Household Crowding and Food Insecurity Among Inuit Families With School-Aged Children in the Canadian Arctic

Objectives. We examined the relation of household crowding to food insecurity among Inuit families with school-aged children in Arctic Quebec.Methods. We analyzed data collected between October 2005 and February 2010 from 292 primary caregiver–child dyads from 14 Inuit communities. We collected information about household conditions, food security, and family socioeconomic characteristics by interviews. We used logistic regression models to examine the association between household crowding and food insecurity.Results. Nearly 62% of Inuit families in the Canadian Arctic resided in more crowded households, placing them at risk for food insecurity. About 27% of the families reported reducing the size of their children’s meals because of lack of money. The likelihood of reducing the size of children’s meals was greater in crowded households (odds ratio = 3.73; 95% confidence interval = 1.96, 7.12). After we adjusted for different socioeconomic characteristics, results remained statistically significant.Conclusions. Interventions operating across different levels (community, regional, national) are needed to ensure food security in the region. Targeting families living in crowded conditions as part of social and public health policies aiming to reduce food insecurity in the Arctic could be beneficial.Inadequate housing conditions (e.g., crowding and structural damage) are prevalent among First Nations and Inuit communities in Canada and elsewhere.1 In Nunavik, the Inuit homeland in Arctic Quebec, Canada, the government promoted the relocation of many Inuit families to fledgling communities during the 1950s. Relocated families were moved to small, poorly heated and insulated accommodations. Since then, different programs have been designed by the federal, provincial, territorial, and regional governments to address the housing problem in Nunavik and across the Canadian Arctic.2 At present, more than 90% of the Nunavik population has reported living in social (subsidized) housing.3 In this region, social housing units are allocated locally through a point-based system set according to specific criteria, so that applicants most in need are given first priority (e.g., families with lower income, with young children, and living in overcrowded dwellings).2 Rent is set according to household income, while also considering the cost of living.4 Thus, in Nunavik, housing tenure does not differentiate between households on the basis of financial security or income level, given that nearly all of the population resides in social housing. Such organization rather highlights the high degree of financial need throughout this population and a limited private residential market unattainable by most of the population.Household overcrowding, generally defined as more than 1 person per room,5 is particularly problematic in Nunavik. According to Statistics Canada, 49% of the 2006 population lived in overcrowded houses.5 Often, overcrowding is approached as a consequence of economic difficulties. Living in smaller homes or in shared accommodation has been known as a way to lower living costs to dedicate the available financial resources to other basic necessities.6 In such situations, overcrowded households may experience higher food insecurity as a result of a precarious economic situation. In the particular case of Nunavik, however, crowding is a direct consequence of an underlying, and persistent, lack of housing. Household crowding in Nunavik is not only a product of financial difficulties but also an effect of the rapidly growing and young population. Between 2001 and 2006, the population in Nunavik increased by 12% compared with 4% for the province of Quebec. During the past 3 decades, the population has doubled from 5860 in 1986 to 12 090 in 2011.7 In 2008, it was estimated that more than 900 new housing units were needed, but only 239 units were constructed.8 The housing backlog is further compounded by high costs of construction and short building seasons.The housing situation in Nunavik and throughout the Canadian Arctic raises concerns, in terms of both public health and the health of each individual resident, especially that of children.9–14 Indeed, studies have shown that household crowding is associated with poorer respiratory health, especially among children.12,15 In crowded dwellings, the lack of privacy and the difficulty of withdrawing from (unwanted) social interactions may limit the ability of controlling one’s home situation and lead to “overarousal.”16 Household crowding also has been identified as eliciting chronic stress responses in adults,17 anger and depression18 with possible repercussions on behaviors,19–22 withdrawal,23 and reduced social support24 that, we contend, could influence household food insecurity.Food insecurity occurs when it is not possible to obtain safe, sufficient, and nutritiously adequate foods for a healthy life in socially and culturally acceptable ways.25–27 Studies have shown that in a situation of food insecurity, adults generally first reduce their own food consumption. As the situation becomes more severe, children’s diets also will be reduced, particularly in low-income households with single mothers.28,29 In 2012, 14% of the households in Canada experienced food insecurity.30 In Canadian Arctic communities, food insecurity is high: 62.2% and 31.6% of children live in food-insecure households in Nunavut and Northwest Territories, respectively.30 In Nunavik, the proportion of Inuit children experiencing food insecurity reached 30% in 2006.31 Studies emphasize that a reduction of the quality in diet and nutrient intake resulting from food insecurity is linked to various health issues in children, including poor health,25,32–34 developmental delays,35 and poor mental health.36Access to food products supplied from southern regions of Quebec comes at a very high cost to Nunavik, with an average price 57% higher than in the provincial capital.37 Despite efforts to redress this situation, food costs remain very high and often inaccessible to many Nunavik families who must resort to reducing the amount of food supplies or buying products of lower nutritional quality,38 which compromises health and well-being.36,37,39In a study conducted among low-income families in the United States, Cutts et al.40 found a higher risk of food insecurity and child food insecurity in households with higher housing insecurity. In their study, crowding and multiple moves were considered as indicators of housing insecurity. This association was independent of maternal and family characteristics such as education and household employment. In a recent study involving Inuit households from Nunavut, in the eastern Canadian Arctic, Huet et al.41 reported higher food insecurity among Inuit living in overcrowded households and in houses requiring major repairs. This observation, however, was based on bivariate associations between housing conditions and food insecurity and did not account for other factors such as socioeconomic conditions. These studies nonetheless suggest that food insecurity is not only explained in terms of low socioeconomic status and poverty.40,42We examined whether household crowding was associated with food insecurity among Inuit families with school-aged children, independently of socioeconomic disadvantage.     

Mother-Perceived Social Capital and Children’s Oral Health and Use of Dental Care in the United States

