Recent Social Disparities and Health (C2S) Research

Social Disparities, Stress, and Health

Brian Mustanski
Brian Mustanski, professor of medical social sciences and IPR
associate, discusses the state of LGBTQ health at an August 18
symposium organized by the Institute for Sexual and Gender
Minority Health and Wellbeing (ISGMH), which he directs.

Increasing Awareness of PrEP
Young men who have sex with men have a high risk of HIV and stand to benefit significantly from pre-exposure prophylaxis (PrEP), a drug that prevents HIV infection. However, do these young men know about and use PrEP? In AIDS and Behavior, IPR associates Gregory Phillips II and Brian Mustanski, both medical social sciences faculty, explore awareness and use of PrEP among a sample of 759 racially diverse young gay men aged 18–29. While 67 percent reported being aware of PrEP, less than 9 percent said they used it. For those who did not use the drug, more than 30 percent had either never heard of PrEP, or had heard of it but did not know what it was. Among respondents who did know about PrEP, uncertainty about how to access it was the most common reason for not using the drug. Other barriers included its price, concerns about its side effects, and lacking health insurance. Phillips is currently working with the Chicago Department of Public Health on several projects that could inform future interventions to address the lack of awareness and uptake of PrEP. Both researchers are part of the Institute for Sexual and Gender Minority Health and Wellbeing, which Mustanski directs.

Safety Net Helps HIV-Positive Women
How do women remake, not simply rebuild, their lives after trauma? Drawing upon data from her Health, Hardship, and Renewal Study of women living with HIV/AIDS, IPR sociologist and African-American studies researcher Celeste Watkins-Hayes presents a theory of transformative projects in her book “Remaking a Life, Reversing an Epidemic: HIV/AIDS and the Politics of Transformation,” which is under contract with the University of California Press. Watkins-Hayes argues that through a multidimensional process, individuals fundamentally shift how they conceptualize, strategize around, and address struggles related to inequalities that affect their everyday lives. This entails the adoption of a radically different set of approaches to negotiate questions of physical, social, economic, and political survival in moments of crisis and extreme distress. Watkins-Hayes traces the unique safety net that has been critical in allowing HIV-positive women to launch successful transformative projects. She points out that the AIDS service and healthcare infrastructure offers important lessons for how to think about assisting other socially and economically marginalized populations, not just those with HIV/AIDS. As such, her book documents how radical improvements in social well-being occur and seeks to explain instances in which the efforts fail.

Stress and Vulnerability to Drug Use
Emerging research suggests that exposure to chronic stress affects health-related behaviors and forecasts chronic diseases later in life. In new research funded by the National Institutes of Health (NIH), IPR health psychologist Greg Miller is investigating whether stress specifically affects youth’s vulnerability to drug use and HIV. The study will examine the neuroendocrine, inflammatory, and neurocognitive pathways through which exposure to stress among rural African-American youth can lead to drug use and behaviors increasing the risk of HIV. Miller and his colleagues will also study what protects youth with chronic stress from engaging in drug use and HIV-related behavior. The researchers seek to translate their findings into new and refined preventive interventions.

Health Effects of the Great Recession
How did the Great Recession affect the health of African-American youth? IPR health psychologists Edith Chen and Miller investigate in Brain, Behavior, and Immunity. They follow 330 African-American adolescents in Georgia from 2007–10, dividing them into three groups: those with stable low economic hardship, those who moved down the socioeconomic ladder, and those who had stable levels of high economic hardship. Chen and Miller find that the longer adolescents experience economic hardship, the higher their epigenetic aging, meaning their cells look “older” than they are chronologically. More time spent under economic hardship also correlates with higher allostatic load scores—a measure that includes body mass index (BMI) and levels of stress hormones like cortisol—as well as a worse self-report of health. In addition, adolescents who experienced downward mobility have higher levels of allostatic load than teens who had stable levels of low hardship. The findings suggest that the health problems of African-American youth might partially be shaped by macroeconomic societal conditions, and effects on biological markers can be detected relatively early in life.

