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The epidemiologic and demographic consequences of the health transition, coupled with worldwide pressures for health care reform according to neoliberal tenets, will create new opportunities, and well as new problems, for organized systems of indigenous medicine. Spiraling costs of biomedically-based health care, coupled with an increasing global burden of chronic, degenerative diseases and mental disorder, will produce significant incentives for the expansion of indigenous alternatives. Yet this expansion will be accompanied by pressures to rationalize and modernize health care services according to the structurally dominant scientific paradigm. Without concerted effort to maintain native epistemologies, indigenous medical systems face an inevitable slide into narrow herbal traditions and a loss of those elements of diagnosis and therapy which may be the most valuable and effective. Analyzing the case of Tibetan medicine and other Asian medical systems, I show how this process occurs and how it is resisted. I conclude by discussing the policy dimensions of this problem. [ABSTRACT FROM AUTHOR]

Recent decades of improvements to routine health information systems in low- and middle-income countries (LMICs) have increased the volume of health data collected. However, countries continue to face several challenges with quality production and use of information for decision-making at sub-national levels, limiting the value of health information for policy, planning and research. Improving the quality of data production and information use is thus a priority in many LMICs to improve decision-making and health outcomes. This qualitative study identified the challenges of producing and using routine health information in Western Province, Zambia. We analysed the interview responses from 37 health and social sector professionals at the national, provincial, district and facility levels to understand the barriers to using data from the Zambian health management information system (HMIS). Respondents raised several challenges that we categorized into four themes: governance and health system organization, geographic barriers, technical and procedural barriers, and challenges with human resource capacity and staff training. Staff at the facility and district levels were arguably the most impacted by these barriers as they are responsible for much of the labour to collect and report routine data. However, facility and district staff had the least authority and ability to mitigate the barriers to data production and information use. Expectations for information use should therefore be clearly outlined for each level of the health system. Further research is needed to understand to what extent the available HMIS data address the needs and purposes of the staff at facilities and districts., (© The Author(s) 2023. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

There has been a growing use of social media by patients to share their healthcare experiences and produce information that can be helpful to other patients seeking healthcare services. These stories can reveal issues in healthcare quality. However, faced with the inherent risks of social media, healthcare providers have been skeptical about the value of these stories, and many healthcare systems have adopted restrictive and protective policies to control the use of social media by healthcare providers. This study explores healthcare providers' and administrators' perspectives on patient stories on social media and whether they can use the stories to evaluate healthcare experiences. Semi-structured interviews (n = 21) were conducted with healthcare providers and administrators, including physicians, nurses, and quality managers in Ontario, Canada, between April 2018 and May 2019. Inductive and data-driven thematic analysis was used to analyze the data. Several barriers prevent healthcare providers from realizing the benefits of social media, including concerns about the quality of patients' feedback, the professional codes of conduct, and the time and effort required to process these stories. The study findings suggest that cultural changes in the healthcare system might be required to foster the use of social media for healthcare quality improvement and enable the development of a safe patient-provider communication environment that facilitates the exchange of constructive feedback between the two parties without the fear of legal consequences, breaches of patient privacy, or violation of professional codes of conduct., (© 2021 John Wiley & Sons Ltd.)

Background: Patient experience has a direct impact on patients' engagement in healthcare, their commitment to treatment plans, and their relationship with their healthcare providers, all of which can impact their health outcomes. The complexity of the healthcare system, the increasing health needs of the population, and the priority and knowledge differences among healthcare stakeholders impact how they conceptualize and seek to achieve the ideal patient experience and the weights that they give to different elements of this experience., Aims: This study sought to understand the perspectives of healthcare providers and administrators in Ontario regarding the factors affecting the patient experience., Materials & Methods: Qualitative data were collected between April 2018 and May 2019. Twenty-one semi-structured interviews were conducted. Interviewees included physicians, nurses, optometrists, dietitians, quality managers, and policymakers. Thematic analysis was used to analyse the data, utilizing and extending a previously developed patient experience framework., Results: Several themes emerged in the data, and they represent two perspectives on patient experience: the biomedical perspective, which prioritizes health outcomes and gives high weights to healthcare experience factors that can be controlled by healthcare providers, while ignoring other factors, and the sociopolitical perspective, which recognizes the impacts of healthcare politics and the social context of health on patient experience in Ontario., Conclusion: The study is timely in light of the current changes in the Ontario healthcare system and the healthcare reform started by the new government, as it sheds light on the possible negative impact of healthcare policy and politics on patient experience., (© 2021 John Wiley & Sons Ltd.)

