A structural equation modeling approach to understanding pathways that connect socioeconomic status and smoking

The mediating role of community identity in the relationship between social class and life satisfaction: Evidence from Chinese community residents

Research has shown that social class is an important predictor of life satisfaction. However, the underlying mechanism for this relationship is yet to be fully elucidated. The study examined the underlying mechanism based on the social identity approach to health. Study 1 recruited 577 community residents to complete self-report questionnaires. Correlation analysis showed that social class, community identity, and life satisfaction were positively correlated with each other. Regression analysis showed that community identity mediated the relationship. To increase the replicability and derive causal inference of the results, Study 2 was a randomized control trial (N = 76) that used the resource-availability task to manipulate subjective social class, and found that life satisfaction in the lower-class group was significantly lower than that in the control group. Further analysis showed that social class predicted life satisfaction through the mediating role of community identity. The findings provide potential strategies to enhance community residents' life satisfaction.

The Uncontrollable Mortality Risk Hypothesis: Theoretical foundations and implications for public health

The 'Uncontrollable Mortality Risk Hypothesis' employs a behavioural ecological model of human health behaviours to explain the presence of social gradients in health. It states that those who are more likely to die due to factors beyond their control should be less motivated to invest in preventative health behaviours. We outline the theoretical assumptions of the hypothesis and stress the importance of incorporating evolutionary perspectives into public health. We explain how measuring perceived uncontrollable mortality risk can contribute towards understanding socioeconomic disparities in preventative health behaviours. We emphasize the importance of addressing structural inequalities in risk exposure, and argue that public health interventions should consider the relationship between overall levels of mortality risk and health behaviours across domains. We suggest that measuring perceptions of uncontrollable mortality risk can capture the unanticipated health benefits of structural risk interventions, as well as help to assess the appropriateness of different intervention approaches.

Disparities in Patient Family Social Determinants of Health in a Large Urban Pediatric Health System

INTRODUCTION

This analysis sought to identify disparities in social determinants of health (SDOH) outcomes at a Texas pediatric hospital.

METHODS

This retrospective study used electronic health records of pediatric patients families surveyed August -December 2022. Outcomes for health literacy, social support, food, transportation, energy, digital, and housing insecurity, and tobacco exposure were analyzed across demographic categories.

RESULTS

Among 15,294 respondents to the survey (mean child age, 8.73 years; 43.68% Hispanic, 29.73% non-Hispanic White, 18.27% non-Hispanic Black, 6.79% other race/ethnicity; 53.95% male), 50.25% of respondents reported at least one SDOH, whereas 23.39% reported two or more SDOH. The most prevalent SDOH was lack of social support (3,456, 23.91%). Hispanic, non-Hispanic Black, and other race/ethnicity respondents, non-English speakers, and public insurance users had higher odds of reporting almost all SDOH in logistic regression models adjusted for age, race/ethnicity, language, gender, and insurance type.

DISCUSSION

Race/ethnicity, language, and insurance type disparities were identified for all SDOH.

Impact on Fecal Microbiota and Health-Related Markers of an Intervention Focused on Improving Eating Behavior in People at Risk of Food Insecurity

Non-communicable diseases are particularly prevalent among low-income individuals and are associated with the consumption of processed foods, fat, and sugars. This work aims to evaluate the impacts of a nutrition education intervention for low socio-economic individuals on sensory perception, health-related parameters and gut microbiota. Twenty low-income adults underwent a 4-week intervention. Dietary information (three 24 h recalls), detection thresholds and discrimination scores (salty and sweet), and severity of depressive symptoms (Beck Depression Inventory-II (BDI-II)) were collected. Fecal microbial composition and short chain fatty acids were determined by 16S ribosomal RNA-gene sequencing and gas chromatography, respectively. After the intervention, 35% of subjects presented higher compliance with dietary recommendations, increased consumption of vegetables and lignans and reduced consumption of processed meats and nitrosamines, together with depleted levels of Actinomycetota. Higher discrimination for salty and sweet and lower BDI-II scores were also obtained. This nutrition education intervention entailed changes in dietary intake towards healthier food options, reduced potentially carcinogenic compounds and improved scores for discrimination and severity of depressive symptoms. The confirmation of these results in future studies would enable the design of strategic policies contributing to the optimal nutrition of materially deprived families through affordable healthy plant-based interventions.

Helping low-income smokers quit: findings from a randomized controlled trial comparing specialized quitline services with and without social needs navigation

Background

Quitting smoking is especially challenging for low-income smokers due to high stress, high smoking prevalence around them, and limited support for quitting. This study aimed to determine whether any of three interventions designed specifically for low-income smokers would be more effective than standard tobacco quitline services: a specialized quitline, the specialized quitline with social needs navigation, or the standard quitline with social needs navigation.

Methods

Using a randomized 2 × 2 factorial design, low-income daily cigarette smokers (n = 1944) in Missouri, USA who called a helpline seeking assistance with food, rent or other social needs were assigned to receive Standard Quitline alone (n = 485), Standard Quitline + Social Needs Navigation (n = 484), Specialized Quitline alone (n = 485), or Specialized Quitline + Social Needs Navigation (n = 490). The target sample size was 2000, 500 per group. The main outcome was 7-day self-reported point prevalence abstinence at 6-month follow-up. Multiple imputation was used to impute outcomes for those missing data at 6-month follow-up. Binary logistic regression analyses were used to assess differences between study groups.

Findings

Participants were recruited from June 2017 to November 2020; most were African American (1111 [58%]) or White (666 [35%]), female (1396 [72%]), and reported <$10,000 (957 [51%]) or <$20,000 (1529 [82%]) annual pre-tax household income. At 6-month follow-up (58% retention), 101 participants in the Standard Quitline group reported 7-day point prevalence abstinence (20.8% of those assigned at baseline, 38.1% after imputation). Quit rates in the Specialized Quitline (90 quitters, 18.6%, 38.1%) and Specialized Quitline + Social Needs Navigation (103 quitters, 21.0%, 39.8%) were not different from the Standard Quitline. Quit rates for Standard Quitline + Social Needs Navigation (74 quitters, 15.3%, 30.1%) were significantly lower than Standard Quitline (OR = 0.70, 95% CI = 0.50-0.98).

Interpretation

A specialized version of a state tobacco quitline was no more effective than standard quitline services in helping low-income smokers quit. Adding social needs navigation to a standard quitline decreased its effectiveness.

