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Abstract: The US Institute of Medicine''s (IOM) influential 2003 report has focused attention on disparities in treatment outcomes and health status for American minorities, zeroing in on the role of unconscious bias in the unequal clinical disposition of minority patients. In keeping with the IOM''s focus, current examinations of health disparities in the US tend to explore bias in clinical decision-making to the neglect of the political economic trends that buffet health care safety net sites and create the need for financial shortcuts. This paper recontextualizes the study of health disparities in the US by placing it against the backdrop of private sector trends emphasizing fiscal austerity and increased workforce productivity in health care. The social science literature on workers in human service bureaucracies, only recently applied to health care workers, suggests that higher demands for system “accountability” and worker “efficiency” may encourage providers to take shortcuts by treating individuals as mass categories. This ethnography of a Latino mental health clinic in the Northwestern USA shows that new private-sector measures of “productivity” take a toll on both the Latina clinicians whose invisible work subsidizes the system as well as on particular categories of patients—the uninsured and immigrants with serious psychosocial issues. While clinicians attempt to buffer the impacts of such reforms on patients, they also resort to means to increase their productivity such as firing repeated no-show patients and denial of care to the uninsured. This study is relevant for the health care of the poor in all health care systems considering restructuring along managerial principles to increase system ‘efficiencies.’ [Copyright &y& Elsevier]

Abstract: This paper examines the development of innovation in human tissue technologies as a form of regenerative medicine, firstly by applying ‘pollution ideas’ to contemporary trends in its risk regulation and to the processes of regulatory policy formation, and secondly by analysing the classificatory processes deployed in regulatory policy. The analysis draws upon data from fieldwork and documentary materials with a focus on the UK and EU (2002–05) and explores four arenas: governance and regulatory policy; commercialisation and the market; ‘evidentiality’ manifest in evidence-based policy; and publics’ and technology users’ values and ethics. The analysis suggests that there is a trend toward ‘purification’ across these arenas, both material and socio-political. A common process of partitioning is found in stakeholders’ attempts to define a clear terrain, which the field of tissue-engineered technology might occupy. We conclude that pollution ideas and partitioning processes are useful in understanding regulatory ordering and innovation in the emerging technological zone of human tissue engineering. [Copyright &y& Elsevier]

Abstract: Migraine is a common, debilitating and costly disorder. Yet help-seeking for and rates of diagnosis of migraine are low. Drawing on ethnographic observations of pharmaceutical marketing practices at professional headache conferences and a content analysis of migraine advertising, principally in the USA, this paper demonstrates: (1) that the pharmaceutical industry directs its marketing of migraine medication to women; and (2) as part of this strategy, pharmaceutical advertisements portray women as the prototypical migraine sufferer, through representations that elicit hegemonic femininity. This strategy creates the impression that migraine is a “women''s disorder”, which, in turn, exacerbates gender bias in help seeking and diagnosis of migraine and reifies presumptions about the epidemiology of the disorder. I conclude that these pharmaceutical marketing practices have a paradoxical effect: even as they educate and raise awareness about migraine, they also create barriers to help seeking and diagnosis. [Copyright &y& Elsevier]

Abstract: Hundreds of studies have documented disparities in medical treatment in the USA. These findings have generated research and initiatives intended to understand and ameliorate such disparities. Many articles examine disadvantaged patients’ beliefs and attitudes toward health care, but generally limit their investigation to how these beliefs and attitudes influence adherence and utilization. Thus, this approach fails to consider whether patients use particular strategies to overcome providers’ potentially negative perceptions of them and/or obtain quality medical care. In this paper, we examine positive self-presentation as a strategy that may be used by disadvantaged groups to improve their medical treatment. Analysis of survey data (the 2004 Greater Cincinnati Survey) suggests that both African Americans and lower socioeconomic status persons are more likely than whites or higher socioeconomic status persons to report that positive self-presentation is important for their getting the best medical care. Based on these findings, we suggest several routes for future research that will advance our understanding of patients’ everyday strategies for getting the best health care. [Copyright &y& Elsevier]

Abstract: There has been an accelerated movement in the USA dialysis market towards affiliation with chain organizations. But little is known about the impact of this strategy of consolidation on provider performance of efficiency. This paper examines whether affiliation with multi-center dialysis chains creates a difference in technical efficiency. Data were obtained from 1994 to 2000 Independent Renal Facility Cost Report Data files of the Centers for Medicare and Medicaid Studies. Using multiple time series design with a comparison group, technical efficiency was examined through an intertemporal data envelopment analysis. The results showed that mean efficiency scores of chain-affiliated facilities in both pre- and post-affiliation periods are slightly higher than those of their independent counterparts, but the difference was not statistically significant. Members of the first and second largest chains did not appear to gain benefit from affiliation. In conclusion, greater technical efficiency of affiliated facilities is not the result of system engagement but rather the result of organizational maturation, or organizational learning. Engagement with the two largest systems does not provide members with its theoretical premises to achieve technically efficient production of dialysis treatments in multiple product markets. [Copyright &y& Elsevier]

Abstract: This paper uses data from a study of 196 infertile women from the Midwestern US to examine a general theory of helpseeking behavior applied to infertility. All of these women report meeting the medical definition of infertility—12 months or more of regular intercourse without conception—at some point in their lives. Only 35 percent of this sample of infertile women identified themselves as having had fertility problems and only 40 percent had sought medical treatment. Drawing on prior theories of helpseeking, we examine the effects of symptom salience, life course cues, attitudes, predisposing factors, and enabling conditions on helpseeking. We posit a model in which a cognitive dimension (perceived infertility) mediates between these predictors and medical helpseeking. Symptom salience (experienced infertility while actively trying to get pregnant), low parity, and poor subjective health are significantly related to perceived infertility, which is, in turn, significantly associated with helpseeking for infertility. Supporting the conclusion that the cognitive dimension of identifying oneself as infertile is critical to helpseeking, the relationship of symptom salience to helpseeking is partially mediated by perceived problems. Internal health locus of control is associated with lower odds of helpseeking but not to perceived infertility. [Copyright &y& Elsevier]

Abstract: This paper examines the cumulative prevalence of victimization and its impact on mental health in a nationally representative sample of 2030 children aged 2–17 in the USA. Telephone interviews conducted with both caregivers and youth revealed socio-demographic variations in lifetime exposure to most forms of victimization, with ethnic minorities, those lower in socio-economic status, and those living in single parent and stepfamilies experiencing greater victimization. Sexual assault, child maltreatment, witnessing family violence, and other major violence exposure each made independent contributions to levels of both depression and anger/aggression. Other non-victimization adversities also showed substantial independent effects, while in most cases, each victimization domain remained a significant predictor of mental health. Results suggest that cumulative exposure to multiple forms of victimization over a child''s life-course represents a substantial source of mental health risk. [Copyright &y& Elsevier]

