The DOI matches its Crossref record; 65 of the 67 references it cites were found in a registry or an index; none of the 27 sources its claims cite is checked for support yet.
Syndemics and Health Disparities: A Methodological Note
Open accessAbstract
In the theory of syndemics, diseases are hypothesized to co-occur in particular temporal or geographical contexts due to harmful social conditions (disease concentration) and to interact at the level of populations and individuals, with mutually enhancing deleterious consequences for HIV risk (disease interaction). Since its original elaboration more than 20 years ago, the epidemiological literature on syndemic problems has followed a questionable trajectory, stemming from the use of a specific type of regression model specification that conveys very little information about the theory of syndemics. In this essay we critically review the dominant approaches to modeling in the literature on syndemics; highlight the stringent assumptions implicit in these models; and describe some meaningful public health implications of the resulting analytical ambiguities. We conclude with specific recommendations for empirical work in this area moving forward.
Overview
AI snapshot
Written from the paper’s full text.
TL;DR
This methodological essay argues that common syndemics analyses using a summed count of psychosocial and structural problems cannot establish synergistic interaction, because a positive count coefficient can occur even under purely additive effects. It recommends using fully saturated interaction models to test syndemic theory and discusses implications for intervention design.
Key findings
- In the systematic review cited (Tsai & Burns), 27 of 40 studies (68%) showed co-occurrence via Venn diagrams, correlation matrices, or odds ratio matrices, and 31 of 40 (78%) used a sum score of problems.
- Algebraically, the sum-score coefficient can be positive and significant when the true data-generating process is additive; the sum score imposes equal effects across problems rather than testing synergy.
- The saturated model with all product terms is the only specification that flexibly conveys interaction; the continuous sum-score model should be abandoned, and the ordinal sum-score model still assumes two-way product terms are zero.
- Public health consequences include unclear excess concern for true syndemics, missed targeted intervention opportunities, and the multi-component “treatment package” not necessarily being optimal; alternatives include sequential, collateral, or fractional factorial strategies.
Methods
- Critical methodological essay, not an empirical study; uses a hypothetical cohort of homeless and marginally housed women with violence, food insecurity, mental illness, and a binary HIV-related outcome.
- Compares linear regression specifications: additive main-effects model, fully saturated interaction model, continuous sum score, and ordinal sum score; draws on a prior systematic review of 40 syndemics studies.
- Main analysis is algebraic demonstration and discussion of assumptions, sample size/power, and recommendations.
Limitations
- Stated: small samples may prevent full interaction estimation and yield wide confidence intervals; collinearity among co-occurring problems worsens imprecision; type II error may miss true syndemics or understate the number of interacting epidemics. Authors counter that nearly half of reviewed studies could fit saturated models by conventional rules.
- Stated: sum-score specifications impose strong assumptions (e.g., equal main effects or zero two-way interactions) that are rarely justified by theory.
- Evident from text: no new data are analyzed; the illustration is hypothetical and the critique relies on prior review and selected examples, so the recommendations are not empirically validated here.
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Claims the paper makes
36 Own interpretation · 18 Not checked yet
In the paper
“Most studies that have been conducted with the expressed aim of generating empirical support for the theory of syndemics have not operationalized the concept of disease interaction in a way that actually supports the theory’s predictions about mutually enhancing epidemics [11].”
§ Syndemics and health disparities: a methodological note > Introduction
What the sources say
- Not checked yetcites [11] Tsai AC, Burns BFO. Syndemics of psychosocial problems and HIV risk: a systematic review of empirical tests of the disease interaction concept. Soc Sci Med. 2015;139(1):26–35. source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
None of the sources cited for this claim have been checked yet.
In the paper
“While psychosocial and structural problems commonly and undoubtedly do cluster among vulnerable populations [5,6]”
§ Syndemics and health disparities: a methodological note > Introduction
What the sources say
- Not checked yetcites [5] Farmer P, Lindenbaum S, Good MJ. Women, poverty and AIDS: an introduction. Cult Med Psychiatry. 1993;17(4):387–97. source
- Not checked yetcites [6] Farmer P. Women, poverty, and AIDS. In: Farmer P, Connors M, Simmons J, editors. Women, poverty and AIDS: sex, drugs, and structural violence. Monroe: Common Courage Press; 1996. p. 3–38.
boostedcorrelational- Asserted: passes — The authors put it forward as true.