Trial registration

ClinicalTrials.gov Identifier: NCT03194958.

Funding

National Cancer Institute: R01CA201429.

Income inequality and daily use of cannabis, cigarettes, and e-cigarettes among Canadian secondary school students: Results from COMPASS 2018-19

INTRODUCTION

Cannabis, cigarette, and e-cigarette use among Canadian adolescents is a major public health concern. Income inequality has been associated with adverse mental health among youth and may contribute to the risk of frequent cannabis, cigarette, and e-cigarette use. We tested the association between income inequality and the risk of daily cannabis, cigarette, and e-cigarette use among Canadian secondary school students.

METHODS

We used individual-level survey data from Year 6 (2018/19) of Cannabis, Obesity, Mental health, Physical activity, Alcohol use, Smoking, and Sedentary Behavior (COMPASS) and area-level data from the 2016 Canadian Census. Three-level logistic models were used to assess the relationship between income inequality and adolescent daily and current cannabis use, cigarette smoking, and e-cigarette use.

RESULTS

The analytic sample included 74,501 students aged 12-19. Students were most likely to report being male (50.4%), white (69.1%), and having weekly spending money over $100 (23.5%). We found that a standard deviation unit increase in Gini coefficient was significantly associated with increased likelihood of daily cannabis use (OR=1.25, 95% CI = 1.01-1.54) when adjusting for relevant covariates. We found no significant relationship between income inequality and daily smoking. While Gini was not significantly associated with daily e-cigarette use, we observed a significant interaction between Gini and gender (OR=0.87, 95% CI= 0.80-0.94), indicating that increased income inequality was associated with higher risk of reporting daily e-cigarette use among females only.

DISCUSSION

An association between income inequality and the likelihood of reporting daily cannabis use across all students and daily e-cigarette use in females were observed. Schools in higher income inequality areas may benefit from targeted prevention and harm reduction programs. Results emphasize the need for upstream discussion on policies that can mitigate the potential effects income inequality.

Clinical Markers Associated With Risk of Suicide or Drug Overdose Among Individuals With Smoking Exposure: A Longitudinal Follow-up Study of the COPDGene Cohort

BACKGROUND

Studies have shown that COPD and smoking are associated with increased suicide risk. To date, there are no prospective studies examining suicide risk among individuals with smoking exposure along a spectrum of pulmonary diseases ranging from normal spirometry to severe COPD.

RESEARCH QUESTION

Which clinical variables predict death by suicide or overdose of indeterminate intent in a large cohort of individuals with smoking exposure within the Genetic Epidemiology of COPD (COPDGene) study?

STUDY DESIGN AND METHODS

We studied data from 9,930 participants involved in COPDGene, a multisite, prospective cohort study of individuals with smoking exposure. Primary cause of adjudicated deaths was identified by using death certificates, family reports, and medical records. Time to death by suicide/overdose was examined as the primary outcome in Cox regression models including age, sex, race, BMI, pack-years, current smoking status, airflow limitation (FEV1 % predicted), dyspnea (modified Medical Research Council scale score ≥ 2), 6-min walk distance, supplemental oxygen use, and severe exacerbations in the prior year with time-varying covariates and other causes of death as a competing risk.

RESULTS

The cohort was 47% female and 33% Black (67% White); they had a mean ± SD age of 59.6 ± 9.0 years and a mean FEV1 % predicted of 76.1 ± 25.5. Sixty-three individuals died by suicide/overdose. Factors associated with risk of suicide/overdose were current smoking (hazard ratio [HR], 6.44; 95% CI, 2.64-15.67), use of sedative/hypnotics (HR, 2.33; 95% CI, 1.24-4.38), and dyspnea (HR, 2.23; 95% CI, 1.34-3.70). Lower risk was associated with older age (per-decade HR, 0.45; 95% CI, 0.31-0.67), higher BMI (HR, 0.95; 95% CI, 0.91-0.99), and African-American race (HR, 0.41; 95% CI, 0.23-0.74). Severity of airflow limitation (FEV % predicted) was not associated with suicide risk.

INTERPRETATION

In this well-characterized cohort of individuals with smoking exposure with and without COPD, risk factors for suicide/overdose were identified that emphasize the subjective experience of illness over objective assessments of lung function.

Trends in Socio-economic Inequality in Smoking Among Middle-aged and Older Adults in China: Evidence From the 2011 and 2018 China Health and Retirement Longitudinal Study

INTRODUCTION

Socio-economic inequalities in smoking and related health problems are a public health concern worldwide. To support the development of effective tobacco control policies, this study examines trends in smoking rates according to socio-economic status (SES) in China.

AIMS AND METHODS

We analyzed data from repeated cross-sectional China Health and Retirement Longitudinal Study (CHARLS) on adults aged ≥45 years for the years 2011 and 2018, which involved 16 471 participants in 2011 and 19 367 in 2018. We then estimated the SES of individuals based on four types of wealth-related variables, namely, education, occupation, household characteristics, and durable consumer goods. Principal-component analysis was conducted to measure SES, and the Erreygers normalised concentration index (ECI) was used to calculate socio-economic inequality in current smoking by gender, age, and region.

RESULTS

The overall ECI (95% confidence interval) for women was -0.042 (-0.054 to -0.031) and -0.038 (-0.047 to -0.029) for 2011 and 2018, respectively. The ECI (95% confidence interval) for men was -0.077 (-0.101 to -0.050) and -0.019 (-0.042 to 0.005) for 2011 and 2018, respectively. The inequality in smoking by SES for adults aged < 60 years in the Northeast region increased during 2011-2018, from -0.069 (-0.144 to 0.006) to -0.119 (-0.199 to -0.038) for women and from 0.009 (-0.115 to 0.132) to -0.164 (-0.296 to -0.032) for men.

CONCLUSIONS

smoking inequality by socio-economic among adults aged ≥45 years declined in recent years in China. However, smoking inequality by SES increased in other population groups.

IMPLICATIONS

Our research indicated that socio-economic inequality of current smoking among residents aged 45 years and older declined in 2018 when compared with 2011 numbers, particularly for men aged ≥ 60 years. Women in the Northeast region displayed more significant smoking inequality by SES than women in other regions did. During the study period, there was an increase in inequality in smoking by SES for adults aged < 60 years in the Northeast region. Thus, tobacco control policies and interventions should be targeted at high-risk subpopulations with lower SES, particularly in Northeast China.

