentives of any type, did not make a significant difference in the likelihood of specimen return. The more deprived individuals were, as calculated using Index of Multiple Deprivation (IMD), the less likely they were to return a sample. The extent to which incentive structures influenced sample return was not moderated by IMD score. Non-cash financial incentives for chlamydia testing do not seem to affect the specimen return rate in a chlamydia screening program where test kits are requested online, mailed to requestors and returned by mail. They also do not appear more or less effective in influencing test return depending on deprivation level.
Highlights
•This chlamydia testing study is one of the largest, most thorough incentives trials.•Non-cash financial incentives had no impact on chlamydia testing for young adults.•Incentives were no more or less effective depending on socioeconomic status.•The results are surprising given the theoretical underpinnings of the incentives' designs.•Context is important in the success of any policies designed to change behavior.
doi:10.1016/j.socscimed.2013.11.018
PMCID: PMC3969100  PMID: 24373390
UK; Financial incentives; Sexually transmitted infections; Socioeconomic status
13.  Effects of an HIV peer prevention intervention on sexual and injecting risk behaviors among injecting drug users and their risk partners in Thai Nguyen, Vietnam: A randomized controlled trial 
Globally, 30% of new HIV infections outside sub-Saharan Africa involve injecting drug users (IDU) and in many countries, including Vietnam, HIV epidemics are concentrated among IDU. We conducted a randomized controlled trial in Thai Nguyen, Vietnam, to evaluate whether a peer oriented behavioral intervention could reduce injecting and sexual HIV risk behaviors among IDU and their network members. 419 HIV-negative index IDU aged 18 years or older and 516 injecting and sexual network members were enrolled. Each index participant was randomly assigned to receive a series of six small group peer educator-training sessions and three booster sessions in addition to HIV testing and counseling (HTC) (intervention; n = 210) or HTC only (control; n = 209). Follow-up, including HTC, was conducted at 3, 6, 9 and 12 months post-intervention. The proportion of unprotected sex dropped significantly from 49% to 27% (SE (difference) = 3%, p < 0.01) between baseline and the 3-month visit among all index-network member pairs. However, at 12 months, post-intervention, intervention participants had a 14% greater decline in unprotected sex relative to control participants (Wald test = 10.8, df = 4, p = 0.03). This intervention effect is explained by trial participants assigned to the control arm who missed at least one standardized HTC session during follow-up and subsequently reported increased unprotected sex. The proportion of observed needle/syringe sharing dropped significantly between baseline and the 3-month visit (14% vs. 3%, SE (difference) = 2%, p < 0.01) and persisted until 12 months, but there was no difference across trial arms (Wald test = 3.74, df = 3, p = 0.44).
doi:10.1016/j.socscimed.2013.07.006
PMCID: PMC3938286  PMID: 24034963
Vietnam; Injecting drug use; HIV; Randomized controlled trial; Peer network; Intervention; Evaluation
14.  Weighing the evidence: Risks and benefits of participatory documentary in corporatized clinics 
This paper describes the effects of one U.S.-based public psychiatry clinic’s shift to a centralized, corporate style of management, in response to pressures to cut expenditures by focusing on “evidence based” treatments. Participant observation research conducted between 2008 and 2012 for a larger study involving 127 interviews with policy makers, clinic managers, clinical practitioners and patients revealed that the shift heralded the decline of arts based therapies in the clinic, and of the social networks that had developed around them. It also inspired a participatory video self-documentary project among art group members, to portray the importance of arts-based therapies and garner public support for such therapies. Group members found a way to take action in the face of unilateral decision making, but experienced subsequent restrictions on clinic activities and discharge of core members from the clinic. The paper ends with a discussion of biopolitics, central legibility through corporate standardization, and the potential and risks of participatory documentaries to resist these trends.
doi:10.1016/j.socscimed.2013.05.030
PMCID: PMC3935432  PMID: 23932854
United States; Ethnography; Participatory research; Managed care; Evidence based medicine; Recovery; Arts therapy; Documentary; Psychiatry; Addiction
15.  Time in the United States, social support and health behaviors during pregnancy among women of Mexican descent 
Social science & medicine (1982)  2006;62(12):3048-3061.
