Modifiable Social Factors Research Articles

Prevalence and distribution of unintended pregnancy: the Understanding Fertility Management in Australia National Survey

ObjectiveMistimed, unexpected or unwanted pregnancies occur in Australia, despite widespread contraception use. The objective was to estimate prevalence and ascertain modifiable social factors for prevention of unintended pregnancy. MethodsNational population‐based survey of women and men aged 18–51 years recruited from a random sample of electors on the Australian Electoral Roll in 2013. Data were weighted to reduce non‐response bias. Factors associated with unintended pregnancy were identified in multivariable analyses. ResultsData from 2,235 completed questionnaires were analysed (Women: 69%; Men: 31%). Of those ever pregnant or partner in pregnancy (59%), 40% had experienced an unintended pregnancy. Adjusting for other risks, ever having experienced sexual coercion (AOR, 95%CI=Women 1.948; 1.458–2.601; Men 1.657, 1.014–2.708); socioeconomic disadvantage (AOR, 95%CI=Women 1.808, 1.373, 2.381; Men 1.360, 1.004–1.841), living in a rural area (AOR, 95%CI=Women 1.403, 1.056–1.864; Men 1.583, 1.161–2.159), and for men being born overseas (AOR, 95%CI 1.989, 1.317–3.002) were significantly associated with unintended pregnancy. ConclusionsExperiences of sexual coercion, social disadvantage, rural residence and overseas birth are independently associated with unintended pregnancy in Australia. ImplicationsPublic health policy and health service initiatives should prioritise prevention of sexual coercion, reduction of social inequality and reduction of geographic inequality for those in rural areas.

Mental distress and potentially modifiable social factors in post-conflict Sri Lanka

Mental distress and potentially modifiable social factors in post-conflict Sri Lanka

Associations of mental distress with residency in conflict zones, ethnic minority status, and potentially modifiable social factors following conflict in Sri Lanka: a nationwide cross-sectional study

The subject of post-conflict mental health lacks studies that are nationally representative or large enough to allow robust examination of levels of distress according to residency in geographical zones of conflict and ethnic minority status. We undertook a nationwide study in Sri Lanka to address these issues. We used tablet devices to survey 20,632 people across 18 of 25 districts in Sri Lanka, of which nine were purposefully selected and nine randomly selected districts. Based on their exposure to war and levels of population displacement, these districts were classified as being in the severe, moderate, or minimal conflict zones. Trained local fieldworkers did private interviews with the participants in the local language; responses were entered directly into the tablet devices. The questions assessed exposure to a wide range of stresses, including ongoing adversities, threat or protection issues, and service access factors, and respondents provided categorical responses (yes/no) to a list of items. We used the 25-item Hopkins Symptom Checklist to measure depression and anxiety in participants. We used multivariate analysis and calculated population-attributable fractions to estimate potential improvement in mental distress if modifiable factors were addressed. Our results showed a stepwise increase in symptoms of depression (10%, 33%, 40%) and anxiety (13%, 23%, 23%) across minimal, moderate, and severe conflict zones, respectively. Membership of an ethnic minority group was associated with depression (Tamil odds ratio [OR] 2·4 [95% CI 1·8-3·1], other ethnic minority OR 2·7 [2·1-3·6]) and anxiety (Tamil OR 1·5 [1·1-2·0], other ethnic minority OR 1·5 [1·2-1·8]). Other fixed characteristics associated with depression and anxiety were older age (both depression and anxiety; OR 2·7 [95% CI 2·0-3·7] for anxiety and 2·3 [1·7-3·0] for depression), being married (anxiety only; OR 1·5 [95% CI 1·1-2·1]), and time spent in camps for internally displaced people (anxiety only; OR 1·4 [95% CI 1·0-1·9]). Modifiable characteristics were threat or protection issues (depression OR 1·8 [95% CI 1·2-2·8], anxiety OR 1·8 [1·3-2·6]) and scarcity of food (depression OR 1·4 [1·2-1·6], anxiety OR 1·4 [1·2-2·7]), loss of job (OR 1·2 [95% CI 1·2-1·4] for anxiety), and proximity to army camps (OR 1·6 [95% CI 1·2-2·2] for depression). Allaying of safety concerns had the potential to reduce depression by 53% and anxiety by 57%, with other factors (removal of army camps from proximity and addressing food scarcity, loss of jobs and threat/protection issues) making smaller contributions to a reduction in depression and anxiety. Our findings offer a basis for detecting high-risk groups and provide directions in devising policies and programmes aimed at alleviating psychological distress in Sri Lanka. Restoration of safety seems to be crucial to mental health recovery. Australian National University-Department of Immigration Border Protection Collaborative Research Program.

