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Self-rated health (SRH) is an independent predictor of mortality; studies have investigated correlates of SRH to explain this predictive capability. However, the interplay of a broad array of factors that influence health status may not be adequately captured with parametric multivariate regression. This study investigated associations between several health determinants and SRH using recursive partitioning methods. This non-parametric analytic approach aimed to reflect the social-ecological model of health, emphasizing relationships between multiple health determinants, including biological, behavioral, and from social/physical environments. The study sample of 3648 men and women was drawn from the year 15 (2000–2001) data collection of the CARDIA Study, USA, in order to study a young adult sample. Classification tree analysis identified 15 distinct, mutually exclusive, subgroups (eight with a larger proportion of individuals with higher SRH, and seven with a larger proportion of lower SRH), and multi-domain risk and protective factors associated with subgroup membership. Health determinant profiles were not uniform between subgroups, even for those with similar health status. The subgroup with the largest proportion of higher SRH was characterized by several protective factors, whilst that with the largest proportion of lower SRH, with several negative risk factors; certain factors were associated with both higher and lower SRH subgroups. In the full sample, physical activity, education and income were highest ranked by variable importance (random forests analysis) in association with SRH. This exploratory study demonstrates the utility of recursive partitioning methods in studying the joint impact of multiple health determinants. The findings indicate that factors do not affect SRH in the same way across the whole sample. Multiple factors from different domains, and with varying relative importance, are associated with SRH in different subgroups. This has implications for developing and prioritizing appropriate interventions to target conditions and factors that improve self-rated health status., Highlights • Self-rated health (SRH) is an independent predictor of morbidity and mortality. • Partitioning identified 15 distinct subgroups by SRH status and multidomain factors. • Differing risk factor profiles have implications for strategies to improve SRH. • Physical activity, education, income ranked highest overall in relation to SRH. • This approach reflects a social-ecological perspective on correlates of SRH.

Objective To examine the association between self-reported racial discrimination and allostatic load, and whether the association differs by socioeconomic position. Methods We recruited a purposive cross-section of midlife (ages 30–50) African American women residing in four San Francisco Bay area counties (n = 208). Racial discrimination was measured using the Experience of Discrimination scale. Allostatic load was measured as a composite of 15 biomarkers assessing cardiometabolic, neuroendocrine, and inflammatory activity. We calculated four composite measures of allostatic load and three system-specific measures of biological dysregulation. Multivariable regression was used to examine associations, while adjusting for relevant confounders. Results In the high education group, reporting low (b = −1.09, P = .02, 95% CI = −1.99, −0.18) and very high (b = −1.88, P = .003, 95% CI = −3.11, −0.65) discrimination was associated with lower allostatic load (reference=moderate). Among those with lower education, reporting low (b = 2.05, P = .008, 95% CI = 0.55,3.56) discrimination was associated with higher allostatic load. Similar but less consistent associations were found for poverty status. Associations were similar for cardiometabolic functioning, but not for neuroendocrine or inflammatory activity. Conclusions Racial discrimination may be an important predictor of cumulative physiologic dysregulation. Factors associated with educational attainment may mitigate this association for African American women and other groups experiencing chronic social stress.

Objectives. We explored the relationship between social isolation and mortality in a nationally representative US sample and compared the predictive power of social isolation with that of traditional clinical risk factors. Methods. We used data on 16 849 adults from the Third National Health and Nutrition Examination Survey and the National Death Index. Predictor variables were 4 social isolation factors and a composite index. Comparison predictors included smoking, obesity, elevated blood pressure, and high cholesterol. Unadjusted Kaplan–Meier tables and Cox proportional hazards regression models controlling for sociodemographic characteristics were used to predict mortality. Results. Socially isolated men and women had worse unadjusted survival curves than less socially isolated individuals. Cox models revealed that social isolation predicted mortality for both genders, as did smoking and high blood pressure. Among men, individual social predictors included being unmarried, participating infrequently in religious activities, and lacking club or organization affiliations; among women, significant predictors were being unmarried, infrequent social contact, and participating infrequently in religious activities. Conclusions. The strength of social isolation as a predictor of mortality is similar to that of well-documented clinical risk factors. Our results suggest the importance of assessing patients’ level of social isolation.

