- Applied Grant-Writing Skills for Community and Clinical Research
MED 253 (Win)
- Independent Studies (5)
Prior Year Courses
Studies in humans suggest that leukocyte telomere length may act as a marker of biological aging. We investigated whether individuals in the Nicoya region of Costa Rica, known for exceptional longevity, had longer telomere length than those in other parts of the country. After controlling for age, age squared, rurality, rainy season and gender, the mean leukocyte telomere length in Nicoya was substantially longer (81 base pairs, p<0.05) than in other areas of Costa Rica, providing evidence of a biological pathway to which this notable longevity may be related. This relationship remains unchanged (79 base pairs, p<0.05) after statistically controlling for nineteen potential biological, dietary and social and demographic mediators. Thus the difference in the mean leukocyte telomere length that characterizes this unique region does not appear to be explainable by traditional behavioral and biological risk factors. More detailed examination of mean leukocyte telomere length by age shows that the regional telomere length difference declines at older ages.
View details for DOI 10.1016/j.exger.2013.08.005
View details for Web of Science ID 000325750900017
View details for PubMedID 23988653
To determine the relative importance of familial, dietary, behavioral, psychological and social risk factors for predicting body mass index (BMI) change, and onset of overweight and obesity among adolescent girls.Data from the NHLBI Growth and Health Study (n = 2 150), a longitudinal cohort of girls, were used to identify the most important predictors of change in BMI percentile between the ages of 9 and 19 years, and second, risk for becoming overweight and obese. Forty-one baseline predictors were assessed using a tree-based regression method (Random forest) to rank the relative importance of risk factors.The five factors that best predicted change in BMI percentile (p < 0.05) were related to family socio-economic position (income and parent education) and drive to restrict eating and weight (body dissatisfaction, drive for thinness and unhappiness with physical appearance). The factors that were statistically significant (p < 0.05) predictors of both onset of overweight and obesity were income, ineffectiveness and race.Family socio-economic position and emotion regulation appeared as the top predictors of both BMI change and onset of overweight and obesity. Our results build upon prior findings that policies to prevent the onset of obesity during adolescence be targeted towards girls from lower socio-economic position households. Our findings also suggest several novel psychological factors including ineffectiveness as predictors of obesity during adolescence. These predictive findings offer a direction for future inquiry into adolescent obesity etiology using causal methods.
View details for DOI 10.3109/17477166.2010.545410
View details for Web of Science ID 000292704500028
View details for PubMedID 21244233
Research on earnings and health frequently relies on self-reported earnings (SRE) for a single year, despite repeated criticism of this measure. We use 31 years (1961-1991) of earnings recorded by the United States Social Security Administration (SSA) to predict the 1992 prevalence of disability, diabetes, stroke, heart disease, cancer, depression and death by 2002 in a subset of Health and Retirement Study participants (n = 5951). We compare odds ratios (ORs) for each health outcome associated with self-reported or administratively recorded earnings. Individuals with no 1991 SSA earnings had worse health in multiple domains than those with positive earnings. However, this association diminished as the time lag between earnings and health increased, so that the absence of earnings before approximately 1975 did not predict health in 1992. Among those with positive earnings, lengthening the lag between SSA earnings and health did not significantly diminish the magnitude of the association with diabetes, heart disease, stroke, or death. Longer lags did reduce but did not eliminate the association between earnings and both disability and depression. Despite theoretical limitations of single year SRE, there were no statistically significant differences between the ORs estimated with single-year SRE and those estimated with a 31-year average of SSA earnings. For example, a one unit increase in logged SRE for 1991 predicted a 19% reduction in the odds of dying by 2002 (OR = 0.81; 95% confidence interval: 0.72,0.90), while a similar increase in average SSA earnings for 1961-1991 had an OR of 0.72 (0.63, 0.82). The point estimates for the OR associated with 31 year average SSA earnings were further from the null than the ORs associated with single year SRE for heart disease, depression, and death, and closer to the null for disability, diabetes, and stroke, but none of these differences was statistically significant.
View details for DOI 10.1016/j.socscimed.2010.03.045
View details for Web of Science ID 000280120100002
View details for PubMedID 20580858
View details for PubMedID 21643514
It is unclear whether a linear relationship is an appropriate description of the association between income and biologic markers of coronary heart disease risk. Stronger associations at certain levels of income would have implications for underlying mechanisms.The study is based on a healthy sample of 25-64 year olds (n = 14,022) from a nationally representative cross-sectional study (the 1988-1994 United States Third National Health and Nutrition Examination Survey). We use regression splines to model the shape of the association between income and 8 biologic markers for coronary heart disease risk, controlling for age, race/ethnicity, marital status, and education.Substantial income-biomarker associations were found for 5 outcomes among women (HDL cholesterol, triglycerides, C-reactive protein, systolic blood pressure, and venous blood lead) and for 3 outcomes among men (HDL cholesterol, triglycerides, and venous blood lead). The most common shapes of association were a stronger association at lower income levels and a greater risk level of biomarker near median income.We find that the associations of income with biologic risk markers are often nonlinear. The differences in the shape of association suggest there are multiple pathways through which income is associated with coronary heart disease risk.
