Co-occurring epidemics, syndemics, and population health
Open accessAbstract
As originally theorised, three concepts underlie the notion of a syndemic: disease concentration, disease interaction, and the large-scale social forces that give rise to them. What makes the theory notable are its predictions about how interactions between epidemics amplify disease burden and about how public health planners can (or cannot) effectively intervene to mitigate this burden. The literature on syndemics is critically reviewed and key concepts for measuring effects on population health, including mutual causality, are introduced.
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Claims the paper makes
21 of 47 cited sources checked · 12 supported · 2 flagged · accuracy not yet measured
- Premisecitation
One commonly used specification in the literature encodes an assumption that epidemics A and B have no main effects and affect HIV jointly only when both are present.
“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.”
Quote in the paperSubstantial claim1 of 1 sources checked- cites [19] Tsai, 2016, Syndemics and health disparities: a methodological note, AIDS Behav source
In “Dominant Approaches to Modeling in the Literature on Syndemics” (page unavailable), the paper says the commonly used sum-score specification encodes equal main effects, not null ones, and can produce a positive coefficient without any interaction. It says a different, categorical specification implies an effect only when all problems are present if its coefficients for one or two problems are estimated near zero; that is a conditional result, not an assumption encoded by the specification. (LLM, conf=0.86)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measured
- Premisecitation
Researchers and programme implementers using syndemic theory rarely advocate single-component interventions; multi-component calls are the norm.
“Yet researchers and programme implementers drawing on the theory of syndemics rarely, if ever, advocate for single-component interventions; rather, calls for multi-component interventions are typically the norm.11–13”
Quote in the paperSubstantial claim1 of 3 sources checked- cites [11] Operario, 2010, HIV in transgender communities: syndemic dynamics and a need for multicomponent interventions, J Acquir Immune Defic Syndr source
In “Not Just Testing and Condoms: Need for Multicomponent Interventions,” the paper calls multicomponent interventions necessary for HIV prevention in transgender communities and says several recent papers have called for them. It does not establish that researchers and programme implementers using syndemic theory generally rarely advocate single-component interventions or that multicomponent calls are the norm across the field. (LLM, conf=0.85)
Experimental — accuracy not yet measured - cites [12] Li, 2016, Psychosocial syndemic associated with increased suicidal ideation among men who have sex with men in Shanghai, China, Health Psychol source
- cites [13] Chakrapani, 2017, Syndemics of depression, alcohol use, and victimisation, and their association with HIV-related sexual risk among men who have sex with men and transgender women in India, Glob Public Health source
- Premisecitation
In HIV treatment and prevention, appeals to syndemic theory are almost universally used to justify calls for complex, integrated, or multi-component interventions that target all co-occurring epidemics together.
“In the field of HIV treatment and prevention, appeals to the theory of syndemics are near-universally used to justify calls for complex, integrated and/or multi-component interventions targeting all of the co-occurring epidemics in concert.11–13”
Quote in the paperSubstantial claim1 of 3 sources checked- cites [11] Operario, 2010, HIV in transgender communities: syndemic dynamics and a need for multicomponent interventions, J Acquir Immune Defic Syndr source
The “Not Just Testing and Condoms” section uses syndemic analysis to call for multicomponent HIV prevention interventions addressing interacting problems in transgender communities (page not provided). It does not establish that such appeals are near-universal across HIV treatment and prevention, or that interventions must target every co-occurring epidemic. (LLM, conf=0.88)
Experimental — accuracy not yet measured - cites [12] Li, 2016, Psychosocial syndemic associated with increased suicidal ideation among men who have sex with men in Shanghai, China, Health Psychol source
- cites [13] Chakrapani, 2017, Syndemics of depression, alcohol use, and victimisation, and their association with HIV-related sexual risk among men who have sex with men and transgender women in India, Glob Public Health source
- Interpretationcitation
The sum score does not illuminate either interaction or mutual causality.
“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”
Quote in the paperSubstantial claim1 of 1 sources checked- cites [19] Tsai, 2016, Syndemics and health disparities: a methodological note, AIDS Behav source
- Findingcitation
Most studies have used an empirical specification like the sum score of exposures common in childhood adversity research.
“Rather, the overwhelming majority of studies14 have employed an empirical specification similar to that which has predominated in the literature on childhood adversity, i.e., a sum score of exposures.15–18”
Quote in the paperSubstantial claim3 of 5 sources checked- cites [14] Tsai, 2015, Syndemics of psychosocial problems and HIV risk: a systematic review of empirical tests of the disease interaction concept, Soc Sci Med source
- cites [15] Sameroff, 1987, Intelligence quotient scores of 4-year-old children: social-environmental risk factors, Pediatrics source
- cites [16] Turner, 1995, Lifetime traumas and mental health: the significance of cumulative adversity, J Health Soc Behav source
- cites [17] Felitti, 1998, Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study, Am J Prev Med source
- cites [18] Montez, 2014, Cumulative childhood adversity, educational attainment, and active life expectancy among US adults, Demography source
- Interpretationreasoning
When adverse structural conditions are reduced through economic or legislative changes, individual-level risk factors may matter less or may cease to matter entirely.
“And when these adverse structural conditions are mitigated through economic36 or legislative37, 38 changes, the individual-level risk factors might matter less or (in the extreme, e.g. in settings of perfect gender equality) might cease to matter entirely.”