Efficacy of mindfulness and goal setting interventions for increasing resilience and reducing smoking in lower socio-economic groups: randomised controlled trial protocol

BACKGROUND

Smoking and resulting health problems disproportionately impact low socioeconomic status (SES) individuals. Building resilience presents an approach to 'closing the gap'. Mindfulness-based interventions and setting realistic goals are preferred in low socioeconomic communities. We aim to test if these interventions, delivered online and consolidated with peer support offered via ex-smokers, are successful in promoting smoking cessation and resilience. Our conceptualisation of resilience encompasses the inner capacity/skills and external resources (e.g., social support) which smokers utilise to bounce back from adversity. We include a process evaluation of barriers/facilitators to interventions and cost-effectiveness analysis (from health system perspective).

METHODS

We plan a four-arm parallel 12-month RCT with a 6-month follow-up to test the efficacy of three group-based interventions each followed by peer support. Arm 1: mindfulness-integrated cognitive behavioural therapy; Arm 2: mindfulness training; Arm 3: setting realistic goals; Arm 4: active control group directed to quit services. All interventions will be administered online. Participants are adult smokers in Australia (N = 812) who have an average weekly household income less than $457AUD or receive welfare benefits. Group-based interventions will occur over 6 months, followed by 6 months of forum-based peer support.

PRIMARY OUTCOME

self-reported 14-day period prevalence of smoking abstinence at 6 months, with remote biochemical verification of saliva cotinine (< 30 ng/mL). Secondary outcomes include: internal resilience (Connor-Davidson Resilience Scale-25); external resilience (ENRICHD social support tool); quality adjusted life years (EQ-5D-5L); self-efficacy for smoking abstinence (Smoking-Abstinence Self-Efficacy Questionnaire); motivation to quit smoking (Biener and Abrams Contemplation Ladder); nicotine dependence (Fagerstrom Test for Nicotine Dependency); equanimity (Equanimity Scale-16); stress (Perceived Stress Scale-10); goal assessment/attainment (Problems and Goals Assessment Scale).

DISCUSSION

This study is the first to compare resilience interventions for low SES smokers which have been identified by them as acceptable. Our various repeated measures and process evaluation will facilitate exploration of mechanisms of impact. We intervene within the novel framework of the Psychosocial Model of Resilience, applying a promising paradigm to address a critical and inequitable public health problem. Trial registration Australian New Zealand Clinical Trials Registry ID: ACTRN12621000445875, registered 19 April 2021 ( https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381007&isReview=true ). The Universal Trial Number is U1111-1261-8951.

Clinical Spectrum and Trajectory of Innovative Therapeutic Interventions for Insomnia: A Perspective

Increasing incidences of insomnia in adults, as well as the aging population, have been reported for their negative impact on the quality of life. Insomnia episodes may be associated with neurocognitive, musculoskeletal, cardiovascular, gastrointestinal, renal, hepatic, and metabolic disorders. Epidemiological evidence also revealed the association of insomnia with oncologic and asthmatic complications, which has been indicated as bidirectional. Two therapeutic approaches including cognitive behavioral therapy (CBT) and drugs-based therapies are being practiced for a long time. However, the adverse events associated with drugs limit their wide and long-term application. Further, Traditional Chinese medicine, acupressure, and pulsed magnetic field therapy may also provide therapeutic relief. Notably, the recently introduced cryotherapy has been demonstrated as a potential candidate for insomnia which could reduce pain, by suppressing oxidative stress and inflammation. It seems that the synergistic therapeutic approach of cryotherapy and the above-mentioned approaches might offer promising prospects to further improve efficacy and safety. Considering these facts, this perspective presents a comprehensive summary of recent advances in pathological aetiologies of insomnia including COVID-19, and its therapeutic management with a greater emphasis on cryotherapy.

Prevalence, frequency, intensity, and location of cigarette use among adolescents in China from 2013-14 to 2019: Findings from two repeated cross-sectional studies

BACKGROUND

The burden of disease caused by tobacco use is a grave public health concern in China. Preventing smoking initiation among adolescents will lower the prevalence of adult tobacco use later. Surveillance of tobacco use among adolescents helps set priorities in developing tobacco control policies. We aim to ascertain the prevalence and differences of cigarette use across sex, grade, and region among middle and high school students in 2019 and associated changes from 2013-14 to 2019 among middle school students.

METHODS

Using a multistage stratified cluster-randomized sampling design with national and provincial representativeness, we conducted two school-based cross-sectional surveys in 2013-14 and in 2019. A total of 155 117 middle school students in grades 7-9 in 2013-14 and 288 192 middle and high school students in grades 7-12 in 2019 were interviewed. Self-reported experimental and current (past 30-day) cigarette use among middle school and high school students; frequent use (≥20 days in the past 30 days) and intensity (>20 cigarettes per day) of smoking among current cigarette users; and location of smoking among current cigarette users were investigated. All estimates were weighted based on the complex sampling design.

FINDINGS

The 2013-14 survey (overall response rate: 98.1%) included 155 117 middle school students (47.1% girl). The 2019 survey (overall response rate: 98.7%) included 147 270 middle school students (46.5% girl), 106 432 academic high school students (50.8% girl) and 34 490 vocational high school students (43.8% girl). In 2019, the prevalence rate of experimental and current cigarette use was 12.9% and 3.9% for middle school students, 21.6% and 5.6% for academic high school students, and 30.3% and 14.7% for vocational high school students, respectively, with large sex and regional differences. The prevalences of smoking on 20 or more days and daily cigarette use in the past 30 days were higher in vocational high school (5.9%, 4.1%) than in academic high school (1.8%, 1.2%) and middle school (0.7%, 0.5%), and higher among boys than girls. The proportions of current cigarette users smoking more than 20 cigarettes per day in the past 30 days for girls were higher than for boys in academic high school. Students usually smoke at school and at home. Boys were more likely to use cigarettes in an internet cafe, while girls often smoked at social venues. From 2013-14 to 2019, the prevalences of experimental and current cigarette use declined by 5.0% and 2.0% (percentage points), respectively, among middle school students but increased by 1.4% and 0.5% (percentage points) among rural girls. Among current cigarette users in middle school students, the proportions of heavy cigarette use (>20 cigarettes per day) have increased by 1.8 percentage points, mainly among boys, by 2.2% (percentage points).