View details for DOI 10.1097/EDE.0b013e3181c30b89
View details for Web of Science ID 000272872900009
View details for PubMedID 20010209
Environmental and behavioural factors are thought to contribute to all-cause mortality. Here, we develop a method to systematically screen and validate the potential independent contributions to all-cause mortality of 249 environmental and behavioural factors in the National Health and Nutrition Examination Survey (NHANES).We used Cox proportional hazards regression to associate 249 factors with all-cause mortality while adjusting for sociodemographic factors on data in the 1999-2000 and 2001-02 surveys (median 5.5 follow-up years). We controlled for multiple comparisons with the false discovery rate (FDR) and validated significant findings in the 2003-04 survey (median 2.8 follow-up years). We selected 249 factors from a set of all possible factors based on their presence in both the 1999-2002 and 2003-04 surveys and linkage with at least 20 deceased participants. We evaluated the correlation pattern of validated factors and built a multivariable model to identify their independent contribution to mortality.We identified seven environmental and behavioural factors associated with all-cause mortality, including serum and urinary cadmium, serum lycopene levels, smoking (3-level factor) and physical activity. In a multivariable model, only physical activity, past smoking, smoking in participant's home and lycopene were independently associated with mortality. These three factors explained 2.1% of the variance of all-cause mortality after adjusting for demographic and socio-economic factors.Our association study suggests that, of the set of 249 factors in NHANES, physical activity, smoking, serum lycopene and serum/urinary cadmium are associated with all-cause mortality as identified in previous studies and after controlling for multiple hypotheses and validation in an independent survey. Whereas other NHANES factors may be associated with mortality, they may require larger cohorts with longer time of follow-up to detect. It is possible to use a systematic association study to prioritize risk factors for further investigation.
View details for DOI 10.1093/ije/dyt208
View details for PubMedID 24345851
We explored the relationship between social isolation and mortality in a nationally representative US sample and compared the predictive power of social isolation with that of traditional clinical risk factors.We used data on 16,849 adults from the Third National Health and Nutrition Examination Survey and the National Death Index. Predictor variables were 4 social isolation factors and a composite index. Comparison predictors included smoking, obesity, elevated blood pressure, and high cholesterol. Unadjusted Kaplan-Meier tables and Cox proportional hazards regression models controlling for sociodemographic characteristics were used to predict mortality.Socially isolated men and women had worse unadjusted survival curves than less socially isolated individuals. Cox models revealed that social isolation predicted mortality for both genders, as did smoking and high blood pressure. Among men, individual social predictors included being unmarried, participating infrequently in religious activities, and lacking club or organization affiliations; among women, significant predictors were being unmarried, infrequent social contact, and participating infrequently in religious activities.The strength of social isolation as a predictor of mortality is similar to that of well-documented clinical risk factors. Our results suggest the importance of assessing patients' level of social isolation.
View details for DOI 10.2105/AJPH.2013.301261
View details for PubMedID 24028260
Life course theory suggests that early life experiences can shape health over a lifetime and across generations. Associations between maternal pregnancy experience and daughters' age at menarche are not well understood. We examined whether maternal pre-pregnancy BMI and gestational weight gain (GWG) were independently related to daughters' age at menarche. Consistent with a life course perspective, we also examined whether maternal GWG, birth weight, and prepubertal BMI mediated the relationship between pre-pregnancy BMI and daughter's menarcheal age. We examined 2,497 mother-daughter pairs from the 1979 National Longitudinal Survey of Youth. Survival analysis with Cox proportional hazards was used to estimate whether maternal pre-pregnancy overweight/obesity (BMI ≥ 25.0 kg/m(2)) and GWG adequacy (inadequate, recommended, and excessive) were associated with risk for earlier menarche among girls, controlling for important covariates. Analyses were conducted to examine the mediating roles of GWG adequacy, child birth weight and prepubertal BMI. Adjusting for covariates, pre-pregnancy overweight/obesity (HR = 1.20, 95 % CI 1.06, 1.36) and excess GWG (HR = 1.13, 95 % CI 1.01, 1.27) were associated with daughters' earlier menarche, while inadequate GWG was not. The association between maternal pre-pregnancy weight and daughters' menarcheal timing was not mediated by daughter's birth weight, prepubertal BMI or maternal GWG. Maternal factors, before and during pregnancy, are potentially important determinants of daughters' menarcheal timing and are amenable to intervention. Further research is needed to better understand pathways through which these factors operate.
View details for DOI 10.1007/s10995-012-1139-z
View details for Web of Science ID 000325024100008
View details for PubMedID 23054446
Moving to Opportunity (MTO) was a social experiment to test how relocation to lower poverty neighborhoods influences low-income families. Using adolescent data from 4 to 7 year evaluations (aged 12-19, n=2829), we applied gender-stratified intent-to-treat and adherence-adjusted linear regression models, to test effect modification of MTO intervention effects on adolescent mental health. Low parental education, welfare receipt, unemployment and never-married status were not significant effect modifiers. Tailoring mobility interventions by these characteristics may not be necessary to alter impact on adolescent mental health. Because parental enrollment in school and teen parent status adversely modified MTO intervention effects on youth mental health, post-move services that increase guidance and supervision of adolescents may help support post-move adjustment.
View details for DOI 10.1016/j.healthplace.2013.05.002
View details for PubMedID 23792412
Objective: To investigate long-term body mass index (BMI) changes with childbearing. Design and Methods: Adjusted mean BMI changes were estimated by race-ethnicity, baseline BMI and parity using longitudinal regression models in 3943 young females over 10 and 25 year follow-up from the ongoing 1979 National Longitudinal Survey of Youth cohort. Results: Estimated BMI increases varied by group, ranging from a low of 2.1 BMI units for white, non-overweight nulliparas over the first 10 years to a high of 10.1 BMI units for black, overweight multiparas over the full 25-year follow-up. Impacts of parity were strongest among overweight multiparas and primaparas at ten years, ranges 1.4-1.7 and 0.8-1.3 BMI units, respectively. Among non-overweight women at 10 years, parity-related gain varied by number of births among black and whites but was unassociated in Hispanic women. After 25 years, childbearing significantly increased BMI only among overweight multiparous black women. Conclusion: Childbearing is associated with permanent weight gain in some women, but the relationship differs by maternal BMI in young adulthood, number of births, race-ethnicity and length of follow-up. Given that overweight black women may be at special risk for accumulation of permanent, long-term weight after childbearing, effective interventions for this group are particularly needed.
