Clinical Focus

  • Family Medicine
  • Health Disparities

Academic Appointments

Administrative Appointments

  • Assistant Professor, University of California San Francisco (2017 - Present)
  • Affiliate, Center for Population Health Sciences (2015 - Present)
  • Affiliate, Center for Poverty and Inequality (2015 - Present)

Professional Education

  • Ph.D., Stanford University, Epidemiology (2017)
  • Board Certification: Family Medicine, American Board of Family Medicine (2013)
  • Residency:Contra Costa Regional Medical Center (2013) CA
  • Medical Education:Univ of California San Francisco (2010) CA
  • M.S., University of California Berkeley, Health and Medical Sciences (2008)
  • M.P.H., University of California Berkeley, Interdisciplinary Studies (2007)
  • A.B., Harvard University, Chemistry (2003)

Research & Scholarship

Current Research and Scholarly Interests

My research investigates the pathways linking poverty and health disparities. In particular, I study the impact on health outcomes of social and economic factors using interdisciplinary causal inference methods. I am interested in the mechanisms through which adverse socioeconomic conditions get "under the skin" to cause health disparities.

Clinical Trials

  • The EARN-Health Trial of Financial Savings and Health Recruiting

    The current literature in social epidemiology and public health suggests that low financial savings has an unsurprising negative relationship with subjective well-being, and increases the odds of making visits to a healthcare provider, receiving a chronic disease diagnosis, and experiencing medical disability. is a community-based non-profit based in San Francisco with a mission to help low-income workers build lifelong savings habits and financial capability. The organization is one of the largest providers of "goal-based savings accounts" or "matched savings accounts" in the US. The investigators propose to conduct a randomized controlled trial to determine the health effects of Earn's savings program. Through this trial, the investigators will test three principal hypotheses: (1) Participants in the Earn account, as compared to a control group, are hypothesized to demonstrate improved scores on mental health scales assessing depression and anxiety. (2) Participants in the Earn account, as compared to a control group, are hypothesized to experience lower odds of harmful behaviors associated with stress, specifically tobacco and alcohol abuse. The investigators hypothesize that the effect on behaviors will be of smaller effect size, and more delayed, than the effect on mental health outcomes, judging from similar effects observed in the micro-credit literature. (3) The mediating variables between Earn account participation and beneficial health outcomes will include increased optimism and internal locus of control.

    View full details


All Publications

  • Predicting later life health status and mortality using state-level socioeconomic characteristics in early life. SSM - population health Hamad, R., Rehkopf, D. H., Kuan, K. Y., Cullen, M. R. 2016; 2: 269-276


    Studies extending across multiple life stages promote an understanding of factors influencing health across the life span. Existing work has largely focused on individual-level rather than area-level early life determinants of health. In this study, we linked multiple data sets to examine whether early life state-level characteristics were predictive of health and mortality decades later. The sample included 143,755 U.S. employees, for whom work life claims and administrative data were linked with early life state-of-residence and mortality. We first created a "state health risk score" (SHRS) and "state mortality risk score" (SMRS) by modeling state-level contextual characteristics with health status and mortality in a randomly selected 30% of the sample (the "training set"). We then examined the association of these scores with objective health status and mortality in later life in the remaining 70% of the sample (the "test set") using multivariate linear and Cox regressions, respectively. The association between the SHRS and adult health status was ?=0.14 (95%CI: 0.084, 0.20), while the hazard ratio for the SMRS was 0.96 (95%CI: 0.93, 1.00). The association between the SHRS and health was not statistically significant in older age groups at a p-level of 0.05, and there was a statistically significantly different association for health status among movers compared to stayers. This study uses a life course perspective and supports the idea of "sensitive periods" in early life that have enduring impacts on health. It adds to the literature examining populations in the U.S. where large linked data sets are infrequently available.