Quote in the paperSubstantial claim2 of 3 sources checked- cites [36] Aizer, 2010, The gender wage gap and domestic violence, Am Econ Rev source
The Conclusion reports that narrowing the gender wage gap reduces violence against women, supporting the economic-change example. The paper does not examine whether individual-level risk factors become less important or cease to matter as structural conditions improve. The legislative-change citations are separate from this source. (LLM, conf=0.86)
Experimental — accuracy not yet measured - cites [37] Beaman, 2012, Female leadership raises aspirations and educational attainment for girls: a policy experiment in India, Science source
- cites [38] Beaman, 2009, Powerful women: does exposure reduce bias?, Q J Econ source
- Findingcitation
In the syndemics literature, large-scale social forces such as mass incarceration, gender-inequitable norms, the home foreclosure epidemic, and racial segregation may be discussed but have largely gone un-modeled.
“In the literature on syndemics, large-scale social forces like mass incarceration,41, 42 gender-inequitable norms,43 the home foreclosure epidemic,44 and racial segregation45 may be discussed but have largely gone un-modeled.”
Quote in the paperSubstantial claim2 of 4 sources checked- cites [41] Wildeman, 2009, Parental imprisonment, the prison boom, and the concentration of childhood disadvantage, Demography source
- cites [42] Johnson, 2009, The effect of male incarceration dynamics on AIDS infection rates among African-American women and men, J Law Econ source
- cites [43] Jewkes, 2002, Intimate partner violence: causes and prevention, Lancet source
- cites [44] Tsai, 2015, Home foreclosure, health, and mental health: a systematic review of individual, aggregate, and contextual associations, PLoS One source
The Introduction calls home foreclosure an epidemic, and the Discussion reports that all but five reviewed studies used data from only one level, supporting a narrower point about limited multilevel modeling of foreclosure and health. The paper does not assess the syndemics literature or establish that foreclosure has largely gone un-modeled in that literature. (LLM, conf=0.79)
Experimental — accuracy not yet measured
- Premisecitation
The field has largely studied how individual-level outcomes are explained by individual-level covariates.
“The field, however, has largely focused on investigating how individual-level outcomes can be explained by individual-level covariates.14”
- Also stated in: § Introduction · plain
“Although the theory of syndemics is principally a theory about population health, the past two decades’ worth of quantitative literature motivated by the theory has generally focused on studying individuals, rather than populations -- and consequently has had very little to say about population health.”
Quote in the paperSubstantial claim1 of 1 sources checked- cites [14] Tsai, 2015, Syndemics of psychosocial problems and HIV risk: a systematic review of empirical tests of the disease interaction concept, Soc Sci Med source
The Discussion (page unavailable) says the most common approach in the reviewed syndemics studies used a count of psychosocial problems to assess HIV-related outcomes. That supports an individual-level focus in this literature, but the review is limited to psychosocial problems and HIV risk; it does not establish the claim for a broader, unspecified field. (LLM, conf=0.78)
Experimental — accuracy not yet measured
- Rests on an assumption: Syndemic theory is principally a theory about population health.
- Also stated in: § Introduction · plain
- Findingnone given
Most quantitative studies that aim to test disease interaction in syndemic theory have used a specification that illuminates neither syndemic interactions nor mutually causal epidemics.
“Most quantitative studies that aim to test the disease interaction concept in the theory of syndemics have adopted an empirical specification that sheds light on neither syndemic interactions nor mutually causal epidemics.”
Quote in the paperSubstantial claim - Findingreasoning
The empirical basis for enthusiasm about multi-component interventions is limited.
“First, the empirical foundation underlying enthusiasm for multi-component interventions is limited.”
Quote in the paperSubstantial claim - Findingown data
The sum score was the most frequently used specification for testing disease interaction.
“The most frequently used specification to test the disease interaction concept was the sum score (57 [80%]).”
Quote in the paperNot a substantial claim - Findingreasoning
The disease interaction concept has received less empirical support in the literature than the other tenets of syndemic theory.
“Compared with the other tenets of the theory, the concept of disease interaction has received less empirical support in the literature, perhaps owing to its complexity.”
Quote in the paperNot a substantial claim - Findingown data
Although no formal interaction tests were used, sum-score studies were much more likely to use language about synergy or interaction.
“Although no formal tests of interaction were used, these studies were also much more likely to adopt language about “synergy” or “interaction”: 20/57 (35%) of these studies employed such language, compared to 0/14 (0%) of the others (χ2=6·84, P=0·009).”
Quote in the paperNot a substantial claim - Findingnone given
More recent studies in the literature have largely used a similar sum score approach.
“Studies in the literature published more recently have largely adopted a similar approach (Panel).”
Quote in the paperNot a substantial claim - Findingnone given
The quantitative syndemics literature is diversifying by including data on vulnerable populations and people in resource-limited settings outside the U.S.
“the quantitative literature on syndemics is diversifying -- incorporating data on vulnerable populations and those living in resource-limited settings outside of the U.S. -- while simultaneously becoming more accurate in its representations”
Quote in the paperNot a substantial claim - Findingown data
All included studies in the updated review used individual-level data.
“All of the included studies were based on data collected at the individual level (71 [100%]).”
Quote in the paperNot a substantial claim - Findingown data
Studies using the sum score were much more likely than studies using other specifications to describe their findings as showing additive associations between psychosocial problems and outcomes.
“Compared to studies that used other specifications (e.g., a product term in a multiplicative model), the studies that employed the sum score approach were much more likely to characterise their findings as demonstrating that psychosocial problems had “additive associations” with the outcomes of interest (28/57 [49%] vs. 1/14 [7%]; χ2=8·20, P=0·004).”
