Social epidemiology for the 21st century

Connecting to Community: A Social Identity Approach to Neighborhood Mental Health

ACADEMIC ABSTRACT

Integrative theorizing is needed to advance our understanding of the relationship between where a person lives and their mental health. To this end, we introduce a social identity model that provides an integrated explanation of the ways in which social-psychological processes mediate and moderate the links between neighborhood and mental health. In developing this model, we first review existing models that are derived primarily from a resource-availability perspective informed by research in social epidemiology, health geography, and urban sociology. Building on these, the social identity model implicates neighborhood identification in four key pathways between residents' local environment and their mental health. We review a wealth of recent research that supports this model and which speaks to its capacity to integrate and extend insights from established models. We also explore the implications of the social identity approach for policy and intervention.

PUBLIC ABSTRACT

We need to understand the connection between where people live and their mental health better than we do. This article helps us do this by presenting an integrated model of the way that social and psychological factors affect the relationship between someone's neighborhood and their mental health. This model builds on insights from social epidemiology, health geography, and urban sociology. Its distinct and novel contribution is to point to the importance of four pathways through which neighborhood identification shapes residents' mental health. A large body of recent research supports this model and highlights its potential to integrate and expand upon existing theories. We also discuss how our model can inform policies and interventions that seek to improve mental health outcomes in communities.

Defining Spatial Epidemiology: A Systematic Review and Re-orientation

BACKGROUND

Spatial epidemiology has emerged as an important subfield of epidemiology over the past quarter century. We trace the origins of spatial epidemiology and note that its emergence coincided with technological developments in spatial statistics and geography. We hypothesize that spatial epidemiology makes important contributions to descriptive epidemiology and analytic risk-factor studies but is not yet aligned with epidemiology's current focus on causal inference and intervention.

METHODS

We conducted a systematic review of studies indexed in PubMed that used the term "spatial epidemiolog*" in the title, abstract, or keywords. Excluded articles were not written in English, examined disease in animals, or reported biologic pathogen distribution only. We coded the included papers into five categories (review, demonstration of method, descriptive, analytic, and intervention) and recorded the unit of analysis (i.e., individual vs. ecological). We additionally examined articles coded as analytic ecologic studies using scales for lexical content.

RESULTS

A total of 482 articles met the inclusion criteria, including 76 reviews, 117 demonstrations of methods, 122 descriptive studies, 167 analytic studies, and 0 intervention studies. Demonstration studies were most common from 2006 to 2014, and analytic studies were most common after 2015. Among the analytic ecologic studies, those published in later years used more terms relevant to spatial statistics (incidence rate ratio =1.3; 95% confidence interval [CI] = 1.1, 1.5) and causal inference (incidence rate ratio =1.1; 95% CI = 1.1, 1.2).

CONCLUSIONS

Spatial epidemiology is an important and growing subfield of epidemiology. We suggest a re-orientation to help align its practice with the goals of contemporary epidemiology.

Area-level Measures of the Social Environment: Operationalization, Pitfalls, and Ways Forward

People's mental health is intertwined with the social environment in which they reside. This chapter explores approaches for quantifying the area-level social environment, focusing specifically on socioeconomic deprivation and social fragmentation. We discuss census data and administrative units, egocentric and ecometric approaches, neighborhood audits, social media data, and street view-based assessments. We close the chapter by discussing possible paths forward from associations between social environments and health to establishing causality, including longitudinal research designs and time-series social environmental indices.

Integrating the social environment with an equity perspective into the exposome paradigm: A new conceptual framework of the Social Exposome

The importance of the social environment and social inequalities in disease etiology is well-known due to the profound research and conceptual framework on social determinants of health. For a long period, in exposome research with its classical orientation towards detrimental health effects of biological, chemical, and physical exposures, this knowledge remained underrepresented. But currently it gains great awareness and calls for innovations in rethinking the role of social environmental health determinants. To fill this gap that exists in terms of the social domain within exposome research, we propose a novel conceptual framework of the Social Exposome, to integrate the social environment in conjunction with the physical environment into the exposome concept. The iterative development process of the Social Exposome was based on a systematic compilation of social exposures in order to achieve a holistic portrayal of the human social environment - including social, psychosocial, socioeconomic, sociodemographic, local, regional, and cultural aspects, at individual and contextual levels. In order to move the Social Exposome beyond a mere compilation of exposures, three core principles are emphasized that underly the interplay of the multitude of exposures: Multidimensionality, Reciprocity, and Timing and continuity. The key focus of the conceptual framework of the Social Exposome is on understanding the underlying mechanisms that translate social exposures into health outcomes. In particular, insights from research on health equity and environmental justice have been incorporated to uncover how social inequalities in health emerge, are maintained, and systematically drive health outcomes. Three transmission pathways are presented: Embodiment, Resilience and Susceptibility or Vulnerability, and Empowerment. The Social Exposome conceptual framework may serve as a strategic map for, both, research and intervention planning, aiming to further explore the impact of the complex social environment and to alter transmission pathways to minimize health risks and health inequalities and to foster equity in health.

Invited Commentary: Improving Instruments to Counter the Bias in Their Construction

In this issue of the Journal, Villalonga-Olives et al. (Am J Epidemiol. 2023;192(8):1264-1273) examined the psychometric properties of social capital indicators, comparing responses from Black and White people to identify whether there was differential item functioning (DIF) in social capital by race, and also when stratified by educational attainment, as a measure of socioeconomic status. The authors tested whether there is DIF in social capital items between Black and White people and found that DIF across these items was significant although not large, but they were still indicative of measurement error, which they suspected was related to the way these items were developed-that is, based on cultural assumptions tested in mainstream White America. However, some gaps remain to be fleshed out.

