The Role of Primary Care in Advancing Civic Engagement and Health Equity: A Conceptual Framework.

Policy Points Health and civic engagement are reciprocally and longitudinally linked: Poor health is associated with less civic engagement. Well-established social drivers of health and health inequality such as inadequate access to health care, poverty, racism, housing instability, and food insecurity are also drivers of lower civic engagement. A robust primary care system can play a key role in advancing civic engagement (e.g., voting, volunteerism, community service, and political involvement) at the population level but has received little attention. Policy and practice solutions at the individual and structural levels should support and leverage potential synergies among health equity, civic engagement, and primary care. CONTEXT: Health and civic engagement are linked. Healthier people may be able to participate more fully in civic life, although those with poorer health may be motivated to address the roots of their health challenges using collective action. In turn, civically active people may experience better health, and societies with more equitable health and health care may experience healthier civic life. Importantly, a robust primary care system is linked to greater health equity. However, the role of primary care in advancing civic engagement has received little study. METHODS: We synthesize current literature on the links among health, civic engagement, and primary care. We propose a conceptual framework to advance research and policy on the role of primary care in supporting civic engagement as a means for individuals to actualize their health and civic futures. FINDINGS: Current literature supports relationships between health equity and civic engagement. However, this literature is primarily cross-sectional and confined to voting. Our integrative conceptual framework highlights the interconnectedness of primary care structures, health equity, and civic engagement and supports the crucial role of primary care in advancing both civic and health outcomes. Primary care is a potentially fruitful setting for cultivating community and individual health and power by supporting social connectedness, self-efficacy, and collective action. CONCLUSIONS: Health and civic engagement are mutually reinforcing. Commonalities between social determinants of health and civic engagement constitute an important convergence for policy, practice, and research. Responsibility for promoting both health and civic engagement is shared by providers, community organizations, educators, and policymakers, as well as democratic and health systems, yet these entities rarely work in concert. Future work can inform policy and practice to bolster primary care as a means for promoting health and civic engagement.

Endocrine and immune effects of non-convulsive neurostimulation in depression: A systematic review.

BACKGROUND: Non-convulsive neurostimulation is a rapidly-developing alternative to traditional treatment approaches in depression. Modalities such as repetitive Transcranial Magnetic Stimulation (rTMS), transcranial Direct Current Stimulation (tDCS), Vagal Nerve Stimulation (VNS) and Deep Brain Stimulation (DBS) are now recognized as potential treatments. How non-convulsive neurostimulation interventions impact the neurohormonal and neuroimmune changes that accompany depression remains relatively unknown. If this type of intervention can drive endocrine, immune, as well symptom changes in depression, non-convulsive neurostimulation may represent a viable, multi-faceted treatment approach in depression. We were therefore interested to understand the state of the literature in this developing area. METHODS: A systematic review of all studies that examined the impact of non-convulsive neurostimulation interventions on the hypothalamic-pituitary-adrenal (HPA) axis and immune function in the form of cytokine production in depression. RESULTS: We identified 15 human studies, 9 that examined rTMS, 2 that examined tDCS, 2 that examined VNS and 2 that examined electroacupuncture. 11 animal studies were also identified, 3 that examined rTMS, 2 that examined DBS and 6 that examined electroacupuncture. All types of non-convulsive neurostimulation were able to revert the increases in cortisol, ACTH and other components of the HPA axis that are seen in depressed patients, as well as to modulate the levels of key cytokines known to be up-regulated in depression, such as IL-1ß, IL-6 and TNF-α. Changes in the HPA axis and levels of cytokines in response to non-convulsive neurostimulation often did not correlate with change in depressive symptoms. Most studies were not controlled trials and thus, significant methodologic variability existed. Furthermore, many human studies lacked a sham stimulation comparator arm. We were unable to conduct relevant meta-analyses due to the design heterogeneities, heterogeneity in the reported outcome measures and the limited number of studies retrieved. Animal studies generally supported the findings of those in human, but again, significant variability in methodology and study design were evident. CONCLUSIONS: Non-convulsive neurostimulation interventions show promise in their ability to alter the endocrine and immune disturbances that accompany depression. Further research, which includes blinded, sham-controlled comparator designs is required.

Influence of product placement in children's movies on children's snack choices.

