Race and epidemiology: strategies to build on biological differences

In the current controversies about race and racial differences in health, epidemiology is seen as the authority that confirms or refutes the scientific truth of these differences. Pointing out the current discussions about the limitations of risk factor epidemiology, hegemonic branch of the epidemiological approaches, it is the aim of this article to highlight the ideological character of the causal assumptions and epistemological strategies that restate and reify the racial differences in health based on biological determinism and statistical reductionism. The objective of this work is to highlight the possibilities of contestation of some interpretations about epidemiological findings on racial differences in health, emphasizing the political and ideological aspects of science and providing the investigators with arguments that can help to overcome the racialism that permeates certain causal hypothesis about human diversity and disease.     

Information-gathering and attentional strategies: individual differences in medical students

Information-gathering in medical students was investigated by means of a new system for classifying the questions asked in the clinical interview. The students interviewed two patients of the same age and sex at a clinic for a chronic condition. Analysis of video tapes of these interviews revealed wide variation among the students in their use of five types of questions. It was hypothesized that this variation could be traced to individual differences in four attentional strategies. This hypothesis was confirmed, suggesting that some attentional factors in the interviewer play a role in how the patient is interrogated.     

Ethnic differences in anticipated discrimination, generalised trust in other people and self-rated health: a population-based study in Sweden

This paper investigates the relationship between anticipation that employers may discriminate against certain people (not specified, but not specifically the respondent) according to race, colour of skin, religion or cultural background, and self-rated health, adjusting for social capital in the form of generalised (horizontal) trust in other people. It also investigates ethnic differences in anticipated discrimination in relation to self-rated health. The 2004 Public Health Survey in the Scania region of Sweden is a cross-sectional study. Twenty-seven thousand nine hundred and sixty-three respondents aged 18-80 years answered a postal questionnaire, which represents 59% of the random sample. A logistic regression model was used to assess the association between anticipated discrimination and self-rated health. Multivariate analyses of self-rated health were performed in order to investigate the importance of possible confounders (age, country of origin, education, economic stress, and generalised trust) on this association. Of the men and the women, 28.7 and 33.2%, respectively, rated their health as poor. Of the respondents, 16.0 and 28.7% reported that they anticipated that 'most employers' or 'approximately 50% of employers' would discriminate, respectively. Respondents with high age, born outside Sweden, with low/medium education, economic stress, low horizontal trust, and with anticipation that most or approximately 50% of employers (among men born in Sweden and all women) would discriminate had significantly higher odds ratios of poor self-rated health. Multiple adjustments had a slight effect on the significant relationship between anticipated discrimination and poor self-rated health for both men and women. The introduction of generalised trust in the models reduced the odds ratios to a limited extent. In conclusion, the anticipation that employers may discriminate against certain people (not the respondent) according to race, colour of skin, religion or cultural background is associated with poor self-rated health. However, this is a cross-sectional exploratory study and causality may go in both directions.     

Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries: the CARDIA Study

OBJECTIVES: We examined the effects of self-reported experiences of racial discrimination on Black-White differences in preterm (less than 37 weeks gestation) and low-birthweight (less than 2500 g) deliveries. METHODS: Using logistic regression models, we analyzed data on 352 births among women enrolled in the Coronary Artery Risk Development in Young Adults Study. RESULTS: Among Black women, 50% of those with preterm deliveries and 61% of those with low-birthweight infants reported having experienced racial discrimination in at least 3 situations; among White women, the corresponding percentages were 5% and 0%. The unadjusted odds ratio for preterm delivery among Black versus White women was 2.54 (95% confidence interval [CI]=1.33, 4.85), but this value decreased to 1.88 (95% CI=0.85, 4.12) after adjustment for experiences of racial discrimination and to 1.11 (95% CI=0.51, 2.41) after additional adjustment for alcohol and tobacco use, depression, education, and income. The corresponding odds ratios for low birthweight were 4.24 (95% CI=1.31, 13.67), 2.11 (95% CI=0.75, 5.93), and 2.43 (95% CI=0.79, 7.42). CONCLUSIONS: Self-reported experiences of racial discrimination were associated with preterm and low-birthweight deliveries, and such experiences may contribute to Black-White disparities in perinatal outcomes.     