The past quarter century has seen an explosion of concern about widening health inequities in the United States and worldwide. These inequities are central to the research mission in 2 arenas of public health: social epidemiology and community-engaged interventions. Yet only modest success has been achieved in eliminating health inequities. We advocate dialogue and reciprocal learning between researchers with these 2 perspectives to enhance emerging transdisciplinary language, support new approaches to identifying research questions, and apply integrated theories and methods. We recommend ways to promote transdisciplinary training, practice, and research through creative academic opportunities as well as new funding and structural mechanisms.

Binge drinking is a substantial and growing health problem. Community norms about drinking and drunkenness may influence individual drinking problems. Using data from the New York Social Environment Study (n = 4,000) conducted in 2005, the authors examined the relation between aspects of the neighborhood drinking culture and individual alcohol use. They applied methods to address social stratification and social selection, both of which are challenges to interpreting neighborhood research. In adjusted models, permissive neighborhood drinking norms were associated with moderate drinking (odds ratio (OR) = 1.28, 95% confidence interval (CI): 1.05, 1.55) but not binge drinking; however, social network and individual drinking norms accounted for this association. By contrast, permissive neighborhood drunkenness norms were associated with more moderate drinking (OR = 1.20, 95% CI: 1.03, 1.39) and binge drinking (OR = 1.92, 95% CI: 1.44, 2.56); the binge drinking association remained after adjustment for social network and individual drunkenness norms (OR = 1.58, 95% CI: 1.20, 2.08). Drunkenness norms were more strongly associated with binge drinking for women than for men (p(interaction) = 0.006). Propensity distributions and adjustment for drinking history suggested that social stratification and social selection, respectively, were not plausible explanations for the observed results. Analyses that consider social and structural factors that shape harmful drinking may inform efforts targeting the problematic aspects of alcohol consumption.

Objectives. There is a critical need for effective, large-scale health communication programs to support parents of children aged 0–5 years. We evaluated the effectiveness of the Kit for New Parents, a multimedia health and parenting resource now distributed annually to 500000 parents in California. Methods. In this quasi-experimental study, 462 mothers in the intervention group and 1011 mothers in the comparison group, recruited from prenatal and postnatal programs, completed a baseline interview about health-relevant parenting knowledge, and mothers in the intervention group received the kit. Both groups were reinterviewed 2 months later. At 14-months postbaseline, 350 mothers in the intervention group and a sample of 414 mothers who had equivalent demographic characteristics (comparison group) were interviewed about parenting knowledge and practices. Results. Of the mothers in the intervention group, 87% reported using the kit within 2 months after receiving it, and 53% had shared it with their partner. At both follow-ups, mothers in the intervention group showed greater gains in knowledge and reported better practices at 14 months than did mothers in the comparison group. Gains were greater for prenatal recipients and for Spanish speakers. Providers considered the kit a valuable resource for their parenting programs. Conclusions. The kit is an effective, low-cost, statewide health intervention for parents.

Social class gradients have been explored in adults and children, but not extensively during adolescence. The first objective of this study was to examine the association between adolescent risk behaviors and a new indicator of adolescent relative social position, adolescent perceived social mobility. Second, it investigated potential underlying demographic, socioeconomic and psychosocial determinants of this indicator. Data were taken from the 2004 urban adolescent module of Oportunidades, a cross-sectional study of Mexican adolescents living in poverty. Perceived social mobility was calculated for each subject by taking the difference between their rankings on two 10-rung ladder scales that measured (1) projected future social status and (2) current subjective social status within Mexican society. Adolescents with higher perceived social mobility were significantly less likely to report alcohol consumption, drinking with repercussions, compensated sex, police detainment, physical fighting, consumption of junk food or soda, or watching ≥ 4 hours of television during the last viewing. They were significantly more likely to report exercising during the past week and using a condom during last sexual intercourse. These associations remained significant with the inclusion of covariates, including parental education and household expenditures. Multiple logistic regression analyses show higher perceived social mobility to be associated with staying in school longer and having higher perceived control. The present study provides evidence for the usefulness of perceived social mobility as an indicator for understanding the social gradient in health during adolescence. This research suggests the possibility of implementing policies and interventions that provide adolescents with real reasons to be hopeful about their trajectories.

