Working Conditions and Racial and Ethnic Disparities in Self-rated Health

OBJECTIVE

The aims of the study are to examine racial and ethnic differences in occupational physical demands, substantive complexity, time pressure, work hours, and establishment size and to assess whether working conditions contribute to racial and ethnic differences in self-rated health.

METHODS

We used 2017 and 2019 Panel Study of Income Dynamics data for 8439 adults. Using path models, we examined working conditions among Black, Latino, and White workers and explored whether those conditions mediated racial and ethnic differences in incident poor self-rated health.

RESULTS

Some working conditions disproportionately affected Black workers (high physical demands, low substantive complexity), Latino workers (low substantive complexity, small establishments), and White workers (time pressure). Time pressure predicted worse self-rated health; there was no evidence that the working conditions studied mediated racial/ethnic differences.

CONCLUSIONS

Working conditions vary by racial and ethnic group; some predict worse health.

Housing instability and mental health among renters in the michigan recession and recovery study

OBJECTIVE

To examine whether housing instability-inclusive of eviction, homelessness, moving in with others, moving for cost reasons, or frequent moves-is associated with mental health among renters in the aftermath of the Great Recession of 2007-09.

STUDY DESIGN

A panel survey study.

METHODS

We used data from the Michigan Recession and Recovery Study (2009-10, 2011 and 2013), a population-representative sample of working-aged adults, and logistic regression with propensity score weights to examine the association between housing instability over a year and a half and anxiety attack or depression symptoms at follow-up.

RESULTS

Respondents with any housing instability were 14 percentage points more likely to have had a recent anxiety attack, and those who had moved for cost reasons were 16 percentage points more likely. Respondents who experienced eviction were significantly more likely to meet criteria for major or minor depression at follow-up, by 13 percentage points.

CONCLUSIONS

Prior evidence of an association between housing instability and mental health is supported by these findings, which are robust to potential confounders, including financial and life shocks, housing quality, and neighborhood poverty concentration.

Burgard and Amanda Sonnega

[This corrects the article DOI: 10.1093/workar/waw038.][This corrects the article DOI: 10.1093/workar/waw038.].

Stability and Change in Health Behavior Profiles of U.S. Adults

OBJECTIVES

While understanding of complex within-person clustering of health behaviors into meaningful profiles of risk is growing, we still know little about whether and how U.S. adults transition from one profile to another as they age. This study assesses patterns of stability and change in profiles of tobacco and alcohol use and body mass index (BMI).

METHOD

A nationally representative cohort of U.S. adults 25 years and older was interviewed up to 5 times between 1986 and 2011. Latent transition analysis (LTA) models characterized the most common profiles, patterning of transitions across profiles over follow-up, and assessed whether some were associated with higher mortality risk.

RESULTS

We identified 5 profiles: "health promoting" with normal BMI and moderate alcohol consumption; "overweight"; "current smokers"; "obese"; and "nondrinkers". Profile membership was largely stable, with the most common transitions to death or weight gain. "Obese" was the most stable profile, while "smokers" were most likely to transition to another profile. Mortality was most frequent in the "obese" and "nondrinker" profiles.

DISCUSSION

Stability was more common than transition, suggesting that adults sort into health behavior profiles relatively early. Women and men were differently distributed across profiles at baseline, but showed broad similarity in transitions.

Informal and Formal Social Integration Shape Eating and Drinking of Older Black and White Americans

Objective: Health behaviors are seen as one possible pathway linking race to health outcomes. Social integration has also been consistently linked to important health outcomes but has not been examined as a mechanism accounting for racial differences in health behaviors among older U.S. adults. Method: We use data from the American's Changing Lives (ACL) Study to explore racial differences in measures of social integration and whether they help account for racial differences in several dietary behaviors and alcohol use. Results: We find differences by race and social integration measures in dietary behaviors and alcohol use. Net of socioeconomic status, health status, and reported discrimination, variation in social integration helps to account for racial differences in some health behaviors. Discussion: Our results highlight the nuanced role of social integration in understanding group differences in health behaviors. Interventions should consider such complexities when including aspects of social integration in their design.

Gender differences in the association of living and working conditions and the mental health of trafficking survivors

OBJECTIVES

To assess the association of living and working conditions experienced during trafficking with mental health of female and male survivors.

METHODS

We analyzed a cross-sectional study of 1015 survivors who received post-trafficking services in Cambodia, Thailand, and Vietnam. Modified Poisson regression models were conducted by gender to estimate prevalence ratios.

RESULTS

For females, the elevated prevalence of anxiety, depression, and post-traumatic stress disorder (PTSD) symptoms was associated with adverse living conditions, while for males the prevalence of anxiety (PR = 2.21; 95% CI 1.24-3.96) and depression (PR = 2.63; 95% CI 1.62-4.26) more than doubled and almost tripled for PTSD (PR = 2.93; 95% CI 1.65-5.19) after adjustment. For males in particular, excessive and extreme working hours per day were associated with more than a four- and threefold greater prevalence of PTSD. Being in a detention center or jail was associated with all three mental health outcomes in males.