Pathways from climate change to emotional wellbeing: A qualitative study of Kenyan smallholder farmers living with HIV

Climate change is associated with adverse mental and emotional health outcomes. Social and economic factors are well-known drivers of mental health, yet comparatively few studies examine the social and economic pathways through which climate change affects mental health. There is additionally a lack of research on climate change and mental health in sub-Saharan Africa. This qualitative study aimed to identify potential social and economic pathways through which climate change impacts mental and emotional wellbeing, focusing on a vulnerable population of Kenyan smallholder farmers living with HIV. We conducted in-depth, semi-structured interviews with forty participants to explore their experience of climate change. We used a thematic analytical approach. We find that among our study population of Kenyan smallholder farmers living with HIV, climate change is significantly affecting mental and emotional wellbeing. Respondents universally report some level of climate impact on emotional health including high degrees of stress; fear and concern about the future; and sadness, worry, and anxiety from losing one's home, farm, occupation, or ability to support their family. Climate-related economic insecurity is a main driver of emotional distress. Widespread economic insecurity disrupts systems of communal and family support, which is an additional driver of worsening mental and emotional health. Our study finds that individual adaptive strategies used by farmers in the face of economic and social volatility can deepen economic insecurity and are likely insufficient to protect mental health. Finally, we find that agricultural policies can worsen economic insecurity and other mental health risk factors. Our proposed conceptual model of economic and social pathways relevant for mental health can inform future studies of vulnerable populations and inform health system and policy responses to protect health in a changing climate.

Community-Level Social Support to Mitigate the Impact of Combined Frailty and Multimorbidity on Psychological Distress Among Rural Chinese Older Adults During the COVID-19 Pandemic: Multilevel Modeling Study

BACKGROUND

Accumulating research provides evidence that the psychological health of older people deteriorated from before to during the COVID-19 pandemic. Unlike robust individuals, coexisting frailty and multimorbidity expose older adults to more complicated and wide-ranging stressors. Community-level social support (CSS) is also an important impetus for age-friendly interventions, and it is 1 of the components of social capital that is seen as an ecological-level property. To date, we have not found research that examines whether CSS buffered the adverse impacts of combined frailty and multimorbidity on psychological distress in a rural setting during COVID-19 in China.

OBJECTIVE

This study explores the combined effect of frailty and multimorbidity on psychological distress in rural Chinese older adults during the COVID-19 pandemic and examines whether CSS would buffer the aforementioned association.

METHODS

Data used in this study were extracted from 2 waves of the Shandong Rural Elderly Health Cohort (SREHC), and the final analytic sample included 2785 respondents who participated in both baseline and follow-up surveys. Multilevel linear mixed effects models were used to quantify the strength of the longitudinal association between frailty and multimorbidity combinations and psychological distress using 2 waves of data for each participant, and then, cross-level interactions between CSS and combined frailty and multimorbidity were included to test whether CSS would buffer the adverse impact of coexisting frailty and multimorbidity on psychological distress.

RESULTS

Frail older adults with multimorbidity reported the most psychological distress compared to individuals with only 1 or none of the conditions (β=.68, 95% CI 0.60-0.77, P<.001), and baseline coexisting frailty and multimorbidity predicted the most psychological distress during the COVID-19 pandemic (β=.32, 95% CI 0.22-0.43, P<.001). Further, CSS moderated the aforementioned association (β=-.16, 95% CI -0.23 to -0.09, P<.001), and increased CSS buffered the adverse effect of coexisting frailty and multimorbidity on psychological distress during the COVID-19 pandemic (β=-.11, 95% CI -0.22 to -0.01, P=.035).

CONCLUSIONS

Our findings suggest that more public health and clinical attention should be paid to psychological distress among multimorbid older adults with frailty when facing public health emergencies. This research also suggests that community-level interventions prioritizing social support mechanisms, specifically improving the average levels of social support within communities, may be an effective approach to alleviate psychological distress for rural older adults who concurrently manifest frailty and multimorbidity.

Socioeconomic determinants of demand for dental cosmetic treatments

Introduction

The demand for cosmetic dentistry is a growing trend globally. Increased media coverage, availability of free online information, and the improved economic status of the general population have led to an increase in the patient's aesthetic expectations. Since no study has measured the relationship between the economic status of people and the choice of cosmetic dentistry in Iran and due to the growing demand for it, this study was designed.

Method

In this descriptive epidemiological study, we visited three completely different areas in terms of Socioeconomic status (SES) in Tehran. A checklist was used to record the gender, job, age, education level, maternal status, and source of payment for cosmetic dentistry treatment.

Result

The majority of the volunteers for dental cosmetic restoration were 23-26 years. Of 498 cosmetic restoration volunteers, 50 were men and 448 were women. As for the education level, most of the participants had a high school diploma. The cost of cosmetic restoration of 351 patients (70%) was paid by the parents or the spouse, and 147 patients paid the cost from their income. Our study showed that 7% of visits to dental clinics were only for cosmetic treatment demands in Tehran in 2021.

Conclusion

Type of job, education level, and marital status had no significant relationship with the choice of cosmetic treatment while age had a significant relationship with the choice of cosmetic dental restoration treatment. In addition, the choice of cosmetic dental treatment was completely related to gender, and women were the main users of it.

Network social capital and health information acquisition

OBJECTIVE

This study examines the associations of network social capital with obtaining health information from health care professionals, the media, and laypeople. We also investigate whether and how the relationship between social capital and health information acquisition differs by personal health literacy. We used a position generator to measure network social capital.

METHODS

We conducted a survey with a nationally representative sample (N = 626) in the United States in April 2014.

RESULTS

Network social capital was positively associated with obtaining health information from health professionals, the media, and laypeople. Also, the associations of social capital with health information acquisition from health professionals were enhanced among those with adequate personal health literacy. However, health literacy did not moderate the relationship between social capital and health information acquisition from the media and laypeople.

CONCLUSION

Social capital may encourage individuals to utilize health information sources. Also, health literacy might reinforce the linkage between social capital and acquiring health information from health professionals.

PRACTICE IMPLICATIONS

Social capital interventions may promote health information acquisition. Also, health professionals should communicate with patients in a patient-centered way so that low-literate individuals easily understand health information. Moreover, a universal precaution approach should be employed.

Intersectional inequalities in industrial air toxics exposure in the United States

Environmental justice and health research demonstrate unequal exposure to environmental hazards at the neighborhood-level. We use an innovative method-eco-intersectional multilevel (EIM) modeling-to assess intersectional inequalities in industrial air toxics exposure across US census tracts in 2014. Results reveal stark inequalities in exposure across analytic strata, with a 45-fold difference in average exposure between most and least exposed. Low SES, multiply marginalized (high % Black, high % female-headed households) urban communities experienced highest risk. These inequalities were not described by additive effects alone, necessitating the use of interaction terms. We advance a critical intersectional approach to evaluating environmental injustices.

