Impact of change over time in self-reported discrimination on blood pressure: implications for inequities in cardiovascular risk for a multi-racial urban community

Objectives: The 21st century has seen a rise in racism and xenophobia in the United States. Few studies have examined the health implications of heightened institutional and interpersonal racism. This study examines changes in reported discrimination and associations with blood pressure over time among non-Latino Blacks (NLBs), Latinos, and non-Latino Whites (NLWs) in an urban area, and variations by nativity among Latinos.Design: Data from a probability sample of NLB, Latino, and NLW Detroit, Michigan residents were collected in 2002-2003, with follow-up at the same addresses in 2007-2008. Surveys were completed at 80% of eligible housing units in 2008 (n = 460). Of those, 219 participants were interviewed at both time points and were thus included in this analysis. Discrimination patterns across racial/ethnic groups and associations with blood pressure were examined using generalized estimating equations.Results: From 2002 to 2008, NLBs and Latinos reported heightened interpersonal and institutional discrimination, respectively, compared with NLWs. There were no differences in associations between interpersonal discrimination and blood pressure. Increased institutional discrimination was associated with stronger increases in systolic and diastolic blood pressure for NLBs than NLWs, with no differences between Latinos and NLWs. Latino immigrants experienced greater increases in blood pressure with increased interpersonal and institutional discrimination compared to US-born Latinos.Conclusions: Together, these findings suggest that NLBs and Latinos experienced heightened discrimination from 2002 to 2008, and that increases in institutional discrimination were more strongly associated with blood pressure elevation among NLBs and Latino immigrants compared to NLWs and US-born Latinos, respectively. These findings suggest recent increases in discrimination experienced by NLBs and Latinos, and that these increases may exacerbate racial/ethnic health inequities.

Social Determinants and Disparities in Health: Their Crucifixion, Resurrection, and Ultimate Triumph(?) in Health Policy

David Mechanic has been a principal founder of modern sociological and social science approaches to health, especially in relation to health policy. These approaches have since the 1950s and 1960s resurrected ideas that had currency in the mid-nineteenth century but seemed crucified, dead, and buried by the rise of modern biomedicine from the mid-nineteenth century through the mid-twentieth century. Problems and lacunae in purely biomedical approaches to health in the later twentieth century, along with developments of new biopsychosocial approaches to health, have spawned a return toward ideas of Rudolf Virchow and mid-nineteenth-century social medicine that social determinants and disparities are major drivers of population health. Since individual health and population health constitute the major determinants of health care utilization and expenditures, social determinants and disparities in health are arguably the foundation of a new "demand-side" health policy that can resolve America's paradoxical health policy crisis of spending increasingly more than any nation on health care and insurance yet achieving increasingly worsening health outcomes relative to virtually all developed countries and some developing ones as well, something that current "supply-side" health policy, including Obamacare, cannot do, important as it is for expanding access to health insurance and care.

Dynamics of health behaviours and socioeconomic differences in mortality in the USA

BACKGROUND

To measure the explanatory role of behavioural factors to educational and income disparities in mortality among US adults (ages 25+).

METHODS

Data were from four waves of the American Changing Lives Study (N=3617). There were 1832 deaths between 1986 and 2011. Smoking, physical activity, alcohol and body mass index were examined.

RESULTS

Those with 0-11 years of schooling had an 88% (95% CI 48% to 139%) increased risk of dying compared to those with 16+years of schooling. Behavioural factors explained 41% (95% CI 26% to 55%) and 50% (95% CI 30% to 70%) of this excess in models that treated behavioural factors as fixed (single point in time) and time varying (repeated), respectively. The lowest income group (bottom 20th centile) had a 209% (95% CI 172% to 256%) increased risk of dying relative to the highest income group (top 40th centile). Behavioural factors explained 24% (fixed, 95% CI 13% to 35%) and 39% (repeated, 95% CI 22% to 56%) of this difference. Analyses of deaths by causes indicated that behavioural factors were more consequential to disparities in cardiovascular mortality, explaining up to 83% of educational differences, compared to cancer and other death causes.

CONCLUSIONS

Behavioural factors are one of a number of factors which explain socioeconomic mortality disparities, but their estimated explanatory role depends on a number of parameters including the socioeconomic status measure examined, the cause of death and age. In this nationally representative sample, findings based on repeated measures did not warrant a re-evaluation of earlier estimates.

Individual joblessness, contextual unemployment, and mortality risk

Longitudinal studies at the level of individuals find that employees who lose their jobs are at increased risk of death. However, analyses of aggregate data find that as unemployment rates increase during recessions, population mortality actually declines. We addressed this paradox by using data from the US Department of Labor and annual survey data (1979-1997) from a nationally representative longitudinal study of individuals-the Panel Study of Income Dynamics. Using proportional hazards (Cox) regression, we analyzed how the hazard of death depended on 1) individual joblessness and 2) state unemployment rates, as indicators of contextual economic conditions. We found that 1) compared with the employed, for the unemployed the hazard of death was increased by an amount equivalent to 10 extra years of age, and 2) each percentage-point increase in the state unemployment rate reduced the mortality hazard in all individuals by an amount equivalent to a reduction of 1 year of age. Our results provide evidence that 1) joblessness strongly and significantly raises the risk of death among those suffering it, and 2) periods of higher unemployment rates, that is, recessions, are associated with a moderate but significant reduction in the risk of death among the entire population.

Racial/ethnic disparities in hypertension prevalence: reconsidering the role of chronic stress

OBJECTIVES

We investigated the association between anticipatory stress, also known as racism-related vigilance, and hypertension prevalence in Black, Hispanic, and White adults.

METHODS

We used data from the Chicago Community Adult Health Study, a population-representative sample of adults (n = 3105) surveyed in 2001 to 2003, to regress hypertension prevalence on the interaction between race/ethnicity and vigilance in logit models.