CONCLUSIONS

Providers and stakeholders need to consider the complex mental health trauma of the differential effects of living and working conditions for female and male survivors during trafficking to support treatment and recovery.

Marital status and cognitive impairment in the United States: evidence from the National Health and Aging Trends Study

PURPOSE

We provide population-based longitudinal evidence of marital status differences in the risk of cognitive impairment and dementia in the United States.

METHODS

Data were from the longitudinal National Health and Aging Trends Study, 2011-2018. The sample included 7508 respondents aged 65 years and older who contributed 25,897 person-year records. We estimated discrete-time hazard models to predict the risk of dementia and cognitive impairment, not dementia (CIND), as well as impairment in three major cognitive domains: memory, orientation, and executive function.

RESULTS

Relative to their married counterparts, divorced and widowed elders had higher odds of dementia and CIND, as well as higher odds of impairment in each of the cognitive domains. Never-married elders had higher odds of impairment in memory and orientation than their married counterparts but did not differ significantly in the odds of impaired executive function, dementia, or CIND. Cohabiting elders did not differ significantly from married respondents on any measure of cognitive impairment. We found no gender differences in the associations between marital status and the measures of cognitive impairment.

CONCLUSIONS

Marital status is a potentially important but overlooked social risk/protective factor for cognitive impairment. Divorced and widowed older adults are particularly vulnerable to cognitive impairment.

Material hardship and sleep: results from the Michigan Recession and Recovery Study

OBJECTIVE

Sleep is unequally distributed in the US population. People with low socioeconomic status report worse quality and shorter sleep than people with high socioeconomic status. Past research hypothesized that a potential reason for this link could be exposure to material hardship. This study examines the associations between several material hardships and sleep outcomes.

METHODS

We use population-representative cross-sectional data (n = 730) from the Michigan Recession and Recovery Study collected in 2013 and examine the associations between 6 indicators of material hardship (employment instability, financial problems, housing instability, food insecurity, forgone medical care, and the total number of material hardships reported) and 3 sleep outcomes (short sleep, sleep problems, and nonrestorative sleep). We build multivariable logistic regression models controlling for respondents' characteristics and light pollution near their residence.

RESULTS

In unadjusted models, all material hardships were associated with negative sleep outcomes. In adjusted models, forgone medical care was a statistically significant predictor of nonrestorative sleep (average marginal effect 0.16), as was employment instability (average marginal effect 0.12). The probability of sleep problems and nonrestorative sleep increased with a greater number of hardships overall (average marginal effects of .02 and .05, respectively). We found marginally statistically significant positive associations between food insecurity and short sleep and sleep problems.

CONCLUSIONS

This study finds that, except when considering foregone medical care, employment instability, and total count of material hardships, associations between material hardship and negative sleep outcomes are not statistically significant after adjusting for a robust set of sociodemographic and health characteristics.

Mental health, violence and psychological coercion among female and male trafficking survivors in the greater Mekong sub-region: a cross-sectional study

BACKGROUND

Human trafficking is a pervasive global crime with important public health implications that entail fundamental human rights violations in the form of severe exploitation, violence and coercion. Sex-specific associations between types of violence or coercion and mental illness in survivors of trafficking have not been established.

METHODS

We conducted a cross-sectional study with 1015 female and male survivors of trafficking (adults, adolescents and children) who received post-trafficking assistance services in Cambodia, Thailand or Vietnam and had been exploited in various labor sectors. We assessed anxiety and depression with the Hopkins Symptoms Checklist (HSCL-25) and post-traumatic stress disorder (PTSD) symptoms with the Harvard Trauma Questionnaire (HTQ), and used validated questions from the World Health Organization International Study on Women's Health and Domestic Violence to measure physical and sexual violence. Sex-specific modified Poisson regression models were estimated to obtain prevalence ratios (PRs) and their 95% confidence intervals (CI) for the association between violence (sexual, physical or both), coercion, and mental health conditions (anxiety, depression and PTSD).

RESULTS

Adjusted models indicated that for females, experiencing both physical and sexual violence, compared to not being exposed to violence, was a strong predictor of symptoms of anxiety (PR = 2.08; 95% CI: 1.64-2.64), PTSD (PR = 1.55; 95% CI: 1.37-1.74), and depression (PR = 1.57; 95% CI: 1.33-1.85). Among males, experiencing physical violence with additional threats made with weapons, compared to not being exposed to violence, was associated with PTSD (PR = 1.59; 95% CI: 1.05-2.42) after adjustment. Coercion during the trafficking experience was strongly associated with anxiety, depression, and PTSD in both females and males. For females in particular, exposure to both personal and family threats was associated with a 96% elevated prevalence of PTSD (PR = 1.96; 95% CI: 1.32-2.91) and more than doubling of the prevalence of anxiety (PR = 2.11; 95% CI: 1.57-2.83).

CONCLUSIONS

The experiences of violence and coercion in female and male trafficking survivors differed and were associated with an elevated prevalence of anxiety, depression, and PTSD in both females and males. Mental health services must be an integral part of service provision, recovery and re-integration for trafficked females and males.