Social Capital, Black Social Mobility, and Health Disparities

This review aims to delineate the role of structural racism in the formation and accumulation of social capital and to describe how social capital is leveraged and used differently between Black and White people as a response to the conditions created by structural racism. We draw on critical race theory in public health praxis and restorative justice concepts to reimagine a race-conscious social capital agenda. We document how American capitalism has injured Black people and Black communities' unique construction of forms of social capital to combat systemic oppression. The article proposes an agenda that includes communal restoration that recognizes forms of social capital appreciated and deployed by Black people in the United States that can advance health equity and eliminate health disparities. Developing a race-conscious social capital framing that is inclusive of and guided by Black community members and academics is critical to the implementation of solutions that achieve racial and health equity and socioeconomic mobility.

Risks and Opportunities to Ensure Equity in the Application of Big Data Research in Public Health

The big data revolution presents an exciting frontier to expand public health research, broadening the scope of research and increasing the precision of answers. Despite these advances, scientists must be vigilant against also advancing potential harms toward marginalized communities. In this review, we provide examples in which big data applications have (unintentionally) perpetuated discriminatory practices, while also highlighting opportunities for big data applications to advance equity in public health. Here, big data is framed in the context of the five Vs (volume, velocity, veracity, variety, and value), and we propose a sixth V, virtuosity, which incorporates equity and justice frameworks. Analytic approaches to improving equity are presented using social computational big data, fairness in machine learning algorithms, medical claims data, and data augmentation as illustrations. Throughout, we emphasize the biasing influence of data absenteeism and positionality and conclude with recommendations for incorporating an equity lens into big data research.

The challenges of measuring social cohesion in public health research: A systematic review and ecometric meta-analysis

The relationship between social cohesion and health has been studied for decades. Yet, due to the contextual nature of this concept, measuring social cohesion remains challenging. Using a meta-analytical framework, this review's goal was to study the ecometric measurement properties of social cohesion in order to describe dissimilarities in its measurement as well as bring a new perspective on the empirical usefulness of the concept itself. To this end, we analysed if, and to what extent, contextual-level reliability and intersubjective agreement of 78 social cohesion measurements varied under different measurement conditions like measurement instrument, spatial unit, ecometric model specification, or region. We found consistent evidence for the contextual nature of social cohesion, however, most variation existed between individuals, not contexts. While contextual dependence in response behaviour was fairly insensitive to item choices, population size within chosen spatial units of social cohesion measurements mattered. Somewhat counterintuitively, using spatial units with, on average, fewer residents did not yield systematically superior ecometric properties. Instead, our results underline that precise theory about the relevant contextual units of causal relationships between social cohesion and health is vital and cannot be replaced by empirical analysis. Although adjustment for respondent's characteristics had only small effects on ecometric properties, potential pitfalls of this analytic strategy are discussed in this paper. Finally, acknowledging the sensitivity of measuring social cohesion, we derived recommendations for future studies investigating the effects of contextual-level social characteristics on health.

•

Social cohesion aims to describe aspects of the social environment we live in but its measurement remains challenging.

•

We meta-analysed the ecometric properties of 78 social cohesion measurements.

•

There is modest but consistent evidence for the contextual nature of social cohesion.

•

Contextual dependence in individual response behaviour is sensitive to the chosen spatial unit.

•

Meta-ecometrics studies the empirical usefulness of theoretical concepts aiming to describe social environments.

Factors Associated with Oral Cancerous and Precancerous Lesions in an Underserved Community: A Cross-Sectional Study

Street-involved people with limited access to regular healthcare have an increased risk of developing oral cancer and a lower survival rate. The objective of this study was to measure the prevalence of oral cancerous/precancerous lesions and determine their associated risk factors in a high-risk, underserved population. In this cross-sectional study, English-speaking adults aged 18 years and older living in a marginalized community in Edmonton were recruited from four non-profit charitable organizations. Data were collected through visual oral examinations and a questionnaire. Descriptive statistics, chi-squared tests, and logistic regressions were applied. In total, 322 participants with a mean (SD) age of 49.3 (13.5) years completed the study. Among them, 71.1% were male, 48.1% were aboriginal, and 88.2% were single. The prevalence of oral cancerous lesions was 2.4%, which was higher than the recorded prevalence in Canada (0.014–1.42: 10,000) and in Alberta (0.011–1.13: 10,000). The clinical examinations indicated that 176 (54.7%) participants had clinical inflammatory changes in their oral mucosa. There was a significant association between clinical inflammatory oral lesions and oral cancerous/precancerous lesions (p < 0.001). Simple logistic regression showed that the risk of the presence of oral cancerous/precancerous lesions was two times higher in participants living in a shelter or on the street than in those living alone (OR = 2.06; 95% CI: 1.15–3.82; p-value: 0.021). In the multiple logistic regression analysis, the risk of oral cancerous/precancerous lesions was 1.68 times higher in participants living in a shelter or on the street vs. living alone after accounting for multiple predictors (OR = 1.67; 95% CI: 1.19–2.37; p-value: 0.022). The results demonstrated a high prevalence of cancerous/precancerous lesions among the study participants, which was significantly associated with clinical inflammatory oral lesions. The evidence supports the need for developing oral cancer screening and oral health promotion strategies in underserved communities.

Social Epidemiology: Past, Present, and Future

In a context where epidemiologic research has been heavily influenced by a biomedical and individualistic approach, the naming of “social epidemiology” allowed explicit emphasis on the social production of disease as a powerful explanatory paradigm and as critically important for interventions to improve population health. This review briefly highlights key substantive areas of focus in social epidemiology over the past 30 years, reflects on major advances and insights, and identifies challenges and possible future directions. Future opportunities for social epidemiology include grounding research in theoretically based and systemic conceptual models of the fundamental social drivers of health; implementing a scientifically rigorous yet realistic approach to drawing conclusions about social causes; using complementary methods to generate valid explanations and identify effective actions; leveraging the power of harmonization, replication, and big data; extending interdisciplinarity and diversity; advancing emerging critical approaches to understanding the health impacts of systemic racism and its policy implications; going global; and embracing a broad approach to generating socially useful research.

Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

A psychometric assessment of a network social capital scale among sexual minority men and gender minority individuals

BACKGROUND

Social capital, the potential for individuals to access resources through group memberships, is linked to a constellation of health outcomes. We modified a previously evaluated Constructed Family Social Capital Scale for gay, bisexual and other men who have sex with men who belong to constructed families to create a new measure of social capital within sexual minority men and gender minority individuals' social networks.

METHODS

Participants were recruited from a Pride festival in Milwaukee, Wisconsin in 2018 to complete a cross-sectional survey. This analysis is restricted to 383 participants who identified as sexual minority men or gender minority individuals and completed nine items measuring social capital within their social networks. We conducted exploratory and confirmatory factor analyses to assess factor structure. Internal consistency was measured using Cronbach's alpha.

RESULTS

Reliability was high, indicating the scale's utility to assess Network Social Capital among sexual minority men and gender minority individuals. A single-factor solution with high factor loadings was found for the nine-item scale.

CONCLUSIONS

This study extended the psychometric properties of a preliminary social capital instrument modified from a prior study in a different population and context. The modified measure has implications for use among sexual minority men and gender minority individuals to measure social capital within social networks. Previous studies suggest that interventions to enhance social capital among sexual minority men and gender minority individuals may be beneficial for HIV prevention interventions. This tool may be relevant for the evaluation of social capital interventions within networks of sexual minority men and gender minority individuals.

Does social capital increase healthcare financing's projection? Results from the rural household of Uttar Pradesh, India

In the absence of adequate social security, out-of-pocket health expenditure compels households to adopt coping strategies, such as utilizing savings, selling assets, or acquiring external financial support (EFS) by borrowing with interest. Households' probability of acquiring EFS and its amount (intensity) depends on its social capital – the nature of social relationships and resources embedded within social networks. This study examines the effect of social capital on the probability and intensity of EFS during health events in Uttar Pradesh (UP), India. The analysis used data from a cross-sectional survey of 6218 households, reporting 3066 healthcare events, from two districts of UP. Household heads (HH) reported demographic, socioeconomic, and health-related information, including EFS, for each household member. Self-reported data from Shortened and Adapted Social Capital Assessment Tool in India (SASCAT-I) was used to generate four unique social capital measures (organizational participation, social support, trust, and social cohesion) at HH and community-level, using multilevel confirmatory factor analysis. After descriptive analysis, two-part mixed-effect models were implemented to estimate the probability and intensity of EFS as a function of social capital measures, where multilevel mixed-effects probit regression was used as the first-part and multilevel mixed-effects linear model with log link and gamma distribution as the second-part. Controlling for all covariates, the probability of acquiring EFS significantly increased (p = 0.04) with higher social support of the HH and significantly decreased (p = 0.02) with higher community social cohesion. Conditional to receiving any EFS, higher social trust of the HH resulted in higher intensity of EFS (p = 0.09). Social support and trust may enable households to cope up with financial stress. However, controlling for the other dimensions of social capital, high cohesiveness with the community might restrict a household's access to external resources demonstrating the unintended effect of social capital exerted by formal or informal social control.

•

Social support assists household head to acquire external financing for healthcare payment.

•

But higher social support may not secure higher intensity of receiving external financing.

•

However, trust is a catalyst to acquire more financing conditional of any external financing was acquire in the first place.

•

Living in a cohesive community may restrict access to external financial resources.

Examining the multilevel associations between psychological wellbeing and social trust: A primary analysis of survey data

The present study examines the associations between multiple measures of social trust and two outcomes of psychological wellbeing (happiness and depression) among South Korean adults (n = 1549) living in residential communities, that is, administrative districts (n = 77) in and around the capital city of Seoul. Based on multilevel modeling, we find that familial trust positively predicts happiness at both individual and contextual levels; and it negatively predicts depression at the individual level only. In comparison, peer trust is negatively related only to depression at the individual level, albeit marginally. Lastly, general trust significantly predicts both outcomes at the community, but not individual, level. These mixed findings suggest that the trust-wellbeing relationship depends critically on issues of definition (how the variables are conceptualized) and measurement (how they are operationalized according to different units of analysis). Our study offers implications for the literature on social determinants of mental health broadly and, more specifically, on the role of social trust.

'Known to be unhealthy': Exploring how social epidemiological research constructs the category of low socioeconomic status

We examine how the category of low socioeconomic status (LSES) was constructed in European social epidemiological research and policy advice from 1977 to 2019. We analysed 22 empirical social epidemiological research publications on LSES and health, as well as six scientific advisory reports that offered government officials an overview of scientific evidence on health inequalities. We show the construction and reification of LSES as a problematic group in dominant thought, which consists of the following components: 1) the proliferation of SES concepts, indicators and groups labelled LSES; 2) generalisation through which LSES is constructed as a single population; 3) problematisation through which LSES is constructed as an inherently unhealthy population; and 4) individualisation by which a LSES personality is presented as an explanation of health differences. We also show how this knowledge is extrapolated into the policy domain in the form of scientific advisory reports. These findings provide evidence of the construction of LSES as an inherently unhealthy population through hyperproliferation and references to the objectivity of scientific research. With respect to the LSES category, the dynamics of research and policy resemble those regarding categories of ethnicity and gender. We conclude that if the construction of LSES remains unquestioned, social epidemiology might continue to (re)produce what it examines: LSES populations 'known to be unhealthy'.

Eviction Moratoria Expiration and COVID-19 Infection Risk Across Strata of Health and Socioeconomic Status in the United States

IMPORTANCE

Housing insecurity induced by evictions may increase the risk of contracting COVID-19.

OBJECTIVE

To estimate the association of lifting state-level eviction moratoria, which increased housing insecurity during the COVID-19 pandemic, with the risk of being diagnosed with COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included individuals with commercial insurance or Medicare Advantage who lived in a state that issued an eviction moratorium and were diagnosed with COVID-19 as well as a control group comprising an equal number of randomly selected individuals in these states who were not diagnosed with COVID-19. Data were collected from OptumLabs Data Warehouse, a database of deidentified administrative claims. The study used a difference-in-differences analysis among states that implemented an eviction moratorium between March 13, 2020, and September 4, 2020.