INTERPRETATION

From 2013-14 to 2019, the prevalences of experimental and current cigarette use among middle school students decreased overall but increased among rural girls, while the intensity of cigarette use rose among boys. Cigarette use among Chinese adolescents differs across sex and regions, with higher rates among boys, in rural areas, and in the Western region (low socioeconomic status). Smoking is much more prevalent in vocational high schools than the other settings. Effective targeted tobacco control interventions among adolescents are urgently needed in China.

FUNDING

Dr. Zhuo Chen is supported by National Natural Science Foundation (Grant#: 72174098) through the University of Nottingham Ningbo China.

Interrogating Patterns of Cancer Disparities by Expanding the Social Determinants of Health Framework to Include Biological Pathways of Social Experiences

The objective of this article is to call for integrating biological pathways of social experiences in the concept model of cancer disparities and social determinants of health (SDH) fields. Black, Indigenous, and People of Color (BIPOC) populations experience more negative outcomes across the cancer continuum. Social conditions are instrumental in better understanding the contemporary and historical constructs that create these patterns of disparities. There is an equally important body of evidence that points to the ways that social conditions shape biological pathways. To date, these areas of research are, for the most part, separate. This paper calls for a bridging of these two areas of research to create new directions for the field of cancer disparities. We discuss inflammation, epigenetic changes, co-morbidities, and early onset as examples of the biological consequences of social conditions that BIPOC populations experience throughout their lifespan that may contribute to disproportionate tumorigenesis and tumor progression.

Quantifying the contribution of modifiable risk factors to socio-economic inequities in cancer morbidity and mortality: a nationally representative population-based cohort study

BACKGROUND

Compared with those with a higher socio-economic position (SEP), individuals with a lower SEP have higher cancer morbidity and mortality. However, the contribution of modifiable risk factors to these inequities is not known. This study aimed to quantify the mediating effects of modifiable risk factors to associations between SEP and cancer morbidity and mortality.

METHODS

This study used a prospective observational cohort design. We combined eight cycles of the Canadian Community Health Survey (2000/2001-2011) as baseline data to identify a cohort of adults (≥35 years) without cancer at the time of survey administration (n = 309 800). The cohort was linked to the Discharge Abstract Database and the Canadian Mortality Database for cancer morbidity and mortality ascertainment. Individuals were followed from the date they completed the Canadian Community Health Survey until 31 March 2013. Dates of individual first hospitalizations for cancer and deaths due to cancer were captured during this time period. SEP was operationalized using a latent variable combining measures of education and household income. Self-reported modifiable risk factors, including smoking, excess alcohol consumption, low fruit-and-vegetable intake, physical inactivity and obesity, were considered as potential mediators. Generalized structural equation modelling was used to estimate the mediating effects of modifiable risk factors in associations between low SEP and cancer morbidity and mortality in the total population and stratified by sex.

RESULTS

Modifiable risk factors together explained 45.6% of associations between low SEP and overall cancer morbidity and mortality. Smoking was the most important mediator in the total population and for males, accounting for 15.5% and 40.2% of the total effect, respectively. For females, obesity was the most important mediator.

CONCLUSIONS

Modifiable risk factors are important mediators of socio-economic inequities in cancer morbidity and mortality. Nevertheless, more than half of the variance in these associations remained unexplained. Midstream interventions that target modifiable risk factors may help to alleviate inequities in cancer risk in the short term. However, ultimately, upstream interventions that target structural determinants of health are needed to reduce overall socio-economic inequities in cancer morbidity and mortality.

Association between heaviness of cigarette smoking and serious psychological distress is stronger in women than in men: a nationally representative cross-sectional survey in Japan

BACKGROUND

Higher smoking prevalence in people with serious psychological distress (SPD) is well-recognized. However, gender and age differences in the association between heaviness of cigarette smoking and SPD have not been fully investigated.

METHODS

We used anonymized data from a nationally representative survey in Japan (33,925 men and 37,257 women). SPD was measured using the Kessler 6-item Psychological Distress Scale and defined as ≥ 13 points. Multiple logistic regression analyses stratified by gender and age-groups (20-44 years, 45-64 years, and ≥ 65 years) were used to estimate adjusted odds ratio (aOR) and 95% confidence interval (CI) for SPD.

RESULTS

After adjusting for sociodemographic confounders including education, equivalent household expenditures, and employment contract, women had a significant association between heavier smoking and more frequent SPD: compared to never-smokers, aORs (95% CIs) of ex-smokers, current light smokers who smoked 1-10 cigarettes per day (CPD), current moderate smokers 11-20 CPD, and current heavy smokers ≥ 21 CPD were 1.22 (0.92-1.63), 1.52 (1.25-1.84), 1.75 (1.46-2.09), and 2.22 (1.59-3.10), respectively (P-trend < 0.001). A significant positive association among women was consistent across all age-groups. Among men, there was no association between heaviness of cigarette smoking and SPD in all age-groups, and only current heavy smokers aged 20-44 years had a significantly higher OR for SPD (aOR, 1.37 [95% CI, 1.02-1.85]) than never-smokers.

CONCLUSIONS

There was a positive association between heaviness of cigarette smoking and SPD only among women, but not among men. For female smokers experiencing mental disorders, there is a need not only to improve mental health services but also to improve smoking-cessation support.

Financial strain and electronic nicotine delivery systems use among U.S. young adults: A longitudinal panel analysis, 2013-2018

INTRODUCTION

Financial strain is associated with an increased likelihood of cigarette smoking, but less is known about its association with electronic nicotine delivery systems (ENDS) use. This study examined longitudinal associations of financial strain with ENDS use behaviors among young adults.

METHODS

We analyzed in 2020 four waves (2013-2018) of the Population Assessment of Tobacco and Health, a nationally representative longitudinal study. A total of 5740 U.S. young adults (aged 18-24 years at baseline) had matched data for all four waves. We used generalized linear mixed modeling which accounts for correlations between repeated measures. Weighted logistic regressions assessed the association between financial strain and three different types of ENDS use behaviors (i.e., everyday, some-day, and experimental use), adjusting for major confounders including poverty, mental health symptoms, and other substance use behaviors.

RESULTS

Frequency and proportion of everyday ENDS use showed a linear increase over time whereas some-day and experimental uses showed quadratic trends, increasing with a peak at Wave 2 and then decreasing over time. Financial strain prospectively predicted some-day (adjusted odds ratio [AOR] = 1.32; 95% CI = 1.03-1.69) and experimental (AOR = 1.25; 95% CI = 1.02-1.52) ENDS use, but not everyday use.