Association of a Negative Wealth Shock With All-Cause Mortality in Middle-aged and Older Adults in the United States

Importance

A sudden loss of wealth-a negative wealth shock-may lead to a significant mental health toll and also leave fewer monetary resources for health-related expenses. With limited years remaining to regain lost wealth in older age, the health consequences of these negative wealth shocks may be long-lasting.

Objective

To determine whether a negative wealth shock was associated with all-cause mortality during 20 years of follow-up.

Design, Setting, and Participants

The Health and Retirement Study, a nationally representative prospective cohort study of US adults aged 51 through 61 years at study entry. The study population included 8714 adults, first assessed for a negative wealth shock in 1994 and followed biennially through 2014 (the most recent year of available data).

Exposures

Experiencing a negative wealth shock, defined as a loss of 75% or more of total net worth over a 2-year period, or asset poverty, defined as 0 or negative total net worth at study entry.

Main Outcomes and Measures

Mortality data were collected from the National Death Index and postmortem interviews with family members. Marginal structural survival methods were used to account for the potential bias due to changes in health status that may both trigger negative wealth shocks and act as the mechanism through which negative wealth shocks lead to increased mortality.

Results

There were 8714 participants in the study sample (mean [SD] age at study entry, 55 [3.2] years; 53% women), 2430 experienced a negative wealth shock during follow-up, 749 had asset poverty at baseline, and 5535 had continuously positive wealth without shock. A total of 2823 deaths occurred during 80 683 person-years of follow-up. There were 30.6 vs 64.9 deaths per 1000 person-years for those with continuously positive wealth vs negative wealth shock (adjusted hazard ratio [HR], 1.50; 95% CI, 1.36-1.67). There were 73.4 deaths per 1000 person-years for those with asset poverty at baseline (adjusted HR, 1.67; 95% CI, 1.44-1.94; compared with continuously positive wealth).

Conclusions and Relevance

Among US adults aged 51 years and older, loss of wealth over 2 years was associated with an increased risk of all-cause mortality. Further research is needed to better understand the possible mechanisms for this association and determine whether there is potential value for targeted interventions.

Working, Parenting and Work-Home Spillover: Gender Differences in the Work-Home Interface across the Life Course

In this study, we bring a life course approach to work-family research and ask how work-home spillover changes as men and women move through different parenting stages. We use two waves of the Mid-Life in the United States Study (MIDUS I and II, 1996-2004, N=1,319) and estimate change-score models to document the association between five parenting transitions (becoming a parent, starting to parent a school-aged child, an adolescent, young adult, or adult child) and changes in both positive and negative work-to-home (WHS) and home-to-work (HWS) spillover, testing for gender differences in these associations. We find that moving through parenting stages is related to within-person changes in reports of work-home spillover, and that mothers and fathers encounter changes in spillover at different points in the life course. Our findings detail how transitions through parenthood produce a gendered life course, and speaks to the need for policies to support working parents throughout the life course.

Occupational Differences in BMI, BMI Trajectories, and Implications for Employment Status among Older U.S. Workers

We examined associations between employment and obesity, arguing that risk for unhealthy weight may vary across occupational groups because they shape workplace exposures, social class standing, material resources, and norms and expectations about healthy behaviors and weight. We used a large sample of 51-61-year-old workers from the Health and Retirement study, tracking their body mass index (BMI) over time while accounting for potentially confounding influences of socioeconomic status and gender and exploring whether gender modified associations between occupational group, BMI, and retirement timing. Compared with women in professional occupations, women managers were less likely to be obese at baseline and were less likely to be in the obese upward trajectory class, while female professionals and operators and laborers were less likely than women in farm and precision production to be in the normal stable trajectory. Male professionals were less likely than men in sales, service, and operator and laborer positions to be obese at baseline and more often followed the normal upward trajectory than most other groups, though they and farm and precision production men were more likely to be in the overweight to obese trajectory than men in service occupations. Adjustment for sociodemographic and lifestyle characteristics reduced associations more for men than for women. While retirement risk differed across occupational groups, most of these differences were explained by socioeconomic, demographic, and lifestyle characteristics, especially for men. Obesity at baseline was an independent predictor of retirement but did not further explain differences in the timing of retirement by occupational group.

Increasing educational attainment and mortality reduction: a systematic review and taxonomy

Background

Understanding the relationship between increasing educational attainment and mortality reduction has important policy and public health implications. This systematic review of the literature establishes a taxonomy to facilitate evaluation of the association between educational attainment and early mortality.

Methods

Following PRISMA guidelines, we searched Ovid Medline, Embase, PubMed and hand searches of references for English-language primary data analyses using education as an independent variable and mortality as a dependent variable. Initial searches were undertaken in February 2015 and updated in April 2016.

Results

One thousand, seven hundred and eleven unique articles were identified, 418 manuscripts were screened and 262 eligible studies were included in the review. After an iterative review process, the literature was divided into four study domains: (1) all-cause mortality (n = 68, 26.0%), (2) outcome-specific mortality (n = 89, 34.0%), (3) explanatory pathways (n = 51, 19.5%), and (4) trends over time (n = 54, 20.6%). These four domains comprise a novel taxonomy that can be implemented to better quantify the relationship between education and mortality.