Abstract: This paper is concerned with the historical attempt over the last 20 years to improve integration between primary and specialist mental health care. Semi-structured interviews were carried out during the period December 2000–March 2001 with primary care workers, specialist medical and nursing staff, managers and other key informants in one large group model Health Maintenance Organization in the USA. Both overt (financial) and covert (attitudinal and conceptual) barriers to the integration of mental health and primary care were identified and the impact of these barriers on organizational development is discussed with reference to Activity Theory. The nature and quality of interprofessional conversation in an organization may be important mediating factors in addressing covert barriers to integration between primary and specialist mental health services. There may be insufficient actual contact between different groups of workers in primary and specialist care to enable these professionals to share ideas, challenge mutual assumptions and understand each others’ viewpoints about the nature of their work, the covert barriers to integration. Workers may differ in the conceptual models of mental health care they utilize, their views about access to services, and the amount of information they require. In order to integrate services effectively, these issues will require discussion. Financial pressures in the system may lead to failure on the part of management to sanction and encourage opportunities for interprofessional conversation and the geographical distance between places of work may also limit opportunities for contact. However, an alternative explanation might be that attitudinal and other covert barriers to integration effectively prevent, in the first place, the development of such a shared space in which these covert barriers might actually be addressed. [Copyright &y& Elsevier]

The internet is one of a range of health information sources available to adolescents. It is recognised that young people have difficulties accessing traditional health services; in theory, the internet offers them confidential and convenient access to an unprecedented level of information about a diverse range of subjects. This could redress adolescents' state of relative health `information poverty', compared to adults. This paper seeks to explore United Kingdom (UK) and United States (US) adolescents' perceptions and experiences of using the internet to find `information about health and medicines, in the context of the other health information sources that are available to them. The study involved a series of 26 single-gender focus groups with 157 English-speaking students aged 11-19 years sima the UK and the US. Many students reported that the internet was their primary general information source. information sources were defined during analysis in terms of previous experience of the source, saliency of the available i information, and credibility of the source (defined in terms of expertise, trustworthiness and empathy). Most focus group participants had extensive personal experience with the internet and some information providers therein (notably search engines). Internet health information was regarded generally as salient. Its saliency was increased through active searching and personalisation. Perceived credibility of the internet varied because expertise and trustworthiness were sometimes difficult to determine, and empathy could be facilitated through online communities but the individual could control disclosure. The internet combines positive features of traditional lay and professional, personal and impersonal sources. Although it is unlikely to supplant the role of trusted peers and adults, the internet has found an important place among adolescents repertory of health information sources. [ABSTRACT FROM AUTHOR]

Domestic violence and sexual abuse are important correlates of HIV risk in women. This paper examines the links between HIV risk and domestic violence in women in a region with the highest HIV/AIDS rates in the United States. The theoretical framework incorporates Butler''s (1993) and (1990) concept of performative gender and Collins’ (2000) “controlling images” of African American women as a context for domestic violence in the Deep South. Two focus groups were convened to develop a definition of domestic violence as HIV risk; 50 in-depth individual interviews of HIV-positive women were subsequently conducted for specific information on the topic. A final focus group was conducted for verification and feedback. The interview data revealed that controlling images of women as sexualized bodies were enacted through rape, sexual coercion, and name-calling in intimate relationships. The main finding was that the women lacked the ability to control sexual activities (including condom use) in abusive relationships with HIV-positive men. The women used various strategies to escape abusive partners and to obtain treatment for HIV/AIDS. The study concludes that the links between gender inequity, domestic violence, and HIV transmission should appear in prevention materials to encourage domestic violence screening in health settings, and to provide abused women with information on the not-so-obvious risks of being infected in abusive relationships. [Copyright &y& Elsevier]

Studies on the risk of intentional re-injury tend to use samples of admissions to hospitals and conclude that prior intentional injury is predictive of future such admissions. Limiting samples to persons receiving medical attention misses the equally important population of those intentionally injured but not receiving medical attention. Approximately 2 million violence–related injuries go medically unevaluated each year in the United States. A significant portion of these are severe. Including this population captures the dark figure of untreated intentional injury and allows for the estimation of the effects of medical intervention on future risk. This paper tests the hypothesis that those going without medical evaluation will have higher odds of injury recurrence than the traditionally studied population of those receiving health care. Data are drawn from the National Crime Victimization Survey (NCVS), an ongoing and nationally representative longitudinal survey of households in the United States. The NCVS collects information at the household and person-level, and when victimization is identified through screener questions, at the incident-level. In addition to capturing crime and violence reported to the police and medical professionals, this methodology captures incidents that go unreported and untreated. Controlling for correlates of violence and reinjury, persons injured in violent events receiving medical attention alone, or in combination with police notification, are at substantially lower risk of incurring future violence and violence-related injuries than persons injured but not receiving medical or police attention. [Copyright &y& Elsevier]

Recent work on health and place has examined the impact of the environment on health. At the local level, research has followed several strands, such as contextual effects of neighborhoods, the impact of differential access to services and amenities, effects of a neighborhood''s collective efficacy, and the relationship between social capital and health. Of these four approaches, social capital has generated the most debate; some scholars discuss social capital as a key epidemiological variable, while others discount or dismiss its utility. We undertook this research to assess whether the concept of social capital could increase our understanding of the impact of neighborhoods on residents’ health. We utilized key informant interviews and focus groups to understand ways in which residents of diverse neighborhoods in one large California city perceived that their local communities were affecting health. We argue in this paper that using the term “social capital” to discuss social resources and their mobilization in a particular neighborhood highlights the ways in which social resources can vary in relation to economic resources, and that residents of neighborhoods with differing levels of services and amenities face different issues when mobilizing to improve their neighborhoods. Additionally, the projects that people invest in vary by neighborhood socioeconomic status. We draw on the paired concepts of “bridging” and “bonding” social capital, and discuss that while stores of bonding social capital may be more uniform across neighborhoods of varying SES, bridging social capital tends to be found in greater amounts in neighborhoods of higher SES which allows them greater success when mobilizing to improve their neighborhoods. [Copyright &y& Elsevier]