Quote in the paperSubstantial claim - Findingnone given
None of the included studies used ecological, multilevel, or experimental/quasi-experimental designs.
“None have been based on ecological, multilevel, or experimental/quasi-experimental study designs.”
Quote in the paperSubstantial claim - Interpretationcitation
There is an inconsistency between calls for multi-component interventions and the statistical models used to support those calls.
“Most striking is the inconsistency between the calls for multi-component interventions and the statistical models used to support such recommendations.”
Quote in the paperSubstantial claim - Interpretationreasoning
The disease concentration aspect is not the distinctive contribution of syndemic theory.
“This aspect of the theory of syndemics is not necessarily what makes its contribution distinctive.”
Quote in the paperSubstantial claim - Interpretationreasoning
A single-component intervention would likely have less preventive impact than a multi-component intervention.
“The preventive impact of the single-component intervention would likely be less than the impact of the multi-component intervention”
Quote in the paperNot a substantial claim - Interpretationreasoning
When epidemics are mutually causal, a single-component intervention targeting one epidemic would likely be ineffective because the other epidemics would continue to drive the targeted epidemic.
“It is true that, in the setting of mutually causal epidemics, single-component intervention strategies targeting a single epidemic would likely be ineffective, because the other epidemics ignored by the intervention would continue to exert their reciprocal, driving forces on the epidemic of focus.”
Quote in the paperSubstantial claim - Premisecitation
Enteric pathogens have multiple sufficient pathways to diarrhoea that may overlap and interact at multiple levels of analysis.
“Enteric pathogens, for example, have multiple sufficient pathways to diarrhoea that may overlap and interact at multiple levels of analysis.22–25”
Quote in the paperNot a substantial claim0 of 4 sources checked- cites [22] Wagner, 1958, Excreta disposal for rural areas and small communities, Monogr Ser World Health Organ source
- cites [23] Briscoe, 1984, Intervention studies and the definition of dominant transmission routes, Am J Epidemiol source
- cites [24] VanDerslice, 1995, Environmental interventions in developing countries: interactions and their implications, Am J Epidemiol source
- cites [25] Curtis, 2000, Domestic hygiene and diarrhoea—pinpointing the problem, Trop Med Int Health source
- Interpretationreasoning
If a syndemic involves synergistic epidemics that are not mutually causal, single-component interventions may be efficient and could have a greater impact on HIV than expected without synergy.
“On the other hand, if a syndemic is characterised by synergistically interacting epidemics that are not mutually causal, then there may be opportunities to implement efficient single-component interventions that could potentially have a greater impact on the HIV epidemic than would otherwise be expected if no synergy were present (Web Appendix Panel).”
Quote in the paperSubstantial claim - Interpretationnone given
Scenarios with multiple sufficient risk factors for disease are less rare than sufficient cause interactions.
“While there may be few examples of sufficient cause interactions in the literature on syndemics, less rare are scenarios in which there are multiple sufficient risk factors for disease.”
Quote in the paperNot a substantial claim - Interpretationreasoning
The individualistic fallacy causes the field to miss critical opportunities to understand how epidemics interact at both population and individual levels.
“The individualistic fallacy therefore leads the field to miss critical opportunities to understand how epidemics interact both at the level of populations and at the level of individuals.”
Quote in the paperSubstantial claim - Interpretationreasoning
Studies that ignore ecological interactions and focus only on individual-level risk factors within relatively homogeneous populations may wrongly conclude that individual-level interactions are the main determinants of disease.
“Studies that ignore interactions with ecological influences to focus exclusively on how individual-level risk factors interact to affect disease outcomes within relatively homogeneous populations may erroneously conclude that interactions between individual-level risk factors are the principal determinants of disease.”
Quote in the paperSubstantial claim - Interpretationreasoning
The omission of population-level studies has led the field away from investigating distal syndemic causes that, if eliminated, would offer greater potential for efficient prevention.
“because it has led the field away from investigating the distal syndemic causes that, if eliminated, hold even greater potential for efficient prevention strategies.”
Quote in the paperSubstantial claim
- Classified as probably not a substantial claim. 22
- May combine two claims. 11
Probably not a substantial claim: may not pass S3 (load-bearing).
FindingcitationThe quantitative syndemics literature is increasingly discarding the uninformative language of additive associations.
“while simultaneously becoming more accurate in its representations and increasingly discarding the uninformative19 language of “additive associations.””
Quote in the paperNot a substantial claim1 of 1 sources checked- cites [19] Tsai, 2016, Syndemics and health disparities: a methodological note, AIDS Behav source
The Recommendations section (page unavailable) explicitly recommends modeling additive associations when that is the research objective; it calls the sum-score approach uninformative for detecting interactions, not the language of additive associations uninformative in general. The section on dominant modeling approaches says sum-score analyses appeared in 31 of 40 studies reviewed, rather than showing that the literature was increasingly discarding them. (LLM, conf=0.84)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measured
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationWhen multiple sufficient pathways exist, multi-component interventions targeting all pathways together are necessary for effective diarrhoeal disease control.
“Under such conditions, multi-component intervention strategies targeting all of the pathways in concert are necessary for effective diarrhoeal disease control.26”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites [26] Eisenberg, 2007, Integrating disease control strategies: balancing water sanitation and hygiene interventions to reduce diarrheal disease burden, Am J Public Health source
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationTsai and Venkataramani examined the implicit assumptions in the sum score approach and showed how it could mislead programme implementers and policymakers.
“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.”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites [19] Tsai, 2016, Syndemics and health disparities: a methodological note, AIDS Behav source
May combine two claims.
