Does psychological distress contribute to racial and socioeconomic disparities in mortality?

Do Locus of Control, Self-esteem, Hope and Shame Mediate the Relationship Between Financial Hardship and Mental Health?

In a longitudinal study of 104 participants, the psychological factors of economic locus of control, self-esteem, hope and shame were explored for their impact on the relationship between financial hardship and mental health. Participants completed measures of financial hardship, the psychological factors and measures of mental health three times at three-monthly intervals. A hierarchical regression analyses indicated that subjective financial hardship, hope and shame significantly predicted mental health outcomes. Mediation analyses demonstrated that hope mediated the relationship between subjective financial hardship and depression, stress and wellbeing; that shame mediated the relationship between subjective financial hardship and anxiety; and that neither shame nor hope mediated the relationship between subjective financial hardship and suicide ideation.

The Role of Hopelessness in the Health of Low-Class Rural Chinese Residents

It is well known that health inequality has been happening between rural and urban Chinese populations, however, the health differences among rural Chinese residents remain unclear. This study aims to assess the physical and mental health of rural Chinese residents in different social classes, and then to examine the mediating role of hopelessness between social class and health-related quality of life (HRQOL). A stratified multi-stage sampling was used to recruit 2003 rural residents responding to the 12-item Short Form Health Survey (SF-12). The results showed that lower-class rural Chinese residents reported lower physical and mental health as well as a higher level of hopelessness. Furthermore, hopelessness could fully mediate the association between social class and physical and mental health. These findings will generate significant implications for identifying those at particular risk for lower quality of life and designing social work intervention programs in rural China's context.

Prime Time Sister Circles(®)II: Evaluating a Culturally Relevant Intervention to Decrease Psychological and Physical Risk Factors for Chronic Disease in Mid-Life African American Women

PURPOSE

This article presents the results of two evaluation studies of the Prime Time Sister Circles(®) (PTSC). The PTSC is a gender, cultural, and age specific, curriculum-based, low-cost, short-term, replicable support group approach aimed at reducing key modifiable health risk factors for chronic illnesses in midlife African American women.

METHODS

Study 1 includes an evaluation of 31 PTSCs (N=656 women) documenting changes in psychological and attitudinal outcomes (health satisfaction, health locus of control), behavioral outcomes (healthy eating patterns, physical activity, stress management), and clinical outcomes (weight, BMI, blood pressure, non-fasting blood sugar). Study 2 includes evaluation of a subset of the PTSC sites (N=211 women) with comparison (N=55 women) data from those same locations.

RESULTS

Study 1 showed significant changes (p<.0001) in the PTSC women's reports of (lower) stress, (higher) health locus of control, (increased) health satisfaction, (increased) physical activity, and (healthier) eating patterns. The PTSC women demonstrated a significant weight reduction at posttest (p <.0001) and had slightly better clinical outcomes in BMI, hypertension, and non-fasting blood sugar. Results document the sustainability of selected changes over a six-month period. Findings from the Study 2 strengthen the effectiveness claims of the PTSC intervention with significant changes for the PTSC women on selected outcomes and little changes for the comparison women.

CONCLUSIONS

Results reaffirm findings regarding the effectiveness of the PTSC, as originally reported in Gaston, Porter, and Thomas (2007) and extends the credibility of findings by examining participants' clinical outcomes in addition to self-reports.

Psychosocial and socioeconomic determinants of cardiovascular mortality in Eastern Europe: A multicentre prospective cohort study

BACKGROUND

Eastern European countries have some of the highest rates of cardiovascular disease (CVD) mortality, much of which cannot be adequately accounted for by conventional CVD risk factors. Psychosocial and socioeconomic factors may affect risk of CVD, but relatively few studies on this issue have been undertaken in Eastern Europe. We investigated whether various psychosocial factors are associated with CVD mortality independently from each other and whether they can help explain differences in CVD mortality between Eastern European populations.

METHODS

Participants were from the Health, Alcohol and Psychological factors in Eastern Europe (HAPIEE) cohort study in Russia, Poland and the Czech Republic, including a total of 20,867 men and women aged 43-74 years and free of CVD at baseline examination during 2002-2005. Participants were followed-up for CVD mortality after linkage to national mortality registries for a median of 7.2 years.

RESULTS

During the follow-up, 556 participants died from CVD. After mutual adjustment, six psychosocial and socioeconomic factors were associated with increased risk of CVD death: unemployment, low material amenities, depression, being single, infrequent contacts with friends or relatives. The hazard ratios [HRs] for these six factors ranged between 1.26 [95% confidence interval 1.14-1.40] and 1.81 [95% confidence interval 1.24-2.64], fully adjusted for each other, and conventional cardiovascular risk factors. Population-attributable fractions ranged from 8% [4%-13%] to 22% [11%-31%] for each factor, when measured on average across the three cohorts. However, the prevalence of psychosocial and socioeconomic risk factors and their HRs were similar between the three countries. Altogether, these factors could not explain why participants from Russia had higher CVD mortality when compared to participants from Poland/Czech Republic. Limitations of this study include measurement error that could lead to residual confounding; and the possibilities for reverse causation and/or unmeasured confounding from observational studies to lead to associations that are not causal in nature.

CONCLUSIONS

Six psychosocial and socioeconomic factors were associated with cardiovascular mortality, independent of each other. Differences in mortality between cohorts from Russia versus Poland or Check Republic remained unexplained.

Do racial patterns in psychological distress shed light on the Black-White depression paradox? A systematic review

PURPOSE

Major epidemiologic studies in the US reveal a consistent "paradox" by which psychiatric outcomes such as major depressive disorder (MDD) are less prevalent among Blacks relative to Whites, despite greater exposure to social and economic stressors and worse physical health outcomes. A second paradox, which has received less attention and has never been systematically documented, is the discrepancy between these patterns and Black-White comparisons in psychological distress, which reveal consistently higher levels among Blacks. By systematically documenting the latter paradox, this paper seeks to inform efforts to explain the first paradox.

METHODS

We conduct a systematic review of the literature estimating the prevalence of MDD and levels of psychological distress in Blacks and Whites in the US.

RESULTS

The literature review yielded 34 articles reporting 54 relevant outcomes overall. Blacks have a lower prevalence of MDD in 8 of the 9 comparisons observed. In contrast, Blacks have higher levels of psychological distress (in terms of "high distress" and mean scores) than Whites in 42 of the 45 comparisons observed. Tests of statistical significance, where available, confirm this discrepant pattern.

CONCLUSIONS

A systematic review of the epidemiologic evidence supports the existence of a "double paradox" by which Blacks' lower prevalence of MDD relative to Whites' is inconsistent with both the expectations of social stress theory and with the empirical evidence regarding psychological distress. Efforts to resolve the Black-White depression paradox should account for the discordant distress results, which seem to favor artifactual explanations.

