Showing papers in "Journal of Health and Social Behavior in 2001"

Volunteer work and well-being.

Abstract: Using two waves of panel data from Americans' Changing Lives (House 1995) (N = 2,681), we examine the relationships between volunteer work in the community and six aspects of personal well-being: happiness, life satisfaction, self-esteem, sense of control over life, physical health, and depression. Prior research has more often examined the effects of voluntary memberships than of volunteer work, has used cross-sectional rather than longitudinal data, and, when longitudinal, has emphasized social causation over selection effects. Focusing only on the consequences of volunteer work overlooks the antecedents of human agency. People with greater personality resources and better physical and mental health should be more likely to seek (or to be sought for) community service. Hence, we examine both selection and social causation effects. Results show that volunteer work indeed enhances all six aspects of well-being and, conversely, people who have greater well-being invest more hours in volunteer service. Given this, further understanding of self- versus social-selection processes seems an important next step. Do positive, healthy people actively seek out volunteer opportunities, or do organizations actively recruit individuals of these types (or both)? Explaining how positive consequences flow from volunteer service may offer a useful counterpoint to stress theory, which has focused primarily on negative life experiences and their sequelae.

Neighborhood disadvantage, disorder, and health.

Abstract: We examine the question of whether living in a disadvantaged neighborhood damages health, over and above the impact of personal socioeconomic characteristics. We hypothesize that (1) health correlates negatively with neighborhood disadvantage adjusting for personal disadvantage, and that (2) neighborhood disorder mediates the association, (3) partly because disorder and the fear associated with it discourage walking and (4) partly because they directly impair health. Data are from the 1995 Community, Crime, and Health survey, a probability sample of 2,482 adults in Illinois, with linked information about the respondent's census tract. We find that residents of disadvantaged neighborhoods have worse health (worse self-reported health and physical functioning and more chronic conditions) than residents of more advantaged neighborhoods. The association is mediated entirely by perceived neighborhood disorder and the resulting fear. It is not mediated by limitation of outdoor physical activity. The daily stress associated with living in a neighborhood where danger, trouble, crime and incivility are common apparently damages health. We call for a bio-demography of stress that links chronic exposure to threatening conditions faced by disadvantaged individuals in disadvantaged neighborhoods with physiological responses that may impair health.

Neighborhood disadvantage, stress, and drug use among adults.

Abstract: This paper explores the relationships among neighborhood disadvantage, stress, and the likelihood of drug use in a sample of adults (N = 1,101). Using the 1995 Detroit Area Study in conjunction with tract-level data from the 1990 census, we find a positive relationship between neighborhood disadvantage and drug use, and this relationship remains statistically significant net of controls for individual-level socioeconomic status. Neighborhood disadvantage is moderately associated with drug related behaviors, indirectly through increased social stressors and higher levels of psychological distress among residents of disadvantaged neighborhoods. A residual effect of neighborhood disadvantage remains, net of a large number of socially relevant controls. Finally, results from interactive models suggest that the relationship between neighborhood disadvantage and drug use is most pronounced among individuals with lower incomes.

The impact of childhood abuse and neglect on adult mental health: a prospective study

Abstract: This paper examines the impact of three types of victimization in childhood--sexual abuse, physical abuse, and neglect--on lifetime measures of mental health among adults. In contrast to research that relies on retrospective recall of childhood victimization, this work uses a prospective sample gathered from records of documented court cases of childhood abuse and neglect in a midwestern city around 1970. These subjects were interviewed about twenty years later. In addition, this research compares outcomes of the 641 members of the abuse and neglect group with a matched control group of 510 persons who did not have documented cases of abuse or neglect. The results indicate that men who were abused and neglected as children have more dysthymia and antisocial personality disorder as adults than matched controls, but they did not have more alcohol problems. Abused and neglected women report more symptoms of dysthymia, antisocial personality disorder, and alcohol problems than controls. After controlling for stressful life events, however, childhood victimization had little direct impact on any lifetime mental health outcome. This research indicates the importance of adopting an approach that places childhood victimization in the context of other life stressors and of prospective changes over the life course.

Perceived discrimination and early substance abuse among American Indian children.