PremisecitationPower imbalances within relationships and men's beliefs about gender roles are thought to be risk factors for violence against women.
“To take a specific example: power imbalances within relationships30, 31 and men’s beliefs about gender roles32 are thought to be risk factors for cases of violence against women.”
Quote in the paperNot a substantial claim3 of 3 sources checked- cites [30] Conroy, 2016, Relationship power and sexual violence among HIV-positive women in rural Uganda, AIDS Behav source
- cites [31] Hatcher, 2012, Sexual relationship power and depression among HIV-infected women in Rural Uganda, PLoS One sourceExperimental — accuracy not yet measured
- cites [32] Shannon, 2012, Gender inequity norms are associated with increased male-perpetrated rape and sexual risks for HIV infection in Botswana and Swaziland, PLoS One sourceExperimental — accuracy not yet measured
May combine two claims.
PremisecitationThese risk factors may be most likely to raise the risk of violence where women are structurally disadvantaged relative to men in land ownership and access to production, or where violence against women is normative.
“These risk factors might be most likely to elevate the risk of violence in settings where women are structurally disadvantaged, either by law or by tradition, relative to men in terms of land ownership and access to other factors of production,33 or in settings where violence against women is normative.34, 35”
Quote in the paperNot a substantial claim3 of 3 sources checked- cites [33] Heise, 2015, Cross-national and multilevel correlates of partner violence: an analysis of data from population-based surveys, Lancet Glob Health source
The Results and Discussion (page numbers unavailable in our copy) associate discrimination in women's access to land and property with higher partner-violence risk, supporting the description of structurally disadvantaged settings. They do not show that the unspecified risk factors in the citing sentence are more likely to elevate risk specifically in those settings. The normative-violence clause is attached to other citations, not this source. (LLM, conf=0.82)
Experimental — accuracy not yet measured - cites [34] Tsai, 2012, Proximate context of gender-unequal norms and women's HIV risk in sub-Saharan Africa, AIDS source
The citation to this paper is attached to the clause about settings where violence against women is normative, not the land-ownership clause. The Methods measure norms about wife-beating, and the Results and Discussion relate those norms to condom use, but no passage assesses whether the cited risk factors raise the risk of violence more in such settings. Searched for violence risk and structural disadvantage. (LLM, conf=0.72)
Experimental — accuracy not yet measured - cites [35] Tsai, 2013, Intimate partner violence and population mental health: why poverty and gender inequities matter, PLoS Med source
Probably not a substantial claim: may not pass S4 (based).
Findingnone givenThe authors are not aware of any examples of sufficient cause interaction in the syndemics literature.
“We are unaware of any such examples in the literature on syndemics.”
Quote in the paperNot a substantial claimMay combine two claims.
FindingreasoningSince its original formulation, syndemic theory has had little empirical support for either disease interaction or mutually causal epidemics.
“Since its original conceptualization, the theory of syndemics has received scant empirical support either for its concept of disease interaction or for the model of mutually causal epidemics.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Findingown dataThe updated systematic search identified 31 new studies to combine with the 40 studies from the original review.
“Of 87 records returned in the PubMed search, 23 met criteria for inclusion; of 119 records returned in the Google Scholar search, after excluding duplicates an additional 4 conference presentations, 2 journal articles, and 1 doctoral dissertation met criteria for inclusion. These 31 newly identified studies were combined with the 40 studies identified in the original systematic review”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataThe share of studies describing additive associations fell from 50% before the review to 29% after it, but the change was not statistically significant.
“Second, the percentage of studies describing “additive associations” has also declined (20/40 [50%] vs. 9/31 [29%]; χ2=3·18, P=0·08).”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Findingown dataThe share of studies based solely on U.S. data fell from 80% before the review to 68% after it, but the change was not statistically significant.
“First, the proportion of studies based solely on data collected in the U.S. has declined (32/40 [80%] vs. 21/31 [68%]; χ2=1·39, P=0·24).”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim. May combine two claims.
PremisecitationSuch response patterns may be considered a special case of the syndemic model in the left panel of the Figure and are often called sufficient cause interaction.
“Response patterns of this type might be considered a special case of the syndemic model in the left panel of the Figure and are often referred to as a “sufficient cause interaction.”20, 21”
Quote in the paperSubstantial claim0 of 2 sources checkedProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationIn one framing of syndemic interaction, the disease burden from combined health risks is greater than the sum of the burdens from each risk considered separately.
“At times, its framing language has focused specifically on interaction (or synergism): the disease burden attributable to health risks in combination exceeds the sum of the disease burden of the health risks when considered separately.9”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [9] Rothman, 1974, Synergy and antagonism in cause–effect relationships, Am J Epidemiol source
Probably not a substantial claim: may not pass S2 (checkable).
InterpretationreasoningThese findings reveal important methodological gaps in the literature.
“These findings illustrate important methodological gaps in the literature.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim. May combine two claims.
Interpretationnone givenThe two models of co-occurring epidemics imply different treatment or prevention strategies, but the distinction between them has largely been blurred.
“Notably, these two models imply different treatment or prevention strategies -- but the conceptual distinctions between the two have largely been blurred.”
Quote in the paperSubstantial claimClassified as probably not a substantial claim.
Premisenone givenDisease interaction means that co-occurring epidemics interact at population and individual levels, producing mutually worsening health consequences.
“The concept of disease interaction in the theory of syndemics holds that co-occurring epidemics interact at the level of populations and individuals, with mutually enhancing deleterious consequences for health.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationThe most highly cited summary of syndemic theory describes examples that use only the language of interaction.
