Direct Effect Of Socioeconomic Status Research Articles

Socioeconomic status and health literacy as the important predictors of general health in Iran: a structural equation modeling approach


 Background: We aimed to determine the level of health literacy (HL), and its association with general health. In addition, we investigated the direct and indirect association of socioeconomic status (SES) and general health among the adult population in Iran.
 Methods: This cross-sectional study involved 750 literate adults' people. The SES was assessed based on the owning of assets. HL was evaluated using a validated questionnaire in Iran. General health was assessed using the WHO general health questionnaire. The simple and adjusted linear regression models, and structural equation modeling (SEM) were used for data analysis.
 Results: In adjusted model, female gender, higher level of education, use of books, pamphlets, or brochures as a source of health information, the higher level of SES were positively associated with higher HL. In addition, the HL was significantly associated with higher scores of general health. Results of SEM showed that the direct effect of SES on general health was not significant, but the indirect effect via HL was significant (path coefficient: 0.24; p<0.001).
 Conclusion: Results of our study indicated HL is strongly associated with general health among the adult population. SES had a significant indirect association with general health via the effect on health literacy.

Mediating effects of motivation and socioeconomic status on reading achievement: a secondary analysis of PISA 2018

BackgroundResearch has shown that students from socially disadvantaged backgrounds are more likely to have lower academic performance compared to children from better-off families. However, the way that socioeconomic status (SES) influences student learning outcomes has not yet been fully examined. Thus, this study explores the indirect effects of students’ SES on reading achievement through academic motivation. Specifically, the mediating role of the following three motivation elements is investigated: mastery-approach orientation of achievement goals,enjoyment of reading, and expected occupational status.MethodsStructural Equation Modelling (SEM) was used to test the hypothesized mediation model in each European country (n = 38) that took part in the PISA 2018 cycle. Specifically, data was obtained from 237,366 15-year-old students. Common measures for SES, academic motivation, and reading achievement were employed to examine whether the selected academic motivation elements have similar effects in each country. Confirmatory Factor Analysis (CFA) was used to validate the factorial structure of mediators and test their measurement invariance across the samples.ResultsWithin-country SEM analysis revealed that expected occupational status partially mediates the relationship between SES and reading achievement in all countries. Enjoyment of reading fitted well as a mediator in almost all countries (n = 37), whereas mastery-approach orientation of achievement goals only appeared as a mediator in 11 countries. The direct effect of SES on academic achievement was significantly reduced in all models.ConclusionsThis study provides evidence that enjoyment of reading and expected occupational status can be treated as mediators in the relationship between SES and reading achievement in European countries. Implications for research and theory for promoting equity in education are drawn. It is argued that schools and teachers should encourage students to participate in activities that foster their intrinsic motivation towards reading and raise their educational and occupational expectations, especially for those coming from socially disadvantaged backgrounds.

Direct and Indirect Effects of Socioeconomic Status and Discrimination on Subjective Cognitive Decline: A Longitudinal Study of African American Women.

The present study builds on recent findings suggesting that the stress of institutional and interpersonal racism may contribute to African Americans' elevated risk for dementia. We investigated the extent to which 2 consequences of racism-low socioeconomic status (SES) and discrimination-predict self-reported cognitive decline (SCD) 19years later. Further, we examined potential mediating pathways that might link SES and discrimination to cognitive decline. Potential mediators included depression, accelerated biological aging, and onset of chronic illnesses. Hypotheses were tested using a sample of 293 African American women. SCD was assessed using the Everyday Cognition Scale. Structural equation modeling was used to assess the effects of SES and racial discrimination, both measured in 2002, on SCD reported in 2021. Turning to the mediators, midlife depression was assessed in 2002, accelerated aging in 2019, and chronic illness in 2019. Age and prodrome depression were included as covariates. There were direct effects of SES and discrimination on SCD. In addition, these 2 stressors showed a significant indirect effect on SCD through depression. Finally, there was evidence for a more complex pathway where SES and discrimination accelerate biological aging, with accelerated aging, in turn leading to chronic illness, which then predicted SCD. Results of the present study add to a growing literature indicating that living in a racialized society is a central factor in explaining the high risk for dementia among Black Americans. Future research should continue to emphasize the various ways that exposure to racism over the life course effects cognition.