The resurgence of tuberculosis in recent years has obliged us to reconsider the existing explanations of the disease. Whereas biomedical literature tends to explain tuberculosis in terms of biological factors (e.g., bacterial infection), social scientists have examined various cultural, environmental, and politico-economic factors. In this paper, sociocultural approaches to tuberculosis are reviewed according to their emphasis on cultural, environmental, and politico-economic factors. Then how the public health establishment considers biological, cultural, environmental and politico-economic factors will be examined through a case study of immigrant tuberculosis. While public health facilities emphasize biological factors in the control of immigrant tuberculosis, an ethnographic study of tuberculosis among Chinese immigrants in New York City provides detailed contexts that illustrate the cultural, environmental, and politico-economic forces shaping tuberculosis and supports an emerging theorization of tuberculosis that encompasses a heterogeneous collection of factors. Finally, a number of implications for public health interventions will be discussed. [Copyright &y& Elsevier]

The paper analyses geographical variations in use of acute psychiatric inpatient services within New York City and how these have changed from 1990 to 2000. We review literature suggesting reasons for the variations observed. Data from the New York State Department of Health Statewide Planning Research and Cooperative System were combined with population census data to produce age standardized ratio indicators of admissions and of bed days, as measures of use of general hospitals for psychiatric conditions, by males aged 15–64, in Zip Code Areas of New York City, in 1990 and 2000. Geographical variations in hospital use were related to proximity to general hospitals with psychiatric beds and to socio-economic status of local populations (as recorded in the 1990 and 2000 population censuses). Areas close to psychiatric hospitals areas show high admission levels. Controlling for this, Zip Code Areas with higher concentrations of poverty, of African American residents or of persons living alone were associated with relatively high admission ratios. These relationships vary somewhat between diagnostic groups. Area inequalities in standardized admission ratios persisted and widened between 1990 and 2000, and the highest hospital admission ratios were increasingly concentrated where social and economic disadvantage was greatest. Various possible reasons for this trend are explored. We conclude that increasing intensity of poverty in disadvantaged areas is not likely to provide an explanation and that the trends are more likely to result from changes in hospital management and funding affecting access to hospital services. [Copyright &y& Elsevier]

The notion that the tort liability system deters negligence in health care has been invoked to make the “business case for patient safety.” However, existing data on the relationship between hospital adverse events and malpractice claims typically are interpreted as evidence that the tort system does not deter negligence because of the poor fit between those who are negligently injured and those who sue. Using a familiar analogy from epidemiology—the problem of false positives in screening tests for rare diseases—and data from two large studies of medical injuries and malpractice claims in the United States, this paper presents an argument that the standard interpretation overlooks a complexity in the data. Although most malpractice claims do not actually involve a negligent injury, a patient who suffers a negligent injury is more than 20 times more likely, on average, to file a claim than a patient who does not. However, because malpractice claiming is a rare event with many false positives, for the average hospital or group practice, even substantial improvements in rates of negligent injury will not lead to a large reduction in claims rates. These findings suggest that the strength of the business case for patient safety depends on the perspective from which one views the data. [Copyright &y& Elsevier]

This paper examines the association between US county occupational structure, services availability, prevalence of risk factors, and coronary mortality rates by sex and race, for 1984–1998. The 3137 US counties were classified into five occupational structure categories; counties with the lowest percentages of the labor force in managerial, professional, and technical occupations were classified in category I (5–16%), counties with the highest percentages were in category V (32–59%). Directly age-adjusted coronary heart disease (CHD) mortality rates, for aged 35–64 years, (from vital statistics and Census data), per-capita services (County Business Patterns), and the prevalence of CHD risk factors (Behavioral Risk Factor Surveillance Surveys data) were calculated for each occupational structure category. CHD mortality rates and the prevalence of risk factors were inversely monotonically associated with occupational structure categories for white men and women but not among black men and women. Numbers of producer services for banking, business credit, overall business services and personnel/employment services were 2–12 times greater in category V versus I counties. Consumer services such as fruit/vegetable markets, fitness facilities, doctor offices and social services were 1.6–3 times greater in category V versus I counties. Residential racial segregation scores remained high in most areas despite declines during 1980–1990; occupational segregation by race and gender were shown indicating continued institutional racism. An ecological model for conceptualizing communities and health and the overall influence of state and national occupational structure is discussed; intervention strategies such as decreased wage disparities and ‘living wage’ standards and development is discussed. [Copyright &y& Elsevier]

Regulations of junior doctors’ work hours were first enacted in the United States (US) and United Kingdom (UK) over a decade ago, with the goals of improving patient care and doctors’ well-being while maintaining a high quality of medical training. This study examines experiences and attitudes regarding the implementation of these regulations among physicians and surgeons at two teaching hospitals, one in South-East England, and the other in New England, US. This paper presents the findings of a survey questionnaire and a series of in-depth interviews administered to a sample of junior doctors and the consultants responsible for their supervision. The study finds that the different policy mechanisms employed in the two countries have had different degrees of success in reducing the work hours of junior doctors. The results also indicate, however, that even in settings in which hours have been reduced significantly, the regulations have only had limited effects on the quality of medical care, junior doctors’ well-being, and the quality of medical education. A number of barriers to the success of the regulations in achieving their objectives are identified, and the relative merits of political action and professional self-regulation are discussed. This research suggests that recently enacted policies requiring further reductions in junior doctors’ hours in both the US and UK may face similar barriers when implemented. Understanding the lessons that emerge from implementation of the original regulations is essential if future reforms are to succeed and a high-quality system of health care is to be sustained. [Copyright &y& Elsevier]

This paper considers occupational back injuries as they are described by injured workers, including the impact on their abilities to function in family and social roles. In this study, we interviewed people with work-related back injuries in Florida and Wisconsin. The sample was chosen from among workers who either lost more than 28 days from work or who received workers’ compensation permanent partial disability benefits. Respondents indicated a wide range of limitations on family and social roles, including physical impacts that hampered respondents’ ability to do household chores, to take part in raising children, and to engage in leisure activities with their spouses. Spouses and children took over family responsibilities once carried on by injured workers. The impacts of limitations resulted in a restructuring of family and social roles, relationships, and self-identities. In addition, these impacts led to depression and anger among the injured workers and to stress and strain in family relationships. Unlike the effects on work, many of these outcomes are not valued in the marketplace and, as a consequence, are less visible. They are nonetheless important and suggest that priorities based only on economic outcomes may understate the importance of preventive activities. Moreover, they suggest that attention should be focused on social structural factors such as the provision of medical services and social support to reduce the impact of chronic back pain on family members. [Copyright &y& Elsevier]