CONCLUSIONS

The findings of the current study indicate the need for distinctly different approaches for non-daily ENDS users from daily users. Our findings further suggest that ENDS use prevention and cessation efforts should consider financial strain of young adults particularly for non-daily users to thwart them from progressing towards nicotine dependence and long-term use.

[Social inequalities in healthcare provision for patients with coronary heart disease: Results from the GEDA (German Health Update) study 2014/2015]

INTRODUCTION

Little is known about social inequalities in outpatient long-term care of coronary heart disease (CHD) in Germany.

METHODS

Regression analyses are based on the responses of women and men who participated in the national cross-sectional study "German Health update" (GEDA) 2014/2015 and had self-reported CHD (N=920). Outpatient healthcare of CHD was analysed on the basis of the self-reported administration of antihypertensive and cholesterol-lowering drugs, and the frequency of general practitioner (GP) contacts.

RESULTS

On average, respondents visited their GP 7.5 times a year (mean). 46 % did not receive guideline-consistent treatment, i. e. both antihypertensive and cholesterol-lowering drugs. Respondents of lower social status consulted their GP more frequently (approx. two visits per year) than those of higher social status (AME: 1.94; 95% CI 0.56 to 3.31). Regarding treatment with antihypertensive and cholesterol-lowering drugs, there were no significant differences for either gender or social status. Nevertheless, the probability that respondents with increased levels of blood lipids or cholesterol took only one or none of the two medications recommended for long-term treatment of CHD was reduced by 54 percentage points (AME: -0,54; 95% CI -0,61 to -0,48).

DISCUSSION

There are no social inequalities in the treatment of CHD patients with antihypertensive and cholesterol-lowering drugs, but inequalities exist in the frequency of visits to the GP who is more often consulted by the more socially disadvantaged patients.

CONCLUSION

With about 7.5 consultations per year, CHD patients visit their general practitioner more often than average, but in about half of these patients the medication supply is less than optimal. This may indicate a deficit in the medical treatment of CHD that cannot be explained by social inequalities. A possible starting point for improving healthcare, especially for patients without other risk factors, is to focus more strongly on a guideline-based approach to prescribing medication for CHD patients.

Investigating Mechanisms for Maternal Education Disparities in Enacting Health-Promoting Infant Care Practices

BACKGROUND

Although higher education and healthier practices are positively associated, the explanatory mechanisms for this association remain unclear. The purpose of this study was to better understand mechanisms underlying this association by examining maternal adherence to 2 health-promoting infant care practices: supine placement and breastfeeding.

METHODS

We analyzed nationally representative data from the Study of Attitudes and Factors Effecting Infant Care, which surveyed US mothers after infant birth and 2 months thereafter. Using the Theory of Planned Behavior as a framework, we used structural equation models to elucidate mediational pathways from maternal education to supine infant placement or any breastfeeding.

RESULTS

Data from 3297 mothers demonstrated 77.0% of infants usually were placed supine, and 57.8% received any breastfeeding. The overall direct effect of maternal educational level on supine placement and any breastfeeding was odds ratio (OR) 1.31 (95% confidence interval [CI] 1.11-1.54) and OR 2.82 (95% CI 2.35-3.37), respectively. In pathway analyses, the strongest associations with both supine position and breastfeeding were seen with positive attitudes (supine: aOR 18.96, 95% CI 9.00-39.92; breastfeeding: aOR 3.86, 95% CI 2.19-6.82) and positive social norms (supine: aOR 6.69, 95% CI 4.52-9.89; breastfeeding: aOR 5.17, 95% CI 4.28-6.23). Mothers with more education had higher odds of both positive attitudes and positive norms for the 2 practices.

CONCLUSIONS

The associations linking educational attainment with health practices are intricate, with multiple mediating pathways. Attitudes and social norms are powerful forces that mediate the association between maternal educational attainment and both infant supine positioning and breastfeeding, and may be important mediators for other health behaviors.

Individual and neighbourhood socioeconomic status increase risk of avoidable hospitalizations among Canadian adults: A retrospective cohort study of linked population health data

INTRODUCTION

Avoidable hospitalizations refer to acute care use for conditions that should normally be managed in primary care settings. Lower socioeconomic status that is often measured using area-based indicators (e.g. median household income) has been shown to increase risk of avoidable hospitalizations. However, both area- and individual-level socioeconomic status can contribute to hospitalization risk, but previous data limitations have prevented separate analyses. Further, the joint effect of individual and neighbourhood socioeconomic status has not been established in the Canadian population. To address this, this study links individual-level household income and neighbourhood-level material deprivation data within a population-based Canadian cohort.

OBJECTIVES

To determine the individual and joint effect of individual-level household income and neighbourhood-level material deprivation on risk of hospitalization for a set of chronic ambulatory care sensitive conditions using linked health survey, hospital discharge, and census-derived data.

METHODS

A pooled cohort was created by linking sociodemographic and health information from eight cycles of the Canadian Community Health Survey (2000/2001 - 2010) to hospital discharge records and Canadian Marginalization Indices (2001, 2006) (N = 354,595). The primary outcome variable was risk of index hospitalization with a primary diagnosis of angina, asthma, congestive heart failure, chronic obstructive pulmonary disease, diabetes, epilepsy, or hypertension. The primary exposure variable was joint individual-level national household income quintile and neighbourhood-level material deprivation quintile. Relative risk (RR) was estimated by constructing modified Poisson regression models with robust error variance.

RESULTS

In fully adjusted models with income and deprivation considered separately, individuals in the lowest household income quintile and highest material deprivation quintile were at increased risk of hospitalization (Income RR: 1.82 (95% CI 1.56-2.13) Deprivation RR: 1.67 (1.44-1.95)). When income and deprivation were jointly considered, those with low individual income living in high deprivation neighbourhoods were at greatest risk of hospitalization (RR 1.83 (95% CI 1.63 - 2.05)).

CONCLUSION

Both individual income and neighbourhood deprivation separately and jointly increase risk of avoidable hospitalizations. Additional research is needed to understand their mechanisms of action. However, both levels should be considered when designing effective policies and interventions to reduce avoidable hospitalizations.

