Social aspects of coronary heart disease in two adjacent, ethnically different communities

Self-Reported Experiences of Discrimination and Cardiovascular Disease

Researchers have long speculated that exposure to discrimination may increase cardiovascular disease (CVD) risk but compared to other psychosocial risk factors, large-scale epidemiologic and community based studies examining associations between reports of discrimination and CVD risk have only emerged fairly recently. This review summarizes findings from studies of self-reported experiences of discrimination and CVD risk published between 2011-2013. We document the innovative advances in recent work, the notable heterogeneity in these studies, and the considerable need for additional work with objective clinical endpoints other than blood pressure. Implications for the study of racial disparities in CVD and clinical practice are also discussed.

Individual and neighbourhood determinants of social participation and social capital: a multilevel analysis of the city of Malmö, Sweden

The aim of this study was to analyse the impact of neighbourhood on individual social capital (measured as social participation). The study population consisted of 14,390 individuals aged 45-73 that participated in the Malmö diet and cancer study in 1992-1994, residing in 90 neighbourhoods of Malmö, Sweden (population 250,000). A multilevel logistic regression model, with individuals at the first level and neighbourhoods at the second level, was performed. The study analysed the effect (intra-area correlation and cross-level modification) of the neighbourhood on individual social capital after adjustment for compositional factors (e.g. age, sex, educational level, occupational status, disability pension, living alone, sick leave, unemployment) and, finally, one contextual migration factor. The prevalence of low social participation varied from 23.0% to 39.7% in the first and third neighbourhood quartiles, respectively. Neighbourhood factors accounted for 6.3% of the total variance in social participation, and this effect was reduced but not eliminated when adjusting for all studied variables (-73%), especially the occupational composition of the neighbourhoods (-58%). The contextual migration variable further reduced the variance in social participation at the neighbourhood level to some extent. Our study supports Putnam's notion that social capital, which is suggested to be an important factor for population health and possibly for health equity, is an aspect that is partly contextual in its nature.

Social capital and health: implications for public health and epidemiology

Public health and its "basic science", epidemiology, have become colonised by the individualistic ethic of medicine and economics. Despite a history in public health dating back to John Snow that underlined the importance of social systems for health, an imbalance has developed in the attention given to generating "social capital" compared to such things as modification of individual's risk factors. In an illustrative analysis comparing the potential of six progressively less individualised and more community-focused interventions to prevent deaths from heart disease, social support and measures to increase social cohesion faired well against more individual medical care approaches. In the face of such evidence public health professionals and epidemiologists have an ethical and strategic decision concerning the relative effort they give to increasing social cohesion in communities vs expanding access for individuals to traditional public health programs. Practitioners' relative efforts will be influenced by the kind of research that is being produced by epidemiologists and by the political climate of acceptability for voluntary individual "treatment" approaches vs universal policies to build "social capital". For epidemiologists to further our emerging understanding of the link between social capital and health they must confront issues in measurement, study design and analysis. For public health advocates to sensitise the political environment to the potential dividend from building social capital, they must confront the values that focus on individual-level causal models rather than models of social structure (dis)integration. The evolution of explanations for inequalities in health is used to illustrate the nature of the change in values.

Notes on an evolutionary medicine

OBJECTIVE

Medicine does not have a comprehensive theory of health, ill-health, and disease. Its explanations of disease are firmly rooted in pathological anatomy brought about by infection, intoxication, trauma, and mutations in genes. Because medical concepts have been influenced mainly by classical physics, it is mechanistic, materialistic, deterministic, reductionistic, linear-causal, and strongly biased toward proximate explanations of disease. Of late, many thoughtful persons have attempted to provide medicine with a more comprehensive theory that integrates the documented roles of physical, social, environmental, and psychological factors in the etiology and pathogenesis of ill-health and disease (eg, Refs. 1-3).

