Spiraling Risk: Visualizing the multilevel factors that socially pattern HIV risk among gay, bisexual & other men who have sex with men using Complex Systems Theory.

PURPOSE OF REVIEW: Global disparities in HIV infection, particularly among gay, bisexual, and other men who have sex with men (GBMSM), indicate the importance of exploring the multi-level processes that shape HIV's spread. We used Complex Systems Theory and the PRISMA guidelines to conduct a systematic review of 63 global reviews to understand how HIV is socially patterned among GBMSM. The purpose was to conduct a thematic analysis of the reviews to (1) synthesize the multi-level risk factors of HIV risk, (2) categorize risk across the socioecological model, and (3) develop a conceptual model that visualizes the interrelated factors that shape GBMSMS's HIV "risk." RECENT FINDINGS: We included 49 studies of high and moderate quality studies. Results indicated that GBMSM's HIV risk stems from the individual, interpersonal, and structural levels of the socioecological model. We identified a few themes that shape GBMSM's risk of HIV infection related to biomedical prevention methods; sexual and sex-seeking behaviors; behavioral prevention methods; individual-level characteristics and syndemic infections; lived experiences and interpersonal relationships; country-level income; country-level HIV prevalence; and structural stigma. The multi-level factors, in tandem, serve to perpetuate GBMSM's risk of HIV infection globally. The amalgamation of our thematic analyses from our systematic reviews of reviews suggests that the risk of HIV infection operates in an emergent, dynamic, and complex nature across multiple levels of the socioecological model. Applying complex systems theory indicates how multilevel factors create a dynamic and reinforcing system of HIV risk among GBMSM.

The relationship between socioeconomic position and depression among a US nationally representative sample of African Americans.

PURPOSE: Findings from previous studies have not revealed significant, inverse relationships between socioeconomic position (SEP) and depression among African Americans. This study examined the relationship between multiple indicators of SEP and Major Depressive Episode (MDE) among African Americans. METHODS: Data were drawn from the National Survey of American Life main interview and re-interview. MDE, at both 12 month and lifetime intervals, was assessed using the World Mental Health version of the Composite International Diagnostic Interview. Logistic regression models were adjusted for demographics. RESULTS: For 12-month MDE, household income and unemployment predicted greater odds of MDE among African American men, while there was an inverse relationship between education and 12-month MDE. Only unemployment was significantly associated with lifetime MDE among African American men. For African American women, a significant inverse relationship between household income and 12-month MDE was observed. CONCLUSIONS: Findings garnered from this study indicate that it is important to consider multiple measures of SEP in the prediction of depression among African Americans, and that the pattern of association between SEP and depression varies according to sex. Considering the paucity of studies that have explored the relationship between SEP and depression, additional research is needed to more firmly establish the relationship between SEP and depression. It is also important to consider stressors that may affect the relationship between SEP and depression among African Americans.

Widening Black/White mortality differentials among US children during the 1980s.

OBJECTIVES: With the exception of infants, mortality rate differentials among Black and White children have received very little attention. We address four empirical questions: 1) Did the Black/White childhood mortality disparity grow between 1980 and 1990? 2) What causes of death account for Black/White disparities in childhood mortality and temporal changes in the size of this disparity? 3) Do economic disparities between Black and White families account for Black/White childhood mortality differentials in 1980 or 1990? 4) Do growing economic disparities between Black and White families explain any growth in childhood mortality differentials? METHODS: Childhood mortality patterns and causes of excess deaths in Black children are examined in the nation overall and in three major metropolitan areas-Chicago, Detroit, and New York-using a dataset combining death certificate and Census data. Logistic regression analyses utilize Census socioeconomic information to identify the relationship between mortality risk and local area income in the metro areas. RESULTS: Black children's relative mortality disadvantage grew more severe during the 1980s, with startling growth in Black/White disparities seen in many age- and sex-specific metro populations. While White children generally experienced marked mortality declines, Black children's rates fell more slowly or actually increased, most dramatically among adolescent boys in Detroit and Chicago. Excess deaths among younger Black children were most often fire-related, while homicide was the predominant cause at older ages. Regression analyses confirmed that areal income was significantly and strongly related to child mortality at both time points in all study areas. However, the deterioration in areal income for Black children relative to Whites from 1980 to 1990 did not explain their worsening mortality rates over the time period. CONCLUSIONS: Black children are increasingly suffering excess deaths relative to White children. We find that Black children's mortality disadvantage is largely accounted for by areal economic disadvantage; however, expanding death rate disparities over time represented more than simply growth in income differentials. Our results suggest that other adverse exposures also have increasingly served to compromise Black children's life chances during the 1980s.