Educational Attainment and Lifestyle Risk Factors Associated With All-Cause Mortality in the US

The US has experienced increasing socioeconomic inequalities and stagnating life expectancy. Past studies have not disentangled 2 mechanisms thought to underlie socioeconomic inequalities in health, differential exposure and differential vulnerability, that have different policy implications. To evaluate the extent to which the association between socioeconomic status (SES) and all-cause mortality can be decomposed into a direct effect of SES, indirect effects through lifestyle factors (differential exposure), and joint effects of SES with lifestyle factors (differential vulnerability). This nationwide, population-based cohort study used the cross-sectional US National Health Interview Survey linked to the National Death Index. Civilian, noninstitutionalized US adults aged 25 to 84 years were included from the 1997 to 2014 National Health Interview Survey and were followed up until December 31, 2015. Data were analyzed from May 1 to October 31, 2021. A causal mediation model using an additive hazard and marginal structural approach was used. Both SES (operationalized as educational attainment) and lifestyle risk factors (smoking, alcohol use, obesity, and physical inactivity) were assessed using self-reported questionnaires. Time to all-cause mortality. Participants included 415 764 adults (mean [SD] age, 49.4 [15.8] years; 55% women; 64% non-Hispanic White), of whom 45% had low educational attainment and 27% had high educational attainment. Participants were followed up for a mean (SD) of 8.8 (5.2) years during which 49 096 deaths (12%) were observed. Low educational attainment (compared with high) was associated with 83.6 (men; 95% CI, 81.8-85.5) and 54.8 (women; 95% CI, 53.4-56.2) additional deaths per 10 000 person-years, of which 66% (men) and 80% (women) were explained by lifestyle factors. Inequalities in mortality were primarily a result of greater exposure and clustering of unhealthy lifestyle factors among low SES groups; with some exceptions among women, little evidence of differential vulnerability was identified. In this cohort study, differential exposure to lifestyle risk factors was an important mediator of socioeconomic inequalities in mortality. Public health interventions are needed, particularly among low SES groups, to address smoking, physical inactivity, alcohol use, and the socioenvironmental contexts within which these risk factors develop.

Factors Affecting Depression in Middle-Aged and Elderly Men Living Alone: A Cross-Sectional Path Analysis Model.

The main objectives of this cross-sectional study were to determine the relationship between socioeconomic status (SES) and depression and to estimate the mediating effects of social network satisfaction, self-esteem, and perceived health status among middle-aged and elderly men living alone, based on the reserve capacity model. Secondary data from a sample of 394 middle-aged and elderly men aged 45 years or older from the 15th Korea Welfare Panel Study (KOWEPS) were analyzed. A path analysis model was constructed to evaluate the relationship among SES, social network satisfaction, self-esteem, perceived health status, and depression. The path analysis exhibited significant direct effects of social network satisfaction, self-esteem, and perceived health status on depression and significant indirect effects of SES on depression. There was no direct effect of SES on depression. Social network satisfaction and self-esteem had significant mediating effects of SES on depression. Among middle-aged and elderly men, intrapersonal reserves, which are psychosocial factors including social network satisfaction, self-esteem, and perceived health status, showed more association with depression than tangible reserves such as SES. This suggests that interventions promoting self-esteem and perceived health status could prevent depression.

Periodontal Status as Mediator of the Association between Socioeconomic Status and Oral Health-Related Quality of Life in Pregnant Women.

To test periodontal status as a mediator between socioeconomic status (SES) and oral health-related quality of life (OHRQoL) in pregnant women. Secondary cross-sectional analysis of baseline data from a randomised clinical trial with 303 pregnant women. Demographic variables, SES, smoking, interproximal hygiene, and self-reported gingival bleeding were collected as independent variables. The Oral Health Impact Profile-14 was used to assess OHRQoL. The relationship between SES, periodontal status and OHRQoL was investigated in structural equation modelling. There was a moderate association of SES with periodontal status (standardised coefficient SC = -0.26, p⟨0.01) and number of teeth (SC = 0.24, p⟨0.01). Periodontal status and the number of teeth were also associated with OHRQoL (respectively, SC = 0.25, p⟨0.01 and SC = -0.31, p⟨0.01), but SES was only indirectly related to OHRQoL (SC = -0.17, p⟨0.01). Socioeconomic inequalities in quality of life were mainly explained by the remaining number of teeth, contributing to about 47%, and periodontal status, contributing to about 41%. There was no direct effect of SES on OHRQoL in pregnant women. Periodontal status and missing teeth each explained almost half of the total indirect association.

