The role of individual and neighborhood factors: HIV acquisition risk among high-risk populations in San Francisco.

We examined socioeconomic status and social and sexual network factors and their relationship to HIV acquisition risk among HIV-negative Black MSM (BMSM), White MSM (WMSM) and transfemales (male to female transgenders). Geographic analysis examined residential patterns and neighborhood patterns of HIV prevalence in San Francisco. Factors associated with engaging in more episodes of potentially HIV serodiscordant unprotected receptive anal intercourse were analyzed. Transfemales and BMSM were more likely to live in areas of higher HIV prevalence and lower income compared to WMSM. BMSM and transfemales had lower socioeconomic scores (SES) scores compared to WMSM. BMSM were more likely to report serodiscordant partnerships and higher numbers of potentially serodiscordant unprotected sex acts. Decreasing individual SES did not predict serodiscordant partnerships in any group. Increasing neighborhood HIV prevalence predicted an increase in the number of potentially serodiscordant unprotected sex acts among transfemales and BMSM but only significantly so for transfemales. Prevention interventions must consider neighborhood HIV prevalence, and HIV prevalence in social/sexual networks, in addition to considering individual level behavior change or poverty reduction.

Beyond screening for domestic violence: a systems model approach in a managed care setting.

BACKGROUND: Implementation of screening guidelines for domestic violence has been challenging. The multifaceted "systems model" may provide an effective means to improve domestic violence screening, identification, and intervention in the healthcare setting. METHODS: We developed: (1) a systems model approach using tools for effective referral, evaluation, and reporting of domestic violence; (2) materials for distribution to female patients; (3) training for social service and mental health clinicians to provide domestic violence evaluation; and (4) strong links to the community. SETTING: A nonprofit, managed care facility in Richmond, California. PARTICIPANTS: Staff and members of the managed care plan. MAIN OUTCOME MEASURES: (1) Increased screening for domestic violence by clinicians; (2) increased awareness of the healthcare facility as a resource for domestic violence assistance; and (3) increased member satisfaction with the health plan's efforts to address domestic violence. RESULTS: The number of clinician referrals and patient self-referrals to an on-site domestic violence evaluator increased more than twofold. A pre-intervention and post-intervention phone survey of members seen for routine checkup showed an increase in member recall of being asked about domestic violence. After intervention, statistically significant increases were seen in members' perception that the health plan was concerned about the health effects of domestic violence (p<0.0001) and about members' satisfaction with the health plan's efforts to address this issue (p<0.0001). CONCLUSIONS: A systems model approach improved domestic violence services in a managed care health setting within 1 year and affected clinicians' behavior as well as health plan members' experience. This successful implementation makes it possible to address critical research questions about the impact of a healthcare intervention for victims of domestic violence in a managed healthcare setting.

Anger expression and hypertension in transit workers.

One hypothesis in the literature on anger and hypertension is that a chronic tendency to suppress anger is an etiological factor in the development of hypertension. The present study assessed the relationship between anger expression and hypertension in a multicultural sample of 1,407 San Francisco bus drivers. Simple and multiple regression analyses revealed no significant differences between suppressed or expressed anger and hypertension. Thus, the results of this study do not support the hypothesis that suppressed anger is an etiological factor in hypertension.

Promoting health: intervention strategies from social and behavioral research.

This report, released by the Division of Health Promotion and Disease Prevention within the Institute of Medicine at the National Academy of Sciences, asserts that behavioral and social interventions such as health promotion and disease prevention offer great promise to reduce disease morbidity and mortality in the United States, but as yet their potential has not been recognized or tapped by the federal government. Two overarching recommendations are the need to address generic social and behavioral determinants of health rather than the clinical causes of disease and death, and the need to intervene at multiple levels of influence including the individual, interpersonal, institutional, community, and policy levels. Seven recommendations for intervention strategies, nine recommendations for research, and three recommendations for funding are offered.

The social environment and health: a discussion of the epidemiologic literature.

The environment can be thought of in terms of physical and social dimensions. The social environment includes the groups to which we belong, the neighborhoods in which we live, the organization of our workplaces, and the policies we create to order our lives. There have been recent reports in the literature that the social environment is associated with disease and mortality risks, independent of individual risk factors. These findings suggest that the social environment influences disease pathways. Yet much remains to be learned about the social environment, including how to understand, define, and measure it. The research that needs to be done could benefit from a long tradition in sociology and sociological research that has examined the urban environment, social areas, social disorganization, and social control. We summarize this sociological literature and discuss its relevance to epidemiologic research.

The impact of emotions on cardiovascular health.

