Aging, Race, and Health Disparities: Recommendations From the Research Centers Collaborative Network

Racial disparities in adverse health outcomes with aging have been well described. Yet, much of the research focuses on racial comparisons, with relatively less attention to the identification of underlying mechanisms. To address these gaps, the Research Centers Collaborative Network held a workshop on aging, race, and health disparities to identify research priorities and inform the investigation, implementation, and dissemination of strategies to mitigate disparities in healthy aging. This article provides a summary of the key recommendations and highlights the need for research that builds a strong evidence base with both clinical and policy implications. Successful execution of these recommendations will require a concerted effort to increase participation of underrepresented groups in research through community engagement and partnerships. In addition, resources to support and promote the training and development of health disparities researchers will be critical in making health equity a shared responsibility for all major stakeholders.

Optimizing Postpartum Care in Rural Communities: Insights from Women in Arizona and Implications for Policy

OBJECTIVES

Optimal postpartum care promotes healthcare utilization and outcomes. This qualitative study investigated the experiences and perceived needs for postpartum care among women in rural communities in Arizona, United States.

METHODS

We conducted in-depth interviews with thirty childbearing women and analyzed the transcripts using reflexive thematic analysis to gauge their experiences, needs, and factors affecting postpartum healthcare utilization.

RESULTS

Experiences during childbirth and multiple structural factors, including transportation, childcare services, financial constraints, and social support, played crucial roles in postpartum care utilization for childbearing people in rural communities. Access to comprehensive health information and community-level support systems were perceived as critical for optimizing postpartum care and utilization.

CONCLUSIONS FOR PRACTICE

This study provides valuable insights for policymakers, healthcare providers, and community stakeholders in enhancing postpartum care services for individuals in rural communities in the United States.

Structural Determinants of Stimuli-Responsiveness in Amphiphilic Macromolecular Nano-assemblies

Stimuli-responsive nano-assemblies from amphiphilic macromolecules could undergo controlled structural transformations and generate diverse macroscopic phenomenon under stimuli. Due to the controllable responsiveness, they have been applied for broad material and biomedical applications, such as biologics delivery, sensing, imaging, and catalysis. Understanding the mechanisms of the assembly-disassembly processes and structural determinants behind the responsive properties is fundamentally important for designing the next generation of nano-assemblies with programmable responsiveness. In this review, we focus on structural determinants of assemblies from amphiphilic macromolecules and their macromolecular level alterations under stimuli, such as the disruption of hydrophilic-lipophilic balance (HLB), depolymerization, decrosslinking, and changes of molecular packing in assemblies, which eventually lead to a series of macroscopic phenomenon for practical purposes. Applications of stimuli-responsive nano-assemblies in delivery, sensing and imaging were also summarized based on their structural features. We expect this review could provide readers an overview of the structural considerations in the design and applications of nanoassemblies and incentivize more explorations in stimuli-responsive soft matters.

Spiraling Risk: Visualizing the multilevel factors that socially pattern HIV risk among gay, bisexual & other men who have sex with men using Complex Systems Theory

PURPOSE OF REVIEW

Global disparities in HIV infection, particularly among gay, bisexual, and other men who have sex with men (GBMSM), indicate the importance of exploring the multi-level processes that shape HIV's spread. We used Complex Systems Theory and the PRISMA guidelines to conduct a systematic review of 63 global reviews to understand how HIV is socially patterned among GBMSM. The purpose was to conduct a thematic analysis of the reviews to (1) synthesize the multi-level risk factors of HIV risk, (2) categorize risk across the socioecological model, and (3) develop a conceptual model that visualizes the interrelated factors that shape GBMSMS's HIV "risk."

RECENT FINDINGS

We included 49 studies of high and moderate quality studies. Results indicated that GBMSM's HIV risk stems from the individual, interpersonal, and structural levels of the socioecological model. We identified a few themes that shape GBMSM's risk of HIV infection related to biomedical prevention methods; sexual and sex-seeking behaviors; behavioral prevention methods; individual-level characteristics and syndemic infections; lived experiences and interpersonal relationships; country-level income; country-level HIV prevalence; and structural stigma. The multi-level factors, in tandem, serve to perpetuate GBMSM's risk of HIV infection globally. The amalgamation of our thematic analyses from our systematic reviews of reviews suggests that the risk of HIV infection operates in an emergent, dynamic, and complex nature across multiple levels of the socioecological model. Applying complex systems theory indicates how multilevel factors create a dynamic and reinforcing system of HIV risk among GBMSM.