Gender and the structure of self-rated health across the adult life span

Despite the widespread use of self-rated health (SRH) in population health studies, the meaning of this holistic health judgment remains an open question. Gender differences in health, an issue of utmost importance in population research and policy, are often measured with SRH; the comparisons could be biased if men and women differ in how they form their health judgment. The aim of this study is to examine whether men and women differ in how health inputs predict their health rating across the adult life span. We use the 2002-2015 National Health Interview Survey data from US-born respondents aged 25-84. Ordered logistic models of SRH as a function of 24 health measures including medical conditions and symptoms, mental health, functioning, health care utilization, and health behaviors, all interacted with gender, test how the measures influence health ratings and the extent to which these influences differ by gender. Using a Bayesian approach, we then compare how closely a select health measure (K6 score) corresponds to SRH levels among men and women. We find little systematic gender difference in the structure of SRH: men and women use wide-ranging health-related frames of reference in a similar way when making health judgments, with some exceptions: mid-life and older men weigh physical functioning deficits and negative health behaviors more heavily than women. Women report worse SRH than men on average but this only holds through mid-adulthood and is reversed at older ages; moreover, the female disadvantage disappears when differences in socio-economic and health covariates are considered. Our findings suggest that the meaning of SRH is similar for women and men. Both groups use a broad range of health-related information in forming their health judgment. This conclusion strengthens the validity of SRH in measuring gender differences in health.

Do Psychological Characteristics Explain Socioeconomic Stratification of Self-rated Health?

This study evaluated whether negative emotions explain socioeconomic status (SES) stratification of self-rated health (SRH) and whether this putative relation is independent of established SRH determinants. Mood disorders, trait negative affect and health status indices were assessed in a representative cross-sectional survey of 3032 adults in the National Survey of Midlife Development in the United States (MIDUS). Adjustment for health behaviors and health status appreciably reduced SES influence on SRH, but adjustment for negative emotions did not. However, both psychological resources (e.g. social support, extraversion) and negative emotions independently predicted SRH. Detection of SRH determinants was sensitive to binary versus ordinal SRH definitions.

The Role of Psychosocial Processes in Explaining the Gradient Between Socioeconomic Status and Health

The gradient between socioeconomic status (SES) and health is well established: Many measures of health show that health increases as SES increases. However, the mechanisms underlying this association are not well understood. Behavioral, cognitive, and affective tendencies that develop in response to the greater psychosocial stress encountered in low-SES environments may partially mediate the impact of SES on health. Although these tendencies might be helpful for coping in the short term, over time they may contribute to the development of allostatic load, which increases vulnerability to disease. Debate remains regarding the direction of causation between SES and health, the impact of income inequality, the interaction of SES with race-ethnicity and gender, and the effects of SES over the life course.

Trends in life satisfaction in European and North-American adolescents from 2002 to 2010 in over 30 countries

BACKGROUND

Life satisfaction (LS) is an indicator which is widely used for assessing the perception of a child's feeling about his life.

METHODS

LS is assessed in Health Behaviour in School-aged Children via the Cantril ladder with 10 steps indicating the worst and best possible life. This range of values (0-10) was dichotomized into 'low' (0-5) vs. 'high' (6-10). Countries, age groups and genders were compared based on the odds ratio (OR) of declaring a higher LS in 2010 with respect to 2002.

RESULTS

Analyzing the difference between 2002 and 2010, six countries from Western Europe show decreasing LS: Austria, Canada, Switzerland, Denmark, Finland and Greenland. In contrast, a group of Eastern European Countries, that is, Estonia, Croatia, Lithuania, Latvia, Russia and Ukraine, show a significant increase in LS. Data on gender and age differences confirm the lower rating of LS in girls and a decreasing rating with age.

CONCLUSION

The LS scale appears to be a tool capable of discriminating the level of wellbeing of adolescent population among countries.

High Blood Pressure and Related Factors Among Individuals at High Risk for HIV/Sexually Transmitted Infections

Data from a social network-based human immunodeficiency virus (HIV)/sexually transmitted infection (STI) prevention study with a total of 330 men and women at high risk for HIV/STIs were used to examine the relationships between substance use, depressive symptoms, general health, cardiovascular disease risk factors, sociodemographic characteristics, and systolic/diastolic blood pressure (SBP/DBP). Approximately 60% of the participants had prehypertension to stage 2 hypertension. In the base model, older patients (P<.0001), men (P=.003), and patients with poorer self-reported health (P=.029) were significantly associated with high SBP, whereas older age (P<.001) and higher body mass index (P<.001) were significantly associated with higher DBP. After adjusting for the base model, high frequency of alcohol drinking and high frequency of binge drinking remained significant for high SBP and DBP. These data suggest that future cardiovascular disease programs should target moderate alcohol consumption to improve blood pressure among individuals at high risk for HIV/STIs.

Positivity and indicators of health among African Americans with diabetes

OBJECTIVES

To examine the utility of the positivity ratio to distinguish differences in psychological and physiological health in African Americans with type 2 diabetes.

METHODS

Study participants (N = 93) were recruited through radio and church announcements and grouped by their positivity ratio.

RESULTS

Multivariate analyses showed flourishing individuals had the highest resilience and lowest depressive symptoms and HbA1c (A1C), whereas depressed individuals recorded the lowest resilience and highest depressive symptoms and A1C. Small to large effect sizes were reported.

CONCLUSIONS

Further support for the utility and generalizability of the positivity ratio was provided. Cultivating positive emotions may improve the health of individuals with type 2 diabetes.

Consistent associations between measures of psychological stress and CMV antibody levels in a large occupational sample

Cytomegalovirus (CMV) is a herpes virus that has been implicated in biological aging and impaired health. Evidence, largely accrued from small-scale studies involving select populations, suggests that stress may promote non-clinical reactivation of this virus. However, absent is evidence from larger studies, which allow better statistical adjustment for confounding and mediating factors, in more representative samples. The present study involved a large occupational cohort (N=887, mean age=44, 88% male). Questionnaires assessed psychological (i.e., depression, anxiety, vital exhaustion, SF-12 mental health), demographic, socioeconomic (SES), and lifestyle variables. Plasma samples were analyzed for both the presence and level of CMV-specific IgG antibodies (CMV-IgG), used as markers for infection status and viral reactivation, respectively. Also assessed were potential biological mediators of stress-induced reactivation, such as inflammation (C-reactive protein) and HPA function (awakening and diurnal cortisol). Predictors of CMV infection and CMV-IgG among the infected individuals were analyzed using logistic and linear regression analyses, respectively. Confirming prior reports, lower SES (education and job status) was positively associated with infection status. Among those infected (N=329), higher CMV-IgG were associated with increased anxiety (β=.14, p<.05), depression (β=.11, p=.06), vital exhaustion (β=.14, p<.05), and decreased SF-12 mental health (β=-.14, p<.05), adjusting for a range of potential confounders. Exploratory analyses showed that these associations were generally stronger in low SES individuals. We found no evidence that elevated inflammation or HPA-function mediated any of the associations. In the largest study to date, we established associations between CMV-IgG levels and multiple indicators of psychological stress. These results demonstrate the robustness of prior findings, and extend these to a general working population. We propose that stress-induced CMV replication warrants further research as a psychobiological mechanism linking stress, aging and health.