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- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“it becomes apparent that b8 does not provide evidence of synergy but rather simply encodes the assumptions that that β1 = β2 = β3.”
§ Syndemics and health disparities: a methodological note > Dominant Approaches to Modeling in the Literature on Syndemics
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It is worth noting that if b9 and b10 are estimated to be close to zero and b11 is positive and statistically significant, then the results obtained using Eq. (5) are identical to those that would be obtained using Eq. (2) when b1, b2, b3, b4, b5, and b6 are estimated to be close to zero, and b7 is positive and statistically significant.”
§ Syndemics and health disparities: a methodological note > Dominant Approaches to Modeling in the Literature on Syndemics
hedged- Asserted: passes — The authors put it forward as true.
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- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: unclear — It is unclear why the paper says it holds.
In the paper
“The sum score approach to modeling, which currently dominates the literature [11], does not generate estimates with clear programmatic implications for public health policy to address syndemics.”
§ Syndemics and health disparities: a methodological note > The Public Health Case for Analytical Clarity
What the sources say
- Not checked yetcites [11] Tsai AC, Burns BFO. Syndemics of psychosocial problems and HIV risk: a systematic review of empirical tests of the disease interaction concept. Soc Sci Med. 2015;139(1):26–35. source
boosted- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
In the paper
“As summarized by Tsai & Burns [11], most studies in the syndemics literature have not subjected their data to the empirical test described in Eq. (2).”
§ Syndemics and health disparities: a methodological note > Dominant Approaches to Modeling in the Literature on Syndemics
What the sources say
- Not checked yetcites [11] Tsai AC, Burns BFO. Syndemics of psychosocial problems and HIV risk: a systematic review of empirical tests of the disease interaction concept. Soc Sci Med. 2015;139(1):26–35. source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
None of the sources cited for this claim have been checked yet.
In the paper
“which is itself independently associated with HIV risk [23,24]”
§ Syndemics and health disparities: a methodological note > Modeling Interactions between Co-Occurring Psychosocial and Structural Problems
What the sources say
- Not checked yetcites [23] Tsai AC, Subramanian SV. Proximate context of gender-unequal norms and women’s HIV risk in sub-Saharan Africa. AIDS. 2012;26(3):381–6. source
- Not checked yetcites [24] Jewkes RK, Dunkle K, Nduna M, Shai N. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Lancet. 2010;376(9734):41–8. source
plaincorrelational- Asserted: passes — The authors put it forward as true.
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- Load-bearing: passes — The paper’s conclusions depend on it.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“If, for example, b1, b2, and b4 are positive and statistically significant, then one could achieve some degree of HIV risk reduction by implementing a food security intervention in isolation, even if violence and mental illness continued unabated.”
§ Syndemics and health disparities: a methodological note > Modeling Interactions between Co-Occurring Psychosocial and Structural Problems
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“If b1, b2, and b3 (i.e., the estimates of β1, β2, and β3) are positive and statistically significant, then maximizing HIV risk reduction in this population would require addressing violence, food insecurity, and mental illness -- either through three separate interventions or through a single multi-component intervention.”
§ Syndemics and health disparities: a methodological note > Modeling Interactions between Co-Occurring Psychosocial and Structural Problems
hedgeddirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Thus, when b1, b2, and b3 are positive, the estimated coefficient on the sum score covariate (b8) in Eq. (4) will also be positive, as the implied effect on Y increases as each additional psychosocial and/or structural problem is added to the model.”
§ Syndemics and health disparities: a methodological note > Dominant Approaches to Modeling in the Literature on Syndemics
hedgeddirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“More flexibly specifying the sum score as a categorical variable does not resolve this problem or other ambiguities.”
§ Syndemics and health disparities: a methodological note > Dominant Approaches to Modeling in the Literature on Syndemics
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
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In the paper
“Tsai & Burns [11] showed that nearly half of the studies included in their review would have permitted fully saturated regression models given the sample sizes and conventional rules of thumb.”