Conclusions

We propose an organizational taxonomy for the education-mortality literature based upon study characteristics that will allow for a more in-depth understanding of this association. Our review suggests that studies that include mediators or subgroups can explain part, but not all, of the relationship between education and early mortality.

Trial registration

PROSPERO registration # CRD42015017182.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4754-1) contains supplementary material, which is available to authorized users.

Negative wealth shock and short-term changes in depressive symptoms and medication adherence among late middle-aged adults

BACKGROUND

Experiencing a negative wealth shock in late middle age may cause high levels of stress and induce reductions in health-related consumption.

METHODS

We used data on late middle age individuals (51-64 years) from the longitudinal US-based Health and Retirement Study (N=19 281) to examine the relationship between negative wealth shock and short-term outcomes that serve as markers of the pathways from wealth shock to health: elevated depressive symptoms, as a marker of the stress pathway and cost-related medication non-adherence (CRN), as a marker of the consumption pathway. Negative wealth shock was considered to be a loss of total net worth of 75% or more.

RESULTS

Using a nested cross-over approach-a within-person design among exposed individuals only that adjusts by design for all time-invariant individual characteristics-we found that negative wealth shock was significantly associated with increased odds of elevated depressive symptoms (OR=1.50, CI 1.10 to 2.05), but was not significantly associated with higher odds of CRN (OR=1.18, CI 0.76 to 1.82), even after further adjustment for time-varying sociodemographic and health covariates.

CONCLUSIONS

Negative wealth shock during late middle age confers an increased risk of elevated depressive symptoms, but does not change levels of CRN. Personal and policy factors that may buffer the mental health risks of negative wealth shock, such as social support and social welfare policy, should be considered.

Histories of Perceived Job Insecurity and Psychological Distress Among Older U.S. Adults

Changes in the labor market and employment contracts over the past several decades and a recent global recession have increased the salience of perceived job insecurity as a risk factor for poor mental health. We use 25 years of prospective data from the Americans' Changing Lives study to examine long-term histories of perceived job insecurity and their link to psychological distress. We build on the prior literature by using a much longer window of exposure and accounting for involuntary job losses over the lengthy observation period. We find that persistent perceived job insecurity is strongly and significantly associated with greater psychological distress among U.S. workers in the latter part of their careers. Moreover, considering histories of exposure reveals more nuance in the sociodemographic characteristics and employment interruptions that predict persistent or intermittent insecurity and that identify contemporary older workers at particular risk.

Housing Assistance and Housing Insecurity: A Study of Renters in Southeastern Michigan in the Wake of the Great Recession

This article examines the factors shaping longitudinal patterns of housing insecurity in the wake of the Great Recession, with a focus on whether housing assistance helped renters who received it. We use data from the first two waves (2009-10 and 2011) of the Michigan Recession and Recovery Study, a population-representative sample of working-aged adults from Southeast Michigan. We use detailed reports from renters and other non-homeowners to construct measures of instability and cost-related housing problems at both waves, and we compare the changes in these over follow-up between housing assistance recipients and their income-eligible but non-recipient counterparts. Our findings suggest that receiving housing assistance reduced the chance of experiencing housing insecurity problems over follow-up regardless of baseline housing insecurity.

Gynecologic pain related to occupational stress among female factory workers in Tianjin, China

BACKGROUND

Dysmenorrhea, dyspareunia, and non-cyclic pelvic pain are health concerns for factory workers in China and may be increased by occupational stress.

OBJECTIVES

To estimate the prevalence and demographic and occupational factors associated with three types of gynecologic pain among female factory workers in Tianjin.

METHODS

The study included 651 female workers from three factories in Tianjin, China. Logistic regression models were estimated to determine associations between occupational stress and gynecologic pain.

RESULTS

Occupational stress including high job strain, exhaustion, and stress related to working conditions was a risk factor for gynecologic pain. High job strain and poor job security were associated with an increased risk for dysmenorrhea. Compulsory overtime and exhaustion were associated with increased non-cyclic pelvic pain. Working overtime and exhaustion were associated with increased dyspareunia.

CONCLUSIONS

As China's population of female factory workers grows, research on the reproductive health of this population is essential.

Challenges of health measurement in studies of health disparities

Health disparities are increasingly studied in and across a growing array of societies. While novel contexts and comparisons are a promising development, this commentary highlights four challenges to finding appropriate and adequate health measures when making comparisons across groups within a society or across distinctive societies. These challenges affect the accuracy with which we characterize the degree of inequality, limiting possibilities for effectively targeting resources to improve health and reduce disparities. First, comparisons may be challenged by different distributions of disease and second, by variation in the availability and quality of vital events and census data often used to measure health. Third, the comparability of self-reported information about specific health conditions may vary across social groups or societies because of diagnosis bias or diagnosis avoidance. Fourth, self-reported overall health measures or measures of specific symptoms may not be comparable across groups if they use different reference groups or interpret questions or concepts differently. We explain specific issues that make up each type of challenge and show how they may lead to underestimates or inflation of estimated health disparities. We also discuss approaches that have been used to address them in prior research, note where further innovation is needed to solve lingering problems, and make recommendations for improving future research. Many of our examples are drawn from South Africa or the United States, societies characterized by substantial socioeconomic inequality across ethnic groups and wide disparities in many health outcomes, but the issues explored throughout apply to a wide variety of contexts and inquiries.