Debt and Your Health
Do debtors have worse health than those who do not owe money? IPR anthropologist Thomas McDade, who is Carlos Montezuma Professor of Anthropology, is continuing research on the impact of financial debt on health, with funding from the National Institute on Minority Health and Health Disparities. The work builds on a 2013 study in Social Science and Medicine, which found a higher debt-to-asset ratio was associated with higher perceived stress and depression, higher diastolic blood pressure, and worse self-reported general health. To further elucidate the effects of financial debt on health, the current research team—which includes IPR anthropologist Christopher Kuzawa and IPR associate Frank Penedo, who is Roswell Park Professor in Medical Social Sciences—is analyzing results from the National Longitudinal Study of Adolescent to Adult Health (AddHealth) for three different biomarkers: glycated hemoglobin, C-reactive protein, and Epstein-Barr virus antibodies. They are also using analyses within the Panel Study of Income Dynamics to consider the potential intergenerational consequences of debt.

Financial Toxicity Among Cancer Patients
Cancer treatment is expensive, often leading to financial distress for patients. However, there is no validated, standardized patient-reported outcome measure to assess this distress. In Cancer, IPR associate David Cella, Ralph Seal Paffenbarger Professor of Medical Social Sciences, and his colleagues evaluate the Comprehensive Score for Financial Toxicity (COST) measure. The researchers collected data about 233 patients with stage IV tumors, which are the most aggressive type, including patients’ clinical trial participation, healthcare use, willingness to discuss costs, psychological distress, and health-related quality of life. The results validate COST as a measure of financial toxicity specifically developed for patients with cancer. In addition, the COST measure correlates with health-related quality of life, making it a clinically relevant patient-centered measure. Cella and his colleagues conclude that incorporating financial toxicity assessments into research and clinical trials will keep patients at the center of financial distress evaluations.

Greg Miller Edith Chen Simone Ispa-Landa
From left: IPR health psychologists Greg
Miller and Edith Chen question IPR 
sociologist Simone Ispa-Landa about
her findings on the experiences of urban
African-American students bused to 
suburban schools that are overwhelmingly

Skin-Deep Resilience
African-Americans from low-income families who go on to succeed academically and socially might pay a price, according to research by Miller. Together with Chen, he examines how these positive outcomes are associated with worse health. In a study published in Health Psychology, the researchers had 514 healthy adults complete questionnaires about their socioeconomic condition, conscientiousness, lifestyle, and psychological and social health. Participants were then given a rhinovirus that causes upper respiratory infection and monitored for five days. African-Americans from disadvantaged backgrounds who scored high in conscientiousness—meaning they were organized, self-disciplined, and purposeful—fared better in terms of educational attainment, depressive symptoms, and quality of close relationships. However, individuals who displayed this “skin-deep resilience” were also more likely to become ill following inoculation. The results suggest resilience might be a double-edged sword for African-Americans from disadvantaged backgrounds, as the same characteristics associated with success predicted increased vulnerability to health problems.

The Price of Empathy
Parents who are able to empathize with their children help them to develop many important social-emotional characteristics, such as effective control of their emotions, less depression and aggression, and greater empathy themselves. Empathetic parents might also contribute to better physiological profiles in their children. But what are the psychological and physiological effects of being empathetic? Being empathetic might be psychologically beneficial, bringing feelings of self-esteem, pride, and satisfaction. However, at the same time, empathy might take a physiological toll on parents. To determine what costs empathy might take on parents’ physiology, Chen, Northwestern psychology graduate student Erika Manczak, and Anita DeLongis of the University of British Columbia studied 247 pairings of one parent and one adolescent child. They examined blood samples from both parents and adolescents for markers of systemic inflammation. Parents reported on their feelings of empathy, well-being, and self-esteem, and also assessed their child’s emotional regulation. Adolescents also recorded two weeks of daily diary entries on their ability of regulate their emotions. For adolescents, parental empathy was significantly associated with both better emotional regulation and less systemic inflammation. For their parents, on the other hand, being empathetic had mixed results: Empathy was associated with higher self-esteem and purpose in life, but also with higher systemic inflammation. The study was published in Health Psychology.