A cross-sectional survey examining motivation and beliefs to participating in a web-based prospective cohort study on nutrition and health among individuals with a low socioeconomic status

Background

Prospective cohort studies may support public health efforts in reducing health inequalities. However, individuals with a low socioeconomic status (SES) are generally underrepresented in health research. This study aimed to examine the intention and determinants of intention of individuals with a low SES towards participation in a Web-based prospective project on nutrition and health (NutriQuébec) in order to develop recruitment and retention strategies.

Methods

A cross-sectional survey based on the Theory of planned behaviour was conducted in the Province of Québec, Canada. Low SES individuals (high school or less and annual household income < $55,000 CAN) were recruited through a Web panel of a polling firm to assess intention, attitude, subjective norm and perceived behavioural control (PBC) towards participation in the NutriQuébec project. Linear regression and logistic regression analyses were conducted.

Results

Mean age of respondents (184 women, 141 men) was 57.6 y (SD = 13.6). Attitude (ß = 0.54, 95%CI: 0.41–0.68) and PBC (ß = 0.50, 95%CI: 0.37–0.63) were significantly associated with intention. Participants who agreed that participating in the study would contribute to an improvement in 1) collective health (odds ratio [OR] = 2.15, 95%CI: 1.27–3.64) and in 2) one’s lifestyle habits (OR = 1.70, 95%CI: 1.04–2.78) were more likely to express positive intention compared to participants who did not agree with these statements. Participants who agreed to participate in the study even 1) in the absence of a financial incentive (OR = 1.43, 95%CI: 1.04–1.99) and even 2) if the completion of questionnaires took up to two hours (OR = 1.78, 95%CI: 1.27–2.48) were also more likely to express high intention. Receiving a personalized brief health assessment (OR = 1.61, 95%CI: 1.13–2.30) and the use of simple questions in the questionnaires (OR = 1.54, 95%CI: 1.05–2.25) were facilitating factors associated with high intention. Participants believing that participation would be too time-consuming were less likely to have positive intention (OR = 0.57, 95%CI: 0.43–0.75).

Conclusions

The development of a positive attitude and a high PBC towards participation in the NutriQuébec project will be necessary to obtain representative data of low SES adults.

Socioeconomic disparities in smoking are partially explained by chronic financial stress: marginal structural model of older US adults

BACKGROUND

A persistent socioeconomic gradient in smoking has been observed in a variety of populations. While stress is hypothesised to play a mediating role, the extent of this mediation is unclear. We used marginal structural models (MSMs) to estimate the proportion of the effect of socioeconomic status (SES) on smoking, which can be explained by an indicator of stress related to SES, experiences of chronic financial stress.

METHODS

Using the Health and Retirement Study (waves 7-12, 2004-2014), a survey of older adults in the USA, we analysed a total sample of 15 260 people. A latent variable corresponding to adult SES was created using several indicators of socioeconomic position (wealth, income, education, occupation and labour force status). The main analysis was adjusted for other factors that influence the pathway from adult SES to stress and smoking, including personal coping resources, health-related factors, early-life SES indicators and other demographic variables to estimate the proportion of the effect explained by these pathways.

RESULTS

Compared with those in the top SES quartile, those in the bottom quartile were more than four times as likely to be current smokers (rate ratio 4.37, 95% CI 3.35 to 5.68). The estimate for the MSM attenuated the effect size to 3.34 (95% CI 2.47 to 4.52). Chronic financial stress explained 30.4% of the association between adult SES and current smoking (95% CI 13 to 48).

CONCLUSION

While chronic financial stress accounts for part of the socioeconomic gradient in smoking, much remains unexplained.

Do inequalities add up? Intersectional inequalities in smoking by sexual orientation and education among U.S. adults

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Among men, inequalities in cigarette smoking are primarily driven by socio-economic inequalities.

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Among women, inequalities in cigarette smoking are primarily driven by sexual orientation inequalities.

Introduction

Inequalities in smoking by socio-economic status (SES) are well-known. A growing body of literature has demonstrated additional inequalities in smoking by sexual orientation. This study used an intersectional lens to examine smoking at the intersection of sexual orientation and education.

Methods

Data come from 28,362 adult participants in Wave 2 (2014–2015) of the Population Assessment of Tobacco and Health (PATH) Study. We used educational level (less than high school education (HS); HS or more) and sexual orientation (heterosexual; sexual minority) to form four intersectional positions.

We estimated prevalence differences in smoking corresponding to joint, referent, and excess intersectional inequalities using weighted linear binomial regression models. Results were stratified by gender and adjusted for ethnicity and age.

Results

The adjusted joint inequality represented 7.6% points (p.p.) (95% CI: 2.5, 12.8) difference in smoking between the doubly advantaged (heterosexual with HS or more) and doubly disadvantaged (sexual minority with less than HS) positions. Joint inequality was decomposed into referent SES inequality (12.5 p.p. (95% CI: 10.5, 14.4)); referent sexual orientation inequality (9.7 p.p. (95% CI: 6.8, 12.6)); and a substantial negative excess intersectional inequality (−14.6 p.p. (95% CI: −20.8, −8.3)), attributed to an unexpectedly low prevalence of smoking among doubly disadvantaged persons. Similar overall patterns were found in the stratified analyses.

Conclusions

We found that “doubly-disadvantaged” group of low-educated sexual minority adults did not have the greatest burden of smoking; whereas, low-educated heterosexual adults had the highest smoking prevalence. Our findings support tailoring cessation interventions to disadvantaged groups’ different needs.

Beliefs Related to Participation in a Large Web-Based Prospective Survey on Diet and Health Among Individuals With a Low Socioeconomic Status: Qualitative Study

BACKGROUND

NutriQuébec is a Web-based prospective study on the relationship between diet and health as well as the impact of food-related health policies in the adult population of Québec, Canada. Recruitment and retention of individuals with a low socioeconomic status (SES) in such a study are known to be challenging, yet critical for achieving representativeness of the entire population.

OBJECTIVE

This study aimed to identify the behavioral, normative, and control beliefs of individuals with a low SES regarding participation in the NutriQuébec project and to identify their preferences regarding recruitment methods.

METHODS

A total of four focus groups were conducted in community centers located in low-income areas of Québec City, Canada. On the basis of the theory of planned behavior, participants' beliefs associated with attitude, subjective norm, and perceived behavioral control regarding hypothetical participation in the NutriQuébec project were identified. Focus groups were recorded, transcribed, and coded by two analysts.

