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When biomedical knowledge and technology create the capacity for humans to avoid disease and circumvent early death, sociological factors become more, not less important for population health. The transformation of disease causation from cruel fate, accident, and bad luck to circumstances that are under some degree of human control facilitates a powerful social shaping of disease and death. When humans have control, it is their policies, their knowledge, and their behaviors that shape the consequences of biomedical accomplishments, and thereby extant patterns of disease and death. I propose a \"social shaping approach\" that can frame our understanding of these processes and allow us to take action to optimize population health. Support for this approach is garnered from evidence of dramatic improvements in population health and in the uneven distribution of those improvements across persons, places, and times. Health improvements suggest that humans have gained control of disease whereas the uneven and very slow spread of such improvements underscores the critical importance of social factors. But the evidence presented represents a stick figure at best, one that needs to be filled in by a well-supported \"epidemiological sociology\" that uses a wide range of sociological concepts and theories to elucidate the social shaping of disease and death. Absent a robust societal investment in epidemiological sociology, population health will reside below its optimal level and the maldistribution of health-enhancing innovations will continue to create health disparities.

Objective. People with severe mental illness (SMI) may be at increased risk for several adverse health conditions, including HIV/AIDS. This disproportionate disease burden has been studied primarily at the individual rather than community level, in part due to the rarity of data sources linking individual information on medical and mental health characteristics with community-level data. We demonstrated the potential of Medicaid data to address this gap. Methods. We analyzed data on Medicaid beneficiaries with schizophrenia from eight states that account for 66% of cumulative AIDS cases nationally. Results. Across 44 metropolitan statistical areas (MSAs), the treated prevalence of HIV among adult Medicaid beneficiaries diagnosed with schizophrenia was 1.56% (standard deviation = 1.31%). To explore possible causes of variation, we linked claims files with a range of MSA social and contextual variables including local AIDS prevalence rates, area-based economic measures, crime rates, substance abuse treatment resources, and estimates of injection drug users (IDUs) and HIV infection among IDUs, which strongly predicted community infection rates among people with schizophrenia. Conclusions. Effective strategies for HIV prevention among people with SMI may include targeting prevention efforts to areas where risk is greatest; examining social network links between IDU and SMI groups; and implementing harm reduction, drug treatment, and other interventions to reduce HIV spread among IDUs. Our findings also suggest the need for research on HIV among people with SMI that examines geographical variation and demonstrates the potential use of health-care claims data to provide epidemiologie insights into small-area variations and trends in physical health among those with SMI.

Child mortality, defined here as mortality under age five, is not evenly distributed but found in clusters. In a contemporary polygamous population in Ghana with extended families, we separate clustering at the parental and household levels, which are often overlapping and inseparable in other historical studies. For eight years, we followed 28,994 individuals, including 9,288 children under the age of five, in 1,703 households. We identified four determinants that had a significant effect on child mortality: sex of the child, age of the child, drinking source, and socioeconomic status. After correcting for these determinants, we still identified significant clustering of child mortality at the level of the village (covariance [cov] = 0.02, p = .04), household (cov = 0.14, p = .003), father (cov = 0.24, p = .001), and mother (cov = 0.18, p = .05). The present data provide clues regarding the levels at which to look for unidentified determinants of child mortality and suggest that the importance of the father could be larger than previously thought.

We undertook a survey of clinical pathways across the 25 European Union countries. Fifty one questionnaires were completed by largely self-selected experts from 17 countries. Respondents reported that pathways were important and were becoming increasingly widely used (although the rate of progress was highly variable). One important constraint was reported to be a cultural aversion among doctors that arises at least in part from the implication that pathways require multidisciplinary teamwork which will prejudice medical autonomy. In other words, pathways challenge clinical professional subcultures. Other constraints included lack of encouragement by external parties, such as purchasers, with limited financial support for pathway development and implementation and service purchasing that did not reward care providers who use pathways. The obvious implication of the survey is that more needs to be done to achieve a common understanding of pathways. In spite of the large quantity of published papers, survey respondents reported that there are many health professionals who have only a superficial understanding at best. (author abstract)

The research reported here identified and evaluated gaps in Canadian knowledge and research activity concerning the role of income and its distribution in influencing health outcomes. The study consisted of an analysis of 241 recent Canadian research studies, the components of which were compared with 40 U.K. and 40 Finnish studies that applied advanced conceptualizations of the income-health relationship. Canadian health researchers rarely made explicit their conceptualizations of how income was approached in their studies, and most did not identify the structural mechanisms that mediate the income-health relationship. There were few Canadian longitudinal studies capable of illuminating the role of income in health across the lifespan. Many Canadian studies identified pathways by which income might influence health, but these conceptualizations were underdeveloped. Canadian researchers need to strengthen their conceptualizations of how income and its distribution affect health. While empirical research is only one contributor to positive policy change, the narrow nature of Canadian work will do little to influence this process. Interdisciplinary work on the political, economic, and social forces that contribute to income inequalities has the potential, when combined with political and social action, to facilitate public policy in support of health.

We investigated the association between a U.S. National Institutes of Health (NIH) R01 applicant's self-identified race or ethnicity and the probability of receiving an award by using data from the NIH IMPAC II grant database, the Thomson Reuters Web of Science, and other sources. Although proposals with strong priority scores were equally likely to be funded regardless of race, we find that Asians are 4 percentage points and black or African-American applicants are 13 percentage points less likely to receive NIH investigator-initiated research funding compared with whites. After controlling for the applicant's educational background, country of origin, training, previous research awards, publication record, and employer characteristics, we find that black applicants remain 10 percentage points less likely than whites to be awarded NIH research funding. Our results suggest some leverage points for policy intervention.