Inequality in life expectancy, functional status, and active life expectancy across selected black and white populations in the United States.

We calculated population-level estimates of mortality, functional health, and active life expectancy for black and white adults living in a diverse set of 23 local areas in 1990, and nationwide. At age 16, life expectancy and active life expectancy vary across the local populations by as much as 28 and 25 years respectively. The relationship between population infirmity and longevity also varies. Rural residents outlive urban residents, but their additional years are primarily inactive. Among urban residents, those in more affluent areas outlive those in high-poverty areas. For both whites and blacks, these gains represent increases in active years. For whites alone they also reflect reductions in years spent in poor health.

Understanding and eliminating racial inequalities in women's health in the United States: the role of the weathering conceptual framework.

I emphasize 3 features of racial inequality in women's health: It is greatest during young and middle adulthood; in some instances its severity is far greater than national comparisons suggest; and excessive levels of chronic morbidity and disability are widespread among African-American women, regardless of socioeconomic position. I propose that the weathering framework better captures these aspects of health inequality than do developmental models or those that focus on the role of poverty or individual unhealthy behaviors alone. Instead, weathering suggests that African-American women experience early health deterioration as a consequence of the cumulative impact of repeated experience with social, economic, or political exclusion. This includes the physical cost of engaging actively to address structural barriers to achievement and well-being. The weathering framework can be applied to research, to clinical and public health practice, and to social policy and political action.

To mitigate, resist, or undo: addressing structural influences on the health of urban populations.

Young to middle-aged residents of impoverished urban areas suffer extra-ordinary rates of excess mortality, to which deaths from chronic disease contribute heavily. Understanding of urban health disadvantages and attempts to reverse them will be incomplete if the structural factors that produced modern minority ghettos in central cities are not taken into account. Dynamic conceptions of the role of race/ethnicity in producing health inequalities must encompass (1) social relationship between majority and minority populations that privilege the majority population and (2) the autonomous institutions within minority populations that members develop and sustain to mitigate, resist, or undo the adverse effects of discrimination. Broad social and economic policies that intensify poverty or undermine autonomous protections can reap dire consequences for health. Following from this structural analysis and previous research, guiding principles for action and suggestions for continued research are proposed. Without taking poverty and race/ethnicity into account, public health professionals who hope to redress the health problems of urban life risk exaggerating the returns that can be expected of public health campaigns or overlooking important approaches for mounting successful interventions.

Health inequality and population variation in fertility-timing.

We estimate the impact of fertility-timing on the chances that children in poor urban African American communities will have surviving and able-bodied parents until maturity. To do so, we use census and vital statistics data to compute age- and sex-specific rates of mortality and functional limitation among prime-aged adult residents of impoverished African American areas in Harlem, Detroit, Chicago, and the Watts area of Los Angeles and for blacks and whites nationwide. Findings are consistent with the hypothesis that the early fertility-timing characteristic of poor urban African American populations mitigates some of the costs to families associated with excess mortality and early health deterioration in young through middle adulthood.

Poverty, time, and place: variation in excess mortality across selected US populations, 1980-1990.

STUDY OBJECTIVE: To describe variation in levels and causes of excess mortality and temporal mortality change among young and middle aged adults in a regionally diverse set of poor local populations in the USA. DESIGN: Using standard demographic techniques, death certificate and census data were analysed to make sex specific population level estimates of 1980 and 1990 death rates for residents of selected areas of concentrated poverty. For comparison, data for whites and blacks nationwide were analysed. SETTING: African American communities in Harlem, Central City Detroit, Chicago's south side, the Louisiana Delta, the Black Belt region of Alabama, and Eastern North Carolina. Non-Hispanic white communities in Cleveland, Detroit, Appalachian Kentucky, South Central Louisiana, Northeastern Alabama, and Western North Carolina. PARTICIPANTS: All black residents or all white residents of each specific community and in the nation, 1979-1981 and 1989-1991. MAIN RESULTS: Substantial variability exists in levels, trends, and causes of excess mortality in poor populations across localities. African American residents of urban/northern communities suffer extremely high and growing rates of excess mortality. Rural residents exhibit an important mortality advantage that widens over the decade. Homicide deaths contribute little to the rise in excess mortality, nor do AIDS deaths contribute outside of specific localities. Deaths attributable to circulatory disease are the leading cause of excess mortality in most locations. CONCLUSIONS: Important differences exist among persistently impoverished populations in the degree to which their poverty translates into excess mortality. Social epidemiological inquiry and health promotion initiatives should be attentive to local conditions. The severely disadvantageous mortality profiles experienced by urban African Americans relative to the rural poor and to national averages call for understanding.