Mediation Effect of Metal Mixtures in the Association Between Socioeconomic Status and Self-rated Health Among US Adults: A Weighted Quantile Sum Mediation Approach

This study aimed to examine the association between socioeconomic status (SES) and self-rated health (SRH) among US adults and the extent to which blood and urinary metal mixtures explain this association. We used 14 years of repeated cross-sectional data that consists of seven consecutive NHANES cycles from 2003 to 2016 (n = 9497). SRH was measured using a 5-point Likert scale, and SES was measured by family income to poverty ratio (FMPIR), levels of education, and employment status. Blood concentration of lead, mercury, and cadmium, and urinary concentrations of ten heavy metals (arsenic, barium, cadmium, cesium, cobalt, lead, mercury, molybdenum, thallium, tungsten) were used as metal mixtures. The total effect of SES on SRH was examined by linear regression model. The direct effect of SES on blood and urinary metal mixtures was examined by the weighted quantile sum (WQS) regression with repeated holdout validation method, and the average causal mediation effects of blood and urinary metal mixtures were examined by model-based causal mediation technique. Results showed that SES indicators [education β: 0.17; 95% Confidence Interval (CI): 0.15, 0.18; employment β: 0.16; 95% CI: 0.12, 0.21; and FMPIR β: 0.09; 95% CI: 0.08, 0.11] were significantly positively, and the WQS indices of blood and urine metal mixtures (blood β: −0.04; 95% CI: − 0.05, − 0.03, urine β: − 0.07; 95% CI: − 0.13, − 0.004) were significantly inversely associated with SRH in the US adults. The novel finding was the mechanism between SES and SRH that exposure to heavy metals may explain socioeconomic inequalities in SRH in the US general population. Longitudinal studies are needed to corroborate this study results.

Family Contributions to School Performance of Adolescents: The Role of Fathers’ Perceived Involvement

Parental involvement is a valuable contribution to early adolescent behavior, particularly in educational contexts. This study analyzes the role of father’s socioeconomic status (SES) and perceived involvement (PI) when understanding school performance (SP) of adolescents, considering that involvement could be expressed as home-based and school-based. In a cross-sectional design, a sample from Colombia (South America) composed of 419 fathers (mean age = 42.2 years; SD = 7.37) and their adolescents (mean age = 12.63 years; SD = 0.86) completed self-administered questionnaires to measure SES, PI, and SP, and structural equation modeling was used to evaluate relations. Results indicate that the contribution of fathers to adolescent SP implies PI, considering that the direct effect of SES on SP is significant but small in comparison to the mediated path through PI. This article addresses the relevance of father’s contribution through involvement to understand the SP of adolescents, suggesting issues for studying the role of fathers in the adolescent’s outcomes.

Physical Exercise, Social Interaction, Access to Care, and Community Service: Mediators in the Relationship Between Socioeconomic Status and Health Among Older Patients With Diabetes.

The differences in socioeconomic status (SES) will cause a disparity in the health of the elderly. Taking diabetes as an example, previous studies have focused on risk factors of diabetes, while the relationship and mechanism between SES, multi-faceted factors, and the health of older patients with diabetes are not well-understood. This study aims to investigate the association between SES and health in older patients with diabetes and the interrelated mediators between them. Based on the data of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) in 2018, structural equation modeling (SEM) was used to test whether physical exercise, social interaction, access to care, and community service mediated the effect of SES on the health in older patients with diabetes. We found support for the model in which SES predicted the health in older patients with diabetes (comparative fit index = 0.910, incremental fit index = 0.911, goodness-of-fit index = 0.982, adjusted goodness-of-fit index = 0.959, standardized root mean square residual = 0.037, and root mean square error of approximation = 0.061). The total indirect effect of SES on the health accounted for 55.52% of the total effect. Results indicated that physical exercise (β = 0.108, p < 0.01), social interaction (β = 0.253, p < 0.001), and community service (β = 0.111, p < 0.001) had significant positive effects on the health of older patients with diabetes. SES was positively associated with physical exercise (β = 0.417, p < 0.001) and community service (β = 0.126, p < 0.01). Although no direct effect of SES on the health was found, SES mediated the positive effect in their relationship by physical exercise (indirect effect = 0.045, p < 0.01), and community service (indirect effect = 0.014, p < 0.05). This study showed the health disparities of older patients with diabetes were influenced by individual-level (physical exercise, social interaction) and environmental-level (community service). It suggests that a lack of physical exercise and health-related community service may impair the health of older patients with diabetes with low SES, which recommends individuals' positive actions and environmental supports for promoting health of regarding population.