Public and professional discourses in American society about what constitutes a "good death" have flourished in recent decades, as illustrated by the pivotal SUPPORT study and the growing palliative care movement. This paper examines a distinctive medical discourse from high-technology academic medical centers through an analysis of how physicians who are specialists in internal medicine tell stories about the deaths of patients in their care. 163 physicians from two major academic medical centers in the United States completed both qualitative open interviews and quantitative attitudinal measures on a recent death and on the most emotionally powerful death they experienced in the course of their careers. A subsample of 75 physicians is the primary source for the qualitative analysis, utilizing Atlas-ti. "Good death" and "bad death" are common in popular discourse on death and dying. However, these terms are rarely used by physicians in this study when discussing specific patients and individual deaths. Rather, physicians' narratives are nuanced with professional judgments about what constitutes quality end-of-life care. Three major themes emerge from these narratives and frame the positive and negative characteristics of patient death. Time and Process: whether death was expected or unexpected, peaceful, chaotic or prolonged; Medical Care and Treatment Decisions: whether end-of-life care was rational and appropriate, facilitating a "peaceful" or "gentle" death, or futile and overly aggressive, fraught with irrational decisions or adverse events; Communication and Negotiation: whether communication with patients, family and medical teams was effective, leading to satisfying management of end-of-life care, or characterized by misunderstandings and conflict. [ABSTRACT FROM AUTHOR]

Japan and the United States are both post-industrial societies, characterized by distinct trajectories of dying. Both contain multiple "cultural scripts" of the good death. Seale (Constructing Death: the Sociology of Dying and Bereavement, Cambridge University Press, Cambridge, 1998) has identified at least four "cultural scripts", or ways to die well, that are found in contemporary anglophone countries: modern medicine, revivalism, an anti-revivalist script and a religious script. Although these scripts can also be found in Japan, different historical experiences and religious traditions provide a context in which their content and interpretation sometimes differ from those of the anglophone countries. To understand ordinary people's ideas about dying well and dying poorly, we must recognize not only that post-industrial society offers multiple scripts and varying interpretive frameworks, but also that people actively select from among them in making decisions and explaining their views. Moreover, ideas and metaphors may be based on multiple scripts simultaneously or may offer different interpretations for different social contexts. Based on ethnographic fieldwork in both countries, this paper explores the metaphors that ordinary patients and caregivers draw upon as they use, modify, combine or ignore these cultural scripts of dying. Ideas about choice, time, place and personhood, elements of a good death that were derived inductively from interviews, are described. These Japanese and American data suggest somewhat different concerns and assumptions about human life and the relation of the person to the wider social world, but indicate similar concerns about the process of medicalised dying and the creation of meaning for those involved. [ABSTRACT FROM AUTHOR]

In this paper, we attempt to verify that neighborhood economic structure influences individual health over and above other individual characteristics, and to comparatively evaluate the effects of neighborhood concentrated affluence, concentrated poverty and income inequality in relation to individual health in the USA. We also explore physical environment, health-enhancing services, social hazards (crime) and social resources as mechanisms operating at the neighborhood level that may help to explain the influence of structural economic conditions on health. We use Hierarchical Ordinal Logit Models to examine a rich multi-level data set.Results indicate that affluence exerts significant contextual effects on self-rated health while poverty and income inequality at the neighborhood level are not important structural factors. Moreover, we find that a composite measure of social resources distinguishes itself in both explaining the impact of concentrated affluence and exerting an independent contextual effect on individual health. Physical environment, or the level of physical disorder in the neighborhood, also mediates the effect of affluence on self-rated health, although to a lesser degree than social resources.Our empirical findings suggest that different dimensions of economic structure do not in fact have unique and additive contributions to individual health; the presence of affluent residents is essential to sustain neighborhood social organization which in turn positively affect health. [Copyright &y& Elsevier]

This paper explores the idea that in societies that experience racial tension, increasing racial heterogeneity will be associated with poorer health outcomes, and this effect will be observable in the health of both the minority and the majority group. Here, the association between mortality and racial homogeneity in the United States is examined. The level of racial homogeneity, indexed by the proportion of blacks in each state of the 50 states in the US, was examined in relation to all-cause mortality, adjusted for age and disaggregated by race and sex. The level of poverty in each state was controlled for in ordinary least squares regression models. The level of racial homogeneity was significantly associated with age adjusted mortality rates for both blacks and whites, accounting for around 30% of the variance in mortality rates in the total population and the white population. Every 1% increase in the percentage of the state population who were black was associated with an increase in the total mortality rate of 5.06 per 100,000 and an increase in the white mortality rate of 3.58 per 100,000. Based on the data, this suggests, for example, that racial heterogeneity in Mississippi accounts for around 14% of the white mortality rate and in New York and Delaware it accounts for around 7%. These results appear to support the social cohesion thesis that in societies that are intolerant, mortality rates will increase as the proportion of racial or ethnic minorities increase in population. Limitations and explanations for the findings are discussed. [Copyright &y& Elsevier]

Economic restructuring in the health services industry in the USA exemplifies general patterns of economic change propelled by neoliberalism, especially industry privatization, diminished social services, and dependence on “flexible” labor and management regimes. Combined with the widespread entry of women into the labor force, an aging population, and minimal assistance for high quality long-term care at the end of life, these economic and social conditions raise a set of difficult policy questions for health services planning. Set in these broad contexts, this paper situates access to and experience of health services in the home, the hospital, and nursing facility, to demonstrate how economic changes have relocated and redefined health services in ways that distinctively impact how people experience the places where they receive care. This place switching of health services externalizes costs of subacute and “daily life care” (the so-called custodial care) to the sphere of the individual, their family, and communities. The theoretical analysis uses current geographical and philosophical approaches to place and space, and considers the tensions between institutionally managed health care space, and the patient''s experience of receiving health services in place. The place/space dilemma of health services provision is examined through several interrelated subjects: long-term care at the end of life, gendered characteristics of care giving, the limitations of Medicare and Medicaid, historical changes in hospital length of stay, the restructuring of nursing practices, and the “no-care zone”. The analysis is based on examples of stroke and incontinence care to demonstrate the importance of considering place and space issues in health care planning. [Copyright &y& Elsevier]

An increasing proportion of newly diagnosed AIDS cases is being reported among African American urban women. Recent research regarding the psychosocial and behavioral impact of a mother''s HIV status on her uninfected children as well as a growing body of clinical evidence suggest that these children are extremely vulnerable and at risk for problems in psychosocial adjustment. The present paper reports the results of research designed to examine the pathways by which a mother''s HIV-positive status affects the psychosocial adjustment of her uninfected school-age child. The principal predictor variables of the model are family sociodemographic characteristics, social support available to mother and child, HIV-related symptom distress in the mother, coping strategies of both mother and child, emotional distress of the mother, and quality of the parent–child relationship. The dependent variable is the psychosocial adjustment of the child. Data were collected on 147 mother–child dyads using standardized questionnaires and personal interviews. Eighty-six percent of the mothers were African American and over 96% were on public assistance. Structural equation modeling was used to test the proposed model of mother–child coping and adjustment. After adding three paths, the model had a good fit to the data (comparative fit index=0.94; root mean square estimate of error=0.06). Five model constructs accounted for 36% of the variance in child adjustment. The constructs in order of importance were maternal HIV-associated stressors, maternal emotional distress, child social support, child coping, and quality of parent–child relationship. [Copyright &y& Elsevier]

