Women in Academic Medicine: Measuring Stereotype Threat Among Junior Faculty.

BACKGROUND: Gender stereotypes in science impede supportive environments for women. Research suggests that women's perceptions of these environments are influenced by stereotype threat (ST): anxiety faced in situations where one may be evaluated using negative stereotypes. This study developed and tested ST metrics for first time use with junior faculty in academic medicine. METHODS: Under a 2012 National Institutes of Health Pathfinder Award, Stanford School of Medicine's Office of Diversity and Leadership, working with experienced clinicians, social scientists, and epidemiologists, developed and administered ST measures to a representative group of junior faculty. RESULTS: 174 School of Medicine junior faculty were recruited (62% women, 38% men; 75% assistant professors, 25% instructors; 50% white, 40% Asian, 10% underrepresented minority). Women reported greater susceptibility to ST than did men across all items including ST vulnerability (p < 0.001); rejection sensitivity (p = 0.001); gender identification (p < 0.001); perceptions of relative potential (p = 0.048); and, sense of belonging (p = 0.049). Results of career-related consequences of ST were more nuanced. Compared with men, women reported lower beliefs in advancement (p = 0.021); however, they had similar career interest and identification, felt just as connected to colleagues, and were equally likely to pursue careers outside academia (all p > 0.42). CONCLUSIONS: Innovative ST metrics can provide a more complete picture of academic medical center environments. While junior women faculty are susceptible to ST, they may not yet experience all of its consequences in their early careers. As such, ST metrics offer a tool for evaluating institutional initiatives to increase supportive environments for women in academic medicine.

Social disparities in dietary habits among women: Geographic Research on Wellbeing (GROW) Study.

OBJECTIVE: Relationships among race/ethnicity, individual socio-economic status (SES), neighbourhood SES and acculturation are complex. We sought to answer whether: (i) race/ethnicity, individual SES and neighbourhood SES have independent effects on women's fruit and vegetable consumption (FVC); (ii) SES modifies the effects of race/ethnicity on FVC; and (iii) nativity modifies the effect of Latina ethnicity on FVC. DESIGN: Cross-sectional surveys from the population-based Geographic Research on Wellbeing (GROW) Study were linked with census-tract level data. FVC was indicated by (i) consuming fruits and vegetables less often than daily (LOWFV) and (ii) not having fruits and vegetables in the home very often. Other variables included age, marital status, race/ethnicity, country of birth, educational attainment, family income and longitudinal neighbourhood poverty (based on latent class growth models). Weighted logistic regression models accounting for the complex sample design were constructed. SETTING: California, USA, 2012-2013. SUBJECTS: Women (n 2669). RESULTS: In adjusted models, race/ethnicity, education and income were independently associated with FVC, but not neighbourhood poverty. Women of colour, high-school graduates and women with incomes at 301-400 % of the federal poverty level were at higher odds of LOWFV compared with non-Hispanic Whites, college graduates and those with incomes >400 % of the federal poverty level. Little evidence for interactions between race/ethnicity and individual or neighbourhood SES was found; similar patterns were observed for immigrant and US-born Latinas. CONCLUSIONS: Addressing the dietary needs of lower-SES communities requires multilevel interventions that simultaneously provide culturally tailored nutrition education and address the physical and economic accessibility of culturally acceptable fruits and vegetables.

The Stanford Medical Youth Science Program: educational and science-related outcomes.