RESULTS

Blacks reported the highest vigilance levels. For Blacks, each unit increase in vigilance (range = 0-12) was associated with a 4% increase in the odds of hypertension (odds ratio [OR] = 1.04; 95% confidence interval [CI] = 1.00, 1.09). Hispanics showed a similar but nonsignificant association (OR = 1.05; 95% CI = 0.99, 1.12), and Whites showed no association (OR = 0.95; 95% CI = 0.87, 1.03).

CONCLUSIONS

Vigilance may represent an important and unique source of chronic stress that contributes to the well-documented higher prevalence of hypertension among Blacks than Whites; it is a possible contributor to hypertension among Hispanics but not Whites.

Do special occasions trigger psychological distress among older bereaved spouses? An empirical assessment of clinical wisdom

OBJECTIVES

Mental health professionals have suggested that widowed persons experience heightened psychological distress on dates that had special meaning for them and their late spouse, such as a wedding anniversary or the late spouse's birthday. This study examined the effects of such occasions on grief, anxiety, and depressive symptoms in a community sample of older widowed persons.

METHODS

OLS regression models were estimated using data from the Changing Lives of Older Couples (CLOC) study, a large prospective probability study of late-life widowhood. Participants were interviewed prior to and both 6 and 18 months after spousal loss; married matched controls were interviewed at comparable times.

RESULTS

Widowed persons reported heightened psychological distress when interviewed during the month of their late spouse's birthday, a post-holiday period (January), and in June, a month associated with wedding anniversaries and graduations in the United States. The distressing effects of special occasions on psychological symptoms were evidenced only within the first 6 months postloss, and were not apparent at the 18-month follow-up.

DISCUSSION

Our results support the clinical observation that persons in the early stages of spousal bereavement are at increased risk of psychological distress at times with special significance to the couple. We highlight methodological and clinical implications.

Contextualizing nativity status, Latino social ties, and ethnic enclaves: an examination of the 'immigrant social ties hypothesis'

OBJECTIVES

Researchers have posited that one potential explanation for the better-than-expected health outcomes observed among some Latino immigrants, vis-à-vis their US-born counterparts, may be the strength of social ties and social support among immigrants.

METHODS

We examined the association between nativity status and social ties using data from the Chicago Community Adult Health Study's Latino subsample, which includes Mexicans, Puerto Ricans, and other Latinos. First, we used ordinary least squares (OLS) regression methods to model the effect of nativity status on five outcomes: informal social integration; social network diversity; network size; instrumental support; and informational support. Using multilevel mixed-effects regression models, we estimated the association between Latino/immigrant neighborhood composition and our outcomes, and whether these relationships varied by nativity status. Lastly, we examined the relationship between social ties and immigrants' length of time in the USA.

RESULTS

After controlling for individual-level characteristics, immigrant Latinos had significantly lower levels of social ties than their US-born counterparts for all the outcomes, except informational support. Latino/immigrant neighborhood composition was positively associated with being socially integrated and having larger and more diverse social networks. The associations between two of our outcomes (informal social integration and network size) and living in a neighborhood with greater concentrations of Latinos and immigrants were stronger for US-born Latinos than for immigrant Latinos. US-born Latinos maintained a significant social ties advantage over immigrants - regardless of length of time in the USA - for informal social integration, network diversity, and network size.

CONCLUSION

At the individual level, our findings challenge the assumption that Latino immigrants would have larger networks and/or higher levels of support and social integration than their US-born counterparts. Our study underscores the importance of understanding the contexts that promote the development of social ties. We discuss the implications of these findings for understanding Latino and immigrant social ties and health outcomes.

Social connectedness and disease transmission: social organization, cohesion, village context, and infection risk in rural Ecuador

Social networks are typically seen as conduits for the spread of disease and disease risk factors. However, social relationships also reduce the incidence of chronic disease and potentially infectious diseases. Seldom are these opposing effects considered simultaneously. We have shown how and why diarrheal disease spreads more slowly to and in rural Ecuadorian villages that are more remote from the area's population center. Reduced contact with outside individuals partially accounts for remote villages' relatively lower prevalence of diarrheal disease. But equally or more important is the greater density of social ties between individuals in remote communities, which facilitates the spread of individual and collective practices that reduce the transmission of diarrheal disease.

Variations in hypertension-related outcomes among Blacks, Whites and Hispanics in two large urban areas and in the United States

OBJECTIVE

This study compared the hypertension prevalence, awareness, treatment and control in Chicago, Illinois and Detroit, Michigan to that of the general United States population (aged > or = 25 years) for the period 2001-2003. We examined whether and how much 1) urban populations have less favorable hypertension-related outcomes and 2) the rates of racial/ethnic minorities lag behind those of Whites in order to determine if the national data understate the magnitude of hypertension-related outcomes and racial/ethnic disparities in two large cities in the Midwestern region of the United States and perhaps others.

METHODS

Unstandardized and standardized hypertension-related outcome rates were estimated.

RESULTS

The hypertension-related outcomes among Chicago and Detroit residents lag behind the United States by 8%-14% and 10%-18% points, respectively. Additionally, this study highlights the complexity of the racial/ethnic differences in hypertension-related outcomes, where within each population, Blacks were more likely to have hypertension and to be aware of their hypertension status than Whites, and no less likely to be treated. Conversely, Hispanics were less likely to have hypertension and also less likely to be aware of their status when they do have hypertension when compared to Whites.

CONCLUSION

At a time when efficacious treatment for hypertension has been available for more than 50 years, continued racial/ethnic differences in the prevalence, awareness, treatment and control of hypertension is among public health's greatest challenges. To achieve the proposed national hypertension-related goals, future policies must consider the social context of hypertension within central cities of urban areas.