Socioeconomic Status and Heart Disease
Over the past several decades, morbidity and mortality from coronary heart disease (CHD) have significantly declined. This trend, however, varies across demographic groups—low-income individuals continue to develop and die from CHD at higher rates more typical of the 1970s. Miller and his colleagues, including former IPR postdoctoral fellow Camelia Hostinar (now at the University of California, Davis), are investigating whether youth show socioeconomic disparities in immunologic, neural, and psychosocial development, and the implications for early risk of CHD. The researchers are conducting a multilevel study of 250 youth from economically diverse backgrounds, who were enrolled in the study as eighth graders and will be reassessed in tenth grade. The NIH-funded study aims to determine how socioeconomic status relates to children’s brain and immune development, and what implications that has for behavioral and biological processes that increase the risk of CHD. Miller and his colleagues also seek to uncover whether youth from lower-SES backgrounds who encounter positive social influences—specifically role models and high levels of maternal warmth—will develop personal resources like trust, emotion-regulation skills, and self-esteem that help them navigate the challenges of high school and low-SES life more broadly. The researchers hypothesize those resources will shift low-SES youth off their expected risk trajectory, resulting in immune and neural patterns similar to higher-SES youth.

Intergenerational Perspectives on Health Disparities

How Maternal Health Affects Offspring
Do maternal health and nutrition have intergenerational effects on birth outcomes? With National Science Foundation (NSF) funding, Kuzawa is following women in the Cebu Longitudinal Health and Nutrition Survey who have become pregnant. The women, who are now having children of their own, were in utero when the Cebu study began in 1983. Kuzawa and his colleagues, including McDade and Miller, are using the lifetime of information on mothers’ nutrition, early-life morbidity, infant feeding, and growth to shed light on the factors that predict their offspring’s birth weight. They also seek to discover when in a mother’s life cycle these factors have the strongest intergenerational impacts. In addition, an NIH-funded proposal will enable the researchers to collect placentas from some of the women to assess epigenetic changes that might link a woman’s early-life experience with her child’s fetal growth rate and birth size. Kuzawa discussed this research at a November 17 Health Inequality Network conference that he organized as part of the Human Capital and Economic Opportunity Global Working Group, directed by economics Nobel laureate James Heckman.

Telomere Length Across Generations
People are increasingly putting off starting a family until later in life, leading to growing concern about the effects of mothers’ and fathers’ ages on the biology of their offspring. In another NSF-funded study, Kuzawa is examining telomere length, an important genetic marker of aging that is linked to cardiovascular disease and poorer immune system regulation. In previous work with Dan Eisenberg, a former Northwestern graduate research assistant now at the University of Washington, he collected telomere data from Cebu participants. The data showed that the age of a person’s father when he or she was conceived affected the length of the telomeres he or she inherited, and this effect was cumulative across two generations. Kuzawa is assessing whether this finding holds true over more than two generations, laying the foundation for questions related to the possible intergenerational health impacts of reproductive decisions. He is also examining intergenerational impacts of fathers’ stress on offspring in Florida, in collaboration with IPR Director David Figlio, an education economist, IPR economist Jonathan Guryan, and IPR research associate Krzysztof Karbownik. Figlio is Orrington Lunt Professor of Human Development and Social Policy and of Economics.

Weight Gain in Fatherhood
How does becoming a father affect BMI? Pediatrician and IPR associate Craig Garfield, IPR developmental psychobiologist Emma Adam, IPR developmental psychologist Lindsay Chase-Lansdale, and McDade studied more than 10,000 men over 20 years as they moved out of their teen years into fatherhood. The researchers find becoming a father is linked with an increase in BMI, whether or not the father lives with his child. Fathers who live in the same home as their child have the biggest overall increase in BMI, with the greatest increase occurring in early fatherhood. In the American Journal of Men’s Health, the researchers conclude that their findings support the need for obesity prevention specifically designed for young men and men transitioning to fatherhood. They highlight the influence of fathers’ weight on children’s outcomes as a key reason to focus preventive efforts on young men. Chase-Lansdale is Frances Willard Professor of Human Development and Social Policy and Associate Provost for Faculty.

Involving Fathers in Their Child’s Care
Though mothers still shoulder the bulk of childcare, a recent clinical report from the American Academy of Pediatrics shows that fathers are now more involved in their children’s lives than ever before. Garfield was the lead author of the report, which regroups a wealth of data from qualitative and quantitative studies produced since the previous report in 2004. The number of single dads raising children has increased 60 percent in the past 10 years, and the time fathers spent caring for their children more than doubled between 1965 and 2011. According to the report, this changing environment speaks to a need for pediatricians to make greater efforts to engage fathers. The report offers recommendations for how pediatricians can involve fathers more in care and calls on pediatricians to promote flexible work schedules and policies such as the Family Medical Leave Act.