Objectives. We examined the association between mother-perceived neighborhood social capital and oral health status and dental care use in US children.Methods. We analyzed data for 67 388 children whose mothers participated in the 2007 National Survey of Children’s Health. We measured mothers’ perceived social capital with a 4-item social capital index (SCI) that captures reciprocal help, support, and trust in the neighborhood. Dependent variables were mother-perceived ratings of their child’s oral health, unmet dental care needs, and lack of a previous-year preventive dental visit. We performed bivariate and multivariable logistic regression analyses for each outcome.Results. After we controlled for potential confounders, children of mothers with high (SCI = 5–7) and lower levels (SCI ≥ 8) of social capital were 15% (P = .05) and about 40% (P ≤ .02), respectively, more likely to forgo preventive dental visits than were children of mothers with the highest social capital (SCI = 4). Mothers with the lowest SCI were 79% more likely to report unmet dental care needs for their children than were mothers with highest SCI (P = .01).Conclusions. A better understanding of social capital’s effects on children’s oral health risks may help address oral health disparities.It is well established that children living in families with low income and low educational attainment have poorer oral health and access to dental care than children with more affluent and educated families.1,2 Previous research has rigorously described oral health disparities by sociodemographic characteristics of individuals over the years, but only more recently have investigations begun to study the influence of larger contextual, environmental, and societal factors on the population’s oral health.3–6As part of this broader interest in the social determinants of health, the social connections that people have within their communities are receiving growing interest in public health research. This interest is rooted, in part, in the potential for people’s social connections to reduce health inequities through the mobilization of resources in society to better facilitate access to horizontally and vertically available social capital. Furthermore, social capital in the neighborhood may be particularly important for children’s well-being because the neighborhood is usually a central context for children’s psychosocial development. Children learn many of their social skills and values from within their neighborhood social networks.7 Especially in the absence of different kinds of support for children within the family,8 adult intervention on behalf of children in the neighborhood could serve as an important buffer against stressors and social risk factors embedded in the context of children’s lives.Although there is no consensus definition or a standardized approach to measuring social capital, it usually is thought of as consisting of some aspect of social structure and actions of individuals embedded in that structure.7 In social cohesion theory, social capital is conceptualized as the collective resources, such as trust, norms, and reciprocity, available to members of social groups, usually defined by geographic locales.9,10 This “social cohesion” school of social capital has been criticized for overlooking some aspects of social capital such as differences in residents’ abilities to access social capital and its potential negative effects on health.9,11 Nevertheless, greater social capital, measured by various features of social organizations in the community, has been linked to lower mortality and morbidity as well as self-reported better health outcomes.12 The hypothesized mechanisms are that social capital can influence health through (1) the diffusion of knowledge about health promotion, (2) maintenance of healthy behavioral norms or prevention of deviant health-related behaviors through informal social control, (3) promotion of access to local services and amenities, and (4) psychosocial processes that provide effective support, build self-esteem, and foster mutual respect.13It has been reported in the dental literature that a greater number of churches in neighborhood clusters was associated with the reduced severity of dental caries among low-income African American preschool children residing in Detroit, Michigan.3 Bramlett et al. previously examined various child-, family-, and neighborhood-level factors available in the 2003 National Survey of Children’s Health (NSCH) along with state-level factors from a variety of surveillance and census databases to test a multilevel conceptual model of determinants of young children’s oral health.5 Factors related to neighborhood cohesiveness and physical safety were correlated with parent-rated oral health status in children aged 1 through 5 years.5 Lower neighborhood social capital and community empowerment opportunities were also linked to higher rates of dental injuries14 and more dental caries among Brazilian adolescents.15Hypothesized sociobehavioral mechanisms linking social capital to health, empirical evidence on the association of social capital and general health, and initial evidence on the association of social capital–related variables and oral health strongly support further study of its potential impact on children’s oral health. It is evident from the literature that maternal oral health status, knowledge, and self-efficacy have a significant influence on children’s oral health behaviors and outcomes.16–19 In addition, gender may affect one’s perception of neighborhood social capital, patterns, and levels of social engagement and community participation.20,21 Little is known, however, about how social capital is perceived by female caregivers of children and how it might influence their behaviors and their children’s oral health. The purposes of this study were, therefore, to (1) describe the distribution of perceived social capital, using population-based data of self-reported neighborhood social cohesion among US mothers of children younger than 18 years, and (2) determine the association between neighborhood social capital and children’s oral health status and use of dental care.     

A Hierarchy of Unhealthy Food Promotion Effects: Identifying Methodological Approaches and Knowledge Gaps

We assessed the evidence for a conceptual “hierarchy of effects” of marketing, to guide understanding of the relationship between children’s exposure to unhealthy food marketing and poor diets and overweight, and drive the research agenda. We reviewed studies assessing the impact of food promotions on children from MEDLINE, Web of Science, ABI Inform, World Health Organization library database, and The Gray Literature Report. We included articles published in English from 2009 to 2013, with earlier articles from a 2009 systematic review. We grouped articles by outcome of exposure and assessed outcomes within a framework depicting a hierarchy of effects of marketing exposures. Evidence supports a logical sequence of effects linking food promotions to individual-level weight outcomes. Future studies should demonstrate the sustained effects of marketing exposure, and exploit variations in exposures to assess differences in outcomes longitudinally.Systematic reviews have shown that food marketing has an effect on children’s food preferences and consumption.1,2 The lack of evidence directly linking food marketing to children’s weight has proved a barrier to policymakers introducing legislation to limit this practice.3 Food companies would not invest so heavily in marketing to children and in lobbying against legislation to limit marketing4 if this did not increase product sales. Nevertheless, evidence is needed to define the mechanisms that underpin marketing’s influence on children’s weight, and the magnitude of these effects.The argument supporting the need to regulate children’s exposure to unhealthy food marketing hinges on 3 pieces of evidence: (1) food marketing not only encourages brand switching within a product category but also attracts new consumers to the broad food group, (2) the majority of promoted foods are energy-dense and nutrient-poor (“unhealthy”), and (3) consumption of promoted foods contributes to excess energy intake that is not compensated for, leading to weight gain and diet-related disease.4Recent and complex theories recognize marketing as one form of socialization agent that transmits norms, attitudes, motivations, and behaviors to the learner.5,6 Social and learning theories posit that exposure to positive media messages cues children to want portrayed products and to model observed behaviors.5,7 Importantly, these theories suggest that such effects can occur even in the absence of conscious perception of marketing stimuli.6 Less prominent elements of marketing, and the emotions that are evoked, may be stored in memory and individuals may not consciously acknowledge or believe that a promotion has affected them when it has.8The effect of promotions on children’s weight outcomes can be explained by a cascade of effects in which exposure to promotions influences children’s brand awareness, preferences, and consequently their purchases and consumption,9 similar to the hierarchy of effects underpinning social marketing.10 Earlier systematic reviews on this topic have variously grouped these outcomes of exposure as potential determinants of behavior (preferences, attitudes, knowledge, beliefs), effects on behavior (purchase, purchase requests, consumption patterns), and diet-related health outcomes (e.g., body weight)11; or as mediators of diet (preferences, beliefs, purchase requests), diet (short-term consumption, usual dietary intake), and diet-related health outcomes.2 In marketing literature, the relationship between brand awareness and consumption is referred to as “brand equity.”12 Brand equity is achieved when a brand is highly recognizable and associated with positive attributes.12 With this review, we aimed to outline a conceptual pathway of effects of how marketing may ultimately influence children’s weight. We also sought to collate information on methods used to measure the impact of food promotions on different levels of effects. Within the term “marketing,”13 this review specifically focused on food advertising, sponsorships, and sales promotions (collectively referred to as promotions).     