Abstract: This study investigated internalizing and externalizing symptoms as potential mediators of the relationship between perceived discrimination and early substance abuse among 195 American Indian 5 through 8 graders from three reservations that share a common culture (e.g., language, spiritual beliefs, and traditional practices) in the upper Midwest. The findings indicated that, although perceived discrimination contributed significantly to internalizing symptoms among the adolescents, internalizing symptoms were unrelated to early substance abuse. Rather, the effects of perceived discrimination on early substance abuse were mediated by adolescent anger and delinquent behaviors. The results are discussed in terms of the consequences of perceived discrimination on the development of American Indian early adolescents.

A longitudinal study of the role and significance of mattering to others for depressive symptoms.

Abstract: This paper addresses the hypothesis that the experience of mattering to others is inversely related to depressive symptomatology. We also assess the extent to which mattering overlaps or is redundant with other measures of personal and social resources. Based on multivariate analyses of two waves of data from a large urban community sample (n = 1,300), we identify three important findings. First, women experience substantially higher levels of mattering than do men. Therefore, if men and women had equal levels of mattering, women would report even higher depression scores relative to men. Second, it is clear that mattering and sub-dimensions of social support are substantially more confounded among men than among women. Finally, analyses confirm that mattering is conditionally predictive of depression by gender. Specifically, variations in mattering are predictive of depression for women, but not for men. This relationship is confirmed both cross-sectionally and over time.

Age and the effect of economic hardship on depression.

Abstract: The amount of depression associated with economic hardship among adults may depend on age. This study tests alternative hypotheses about the interaction. The first asserts that the amount of depression associated with economic hardship decreases with older age because of maturity and experience. The second, the opposite, asserts that the amount increases with older age because of increasingly limited future opportunities for recovery. The study analyzes data from 2,592 households in the 1995 and 1998 telephone survey of Aging, Status, and the Sense of Control (ASOC). Regression analyses find that the amount of depression associated with economic hardship decreases with older age, both cross-sectionally and over time. No model shows an increase with age in the depression associated with economic hardship. However, regressions do show that not having household wage income or having a disabling or life threatening chronic disease increases the depression associated with economic hardship. Those interactions somewhat suppress the moderating effect of older age on the association between economic hardship and depression.

Evidence-based medicine, clinical uncertainty, and learning to doctor.

Abstract: For the past two decades, evidence-based medicine (EBM), or the reliance on current scientific evidence to reach medical decisions, has been embraced as a new paradigm to standardize clinical care. Drawing from in-depth interviews with seventeen pediatric residents in two residency programs, we evaluate the extent to which the medical sociology scholarship on uncertainty analytically elucidates the recent influx of EBM during residency training. Our findings suggest that residents interpret EBM in varying ways to match their work practices: "Librarians" consult the literature while "researchers" evaluate it critically. For both groups, EBM might generate new uncertainties due to the increased reliance on information technologies and epidemiology. Whether EBM reduces uncertainty depends upon the residents' understanding of standardized knowledge and consequent incorporation of EBM in their clinical practice. Contrary to the predictions of some sociologists, EBM does not lead to a diminishment of humanitarian values in medical care. Nor does EBM lead to a science-based meritocracy on the patient ward, as claimed by some EBM advocates. Our conceptual updating of uncertainty emphasizes the continuous management of uncertainty during the medical socialization process. We argue that managing uncertainty develops along with what we term evidence-based clinical judgment.

Modeling processes in recovery from mental illness: relationships between symptoms, life satisfaction, and self-concept.

Abstract: For persons with severe mental illness, controlling symptoms, regaining a positive sense of self, dealing with stigma and discrimination, and trying to lead a productive and satisfying life is increasingly referred to as the ongoing process of recovery. Drawing on psychiatric-medical and stress-social support models, and theories of self-concept and stigma, this study examines social-psychological processes in recovery from mental illness, Using longitudinal questionnaire data from 610 persons in self-help groups and outpatient treatment, I estimate a series of models of the relationships between key elements identified as part of the recovery process: symptoms, self-concept, and life satisfaction. The results show that these elements affect each other in a reciprocal manner. Moreover, findings indicate a key role for self-esteem, which mediates the effect of life satisfaction on symptoms. The study suggests a general framework for examining processes involved in recovery from mental illness.

Socioeconomic status and depressive syndrome: the role of inter- and intra-generational mobility, government assistance, and work environment.