Robin Nusslock Chris Kuzawa
IPR anthropologist Christopher Kuzawa
(right) discusses the intergenerational
transmission of health with psychologist
and IPR associate Robin Nusslock.

How Testosterone Affects Fatherhood
A man’s testosterone levels drop when he becomes a father, according to a groundbreaking 2011 study by Kuzawa and his colleagues, including McDade. Kuzawa is currently following up on the research, seeking to understand the role of biological changes that fatherhood initiates and if and how these changes predict relationship stability and the developmental outcomes of their children. The study, funded by the NSF, explores if new fathers who experience larger declines in testosterone are better parents and spouses than those with smaller declines, if a father’s testosterone level affects his child’s performance in school, and if living with his child affects his testosterone levels. The work is in collaboration with the Cebu study, which has followed the same families in the Philippines for more than three decades.

Early Environments on Health Trajectories

Late-Term vs. Full-Term Births
Late-term gestation is associated with an increased risk of health complications in the weeks after birth, but little is known about the long-term cognitive and physical outcomes associated with birth at 41 weeks, or one to two weeks later than a typical gestation. Figlio analyzed Florida birth certificates linked to Florida public school records for more than 1.4 million births. With Guryan, Karbownik, and pediatrician Jeffrey Roth of the University of Florida, he finds that late-term infants had higher average test scores in elementary and middle school than full-term infants, and they also had a higher chance of being gifted and were less likely to exhibit poor cognitive outcomes. Late-term infants, however, did not fare as well physically—they had a higher rate of physical disabilities by the time they were in school and higher rates of abnormal conditions at birth than infants born at 39 or 40 weeks gestation. The findings, published in JAMA Pediatrics, provide additional data for expectant parents and physicians when considering whether to induce delivery at full term or wait another week.

Effects of Having a Disabled Sibling
Figlio, Guryan, and Karbownik are continuing to investigate how having a disabled sibling influences a child’s cognitive development. In families with three children, the researchers are comparing the school outcomes of first- and second-born siblings who have a younger sibling who is disabled to those in families where the third child is not disabled. They discover that when the youngest child is disabled, the middle child has a cognitive disadvantage relative to the oldest child compared with the sibling outcomes in families without a disabled child. This suggests that, in addition to effects on all the children in a household with three children and the youngest disabled, the middle child will experience additional, negative effects from having a younger, disabled sibling.

Investigating Adolescent Stress
How does stress affect the health of adolescents? McDade has helped integrate biomarker data collection into Wave IV of the National Longitudinal Study of Adolescent to Adult Health (AddHealth), a dataset he is using to investigate social status, neighborhood factors, and social relationships as sources of stress that affect mental and physical health in young adults. This is the largest ever study of stress to include objective indicators of physiological function and health, and findings from the research will advance the understanding of how social contexts “get under the skin” to affect health in young adults. The project, which received funding from the NIH, also involves Adam, Chase-Lansdale, and IPR faculty emeritus Thomas D. Cook.

Discrimination’s Effect on Stress
Adam is continuing her work on discrimination and health, examining 20 years of prospective data gathered from adolescence through young adulthood. The data include detailed information on exposure to stressors related to race, in addition to measures of family functioning and racial/ethnic identity. Adam is also looking at a wide range of stress-sensitive biological measures, including measures of gene expression relevant to the regulation of biological stress. The preliminary results indicate that a cumulative developmental history of higher perceived discrimination is linked with flatter cortisol diurnal rhythms and lower overall cortisol levels in early adulthood—both indicators of chronic stress. In addition, experiences of discrimination during adolescence have particularly strong effects on adult stress biology. Adam concludes that histories of discrimination help to explain racial and ethnic disparities in cortisol rhythms. She also reveals that positive resources, such as having a strong racial or ethnic identity, can help to reverse the negative effects of racial discrimination on adult stress biology.