“They’re Going to Die Anyway”: Smoking Shelters at Veterans’ Facilities

Military personnel and veterans are disadvantaged by inadequate tobacco control policies. We conducted a case study of a Department of Veterans Affairs (VA) effort to disallow smoking and tobacco sales in VA facilities.Despite strong VA support, the tobacco industry created a public relations–focused grassroots veterans’ opposition group, eventually pushing the US Congress to pass a law requiring smoking areas in every VA health facility. Arguing that it would be unpatriotic to deny veterans this “freedom” they had ostensibly fought for and that banning smoking could even harm veterans’ health, industry consultants exploited veterans’ organizations to protect tobacco industry profits.Civilian public health advocates should collaborate with veterans to expose the industry’s manipulation, reframe the debate, and repeal the law.THE US MILITARY, COMPOSED primarily of working-class young people, has long been an important source of new smokers for the tobacco industry.1 Although approaching civilian prevalence in recent years,2 tobacco use among military personnel has historically been much higher than that among civilian populations, resulting in greater morbidity and mortality among veterans.3 The tobacco industry has repeatedly interfered with the military’s attempts to discourage smoking.4–6 The tobacco industry exerts influence on civilian overseers of the military through campaign contributions to Congress members, especially those from tobacco-growing states.7 Congress has berated and intimidated military leaders who promote tobacco control4,6 and has written industry-favored policies into law.5,6On discharge from service, the interests of the 24 million veterans of the US armed services are overseen by the Department of Veterans Affairs (VA).3 In 2007, one third of veterans were enrolled in the VA’s health care system, which includes 171 hospitals throughout the United States.8 Veterans smoke at higher rates than do nonveterans,9 are more likely to die prematurely,10 and incur high costs for treating tobacco-caused illnesses.3 For example, each year the VA spends $5 billion to treat chronic obstructive pulmonary disease, 80% of which is attributable to smoking.3 Whether veterans or governments bear the costs, many veterans experience shortened lifespans, physical suffering, and financial hardship because of tobacco use.By the late 1980s, nearly all civilian hospitals prohibited indoor smoking.11,12 In March 1991, the Joint Commission on the Accreditation of Healthcare Organizations, now the Joint Commission, declared that “Accredited hospitals will have to disseminate and enforce a hospitalwide no-smoking policy.”11 Since that time, many hospitals have established not only smoke-free buildings but also smoke-free grounds, partly as a result of concerns about risks of exposure to outdoor secondhand smoke.13 Knowledge about the benefits of cessation, even late in life, has expanded,14 and studies now show that quitting smoking before surgery can lead to better outcomes.15 Denormalizing smoking16,17 and reducing its visibility18 may improve cessation rates, and cessation tends to spread through social networks.19 Smoke-free health facilities, thus, have the potential to improve the health of patients with direct cessation support and by establishing and promoting tobacco-free norms.Although, like many civilian hospital systems, the VA took steps to restrict smoking and tobacco sales at its health care facilities, the tobacco industry, acting through a front group, persuaded Congress to require smoking areas in all VA hospitals. In this archival case study, we explored the enduring legacy of this action and drew lessons for addressing tobacco’s contributions to veterans’ disease burden.     

Environmental Factors Associated With Social Participation of Older Adults Living in Metropolitan,Urban, and Rural Areas: The NuAge Study

Objectives. We compared the social participation of older adults living in metropolitan, urban, and rural areas, and identified associated environmental factors.Methods. From 2004 to 2006, we conducted a cross-sectional study using an age-, gender-, and area-stratified random sample of 1198 adults (aged 67–82 years). We collected data via interviewer-administered questionnaires and derived from Canadian censuses.Results. Social participation did not differ across living areas (P = .09), but after controlling for potential confounding variables, we identified associated area-specific environmental variables. In metropolitan areas, higher social participation was associated with greater proximity to neighborhood resources, having a driver’s license, transit use, and better quality social network (R² = 0.18). In urban areas, higher social participation was associated with greater proximity to neighborhood resources and having a driver’s license (R² = 0.11). Finally, in rural areas, higher social participation was associated with greater accessibility to key resources, having a driver’s license, children living in the neighborhood, and more years lived in the current dwelling (R² = 0.18).Conclusions. To enhance social participation of older adults, public health interventions need to address different environmental factors according to living areas.Social participation, which is defined as the involvement of the person in activities that provide interactions with others in the community,1 is a key element of successful2 and healthy3,4 aging that ensures survival and development of people in society throughout their existence.5 As a modifiable target of health interventions, social participation is conceptualized by the Human Development Model and Disability Creation Process to be the result of bidirectional interaction between personal and environmental factors.5 Some personal factors,6 including age, gender, and health, are recognized as being related to social participation.2 Environmental factors (i.e., aspects that are extrinsic to individuals and generate a reaction from them)7 relate to the immediate social and physical environment to which individuals, especially older adults, are exposed. Environmental factors may act as facilitators or barriers to the accomplishment of social and community activities.5 Environmental factors are also important because interventions targeting the environment may have a greater impact on an individual’s social participation than those targeting individual factors.8To date, some theoretical and empirical evidence supports associations between specific environmental factors and social participation.9 For example, the Human Development Model and Disability Creation Process showed that support, attitude, services, systems, policies, and accessibility of the physical environment can be associated with social participation.5 Another study demonstrated that user-friendliness of the physical environment and access to transport facilities promote older adults’ social participation in both urban and rural areas.10 Favorable characteristics, such as proximity to resources and services, including access to food shopping, health services, banking, and social or sports clubs, are also important factors.11,12 Moreover, independently of individual demographic and socioeconomic characteristics, older adults living in affluent areas are less likely to have lower social participation.13 Support from the social environment14 and resource accessibility in the physical environment11 may be seen as imperatives to help individuals with disabilities living in the community.15 The presence of local resources may have an impact on the likelihood of initiating and maintaining social links with community members.16 However, little is known about which environmental factors are associated with social participation of older adults according to living area. Living in metropolitan, urban, or rural areas can have an impact on many personal factors, such as health and well-being, as well as on several environmental factors (e.g., neighborhood socioeconomic status or access to services and transportation). For example, access to public transport for people living in rural areas may be limited, which can be a challenge.17 To our knowledge, only 1 study18 compared social participation of older people living in metropolitan, urban, and rural areas. Despite area differences in income, access to public transportation, services and resources, automobile use, satisfaction with social support, and sense of security, no significant difference was found in social participation and its associated factors.18 In our study, which involved 350 older adults, we operationalized social participation by the level of difficulty and assistance required in targeted daily activities and social roles. Because having a better understanding of older adults’ social participation according to their living environment could improve the development of public health services, further studies operationalizing social participation by the frequency of involvement in social activities and considering other environmental factors are needed. We aimed to compare social participation of older adults living in metropolitan, urban and rural areas, and identified associated environmental factors.     