Use of census-based aggregate variables to proxy for socioeconomic group: evidence from national samples.

Increasingly, investigators append census-based socioeconomic characteristics of residential areas to individual records to address the problem of inadequate socioeconomic information on health data sets. Little empirical attention has been given to the validity of this approach. The authors estimate health outcome equations using samples from nationally representative data sets linked to census data. They investigate whether statistical power is sensitive to the timing of census data collection or to the level of aggregation of the census data; whether different census items are conceptually distinct; and whether the use of multiple aggregate measures in health outcome equations improves prediction compared with a single aggregate measure. The authors find little difference in estimates when using 1970 compared with 1980 US Bureau of the Census data or zip code compared with tract level variables. However, aggregate variables are highly multicollinear. Associations of health outcomes with aggregate measures are substantially weaker than with microlevel measures. The authors conclude that aggregate measures can not be interpreted as if they were microlevel variables nor should a specific aggregate measure be interpreted to represent the effects of what it is labeled.

Excess mortality among blacks and whites in the United States.

BACKGROUND: Although the general relations between race, socioeconomic status, and mortality in the United States are well known, specific patterns of excess mortality are not well understood. METHODS: Using standard demographic techniques, we analyzed death certificates and census data and made sex-specific population-level estimates of the 1990 death rates for people 15 to 64 years of age. We studied mortality among blacks in selected areas of New York City, Detroit, Los Angeles, and Alabama (in one area of persistent poverty and one higher-income area each) and among whites in areas of New York City, metropolitan Detroit, Kentucky, and Alabama (one area of poverty and one higher-income area each). Sixteen areas were studied in all. RESULTS: When they were compared with the nationwide age-standardized annual death rate for whites, the death rates for both sexes in each of the poverty areas were excessive, especially among blacks (standardized mortality ratios for men and women in Harlem, 4.11 and 3.38; in Watts, 2.92 and 2.60; in central Detroit, 2.79 and 2.58; and in the Black Belt area of Alabama, 1.81 and 1.89). Boys in Harlem who reached the age of 15 had a 37 percent chance of surviving to the age of 65; for girls, the likelihood was 65 percent. Of the higher-income black areas studied, Queens--Bronx had the income level most similar to that of whites and the lowest standardized mortality ratio (men, 1.18; women, 1.08). Of the areas where poor whites were studied, Detroit had the highest standardized mortality ratios (men, 2.01; women, 1.90). On the Lower East Side of Manhattan, in Appalachia, and in Northeast Alabama, the ratios for whites were below the national average for blacks (men, 1.90; women, 1.95). CONCLUSIONS: Although differences in mortality rates before the age of 65 between advantaged and disadvantaged groups in the United States are sometimes vast, there are important differences among impoverished communities in patterns of excess mortality.

Black/white differences in the relationship of maternal age to birthweight: a population-based test of the weathering hypothesis.

This study seeks to explore if early health deterioration ('weathering') among young adult African American women contributes to observed increases with maternal age in the black/white disparity in birth outcome. Theoretically, 'weathering' is constructed as being a physical consequence of social inequality. Thus, we also examine whether African American mothers vary in their age trajectories of poor birth outcome with respect to social class. Black or white singleton first births to Michigan residents aged 15-34 in 1989 (N = 54,888 births) are analyzed, using data drawn from linked birth and infant death certificates augmented with census-based economic information. We find among blacks, but not whites, advancing maternal age above 15 years is associated with increased odds of LBW and VLBW. Among blacks in low-income areas, the odds of LBW increase 3-fold, and of VLBW 4-fold, between maternal ages 15 and 34. The findings suggest that African American women, on average, and those residing in low-income areas, in particular, experience worsening health profiles between their teens and young adulthood, contributing to their increasing risk of LBW or VLBW with advancing maternal age and to the black-white gap in this risk. The findings suggest the importance of comprehensive prevention strategies to improve the health of socioeconomically disadvantaged African American women prior to pregnancy and the reduction of social inequalities that impact health.

What teen mothers know.