Scholarship on the health impacts of resource extraction displays prominent gaps and apparent corporate and neocolonial footprints that raise questions about how science is produced. We analyze production of knowledge, on the health impacts of mining, carried out in relation to the Canadian International Resources and Development Institute (CIRDI), a university-based organization with substantial extractive industry involvement and links to Canada's mining-dominated foreign policy. We use a "political ecology of knowledge" framework to situate CIRDI in the context of neoliberal capitalism, neocolonial sustainable development discourses, and mining industry corporate social responsibility techniques. We then document the interactions of specific health disciplinary conventions and knowledges within CIRDI-related research and advocacy efforts involving a major Canadian global health organization. This analysis illustrates both accommodation and resistance to large-scale political economic structures and the need to directly confront the global North governments and sectors pushing extractive-led neoliberal development globally. Resumen La investigación sobre los impactos en la salud de la extracción de recursos naturales delata brechas importantes y huellas corporativas y neocoloniales, que plantean dudas acerca de cómo se produce la ciencia. Analizamos la producción de conocimiento sobre los impactos en la salud de la minería en relación con el Instituto Canadiense de Desarrollo y Recursos Internacionales (CIRDI, siglas en inglés), una organización universitaria que cuenta con participación sustancial de la industria extractiva y tiene vínculos con la política exterior de Canadá, la cual es dominada por intereses mineros. Utilizamos un marco de "ecología política del conocimiento" para situar a CIRDI en el contexto del capitalismo neoliberal, los discursos neocoloniales de desarrollo sostenible y las técnicas de responsabilidad social corporativa de la industria minera. Luego, documentamos las interacciones entre los conocimientos y convenciones disciplinarias de salud dentro de los esfuerzos de investigación y promoción relacionados con CIRDI que involucran a una importante organización canadiense de salud global. Este análisis muestra tanto la complacencia como la resistencia a las estructuras políticas económicas a gran escala, y la necesidad de confrontar directamente a los gobiernos y sectores del Norte global que manejan el desarrollo neoliberal impulsado por la extracción a nivel mundial.

At the beginning of 2019, a sudden surge of malaria cases was observed in the district of Riaba, Bioko Island. Between January and April, confirmed malaria cases increased 3.8-fold compared to the same period in 2018. Concurrently, anopheline human biting rate (HBR) increased 2.1-fold. During the outbreak, 82.2% of the district population was tested for malaria with a rapid diagnostic test; 37.2% of those tested had a detectable infection and were treated according to national guidelines. Vector control interventions, including indoor residual spraying and larval source management were scaled-up. After the interventions, the number of confirmed cases decreased by 70% and the overall parasite prevalence in the communities by 43.8%. Observed prevalence in a follow up malaria indicator survey, however, was significantly higher than elsewhere on the island, and higher than in previous years. There was no significant reduction in HBR, which remained high for the rest of the year. The surge was attributed to various factors, chiefly increased rainfall and a large number of anthropogenic anopheline breeding sites created by construction works. This case study highlights the need for sustained vector control interventions and multi-sector participation, particularly in malaria control and elimination settings with persistently high local malaria receptivity.