    View details for PubMedID 27713921

  • Changing national guidelines is not enough: the impact of 1990 IOM recommendations on gestational weight gain among US women. International journal of obesity Hamad, R., Cohen, A. K., Rehkopf, D. H. 2016; 40 (10): 1529-1534


    Gestational weight gain (GWG) is associated with both long- and short-term maternal and child health outcomes, particularly obesity. Targeting maternal nutrition through policies is a potentially powerful pathway to influence these outcomes. Yet prior research has often failed to evaluate national policies and guidelines that address maternal and child health. In 1990, the U.S. Institute of Medicine (IOM) released guidelines recommending different GWG thresholds based on women's pre-pregnancy body mass index (BMI), with the goal of improving infant birth weight. In this study, we employ quasi-experimental methods to examine whether the release of the IOM guidelines led to changes in GWG among a diverse and nationally representative sample of women.Our sample included female participants of the National Longitudinal Survey of Youth who self-reported GWG for pregnancies during 1979-2000 (n=7442 pregnancies to 4173 women). We compared GWG before and after the guidelines were released using difference-in-differences (DID) and regression discontinuity (RD) analyses.In DID analyses we found no reduction in GWG among overweight/obese women relative to normal/underweight women. Meanwhile, RD analyses demonstrated no changes in GWG by pre-pregnancy BMI for either overweight/obese or normal/underweight women. Results were similar for women regardless of educational attainment, race or parity.These findings suggest that national guidelines had no effect on weight gain among pregnant women. These results have implications for the implementation of policies targeting maternal and child health via dietary behaviors.

    View details for DOI 10.1038/ijo.2016.97

    View details for PubMedID 27200502

  • Racial and Socioeconomic Variation in Genetic Markers of Telomere Length: A Cross-Sectional Study of U.S. Older Adults. EBioMedicine Hamad, R., Tuljapurkar, S., Rehkopf, D. H. 2016; 11: 296-301


    Shorter telomere length (TL) has been associated with stress and adverse socioeconomic conditions, yet U.S. blacks have longer TL than whites. The role of genetic versus environmental factors in explaining TL by race and socioeconomic position (SEP) remains unclear.We used data from the U.S. Health and Retirement Study (N=11,934) to test the hypothesis that there are differences in TL-associated SNPs by race and SEP. We constructed a TL polygenic risk score (PRS) and examined its association with race/ethnicity, educational attainment, assets, gender, and age.U.S. blacks were more likely to have a lower PRS for TL, as were older individuals and men. Racial differences in TL were statistically accounted for when controlling for population structure using genetic principal components. The GWAS-derived SNPs for TL, however, may not have consistent associations with TL across different racial/ethnic groups.This study showed that associations of race/ethnicity with TL differed when accounting for population stratification. The role of race/ethnicity for TL remains uncertain, however, as the genetic determinants of TL may differ by race/ethnicity. Future GWAS samples should include racially diverse participants to allow for better characterization of the determinants of TL in human populations.

    View details for DOI 10.1016/j.ebiom.2016.08.015

    View details for PubMedID 27566956

  • Telomere length and health outcomes: A two-sample genetic instrumental variables analysis. Experimental gerontology Hamad, R., Walter, S., Rehkopf, D. H. 2016; 82: 88-94


    Previous studies linking telomere length (TL) and health have been largely associational.We apply genetic instrumental variables (IV) analysis, also known as Mendelian randomization, to test the hypothesis that shorter TL leads to poorer health.This method reduces bias from reverse causation or confounding.We used two approaches in this study that rely on two separate data sources: (1) individual-level data from the Health and Retirement Study (HRS) (N=3734), and (2) coefficients from genome-wide association studies (GWAS).We employed two-sample genetic IV analyses, constructing a polygenic risk score (PRS) of TL-associated single nucleotide polymorphisms.The first approach examined the association of the PRS with nine individual health outcomes in HRS.The second approach took advantage of estimates available in GWAS databases to estimate the impact of TL on five health outcomes using an inverse variance-weighted meta-analytic technique.Using individual-level data, shorter TL was marginally statistically significantly associated with decreased risk of stroke and increased risk of heart disease.Using the meta-analytic approach, shorter TL was associated with increased risk of coronary artery disease (OR 1.02 per 100 base pairs, 95%CI: 1.00, 1.03).With the exception of a small contribution to heart disease, our findings suggest that TL may be a marker of disease rather than a cause. They also demonstrate the utility of the inverse variance-weighted meta-analytic approach when examining small effect sizes.