Is the association of subjective SES and self-rated health confounded by negative mood? An experimental approach

OBJECTIVE

Lower subjective socioeconomic status (SSS) consistently shows associations with poorer health with the strongest relationships emerging with global self-rated health. Though often interpreted as reflecting the impact of low SSS on health, the association could also arise from confounding SSS with negative affect. In this research we sought to determine if negative affect confounds, or alternatively, is on the causal pathway linking SSS to self-rated health.

METHOD

Three-hundred adult participants--recruited from throughout the United States--were randomized to experience sadness, shame, or a neutral mood induction in which they wrote about and visualized a particularly emotionally evocative event. Participants subsequently completed measures of SSS, self-rated health, depression, and negative mood.

RESULTS

Consistent with predictions, neither SSS scores nor the association of SSS with self-rated health, depression, and chronic negative affect differed by mood induction condition, controlling for demographic factors that covary with SSS (e.g., age, gender, education, income). Moreover, chronic negative affect partially explained the relationship between SSS and self-rated health, independent of manipulated mood.

CONCLUSIONS

These findings support the utility of the measurement of SSS, and provide evidence suggesting that chronic negative affect is a likely mediator of the SSS association with global health rather than a confounder.

Estimated deaths attributable to social factors in the United States

OBJECTIVES

We estimated the number of deaths attributable to social factors in the United States.

METHODS

We conducted a MEDLINE search for all English-language articles published between 1980 and 2007 with estimates of the relation between social factors and adult all-cause mortality. We calculated summary relative risk estimates of mortality, and we obtained and used prevalence estimates for each social factor to calculate the population-attributable fraction for each factor. We then calculated the number of deaths attributable to each social factor in the United States in 2000.

RESULTS

Approximately 245,000 deaths in the United States in 2000 were attributable to low education, 176,000 to racial segregation, 162,000 to low social support, 133,000 to individual-level poverty, 119,000 to income inequality, and 39,000 to area-level poverty.

CONCLUSIONS

The estimated number of deaths attributable to social factors in the United States is comparable to the number attributed to pathophysiological and behavioral causes. These findings argue for a broader public health conceptualization of the causes of mortality and an expansive policy approach that considers how social factors can be addressed to improve the health of populations.

Primary language, income and the intensification of anti-glycemic medications in managed care: the (TRIAD) study

BACKGROUND

Patients who speak Spanish and/or have low socioeconomic status are at greater risk of suboptimal glycemic control. Inadequate intensification of anti-glycemic medications may partially explain this disparity.

OBJECTIVE

To examine the associations between primary language, income, and medication intensification.

DESIGN

Cohort study with 18-month follow-up.

PARTICIPANTS

One thousand nine hundred and thirty-nine patients with Type 2 diabetes who were not using insulin enrolled in the Translating Research into Action for Diabetes Study (TRIAD), a study of diabetes care in managed care.

MEASUREMENTS

Using administrative pharmacy data, we compared the odds of medication intensification for patients with baseline A1c ≥ 8%, by primary language and annual income. Covariates included age, sex, race/ethnicity, education, Charlson score, diabetes duration, baseline A1c, type of diabetes treatment, and health plan.

RESULTS

Overall, 42.4% of patients were taking intensified regimens at the time of follow-up. We found no difference in the odds of intensification for English speakers versus Spanish speakers. However, compared to patients with incomes <$15,000, patients with incomes of $15,000-$39,999 (OR 1.43, 1.07-1.92), $40,000-$74,999 (OR 1.62, 1.16-2.26) or >$75,000 (OR 2.22, 1.53-3.24) had increased odds of intensification. This latter pattern did not differ statistically by race.

CONCLUSIONS

Low-income patients were less likely to receive medication intensification compared to higher-income patients, but primary language (Spanish vs. English) was not associated with differences in intensification in a managed care setting. Future studies are needed to explain the reduced rate of intensification among low income patients in managed care.

The contribution of psychological distress to socio-economic differences in cause-specific mortality: a population-based follow-up of 28 years

BACKGROUND

Psychological factors associated with low social status have been proposed as one possible explanation for the socio-economic gradient in health. The aim of this study is to explore whether different indicators of psychological distress contribute to socio-economic differences in cause-specific mortality.

METHODS

The data source is a nationally representative, repeated cross-sectional survey, "Health Behaviour and Health among the Finnish Adult Population" (AVTK). The survey results were linked with socio-economic register data from Statistics Finland (from the years 1979-2002) and mortality follow-up data up to 2006 from the Finnish National Cause of Death Register. The data included 32,451 men and 35,420 women (response rate 73.5%). Self-reported measures of depression, insomnia and stress were used as indicators of psychological distress. Socio-economic factors included education, employment status and household income. Mortality data consisted of unnatural causes of death (suicide, accidents and violence, and alcohol-related mortality) and coronary heart disease (CHD) mortality. Adjusted hazard ratios were calculated using the Cox regression model.

RESULTS

In unnatural mortality, psychological distress accounted for some of the employment status (11-31%) and income level (4-16%) differences among both men and women, and for the differences related to the educational level (5-12%) among men; the educational level was associated statistically significantly with unnatural mortality only among men. Psychological distress had minor or no contribution to socio-economic differences in CHD mortality.

CONCLUSIONS

Psychological distress partly accounted for socio-economic disparities in unnatural mortality. Further studies are needed to explore the role and mechanisms of psychological distress associated with socio-economic differences in cause-specific mortality.

The prevalence of hopelessness among adults: disability and other related factors

BACKGROUND

Hopelessness has become an important issue in the fields of health and social care.

OBJECTIVE

This study aims to determine the prevalence of hopelessness and its association with the current health condition, disability, and other socio-demographic characteristics.

METHOD

The cross-sectional study sampled a population of 501 adults in Bolu, Turkey. Questionnaires included the Household Questionnaire, the Health Condition Questionnaire, Beck Hopelessness Scale, and Brief Disability Questionnaire. Data were collected through face-to-face home interviews between September 29 and October 11, 2003.

RESULTS

The prevalence of hopelessness was 30.9%. It was higher among the literate (60.0%) (p < 0.05), males (35.0%) (p > 0.05), and agricultural workers and peasants (50.0%, 41.9%) (p < 0.05). Almost half of the participants were disabled, and 44.6% of the subjects with disabilities were hopeless (p < 0.05). Being without hope was statistically significant with gender, social class, perceived health, and disability (p < 0.05). The risk of hopelessness increased in subjects with perceived bad health, lowered social class, and disability, compared with the reference groups.

CONCLUSIONS

In this study, hopelessness prevalence was high and it was also associated with the current state of health, perceived health, disability, and some socio-demographic variables. It will be important to increase the number of studies related to hopelessness and associated factors for improved mental health services planning at population level.