Among women of Mexican descent, increased acculturation in the United States has been associated with poorer health behaviors during pregnancy. This study examined a population of low-income women of Mexican descent in an agricultural community to determine whether social support patterns were associated with age at arrival in the U.S.; whether social support was associated with pregnancy behaviors; and whether increased social support could prevent some of the negative pregnancy behaviors that accompany acculturation. Participants were 568 pregnant women enrolled in prenatal care in the Salinas Valley, California. Participants were predominantly Spanish-speaking, born in Mexico, and from farmworker families. Information on social networks, social support, age at arrival in the United States, and pregnancy health behaviors was gathered during interviews conducted during pregnancy and immediately after delivery. Poorer health behaviors were observed among women who had come to the U.S. at a younger age. Social support during pregnancy was lowest among women who had come to the U.S. at an older age. High parity, low education, and low income were also associated with low social support. Higher social support was associated with better quality of diet, increased likelihood of using prenatal vitamins, and decreased likelihood of smoking during pregnancy. High social support also appeared to prevent the negative impact of life in the U.S. on diet quality. Women with intermediate or low levels of social support who had spent their childhoods in the U.S. had significantly poorer diet quality than women who had spent their childhoods in Mexico. However, among women with high social support, there was no difference in diet quality according to country of childhood. Thus, in the case of diet quality, increased social support appears to prevent some of the negative pregnancy behaviors that accompany time in the U.S. among women of Mexican descent.
doi:10.1016/j.socscimed.2005.11.036
PMCID: PMC3934499  PMID: 16403596
16.  Working Outside of the Box: How HIV Counselors in Sub-Saharan Africa Adapt Western HIV Testing Norms 
Social science & medicine (1982)  2010;71(5):986-993.
The delivery of HIV counseling and testing programs throughout Sub-Saharan Africa relies on the work performed by trained HIV counselors. These individuals occupy a critical position: they are intermediaries between the rule-making of international and national policymakers, and the norms of the communities in which they live and work. This paper explains when, how and why HIV counselors adapt Western testing guidelines (the ‘3Cs’- consent, confidentiality and counseling) to local concerns, attempting to maintain the fidelity of testing principles, while reducing the harm they perceive may arise as a consequence of strict adherence to them. Data for this study come from Malawi: a poor, largely rural African country, where HIV prevalence is ranked 9th highest in the world. The analysis is based on 25 interviews with HIV counselors and a unique set of field journals, and captures local experiences and the moral quandaries that counselors in rural Sub-Saharan Africa face. The findings of this inquiry provide new insights into the implementation of HIV testing in rural African settings, insights that may guide HIV prevention policy.
doi:10.1016/j.socscimed.2010.05.020
PMCID: PMC3934752  PMID: 20619944
Malawi; Africa; HIV/AIDS; Counselors; HIV Testing; Consent; Confidentiality; Counseling; rural
17.  The uneven tides of the health transition 
Social science & medicine (1982)  2002;55(2):313-322.
As spectacular mortality reductions have occurred in all developing nations at all national income levels, the epidemiologic transition theory suggests that cause-of-mortality patterns should shift from communicable diseases especially prevalent among infants and children to problems resulting from non-communicable conditions at older ages. Global estimates confirm this expectation, and mortality from these latter conditions has become predominant worldwide, leading some observers to argue for a corresponding shift in the public health agenda. In this paper, we nuance this finding by studying the important poverty-gradient concealed in the global estimates.
Our results demonstrate the remaining cause-of-death disparities between the world’s poorest and richest populations. We find that the poorest population (1st quintile) experiences higher mortality than the richest population (5th quintile) in each of the three main groups of mortality causes but that the excess mortality of the poorest population is mostly due to the higher incidence of communicable diseases (77% of excess deaths). Overall, those diseases only account for 34.2% of deaths in the world but still dominate mortality causes among the poorest 20% of the world population (58.6% of all deaths). Moreover, these results appear robust to alternative estimates of the international distribution of the world’s poorest people.
While recognizing the emerging agenda of the non-communicable conditions, we thus underscore the “unfinished agenda” of communicable diseases in many countries. As populations affected by these diseases are predominantly among the poorer, equity considerations should caution against a premature shift away from these diseases.