The roles of social economic status and undernutrition in regional disparities of the under‐five mortality rate in Vietnam

From 2005 to 2017, the prevalence of mortality in Vietnamese children under five years old showed large regional disparities. In 2017, mortality in the wealthiest region was 12.6‰, whereas the most disadvantaged region it was three times as high, at 36‰. This study aims to identify factors affecting regional disparities of the under-five mortality rate (U5MR) in Vietnam. We applied Structural Equation Modelling to estimate the degree and the pathway through which undernutrition and socio-economic status (SES) contributed to the under-five mortality disparities. SES is estimated as a common latent factor of three socio-economic measures, that is, education, poverty and income. The direct effect of SES on U5MR is at 2.16 through the underweight pathway, which is 5 times higher than the effect of underweight on U5MR. Through the stunting channel, this direct impact is 1.43, nearly twice as high as the impact of the stunting rate. SES also has an indirect effect on U5MR through these undernutrition pathways. In total, we estimate that an increase in SES index will make the U5MR increase by 2.73‰. Among the three indicators of SES, poverty conveys the strongest signal of a considerable change in SES, thus to a subsequent change in U5MR. Among two types of undernutrition, the effect of stunting on U5MR is dominant, more than 3 times as high as that of underweight. These findings have important implications for socio-economic and health interventions: those that strongly focus on the reduction of regional poverty and stunting rates would be effective in bridging the regional gap in the U5MR in Vietnam.

Analysis of socioeconomic status and other factors affecting patient-graft survival in patients undergoing liver transplantation.

Background and AimLiver transplantation is performed in increasing numbers due to advances in surgical techniques and the introduction of diverse immunosuppressive drugs. The present study aims to analyze the effects of socioeconomic status and education level on patient and graft survival, in addition to all these factors.Material and MethodsAll patients aged 18 years and above who underwent consecutive liver transplantation at the Liver Transplantation Unit of Department of General Surgery at the Dokuz Eylül University Hospital and whose data were available were included in this study.ResultsIncompliance was noted in 68.3% of the 278 patients. On the other hand, patient compliance did not have a significant effect on graft and patient survival. However, decreased levels in the parameters, such as education status, vocational status and socioeconomic status, were found to be correlated with patient compliance. A significant correlation was not found between these factors and patient and graft survival.ConclusionAlthough a direct effect of socioeconomic status on patient and graft survival could not be shown the significant association of vocational status and education status which determine socioeconomic level with parameters other than patient and graft survival may affect the success of liver transplants.

Factors associated with overweight and obesity in adults using structural equation model: mediation effect of physical activity and dietary pattern.

This study aimed to determine the indirect effect of risk factors associated with overweight and obesity through physical activity (PA) and dietary pattern (DP), using structural equation model in the adults' population. This cross-sectional study was conducted on 10,000 adults from baseline data of Ravansar Non Communicable Disease cohort study, in the west region of Iran in 2018. Structural equation modeling was used to assess the causal effects of associated factors on obesity and overweight as the outcome. In general, the population at higher economic level was significantly more dependent on the healthy DP. The direct effect of socioeconomic status (SES) on overweight and obesity was - 0.070, the indirect effect was 0.127, and the total effect was 0.057. When stratified by gender, in women, SES had a weak direct effect (β = 0.024) and indirectly, through the variables of PA and DP, had a significant effect (β = 0.088) on the outcome. The same situation has been observed in men. That is a weak direct effect of SES (β = 0.070) and a significantly indirect effect, through three variables such as PA, DP, and smoking status, on the outcome. Factors associated with overweight and obesity not only by direct effect, but also can indirectly and through mediators (such as DP and PA as two important mediation variables) cause this outcome. LEVELOF EVIDENCE: Level V, cross-sectional descriptive study.