The Unequal Burden of Weight Gain: An Intersectional Approach to Understanding Social Disparities in BMI Trajectories from 1986 to 2001/2002

The implications of recent weight gain trends for widening social disparities in body weight in the United States are unclear. Using an intersectional approach to studying inequality, and the longitudinal and nationally representative American's Changing Lives study (19862001/2002), we examine social disparities in body mass index trajectories during a time of rapid weight gain in the United States. Results reveal complex interactive effects of gender, race, socioeconomic position and age, and provide evidence for increasing social disparities, particularly among younger adults. Most notably, among individuals who aged from 25-39 to 45-54 during the study interval, low-educated and low-income black women experienced the greatest increase in BMI, while high-educated and high-income white men experienced the least BMI growth. These new findings highlight the importance of investigating changing disparities in weight intersectionally, using multiple dimensions of inequality as well as age, and also presage increasing BMI disparities in the U.S. adult population.

Education and levels of salivary cortisol over the day in US adults

BACKGROUND

Dysregulation of the hypothalamic-pituitary-adrenal axis is hypothesized to be an important pathway linking socioeconomic position and chronic disease.

PURPOSE

This paper tests the association between education and the diurnal rhythm of salivary cortisol.

METHODS

Up to eight measures of cortisol (mean of 5.38 per respondent) over 2 days were obtained from 311 respondents, aged 18-70, drawn from the 2001-2002 Chicago Community Adult Health Study. Multi-level models with linear splines were used to estimate waking level, rates of cortisol decline, and area-under-the-curve over the day, by categories of education.

RESULTS

Lower education (0-11 years) was associated with lower waking levels of cortisol, but not the rate of decline of cortisol, resulting in a higher area-under-the-curve for more educated respondents throughout the day.

CONCLUSIONS

This study found evidence of lower cortisol exposure among individuals with less education and thus does not support the hypothesis that less education is associated with chronic over-exposure to cortisol.

Social security and mortality: the role of income support policies and population health in the United States

Social Security is the most important and effective income support program ever introduced in the United States, alleviating the burden of poverty for millions of elderly Americans. We explored the possible role of Social Security in reducing mortality among the elderly. In support of this hypothesis, we found that declines in mortality among the elderly exceeded those among younger age groups following the initial implementation of Social Security in 1940, and also in the periods following marked improvements in Social Security benefits via legislation and indexing of benefits that occurred between the mid-1960s and the early 1970s. A better understanding of the link between Social Security and health status among the elderly would add a significant and missing dimension to the public discourse over the future of Social Security, and the potential role of income support programs in reducing health-related socioeconomic disparities and improving population health.

Cognitive function in the community setting: the neighbourhood as a source of 'cognitive reserve'?

BACKGROUND

Existing research has found a positive association between cognitive function and residence in a socioeconomically advantaged neighbourhood. Yet, the mechanisms underlying this relationship have not been empirically investigated.

OBJECTIVE

To test the hypothesis that neighbourhood socioeconomic structure is related to cognitive function partly through the availability of neighbourhood physical and social resources (eg, recreational facilities, community centres and libraries), which promote cognitively beneficial activities such as exercise and social integration.

METHODS

Using data from a representative survey of community-dwelling adults in the city of Chicago (N=949 adults aged 50 and over), cognitive function was assessed with a modified version of the Telephone Interview for Cognitive Status instrument. Neighbourhood socioeconomic structure was derived from US census indicators. Systematic social observation was used to directly document the presence of neighbourhood resources on the blocks surrounding each respondent's residence.

RESULTS

Using multilevel linear regression, residence in an affluent neighbourhood had a net positive effect on cognitive function after adjusting for individual risk factors. For white respondents, the effects of neighbourhood affluence operated in part through a greater density of institutional resources (eg, community centres) that promote cognitively beneficial activities such as physical activity. Stable residence in an elderly neighbourhood was associated with higher cognitive function (potentially due to greater opportunities for social interaction with peers), but long term exposure to such neighbourhoods was negatively related to cognition.

CONCLUSIONS

Neighbourhood resources have the potential to promote 'cognitive reserve' for adults who are ageing in place in an urban setting.

Language of interview, self-rated health, and the other Latino health puzzle

OBJECTIVES

We investigated whether the conventional Spanish translation of the self-rated health survey question helps explain why Latinos' self-rated health is worse than Whites' despite more objective health measures showing them to be as healthy as or healthier than are Whites.

METHODS

We analyzed the relationship between language of interview and self-rated health in the Chicago Community Adult Health Study (2001-2003) and the 2003 Behavioral Risk Factor Surveillance System.

RESULTS

Being interviewed in Spanish was associated with significantly higher odds of rating health as fair or poor in both data sets. Moreover, adjusting for language of interview substantially reduced the gap between Whites and Latinos. Spanish-language interviewees were more likely to rate their health as fair (regular in Spanish) than as any other choice, and this preference was strongest when compared with categories representing better health (good, very good, and excellent).

CONCLUSIONS

Our findings suggest that translation of the English word "fair" to regular induces Spanish-language respondents to report poorer health than they would in English. Self-rated health should be interpreted with caution, especially in racial/ethnic comparisons, and research should explore alternative translations.

Socioeconomic and behavioral risk factors for mortality in a national 19-year prospective study of U.S. adults

Many demographic, socioeconomic, and behavioral risk factors predict mortality in the United States. However, very few population-based longitudinal studies are able to investigate simultaneously the impact of a variety of social factors on mortality. We investigated the degree to which demographic characteristics, socioeconomic variables and major health risk factors were associated with mortality in a nationally-representative sample of 3617 U.S. adults from 1986 to 2005, using data from the 4 waves of the Americans' Changing Lives study. Cox proportional hazard models with time-varying covariates were employed to predict all-cause mortality verified through the National Death Index and death certificate review. The results revealed that low educational attainment was not associated with mortality when income and health risk behaviors were included in the model. The association of low income with mortality remained after controlling for major behavioral risks. Compared to those in the "normal" weight category, neither overweight nor obesity was significantly associated with the risk of mortality. Among adults age 55 and older at baseline, the risk of mortality was actually reduced for those were overweight (hazard rate ratio = 0.83) and those who were obese (hazard rate ratio = 0.68), controlling for other health risk behaviors and health status. Having a low level of physical activity was a significant risk factor for mortality (hazard rate ratio = 1.58). The results from this national longitudinal study underscore the need for health policies and clinical interventions focusing on the social and behavioral determinants of health, with a particular focus on income security, smoking prevention/cessation, and physical activity.