Abstract: The relationship of socioeconomic status to psychiatric disorders is one of the most important aspects of the relationship of social structure to mental life, and one of the most consistent relationships in the field of psychiatric epidemiology. Research on the issue extends back to the 19th century (Commission on Lunacy 1971), and includes classic research such as the New Haven study in the 1950’s (Hollingshead and Redlich 1958) and the Midtown Manhattan Study in the 1960’s (Langner and Michael 1963). Reviews of the literature show that lower class individuals, by a variety of definitions, have higher rates of mental disorders (Dohrenwend and Dohrenwend 1969; Ortega and Corzine 1990; Kohn, Dohrenwend, and Mirotznik 1998; Eaton and Muntaner 1999; Yu and Williams 1999). The relationship of socioeconomic status to mental disorder differs depending on the definition and measurement of disorder. The inverse relationship is strongest for schizophrenia and anti-social personality disorder. For more general constructs of mental distress and demoralization, the evidence also is consistently in favor of a strong inverse relationship between socioeconomic status and psychological disorder, or to a score on a scale of distress or demoralization (Ortega and Corzine 1990). Many scales measuring “depression” are difficult to distinguish, theoretically and empirically, from demoralization (Link and Dohrenwend 1980). Prior to 1980, the diagnoses for disorders of mood were divided into those of psychotic intensity, such as manic depressive illness (now bipolar disorder) and affective psychosis (now major depressive disorder with psychotic features), and those without psychosis, such as neurosis. The evidence was relatively clear, as early as the classic study of Faris and Dunham (1939), and continuing to the present, that manic depressive illness and affective psychosis were not associated with socioeconomic status and that schizophrenia was associated with socioeconomic status. For neurosis, which included the depressive subtype, there were studies that suggested an inverse relationship and studies that failed to observe it (Dohrenwend and Dohrenwend 1969). Except where explicitly noted, below we focus on depressive syndrome, which is a constellation of symptoms across a range of symptom types occurring together during a specified period of time. Shifting from sadness and demoralization to depressive syndrome is not trivial, as the depressive syndrome is more persistent and includes vegetative and somatic aspects that can lead to physical disorders (Pratt et al. 1996; Eaton et al, 1996), psychiatric treatment (Thase and Kupfer 1996), and disability (Judd et al, 1996). Most studies of socioeconomic status and mental disorder present data on prevalence rates-that is, the proportion in the population with the disorder—which leaves unresolved the question of temporal order and therefore the direction of causation. This has been dubbed the “causation-selection” issue, or the “stress-selection” issue (Dohrenwend et al. 1992). There are at least four possible explanations for the cross-sectional association of lower socioeconomic status with high prevalence of mental disorder: (1) lower socioeconomic status raises risk for mental disorder, through some sort of etiologic process (“the causation interpretation”); (2) lower socioeconomic status prolongs the duration of episodes of mental disorders through an etiologic process possibly unrelated to causation (“chronicity interpretation”); (3) the mental disorder leads to downward social mobility (“drift interpretation”); or (4) the mental disorder hinders the attainment of socioeconomic status that might otherwise be expected (“selection interpretation”). All four processes can work simultaneously to produce the prevalence result. All four processes are important for understanding the effects of social structure and for alleviating human suffering connected to both low socioeconomic status and to mental disorders. Measurement of incidence—the rate at which new cases form—eliminates the chronicity, selection, and drift interpretation, allowing focus on etiology. A complication in studying socioeconomic status is that it is influenced by family background, and that it changes over the life span. Likewise, depression ebbs and flows over the life course. Figure 1 shows these relationships in a heuristic path diagram which connects the status attainment process to the study of the transmission and natural history of depression. The top part of the figure refers to the status attainment process, and the bottom to the psychiatric epidemiologic study of depression. The important family background variables for socioeconomic status which have arisen in the literature on the status attainment process include occupational status of the main breadwinner prior to the start of the offspring’s occupational career (often pegged at age 16), and educational attainment of the father, the mother, or both. Important family background variables for the study of mental disorder which have arisen in the literature on psychiatric genetics include the occurrence of the disorder among first degree relatives. Few studies of socioeconomic status and mental disorder include data on family background of mental disorder, which means that the estimations are potentially biased. FIGURE 1 Socioeconomic Status and Psychopathology Inter- and Intra-generational Models. This analysis focuses on the diagonals in the figure. Study of the selection interpretation requires inter-generational data (lower left to upper right diagonal in left part of figure) and study of drift requires intra-generational data (lower left to upper right diagonal in right part of figure). Socioeconomic status can have transient effects, as shown in the nearly vertical downward arrows in the figure, and these are most probably related to acute stressors connected to the economic system. Socioeconomic status can have effects which are more extended in time, including socialization processes in childhood and youth (upper left to lower right diagonal in left part of figure), and to adult socialization processes (upper left to lower right diagonal in right part of figure). Although the figure covers the entire life span, the causal influences are probably operating most strongly during the period of young adulthood, which is the age of highest risk of onset for common mental disorders, as well as the period during which the occupational career is being formed.