“The most highly cited précis of the theory of syndemics10 describes numerous exemplars that draw exclusively on the language of interaction”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [10] Singer, 2003, Syndemics and public health: reconceptualizing disease in bio-social context, Med Anthropol Q source
Probably not a substantial claim: may not pass S3 (load-bearing).
Premisenone givenDisease concentration means that two or more epidemics occur together in particular times or places because of harmful social conditions.
“The concept of disease concentration holds that two or more epidemics co-occur in particular temporal or geographical contexts due to harmful social conditions.”
Quote in the paperNot a substantial claimMay combine two claims.
InterpretationreasoningSufficient cause interaction does not support a multi-component intervention targeting both epidemics A and B; instead, it suggests that a single-component intervention targeting either A or B would suffice.
“Moreover, the presence of sufficient cause interaction does not militate for a multi-component intervention targeting both epidemics A and B for effective HIV prevention. Rather it suggests the opposite: that a single-component intervention targeting either epidemic A or B would suffice (because if either exposure were to be eliminated then the outcome could not occur).”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Premisenone givenOther statements of syndemic theory use the language of mutual causality or bidirectionality.
“Other statements of the theory have instead adopted the language of mutual causality (or bidirectionality).”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S2 (checkable).
InterpretationreasoningThe conceptual basis for opposing single-component interventions does not necessarily follow from a close reading of syndemic theory.
“Second, the conceptual foundation underlying the bias against single-component interventions does not necessarily follow from a close reading of the theory of syndemics.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
PremisecitationThe original theory of syndemics rests on three ideas: disease clustering, disease interplay, and broad social forces.
“As originally theorised, three concepts underlie the notion of a syndemic: disease concentration, disease interaction, and the large-scale social forces that give rise to them.1, 2”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [1] Singer, 1996, A dose of drugs, a touch of violence, a case of AIDS: conceptualizing the SAVA syndemic, Free Inq Creative Sociol
Not checked in the free run.
- cites [2] Singer, 2011, Toward a critical biosocial model of ecohealth in southern Africa: the HIV/AIDS and nutrition insecurity syndemic, Ann Anthropol Pract source
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationThe canonical account of the triad of substance abuse, violence, and HIV emphasizes reciprocal causal pathways among these conditions.
“The canonical elaboration of the unhappy triad of substance abuse, violence, and HIV,1 for example, focuses on the ways in which substance abuse increases the risk of violence and HIV acquisition, violent victimisation increases the risk of HIV acquisition and begets further substance abuse, and persons with HIV are often subjected to violence”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [1] Singer, 1996, A dose of drugs, a touch of violence, a case of AIDS: conceptualizing the SAVA syndemic, Free Inq Creative Sociol
Not checked in the free run.
Classified as probably not a substantial claim.
PremisecitationSinger states that disease interaction occurs at both population and individual levels.
“For example, Singer 27 notes: “Recently, in our efforts to further delineate the concept of syndemic [sic], we have drawn attention to the fact that disease interaction occurs at both the population and individual levels” (p.39).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [27] Singer, 2006, A dose of drugs, a touch of violence, a case of AIDS, part 2: further conceptualizing the SAVA syndemic, Free Inq Creative Sociol
Not checked in the free run.
May combine two claims.
InterpretationcitationEven though individual-level risk factors are generally accepted as more proximate and more amenable to causal attribution, shifting attention to large-scale social forces could yield more efficient population-level prevention of syndemic disease burden.
“the field can achieve more efficient population-level prevention of the disease burden wrought by syndemics if attention is shifted toward eliminating the large-scale social forces that condition the distributions of individual-level risk factors or expedite their interaction and translation into diseased states.”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [39] Rose, 1985, Sick individuals and sick populations, Int J Epidemiol source
- cites [40] Rose, 1992
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
Probably not a substantial claim: may not pass S3 (load-bearing).
InterpretationreasoningThe force of the multi-component recommendation for diarrhoeal disease control does not depend on syndemic synergy.
“But the force of this programmatic recommendation is not contingent upon an appeal to syndemic synergy.”
Quote in the paperNot a substantial claimMay combine two claims.
InterpretationreasoningThe omission of population-level studies is significant and represents the individualistic fallacy.
“The omission of population-level studies is significant -- representative of the “individualistic fallacy”28, 29”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [28] Riley, 1963
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites [29] Diez-Roux, 1998, Bringing context back into epidemiology: variables and fallacies in multilevel analysis, Am J Public Health source
Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).
Premisenone givenAs theorised, syndemics are a complex, multilevel phenomenon.
“As theorised, syndemics are a complex, multilevel phenomenon.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
PremisecitationSyndemic theory, and especially its disease interaction concept, involves multiple levels of analysis.
“The theory of syndemics -- and, specifically, its concept of disease interaction -- involves multiple levels of analysis.10”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [10] Singer, 2003, Syndemics and public health: reconceptualizing disease in bio-social context, Med Anthropol Q source
Probably not a substantial claim: may not pass S2 (checkable).
InterpretationreasoningData from multiple levels of analysis should be used to validate syndemic theory.
“By implication, data from multiple levels of analysis should be mobilised in order to gain purchase on validating the theory.”
Quote in the paperNot a substantial claim
The paper relies on this without support.
Syndemic theory is principally a theory about population health.
“Although the theory of syndemics is principally a theory about population health, the past two decades’ worth of quantitative literature motivated by the theory has generally focused on studying individuals, rather than populations -- and consequently has had very little to say about population health.”