View details for DOI 10.1002/oby.20503
View details for Web of Science ID 000323521500003
View details for PubMedID 23630108
We test the hypothesis suggested in the literature that an acute income gain in the form of the earned income tax credit reduces the odds of a very low-weight birth among low-income non-Hispanic black mothers. We apply ecological time series and supplemental individual-level logistic regression methods to monthly birth data from California between 1989 and 1997. Contrary to our hypothesis, the odds of very low-weight birth increases above its expected value two months after mothers typically receive the credit. We discuss our findings in relation to the epidemiologic literature concerned with ambient events during pregnancy and recommend further investigation.
View details for DOI 10.1080/19485565.2013.833802
View details for Web of Science ID 000326868400003
View details for PubMedID 24215256
Few studies have explored how patient-physician interactions influence patients' quality of life (QOL). In a prospective cohort study of 1,855 women diagnosed with invasive breast cancer in the Kaiser Permanente Northern California Medical Care Program from 2006 to 2011, we examined associations between patient-physician interactions during cancer treatment and QOL, overall and by racial/ethnic group. Participants completed the interpersonal processes of care (IPC) survey at approximately 8 months post-diagnosis to assess specific domains of the patient-physician interaction during the months after cancer diagnosis. Domains included: compassion, elicited concerns, explained results, decided together, lack of clarity, discrimination due to race/ethnicity, and disrespectful office staff. The functional assessment of cancer therapy-breast cancer was completed concurrently to measure QOL. Linear regression models examined the association of IPC with QOL, first adjusting for patient covariates including age, race, clinical factors, and psychosocial measures and then for physician characteristics such as age, sex, race/ethnicity, and specialty. For all participants (n = 1,855), IPC scores suggesting greater lack of clarity, discrimination due to race/ethnicity, and disrespectful office staff in patient-physician interactions were associated with lower QOL (P< 0.01). IPC scores suggesting physicians demonstrating compassion, eliciting concerns, or explaining results were associated with higher QOL (P< 0.01). Among Whites (n = 1,306), only the associations with higher QOL remained. African Americans (n = 110) who reported higher scores on physician compassion and elicited concerns had higher QOL, whereas higher scores for disrespectful office staff had lower QOL. No associations were observed among Asians (n = 201) and Hispanics (n = 186). After further adjustment for physician factors, the associations among Whites remained, whereas those among African Americans disappeared. In the breast cancer treatment setting, characteristics of the patient-physician interaction as perceived by the patient are associated with QOL, yet were not specific to patient race/ethnicity.
View details for DOI 10.1007/s10549-013-2569-z
View details for Web of Science ID 000321069600028
View details for PubMedID 23715629
BACKGROUND: Breast cancer survivors are less likely to be employed than similar healthy women, yet effects of employment on the well being of survivors are largely unknown. In a prospective cohort study of 2013 women diagnosed from 2006 to 2011 with invasive breast cancer in Kaiser Permanente Northern California, we describe associations between hours worked per week and change in employment with quality of life (QOL) from diagnosis through active treatment. METHODS: Participants completed information on employment status and QOL approximately 2 and 8 months post-diagnosis. QOL was assessed by the Functional Assessment of Cancer Therapy-Breast Cancer. Multivariable linear regression models were adjusted for potential confounders including demographic, diagnostic, and medical care factors to examine associations between employment and QOL. RESULTS: At baseline, overall well being was higher for women who worked at least some hours per week compared with women who were not working. Women working 1-19 h/week at baseline also had higher functional well being compared with women who were not working. There was a significant, positive association between hours worked per week and physical and social well being. At the 6-month follow-up, women working at least 20 h/week had higher physical and functional well being than those who were not working. Lower scores for physical and functional well being were observed among women who stopped working during the 6-month follow-up period. CONCLUSIONS: Continuing to work after a breast cancer diagnosis may be beneficial to multiple areas of QOL. Strategies to help women continue working through treatment should be explored. Copyright © 2012 John Wiley & Sons, Ltd.
View details for DOI 10.1002/pon.3157
View details for Web of Science ID 000320105500029
View details for PubMedID 22912069
The purpose of this study was to examine the association between socioeconomic status (SES) and leukocyte telomere length (LTL) - a marker of cell aging that has been linked to stressful life circumstances - in a nationally representative, socioeconomically and ethnically diverse sample of US adults aged 20-84. Using data from the National Health and Nutrition Examination Survey (NHANES), 1999-2002, we found that respondents who completed less than a high school education had significantly shorter telomeres than those who graduated from college. Income was not associated with LTL. African-Americans had significantly longer telomeres than whites, but there were no significant racial/ethnic differences in the association between education and telomere length. Finally, we found that the association between education and LTL was partially mediated by smoking and body mass index but not by drinking or sedentary behavior.
View details for DOI 10.1016/j.socscimed.2013.02.023
View details for Web of Science ID 000317880300001
View details for PubMedID 23540359
One of the largest health disparities in the USA is in obesity rates between Black and White females.The objective of this study was to test the hypothesis that the stress-obesity link is stronger in Black females than in White females aged 10-19.Multilevel modeling captured the dynamic of acute (1 month) and chronic (10 years) stress and body mass index (BMI; weight in kilograms divided by height in meters squared) change in the National Heart, Lung, and Blood Institute Growth and Health Study, which consists of 2,379 Black and White girls across a span of socioeconomic status. The girls were assessed longitudinally from ages 10 to 19.Higher levels of stress during the 10 years predicted significantly greater increases in BMI over time compared to lower levels of stress. This relationship was significantly stronger for Black compared to White girls.Psychological stress is a modifiable risk factor that may moderate early racial disparities in BMI.