Social inequalities and exercise during adulthood: toward an ecological perspective.

Abstract: Grounded in ecological theory, this study examines the association among participation in regular vigorous exercise and social status, aspects of prominent life settings, interactions between life settings, and more proximal individual resources and processes using data from the National Survey of Midlife Development in the United States (N = 3, 032). Among women, a higher level of earnings was associated with more vigorous exercise, yet those women with more education had a steeper decline in exercise across adulthood. Among men, those with the lowest level of education had the steepest decline in physical activity across adulthood, and earnings did not affect exercise patterns. Less participation in vigorous exercise among blacks, in contrast to nonblacks, was explained by their tendency to live in less safe neighborhoods and having more functional health problems. Finally, contextual factors from multiple domains were independently associated with participation in regular exercise. Consistent with ecological theory, these results suggest that interventions to promote exercise habits among adults need to consider the independent and interactive effects of multiple contextual factors.

Social distance and patients' rating of healthcare providers.

Abstract: Racial inequity in the provision of healthcare is widely recognized. In this paper, I assess the role of social distance from healthcare providers in accounting for whites' higher rating of healthcare providers. Using data from the Detroit Area Study, I test whether having higher socioeconomic status, like most healthcare providers, and racial concordance with healthcare provider account for the gap in satisfaction between whites and African Americans. I find that socioeconomic status and racial concordance variables account for a portion of whites' higher rating of the respect shown by their healthcare provider. Racial differences in evaluation of time spent with healthcare provider are accounted for by socioeconomic status, but not racial concordance. As researchers explore the causes of and remedies for the racial disparity in use and evaluation of healthcare, the subtle and indirect effects of race on the patient-healthcare provider relationship must be considered.

Part-time work and hurried adolescence: the links among work intensity, social activities, health behaviors, and substance use.

Abstract: The present study examines adolescents' part-time work intensity and its relation to participation in various activities as well as substance use. We consider mechanisms articulated in two theoretical perspectives on how high work intensity is associated with substance use: (1) the "time trade-off perspective," and (2) "the precocious development perspective." Nationally representative data were drawn from the "Monitoring the Future" project from 8th, 10th and 12th grade students (overall N approximately 380,000) to address our research questions. Work intensity was found to be linked to more time spent on unstructured social activities, but to less time spent engaged in sports, health behaviors, and school-related activities. Social time use and health behaviors were found to partially mediate the relationship between work hours and substance use. Overall, results provide evidence for a combination of both perspectives. Language: en

Status, role, and resource explanations for age patterns in psychological distress.

Abstract: Using data from the 1996 and 1998 General Social Surveys, we explore the relationships among age, age-linked personal and social qualities, and two measures of psychological distress: depression (1996) and generalized distress (1998). Our study has three aims: (1) to replicate the u-shaped age-distress relationship in two recent U.S. data sets, (2) to confirm and elaborate on the mediators of the parabolic association, and (3) to explore the possible suppressor effects. In 1996, depression decreases from young adulthood into midlife and increases among the oldest-old. Less education, lower control, and widowhood contribute to old-age upturn; however, fewer time demands and greater financial satisfaction suppress the upward curve. Conversely, greater control, less shame, and greater religious attendance contribute to the decline through midlife; however, poorer health in midlife suppress that decline. Age patterns in distress are similar in the 1998 sample. Greater satisfaction with finances and fewer religious doubts contribute to the downward slope; however, declining levels of health suppress that downturn. Less education and retired status contribute to the old-age upturn. In sum, personal and social conditions have opposing influences on the parabolic relationship between age and distress.