Recent research suggests that the maintenance of emotional well-being is critical to cardiovascular health. People who feel lonely, depressed, and isolated have been found to be significantly more likely to suffer illnesses and to die prematurely of cardiovascular diseases than those who have adequate social support. Consequently, the development of appropriate interventions to improve the emotional health of people with certain psychosocial risk factors has become an important research goal. It is anticipated that such interventions will increase the life expectancy of people at risk and that it may also save millions of dollars in medical care costs. First, however, researchers in this field must identify specific emotional risk factors and must agree upon a working definition of "good emotional health." Such explicit definitions, as well as additional data, are essential to educating physicians and insurers so that consideration of emotional health can be integrated into basic medical care.

Psychosocial job factors, physical workload, and incidence of work-related spinal injury: a 5-year prospective study of urban transit operators.

STUDY DESIGN: Five-year prospective cohort study of 1449 transit operators. OBJECTIVES: To investigate psychosocial job factors as predictors of work-related spinal injuries, controlling for current and past physical workload. SUMMARY OF BACKGROUND DATA: The association between psychosocial job factors and spinal disorders may be confounded by physical workload. A 1991 prospective study of Boeing workers found psychosocial but not physical factors to be associated with spinal injuries. However, data on physical workload were limited. Recent cross-sectional studies of transit drivers showed both physical and psychosocial factors to be independently associated with back and neck pain. This study was designed to test these findings prospectively. METHODS: Spinal injuries were ascertained from workers' compensation records, employment history from company records, and psychosocial factors from questionnaires. Logistic regression models adjusted for age, gender, height, weight, vehicle type, and current and past physical workload. RESULTS: During follow-up, 320 drivers reported a first spinal injury. Spinal injury was predicted by psychological job demands (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.33-1.95); job dissatisfaction (OR, 1.56; 95% CI, 1.09-2.23); and the frequency of job problems (OR, 1.52; 95% CI, 1.02-2.26). Marginally significant associations were found for low supervisor support (OR, 1.30; 95% CI, 0.99-1.72) and female gender (OR, 1.49; 95% CI, 0.95-2.32). Compared with full-time work, part-time work was associated with a 2.7-fold reduced risk for spinal injury (OR, 0.37; 95% CI, 0.15-0.93). Cable car crews performing the heaviest physical labor had a threefold increased risk of spinal injury compared with bus drivers (OR, 3.04; 95% CI, 1.85-5.00). CONCLUSIONS: Physical workload and psychosocial job factors both independently predict spinal injury in transit vehicle operators.

Socioeconomic status, neighborhood social conditions, and neural tube defects.

OBJECTIVES: This study evaluated the contributions of lower socioeconomic status (SES) and neighborhood socioeconomic characteristics to neural tube defect etiology. The influence of additional factors, including periconceptional multivitamin use and race/ethnicity, was also explored. METHODS: Data derived from a case-control study of California pregnancies from 1989 to 1991. Mothers of 538 (87.8% of eligible) case infants/fetuses with neural tube defects and mothers of 539 (88.2%) nonmalformed infants were interviewed about their SES. Reported addresses were linked to 1990 US census information to characterize neighborhoods. RESULTS: Twofold elevated risks were observed for several SES indicators. Risks were somewhat confounded by vitamin use, race/ethnicity, age, body mass index, and fever but remained elevated after adjustment. A risk gradient was seen with increasing number of lower SES indicators. Women with 1 to 3 and 4 to 6 lower SES indicators had adjusted odds ratios of 1.6 (1.1-2.2) and 3.2 (1.9-5.4), respectively, compared with women with no lower SES indicators. CONCLUSIONS: Both lower SES and residence in a SES-lower neighborhood increased the risk of an neural tube defect-affected pregnancy, with risks increasing across a gradient of SES indicators.

Social and economic disparities in health: thoughts about intervention.

It is now well established that inequalities in income lead to high morbidity and mortality rates. Certain explanations for this phenomenon are explored: (1) Instead of income inequalities causing disease, the inequalities are determined by powerful cultural forces. (2) The rich get richer and the poor get poorer. (2) Wealthier people can buy the means to protect their health. (4) Poorer people suffer not from poverty, but from relative deprivation. (5) Those with the weakest genes drift into the lower income groups. It is difficult to develop interventions directed to these possibilities. The concept of "control and destiny" is a possible explanation for the relation between inequalities and disease; unlike the other explanations, this idea is amenable to intervention.

Disease and injury in California with projections to the year 2007. Implications for medical education.