Race/Ethnicity, educational attainment, and foregone health care in the United States in the 2007-2009 recession

OBJECTIVES

This study assessed possible associations between recessions and changes in the magnitude of social disparities in foregone health care, building on previous studies that have linked recessions to lowered health care use.

METHODS

Data from the 2006 to 2010 waves of the National Health Interview Study were used to examine levels of foregone medical, dental and mental health care and prescribed medications. Differences by race/ethnicity and education were compared before the Great Recession of 2007 to 2009, during the early recession, and later in the recession and in its immediate wake.

RESULTS

Foregone care rose for working-aged adults overall in the 2 recessionary periods compared with the pre-recession. For multiple types of pre-recession care, foregoing care was more common for African Americans and Hispanics and less common for Asian Americans than for Whites. Less-educated individuals were more likely to forego all types of care pre-recession. Most disparities in foregone care were stable during the recession, though the African American-White gap in foregone medical care increased, as did the Hispanic-White gap and education gap in foregone dental care.

CONCLUSIONS

Our findings support the fundamental cause hypothesis, as even during a recession in which more advantaged groups may have had unusually high risk of losing financial assets and employer-provided health insurance, they maintained their relative advantage in access to health care. Attention to the macroeconomic context of social disparities in health care use is warranted.

Bad Jobs, Bad Health? How Work and Working Conditions Contribute to Health Disparities

In this review, we touch on a broad array of ways that work is linked to health and health disparities for individuals and societies. First focusing on the health of individuals, we discuss the health differences between those who do and do not work for pay, and review key positive and negative exposures that can generate health disparities among the employed. These include both psychosocial factors like the benefits of a high status job or the burden of perceived job insecurity, as well as physical exposures to dangerous working conditions like asbestos or rotating shift work. We also provide a discussion of the ways differential exposure to these aspects of work contributes to social disparities in health within and across generations. Analytic complexities in assessing the link between work and health for individuals, such as health selection, are also discussed. We then touch on several contextual level associations between work and the health of populations, discussing the importance of the occupational structure in a given society, the policy environment that prevails there, and the oscillations of the macroeconomy for generating societal disparities in health. We close with a discussion of four areas and associated recommendations that draw on this corpus of knowledge but would push the research on work, health and inequality toward even greater scholarly and policy relevance.

Tough Choices in Tough Times

Debt is a ubiquitous component of households’ financial portfolios. Yet we have scant understanding of how household debt constrains spending on needed health care. Diverse types of debt have different financial properties and recent work has shown that they may have varying implications for spending on needed health care. In this article, we explore the associations between indebtedness and medication nonadherence. First, we consider overall debt levels and then we disaggregate debt into types. We use a population-based sample of 434 residents of southeast Michigan who had been prescribed medications, collected in 2009-2010, the wake of the Great Recession. We find no association between medication nonadherence and total indebtedness. However, when we assess each type of debt separately, we find that having medical or credit card debt is positively associated with medication nonadherence, even net of household income, net worth, and other characteristics. Furthermore, patients with greater amounts of medical or credit card debt are more likely to be nonadherent than those with less. Our results suggest that credit card debt and medical debt may have serious implications for the relative affordability of prescription medications. These associations have been overlooked in past research and deserve further examination.

"Every shut eye, ain't sleep": The role of racism-related vigilance in racial/ethnic disparities in sleep difficulty

Although racial/ethnic disparities in health have been well-characterized in biomedical, public health, and social science research, the determinants of these disparities are still not well-understood. Chronic psychosocial stress related specifically to the American experience of institutional and interpersonal racial discrimination may be an important determinant of these disparities, as a growing literature in separate scientific disciplines documents the adverse health effects of stress and the greater levels of stress experienced by non-White compared to White Americans. However, the empirical literature on the importance of stress for health and health disparities specifically due to racial discrimination, using population-representative data, is still small and mixed. In this paper, we explore the association between a novel measure of racially-salient chronic stress - "racism-related vigilance" - and sleep difficulty. We found that, compared to the White adults in our sample, Black (but not Hispanic) adults reported greater levels of vigilance. This vigilance was positively associated with sleep difficulty to similar degrees for all racial/ethnic groups in our sample (White, Black, Hispanic). Black adults reported greater levels of sleep difficulty compared to White adults. This disparity was slightly attenuated after adjustment for education and income. However, this disparity was completely attenuated after adjustment for racism-related vigilance. We found similar patterns of results for Hispanic compared to White adults, however, the disparities in sleep difficulty were smaller and not statistically significant. Because of the importance of sleep quality to health, our results suggest that the anticipation of and perseveration about racial discrimination is an important determinant of racial disparities in health.

Debt and foregone medical care

Most American households carry debt, yet we have little understanding of how debt influences health behavior, especially health care seeking. We examined associations between foregone medical care and debt using a population-based sample of 914 southeastern Michigan residents surveyed in the wake of the late-2000s recession. Overall debt and ratios of debt to income and debt to assets were positively associated with foregoing medical or dental care in the past 12 months, even after adjusting for the poorer socioeconomic and health characteristics of those foregoing care and for respondents' household incomes and net worth. These overall associations were driven largely by credit card and medical debt, while housing debt and automobile and student loans were not associated with foregoing care. These results suggest that debt is an understudied aspect of health stratification.