    View details for DOI 10.1016/j.exger.2016.06.005

    View details for PubMedID 27321645

  • The Effects of Job Insecurity on Health Care Utilization: Findings from a Panel of U.S. Workers. Health services research Hamad, R., Modrek, S., Cullen, M. R. 2016; 51 (3): 1052-1073


    To examine the impacts of job insecurity during the recession of 2007-2009 on health care utilization among a panel of U.S. employees.Linked administrative and claims datasets on a panel of continuously employed, continuously insured individuals at a large multisite manufacturing firm that experienced widespread layoffs (N=9,486).We employed segmented regressions to examine temporal discontinuities in utilization during 2006-2012. To assess the effects of job insecurity, we compared individuals at high- and low-layoff plants. Because the dataset includes multiple observations for each individual, we included individual-level fixed effects.We found discontinuous increases in outpatient (3.5 visits/month/10,000 individuals, p=.002) and emergency (0.4 visits/month/10,000 individuals, p=.05) utilization in the panel of all employees. Compared with individuals at low-layoff plants, individuals at high-layoff plants decreased outpatient utilization (-4.0 visits/month/10,000 individuals, p=.008), suggesting foregone preventive care, with a marginally significant increase in emergency utilization (0.4 visits/month/10,000 individuals, p=.08).These results suggest changes in health care utilization and potentially adverse impacts on employee health in response to job insecurity during the latest recession. This study contributes to our understanding of the impacts of economic crises on the health of the U.S. working population.

    View details for DOI 10.1111/1475-6773.12393

    View details for PubMedID 26416343

  • Long-term effects of neighbourhood deprivation on diabetes risk: quasi-experimental evidence from a refugee dispersal policy in Sweden LANCET DIABETES & ENDOCRINOLOGY White, J. S., Hamad, R., Li, X., Basu, S., Ohlsson, H., Sundquist, J., Sundquist, K. 2016; 4 (6): 517-524


    Although studies have shown associations between neighbourhood quality and chronic disease outcomes, such associations are potentially confounded by the selection of different types of people into different neighbourhood environments. We sought to identify the causal effects of neighbourhood deprivation on type 2 diabetes risk, by comparing refugees in Sweden who were actively dispersed by government policy to low-deprivation, moderate-deprivation, or high-deprivation neighbourhoods.In this quasi-experimental study, we analysed national register data for refugees who arrived in Sweden aged 25-50 years, at a time when the government policy involved quasi-random dispersal of refugees to neighbourhoods with different levels of poverty and unemployment, schooling, and social welfare participation. Individuals in our sample were assigned to a neighbourhood categorised as high deprivation (?1 SD above the mean), moderate deprivation (within 1 SD of the mean), or low deprivation (?1 SD below the mean). The primary outcome was new diagnosis of type 2 diabetes between Jan 1, 2002, and Dec 31, 2010. We used multivariate logistic and linear regressions to assess the effects of neighbourhood deprivation on diabetes risk, controlling for potential confounders affecting neighbourhood assignment and assessing effects of cumulative exposure to different neighbourhood conditions.We included data for 61?386 refugees who arrived in Sweden during 1987-91 and who were assigned to one of 4833 neighbourhoods. Being assigned to an area deemed high deprivation versus low deprivation was associated with an increased risk of diabetes (odds ratio [OR] 122, 95% CI 107-138; p=0001). In analyses that included fixed effects for assigned municipality, the increased diabetes risk was estimated to be 085 percentage points (95% CI -0030 to 1728; p=0058). Neighbourhood effects grew over time such that 5 years of additional exposure to high-deprivation versus low-deprivation neighbourhoods was associated with a 9% increase in diabetes risk.This study makes use of a pre-existing governmental natural experiment to show that neighbourhood deprivation increased the risk of diabetes in refugees in Sweden. This finding has heightened importance in the context of the current refugee crisis in Europe.US National Heart, Lung, and Blood Institute, US National Center for Advancing Translational Sciences, US National Institute on Minority Health and Health Disparities, Swedish Research Council.