Risk, lifestyle and non-communicable diseases of poverty

Common discourse in public health and preventive medicine frames non-communicable diseases, including cardiovascular and metabolic diseases, as diseases of 'lifestyle'; the choice of terminology implies that their prevention, control and management are amenable to individual action. In drawing attention to global increases in the incidence and prevalence of non-communicable disease, however, we increasingly observe that these are non-communicable diseases of poverty. In this article, we call for the reframing of discourse to emphasize the underlying social and commercial determinants of health, including poverty and the manipulation of food markets. We demonstrate this by analysing trends in disease, which indicate that diabetes- and cardiovascular-related DALYS and deaths are increasing particularly in countries categorized as low-middle to middle levels of development. In contrast, countries with very low levels of development contribute least to diabetes and document low levels of CVDs. Although this might suggest that NCDs track increased national wealth, the metrics obscure the ways in which the populations most affected by these diseases are among the poorest in many countries, and hence, disease incidence is a marker of poverty not wealth. We also illustrate variations in five countries - Mexico, Brazil, South Africa, India and Nigeria - by gender, and argue that these differences are associated with gender norms that vary by context rather than sex-specific biological pathways.We tie these trends to shifts in food consumption from whole foods to ultra-processed foods, under colonialism and with continued globalization. Industrialization and the manipulation of global food markets influence food choice in the context of limited household income, time, and household and community resources. Other factors that constitute risk factors for NCDs are likewise constrained by low household income and the poverty of the environment for people with low income, including the capacity of individuals in sedentary occupations to engage in physical activity. These contextual factors highlight extremely limited personal power over diet and exercise. In acknowledging the importance of poverty in shaping diet and activity, we argue the merit in using the term non-communicable diseases of poverty and the acronym NCDP. In doing so, we call for greater attention and interventions to address structural determinants of NCDs.

'Harnessing the power of the law': a qualitative analysis of the legal determinants of health in English urban planning and recommendations for fairer and healthier decision-making

BACKGROUND

Urban environments impact negatively on the risks of non-communicable diseases and perpetuate health inequalities. Against this, law could play a critical role, notably through implementing and securing visions of health and well-being, and evidence-based interventions.

METHODS

Seven teams conducted 123 interviews with 132 actors in urban planning in England. Teams had expertise in urban planning, transport, real estate, public health, public policy, administration, and management. An additional team with expertise in law analysed data from all interviews to explore how the law is perceived and used to promote health in urban planning.

RESULTS

Six issues were identified as preventing actors from using the law to improve health in urban planning: (i) density and complexity of the law; (ii) weak and outdated regulatory standards; (iii) absence of health from legal requirements in the decision-making process; (iv) inconsistent interpretations by actors with competing interests; (v) lack of strong health evidence-based local planning policies; and (vi) inertia of the law.

CONCLUSIONS

The legal determinants of health listed in the Lancet-O'Neill Commission's report need to be strengthened at the local level to effectively deploy law in English urban development. The findings call for strong, evidence-based local planning policies and decision-making frameworks, placing health as (one of the) core value(s) of urban planning and showing what types of development benefit health, i.e., prevent NCDs risks and reduce health inequalities on the long term. The legal capacity of local government should be strengthened to empower decision-makers in shaping urban development that promotes health for everyone.

Determinants of health among people who use illicit drugs in the conflict-affected countries of Afghanistan, Colombia and Myanmar: a systematic review of epidemiological evidence

BACKGROUND

Afghanistan, Colombia and Myanmar are the world's leading heroin and cocaine producers and have also experienced prolonged periods of armed conflict. The link between armed conflict and drug markets is well established but how conflict impacts on the health and social determinants of people who use drugs is less clear. The aim was to investigate health outcomes and associated factors among people who use illicit drugs in Afghanistan, Colombia and Myanmar.

METHODS

We conducted a systematic review searching Medline, EMBASE, PsychINFO and Global Health databases using terms relating to Afghanistan, Colombia and Myanmar; illicit drug use (all modes of drug administration); health and influencing factors. Quality assessment was assessed with the Newcastle-Ottawa-Scale and papers were analysed narratively.

RESULTS

35 studies were included in Afghanistan (n = 15), Colombia (n = 9) and Myanmar (n = 11). Health outcomes focused predominantly on HIV, Hepatitis C (HCV), Hepatitis B and sexually transmitted infections (STIs), with one study looking at human rights violations (defined as maltreatment, abuse and gender inequality). Drug use was predominantly injection of heroin, often alongside use of amphetamines (Myanmar), cocaine and cocaine-based derivatives (Colombia). Only one study measured the effect of a period of conflict suggesting this was linked to increased reporting of symptoms of STIs and sharing of needles/syringes among people who inject drugs. Findings show high levels of external and internal migration, alongside low-income and unemployment across the samples. External displacement was linked to injecting drugs and reduced access to needle/syringe programmes in Afghanistan, while initiation into injecting abroad was associated with increased risk of HCV infection. Few studies focused on gender-based differences or recruited women. Living in more impoverished rural areas was associated with increased risk of HIV infection.

