Socio-economic health inequalities: Their origins and implications

Abstract

Evidence attests to substantial variations in health contingent on socioeconomic position. It is argued that these effects cannot be dismissed as artefact nor can they be explained, in the main, by either social selection or an unequal distribution of accepted behavioural risk factors among different social groups. The most likely explanation would seem to be social causation. However, it is continuing social and material inequality that appears most implicated; accounts which locate the effects in childhood social and material causes are far less compelling. The persistence of socioeconomic health differentials into the materially better-off social strata and the possible determining role of relative as well as absolute living standards suggest that psychological, in addition to material, variables are likely to be involved. Isolating the key psychological variables and identifying the nature of their influences will not be easy tasks, although social relations, psychological stress, uplifts, and control have emerged as possible candidates. However, psychological mediators of this sort most probably constitute surface rather than basic causes. Socio-economic inequality, it is contended, remains the basic cause, and, as such, the proper target for intervention. Psychological interventions are unlikely to yield much in the way of dividends in this context and indeed could inadvertently contribute to victim blaming.     

Psychosocial factors associated with hiv testing amongst scottish gay men

This article describes the relationship between HIV testing and a range of psychosocial, sexual and socio-demographic variables. Trained research staff distributed a self-report questionnaire in the gay bars of Glasgow and Edinburgh, in May 2000. Questionnaires were completed by 803 men (a response rate of 78%). We present the results of both bivariate and multivariate analyses identifying key variables associated with never having had an HIV test. Thus we outline some psychosocial barriers to HIV testing. Multivariate analysis indicated that the most important factor associated with never having tested was fear of a positive result; this was particularly true for those men who reported higher levels of risky sexual conduct. We discuss the relevance of these findings in terms of presenting a psychosocial agenda which demands that stigma and the social exclusion of HIV positive people should be addressed before gay men are encouraged to seek HIV testing.     

Understanding the impact of HIV diagnosis amongst gay men in Scotland: An interpretative phenomenological analysis

Objectives: Although a wide literature details the psychological impact of human immunodeficiency virus (HIV) diagnosis, it predates the introduction of effective treatment for HIV (i.e. anti-retroviral therapies, ARTs). This article explores the psychological impact of HIV diagnosis in post-ART accounts. This is important, given the recent policy developments which focus upon increasing HIV testing and thus diagnoses.

Design: This study presents a qualitative exploration of the experiential accounts of HIV-positive gay men living in Scotland. A total of 14 HIV-positive gay men took part in open-ended interviews.

Methods: Interpretative phenomenological analysis was employed to identify recurrent themes across the interviews.

Results: Our analysis focuses upon the participants’ struggles in adjusting to their HIV status. Diagnosis was a deeply shocking and unexpected experience. Stigma and fear of prejudice dominated their accounts. HIV was understood, variously, as a shameful, fatal and life-changing condition. Overall, within these accounts there was little sense of HIV normalisation.

Conclusions: In Scotland, where HIV prevalence is low, and where no accessible HIV-positive sub-culture exists, there is on-going psychological distress and morbidity amongst gay men testing HIV positive. As HIV-related policy increasingly focuses on increasing rates of antibody testing, there is a need to reduce the psychosocial costs associated with HIV-positive diagnoses.     

Affective and health-related outcome expectancies for physical activity in older adults

This study tests the effects of affective and health-related outcome expectancies on physical exercise, assuming stronger direct and indirect (via intention) effects from affective outcome expectancy to physical exercise than from health-related outcome expectancy to exercise. Physical exercise and social cognitive variables were assessed at baseline, and 6- and 12-month follow-up in 335 older adults (60–95 years of age). Applying structural equation modelling, there was a direct effect from affective, but not from health-related outcome expectancy on intentions and behaviour. Also, the indirect effect from self-efficacy on physical exercise via affective outcome expectancy was significant, whereas the mediation via health-related outcome expectancy was not. These findings emphasise the relative importance of affective versus health-related outcome expectancies in predicting intentions and physical exercise in older adults and highlight the importance to separate these facets at a conceptual level to enhance both theory development and health promotion.     

Word Memory Test Performance in Children

One-hundred and thirty-five children between the ages of 7 and 18 years were evaluated clinically. Their diagnoses included Fetal Alcohol Syndrome (FAS) or Effects, Schizophrenia, Bipolar Mood Disorder, various neurological diseases, Attention Deficit Hyperactivity Disorder (ADHD), Conduct Disorder, Oppositional-Defiant Disorder and learning disabilities. As part of a comprehensive neuropsychological assessment, the children were given the Word Memory Test (WMT; Green, Allen, & Astner, 1996; Green & Astner, 1995), containing various subtests which measure, respectively, effort and verbal memory. Although age and verbal intelligence are known to affect scores on most ability tests, they were not found to be significant determinants of WMT effort scores. Younger children did not score any lower on the effort subtests than older children. The children scored as well as a group of parents seeking custody of their children and they scored higher than adult patients with mild head injuries. The computerized WMT requires some basic reading skills and some children with lower than a grade 3 reading level scored at a relatively low level on the effort subtests. The current data suggest that most children with at least a grade 3 reading level can pass the WMT using the adult criteria. It is concluded that the WMT is potentially useful in the evaluation of effort during pediatric neuropsychological evaluations. Further research is needed to replicate these findings and to develop child norms for the memory subtests.     