With the advent of the Human Genome Project and widespread fears over human cloning and medical privacy, a number of states have moved to protect genetic privacy. Oregon''s unique Genetic Privacy Act of 1995, which declared that an individual had property rights to their DNA, has provoked national and international interest and controversy. This paper critically reviews the literature on genetic privacy and gene patenting from law, philosophy, science and anthropology. The debate in Oregon, from 1995 to 2001, illustrates many of the key issues in this emerging area. Both sides of the debate invoke the property metaphor, reinforcing deterministic assumptions and avoiding more fundamental questions about the integrity of the body and self-identity. The anthropological critique of the commodification of the body, and the concept of ‘embodiment’ are useful in analyzing the debate over DNA as property. [Copyright &y& Elsevier]

Human migration can make it more difficult to detect geographic differences in disease risk because of the spatial diffusion of people originally exposed in a given geographic area. There are also situations where migration can facilitate the detection of disease attributable to environmental hazards. This paper assesses the effects that migration has on the ability to detect regional variability in disease risk. Several characteristics of migration are discussed, including some that are not widely known. Because of regional variations in mobility rates and other characteristics of the migration process, there is substantial regional variation in the ability to detect spatial variation in risk. [ABSTRACT FROM AUTHOR]

This paper focuses on the issue of how a research project can shift from a positivist to a nonpositivist framework. Specific attention is given to changes in research methods and philosophical paradigm that emerged while conducting a study on the replacement of immigrant physicians in rural America. In its original conceptualization, the study was expected to yield a simple, right answer. Specifically, one or more types of health professionals (e.g., nurse practitioners, National Health Service Corps physicians) would be identified as expected replacements in the event of a cutback on immigrant physicians. However, as the research progressed, the quest for a simple, right answer became less realistic. The theoretical framework, methods, and research question changed, thereby allowing for greater complexity and ambiguity than anticipated at the outset of the study. What had been a positivist, statistical study was now a nonpositivist, qualitative study, and the research question shifted to include individual perspectives. An overview of such transitions leads to a discussion of the importance of context and ambiguity in research. [ABSTRACT FROM AUTHOR]

A new literature has recently emerged which suggests that among the developed economies, at least in terms of health status, the distribution of income may be more important than its absolute level. In this literature, the effect of income inequality, in particular, relative inequality on health status is tested by examining the relationship between aggregate mortality and a single measure of inequality (such as the Atkinson Index). In this paper we look at whether a single measure of income inequality, even augmented by a measure of representative income can at the aggregate level, distinguish between the effects of relative as opposed to absolute income. An alternative approach that uses disaggregated income to distinguish between the effects of changes in relative and absolute income levels is applied to data from the 1990 US Census and mortality figures from the National Centre for Health Statistics. Our results indicate that the rate of mortality is sensitive to absolute, but not relative poverty and therefore suggest that to improve the health of the poor the focus must be on raising their absolute standard of living. The results also indicate that government supported programs may have important health enhancing effects and may therefore represent a key policy tool to improve the health of those at the bottom of the income distribution. [ABSTRACT FROM AUTHOR]

When and how do politicians talk about public health crises? Using evidence from the opioid crisis in the United States, this paper assembles and analyzes novel data on Congressional statements to explore the conditions under which politicians (1) issue public statements about opioids and (2) frame the opioid crisis as a predominantly public health or law enforcement problem. We examined 3.8 million Congressional floor speeches and 111,000 public statements to identify (1) floor speeches about drug crises in the 97th to 114th Congresses (1981–2017) and (2) public statements about the opioid crisis in the 116th Congress (2019–2020). Moderate ideology, women, greater overdose deaths, and larger white populations are associated with significantly higher frequencies of opioid statements. Using a dictionary-based text analysis approach, we find that ideologically liberal and African American legislators are more likely to use public health framing, while ideologically conservative members are more likely to use law enforcement framing and refer to national borders or foreign countries in opioid statements. Democrats/liberals more often referenced medication treatment for opioids. These findings imply two broader conclusions about the nature of political discourse in public health crises. First, that political extremists are least likely to talk about opioids suggests that increasing partisan polarization may result in less discussion, emphasis, and expertise in public health issues. Second, the tenor of discourse about opioids and other public health crises is likely to change with partisan electoral waves, potentially hindering long term planning of public health capacity. • Public statements by members of Congress are a source of information about opioids. • We study determinants of the frequency and content of opioid public statements. • Moderates, women, and more impacted districts issue more opioid statements. • Liberal and African American members more often use public health language. • 25% of Democrats and 50% of Republicans used mostly law enforcement language. [ABSTRACT FROM AUTHOR]

In light of recent discussions about shifting employees from traditional workplaces to virtual employment, we are motivated by the question of whether this phenomenon will end up saving lives even in the absence of an infectious disease outbreak. Motor vehicle incidents are the leading cause of work-related fatalities in the US, killing more than 1200 workers each year, which make up about a quarter of all work-related deaths. Not only are motor vehicle crashes the top killer at work, but economic expansions can further increase occupational and traffic deaths as they both tend to be procyclical. In this paper, we examine the effects of business cycles on traffic fatalities in the US with a special focus on work-related deaths. Specifically, we implement a longitudinal design across all 50 states by compiling quarterly data for 2004–2012 and consider macroeconomic fluctuations around the Great Recession. Our findings show that traffic deaths during prosperous times are not solely due to an increase in risky behaviors such as drunk driving, but directly related to work. Given the highly preventable nature of traffic crashes, policy makers, public health advocates, and employers can develop effective strategies, including remote work arrangements, to improve both occupational and traffic safety. [ABSTRACT FROM AUTHOR]