View details for DOI 10.1007/s12160-012-9398-x
View details for Web of Science ID 000314293300002
View details for PubMedID 22993022
Although many have studied the association between educational attainment and obesity, studies to date have not fully examined prior common causes and possible interactions by race/ethnicity or gender. It is also not clear if the relationship between actual educational attainment and obesity is independent of the role of aspired educational attainment or expected educational attainment. The authors use generalized linear log link models to examine the association between educational attainment at age 25 and obesity (BMI?30) at age 40 in the USA's National Longitudinal Survey of Youth 1979 cohort, adjusting for demographics, confounders, and mediators. Race/ethnicity but not gender interacted with educational attainment. In a complete case analysis, after adjusting for socioeconomic covariates from childhood, adolescence, and adulthood, among whites only, college graduates were less likely than high school graduates to be obese (RR = 0.69, 95%CI: 0.57, 0.83). The risk ratio remained similar in two sensitivity analyses when the authors adjusted for educational aspirations and educational expectations and analyzed a multiply imputed dataset to address missingness. This more nuanced understanding of the role of education after controlling for a thorough set of confounders and mediators helps advance the study of social determinants of health and risk factors for obesity.
View details for DOI 10.1016/j.socscimed.2012.11.025
View details for Web of Science ID 000314739300005
View details for PubMedID 23246398
The aim of this study was to examine the association of the discrepancy between externally and self-assessed measures of work environment with long- and short-term sickness absence.The study population included 6997 middle-aged men and women from the Whitehall II cohort, whose work characteristics were examined at baseline (1985-1988) through both an external evaluation and self-report, with a follow-up of up to 13 years of sickness absence reporting from administrative records. The primary exposure of interest was the discrepancy between measures of work stress for fast job pace, conflicting demands, and decision latitude.In mutually adjusted models, external measures of job characteristics were more strongly associated with higher rates of sickness absence compared with self-assessed measures, for both lower frequency of fast work pace and lower conflicting demands (i.e., "passive" levels). Individuals who self-reported higher frequencies of fast work pace and conflicting demands than were reported through external assessment had higher rates of short-term sickness absence [incident rate ratios (IRR) of 1.13 (95% confidence interval [95% CI] 1.11-1.15) and IRR 1.14 (95% CI 1.11-1.16), respectively]. There was no difference in rates of sickness absence found for decision latitude [IRR 1.02 (95% CI 1.00-1.04)].Our findings demonstrate that the discrepancy between externally and self-assessed job demand measures have additional predictive power beyond each individual measure of job structure, which may be related to the extent of cognitive and emotional processing of assessment questions as compared to decision latitude measures.
View details for Web of Science ID 000283701800004
View details for PubMedID 20725704
Despite different levels of economic development, Costa Rica and the USA have similar mortalities among adults. However, in the USA there are substantial differences in mortality by educational attainment, and in Costa Rica there are only minor differences. This contrast motivates an examination of behavioural and biological correlates underlying this difference.The authors used data on adults aged 60 and above from the Costa Rican Longevity and Healthy Ageing Study (CRELES) (n=2827) and from the US National Health and Nutrition Examination Survey (NHANES) (n=5607) to analyse the cross-sectional association between educational level and the following risk factors for cardiovascular disease (CVD): ever smoked, current smoker, sedentary, high saturated fat, high carbohydrates, high calorie diet, obesity, severe obesity, large waist circumference, HDL cholesterol, LDL cholesterol, triglycerides, hemoglobin A1c, fasting glucose, C-reactive protein, systolic blood pressure and BMI.There were significantly fewer hazardous levels of risk biomarkers at higher levels of education for more than half (10 out of 17) of the risk factors in the USA, but for less than a third of the outcomes in Costa Rica (five out of 17).These results are consistent with the context-specific nature of educational differences in risk factors for CVD and with a non-uniform nature of association of CVD risk factors with education within countries. Our results also demonstrate that social equity in mortality is achieved without uniform equity in all risk factors.
View details for DOI 10.1136/jech.2009.086926
View details for Web of Science ID 000281308900016
View details for PubMedID 19822554
The purpose of this study was to investigate the associations between gestational weight gain (GWG) and small- and large-for-gestational-age (SGA, LGA), cesarean delivery, child overweight, and maternal postpartum weight retention in a diverse sample of women in the Unites States.We estimated associations between GWG (continuous and within categories defined by the Institute of Medicine), maternal prepregnancy body mass index, and each outcome in 4496 births in the National Longitudinal Survey of Youth 1979, which was a prospective cohort.GWG (kilograms) was associated with decreased risk of SGA and increased risk of LGA, cesarean delivery, postpartum weight retention, and child overweight independent of maternal demographic and pregnancy characteristics. Gain above the Institute of Medicine guidelines was associated with decreased risk of SGA and increased risk of all other outcomes.Excessive gain may have long-term consequences for maternal and child body size, but the benefits of lower gain must be balanced against risk of SGA.
View details for DOI 10.1016/j.ajog.2009.12.007
View details for PubMedID 20132923
This article places socioeconomic gradients in health into a broader international and historical context. The data we present supports the conclusion that current socioeconomic gradients in health within the United States are neither inevitable nor immutable. This literature reveals periods in the United States with substantially smaller gradients, and identifies many examples of other countries whose different social policy choices appear to have led to superior health levels and equity even with fewer aggregate resources. The article also sheds light on the potential importance of various hypothesized mechanisms in driving major shifts in U.S. population health patterns. While it is essential to carefully examine individual mechanisms contributing to health patterns, it is also illuminating to take a more holistic view of the set of factors changing in conjunction with major shifts in population health. In this article, we do so by focusing on the period of the 1980s, during which U.S. life expectancy gains slowed markedly relative to other developed countries, and U.S. health disparities substantially increased. A comparison with Canada suggests that exploring broad social policy differences, such as the weaker social safety net in the United States, may be a promising area for future investigation.