Birth weight and income: interactions across generations.

Abstract: This paper attempts to answer a series of questions regarding the interaction of income and birth weight across generations. First, does the effect of the income of a mother during her pregnancy on her infant’s birth weight depend on the family’s birth weight history (genetic predisposition)? Second, does the effect of low birth weight status on adult life chances depend on income during early childhood? These questions have implications for the way we envision the biological and social worlds as interacting across generations. To address these issues, this study uses intergenerational data from the Panel Study of Income Dynamics, survey years 1968 through 1992. Results of sibling comparisons (family-fixed-effects models) demonstrate that maternal income has a significant impact on birth weight for those infants who are already at high risk hereditarily (i.e., who have a low birth weight parent). However, it is not clear whether income acts as a developmental buffer for low birth weight infants as their lives progress. These findings suggest the existence of biosocial interactions between hereditary predisposition and socio-economic environment.

Communal bereavement and the incidence of very low birthweight in Sweden.

Abstract: Prime minister Olof Palme's murder in 1986 and the sinking of the ferry Estonia in 1994 were stressful events for many Swedes, but did that stress affect health? We used an interrupted time-series design to measure the association between these events and the incidence of very low birthweight. Effects of male unemployment, size of the birth cohort, and temperature were controlled in our analysis of data for the period 1973-1995. The incidence of very low birthweight rose significantly in the months following the Palme murder and the Estonia catastrophe. Events that trigger communal bereavement at the scale we study may seem rare but they do occur (e.g., destruction of the World Trade Center and attack on the Pentagon). Events with less visibility, moreover, may induce communal bereavement in smaller populations defined by geography or organizational participation.

The profession of medicine and the public: examining Americans' changing confidence in physician authority from the beginning of the 'health care crisis' to the era of health care reform.

Abstract: Recent work on the sociology of the professions, in general, and on the profession of medicine, in particular, target dramatic changes in the organization of social institutions, "boundary work" among professionals, and the implications of both for professional power. However, public attitudes cited in theories as a critical linchpin of professional status remain relatively unexplored in the face of these changes and widespread contentions of public dissatisfaction. Using data from the 1976 National Survey of Access to Care (Aday, Andersen, and Fleming 1980) and the 1998 General Social Survey (Davis, Smith, and Mardsen 1998), we take advantage of a unique opportunity to compare the public's attitudes across a 20-year period. We examine individuals' evaluations of the way physicians do their work and their ability to confront health problems. Three findings support a complex view of public sentiments. First, while public confidence in physicians remains relatively high, we document a crystallization of attitudes reflecting greater negative and fewer positive sentiments. Second, while neither the structure of attitudes nor the role of sociodemographic characteristics in explaining attitudes has significantly shifted over time, in 1998 health status and insurance status are correlated with negative attitudes. Third, using General Social Survey time trend data on the confidence in medicine compared to other professions (science and education), we find support for a general public response to social institutions, with confidence in medicine tracking closely with confidence in science in level, and education in pattern. We end with four possible explanations of our findings, including and a general discussion of the role of the public in the professional status of physicians and its implications for social change in the institution of medicine.

Cigarette diffusion and sex differences in smoking.

Abstract: Because the recent narrowing of the sex differential in smoking (and mortality from smoking-related causes) coincides with movement toward gender equality and independence among women, it suggests that rising status among women has contributed to their adoption of male smoking behavior (and ultimately to worsening longevity). However, an alternative "cigarette diffusion" explanation suggests that convergence in male and female smoking is the byproduct of a female lag in the process of cigarette adoption, diffusion, and abatement. Using multilevel models and data for 16 European nations from 1988-1995, the analysis demonstrates consistent support for the predictions of the cigarette diffusion explanation. Smoking of men and women becomes more similar in nations that have the longest history of cigarette use rather than the greatest gender equality.

Migration, social support and perinatal health: an origin-destination analysis of Puerto Rican women.