Background: Indoor and outdoor fine particulate matter (PM 2.5 ) are both leading risk factors for death and disease, but making indoor measurements is often infeasible for large study populations., Methods: We developed models to predict indoor PM 2.5 concentrations for pregnant women who were part of a randomized controlled trial of portable air cleaners in Ulaanbaatar, Mongolia. We used multiple linear regression (MLR) and random forest regression (RFR) to model indoor PM 2.5 concentrations with 447 independent 7-day PM 2.5 measurements and 87 potential predictor variables obtained from outdoor monitoring data, questionnaires, home assessments, and geographic data sets. We also developed blended models that combined the MLR and RFR approaches. All models were evaluated in a 10-fold cross-validation., Results: The predictors in the MLR model were season, outdoor PM 2.5 concentration, the number of air cleaners deployed, and the density of gers (traditional felt-lined yurts) surrounding the apartments. MLR and RFR had similar performance in cross-validation (R 2  = 50.2%, R 2  = 48.9% respectively). The blended MLR model that included RFR predictions had the best performance (cross validation R 2  = 81.5%). Intervention status alone explained only 6.0% of the variation in indoor PM 2.5 concentrations., Conclusions: We predicted a moderate amount of variation in indoor PM 2.5 concentrations using easily obtained predictor variables and the models explained substantially more variation than intervention status alone. While RFR shows promise for modelling indoor concentrations, our results highlight the importance of out-of-sample validation when evaluating model performance. We also demonstrate the improved performance of blended MLR/RFR models in predicting indoor air pollution., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: The Sustainable Development Goals call for the effective governance of shared natural resources in ways that support inclusive growth, safeguard the integrity of the natural and physical environment, and promote health and well-being for all. For large-scale resource extraction projects -- e.g. in the mining sector -- environmental regulations and in particular environmental impact assessments (EIA) provide an important but insufficiently developed avenue to ensure that wider sustainable development issues, such as health, have been considered prior to the permitting of projects., Methods: In recognition of the opportunity provided in EIA to influence the extent to which health issues would be addressed in the design and delivery of mining projects, an international and intersectoral partnership, with the support of WHO and public funds from Canadian sources, engaged over a period of six years in a series of capacity development activities and knowledge translation/dissemination events aimed at influencing policy change in the extractives sector so as to include consideration of human health impacts., Results: Early efforts significantly increased awareness of the need to include health considerations in EIAs. Coupling effective knowledge translation about health in EIA with the development of networks that fostered good intersectoral partnerships, this awareness supported the development and implementation of key pieces of legislation. These results show that intersectoral collaboration is essential, and must be supported by an effective conceptual understanding about which methods and models of impact assessment, particularly for health, lend themselves to integration within EIA., Conclusions: The results of our partnership demonstrate that when specific conditions are met, integrating health into the EIA system represents a promising avenue to ensure that mining activities contribute to wider sustainable development goals and objectives.

Funding options for global health research prominently include grants from corporations, as well as from foundations linked to specific corporations. While such funds can enable urgently-needed research and interventions, they can carry the risk of skewing health research priorities and exacerbating health inequities. With the objective of promoting critical reflection on potential corporate funding options for global health research, we propose a set of three questions developed through an open conference workshop and reflection on experiences of global health researchers and their institutions: 1) Does this funding allow me/us to retain control over research design, methodology and dissemination processes? 2) Does accessing this funding source involve altering my/our research agenda (i.e., what is the impact of this funding source on research priorities)? 3) What are the potential "unintended consequences" of accepting corporate funding, in terms of legitimizing corporations or models of development that are at the root of many global health problems? These questions outline an intentional and cautionary approach to decision-making when corporate funding for global health research is being considered by funding agencies, institutions, researchers and research stakeholders.