§ Syndemics and health disparities: a methodological note > Addressing Concerns about Sample Size
What the sources say
- Not checked yetcites [11] Tsai AC, Burns BFO. Syndemics of psychosocial problems and HIV risk: a systematic review of empirical tests of the disease interaction concept. Soc Sci Med. 2015;139(1):26–35. source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“But this finding also implies that a food security intervention administered in isolation would have a greater impact on reducing HIV risk if provided to women experiencing intimate partner violence compared with a food security intervention provided to women not experiencing violence.”
§ Syndemics and health disparities: a methodological note > The Public Health Case for Analytical Clarity
hedgeddirect- Asserted: passes — The authors put it forward as true.
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- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“However, Eq. (5) still imposes a number of strong assumptions on several of the product terms in Eq. (2), namely that β4 = β5 = β6 = 0.”
§ Syndemics and health disparities: a methodological note > Dominant Approaches to Modeling in the Literature on Syndemics
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Investigators may also falsely conclude that a syndemic consists of the co-occurrence and synergistic interaction of fewer epidemics than is actually the case.”
§ Syndemics and health disparities: a methodological note > Addressing Concerns about Sample Size
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
In the paper
“The issue of statistical imprecision is exacerbated by potential collinearity between the psychosocial and structural problems of interest (which is likely to occur given the very hypothesis motivating research on syndemics, i.e., that these problems frequently co-occur) [11].”
§ Syndemics and health disparities: a methodological note > Addressing Concerns about Sample Size
What the sources say
- Not checked yetcites [11] Tsai AC, Burns BFO. Syndemics of psychosocial problems and HIV risk: a systematic review of empirical tests of the disease interaction concept. Soc Sci Med. 2015;139(1):26–35. source
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“But such an interpretation of the coefficient in our hypothetical example would be inconsistent with the data-generating process (which is known with certainty in this example to be additive).”
§ Syndemics and health disparities: a methodological note > Dominant Approaches to Modeling in the Literature on Syndemics
hedged- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The optimal strategy should depend on their causal structure.”
§ Syndemics and health disparities: a methodological note > The Public Health Case for Analytical Clarity
plainconditional- Asserted: passes — The authors put it forward as true.
- Checkable: unclear — It is unclear whether it could be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
In the paper
“Among the 40 studies included in the systematic review by Tsai & Burns [11], 27 (68%) demonstrated the co-occurrence of psychosocial and structural problems using one of these representations.”
§ Syndemics and health disparities: a methodological note > Modeling Interactions between Co-Occurring Psychosocial and Structural Problems
What the sources say
- Not checked yetcites [11] Tsai AC, Burns BFO. Syndemics of psychosocial problems and HIV risk: a systematic review of empirical tests of the disease interaction concept. Soc Sci Med. 2015;139(1):26–35. source
boostedcorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
In the paper
“Evidence from a variety of contexts worldwide suggests, for example, that food insecurity is associated with HIV risk among women [22]”
§ Syndemics and health disparities: a methodological note > Modeling Interactions between Co-Occurring Psychosocial and Structural Problems
What the sources say
- Not checked yetcites [22] Weiser SD, Leiter K, Bangsberg DR, et al. Food insufficiency is associated with high-risk sexual behavior among women in Botswana and Swaziland. PLoS Med. 2007;4(10):1589–97 discussion 1598. source
hedgedcorrelational- Asserted: passes — The authors put it forward as true.
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- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Therefore, if evidence in support of additivity is being sought, there is no mathematical reason to prefer Eqs. (4) or (5) over Eq. (1).”
§ Syndemics and health disparities: a methodological note > Dominant Approaches to Modeling in the Literature on Syndemics
plain- Asserted: passes — The authors put it forward as true.
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None of the sources cited for this claim have been checked yet.
In the paper
“First, Eq. (2) can be fitted subject to linear equality restrictions, which would reduce the number of parameters to be estimated [56,57].”
§ Syndemics and health disparities: a methodological note > Addressing Concerns about Sample Size
What the sources say
- Not checked yetcites [56] Durbin J. A note on regression when there is extraneous information about one of the coefficients. J Am Stat Assoc. 1953;48(264):799–808. source
- Not checked yetcites [57] Chipman JS, Rao MM. The treatment of linear restrictions in regression analysis. Econometrica. 1964;32(1–2):198–209. source
plaindirect- Asserted: passes — The authors put it forward as true.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“However, an intervention to enhance food security would be predicted to have a greater preventive impact if bundled with an intervention to reduce violence than would otherwise be predicted by Eq. (1) where no synergistic effects are observed.”