RESULTS

Participants (16 men and 12 women) were aged between 28 and 72 years, and a majority of the participants had an annual household income of Can $19,999 or less. The main perceived advantages of participating in the NutriQuébec project were contributing to improved collective health and supporting research. The only disadvantage identified was the risk of having to fill out too many questionnaires. Participants could not, in general, identify persons from their entourage who would approve or disapprove their participation in the study. The main facilitators identified were obtaining a brief health assessment and the ability to complete questionnaires in a way that is not Web-based. The main barrier was the lack of internet access. The preferred means of recruitment were through social media, television, and community centers.

CONCLUSIONS

These results provide insightful information regarding the best methods and messages to use in order to recruit and retain individuals with a low SES in a population-based prospective study on lifestyle and health on the internet.

School Smoking Policies and Health Science Students' Use of Cigarettes, Shisha, and Dipping Tombak in Sudan

The relationship between school smoking policies and students' tobacco use is ambiguous, and little is known about the effect of these policies in low- and middle-income countries. This study was designed to assess the effects of schools' smoking policies and the exposure to residential smoking on cigarette smoking and the use of different kinds of tobacco products by Health Science students. Self-reports of cigarette smoking, use of shisha (smoking of fruits-mixed tobacco using a bowl and a connected hose); dipping tombak (local smokeless tobacco that users usually place inside oral cavity in the groove behind the lower lip), and tobacco use on school premises are analyzed. A cross-sectional survey was carried out using a modified self-report questionnaire, originally developed by WHO, among a representative sample of 1,590 third-year HSS from 25 schools drawn from 13 universities, using a multi-stages sampling technique. The response rate was 100% for schools and 68% for students. A multilevel analysis was performed by nesting student-level in school-level variables. Results from the adjusted models revealed that, when students reported awareness of smoking restriction, they were more likely to be current smokers (OR = 2.91; 95% CI: 1.68–5.02; p = 0.021) and shisha users (OR = 2.17; 95% CI: 1.54–3.06; p = 0.021). Results from additional analysis performed among tobacco users only, showed increased risk of smokers and tombak dippers who smoked or dipped on school premises (OR = 2.38; 95% CI: 1.34–4.25; p = 0.003, OR = 2.60; 95% CI: 1.22–5.56; p = 0.013, respectively). Current smokers (OR = 3.12; 95% CI: 1.98–4.92; p = ≤ 0.001), ever smokers (OR = 1.66; 95% CI: 1.31–2.10; p = ≤ 0.001) and shisha users (OR = 1.73; 95% CI: 1.36–2.21; p = ≤ 0.001) were exposed to residential smoking on one or more days during the previous 7 days. High percentages of those who used any kind of tobacco products reported being aware of school smoking policies, indicating no clear evidence that school smoking policies had an effect on use of any of the mentioned tobacco products. The lack of compliance with school policies shows the need for further policy enforcement and sustainability, taking into account the effect of residential smoking and social influences.

What drives us apart? Decomposing intersectional inequalities in cigarette smoking by education and sexual orientation among U.S. adults

Background

Socio-economic and sexual orientation inequalities in cigarette smoking are well-documented; however, there is a lack of research examining the social processes driving these complex inequalities. Using an intersectional framework, the current study examines key processes contributing to inequalities in smoking between four intersectional groups by education and sexual orientation.

Methods

The sample (28,362 adults) was obtained from Wave 2 (2014–2015) of the Population Assessment of Tobacco and Health (PATH) Study. Four intersectional positions were created by education (high- and low-education) and sexual orientation (heterosexual or lesbian, gay, bisexual, or queer/questioning (LGBQ). The joint inequality, the referent socio-economic inequality, and the referent sexual orientation inequality in smoking were decomposed by demographic, material, tobacco marketing-related, and psychosocial factors using non-linear Oaxaca decomposition.

Results

Material conditions made the largest contribution to the joint inequality (9.8 percentage points (p.p.), 140.9%), referent socio-economic inequality (10.01 p.p., 128.4%), and referent sexual orientation inequality (4.91 p.p., 59.8%), driven by annual household income. Psychosocial factors made the second largest contributions to the joint inequality (2.12 p.p., 30.3%), referent socio-economic inequality (2.23 p.p., 28.9%), and referent sexual orientation inequality (1.68 p.p., 20.5%). Referent sexual orientation inequality was also explained by marital status (20.3%) and targeted tobacco marketing (11.3%).

Conclusion

The study highlights the pervasive role of material conditions in inequalities in cigarette smoking across multiple dimensions of advantage and disadvantage. This points to the importance of addressing material disadvantage to reduce combined socioeconomic and sexual orientation inequalities in cigarette smoking.

Understanding the effect of socio-economic characteristics and psychosocial factors on household water treatment practices in rural Nepal using Bayesian Belief Networks

About 20 Million (73%) people in Nepal still do not have access to safely managed drinking water service and 22 million (79%) do not treat their drinking water before consumption. Few studies have addressed the combination of socio-economic characteristics and psychosocial factors that explain such behaviour in a probabilistic manner. In this paper we present a novel approach to assess the usage of household water treatment (HWT), using data from 451 households in mid and far-western rural Nepal. We developed a Bayesian belief network model that integrates socio-economic characteristics and five psychosocial factors. The socio-economic characteristics of households included presence of young children, having been exposed to HWT promotion in the past, level of education, type of water source used, access to technology and wealth level. The five psychosocial factors capture households' perceptions of incidence and severity of water-borne infections, attitudes towards the impact of poor water quality on health, water treatment norms and the knowledge level for performing HWT. We found that the adoption of technology was influenced by the psychosocial factors norms, followed by the knowledge level for operating the technology. Education, wealth level, and being exposed to the promotion of HWT were the most influential socio-economic characteristics. Interestingly, households who were connected to a piped water scheme have a higher probability of HWT adoption compared to other types of water sources. The scenario analysis revealed that interventions that only target single socio-economic characteristics do not effectively boost the probability of HWT practice. However, interventions addressing several socio-economic characteristics increase the probability of HWT adoption among the target groups.

Prevalence and smokers' profile: comparisons between the psychiatric population and the general population

Objectives:

to identify the prevalence of smokers between the psychiatric population and the general population; to compare the personal, socio-demographic and clinical profile of smokers and non-smokers in the psychiatric population and the general population; to compare the reasons for smoking of these two population groups.