Abstract: Using pooled origin-destination data from the Puerto Rican Maternal and Infant Health Study, we investigate linkages between migration, social support, and perinatal health. We document differences in social support between three groups of Puerto Rican women: non-migrant women in Puerto Rico, first-generation migrants to the U.S. mainland, and mainland-born women. The role of social support in producing differences in perinatal health outcomes between the groups is assessed. The analysis shows striking differences in social support between island and mainland women, but little systematic variation among mainland women by generation of U.S. residence. The lower level of social support available to mainland women is not reflected in the health outcomes examined, which do not generally worsen with migration to the United States (with the exception of maternal smoking). Nonetheless, we show that social support has important implications for stress, which in turn increases the risk of poor health behavior and compromised infant health.

Infidelity, initiation, and the emotional climate of divorce : Are there implications for mental health?

Abstract: A large literature has examined the role of "secondary" stressors, such as problems with finances, social support, residential mobility, and children, in producing the well-documented association between divorce and a variety of psychopathological conditions. Much less attention, however, has been paid to variation in the "primary" disruption experience. We address this omission using data from the National Survey of Families and Households to investigate the interrelationships among depression, initiator status, and spousal infidelity. While we find little evidence of direct effects of initiator status or spousal infidelity on post-divorce depression, the importance of these characteristics emerges when they are considered in an interactive context. Specifically, while divorce initiation is associated with reduced depression among individuals with unfaithful spouses, initiation is associated with increased depression in the absence of spousal infidelity. Taken together, our findings suggest that characteristics of the divorce experience may interact in complex ways to produce variation in mental health outcomes.

A gulf of difference: disputes over Gulf War-related illnesses.

Abstract: The social discovery of Gulf War-related illnesses, like other occupational and environmental disease, is firmly rooted in ongoing disputes over causation. Pressure from veterans groups, as well as intra-governmental disputes, have driven innovative research directions and challenged the dominant epidemiological paradigm. This dominant epidemiological paradigm was originally a position that viewed stress as the primary causal factor. In the emerging dominant epidemiological paradigm, researchers view veterans' symptoms as similar to other multi-symptom diseases and conditions, but with a firmer respect for the reality of those symptoms. In addition, some researchers pursue interactions between stress and physical exposure. We examine the evolution of the DEP to demonstrate that in many disease disputes, an affected population challenges government and science decision-making, and even ways of knowing, in an attempt to negotiate a disease definition and etiology that results in better treatment and prevention. After considerable research effort, only limited evidence has been found for environmental causation, and even many researchers sympathetic to veterans are doubtful that much more will be found. We analyze the social discovery and ongoing contestation of these illnesses, and the consequent effects on health and public policy. For extension to other disease disputes, we provide an overall model of disease discovery and contestation, examining the key forces of government, science, and citizens.

The effects of income inequality and income level on mortality vary by population size in Texas counties.

Abstract: Objectives: This study uses the counties of Texas to empirically test the predictions of Wilkinson's theory on the role of income and inequality in explaining health differentials in populations. Wilkinson predicts (1) that health is affected more by income inequality than average income in areas with large population, and (2) that health is affected more by average income than income inequality in areas with small population. We investigate how large the population ofa unit must be for income inequality within the unit to affect mortality. Methods: Measures of income inequality were computed from the 1990 U.S. census data and mortality was computed from Vital Statistics data. Poisson regressions estimated the age-adjusted relative risk of the top quintile relative to the bottom quintile for equality and for income among selections of Texas counties based on population size. County ethnic composition, educational level, and health care access were controlled for. Results: Among counties with populations greater than 150,000, the risk of death was lower in counties with more equal income distribution than in counties with less equal income distribution. Among counties with population less than 150,000, median income affected relative risk in counties with less than 30 percent Hispanics, but not in those with more than 30 percent Hispanics. Conclusions: This study provides some support for the predictions of Wilkinson's theory.

The role of sociology in the study of mental health ... and the role of mental health in the study of sociology.

Abstract: This essay considers the dual roles occupied by the sociologist of mental health. These roles involve the articulation of social causation in the study of mental health outside of the discipline, coupled with the articulation within the discipline of the importance of mental health in the study of sociology. I consider these roles both through examples and speculation, emphasizing the unique combination of conceptual and methodological tools that define the intellectual terrain of this area of sociology. The advantage of this dual role--of looking outward while also looking inward--is that we are able to draw from the essential developments and innovations from one source and "move" these insights toward the other. The difficulties of this position are also clear: As an area, we may be structurally marginal from both perspectives, at the same time that we offer considerable analytic power that could significantly impact the direction of research involving mental health in both realms.