Biomedical preparatory programs (pipeline programs) have been developed at colleges and universities to better prepare youth for entering science- and health-related careers, but outcomes of such programs have seldom been rigorously evaluated. We conducted a matched cohort study to evaluate the Stanford Medical Youth Science Program's Summer Residential Program (SRP), a 25-year-old university-based biomedical pipeline program that reaches out to low-income and underrepresented ethnic minority high school students. Five annual surveys were used to assess educational outcomes and science-related experience among 96 SRP participants and a comparison group of 192 youth who applied but were not selected to participate in the SRP, using ~2:1 matching on sociodemographic and academic background to control for potential confounders. SRP participants were more likely than the comparison group to enter college (100.0 vs. 84.4 %, p = 0.002), and both of these matriculation rates were more than double the statewide average (40.8 %). In most areas of science-related experience, SRP participants reported significantly more experience (>twofold odds) than the comparison group at 1 year of follow-up, but these differences did not persist after 2-4 years. The comparison group reported substantially more participation in science or college preparatory programs, more academic role models, and less personal adversity than SRP participants, which likely influenced these findings toward the null hypothesis. SRP applicants, irrespective of whether selected for participation, had significantly better educational outcomes than population averages. Short-term science-related experience was better among SRP participants, although longer-term outcomes were similar, most likely due to college and science-related opportunities among the comparison group. We discuss implications for future evaluations of other biomedical pipeline programs.

A metabolic-epidemiological microsimulation model to estimate the changes in energy intake and physical activity necessary to meet the Healthy People 2020 obesity objective.

OBJECTIVES: We combined a metabolic and an epidemiological model of obesity to estimate changes in calorie intake and physical activity necessary to achieve the Healthy People 2020 objective of reducing adult obesity prevalence from 33.9% to 30.5%. METHODS: We used the National Health and Nutrition Examination Survey (1999-2010) to construct and validate a microsimulation model of the US population aged 10 years and older, for 2010 to 2020. RESULTS: Obesity prevalence is expected to shift toward older adults, and disparities are expected to widen between White, higher-income groups and minority, lower-income groups if recent calorie consumption and expenditure trends continue into the future. Although a less than 10% reduction in daily calorie intake or increase in physical activity would in theory achieve the Healthy People 2020 objective, no single population-level intervention is likely to achieve the target alone, and individual weight-loss attempts are even more unlikely to achieve the target. CONCLUSIONS: Changes in calorie intake and physical activity portend rising inequalities in obesity prevalence. These changes require multiple simultaneous population interventions.

Impact of neighborhood and individual socioeconomic status on survival after breast cancer varies by race/ethnicity: the Neighborhood and Breast Cancer Study.

BACKGROUND: Research is limited on the independent and joint effects of individual- and neighborhood-level socioeconomic status (SES) on breast cancer survival across different racial/ethnic groups. METHODS: We studied individual-level SES, measured by self-reported education, and a composite neighborhood SES (nSES) measure in females (1,068 non-Hispanic whites, 1,670 Hispanics, 993 African-Americans, and 674 Asian-Americans), ages 18 to 79 years and diagnosed 1995 to 2008, in the San Francisco Bay Area. We evaluated all-cause and breast cancer-specific survival using stage-stratified Cox proportional hazards models with cluster adjustment for census block groups. RESULTS: In models adjusting for education and nSES, lower nSES was associated with worse all-cause survival among African-Americans (P trend = 0.03), Hispanics (P trend = 0.01), and Asian-Americans (P trend = 0.01). Education was not associated with all-cause survival. For breast cancer-specific survival, lower nSES was associated with poorer survival only among Asian-Americans (P trend = 0.01). When nSES and education were jointly considered, women with low education and low nSES had 1.4 to 2.7 times worse all-cause survival than women with high education and high nSES across all races/ethnicities. Among African-Americans and Asian-Americans, women with high education and low nSES had 1.6 to 1.9 times worse survival, respectively. For breast cancer-specific survival, joint associations were found only among Asian-Americans with worse survival for those with low nSES regardless of education. CONCLUSIONS: Both neighborhood and individual SES are associated with survival after breast cancer diagnosis, but these relationships vary by race/ethnicity. IMPACT: A better understanding of the relative contributions and interactions of SES with other factors will inform targeted interventions toward reducing long-standing disparities in breast cancer survival.

Engaging students in community health: a public health advocacy curriculum.