Method:

this is a cross-sectional descriptive-analytical epidemiological study with 378 patients from three services: Ambulatory Mental Health, Psychiatric Hospital, and Basic Health Unit. Interviews were conducted with three questionnaires. The Chi-square and Kruskal-Wallis tests were applied.

Results:

in the total of the 378 participants, 67% were women and 69% were over 40 years old. There was a higher prevalence of smokers among men, young people, illiterates, singles and with more than one government benefit. Smokers prevailed among schizophrenics, chronic patients, who used ≥ 3 psychotropic drugs and had a history of ≥ 4 psychiatric hospitalizations and/or suicide attempts. The main reason for smoking was the improvement of negative feelings.

Conclusion:

the prevalence of smokers is higher in the psychiatric population (especially among severely ill patients) and among men, young people, unmarried and with socioeconomic losses. The main reason for smoking is tension/relaxation relief. This study provides nurses and other professionals with knowledge capable of subsidizing the planning of smoking interventions in the Brazilian population.

Work-Life Conflict among U.S. Long-Haul Truck Drivers: Influences of Work Organization, Perceived Job Stress, Sleep, and Organizational Support

Work-life balance and job stress are critical to health and well-being. Long-haul truck driving (LHTD) is among the unhealthiest and most unsafe occupations in the U.S. Despite these disparities, there are no extant published studies examining the influence of work, stress and sleep outcomes on drivers’ work-life balance. The current study investigated whether adverse work organization, stress, and poor sleep health among LHTDs are significantly associated with work-life conflict. Logistic regression was used to examine how work organization characteristics, job stress, and sleep influenced perceived stress and a composite measure of work-life conflict among a sample of 260 U.S. LHTDs. The pattern of regression results dictated subsequent analyses using structural equation modeling (SEM). Perceived job stress was the only statistically significant predictor for work-life balance. Fast pace of work, sleep duration and sleep quality were predictors of perceived job stress. SEM further elucidated that stress mediates the influences of fast work pace, supervisor/coworker support, and low sleep duration on each of the individual work-life balance indicators. There is an urgent need to address work conditions of LHTDs to better support their health, well-being, and work-life balance. Specifically, the findings from this study illustrate that scheduling practices and sleep outcomes could alleviate job stress and need to be addressed to more effectively support work-life balance. Future research and interventions should focus on policy and systems-level change.

The Association Between Education and Smoking Prevalence, Independent of Occupation: A Nationally Representative Survey in Japan

Background

Higher smoking prevalence in less educated persons and manual workers is well known. This study examines the independent relationship of education and occupation with tobacco use.

Methods

We used anonymized data from a nationwide population survey (30,617 men and 33,934 women). Education was divided into junior high school, high school, or university attainment. Occupation was grouped into upper non-manual, lower non-manual, and manual. Poisson regression models stratified by age and gender were used to estimate adjusted prevalence ratio (PR) and 95% confidence interval (CI) for current smoking.

Results

After adjustment for covariates, education, and occupation, education was significantly related to current smoking in both genders; compared to university graduates, PRs of junior high school graduates aged 20–39, 40–64, and ≥65 were 1.74 (95% CI, 1.53–1.98), 1.50 (95% CI, 1.36–1.65), and 1.28 (95% CI, 1.08–1.50) among men, and 3.54 (95% CI, 2.92–4.30), 2.72 (95% CI, 2.29–3.23), and 1.74 (95% CI, 1.14–2.66) among women, respectively. However, significantly higher smoking prevalence in manual than in upper non-manual was found only in men aged 20–64; compared to upper non-manual, the PRs of manual workers aged 20–39, 40–64, and ≥65 were 1.11 (95% CI, 1.02–1.22), 1.18 (95% CI, 1.10–1.27), and 1.10 (95% CI, 0.89–1.37) among men, and 0.95 (95% CI, 0.75–1.20), 0.92 (95% CI, 0.75–1.12), and 0.46 (95% CI, 0.22–0.95) among women, respectively.

Conclusions

Independent of occupation, educational disparities in smoking existed, regardless of age and gender. Occupation-smoking relationship varied with age and gender. Our study suggests that we should pay attention to social inequality in smoking as well as national smoking prevalence.

Posttraumatic stress symptoms, shame, and substance use among Asian Americans

BACKGROUND

To examine the association between posttraumatic stress symptoms (PTSS) and substance use among Asian Americans and the influence of a culturally-relevant moderator, shame.

METHODS

From 2016 to 2017, 199 participants from Amazon Mechanical Turk and a university subject pool completed an online survey. Chi-square and Kruskal-Wallis tests explored demographic and clinical differences among three Asian American ethnic subgroups (East Asians, South Asians, and Southeast Asians). Generalized linear models assessed the association between PTSS and substance use (alcohol, tobacco, and other drugs) and the moderation of this relationship by shame.

RESULTS

Ethnic subgroups significantly differed on all three substance use variables. The severity in PTSS was significantly associated with hazardous drug use (IRR = 1.03, (1.01, 1.05), p = .003). The association between PTSS and days of tobacco use and binge drinking was significantly moderated by shame. Low levels of shame increased the effect of PTSS on binge drinking (IRR = 1.05, (1.00, 1.10), p = .035) and tobacco use (IRR = 1.15, (1.11, 1.19), p < .001). High levels of shame had no effect of PTSS on binge drinking (IRR = 1.01, (0.99, 1.03), p = .54) and a reduced effect on tobacco use (IRR = 1.07, (1.05, 1.09), p < .001).

CONCLUSIONS

Among Asian Americans, the association of PTSS and substance use depends on shame. Lower levels of shame are a risk factor, increasing the effect of PTSS on substance use. Culturally-modified addiction treatments should assess for shame among Asian Americans and attend to ethnic sub-group diversity in substance use.

Sleep health disparity: the putative role of race, ethnicity and socioeconomic status

Sleep plays a pivotal role in both physical and mental health. Sleep quality can be affected by many socio demographic factors, such as race and/or ethnicity, as well as socio economic status (SES). Chronic sleep deprivation is associated with unhealthy behaviors such as alcohol abuse and also places individuals at risk for chronic diseases including obesity, cardiovasculardisease (CVD), depression, and/or anxiety. This review explores the common socio demographic factors and SES that can lead to sleep disturbances. Among these factors are shift work, poor dietary habits, smoking and alcohol abuse. Such factors need to be considered by health care providers in the clinical assessment and management plans of patients with sleep disorders.