Background: The etiologic role of biomechanical factors for low back injury (LBI) needs to be confirmed in prospective studies that control for psychosocial factors. Methods: Complete baseline information on 1,233 vehicle operators was gathered during medical examinations and by questionnaire. First LBI during 7.5 years of follow-up was ascertained from insurance records. Hazard ratios and etiologic fractions were analyzed with Cox regression models stratified by injury severity and controlling for age, sex, height, weight, ethnicity, and biomechanical and psychosocial job factors. Severe LBI was defined as medically diagnosed postlaminectomy syndrome, spinal stenosis, herniated lumbar disc, sciatica, or spinal instability. Results: An exponential dose-response relationship was found between weekly driving hours and incidence of first LBI. Indicators of physical workload were more strongly associated with more severe low back injuries compared to less severe injuries. Rates of severe LBI increased 39% for every 10-hr increase in weekly driving (hazard ratio 1.39, 95% confidence interval 1.15-1.68). Higher risks of severe LBI were also found among operators performing heavy physical labor on cable cars (hazard ratio 2.76, 95% confidence intervals 1.24-614) or reporting more ergonomic problems at baseline HR for upper quartile 1.65 (95% confidence interval 1.08-2.50). Estimates of etiologic fractions suggest that reduction of ergonomic problems to the low level currently experienced by 25% of drivers would result in a 19% reduction of severe LBI among all drivers. A change from full- (more than 30 hr) to part-time driving (20-30 hr) could reduce the number of severe LBI by 59%, although this gain would be reduced to 28% at the company level if injuries expected among additional employees, hired to maintain full service are included. Conclusions: Duration of professional driving and ergonomic problems are independent and preventable risk factors for LBI even after adjustment for psychosocial factors. (C) 2004 Wiley-Liss, Inc.

SUMMARY With the rapid rise in health care costs, it has become imperative that departments of health services find effective and affordable ways to prevent disease and promote health. During the past 20 years, most of the major educational interventions in the US designed to prevent disease by changing behavior have not been as successful as expected. At the same time, there is increasing evidence that community participation, a central feature of the ‘new public health’, is a powerful component of the programs that have been successful. In this paper, we describe and evaluate an intervention that heavily involves the community. The Wellness Guide is a comprehensive health promotion guide developed with community participation to improve the wellness knowledge, attitudes and behaviors of recipients. 100 000 copies of The Guide in English

Educational attainment is a well-established social determinant of health. It affects health through many mechanisms such as neural development, biological aging, health literacy and health behaviors, sense of control and empowerment, and life chances. Education—from preschool to beyond college—is also one of the social determinants of health for which there are clear policy pathways for intervention. We reviewed evidence from studies of early childhood, kindergarten through 12th grade, and higher education to identify which components of educational policies and programs are essential for good health outcomes. We have discussed implications for public health interventions and health equity.

Studies examining associations between racial discrimination and cardiovascular health outcomes have been inconsistent, with some studies finding the highest risk of hypertension among African Americans who report no discrimination. A potential explanation of the latter is that hypertension and other cardiovascular problems are fostered by internalization and denial of racial discrimination. To explore this hypothesis, the current study examines the role of internalized negative racial group attitudes in linking experiences of racial discrimination and history of cardiovascular disease among African American men. We predicted a significant interaction between reported discrimination and internalized negative racial group attitudes in predicting cardiovascular disease. Weighted logistic regression analyses were conducted among 1216 African American men from the National Survey of American Life (NSAL; 2001– 2003). We found no main effect of racial discrimination in predicting history of cardiovascular disease. However, agreeing with negative beliefs about Blacks was positively associated with cardiovascular disease history, and also moderated the effect of racial discrimination. Reporting racial discrimination was associated with higher risk of cardiovascular disease among African American men who disagreed with negative beliefs about Blacks. However, among African American men who endorsed negative beliefs about Blacks, the risk of cardiovascular disease was greatest among those reporting no discrimination. Findings suggest that racial discrimination and the internalization of negative racial group attitudes are both risk factors for cardiovascular disease among African American men. Furthermore, the combination of internalizing negative beliefs about Blacks and the absence of reported racial discrimination appear to be associated with particularly poor cardiovascular health. Steps to address racial discrimination as well as programs aimed at developing a positive racial group identity may help to improve cardiovascular health among African American men.

Introduction Studies of the relationship between work time and health have been inconclusive. Consequently, we sought to examine the effect of work time on progression of atherosclerosis. Methods This prospective study of 621 middle-aged Finnish men evaluated effects of baseline and repeat measures of work time on 11-year progression of ultrasonographically assessed carotid intima-media thickness (IMT) and interactions with cardiovascular disease. Multiple linear regression models adjusted for 21 biological, behavioral, and psychosocial risk factors. Results Working 3 (minimum), 5 (medium), or 7 (maximum) days per week at baseline was associated with 23%, 31%, and 40% 11-year increases in IMT, respectively. The relative change ratio (RCR) at maximum vs minimum was 1.14 for baseline days worked per week and 1.10 for hours worked per year of follow-up. Significant interactions existed between cardiovascular disease and work time. Men with ischemic heart disease (IHD) who worked the maximum of 14.5 hours per day experienced a 69% increase in IMT compared with a 29% increase in men without IHD. The RCR ratio for IHD (RCRIHD/RCRno IHD) was 1.44 for hours per day. Similarly, the RCR ratio for baseline carotid artery stenosis was 1.29 for hours per day and 1.22 for hours per year. Conclusion Increases in work time are positively associated with progression of carotid atherosclerosis in middle-aged men, especially in those with preexisting cardiovascular disease. Our findings are consistent with the hemodynamic theory of atherosclerosis.

Although neighborhoods with more collective efficacy have better health in general, recent work suggests that social norms and collective efficacy may in combination influence health behaviors such as smoking.Using data from the New York Social Environment Study (conducted in 2005; n=4000), we examined the separate and combined associations of neighborhood collective efficacy and anti-smoking norms with individual smoking. The outcome was current smoking, assessed using the World Mental Health Comprehensive International Diagnostic Interview (WMH-CIDI) tobacco module. Exposures of interest were neighborhood collective efficacy, measured as the average neighborhood response on a well-established scale, and neighborhood anti-smoking norms, measured as the proportion of residents who believed regular smoking was unacceptable. All analyses adjusted for demographic and socioeconomic characteristics, as well as history of smoking prior to residence in the current neighborhood, individual perception of smoking level in the neighborhood, individual perception of collective efficacy, and individual smoking norms.In separate generalized estimating equation logistic regression models, neighborhood collective efficacy was not associated with smoking (OR 1.06, 95% CI 0.84-1.34) but permissive neighborhood smoking norms were associated with more smoking (OR 1.34, 95% CI 1.03-1.74), particularly among residents with no prior history of smoking (OR 2.88, 95% CI 1.92-4.30). When considered in combination, where smoking norms were permissive, higher collective efficacy was associated with more smoking; in contrast, where norms were strongly anti-smoking, higher collective efficacy was associated with less smoking.Features of the neighborhood social environment may need to be considered in combinations to understand their role in shaping health and health behavior.

Public health research and practice is faced with three problems: 1) a focus on disease instead of health, 2) consideration of risk factor/disease relationships one at a time, and 3) attention to individuals with limited regard for the communities in which they live. We propose a framework for health-focused research and practice. This framework encompasses individual and community pathways to health while incorporating the dynamics of context and overall population vulnerability and resilience. Individual pathways to health may differ, but commonalities will exist. By understanding these commonalities, communities can work to support health-promoting pathways in addition to removing barriers. The perspective afforded by viewing health as a dynamic process instead of as a collection of risk factors and diseases expands the number of approaches to improving health globally. Using this approach, multidisciplinary research teams working with active community participants have the potential to reshape health and intervention sciences.

This is an account of the early days of research on social determinants as I experienced them. I describe my time as one of four Fellows in a new training program in Medical Sociology at Yale University and how I came to be the first Sociologist employed in the U.S. Public Health Service. I then became the first Executive Secretary of a new Study Section at NIH dealing with a small number of research grant proposals in the field of Epidemiology. My account deals with some of my experiences in this developing field, culminating with my appointment as the first Sociologist to become a Professor of Epidemiology in a School of Public Health.

One of the major goals in the field of health promotion and disease prevention is to identify risk factors for disease so that information about these risk factors can then be shared with people. Our hope is that people will use this information to change their behavior to lower their disease risk. There are three major problems with this model that require our serious attention. The first problem is that after decades of epidemiologic research, it has proven very difficult to identify disease risk factors. Consider, for example, the case of coronary heart disease. For over 50 years, extensive research has been done all over the world to identify risk factors for this disease. As a result, we now have knowledge about many of them including serum cholesterol, high blood pressure, cigarette smoking, physical inactivity, obesity, diabetes and so on. In spite of this success, however, most of the coronary heart disease that occurs is not explained by these risk factors. It is estimated that all of the risk factors we know about, combined, explain less than half of the CHD that occurs.1 This does not, of course, diminish the importance of the risk factors we have identified, but it does suggest that things are more complicated than we had thought. The problem we have with CHD is very much the same for many other diseases as well. The second problem is that even when we do identify disease risk factors, we have a very difficult time in getting people to change their behavior. Many research studies have shown that even when people know about risk factors for disease, this often does not result in their changing behavior to lower risk. Most behavior changes occur, in fact, in response to a variety of environmental and community forces that constrain …

It is now well established that inequalities in income lead to high morbidity and mortality rates. Certain explanations for this phenomenon are explored: (1) Instead of income inequalities causing disease, the inequalities are determined by powerful cultural forces. (2) The rich get richer and the poor get poorer. (3) Wealthier people can buy the means to protect their health. (4) Poorer people suffer not from poverty, but from relative deprivation. (5) Those with the weakest genes drift into the lower income groups. It is difficult to develop interventions directed to these possibilities. The concept of “control and destiny” is a possible explanation for the relation between inequalities and disease; unlike the other explanations, this idea is amenable to intervention.

Levine and Dohrenwend are to be congratulated for their excellent presentations. Their views, together with those presented by others, have clarified many dimensions of what has transpired during this meeting. This has been a good meeting. The benefits have, of course, been varied for each depending on past experiences and expectations. For some, this meeting has provided a set of references and a review of the literature; others have obtained a broader sense of where they stand in this field; for yet others, the meeting has been primarily helpful as it approached a clarification of methodologic and theoretical problems. It might now be well to briefly consider some aspects of the work that yet need to be done; to pose the question of "where do we go from here?" Much of what needs to be done has already been considered throughout these sessions. Another summary will not be attempted here since all recognize these critical needs and deficiencies. More relevant and more precise questions must be posed in research. A set of theoretically integrated and meaningful ideas and hypotheses must be developed. Methods more appropriate to the job of testing hypotheses are needed. In addition, of course, the hypotheses need to be tested in various population groups to extend the generality of the findings. All have been impressed with the need for more precise and meaningful work in this area of research. Instead of presenting a more detailed or comprehensive list of things which should be done, another strategy, a perspective, should be considered which may be helpful in the common pursuit of meaningful and productive research in this field.