Individual risk assessment and behavior change dominate the content of high school health education instruction whereas broader social, political, and economic factors that influence health-known as upstream causes-are less commonly considered. With input from instructors and students, we developed a 10-lesson experiential Public Health Advocacy Curriculum that uses classroom-based activities to teach high school students about the upstream causes of health and engages them in community-based health advocacy. The Curriculum, most suitable for health- or advocacy-related elective classes or after-school programs, may be taught in its entirety or as single lessons integrated into existing coursework. Although students at many schools are using the Curriculum, it has been formally evaluated with 110 predominantly Latino students at one urban and one semirural public high school in Northern California (six classes). In pre-post surveys, students showed highly significant and positive changes in the nine questions that covered the three main Curriculum domains (Upstream Causes, Community Exploration, and Public Health Advocacy), p values .02 to <.001. The Curriculum is being widely disseminated without charge to local, national, and international audiences, with the objective of grooming a generation of youth who are committed to the public health perspective to health.

Addressing food insecurity in a Native American reservation using community-based participatory research.

The food insecurity faced by many Native American communities has numerous implications for the health and welfare of families. To identify and address upstream causes of food insecurity in a rural California reservation, we conducted a community assessment using the Tool for Health and Resilience in Vulnerable Environments (THRIVE). Guided by a community-based participatory research orientation, the THRIVE tool was adapted using digital storytelling and implemented in a series of focus groups. As a result of the THRIVE assessment, community members identified racial injustice and physical and financial barriers to accessing healthy and culturally appropriate foods as areas of greatest importance. Subsequently, the project partnership developed policies to reduce identified barriers which included an integrated community supported agriculture and commodity food program, the introduction of Electronic Benefits Transfer and culturally appropriate foods at the local farmers' market and reallocation of shelf space at the grocery store to include vegetables and fruits as well as special foods for diabetics. Results suggest that a participatory research orientation coupled with the use of a culturally adapted THRIVE tool may be an effective means for identifying structural determinants of food insecurity and initiating novel policy interventions to reduce health disparities experienced by Native American communities.

Neighborhood deprivation and psychiatric medication prescription: a Swedish national multilevel study.

PURPOSE: Previous studies of neighborhood deprivation and mental disorders have yielded mixed results, possibly because they were based on different substrata of the population. We conducted a national multilevel study to determine whether neighborhood deprivation is independently associated with psychiatric medication prescription in a national population. METHODS: Nationwide outpatient and inpatient psychiatric medication data were analyzed for all Swedish adults (N = 6,998,075) after 2.5 years of follow-up. Multilevel logistic regression was used to estimate the association between neighborhood deprivation (index of education, income, unemployment, and welfare assistance) and prescription of psychiatric medications (antipsychotics, antidepressants, anxiolytics, or hypnotics/sedatives), after adjusting for broadly measured individual-level sociodemographic characteristics. RESULTS: For each psychiatric medication class, a monotonic trend of increasing prescription was observed by increasing level of neighborhood deprivation. The strongest associations were found for antipsychotics and anxiolytics, with adjusted odds ratios of 1.40 (95% confidence interval [CI], 1.36-1.44) and 1.24 (95% CI, 1.22-1.27), respectively, comparing the highest- to the lowest-deprivation neighborhood quintiles. CONCLUSIONS: These findings suggest that neighborhood deprivation is associated with psychiatric medication prescription independent of individual-level sociodemographic characteristics. Further research is needed to elucidate the mechanisms by which neighborhood deprivation may affect mental health and to identify the most susceptible groups in the population.

Differences in neighborhood accessibility to health-related resources: a nationwide comparison between deprived and affluent neighborhoods in Sweden.

This nationwide Swedish study used geocoded data from all businesses in Sweden to examine the distribution of 12 main categories of goods, services, and resources in 6986 neighborhoods, categorized as low, moderate, and high neighborhood deprivation. The main findings were that high- and moderate-deprivation neighborhoods had a significantly higher prevalence of all types of goods, services, and resources than low-deprivation neighborhoods. These findings do not support previous research that hypothesizes that poorer health among people in deprived neighborhoods is explained by a lack of health-promoting resources, although a higher presence of health-damaging resources may play a role.