In this article, as part of an evaluation of the future of medical education in California, we characterize the distribution of disease and injury in California; identify major factors that affect the epidemiology of disease and injury in California, and project the burden of disease and injury for California's population to the year 2007. Our goal is to elucidate the major causes of illness and disability at present and in the near future in order to focus state resources on the interventions likely to have the greatest impact. Data from various governmental agencies were utilized; the base year, 1993, is the most recent year with sufficient information available when this report was prepared. Several major risk factors have decreased, including smoking (30% decline from 1984 to 1993) and drinking and driving. However, hypertension prevalence has not changed, and overweight has increased dramatically. Poverty continues to burden about 15% of Californians, with poverty highest among children. During 1993, 220,271 Californians died, with 3 major causes accounting for 61% of these deaths: coronary heart disease (31%), cancer (23%), and stroke (7%). In terms of potential years of life lost (years lost before age 65), the most important causes of death in 1993 were unintentional injury (756 years lost/100,000 population), cancer (632 years), and the acquired immunodeficiency syndrome (AIDS; 491 years). Mortality rates were highest among blacks and lowest among Asians. Overall mortality in California has been declining for decades; in just 1 decade, from 1980 to 1991, mortality declined from 780 to 680 deaths per 100,000 population. Several major causes of death have declined, including coronary heart disease, stroke, unintentional injury, cirrhosis, and suicide, while others have increased, for example, chronic obstructive lung disease and diabetes mellitus. Death from AIDS increased dramatically in the past decade, but is leveling off, and death from cancer is beginning to decline. Rates for overall mortality and morbidity, and for most specific conditions, should continue to decline. A projected 28% population increase by 2007 will yield a corresponding increase in the absolute level of disease cases and death; a disproportionate increase in younger and older groups will yield increased conditions affecting young (unintentional injury, AIDS) and older (heart disease, cancer, stroke, diabetes mellitus) people. Californians should experience overall improved health in coming years, reaping benefits of reduced environmental and behavioral risk factors as well as improved medical treatment and rehabilitation. Coordinated strategies for health promotion, disease prevention, delivery of medical treatment, and rehabilitation are needed to maintain and improve present levels of health across the life span.

Psychosocial job factors associated with back and neck pain in public transit operators.

OBJECTIVES: This cross-sectional study examined associations between psychosocial job factors and the prevalence of nondisabling back and neck pain in professional drivers after physical work load was taken into account. METHODS: A total of 1449 transit vehicle operators completed a medical examination and a questionnaire yielding information on demographic and anthropometric variables, health status, and physical and psychosocial job factors. Company records were used to supplement information on employment history. Physical work load was measured in life-time years and current weekly hours of professional driving. The relation of psychosocial factors with back or neck pain was analyzed by logistic regression models adjusted for past and current physical work load, vehicle type, age, gender, body height, and weight. RESULTS: The main result of this study was that both physical work load and psychosocial factors were simultaneously and independently associated with back or neck pain. Psychosocial factors associated with back or neck pain included extended uninterrupted driving driving periods, frequency of job problems, high psychosocial demands, high job dissatisfaction, and low supervisory support. An analysis of specific job problems is provided which may be useful in setting priorities for research and intervention efforts in this high risk occupation. CONCLUSION: The results provide support for the role of psychosocial job characteristics in the etiology of back or neck pain in occupational settings.

Objective measurement of occupational stress factors--an example with San Francisco urban transit operators.

Eighty-one observational work analyses were conducted to measure stressors independently of worker appraisal in the San Francisco transit system. On the basis of action regulation theory, stress factors were defined as hindrances for task performance due to poor work organization or technological design. Stressors included (a) work barriers, defined as obstacles that cause extra work or unsafe behavior; (b) time pressure; (c) monotonous conditions; and (d) time binding, defined as control over timing. Reliability, measured as interrater agreement, ranged between 80 and 97%, with kappas of .46-.70. Validity analyses were done with 71 transit operators who participated in the observations and 177 operators who were assigned mean line-specific observational stressor measures. High odds ratios (ORs) were found for barriers and psychosomatic complaints (OR = 3.8, p = .00), time pressure and relaxation time needed after work (OR = 3.1, p = .05), and barriers and smoking to cope (OR = 3.8, p = .02). Using observational data in conjunction with self-report data can reduce confounding and improve interpretability of stress and health studies.

Psychosocial work environment and sickness absence among British civil servants: the Whitehall II study.

OBJECTIVES: This study sought to examine the association between the psychosocial work environment and subsequent rates of sickness absence. METHODS: The analyses were based on a cohort of male and female British civil servants (n=9072). Rates of short spells (7 days) of sickness absence were calculated for different aspects of the psychosocial work environment, as measured by self-reports and personnel managers' ratings (external assessments). RESULTS: Low levels of work demands, control, and support were associated with higher rates of short and long spells of absence in men and, to a lesser extent, in women. The differences were similar for the self-reports and external assessments. After adjustment for grade of employment, the differences were diminished but generally remained significant for short spells. The combination of high demands and low control was only associated with higher rates of short spells in the lower grades. CONCLUSIONS: The psychosocial work environment predicts rates of sickness absence. Increased levels of control and support at work could have beneficial effects in terms of both improving the health and well-being of employees and increasing productivity.