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 three models of co-occurring epidemics-mutually causal, synergistically interacting, and serially causal-generate starkly different predictions about the potential effectiveness of treatment or prevention strategies.
“This practice contributes to ongoing confusion in the field because the three different models of co-occurring epidemics generate starkly different predictions about the potential effectiveness of treatment or prevention strategies.”
From Syndemics: a theory in search of data or data in search of a theory? (2018) · cites this paper as Tsai et al., 2017
In “Measuring syndemics” (page unavailable), the paper says that two models—mutual causality and synergistic interaction—imply different treatment or prevention strategies. The “Interpretation” passage explains how their predictions for single-component interventions differ. Our copy does not describe a third, serially causal model or compare its intervention predictions. (LLM, conf=0.88)
Experimental — accuracy not yet measuredThe sum score specification offers an appropriate test for none of the three models of co-occurring epidemics.
“Irrespective of the model or models that emerge conceptually victorious from the scrum when the dust settles, this point is worth emphasizing: the sum score specification offers an appropriate test for none of these models.”
From Syndemics: a theory in search of data or data in search of a theory? (2018) · cites this paper as Tsai et al., 2017
In “Measuring syndemics” (page unavailable), the paper says a sum score sheds light on neither interaction nor mutual causality, supporting the claim for the two models it describes. It does not identify a third model or establish that a sum score is inappropriate for testing it. (LLM, conf=0.86)
Experimental — accuracy not yet measuredTo date, the field has focused exclusively on investigating how individual-level outcomes can be explained by individual-level covariates.
“To date, the field has focused exclusively on investigating how individual-level outcomes can be explained by individual-level covariates (Tsai & Burns, 2015; Tsai et al., 2017).”
From Syndemics: a theory in search of data or data in search of a theory? (2018) · cites this paper as Tsai et al., 2017
In “Syndemics and the ‘individualistic fallacy’” (page not provided), the paper says the field has largely focused on explaining individual-level outcomes with individual-level covariates. The claim’s “exclusively” overstates that qualified finding. (LLM, conf=0.90)
Experimental — accuracy not yet measuredSyndemic research calls for multi-level analyses to understand interactions at the individual and population level.
“Syndemic research also calls for multi-level analyses to understand interactions at the individual and population level [ 9 ].”
From Syndemic contexts: findings from a review of research on non-communicable diseases and interviews with experts (2021) · cites this paper as [9]
Systematic reviews have shown that most epidemiological studies in the syndemics literature, all using individual-level data, have attempted to document syndemics with the sum score specification.
“Systematic reviews have shown that most epidemiological studies in this literature -- all of which are based on individual-level data -- have attempted to document the existence of syndemics by using the “sum score” specification (Tsai & Burns, 2015; Tsai et al., 2017).”
From Syndemics: a theory in search of data or data in search of a theory? (2018) · cites this paper as Tsai et al., 2017
One of the most commonly used specifications of the sum score essentially encodes an assumption that a sufficient cause interaction exists.
“Further, one of the most commonly used specifications of the sum score essentially encodes an assumption that there exists a sufficient cause interaction (Tsai et al., 2017).”
From Syndemics: a theory in search of data or data in search of a theory? (2018) · cites this paper as Tsai et al., 2017
The literature showed little improvement two years later.
“The literature showed little improvement two years later (Tsai, Mendenhall, Trostle, & Kawachi, 2017).”
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, Mendenhall, Trostle, & Kawachi, 2017
None of the empirical studies in the syndemics literature were based on ecological or multilevel data.
“In the systematic review by Tsai and Burns (2015) subsequently updated by Tsai et al. (2017), none of the empirical studies in the syndemics literature were based on ecological or multilevel data.”
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 et al. (2017)
Tsai et al. (2017) reported that syndemic studies continue to use the language of synergistic interaction but fail to test for such a relationship in their methods.
“Tsai et al. (2017) reported that while there are signs of greater attention to vulnerable populations both within and beyond the U.S., syndemic studies continue to use the language of synergistic interaction but fail to test for such a relationship in their methods.”
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 et al. 2017
The authors' findings support the argument by Tsai and colleagues that synergy cannot be assumed from a cumulative relationship between number of syndemic conditions and sexual risk behaviors, and that formal methods are needed to evaluate synergistic interaction.
“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, Mendenhall et al. 2017
Instead of testing disease interaction, specific health outcomes were added to post-hoc analyses when deemed appropriate to examine how some health outcomes may influence others.
“Instead of testing disease interaction [102, 103], we added specific health outcomes to post-hoc analyses when deemed appropriate to examine how some health outcomes may influence others.”
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Newly included studies total 30, not 31
MinorThe 23 PubMed studies and 4 conference presentations, 2 journal articles, and 1 dissertation from Google Scholar add up to 30. The stated total of 31 is one higher.
Reported 31 · recomputed 30
“Of 87 records returned in the PubMed search, 23 met criteria for inclusion; of 119 records returned in the Google Scholar search, after excluding duplicates an additional 4 conference presentations, 2 journal articles, and 1 doctoral dissertation met criteria for inclusion. These 31 newly identified studies”
Newly identified study count does not match its components
MinorThe 23 PubMed studies and 4 conference presentations, 2 journal articles, and 1 dissertation from Google Scholar total 30, not 31. The stated combined total of 71 relies on the unsupported count of 31.