BACKGROUND: Media exposure affects health, including obesity risk. Children's movies often contain food placements-frequently unhealthy foods. However, it is not known if these cues influence children's food choices or consumption after viewing. We explored whether children's snack choices or consumption differs based on: 1) recent exposure to movies with high versus low product placement of unhealthy foods; and 2) children's weight status. METHODS: Children ages 9-11 were assigned to watch a high ("Alvin and the Chipmunks," n = 54) or low ("Stuart Little," n = 60) product-placement movie. After viewing, participants selected a snack choice from each of five categories, several of which were specifically featured in "Alvin." Uneaten snacks from each participant were weighed upon completion. Snack choice and amount consumed by movie were compared by t-tests, and differences in snack choices by movie were tested with logistic regression. RESULTS: Participants consumed an average of 800.8 kcal; mean kcal eaten did not vary by movie watched. Participants who watched the high product-placement movie had 3.1 times the odds (95% CI 1.3-7.2) of choosing cheese balls (most featured snack) compared to participants who watched the low product-placement movie. Children who were overweight or obese consumed a mean of 857 kcal (95% CI: 789-925) compared to 783 kcal (95% CI: 742-823, p = 0.09) for children who were underweight or healthy weight. Children's weight status did not significantly affect their choice of snack. CONCLUSIONS: Branding and obesogenic messaging in children's movies influenced some choices that children made about snack foods immediately following viewing, especially food with greatest exposure time in the film, but did not affect total calories consumed. Future studies should examine how the accumulation of these messages affects children's long-term food choices.

The unbuilt environment: culture moderates the built environment for physical activity.

BACKGROUND: While research has demonstrated a link between the built environment and obesity, much variation remains unexplained. Physical features are necessary, but not sufficient, for physical activity: residents must choose to use these features in health-promoting ways. This article reveals a role for local culture in tempering the effect of the physical environment on physical activity behaviors. METHODS: We developed Systematic Cultural Observation (SCO) to observe place-based, health-related culture in Lenoir County, NC (population ~60,000). Photographs (N = 6450) were taken systematically from 150 most-used road segments and geocoded. Coders assessed physical activity (PA) opportunities (e.g., public or private activity spaces, pedestrian-friendly features) and presence of people in each photograph. RESULTS: 28.7% of photographs contained some PA feature. Most were private or pedestrian; 3.1% contained public PA space. Only 1.5% of photographs with any PA features (2% of those with public PA space, 0.7% of those with private) depicted people despite appropriate weather and daylight conditions. CONCLUSIONS: Even when PA opportunities existed in this rural county, they were rarely used. This may be the result of culture ("unbuilt environment") that disfavors physical activity even in the presence of features that allow it. Policies promoting built environments designed for healthy lifestyles should consider local culture (shared styles, skills, habits, and beliefs) to maximize positive outcomes.

A community-based transformation.

In the early stages of my medical training I wanted to be an academic. I saw little value in endeavours that extended beyond the tertiary-care hospital. This all changed when I was mandated to complete a community-based oncology research project as part of my second year of medical school. During that project, I had the good fortune to work with a motivated community agency and a strong focus group of individuals who were touched by cancer. This dynamic combination of mentors forced me to reevaluate my earlier assumptions about community-based research, and I ultimately left the project with a stronger sense of how my efforts as a clinician could make an impact in the community, supporting those who in turn support the patient outside of the hospital. Learning that the course of many illnesses is determined at least as much by caregiver support as it is by active intervention by the physician, I finally came to appreciate that community and hospital work support each other in modern medical care. By addressing the social determinants of health, physicians can improve the care of their patients, regardless of their prognosis, and increase the impact that they have on the health of entire families.

Back in the Day: Nostalgia Frames Rural Residents' Perspectives on Diet and Physical Activity.

OBJECTIVE: To observe and interpret cultural influences on health behaviors in a rural area with a high prevalence of obesity. DESIGN: Descriptive, qualitative study. SETTING: Lenoir County, NC, US. PARTICIPANTS: Four focus groups (n = 33) were conducted. Participants were 76% African American and with an average of 25 years of county residence. PHENOMENON OF INTEREST: Diet, physical activity, environment ANALYSIS: Content analysis and thematic data analysis to identify key themes using qualitative analysis software. RESULTS: Participants frequently evoked nostalgia to frame recurrent themes including decreased opportunities for physical activity and changing food access and preparation in the community, contrasting with memories of enjoying local produce and safe outdoor recreation. They interpreted present health behaviors in the context of these past losses. CONCLUSIONS AND IMPLICATIONS: Nostalgia is an important element in our participants' cultural repertoires, revealing elements of place-based culture. Nostalgic narratives may foster a sense of reduced options for healthy eating and exercise by over-emphasizing loss. The incorporation of place-specific obesogenic cultural factors, including the way residents juxtapose past and present, may improve obesity interventions in rural settings.