    View details for DOI 10.1016/S2213-8587(16)30009-2

    View details for Web of Science ID 000376462800017

    View details for PubMedID 27131930

  • Poverty and Child Development: A Longitudinal Study of the Impact of the Earned Income Tax Credit AMERICAN JOURNAL OF EPIDEMIOLOGY Hamad, R., Rehkopf, D. H. 2016; 183 (9): 775-784


    Although adverse socioeconomic conditions are correlated with worse child health and development, the effects of poverty-alleviation policies are less understood. We examined the associations of the Earned Income Tax Credit (EITC) on child development and used an instrumental variable approach to estimate the potential impacts of income. We used data from the US National Longitudinal Survey of Youth (n = 8,186) during 1986-2000 to examine effects on the Behavioral Problems Index (BPI) and Home Observation Measurement of the Environment inventory (HOME) scores. We conducted 2 analyses. In the first, we used multivariate linear regressions with child-level fixed effects to examine the association of EITC payment size with BPI and HOME scores; in the second, we used EITC payment size as an instrument to estimate the associations of income with BPI and HOME scores. In linear regression models, higher EITC payments were associated with improved short-term BPI scores (per $1,000, ? = -0.57; P = 0.04). In instrumental variable analyses, higher income was associated with improved short-term BPI scores (per $1,000, ? = -0.47; P = 0.01) and medium-term HOME scores (per $1,000, ? = 0.64; P = 0.02). Our results suggest that both EITC benefits and higher income are associated with modest but meaningful improvements in child development. These findings provide valuable information for health researchers and policymakers for improving child health and development.

    View details for DOI 10.1093/aje/kwv317

    View details for Web of Science ID 000376097600001

    View details for PubMedID 27056961

  • Changing national guidelines is not enough: The impact of 1990 IOM recommendations on gestational weight gain among U.S. women International Journal of Obesity Hamad, R., Cohen, A. K., Rehkopf, D. H. 2016

    View details for DOI 10.1038/ijo.2016.97

  • Predicting later life health status and mortality using state-level socioeconomic characteristics in early life SSM - Population Health Hamad, R., Rehkopf, D. H., Kuan, K. Y., Cullen, M. R. 2016; 2
  • Hamad and Rehkopf Respond to "Income and Health: Financial Credits as Instruments". American journal of epidemiology Hamad, R., Rehkopf, D. H. 2016; 183 (9): 790-1

    View details for DOI 10.1093/aje/kwv315

    View details for PubMedID 27056960

  • Poverty, Pregnancy, and Birth Outcomes: A Study of the Earned Income Tax Credit PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Hamad, R., Rehkopf, D. H. 2015; 29 (5): 444-452


    Economic interventions are increasingly recognised as a mechanism to address perinatal health outcomes among disadvantaged groups. In the US, the earned income tax credit (EITC) is the largest poverty alleviation programme. Little is known about its effects on perinatal health among recipients and their children. We exploit quasi-random variation in the size of EITC payments to examine the effects of income on perinatal health.The study sample includes women surveyed in the 1979 National Longitudinal Survey of Youth (n?=?2985) and their children born during 1986-2000 (n?=?4683). Outcome variables include utilisation of prenatal and postnatal care, use of alcohol and tobacco during pregnancy, term birth, birthweight, and breast-feeding status. We first examine the health effects of both household income and EITC payment size using multivariable linear regressions. We then employ instrumental variables analysis to estimate the causal effect of income on perinatal health, using EITC payment size as an instrument for household income.We find that EITC payment size is associated with better levels of several indicators of perinatal health. Instrumental variables analysis, however, does not reveal a causal association between household income and these health measures.Our findings suggest that associations between income and perinatal health may be confounded by unobserved characteristics, but that EITC income improves perinatal health. Future studies should continue to explore the impacts of economic interventions on perinatal health outcomes, and investigate how different forms of income transfers may have different impacts.