Gender and Time for Sleep among U.S. Adults

Do women really sleep more than men? Biomedical and social scientific studies show longer sleep durations for women, a surprising finding given sociological research showing women have more unpaid work and less high-quality leisure time compared to men. We assess explanations for gender differences in time for sleep, including compositional differences in levels of engagement in paid and unpaid labor, gendered responses to work and family responsibilities, and differences in napping, bedtimes, and interrupted sleep for caregiving. We examine the overall gender gap in time for sleep as well as gaps within family life-course stages based on age, partnership, and parenthood statuses. We analyze minutes of sleep from a diary day collected from nationally representative samples of working-age adults in the American Time Use Surveys of 2003 to 2007. Overall and at most life course stages, women slept more than men. Much of the gap is explained by work and family responsibilities and gendered time tradeoffs; as such, gender differences vary across life course stages. The gender gap in sleep time favoring women is relatively small for most comparisons and should be considered in light of the gender gap in leisure time favoring men at all life course stages.

Couples' reports of household decision-making and the utilization of maternal health services in Bangladesh

This study examines the association between maternal health service utilization and household decision-making in Bangladesh. Most studies of the predictors of reproductive health service utilization focus on women's reports; however, men are often involved in these decisions as well. Recently, studies have started to explore the association between health outcomes and reports of household decision-making from both husbands and wives as matched pairs. Many studies of household decision-making emphasize the importance of the wife alone making decisions; however, some have argued that joint decision-making between husbands and wives may yield better reproductive health outcomes than women making decisions without input or agreement from their partners. Husbands' involvement in decision-making is particularly important in Bangladesh because men often dominate household decisions related to large, health-related purchases. We use matched husband and wife reports about who makes common household decisions to predict use of antenatal and skilled delivery care, using data from the 2007 Bangladesh Demographic and Health Survey. Results from regression analyses suggest that it is important to consider whether husbands and wives give concordant responses about who makes household decisions since discordant reports about who makes these decisions are negatively associated with reproductive health care use. In addition, compared to joint decision-making, husband-only decision-making is negatively associated with antenatal care use and skilled delivery care. Finally, associations between household decision-making arrangements and health service utilization vary depending on whose report is used and the type of health service utilized.

Husbands' involvement in delivery care utilization in rural Bangladesh: A qualitative study

Background

A primary cause of high maternal mortality in Bangladesh is lack of access to professional delivery care. Examining the role of the family, particularly the husband, during pregnancy and childbirth is important to understanding women's access to and utilization of professional maternal health services that can prevent maternal mortality. This qualitative study examines husbands' involvement during childbirth and professional delivery care utilization in a rural sub-district of Netrokona district, Bangladesh.

Methods

Using purposive sampling, ten households utilizing a skilled attendant during the birth of the youngest child were selected and matched with ten households utilizing an untrained traditional birth attendant, or dhatri. Households were selected based on a set of inclusion criteria, such as approximate household income, ethnicity, and distance to the nearest hospital. Twenty semi-structured interviews were conducted in Bangla with husbands in these households in June 2010. Interviews were transcribed, translated into English, and analyzed using NVivo 9.0.

Results

By purposefully selecting households that differed on the type of provider utilized during delivery, common themes--high costs, poor transportation, and long distances to health facilities--were eliminated as sufficient barriers to the utilization of professional delivery care. Divergent themes, namely husbands' social support and perceived social norms, were identified as underlying factors associated with delivery care utilization. We found that husbands whose wives utilized professional delivery care provided emotional, instrumental and informational support to their wives during delivery and believed that medical intervention was necessary. By contrast, husbands whose wives utilized an untrained dhatri at home were uninvolved during delivery and believed childbirth should take place at home according to local traditions.

Conclusions

This study provides novel evidence about male involvement during childbirth in rural Bangladesh. These findings have important implications for program planners, who should pursue culturally sensitive ways to involve husbands in maternal health interventions and assess the effectiveness of education strategies targeted at husbands.

Shape of the BMI-mortality association by cause of death, using generalized additive models: NHIS 1986-2006

OBJECTIVE

Numerous studies have examined the association between body mass index (BMI) and mortality. The precise shape of their association, however, has not been established. We use nonparametric methods to determine the relationship between BMI and mortality.

METHOD

Data from the National Health Interview Survey-Linked Mortality Files 1986-2006 for adults aged 50 to 80 are analyzed using a Poisson approach to survival modeling within the generalized additive model (GAM) framework.

RESULTS

The BMI-mortality association is more V shaped than U shaped, with the odds of dying rising steeply from the lowest risk point at BMIs of 23 to 26. The association varies considerably by time since interview and cause of death. For instance, the association has an inverted J shape for respiratory causes but is monotonically increasing for diabetes deaths.

DISCUSSION

Our findings have implications for interpreting results from BMI-mortality studies and suggest caution in translating the findings into public health messages.