Explaining Racial Disparities in Infant Health in Brazil

Objectives. We sought to quantify how socioeconomic, health care, demographic, and geographic effects explain racial disparities in low birth weight (LBW) and preterm birth (PTB) rates in Brazil.Methods. We employed a sample of 8949 infants born between 1995 and 2009 in 15 cities and 7 provinces in Brazil. We focused on disparities in LBW (< 2500 g) and PTB (< 37 gestational weeks) prevalence between infants of African ancestry alone or African mixed with other ancestries, and European ancestry alone. We used a decomposition model to quantify the contributions of conceptually relevant factors to these disparities.Results. The model explained 45% to 94% of LBW and 64% to 94% of PTB disparities between the African ancestry groups and European ancestry. Differences in prenatal care use and geographic location were the most important contributors, followed by socioeconomic differences. The model explained the majority of the disparities for mixed African ancestry and part of the disparity for African ancestry alone.Conclusions. Public policies to improve children’s health should target prenatal care and geographic location differences to reduce health disparities between infants of African and European ancestries in Brazil.Large health disparities exist between Black and White infants in Brazil.1−4 Infant mortality is more than twice as common among Black as White infants in Southern Brazil (30.4 vs 13.9 per 1000).5 Poor birth outcomes including low birth weight (LBW) and preterm birth (PTB) are also more common among Black infants. Racial disparities are also reported in prenatal and postnatal care, with White mothers having more and higher-quality prenatal visits and greater use of postnatal care.6,7Documenting the prevalence and magnitude of racial disparities in infant’s and children’s health is important. However, of more importance is explaining these disparities and identifying the pathways through which they arise to identify contributors that can be targeted by policy interventions. Such effort has lifelong implications because of the importance of children’s health for adult health and human capital attainment.8−12 Because children’s health may have multiplicative effects on health over life, early health disparities may extend into large health and human capital disparities later in life.13,14Studies in the United States have shed light on several pathways that lead to racial disparities in infant’s and children’s health.15−21 Individual-level factors including socioeconomic status (SES),22 maternal age, prenatal care use,22−24 and stressful life events before delivery,17 as well as differences in health care access and quality25−27 and social inequalities because of residential segregation and poverty,15,28,29 are thought to be important contributors to racial disparities in infants’ health in the United States.To our knowledge, there are no studies that simultaneously quantify the contributions of a large number of conceptually relevant factors to racial disparities in infants’ health in Brazil. In this study, we examined the extent to which socioeconomic, health care, demographic, and geographic effects explain disparities in LBW (< 2500 grams) and PTB (< 37 gestational weeks) rates by African ancestry in Brazil. Unlike any previous study for Brazil, we evaluated the contributions of the explanatory factors to the disparities by different degrees of African ancestry. We focused on disparities by African ancestry because they are the most prevalent and affect a large percentage of the Brazilian population.1−5Our study is the first to simultaneously quantify the contributions of several factors both as a group and each on its own (with control for the others) to explaining racial disparities in infant health in Brazil. Such a study is needed not only because Brazil is the largest country in South America but also because there are many historical, demographic, economic, social, cultural, and health care system differences between Brazil and other racially admixed countries such as the United States. These differences limit the generalizability of studies of racial infant health disparities in the United States to the Brazilian population as these differences may modify the underlying factors and the extent of their contributions to the disparities.There is a sharp contrast in perception of race between Brazil and the United States.30 Race for individuals of African and European ancestry in Brazil has been historically and socially defined on a “continuum” of skin color including Black, Brown (mixed between Black and White), or White, instead of the Black or White color line as in the United States. This is in part because of the large racial admixing in Brazil.31 The difference in perceptions of racial identity between Brazil and the United States implies potential differences in cultural and socioeconomic factors related to race and how these may affect health and contribute to racial disparities. Brazil also differs significantly in its economic growth and extent of economic disparities by race from the United States.32 Finally, there are major differences in access to and quality of health care between Brazil and the United States.33,34 For all of these reasons, a study that explains the racial disparities in LBW and PTB in Brazil is needed to draw inferences that can help to inform policymaking and interventions to reduce these disparities in that country.     

Sex and Gender in the US Health Surveillance System: A Call to Action

Youth Risk Behavior Survey (YRBS) data have exposed significant sexual orientation disparities in health. Interest in examining the health of transgender youths, whose gender identities or expressions are not fully congruent with their assigned sex at birth, highlights limitations of the YRBS and the broader US health surveillance system.In 2009, we conducted the mixed-methods Massachusetts Gender Measures Project to develop and cognitively test measures for adolescent health surveillance surveys. A promising measure of transgender status emerged through this work.Further research is needed to produce accurate measures of assigned sex at birth and several dimensions of gender to further our understanding of determinants of gender disparities in health and enable strategic responses to address them.Healthy People 2020 extends a commitment to

assess health disparities in the US population by tracking rates of illness, death, chronic conditions, behaviors, and other types of outcomes in relation to demographic factors1

and aims to “achieve health equity, eliminate disparities, and improve the health of all groups.”2 Youth Risk Behavior Survey data have exposed significant sexual orientation disparities3–8 in health in jurisdictions that included measures of sexual orientation on their surveys.However, gaps in the US health surveillance system inhibit efforts to improve the health of both transgender people9–11 and the nontransgender (cisgender) majority. Demographic measures that would enable the population to be classified as trans- or cisgender are rarely included in the health surveillance system. Such measures, often used in combination, include sex (assigned at birth), gender identity (current), and transgender status (transgender is an identity for some individuals and an adjective or status for others). Data about additional dimensions of gender (e.g., expression, beliefs about gender) that could be used to tackle persistent health disparities are also not collected, and these gaps represent untapped potential to improve population health.Although sex and gender identity are often static and concordant for the vast majority of Americans, both sex and gender (more broadly) are multidimensional constructs and can vary over time—particularly for transgender people. The term sex refers to biological differences between male, female, and intersex people (hormones, secondary sex characteristics, reproductive anatomy) that can be altered through the use of hormones and surgical interventions.12 The assignment of individuals to a sex category by medical practitioners at birth is typically based on the appearance of external genitalia and is recorded on the birth certificate as male or female (and assumes a legal status). Legal sex can sometimes be changed on legal documents (e.g., birth certificate, driver’s license, passport) through a complex set of legal procedures. Gender has psychological (identity—an internal sense of being a boy or girl, genderqueer, etc.), social (beliefs about gender, the roles that one assumes, community affiliation), and behavioral (gender expression, how one expresses one’s identity through appearance and actions and is perceived by others) dimensions.13Unfortunately, sex and gender are rarely explicitly measured, and when data are collected, a range of measures and approaches are used. In recognition of the importance of sex and gender identity as demographic characteristics of the US population, and variability in their measurement, the Institute of Medicine,14 US Department of Health and Human Services,15 and Centers for Disease Control and Prevention16 have called for a national data standard for sex and research to create valid measures of gender identity. Although the Youth Risk Behavior Survey relies on self-reported sex, other health surveillance surveys, such as the Behavioral Risk Factor Surveillance System,17 are telephone administered and classify respondents as male or female according to the sound of their voice, or, as in the in-person National Health Interview Survey,18 use visual appearance, with direct questioning about the respondent’s sex by the interviewer “if necessary”17 or “not apparent,”18 respectively. These data are used as measures of both sex and gender identity19,20; however, they actually measure the interviewer’s perception of the respondent’s gender identity.Data about other dimensions of gender, such as gender expression and beliefs about gender (the individual-level analog to gender norms, a societal-level construct), are not collected in the health surveillance system, despite growing bodies of research that highlight their importance as health determinants. Research conducted in lesbian, gay, and bisexual, as well as general, primarily heterosexual cisgender samples, indicates that individuals whose gender expression fails to conform to sex-linked social expectations (e.g., masculine girls and women, feminine boys and men) are at increased risk for violence,21–28 discrimination,23 posttraumatic stress disorder,28 and depression.29 Violence23,30–38 and discrimination39–41 against transgender people, who are gender nonconforming by identity or expression in relation to their assigned sex at birth, is commonplace.Research conducted in the general population shows that beliefs about gender (e.g., violence is acceptable, exercising caution is not masculine, being assertive is not feminine)42 are associated with aggression43–47 and alcohol use.44,48 Thus, strategies to ameliorate persistent public health problems, such as high mortality among men from injury, homicide, and suicide,49 might be advanced by the collection of gender data. Long-standing disparities in depression that disfavor women50,51 might also be addressed by reducing girls’ and women’s exposure to violence52 and by modifying emotional coping styles (e.g., rumination is more common among girls and women,53 whereas problem solving is positively associated with masculine traits and negatively associated with depression54).     