Association between depression and intima-media thickness of carotid bulb in asymptomatic young adults

OBJECTIVE

Although there is growing evidence that symptoms of depression influence the development of coronary artery disease, information on the underlying subclinical atherosclerotic process is scant in young adults. The study examined the association between symptoms of depression and subclinical atherosclerosis, determined by carotid intima-media thickness in asymptomatic young individuals.

METHODS

A cross-sectional study was performed in Bogalusa, Louisiana, a semi-rural biracial (black-white) community. A sample of 996 individuals aged 24 to 44 years (71% were white and 43% were male) enrolled in the Bogalusa Heart Study. The variables included symptoms of depression measured by the Center for Epidemiological Studies-Depression Scale; intima-media thickness of different segments of carotid artery by B-mode ultrasonography; measures of adiposity and glucose homeostasis, lipoproteins, and blood pressure; and cigarette smoking status.

RESULTS

Both the adjusted and the unadjusted associations between depression score and carotid bulb intima-media thickness were significant, whereas similar associations with internal carotid and common carotid thickness were nonsignificant. In the multivariable regression model, after adjusting for all covariates, a positive effect of depression scores (Center for Epidemiological Studies-Depression score) and a negative effect of interaction between depression score ratio of total cholesterol (TC)/high-density lipoprotein (HDL) were significant. In a subgroup analysis (among individuals with a ratio of TC/HDL < or = 5) a positive effect of depression on carotid bulb intima-media thickness was significant, whereas the interaction between depression and ratio of TC/HDL was nonsignificant. In subsequent analysis, if individuals with a higher ratio of TC/HDL were included, both depression and negative interaction term were significant.

CONCLUSION

The observations show the detrimental effect of depression on subclinical vascular changes in asymptomatic young individuals. The findings underscore the need for considering depression in risk factor profiling. Further study is recommended to investigate the basis of a lower carotid bulb intima-media thickness among subjects with a high depression score and a high ratio of TC/HDL.

Maternal care and birth outcomes among ethnic minority women in Finland

Background

Care during pregnancy and labour is of great importance in every culture. Studies show that people of migrant origin have barriers to obtaining accessible and good quality care compared to people in the host society. The aim of this study is to compare the access to and use of maternity services, and their outcomes among ethnic minority women having a singleton birth in Finland.

Methods

The study is based on data from the Finnish Medical Birth Register in 1999–2001 linked with the information of Statistics Finland on woman's country of birth, citizenship and mother tongue. Our study data included 6,532 women of foreign origin (3.9% of all singletons) giving singleton birth in Finland during 1999–2001 (compared to 158,469 Finnish origin singletons).

Results

Most women have migrated during the last fifteen years, mainly from Russia, Baltic countries, Somalia and East Europe. Migrant origin women participated substantially in prenatal care. Interventions performed or needed during pregnancy and childbirth varied between ethnic groups. Women of African and Somali origin had most health problems resulted in the highest perinatal mortality rates. Women from East Europe, the Middle East, North Africa and Somalia had a significant risk of low birth weight and small for gestational age newborns. Most premature newborns were found among women from the Middle East, North Africa and South Asia. Primiparous women from Africa, Somalia and Latin America and Caribbean had most caesarean sections while newborns of Latin American origin had more interventions after birth.

Conclusion

Despite good general coverage of maternal care among migrant origin women, there were clear variations in the type of treatment given to them or needed by them. African origin women had the most health problems during pregnancy and childbirth and the worst perinatal outcomes indicating the urgent need of targeted preventive and special care. These study results do not confirm either healthy migrant effect or epidemiological paradox according to which migrant origin women have considerable good birth outcomes.

Effects of perceived discrimination on mental health and mental health services utilization among gay, lesbian, bisexual and transgender persons

OBJECTIVES

Previous research has found that lesbian, gay, bisexual and transgender (LGBT) individuals are at risk for a variety of mental health disorders. We examined the extent to which a recent experience of a major discriminatory event may contribute to poor mental health among LGBT persons.

METHODS

Data were derived from a cross-sectional strata-cluster survey of adults in Hennepin County, Minnesota, who identified as LGBT (n=472) or heterosexual (n=7,412).

RESULTS

Compared to heterosexuals, LGBT individuals had poorer mental health (higher levels of psychological distress, greater likelihood of having a diagnosis of depression or anxiety, greater perceived mental health needs, and greater use of mental health services), more substance use (higher levels of binge drinking, greater likelihood of being a smoker and greater number of cigarettes smoked per day), and were more likely to report unmet mental healthcare needs. LGBT individuals were also more likely to report having experienced a major incident of discrimination over the past year than heterosexual individuals. Although perceived discrimination was associated with almost all of the indicators of mental health and utilization of mental health care that we examined, adjusting for discrimination did not significantly reduce mental health disparities between heterosexual and LGBT persons.

CONCLUSION

LGBT individuals experienced more major discrimination and reported worse mental health than heterosexuals, but discrimination did not account for this disparity. Future research should explore additional forms of discrimination and additional stressors associated with minority sexual orientation that may account for these disparities.

So much to do, so little time: care for the socially disadvantaged and the 15-minute visit

There is so much to do in primary care, and so little time to do it. During 15-minute visits, physicians are expected to form partnerships with patients and their families, address complex acute and chronic biomedical and psychosocial problems, provide preventive care, coordinate care with specialists, and ensure informed decision making that respects patients' needs and preferences. This is a challenging task during straightforward visits, and it is nearly impossible when caring for socially disadvantaged patients with complex biomedical and psychosocial problems and multiple barriers to care. Consider the following scenario.

Health disparities and health-seeking behavior among Latino men: a review of the literature

Many studies examining Latino health-seeking behavior have focused on comparing Latinos with other ethnic groups, primarily with Whites and African Americans. However, without the benefit of intragroup or intracultural comparisons, such studies fail to identify the subtle variation in health-seeking strategies and the range of needs within the Latino ethnic group, and thus are compromised in their capacity to guide and improve practice and policy. This article reviews the literature regarding health-seeking behavior and Latino men. Important factors identified include gender, occupation, and responsiveness of the health care system along with characteristics of the individual.

Psychological factors as mechanisms for socioeconomic disparities in health: a critical appraisal of four common factors

Social epidemiology has increasingly looked to psychological factors as both risk factors for physical health and mechanisms behind disparities. Yet, there has been little resolution to the question of whether psychological factors explain disparities, and skepticism has begun to mount about whether psychological factors are causally linked to health. Furthermore, some have questioned the nature of the relationship: most research suggests that psychological factors mediate the relationship between socioeconomic status and health, but recent research suggests that they moderate the relationship. The present paper attempts to provide a more comprehensive appraisal of the current debate. It uses four popular psychological factors (i.e., self-esteem, mastery, neuroticism, and depressive symptoms), three health outcomes, and a nationally representative, three-panel longitudinal survey. The results illustrate the promise and limitations of psychological mechanisms. In the cross-section, the results provide evidence for substantial moderating effects, but these effects disappear entirely when estimated prospectively. The results also provide some evidence for mediating effects, but these effects are very weak and the prospective effects of psychological factors diminish over time and with controls for baseline health. Implications for theories of socioeconomic status and health are discussed and a more social psychologically sophisticated approach is encouraged.