Family relationships and troubled sleep among U.S. adults: examining the influences of contact frequency and relationship quality

Sleep is essential for health and daily functioning, and social relationships may be a key social factor influencing sleep, yet sleep has been understudied in the literature on social relationships and health. This study used data from the National Survey of Midlife Development in the United States to examine associations between troubled sleep and family contact, social support, and strain. Results show that having strained family relationships is associated with more troubled sleep, while supportive family relationships are associated with less troubled sleep. Family strain is more consequential for sleep than support, and sleep troubles are greatest when family relationships are highly strained and provide inadequate emotional support. Family strain is also more harmful to sleep among individuals who are in frequent contact with family members. These findings underscore the importance of focusing on both negative and positive aspects of relationships and highlight the significance of family relationships for sleep.

Metropolitan-level racial residential segregation and black-white disparities in hypertension

Few studies have examined geographic variation in hypertension disparities, but studies of other health outcomes indicate that racial residential segregation may help to explain these variations. The authors used data from 8,071 black and white participants in the National Health and Nutrition Examination Survey (1999-2006) who were aged 25 years or older to investigate whether black-white hypertension disparities varied by level of metropolitan-level racial residential segregation and whether this was explained by race differences in neighborhood poverty. Racial segregation was measured by using the black isolation index. After adjustment for demographics and individual-level socioeconomic position, blacks had 2.74 times higher odds of hypertension than whites (95% confidence interval (CI): 2.32, 3.25). However, race differences were significantly smaller in low- than in high-segregation areas (P(interaction) = 0.006). Race differences in neighborhood poverty did not explain this heterogeneity, but poverty further modified race disparities: Race differences were largest in segregated, low-poverty areas (odds ratio = 4.14, 95% CI: 3.18, 5.38) and smallest in nonsegregated, high-poverty areas (odds ratio = 1.24, 95% CI: 0.77, 2.01). These findings suggest that racial disparities in hypertension are not invariant and are modified by contextual levels of racial segregation and neighborhood poverty, highlighting the role of environmental factors in the genesis of disparities.

Dynamics of inequality: mother's education and infant mortality in China, 1970-2001

In this study, the authors analyze the dynamic relationship between Chinese women's education, their utilization of newly available medical pregnancy care, and their infants' mortality risk. China has undergone enormous social, economic, and political changes over recent decades and is a novel context in which to examine the potential influence of social change and technological innovation on health disparities. The authors consider efficacy, or the ability to quickly absorb and effectively utilize new medical innovations, and argue that the social stratification of efficacy provides an important conceptual link between education and the greater likelihood of benefitting from medical innovations. Using the 2001 National Family Planning and Reproductive Health Survey data and multilevel, multiprocess models, the authors show that Chinese infants born to better educated mothers retained a survival advantage over the turbulent decades between 1970 and 2000. This occurs largely because educated mothers more actively sought prenatal care and professional delivery assistance use.

Overweight adults may have the lowest mortality--do they have the best health?

Numerous recent studies have found that overweight adults experience lower overall mortality than those who are underweight, normal-weight, or obese. These highly publicized findings imply that overweight may be the optimal weight category for overall health via its association with longevity-a conclusion with important public health implications. In this study, the authors examined the association between body mass index (BMI; (weight (kg)/height (m)(2))) and 3 markers of health risks using a nationally representative sample of US adults aged 20-80 years (n = 9,255) from the National Health and Nutrition Examination Survey (2005-2008). Generalized additive models, a type of semiparametric regression model, were used to examine the relations between BMI and biomarkers of inflammation, metabolic function, and cardiovascular function (C-reactive protein, hemoglobin A(1c), and high density lipoprotein cholesterol, respectively). The association between BMI and each biomarker was monotonic, with higher BMI being consistently associated with worse health risk profiles at all ages, in contrast to the U-shaped relation between BMI and mortality. Prior results suggesting that the overweight BMI category corresponds to the lowest risk of mortality may not be generalizable to indicators of health risk.

Body weight and health from early to mid-adulthood: a longitudinal analysis

We analyze the influence of body weight in early adulthood, and changes in weight over time, on self-rated health as people age into middle adulthood. While prior research has focused on cross-sectional samples of older adults, we use longitudinal data from the NHANES I Epidemiologic Follow-up Study and double-trajectory latent growth models to study the association between body mass index (BMI) and self-rated health trajectories over 20 years. Results indicate that high BMI in early adulthood and gaining more weight over time are both associated with a faster decline in health ratings. Among white women only, those with a higher BMI at the baseline also report lower initial self-rated health. A small part of the weight-health association is due to sociodemographic factors, but not baseline health behaviors or medical conditions. The findings provide new support for the cumulative disadvantage perspective, documenting the increasing health inequalities in a cohort of young adults.

Putting work to bed: stressful experiences on the job and sleep quality

Most adults spend one-third of every day sleeping and another third of most days at work. However there is little analysis of the possible connections between common workplace experiences and sleep quality. This study uses the longitudinal and nationally-representative Americans' Changing Lives study to examine whether and how common conditions and experiences at work may 'follow workers home" and impinge on their quality of sleep. We also explore how competing stressful experiences at home may influence sleep quality, and whether these are more salient than work experiences. Results show that frequently being bothered or upset at work is associated with poorer sleep quality, and the association is not explained by stressful experiences at home. These findings are discussed in relation to the sociological literatures on work, stress, and emotion.