§ Syndemics and health disparities: a methodological note > Modeling Interactions between Co-Occurring Psychosocial and Structural Problems
hedgedconditional- Asserted: passes — The authors put it forward as true.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Interaction terms that are not statistically significant may leave investigators unable to precisely identify syndemics that truly exist.”
§ Syndemics and health disparities: a methodological note > Addressing Concerns about Sample Size
hedgedconditional- Asserted: passes — The authors put it forward as true.
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In the paper
“Instead, in 31 of the 40 studies (78%) reviewed, the analysis was based on an ordinal variable created as follows: (3)X4=∑i=13Xi”
§ Syndemics and health disparities: a methodological note > Dominant Approaches to Modeling in the Literature on Syndemics
What the sources say
- Not checked yetcites [11] Tsai AC, Burns BFO. Syndemics of psychosocial problems and HIV risk: a systematic review of empirical tests of the disease interaction concept. Soc Sci Med. 2015;139(1):26–35. source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Probably not a substantial claim. 20
- It may state two separate claims as one. 15
None of the sources cited for this claim have been checked yet.
In the paper
“In Singer’s [1–3] theory of syndemics, diseases are hypothesized to co-occur in particular temporal or geographical contexts due to harmful social conditions (disease concentration) and to interact at the level of populations and individuals, with mutually enhancing deleterious consequences for HIV risk (disease interaction).”
§ Syndemics and health disparities: a methodological note > Introduction
What the sources say
- Not checked yetcites [1] Singer M. AIDS and the health crisis of the U.S. urban poor; the perspective of critical medical anthropology. Soc Sci Med. 1994;39(7):931–48. source
- Not checked yetcites [2] Singer M. A dose of drugs, a touch of violence, a case of AIDS: conceptualizing the SAVA syndemic. Free Inq Creat Sociol. 1996;24(2):99–110.
- Not checked yetcites [3] Singer M. A dose of drugs, a touch of violence, a case of AIDS, part 2: further conceptualizing the SAVA syndemic. Free Inq Creat Sociol. 2006;34(1):39–53.
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“it remains unclear whether they co-occur independently, whether they co-occur and are mutually enhancing (i.e., interact with each other), or whether they co-occur and are mutually causal (i.e., cause each other).”
§ Syndemics and health disparities: a methodological note > Introduction
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper may give no reason why it holds. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Since its original elaboration more than 20 years ago, the epidemiological literature on syndemics can best be characterized as following a problematic trajectory.”
§ Syndemics and health disparities: a methodological note > Introduction
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. It may be too vague to check against evidence. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Stated simply, sum scores can help to demonstrate that being subjected to multiple psychosocial and structural problems is associated with adverse health outcomes -- not that they interact with each other to worsen health outcomes.”
§ Syndemics and health disparities: a methodological note > Dominant Approaches to Modeling in the Literature on Syndemics
plaincorrelational- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Recommendations of this nature, however, are rarely issued in the syndemics literature, perhaps owing to the empirical ambiguities described above.”
§ Syndemics and health disparities: a methodological note > The Public Health Case for Analytical Clarity
hedged- Asserted: passes — The authors put it forward as true.
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- Load-bearing: fails — The paper’s conclusions may not depend on it.
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Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“While concerns about type II error are valid, they may be overstated.”
§ Syndemics and health disparities: a methodological note > Addressing Concerns about Sample Size
hedged- Asserted: passes — The authors put it forward as true.
- Checkable: unclear — It is unclear whether it could be checked against evidence.
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It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Failure to reject the null could support the use of the more restricted specification. However, rejection of the null would speak to important differences in the lower-order product terms that are obfuscated in Eq. (5), and researchers would still be provided with valuable information about the true underlying structure of the model.”
§ Syndemics and health disparities: a methodological note > Addressing Concerns about Sample Size
hedged- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Such analyses demonstrate that psychosocial and structural problems co-occur in at-risk populations -- thereby supporting one aspect of the theory of syndemics -- but do not necessarily implicate synergy or mutual causality.”