    View details for DOI 10.1111/ppe.12211

    View details for Web of Science ID 000359633400010

  • Microcredit participation and women's health: results from a cross-sectional study in Peru INTERNATIONAL JOURNAL FOR EQUITY IN HEALTH Hamad, R., Fernald, L. C. 2015; 14


    Social and economic conditions are powerful determinants of women's health status. Microcredit, which involves the provision of small loans to low-income women in the hopes of improving their living conditions, is an increasingly popular intervention to improve women's socioeconomic status. Studies examining the health effects of microcredit programs have had mixed results.We conduct a cross-sectional study among female clients of a non-profit microcredit program in Peru (N?=?1,593). The predictor variable is length of microcredit participation. We conduct bivariate and multivariate linear regressions to examine the associations between length of microcredit participation and a variety of measures of women's health. We control for participants' sociodemographic characteristics.We find that longer participation is associated with decreased depressive symptoms, increased social support, and increased perceived control, but these differences are attenuated with the inclusion of covariates. We find no association between length of participation and contraception use, cancer screening, or self-reported days sick.These results demonstrate a positive association between length of microcredit participation and measures of women's psychological health, but not physical health. These findings contribute to the discussion on the potential of microcredit programs to address the socioeconomic determinants of health, and suggest that addressing socioeconomic status may be a key way to improve women's health worldwide.

    View details for DOI 10.1186/s12939-015-0194-7

    View details for Web of Science ID 000358905200002

    View details for PubMedID 26242582

  • Large-Scale Automated Analysis of News Media: A Novel Computational Method for Obesity Policy Research OBESITY Hamad, R., Pomeranz, J. L., Siddiqi, A., Basu, S. 2015; 23 (2): 296-300


    Analyzing news media allows obesity policy researchers to understand popular conceptions about obesity, which is important for targeting health education and policies. A persistent dilemma is that investigators have to read and manually classify thousands of individual news articles to identify how obesity and obesity-related policy proposals may be described to the public in the media. A machine learning method called "automated content analysis" that permits researchers to train computers to "read" and classify massive volumes of documents was demonstrated.14,302 newspaper articles that mentioned the word "obesity" during 2011-2012 were identified. Four states that vary in obesity prevalence and policy (Alabama, California, New Jersey, and North Carolina) were examined. The reliability of an automated program to categorize the media's framing of obesity as an individual-level problem (e.g., diet) and/or an environmental-level problem (e.g., obesogenic environment) was tested.The automated program performed similarly to human coders. The proportion of articles with individual-level framing (27.7-31.0%) was higher than the proportion with neutral (18.0-22.1%) or environmental-level framing (16.0-16.4%) across all states and over the entire study period (P?

    View details for DOI 10.1002/oby.20955

    View details for Web of Science ID 000349040400009

    View details for PubMedID 25522013

  • Psychological Well-Being During the Great Recession: Changes in Mental Health Care Utilization in an Occupational Cohort AMERICAN JOURNAL OF PUBLIC HEALTH Modrek, S., Hamad, R., Cullen, M. R. 2015; 105 (2): 304-310


    Objectives. We examined the mental health effects of the Great Recession of 2008 to 2009 on workers who remained continuously employed and insured. Methods. We examined utilization trends for mental health services and medications during 2007 to 2012 among a panel of workers in the 25 largest plants, located in 15 states, of a US manufacturing firm. We used piecewise regression to compare trends from 2007 to 2010 in service and medication use before and after 2009, the year of mass layoffs at the firm and the peak of the recession. Our models accounted for changes in county-level unemployment rates and individual-level fixed effects. Results. Mental health inpatient and outpatient visits and the yearly supply of mental health-related medications increased among all workers after 2009. The magnitude of the increase in medication usage was higher for workers at plants with more layoffs. Conclusions. The negative effects of the recession on mental health extend to employed individuals, a group considered at lower risk of psychological distress.

    View details for DOI 10.2105/AJPH.2014.302219

    View details for Web of Science ID 000351922500035

    View details for PubMedID 25521885

  • Using "big data" to capture overall health status: properties and predictive value of a claims-based health risk score. PloS one Hamad, R., Modrek, S., Kubo, J., Goldstein, B. A., Cullen, M. R. 2015; 10 (5)