In this paper we propose a new category of International Medical Graduates (IMGs) who are forced to leave their home countries: "refugee physicians." In US social science scholarship, IMGs are divided into US citizen IMG (USIMG) and non-US citizen IMG (non-USIMG). For purposes of US medical licensure qualifications and recordkeeping, US- and non-USIMGs are lumped together. These categorizations are too blunt to demonstrate important differences among non-USIMGs. The category of "refugee physicians" distinguishes non-USIMGs who are forced to flee their homelands from other IMGs. We define and develop this category based on qualitative in-depth interviews conducted in 2019 with 28 non-USIMGs who fled to the US within the past 15 years. Using narrative analysis, we constructed "flight biographies," storied chronological events and experiences, for each physician. The flight biographies highlight the medical and political contexts in which they were forced to flee and are situated in the US. Two representative cases demonstrate how and why lumping refugee physicians together with other IMGs obscures the constraints and challenges that set them apart from the other IMG categories. First, the term refugee physician focuses attention on how physicians are located among forcibly displaced people worldwide, including their distinct relationships to their home countries, transit countries in which some of them seek sanctuary, and the US, where some requested asylum and others have been resettled. Second, because refugee is an umbrella term that blends categories of law, policy, social science, and everyday usage it encompasses a wide variety of lived experiences along a continuum of compulsion to leave. Finally, refugee physician illuminates the group's distinct relationship to medical licensure and brings into focus structural barriers that impede their goal of gaining a US medical license. • Qualitative interviews with 28 forcibly displaced International Medical Graduates in the US. • Thematic narrative analysis of two representative cases. • Identifies unique challenges of forced migrants in the US who are IMGs. • Proposes a new category of International Medical Graduates – "Refugee Physicians". [ABSTRACT FROM AUTHOR]

Health disparities research often focuses on the social patterning of health outcomes. Increasingly, there has been an emphasis on understanding the mechanisms perpetuating disparities, even after issues of patient access to health services are addressed. The following study utilizes a novel dataset of electronic medical records (EMR), radiology records, and U.S. Census data to investigate the racial/ethnic patterning of provider-patient communication among patients diagnosed with incidental medical findings requiring follow-up. My results indicate that racial/ethnic disparities in follow-up adherence stem from initial disparities in provider-patient communication. These communication disparities persist even after accounting for multiple socioeconomic, health, and provider characteristics, indicating a bias in medicine, whereby providers are less likely to communicate information about incidental medical findings to patients of color relative to White patients. This paper has important clinical implications, as it sheds new light on why we might see low adherence to medical advice among patients of color. Findings also have social, political, and policy relevance, as they suggest an important mechanism through which health inequalities persist. To finally eliminate racial/ethnic health inequalities in the United States, racial bias and discrimination within medical and public health infrastructures must be eliminated. • Examines if disparate provider-patient communication of incidental medical findings occurs. • Finds provider-patient communication occurs disparately across patient racial groups. • Effects strongest for Hispanic and Black patients; disparities remain after including controls. • Access to primary care somewhat attenuates communication disparities. • Policies must address provider communication bias and ensure access to primary care. [ABSTRACT FROM AUTHOR]

The role of fetal development in abortion work is unresolved, mirroring a broader cultural ambivalence regarding the fetus. The collective, cultural notion of fetuses tends to lie on a dichotomy between "clump of cells" and "baby," with little public attention to the realities of fetal development during all stages of pregnancy. This tension is exacerbated by an absence of medically accurate images of aborted fetal tissue available to lay audiences. In this paper, we examine how independent abortion providers manage contradictory messages surrounding the fetus when providing patient-centered pregnancy tissue viewing (PCV). More specifically, we investigate how providers navigate public and private understandings of the fetus in their healthcare provision amidst a void of nuanced fetal imagery. Through interviews with 25 independent abortion providers in the United States, we analyze the discursive framings providers employ to make sense of the fetus and provision of PCV. Using a symbolic interactionism framework, we grouped results into three overarching themes: tensions in language, the impact of gestation as de- or re-stigmatizing, and looking as "making it more real." Our findings support the notion that the fetus is largely socially constructed, mutable, and variant across individuals, context, and time; our findings also highlight abortion providers' ability to hold nuanced and sometimes conflicting thoughts and feelings about fetuses while providing patient-centered care. This study addresses a largely overlooked practice within medical sociology and furthers our understanding of how cultural narratives shape the provision and meanings of patient-centered care, the professional socialization of healthcare workers, and the patient-provider interaction. • The "baby vs clump of cells" cultural binary affects interactions in the clinic. • Fetal symbolism is malleable and variant across individuals, context, and time. • Providers use mirroring and affect assessment to navigate cultural fetal ambiguity. • Language and gestational age shape fetal meaning and PCV makes abortion "more real." • Providers can have complicated feelings about fetuses but be confident in their work. [ABSTRACT FROM AUTHOR]

2020 in the United States was marked by two converging crises—the COVID-19 pandemic and the large-scale uprisings in support of Black lives. These crises were met with both a counterproductive and inadequate response from the federal government. We examine these converging crises at the individual, social, and political scales. The biological realities of COVID-19 impact different populations in widely varied ways—the poor, the elderly, Black, Indigenous, and people of color, and those living with comorbidities get sick and die at the highest rates. Social distancing guidelines shifted millions of people to work-from-home and millions more lost their jobs, even as care laborers, preponderantly women, Black, Indigenous, and people of color, were asked to put their and their loved ones' lives on the line for the continuation of all of our lives. These biological, social, and economic crises have been punctuated by civil unrest, as millions took to the streets for racial justice, noting the unequal impacts of the pandemic. These converging crises have laid bare decades of neoliberal and neoconservative policies and ideologies, undergirded as they have been by racial capitalism, for their fundamental uncaringness. In this paper, we argue that this pandemic not only made a wider population more acutely aware of the necessity and importance of the need to care and for caring labors, but also that we stand at the precipice of potentiality--of producing a more caring society. To frame our argument, we draw on Nancy Scheper-Hughes and Margaret Lock's (1987) framework of three bodies—individual, social, and political—to unpack the multi-scalar entanglements in the differential impacts of COVID-19, questions of care, and their articulation in the current political-economic context. [ABSTRACT FROM AUTHOR]

Enthusiasm for so-called 'personalized' or 'precision' medicine has encouraged the growth of the molecular diagnostics industry and the proliferation of high-priced proprietary tests that can predict, diagnose or inform the treatment of diverse clinical conditions. Through a case study of non-invasive prenatal testing (NIPT), we explore how the mechanisms governing the development and dissemination of this novel prenatal screening test are most aptly understood as a 'regulatory regime.' We describe how private actors tied to the manufacturers of this test form a network of "experts" that contribute to the coordination of this regime by virtue of their efforts to navigate the governance of test adoption and also form spaces in which the standards governing test adoption are developed. We draw attention to private actors in this regime to demonstrate that they are a constitutive element of the public policy system governing biomedical innovation and adoption. Through this case study of NIPT we deepen our previous analysis of the role of consultants in navigating and shaping a regulatory regime (Holloway and Miller, 2020) and offer new insight about how scientists work with consultants to shape a regulatory regime that serves industry interests. Our work indicates that the private actors tied to the manufacturers of NIPT (experts employed by industry to court scientists and lobby payers, scientists collaborating with industry, key opinion leaders involved with clinical practice guidelines, lobbyists and consultants), constitute an 'invisible college' that navigates the governance of test adoption. The formations and negotiations over standards for NIPT identified in this paper comprise a new institutional norm: a polycentric regulatory regime permeated by commercial interests. The institutionalization of this regime has implications for accountability, transparency and test quality amidst a proliferation of new proprietary molecular tests.' • A case study of mechanisms governing the dissemination of NIPT in the US. • Private actors tied to the manufacturers of NIPT constitute an invisible college. • These actors engage in various levels of knowledge production. • The invisible college navigates test adoption in a regulatory regime.. • This regime has implications for accountability, transparency and test quality. [ABSTRACT FROM AUTHOR]

Presents information on a paper which looked age and sex differentials in morbidity at the start of an epidemiological transition. Discussion on the national point prevalence rates of adult morbidity over the early phase of the United States epidemiologic transition; Perception on the historical data report health status at the individual level; Prevalence of specific disease and disability states in the distribution of disease by major cause for males and females.