Workplace privacy: HIV testing, disclosure, and discrimination

Human immunodeficiency virus (HIV) testing and the disclosure of HIV-related information pose questions of privacy and public policy that are of concern in both public- and private-sector workplaces. Public-sector employees have constitutional protection from discrimination on the basis of their HIV-positive status. The Americans with Disabilities Act (ADA) is an important source of protection for private-sector employees. There are also other federal laws that provide protection from discrimination. However, the scope of these laws is unclear. Similarly, while some state legislatures have attempted to set standards to protect the privacy of HIV-positive employees, laws vary from state to state. Case precedent is also inconsistent. This article examines some current issues regarding HIV testing, employee privacy, and protection from discrimination.     

Revision of the Italian psychiatric reform: north/south differences and future strategies

The Italian psychiatric reform of 1978 shifted the care of the mentally ill from the asylum to the community, by prohibiting new admissions to asylums and providing new community-oriented services. Ten years later, the Italian government is reviewing the effects of the psychiatric reform and is considering drastic revisions of the Law. However, few data are available to evaluate the impact of the new legislation on a national basis. The present cross-sectional study, conducted in North-Central and Southern Italy, showed that a more socially disadvantaged patient population was treated in Southern Italian mental health services. In both geographic regions, the probability of being currently treated in mental hospitals as compared to community services was increased by poor education, being unmarried, having a schizophrenia or organic diagnosis, a long psychiatric history, a long previous hospitalization, or a poor prognosis. However, a long psychiatric history was the main factor associated with current mental hospital treatment in Southern Italy but not in the North-Center, thus suggesting that the psychiatric reform has had different impacts on Northern and Southern mental hospitals. The inadequate provision of community-oriented services in Southern Italy regions, and the presence of private mental hospitals that are publicly reimbursed, contribute importantly to the unsatisfactory situation of mental health care delivery in Southern Italy. The reinstitutionalization of mental patients is currently proposed by some political parties in Italy. This article argues that new legislation must address the provision of effective community services in the South, better definition of the role of the private sector, and the creation of an effective information system to monitor the implementation of the proposed measures.     

Doctors and their spouses speak: stress in medical practice

Abstract Many sociological articles assume that the patient-doctor relationship is satisfactory for the doctor and unsatisfactory for the patient. This paper describes a research project on stress among doctors and their families. It seems that the stress the doctor feels may significantly contribute to the problems of the patient-doctor relationship. For example, doctors who cannot cope with their own stress may find it difficult to help their patients cope with stress. The implications of these findings are discussed in the context of the social structure of medical practice and medical education.     