Glucocorticoid Resistance: Is It a Requisite for Increased Cytokine Production in Depression? A Systematic Review and Meta-Analysis.

Background: Glucocorticoid resistance-reduced function of the glucocorticoid receptor (GR)-is seen in many depressed patients. It is argued that this resistance to glucocorticoids leads to failure of normal feedback regulation on the immune system. High levels of pro-inflammatory cytokines result. Purpose: We sought to identify evidence supporting or refuting a link between glucocorticoid resistance and immune dysregulation in depression and to summarize retrieved evidence in aggregate form. Methods: We systematically reviewed and meta-analyzed studies that examined cytokine levels in depressed patients compared with controls and that also reported a measure of glucocorticoid resistance. These measures included plasma cortisol, the dexamethasone suppression test (DST), GR expression levels, and the results of in vitro assays of GR function. We conducted four separate meta-analyses to test for moderating effects of glucocorticoid resistance on cytokine production in depression. Results: After sub-grouping 32 studies by the ratio of cortisol levels in patients compared with controls, we observed a trend for increasing glucocorticoid resistance (i.e., the most hypercortisolemic patients) to be associated with increased production of interleukin (IL)-6 [d = 0.94; 95% CI (0.29, 1.59)] and tumour necrosis factor (TNF)-α [d = 0.46; 95% CI (0.12, 0.79)]. We stratified nine studies that reported DST results by relative glucocorticoid resistance between patients and controls, identifying a trend for higher glucocorticoid resistance in patients, compared with controls, to be associated with higher cytokine production in patients (170 patients and 187 controls). This was particularly evident when studies were sub-grouped by source of cytokine-plasma (d = 1.04; 95% CI, 0.57-1.50) versus in vitro (d = 0.24; 95% CI, -0.20 to 0.67). Stratifying the four studies (147 patients and 118 controls) that used in vitro assays of GR function or GR expression to quantify glucocorticoid resistance revealed variable contributions to cytokine production in patients compared with controls (overall effect size: d = 1.35; 95% CI 0.53-2.18). Combining our analyses of studies that reported DST results with those that used in vitro assays of GR function or GR expression to quantify glucocorticoid resistance (302 patients and 277 controls), we noted that although depressed patients produced more cytokines than controls (d = 1.02; 95% CI, 0.55-1.49), there was no evident positive correlation between glucocorticoid resistance and inflammation. Conclusions: Our work provides some support for a model conceptualizing glucocorticoid resistance as a requisite for increased inflammation in depression. The limited number of studies identified highlights the need for purpose-designed investigations that directly examine the relationship between glucocorticoid resistance and cytokine production in depression.

Concordance of Child and Parent Reports of Children's Screen Media Use.

OBJECTIVE: Little is known about the concordance of parent and child reports of children's media consumption, even though parents are often asked to report for their children in clinical care settings. Our objective was to understand how parent and child reports of children's media consumption differ in an era of changing screen media consumption via personal devices. METHODS: As part of a larger study about the reception of health-related cues from children's media, children ages 9 to 11 years (N = 114) and their parents independently completed identical questionnaires about specific media use and health behaviors. To examine concordance between child and parent reports of children's screen media use, we calculated the mean number of minutes per day and proportions reported by the child and parent and assessed concordance with t-tests and chi-square tests. RESULTS: On a typical day, children reported nearly an hour each of video and app game use, computer use, and television exposure. Overall, child and parent reports were similar, usually within 10 minutes of each other; however, among 3 measures of TV use, parents consistently reported less TV exposure than children. There was significant discordance in the percentages of parents and children reporting the presence of a TV in the child's room. CONCLUSIONS: Parent and child reports of children's media use were generally concordant; however, there were important disagreements, such as TV use in the child's room and during meals. We discuss possible causes of discrepancies and implications.

Recognition of bacteria in the cytosol of Mammalian cells by the ubiquitin system.