Mothers, places and small for gestational age births: a cohort study.

OBJECTIVE: This study examines whether neighbourhood deprivation increases the risk of giving birth to a small for gestational age (SGA) infant, after accounting for individual-level maternal socioeconomic characteristics. DESIGN: An open cohort of women, aged 20-44 years, was followed from 1 January 1992 through 31 December 2004 for first singleton births. The women's residential addresses during the two consecutive years preceding the birth of their infants were geocoded and classified into three levels of neighbourhood deprivation. Gestational age was confirmed by ultrasound examinations. Multilevel logistic regression models were used in the statistical analysis. SETTING: Sweden. RESULTS: During the study period, women gave birth to 720 357 infants, of whom 20 487 (2.8%) were SGA. Age-adjusted incidence rates of SGA births increased with increasing level of neighbourhood deprivation. In the total population, 2.5% of births in the least deprived neighbourhoods and 3.5% of births in the most deprived neighbourhoods were SGA. A similar pattern of higher incidence with increasing level of neighbourhood-level deprivation was observed across all individual-level sociodemographic categories, including maternal age, marital status, family income, educational attainment, employment, mobility and urban/rural status. High neighbourhood-level deprivation remained significantly associated with SGA risk after adjusting for maternal sociodemographic characteristics (OR 1.28, 95% CI 1.22 to 1.34). CONCLUSIONS: This study is the largest to date of the influence of neighbourhood on SGA birth, with SGA confirmed by ultrasound examination. Results suggest that the characteristics of a mother's neighbourhood affect the risk of delivering an SGA infant independently of maternal sociodemographic characteristics.

Targeting the taqueria: implementing healthy food options at Mexican American restaurants.

As part of a 5-year community-based intervention in Salinas, California, the Steps to a Healthier Salinas team developed a taqueria intervention addressing obesity and diabetes among Mexican Americans. The authors present: (a) a comparison of service/entrée options for Salinas taquerias (n = 35) and fast-food restaurants ( n = 38) at baseline, (b) a case study of one taqueria, (c) a description of a healthy nutrition tool kit tailored to taquerias, and (d) an evaluation of the intervention at Year 3. It was found that traditional Mexican American-style menu offerings at taquerias tended to be healthier than American-style fast-food restaurant offerings. In addition, the initial response to the intervention has shown positive changes, which include the taqueria owners promoting available healthy menu items and modifying other menu offerings to reduce fats and increase fruit and vegetable availability. This, in turn, has led to a transition of the owners' perceptions of themselves as gatekeepers for a healthy community.

Perceived medical discrimination and cancer screening behaviors of racial and ethnic minority adults.

BACKGROUND: Discrimination has been shown as a major causal factor in health disparities, yet little is known about the relationship between perceived medical discrimination (versus general discrimination outside of medical settings) and cancer screening behaviors. We examined whether perceived medical discrimination is associated with lower screening rates for colorectal and breast cancers among racial and ethnic minority adult Californians. METHODS: Pooled cross-sectional data from 2003 and 2005 California Health Interview Survey were examined for cancer screening trends among African American, American Indian/Alaskan Native, Asian, and Latino adult respondents reporting perceived medical discrimination compared with those not reporting discrimination (n = 11,245). Outcome measures were dichotomous screening variables for colorectal cancer among respondents ages 50 to 75 years and breast cancer among women ages 40 to 75 years. RESULTS: Women perceiving medical discrimination were less likely to be screened for colorectal [odds ratio (OR), 0.66; 95% confidence interval (95% CI), 0.64-0.69] or breast cancer (OR, 0.52; 95% CI, 0.51-0.54) compared with women not perceiving discrimination. Although men who perceived medical discrimination were no less likely to be screened for colorectal cancer than those who did not (OR, 1.02; 95% CI, 0.97-1.07), significantly lower screening rates were found among men who perceived discrimination and reported having a usual source of health care (OR, 0.30; 95% CI, 0.28-0.32). CONCLUSIONS: These findings of a significant association between perceived racial or ethnic-based medical discrimination and cancer screening behaviors have serious implications for cancer health disparities. Gender differences in patterns for screening and perceived medical discrimination warrant further investigation.