Social network concordance in food choice among spouses, friends, and siblings

Objectives. We investigated whether eating behaviors were concordant among diverse sets of social ties.Methods. We analyzed the socioeconomic and demographic distribution of eating among 3418 members of the Framingham Heart Study observed from 1991 to 2001. We used a data-classification procedure to simplify choices into 7 nonoverlapping patterns that we matched with information on social network ties. We used correlation analysis to examine eating associations among 4 types of peers (spouses, friends, brothers, and sisters). Longitudinal multiple logistic regression was used to evaluate evidence for peer influences on eating.Results. Of all peer types, spouses showed the strongest concordances in eating patterns over time after adjustment for social contextual factors. Across all peers, the eating pattern most likely to be shared by socially connected individuals was “alcohol and snacks.” Models estimating one''s current eating pattern on the basis of a peer''s prior eating provided supportive evidence of a social influence process.Conclusions. Certain eating patterns appeared to be socially transmissible across different kinds of relationships. These findings represent an important step in specifying the relevant social environment in the study of health behaviors to include eating.Food consumption is incontrovertibly linked with public health outcomes ranging from obesity to cardiovascular disease and diabetes.^1,2 Research has found that eating with others affects what an individual consumes³ and, more recently, that obesity status is influenced by ties in social networks.⁴ Together, this knowledge highlights the value of understanding the roles that relationships play in our eating behaviors. To date, however, there has been little research investigating the relationship between patterns of food consumption and the complex patterns of human connectedness. To what degree is the eating behavior of one''s peers associated with what one eats?Research on commensality and health concordance gives some insight into this question. For instance, eating with others is associated with greater ingestion than when food is consumed alone⁵; friends and family members are associated with greater “social facilitation” than are other kinds of relationships, including co-workers, classmates, lovers, or roommates³; family members are more likely to eat together than friends are⁶; and cognitive dietary restraint, disinhibition, and susceptibility to hunger have a significant familial resemblance.⁷ Research on diet in the context of health concordance has found that newly coupled individuals tend to increase their consumption of fruits and vegetables, low-fat foods, and breakfasts together, while consuming less take-out food,⁸ and that spouses’ nutrient consumption is modestly correlated.⁹ Couples shape one another''s choices, although female partners tend to have more influence over male choices.¹⁰ However, a great deal of what we know of commensality has been gleaned from laboratory research rather than real-world studies of eating behavior, thereby excluding the social environment. Similarly, our knowledge of diet concordance in observational studies has largely issued from small-scale, cross-sectional designs.¹¹Previous work on social networks and health has found that weight status is related to patterns of social relations^4,12 and that drinking behaviors can spread in a social network.¹³ However, whether food consumption per se is subject to similar forms of peer influence in a network setting has not been examined. Our objective was to investigate whether connections with particular kinds of intimate relations (spouses, friends, and siblings) were predictive of eating patterns of connected individuals in a large prospective cohort study over time. To address this question, food patterns were first enumerated from food-frequency questionnaires. We then performed a series of correlation analyses to assess food pattern concordance, and we fit a series of longitudinal multiple logistic regression models to test for peer influence on eating among close social contacts.     

Intimacy and marital satisfaction in spouses

The aim of this study was to investigate the relationship between intimacy and marital satisfaction of couples in different stages of the family life cycle. The Personal Assessment of Intimacy in Relationships (PAIR) questionnaire (Schaefer & Olson, 1981) and a subscale of the Enriching and Nurturing Relationship Issues, Communication and Happiness (ENRICH) questionnaire (Olson, Fournier, & Druckman, 1982) were administered to 57 couples. Significant differences between men and women were found on two of the five aspects of experienced intimacy (sexual and recreational) as well as for social and sexual discrepancy scores (difference between experienced and desired intimacy). With the exception of social intimacy as experienced by women, a positive correlation was found for both sexes between all the components of experienced intimacy and marital satisfaction. No differences were found for experienced intimacy or marital satisfaction according to family developmental stages.     

Racial differences in primary care opioid risk reduction strategies

PURPOSE Racial disparities in treating pain with opioids are widely reported; however, differences in use of recommended strategies to reduce the risk of opioid misuse by race/ethnicity have not been evaluated.METHODS In a retrospective cohort of black and white patients with chronic noncancer pain prescribed opioid analgesics for at least 3 months, we assessed physicians’ use of 3 opioid risk reduction strategies: (1) urine drug testing, (2) regular office visits (at least 1 visit per 6 months on opioids and within 30 days of an opioid change), and (3) restricted early opioid refills (receipt of a refill >1 week early less than twice). Nonlinear mixed effect regression models accounted for clustering within physician and adjusted additively for demographics, substance abuse, mental health and medical comorbidities, health care factors, and practice site.RESULTS Of the 1,612 patients studied, 62.1% were black. Black patients were more likely than white patients to receive urine drug testing (10.4% vs 4.1%), regular office visits (56.4% vs 39.0%), and restricted early refills (79.4% vs 72.0%) (P <.001 for each). In fully adjusted models, black patients had significantly higher odds than their white counterparts of receiving regular office visits (odds ratio = 1.51; 95% confidence interval, 1.06–2.14) and restricted early refills (odds ratio = 1.55; 95% confidence interval, 1.03–2.32), but not urine drug testing (odds ratio = 1.41; 95% confidence interval, 0.78–2.54).CONCLUSIONS In this cohort of primary care patients receiving opioid analgesics on a long-term basis, use of risk reduction strategies was very limited overall; however, black patients were more likely than white patients to receive 2 of 3 guideline-recommended strategies. These data raise questions about lax monitoring, especially for white patients taking opioids long term.     