View details for DOI 10.1111/j.1749-6632.2009.05384.x
View details for Web of Science ID 000277908000003
View details for PubMedID 20201866
Early menarche is a risk factor for breast cancer. We investigated the variation in age at menarche by socioeconomic status (SES) and race.A cohort study was conducted on 1,091 black and 986 white girls from the three sites in the United States as part of the NHLBI Growth and Health Study (NGHS), who were aged 9-10 years at baseline and followed through adolescence over a 10-year period with annual exams. Using logistic regression models, we evaluated the nature and strength of associations between two socioeconomic indicators (household income and parental education) and early menarche (<12 years old) unadjusted and adjusted for anthropometry and maternal age at menarche.Proportionately, more black girls were menarcheal before 12 years of age compared to their white counterparts (46%, n = 468 vs. 26%, n = 240, respectively, p < 0.0001). Parental education was not a significant predictor of early menarche. The graded association between household income and age at menarche was strong and significant among black girls but less clear among white girls. Compared with those in the lowest quartile of household income, white girls in the highest quartile were at a significantly lower risk of early menarche [adjusted odds ratio (OR) = 0.37, 95% confidence intervals (CIs) 0.18-0.80]. The inverse was true for black girls: those in the highest quartile of household income were at an increased risk of early menarche (adjusted OR = 2.15, 95% CI 1.27-3.63)The SES factor selected (household income versus parental education) affected the findings regarding racial differences in the timing of menarche. It will be important for future studies to elucidate the link between household income and age at menarche in developed countries.
View details for DOI 10.1007/s10552-008-9284-9
View details for Web of Science ID 000266340200023
View details for PubMedID 19107561
An examination of where in the income distribution income is most strongly associated with risk of mortality will provide guidance for identifying the most critical pathways underlying the connections between income and mortality, and may help to inform public health interventions to reduce socioeconomic disparities. Prior studies have suggested stronger associations at the lower end of the income distribution, but these studies did not have detailed categories of income, were unable to exclude individuals whose declining health may affect their income and did not use methods to determine exact threshold points of non-linearity. The purpose of this study is to describe the non-linear risks of all-cause and cause-specific mortality across the income distribution.We examined potential non-linear risk of mortality by family income level in a population that had not retired early, changed jobs, or changed to part-time work due to health reasons, in order to minimize the effects of illness on income. We used data from the US National Health and Nutrition Examination Survey (1988-1994), among individuals age 18-64 at baseline, with mortality follow-up to the year 2001 (ages 25-77 at the end of follow-up, 106 037 person-years of time at risk). Differential risk of mortality was examined using proportional hazard models with penalized regression splines in order to allow for non-linear associations between mortality risk and income, controlling for age, race/ethnicity, marital status, level of educational attainment and occupational category.We observed significant non-linear risks of all-cause mortality, as well as for certain specific causes of death at different levels of income. Typically, risk of mortality decreased with increasing income levels only among persons whose family income was below the median; above this level, there was little decreasing risk of mortality with higher levels of income. There was also some variation in mortality risk at different levels of income by cause and gender.The majority of the income associated mortality risk in individuals between the ages of 18-77 in the United States is among the population whose family income is below the median (equal to $20,190 in 1991, 3.2 times the poverty level). Efforts to decrease socioeconomic disparities may have the greatest impact if focused on this population.
View details for DOI 10.1186/1471-2458-8-383
View details for Web of Science ID 000261409300001
View details for PubMedID 19000311
The authors conducted a meta-analytic review to assess the prevalence of major depressive disorder and depressive symptoms among Latinos compared with non-Latino Whites in the United States using community-based data. Random-effects estimates were calculated for 8 studies meeting inclusion criteria that reported lifetime prevalence of major depressive disorder (combined N = 76,270) and for 23 studies meeting inclusion criteria that reported current prevalence of depressive symptoms (combined N = 38,997). Findings did not indicate a group difference in lifetime prevalence of major depressive disorder (odds ratio = 0.89, 95% confidence interval = 0.72, 1.10). Latinos reported more depressive symptoms than non-Latino Whites (standardized mean difference = 0.19, 95% confidence interval = 0.12, 0.25); however, this effect was small and does not appear to suggest a clinically meaningful preponderance of depressive symptoms among Latinos. Findings are examined in the context of theories on vulnerability and resilience, and recommendations for future research are discussed.
View details for DOI 10.1037/0022-006X.76.3.355
View details for Web of Science ID 000256326700001
View details for PubMedID 18540730
Debates exist as to whether, as overall population health improves, the absolute and relative magnitude of income- and race/ethnicity-related health disparities necessarily increase-or decrease. We accordingly decided to test the hypothesis that health inequities widen-or shrink-in a context of declining mortality rates, by examining annual US mortality data over a 42 year period.Using US county mortality data from 1960-2002 and county median family income data from the 1960-2000 decennial censuses, we analyzed the rates of premature mortality (deaths among persons under age 65) and infant death (deaths among persons under age 1) by quintiles of county median family income weighted by county population size. Between 1960 and 2002, as US premature mortality and infant death rates declined in all county income quintiles, socioeconomic and racial/ethnic inequities in premature mortality and infant death (both relative and absolute) shrank between 1966 and 1980, especially for US populations of color; thereafter, the relative health inequities widened and the absolute differences barely changed in magnitude. Had all persons experienced the same yearly age-specific premature mortality rates as the white population living in the highest income quintile, between 1960 and 2002, 14% of the white premature deaths and 30% of the premature deaths among populations of color would not have occurred.The observed trends refute arguments that health inequities inevitably widen-or shrink-as population health improves. Instead, the magnitude of health inequalities can fall or rise; it is our job to understand why.
View details for DOI 10.1371/journal.pmed.0050046
View details for Web of Science ID 000254928800014
View details for PubMedID 18303941
Eliminating health disparities is a fundamental, though not always explicit, goal of public health research and practice. There is a burgeoning literature in this area, but a number of unresolved issues remain. These include the definition of what constitutes a disparity, the relationship of different bases of disadvantage, the ability to attribute cause from association, and the establishment of the mechanisms by which social disadvantage affects biological processes that get into the body, resulting in disease. We examine current definitions and empirical research on health disparities, particularly disparities associated with race/ethnicity and socioeconomic status, and discuss data structures and analytic strategies that allow causal inference about the health impacts of these and associated factors. We show that although health is consistently worse for individuals with few resources and for blacks as compared with whites, the extent of health disparities varies by outcome, time, and geographic location within the United States. Empirical work also demonstrates the importance of a joint consideration of race/ethnicity and social class. Finally, we discuss potential pathways, including exposure to chronic stress and resulting psychosocial and physiological responses to stress, that serve as mechanisms by which social disadvantage results in health disparities.