CONCLUSIONS

More research is needed to understand the impact of armed-conflict and drug production on the health of people who use drugs. The immediate scale-up of harm reduction services in these countries is imperative to minimize transmission of HIV/HCV and address harms associated with amphetamine use and other linked health and social care needs that people who use drugs may face.

Neutrality, conflict, and structural determinants of health in a Jerusalem emergency department

BACKGROUND

Medical neutrality is a normative arrangement that differentiates a zone of medical treatment disconnected from the field of politics. While medical neutrality aims to ensure impartial healthcare for all and to shield the healthcare personnel from political demands, it can also divert attention away from conflicts and their effects on health inequity. This article analyzes how healthcare professionals understand and negotiate the depoliticized space of the emergency department (ED) through their views on neutrality. It also examines how medical staff use depoliticized concepts of culture to account for differences in the health status of patients from disadvantaged groups. These questions are examined in the context of the Israeli-Palestinian conflict.

METHODS

Twenty-four in-depth, semi-structured interviews were conducted with healthcare personnel in a Jerusalem hospital's ED. All but one of the participants were Jewish. The interviews were analyzed using qualitative content analysis and Grounded Theory.

RESULTS

The ED staff endorsed the perspective of medical neutrality as a nondiscriminatory approach to care. At the same time, some medical staff recognized the limits of medical neutrality in the context of the Israeli-Palestinian conflict and negotiated and challenged this concept. While participants identified unique health risks for Arab patients, they usually did not associate these risks with the effects of conflict and instead explained them in depoliticized terms of cultural and behavioral differences. Culture served as a non-controversial way of acknowledging and managing problems that have their roots in politics.

CONCLUSIONS

The normative demand for neutrality works to exclude discussion of the conflict from clinical spaces. The normative exclusion of politics is a vital but under-appreciated aspect of how political conflict operates as a structural determinant of health. Healthcare personnel, especially in the ED, should be trained in structural competency. This training may challenge the neglect of issues that need to be solved at the political level and enhance health equity, social justice, and solidarity.

Stigmatizing Policies Interact with Mental Health and Sexual Behaviours to Structurally Induce HIV Diagnoses Among European Men Who Have Sex with Men

Structural stigma shapes men who have sex with men's (MSM's) mental health and sexual behaviours. The aim of this study was to examine how stigmatizing policies interact with downstream anxiety/depression and sexual behaviours to structurally pattern HIV disparities among European MSM. We conducted a secondary data analysis of the European Men-who-have-sex-with-men Internet Survey (EMIS) from 2017. We included a total of 98,600 participants living in 39 European countries. We used the Rainbow Index, a score given to countries based on their sexual and gender minority policies as the predictor of HIV diagnosis. We conducted adjusted random intercept and slope multi-level logistic regressions. In adjusted models, higher Rainbow Index scores was associated with lower predictive probabilities of diagnosed HIV, regardless of the number of condomless intercourse partners. The predictive probability of HIV diagnosis was also lower, regardless of severity of anxiety/depression, where the Rainbow Index score was better. Country-level policies interact with downstream sexual behaviours and anxiety/depression to structurally influence HIV diagnosis among MSM in Europe.

Invisible and unequal: Unincorporated community status as a structural determinant of health

Despite increasing awareness of the importance of political determinants of health, place-based research has not interrogated one of the most common political statuses: the impact of living in a community without municipal incorporation. In 2010 an estimated 37% of the U.S. population lived in an unincorporated area; despite their ubiquity, unincorporated communities are largely absent from the public health literature. Residents of unincorporated areas typically do not have their own local (e.g., city or municipal) government. This lack of representation leads to political exclusion and diminished access to resources, especially for low-income communities of color, Furthermore, by not disaggregating health data to unincorporated communities, residents are subsumed into county or census tract data that may not be reflective of their community's composition or context. Without jurisdictional distinction in research, there is no accountability for the manufacturing of health inequities in unincorporated communities . In the absence of empirical research on unincorporated communities, this paper uses the Commission on Social Determinants of Health (CSDH) Framework of the World Health Organization to argue that lack of municipal status is a structural determinant of health responsible for social conditions which generate cumulative health risks for residents. This includes using existing evidence on social conditions typical of unincorporated communities to describe patterns of residential segregation, neighborhood disadvantage, and environmental hazards that may increase residents' exposure to unhealthy environments in unincorporated communities. Finally, we provide an agenda for future public health research that can begin to address this health and racial equity gap for low-income unincorporated communities of color who have, until now, been absent in health equity discourse.