Epidemiologic studies have consistently reported associations between outdoor fine particulate matter (PM 2.5 ) air pollution and adverse health effects. Although Asia bears the majority of the public health burden from air pollution, few epidemiologic studies have been conducted outside of North America and Europe due in part to challenges in population exposure assessment. We assessed the feasibility of two current exposure assessment techniques, land use regression (LUR) modeling and mobile monitoring, and estimated the mortality attributable to air pollution in Ulaanbaatar, Mongolia. We developed LUR models for predicting wintertime spatial patterns of NO 2 and SO 2 based on 2-week passive Ogawa measurements at 37 locations and freely available geographic predictors. The models explained 74% and 78% of the variance in NO 2 and SO 2 , respectively. Land cover characteristics derived from satellite images were useful predictors of both pollutants. Mobile PM 2.5 monitoring with an integrating nephelometer also showed promise, capturing substantial spatial variation in PM 2.5 concentrations. The spatial patterns in SO 2 and PM, seasonal and diurnal patterns in PM 2.5 , and high wintertime PM 2.5 /PM 10 ratios were consistent with a major impact from coal and wood combustion in the city's low-income traditional housing (ger) areas. The annual average concentration of PM 2.5 measured at a centrally located government monitoring site was 75 μg/m 3 or more than seven times the World Health Organization's PM 2.5 air quality guideline, driven by a wintertime average concentration of 148 μg/m 3 . PM 2.5 concentrations measured in a traditional housing area were higher, with a wintertime mean PM 2.5 concentration of 250 μg/m 3 . We conservatively estimated that 29% (95% CI, 12-43%) of cardiopulmonary deaths and 40% (95% CI, 17-56%) of lung cancer deaths in the city are attributable to outdoor air pollution. These deaths correspond to nearly 10% of the city's total mortality, with estimates ranging to more than 13% of mortality under less conservative model assumptions. LUR models and mobile monitoring can be successfully implemented in developing country cities, thus cost-effectively improving exposure assessment for epidemiology and risk assessment. Air pollution represents a major threat to public health in Ulaanbaatar, Mongolia, and reducing home heating emissions in traditional housing areas should be the primary focus of air pollution control efforts.

This study examined the association of human and environmental factors with the presence of Aedes aegypti, the vector for dengue fever and yellow fever viruses, in a desert region in the southwest United States and northwest Mexico. Sixty-eight sites were longitudinally surveyed along the United States-Mexico border in Tucson, AZ, Nogales, AZ, and Nogales, Sonora during a 3-year period. Aedes aegypti presence or absence at each site was measured three times per year using standard oviposition traps. Maximum and minimum temperature and relative humidity were measured hourly at each site. Field inventories were conducted to measure human housing factors potentially affecting mosquito presence, such as the use of air-conditioning and evaporative coolers, outdoor vegetation cover, and access to piped water. The results showed that Ae. aegypti presence was highly variable across space and time. Aedes aegypti presence was positively associated with highly vegetated areas. Other significant variables included microclimatic differences and access to piped water. This study demonstrates the importance of microclimate and human factors in predicting Ae. aegypti distribution in an arid environment.

This article presents results of research undertaken to identify factors that affect the vulnerability of rural Mongolian herders to climate change. Findings suggest that models of market development instituted since 1990 have failed to recognize and support key elements of the pastoralist adaptive strategy. A retreating state presence has led to the collapse of regulatory regimes needed to safeguard critical common resources. This in turn has produced considerable social differentiation in the countryside, a breakdown in cooperative institutions, and conflicts over water and pasture. In a context of climate change, these changes seriously threaten the sustainability of the rural economy, leading to livelihood insecurity, growing rural poverty, and increasing rates of migration to shantytowns surrounding the capital city of Ulaanbaatar. The newly vulnerable poor are at higher risk for poor health and malnutrition.

Aims: The purpose of this study was to investigate the prevalence and determinants of domestic violence in Mongolian women., Methods: The survey was administered to 5500 people in 1000 households randomly selected from two districts of Ulaanbaatar, Mongolia., Results: The response rate was 90.3% (total of 4967, and 3338 were women.). About 37.7% of respondents reported that they were affected by some type of domestic violence during the previous 6 months; 17.9% of all respondents reported physical violence, 21.9% reported emotional violence, 10% reported sexual abuse, and 6.9% reported financial violence. Major risk factors for violence against women included having only a primary education or less, low income, living in a rented house, and living with an unemployed partner who uses alcohol., Conclusions: Domestic or intimate partner violence (IPV) is widespread in Mongolia and is usually committed in family circles, often away from public view. This study suggests that increasing employment for men may help reduce poverty and alcohol abuse and, thus, IPV.