Reported 31 · recomputed 30
“Of 87 records returned in the PubMed search, 23 met criteria for inclusion; of 119 records returned in the Google Scholar search, after excluding duplicates an additional 4 conference presentations, 2 journal articles, and 1 doctoral dissertation met criteria for inclusion. These 31 newly identified studies were combined with the 40 studies identified in the original systematic review”
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Flagged first, then by citations
1 of the 53 references couldn’t be matched to a known paper.
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Cited by
Sorted by citations
The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report
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“Concomitant with the rapid expansion in the magnitude of the opioid overdose crisis is an expansion in its scope, with increasingly syndemic [6] involvement of cocaine and psychostimulants [7–10].”
BackgroundSelf-citationSystemic racism, chronic health inequities, and COVID ‐19: A syndemic in the making?
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BackgroundCOPD and multimorbidity: Recognising and addressing a syndemic occurrence
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“Systematic reviews have shown that most epidemiological studies in this literature -- all of which are based on individuallevel data -- have attempted to document the existence of syndemics by using the “sum score” specification (Tsai & Burns, 2015; Tsai et al., 2017).”
BackgroundMethodInfluentialSelf-citationSyndemics: a new path for global health research
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“The COVID-19 epidemic should be further researched in the context of other NCD epidemics and underlying social and economic determinants and risk factors following a syndemic approach to enable predictions based on how interactions between epidemics amplify disease burden as well as improving disease prevention and ca…”
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Whither syndemics?: Trends in syndemics research, a review 2015–2019
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“Situations of harmful disease clusters or adverse additive co-morbidities reveal that addressing only one factor in the relationship could positively influence the outcomes of the others, given mutually or serially causal dynamics (Tsai, 2018; Tsai et al., 2017).”
BackgroundThe Syndemics and Structural Violence of the COVID Pandemic: Anthropological Insights on a Crisis
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The SARS-CoV-2 pandemic: A syndemic perspective
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“…to family planning services, prenatal surveillance consultations, vaccinations or nutritional counseling, and institutional births were reduced considerably, associated in many developing countries with lack of public transport, leading to increases in mortality amenable to health care [24,29].”
Peru – Progress in health and sciences in 200 years of independence
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Self-citationSyndemic theory, methods, and data
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Self-citationBoateng, G. O., Workman, C. L., Miller, J. D., Onono, M., Neilands, T. B., & Young, S. L. (2022) · Social Science & Medicine · doi:10.1016/j.socscimed.2020.113043 · Cited by 90 · see citing works
“Although existing syndemic literature has cogently demonstrated that diseases such as depression concentrate among certain at-risk populations, Tsai and others argue that few studies have clearly demonstrated the exact relationship between examined co-factors (Tsai et al., 2017; Tsai and Burns, 2015; Tsai and Venkatar…”
BackgroundCOVID-19 como sindemia: modelo teórico e fundamentos para a abordagem abrangente em saúde
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“sistematização da rede de atenção, contemplando o estabelecimento e fluxos regulatórios, e o transporte inter-hospitalar; (2) definição da rede de urgência à COVID-19; (3) orientação da assistência hospitalar, com otimização do manejo clínico e estimativa da necessidade de profissionais; (4) atenção aos casos graves,…”
BackgroundMoore, J. X., Gilbert, K. L., Lively, K. L., Laurent, C., Chawla, R., Li, C., Johnson, R., Petcu, R., Mehra, M., Spooner, A., et al. (2021) · Vaccines · doi:10.3390/vaccines9080879 · Cited by 66 · see citing works
Syndemics and clinical science
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Longitudinal Effects of Syndemics on ART Non-adherence Among Sexual Minority Men
Harkness, A., Bainter, S. A., O’Cleirigh, C. M., Mendez, N. A., Mayer, K. H., & Safren, S. A. (2018) · AIDS and Behavior · doi:10.1007/s10461-018-2180-8 · Cited by 59 · see citing works
“Instead of testing these interactions, we tested whether there was mutual causality, or, whether each of the syndemic conditions are predictive of one another (See Table 3), another aspect of syndemics theory [10, 46].”
Sudden infant death and social justice: A syndemics approach
Bartick, M., & Tomori, C. (2018) · Maternal and Child Nutrition · doi:10.1111/mcn.12652 · Cited by 58 · see citing works
McKee, G. R., Butt, Z. A., Wong, S., Salway, T. J., Gilbert, M., Wong, J., Alvarez, M., Chapinal, N., Darvishian, M., TYNDALL, M. W., et al. (2018) · EClinicalMedicine · doi:10.1016/j.eclinm.2018.10.006 · Cited by 57 · see citing works
“We also evaluated interactions across underlying factors that contribute to the risks of acquiring multiple infections, as identified as a major gap in recent series on syndemics [11].”