The riskscape and the color line: examining the role of segregation in environmental health disparities

Environmental health researchers, sociologists, policy-makers, and activists concerned about environmental justice argue that communities of color who are segregated in neighborhoods with high levels of poverty and material deprivation are also disproportionately exposed to physical environments that adversely affect their health and well-being. Examining these issues through the lens of racial residential segregation can offer new insights into the junctures of the political economy of social inequality with discrimination, environmental degradation, and health. More importantly, this line of inquiry may highlight whether observed pollution--health outcome relationships are modified by segregation and whether segregation patterns impact diverse communities differently. This paper examines theoretical and methodological questions related to racial residential segregation and environmental health disparities. We begin with an overview of race-based segregation in the United States and propose a framework for understanding its implications for environmental health disparities. We then discuss applications of segregation measures for assessing disparities in ambient air pollution burdens across racial groups and go on to discuss the applicability of these methods for other environmental exposures and health outcomes. We conclude with a discussion of the research and policy implications of understanding how racial residential segregation impacts environmental health disparities.

Mastery, perceived stress and health-related behaviour in northeast Arnhem Land: a cross-sectional study

BACKGROUND

Indigenous peoples in Australia are disadvantaged on all markers of health and social status across the life course. Psychosocial factors are implicated in the aetiology of chronic diseases and in pathways underpinning social health disparities. Minimal research has investigated psychosocial factors and health in Indigenous peoples. This study evaluated associations between mastery, perceived stress, and health-related behaviour for a remote Indigenous population in Australia.

METHODS

Complete data on mastery (the degree to which individuals feel in control of their lives), perceived stress, physical activity, and fruit and vegetable consumption were obtained for 177 participants in a community-based chronic disease risk factor survey. Psychosocial questionnaires were completed as an option during community screening (response rate = 61.9%). Extensive consultation facilitated the cross-cultural adaptation of measures.

RESULTS

Mastery was inversely correlated with perceived stress measures (p < 0.009): recent stress, r = -0.47; chronic stress, r = -0.41; and youth stress, r = -0.30. Relationships between mastery and behaviour varied according to age group (<25 or > or =25 years) for physical activity (p = 0.001) and vegetable consumption (p = 0.005). Individuals aged > or =25 years engaging in < or =2 bouts of physical activity/week had lower mastery than individuals engaging in > or =3 bouts/week, with means (95% CI) of 14.8 (13.7-15.8) and 17.1 (15.3-19.0), respectively (p = 0.026). Individuals aged > or =25 years eating vegetables < or =3 times/week had lower mastery than those eating vegetables > or =4 times/week (p = 0.009) [means 14.7 (13.8-15.5) and 17.3 (15.5-19.1), respectively]. Individuals <25 years engaging in < or =2 bouts of physical activity/week had greater mastery than individuals engaging in > or =3 bouts/week (p = 0.022) [means 17.2 (15.2-19.2) and 13.8 (11.9-15.7), respectively]. For men > or =25 years and women > or =15 years, mastery was inversely related to age (p < 0.002). Men <25 years had less mastery than women of equivalent age (p = 0.001) [means 13.4 (12.1-14.7) and 17.5 (15.3-19.8), respectively].

CONCLUSION

Consistent with previous research, this study provides additional support for a link between mastery and health-related behaviour, and extends evidence of this association to a remote Indigenous population. Mastery's association with perceived stress, its age-specific association with health behaviour, and findings of low mastery amongst young men, highlights a need for life course research accounting for contextual factors affecting Indigenous peoples.

Relationship between symptoms of depression, functional health status, and chronic disease among a residential sample of African Americans

Depression and psychological distress often go unrecognized and untreated in primary care settings. The association between depression, socioeconomic status, and chronic disease underscore the importance of incorporating mental health education and screening into community-based health initiatives. This is particularly critical for African Americans who bear a disproportionate burden of poverty and chronic disease. This descriptive study assessed associations between symptoms of depression, socioeconomic status, healthcare utilization, physical and mental health functioning, and reactions to race among a sample of low-income African Americans. Consistent with the findings of previous research, respondents with symptoms of depression reported lower levels of physical and mental health functioning, and perceived that they had been treated worse by others at work, and had worse healthcare experiences than those of other races. Community-based programs for reducing disparities in physical illness may need to address the burden of undiagnosed and untreated depression in order to become optimally effective.

Supplemental private health insurance and depressive symptoms in older married couples

Stress process theory is applied to examine lack of supplemental private health insurance as a risk factor for depressive symptomatology among older married couples covered by Medicare. Dyadic data from 130 African-American couples and 1,429 White couples in the 1993 Asset and Health Dynamics Among the Oldest-Old Survey were analyzed using hierarchical generalized linear modeling. Lack of supplemental insurance is operationalized at the household level in terms of neither spouse covered, one spouse covered, or both spouses covered. Controlling for covariates at both individual and couple levels, supplemental insurance has significant impact on depression, but the pattern differs by race. White couples report the highest depression when neither spouse is covered by private health insurance; African-American couples report the highest depression when only one spouse is covered. Results suggest lack of supplemental private health insurance coverage is a stressor that significantly affects depressive symptoms.

Genetic effects on physical health: lower at higher income levels

Given the robust finding that people in higher income groups tend to experience better physical health, there is interest in identifying mechanisms underlying this gradient. Using a nationwide sample of 719 twin pairs from the National Survey of Midlife Development in the United States, we investigated the possibility that gene-environment interaction underlies the income-health gradient. We observed that genetic variance associated with 2 measures of physical health, number of chronic illnesses and body mass index, each declined significantly with increasing income. This interaction effect could not be removed by adjusting income for the presence of health insurance coverage and education, suggesting that the interaction is not simply a result of differences in levels of those characteristics with income.

Do depression and anxiety mediate the link between educational attainment and CHD?

OBJECTIVE

Depression and anxiety are frequently hypothesized yet rarely examined pathways linking low socioeconomic status (SES) to coronary heart disease (CHD). This study evaluates depression and anxiety as mediators of the association between educational attainment and incident CHD.

METHODS

Subjects (n = 6265, age 25-74) were participants in NHANES I and follow-up studies, a longitudinal, nationally representative study of the US population. Measures of educational attainment and depressive and anxious symptoms (General Well-Being Schedule) were derived from the baseline interview and incident CHD from hospital records and death certificates. Analyses included logistic regression and Cox proportional hazards models.