Two of the disciplines that have come to infuse global health with some of its current vibrancy are epidemiology and anthropology, disciplines that focus, in one way or another, on the causal importance of human behaviour in socio-political, ecological, evolutionary, and cultural context. One of the little-known stories in the history of twentieth century global health involves the works of a number of pioneering interdisciplinary scholar-practitioners, who urged a synthesis of epidemiological and anthropological perspectives in what was then called 'tropical medicine'. One of these pioneers was Frederick L. Dunn, who forwarded lasting insights about the importance of human behavioural research in understanding infectious disease. This article provides a historical-biographical accounting of Dunn's contributions to public health in the second half of the twentieth century, arguing that his persistent advocacy of multi-level, social behavioural research and his notion of 'causal assemblages' were critical in the early development of the twentieth century discipline of global health.

Driven in part by a resurgent interest in social inequality and health, and in part by increasing scrutiny of the social and health consequences of neoliberal economic reform, principles of health equity and social justice, the centerpieces of the Health for All strategy drafted at Alma Ata in 1978, are once again at center stage in global public health debates. Whether and how equity in access to health care can be maintained in a context of market-based health sector reform has not been systematically addressed, particularly from the perspective of local communities. This paper will explore how health reform affects health care in post-socialist Mongolia. Through a mixed-methods household-based study of low-to-middle income communities in urban and rural Mongolia we find that despite explicit and concerted efforts to reduce inequities, the reform system is unable to provide equitable health care either vertically or horizontally. Emphasis on privatization of the secondary and tertiary sectors of the system, coupled with deployment of universally-accessible, but from a clinical standpoint, limited, version of essential primary care, produces a fragmented system. Particularly for the vulnerable poor, access to services beyond the primary care system is compromised by financial, opportunity, and informational cost barriers. This research suggests that new models of health reform are needed that will effectively bridge the growing gaps between public and private resources, primary and secondary and/or tertiary care, and clinical and public health services.

Beginning in 1990, Mongolia, a former client state of what was then the Soviet Union, undertook liberal economic reforms. These came as a great shock to Mongolia and Mongolians, and resulted in food shortages, reports of famine, widespread unemployment, and a collapse of public health and health care. Although economic conditions have stabilized in recent years, unemployment and poverty are still at disturbingly high levels. One important consequence of the transition has been the transformation of the rural, primarily pastoral, economy. With de-collectivization, herding households have been thrown into a highly insecure subsistence mode of production, and, as a consequence, have become vulnerable to local fluctuations in rainfall and availability and quality of forage, and many now lack access to traded staples and essential commodities. Household food insecurity, malnutrition, and migration of impoverished households to provincial centers and the capital of Ulaanbaatar are one result. Reductions to investments in the health sector have also eroded the quality of services in rural areas, and restricted access to those services still functioning. Evidence suggests that women are particularly vulnerable to these political-ecological changes, and that this vulnerability is manifested in increasing rates of poor reproductive health and maternal mortality. Drawing on case-study ethnographic and epidemiological data, this article explores the links between neoliberal economic reform and maternal mortality in Mongolia.

Accurate death certification is essential to high-quality mortality statistics. Physicians who certify disproportionately large numbers of deaths can significantly affect the validity of the resultant mortality data. In Taiwan in 1994, 110 death certifiers issued more than 100 death certificates each; and nine of these high-frequency certifiers issued more than 500 death certificates. We explore the cultural, political, economic, historical, and social contexts of high-frequency death certification in Taiwan. Because of the traditional belief in Taiwan that one must die at home for the soul to be incorporated into the collective ancestral tablet of the household, many families bring their loved ones home from the hospital just before death. Hospital physicians cannot legally issue a death certificate in these cases because they did not witness the dying process. Although the government introduced an administrative certification system to handle these outside-hospital deaths, the great demands of this system have attracted many 'special exam' doctors (doctors with no formal medical degree) to adopt death certification as a full-time business. In this context, it is not surprising that 'routinization' of death certification (J. Health Soc. Behav. 32 (1991) 273) has led to low-quality reporting among these certifiers. We argue that attempts to improve the quality of mortality statistics should take into account the unique sociocultural contexts of different countries.