The transition from medical school to residency is a critical step in the careers of physicians. Because of the standardized application process-wherein schools submit summative Medical Student Performance Evaluations (MSPE's)-it also represents a unique opportunity to assess the possible prevalence of racial and gender disparities, as shown elsewhere in medicine. The authors conducted textual analysis of MSPE's from 6,000 US students applying to 16 residency programs at a single institution in 2014-15. They used custom software to extract demographic data and keyword frequency from each MSPE. The main outcome measure was the proportion of applicants described using 24 pre-determined words from four thematic categories (\"standout traits\", \"ability\", \"grindstone habits\", and \"compassion\"). The data showed significant differences based on race and gender. White applicants were more likely to be described using \"standout\" or \"ability\" keywords (including \"exceptional\", \"best\", and \"outstanding\") while Black applicants were more likely to be described as \"competent\". These differences remained significant after controlling for United States Medical Licensing Examination Step 1 scores. Female applicants were more frequently described as \"caring\", \"compassionate\", and \"empathic\" or \"empathetic\". Women were also more frequently described as \"bright\" and \"organized\". While the MSPE is intended to reflect an objective, summative assessment of students' qualifications, these data demonstrate for the first time systematic differences in how candidates are described based on racial/ethnic and gender group membership. Recognizing possible implicit biases and their potential impact is important for faculty who strive to create a more egalitarian medical community.

We have used 19.9 million papers over 5 decades and 2.1 million patents to demonstrate that teams increasingly dominate solo authors in the production of knowledge. Research is increasingly done in teams across nearly all fields. Teams typically produce more frequently cited research than individuals do, and this advantage has been increasing over time. Teams now also produce the exceptionally high-impact research, even where that distinction was once the domain of solo authors. These results are detailed for sciences and engineering, social sciences, arts and humanities, and patents, suggesting that the process of knowledge creation has fundamentally changed.

Background. Transgender women (transwomen) in the United States have been shown to have high HIV risk with Black and Hispanic transwomen being particularly vulnerable. Growing research on transgender men (transmen) also shows increased HIV risk and burden, although not as much is known for this transgender population. Objectives. This systematic review estimates the prevalence of self-reported and laboratory-confirmed HIV infection, reported sexual and injection behaviors, and contextual factors associated with HIV risk of transgender persons living in the United States. Search Methods. We searched the HIV Prevention Research Synthesis database and MEDLINE, EMBASE, PsycINFO, CINAHL, and Sociological Abstracts databases from January 2006 to March 2017 and January 2006 to May 2017, respectively. Additional hand searches were conducted in December 2017 to obtain studies not found in the literature searches. Selection Criteria. Eligible reports were published US-based studies that included transgender persons and reported HIV status. Data collection and analysis. Data were double-coded and quality assessed. We used random-effects models employing the DerSimonian–Laird method to calculate overall prevalence of HIV infection, risk behaviors, and contextual factors for transwomen, transmen, and race/ethnicity subgroups. Main Results. We reviewed 88 studies, the majority of which were cross-sectional surveys. Overall laboratory-confirmed estimated prevalence of HIV infection was 9.2% (95% confidence interval [CI] = 6.0%, 13.7%; κ = 24). Among transwomen and transmen, HIV infection prevalence estimates were 14.1% (95% CI = 8.7%, 22.2%; κ = 13) and 3.2% (95% CI = 1.4%, 7.1%; κ = 8), respectively. Self-reported HIV infection was 16.1% (95% CI = 12.0%, 21.2%; κ = 44), 21.0% (95% CI = 15.9%, 27.2%; κ = 30), and 1.2% (95% CI = 0.4%, 3.1%; κ = 7) for overall, transwomen, and transmen, respectively. HIV infection estimates were highest among Blacks (44.2%; 95% CI = 23.2%, 67.5%; κ = 4). Overall, participation in sex work was 31.0% (95% CI = 23.9%, 39.0%; κ = 39). Transwomen (37.9%; 95% CI = 29.0%, 47.7%; κ = 29) reported higher participation in sex work than transmen (13.1%; 95% CI = 6.6%, 24.3%; κ = 10; P = .001). Most outcomes indicated high heterogeneity in the overall and subgroup analyses. Conclusions. The availability of more data allowed us to calculate estimates separately for transwomen and transmen. HIV prevalence estimates for US transwomen were lower than previous estimates, but estimates for HIV prevalence and participation in sex work were higher when compared with transmen. Evidence gaps remain for transmen and the syndemic relationship of HIV, risky behaviors, and contextual factors specific to the transgender experience. Public Health Implications. This study highlights gender disparities for HIV and risky sexual behavior, as well as evidence gaps that exist for transmen. Tailored programs and services for the transgender population need to be developed to encourage use of and access to HIV prevention services.

This study examined two types of potential sources of racial-ethnic disparities in medical care: implicit biases and time pressure. Eighty-one family physicians and general internists responded to a case vignette describing a patient with chest pain. Time pressure was manipulated experimentally. Under high time pressure, but not under low time pressure, implicit biases regarding blacks and Hispanics led to a less serious diagnosis. In addition, implicit biases regarding blacks led to a lower likelihood of a referral to specialist when physicians were under high time pressure. The results suggest that when physicians face stress, their implicit biases may shape medical decisions in ways that disadvantage minority patients.