Childhood Irritability and Mental Illness
In the Multidimensional Assessment of Preschoolers Study (MAPS), IPR clinical and developmental psychologist Lauren Wakschlag is assessing disruptive behavior, including irritability and callous traits, which can indicate an increased risk for mental illnesses. Her goal is to identify whether such behaviors are normal as early as possible to offer early detection and prevention. She proposes a longitudinal follow-up of the study, linking the MAPS early childhood data to early school age and preadolescent outcomes. Wakschlag aims to specify dimensional attributes of temper loss and a lack of concern for others in early childhood that predict chronic clinical patterns and preadolescent neurocognitive disruptions. She is currently collaborating with Figlio to use the MAPS dataset to test mechanisms of early gender-related health disparities in child behavior and development. The study findings will lay the groundwork for targeted prevention designed to change the life span trajectories of mental disorder at its earliest stages.

The When-to-Worry Study
Wakschlag is also studying irritability in infants and young children in an effort to differentiate patterns that mark risk for clinical progression. With clinical psychologist and IPR associate Amélie Petitclerc, she is conducting a cross-sectional survey of 2,000 12–36 month olds and gathering bimonthly reports from some of the parents. Wakschlag is also assessing maturation of the prefrontal cortex, an area of the brain involved in personality expression and moderating social behavior, using the Language Environment Analysis (LENA) Pro device for real-time monitoring of irritable vocalizations. By specifying which factors of irritability are seen over time, she aims to improve predictions of irritability’s clinical progression and to map developmentally atypical patterns to disruptions in the maturation of certain brain regions. She hypothesizes that uncommon patterns of irritability will predict slowed executive function development and abnormal prefrontal cortex anatomy. IPR psychologist Sandra Waxman is collaborating with Wakschlag on how children vocalize their irritability.

The Environment and Neurodevelopment
How does the surrounding environment—including chemical, biological, social, and behavioral factors—affect children’s neurodevelopment? Wakschlag is leading the neurodevelopment section of the Environmental Influences on Child Health Outcomes: Patient Reported Outcomes (ECHO PRO) Measurement Core, which is headed by Cella. The NIH-funded ECHO PRO consortium is gathering adult and pediatric exposure to these factors and health assessments, as well as recording both observational and performance measures of child functioning. The data will help determine the longitudinal impact of prenatal, perinatal, and postnatal environmental exposures on pediatric health outcomes. Neurodevelopment is one of four focus areas, with investigators assessing outcomes like autism, attention-deficit hyperactivity disorder (ADHD), and depression.

Toxic Waste and Human Development
Over the last 60 years, the United States produced millions of tons of hazardous wastes, which were dispersed into the air, water, and ground. What are the short- and long-term effects of prenatal exposure to these environmental toxicants? Figlio, Roth, and former IPR graduate research assistant Claudia Persico, now at the University of Wisconsin–Madison, use population-level data from Florida to ascertain the effects on children near a Superfund site—a toxic waste site identified by the Environmental Protection Agency as particularly severe. In an IPR working paper, they find children conceived to mothers living within two miles of a Superfund site before it was cleaned have lower test scores, are more likely to repeat a grade, and are more likely to be suspended from school than their siblings who were conceived after the site was cleaned. In addition, children conceived to mothers living within one mile of a Superfund site before it was cleaned are 10 percentage points more likely to be diagnosed with a cognitive disability than their later-born siblings.

Improving Health Through Peer Education
IPR anthropologist Sera Young is assessing if an educational intervention focusing on nutrition, climate change, gender equity, and an ecological approach to agriculture can improve food security and infant feeding practices in Africa, while also empowering women. The curriculum, aimed at rural Tanzanian farmers, integrates information from a variety of disciplines. Each intervention village will choose two mentor farmers, one male and one female, who will receive training from existing mentor farmers in Malawi. These mentor farmers will conduct monthly visits to participating households, providing them with support as they experiment with agro-ecological practices and new behaviors regarding nutrition and gender equality. The researchers will measure dietary diversity scores once each year throughout the four-year study, and also assess the proportion of children who are stunted. According to Young, this novel, peer-based approach to improving health outcomes could prove highly sustainable.

Sera Young
IPR anthropologist Sera Young conducts
a "go-along" interview in Kenya, traveling
with a local woman as she gathers water
to learn more about water insecurity.