Improving health in children with disabilities: an intervention-development study to support participation in leisure in 8-12 year olds with communication and mobility limitations

Participation (i.e. involvement in life situations, such as leisure, education and self-care) is a fundamental health outcome for all children. Children with communication and mobility limitations experience restrictions to their participation in leisure, and the gap widens at age 8-12 years. These restrictions have negative consequences for their development and longer-term health and wellbeing. Evidence indicates that personal factors (e.g. child's motivation) and social-environmental factors (e.g. family behaviours) determine participation in leisure; however these pathways have rarely been systematically investigated and targeted in intervention-development research. The proposed study will address three questions: What modifiable personal and social-environmental factors influence participation in leisure in 8-12 years with communication and mobility limitations? What intervention techniques should National Health Service (NHS) clinicians use to target these factors? And, how should clinicians go about delivering these techniques? The methods will consist of two systematic reviews of current evidence; a Delphi study involving parents, clinicians and researchers; focus groups with parents, clinicians and children; and three mixed methods (QUANT+qual) single case studies. The primary output will be an intervention manual containing: (i) clearly specified, replicable intervention techniques for targeting modifiable personal and social environmental factors related to children's participation in leisure; and (ii) clear descriptions of feasible and acceptable approaches to delivering the techniques in NHS settings. The manual will enable NHS clinicians to provide evidence-based participation support, and will be a basis for further evaluation of participation interventions techniques. The secondary output will be a design for a feasibility trial of selected intervention techniques.

Essential Hypertension among Egyptian Adults

Background: hypertensive diseases represent a major disease burden in Egypt. The prevalence of hypertension in Egypt in 2008 among adults of age ≥ 25 was 17.6%. In 60% of patients, hypertension is usually associated with cardiovascular risk factors. This leads to increased cardiovascular morbidity and mortality. Management of hypertension in Egypt is not easy because of treatment costs and inefficient primary health care system. There is a need for developing national hypertension guidelines to improve the rates of awareness, treatment and control of hypertension with the final goal of preventing and decreasing mortality and morbidity. Aim of work: to assess the essential hypertension status among the Egyptian adult population of age≥ 25 and to study the modifiable social and environmental risk factors, health consequences, and assess the cardiovascular and non-cardiovascular complications to help disease prevention and limitation of complications. Patients and methods: this study was conducted on 312 patients of age ≥ 25 with essential hypertension. All patient were subjected to full medical history and physical examination that including measurement of blood pressure (BP) and fundus examination. Anthropometric measurements including height, weight, waist circumferences, and hip circumferences were also measured. Waist to hip ratio and body mass index (BMI) were calculated. Laboratory investigations were performed including complete blood count (CBC), fasting blood glucose, measurement of creatinine, uric acid and lipid profile. Microalbuminuria was also assessed. Other investigations including electrocardiogram and echocardiograph were done. Results: Male patients were 134(42.9%), while females were 178(57.1%). Their ages ranged from 30 to 85 years with a mean ±SD of 55.16±9.4years.Dyslipidemia was found in 152 (49%) patients. Left ventricular diastolic dysfunction (LVDD) was represented in160 (51%) patients. Uncontrolled BP was represented in (73%), (66%) and (55%) of non-educated, mild to moderate educated and high educated patients respectively. Retinopathy was found in 121 (38.8%) patients, 76 (60%) patients were hypertensive diabetic and 45 (24%) patients were hypertensive non-diabetic. Albumin in urine was present in 20%of patients. Conclusion: strategies that enhance public awareness of hypertension and increase access to affordable medications are urgently needed. Prevention of hypertension needs both a population strategy and an intensive strategy focused on individuals at high risk. The complications of hypertension can be prevented by adequate blood pressure control with screening programs to identify the population at risk

