The role of individual and neighborhood factors: HIV acquisition risk among high-risk populations in San Francisco.

We examined socioeconomic status and social and sexual network factors and their relationship to HIV acquisition risk among HIV-negative Black MSM (BMSM), White MSM (WMSM) and transfemales (male to female transgenders). Geographic analysis examined residential patterns and neighborhood patterns of HIV prevalence in San Francisco. Factors associated with engaging in more episodes of potentially HIV serodiscordant unprotected receptive anal intercourse were analyzed. Transfemales and BMSM were more likely to live in areas of higher HIV prevalence and lower income compared to WMSM. BMSM and transfemales had lower socioeconomic scores (SES) scores compared to WMSM. BMSM were more likely to report serodiscordant partnerships and higher numbers of potentially serodiscordant unprotected sex acts. Decreasing individual SES did not predict serodiscordant partnerships in any group. Increasing neighborhood HIV prevalence predicted an increase in the number of potentially serodiscordant unprotected sex acts among transfemales and BMSM but only significantly so for transfemales. Prevention interventions must consider neighborhood HIV prevalence, and HIV prevalence in social/sexual networks, in addition to considering individual level behavior change or poverty reduction.

Conceptual and methodological issues for behavioral pediatrics research.

Three prescriptions are made to improve behavioral pediatrics research: (1) Focus behavioral pediatrics on preventive research from environmental and social perspectives. (2) Ground research questions more extensively within a conceptual framework. (3) Enhance research quality with reliable, valid measurement. Conceptual and methodological improvements in research will facilitate integration of the multidisciplinary, multimethodological, and multitheoretical scope of behavioral pediatrics and further its contributions to science.

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

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

Blood pressure and blood lead concentration in bus drivers.

San Francisco bus drivers have an increased prevalence of hypertension. This study examined relationships between blood lead concentration and blood pressure in 342 drivers. The analysis reported in this study was limited to subjects not on treatment for hypertension (n = 288). Systolic and diastolic pressures varied from 102 to 173 mm Hg and from 61 to 105 mm Hg, respectively. The blood lead concentration varied from 2 to 15 micrograms/dL. The relationship between blood pressure and the logarithm of blood lead concentration was examined using multiple regression analysis. Covariates included age, body mass index, sex, race, and caffeine intake. The largest regression coefficient relating systolic blood pressure and blood lead concentration was 1.8 mm Hg/ln (micrograms/dL) [90% C. I., -1.6, 5.3]. The coefficient for diastolic blood pressure was 2.5 mm Hg/ln (micrograms/dL) [90% C. I., 0.1, 4.9]. These findings suggest effects of lead exposure at lower blood lead concentrations than those concentrations that have previously been linked with increases in blood pressure.

Excess risk of sickness and disease in bus drivers: a review and synthesis of epidemiological studies.

In an extensive search of available literature, 22 epidemiological studies that have examined health risks of bus drivers were identified. These studies focus on three main disease categories: (1) cardiovascular disease, including hypertension, (2) gastrointestinal illnesses, including peptic ulcer and digestive problems, and (3) musculoskeletal problems including back and neck pain. The studies consistently report that bus drivers have higher raes of mortality, morbidity, and absence due to illness when compared to employees from a wide range of other occupational groups. Increased disease rates have been found for drivers regardless of the use of different research methodologies, measurement techniques and comparison groups. When evaluating the impact of bias on the estimates of risk, it appears likely that findings are conservative: strong systematic selective factors have probably favoured the elimination of those in poorer health both at the time of entry into and exit from the job of bus driving and other sources of bias have most likely caused underestimations of risk. Nevertheless, there remain questions that need careful assessment before firm conclusions can be made about whether increased disease rates result from driving a bus. Such questions, coupled with the consistent findings of heightened risk of disease, make urban bus drivers an appropriate and promising occupational group in which to study further the potential adverse effects of the work environment on employee health.