"We've Got Our Own Beliefs, Attitudes, Myths": A Mixed Methods Assessment of Rural South African Health Care Workers' Knowledge of and Attitudes Towards PrEP Implementation

South Africa maintains the world's largest HIV prevalence, accounting for 20.4% of people living with HIV internationally. HIV Pre-exposure prophylaxis (PrEP) has demonstrated efficacy; however, there is limited data on PrEP implementation in South Africa, particularly in rural areas. Using grounded theory analysis of semi-structured interviews and exploratory factor analyses of structured surveys, this mixed methods study examines healthcare workers' (HCWs)' beliefs about their patients and the likelihood of PrEP uptake in their communities. The disproportionate burden of HIV among Black South Africans is linked to the legacy of apartheid and resulting disparities in wealth and employment. HCWs in our study emphasized the importance of addressing these structural barriers, including increased travel burden among men in the community looking for work, poor transportation infrastructure, and limited numbers of highly skilled clinical staff in their rural community. HCWs also espoused a vision of PrEP that prioritizes women due to perceived constraints on their sexual agency, and that minimizes the impact of HIV-related stigma on PrEP implementation. However, HCWs' additional concerns for risk compensation may reflect dominant social mores around sexual behavior. In recognition of HCWs' role as both informants and community members, implementation scientists should invite local HCWs to partner as early as the priority-setting stage for PrEP interventions. Inviting leadership from local HCWs may increase the likelihood of delivery plans that account for unique local context and structural barriers researchers may otherwise struggle to uncover.

Neighborhood Social Cohesion and Inequalities in COVID-19 Diagnosis Rates by Area-Level Black/African American Racial Composition

Geographic inequalities in COVID-19 diagnosis are now well documented. However, we do not sufficiently know whether inequalities are related to social characteristics of communities, such as collective engagement. We tested whether neighborhood social cohesion is associated with inequalities in COVID-19 diagnosis rate and the extent the association varies across neighborhood racial composition. We calculated COVID-19 diagnosis rates in Philadelphia, PA, per 10,000 general population across 46 ZIP codes, as of April 2020. Social cohesion measures were from the Southeastern Pennsylvania Household Health Survey, 2018. We estimated Poisson regressions to quantify associations between social cohesion and COVID-19 diagnosis rate, testing a multiplicative interaction with Black racial composition in the neighborhood, which we operationalize via a binary indicator of ZIP codes above vs. below the city-wide average (41%) Black population. Two social cohesion indicators were significantly associated with COVID-19 diagnosis. Associations varied across Black neighborhood racial composition (p <0.05 for the interaction test). In ZIP codes with ≥41% of Black people, higher collective engagement was associated with an 18% higher COVID-19 diagnosis rate (IRR=1.18, 95%CI=1.11, 1.26). In contrast, areas with <41% of Black people, higher engagement was associated with a 26% lower diagnosis rate (IRR=0.74, 95%CI=0.67, 0.82). Neighborhood social cohesion is associated with both higher and lower COVID-19 diagnosis rates, and the extent of associations varies across Black neighborhood racial composition. We recommend some strategies for reducing inequalities based on the segmentation model within the social cohesion and public health intervention framework.

Structural and technological determinants of carbon intensity reduction of China's electricity generation

Electricity generation is the largest sector with decarbonization potential for China and the world. Based on the new emission factors, this paper aims to identify the structural and technological determinants of provincial carbon intensity in the electricity generation sector (CIE) using the multiplicative LMDI-II method. Results demonstrate that (1) China's overall CIE decreases by 7.3% in 2001-2015, and the research period can be divided into four stages according to CIE changes (i.e., rapid growth, rapid decline, slow growth, and transition). The CIE in the 12th FYP estimated in this paper, 24.9% lower than that using the emission factors from IPCC, is closer to China's actual situation. (2) There exists huge heterogeneity in the determinants of provincial CIE changes in four stages. CIE growth in the Northwest and Northeast is caused by the coal-dominated energy structure. CIE growth in the Southwest is attributed to the electricity structure effect, while that of the Coast region is caused by the geographic distribution effect. The electricity efficiency effect is attributed to the CIE growth for these regions and the Southwest should also place focus on the electricity trade effect. The impact of electricity trade-related factors depends on the region being a net exporter or importer of electricity. (3) To achieve carbon intensity reduction targets, 30 provinces are categorized into four types based on various combinations of structural and technological determinants. The findings provide insights into capturing future emission-mitigating focus as well as defining the emission-mitigating responsibilities between electricity exporters and importers in China.