§ Syndemics and health disparities: a methodological note > Modeling Interactions between Co-Occurring Psychosocial and Structural Problems
boostedcorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“If the primary analytic objective is to provide evidence of disease interaction, then Eq. (2) should be used, because it is the only specification that fully and flexibly conveys important information about how syndemic problems interact to worsen HIV risk.”
§ Syndemics and health disparities: a methodological note > Recommendations
boosteddirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
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Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“To summarize, the sum score conveys very little information about the theory of syndemics: given a known data-generating process that explicitly excludes the possibility of interactions between the covariates, the estimated coefficient b8 on the sum score in Eq. (4) can nonetheless be positive and statistically significant.”
§ Syndemics and health disparities: a methodological note > Dominant Approaches to Modeling in the Literature on Syndemics
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Third, even if valid concerns persist about statistical power to reject the null hypothesis for any specific regression coefficient, researchers could still estimate Eq. (2) while employing joint significance tests to determine whether some of the product terms are collectively important.”
§ Syndemics and health disparities: a methodological note > Addressing Concerns about Sample Size
hedged- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The manner in which they interact (or not) has implications for the types of interventions needed to reduce HIV risk, and whether these interventions necessarily need to be bundled to maximize their effectiveness.”
§ Syndemics and health disparities: a methodological note > Modeling Interactions between Co-Occurring Psychosocial and Structural Problems
plainconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Because the effects of these co-occurring epidemics are simply additive, Eq. (1) does not implicate a syndemic: all three epidemics need not be addressed jointly in order to reduce HIV risk.”
§ Syndemics and health disparities: a methodological note > Modeling Interactions between Co-Occurring Psychosocial and Structural Problems
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Second, if syndemic problems actually do interact in ways that synergistically elevate HIV risk, but Eqs. (4) and (5) continue to dominate the literature, then the field is missing critical opportunities to identify these synergies and support the development of appropriately targeted interventions.”
§ Syndemics and health disparities: a methodological note > The Public Health Case for Analytical Clarity
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. It may state two separate claims as one.
In the paper
“When b9, b10, and b11 are positive and statistically significant, and b11 > b10 > b9, this pattern of estimates is also interpreted as evidence of “additive interplay” (p.941) between psychosocial and structural problems that magnifies vulnerability to HIV risk [30].”
§ Syndemics and health disparities: a methodological note > Dominant Approaches to Modeling in the Literature on Syndemics
What the sources say
- Not checked yetcites [30] Stall R, Mills TC, Williamson J, et al. Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. Am J Public Health. 2003;93(6):939–42. source
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
None of the sources cited for this claim have been checked yet.
In the paper
“Second, researchers can group some of the variables into broader clusters (e.g., mental health, socioeconomic, etc) [32,63], especially for variables whose correlation approaches unity [64]. This maneuver can reduce the number of parameters to be estimated in Eq. (2).”
§ Syndemics and health disparities: a methodological note > Addressing Concerns about Sample Size
What the sources say
- Not checked yetcites [32] Sameroff AJ, Seifer R, Barocas R, Zax M, Greenspan S. Intelligence quotient scores of 4-year-old children: social-environmental risk factors. Pediatrics. 1987;79(3):343–50. source
- Not checked yetcites [63] Friedman EM, Montez JK, Sheehan CM, Guenewald TL, Seeman TE. Childhood adversities and adult cardiometabolic health: does the quantity, timing, and type of adversity matter? J Aging Health. 2015;27(8):1311–38. source
- Not checked yetcites [64] Arata CM, Langhinrichsen-Rohling J, Bowers D, O’Brien N. Differential correlates of multi-type maltreatment among urban youth. Child Abuse Negl. 2007;31(4):393–415. source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“A critical point of departure, however, is that while b8 may provide important information about the effects of cumulative adversities, it does not provide information about synergistic interactions between these adversities.”
§ Syndemics and health disparities: a methodological note > Dominant Approaches to Modeling in the Literature on Syndemics
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Eq. (5) may, under certain conditions, provide more information than Eq. (4), but the strong assumptions required of the data suggest Eq. (2) is still to be preferred.”