METHOD

Until very recently (4), no one has clearly pointed out that such a comprehensive theory should be guided by the concepts of evolutionary and organismic biology. Darwin's great theory states that evolution is "driven," but not exclusively so, by natural and sexual selection. Natural selection acts on variants that differ in adaptive capacities. Those capable of adaptation survive to reproduce. Failure to adapt reduces reproductive fitness and success, and leads to injury or death. But this formulation could be expanded to regard ill-health and disease as adaptive failures, whereas health usually may be conceived of as equivalent to adaptive success. Adaptations are determined by many factors-genetic, morphological, physiological, and behavioral. Selective pressures are many and varied. However, social primates are at a selective advantage, and are among the most successful species and varieties. Social behavior (eg, support) seems to enhance the chances of survival and reproductive fitness. Physiological (immunological, metabolic, cardiovascular) and behavioral adaptations are geared specifically for interactions with the environment. Emotions have evolved as ways of matching physiological responses with environmental demands and signaling the organism's state.

RESULTS

This study will review aspects of evolutionary theory that would lead to a unified, integrated theory of health, illness, and disease, and to a clearer taxonomy in medicine.

Community social change and mortality

This paper first reviews the types of explanations that have been used in analyzing unequal distribution in coronary heart disease among different groups and changes in prevalence over time. The explanations have mostly focused on the individual: individual behaviors, personalities, stressors, or social ties. It is suggested here that a shift in focus to community-level characteristics may also aid in understanding changes in mortality. Data are presented from Roseto, PA--a town that became known in the 1960's for its strong Italian traditions and very low mortality from myocardial infarction and that subsequently experienced a sharp rise in mortality--and from the adjacent comparison town of Bangor. Data collected over several decades--in some cases as far back as 1925--on marriages, population composition, organizational memberships, voting patterns, and social class indicators suggest that important community changes that accelerated significantly in the 1960's coincided with and may help to explain Roseto's loss of protection from coronary heart disease deaths after 1965.

The Roseto effect: a 50-year comparison of mortality rates

OBJECTIVES

Earlier studies found striking differences in mortality from myocardial infarction between Roseto, a homogeneous Italian-American community in Pennsylvania, and other nearby towns between 1955 and 1965. These differences disappeared as Roseto became more "Americanized" in the 1960s. The present study extended the comparison over a longer period of time to test the hypothesis that the findings from this period were not due to random fluctuations in small communities.

METHODS

We examined death certificates for Roseto and Bangor from 1935 to 1985. Age-standardized death rates and mortality ratios were computed for each decade.

RESULTS

Rosetans had a lower mortality rate from myocardial infarction over the course of the first 30 years, but it rose to the level of Bangor's following a period of erosion of traditionally cohesive family and community relationships. This mortality-rate increase involved mainly younger Rosetan men and elderly women.

CONCLUSIONS

The data confirmed the existence of consistent mortality differences between Roseto and Bangor during a time when there were many indicators of greater social solidarity and homogeneity in Roseto.

Job stress, cigarette smoking and cessation: the conditioning effects of peer support

Relationships between questionnaire measures of job stress and smoking intensity (SI) and cessation were studied among 560 disease-free smoking males and 310 quitters all members of 22 kibbutzim. The main-effect hypothesis that stress is positively related to SI and negatively to cessation received some support in correlational and multiple regression analyses for the entire sample. Hours of work, work addiction, lack of influence, intrinsic impoverishment and lack of support were positively associated with SI. Conflict, responsibility, hours of work, low status, lack of influence and harsh working conditions were negatively associated with cessation. When peer support was dichotomized into low and high, we found that persons reporting low support smoked significantly more than those who reported high support. Seeking effects of both hours of work and support on SI, we found additive main effects but no interaction effect. The average number of cigarettes smoked by people who worked less than 8 hours and reported high support was 17, whereas people who worked more than 8 hours and reported low support smoked an average of 22 cigarettes a day. The buffering effect of support on the relationship between stress and both SI and cessation of smoking was examined by means of interaction analysis. No buffer effect was evident for SI. However, for respondents reporting low support more job stressors were negatively related to cessation than among those reporting high support, confirming the support-buffer hypothesis. Suggestions regarding better measurement of support are discussed. We conclude with the hypothesis that social support may be detrimental to the smoker, depending on the smoking attitudes and behaviors of the 'supportive' others.