Abstract B01: The role of social support in alcohol consumption and alcohol dependence

Abstract Introduction: Alcohol consumption is associated with increased risk for some cancers, such as oral cavity, pharynx, larynx, esophagus, liver and female breast cancers. Along with genetic factors, the psychosocial environment elevates the proclivity for high alcohol consumption and dependence. We examined whether social support, an important feature of the psychosocial environment, influences alcohol consumption and alcohol dependence. Methods: We analyzed baseline alcohol and psychosocial environment data in the Women and Their Children's Health Study, which has enrolled over 2,800 women residing in seven coastal Louisiana parishes affected by the Deepwater Horizon Oil Spill. A comprehensive telephone interview was used to ascertain alcohol consumption, alcohol dependence and social support. We utilized multinomial logistic regression to estimate odds ratios and 95% confidence intervals for the association between social support and alcohol consumption/alcohol dependence. Alcohol consumption/alcohol dependence was defined using the following categories: never drinkers, current drinkers without alcohol dependence, and alcohol dependence as defined by the CAGE questionnaire. Age, race and depression were considered as confounders a priori, and we evaluated income, education, current employment status, oil spill exposure, smoking status, self-efficacy and marital status as potential confounders. Results: After restricting the dataset to subjects with available data on all predictors, 2,336 women were included in the analysis. The mean age was 44.8 years, with 57.3% of the population White. 69.9% of the cohort were non-drinkers, 28.1% reported currently drinking alcohol but did not classify as alcohol dependent, and 2.0% classified as alcohol dependent. We observed that women with low social support were significantly less likely to drink alcohol compared to women with high social support (aOR=0.69; 95% CI=0.53-0.88). Although not significant, a similar relationship for social support was seen when comparing alcohol dependent women and non-drinkers (aOR=0.60; 95% CI=0.28-1.28). In addition, we observed that depressed women were significantly less likely to be current drinkers compared to non-depressed women (aOR=0.78; 95% CI=0.62-0.98). However, depressed women were significantly more likely to be alcohol dependent (aOR=3.26; 95% CI=1.74, 6.10). Conclusion: Our data suggests that women with low social support are less likely to drink alcohol and to be less dependent on alcohol. Therefore, we infer that high social support may in fact confer elevated drinking behaviors among women. Since alcohol is a component cause for several cancers and the control of alcohol intake should reduce incidence and mortality of these cancers, identification and understanding of the modifiable social factors responsible for alcohol intake is also critical in the prevention of alcohol related cancers. Citation Format: Lauren E. Cole, Edward S. Peters, Edward J. Trapido. The role of social support in alcohol consumption and alcohol dependence. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr B01.

Reshaping Pediatric Practice

When pediatrician Donald Berwick became Administrator of the Centers for Medicare and Medicaid Services, he brought with him a simple framework to reorganize that agency and through it the US health care system.1 The “Triple Aim” sets 3 goals: (1) reducing per capita costs of health care, (2) improving the experience of care by addressing quality and satisfaction, and (3) improving the health of populations. Combined, these aims redefined the role of the Centers for Medicare and Medicaid Services from financier of health care services to public fiduciary and change agent. They also are likely to reshape the role and organization of pediatrics in the United States. Despite its reputation as a low-cost service, child health care will be examined for overuse and inefficiencies. Preventive care will be scrutinized. Interventions will target the small group of children who account for the majority of health care expenditures,2 and there will be greater interest in modifiable social factors that ramp up the costs of care for many children. And despite their low incomes relative to other specialists, pediatricians in the United States will not be immune from payment reform and possibly reduced reimbursement. Pediatricians will experience increasing pressure to reduce variations in the quality of care among neonates and children with chronic and complex health problems who are at heightened risk for poor outcomes.3 Recent shifts in the prevalence of a number of pediatric morbidities are placing new demands on child health care providers for which they may be … Address correspondence to Edward Schor, MD, Lucile Packard Foundation for Children's Health, 400 Hamilton Ave, Suite 340, Palo Alto, CA 94301. E-mail: edward.schor{at}lpfch.org

Correlates of Posttraumatic Growth in Adult Sexual Assault Victims.