Prevalence of hypertension in bus drivers.

This paper reports the results of a cross-sectional study conducted to evaluate the prevalence of hypertension in 1500 black and white male bus drivers from a large urban transit system in the US. Data for this study were compiled from the files of an occupational health clinic which conducts biennial medical examinations for drivers' license renewal. To test whether prevalence of hypertension was higher among bus drivers than among employed individuals in general, drivers were compared to three groups: individuals from both a national and local health survey and individuals undergoing baseline health examinations prior to employment as bus drivers. After adjustment for age and race, hypertension rates for bus drivers were significantly greater than rates for each of the three comparison groups. These findings support previous results from international studies of bus drivers suggesting that exposure to the occupation of driving a bus may carry increased health risk. This research has expanded into an on-going study which has the goals of clarifying the extent of hypertension in bus drivers and identifying specific behavioural and occupational factors that may be responsible for increased risk of cardiovascular disease.

Beyond screening for domestic violence: a systems model approach in a managed care setting.

BACKGROUND: Implementation of screening guidelines for domestic violence has been challenging. The multifaceted "systems model" may provide an effective means to improve domestic violence screening, identification, and intervention in the healthcare setting. METHODS: We developed: (1) a systems model approach using tools for effective referral, evaluation, and reporting of domestic violence; (2) materials for distribution to female patients; (3) training for social service and mental health clinicians to provide domestic violence evaluation; and (4) strong links to the community. SETTING: A nonprofit, managed care facility in Richmond, California. PARTICIPANTS: Staff and members of the managed care plan. MAIN OUTCOME MEASURES: (1) Increased screening for domestic violence by clinicians; (2) increased awareness of the healthcare facility as a resource for domestic violence assistance; and (3) increased member satisfaction with the health plan's efforts to address domestic violence. RESULTS: The number of clinician referrals and patient self-referrals to an on-site domestic violence evaluator increased more than twofold. A pre-intervention and post-intervention phone survey of members seen for routine checkup showed an increase in member recall of being asked about domestic violence. After intervention, statistically significant increases were seen in members' perception that the health plan was concerned about the health effects of domestic violence (p<0.0001) and about members' satisfaction with the health plan's efforts to address this issue (p<0.0001). CONCLUSIONS: A systems model approach improved domestic violence services in a managed care health setting within 1 year and affected clinicians' behavior as well as health plan members' experience. This successful implementation makes it possible to address critical research questions about the impact of a healthcare intervention for victims of domestic violence in a managed healthcare setting.

Sickness absence as a measure of health status and functioning: from the UK Whitehall II study.

STUDY OBJECTIVE: To investigate the relationship between self reported health status and sickness absence. DESIGN: Analysis of questionnaire and sickness absence data from the first phase of the Whitehall II study--a longitudinal study set up to investigate the degree and causes of the social gradient in morbidity and mortality. SETTING: London offices of 20 civil service departments. PARTICIPANTS: Altogether 6895 male and 3413 female civil servants aged 35-55 years. Analysis was conducted on 88% of participants who had complete data for the present analysis. MAIN RESULTS: A strong inverse relation between the grade of employment (measure of socioeconomic status) and sickness absence was observed. Men in the lowest grade had rates of sickness absence six times higher than those in the highest grade. For women the corresponding differences were two to five times higher. In general, the longer the duration of absence, the more strongly did baseline health predict rates of absence. However, the health measures also predicted shorter spells, although to a lesser extent. Job satisfaction was strongly related to sickness absence with higher rates in those who reported low job satisfaction. After adjusting for health status the association remained for one to two day absences, but was greatly reduced for absences longer than three days. CONCLUSION: There was a strong association between ill health and sickness absence, particularly for longer spells. The magnitude of the association may have been underestimated because of the strength of the association between grade of employment and sickness absence. It is proposed that sickness absence be used as an integrated measure of physical, psychological, and social functioning in studies of working populations.