Health Among Caregivers of Children With Health Problems: Findings From a Canadian Population-Based Study

Objectives. We used population-based data to evaluate whether caring for a child with health problems had implications for caregiver health after we controlled for relevant covariates.Methods. We used data on 9401 children and their caregivers from a population-based Canadian study. We performed analyses to compare 3633 healthy children with 2485 children with health problems. Caregiver health outcomes included chronic conditions, activity limitations, self-reported general health, depressive symptoms, social support, family functioning, and marital satisfaction. Covariates included family (single-parent status, number of children, income adequacy), caregiver (gender, age, education, smoking status, biological relationship to child), and child (age, gender) characteristics.Results. Logistic regression showed that caregivers of children with health problems had more than twice the odds of reporting chronic conditions, activity limitations, and elevated depressive symptoms, and had greater odds of reporting poorer general health than did caregivers of healthy children.Conclusions. Caregivers of children with health problems had substantially greater odds of health problems than did caregivers of healthy children. The findings are consistent with the movement toward family-centered services recognizing the link between caregivers'' health and health of the children for whom they care.Caring for a child with health problems can entail greater than average time demands,^1,2 medical costs,^3,4 employment constraints,^5,6 and childcare challenges.^6–8 These demands may affect the health of caregivers, a notion supported by a variety of small-scale observational studies that have shown increased levels of stress, distress, emotional problems, and depression among caregivers of children with health problems.^1,2,5,9–12Whether these problems are caused by the additional demands of caring for children with health problems or by confounding variables is difficult to answer definitively. The literature reports the identification of a variety of factors purported to be associated with caregiver health, including contextual factors such as socioeconomic status^13–17; child factors such as level of disability,^{1,11,13,18–21} presence of behavior problems,^22–25 and overall child adjustment²⁶; and caregiver-related characteristics such as coping strategies^11,22,27 and support from friends and family.^15,17,28,29 In general, this work has been based on small clinic-based samples^9,30 or specific child populations (e.g., cerebral palsy,^5,25 attention-deficit/hyperactivity disorder^31,32), and typically has been hampered by limited generalizability and a lack of careful, multivariate analysis. Furthermore, most studies have focused on caregivers'' psychological health,^1,2,5,9–12 although physical health effects may also exist among caregivers.^5,19,25,33One of the few studies to involve large-scale, population-based data compared the health of 468 caregivers of children with cerebral palsy to the health of a population-based sample of Canadian parents.⁵ The study showed that caregivers of children with cerebral palsy had poorer health on a variety of physical and psychological health measures. Furthermore, the data were consistent with a stress process model,^5,25 which proposes that additional stresses associated with caring for a child with cerebral palsy directly contribute to poorer caregiver health. However, these findings were based on a specific subpopulation of caregivers and univariate comparisons that could not control for potentially important confounders such as variation in caregiver education, income, and other demographic factors.We used population-based data to test the hypothesis that the health of caregivers of children with health problems would be significantly poorer than that of caregivers of healthy children, even after we controlled for relevant covariates. Our approach of using large-scale, population-based data representing a broad spectrum of childhood health problems³⁴ makes 4 key contributions to the current literature. First, our use of population-based data rather than small-scale, clinic-based studies yielded results that are potentially generalizable to a wide group of caregivers caring for children with health problems. Second, our examination of children with and without health problems allowed us to examine caregiver health effects across a wide variety of caregiving situations. Third, consideration of physical health outcomes (in addition to more regularly studied psychological outcomes) increased our knowledge of the breadth of caregiver health issues. Finally, controlling for relevant covariates allowed us to rule out a number of alternative explanations for caregiver health effects.     

The association between social factors and physical activity among low-income adults living in public housing

Objectives. We sought to examine the association between structural, functional, and normative social factors and physical activity among urban, low-income, racially/ethnically diverse adults.Methods. We conducted a baseline cross-sectional survey among residents of 12 low-income housing communities in metropolitan Boston, Massachusetts. Participants were also asked to wear a pedometer for 5 days. We analyzed complete data from 1112 residents (weighted n = 1635).Results. Residents with smaller social networks were significantly less physically active than were residents with larger social networks (b = −1503.7; P = .01) and residents with conflicting demands were more active than were residents with none (b = 601.6; P = .01), when we controlled for employment status, gender, poverty level, current health status, age, and perceived safety. Social networks were most strongly associated with physical activity among Hispanics and younger residents (aged 18–35 years).Conclusions. These findings indicate that social factors, including social networks and role-related conflicting demands, may be important drivers of physical activity among low-income populations. Researchers and practitioners should consider social factors in developing multilevel physical activity interventions for this population.A large proportion of adults in the United States remains physically inactive, despite consistent evidence of the benefits of reduced chronic disease morbidity and mortality that regular physical activity confers.¹ As with many health behaviors, patterns in physical activity differ according to a number of sociodemographic factors including age, race/ethnicity, gender, and work status.^2–6 Increasing participation in physical activity among all segments of the population necessitates understanding the determinants of physical activity that can then be effectively targeted through programs and policies.Recognition is growing of the role the social environment has in influencing physical activity.^5,7,8 The research conducted in this area suggests that a range of potentially modifiable social factors plays an important role in shaping physical activity patterns. These factors may be organized as: (1) structural, which may include the existence and quantity of social ties,⁹ as well as the roles and responsibilities that may stem from one''s social position and life circumstances^10,11; (2) functional, including perceptions of social support¹² and social cohesion¹³; and (3) normative, pertaining to social norms for physical activity.^14,15With respect to structural social factors, evidence of associations with physical activity has been mixed. For example, some studies have found a significant positive association between marital status and physical activity,¹⁶ whereas other studies report no association.^17,18 However, other social network indicators (e.g., network size, frequency and quantity of contact, homogeneity) have been associated with energy expenditure, exercise adherence, and increased level of physical activity.^19–21 Participation or membership in groups has also been identified as a potentially important factor that may influence physical activity.^22,23 Additionally, having multiple role-related responsibilities or demands stemming from social or familial relationships or one''s social position may have important consequences for health behaviors,^10,11,24 and these factors may be particularly influential among lower-income populations.^19,25,26With respect to functional aspects, social support from friends and family and having a companion for activity have consistently emerged as important correlates of leisure-time physical activity and walking.^{17,22,27–37} Some evidence has shown that greater levels of social capital, social cohesion, trust of neighbors, and sense of community are associated with greater participation in leisure-time physical activity^38,39 and higher levels of walking for leisure and transportation.^40–43 By contrast, much of the literature on social norms and normative influences has reported no or weak associations with physical activity,⁵ with some exceptions.^19,44Although researchers are beginning to understand the important role of social factors in relation to physical activity, very little is still understood about how these factors influence low-income, racially/ethnically diverse populations who bear a disproportionate burden of chronic disease incidence, morbidity, and mortality. The current research was guided by the social–contextual framework, conceptualized by Sorensen et al.²⁵ to inform the development of cancer prevention interventions among working-class, multiethnic populations. This transdisciplinary framework recognizes that health behaviors occur within a larger social context, and identifies factors across multiple levels (e.g., interpersonal, community) that may influence health behaviors and outcomes, directly or indirectly, through mediating mechanisms. McNeill et al.⁴⁵ provided conceptual model.We investigated whether a range of social factors contributes to differences in physical activity among urban, racially/ethnically diverse adults living in low-income housing. We extended the social–contextual framework to enhance the specificity and organization of the social factors being considered. Specifically, we conceptualized social factors as (1) structural (social networks, social participation, conflicting demands, and role responsibilities); (2) functional (general social support, social support for physical activity, and social cohesion); and (3) normative (social norms). We hypothesized that each of these social factors would be positively associated with physical activity. We also examined whether female gender, racial/ethnic minority status, and age moderated these associations, as these populations are typically believed to be less active and suffer a disproportionate burden of activity-related chronic disease.     