Measurement of the local food environment: a comparison of existing data sources

Studying the relation between the residential environment and health requires valid, reliable, and cost-effective methods to collect data on residential environments. This 2002 study compared the level of agreement between measures of the presence of neighborhood businesses drawn from 2 common sources of data used for research on the built environment and health: listings of businesses from commercial databases and direct observations of city blocks by raters. Kappa statistics were calculated for 6 types of businesses-drugstores, liquor stores, bars, convenience stores, restaurants, and grocers-located on 1,663 city blocks in Chicago, Illinois. Logistic regressions estimated whether disagreement between measurement methods was systematically correlated with the socioeconomic and demographic characteristics of neighborhoods. Levels of agreement between the 2 sources were relatively high, with significant (P < 0.001) kappa statistics for each business type ranging from 0.32 to 0.70. Most business types were more likely to be reported by direct observations than in the commercial database listings. Disagreement between the 2 sources was not significantly correlated with the socioeconomic and demographic characteristics of neighborhoods. Results suggest that researchers should have reasonable confidence using whichever method (or combination of methods) is most cost-effective and theoretically appropriate for their research design.

Racial and socioeconomic disparities in residential proximity to polluting industrial facilities: evidence from the Americans' Changing Lives Study

OBJECTIVES

We sought to demonstrate the advantages of using individual-level survey data in quantitative environmental justice analyses and to provide new evidence regarding racial and socioeconomic disparities in the distribution of polluting industrial facilities.

METHODS

Addresses of respondents in the baseline sample of the Americans' Changing Lives Study and polluting industrial facilities in the Environmental Protection Agency's Toxic Release Inventory were geocoded, allowing assessments of distances between respondents' homes and polluting facilities. The associations between race and other sociodemographic characteristics and living within 1 mile (1.6 km) of a polluting facility were estimated via logistic regression.

RESULTS

Blacks and respondents at lower educational levels and, to a lesser degree, lower income levels were significantly more likely to live within a mile of a polluting facility. Racial disparities were especially pronounced in metropolitan areas of the Midwest and West and in suburban areas of the South.

CONCLUSIONS

Our results add to the historical record demonstrating significant disparities in exposures to environmental hazards in the US population and provide a paradigm for studying changes over time in links to health.

Relational pathways between socioeconomic position and cardiovascular risk in a multiethnic urban sample: complexities and their implications for improving health in economically disadvantaged populations

BACKGROUND

The study was designed to provide evidence of a cascade effect linking socioeconomic position to anthropometric indicators of cardiovascular disease (CVD) risk through effects on psychosocial stress, psychological distress and health-related behaviours, and consider implications for disease prevention and health promotion.

METHODS

A cross-sectional stratified two-stage probability sample of occupied housing units in three areas of Detroit, Michigan, was used in the study. 919 adults aged > or =25 years completed the survey (mean age 46.3; 53% annual household income <$20 000; 57% non-Hispanic black, 22% Latino, 19% non-Hispanic white). Variables included self-report (eg, psychosocial stress, depressive symptoms, health behaviours) and anthropometric measurements (eg, waist circumference, height, weight). The main outcome variables were depressive symptoms, smoking status, physical activity, body mass index and waist circumference.

RESULTS

Income was inversely associated with depressive symptoms, likelihood of current smoking, physical inactivity and waist circumference. These relationships were partly or fully mediated by psychosocial stress. A suppressor effect of current smoking on the relationship between depressive symptoms and waist circumference was found. Independent effects of psychosocial stress and psychological distress on current smoking and waist circumference were found, above and beyond the mediated pathways.

CONCLUSIONS

The results suggest that relatively modest improvements in the income of economically disadvantaged people can set in motion a cascade of effects, simultaneously reducing exposure to stressful life conditions, improving mental well-being, increasing health-promoting behaviours and reducing anthropometric risks associated with CVD. Such interventions offer important opportunities to improve population health and reduce health disparities.

Mobility disability and the urban built environment

Research on the effects of the built environment in the pathway from impairment to disability has been largely absent. Using data from the Chicago Community Adult Health Study (2001-2003), the authors examined the effect of built environment characteristics on mobility disability among adults aged 45 or more years (n = 1,195) according to their level of lower extremity physical impairment. Built environment characteristics were assessed by using systematic social observation to independently rate street and sidewalk quality in the block surrounding each respondent's residence in the city of Chicago (Illinois). Using multinomial logistic regression, the authors found that street conditions had no effect on outdoor mobility among adults with only mild or no physical impairment. However, among adults with more severe impairment in neuromuscular and movement-related functions, the difference in the odd ratios for reporting severe mobility disability was over four times greater when at least one street was in fair or poor condition (characterized by cracks, potholes, or broken curbs). When all streets were in good condition, the odds of reporting mobility disability were attenuated in those with lower extremity impairment. If street quality could be improved, even somewhat, for those adults at greatest risk for disability in outdoor mobility, the disablement process could be slowed or even reversed.