Many low and middle-income countries in Asia experience greater food availability as their economies grow, potentially solving previous problems of undernutrition. However, economic growth may not sufficiently reduce undernutrition and instead increase over nutrition, creating a double burden of malnutrition. In this paper we investigate one of the most prevalent and seemingly paradoxical manifestations of the double burden, a stunted child and an overweight mother (SCOM) living in the same household. We use household-level data from 11 Asian countries from 2005 to 2018, as well as macroeconomic data on the Gross Domestic Product (GDP) and the GDP growth of these countries to estimate which household-level and macroeconomic factors predict SCOM. We also determine the relative predictive power of our variables for SCOM and investigate if predictors of SCOM also predict other forms of malnutrition. We find that the predictive power of household-level factors for SCOM is comparatively more important than that of macroeconomic variables. Additionally, we explore the effect of including population subgroup-level trends in maternal overweight and child stunting on the predictive power of our macro-level and household-level variables. The increasing prevalence of SCOM is driven by a rise in maternal overweight, coupled with stagnant rates of child stunting, but remains a unique phenomenon that differs from other indicators of malnutrition. This supports explanations that suggest increasing consumption of high-energy but low-nutrient foods is the underlying cause of SCOM, leading to weight gain in adults and stunting in under-five children. • Increasing rates of Asian households with overweight mothers and stunted children. • A nutritional transition in the wake of economic growth an often-conjectured driver. • Known household-level determinants confirmed in large cross-country dataset. • Both growth and household-level determinants are predictors of the double burden. • Household-level factors with greater direct predictive power than economic growth. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has triggered a notable increase in the expression of prejudicial and xenophobic attitudes that threaten the wellbeing of minority groups and contribute to the overall public health toll of the virus. However, while there is evidence documenting the growth in discrimination and xenophobia, little is known about how the COVID-19 outbreak is activating the expression of such negative attitudes. The goal of the current paper therefore was to investigate what aspects of the COVID-19 pandemic may be contributing to this rise in expressions of prejudice and xenophobia. More specifically, this study used an experimental design to assess the effects of using stigmatized language to describe the virus as well as the threat to physical health and economic wellbeing posed by the virus on COVID-19 prejudice. Data were collected from a national sample of 1451 adults residing within the United States. Results from 2 × 2 x 2 between-subjects analyses of covariance demonstrated that emphasizing the connection between China and COVID-19, rather than framing the virus neutrally, increased negative attitudes toward Asian Americans, beliefs that resources should be prioritized for Americans rather than immigrants, and general xenophobia. Emphasizing the severity of the economic impact of the virus also increased beliefs that Asian Americans are a threat to resources and general xenophobia. In contrast, messages which emphasized the serious health risks of COVID-19 did not increase bias toward Asian Americans or xenophobia. Our findings suggest that specific types of public health messaging related to infectious diseases, especially framing the virus in terms of its country of origin or its likely economic impact, may elicit prejudice and xenophobia. Public health campaigns that emphasize the severity of the virus, however, are not likely to trigger the same negative attitudes. Implications for public health responses to health crises are discussed. • The framing of COVID-19 information shapes prejudice and xenophobia. • Emphasizing COVID-19's origin in China increases anti-Asian and xenophobic attitudes. • Emphasizing severe economic harm also increases negative outgroup attitudes. • Messaging about the health threat of the virus is unrelated to outgroup bias. [ABSTRACT FROM AUTHOR]

Two important changes are happening in health care in the US. As hospitals close in high numbers, the geographies of health care services are changing. Also, the ageing of the population brings about new and complex care needs. These are not discrete trends, as ageing impacts the who, what, and where of care needs, and hospital closures remakes the geographies of where people overall access care. Developed out of research on the impacts of hospital restructuring on workers, patients, and communities, this paper aims to understand how health care financing, care needs for the ageing, and new geographies of health services are intertwined. To do so, I look back to 1980s policy changes to Medicare, the federal health insurance program for the elderly and disabled. In 1982, Congress made two important changes to Medicare. The program began covering hospice services, constituting an expansion of care, and the government drastically changed the way it reimburses providers, effectively a contraction of the program. I trace the impacts of these changes over the next decades through analysis of media coverage and secondary research on hospital budgets. Drawing on the concept of palliative space-time, I identify a contradictory logic of death at the center of this expansion and contraction of the health care system. This death logic works to destabilize an already uneven geography of health service. Yet, this crisis has the potential for more just geographies of health and care. • US population ageing poses new challenges for caring for people as they age. • Hospital closures across the US alter how and where people receive care. • Palliative Space-time shows systems that struggle to exist but have radical potential. • Palliative Space-time helps analyse health systems, death, and care. [ABSTRACT FROM AUTHOR]

This study asks whether and when patients treat their doctors as having the right to give behavior change advice. Drawing on 171 primary care consultations video-recorded in the U.S. between 2014 and 2016, this study uses Conversation Analysis to examine physicians' behavior change advice following a patient's disclosure of medically problematic behavior such as physical inactivity. The basis on which the physician provides this advice is associated with clear regularities in patient response. Physicians may produce treatment-implicative advice that is unambiguously framed as a treatment plan for a specific health issue such as rising blood pressure. Alternatively, physicians may produce advice that is not overtly framed as treatment. This plain advice appeals to a model of care based in medical surveillance and prevention - a physician should not need to account for advising a patient to reduce risk factors. Though all advice is clinically relevant for preventing or controlling medical conditions, treatment-implicative advice is interactionally rooted in a physician's authority to treat illness. Patients show a strong social-interactional preference for treatment-implicative advice, even accepting 'behavior change' treatment recommendations at a higher rate than pharmaceutical treatment recommendations. In contrast, patients are highly resistant towards plain behavior change advice. This study explores the implications of advice formats for understanding modern orientations towards surveillance medicine in the age of preventive care. • This paper examines how behavior change advice is given in US Primary Care. • Conversation Analysis is used to examine video-recorded healthcare consultations. • Patients treat physicians' authority to advise behavior change as conditional. • Patients typically accept advice framed as treatment for a medical problem. • Patients rarely accept plain advice that is not presented as treatment. [ABSTRACT FROM AUTHOR]