    Investigators across many fields often struggle with how best to capture an individual's overall health status, with options including both subjective and objective measures. With the increasing availability of "big data," researchers can now take advantage of novel metrics of health status. These predictive algorithms were initially developed to forecast and manage expenditures, yet they represent an underutilized tool that could contribute significantly to health research. In this paper, we describe the properties and possible applications of one such "health risk score," the DxCG Intelligence tool.We link claims and administrative datasets on a cohort of U.S. workers during the period 1996-2011 (N = 14,161). We examine the risk score's association with incident diagnoses of five disease conditions, and we link employee data with the National Death Index to characterize its relationship with mortality. We review prior studies documenting the risk score's association with other health and non-health outcomes, including healthcare utilization, early retirement, and occupational injury.We find that the risk score is associated with outcomes across a variety of health and non-health domains. These examples demonstrate the broad applicability of this tool in multiple fields of research and illustrate its utility as a measure of overall health status for epidemiologists and other health researchers.

    View details for DOI 10.1371/journal.pone.0126054

    View details for PubMedID 25951622

  • The EARN-Health Trial: protocol for a randomised controlled trial to identify health effects of a financial savings programme among low-income US adults. BMJ open Basu, S., Hamad, R., White, J. S., Modrek, S., Rehkopf, D. H., Cullen, M. R. 2015; 5 (10)


    A theory within the social epidemiology field is that financial stress related to having inadequate financial savings may contribute to psychological stress, poor mental health and poor health-related behaviours among low-income US adults. Our objective is to test whether an intervention that encourages financial savings among low-income US adults improves health behaviours and mental health.A parallel group two-arm controlled superiority trial will be performed in which 700 participants will be randomised to the intervention or a wait list. The intervention arm will be provided an online Individual Development Account (IDA) for 6?months, during which participants receive a $5 incentive (3.2, ?4.5) for every month they save $20 in their account (12.8, ?18), and an additional $5 if they save $20 for two consecutive months. Both groups will be provided links to standard online financial counselling materials. Online surveys in months 0 (prior to randomisation), 6 and 12 (6?months postintervention) will assess self-reported health behaviours and mental health among participants in both arms. The surveys items were tested previously in the US Centers for Disease Control and Prevention national health interviews and related health studies, including self-reported overall health, health-related quality of life, alcohol and tobacco use, depression symptoms, financial stress, optimism and locus of control, and spending and savings behaviours. Trial data will be analysed on an intent-to-treat basis.This protocol was approved by the Institutional Review Board of Stanford University (Protocol ID: 30641). The findings of the trial will be disseminated through peer-reviewed publication.Identifier NCT02185612; Pre-results.

    View details for DOI 10.1136/bmjopen-2015-009366

    View details for PubMedID 26443663

  • Microcredit participation and child health: results from a cross-sectional study in Peru JOURNAL OF EPIDEMIOLOGY AND COMMUNITY HEALTH Moseson, H., Hamad, R., FERNALD, L. 2014; 68 (12): 1175-1181
  • Microcredit participation and nutrition outcomes among women in Peru JOURNAL OF EPIDEMIOLOGY AND COMMUNITY HEALTH Hamad, R., Fernald, L. C. 2012; 66 (6)


    Microcredit services--the awarding of small loans to individuals who are too poor to take advantage of traditional financial services--are an increasingly popular scheme for poverty alleviation. Several studies have examined the ability of microcredit programmes to influence the financial standing of borrowers, but only a few studies have examined whether the added household income improves health and nutritional outcomes among household members. This study examined the hypothesis that longer participation in microcredit services would be associated with better nutritional status in women.Cross-sectional data were obtained in February 2007 from 1593 female clients of a microcredit organisation in Peru. The primary predictor variable was length of time as a microcredit client measured in number of completed loan cycles (range 0 to 5.5 years, average loan size US$350). The outcome variables were age-adjusted body mass index (BMI), haemoglobin levels (g/dl) and food insecurity measured using the US household food security survey module. Extensive data on demographic and socioeconomic status were also collected.Longer microcredit participation was associated with higher BMI (?=0.05, p=0.06), higher haemoglobin levels (?=0.07, p<0.01) and lower food insecurity (?=-0.13, p<0.01). With the inclusion of demographic and socioeconomic variables, the associations with higher haemoglobin (?=0.03, p=0.04) and lower food insecurity (?=-0.08, p<0.01) were sustained.This study supports the notion that microcredit participation has positive effects on the nutritional status of female clients. Further research should explore more definitive causal pathways through which these effects may occur and should examine the effects on other household members.