In the United States, low-income or minority populations tend toward earlier births than the more advantaged. In disadvantaged populations, one factor that may exert pressure toward early births is "weathering," or pervasive health uncertainty. Are subjective perceptions of health related to fertility timing? Drawing on a small sample of intensive interviews with teenage mothers-to-be, I suggest that low-income African American teenagers may expect uncertain health and short lifespans. Where family economies and caretaking systems are based on kin networks, such perceptions may influence the decision to become a young mother. Heuristic typologies of ways socially situated knowledge may contribute to the reproduction of fertility timing practices contrast the experiences of poor African American interviewees, working class white interviewees, and middle-class teens who typically postpone childbearing.

Age patterns of smoking in US black and white women of childbearing age.

OBJECTIVES: The purpose of the study was to describe age patterns of smoking among Black and White women of reproductive age, with cohort membership controlled for. METHOD: Data from the 1987 National Health Interview Survey Cancer Supplement, weighted to be nationally representative, were used to calculate the fractions of women who were ever smokers, quitters, and current smokers by age and race. Summary distributions of age patterns of smoking behaviors by race were estimated; proportional hazard models were used to avoid confounding of age and cohort. RESULTS: White women begin smoking at younger ages than do Blacks but are more likely to quit and to do so at young ages. Rates of current smoking converge between Blacks and Whites by age 25, and may cross over by 30. Education-standardized results show larger Black-White differentials in ever smoking and smaller differences in quitting. CONCLUSIONS: Our findings confirm that women's age patterns of smoking vary by race. Age x race interactions should be considered in smoking research and anti-tobacco interventions. For Black women, delayed initiation and failure to quit call for increased emphasis on interventions tailored to adults. These findings have possible implications for understanding Black-White differences in low birthweight, child health, and women's health.

The socioeconomic costs of teenage childbearing: evidence and interpretation.

There is little evidence to support the reasons suggested by Hoffman et al. for treating the results based on the NLSYW as outliers. There is even some evidence that might lead one to favor the NLSYW estimates. After some investigation, which of the range of within-family estimates across data sets is most accurate remains unsettled (although exploring differences in cross-sectional estimates from the sisters subsamples seems promising). In addition, we believe there is evidence to support the hypothesis that within-family estimates are upwardly biased because of within-family heterogeneity and endogeneity, but the importance and magnitude of such bias is also an open question. Although we have highlighted here what we believe to be the main points of disagreement between ourselves and Hoffman et al., we hope readers will not lose sight of the areas of agreement between the two studies, which are substantial, or of the empirical support for our key findings that Hoffman et al.'s replication study has provided. To us, the findings of both studies suggest that future research should account empirically for potential biases from (possibly unmeasured) heterogeneity in family background. Because the prevailing beliefs about the consequences of teen childbearing have been based on cross-sectional comparisons that lack detailed family background controls, these beliefs now should be open for reconsideration and should be subjected to reevaluation. Several recent empirical attempts have been made to take heterogeneity or endogeneity bias into account. These studies support this conclusion and caution against drawing causal inferences from existing estimates of the effects of teen births. We continue to recognize the limitations of currently available methods and data for accounting for unobserved heterogeneity and selectivity (e.g., Griliches 1979; Manski 1989). Therefore we encourage the enhancement of data sets and the continued empirical investigation of questions that have been raised about possible biases of sibling estimation and other methodological approaches. We hope that with new rounds of research, advances will continue to further the understanding of these important social processes. Given the difficulty of accounting adequately for selection into teen childbearing across and within populations, and even within families, and given the conflicting within-family estimates, we believe that the size of any "true effects" of teen births on socioeconomic status must be considered an open question.

Maternal youth or family background? On the health disadvantages of infants with teenage mothers.

The health disadvantages of infants with teenage mothers are well documented. Because poor and minority women are disproportionately represented among teen mothers, differences in infant health by maternal age may reflect family background (pre-childbearing) characteristics rather than the effects of maternal age. To control for differences in family background, the authors compared birth outcomes and maternal behaviors that could affect fetal or infant health among sisters in the US National Longitudinal Survey of Youth (1979-1988). They compared sisters who had first births at different ages in order to study the relation between maternal age and low birth weight, prenatal care, smoking and alcohol use during pregnancy, breast feeding, and well-child visits. The authors found evidence that maternal family background accounts for many of the health-related disadvantages of the firstborn infants of teenage mothers. The findings suggest that disadvantaged black primiparous women in their twenties may be an important and possibly underemphasized target population for interventions designed to reduce excess black low birth weight and infant mortality rates.

The weathering hypothesis and the health of African-American women and infants: evidence and speculations.