EXPOSURES

Time since state-level eviction moratoria were lifted.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was a binary variable indicating whether an individual was diagnosed with COVID-19 for the first time in a given week with International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code U07.1. The study analyzed changes in COVID-19 diagnosis before vs after a state lifted its moratorium compared with changes in states that did not lift it. For sensitivity analyses, models were reestimated on a 2% random sample of all individuals in the claims database during this period in these states.

RESULTS

The cohort consisted of 509 694 individuals (254 847 [50.0%] diagnosed with COVID-19; mean [SD] age, 47.0 [23.6] years; 239 056 [53.3%] men). During the study period, 43 states and the District of Columbia implemented an eviction moratorium and 7 did not. Among the states that implemented a moratorium, 26 (59.1%) lifted their moratorium before the US Centers for Disease Control and Prevention issued their national moratorium, while 18 (40.1%) maintained theirs. In a Cox difference-in-differences regression model, individuals living in a state that lifted its eviction moratorium experienced higher hazards of a COVID-19 diagnosis beginning 5 weeks after the moratorium was lifted (hazard ratio [HR], 1.39; 95% CI, 1.11-1.76; P = .004), reaching an HR of 1.83 (95% CI, 1.36-2.46; P < .001) 12 weeks after. Hazards increased in magnitude among individuals with preexisting comorbidities and those living in nonaffluent and rent-burdened areas. Individuals with a Charlson Comorbidity Index score of 3 or greater had an HR of 2.37 (95% CI, 1.67-3.36; P < .001) at the end of the study period. Those living in nonaffluent areas had an HR of 2.14 (95% CI, 1.51-3.05; P < .001), while those living in areas with a high rent burden had an HR of 2.31 (95% CI, 1.64-3.26; P < .001).

CONCLUSIONS AND RELEVANCE

The findings of this difference-in-differences analysis suggest that eviction-led housing insecurity may have exacerbated the COVID-19 pandemic.

Come together to promote health: case study and theoretical perspectives from a Kenyan community-based program

Over the past four decades, group-based microfinance programs have spread rapidly throughout south Asia, sub-Saharan Africa and Latin America. Recent evaluations of the programs have identified social capital as a common byproduct of frequent association by members, increasing trust, belonging and normative influence. Concurrently, social capital is increasingly recognized as an important health determinant. We present an overview of a program intervention operating in Kenya that utilizes a microfinance approach to produce social capital, and seeks to leverage that social capital to promote health at three levels-the village, group, and individual. A theory of change is presented for each of these three levels, demonstrating conceptually and with program examples how social capital can be applied to promote health. Related social theories and approaches, further research and program directions are given for each of the three levels. We identify potential to improve a broad range of health outcomes through this innovative model, which requires engagement with health promotion researchers and planners in low- and middle-income countries for further refinement and validation.

Social inequalities, debt, and health in the United States

Background

Household financial debt has more than tripled since the 1980s in the United States. The experience of indebtedness is socially structured and there is mounting evidence that debt is linked to decrements in health. However, it is unclear whether debt contributes to social disparities in health.

Objective

We examined whether household debt, measured by debt in excess of income and wealth, mediated education-based social inequalities in health, including cardiovascular risk factors (hypertension) and chronic conditions (diabetes, coronary heart disease, and psychiatric problems).

Method

We used longitudinal data from a sample of over 10,500 adults aged 18 years and older surveyed biennially between 1999 and 2015 as part of the Panel Study of Income Dynamics (PSID). We estimated the total effect of education on our health outcomes. To assess mediation by levels of household debt, we then estimated the controlled direct effect of education through pathways not mediated by levels of household debt, after accounting for lagged time-varying confounders and loss to follow-up using marginal structural models.

Results

Compared to respondents with at least a high school education, respondents with less than a high school education reported higher household debts in excess of income and wealth; they also reported a higher incidence of hypertension [risk ratio (RR) = 1.25, 95%CI = 1.13, 1.39), coronary heart disease (RR = 1.42, 95%CI: 1.25, 1.62), diabetes (RR = 1.50, 95%CI: 1.34, 1.68), and psychiatric problems (RR = 1.39, 95%CI: 1.24, 1.56). Compared to the total effects, the controlled direct effects of education on health were attenuated, particularly for death or first onset of hypertension and coronary heart disease, after fixing levels of household debt-to-income and debt-to-wealth.

Conclusion

Our results provide early evidence that household debt in excess of wealth partly mediates education-based inequalities in hypertension and coronary heart disease in the United States, with less consistent evidence for other chronic conditions.

Exponential-growth prediction bias and compliance with safety measures related to COVID-19

Objective

We define prediction bias as the systematic error arising from an incorrect prediction of the number of positive COVID cases x-weeks hence when presented with y-weeks of prior, actual data on the same. Our objective is to investigate the importance of an exponential-growth prediction bias (EGPB) in understanding why the COVID-19 outbreak has exploded. To that end, our goal is to document EGPB in the comprehension of disease data, study how it evolves as the epidemic progresses, and connect it with compliance of personal safety guidelines such as the use of face coverings and social distancing. We also investigate whether a behavioral nudge, cost less to implement, can significantly reduce EGPB.

Rationale

The scientific basis for our inquiry is the received wisdom that infectious disease spread, especially in the initial stages, follows an exponential function meaning few positive cases can explode into a widespread pandemic if the disease is sufficiently transmittable. If people suffer from EGPB, they will likely make incorrect judgments about their infection risk, which in turn, may lead to reduced compliance of safety protocols.

Method

To collect data on prediction bias, we ran an incentivized, experiment on a global, online platform with participation from people in forty-three countries, each at different stages of progression of COVID-19. We also constructed several indices of compliance by surveying participants about their frequency of hand-washing and use of sanitizers and masks; their willingness to pay for masks; their view about the social appropriateness of others’ behavior; and their like/dislike of government responses. The prediction data was used to construct several measures of EGPB. Our experimental design permits us to identify the root of under-prediction as EGPB arising from the general tendency to underestimate the speed at which exponential processes unfold.