A longitudinal analysis of the distinction between for-profit and not-for-profit hospitals in America.

Abstract: Have changes in the hospital industry forced not-for-profit hospitals to become more like for-profit hospitals in measures of efficiency and community service? As a result, are not-for-profit hospitals moving away from their community service missions? In recent years researchers have asserted that the once-salient distinctions between not-for-profit and for-profit hospitals are quickly eroding and that this convergence threatens the community service that not-for-profit hospitals have historically provided. Neo-institutionalists explain that regulatory changes often force differing organization types to pursue similar strategies (Fligstein 1991, 1985; DiMaggio and Powell 1983). Guided by this theory, the present research analyzes if regulatory changes and the implementation of similar strategies result in not-for-profit and for-profit hospitals having similar efficiency and community service outcomes.

Changes in self-efficacy and readiness for smoking cessation among women with high school or less education.

Abstract: The most common theory of smoking cessation postulates that readiness to quit begins with changes in attitudes that move the smoker toward behavioral change and eventual cessation. However, trends in smoking indicate that many who currently smoke are not ready to quit. Hence, strategies that both enhance readiness and focus on quitting are likely to be most effective. We hypothesize that an intervention addressed to motivating behavior change will enhance readiness to change, which will in turn increase the smokers self-efficacy regarding further change. A smoking cessation intervention that combined a self-help booklet and televised segments was developed to address these issues in a population of women smokers with high school or less education. Readiness to quit was measured prior to the intervention, immediately following the intervention, and again at six and 12 months after intervention. The results indicate that the intervention had its effects on readiness to quit, which in turn affected self-efficacy, which further enhanced readiness to quit. These findings indicate that interventions aimed at this group of smokers may need to provide achievable objectives that focus on preparing the smoker to quit as well as promote cessation.

Mortality selection and sample selection: a comment on Beckett.

Abstract: Mortality Selection and Sample Selection: A Comment on Beckett* ANDREW NOYMER University of CaIifornia—BerkeIey Journal of Health and Social Behavior 2001, Vol 42 (Septmber): 326-327 In an interesting article, Megan Beckett (2000) examines the important question of converging health inequalities in later life. Many studies have shown that the differences in health across socioeconomic strata narrow at older ages. Using panel data from the National Health and Nutrition Examination Survey (NHANES), Beckett shows that the converging health inequality cannot be accounted for by mortality selection. The pre- sent comment reconsiders Beckett’s approach to the selection problem, which, while creative, is open to multiple interpretations. Consider the phenomenon that would cause converging health inequalities at later ages to be an “artifact,” as Beckett puts it, of mortality selection. At younger ages, persons with high- er socioeconomic status (SES) have lower lev- els of health problems than those with lower SES. At older ages, the prevalence of health problems in the two groups is closer to parity. If patterns in morbidity are mirrored in mortal- ity, then at older ages a lower SES cohort (higher morbidity and mortality) will be small- er compared to its starting size than a higher SES cohort (lower morbidity and mortality). Since the seminal work of Vaupel, Manton, and Stallard (1979) and Keyfitz and Littman (1979), many demographers have assumed that there are different rates of “frailty” within a population, which determine an individual’s deviation, at any age, from some baseline mor- tality risk. According to the frailty hypothesis, those who die at young ages tend to have high frailty, which skews the distribution of sur- vivors to be more robust. If this condition of nonrandom mortality risks is met, then the aged low SES cohort will be more robust than ‘Address correspondence to: Andrew Noymer, Departments of Sociology and Demography, University of Califomia-—Berkeley, 2232 Pied- mont Avenue, Berkeley, CA 94720; email: andrew@demog.berkeley.edu. when it started out. This reversal of fortune over the life course is called “cohort inversion” (Hobcraft, Menken, and Preston 1982). On the other hand, the low mortality, high SES cohort will have a much less-changed frailty distribu- tion, and will experience less cohort inversion. The greater cohort inversion of the low SES cohort could be enough to overcome the mor- tality disadvantage of being low SES. This problem must be analyzed cautiously, however, as the entire framework for understanding mortality selection effects rests on a counter- factual foundation. If we hold that convergence is a result of mortality selection, we imply that an intrinsic differential persists into older ages and that we would observe it were it not for the selection efiect. On the other hand, if we hold that the convergence is either intrinsic or the result of, for example, access to Medicare (Beckett 2000), we posit that even without selection we would see convergence. In both cases, there is the troubling verb “would.” In reality, we can only observe vital rates that do occur, not those that would occur if some con- dition is met. The general problem of sample selection is encountered frequently in the social sciences (cf. Stolzenberg and Relles 1997; Winship and Mare 1992), and as Beckett (2000) notes, dif- ferential mortality is just a special case of the more general problem. Although we cannot simply “control for” (i.e., condition on) selec- tion bias the same way we would a confound- ing variable, statistical techniques do exist that try to counteract the bias. However, mortality selection is a very special case of sample selec- tion, all the more so if the dependent variable in question is itself health-related. Because of cohort inversion, sample selection due to mor- tality has causal implications beyond nonran- dom missing data in panel followups. This is what makes Beckett’s approach problematic. Consider the statistical technique used by Beckett to set up the hypothetical of no mor- 326