View details for DOI 10.1146/annurev.publhealth.29.020907.090852
View details for Web of Science ID 000255349400018
View details for PubMedID 18031225
To evaluate whether there is an association between socioeconomic position (SEP) and the metabolic syndrome at various ages, including adolescent, middle-aged and older participants in gender-specific analyses.Participants were from the 1999-2002 National Health and Nutrition Examination Survey. SEP was measured by income and years of education. Metabolic syndrome was measured in adults using the American Heart Association guidelines and in adolescents using methods based on national reference data. Cross-sectional multivariable-adjusted logistic regression analyses were performed.In women aged 25 to 45 and 46 to 65 years, income below the poverty line (poverty income ratio [PIR] less than one) was associated with higher odds of metabolic syndrome compared with PIR greater than 3 (odds ratio [OR] = 4.90; 95% confidence interval (CI) = 2.24, 10.71, and OR = 2.54; CI = 1.38, 4.67, for the respective age groups) after adjustment for age, race/ethnicity, and menopause. Similar findings were observed for educational attainment. In adolescents, older adults (aged >65 years), and males, income and education were not related to the metabolic syndrome.This report demonstrates that SEP is associated with the metabolic syndrome in females aged 25 to 65 years and is less strongly associated in males, adolescents, or older participants. These findings provide physiologic mechanistic evidence linking SEP to risk for coronary heart disease.
View details for DOI 10.1016/j.annepidem.2007.05.003
View details for Web of Science ID 000250067200005
View details for PubMedID 17697786
The aim of the study is to examine whether socioeconomic position (SEP) is associated with metabolic syndrome and whether the association differs by gender and race/ethnicity.Study participants were from the Third National Health and Nutrition Examination Survey. SEP was measured by using education and poverty income ratio (PIR). Metabolic syndrome was measured according to the National Institutes of Health guidelines. Multivariable-adjusted logistic regression analyses were performed.Low education (<12 years) was associated with metabolic syndrome in women (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.39-2.24) and less so in men (OR, 1.27; 95% CI, 0.97-1.66) versus more than 12 years of education. For income, low PIR (
View details for DOI 10.1016/j.annepidem.2006.07.002
View details for Web of Science ID 000243281300003
View details for PubMedID 17140811
View details for DOI 10.1016/j.annepidem.2006.07.002
View details for Web of Science ID 000243281300003
View details for PubMedID 17140811
We compared all-cause mortality rates stratified by individual-level education and by census tract area-based socioeconomic measures for Massachusetts (1999-2001). Among persons aged 25 and older, the age-adjusted relative index of inequality was slightly higher for the census tract than for the individual education measures (1.5 vs 1.2, respectively). Only the census tract socioeconomic measures could provide a relative index of inequality (2-3) for deaths before age 25 or detect expected socioeconomic disparities for deaths among persons 65 and older (relative index of inequality= approximately 1.2 vs 0.8 for census tract measures and individual education, respectively).
View details for DOI 10.2105/AJPH.2005.075408
View details for Web of Science ID 000242474500010
View details for PubMedID 16809582
The absence of individual-level socioeconomic information in most US health surveillance data necessitates using area-based socioeconomic measures (ABSMs) to monitor health inequalities. Using the 1989-1991 birth weight data from Massachusetts, the authors compared estimates of health disparities detected with census tract- and block group-level ABSMs pertaining to poverty and education, as well as parental education, both independently and together. In separate models, adjusted for infant's sex, mother's age, and parents' race/ethnicity, worst-off categories of census tract ABSMs and parental education had a comparable birth weight deficit of approximately 70 g. Similar results were observed for low birth weight (<2,500 g), with worst-off categories of census tract ABSMs and parental education having an odds ratio of approximately 1.37 (p < 0.001). In mutually adjusted models for birth weight and low birth weight, census tract ABSMs still detected an effect estimate nearly 50% of that detected by parental education. Additionally, census tract ABSMs detected socioeconomic gradients in birth weight among births to mothers aged less than 25 years, an age group in which educational attainment is unlikely to be completed. These results suggest that aptly chosen ABSMs can be used to monitor socioeconomic inequalities in health. The risk, if any, in the absence of individual-level socioeconomic information is a conservative estimate of socioeconomic inequalities in health.
View details for DOI 10.1093/aje/kwj313
View details for Web of Science ID 000241432000002
View details for PubMedID 16968866
The identification and documentation of health disparities are important functions of public health surveillance. These disparities, typically falling along lines defined by gender, race/ethnicity, and social class, are often made visible in urban settings as geographic disparities in health between neighborhoods. Recognizing that premature mortality is a powerful indicator of disparities in both health status and access to health care that can readily be monitored using routinely available public health surveillance data, we undertook a systematic analysis of spatial variation in premature mortality in Boston (1999-2001) across neighborhoods and sub-neighborhoods in relation to census tract (CT) poverty. Using a multilevel model based framework, we estimated that the incidence of premature mortality was 1.39 times higher (95% credible interval 1.09-1.78) among persons living in the most economically deprived CTs (>/=20% below poverty) compared to those in the least impoverished tracts (<5% below poverty). We present maps of model-based standardized mortality ratios that show substantial within-neighborhood variation in premature mortality and a sizeable decrease in spatial variation after adjustment for CT poverty. Additionally, we present maps of model-based direct standardized rates that can more readily be compared to externally published rates and targets, as well as maps of the population attributable fraction that show that in some of Boston's poorest neighborhoods, the proportion of excess deaths associated with CT poverty reaches 25-30%. We recommend that these methods be incorporated into routine analyses of public health surveillance data to highlight continuing social disparities in premature mortality.