Observed variation between populations in fertility-timing distributions has been thought to contribute to infant mortality differentials. This hypothesis is based, in part, on the belief that the 20s through early 30s constitute "prime" childbearing ages that are low-risk relative to younger or older ages. However, when stratified by racial identification over the predominant first child-bearing ages, maternal age patterns of neonatal mortality vary between groups. Unlike non-Hispanic white infants, African-American infants with teen mothers experience a survival advantage relative to infants whose mothers are older. The black-white infant mortality differential is larger at older maternal ages than at younger ages. While African Americans and non-Hispanic whites differ on which maternal ages are associated with the lowest risk of neonatal mortality, within each population, first births are most frequent at its lowest-risk maternal ages. As a possible explanation for racial variation in maternal age patterns of births and birth outcomes, the "weathering hypothesis" is proposed: namely, that the health of African-American women may begin to deteriorate in early adulthood as a physical consequence of cumulative socioeconomic disadvantage.

Patterns of blood lead levels in US black and white women of childbearing age.

While high-dose lead exposure has long been known to be detrimental to reproductive functioning, several recent studies have reported adverse effects such as shortened gestation, decreased birthweight, and increased incidence of spontaneous abortion in association with maternal blood lead levels as low as 0.48 to 0.72 mumol/L (10 to 15 micrograms/dL). Using data from the second National Health and Nutrition Examination Survey, we examined patterns of blood lead levels by age for US black and white women of childbearing age. We found that sizable percentages of women have blood lead levels that may place them at risk for poor reproductive outcomes and that disparities exist between the racially identified groups. Black women tend to have higher lead levels than white women, and the magnitude of this difference is larger among older compared to younger age-groups of reproductive-age women. This disparity may reflect the cumulative effect of differential environmental exposure to lead and may have implications for the excessive incidence of adverse reproductive outcomes currently seen in US black women.

Differences in hypertension prevalence among U.S. black and white women of childbearing age.

Hypertension and its sequelae complicate pregnancy and can result in poor perinatal outcomes. Overall, U.S. blacks are more likely to be hypertensive than whites, but the degree to which this is true among women of childbearing age (including teenagers) is unknown. Using data from the second National Health and Nutrition Examination Survey (NHANES II), the authors describe hypertension prevalence rates for 422 black and 2,700 white reproductive-age women. The authors present observed data and also predicted prevalence rates derived by modeling the odds of hypertension using logistic regression statistical techniques. They find that black-white differences in hypertension prevalence are negligible among teenagers, but they are pronounced in the older reproductive ages. They estimate that twice the proportion of black women relative to white are hypertensive during pregnancy. Their results suggest that differential rates of hypertension between black and white women may contribute to the persistent excess infant mortality among blacks, but conclusive results cannot be determined from these data. These data are also valuable for the design and evaluation of screening, intervention, and followup programs for hypertensive disease among young women.

A note on the measurement of hypertension in HHANES.

Using data from the HHANES, we found the rates of elevated blood pressure readings on clinical examination to be extremely low for a sample of Mexican American and Puerto Rican women. The prevalence rates were one-fourth to one-fifth the rates found for a comparable sample of White women from NHANESII. These findings are discrepant with the little that is known about hypertension prevalence among Hispanics and with estimates of hypertension prevalence for Mexican Americans and Puerto Ricans drawn from NHANESII. While our HHANES samples women had much lower rates of clinical high blood pressure than Whites, they reported hypertension histories in excess of Whites. Rates of medicine usage among Hispanics were insufficiently large for effective treatment to explain the disparity. The prevalence estimates increased, but the relative discrepancies remained when we altered our sample specifications and clinical high blood pressure measure. A possible explanation for these discrepancies is that few physicians performed the majority of blood pressure readings in our HHANES sample. This may have been statistically inefficient. The discrepancies noted suggest that HHANES may not be a reliable source of information on hypertension among Hispanic women.

Black/white differences in women's reproductive-related health status: evidence from vital statistics.

Maternal-age-specific neonatal mortality risk differs by race, with the mid-20s risk low for whites but not blacks. This may be partially due to worsening health for black relative to white women. We analyzed deaths to young women in the aggregate and classified by causes that are also pregnancy risk factors. Over the predominant child-bearing ages, mortality increases for blacks exceeded those for whites, usually by at least 25%. These indicators that black/white health differences widen as women progress through young adulthood suggest that such discrepancies may play a role in the black/white infant mortality differential, which merits further research.