PP05 The First Choice Of Health Institutions Of Elderly In Zhejiang And Qinghai, China

IntroductionThe utilization of medical resources in China is unbalanced and insufficient. In order to find a way to maximize their utilization to face challenges in the upcoming decade, this study aims to investigate the elderly's first choice of health institutions when they were ill in the Zhejiang and Qinghai provinces, and to explore the potential pathways related to their choices, respectively.MethodsThe data used in this study was from cross-sectional surveys in Zhejiang and Qinghai. According to the Anderson Health Service Utilization Model, we applied structural equation modeling to explore the complex pathways from socioeconomic status (SES), accessibility, and health status to the elderly's first choice of health institutions.ResultsThe proportion of the elderly who selected community health institutions (CHI) as their first choice of medical institutions in Qinghai was higher than in Zhejiang. The Zhejiang model revealed a significantly negative direct effect of SES and significantly positive direct effects of accessibility to CHI and health status on the choice of institutions, and a significantly positive indirect effect of SES on choice of institutions, through the mediating factor of health status. SES played an important role in the Zhejiang model in direct and indirect ways. In the Qinghai model, only SES and accessibility to CHI had significantly direct effects on the choice of institutions, with accessibility to CHI having the biggest effects. SES had a significant and positive indirect impact on choice of institutions, through the factor of accessibility to CHI.ConclusionsA better understanding of the complex pathways from factors to elderly's choices of health institutions was essential, which may inform priorities for maximizing the utilization of CHI further and prepare to face challenges in the new decade. Through this research method, policymakers could explore the specific pathways based on their own economic and societal status.

Effects of Socioeconomic Status, Parent-Child Relationship, and Learning Motivation on Reading Ability.

Against the background of Chinese culture, we investigated the relationship between family socioeconomic status (SES) and children’s reading ability. Participants included 2294 middle-school students in grade 8. SES was measured by parents’ education level, parents’ occupational prestige, and family property, and children’s reading ability was estimated with item response theory. In addition, we adopted an 8-item parent–child relationship scale and a 22-item learning motivation scale that included four dimensions. We examined whether the parent–child relationship mediated the relationship between family SES and reading ability and whether this was moderated by learning motivation. The results indicated that the parent–child relationship played a mediating role in the relationship between SES and reading ability. This relationship was moderated by students’ learning motivation. The direct effects of SES on reading ability at high, medium, and low levels of learning motivation were 0.24, 0.32, and 0.40, respectively.

Socioeconomic status, family negative emotional climate, and anti-inflammatory gene expression among youth with asthma

The glucocorticoid receptor gene NR3C1 is an important down-regulator of inflammation and is typically under-expressed in individuals with low socioeconomic status (SES). Negative emotionality has been suggested as a potential mediator of SES disparities in health outcomes. In this study, we expand this literature by naturalistically assessing negative emotionality in a key emotional environment: the family. In a sample of 104 youth with asthma (10–17 years) and their primary caregiver, we assessed SES via caregiver report, emotional expression by youth and parents in the home over four days using the electronically activated recorder (EAR), and NR3C1 expression via blood collected from youth. Although there was not a direct effect of SES on NR3C1 expression, bootstrapping mediation analyses showed a significant indirect path such that lower SES was associated with a more negative family emotional climate, which in turn predicted reduced NR3C1 expression. No mediation effects were found for family positive emotional climate. This research demonstrates the importance of examining the effects of SES on emotion expression in the family context and suggests a critical biopsychosocial pathway underlying SES-based health disparities that may extend beyond youth.

A structural equation modeling approach to understanding pathways that connect socioeconomic status and smoking.

The inverse association between socioeconomic status and smoking is well established, yet the mechanisms that drive this relationship are unclear. We developed and tested four theoretical models of the pathways that link socioeconomic status to current smoking prevalence using a structural equation modeling (SEM) approach. Using data from the 2013 National Health Interview Survey, we selected four indicator variables (poverty ratio, personal earnings, educational attainment, and employment status) that we hypothesize underlie a latent variable, socioeconomic status. We measured direct, indirect, and total effects of socioeconomic status on smoking on four pathways through four latent variables representing social cohesion, financial strain, sleep disturbance, and psychological distress. Results of the model indicated that the probability of being a smoker decreased by 26% of a standard deviation for every one standard deviation increase in socioeconomic status. The direct effects of socioeconomic status on smoking accounted for the majority of the total effects, but the overall model also included significant indirect effects. Of the four mediators, sleep disturbance and psychological distress had the largest total effects on current smoking. We explored the use of structural equation modeling in epidemiology to quantify effects of socioeconomic status on smoking through four social and psychological factors to identify potential targets for interventions. A better understanding of the complex relationship between socioeconomic status and smoking is critical as we continue to reduce the burden of tobacco and eliminate health disparities related to smoking.