Socioeconomic status and health. The challenge of the gradient.

Socioeconomic status (SES) is consistently associated with health outcomes, yet little is known about the psychosocial and behavioral mechanisms that might explain this association. Researchers usually control for SES rather than examine it. When it is studied, only effects of lower, poverty-level SES are generally examined. However, there is evidence of a graded association with health at all levels of SES, an observation that requires new thought about domains through which SES may exert its health effects. Variables are highlighted that show a graded relationship with both SES and health to provide examples of possible pathways between SES and health end points. Examples are also given of new analytic approaches that can better illuminate the complexities of the SES-health gradient.

Promoting health: intervention strategies from social and behavioral research.

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

Psychosocial job factors, physical workload, and incidence of work-related spinal injury: a 5-year prospective study of urban transit operators.

STUDY DESIGN: Five-year prospective cohort study of 1449 transit operators. OBJECTIVES: To investigate psychosocial job factors as predictors of work-related spinal injuries, controlling for current and past physical workload. SUMMARY OF BACKGROUND DATA: The association between psychosocial job factors and spinal disorders may be confounded by physical workload. A 1991 prospective study of Boeing workers found psychosocial but not physical factors to be associated with spinal injuries. However, data on physical workload were limited. Recent cross-sectional studies of transit drivers showed both physical and psychosocial factors to be independently associated with back and neck pain. This study was designed to test these findings prospectively. METHODS: Spinal injuries were ascertained from workers' compensation records, employment history from company records, and psychosocial factors from questionnaires. Logistic regression models adjusted for age, gender, height, weight, vehicle type, and current and past physical workload. RESULTS: During follow-up, 320 drivers reported a first spinal injury. Spinal injury was predicted by psychological job demands (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.33-1.95); job dissatisfaction (OR, 1.56; 95% CI, 1.09-2.23); and the frequency of job problems (OR, 1.52; 95% CI, 1.02-2.26). Marginally significant associations were found for low supervisor support (OR, 1.30; 95% CI, 0.99-1.72) and female gender (OR, 1.49; 95% CI, 0.95-2.32). Compared with full-time work, part-time work was associated with a 2.7-fold reduced risk for spinal injury (OR, 0.37; 95% CI, 0.15-0.93). Cable car crews performing the heaviest physical labor had a threefold increased risk of spinal injury compared with bus drivers (OR, 3.04; 95% CI, 1.85-5.00). CONCLUSIONS: Physical workload and psychosocial job factors both independently predict spinal injury in transit vehicle operators.

Psychosocial job factors associated with back and neck pain in public transit operators.

OBJECTIVES: This cross-sectional study examined associations between psychosocial job factors and the prevalence of nondisabling back and neck pain in professional drivers after physical work load was taken into account. METHODS: A total of 1449 transit vehicle operators completed a medical examination and a questionnaire yielding information on demographic and anthropometric variables, health status, and physical and psychosocial job factors. Company records were used to supplement information on employment history. Physical work load was measured in life-time years and current weekly hours of professional driving. The relation of psychosocial factors with back or neck pain was analyzed by logistic regression models adjusted for past and current physical work load, vehicle type, age, gender, body height, and weight. RESULTS: The main result of this study was that both physical work load and psychosocial factors were simultaneously and independently associated with back or neck pain. Psychosocial factors associated with back or neck pain included extended uninterrupted driving driving periods, frequency of job problems, high psychosocial demands, high job dissatisfaction, and low supervisory support. An analysis of specific job problems is provided which may be useful in setting priorities for research and intervention efforts in this high risk occupation. CONCLUSION: The results provide support for the role of psychosocial job characteristics in the etiology of back or neck pain in occupational settings.

Anger expression and hypertension in transit workers.