Prevalence,Harm Perceptions,and Reasons for Using Noncombustible Tobacco Products Among Current and Former Smokers

Objectives. We provided estimates of noncombustible tobacco product (electronic nicotine delivery systems [ENDS]; snus; chewing tobacco, dip, or snuff; and dissolvables) use among current and former smokers and examined harm perceptions of noncombustible tobacco products and reasons for their use.Methods. We assessed awareness of, prevalence of, purchase of, harm perceptions of, and reasons for using noncombustible tobacco products among 1487 current and former smokers from 8 US designated market areas. We used adjusted logistic regression to identify correlates of noncombustible tobacco product use.Results. Of the sample, 96% were aware of at least 1 noncombustible tobacco product, but only 33% had used and 21% had purchased one. Noncombustible tobacco product use was associated with being male, non-Hispanic White, younger, and more nicotine dependent. Respondents used noncombustible tobacco products to cut down or quit cigarettes, but only snus was associated with a higher likelihood of making a quit attempt. Users of noncombustible tobacco products, particularly ENDS, were most likely to endorse the product as less harmful than cigarettes.Conclusions. Smokers may use noncombustible tobacco products to cut down or quit smoking. However, noncombustible tobacco product use was not associated with a reduction in cigarettes per day or cessation.The use of noncombustible tobacco products has increased rapidly in recent years1–3 and may continue to rise in response to restrictions such as smoke-free indoor air laws and rising cigarette taxes.4–8 Noncombustible tobacco products can be grouped into 2 broad categories—aerosolized products such as e-cigarettes, or more accurately termed electronic nicotine delivery systems (ENDS), which deliver nicotine primarily through vapor inhalation that mimics smoking a traditional cigarette,9 and smokeless tobacco products such as chew, dip, or snuff; snus; and dissolvables, which deliver nicotine via oral mucosal absorption.10 These products are marketed to appeal to unique target audiences,9,11–13 such as smokers and young adults, and vary in levels of harmful constituents.9Noncombustible tobacco products are a critical part of the tobacco industry’s strategy to navigate the changing tobacco product landscape. Phillip Morris14,15 and RJ Reynolds16 have announced their intent to develop and market noncombustible tobacco products as part of a shift to reduced harm products.17 In some cases, noncombustible tobacco products have been used to expand the appeal of established cigarette brands to a broader spectrum of consumers, as with RJ Reynolds’s Camel Snus product.18 Most ENDS are marketed and sold independently; however, this is changing with Lorillard’s acquisition of blu eCigs in 201219,20 and the recent launches of RJ Reynolds’s Vuse digital vapor cigarettes21,22 and Altria’s MarkTen e-cigarettes.23Noncombustible tobacco product awareness and prevalence vary by product. In 2010, approximately 40% of adults reported awareness of e-cigarettes,24,25 rising to nearly 60% in 201125; awareness approached 75% among current and former smokers in 2010 to 2011.26 Between 1.8% and 3.4% of the adult general population has tried an e-cigarette,24,25,27,28 including up to 21.2% of current smokers.25,26 More than 40% of adults have heard of snus,29 5% have tried the product,29 and 1.4% are current users.30 Awareness of dissolvables is low (10%), and use is even lower (0.5%).29 Noncombustible tobacco product use is highest among young adults26,31 and smokers.24,27,28Although use of noncombustible tobacco products could potentially reduce harm associated with smoking if they replace cigarettes,32,33 some studies suggest that current smokers who use noncombustible tobacco products do not reduce combustible use and may delay cessation.12,34–37 For example, a study by Wetter et al.38 found that dual users of smokeless tobacco products and cigarettes were less likely to quit than were either smokeless tobacco product or cigarette users alone. This is of concern given the rising rates of dual use; a recent study reported that 30% of young adults who smoke cigarettes use at least 1 other tobacco product.31 Dual use is more prevalent among men,39,40 those of lower socioeconomic status,39,41 and youths and young adults.35,41,42Studies show that most users (65%–85%) perceive ENDS as less harmful than cigarettes,24,26,43 and 40% to 50% perceive snus and dissolvables as equally harmful as cigarettes.29 Few studies have examined reasons for use; one study of visitors to ENDS and smoking cessation Web sites found that nearly 85% used ENDS because they believed that they were less toxic than tobacco; other responses included use of ENDS to deal with cravings or withdrawal, to quit smoking, and to save money.43 Focus group research has shown that adults associate snus and dissolvables with historic images of chewing tobacco,34,44 express skepticism that the products are safer than cigarettes,34 do not view them as substitutes for cigarettes,34,44 and express concern about the user’s lack of control of nicotine ingestion relative to cigarettes.44 By contrast, young adults expressed positive perceptions of snus, dissolvables, and ENDS, in part because of a willingness to experiment with new products and because they are available in flavors.45With the ever-changing tobacco marketplace and the tobacco companies’ commitment to the development and promotion of noncombustible tobacco products, surveillance is critical. This study built on previous research to provide current estimates of noncombustible tobacco product use among current and former smokers and examined harm perceptions of noncombustible tobacco products and reasons for their use.     

The Role of Young Adults’ Pleasure Attitudes in Shaping Condom Use

Condoms can help young adults protect themselves from sexually transmitted infections and unintended pregnancy. We examined young people’s attitudes about whether condoms reduced pleasure and how these attitudes shape condom practices. We used a nationally representative sample of 2328 heterosexually active, unmarried 15- to 24-year-old young adults to document multivariate associations with condom nonuse at the last sexual episode. For both young men and women, pleasure-related attitudes were more strongly associated with lack of condom use than all sociodemographic or sexual history factors. Research and interventions should consistently assess and address young people’s attitudes about how condoms affect pleasure.Because of their unique ability to prevent both pregnancy and sexually transmitted infections (STIs), male condoms are a vital public health tool. For decades, researchers have worked to understand and promote young adults’ consistent condom use. Although 15- to 24-year-old young adults represent only 25% of the sexually experienced population in the United States, they account for 53% of all unintended pregnancies1 and nearly half of all new STI cases.2Many studies document the sociodemographic and sexual history factors most associated with young adults’ condom use,3–5 including age, education, and number of sexual partners.6 Research also explores psychosocial factors such as self-esteem7,8 and condom self-efficacy,9 as well as gender inequality that may render condom use especially difficult for young women.10 Relatively little research explores young people’s attitudes about condoms and sexual pleasure.Burgeoning research among samples of “older” adults11,12 and college students13,14 has suggested that attitudes about how condoms affected sexual pleasure might influence condom use practices, although this work has primarily focused on men.15,16 One exploratory mixed-gender study documented that both adult women and men who reported that condoms undermine arousal and enjoyment were least likely to use them.17 However, fewer studies have explored such pleasure attitudes among adolescents and young adults, especially among young women,18 and no nationally representative studies of this topic exist for any age group. We addressed these limitations using a nationally representative sample of young adult women and men to assess how attitudes about condoms and sexual pleasure might be related to condom practices.     