Putting work to bed: stressful experiences on the job and sleep quality

Most adults spend one-third of every day sleeping and another third of most days at work. However there is little analysis of the possible connections between common workplace experiences and sleep quality. This study uses the longitudinal and nationally-representative Americans' Changing Lives study to examine whether and how common conditions and experiences at work may 'follow workers home" and impinge on their quality of sleep. We also explore how competing stressful experiences at home may influence sleep quality, and whether these are more salient than work experiences. Results show that frequently being bothered or upset at work is associated with poorer sleep quality, and the association is not explained by stressful experiences at home. These findings are discussed in relation to the sociological literatures on work, stress, and emotion.

Downward social mobility and major depressive episodes among Latino and Asian-American immigrants to the United States

The authors analyzed the association between downward social mobility in subjective social status among 3,056 immigrants to the United States and the odds of a major depressive episode. Using data from the National Latino and Asian American Study (2002-2003), the authors examined downward mobility by comparing immigrants' subjective social status in their country of origin with their subjective social status in the United States. The dependent variable was the occurrence of a past-year episode of major depression defined according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Logistic regression models were used to control for a variety of sociodemographic and immigration-related characteristics. Analyses suggested that a loss of at least 3 steps in subjective social status is associated with increased risk of a depressive episode (odds ratio = 3.0, 95% confidence interval: 1.3, 6.6). Other factors independently associated with greater odds of depression included Latino ethnicity, female sex, having resided for a longer time in the United States, and being a US citizen. The findings suggest that immigrants who experience downward social mobility are at elevated risk of major depression. Policies or interventions focused only on immigrants of low social status may miss another group at risk: those who experience downward mobility from a higher social status.

Community characteristics, sexual initiation, and condom use among young Black South Africans

Individual and household-level characteristics that influence sexual behavior have been extensively studied in South Africa, but community characteristics have received limited attention. We use multilevel discrete time hazard models and multilevel logistic regression models to analyze data from a representative sample of young people in KwaZulu Natal, and from several sources of community data. Results suggest that, net of individual and household characteristics, higher levels of community concentrated disadvantage are associated with increased hazard of sexual initiation and higher risk of unprotected sex. Social disorder increases the hazard of sexual initiation, while greater community social cohesion is associated with delayed sexual debut, although the latter association appears stronger for young men than for young women. We discuss these results and the ways they vary from predictions based on US. theory in light of conditions prevailing in contemporary South Africa.

Job Displacement and Social Participation over the Lifecourse: Findings for a Cohort of Joiners

We examine the effects of job displacement, an involuntary event associated with socioeconomic and psychological decline, on social participation. Using more than 45 years of panel data from the Wisconsin Longitudinal Study, we find that job displacement is associated with significant, long-term lower probabilities of subsequent involvement with various forms of social participation for workers displaced during their prime earnings years; displacement is not associated with lower probabilities of involvement for workers displaced in the years approaching retirement. We also find that post-displacement socioeconomic and psychological decline explain very little of the negative effect of job displacement on social participation, and that a single displacement event, rather than a series of multiple displacement events, is most strongly associated with lower probabilities of social involvement.

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

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

Trends and racial differences in infant mortality in South Africa

Racial differences in infant mortality in South Africa are studied using household-level data from 1987 to 1989 and 1998. Logistic regression models are estimated to explore the determinants of the overall trend in infant mortality and racial disparities in infants' survival chances. We do not find evidence for reduced overall risk of infant death among births that occurred from 1993 to 1998 when compared to those that occurred from 1982 to 1989, despite policy and action directed toward this goal by the new government that was elected in early 1994. We also find that persistent inequalities in the personal and household resources of South Africa's four main racial groups substantially account for racial differences in infant survival rates in both periods. These findings are discussed in light of contemporary social and health issues in South Africa.

Alcohol and tobacco use patterns among heterosexually and homosexually experienced California women

BACKGROUND

Mounting evidence suggests that lesbians and bisexual women may be at especially elevated risk for the harmful health effects of alcohol and tobacco use.

METHODS

We report findings from the California Women's Health Survey (1998-2000), a large, annual statewide health surveillance survey of California women that in 1998 began to include questions assessing same-gender sexual behavior.

RESULTS

Overall, homosexually experienced women are more likely than exclusively heterosexually experienced women to currently smoke and to evidence higher levels of alcohol consumption, both in frequency and quantity. Focusing on age cohorts, the greatest sexual orientation disparity in alcohol use patterns appears clustered among women in the 26-35-year-old group. We also find that recently bisexually active women report higher and riskier alcohol use than women who are exclusively heterosexually active. By contrast, among homosexually experienced women, those who are recently exclusively homosexually active do not show consistent evidence of at-risk patterns of alcohol consumption.

DISCUSSION

Findings underscore the importance of considering within-group differences among homosexually experienced women in risk for tobacco and dysfunctional alcohol use.