View details for DOI 10.1007/s11524-006-9089-7
View details for Web of Science ID 000243181900007
View details for PubMedID 17001522
We tested the hypothesis that the US socioeconomic gradient in breast cancer incidence is declining, with the decline most pronounced among racial/ethnic groups with the highest incidence rates.We geocoded the invasive incident breast cancer cases for three US population-based cancer registries covering: Los Angeles County, CA (1978-1982, 1988-1992, 1998-2002; n = 68,762 cases), the San Francisco Bay Area, CA (1978-1982, 1988-1992, 1998-2002; n = 37,210 cases) and Massachusetts (1988-1992, 1998-2002; n = 48,111 cases), linked the records to census tract area-based socioeconomic measures, and, for each socioeconomic stratum, computed average annual breast cancer incidence rates for the 5-year period straddling the 1980, 1990, and 2000 census, overall and by race/ethnicity and gender.Our findings indicate that the socioeconomic gradient in breast cancer incidence is: (a) relatively small (at most 1.2) and stable among US white non-Hispanic and black women; (b) sharper and generally increasing among Hispanic and Asian and Pacific Islander American women; and (c) cannot be meaningfully analyzed without considering effect modification by race/ethnicity and immigration.Our results indicate that secular changes in US socioeconomic gradients in breast cancer incidence exist and vary by race/ethnicity.
View details for DOI 10.1007/s10552-005-0408-1
View details for Web of Science ID 000234754500011
View details for PubMedID 16425100
Despite an extensive literature, there have been widely divergent findings regarding the direction of the association between area socio-economic characteristics and area suicide rates, with high-quality studies finding either a direct relation (higher rates of suicide in higher socio-economic areas), an inverse relation (lower rates of suicide in higher socio-economic areas) or no association.We performed a systematic review of the literature dating from 1897 to 2004 and identified 86 publications with 221 separate analyses that met our inclusion criteria. We examined the percent of direct, inverse and null findings stratified by key study characteristics including size of aggregated area, socio-economic measure used, region of study, control variables and study design.Analyses at the community level are significantly more likely to demonstrate lower rates of suicide among higher socio-economic areas than studies using larger areas of aggregation. Measures of area poverty and deprivation are most likely to be inversely associated with suicide rates and median income is least likely to be inversely associated with suicide rates. Analyses using measures of unemployment and education and occupation were equally likely to demonstrate inverse associations. Study results did not vary significantly by gender or by study design.The heterogeneity of associations is mostly accounted for by study design features that have largely been neglected in this literature. Enhanced attention to size of region and measurement strategies provide a clearer picture of how suicide rates vary by region. Resources for suicide prevention should be targeted to high poverty/deprivation and high unemployment areas.
View details for DOI 10.1017/S003329170500588X
View details for Web of Science ID 000235200800001
View details for PubMedID 16420711
We describe a method to facilitate routine monitoring of socioeconomic health disparities in the United States.We analyzed geocoded public health surveillance data including events from birth to death (c. 1990) linked to 1990 census tract (CT) poverty data for Massachusetts and Rhode Island.For virtually all outcomes, risk increased with CT poverty, and when we adjusted for CT poverty racial/ethnic disparities were substantially reduced. For half the outcomes, more than 50% of cases would not have occurred if population rates equaled those of persons in the least impoverished CTs. In the early 1990s, persons in the least impoverished CT were the only group meeting Healthy People 2000 objectives a decade ahead.Geocoding and use of the CT poverty measure permit routine monitoring of US socioeconomic inequalities in health, using a common and accessible metric.
View details for DOI 10.2105/AJPH.2003.032482
View details for Web of Science ID 000226851000030
View details for PubMedID 15671470
We analyzed neighborhood heterogeneity in associations among mortality, race/ethnicity, and area poverty.We performed a multilevel statistical analysis of Massachusetts all-cause mortality data for the period 1989 through 1991 (n=142836 deaths), modeled as 79813 cells (deaths and denominators cross-tabulated by age, gender, and race/ethnicity) at level 1 nested within 5532 block groups at level 2 within 1307 census tracts (CTs) at level 3. We also characterized CTs by percentage of the population living below poverty level.Neighborhood variation in mortality across CTs and block groups was not accounted for by these areas' age, gender, and racial/ethnic composition. Neighborhood variation in mortality was much greater for the Black population than for the White population, largely because of CT-level variation in poverty rates.Neighborhood heterogeneity in the relationship between mortality and race/ethnicity in Massachusetts is statistically significant and is closely related to CT-level variation in poverty.
View details for DOI 10.2105/AJPH.2003.034132
View details for Web of Science ID 000226851000022
View details for PubMedID 15671462
To characterize vancomycin use at a pediatric tertiary-care hospital, to discriminate between initial (< or = 72 hours) and prolonged (> 72 hours) inappropriate use, and to define patient characteristics associated with inappropriate use.Vancomycin courses were retrospectively reviewed using an algorithm modeled on HICPAC guidelines. Data were collected regarding patient demographics, comorbidities, other medication use, and nosocomial infections. The association between each variable and the outcome of inappropriate use was determined by longitudinal regression analysis. A multivariable model was constructed to assess risk factors for inappropriate initial and prolonged vancomycin use.A pediatric tertiary-care medical center.Children older than 1 year who received intravenous vancomycin from November 2000 to June 2001.Three hundred twenty-seven vancomycin courses administered to 260 patients were evaluated for appropriateness. Of initial courses, 114 (35%) were considered inappropriate. Of 143 prolonged courses, 103 (72%) were considered inappropriate. Multivariable risk factor analysis identified the following variables as significantly associated with inappropriate initial use: admission to the surgery service, having a malignancy, receipt of a stem cell transplant, and having received a prior inappropriate course of vancomycin. No variables were identified as significant risk factors for inappropriate prolonged use.Substantial inappropriate use of vancomycin was identified. Prolonged inappropriate use was a particular problem. This risk factor analysis suggests that interventions targeting patients admitted to certain services or receiving multiple courses of vancomycin could reduce inappropriate use.