The ongoing social transformation of the American healthcare system brings both structural and interpersonal changes to the delivery of healthcare. Some of these changes have been motivated by patients, who increasingly desire emotionally warm interactions with physicians. This is a departure from the detached concern that characterized physician-patient interactions in the mid-twentieth century. Concurrently, medical training continually adapts to trends in medical practice so that future physicians are prepared to enter practice. In this paper, we examine the rise of clinical skills training courses and assessments in medical school, highlighting the changing role of emotion in training about communication in the doctor – patient relationship. Drawing on an interpretive analysis of interviews with and ethnographic observations of medical students and residents from two United States medical schools, we elaborate the concept of clinical empathy to describe the character of emotional engagement in the contemporary clinical encounter. In the analysis we show how standards of emotional conduct are taught in medical school, how clinical empathy is operationalized in the patient encounter, and how clinical empathy may be used instrumentally to smooth the physician's work. Finally, we position the consistent performance of clinical empathy as a form of emotional labor, expanding the reach of studies of emotional labor in professions. • U.S. physicians are expected to demonstrate clinical empathy in medical encounters. • Clinical empathy is a set of emotional conduct norms and interactional skills. • Clinical empathy is taught to medical students in formalized and explicit contexts. • Clinical empathy is an understudied form of physician labor: emotional labor. • As emotional labor, the consequences of clinical empathy should be investigated. [ABSTRACT FROM AUTHOR]

The self-help culture, in the context of the U.S. medical system, demands proactive patient behavior as more responsibility for good health falls on the patient. The presence of health/medical information online alters the dynamics of medical encounters and transforms patients into reflexive consumers or consumer-patients who are engaged in personal health management. This paper examined whether using health information obtained from the Internet to manage personal health care (referred as e-health information consumerism) is associated with subjectively reported negative health outcomes in a representative sample of Internet users in the U.S. These outcomes are conceptualized as experiencing (a) adverse affect (feeling worried and anxious) and (b) health problem due to using Internet information. An online survey (n = 710) was conducted with study participants who were recruited from the largest online probability U.S. research panel developed by a non-profit academic research firm, Knowledge Networks. Analyses included multivariate regressions that included the statistical interactions between e-health information consumerism and the communicational and interactional aspects of medical encounters. Parallel models were tested in the gender-stratified subsamples. Results indicate that robust associations exist between e-health information consumerism and patient-reported health outcomes. Respondents who indicated greater satisfaction with medical communication reported lower averages on experiencing worry and a health problem due to e-health information consumerism. While e-health information consumerism is significantly associated with experiencing a self-reported health problem in both men and women, the association with adverse affect is significant only among women. The moderating role of patient satisfaction with medical communication is stronger among women. Interestingly, the moderating role of patient satisfaction with a medical interaction is stronger among respondents who reported higher averages on experiencing a health problem due to e-health information consumerism. e-Health information consumerism can translate into health benefits if the Internet information is deployed to promote a satisfactory medical partnership. • The growth of online health information challenges the parameters of the sick role. • Information pluralism encourages a consumerist orientation towards health. • The Internet may pose a health risk for physical and emotional well-being. [ABSTRACT FROM AUTHOR]

Unlike other aspects of welfare (e.g. income), health has been relatively neglected when it comes to defining and measuring aspects of poverty. The aim of the paper is twofold: first we elaborate how the concept of 'health poverty' can be defined and measured, and second we apply the methodology to study health poverty in a variety of cases. The measurement of health poverty allows us to gain insights into different sorts of health deprivation in society as a whole, and in specific subgroups. We measure poverty by means of the widely adopted Foster-Greer-Thorbecke (FGT) class of indicators and apply this to three different health variables: cardiovascular risk, health status and life expectancy. Moreover, the FGT class is additively decomposable, making it possible to gauge the contribution of specific subgroups to overall poverty. We provide two applications of these methods. Firstly, we examine changes in the risk of cardiovascular disease (CVD) in the United States using two waves of the NHANES survey from 2005-06 and 2013-14 (n = 3,014 and 4,001 respectively) and use a threshold of 20% 10 year CVD risk to define health poverty. Overall our results indicate a slight decline in the proportion at high CVD risk between these periods. Secondly, we apply poverty measures to health status as measured by the SF-6D index and to empirically derived predictions of life expectancy and estimated using 24,820 individuals from the first 15 waves of the Australian HILDA survey. Trends in poverty over time are compared using several thresholds and decomposed by a variety of sub-groups. Measures of health poverty can be an important instrument for focusing the attention on those with the worst health, or highest risk, in a society and should be used more widely. • Health poverty measures are useful to monitor deprivation in the domain of health. • Health poverty measures accord closely with threshold-based practices in medicine. • Poverty measures can be applied to disease risk, life expectancy and quality of life. [ABSTRACT FROM AUTHOR]

Racial disparities in the end-of-life treatment of patients are a well observed fact of the U.S. healthcare system. Less is known about how the physicians treating patients at the end-of-life influence the care received. Social networks have been widely used to study interactions with the healthcare system using physician patient-sharing networks. In this paper, we propose an extension of the dissimilarity index (DI), classically used to study geographic racial segregation, to study differences in patient care patterns in the healthcare system. Using the proposed measure, we quantify the unevenness of referrals (sharing) by physicians in a given region by their patients' race and how this relates to the treatments they receive at the end-of-life in a cohort of Medicare fee-for-service patients with Alzheimer's disease and related dementias. We apply the measure nationwide to physician patient-sharing networks, and in a sub-study comparing four regions with similar racial distribution, Washington, DC, Greenville, NC, Columbus, GA, and Meridian, MS. We show that among regions with similar racial distribution, a large dissimilarity index in a region (Washington, DC DI = 0.86 vs. Meridian, MS DI = 0.55), which corresponds to more distinct referral networks for black and white patients by the same physician, is correlated with black patients with Alzheimer's disease and related dementias receiving more aggressive care at the end-of-life (including ICU and ventilator use), and less aggressive quality care (early hospice care). • Novel application of the dissimilarity index to social network analysis. • Considered a cohort of patients with Alzheimer's disease and related dementias. • Analyzed racial disparities in end-of-life treatment intensity. • Large dissimilarity index is associated with more intensive end-of-life treatments. [ABSTRACT FROM AUTHOR]