Psychosocial predictors of sudden death: a review and critique

Research and selected case studies concerning psychosocial prediction of sudden death are evaluated under three categories: sudden cardiac, sudden infant and sudden traumatic death. The psychosocial predictors reviewed include novelty-pre-exposure, control-helplessness, restraint, Type A behavior, life change, bereavement, denial, social support and contact, voodoo, psychiatric illness, mother infant separation, submission-defeat, housing, handling and environmental enrichment. Four of these predictors, controllability-helplessness, pre-exposure-novelty, depressive affect and physical restraint are repeatedly cited in both human and animal studies and their importance is critically evaluated. Methodological and substantive recommendations for future research are made and a discussion of possible mechanisms is presented.

Effects of population changes on psychological and physiological strain in kibbutz communities

The present study was directed toward determining the health implications of population policies followed by collective rural communities (kibbutzim) in Israel. It was hypothesized that, controlling for kibbutz longevity, higher rates of out-migration and/or lower rates of in-migration and population growth are associated with subsequent increases in psychological and physiological strain among kibbutz members. The hypothesis was tested by interrelating different sets of data on kibbutz communities, collected at two research centers. Data were subjected to both individual and ecological correlational analyses. At both levels, inconsistent patterns of relationships between demographic characteristics and strain were obtained. The consistent cross-level findings which were significant were contradictory to our hypothesis. Our results suggest that while demographic changes do appear to have some impact on subsequent affective strain among kibbutz members, their detrimental effect is rather weak and is probably mediated by small-group processes, such as peer social support, and by the adequacy of the individual's coping resources.

Life change and illness studies: past history and future directions

A selected review of life changes and illness studies is presented which illustrates both the diversity of samples that have been tests in these studies and the generally positive results which have been obtained. Although early (retrospective) work in this field led to simplistic explanations, later (prospective) studies have begun to document the several intervening variables which occur between subjects' recent life change experiences and their subsequent symptomatology and disease. A life change and illness model is presented to illustrate key intervening variables. The authors believe that future research in the field of life change and illness should concentrate on further delineations of these intervening variables--an effort necessitating active collaboration between social and medical scientists.

Psychosocial factors and myocardial infarction

Two questionnaires totalling 370 questions were used to compare 61 male patients who had survived a first myocardial infarction with a group controlled for age and social status who had not had an infarction. The questionnaires included the Edwards Personal Preference Schedule, providing a measure of 15 personality variables, the Anxiety and Depression Sub-Scales of the MMPI, and the Cochrane and Robertson Life Events Inventory, as well as originally-designed questions based on known risk factors. Significant differences were found in several dimensions of personality as well as in the family histories of myocardial infarction and in certain life styles. The patient group showed a greater sense of independence, greater difficulty in relaxing, and a sence of personal inferiority. Suggestions are offered for the modification of life styles in susceptible individuals as a possible aid to prevention.

Angina pectoris among 10,000 men. II. Psychosocial and other risk factors as evidenced by a multivariate analysis of a five year incidence study

The major independent role played by anxiety and severe psychosocial problems (especially family ones) is demonstrated by this multivariate analysis of a five year prospective study of the development of new angina pectoris among almost 10,000 adult men (average annual incidence = 5.7/1,000). The independent effect of these two variables is considerably augmented by the other significant risk factors of age, total serum cholesterol, systolic or diastolic blood pressure, certain electrocardiographic abnormalities and diabetes mellitus. The presence of all seven risk factors (at a high level) increases the probability of angina pectoris developing within five years to 289/1,000 from 14/1,000, when these factors are low or absent. The wife's love and support is an important balancing factor, which apparently reduces the risk of angina pectoris even in the presence of high risk factors. The implications of these findings to the pathophysiology and prevention of angina are stressed.