Social gradients in oral health in older adults: findings from the English longitudinal survey of aging

Objectives. We examined prospective associations between socioeconomic position (SEP) markers and oral health outcomes in a national sample of older adults in England.Methods. Data were from the English Longitudinal Survey of Aging, a national cohort study of community-dwelling people aged 50 years and older. SEP markers (education, occupation, household income, household wealth, subjective social status, and childhood SEP) and sociodemographic confounders (age, gender, and marital status) were from wave 1. We collected 3 self-reported oral health outcomes at wave 3: having natural teeth (dentate vs edentate), self-rated oral health, and oral impacts on daily life. Using multivariate logistic regression models, we estimated associations between each SEP indicator and each oral health outcome, adjusted for confounders.Results. Irrespective of SEP marker, there were inverse graded associations between SEP and edentulousness, with proportionately more edentate participants at each lower SEP level. Lower SEP was also associated with worse self-rated oral health and oral impacts among dentate, but not among edentate, participants.Conclusions. There are consistent and clear social gradients in the oral health of older adults in England, with disparities evident throughout the SEP hierarchy.The inverse linear relationship between socioeconomic position (SEP) and health is well established.^1–4 The uneven distribution of health across socioeconomic strata has been observed in both industrialized and less developed countries and for most common diseases and causes of death.^1,5–8 In most cases, the association between SEP and health is characterized by a linear graded pattern, with people in each lower SEP category having successively worse levels of health and dying earlier than those that are better off, a characteristic known as the social gradient in health.⁹Although there is clear and consistent evidence about the existence of the social gradient in working-age adults,^10,11 studies in older adults are less consistent, with some showing attenuation of the gradient^12,13 and others reporting that it persisted^14,15 or even increased¹⁶ in magnitude.Oral health is particularly important at older ages with tooth loss shown to be independently associated with disability and mortality.^17–20 Oral health status in older people is also an important determinant of nutritional status.²¹Socioeconomic disparities in oral health have been consistently demonstrated for various indicators, mostly clinical and disease related^22–31 but also subjective measures of oral health and quality of life.^30,32–38 Some of these studies have explicitly assessed the existence of an oral health gradient,^{23,25–31,34–37} but almost all were carried out on adolescents and adults, with very few focusing on older people.^33,36 These few relevant studies are cross-sectional and inconclusive and have used a limited number of SEP indicators (typically, education and occupational class), thereby hindering any comprehensive analysis on the relationship between SEP and oral health.We addressed the gap in the literature about the existence of an oral health gradient at older ages by examining the prospective associations between a wide range of SEP indicators (education, occupation, household income, household wealth, subjective social status [SSS], and childhood SEP) and various oral health outcomes (presence of natural teeth, self-rated oral health, and oral impacts) in a national sample of older adults from the English Longitudinal Survey of Aging (ELSA). We explored whether there are any significant socioeconomic inequalities in oral health among older people in England and, if so, whether these take the form of a gradient.     

A Social Network–Informed Latent Class Analysis of Patterns of Substance Use,Sexual Behavior,and Mental Health: Social Network Study III,Winnipeg, Manitoba,Canada

Objectives. We assessed whether a meaningful set of latent risk profiles could be identified in an inner-city population through individual and network characteristics of substance use, sexual behaviors, and mental health status.Methods. Data came from 600 participants in Social Network Study III, conducted in 2009 in Winnipeg, Manitoba, Canada. We used latent class analysis (LCA) to identify risk profiles and, with covariates, to identify predictors of class.Results. A 4-class model of risk profiles fit the data best: (1) solitary users reported polydrug use at the individual level, but low probabilities of substance use or concurrent sexual partners with network members; (2) social–all-substance users reported polydrug use at the individual and network levels; (3) social–noninjection drug users reported less likelihood of injection drug and solvent use; (4) low-risk users reported low probabilities across substances. Unstable housing, preadolescent substance use, age, and hepatitis C status predicted risk profiles.Conclusions. Incorporation of social network variables into LCA can distinguish important subgroups with varying patterns of risk behaviors that can lead to sexually transmitted and bloodborne infections.Infection with HIV and other sexually transmitted and bloodborne infections (STBBIs) has been described as occurring in a nexus of risk, in which a diverse range of life circumstances interact to create a risk environment.1 This nexus-of-risk concept is similar to the social epidemiology literature, which seeks to better understand how individual, social, and structural factors create a risk environment conducive to disease transmission.2 In addition to their contribution to understanding risk, contextual approaches of this type are important for developing targeted, effective public health interventions. The efficacy of structural HIV prevention interventions is largely determined by whether the social and structural factors underlying transmission are accurately identified.3–5 Further, interventions focused on individual-level behaviors are likely to be more effective when, rather than targeting an entire population with a universal message, they develop communications that resonate with a population subgroup’s particular needs.6Specific statistical techniques facilitate identification of subgroups in social contextual analyses. Latent class analysis (LCA) has proven its worth as an inductive technique that uncovers underlying (latent) profiles or classes of individuals with shared characteristics.7,8 To date, LCA has been applied in several analyses relevant to STBBI risk. Alcohol abuse has been examined in relation to place of consumption,9 sexual behavior,10 and mental disorders.11 Investigations of illicit drug use have focused on profiles associated with specific substances or groups of substances,12,13 with some investigators incorporating routes of administration.6,14–16 Higher-order social and structural factors, analogous to the concept of the nexus of risk, have been incorporated to assess HIV risk in relation to homelessness, incarceration, income level, and housing.5 Smith and Lanza have brought in elements of an individual’s social network to compare theorized network roles with those observed empirically, with the intent to inform opinion leader interventions focused on HIV.17To our knowledge, the analysis by Smith and Lanza is the only LCA concerning HIV and STBBIs to incorporate aspects of social networks.17 Their analysis focuses on the potential influence of social network roles as underlying determinants of the success of HIV interventions. We used social network variables of substance use and sexual behavior to assess whether a meaningful set of subgroups could be identified. An approach of this kind could ultimately provide a more nuanced understanding of risk as well as inform the development of more effective prevention programs.     