PMCID: PMC3931464  PMID: 12144144
Communicable diseases; Poverty; Mortality; Health transition; Health policy
18.  Sociodemographic and Cultural Determinants of Sleep Deficiency: Implications for Cardiometabolic Disease Risk 
Sleep is a biological imperative associated with cardiometabolic disease risk. As such, a thorough discussion of the sociocultural and demographic determinants of sleep is warranted, if not overdue. This paper begins with a brief review of the laboratory and epidemiologic evidence linking sleep deficiency, which includes insufficient sleep and poor sleep quality, with increased risk of chronic cardiometabolic diseases such as obesity, diabetes and hypertension. Identification of the determinants of sleep deficiency is the critical next step to understanding the role sleep plays in human variation in health and disease. Therefore, the majority of this paper describes the different biopsychosocial determinants of sleep, including age, gender, psychosocial factors (depression, stress and loneliness), socioeconomic position and race/ethnicity. In addition, because sleep duration is partly determined by behavior, it will be shaped by cultural values, beliefs and practices. Therefore, possible cultural differences that may impact sleep are discussed. If certain cultural, ethnic or social groups are more likely to experience sleep deficiency, then these differences in sleep could increase their risk of cardiometabolic diseases. Furthermore, if the mechanisms underlying the increased risk of sleep deficiency in certain populations can be identified, interventions could be developed to target these mechanisms, reduce sleep differences and potentially reduce cardiometabolic disease risk.
doi:10.1016/j.socscimed.2012.05.002
PMCID: PMC3443287  PMID: 22682665
19.  Nighttime Parenting Strategies and Sleep-Related Risks to Infants 
A large social science and public health literature addresses infant sleep safety, with implications for infant mortality in the context of accidental deaths and Sudden Infant Death Syndrome (SIDS). As part of risk reduction campaigns in the USA, parents are encouraged to place infants supine and to alter infant bedding and elements of the sleep environment, and are discouraged from allowing infants to sleep unsupervised, from bed-sharing either at all or under specific circumstances, or from sofa-sharing. These recommendations are based on findings from large-scale epidemiological studies that generate odds ratios or relative risk statistics for various practices; however, detailed behavioural data on nighttime parenting and infant sleep environments are limited. To address this issue, this paper presents and discusses the implications of four case studies based on overnight observations conducted with first-time mothers and their four-month old infants. These case studies were collected at the Mother-Baby Behavioral Sleep Lab at the University of Notre Dame USA between September 2002 and June 2004.Each case study provides a detailed description based on video analysis of sleep-related risks observed while mother-infant dyads spent the night in a sleep lab. The case studies provide examples of mothers engaged in the strategic management of nighttime parenting for whom sleep-related risks to infants arose as a result of these strategies. Although risk reduction guidelines focus on eliminating potentially risky infant sleep practices as if the probability of death from each were equal, the majority of instances in which these occur are unlikely to result in infant mortality. Therefore, we hypothesise that mothers assess potential costs and benefits within margins of risk which are not acknowledged by risk-reduction campaigns. Exploring why mothers might choose to manage sleep and nighttime parenting in ways that appear to increase potential risks to infants may help illuminate how risks occur for individual infants.
doi:10.1016/j.socscimed.2012.05.043
PMCID: PMC3505270  PMID: 22818487
infant sleep; sleep-related risks; Sudden Infant Death Syndrome (SIDS); nighttime parenting; USA
20.  Eye of the beholder? Maternal mental health and the quality of infant sleep 
Transactional models of parenting and infant sleep call attention to bidirectional associations among parenting, the biosocial environment, and infant sleep behaviors. Although night waking and bedtime fussing are normative during infancy and early childhood, they can be challenging for parents. The current study, conducted in the United States between 2003 and 2009, examined concurrent and longitudinal associations between maternal mental health and infant sleep during the first year. Concurrent associations at 6 and 12 months and longitudinal associations from 6 to 12 months were studied in a non-clinic referred sample of 171 economically and culturally diverse families. Mothers with poorer mental health reported that their infants had more night waking and bedtime distress and were more bothered by these sleep issues. Associations between infant sleep and maternal mental health were moderated by culture (Hispanic/Asian vs. other) and by stressors that included high parenting stress, more stressful life events, and low family income. Individual differences in maternal well-being may color mothers’ interpretations of infants’ sleep behaviors. It may be prudent to intervene to support maternal mental health when infants are referred for sleep problems.