One hypothesis in the literature on anger and hypertension is that a chronic tendency to suppress anger is an etiological factor in the development of hypertension. The present study assessed the relationship between anger expression and hypertension in a multicultural sample of 1,407 San Francisco bus drivers. Simple and multiple regression analyses revealed no significant differences between suppressed or expressed anger and hypertension. Thus, the results of this study do not support the hypothesis that suppressed anger is an etiological factor in hypertension.

Objective measurement of occupational stress factors--an example with San Francisco urban transit operators.

Eighty-one observational work analyses were conducted to measure stressors independently of worker appraisal in the San Francisco transit system. On the basis of action regulation theory, stress factors were defined as hindrances for task performance due to poor work organization or technological design. Stressors included (a) work barriers, defined as obstacles that cause extra work or unsafe behavior; (b) time pressure; (c) monotonous conditions; and (d) time binding, defined as control over timing. Reliability, measured as interrater agreement, ranged between 80 and 97%, with kappas of .46-.70. Validity analyses were done with 71 transit operators who participated in the observations and 177 operators who were assigned mean line-specific observational stressor measures. High odds ratios (ORs) were found for barriers and psychosomatic complaints (OR = 3.8, p = .00), time pressure and relaxation time needed after work (OR = 3.1, p = .05), and barriers and smoking to cope (OR = 3.8, p = .02). Using observational data in conjunction with self-report data can reduce confounding and improve interpretability of stress and health studies.

Social epidemiology and the work environment.

A major theme in virtually all of Bertil Gardell's work is that the social and work environment affects health and well-being. This concern with the social environment has been a major influence in the development of a new area of research referred to as social epidemiology. In this area of work, difficulties are increasingly being recognized in identifying specific social factors in the environment toward which intervention programs can be directed. An approach to this complex problem is to focus attention on the "mini-environment" of the workplace. Research here has yielded several interesting hypotheses that may have important implications for studies of the larger environment. These hypotheses involve the concepts of control and participation, concepts that are central to all of Gardell's work.

Explaining socioeconomic differences in sickness absence: the Whitehall II Study.

OBJECTIVE: To describe and explain the socioeconomic gradient in sickness absence. DESIGN: Analysis of questionnaire and sickness absence data collected from the first phase of the Whitehall II study. Grade of employment was used as a measure of socioeconomic status. SETTING: 20 civil service departments in London. SUBJECTS: 6900 male and 3414 female civil servants aged 35-55 years. MAIN OUTCOME MEASURES: Rates of short spells (< or = 7 days) and long spells (> 7 days) of sickness absence. RESULTS: A strong inverse relation between grade of employment and sickness absence was evident. Men in the lowest grade had rates of short and long spells of absence 6.1 (95% confidence interval 5.3 to 6.9) and 6.1 (4.8 to 7.9) times higher than those in the highest grade. For women the corresponding rate ratios were 3.0 (2.3 to 3.9) and 4.2 (2.5 to 6.8) respectively. Several risk factors were identified, including health related behaviours (smoking and frequent alcohol consumption), work characteristics (low levels of control, variety and use of skills, work pace, and support at work), low levels of job satisfaction, and adverse social circumstances outside work (financial difficulties and negative support). These risk factors accounted for about one third of the grade differences in sickness absence. CONCLUSION: Large grade differences in sickness absence parallel socioeconomic differences in morbidity and mortality found in other studies. Identified risk factors accounted for a small proportion of the grade differences in sickness absence. More accurate measurement of the risk factors may explain some of the remaining differences in sickness absence but other factors, as yet unrecognised, are likely to be important.

Prevalence of hypertension in bus drivers.

1. To test whether prevalence of hypertension was higher among these bus drivers than among employed individuals in general, drivers were compared to three groups: individuals from both a national and local health survey and individuals undergoing baseline health exams prior to employment as bus drivers. 2. After adjustment for age and race, hypertension rates for bus drivers were significantly greater than rates for the three comparison groups. 3. These findings support previous results from international studies of bus drivers suggesting that exposure to the occupation of driving a bus may carry increased health risk.