C/EBPbeta represses p53 to promote cell survival downstream of DNA damage independent of oncogenic Ras and p19(Arf)

CCAAT/enhancer-binding protein-beta (C/EBPbeta) is a mediator of cell survival and tumorigenesis. When C/EBPbeta(-/-) mice are treated with carcinogens that produce oncogenic Ras mutations in keratinocytes, they respond with abnormally elevated keratinocyte apoptosis and a block in skin tumorigenesis. Although this aberrant carcinogen-induced apoptosis results from abnormal upregulation of p53, it is not known whether upregulated p53 results from oncogenic Ras and its ability to induce p19(Arf) and/or activate DNA-damage response pathways or from direct carcinogen-induced DNA damage. We report that p19(Arf) is dramatically elevated in C/EBPbeta(-/-) epidermis and that C/EBPbeta represses a p19(Arf) promoter reporter. To determine whether p19(Arf) is responsible for the proapoptotic phenotype in C/EBPbeta(-/-) mice, C/EBPbeta(-/-);p19(Arf-/-) mice were generated. C/EBPbeta(-/-);p19(Arf-/-) mice responded to carcinogen treatment with increased p53 and apoptosis, indicating p19(Arf) is not essential. To ascertain whether oncogenic Ras activation induces aberrant p53 and apoptosis in C/EBPbeta(-/-) epidermis, we generated K14-ER:Ras;C/EBPbeta(-/-) mice. Oncogenic Ras activation induced by 4-hydroxytamoxifen did not produce increased p53 or apoptosis. Finally, when C/EBPbeta(-/-) mice were treated with differing types of DNA-damaging agents, including alkylating chemotherapeutic agents, they displayed aberrant levels of p53 and apoptosis. These results indicate that C/EBPbeta represses p53 to promote cell survival downstream of DNA damage and suggest that inhibition of C/EBPbeta may be a target for cancer cotherapy to increase the efficacy of alkylating chemotherapeutic agents.

Upstream solutions: does the supplemental security income program reduce disability in the elderly?

CONTEXT

The robust relationship between socioeconomic factors and health suggests that social and economic policies might substantially affect health, while other evidence suggests that medical care, the main focus of current health policy, may not be the primary determinant of population health. Income support policies are one promising avenue to improve population health. This study examines whether the federal cash transfer program to poor elderly, the Supplemental Security Income (SSI) program, affects old-age disability.

METHODS

This study uses the 1990 and 2000 censuses, employing state and year fixed-effect models, to test whether within-state changes in maximum SSI benefits over time lead to changes in disability among people aged sixty-five and older.

FINDINGS

Higher benefits are linked to lower disability rates. Among all single elderly individuals, 30 percent have mobility limitations, and an increase of $100 per month in the maximum SSI benefit caused the rate of mobility limitations to fall by 0.46 percentage points. The findings were robust to sensitivity analyses. First, analyses limited to those most likely to receive SSI produced larger effects, but analyses limited to those least likely to receive SSI produced no measurable effect. Second, varying the disability measure did not meaningfully alter the findings. Third, excluding the institutionalized, immigrants, individuals living in states with exceptionally large benefit changes, and individuals living in states with no SSI supplements did not change the substantive conclusions. Fourth, Medicaid did not confound the effects. Finally, these results were robust for married individuals.

CONCLUSIONS

Income support policy may be a significant new lever for improving population health, especially that of lower-income persons. Even though the findings are robust, further analyses are needed to confirm their reliability. Future research should examine a variety of different income support policies, as well as whether a broader range of social and economic policies affect health.

Coping with spousal loss: potential buffering effects of self-reported helping behavior

The present study examined the role of self-reported helping behavior in attenuating the helper's depression following spousal loss. Using archival data from the Changing Lives of Older Couples sample (N = 289), the study shows that among bereaved participants who had experienced high loss-related grief, helping behavior (providing instrumental support to others) was associated with an accelerated decline in depressive symptoms for the helper from 6 months to 18 months following spousal loss. This relationship between giving help and recovery from depression was independent of support received, as well as measured health, and interpersonal and demographic factors. Implications of these results for theoretical approaches to the study of close relationships and well-being are discussed.

Coping with spousal loss: potential buffering effects of self-reported helping behavior

The present study examined the role of self-reported helping behavior in attenuating the helper's depression following spousal loss. Using archival data from the Changing Lives of Older Couples sample (N = 289), the study shows that among bereaved participants who had experienced high loss-related grief, helping behavior (providing instrumental support to others) was associated with an accelerated decline in depressive symptoms for the helper from 6 months to 18 months following spousal loss. This relationship between giving help and recovery from depression was independent of support received, as well as measured health, and interpersonal and demographic factors. Implications of these results for theoretical approaches to the study of close relationships and well-being are discussed.

Toward a better estimation of the effect of job loss on health

Previous research has shown that involuntary job loss may have negative health consequences, but existing analyses have not adequately adjusted for health selection or other confounding factors that could reveal the association to be spurious. Using two large, population-based longitudinal samples of U.S. workers from the Americans' Changing Lives Study and the Wisconsin Longitudinal Study, this analysis goes further by using respondents' self-reports of the reasons for job loss and information about the timing of job losses and acute negative health shocks to distinguish health-related job losses from other involuntary job losses. Results suggest that even after adjustment for numerous social background characteristics and baseline health, involuntary job loss is associated with significantly poorer overall self-rated health and more depressive symptoms. More nuanced analyses reveal that among involuntary job losers, those who lose their jobs for health-related reasons have, not surprisingly, the most precipitous declines in health. Job losses for other reasons have substantive and statistically significant effects on depressive symptoms, while effects on self-rated poor health are relatively small.

Understanding social disparities in hypertension prevalence, awareness, treatment, and control: the role of neighborhood context

The spatial segregation of the US population by socioeconomic position and especially race/ethnicity suggests that the social contexts or "neighborhoods" in which people live may substantially contribute to social disparities in hypertension. The Chicago Community Adult Health Study did face-to-face interviews, including direct measurement of blood pressure, with a representative probability sample of adults in Chicago. These data were used to estimate socioeconomic and racial-ethnic disparities in the prevalence, awareness, treatment, and control of hypertension, and to analyze how these disparities are related to the areas in which people live. Hypertension was significantly negatively associated with neighborhood affluence/gentrification, and adjustments for context eliminated the highly significant disparity between blacks/African-Americans and whites, and reduced the significant educational disparity by 10-15% to borderline statistical significance. Awareness of hypertension was significantly higher in more disadvantaged neighborhoods and in places with higher concentrations of blacks (and lower concentrations of Hispanics and immigrants). Adjustment for context completely eliminated blacks' greater awareness, but slightly accentuated the lesser awareness of Hispanics and the greater levels of awareness among the less educated. There was no consistent evidence of either social disparities in or contextual associations with treatment of hypertension, given awareness. Among those on medication, blacks were only 40-50% as likely as whites to have their hypertension controlled, but context played little or no role in either the level of or disparities in control of hypertension. In sum, residential contexts potentially play a large role in accounting for racial/ethnic and, to a lesser degree, socioeconomic disparities in hypertension prevalence and, in a different way, awareness, but not in treatment or control of diagnosed hypertension.