This exploratory study examined how demographics, child sexual abuse (CSA), assault-related factors, and post-assault responses predict posttraumatic growth in a diverse sample (N = 1863) of female adult sexual assault victims. Multiple regression analysis showed that demographics (older age, ethnic minority race, less education) were all significantly related to greater posttraumatic growth, while CSA was unrelated to posttraumatic growth. Assault characteristics were weaker predictors of posttraumatic growth; whereas women's perception of life threat during the assault was related to greater posttraumatic growth. Post-assault factors including: greater levels of maladaptive coping, characterological self-blame, negative social reactions from others, and posttraumatic stress disorder (PTSD) symptoms were all related to less posttraumatic growth. Conversely, positive social reactions from others, perceived control over recovery, adaptive individual coping, and disrupted core beliefs were all related to greater posttraumatic growth. Clinicians should facilitate these modifiable social psychological factors when treating survivors.

Ethnicity and Long-term Prognosis After Myocardial Infarction

Health disparities are systematic differences in health, favoring members of advantaged over disadvantaged groups in the society. This study examines the contribution of multiple socioeconomic status (SES) measures to ethnic differences in after myocardial infarction (MI) prognosis. Patients aged 65 years and younger (n=1040) belonging to Ashkenazi and Mizrahi advantaged and disadvantaged ethnic groups discharged from 8 hospitals in central Israel after incident MI in 1992-1993, were followed up through 2005 for all-cause mortality, recurrent MI, heart failure, and ischemic stroke. Advantaged Ashkenazi had higher education, income, employment, and neighborhood SES compared with disadvantaged Mizrahi. Cardiovascular risk factors varied among the different ethnic groups. Results showed that the association between ethnic group and all outcomes differed substantially between models that included a single SES measure and those that included multiple measures. For example, the hazard ratio for mortality in disadvantaged Mizrahi compared with advantaged Ashkenazi was 1.87 [95% confidence interval (CI), 1.40-2.48] in a model adjusting only for demographic variables; 1.58 (95% CI, 1.18-2.12) in a model adjusting also for income; and 1.03 (95% CI, 0.74-2.04) in a model adjusting for all measured SES indicators. Further adjustment for clinical variables did not appreciably change the results. Findings show that a wide array of modifiable social factors shaped by income, education, and neighborhood socioeconomic conditions can explain ethnic health differences and highlight the importance of using multivariable models of SES.

Clinical risk of stigma and discrimination of mental illnesses: Need for objective assessment and quantification

Stigma and discrimination continue to be a reality in the lives of people suffering from mental illness, particularly schizophrenia, and prove to be one of the greatest barriers to regaining a normal lifestyle and health. Research advances have defined stigma and assessed its implications and have even examined intervention strategies for dealing with stigma. We are of the opinion that stigma is a potential clinical risk factor. It delays treatment seeking, worsens course and outcome, reduces compliance, and increases the risk of relapse; causing further disability, discrimination, and isolation even in persons who have accessed mental health services. The delay in treatment due to stigma causes potential complications like suicide, violence, harm to others, and deterioration in capacity to look after one's physical health. These are preventable clinical complications. In order to deal with the impact of stigma on an individual basis, it needs to be (i) assessed during routine clinical examination, (ii) assessed for quantification in order to obtain measurable objective deliverables, and (iii) examined if treatment can reduce stigma and its impact on individuals. New and innovative anti-stigma programs are required that are clinically driven in order to see the change in life of an individual by removing potential risks. The basic requirement for dealing with an individual's stigma perception/experience is its proper assessment for origin and impact in both a qualitative and quantitative manner. We further argue that quantification would allow for regular assessment and offer more effective intervention for patients. It will also be helpful in identifying modifiable social factors to enhance quality of care planning for management in hospitals and communities. The objective of quantification is to facilitate developing an approach to bring the assessment of stigma into clinical work and formulating customized strategies to deal with stigma at the patient level. It would be expected that the assessment of stigma would become a part of routine clinical assessment to identify barriers to outcome. This article discusses the need for quantification of patients’ experiences of mental illness stigma.