Socioeconomic Status and Bullying: A Meta-Analysis

We examined whether socioeconomic status (SES) could be used to identify which schools or children are at greatest risk of bullying, which can adversely affect children’s health and life.We conducted a review of published literature on school bullying and SES. We identified 28 studies that reported an association between roles in school bullying (victim, bully, and bully-victim) and measures of SES. Random effects models showed SES was weakly related to bullying roles. Adjusting for publication bias, victims (odds ratio [OR] = 1.40; 95% confidence interval [CI] = 1.24, 1.58) and bully-victims (OR = 1.54; 95% CI = 1.36, 1.74) were more likely to come from low socioeconomic households. Bullies (OR = 0.98; 95% CI = 0.97, 0.99) and victims (OR = 0.95; 95% CI = 0.94, 0.97) were slightly less likely to come from high socioeconomic backgrounds.SES provides little guidance for targeted intervention, and all schools and children, not just those with more socioeconomic deprivation, should be targeted to reduce the adverse effects of bullying.Bullying is defined as repeated, harmful behavior, characterized by an imbalance of power between the victim and perpetrator(s).1 There is compelling evidence that school bullying affects children’s health and well being, with the effects lasting long into adulthood.2,3 Victims of school bullying are at greater risk of physical and mental health problems,4,5 including depression,6,7 anxiety,8,9 psychotic or borderline personality symptoms,10,11 and are more likely to self-harm and attempt suicide.12,13 A small proportion of victims are classified as bully-victims, children who are victimized by their peers, but who also bully other children. Bully-victims are at even greater risk for maladjustment,5 exhibiting attention and behavioral difficulties,4,14 displaying poor social skills,15,16 and reporting increased levels of depression and anxiety through adolescence and into adulthood.2 By contrast, the negative outcomes of bullying perpetration are less clear. Bullies have been found more likely to engage in delinquent or antisocial behavior17,18; however, once other family and childhood risk factors are taken into account, they do not appear to be at any greater risk for poorer health, criminal, or social outcomes in adulthood.3Up to one third of children are involved in bullying, as bully, victim, or bully-victim,19,20 and when considered alongside the damaging effects on physical and mental health, bullying can be seen as a major public health concern.21 Identifying risk factors for bullying aids potential efforts in targeting resources, which can prevent youths from becoming involved in bullying, but also limits the impact it has on their health and well being. Traditional risk factors, such as age and gender, show a clear association22,23; however, there are a range of other potential determinants whose relationship to bullying remain unclear. One such determinant is socioeconomic status (SES), which shows some links to bullying, but at present, research findings are inconsistent regarding roles (i.e., bully, victim, or bully-victim).SES is an aggregate concept comprising resource-based (i.e., material and social resources) and prestige-based (individual’s rank or status) indicators of socioeconomic position, which can be measured across societal levels (individual, household, and neighborhood) and at different periods in time.24 It can be assessed through individual measures, such as education, income, or occupation,25,26 but also through composite measures that combine or assign weights to different socioeconomic aspects to provide an overall index of socioeconomic level. There is no standard measure of SES; indicators are used to measure specific aspects of socioeconomic stratification.26 Accordingly, different measures of SES may show varying effects, which can result from differing causal pathways, or through interactions with other social characteristics, such as gender or race.27 The multifaceted nature of SES has resulted in a lack of consistency in how researchers measure its relationship to bullying, and although several studies provide individual assessments of this relationship, as yet there is no clear consensus over whether roles in bullying are associated with individual socioeconomic measures, or in general, with SES.Currently, the literature suggests some link between low SES and victims or bully-victims at school.28,29 Specifically, being a victim has been reported to be associated with poor parental education,30,31 low parental occupation,32 economic disadvantage,33,34 and poverty.35 In addition, several studies found that bully-victims are also more likely to come from low socioeconomic backgrounds,29,30 including low maternal education28 and maternal unemployment.36 However, others found little or no association between SES and victims or bully-victims.37–39 The type of bullying may matter in relation to SES. Victims of physical and relational bullying have been found to more often come from low affluence families, whereas victims of cyber bullying have not.40Compared with victimization, few studies have explored the link between SES and bullying others. Some studies found bullying others to be associated with low SES, including economic disadvantage,34 poverty,35 and low parental education.30 Additionally, where composite measures have been used, children from low socioeconomic backgrounds have been found to bully others slightly more often.29,41 By contrast, others found no association between bullying perpetration and measures of SES.38,39,42There is a small but growing body of literature that examines the relationship between bullying and SES, and although findings tend to suggest that victims, bully-victims, and bullies are more likely to come from low socioeconomic backgrounds, the results are far from conclusive. First, studies differ in their approach to measuring SES; some use composite measures, combining multiple indicators such as parental education, wealth, and occupation, whereas others concentrate on a single socioeconomic indicator, most often parental education, affluence, or occupation. How bullying relates to SES may differ according to which socioeconomic indicator is used; therefore, in interpreting results, one must consider not only how bullying relates to SES in general, but also which socioeconomic indicator was used, and how this may have influenced the result. Furthermore, although several studies indicate an association between bullying and low SES, the reported effect sizes vary greatly across studies, with some reporting weak and others moderate to strong associations. So far, the associations between bullying and SES have not been quantified across a range of studies in a systematic way. To address this gap in the literature, we conducted a systematic review and meta-analysis that aimed to determine more precisely the exact nature and strength of the relationship between SES and bullying. We systematically investigated the association between the role taken in school bullying (victim, bully, or bully-victim) and measures of SES.     

Impact of individual-, environmental-, and policy-level factors on health care utilization among US farmworkers

Objectives. We examined individual-, environmental-, and policy-level correlates of US farmworker health care utilization, guided by the behavioral model for vulnerable populations and the ecological model.Methods. The 2006 and 2007 administrations of the National Agricultural Workers Survey (n = 2884) provided the primary data. Geographic information systems, the 2005 Uniform Data System, and rurality and border proximity indices provided environmental variables. To identify factors associated with health care use, we performed logistic regression using weighted hierarchical linear modeling.Results. Approximately half (55.3%) of farmworkers utilized US health care in the previous 2 years. Several factors were independently associated with use at the individual level (gender, immigration and migrant status, English proficiency, transportation access, health status, and non-US health care utilization), the environmental level (proximity to US–Mexico border), and the policy level (insurance status and workplace payment structure). County Federally Qualified Health Center resources were not independently associated.Conclusions. We identified farmworkers at greatest risk for poor access. We made recommendations for change to farmworker health care access at all 3 levels of influence, emphasizing Federally Qualified Health Center service delivery.US farmworkers face significant disease burden¹ and excessive mortality rates for some diseases (e.g., certain cancers and tuberculosis) and injuries.² Disparities in health outcomes likely stem from occupational exposures and socioeconomic and political vulnerabilities. US farmworkers are typically Hispanic with limited education, income, and English proficiency.³ Approximately half are unauthorized to work in the United States.³ Despite marked disease burden, health care utilization appears to be low.^1,4–9 For example, only approximately half of California farmworkers received medical care in the previous year.⁶ This rate parallels that of health care utilization for US Hispanics, of whom approximately half made an ambulatory care visit in the previous year, compared with 75.7% of non-Hispanic Whites.¹⁰ Disparities in dental care have a comparable pattern.^6,8,11,12 However, utilization of preventive health services is lower for farmworkers^5,7,13,14 than it is for both US Hispanics and non-Hispanic Whites.^15,16Farmworkers face numerous barriers to health care^1,4,17: lack of insurance and knowledge of how to use or obtain it,^6,18 cost,^{5,6,12,13,18–20} lack of transportation,^{6,12,13,19–21} not knowing how to access care,^6,18,20,21 few services in the area or limited hours,^12,20,21 difficulty leaving work,¹⁹ lack of time,^5,13,19 language differences,^6,8,18–20 and fear of the medical system,¹³ losing employment,⁶ and immigration officials.²¹ Few studies have examined correlates of health care use among farmworkers. Those that have are outdated or limited in representativeness.^5,7,14,22,23 Thus, we systematically examined correlates of US health care use in a nationally representative sample of farmworkers, using recently collected data. The sampling strategy and application of postsampling weights enhance generalizability. We selected correlates on the basis of previous literature and the behavioral model for vulnerable populations.²⁴ The behavioral model posits that predisposing, enabling, and need characteristics influence health care use.²⁵ The ecological model, which specifies several levels of influence on behavior (e.g., policy, environmental, intrapersonal),²⁶ provided the overall theoretical framework. To our knowledge, we are the first to extensively examine multilevel correlates of farmworker health care use. We sought to identify farmworkers at greatest risk for low health care use and to suggest areas for intervention at all 3 levels of influence so that farmworker service provision can be improved.