Towards TB elimination: how are macro-level factors perceived and addressed in policy initiatives in a high burden country?

BACKGROUND

Notwithstanding extensive general discussion of the effects of upstream forces on health, there has been limited empirical examination, let alone systematic evidence documenting policy responses to such pathways in the area of tuberculosis (TB) management and control. Our study aimed to gain insight into how macro level drivers of TB are perceived by key stakeholders involved in TB management and control in a high-endemic country, and to assess how such concerns are being addressed in policy initiatives in this setting. South Africa was chosen for this case study due to our team's long-standing collaborations there, its very high burden of TB, and its introduction of a strategic plan to combat this disease.

METHOD

Semi-structured interviews were conducted with 20 key informants who were purposively selected for their knowledge and expertise of TB in South Africa. South Africa's National Strategic Plan for HIV, TB and STIs 2017-2022 was then reviewed to examine how identified themes from the interviews were reflected in this policy document.

RESULTS

A history of colonization, the migrant labour system, economic inequality, poor shelter, health system challenges including TB governance, the HIV epidemic, and pertinent socio-cultural factors were all perceived to be major drivers of the epidemic. Although South Africa's current National Strategic Plan makes a firm discursive commitment to addressing the structural or macro-level drivers of TB, our analysis revealed that this commitment was not clearly reflected in projected budgetary allocations.

CONCLUSION

As in many other high burden settings, macro-level drivers of TB are widely recognized. Nonetheless, while micro-level (biomedical and clinical) measures, such as improving diagnostic procedures and investment in more efficacious drugs, are being (and well should be) implemented, our findings showed that macro-level drivers of TB are underrepresented in budgeting allocations for initiatives to combat this disease. Although it could be argued that structural drivers that undermine health-promoting actions are beyond the purview of the health sector itself, we argue that strategic plans to combat TB in high burden settings need more attention to directly considering such drivers to prompt the necessary changes and reduce the burden of this and other such diseases.

Representation of gender in migrant health studies - a systematic review of the social epidemiological literature

Background

Gender as a social construct contributes to determine who migrates and which migration-related risks and opportunities emerge in all phases of the migration trajectory. Simultaneously, migration influences the individual as well as societal definition and perception of gender roles. An explicit gender perspective in migration-related epidemiological research can contribute to adequately analyse and interpret the health of migrants. This systematic review gives a comprehensive overview on how gender has been conceptualised, operationalised and measured in social epidemiologic studies aiming to assess the influence of gender on health among migrants.

Methods

We searched PubMed, Embase, CINAHL, the Cochrane Library, EconLit and PsycINFO and conducted backward reference searching. Reviewers independently selected studies, extracted data and conducted the quality assessment. Eligible studies actively aimed to understand, identify or explain the influence of gender on migrants’ health, whereby the role of gender can encompass a variety of mechanisms, processes or states of differentiation, discrimination and/or inequality.

Results

Almost all of the 43 studies were cross-sectional and focussed on health outcomes in the post-migration phase. The most common theme of research was the health of male migrants in the US, and in particular of men who have sex with men (MSM). All studies treated gender as a binary variable (men vs. women), without discussing additional types of gender identities. A minority of studies differentiated clearly between sex and gender. Gender was mostly operationalised through attitudes toward gender roles and gender-based discrimination, experienced at the individual level. Community and societal level gender measures capturing structural gender determinants were underrepresented.

Conclusions

The intersections of migration and gender suggested synergistic effects on health that only become visible when considering those two social determinants together. Future research needs to embrace a multilevel and non-binary understanding of gender and reflect on the influence of gender in the different phases of the migration journey.

Systematic review registration

PROSPERO CRD42019124698.

Structural Determinants of Black MSM HIV Testing Coverage (2011-2016)