Social Support, Stressors, and Frailty Among Older Mexican American Adults

There is little research on the effects of stressors and social support on frailty. Older Mexican Americans, in particular, are at higher risk of medical conditions, such as diabetes, that could contribute to frailty. Given that the Mexican American population is rapidly growing in the United States, it is important to determine whether there are modifiable social factors related to frailty in this older group. To address the influence of social support and stressors on frailty among older Mexican Americans, we utilized five waves of the Hispanic Established Populations for the Epidemiologic Study of the Elderly (Hispanic EPESE) to examine the impact of stressors and social support on frailty over a 12-year period. Using a modified version of the Fried and Walston Frailty Index, we estimated the effects of social support and stressors on frailty over time using trajectory modeling (SAS 9.2, PROC TRAJ). We first grouped respondents according to one of three trajectories: low, progressive moderate, and progressive high frailty. Second, we found that the effects of stressors and social support on frailty varied by trajectory and by type of stressor. Health-related stressors and financial strain were related to increases in frailty over time, whereas social support was related to less-steep increases in frailty. Frailty has been hypothesized to reflect age-related physiological vulnerability to stressors, and the analyses presented indicate partial support for this hypothesis in an older sample of Mexican Americans. Future research needs to incorporate measures of stressors and social support in examining those who become frail, especially in minority populations.

Environmental Correlates of Physical Activity in Mexican American Children at Home

Understanding home environments might shed light on factors contributing to reduced physical activity (PA) in children, particularly minorities. Few studies have used microlevel observations to simultaneously assess children's PA and associated conditions in homes. Trained observers assessed PA and associated physical and social environmental variables in the homes of 139 Mexican American children (69 boys, 70 girls; mean age = 6 years) after school. Children spent most time indoors (77%) and being sedentary (74%). Reduced PA was associated with viewing media, being indoors, and parents being present. Increased PA was associated with prompts for PA and other children being present. PA prompts differed by child gender and location and prompter age status. Children are frequently sedentary at home. Microlevel observations showed PA is associated with potentially modifiable social and physical factors, including spending time outdoors. Studies to determine whether interventions on these correlates can improve children's PA are needed.

Comment on “Modifiable family and school environmental factors associated with smoking status among adolescents in Guangzhou, China”

Chen and colleagues describe social factors that are related with Chinese adolescent smoking behaviors [Chen, W., Wen, X., Muscat, J., et al., 2007-this issue. Modifiable family and school environmental factors associated with smoking status among adolescents in Guangzhou, China. Prev. Med. doi:10.1016/j.ypmed.2007.02.009]. These types of studies in China are very much needed given the fact that smoking is a significant health problem in China. Environmental factors may be more important than sometimes thought, since some studies suggest that smoking onset may not be such a ‘reasoned’ process by youngsters (Kremers, S.P., Mudde, A.N., de Vries, N.K., Brug, J., de Vries, H., 2004. Unplanned smoking initiation: new insights and implications for interventions. Patient Educ. Couns. 55 (3), 345–52.). Studies indicate that a multitude of factors are related to smoking onset, and thus deserve attention in a smoking prevention approach (see, e.g., [Tyas, S., Pederson, L., 1998. Psychosocial factors related to adolescent smoking: a critical review of the literature. Tob. Control 7, 409–420; Lantz, P., Jacobson, P., Warner, K., et al., 2000. Investing in youth tobacco control: a review of smoking prevention and control strategies. Tob. Control 9, 47–63]). The study conclusions were derived from a cross-sectional report. Consequently, one needs to be careful in making conclusions about causal pathways [Bauman, K., Fisher, L., 1986. On the measurement of friend behavior in research on friend influence and selection: findings from longitudinal studies of adolescent smoking and drinking. J. Youth Adolesc. 15 (4), 345–353]. Longitudinal studies also suggest the impact of selection mechanisms implying that adolescents were not pressured to start to smoke, but selected smoking friends. Chen, W., Wen, X., Muscat, J., et al.'s [2007-this issue. Modifiable family and school environmental factors associated with smoking status among adolescents in Guangzhou, China. Prev. Med. doi:10.1016/j.ypmed.2007.02.009.] work is important because it describes one of the many steps that are needed in China for realizing effective smoking prevention programs, a study that could be described as one of the first steps in the planning cycle of health promotion [Green, L., Kreuter, M., 1999. Health Promotion Planning: An Educational and Ecological Approach. Mayfield Publishing Company, Mountain View, CA]. Ultimately Chen and colleagues may want to develop smoking prevention interventions. These interventions should indeed incorporate the modifiable social factors, and – as the Chinese data suggest – should be gender sensitive. Consequently, the great challenge for Chen and several other Chinese colleagues will be to develop an integral long-term approach for their country to prevent smoking onset as effectively as possible using comprehensive approaches.