Results

Respondents make predictions about the path of the disease using a model that is substantially less convex than the actual data generating process. This creates significant EGPB, which, in turn, is significantly and negatively associated with non-compliance with safety measures. The bias is significantly higher for respondents from countries at a later stage relative to those at an early stage of disease progression. A simple behavioral nudge that shows prior data in terms of raw numbers, as opposed to a graph, causally reduces EGPB.

Conclusion

Behavioral biases concerning the comprehension of disease data are quantitatively important, and act as severe impediments to effective policy action against the spread of COVID-19. Clear communication of future infection risk via raw numbers could increase the accuracy of risk perception, in turn, facilitating compliance with suggested protective behaviors.

•

Examines bias in the prediction of number of future positive COVID cases.

•

Bias is negatively associated with non-compliance with WHO safety measures.

•

Bias is higher for those in countries at a later stage of disease progression.

•

Showing prior data through raw numbers, as opposed to graphs, causally reduces bias.

Social Capital and Risk of Concurrent Sexual Partners Among African Americans in Jackson, Mississippi

Concurrent sexual partnerships (i.e., relationships that overlap in time) contribute to higher HIV acquisition risk. Social capital, defined as resources and connections available to individuals is hypothesized to reduce sexual HIV risk behavior, including sexual concurrency. Additionally, we do not know whether any association between social capital and sexual concurrency is moderated by gender. Multivariable logistic regression tested the association between social capital and sexual concurrency and effect modification by gender. Among 1445 African Americans presenting for care at an urban STI clinic in Jackson, Mississippi, mean social capital was 2.85 (range 1-5), mean age was 25 (SD = 6), and 62% were women. Sexual concurrency in the current year was lower for women compared to men (45% vs. 55%, χ²(df = 1) = 11.07, p = .001). Higher social capital was associated with lower adjusted odds of sexual concurrency for women compared to men (adjusted Odds Ratio [aOR] = 0.62 (95% CI 0.39-0.97), p = 0.034), controlling for sociodemographic and psychosocial covariates. Interventions that add social capital components may be important for lowering sexual risk among African Americans in Mississippi.

PrEP indicators, social capital and social group memberships among gay, bisexual and other men who have sex with men

Efforts to reduce HIV among gay, bisexual and other men who have sex with men include increasing awareness and uptake of pre-exposure prophylaxis (PrEP). Social capital may facilitate engagement in HIV prevention. Membership of social groups including chosen families (i.e. friends as family relationships) - one potential indicator of social capital - may be protective against HIV risk and infection. In this cross-sectional quantitative study, we examined social capital items and social group membership in association with PrEP outcomes. In 2014, the New Orleans arm of the National HIV Behavioral Surveillance recruited 353 HIV-negative men, of whom 46% identified as Black, Latino or Other Race and 54% as Non-Hispanic White, using venue-based sampling to complete a structured survey. Multivariable logistic regression models tested the relations between social group membership and social capital with PrEP indicators. Men who reported community group participation were more likely to be aware of PrEP compared to those who did not. Men in chosen families associated with a family name were least likely to be aware of and willing to take PrEP compared to those not in any other social groups. Social group membership is a potential social capital indicator for assessing HIV prevention among men.

'When you think your neighbour's cooking pot is better than yours': A mixed-methods exploration of inequality and wellbeing in Ghana

Existing evidence suggests that rising inequality is detrimental to population wellbeing. However, the mediums through which inequality affects wellbeing in the context of low to middle-income countries (LMICs), where absolute and relative deprivation are extreme, remain unknown. As part of a larger research program that aims to develop a Global Index of Wellbeing (GLOWING), this paper explores the linkages between inequality and wellbeing in Ghana. We used key constructs from the capability and ecosocial theoretical frameworks, and a parallel mixed-methods approach. Through path analysis, we examined the pathways between different measures of inequality and wellbeing. Further, qualitative interviews were used to explore perceptions of inequality and links with wellbeing; this provided context and depth to our quantitative results. Results show that inequalities may affect wellbeing by constraining access to basic amenities like water, food, and housing and also through community social capital and cohesion. The implications of the results for policy and practice, specifically to ensuring shared prosperity, are discussed.

Towards a People's Social Epidemiology: Envisioning a More Inclusive and Equitable Future for Social Epi Research and Practice in the 21st Century

Social epidemiology has made critical contributions to understanding population health. However, translation of social epidemiology science into action remains a challenge, raising concerns about the impacts of the field beyond academia. With so much focus on issues related to social position, discrimination, racism, power, and privilege, there has been surprisingly little deliberation about the extent and value of social inclusion and equity within the field itself. Indeed, the challenge of translation/action might be more readily met through re-envisioning the role of the people within the research/practice enterprise-reimagining what "social" could, or even should, mean for the future of the field. A potential path forward rests at the nexus of social epidemiology, community-based participatory research (CBPR), and information and communication technology (ICT). Here, we draw from social epidemiology, CBPR, and ICT literatures to introduce A People's Social Epi-a multi-tiered framework for guiding social epidemiology in becoming more inclusive, equitable, and actionable for 21st century practice. In presenting this framework, we suggest the value of taking participatory, collaborative approaches anchored in CBPR and ICT principles and technological affordances-especially within the context of place-based and environmental research. We believe that such approaches present opportunities to create a social epidemiology that is of, with, and by the people-not simply about them. In this spirit, we suggest 10 ICT tools to "socialize" social epidemiology and outline 10 ways to move towards A People's Social Epi in practice.