Over 30 years into the US HIV/AIDS epidemic, Black men who have sex with men (BMSM) continue to carry the highest burden of both HIV and AIDS cases. There is then, an urgent need to expand access to HIV prevention and treatment for all gay and bisexual men, underscoring the importance of the federal initiative 'Ending the Epidemic: A Plan for America'. This research examines structural factors associated with BMSM HIV testing coverage over time (2011-2016) in 85 US Metropolitan Statistical Areas (MSAs). We calculated MSA-specific annual measures of BMSM HIV testing coverage (2011-2016). Variables suggested by the Theory of Community Action (i.e., need, resource availability, institutional opposition and organized support) were analyzed as possible predictors of coverage using multilevel modeling. Relationships between BMSM HIV testing and the following covariates were positive: rates of BMSM living with HIV (b = 0.28), percent of Black residents employed (b = 0.19), Black heterosexual testing rate (b = 0.46), health expenditures per capita (b = 0.16), ACT UP organization presence in 1992 (b = 0.19), and syringe service presence (b = 0.12). Hard drug arrest rates at baseline (b = - 0.21) and change since baseline (b = - 0.10) were inversely associated with the outcome. Need, resources availability, organized support and institutional opposition are important determinants of place associated with BMSM HIV testing coverage. Efforts to reduce HIV incidence and lessen AIDS-related disparities among BMSM in the US require improved and innovative HIV prevention approaches directed toward BMSM including a fuller understanding of structural factors that may influence place variation in BMSM testing patterns and risk behavior in places of high need.

Procleave: Predicting Protease-specific Substrate Cleavage Sites by Combining Sequence and Structural Information

Proteases are enzymes that cleave and hydrolyse the peptide bonds between two specific amino acid residues of target substrate proteins. Protease-controlled proteolysis plays a key role in the degradation and recycling of proteins, which is essential for various physiological processes. Thus, solving the substrate identification problem will have important implications for the precise understanding of functions and physiological roles of proteases, as well as for therapeutic target identification and pharmaceutical applicability. Consequently, there is a great demand for bioinformatics methods that can predict novel substrate cleavage events with high accuracy by utilizing both sequence and structural information. In this study, we present Procleave, a novel bioinformatics approach for predicting protease-specific substrates and specific cleavage sites by taking into account both their sequence and 3D structural information. Structural features of known cleavage sites were represented by discrete values using a LOWESS data-smoothing optimization method, which turned out to be critical for the performance of Procleave. The optimal approximations of all structural parameter values were encoded in a conditional random field (CRF) computational framework, alongside sequence and chemical group-based features. Here, we demonstrate the outstanding performance of Procleave through extensive benchmarking and independent tests. Procleave is capable of correctly identifying most cleavage sites in the case study. Importantly, when applied to the human structural proteome encompassing 17,628 protein structures, Procleave suggests a number of potential novel target substrates and their corresponding cleavage sites of different proteases. Procleave is implemented as a webserver and is freely accessible at http://procleave.erc.monash.edu/.

Structural determinants of health: a qualitative study on female sex workers in Benin

The objective of this paper is to expose those socio-structural contexts revealing the social injustice and human rights violations that sub-Saharan women face every day when forced into sex work by unemployment or sickness. Results of a qualitative study highlighting some key structural determinants of sex work and HIV infection among FSWs will be presented and examined through the lens of the WHO conceptual framework for action on the social determinants of health. The results showed that most FSWs had lacked the necessary financial support at some point in their lives. Also, both the socioeconomic and political context failed to provide proper support to prevent involvement in sex work and the consequent risks of HIV. The cultural and societal values placed on the health and well-being of FSWs in Benin appear to depend on the degree to which sexual violence and adultery are perceived as a collective social concern. This portrait of FSWs calls for both long-term interventions through a structural determinant approach to HIV prevention, targeting all the women who could face such a financial situation well before their entry into sex work, while maintaining short and medium-term interventions on the intermediary determinants.

Connection to the land as a youth-identified social determinant of Indigenous Peoples' health

BACKGROUND

Social determinants of Indigenous health are known to include structural determinants such as history, political climate, and social contexts. Relationships, interconnectivity, and community are fundamental to these determinants. Understanding these determinants from the perspective of Indigenous youth is vital to identifying means of alleviating future inequities.

METHODS

In 2016, fifteen Yellowknives Dene First Nation (YKDFN) youth in the Canadian Northwest Territories participated in the 'On-the-Land Health Leadership Camp'. Using a strength- and community-based participatory approach through an Indigenous research lens, the YKDFN Wellness Division and university researchers crafted the workshop to provide opportunities for youth to practice cultural skills, and to capture the youth's perspectives of health and health agency. Perspectives of a healthy community, health issues, and health priorities were collected from youth through sharing circles, PhotoVoice, mural art, and surveys.

RESULTS

The overall emerging theme was that a connection to the land is an imperative determinant of YKDFN health. Youth identified the importance of a relationship to land including practicing cultural skills, Elders passing on traditional knowledge, and surviving off the land. The youth framed future health research to include roles for youth and an on-the-land component that builds YKDFN culture, community relations, and traditional knowledge transfer. Youth felt that a symbiotic relationship between land, environment, and people is fundamental to building a healthy community.