Caregivers of elderly relatives: spouses and adult children.

A problem in the provision of home health care for elderly people is the limited number of family members available for caregiving. Current trends in federal, state, and local policy formation suggest an increasing emphasis on the family as an appropriate caregiver. Therefore, it is necessary to examine how family relationships affect the caregivers' responses to their caregiver situation. Data are presented from 206 caregivers enrolled in a larger longitudinal study of family members caring for elderly dependent relatives. The sample is divided into four caregiver groups: (1) spouses who have children, (2) spouses who have no children, (3) adult children who have siblings, and (4) adult children who have no siblings. Measures selected for comparison were perception of burden, caregiver involvement, affective social support, mental health status, and use of community services. Differences were found among the four groups of caregivers. Implications for social work intervention are discussed.     

Bias, discrimination, and obesity.

This article reviews information on discriminatory attitudes and behaviors against obese individuals, integrates this to show whether systematic discrimination occurs and why, and discusses needed work in the field. Clear and consistent stigmatization, and in some cases discrimination, can be documented in three important areas of living: employment, education, and health care. Among the findings are that 28% of teachers in one study said that becoming obese is the worst thing that can happen to a person; 24% of nurses said that they are "repulsed" by obese persons; and, controlling for income and grades, parents provide less college support for their overweight than for their thin children. There are also suggestions but not yet documentation of discrimination occurring in adoption proceedings, jury selection, housing, and other areas. Given the vast numbers of people potentially affected, it is important to consider the research-related, educational, and social policy implications of these findings.     

Intervention research: Science,skills, and strategies

Despite a rich history of etiological research, the field of occupational safety and health does not a have a rigorous history of research on what works and does not work to prevent and control occupational diseases and injuries. National and global transformations of economies and workplaces with enhanced competitiveness require more attention to options for interventions. A three-pronged approach to building a body of knowledge on intervention research in occupational health and safety is identified in this paper. The approach focuses on the science, skills, and strategies that can be useful in intervention research. Scientifically, researches can draw on constructs and techniques from epidemiology, evaluation practice, and clinical trials. Experimental and nonexperimental approaches have value for occupational studies. The skills needed represent a range of disciplines beyond those traditional of health and safety; social scientists, economists, and organizational theorists often need to be part of research teams. Strategic approaches involve more labor-management partnerships, prospective study designs, and the use of intermediate and surrogate indicators. The strategic challenge will be to conduct intervention research against a backdrop of overriding political and economic pressures. (This article is a US Government work and, as such, is in the public domain in the United States of America.) © 1996 Wiley-Liss, Inc.     

Association mapping: methodologies, strategies, and issues

Recent advances in molecular genetic technology allow for detailed characterization of genetic variation and easy cost-efficient accumulation of such data, even for large human samples. One such advance that presents incredible opportunities for identifying associations between genetic polymorphisms and disease-related phenotypes is the ability to quickly type a large number of single-nucleotide polymorphisms (SNPs). Contributors to Group 10 of Genetic Analysis Workshop 14 explored the potential of SNP genotypes for the association mapping of disease-related genes in family-based studies. Using both real data involving alcoholism susceptibility, made available by the Collaborative Study on the Genetics of Alcoholism (COGA), and simulated data involving personality-disorder susceptibility, group members investigated specific methodological issues involved in association mapping, such as multiple testing, single SNPs vs. combinations and haplotypes, and the effect of linkage disequilibrium on SNP-based linkage; evaluated existing methodologies for association mapping using SNPs, short-tandem repeats (STRs), or a combination of the two; and introduced new or modified association-mapping methods, including a gamma random effects (GRE) model and the quantitative trait linkage disequilibrium (QTLD) test. These papers are unified by the application of association-based methods to analyze SNPs, microsatellite markers, or both, to identify chromosomal regions harboring genes that contribute to quantitative endophenotype variation, and thus to disease risk. Their diversity attests to the breadth and flexibility of association-mapping approaches to the genetics of complex disease.