Adolescent Socioeconomic Status and Mental Health Inequalities in the Netherlands, 2001-2017

Even in wealthy countries there are substantial socioeconomic inequalities in adolescent mental health. Socioeconomic status (SES) indicators-parental SES, adolescent subjective SES and adolescent educational level-are negatively associated with adolescent mental health problems, but little is known about the interplay between these SES indicators and whether associations have changed over time. Using data from the Dutch Health Behaviour in School-Aged Children (HBSC) studies (n = 27,020) between 2001 and 2017, we examined associations between three SES indicators and six indicators of adolescent mental health problems. Linear regressions revealed that adolescent subjective SES and adolescent educational level were independently negatively associated with adolescent mental health problems and positively associated with adolescent life satisfaction, but parental SES had negligible independent associations with adolescent mental health problems and life satisfaction. However, when interactions between SES indicators were considered, high adolescent subjective SES was shown to buffer the negative association between parental SES and adolescent mental health problems and the positive association between parental SES and life satisfaction. Despite societal changes between 2001 and 2017, socioeconomic inequalities in adolescent mental health were stable during this period. Findings suggest that all three SES indicators-parental SES, adolescent subjective SES and adolescent educational level-are important for studying socioeconomic inequalities in adolescent mental health.

What determines gender inequalities in social capital in Ukraine?

Background

Social capital is a social determinant of health that has an impact on equity and well-being. It may be unequally distributed among any population. The aims of this study are to investigate the distribution of different forms of social capital between men and women in Ukraine and analyse how potential gender inequalities in social capital might be explained and understood in the Ukrainian context.

Method

The national representative cross-sectional data from the European Social Survey (wave 6) was used with a sample of 1377 women and 797 men. Seven outcomes that represent cognitive and structural social capital were constructed i.e. institutional trust, generalised trust, reciprocity, safety, as well as bonding, bridging and linking forms. Multivariate logistic regression and post-regression Fairlies decompositions were used for the analyses.

Results

There are several findings that resulted from the analyses i), access to institutional trust, linking and bridging social capital is very limited; ii), the odds for almost all forms of social capital (besides safety) are lower for men; iii), feeling about income and age explain most of the gender differences and act positively, as well as offsetting the differences.

Conclusion

Social capital is unequally distributed between different population groups. Some forms of social capital have a stronger buffering effect on women than on men in Ukraine. Reducing gender and income inequalities would probably influence the distribution of social capital within the society.

•

There is a limited access to institutional trust, linking and bridging social capital.

•

The odds for almost all forms of social capital are lower for men (besides safety).

•

Feeling about income and age explain most of the gender differences.

•

Feeling about income and age offset most of the gender differences.

Network Properties Among Gay, Bisexual and Other Men Who Have Sex with Men Vary by Race

The HIV burden among gay, bisexual, and other men who have sex with men (GBM) may be related to variations in network characteristics of the individual's social and sexual network. This study investigates variations in network properties among 188 Black and 295 White GBM recruited in New Orleans during the National HIV Behavioral Surveillance in 2014. Participants described up to five people who provided social support and five sex partners in the past 3 months. Network properties and network dissimilarity indicators were aggregated to the participant level as means or proportions and examined using PROC GLM. White participants reported larger networks (p = 0.0027), had known network members longer (p = 0.0033), and reported more substance use (p < 0.0001) within networks. Black participants reported networks with fewer men (p = 0.0056) and younger members (p = 0.0110) than those of White GBM. Network properties among GBM differ by race in New Orleans which may inform prevention interventions.

Participation in community groups increases the likelihood of PrEP awareness: New Orleans NHBS-MSM Cycle, 2014

Background

Gay, bisexual, and other men who have sex with men (GBM) have the highest proportion of incident HIV infection. Pre-exposure prophylaxis (PrEP) use and screening for sexually transmitted infections (STIs) are primary HIV prevention strategies, however, uptake remains low. Social capital, collective resources generated through social connections, are associated with lower HIV risk and infection. We investigated social capital in association with PrEP indicators among GBM.

Methods

Analyses included (N = 376) GBM from the 2014 National HIV Behavioral Surveillance (NHBS) in New Orleans. Multiple regression methods assessed the association between one item within each of eight domains from the Onyx and Bullen Social Capital Scale and: awareness and willingness to use PrEP. Analyses are adjusted for age, race, education, sexual intercourse with women, and health insurance.

Results

Forty percent of GBM were 18–29 years, 52 percent White. Sixty percent were willing to use PrEP. Social capital was above 50 percent across 7 of 8 indicators. Community group participation (vs no participation) was associated with higher likelihoods of PrEP awareness (adjusted Prevalence Ratio [aPR] = 1.41, 95% Confidence Interval [CI] = 1.02, 1.95). None of the seven remaining social capital indicators were significantly associated with any of the PrEP outcomes.

Conclusions

Community groups and organizations could be targeted for interventions to increase uptake of HIV prevention strategies among GBM in New Orleans

Into the realm of social capital for adolescents: A latent profile analysis

Background

Recent reports of increasing prevalence of frequent health complaints and mental health problems among adolescents call for directing more attention on determinants of adolescent health. The relationship between health and social capital has gained increased attention since the early 2000’s and research at review level confirms the importance of social capital for health outcomes, despite methodological heterogeneity. The aim of this study was to identify distinct profiles of family, school and peer social capital in a nationally representative sample of adolescents and to explore health outcomes in those profiles.

Method

Cross-sectional data from the Swedish Health Behaviour of School-aged Children 2013/14 was used for this study. The analytical sample consisted of 7,804 adolescents aged 11-, 13- and 15-years. Items representing sense of belonging and emotional support were assessed in three contexts; family, school and among peers. Latent profile analyses (LPA) were run to determine social capital profiles. Health outcomes included frequent health complaints and life satisfaction, while socioeconomic status and genders were included as predictors.

Results

The results show that five distinct profiles best represent the data for 11- and 15-year olds, while a four-profile model was optimal for 13-year olds. Some profiles were recurrent between age groups but unique profiles were also found. Health outcomes were significantly different between profiles depending on levels of social capital in the different contexts.

Conclusions

This study provides novel insight into how social capital co-occurs among adolescents within the contexts of family, school and peers and how this translates into differences in health outcomes. The national representativeness of the sample increases the implications of the results and contributes to meaningful insights that help explain the interactions of social capital in multiple contexts, complementing what is previously known about the relationship with adolescent health.