doi:10.1016/j.socscimed.2012.07.006
PMCID: PMC3540198  PMID: 22858167
night waking; infancy; sleep problems; depressive symptoms; anxiety; United States; mothers; ethnicity
21.  Understanding Maternal Smoking during Pregnancy: Does Residential Context Matter? 
The goal of this paper was to investigate whether or not the factors beyond individual characteristics were associated with maternal smoking during pregnancy. Social capital has been found to have both negative and positive implications for health behaviors, and this study attempted to understand its association with maternal smoking during pregnancy. Specifically, the association between county-level social capital and rurality and maternal smoking during pregnancy was investigated. In this study, Putman’s definition of social capital was used (e.g., connections among individuals—social networks and the norms of reciprocity and trustworthiness that arise from them). The ecological dimension of rurality was used to define rurality, where rural areas are smaller in population size and are less densely populated when compared to non-rural areas. Using data for all women who gave birth during the year 2007 in the United States, we implemented a series of multilevel logistic regression models. The results showed that social capital was significantly associated with maternal smoking during pregnancy. Specifically, higher social capital in a county was associated with higher odds that women will smoke during their pregnancy. However, in rural counties, higher social capital was associated with a decrease in the odds that a woman will smoke during her pregnancy. A one unit increase in the social capital index was found to reduce the risk of smoking during pregnancy among those women living in rural counties by 11 percent. The results also showed that improvement of the socioeconomic status of the counties in which women live reduced the risk of maternal smoking during pregnancy. As this study found that factors beyond individual characteristics are important for reducing the risk that women will smoke during pregnancy, county characteristics should be taken into account when developing policies focused on intervening maternal smoking during pregnancy.
doi:10.1016/j.socscimed.2012.11.027
PMCID: PMC3545052  PMID: 23246395
Maternal smoking; pregnancy; social capital; rural; multilevel models; United States
22.  Education and obesity at age 40 among American adults 
Although many have studied the association between educational attainment and obesity, studies to date have not fully examined prior common causes and possible interactions by race/ethnicity or gender. It is also not clear if the relationship between actual educational attainment and obesity is independent of the role of aspired educational attainment or expected educational attainment. The authors use generalized linear log link models to examine the association between educational attainment at age 25 and obesity (BMI≥30) at age 40 in the USA’s National Longitudinal Survey of Youth 1979 cohort, adjusting for demographics, confounders, and mediators. Race/ethnicity but not gender interacted with educational attainment. In a complete case analysis, after adjusting for socioeconomic covariates from childhood, adolescence, and adulthood, among whites only, college graduates were less likely than high school graduates to be obese (RR= 0.69, 95%CI: 0.57, 0.83). The risk ratio remained similar in two sensitivity analyses when the authors adjusted for educational aspirations and educational expectations and analyzed a multiply imputed dataset to address missingness. This more nuanced understanding of the role of education after controlling for a thorough set of confounders and mediators helps advance the study of social determinants of health and risk factors for obesity.
doi:10.1016/j.socscimed.2012.11.025
PMCID: PMC3545063  PMID: 23246398
body weight; educational status; ethnic groups; health status disparities; obesity; social class; socioeconomic factors; United States of America
23.  Unique sleep disorders profile of a population-based sample of 747 Hmong immigrants in Wisconsin 
Concerns regarding sleep disorders in Hmong immigrants in the US emerged when an astonishingly high mortality rate of Sudden Unexplained Nocturnal Death Syndrome (SUNDS) was documented in Hmong men. Stress, genetics, and cardiac abnormalities interacting with disordered sleep were hypothesized as contributing factors to SUNDS. Most recently, sleep apnea has been implicated in nighttime deaths of Brugada Syndrome. This syndrome is thought to comprise a spectrum of sudden cardiac death disorders, including SUNDS. However, little research since has placed SUNDS in its context of Hmong cultural beliefs, health, or the prevalence of other sleep disorders. Because the epidemiology of sleep disorders and terrifying nighttime experiences in Hmong is poorly documented, we investigated the prevalence and correlates of sleep apnea, rapid eye movement (REM) sleep stage related disorders, and insomnia in 3 population-based samples (collected from 1996 to 2001) comprising 747 Hmong immigrants in Wisconsin. Participants were questioned on sleep problems, cultural beliefs, health, and other factors. A random subsample (n = 37) underwent in-home polysomnography to investigate sleep apnea prevalence. Self-report and laboratory findings were compared with similarly collected data from the Wisconsin Sleep Cohort (WSC) study (n = 1170), a population-based longitudinal study of sleep. The results inform a unique Hmong sleep disorder profile of a high prevalence of sleep apnea, sleep paralysis, and other REM-related sleep abnormalities as well the interaction of culturally related nighttime stressors with these sleep problems. For example, experiences of dab tsog (frightening night spirit pressing on chest) was prevalent and related to sleep apnea indicators, sleep paralysis, nightmares, hypnogogic hallucinations, and insomnia. Understanding the role of sleep disorders and the cultural mechanisms that may trigger or condition response to them could ultimately provide a basis for screening and intervention to reduce the adverse health and emotional consequences of these conditions in Hmong.