Recent studies have suggested the existence of innate host surveillance systems for the detection of bacteria in the cytosol of mammalian cells. The molecular details of how bacteria are recognized in the cytosol, however, remain unclear. Here we examined the fate of Salmonella typhimurium, a gram-negative bacterial pathogen that can infect a variety of hosts, in the cytosol of mammalian cells. These bacteria typically occupy a membrane bound compartment, the Salmonella-containing vacuole (SCV), in host cells. We show that some wild-type bacteria escape invasion vacuoles and are released into the cytosol. Subsequently, polyubiquitinated proteins accumulate on the bacterial surface, a response that was witnessed in several cell types. In macrophages but not epithelial cells, the proteasome was observed to undergo a dramatic subcellular relocalization and become associated with the surface of bacteria in the cytosol. Proteasome inhibition promoted replication of S. typhimurium in the cytosol of both cell types, in part through destabilization of the SCV. Surprisingly, the cytosol-adapted pathogen Listeria monocytogenes avoided recognition by the ubiquitin system by using actin-based motility. Our findings indicate that the ubiquitin system plays a major role in the recognition of bacterial pathogens in the cytosol of mammalian cells.

Implicit Weight Bias in Children Age 9 to 11 Years.

OBJECTIVES: Assess implicit weight bias in children 9 to 11 years old. METHODS: Implicit weight bias was measured in children ages 9 to 11 (N = 114) by using the Affect Misattribution Procedure. Participants were shown a test image of a child for 350 milliseconds followed by a meaningless fractal (200 milliseconds), and then they were asked to rate the fractal image as "good" or "bad." We used 9 image pairs matched on age, race, sex, and activity but differing by weight of the child. Implicit bias was the difference between positive ratings for fractals preceded by an image of a healthy-weight child and positive ratings for fractals preceded by an image of an overweight child. RESULTS: On average, 64% of abstract fractals shown after pictures of healthy-weight children were rated as "good," compared with 59% of those shown after pictures of overweight children, reflecting an overall implicit bias rate of 5.4% against overweight children (P < .001). Healthy-weight participants showed greater implicit bias than over- and underweight participants (7.9%, 1.4%, and 0.3% respectively; P = .049). CONCLUSIONS: Implicit bias toward overweight individuals is evident in children aged 9 to 11 years with a magnitude of implicit bias (5.4%) similar to that in studies of implicit racial bias among adults.

Obesogenic Behavior and Weight-Based Stigma in Popular Children's Movies, 2012 to 2015.

BACKGROUND: Obesity-promoting content and weight-stigmatizing messages are common in child-directed television programming and advertisements, and 1 study found similar trends in G- and PG-rated movies from 2006 to 2010. Our objective was to examine the prevalence of such content in more recent popular children's movies. METHODS: Raters examined 31 top-grossing G- and PG-rated movies released from 2012 to 2015. For each 10-minute segment (N = 302) and for movies as units, raters documented the presence of eating-, activity-, and weight-related content observed on-screen. To assess interrater reliability, 10 movies (32%) were coded by more than 1 rater. RESULTS: The result of Cohen's κ test of agreement among 3 raters was 0.65 for binary responses (good agreement). All 31 movies included obesity-promoting content; most common were unhealthy foods (87% of movies, 42% of segments), exaggerated portion sizes (71%, 29%), screen use (68%, 38%), and sugar-sweetened beverages (61%, 24%). Weight-based stigma, such as a verbal insult about body size or weight, was observed in 84% of movies and 30% of segments. CONCLUSIONS: Children's movies include much obesogenic and weight-stigmatizing content. These messages are not shown in isolated incidences; rather, they often appear on-screen multiple times throughout the entire movie. Future research should explore these trends over time, and their effects.

Gender differences in Parkinson's disease depression.

INTRODUCTION: 30-40% of patients with Parkinson's disease (PD) experience depression during their illness; identifying subtypes of depression and groups at risk remains a challenge in routine clinical care. One avenue that remains underexplored is the gender-specific profiles manifested in PD depression. We sought to explore this in a large sample of clinical PD patients. METHODS: 307 patient records at a tertiary referral centre were reviewed for clinical and demographic factors. We used recursive partitioning to determine which items on the Beck Depression Inventory (BDI) were most useful in differentiating patients who scored in the depressed range (≥14) from those who scored in the non-depressed range (≤13). We also used recursive partitioning to identify those BDI items that were most effective in differentiating depressed from non-depressed patients in both genders. RESULTS: We were able to identify a subset of items on the BDI that were most useful in partitioning depressed from non-depressed in the entire cohort. Partitioning of men and women with PD depression relied on different key BDI items, melancholy featuring prominently in women, while the more classical factors associated with depression in PD (apathy and loss of libido) featured more prominently in men. CONCLUSION: Unique factors not previously identified as core features of depression in PD were found most useful in partitioning depressed women from non-depressed women. This raises the possibility that a female-specific depressive profile has been under-appreciated in past work. Additional studies are required to discern how this may impact future research, diagnosis and treatment.