CONCLUSION

Our research confirmed there is a direct and critical relationship between structural context and determinants of Indigenous Peoples' health, and that this should be incorporated into health research and interventions.

How do macro-level structural determinants affect inequalities in mental health? - a systematic review of the literature

BACKGROUND

In Europe and elsewhere there is rising concern about inequality in health and increased prevalence of mental ill-health. Structural determinants such as welfare state arrangements may impact on levels of mental health and social inequalities. This systematic review aims to assess the current evidence on whether structural determinants are associated with inequalities in mental health outcomes.

METHODS

We conducted a systematic review of quantitative studies published between 1996 and 2017 based on search results from the following databases Medline, Embase, PsychInfo, Web of Science, Sociological Abstracts and Eric. Studies were included if they focused on inequalities (measured by socio-economic position and gender), structural determinants (i.e. public policies affecting the whole population) and showed a change or comparison in mental health status in one (or more) of the Organisation for Economic Cooperation and Development (OECD) countries. All studies were assessed for inclusion and study quality by two independent reviewers. Data were extracted and synthesised using narrative analysis.

RESULTS

Twenty-one articles (17 studies) met the inclusion criteria. Studies were heterogeneous with regards to methodology, mental health outcomes and policy settings. More comprehensive and gender inclusive welfare states (e.g. Nordic welfare states) had better mental health outcomes, especially for women, and less gender-related inequality. Nordic welfare regimes may also decrease inequalities between lone and couple mothers. A strong welfare state does not buffer against socio-economic inequalities in mental health outcomes. Austerity measures tended to worsen mental health and increase inequalities. Area-based initiatives and educational policy are understudied.

CONCLUSION

Although the literature on structural determinants and inequalities in mental health is limited, our review shows some evidence supporting the causal effects of structural determinants on mental health inequalities. The lack of evidence should not be interpreted as lack of effect. Future studies should apply innovative methods to overcome the inherent methodological challenges in this area, as structural determinants potentially affect both levels of mental health and social inequalities.

Association between injection in public places and HIV/HCV risk behavior among people who use drugs in Ukraine

BACKGROUND

In Eastern Europe and Central Asia new HIV infections occur at a high rate among people who inject drugs (PWID). Injection risk behavior may be associated with injecting in public places. However, there is a lack of studies exploring this association in Ukraine, which has an HIV prevalence 21-42% among PWID.

METHODS

Data came from a baseline survey of PWID recruited to participate in a behavioral HIV prevention intervention. The association between HIV/HCV injection risk behavior and place of injection (private vs. public) was assessed using multivariable Poisson regression with robust variance estimate.

RESULTS

Most of the sample was male (73%), > 30 years (56%), and reported opioids as their drug of choice (55%). One in six participants (15.8%, n = 57) reported using a syringe after somebody, and 70% (n = 253) reported injecting in public places within last 30-days. In the adjusted model, injection risk behavior was associated with injecting in public places (PrR: 4.24, 95% CI: 1.76-10.20), unstable housing situation (PrR: 2.46, 95% CI:1.26-4.83), higher than secondary education (PrR:1.82, 95%CI:1.04-3.16), injecting with a sex partner day (PrR:2.13, 95% CI:1.28-3.56), and injecting with a stranger (PrR: 1.47, 95% CI: 0.93-2.31).

CONCLUSIONS

Injecting in a public place is associated with increased prevalence of risky behavior. Therefore, understanding and addressing place-based context should be part of the national strategy to fight HIV and HCV in Ukraine. National programs would benefit from expanding models to include contextual and structural determinants of health.

An empirical exploration of female child marriage determinants in Indonesia

BACKGROUND

Child marriage, defined as marriage before age 18, is associated with adverse human capital outcomes. The child marriage burden remains high among female adolescents in Indonesia, despite increasing socioeconomic development. Research on child marriage in Southeast Asia is scarce. No nationally representative studies thus far have examined determinants of child marriage in Indonesia through multivariate regression modeling.

METHODS

We used data from the nationally representative 2012 Indonesian Demographic and Health Survey and the Adolescent Reproductive Health Survey to estimate determinants of child marriage and marital preferences. We ran multivariate models to estimate the association between demographic and socioeconomic characteristics and the following early marriage outcomes: 1) ever been married or cohabited, 2) married or cohabited before 18 years, 3) married or cohabited before 16 years, 4) self-reported marital-age preferences and 5) attitudes approving female child marriage.