Women's perceptions of neighborhood resources and hazards related to diet, physical activity, and smoking: focus group results from economically distinct neighborhoods in a mid-sized U.S. city.

PURPOSE: To investigate women's perceptions of neighborhood resources and hazards associated with poor diet, physical inactivity, and cigarette smoking. DESIGN: After interviewing city officials and analyzing visual assessments, three economically distinct neighborhoods in a mid-sized city were selected. SETTING: Salinas, California, a predominantly Latino city. METHODS: Eight fobcus groups, conducted in Spanish or English in the three neighborhoods. Thematic coding of focus group transcripts identified key concepts. Women also mapped their perceived neighborhood boundaries. Participants. Women who had at least one child under age 18 living with them. RESULTS: Women identified food stores, parks, recreation areas, and schools as key resources in their neighborhoods. They identified fast food restaurants, convenience stores, violent crime, gangs, and drug-associated issues as "hazards". Distinctions between resources and hazards were not always clear cut. For example, parks were sometimes considered dangerous, and fast food restaurants were sometimes considered a convenient and inexpensive way to feed one's family. Women's perceptions of their neighborhood boundaries differed greatly by type of neighborhood-the perceived neighborhood area (in acres) drawn by women in the lower-income neighborhood was one-fourth the size of the area drawn by women in the higher-income neighborhood. CONCLUSION: This qualitative, exploratory study illustrates how resources and hazards in one's neighborhood cannot be viewed as having solely one dimension-each may influence health behaviors both positively and negatively.

Contribution of neighbourhood socioeconomic status and physical activity resources to physical activity among women.

INTRODUCTION: Residence in a deprived neighbourhood is associated with lower rates of physical activity. Little is known about the manifestation of deprivation that mediates this relationship. This study aimed to investigate whether access to physical activity resources mediated the relationship between neighbourhood socioeconomic status and physical activity among women. METHOD: Individual data from women participating in the Stanford Heart Disease Prevention Program (1979-90) were linked to census and archival data from existing records. Multilevel regression models were examined for energy expenditure and moderate and vigorous physical activity as reported in physical activity recalls. RESULTS: After accounting for individual-level socioeconomic status, women who lived in lower-socioeconomic status neighbourhoods reported greater energy expenditure, but undertook less moderate physical activity, than women in moderate-socioeconomic status neighbourhoods. In contrast, women living in higher-socioeconomic status neighbourhoods reported more vigorous physical activity than women in moderate-socioeconomic status neighbourhoods. Although availability of physical activity resources did not appear to mediate any neighbourhood socioeconomic status associations, several significant interactions emerged, suggesting that women with low income or who live in lower-socioeconomic status neighbourhoods may differentially benefit from greater physical activity resource availability. DISCUSSION: Although we found expected relationships between residence in a lower-socioeconomic status neighbourhood and undertaking less moderate or vigorous physical activity among women, we also found that these same women reported greater overall energy expenditure, perhaps as a result of greater work or travel demands. Greater availability of physical activity resources nearby appears to differentially benefit women living in lower-socioeconomic status neighbourhoods and low-income women, having implications for policy-making and planning.

Socioeconomic and food-related physical characteristics of the neighbourhood environment are associated with body mass index.