§ Syndemics and health disparities: a methodological note > Recommendations
hedged- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Eq. (4) cannot convey meaningful information about interactive effects and should be abandoned entirely in the literature on syndemics.”
§ Syndemics and health disparities: a methodological note > Recommendations
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“A close reading of Singer’s [1–3] work yields an understanding in which Eq. (2) should be regarded as the preferred approach to empirical modeling in this literature”
§ Syndemics and health disparities: a methodological note > The Public Health Case for Analytical Clarity
What the sources say
- Not checked yetcites [1] Singer M. AIDS and the health crisis of the U.S. urban poor; the perspective of critical medical anthropology. Soc Sci Med. 1994;39(7):931–48. source
- Not checked yetcites [2] Singer M. A dose of drugs, a touch of violence, a case of AIDS: conceptualizing the SAVA syndemic. Free Inq Creat Sociol. 1996;24(2):99–110.
- Not checked yetcites [3] Singer M. A dose of drugs, a touch of violence, a case of AIDS, part 2: further conceptualizing the SAVA syndemic. Free Inq Creat Sociol. 2006;34(1):39–53.
plain- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“With the strong assumption of no observed confounding, which is commonly and implicitly invoked in this literature, this regression model estimates the causal relationship between the psychosocial and structural problems and HIV risk.”
§ Syndemics and health disparities: a methodological note > Modeling Interactions between Co-Occurring Psychosocial and Structural Problems
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“As is apparent in the equations above, these linear restrictions simply encode the assumptions that already predominate in the syndemics literature but which should be formally motivated on the basis of conceptual considerations or previously published empirical work.”
§ Syndemics and health disparities: a methodological note > Addressing Concerns about Sample Size
plain- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
In the paper
“Moreover, his own work specifically excludes the sum score specification as an adequate test of his theory.”
§ Syndemics and health disparities: a methodological note > The Public Health Case for Analytical Clarity
What the sources say
- Not checked yetcites [39] Singer M, Clair S. Syndemics and public health: reconceptualizing disease in bio-social context. Med Anthropol Q. 2003;17(4):423–41. source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“However, these assumptions are unnecessary because they can be empirically proven (or disproven) using Eq. (1) to show that b1 = b2 = b3.”
§ Syndemics and health disparities: a methodological note > Dominant Approaches to Modeling in the Literature on Syndemics
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Demonstrating the joint statistical significance of a series of two- or three-way product terms could provide concrete evidence to motivate the need for studies with larger sample sizes.”
§ Syndemics and health disparities: a methodological note > Addressing Concerns about Sample Size
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence.
In the paper
“As noted by Stall et al. [55], small sample sizes may preclude full elucidation of all of the interaction effects in Eq. (2), potentially resulting in wide confidence intervals for the parameters of interest.”
§ Syndemics and health disparities: a methodological note > Addressing Concerns about Sample Size
What the sources say
- Not checked yetcites [55] Stall R, Coulter RWS, Friedman MR, Plankey MW. Commentary on “Syndemics of psychosocial problems and HIV risk: a systematic review of empirical tests of the disease interaction concept” by A. Tsai and B. Burns. Soc Sci Med. 2015;145(1):129–31. source
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“When b8 is positive and statistically significant, the data are interpreted as demonstrating “interplay” (p.1269) between the psychosocial and structural problems [28].”
§ Syndemics and health disparities: a methodological note > Dominant Approaches to Modeling in the Literature on Syndemics
What the sources say
- Not checked yetcites [28] Biello KB, Colby D, Closson E, Mimiaga MJ. The syndemic condition of psychosocial problems and HIV risk among male sex workers in Ho Chi Minh City, Vietnam. AIDS Behav. 2014;18(7):1264–71. source
boostedcorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The answer to this question remains unanswered by Eqs. (4) and (5).”
§ Syndemics and health disparities: a methodological note > The Public Health Case for Analytical Clarity
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“That is, because the main effects are all null, public health interventions designed to eliminate the syndemic of X1, X2, and X3 are perfect complements -- implying that no single intervention would be effective if implemented in isolation.”
§ Syndemics and health disparities: a methodological note > Modeling Interactions between Co-Occurring Psychosocial and Structural Problems
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
The cited source doesn’t support the claim as written.