In this paper I discuss the processes by which Tibetan medicine has become globalised, and the ways in which these have come to determine, constrain, and, ultimately, transform local practices of healing in both Tibet and the West. I examine the degree to which globalisation, in particular international market capitalism, operating in this case through the Chinese state, structures the content of primary medical resources, confers legitimacy to certain technologies, and sets the ground rules by which the healers in charge of deploying such technologies are set into conversation with one another. I also argue that the cultural dimensions of globalisation enter the local context through the multiple-stranded flows of people, images, and ideas, and contribute to redefinitions of identity, suffering, and body praxis among patients/consumers in diverse local contexts. I proceed within two registers of analysis. In the first, I analyse these movements in the context of Tibetan medicine as it has been transformed, practised, and used, in the Tibet Autonomous Region of China. In the second, the analytic lens shifts to a focus on Tibetan medicine as a 'global' alternative medicine in North America and Europe. The focus throughout is on the global-local dialectic: how Tibetan medicine is both produced as global commodity and consumed as 'local' tradition.

This article explores the cultural epidemiology of rlung ("loong") disorder among Tibetans living in the cities and towns of the modern Chinese state of Tibet. Rlung, glossed as air or wind, is the most important of the three humors of the classical Tibetan ethnomedical system. Considered by Tibetans to be contingent upon multiple social, emotional, and religious phenomena, rlung disorders are fertile ground for the development of etiological discourses that incorporate the social and political crises that are part of the rapidly changing Tibetan plateau. In this essay I locate rlung disorder in a confluence of Tibetan ethnomedical constructions of the mind-body-universe linkage, in which rlung stands as the chief symbolic mediator, with ethnic conflict, rapid economic development, and the localization of global debates over Tibetan suffering and human rights.

This article presents a cultural and historical analysis of 20th-century Tibetan medicine. In its expansion into the state bureaucracy, Tibetan medicine has acceded to institutional modernity through transformations in theory, practice, and methods for training physicians. Despite Chinese rule in Tibet, however, Tibetan medicine has not yielded completely to state interests. With the collapsing of the traditionally pluralistic Tibetan health system into the professional sector of Tibetan medicine, contemporary Tibetan medicine has become to the laity a font of ethnic revitalization and resistance to the modernization policies of the Chinese state. These processes are particularly evident in the elaboration of disorders of rlung, a class of sicknesses that, collectively, have come to symbolize the suffering inherent in rapid social, economic, and political change.

We examine the results of recent research that considers the relationship of the work environment to drinking behavior and problems. We bring the concept of culture to the foreground in this discussion, and show that much of what alcohol researchers term as work-related risk factors are, in effect, best understood as aspects or dimensions of cultural processes which operate in complex organizations. We identify and review four perspectives on alcohol use in occupational contexts that highlight these cultural processes at work: (1) the development of organizational norms with respect to drinking, definitions of problem drinking, and mechanisms of social control; (2) working conditions that produce in some workers experiences of powerlessness, alienation, or stress which are in turn alleviated by drink; (3) the interaction of cultural factors external to the workplace--regional/national, community, ethnic, and religious--with organizational cultural norms which affect alcohol values, beliefs, and behaviors; and (4) processes that underlie the development of occupationally based drinking subcultures.

We examine the clustering of attendance, illness, and accidental injury problems in a large unionized manufacturing plant using both quantitative and qualitative methods. We find that the distribution of workers into problem groups is related to 1) conflicts over seniority, 2) physical stressors and their influence on perceived desirability of certain kinds of jobs, and 3) organizational conditions and environments congenial to the development of distinct occupational "subcultures." We suggest that the case study approach we apply in this paper is critical to the design of programs of preventive intervention and complements the more commonly applied multiple-site and individually focused, survey approaches.