Socioeconomic position and health: the differential effects of education versus income on the onset versus progression of health problems

This article seeks to elucidate the relationship between socioeconomic position and health by showing how different facets of socioeconomic position (education and income) affect different stages (onset vs. progression) of health problems. The biomedical literature has generally treated socioeconomic position as a unitary construct. Likewise, the social science literature has tended to treat health as a unitary construct. To advance our understanding of the relationship between socioeconomic position and health, and ultimately to foster appropriate policies and practices to improve population health, a more nuanced approach is required--one that differentiates theoretically and empirically among dimensions of both socioeconomic position and health. Using data from the Americans' Changing Lives Study (1986 through 2001/2002), we show that education is more predictive than income of the onset of both functional limitations and chronic conditions, while income is more strongly associated than education with the progression of both.

Inter-rater and test–retest reliability: Methods and results for the neighborhood observational checklist

The popularity of direct or systematic social observation as a method to evaluate the mechanisms by which neighborhood environments impact health and contribute to health disparities is growing. The development of measures with adequate inter-rater and test-retest reliability is essential for this research. In this paper, based on our experiences conducting direct observation of neighborhoods in Detroit, MI, we describe strategies to promote high inter-rater and test-retest reliability and methods to evaluate reliability. We then present the results and discuss implications for future research efforts using direct observation in four areas: methods to evaluate reliability, instrument content and design, observer training, and data collection.

Continuity and change in the social stratification of aging and health over the life course: evidence from a nationally representative longitudinal study from 1986 to 2001/2002 (Americans' Changing Lives Study)

OBJECTIVES

This article overviews previously published and ongoing research from the Americans' Changing Lives (ACL) Study, a longitudinal study of a nationally representative sample of 3,617 adults aged 25 years and older when first interviewed in 1986, focusing on socioeconomic disparities in the way health changes with age during middle and later life, especially in terms of compression of morbidity/functional limitations.

METHODS

A variety of descriptive and multivariate regression and growth curve analyses are done on the ACL sample, now surveyed over four waves spanning 15.5 years between 1986 and 2001/2002 with continuing mortality ascertainment via the National Death Index, death certificate searches, and informant reports.

RESULTS

Both cross-sectional and longitudinal analyses indicate that socioeconomic disparities in health are small in early adulthood, increase through middle and early old age, and then lessen again in later old age. In other terms, compression of morbidity/functional limitations into the later stages of the life course is realized to a much greater degree among the better educated compared with the less educated. Cross-sectional evidence suggests that this reflects differential exposure to or experience of a wide range of psychosocial, environmental, and biomedical risk factors for health (and perhaps their differential impact at different ages and life stages), as well as variations in biological robustness and frailty and also perhaps in the strength of social welfare supports for health at different life stages. Longitudinal analyses reveal several new insights: (a) The flow of causality is much greater from socioeconomic position to health than vice versa; (b) education plays a greater role relative to income in the onset of functional limitations, whereas income has much stronger effects on their progression or course; and (c) educational disparities in the onset and hence of compression of functional limitations over the life course have increased strikingly in later middle and early old age (ages 55-84 years) since 1986.

DISCUSSION

The results indicate that understanding and alleviating social disparities in health are both theoretically and methodologically quintessential problems of life course analysis and research.

Social and physical environments and disparities in risk for cardiovascular disease: the healthy environments partnership conceptual model

The Healthy Environments Partnership (HEP) is a community-based participatory research effort investigating variations in cardiovascular disease risk, and the contributions of social and physical environments to those variations, among non-Hispanic black, non-Hispanic white, and Hispanic residents in three areas of Detroit, Michigan. Initiated in October 2000 as a part of the National Institute of Environmental Health Sciences' Health Disparities Initiative, HEP is affiliated with the Detroit Community-Academic Urban Research Center. The study is guided by a conceptual model that considers race-based residential segregation and associated concentrations of poverty and wealth to be fundamental factors influencing multiple, more proximate predictors of cardiovascular risk. Within this model, physical and social environments are identified as intermediate factors that mediate relationships between fundamental factors and more proximate factors such as physical activity and dietary practices that ultimately influence anthropomorphic and physiologic indicators of cardiovascular risk. The study design and data collection methods were jointly developed and implemented by a research team based in community-based organizations, health service organizations, and academic institutions. These efforts include collecting and analyzing airborne particulate matter over a 3-year period; census and administrative data; neighborhood observation checklist data to assess aspects of the physical and social environment; household survey data including information on perceived stressors, access to social support, and health-related behaviors; and anthropometric, biomarker, and self-report data as indicators of cardiovascular health. Through these collaborative efforts, HEP seeks to contribute to an understanding of factors that contribute to racial and socioeconomic health inequities, and develop a foundation for efforts to eliminate these disparities in Detroit.

Stress, life events, and socioeconomic disparities in health: results from the Americans' Changing Lives Study

It has been hypothesized that exposure to stress and negative life events is related to poor health outcomes, and that differential exposure to stress plays a role in socioeconomic disparities in health. Data from three waves of the Americans' Changing Lives study (n = 3,617) were analyzed to investigate prospectively the relationship among socioeconomic indicators, five measures of stress/negative life events, and the health outcomes of mortality, functional limitations, and self-rated health. The results revealed that (1) life events and other types of stressors are clearly related to socioeconomic position; (2) a count of negative lifetime events was positively associated with mortality; (3) a higher score on a financial stress scale was predictive of severe/moderate functional limitations and fair/poor self-rated health at wave 3; and (4) a higher score on a parental stress scale was predictive of fair/poor self-rated health at wave 3. The negative effects of low income on functional limitations attenuated to insignificance when waves 1 and 2 stress/life event measures were controlled for, but other socioeconomic disparities in health change remained sizable and significant when adjusted for exposure to stressors. The results support the hypothesis that differential exposure to stress and negative life events is one of many ways in which socioeconomic inequalities in health are produced in society.