Development of a social capital scale for constructed families of gay, bisexual, and other men who have sex with men

Despite previous empirical studies which have linked social capital to a number of health outcomes, few studies have investigated sub-group specific social capital among populations at increased risk for HIV infection such as gay, bisexual and other men who have sex with men (GBM). Many GBM of color belong to constructed families in which friends refer to each other with kinship terms such as parents and children. No studies have measured social capital provisions within constructed family networks. This study developed a preliminary instrument for assessing social capital among constructed families. The network level social capital scale incorporated the following theoretical domains hypothesized to define social capital derived from network membership: social influence, multiplex ties, heterogeneity, social cohesion, trust, quality of support, and compositional quality. A cross-sectional survey administered an eight-item scale to 131 GBM who belonged to constructed families. The factor structure and confirmatory factor analysis were assessed. Reliability was evaluated using Cronbach's alpha to measure internal consistency. A final single factor solution was obtained which was comprised of six items with high factor loadings. The resulting measures were highly correlated with an alpha of 0.84 and each factor loading was well above 0.3. This study assessed the psychometric properties of a preliminary network level social capital instrument among GBM in constructed families. Future studies may utilize or adopt this scale to measure network-level social capital within other populations.

Community organizations and mental health after the 2013 Boston Marathon bombings

OBJECTIVE

Disasters are place-based traumatic events, yet contemporary understandings of disaster recovery often do not consider the role of community organizations. We examine organization type and proximity as they relate to post-disaster mental health in a longitudinal study following the 2013 Boston Marathon bombings.

METHOD

Residents of metropolitan Boston (N = 846) were recruited via a probability-based sampling strategy within weeks of the bombings and were surveyed several times over a two-year period. Residents of metropolitan New York (N = 941) were recruited and surveyed at the same time and used for comparison due to similarities in community demographics, geography, and disaster histories. We identified six different organization types nearby resident: safety-based organizations, religious organizations, educational organizations, child- and family-promoting organizations, health-based organizations, and voluntary community organizations. With possible environmental detriments (crowds and noise) or benefits of organizations amplified in areas closest to the resident, the concentration of these local organization types was examined at different distance-based boundaries. Contextual data for both communities came from the U.S. Census, Google Places API, and Guidestar.

RESULTS

For Boston metropolitan area residents, having more safety-based organizations within a half-mile to one-mile area in the aftermath of the bombings was associated with poorer functioning six to seven months later and greater psychological distress two years later. However, the presence of more safety-based organizations in the one to three mile area was associated with decreased psychological distress two years later. More health-based and voluntary community organizations in the half-mile to one-mile area were also associated with fewer fears and worries about future adversity two years post-bombing. Exposure to the bombings and other community traumas moderated this relationship among Boston area participants.

CONCLUSION

Results suggest that local community organizations are not merely buildings or structures but ecological sources of support to those in need after a disaster.

Social capital and HIV/AIDS in the United States: Knowledge, gaps, and future directions

Purpose

Social capital is a well-established predictor of several behavioral health outcomes. However, we know less about the relationship with prevention, transmission, and treatment of HIV/AIDS outcomes in the United States (US).

Methods

In 2017, we conducted a scoping review of empirical studies investigating the relationships between social capital and HIV/AIDS in the US by searching PubMed, Embase, PsycINFO, Web of Science, and Sociological Abstracts with no restriction on publication date, for articles in English language. Sample search terms included: HIV infections OR HIV OR AIDS OR acquired immunodeficiency syndrome OR human immunodeficiency virus AND social capital OR social control, informal OR social participation OR social cohesion OR generalized trust OR social trust OR collective efficacy OR community mob* OR civic participation.

Results

We identified 1581 unique manuscripts and reviewed 13 based on eligibility criteria. The earliest eligible study was published in 2003. More than half (n=7/13) focused on HIV or AIDS diagnosis, then prescribing ART and/or adherence (n=5/13), then linkage and or engagement in HIV care (n=4/13). Fifty eight percent (58%) documented a protective association between at least one social capital measure and an HIV/AIDS outcome. Seven studies used validated social capital scales, however there was substantial variation in conceptual/operational definitions and measures used. Most studies were based on samples from the Northeast. Three studies directly focused on or stratified analyses among subgroups or key populations. Studies were cross-sectional, so causal inference is unknown.

Conclusion

Our review suggests that social capital may be an important determinant of HIV/AIDS prevention, transmission, and treatment outcomes. We recommend future research assess these associations using qualitative and mixed-methods approaches, longitudinally, examine differences across subgroups and geographic region, include a wider range of social capital constructs, and examine indicators beyond HIV diagnosis, as well as how mechanisms like stigma link social capital to HIV/AIDS.

The influence of stunting on obesity in adulthood: results from the EPIPorto cohort

Objective

To retrospectively investigate the association between short stature and increased sitting height ratio (SHR) – indicators of stunting – and obesity markers in adults.

Design

Cross-sectional evaluation of the EPIPorto cohort. Weight, height, sitting height and waist circumference were measured. Obesity was assessed for men and women through BMI and waist-to-height ratio (WHtR). Short stature (women, <152 cm; men, <164 cm) and high SHR (women, ≥54·05 %; men, ≥53·25 %) were taken as stunting measures. OR with 95 % CI were computed using logistic regression models.

Setting

Representative sample of adults from EPIPorto, an adult cohort study from Porto, Portugal.

Subjects

A sample of 1682 adults, aged 18–86 years, was analysed.

Results

Higher obesity prevalence was found among women (BMI≥30·0 kg/m2: 25·5v.13·3 %,P<0·001) and a higher proportion of men presented abdominal obesity (WHtR≥0·5: 80·1v.71·1 %,P<0·001). A positive association was found between short stature and obesity measures for women (multivariate-adjusted OR; 95 % CI: 1·75; 1·17, 2·62 for BMI≥30·0 kg/m2; 1·89; 1·24, 2·87 for WHtR≥0·5). Increased SHR was associated with higher likelihood of having BMI≥30·0 kg/m2in both sexes (multivariate-adjusted OR; 95 % CI: 2·10; 1·40, 3·16 for women; 1·92; 1·07, 3·43 for men) but not with WHtR≥0·5.

Conclusions

Different growth markers are associated with obesity in adults. However, this association depends on the population and anthropometric measures used: short stature is associated with a higher risk of presenting excessive weight in women but not in men; SHR is more sensitive to detect this effect in both sexes.