OBJECTIVE: To determine whether socioeconomic and food-related physical characteristics of the neighbourhood are associated with body mass index (BMI; kg/m(2)) independently of individual-level sociodemographic and behavioural characteristics. DESIGN AND METHODS: Observational study using (1) individual-level data previously gathered in five cross-sectional surveys conducted by the Stanford Heart Disease Prevention Program between 1979 and 1990 and (2) neighbourhood-level data from (a) the census to describe socioeconomic characteristics and (b) data obtained from government and commercial sources to describe exposure to different types of retail food stores as measured by store proximity, and count of stores per square mile. Data were analysed using multilevel modelling procedures. The setting was 82 neighbourhoods in agricultural regions of California. PARTICIPANTS: 7595 adults, aged 25-74 years. RESULTS: After adjusting for age, gender, ethnicity, individual-level socioeconomic status, smoking, physical activity and nutrition knowledge, it was found that (1) adults who lived in low socioeconomic neighbourhoods had a higher mean BMI than adults who lived in high socioeconomic neighbourhoods; (2) higher neighbourhood density of small grocery stores was associated with higher BMI among women; and (3) closer proximity to chain supermarkets was associated with higher BMI among women. CONCLUSION: Living in low socioeconomic neighbourhoods, and in environments where healthy food is not readily available, is found to be associated with increased obesity risk. Unlike other studies which examined populations in other parts of the US, a positive association between living close to supermarkets and reduced obesity risk was not found in this study. A better understanding of the mechanisms by which neighbourhood physical characteristics influence obesity risk is needed.

Inequities in CHD incidence and case fatality by neighborhood deprivation.

BACKGROUND: Research has not firmly established whether living in a deprived neighborhood predicts the incidence and case fatality of coronary heart disease (CHD), and whether effects vary across sociodemographic groups. METHODS: Prospective follow-up study of all Swedish women and men, aged 35 to 74 (1.9 million women, 1.8 million men). Women and men, without a history of CHD, were assessed on December 31, 1995, and followed from January 1, 1996 through December 31, 2000, for first fatal or nonfatal CHD event (130,024 cases); data were analyzed in 2006. Neighborhood-level deprivation (index of education, income, unemployment, welfare assistance) was categorized as low, moderate, and high deprivation. RESULTS: Age-standardized CHD incidence was 1.9 times higher for women and 1.5 times higher for men in high- versus low-deprivation neighborhoods; 1-year case fatality from CHD was 1.6 times higher for women and 1.7 times higher for men in high versus low deprivation neighborhoods. The higher incidence in more deprived neighborhoods was observed across all individual-level sociodemographic groups (age, marital status, family income, education, immigration status, mobility, and urban/rural status). In multilevel logistic regression models, neighborhood deprivation remained significantly associated with both CHD incidence and case fatality for women and men after adjusting for the seven sociodemographic factors (p values <0.01). Effects were slightly stronger for women than men in an ancillary analysis that tested for gender differences. CONCLUSIONS: The clustering of CHD and subsequent mortality among adults in deprived neighborhoods raises important clinical and public health concerns, and calls for a reframing of health problems to include neighborhood social environments, as they may affect health.

Effect of cross-level interaction between individual and neighborhood socioeconomic status on adult mortality rates.

OBJECTIVE: We examined whether the influence of neighborhood-level socioeconomic status (SES) on mortality differed by individual-level SES. METHODS: We used a population-based, mortality follow-up study of 4476 women and 3721 men, who were predominately non-HIspanic White and aged 25-74 years at baseline, from 82 neighborhoods in 4 California cities. Participants were surveyed between 1979 and 1990, and were followed until December 31, 2002 (1148 deaths; mean follow-up time 17.4 years). Neighborhood SES was defined by 5 census variables and was divided into 3 levels. Individual SES was defined by a composite of educational level and household income and was divided into tertiles. RESULTS: Death rates among women of low SES were highest in high-SES neighborhoods (1907/100000 person-years), lower in moderate-SES neighborhoods (1323), and lowest in low-SES neighborhoods (1128). Similar to women, rates among men of low SES were 1928, 1646, and 1590 in high-, moderate-, and low-SES neighborhoods, respectively. Differences were not explained by individual-level baseline risk factors. CONCLUSION: The disparities in mortality by neighborhood of residence among women and men of low SES demonstrate that they do not benefit from the higher quality of resources and knowledge generally associated with neighborhoods that have higher SES.