Relationship between socioeconomic status and quality of life in older adults: a path analysis.

The main objective of this study was to determine the relationship between quality of life, social functioning, depressive symptoms, self-efficacy, physical function, and socioeconomic status (SES) in community-dwelling older adults. A cross-sectional design was used to examine the relationships. A sample of 193 community-dwelling older adults completed the measurements. Structural equation modeling with full information maximum likelihood in LISREL was used to evaluate the relationships between the latent variables (SES, social functioning, depressive symptoms, self-efficacy, physical function, and quality of life). The path analysis exhibited significant effects of SES on physical function, social functioning, depressive symptoms, and self-efficacy (γ = 0.42-0.73), and significant effects in regard to social functioning, depressive symptoms, and self-efficacy on quality of life (γ = 0.27-0.61). There was no direct effect of SES on the quality of life. The model fit indices demonstrated a reasonable fit (χ (2) = 98.3, df = 48, p < 0.001), matching the relative Chi-square criterion and the RMSEA criterion. The model explained 55.5 % of the variance of quality of life. The path analysis indicated an indirect effect of SES on the quality of life by social functioning, depressive symptoms, and self-efficacy in community-dwelling older adults. Physical function did not have a direct effect on the quality of life. To improve the quality of life in older adults, additional focus is required on the socioeconomic psychosocial differences in the community-dwelling older population.

Social Class and Expectations of Rural Adolescents: The Role of Parental Expectations

This study investigated mechanisms involved in the intergenerational transmission of social class, specifically addressing the prediction of career expectations. The results indicated that among rural high school students (N= 200) in Grades 10–12, there was no direct effect of socioeconomic status (SES; as measured by parent education and occupation) on career expectations. However, there was a direct effect of educational expectations on occupational expectations. Building on the importance of educational expectations in the prediction of occupational expectations, the results suggested that perceived parental expectations explain variance in educational expectations. Overall, it seems that the effect of SES on occupational expectations was mediated by educational expectations; therefore, individuals of lower SES who have increased educational expectations are more likely to have occupational expectations similar to those of their higher SES peers. Moreover, increased parental expectations were positively associated with educational expectations among individuals of various SES levels.

Non-attendance and effective equity of access at four public specialist outpatient centers in Hong Kong

This study tests whether socio-economic status (SES), at either the individual or ecologic levels, exerts a direct impact on non-attendance or an indirect impact on attendance through longer waiting time for appointments and/or doctor-shopping behavior at four public specialist outpatient centers in Hong Kong. We collected information through three main sources, namely patients’ referral letters, telephone interviews with both open- and closed-ended questions (e.g. doctor-shopping data) and hospital administrative databases from a total of 6495 attenders and non-attenders enrolled from July 2000 through October 2001. Individual-level SES was measured by education, occupation and monthly household income. Tertiary planning unit (TPU)-level SES data consisted of proportion unemployed, proportion with tertiary education, median income and Gini coefficient. Direct effects of SES on non-attendance were examined by logistic regression. Indirect contributions mediated through waiting time and doctor-shopping were analyzed by structural equation modeling. We found that SES, at the individual or ecologic level, did not exert a direct effect on non-attendance. Instead, TPU-level SES contributed positively to waiting time ( β = 0.06 ± 0.03 , p = 0.048 ), i.e. worse-off neighborhoods (and those with greater income inequality) had a shorter waiting time. Individual-level SES was also directly associated with the likelihood of doctor-shopping ( β = 0.16 ± 0.02 , p < 0.001 ), i.e. the poor were less likely to doctor-shop. Both waiting time ( β = 0.12 ± 0.02 , p < 0.001 ) and doctor-shopping ( β = 0.37 ± 0.02 , p < 0.001 ) were significantly related to non-attendance. Our findings suggest a highly equitable specialist ambulatory care public system in Hong Kong. Health care resources are appropriately targeted at the socially indigent, and the poor are not discriminated against and pushed to seek alternative sources of care by the system. These results should be confirmed using a prospective design.

A Model of Girls' School Delinquency: School Bonding and Reputation

Using a longitudinal national database, the authors conducted a path analysis of girls' school delinquency to determine the indirect and direct effects of socioeconomic status, parental involvement, bonding to school, and girls' self-perception of reputation on school delinquency during middle school and high school. Self-perception of reputation was the most influential factor in girls' school delinquency, followed by bond to school and socioeconomic status. Implications for school counselors are presented.