Associations between subjective social status and physical and mental health functioning among patients with hypertension.

We examine the cross-sectional association between subjective social status and self-rated physical and mental health functioning in 518 Black and White patients enrolled in a community-based hypertension control research study. We found that (1) subjective social status, measured using both a proximal and distal referent group, was positively associated with physical and mental health functioning scores independent of educational level, household income, or both; (2) the effect of subjective social status on physical and mental health functioning differed significantly by race when using the distal, not the proximal, referent group. When the associations differed, they were stronger for Whites than Blacks.

Pass the popcorn: "obesogenic" behaviors and stigma in children's movies.

OBJECTIVE: To determine the prevalence of obesity-related behaviors and attitudes in children's movies. METHODS: A mixed-methods study of the top-grossing G- and PG-rated movies, 2006-2010 (4 per year) was performed. For each 10-min movie segment, the following were assessed: 1) prevalence of key nutrition and physical activity behaviors corresponding to the American Academy of Pediatrics obesity prevention recommendations for families; 2) prevalence of weight stigma; 3) assessment as healthy, unhealthy, or neutral; 3) free-text interpretations of stigma. RESULTS: Agreement between coders was >85% (Cohen's kappa = 0.7), good for binary responses. Segments with food depicted: exaggerated portion size (26%); unhealthy snacks (51%); sugar-sweetened beverages (19%). Screen time was also prevalent (40% of movies showed television; 35% computer; 20% video games). Unhealthy segments outnumbered healthy segments 2:1. Most (70%) of the movies included weight-related stigmatizing content (e.g., "That fat butt! Flabby arms! And this ridiculous belly!"). CONCLUSIONS: These popular children's movies had significant "obesogenic" content, and most contained weight-based stigma. They present a mixed message to children, promoting unhealthy behaviors while stigmatizing the behaviors' possible effects. Further research is needed to determine the effects of such messages on children.

Who trusts? Race, gender, and the September 11 rally effect among young adults.

First proposed by Mueller, the theory of the "rally effect" predicts that public support for government officials will increase when an event occurs that (1) is international; (2) involves the United States; and (3) is specific, dramatic, and sharply focused [Mueller, J.E. 1973. War, Presidents, & Public Opinion. New York: John Wiley & Sons., p. 209). Using the natural experiment of a large (N= 15,127) survey of young adults ages 18-27 that was in the field during the September 11, 2001, terrorist attacks, we confirm the existence of a rally effect on trust in government as well as its subsequent decay. We then use a predictive modeling approach to investigate individual-level dynamics of rallying around the flag and anti-rallying in the face of the national threat. By disaggregating predictors of rallying, we demonstrate remarkably different patterns of response to the attacks based on sex and, particularly, race. The results confirm expectations of national threat inciting a rally effect, but indicate that the dynamics of this rally effect are complex and race and gender-dependent. The article offers previously-unavailable insights into the dynamics of rallying and trust in government.

Parallel public spheres: distance and discourse in letters to the editor.

This article examines letters to the editor as one of the ways citizens seek to enact a public sphere using technological mediation. Using a sample of all letters received by a metropolitan newspaper during a three-month period (N = 1,113), the authors demonstrate that the tone and argumentative styles of letters differ with the scope of the issues the letters address. Local issues evoke more reasoned, conciliatory tones, while issues beyond the local context evoke more emotional, confrontational tones, even after controlling for individual writers' characteristics and anger as a motivation to write.

Structural insights into the transcriptional and translational roles of Ebp1.

The ErbB3-binding protein 1 (Ebp1) is an important regulator of transcription, affecting eukaryotic cell growth, proliferation, differentiation and survival. Ebp1 can also affect translation and cooperates with the polypyrimidine tract-binding protein (PTB) to stimulate the activity of the internal ribosome entry site (IRES) of foot-and-mouth disease virus (FMDV). We report here the crystal structure of murine Ebp1 (p48 isoform), providing the first glimpse of the architecture of this versatile regulator. The structure reveals a core domain that is homologous to methionine aminopeptidases, coupled to a C-terminal extension that contains important motifs for binding proteins and RNA. It sheds new light on the conformational differences between the p42 and p48 isoforms of Ebp1, the disposition of the key protein-interacting motif ((354)LKALL(358)) and the RNA-binding activity of Ebp1. We show that the primary RNA-binding site is formed by a Lys-rich motif in the C terminus and mediates the interaction with the FMDV IRES. We also demonstrate a specific functional requirement for Ebp1 in FMDV IRES-directed translation that is independent of a direct interaction with PTB.