RESULTS

In fully adjusted models, less than high school (relative risk [RR] = 1.46; 95% confidence interval [CI], 1.15-1.86) and some college (RR = 1.40; 95% CI, 1.05-1.88) education were associated with increased CHD risk relative to a college education. High depressive (RR = 1.31; 95% CI, 1.06-1.61) or anxious (RR = 1.35; 95% CI, 1.13-1.62) symptoms were associated with significantly increased CHD risk relative to low symptoms. Low educational levels were associated with increased risk for high depressive (OR = 3.43; 95% CI, 2.34-5.03) and anxious (OR = 1.71; 95% CI, 1.32-2.22) symptoms. However, depressive and anxious symptoms accounted for little of the association between education and CHD.

CONCLUSION

Education and depressive and anxious symptoms are associated with each other and risk of incident CHD. Although depressive and anxious symptoms are highest among those with lowest levels of education, they do not appear to mediate the relation between educational attainment and incident CHD. Findings suggest the importance of interventions to reduce socioeconomic disadvantage and negative affect in preventing CHD.

The income-associated burden of disease in the United States

In this study, we estimate the total burden of disease associated with income in the US. We calculate the relationships between income and life expectancy, health-adjusted life expectancy, annual years of life lost (YLLs), and health adjusted life years (HALYs). We used the 2000 US Medical Expenditure Panel Survey to derive quality of life estimates by income and age, the 1990-1992 US National Health Interview Survey linked to National Death Index data through the end of 1995 to derive mortality risks by income and by age, and 2000 US mortality data from the National Center for Health Statistics to derive current mortality estimates for the US population by age-group. The bottom 80% of adult income earners' life expectancy is 4.3 years and 5.8 HALYs shorter relative to those in the top 20% of earnings. This translates into the loss of 11 million YLLs and 17.4 million HALYs each year. Compared with persons living above the poverty threshold, those living below the poverty threshold live an average of 3.2 million fewer HALYs per year-a difference of 8.5 HALYs per individual between age 18 and death. The income-associated burden of disease appears to be a leading cause of morbidity and mortality in the US.

Cancer-specific beliefs and survival: a population-based study of African-American and White breast cancer patients

OBJECTIVE

Beliefs about cancer and its treatment have been shown to influence cancer stage at diagnosis and, thus, prognosis. The association between these beliefs and survival is understudied, especially among racially/ethnically diverse populations. We investigated the relationship between cancer-specific beliefs and survival in a cohort of African-American and White women with newly diagnosed breast cancer followed for up to 15 years.

METHODS

We examined beliefs about cancer detection, treatment, and curability in a population-based cohort of 145 African-American and 177 White women diagnosed with breast cancer in Connecticut, US, between 1987 and 1989. Cox proportional-hazards models were adjusted for stage at diagnosis, other biomedical variables, socio-demographic and lifestyle factors.

RESULTS

In multivariate models, perceived cancer incurability was associated with a higher risk of death from any cause (hazards ratio (HR)=1.67, 95 confidence interval (CI)=1.11, 2.51). Further control for tumor characteristics, genetic alterations, access to care, and additional psychosocial factors did not alter these findings. Other cancer-specific beliefs examined here were not related to survival.

CONCLUSIONS

Perceived cancer incurability is independently associated with survival among breast cancer patients in fully adjusted models. The identification of the underlying mechanisms of this association has potential for translation into intervention strategies for cancer patients.

Race, Managed Care, And The Quality Of Substance Abuse Treatment

The adoption of managed behavioral health care by state Medicaid agencies has the potential to increase the quality of treatment for racial minorities by promoting access to substance abuse treatment and creating more appropriate utilization patterns. This paper examines three indicators of quality for white, Black, and Hispanic Medicaid clients who received substance abuse treatment in Massachusetts between 1992 and 1996. It evaluates whether a managed behavioral health care carve-out in FY1993 had a positive or negative effect on access, continuity of care, and 30-day re-admissions. Prior to managed care, access and continuity were worse for minorities than for whites. For all clients under managed care, access and continuity improved between 1992 and 1996. Access improved more for Hispanic clients relative to other racial groups. Continuity improved more for Black clients relative to other racial groups. Although seven-day and 30-day re-admissions also increased following managed care, the rate of increase was not significantly greater for minorities. Although managed care had a beneficial impact on the quality of treatment for minority clients, the percent of minority Medicaid-eligible clients who accessed treatment and the percent who achieved continuity of care remained lower than for whites in every year of the study. Managed care reduced, but did not overcome, racial disparities in behavioral health care.

Associations between early-adolescent substance use and subsequent young-adult substance use disorders and psychiatric disorders among a multiethnic male sample in South Florida

OBJECTIVES

We examined the associations among early-adolescent substance use, subsequent young-adult substance use disorders, and psychiatric disorders among a community sample of males.

METHODS

Early-adolescent data were collected in classroom surveys (1990-1993), and young-adult data were collected in face-to-face interviews (1998-2000).

RESULTS

We found strong associations between early-adolescent substance use and young-adult substance use disorders and psychiatric disorders. The magnitudes of these associations varied by racial/ethnic group and were strongest among African Americans and foreign-born Hispanics, who reported the lowest early-adolescent substance use.

CONCLUSIONS

Early-adolescent substance use is most strongly associated with a later pattern of dysfunction among the racial/ethnic groups that reported the lowest levels of early use. The implications of our findings in the context of primary and secondary prevention are discussed.

Should years of schooling be used to guide treatment of coronary risk factors?

PURPOSE

We wanted to compare the risk of death from coronary heart disease (CHD) for patients of low socioeconomic status, measured by educational level, with established risk factors.

METHODS

We undertook a prospective cohort study. Participants included a representative sample of 6,479 adults aged 25 to 74 years in the United States who were free of CHD at enrollment in the first National Health and Nutrition Examination Survey (NHANES I).

RESULTS

Baseline measures included years of education, age, sex, systolic blood pressure, diabetes, total cholesterol level, and smoking. Outcome was death within 10 years from CHD. The relative risk (RR) associated with less than 12 years of education compared with more than 12 years (RR 1.5; 95% confidence interval [CI], 1.2-1.8) was comparable to being male (RR 1.4; 95% CI, 1.2-1.6), smoking (RR 1.4; 95% CI, 1.1-1.6), having a total cholesterol level of greater than 280 mg/dL (RR 1.6; 95% CI, 0.9-2.7), and systolic blood pressure of 130-139 mm Hg (RR 1.6; 95% CI, 1.0-2.4). Findings were comparable for estimates of absolute risk.

CONCLUSIONS

Low educational level is associated with comparable risk as established risk factors for CHD mortality. Incorporation of educational level into risk-based guidelines for treatment could potentially reduce socioeconomic disparities in CHD by lowering thresholds for treatment.