Science and practice: The struggle to bridge the gap

Abstract

Ida Sue Baron, Eileen Fennell, and Kytja Voeller (1995). Pediatric Neuropsychology in the Medical Setting. New York: Oxford University Press. ISBN 0-19-506345-7. 427 pp. US $57.50     

Structural studies of ultrathin zirconia dielectrics

We present detailed structural and chemical studies on ultrathin zirconia films grown by ultraviolet oxidation and natural (no ultraviolet light) oxidation of Zr precursor metal layers on SiO2-passivated Si(100) wafers. Quantitative electron-energy-loss spectroscopy (EELS) was used to obtain the chemical composition and electronic structure on an atomic scale. The EELS OK near-edge fine structure was used as a fingerprint to study the stoichiometry and composition variation in the dielectric stacks. X-ray absorption spectroscopy studies were performed in order to aid interpretation of the EELS results. The electronic structure data are correlated with the electrical performance of the films.     

Implementation of Cognitive Therapy for PTSD in routine clinical care: Effectiveness and moderators of outcome in a consecutive sample

ObjectiveTrauma-focused psychological treatments are recommended as first-line treatments for Posttraumatic Stress Disorder (PTSD), but clinicians may be concerned that the good outcomes observed in randomized controlled trials (RCTs) may not generalize to the wide range of traumas and presentations seen in clinical practice. This study investigated whether Cognitive Therapy for PTSD (CT-PTSD) can be effectively implemented into a UK National Health Service Outpatient Clinic serving a defined ethnically mixed urban catchment area.MethodA consecutive sample of 330 patients with PTSD (age 17–83) following a wide range of traumas were treated by 34 therapists, who received training and supervision in CT-PTSD. Pre and post treatment data (PTSD symptoms, anxiety, depression) were collected for all patients, including dropouts. Hierarchical linear modeling investigated candidate moderators of outcome and therapist effects.ResultsCT-PTSD was well tolerated and led to very large improvement in PTSD symptoms, depression and anxiety. The majority of patients showed reliable improvement/clinically significant change: intent-to-treat: 78.8%/57.3%; completer: 84.5%/65.1%. Dropouts and unreliable attenders had worse outcome. Statistically reliable symptom exacerbation with treatment was observed in only 1.2% of patients. Treatment gains were maintained during follow-up (M = 280 days, n = 220). Few of the selection criteria used in some RCTs, demographic, diagnostic and trauma characteristics moderated treatment outcome, and only social problems and needing treatment for multiple traumas showed unique moderation effects. There were no random effects of therapist on symptom improvement, but therapists who were inexperienced in CT-PTSD had more dropouts than those with greater experience.ConclusionsThe results support the effectiveness of CT-PTSD and suggest that trauma-focused cognitive behavior therapy can be successfully implemented in routine clinical services treating patients with a wide range of traumas.     

Self-efficacy and affect responses to Sprint Interval Training

ObjectivesTo examine the influence of efficacious beliefs on affective states, enjoyment, and satisfaction after performing a maximal intensity exercise task (i.e. Sprint Interval Training (SIT).DesignAn experimental design was utilized and participants were randomized to a high self-efficacy feedback (HE), low self-efficacy feedback (LE), or no feedback control condition.MethodsCollege-aged men and women (n = 74) performed four 30-second maximal sprints, interspersed with 4-min breaks. Following each sprint interval, participants received either positive, negative or no feedback and SIT self-efficacy, affective states (i.e., positive well-being, psychological distress, fatigue), heart rate (HR), and ratings of perceived exertion (RPE) were assessed. Upon terminating the exercise session, enjoyment and satisfaction were assessed.ResultsThere was group equivalency in HR and RPE among participants of each group. The HE group had significantly less of a decline in SIT self-efficacy from pre to post SIT than both the LE and control groups, and reported significantly higher levels of exercise enjoyment than the other two groups. In addition, the HE and control groups reported significantly higher satisfaction than the LE group.ConclusionsWe recommend that exercisers receive positive feedback statements while performing SIT to minimize the decrease in SIT self-efficacy and to bolster feelings of enjoyment and satisfaction.