doi:10.1016/j.socscimed.2012.06.009
PMCID: PMC3616878  PMID: 22832325
USA; Sleep disorders; Sleep paralysis; Hmong health; SUNDS; Sleep apnea; Cultural stress; Brugada syndrome
24.  Economic gradients in early child neurodevelopment: A multi-country study 
Social science & medicine (1982)  2012;78:10.1016/j.socscimed.2012.11.038.
Little is known about the importance of household wealth for child neurodevelopment very early in life including during infancy. Previous studies have focused on specific developmental domains instead of more holistic multi-domain measures of neurodevelopment and on economic effects for the “average” child instead of evaluating the heterogeneity in economic gradients by different levels of developmental ability. Furthermore, not much is known about whether economic gradients in early child neurodevelopment are country-specific or generalizable between populations. We evaluate wealth gradients in child neurodevelopment, an important predictor of future health and human capital, between ages 3 and 24 months in four South American countries. We also assess the heterogeneity in these gradients at different locations of the neurodevelopment distribution using quantile regression. Employing a unique dataset of 2032 children with neurodevelopment measures obtained by physicians in 2005–2006, we find a large positive wealth gradient in neurodevelopment in Brazil. The wealth gradient is larger for children at higher neurodevelopment rankings, suggesting that wealth is associated with child development inequalities in the form of a wider gap between low and high achievers on neurodevelopment in Brazil. This result highlights the need to target poverty in Brazil as a key factor in health and human capital disparities earlier in life rather than later as early developmental deficits will be carried forward and possibly multiplied later in life. More importantly, small or insignificant wealth gradients are generally found in the other countries. These results suggest that wealth gradients in child neurodevelopment are country-specific and vary with population demographic, health, and socioeconomic characteristics. Therefore, findings from previous studies based on specific populations may not be generalizable to other countries. Furthermore, wealth gradients in child neurodevelopment appear to be dynamic rather than fixed and sensitive to population characteristics that modify their intensity.
doi:10.1016/j.socscimed.2012.11.038
PMCID: PMC3654665  PMID: 23273409
Argentina; Brazil; Chile; Ecuador; Child development; Socioeconomic status; Wealth; Disparities
25.  Perceived neighborhood quality, sleep quality, and health status: Evidence from the Survey of the Health of Wisconsin 
Why does living in a disadvantaged neighborhood predict poorer mental and physical health? Recent research focusing on the Southwestern United States suggests that disadvantaged neighborhoods favor poor health, in part, because they undermine sleep quality. Building on previous research, we test whether this process extends to the Midwestern United States. Specifically, we use cross-sectional data from the Survey of the Health of Wisconsin (SHOW), a statewide probability sample of Wisconsin adults, to examine whether associations among perceived neighborhood quality (e.g., perceptions of crime, litter, and pleasantness in the neighborhood) and health status (overall self-rated health and depression) are mediated by overall sleep quality (measured as self-rated sleep quality and physician diagnosis of sleep apnea). We find that perceptions of low neighborhood quality are associated with poorer self-rated sleep quality, poorer self-rated health, and more depressive symptoms. We also observe that poorer self-rated sleep quality is associated with poorer self-rated health and more depressive symptoms. Our mediation analyses indicate that self-rated sleep quality partially mediates the link between perceived neighborhood quality and health status. Specifically, self-rated sleep quality explains approximately 20% of the association between neighborhood quality and self-rated health and nearly 19% of the association between neighborhood quality and depression. Taken together, these results confirm previous research and extend the generalizability of the indirect effect of perceived neighborhood context on health status through sleep quality.
doi:10.1016/j.socscimed.2012.07.021
PMCID: PMC3733364  PMID: 22901794
Sleep; Sleep quality; Neighborhood context; Neighborhood quality; Self-rated health; Depression; Wisconsin; USA

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