S. Leonard Syme

Socioeconomic status and health: the challenge of the gradient.

Socioeconomic status (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.

Promoting Health: Intervention Strategies from Social and Behavioral Research

This report, released by the Division of Health Promotion and Disease Prevention within the Institute of Medicine at the National Academy of Sciences, asserts that behavioral and social interventions such as health promotion and disease prevention offer great promise to reduce disease morbidity and mortality in the United States, but as yet their potential has not been recognized or tapped by the federal government. Two overarching recommendations are the need to address generic social and behavioral determinants of health rather than the clinical causes of disease and death, and the need to intervene at multiple levels of influence including the individual, interpersonal, institutional, community, and policy levels. Seven recommendations for intervention strategies, nine recommendations for research, and three recommendations for funding are offered.

Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: Demographic, physical, dietary and biochemical characteristics

CORONARY heart disease and stroke continue to be the subjects of intensive epidemiologic study in many parts of the world. Particular research interest has been focused on the apparent differences in the prevalence and incidence of coronary heart disease among various racial and geographically separate population groups [l-4]. As a result of these intensive efforts to explain the epidemiology of these diseases and to determine methods of control, pioneering studies have established risk factors for coronary heart disease [.5-lo] and are now establishing such risk factors for cerebrovascular disease as well [l 1, 121. At present, multifactorial causation has been accepted, the strongest evidence being the demonstrated relationship between elevated blood lipid levels, elevated blood pressure levels, and heavy cigarette smoking with coronary atherosclerosis and its clinical manifestations [5-10, 13-161. Studies in many countries have shown that in most populations exhibiting a high serum cholesterol in men, there is also a high prevalence of coronary heart disease [17-191. Usually these people eat a diet high in fat, especially in the form of meat and dairy fat. In most populations with low cholesterol levels and a low prevalence of coronary heart disease, the intake of fat is low and the fat which is ingested is derived primarily from fish and vegetable oils [ 17-201.

Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: Incidence of myocardial infarction and death from coronary heart disease

The incidence of myocardial infarction and death from coronary heart disease was studied in defined samples of 45 to 68 year old Japanese men in Japan, Hawaii and California. The incidence rate was lowest in Japan where it was half that observed in Hawaii (P less than 0.01). The youngest men in the sample in Japan were at particularly low risk. The incidence among Japanese men in California was nearly 50 percent greater than that of Japanese in Hawaii (P less than 0.05). A striking increase in the incidence of myocardial infarction appears to have occurred in the Japanese who migrated to the United States; this increase is more pronounced in California than in Hawaii.

“Culture of Drinking” and Individual Problems with Alcohol Use

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.

Neighborhood smoking norms modify the relation between collective efficacy and smoking behavior

BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS Features of the neighborhood social environment may need to be considered in combinations to understand their role in shaping health and health behavior.

Rethinking disease: Where do we go from here?

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.

Do experiences of racial discrimination predict cardiovascular disease among African American men? The moderating role of internalized negative racial group attitudes

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.

Integration of Social Epidemiology and Community-Engaged Interventions to Improve Health Equity

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.

Strategies for health promotion.

A key element in most efforts to prevent disease and promote health is behavioral change to lower risk. One-to-one programs to help people change their behavior are seriously limited because of the difficulty people have in making behavioral changes and because one-to-one programs do little to modify those forces in the community that continually produce new people at risk. In addition to one-to-one programs, therefore, environmental strategies for disease prevention are needed. Several clues regarding environmental interventions can be gleaned from the study of patterns of disease distributions. Not only are environmental approaches to prevention more efficient and practical than one-to-one programs, they also may shed new light on our understanding of disease etiology.