View details for Web of Science ID 000226369700007
View details for PubMedID 15693408
Use of multilevel frameworks and area-based socioeconomic measures (ABSMs) for public health monitoring can potentially overcome the absence of socioeconomic data in most US public health surveillance systems. To assess whether ABSMs can meaningfully be used for diverse race/ethnicity-gender groups, we geocoded and linked public health surveillance data from Massachusetts and Rhode Island to 1990 block group, tract, and zip code ABSMs. Outcomes comprised death, birth, cancer incidence, tuberculosis, sexually transmitted infections, childhood lead poisoning, and nonfatal weapons-related injuries. Among White, Black, and Hispanic women and men, measures of economic deprivation (e.g., percentage below poverty) were most sensitive to expected socioeconomic gradients in health, with the most consistent results and maximal geocoding linkage evident for tract-level analyses.
View details for Web of Science ID 000185881100016
View details for PubMedID 14534218
Health impact assessment (HIA) seeks to expand evaluation of policy and programmes in all sectors, both private and public, to include their impact on population health. While the idea that the public's health is affected by a broad array of social and economic policies is not new and dates back well over two centuries, what is new is the notion-increasingly adopted by major health institutions, such as the World Health Organisation (WHO) and the United Kingdom National Health Services (NHS)-that health should be an explicit consideration when evaluating all public policies. In this article, it is argued that while HIA has the potential to enhance recognition of societal determinants of health and of intersectoral responsibility for health, its pitfalls warrant critical attention. Greater clarity is required regarding criteria for initiating, conducting, and completing HIA, including rules pertaining to decision making, enforcement, compliance, plus paying for their conduct. Critical debate over the promise, process, and pitfalls of HIA needs to be informed by multiple disciplines and perspectives from diverse people and regions of the world.
View details for Web of Science ID 000184853800008
View details for PubMedID 12933768
Environmental iron concentrations coordinately regulate transcription of genes involved in iron acquisition and virulence via the ferric uptake regulation (fur) system. We identified and sequenced the fur gene and flanking regions of three Bartonella species. The most notable difference between Bartonella Fur and other Fur proteins was a substantially higher predicted isoelectric point. No promoter activity or Fur autoregulation was detected using a gfp reporter gene fused to the 204 nucleotides immediately upstream of the Bartonella fur gene. Bartonella henselae fur gene expression complemented a Vibrio cholerae fur mutant.
View details for Web of Science ID 000170958900035
View details for PubMedID 11544240
The mitochondrial genome of Plasmodium falciparum encodes three protein coding genes and highly fragmented rRNAs. The genome is polycistronically transcribed and, since gene-size transcripts are much more abundant than the polycistronic transcripts, the latter are presumably cleaved to produce the smaller, mature mRNAs and rRNAs. Mapping the transcripts of the P. falciparum mitochondrial protein coding genes shows that the 3' end of each gene directly abuts the 5' end of the gene located immediately downstream. The 5' ends of the protein coding genes are also closely apposed to adjacent genes, with one directly abutting a gene on the same DNA strand and two others separated by just 13 nt from an rDNA fragment encoded on the opposite strand. These mapping data are consistent with production of the mRNAs by cleavage from a polycistronic precursor transcript. Further processing of the mRNAs comes from addition of oligo(A) tails. Unexpectedly, the presence and length of such tails varies in a gene-specific fashion. In this regard, polyadenylation of the P. falciparum mitochondrial mRNAs is more similar to that seen for the P. falciparum mitochondrial rRNAs than that of mitochondrial mRNAs in other organisms.
View details for Web of Science ID 000084168400009
View details for PubMedID 10613702
The mitochondrial genome of Plasmodium falciparum encodes highly fragmented rRNAs. Twenty small RNAs which are putative rRNA fragments have been found and 15 of them have been identified as corresponding to specific regions of rRNA sequence. To investigate the possible interactions between the fragmented rRNAs in the ribosome, we have mapped the ends of many of the small transcripts using primer extension and RNase protection analysis. Results obtained from these studies revealed that some of the rRNA transcripts were longer than the sequences which encode them. To investigate these size discrepancies, we performed 3' RACE PCR analysis and RNase H mapping. These analyses revealed non-encoded oligo(A) tails on some but not all of these small rRNAs. The approximate length of the oligo(A) tail appears to be transcript-specific, with some rRNAs consistently showing longer oligo(A) tails than others. The oligoadenylation of the rRNAs may provide a buffer zone against 3' exonucleolytic attack, thereby preserving the encoded sequences necessary for secondary structure interactions in the ribosome.
View details for Web of Science ID 000080678100025
View details for PubMedID 10325433
The Plasmodium falciparum 6 kb element encodes three protein coding genes and highly fragmented large and small subunit rRNAs; its gene content makes it the probable mitochondrial genome. Many of the genes are encoded so close to each other that there is insufficient room for specific promoters upstream of each gene. RNase protection analysis of two rRNA fragments whose genes are adjacent provided evidence for a polycistronic transcript containing sequences from both, as well as separate small RNAs. To evaluate the possibility of further polycistronic transcription, several sets of oligonucleotide primers located in different regions of the 6 kb element were employed to amplify cDNAs. These analyses have revealed the existence of 6 kb element transcripts as long as 5.9 kb. Both mRNA and rRNA sequences are included on these putative precursor transcripts. Since these types of RNA are known to have different patterns of abundance changes during the erythrocytic portion of the parasite life cycle, RNA stability is presumably an important feature in regulating mitochondrial transcript abundance.
View details for Web of Science ID A1996VM86500009
View details for PubMedID 8898336