In the citing paper
“Tsai and Venkataramani 19 showed, for example, that one of the most commonly employed specifications in the literature essentially encodes an assumption that epidemics A and B have null main effects and exert a joint effect on the HIV epidemic only when both A and B are present.”
From Co-occurring epidemics, syndemics, and population health (2017) · cites this paper as [19]
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredThe cited source doesn’t support the claim as written.
In the citing paper
“while simultaneously becoming more accurate in its representations and increasingly discarding the uninformative19 language of “additive associations.””
From Co-occurring epidemics, syndemics, and population health (2017) · cites this paper as [19]
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Unfortunately, use of conventional methods to test models of synergistic disease interaction or the effectiveness of multicomponent interventions can encounter intractable difficulties due to the resource demands of full factorial study designs (Tsai & Burns, 2015; Tsai & Venkataramani, 2016).”
From Syndemics: a theory in search of data or data in search of a theory? (2018) · cites this paper as Tsai & Venkataramani, 2016
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Tsai and Burns (2015) and Tsai and Venkataramani (2016) demonstrated that researchers in this literature have not successfully accomplished what they set out to achieve”
From Syndemic theory, methods, and data (2022) · cites this paper as Tsai and Venkataramani (2016)
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
In the citing paper
“While helpful, in some instances, for understanding the health effects of cumulative adversities, the sum score sheds light on the co-dynamics of neither interaction nor mutual causality.19”
From Co-occurring epidemics, syndemics, and population health (2017) · cites this paper as [19]
The cited source says what the claim attributes to it.
In the citing paper
“Tsai and Venkataramani 19 then explored the implicit assumptions embedded in the sum score approach, highlighting the consequential ways in which programme implementers and public health policymakers might be led astray in their efforts to counter the large-scale forces leading to concentrated health disadvantage.”
From Co-occurring epidemics, syndemics, and population health (2017) · cites this paper as [19]
The cited source says what the claim attributes to it.
In the citing paper
“A second gap in the literature is occasioned by a major critique of the field -that summing up the associations across variables being used as proxies for syndemics tends to overlook the central tenet of syndemic theory: interaction (Tsai and Burns, 2015; Tsai and Venkataramani, 2016).”
From Syndemic theory, methods, and data (2022) · cites this paper as Tsai and Venkataramani, 2016
The cited source says what the claim attributes to it.
In the citing paper
“It can be shown mathematically that the sum score specification conveys no information about the extent to which the candidate health risks interact (Tsai & Venkataramani, 2016).”
From Syndemics: a theory in search of data or data in search of a theory? (2018) · cites this paper as Tsai & Venkataramani, 2016
The cited source says what the claim attributes to it.
In the citing paper
“that fitting a regression model using the sum score specification can yield a statistically significant estimate consistent with a data-generating process characterized by no interactions between the exposures of interest.”
From Syndemics: a theory in search of data or data in search of a theory? (2018) · cites this paper as Tsai & Venkataramani, 2016
The cited source says what the claim attributes to it.
In the citing paper
“Most of these analyses included the number of exposures as a cumulative count to predict HIV transmission risk, a specification that requires implausible assumptions for interpretation and which has little to do with the interaction concept embedded in syndemic theory (Tsai & Venkataramani, 2016).”
From The syndemic of violence victimisation, drug use, frequent alcohol use, and HIV transmission risk behaviour among men who have sex with men: Cross-sectional, population-based study in India (2019) · cites this paper as Tsai & Venkataramani, 2016
In the citing paper
“Foremost, our findings provide further support for Tsai and colleagues’ (Tsai and Burns 2015, Tsai and Venkataramani 2016, Tsai, Mendenhall et al. 2017) argument that synergy cannot be assumed based on a cumulative relationship of the number of syndemic conditions and sexual risk behaviors and that additional methods are necessary to formally evaluate the presence of synergistic interaction.”
From Is there synergy in syndemics? Psychosocial conditions and sexual risk among men who have sex with men in India (2018) · cites this paper as Tsai and Venkataramani 2016
In the citing paper
“In contrast, however, Tsai and Burns (2015) and Tsai and Venkataramani (2016) point out that such a linear pattern suggests additive effects, but does not support substantial synergistic interactions.”