Food and Water Insecurity Among Women
Young is investigating how water insecurity has an impact on adverse maternal and infant health outcomes among women. It is the first study to investigate the impacts of water insecurity on the physical, mental, and economic well-being of women and children during pregnancy and lactation. The study is evaluating both HIV-infected and uninfected pregnant and lactating women in western Kenya. Understanding the role of water insecurity could change the way that prenatal care and HIV care are provided, according to Young. She hypothesizes that water insecurity is associated with greater viral load and suboptimal infant feeding practices in women with HIV. In another project that could affect prenatal care and HIV care, Young is studying food insecurity for HIV-positive women and their infants in Kisumu, Kenya. Both projects are with the Kenyan Medical Research Institute and Family AIDS Care and Education Services.

Mental Health Among Mexican-Americans
Mexican-American youth are disproportionately vulnerable to depression, anxiety, and suicide. Research has linked these mental health disparities to sociocultural and economic inequalities, but how do such inequalities affect the quality of mental healthcare? IPR anthropologist Rebecca Seligman is using both ethnographic and quantitative methods to examine how culture and ethnicity matter to Mexican-American patients, how healthcare providers deal with Mexican-Americans in mainstream adolescent psychiatric practices, and the experiences and responses to treatment of youth who receive care. Seligman seeks to assess which factors most strongly influence quality of care outcomes, including patient satisfaction, adherence to treatment, and retention. The findings have the potential to improve clinical practices and promote better social, emotional, and behavioral outcomes for already disadvantaged Mexican-American youth struggling with psychological distress. The study is part of an ongoing project investigating how sociocultural influences on the ways in which Mexican-American youth conceptualize and experience their emotions, relationships, and sense of self affect their help-seeking and the experience of mental healthcare.

Mind-Body Interactions in Health
How do social and cultural meanings affect illness and healing? Seligman's chapter in the forthcoming “Handbook of Biology and Society” details the concept of “biolooping,” which sheds light on how social and cultural meanings affect bodily states. Building on the concept of biolooping described in her book, Possessing Spirits and Healing Selves: Embodiment and Transformation in an Afro-Brazilian Region (Palgrave Macmillan, 2014), Seligman examines cases of religious healing, as well as psychiatric disorders and treatments, to illustrate how interacting processes of the mind, body, and brain might condition health and illness. In related work, Seligman draws on research from psychology on “embodied cognition” to theorize the mechanisms through which cognition and bodily states are linked.

Early Warning Signs of Schizophrenia
Psychologist and IPR associate Vijay Mittal and his colleagues have identified early warning signs of schizophrenia that can be spotted in young people before they develop a full-blown psychosis. This early identification could lead to early treatment, which might one day prove effective in mitigating or even preventing future onset of psychotic disorders. Mittal identifies unusual motor behavior, like coordination problems and involuntary jerking movements, as one risk factor. The same basal ganglia brain circuit that governs motor behaviors is implicated in schizophrenia, and people with schizophrenia tend to have irregularities in dopamine, a neurotransmitter that plays a role in starting movement, in that part of the brain. Mittal finds young people who exhibited unusual motor behavior were more likely to develop psychotic behavior than those without them. In addition, Mittal finds subtle handwriting abnormalities can predict schizophrenia risk. He is assessing the potential for tablet-based handwriting assessments for young people who are at high risk. Mittal is also testing whether exercise can help prevent schizophrenia in at-risk populations, and the preliminary results are promising.

Reward Responses and Mood Disorders
The human brain’s reward system is responsible for processing internal and external reward cues and motivating goal-oriented cognition and behavior. Studies have shown how activating this system in the brain can increase an individual’s motivation, goal-oriented cognition, and positive emotions such as happiness, while deactivation leads to decreased motivation to pursue incentives, less goal-oriented cognition, and more negative emotions. In an article published in Behavior Therapy, psychologist and IPR associate Robin Nusslock and his colleagues examine sensitivity to rewards in people with mood disorders such as depression and bipolar disorder. They find that unipolar depression and bipolar disorders sit on opposite ends of the reward sensitivity spectrum: Those with unipolar depression display low sensitivity to rewards, while heightened reward sensitivity appears to be a central characteristic of hypomania/mania. Their findings suggest that abnormal reward sensitivity might make individuals vulnerable to developing unipolar depression and bipolar spectrum disorders, so that identifying abnormalities in the brain’s reward system could hold important implications for identifying and treating mood disorders.