Religion and emotional compensation: results from a prospective study of widowhood

Based on recent applications of attachment theory to religion, the authors predicted that the loss of a spouse would cause widowed individuals to increase the importance of their religious/spiritual beliefs. This hypothesis was examined using the Changing Lives of Older Couples sample from which preloss measures of religiosity were available for widowed individuals and matched controls. A total of 103 widowed individuals provided follow-up data, including reports of religious beliefs and grief, at 6 months, 24 months, and 48 months after the loss. Results indicated that widowed individuals were more likely than controls to increase their religious/spiritual beliefs. This increase was associated with decreased grief but did not influence other indicators of adjustment such as depression. Finally, insecure individuals were most likely to benefit from increasing the importance of their beliefs. Results are discussed in terms of the potential value of applying psychological theory to the study of religion.

Depressive symptoms and mortality risk in a national sample: confounding effects of health status

OBJECTIVE

We examined the association between depressive symptoms and all-cause mortality in a population sample. Published findings on the relation between depressive symptoms and mortality risk point to an inconsistent association and one that is likely influenced by health status. Few studies have assessed this relation in randomly selected population samples.

METHODS

Participants were 3617 noninstitutionalized adults, age 25 years or older, from the Americans' Changing Lives Study, an ongoing longitudinal study of a nationally representative sample. Depressive symptoms were measured by the 11-item version of the Center for Epidemiological Studies Depression Scale (CES-D). Cox proportional hazards models estimated the relative risk of mortality as a function of the CES-D scores at baseline.

RESULTS

In 7.5 years of follow-up, 542 deaths occurred. Each 1-standard unit increase on the CES-D predicted a 21% increased risk of all-cause mortality, adjusting for age, gender, and race (hazard ratio = 1.21, 95% confidence interval = 1.08 to 1.36, p = .001). This association was weakened somewhat following adjustment for education, income, body mass index, smoking and alcohol consumption (hazard ratio = 1.13, 95% confidence interval = 0.99 to 1.28, p = .06). However, control for self-reported functional limitations or chronic health conditions at baseline effectively eliminated the relationship. Analyses limited to participants with good to excellent health or no functional impairments at baseline showed no association between depressive symptoms and subsequent mortality risk. Secondary analyses showed no association between depressive symptoms and cardiovascular mortality.

CONCLUSIONS

These findings from a randomly selected, nationally representative sample do not support the hypothesis that depressive symptoms are independently related to mortality in the general population, after adequate adjustment for the confounding effects of physical health status.

Attendance at religious services and mortality in a national sample

Research and theory increasingly suggest that attendance at religious services is protective against premature mortality. However, prior studies are limited and do not extensively explore potential explanations for the relationship, especially in terms of religious beliefs and behaviors associated with service attendance. This study estimates the impact of service attendance on mortality in a national probability sample and provides the most extensive empirical examination of potential explanations. Individuals who report attending religious services once a month or more (just over 50 percent of the population) have a 30-35 percent reduced risk of death over a 7.5 year follow-up period after adjusting for potential confounding factors. Consistent with prior research, 20-30 percent of this effect may be explained by better health behaviors (especially physical activity) among regular service attendees. Surprisingly, other religious beliefs and behaviors do not explain, and often tend to suppress, the association between service attendance and mortality.

Education, income, and functional limitation transitions among American adults: contrasting onset and progression

BACKGROUND

Although a robust association between socioeconomic status and health has been shown in past research, the processes that explain the connection are not well understood. This paper seeks to advance such understanding in two ways, first by attending to the distinction between onset of a functional health problem and its progression, and second by addressing whether and how education and income relate differently to the onset versus progression of functional health problems.

METHODS

Data come from the Americans' Changing Lives survey (n = 3617). The baseline was conducted in 1986 and outcome status measured in 1994. Activity limitations are categorized into none, mild, moderate, severe. Onset is defined as having no limitation at origin and a limitation at outcome. Progression is defined as limitation of a particular severity at origin and improving, staying the same, or getting worse with respect to the severity. Multinomial regressions determine transition probabilities related to onset and progression.

RESULTS

Those with higher income and education are less likely to experience an onset. Only income associates with progression. Those with the highest income are most likely to improve and least likely to get worse in comparison to those with the lowest income.

CONCLUSIONS

Education, being determined early in life and influencing psychosocial mechanisms throughout life, may have a greater impact on prevention of activity and functional disorders. Income's role may be both as a prevention factor and as a mechanism for management of health problems.

Understanding social factors and inequalities in health: 20th century progress and 21st century prospects

The development of social epidemiology and medical sociology over the last half of the 20th century, in which Leo Reeder played a central role, transformed scientific and popular understanding of the nature and causes of physical health and illness. Viewed in the early 1950s as shaped almost entirely by biological processes and medical care, physical health and illness are now understood to be as much or more a function of social, psychological, and behavioral factors. Utilizing a stress and adaptation conceptual framework, social epidemiology has identified a broad range of psychosocial risk factors for health, most notably: (1) social relationships and support; (2) acute or event-based stress; (3) chronic stress in work and life; and (4) psychological dispositions such as anger/hostility, lack of self-efficacy/control, and negative affect/hopelessness/pessimism, with new risk factors continuing to be identified. However, proliferation of risk factors must be balanced by conceptual integration and causal understanding of the relationships among them, their causes, and consequences. One source of such integration and understanding has been the rediscovery of large and persistent socioeconomic and racial-ethnic disparities in health. Socioeconomic position and race/ethnicity shape individuals' exposure to and experience of virtually all known psychosocial, and well as many environmental and biomedical, risk factors, and these risk factors help to explain the size and persistence of social disparities in health. Improving the socioeconomic position of a broad range of disadvantaged socioeconomic and racial-ethnic strata constitutes a major avenue for reducing exposure to and experience of deleterious risk factors for health, and hence for improving the health of these groups and the overall population. This in turn requires better understanding of the macrosocial forces that influence the socioeconomic position of individuals.