Beyond Money: Toward an Economy of Well-Being

Policy decisions at the organizational, corporate, and governmental levels should be more heavily influenced by issues related to well-being-people's evaluations and feelings about their lives. Domestic policy currently focuses heavily on economic outcomes, although economic indicators omit, and even mislead about, much of what society values. We show that economic indicators have many shortcomings, and that measures of well-being point to important conclusions that are not apparent from economic indicators alone. For example, although economic output has risen steeply over the past decades, there has been no rise in life satisfaction during this period, and there has been a substantial increase in depression and distrust. We argue that economic indicators were extremely important in the early stages of economic development, when the fulfillment of basic needs was the main issue. As societies grow wealthy, however, differences in well-being are less frequently due to income, and are more frequently due to factors such as social relationships and enjoyment at work. Important noneconomic predictors of the average levels of well-being of societies include social capital, democratic governance, and human rights. In the workplace, noneconomic factors influence work satisfaction and profitability. It is therefore important that organizations, as well as nations, monitor the well-being of workers, and take steps to improve it. Assessing the well-being of individuals with mental disorders casts light on policy problems that do not emerge from economic indicators. Mental disorders cause widespread suffering, and their impact is growing, especially in relation to the influence of medical disorders, which is declining. Although many studies now show that the suffering due to mental disorders can be alleviated by treatment, a large proportion of persons with mental disorders go untreated. Thus, a policy imperative is to offer treatment to more people with mental disorders, and more assistance to their caregivers. Supportive, positive social relationships are necessary for well-being. There are data suggesting that well-being leads to good social relationships and does not merely follow from them. In addition, experimental evidence indicates that people suffer when they are ostracized from groups or have poor relationships in groups. The fact that strong social relationships are critical to well-being has many policy implications. For instance, corporations should carefully consider relocating employees because doing so can sever friendships and therefore be detrimental to well-being. Desirable outcomes, even economic ones, are often caused by well-being rather than the other way around. People high in well-being later earn higher incomes and perform better at work than people who report low well-being. Happy workers are better organizational citizens, meaning that they help other people at work in various ways. Furthermore, people high in well-being seem to have better social relationships than people low in well-being. For example, they are more likely to get married, stay married, and have rewarding marriages. Finally, well-being is related to health and longevity, although the pathways linking these variables are far from fully understood. Thus, well-being not only is valuable because it feels good, but also is valuable because it has beneficial consequences. This fact makes national and corporate monitoring of well-being imperative. In order to facilitate the use of well-being outcomes in shaping policy, we propose creating a national well-being index that systematically assesses key well-being variables for representative samples of the population. Variables measured should include positive and negative emotions, engagement, purpose and meaning, optimism and trust, and the broad construct of life satisfaction. A major problem with using current findings on well-being to guide policy is that they derive from diverse and incommensurable measures of different concepts, in a haphazard mix of respondents. Thus, current findings provide an interesting sample of policy-related findings, but are not strong enough to serve as the basis of policy. Periodic, systematic assessment of well-being will offer policymakers a much stronger set of findings to use in making policy decisions.

Social inequality and ethnic differences in smoking in New Zealand

This study tests a generalisation of the 'Wilkinson' thesis that the greater a nation's income inequality, the poorer the average national health status. We consider the effect of socio-economic inequality upon ethnic variations in smoking in New Zealand. Analysis of Maori and Pakeha (New Zealanders of European descent) smoking rates from the 1996 Census is conducted for 73 Territorial Local Authority areas in New Zealand, disaggregated by gender and rural-urban location. Partial correlation is used to control for absolute levels of deprivation and examine the independent effect of ethnic social inequality upon smoking rates. The level of social inequality between Maori and Pakeha has an independent effect on Maori smoking rates. Pakeha smoking rates by contrast are more sensitive to variations in absolute rather than relative deprivation. The effect of inequality is greatest for Maori women, especially among urban residents. By contrast, among Maori men the effects are greatest in rural areas. The results provide some qualified support for the Wilkinson thesis and suggest that policies which address fundamental issues of social inequality will play a small, but significant, role in helping to reduce high smoking rates amongst Maori.

Beyond Money: Toward an Economy of Well-Being

Policy decisions at the organizational, corporate, and governmental levels should be more heavily influenced by issues related to well-being-people's evaluations and feelings about their lives. Domestic policy currently focuses heavily on economic outcomes, although economic indicators omit, and even mislead about, much of what society values. We show that economic indicators have many shortcomings, and that measures of well-being point to important conclusions that are not apparent from economic indicators alone. For example, although economic output has risen steeply over the past decades, there has been no rise in life satisfaction during this period, and there has been a substantial increase in depression and distrust. We argue that economic indicators were extremely important in the early stages of economic development, when the fulfillment of basic needs was the main issue. As societies grow wealthy, however, differences in well-being are less frequently due to income, and are more frequently due to factors such as social relationships and enjoyment at work. Important noneconomic predictors of the average levels of well-being of societies include social capital, democratic governance, and human rights. In the workplace, noneconomic factors influence work satisfaction and profitability. It is therefore important that organizations, as well as nations, monitor the well-being of workers, and take steps to improve it. Assessing the well-being of individuals with mental disorders casts light on policy problems that do not emerge from economic indicators. Mental disorders cause widespread suffering, and their impact is growing, especially in relation to the influence of medical disorders, which is declining. Although many studies now show that the suffering due to mental disorders can be alleviated by treatment, a large proportion of persons with mental disorders go untreated. Thus, a policy imperative is to offer treatment to more people with mental disorders, and more assistance to their caregivers. Supportive, positive social relationships are necessary for well-being. There are data suggesting that well-being leads to good social relationships and does not merely follow from them. In addition, experimental evidence indicates that people suffer when they are ostracized from groups or have poor relationships in groups. The fact that strong social relationships are critical to well-being has many policy implications. For instance, corporations should carefully consider relocating employees because doing so can sever friendships and therefore be detrimental to well-being. Desirable outcomes, even economic ones, are often caused by well-being rather than the other way around. People high in well-being later earn higher incomes and perform better at work than people who report low well-being. Happy workers are better organizational citizens, meaning that they help other people at work in various ways. Furthermore, people high in well-being seem to have better social relationships than people low in well-being. For example, they are more likely to get married, stay married, and have rewarding marriages. Finally, well-being is related to health and longevity, although the pathways linking these variables are far from fully understood. Thus, well-being not only is valuable because it feels good, but also is valuable because it has beneficial consequences. This fact makes national and corporate monitoring of well-being imperative. In order to facilitate the use of well-being outcomes in shaping policy, we propose creating a national well-being index that systematically assesses key well-being variables for representative samples of the population. Variables measured should include positive and negative emotions, engagement, purpose and meaning, optimism and trust, and the broad construct of life satisfaction. A major problem with using current findings on well-being to guide policy is that they derive from diverse and incommensurable measures of different concepts, in a haphazard mix of respondents. Thus, current findings provide an interesting sample of policy-related findings, but are not strong enough to serve as the basis of policy. Periodic, systematic assessment of well-being will offer policymakers a much stronger set of findings to use in making policy decisions.