Epidemiology of Chronic Hepatitis B Infection in South Bronx Community Hospital

Purpose: Prior study reported that prevalence of hepatocellular carcinoma (HCC) and portal hypertension from chronic hepatitis B virus (HBV) infection was 44% among Hispanics and 28% among Blacks. Since our institution predominantly serves these populations therefore we retrospectively studied the epidemiology of HBV infection in our community. Methods: We reviewed medical records all patients age ≥18 years with chronic HBV infection who had been evaluated at the clinics affiliated with Bronx Lebanon Hospital Center between January 1, 2002 and December 31, 2004. Results: 167 patients with chronic HBV infection were identified with mean age of 40 years (range 18–81). Of these, 82 (49%) patients were males. 103 (62%) were African-Americans, 60 (36%) Hispanics and 4 (2%) others. Majority of the patients were covered by health insurance (127, 76%). Co-morbidities included HIV (23, 14%), HCV (8, 5%), HIV and HCV (4, 2%). Of the 16 patients with liver cirrhosis, 9 (56%) were found to be decompensated and 1 (6%) had HCC. Among 68 patients who had HBeAg status known, 23 (34%) had positive HBeAg. Of 78 patients with alpha-fetoprotein (AFP) known, 69 (88%) had AFP level less than 10 ng/mL. Liver imaging study for HCC screening was performed in 80 (48%) patients. 12 (7%) patients underwent HBV treatment. Among 155 patients who were not treated, 107 (69%) had alanine aminotransferase (ALT) level less than upper limit of normal (ULN) without evidence of liver cirrhosis. 48 patients were not eligible for HBV treatment for the following reasons: 20 (42%) were active injection drug or heavy alcohol users, 17 (35%) were non-compliant with visits during the evaluation period and 11 (23%) did not have health insurance coverage. Conclusions: In the South Bronx, nearly half of our patients underwent HCC screening. More than half of patients with liver cirrhosis were decompensated. Most of our patients were not considered to be candidates for treatment because of normal ALT levels and potentially modifiable social factors. Recognition and management of the identified factors may increase rate of HCC screening and HBV treatment.

The Mind of the Terrorist

This article reviews the state of the art of available theories and data regarding the psychology of terrorism. Data and theoretical material were gathered from the world’s unclassified literature. Multiple theories and some demographic data have been published, but very few controlled empirical studies have been conducted investigating the psychological bases of terrorism. The field is largely characterized by theoretical speculation based on subjective interpretation of anecdotal observations. Moreover, most studies and theories fail to take into account the great heterogeneity of terrorists. Many practical, conceptual, and psychological barriers have slowed progress in this important field. Nonetheless, even at this early stage of terrorism studies, preliminary reports suggest that modifiable social and psychological factors contribute to the genesis of the terrorist mind-set. Psychological scholarship could possibly mitigate the risk of catastrophic attack by initiating the long overdue scientific study of terrorist mentalities.