Economic change and health benefits: structural trends in employer-based health insurance.

Abstract: Drawing on structural theories of economic outcomes, we investigated how economic change affects the distribution of health benefits, the main source of health insurance for American workers. Through an aggregate level analysis, we show how the effects of industry level characteristics on the level of health benefits change between 1988 and 1997. Due to the increased reliance on women, nonwhite workers, and part-time labor, we expect declines in the effect sizes of gender and race composition and proportion full-time. In contrast, we predict increases in the effects of proportion small firm employment, proportion union, and industry sector due to rising health care costs, the competitive economic environment, and greater union effectiveness. We analyze data from the March Current Population Surveys for 1987 to 1997 using generalized least-squares regression. The positive effect of proportion white increases over time, while the positive effect of level of full-time work declines. The negative effects of small firm employment and being a retail or nonprofessional service industry increase in magnitude. Both union activity and gender composition have stable effects over the period. The results challenge views of a declining significance of race and gender in the labor market.

Mortality and Sample Selection: Reply to Noymer

Abstract: Andrew Noymer (in this issue) nicely elaboeven more health-based selection on the samrates upon an important limitation with ple would result in substantial increases in estiBeckett's (2000) methodology; i.e., "No one mates of convergence. If health-based seleccan adequately estimate what the health status tion has a minimal impact on the convergence of people out-of-sample is" (p. 117). Her pattern, then imposing even more selection method assumed that the relationships between would have a negligible impact on the converbaseline health status and other observable gence pattern. characteristics at baseline and their follow-up To test between these two hypotheses, we health status (had they been in the sample) predict health status in 1982-84 in the full would have been the same as the relationship sample. Next, we reestimate the same model between baseline characteristics and follow-up restricting the sample to those persons who health status for the people who were actually were alive and responded at the follow-up ten observed. This assumption may overestimate years later. Mortality and attrition rates during the health status of those not observed at folthis interval are substantial: 21.1 percent and low-up and understate the amount of mortality 6.9 percent, respectively. For a simplified preand sample selection. Bearing this in mind, sentation, our health outcome is a Beckett advocated testing the sensitivity of her dichotomized version of the four-category outfindings using different data sets, assumptions come used in Beckett (2000) (coded "1" if any (about health status of out-of-sample responfunctional impairment, "0" if no functional dents), and methods (such as those listed by impairment). Noymer). However, any such method that The results in Table 1 estimate convergence attempts to adjust for the out-of-sample in 1982-84 cross-sectional data with and withrespondents is subject to this same criticism. out 1982-84 to 1992 selection. Education is Thus, we thought the best response to strongly and negatively related to the probabilNoymer's comment would be to reanalyze the ity of reporting functional limitations. The sigNHANES I Epidemiologic Followup Study nificant and positive coefficient associated (NHEFS) data using approaches that do not with the education by age interaction term is make use of projections of health status of outconsistent with a convergence pattern. The of-sample respondents. We devised two comconclusions are identical to those reported in plementary approaches. Beckett (2000) and, more importantly, are vir-