Health status among urban African American women: associations among well-being, perceived stress, and demographic factors

The purpose of this study was to evaluate the associations among health status, well-being, and perceived stress in a sample of urban African American women. African American women (n = 128) (Mean +/- SD, 49.3 +/- 10.5) from Baltimore, Maryland, enrolled in a church-based physical activity randomized trial were included in the analysis. Health status was assessed from the SF-36. Well-being, perceived stress, and demographics were also determined from self-report. Results indicated that the sample reported favorable health status, well-being, and stress levels compared to mean levels reported in the literature. Spearman rank-order correlations indicated that perceived stress score negatively correlated with most health status dimensions and well-being in the present, past, and future. Multiple regression analyses, adjusting for potential demographic confounders, indicated that higher perceived stress was associated with lower health status and well-being. If these results are confirmed in prospective investigations, they suggest that interventions designed to reduce stress may impact health status and future morbidity and mortality.

Alcohol and other drug disorders, comorbidity, and violence: comparison of rural African American and Caucasian women

Tremendous health disparities exist across various segments of the United States population with rural women particularly at risk. African Americans have higher rates of death, disease, and disability than Caucasians. Although prevalence rates for alcohol and other drug use vary across studies, African American women generally report less use than Caucasians. However, African Americans disproportionately experience negative health and social consequence of AOD use. The findings of this study provide rare information about substance abuse in rural African American women. Specifically, this manuscript reports differences between rural African American and Caucasian women (n=267) on AOD use, comorbid Axis I disorders, and violence.

Prognostic significance of psychosocial factors in African-American and white breast cancer patients: a population-based study

BACKGROUND

It has been suggested that psychosocial factors, such as coping and emotional support, influence cancer survival, but results have been inconclusive. Given the scarce data from racially/ethnically diverse populations, the authors investigated the prognostic significance of selected psychosocial variables in a cohort of African-American women and white women with breast cancer.

METHODS

The authors examined the effects of coping styles, perceived emotional support, fatalism, and health locus of control on survival for a population-based cohort of 145 African-American women and 177 white women who were diagnosed with breast cancer in Connecticut between January 1987 and March 1989 and were followed for survival for approximately 10 years. Cox proportional hazards models were adjusted for sociodemographic factors, biomedical factors (American Joint Committee on Cancer stage at diagnosis, histologic grade, comorbidity, obesity, menopausal status, and treatment), and lifestyle factors.

RESULTS

Fully adjusted models showed that lower perceived emotional support (disagreeing with the statement, "cancer is a topic I can talk about freely with my friends/relatives") at diagnosis was associated with a higher risk of death from any cause (hazard ratio, 1.39; 95% confidence interval, 1.09-1.79). Adjustment for additional tumor characteristics (nuclear grade, estrogen and progesterone receptor status) and genetic alterations (p53, HER-2) did not alter the findings. No other psychosocial factors significantly predicted survival in patients with breast cancer.

CONCLUSIONS

Higher levels of perceived emotional support showed a moderate but significant association with increased survival in African-American and white women with breast cancer who were followed for 10 years after diagnosis when adjusting for known prognostic factors. Survival was not related to coping styles, fatalism, or health locus of control.

Depression, substance use, adherence behaviors, and blood pressure in urban hypertensive black men

Relationships between depression, alcohol and illicit drug use, adherence behaviors, and blood pressure (BP) were examined in 190 urban hypertensive Black men enrolled in an ongoing hypertension control clinical trial. More than one fourth (27.4%) of the sample scored greater than 16 on the Center for Epidemiological Studies-Depression Scale (CES-D), indicating a high risk of clinical depression. Depression was significantly associated with an increased likelihood of meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for alcohol abuse or dependence (odds ratio = 5.2; 95% confidence interval = 1.897-14.214). The level of depression was significantly correlated with poor medication (r =.301) and poor dietary compliance (r =.164). Both alcohol intake and illicit drug use were significantly correlated with poor dietary compliance (r =.195 and.185, respectively) and smoking (r =.190 and.269, respectively). Although no direct relationship between depression and the level of BP was substantiated by multivariate analysis, findings of descriptive analyses revealed statistically significant associations among depression, substance use, poor adherence, and poor BP outcomes. Given the harsh environment in which a large number of young urban Black men live, the high prevalence of substance abuse might be an attempt to fight off depression. Further in-depth investigation is needed to identify the role of depression and BP control in urban young Blacks in order to construct effective interventions that address their unique needs.

Sweet blood and social suffering: rethinking cause-effect relationships in diabetes, distress, and duress

I draw upon anthropological engagements with bioscience and embodiment in order to unpack current approaches to defining and preventing diabetes mellitus. The analysis stems from the conviction that carefully considering the symbolic frames through which we conceive of diseases, their origins, their distribution, and their consequences will assist us in planning and implementing interventions to improve population health. I argue that research and interventions focused on the sweetness of blood would benefit from rethinking intersections between diabetes, distress, and duress. In many instances, the lived experience of diabetes is consonant with an understanding of distress (i.e., "social suffering") that expands conventional understandings of population health problems. Diabetes incidence is rising worldwide, but it is rising especially rapidly in Aboriginal and other disadvantaged populations. Notably, diabetes is now three to five times more common in Canada's First Nations population than it is in its non-Aboriginal population. Yet as recently as 50 years ago, diabetes and associated health problems were rare in these groups. To come to grips with such transformations and disparities is to advance the population health research agenda.

Understanding the association between socioeconomic status and physical health: do negative emotions play a role?

In this article, the authors evaluate the possible roles of negative emotions and cognitions in the association between socioeconomic status (SES) and physical health, focusing on the outcomes of cardiovascular diseases and all-cause mortality. After reviewing the limited direct evidence, the authors examine indirect evidence showing that (a) SES relates to the targeted health outcomes, (b) SES relates to negative emotions and cognitions, and (c) negative emotions and cognitions relate to the targeted health outcomes. The authors present a general framework for understanding the roles of cognitive-emotional factors, suggesting that low-SES environments are stressful and reduce individuals' reserve capacity to manage stress, thereby increasing vulnerability to negative emotions and cognitions. The article concludes with suggestions for future research to better evaluate the proposed model.

Depression as a risk factor for non-suicide mortality in the elderly

Depression can be a consequence of medical illness and disability, yet recent literature suggests it may also influence morbidity and mortality through a variety of behavioral and biological mediators. Relatively little is known about the complex temporal relations among behavior, affect, motivation, and pathophysiology to account for the association between depression and mortality. We performed a systematic review of the recent literature (1997-2001) examining the evidence linking depression to non-suicide mortality, describe possible mediators of the depression mortality effect, and identify important next steps in this area of research, including: a) the development of well-specified a-priory mediator models that articulate how depression leads to mortality; b) the conduct of longitudinal studies in which depression and behavioral and pathophyisological mediators are assessed simultaneously; c) treatment studies for depression that include assessments of associated changes in health-related quality of life, medical morbidity, and mortality; and d) treatment studies for behavioral risk factors and medical conditions that include assessment of depressive symptoms.