    View details for DOI 10.1136/jech.2010.108399

    View details for Web of Science ID 000303608800001

    View details for PubMedID 21051776

  • Health education for microcredit clients in Peru: a randomized controlled trial. BMC PUBLIC HEALTH Hamad, R., Fernald, L. C., Karlan, D. S. 2011; 11 (1): 51
  • Small individual loans and mental health: a randomized controlled trial among South African adults BMC PUBLIC HEALTH Fernald, L. C., Hamad, R., Karlan, D., Ozer, E. J., Zinman, J. 2008; 8


    In the developing world, access to small, individual loans has been variously hailed as a poverty-alleviation tool - in the context of "microcredit" - but has also been criticized as "usury" and harmful to vulnerable borrowers. Prior studies have assessed effects of access to credit on traditional economic outcomes for poor borrowers, but effects on mental health have been largely ignored.Applicants who had previously been rejected (n = 257) for a loan (200% annual percentage rate - APR) from a lender in South Africa were randomly assigned to a "second-look" that encouraged loan officers to approve their applications. This randomized encouragement resulted in 53% of applicants receiving a loan they otherwise would not have received. All subjects were assessed 6-12 months later with questions about demographics, socio-economic status, and two indicators of mental health: the Center for Epidemiologic Studies - Depression Scale (CES-D) and Cohen's Perceived Stress scale. Intent-to-treat analyses were calculated using multinomial probit regressions.Randomization into receiving a "second look" for access to credit increased perceived stress in the combined sample of women and men; the findings were stronger among men. Credit access was associated with reduced depressive symptoms in men, but not women.Our findings suggest that a mechanism used to reduce the economic stress of extremely poor individuals can have mixed effects on their experiences of psychological stress and depressive symptomatology. Our data support the notion that mental health should be included as a measure of success (or failure) when examining potential tools for poverty alleviation. Further longitudinal research is needed in South Africa and other settings to understand how borrowing at high interest rates affects gender roles and daily life activities. CCT: ISRCTN 10734925.

    View details for DOI 10.1186/1471-2458-8-409

    View details for Web of Science ID 000264286900001

    View details for PubMedID 19087316

  • Social and economic correlates of depressive symptoms and perceived stress in South African adults JOURNAL OF EPIDEMIOLOGY AND COMMUNITY HEALTH Hamad, R., Fernald, L. C., Karlan, D. S., Zinman, J. 2008; 62 (6): 538-544


    Adults in South Africa demonstrate rates of mental illness at or above levels elsewhere in the developing world. Yet there is a research gap regarding the social context surrounding mental health in this region. The objective of this analysis was to characterize the prevalence and correlates of depressive symptoms and perceived stress among a heterogeneous South African population.Low-income adults (n = 257) in Capetown, Port Elizabeth and Durban were interviewed regarding demographics, income, subjective social status, life events and decision-making. The Center for Epidemiologic Studies Depression Scale (CES-D) and Cohen's Perceived Stress Scale (PSS) were used.CES-D scores were 18.8 (SD 11.7), with 50.4% of men and 64.5% of women exceeding the cut-off at which professional care is recommended (p = 0.03). PSS scores were 18.6 (SD 6.7), with a mean of 17.5 among men and 19.6 among women (p = 0.02). In multivariate regressions, increased CES-D scores were associated with more household members (p<0.1), lower educational attainment (p = 0.07), less income stability (p<0.07), lower subjective social status (p<0.01) and independent decision-making (p = 0.04). Increased PSS scores were associated with female gender (p<0.05), multiracial race (p<0.02), more household members (p<0.1), lower subjective social status (p<0.02) and recent birth or catastrophe (p<0.01).Depressive symptoms and perceived stress are public health concerns in this sample, with more symptoms among those with fewer resources. The prevention of mental illness is critical, especially in vulnerable populations.

    View details for DOI 10.1136/jech.2007.066191

    View details for Web of Science ID 000255805200012

    View details for PubMedID 18477753

Footer Links:

Stanford Medicine Resources: