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Many youth experiencing homelessness (YEH) are surprisingly hopeful. We propose a typology of the hopes for the future (HFTF) of YEH, based on a qualitative study employing grounded theory. YEH fell into four categories: (a) nonmainstream HFTF youth who wished to escape the mainstream, (b) mainstream HFTF youth who wished to integrate into the mainstream, (c) marijuana-economy HFTF youth who aspired to escape homelessness by entering the marijuana economy, and (d) no HFTF youth who did not or could not envision the future. Our finding that some YEH transition between different HFTF suggests a modifiable point of intervention. We share novel findings regarding how the perceived trajectories of some YEH may have been influenced by the evolving legal status of marijuana. Our emic approach to constructing a typology may inform the design of more acceptable/effective interventions. We suggest implications, including ethical quandaries, raised by our findings.

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.

Health researchers and practitioners increasingly recognise the important role communities play in shaping individual health. Health researchers recognise the role of community factors as causes or determinants of health problems; use community-based methods for understanding complex health issues; and design community-level health solutions. In this commentary, we propose a fourth way to think about the role of communities in individual health by arguing that the community engagement process itself has implications for individual health and strong communities. This topic is especially important during adolescence, a developmental window of opportunity during which individuals need meaningful opportunities to contribute to the world around them.

This chapter reviews the more than 100 meta-analyses and systematic reviews of relations between religion/spirituality (R/S) and health that have been published in refereed journals, a far larger number than is generally recognized. The 118 published reviews identified by 2017 were categorized as quantitative meta-analyses (n = 33), qualitative meta-syntheses (n = 7), meta-analyses of case studies (n = 1), or simple systematic reviews (n = 77). They addressed a wide range of substantive topics relevant to every major public health subfield, and incorporated a mean of 33.5 studies per review. Collectively authored by more than 200 distinct individuals, the reviews were published in 83 different journals, 20 in the category of public health. Multiple reviews were published by 14 journals, a majority possessing impact factors above 2.0. Reviewing empirical studies of R/S-health is clearly a very broad-based enterprise not limited to a few individuals or journals. Collectively, the reviews greatly strengthen the case, based on Hill’s criteria, that R/S exerts a causative influence on health. The case for causal influence may now be compelling, and in most cases R/S involvement is associated with better health, although negative associations also exist. Further investigation is warranted to explore the possibility that R/S is a “fundamental cause” of health that maintains an association even when intervening mediating pathways change. This possibility is consistent with the dynamic understandings of R/S presented elsewhere in this volume.

This chapter reviews theories and empirical evidence on relations between religion and spirituality (R/S) and social factors. Religion and spirituality are conceived as evolving over time and residing at both collective and individual levels.

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.

Vacations enable people to help one another, spend time together in pleasant contexts, and renew relational resources. Reasoning that these shared activities spread social and psychological benefits through social networks, we hypothesized that increase in the number of vacationing workers engenders nonlinear decline in psychological distress at the population level. We applied time-series methods to aggregate data on monthly dispensation of antidepressants to the Swedish population for the 147 months starting January 1993. We obtained the data from the pharmacy corporation allied with the national health care system and from governmental sources. Dispensation of antidepressants declined logarithmically with increase in the number of vacationing workers, for men and women alike. The associations held among people beyond retirement age as well as people of working age, further evidence that vacation benefits spread beyond vacationing workers. The results bear on the social regulation of time for restoration as a general determinant of population health.

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.

This study examines the shape of social class gradients for substance use among Mexican adolescents. Substance use and objective and subjective indicators of social class were assessed in house-to-house surveys conducted with 7614 Mexican adolescents in 2004. The sample was designed to be representative of the poorest urban communities in seven Mexican states. The prevalence of current smoking was 16.8%, alcohol consumption was 30.2%, and drug use was 4.6%. Multiple logistic regressions are used to estimate the associations of objective indicators of socioeconomic status (SES) and subjective social status (SSS)-at both community and societal levels-and smoking, alcohol and drug use. Adolescents who perceived themselves as higher in social status in reference to their local community reported more smoking and drinking. Our findings were similar when we used objective measures of SES, such as maternal education and total monthly household expenditures per person. In contrast, adolescents who perceived that they had high social standing in reference to Mexican society as a whole were less likely to report being current smokers and drinkers. We found no significant association between social status and drug use. Research into how adolescents perceive themselves in reference to their peer communities may help strengthen programs and policies aimed at promoting health in vulnerable adolescent populations.

It is well known that people in racial and ethnic minority groups and in lower social-class positions have higher morbidity and mortality rates from virtually every disease. To effectively deal with the problem, we will need to adopt a more appropriate conceptual model that focuses on the fundamental determinants of health, we will need to understand how important this is for all Americans as a society, and we will need to better deal with the issues people care about: their children, homes, jobs, safety, education, families, retirement, and future prospects.

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.

Purpose. To investigate relationships between adolescents' current alcohol, tobacco, and marijuana use; perceptions of neighborhood disorder; and sense of hope. Design. Questionnaires were administered to a nonrandom sample of middle school students during the spring of 1999. Subjects. The ethnically and geographically diverse sample (n = 369), from a range of low socioeconomic status backgrounds, was considered to be at high risk for alcohol, tobacco, and other drug use because of previous enrollment in low socioeconomic status elementary schools. Measures. Alcohol, tobacco, and marijuana use were dichotomized into current and never/no use. Six variables described neighborhood social disorder. Sense of hope was assessed using the Children's Hope Scale. Results. Statistically significant relationships were found between perceived neighborhood disorder and current alcohol (p = .01), tobacco (p = .001), and marijuana (p < .001) use. A statistically significant and independent relationship was found between sense of hope and current alcohol (p = .02), tobacco (p = .02), and marijuana (p = .06) use. Results indicated linear trends in participants' increased use of alcohol, tobacco, and marijuana and (1) perception of higher neighborhood disorder and (2) lower sense of hope. Conclusion. Substance use prevention programs for youth might usefully be directed not only to agdolescents but also to the neighborhoods in which they live. Additionally, it would be important to emphasize creating safer neighborhood environments that support the development of a stronger sense of hope for the future.

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.

To assess whether alcohol, tobacco, and other drug (ATOD) use in elementary school may have serious implications for continued ATOD use in middle school and beyond.Longitudinal analyses were conducted on questionnaire data from 331 middle school students who had previously provided ATOD-use data during elementary school. Non-school personnel administered questionnaires in three participating school districts in three different states. The sample of students was ethnically and geographically diverse, including students from a range of low socioeconomic status backgrounds living in rural, urban or inner-city environments.Middle school alcohol use was almost three times as likely to occur if alcohol use had occurred in elementary school (OR = 2.94, p.001). Elementary school use of tobacco and marijuana also greatly increased the likelihood of middle school use (OR = 5.35, p.001 and OR = 4.25, p.05, respectively).Early use of ATOD is associated with greatly increased odds of later use, which has important implications for the timing of drug prevention programs. Preventive interventions designed for use in pediatric practice settings should commence no later than elementary school, during the middle childhood years.

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.

Is there a problem in epidemiology that requires a rethinking of the way we study disease? No one should be interested in rethinking uqthing unless it is necessary. I think we do have a problem. In fact, I would call it a crisis. There are three elements to this crisis. First, one of our major tasks in epidemiology is to identify risk factors for disease, and we have not done very well in this job. One example of this type of problem is the area of coronary heart disease, a disease that has been studied most aggressively since the 1950s. During these years of massive worldwide effort, a large number of seemingly important risk factors have been identified. The three that everyone agrees on are cigarette smoking, high blood pressure, and high serum cholesterol. Dozens of other risk factors also have been proposed, but not everyone agrees about them, such as obesity, physical inactivity, diabetes, blood lipid and clotting factors, stress, and various hormone factors. When UU of these risk factors are considered together, they explain about 40% of the coronary heart disease that occurs. (1) How is it possible that after 50 years of effort, all of the risk factors we know about, combined, account for less than half of the disease that occurs? Is it possible that we have somehow missed one or two crucial risk factors? This is of course possible, but the relative risk of these risk factors would have to be enormous to account for the other 60% of the coronary heart disease that occurs. It seems not very likely that we would have missed one or two risk factors of such enormous power and importance. And, it must be said, our record of success in the area of coronary heart disease is one of the very best; the results for other diseases is far less impressive. I do not mean to suggest by these remarks that the risk factors we have identified are unimportant. They are important, and they have been useful in the prevention of coronary heart disease, but, clearly, there are other very important issues involved that we do not yet understand.

The present study assessed the relationship between anger expression and health outcomes in a sample of 1,407 San Francisco bus drivers. When controlling for a variety of health-risk factors, the results of multiple logistic regression analyses revealed significant positive associations between high levels of suppressed as well as expressed anger and gastrointestinal, respiratory, and musculoskeletal problems, with one exception (viz., the relationship between expressed anger and gastrointestinal problems was only marginally significant [p = .09]). Although both modes of anger expression were related to these health problems for men, none of the associations were significant for women. The results do not support the view that suppressed anger is more detrimental to health than expressed anger but rather suggest that both modes of coping with anger may increase vulnerability to disease in men.

Approximately half of all causes of mortality in the United States are linked to behavioral factors such as smoking, diet, alcohol use, sedentary lifestyle and accidents (McGinnis & Foege, 1993). One very promising strategy for promoting health and preventing disease, therefore, is to help people change behaviors that increase disease risk—but helping people do this has proven to be a very difficult and challenging problem. One would think that if we informed people of their risks they would rush home and, in the interests of good health, change behaviors that caused the risk. Some people do, but most do not (Smedley & Syme, 2000).

SES is consistently associated with health outcomes, yet little is known about the psychosocial and behavioral mechanisms that might explain this association. Researchers usually control for SES rather than examine it. When it is studied, only effects of lower, poverty-level SES are generally examined. However, there is evidence of a graded association with health at all levels of SES, an observation that requires new thought about domains through which SES may exert its health effects. Variables are highlighted that show a graded relationship with both SES and health to provide examples of possible pathways between SES and health end points. Examples are also given of new analytic approaches that can better illuminate the complexities of the SES-health gradient.

Social risk factors are often less vigorously pursued in clinical assessments of infant risk than are biologic risk factors. We examined the relative importance of early social and biologic risk factors in predicting poor health and educational outcomes in children. The study was composed of all infants born in Winnipeg, Canada, during April-December 1984, who were followed up until age 19 years (n = 4667). Predictors were 3 routinely assessed biologic risks (birth weight, gestational age, and Apgar score) and 3 prominent social factors (mother's age, parent marital status, and socioeconomic status). Outcomes were childhood hospitalization and passage of a required high school examination. Analyses included logistic regression, measures of accuracy, and population attributable risk percent (PAR%). Biologic and social risk factors were associated with similarly steep poor outcomes gradients. Social risk factors had similar, and in some cases stronger, measures of association and accuracy. Using biologic risk criteria alone misclassified as low-risk 65% of cohort children who had high rates of later hospitalization and examination failure. PAR% associated with social risk factors exceeded biologic risk factors in most cases (eg, hospitalization PAR% = 4.4 for offspring of teen mothers vs. 1.7 for low birth weight). In a population-based sample of infants followed-up through adolescence, early social risk factors were as threatening as, and more common than, routinely documented biologic risks-frequently identifying otherwise-unrecognized at-risk children. These findings together suggest that rigorous evaluation of social factors should be made a routine part of clinical assessment to more comprehensively and accurately identify infants at risk for later serious health problems and academic failure.

Three prescriptions are made to improve behavioral pediatrics research: (1) Focus behavioral pediatrics on preventive research from environmental and social perspectives. (2) Ground research questions more extensively within a conceptual framework. (3) Enhance research quality with reliable, valid measurement. Conceptual and methodological improvements in research will facilitate integration of the multidisciplinary, multimethodological, and multitheoretical scope of behavioral pediatrics and further its contributions to science.

An inverse association between socioeconomic status, as measured by years of education, and blood pressure has been reported in a number of studies. However, two secular trends may have changed the nature of this relation: a higher mean level of education in the population and intervention for high blood pressure in the community. Given that education is the most commonly used indicator of social class and measurement is a critical issue in epidemiologic research, a study was initiated to examine the validity of education for predicting blood pressure among 11,554 examined persons aged 25-74 years from the Second National Health and Nutrition Examination Survey (1976-1980) or the Hispanic Health and Nutrition Examination Survey (1982-1984). In univariate analysis, a consistent, inverse association between education and blood pressure was found for whites and blacks, but not for Mexican Americans. After adjustment for age and body mass, the effect persisted only for systolic blood pressure in whites. The association of education and blood pressure was positive in Mexican-American females. Education was inversely related to hypertensive status in whites and in black females. These findings suggest that information on education may be of little value for identifying populations at risk of high blood pressure, particularly if age and body mass are known. However, information on education may be of considerable value in the design and implementation of appropriate interventions.

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.

Studies of the association between type A behavior and coronary heart disease have yielded inconsistent findings. A possible explanation for these inconsistent findings is that type A behavior is simply a marker for other behaviors that are truly related to coronary heart disease. Hostility is one such behavior that has been found in several recent studies to predict coronary heart disease and coronary atherosclerosis; however, several other studies have found null results. In the present study, the predictive power of hostility was tested in a study population of hospitalized men (n = 118) and women (n = 40) scheduled for coronary angiography. Potential coronary risk behaviors were assessed in the angiography patients and they were given the type A Structured Interview. Hostility was measured with the Cook-Medley Hostility Inventory and the Behavior Pattern Hostility Index, a measure of hostility derived from the type A Structured Interview. No significant positive associations were found for either Cook-Medley hostility or behavior pattern hostility and coronary occlusion. This was true whether hostility or coronary occlusion was treated as a dichotomous variable or as a continuous variable. In fact, most of the observed associations were opposite to the predicted direction, although none was statistically significant. Replicating cutpoints of the Cook-Medley Hostility Inventory used in other studies that have reported positive associations with coronary heart disease also yielded null findings. The association between hostility and coronary occlusion was slightly modified by age and sex, but the interaction coefficients were not significant. The sample size yielded adequate statistical power to detect the hypothesized associations, and there was no evidence that selection bias, measurement error, or unexamined confounding accounted for the null findings. These results failed to confirm some earlier reports showing a positive association between hostility and coronary artery disease.

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.

I have been waiting to read this book for 20 years. In 1983, I had a student in one of my classes at Berkeley, a young man named Jim Trostle, who challenged almost everything I said. Trostle was at the time a doctoral student in the Medical Anthropology program at Berkeley (a joint program with the Medical School in San Francisco), and he had taken off a year to get a Masters of Public Health degree. I was a Professor of Social Epidemiology in the School of Public Health, and my research and teaching involved the study of psychosocial factors as they influenced the causation of disease. Trostle argued that I was not paying enough attention to the concept of culture and that my research would suffer as a result. He said that epidemiologists and anthropologists had to find a way to work together so that both could be more effective contributors to human welfare. I thought he might be right, but it was too difficult an idea to take seriously. Epidemiologists use quantitative methods in studies of large populations, whereas anthropologists do qualitative, ethnographic studies in remote Pacific islands. We read different books, we use a different language, and we have very different intellectual histories and traditions. Nevertheless, here was Trostle in my class, learning the new language and trying to find a way to bridge the gap between us. I didn't know if he could accomplish this difficult feat, but I was betting against it.

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.