Socioeconomic disparities in health change in a longitudinal study of US adults: the role of health-risk behaviors

This study investigated the hypothesis that socioeconomic differences in health status change can largely be explained by the higher prevalence of individual health-risk behaviors among those of lower socioeconomic position. Data were from the Americans' Changing Lives study, a longitudinal survey of 3,617 adults representative of the US non-institutionalized population in 1986. The authors examined associations between income and education in 1986, and physical functioning and self-rated health in 1994, adjusted for baseline health status, using a multinomial logistic regression framework that considered mortality and survey nonresponse as competing risks. Covariates included age, sex, race, cigarette smoking, alcohol consumption, physical activity, and Body Mass Index. Both income and education were strong predictors of poor health outcomes. The four health-risk behaviors under study statistically explained only a modest portion of the socioeconomic differences in health at follow-up. For example, after adjustment for baseline health status, those in the lowest income group at baseline had odds of moderate/severe functional impairment in 1994 of 2.11 (95% C.I.: 1.40, 3.20) in an unadjusted model and 1.89 (95% C.I.: 1.23, 2.89) in a model adjusted for health-risk behaviors. The results suggest that the higher prevalence of major health-risk behaviors among those in lower socioeconomic strata is not the dominant mediating mechanism that can explain socioeconomic disparities in health status among US adults.

Psychological adjustment to sudden and anticipated spousal loss among older widowed persons

OBJECTIVES

This study examined if older adults' psychological adjustment to widowhood varies based on whether the death was sudden or anticipated and if these effects are mediated by death context characteristics (e.g., predeath caregiving, nursing home use, spouse's age at death, and couple's communication about the death).

METHODS

The effects of forewarning on multiple indicators of mental health and grief were examined in a sample of 210 widowed persons who participated in the Changing Lives of Older Couples (CLOC) study. The CLOC is a probability sample of 1,532 married individuals aged 65 and older for whom baseline information was collected in 1987-88, with widowed persons reinterviewed 6, 18, and 48 months after spousal loss.

RESULTS

Forewarning did not affect depression, anger, shock, or overall grief 6 or 18 months after the loss. Prolonged forewarning was associated with elevated anxiety both 6 and 18 months after the death. Sudden spousal death elevated survivors' intrusive thoughts at the 6-month follow-up only. Sudden death was associated with slightly higher levels of yearning among women but significantly lower yearning among men both 6 and 18 months after the loss.

DISCUSSION

The findings call into question the widespread belief that grief is more severe if death is sudden and suggest a more complex relationship between bereavement and circumstances of spousal death.

Excess mortality among urban residents: how much, for whom, and why?

OBJECTIVES

The goals of this study were to estimate prospective mortality risks of city residence, specify how these risks vary by population subgroup, and explore possible explanations.

METHODS

Data were derived from a probability sample of 3617 adults in the coterminous United States and analyzed via cross-tabular and Cox proportional hazards methods.

RESULTS

After adjustment for baseline sociodemographic and health variables, city residents had a mortality hazard rate ratio of 1.62 (95% confidence interval [CI] = 1.21, 2.18) relative to rural/small-town residents; suburbanites had an intermediate but not significantly elevated hazard rate ratio. This urban mortality risk was significant among men (hazard rate ratio: 2.25), especially non-Black men, but not among women. Among Black men, and to some degree Black women, suburban residence carried the greatest risk. All risks were most evident for those younger than 65 years.

CONCLUSIONS

The mortality risk of city residence, at least among men, rivals that of major psychosocial risk factors such as race, low income, smoking, and social isolation and merits comparable attention in research and policy.

Marital quality and psychological adjustment to widowhood among older adults: a longitudinal analysis

OBJECTIVES

This study examined whether psychological adjustment to widowhood is affected by three aspects of marital quality--warmth, conflict, and instrumental dependence-assessed prior to the loss.

METHODS

The Changing Lives of Older Couples (CLOC) is a prospective study of a two-stage area probability sample of 1,532 married individuals aged 65 and older. The CLOC includes baseline data on marital quality and mental health and data on grief, anxiety, and depression collected 6, 18, and 48 months after spousal loss.

RESULTS

Widowhood was associated with elevated anxiety among those who were highly dependent on their spouses and lower levels of anxiety among those who were not dependent on their spouses. Levels of yearning were lower for widowed persons whose relationships were conflicted at baseline and higher for those reporting high levels of marital closeness and dependence on their spouses. Women who relied on their husbands for instrumental support had significantly higher levels of yearning than men who depended on their wives.

DISCUSSION

The findings contradict the widespread belief that grief is more severe if the marriage was conflicted and suggest a more complex relationship between bereavement and characteristics of the marriage.

Volunteering and mortality among older adults: findings from a national sample

OBJECTIVES

Although a number of authors have proposed that older volunteers should benefit in terms of better health and well-being, few researchers have examined the issue empirically to see whether this is true. The purpose of this article is to build on this literature by empirically examining the association between volunteering and mortality among older adults.

METHODS

Using data from a nationally representative sample, we use Cox proportional hazards regression to estimate the effects of volunteering on the rate of mortality among persons aged 65 and older.

RESULTS

We find that volunteering has a protective effect on mortality among those who volunteered for one organization or for forty hours or less over the past year. We further find that the protective effects of volunteering are strongest for respondents who report low levels of informal social interaction and who do not live alone.

DISCUSSION

We discuss the possibility that the curvilinear relationship we observe between volunteering and mortality is due to a combination of factors, including self-identity, role strain, and meaningfulness. Other research using more precise data is needed to determine whether these ideas are supportable.