From Is there synergy in syndemics? Psychosocial conditions and sexual risk among men who have sex with men in India (2018) · cites this paper as Tsai and Venkataramani (2016)
In the citing paper
“The authors note that most papers rely on summing the total number of syndemic conditions of individuals (Tsai & Burns, 2015), a technique that is insufficient to demonstrate disease interaction or synergistic effects (Tsai, 2018; Tsai & Venkataramani, 2016).”
From Gendered syndemic of intimate partner violence, alcohol misuse, and HIV risk among peri-urban, heterosexual men in South Africa (2022) · cites this paper as Tsai & Venkataramani, 2016
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ Syndemics and health disparities: a methodological note > Dominant Approaches to Modeling in the Literature on Syndemics
“By construction, X4,n=1 + X4,n=2 + X4,n=3 = 1.”
§ Syndemics and health disparities: a methodological note > Dominant Approaches to Modeling in the Literature on Syndemics
“with 0 problems serving as the reference category”
Citations
Cites
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Comorbidity measures for use with administrative data.
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Mostly Harmless Econometrics: An Empiricist's Companion
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Research works printed but not linked: 3
- Batchelder AB. Psychosocial syndemics of women living with and at-risk for HIV/AIDS (dissertation). New York: Yeshiva University; 2012.
- Ashenfelter O, Haveman RH, Riley JG, Taylor JT. Editorial statement. Am Econ Rev. 1986;76(4):v.
- Bernanke BS. Editorial statement. Am Econ Rev. 2004;94(1):404.
Cited by
Sorted by citations
Global Epidemiology of HIV Infection and Related Syndemics Affecting Transgender People
Poteat, T., Scheim, A. I., Xavier, J. M., Reisner, S. L., & Baral, S. (2016) · JAIDS Journal of Acquired Immune Deficiency Syndromes · doi:10.1097/qai.0000000000001087 · Cited by 400
Systemic racism, chronic health inequities, and COVID ‐19: A syndemic in the making?
Gravlee, C. C. (2020) · American Journal of Human Biology · doi:10.1002/ajhb.23482 · Cited by 390
Co-occurring epidemics, syndemics, and population health
Tsai, A. C., Mendenhall, E., Trostle, J. A., & Kawachi, I. (2017) · The Lancet · doi:10.1016/s0140-6736(17)30403-8 · Cited by 268
Self-citationSyndemics: a theory in search of data or data in search of a theory?
Tsai, A. C. (2018) · Social Science & Medicine · doi:10.1016/j.socscimed.2018.03.040 · Cited by 197
Self-citationWhither syndemics?: Trends in syndemics research, a review 2015–2019
Singer, M., Bulled, N., & Ostrach, B. (2020) · Global Public Health · doi:10.1080/17441692.2020.1724317 · Cited by 133
Metadata
- Authors
- Tsai, A. C., & Venkataramani, A. S.
- Affiliations
- Harvard University (US)
- Corresponding author
- Tsai, Alexander C.
- Venue
- AIDS and Behavior
- Published
- 2015-12-12
- Volume
- 20
- Issue
- 2
- Pages
- 423-430
- ISSN
- 1090-7165 (ISSN-L)
- 1573-3254
- PMC
- PMC4755906
- OpenAlex
- W2191960283
- Cited by
- 176
- References
- 67
- Citations by year
- 2026: 11 · 2025: 17 · 2024: 25 · 2023: 15 · 2022: 27 · 2021: 22 · 2020: 23 · 2019: 10 · 2018: 10 · 2017: 6 · 2016: 3
- FWCI
- 4.90
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- AIDS and Behavior (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (K23MH096620)
- Topics
- Health Sciences › Medicine › Infectious Diseases › HIV/AIDS Research and Interventions
- Health Sciences › Medicine › Epidemiology › HIV, Drug Use, Sexual Risk
- Social Sciences › Health › Health disparities and outcomes
- Keywords
- syndemic, health disparities, disease interaction, HIV risk, regression model specification, social conditions, epidemic modeling, public health implications
- MeSH terms
- Public Health, Regression Analysis, Social Environment, Social Problems, HIV Infections, Health Status Disparities
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