The impact of migration and social change on male and female role expectations is examined in an urban Samoan community. Expanding role expectations and role conflicts in the urban context are linked to differential experiences of stress by gender, which are in turn examined with respect to the health outcomes of arterial pressure, a measure of physical health status, and a psychosomatic complaint index.

We present the findings of research designed to identify the social and environmental precursors of heavy drinking in a population of white assembly-line workers. Using a primarily qualitative approach, we examine alcohol use in relation to the sociocultural characteristics of individuals' community and workplace environments and their early-life socialization experiences. The sample consists of 30 men--15 heavy drinkers and 15 moderate drinkers--who were drawn from the workforce of a large durable goods manufacturing plant that closed in 1982. Workers' accounts of their own and coworkers' drinking suggest that a heavy drinking subculture existed in the workplace. Within this culture, drinking was a normal part of work life, and served to improve social relationships, reduce boredom and dissatisfaction, and to express solidarity in defiance of management rules and working conditions. Membership in this subculture, we believe, was most important for those men who had no interests or social involvements outside the workplace. We compare the characteristics of workers who chose to join this subculture (the heavy drinkers), with those who did not (moderate drinkers). Factors that predicted involvement in the heavy drinking subculture were: a sociocultural background where heavy male drinking was normative, lack of extra-work social resources, and leisure activities restricted to coworkers and work-related contexts. Conversely, moderate drinkers tended to come from moderate drinking backgrounds, and had considerable community and social group involvements that included family and peer networks to the virtual exclusion of coworkers.

The consequences of migration for the Samoan population of California are discussed within the context of other studies focusing on Samoan native and migrant populations in Samoa and Hawaii. The social, cultural and economic characteristics of California Samoans are described and data are presented for body morphology, blood pressure, psychosocial stress and social support, general morbidity patterns and mortality rates for 1978-1982. Although the nature of disease risks appear profound in this population, particularly patterns of extreme obesity and psychosocial stress, mortality rates for heart disease and stroke are less than might be expected among other American groups. Such unexpectedly low mortality rates may represent the relatively healthy experience of older cohorts of migrants, or be a result of proportionally few individuals having lived long enough in California to develop cardiovascular and other chronic disease that have lengthy natural histories. We postulate that at present Samoan social structure, particularly the high status that accrues with aging in traditional Samoan society, may act as a buffer for the risk factors we observed and their expected outcomes. If so, the U.S.-born Samoans who are currently passing through childhood and early adult years with progressively less awareness of Samoan values of family and social structure will exhibit the same risks we describe here, but lack the available social buffers that currently exist for their parents.

This paper presents the findings of a prevention-oriented research project designed to identify the familial and socio-environmental precursors of heavy drinking in a blue-collar population. Using an ethnographic and primarily qualitative approach to data collection, this study examines alcohol use and drinking behavior in relation to both the family as a unit, as well as the sociocultural context in which it is embedded. It reports primarily on features of cultural, workplace, and community environments that are related to heavy or moderate drinking in the subject population. The sample consists of 30 families, 15 where the father is a heavy drinker and 15 where he is a moderate drinker. The sample was drawn from the workforce of a large manufacturing plant that closed in 1982. The social organization of the workplace, including the important factors of job alienation, job stress, inconsistent social controls, and the evolution of a 'drinking culture,' is implicated by this research to be the primary vehicle for promoting high levels of alcohol use. Although the role of the workplace in encouraging certain alcohol behaviors was predominant, the data suggest that it alone may not be sufficient for causing alcohol problems. In particular, the central importance of drinking in work-related social contexts and the relative permissiveness of the work environment was found to promote heavy drinking among individuals who were of sociocultural backgrounds where heavy drinking was permitted or even encouraged; reported a lack of effective male role models when growing up; and restricted leisure activities to male-oriented peer groups most often met through work-related contexts. Conversely factors that appeared protective of developing high-risk drinking patterns were family religious involvement, and participation of fathers in non-work related social groups that usually involved their wives and children. We conclude the paper by offering suggestions as to how these findings might lead to constructive strategies for the primary prevention of alcohol problems in the context of the workplace and community.