RESULTS

Among the child marriage research sample (n = 6578, females aged 20-24 at time of survey), approximately 17% and 6% report being married before 18 and 16 years old respectively. Among the marital preferences research sample (n = 8779, unmarried females 15-24), the average respondent preferred marriage at approximately 26 years and 5% had attitudes approving child marriage. Education, wealth and media exposure have protective effects across marriage outcomes, while rural residence is a risk factor for the same. There are significant variations by region, indicating roles of religious, ethnic and other geographically diverse factors.

CONCLUSION

This research fills a gap in understanding of child marriage determinants in Indonesia. There appears to be little support for child marriage among girls and young women, indicating an entry point for structural interventions that would lead to lasting change. Future research efforts should prioritize rigorous testing of gender-transformative education and economic strengthening interventions, including cost-effectiveness considerations to better understand how interventions and policies can be leveraged to deliver on ending child marriage in Indonesia and globally.

HIV Prevention Among Transgender Populations: Knowledge Gaps and Evidence for Action

PURPOSE OF REVIEW

The purpose of this review is to summarize the available evidence-based HIV prevention interventions tailored for transgender people.

RECENT FINDINGS

A limited number of evidence-based HIV prevention interventions have been tested with transgender populations. Most existing interventions target behavior change among transgender women, with only one HIV prevention program evaluated for transgender men. Studies addressing biomedical interventions for transgender women are ongoing. Few interventions address social and structural barriers to HIV prevention, such as stigma, discrimination, and poverty. Evidence-based multi-level interventions that address the structural, biomedical, and behavioral risks for HIV among transgender populations, including transgender men, are needed to address disparities in HIV prevalence. Future research should address not only pre-exposure prophylaxis uptake and condom use but also structural barriers that limit access to these prevention strategies.

Structural Determinants of Workforce Participation after Retirement in Poland

In this paper, we aim to analyse selected structural determinants of workforce participation after retirement in Poland. By structural determinants we mean characteristics of one's socio-economic position that (a) result from the interplay of social conditions (mechanisms of power, differentiated access to resources) and individual agency, and (b) restrict or facilitate individuals' choices. We conceptualise workforce participation as engaging in either part- or full-time paid employment despite receiving the old-age pension. Our general hypothesis is that working in older age is not only a matter of motivation or psychological traits but also a complex interplay of structural characteristics, accumulated by individuals during their life course. In the paper, we test a number of hypotheses about the role of specific components of socio-economic status (SES), i.e. occupational prestige, education, and wealth, for workforce participation among retirees. We argue that, in case of retirees, the prestige of the last job before retirement is a more reliable measure of the social position than education. Hence, we conduct a more detailed analysis of the role of occupational prestige for the chances of being employed after retirement. The analysis was based on data gathered in the years 2013-2014 within the sixth wave of the Polish Panel Survey POLPAN (www.polpan.org). We extracted a subsample of retirees from this dataset and used logistic regression to test the hypotheses described above. We found that both occupational prestige of the last job before retirement and educational attainments are strong predictors of being in paid work after retirement, however the impact of occupational prestige varies across the groups with the lowest and higher level of retirement pension. We also found that there are horizontal differences in the occupational structure of the chances for workforce participation after retirement and additionally found that being a farm owner increases the propensity to engage in economic activity after retirement. The paper contributes to the field of studies on the relationship between SES and workforce participation after retirement in line with the cumulative advantage/disadvantage theory and shows that resources that individuals have accumulated during the life course can determine their chances of working after retirement just as individual motivations or organisational characteristics do.

Pastoral power in HIV prevention: Converging rationalities of care in Christian and medical practices in Papua New Guinea

In his conceptualisation of pastoral power, Michel Foucault argues that modern healthcare practices derive a specific power technique from pastors of the early Christian church. As experts in a position of authority, pastors practise the care of others through implicitly guiding them towards thoughts and actions that effect self-care, and towards a predefined realm of acceptable conduct, thus having a regulatory effect. This qualitative study of healthcare workers from two Christian faith-based organisations in Papua New Guinea examines the pastoral rationalities of HIV prevention practices which draw together globally circulated modern medical knowledge and Christian teachings in sexual morality for implicit social regulation. Community-based HIV awareness education, voluntary counselling and testing services, mobile outreach, and economic empowerment programs are standardised by promoting behavioural choice and individual responsibility for health. Through pastoral rationalities of care, healthcare practices become part of the social production of negative differences, and condemn those who become ill due to perceived immorality. This emphasis assumes that all individuals are equal in their ability to make behavioural choices, and downplays social inequality and structural drivers of HIV risk that are outside individual control. Given healthcare workers' recognition of the structural drivers of HIV, yet the lack of language and practical strategies to address these issues, political commitment is needed to enhance structural competency among HIV prevention programs and healthcare workers.