Sickness absence as a measure of health status and functioning: from the UK Whitehall II study.

STUDY OBJECTIVE: To investigate the relationship between self reported health status and sickness absence. DESIGN: Analysis of questionnaire and sickness absence data from the first phase of the Whitehall II study--a longitudinal study set up to investigate the degree and causes of the social gradient in morbidity and mortality. SETTING: London offices of 20 civil service departments. PARTICIPANTS: Altogether 6895 male and 3413 female civil servants aged 35-55 years. Analysis was conducted on 88% of participants who had complete data for the present analysis. MAIN RESULTS: A strong inverse relation between the grade of employment (measure of socioeconomic status) and sickness absence was observed. Men in the lowest grade had rates of sickness absence six times higher than those in the highest grade. For women the corresponding differences were two to five times higher. In general, the longer the duration of absence, the more strongly did baseline health predict rates of absence. However, the health measures also predicted shorter spells, although to a lesser extent. Job satisfaction was strongly related to sickness absence with higher rates in those who reported low job satisfaction. After adjusting for health status the association remained for one to two day absences, but was greatly reduced for absences longer than three days. CONCLUSION: There was a strong association between ill health and sickness absence, particularly for longer spells. The magnitude of the association may have been underestimated because of the strength of the association between grade of employment and sickness absence. It is proposed that sickness absence be used as an integrated measure of physical, psychological, and social functioning in studies of working populations.

Socioeconomic status and health. The challenge of the gradient.

Socioeconomic status (SES) is consistently associated with health outcomes, yet little is known about the psychosocial and behavioral mechanisms that might explain this association. Researchers usually control for SES rather than examine it. When it is studied, only effects of lower, poverty-level SES are generally examined. However, there is evidence of a graded association with health at all levels of SES, an observation that requires new thought about domains through which SES may exert its health effects. Variables are highlighted that show a graded relationship with both SES and health to provide examples of possible pathways between SES and health end points. Examples are also given of new analytic approaches that can better illuminate the complexities of the SES-health gradient.

Socioeconomic inequalities in health. No easy solution.

OBJECTIVE: Socioeconomic status (SES) is strongly associated with risk of disease and mortality. Universal health insurance is being debated as one remedy for such health inequalities. This article considers mechanisms through which SES affects health and argues that a broader and more comprehensive approach is needed. DATA SOURCES: Published articles surveyed using MEDLINE and review articles and bibliographies. METHODS AND RESULTS: Research is reviewed on the association of SES with health outcomes in different countries, including those with universal health coverage. Socioeconomic status relates to health at all levels of the SES hierarchy, and access to care accounts for little of this association. Other mechanisms are suggested and implications for policy and clinical practice are discussed. CONCLUSION: Health insurance coverage alone is not likely to reduce significantly SES differences in health. Attention should be paid both in policy decisions and in clinical practice to other SES-related factors that may influence patterns of health and disease.

Explaining socioeconomic differences in sickness absence: the Whitehall II Study.

OBJECTIVE: To describe and explain the socioeconomic gradient in sickness absence. DESIGN: Analysis of questionnaire and sickness absence data collected from the first phase of the Whitehall II study. Grade of employment was used as a measure of socioeconomic status. SETTING: 20 civil service departments in London. SUBJECTS: 6900 male and 3414 female civil servants aged 35-55 years. MAIN OUTCOME MEASURES: Rates of short spells (< or = 7 days) and long spells (> 7 days) of sickness absence. RESULTS: A strong inverse relation between grade of employment and sickness absence was evident. Men in the lowest grade had rates of short and long spells of absence 6.1 (95% confidence interval 5.3 to 6.9) and 6.1 (4.8 to 7.9) times higher than those in the highest grade. For women the corresponding rate ratios were 3.0 (2.3 to 3.9) and 4.2 (2.5 to 6.8) respectively. Several risk factors were identified, including health related behaviours (smoking and frequent alcohol consumption), work characteristics (low levels of control, variety and use of skills, work pace, and support at work), low levels of job satisfaction, and adverse social circumstances outside work (financial difficulties and negative support). These risk factors accounted for about one third of the grade differences in sickness absence. CONCLUSION: Large grade differences in sickness absence parallel socioeconomic differences in morbidity and mortality found in other studies. Identified risk factors accounted for a small proportion of the grade differences in sickness absence. More accurate measurement of the risk factors may explain some of the remaining differences in sickness absence but other factors, as yet unrecognised, are likely to be important.