BackgroundGuadamuz, J., Kapoor, K., Lazo, M., Eleazar, A., Yahya, T., Kanaya, A., Caínzos-Achirica, M., & Bilal, U. (2021) · Current Atherosclerosis Reports · doi:10.1007/s11883-021-00920-9 · Cited by 48 · see citing works
Tomori, C., McFall, A. M., Solomon, S. S., Srikrishnan, A. K., Anand, S., Balakrishnan, P., Mehta, S. H., & Celentano, D. D. (2018) · Social Science & Medicine · doi:10.1016/j.socscimed.2018.03.032 · Cited by 54 · see citing works
Chakrapani, V., Lakshmi, P. V. M., Tsai, A. C., Vijin, P. P., Kumar, P., & Srinivas, V. (2019) · SSM - Population Health · doi:10.1016/j.ssmph.2018.100348 · Cited by 49 · see citing works
Self-citationWe Have No Choice but to Transform: The Future of Medical Education After the COVID-19 Pandemic
Lucey, C. R., Davis, J. A., & Green, M. M. (2021) · Academic Medicine · doi:10.1097/acm.0000000000004526 · Cited by 43 · see citing works
“They must be prepared with the knowledge, dispositions, and skills needed to work collectively in support of our diverse communities to solve chronic syndemic problems as well as to respond to periodic pandemics.(5)”
BackgroundWeight loss interventions and nonalcoholic fatty liver disease: Optimizing liver outcomes
Finer, N. (2022) · Diabetes, Obesity and Metabolism · doi:10.1111/dom.14569 · Cited by 45 · see citing works
“Adapted from Tsai et al.(1) NASH, nonalcoholic steatohepatitis FINER 45”
BackgroundMethodSyndemics: committing to a healthier future
Hart, L., & Horton, R. (2017) · The Lancet · doi:10.1016/s0140-6736(17)30599-8 · Cited by 45 · see citing works
COVID-19, Mental Health, and Chronic Illnesses: A Syndemic Perspective
Saqib, K., Qureshi, A. S., & Butt, Z. A. (2023) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph20043262 · Cited by 44 · see citing works
“The application of syndemic theory in the COVID-19 pandemic may guide public health planners to design effective interventions to mitigate disease burden [108].”
BackgroundThe syndemics of diabetes and depression in Brazil – An epidemiological analysis
Diderichsen, F., & Andersen, I. (2019) · SSM - Population Health · doi:10.1016/j.ssmph.2018.11.002 · Cited by 44 · see citing works
Msomi, N., Naidoo, K., Yende‐Zuma, N., et al. (2020) · BMC Infectious Diseases · doi:10.1186/s12879-020-05575-6 · Cited by 42 · see citing works
Spatial epidemiology: An empirical framework for syndemics research
Shrestha, S., Bauer, C., Hendricks, B. M., & Stopka, T. J. (2020) · Social Science & Medicine · doi:10.1016/j.socscimed.2020.113352 · Cited by 40 · see citing works
Pirrone, I., Dieleman, M., Reis, R., & Pell, C. (2021) · Global Health Action · doi:10.1080/16549716.2021.1927332 · Cited by 37 · see citing works
“Syndemic research also calls for multi-level analyses to understand interactions at the individual and population level [9].”
Ecosyndemics: The potential synergistic health impacts of highways and dams in the Amazon
Tallman, P. S., Riley‐Powell, A. R., Schwarz, L., Salmón-Mulanovich, G., Southgate, T., Pace, C., Valdés‐Velásquez, A., Hartinger, S. M., Paz‐Soldán, V. A., & Lee, G. O. (2020) · Social Science & Medicine · doi:10.1016/j.socscimed.2020.113037 · Cited by 38 · see citing works
Treatment failure in inflammatory arthritis: time to think about syndemics?
Nikiphorou, E., Lempp, H. K., & Kohrt, B. A. (2019) · Rheumatology · doi:10.1093/rheumatology/kez222 · Cited by 39 · see citing works
Rodriguez-Morales, A. J., Suárez, J. A., Rísquez, A., et al. (2018) · Travel Medicine and Infectious Disease · doi:10.1016/j.tmaid.2018.10.010 · Cited by 39 · see citing works
McCloskey, J. C., Kast, W. M., Flexman, J., McCallum, D., French, M. A., & Phillips, M. R. (2017) · Papillomavirus Research · doi:10.1016/j.pvr.2017.10.004 · Cited by 36 · see citing works
Kunzweiler, C. P., Bailey, R. C., Okall, D. O., Graham, S. M., Mehta, S. D., & Otieno, F. (2017) · AIDS and Behavior · doi:10.1007/s10461-017-1941-0 · Cited by 36 · see citing works
“The high prevalence and confluence of multiple psychosocial and physical epidemics in this sample of MSM meet the typical definition of a syndemic [31, 104] and adds to the literature demonstrating that MSM are disproportionately burdened by numerous adverse physical and psychosocial health conditions.”
BackgroundMcCurley, J. L., Gutierrez, A. P., Bravin, J. I., Schneiderman, N., Reina, S. A., Khambaty, T., Castañeda, S. F., Smoller, S., Daviglus, M. L., O’Brien, M. J., et al. (2019) · Annals of Behavioral Medicine · doi:10.1093/abm/kaz009 · Cited by 41 · see citing works
“Beyond recognizing the presence of syndemics when they occur and exploring biological pathways of disease interaction, the Lancet series urges researchers to identify specific adverse social conditions that are associated with and may increase the likelihood of the syndemic in specific populations, as a critical step…”
BackgroundCastrejón‐Pérez, R. C., Aguilar-Salinas, C. A., Gutiérrez‐Robledo, L. M., Cesari, M., & Pérez‐Zepeda, M. U. (2017) · Aging Clinical and Experimental Research · doi:10.1007/s40520-017-0852-2 · Cited by 37 · see citing works
Unmasking the vulnerabilities of uninfected children exposed to HIV
Ramokolo, V., Goga, A. E., Slogrove, A. L., & Powis, K. M. (2019) · BMJ · doi:10.1136/bmj.l4479 · Cited by 32 · see citing works
Noncommunicable diseases, climate change and iniquities: What COVID‐19 has taught us about syndemic
Ciaula, A. D., Krawczyk, M. J., Filipiak, K. J., Geier, A., Bonfrate, L., & Portincasa, P. (2021) · European Journal of Clinical Investigation · doi:10.1111/eci.13682 · Cited by 35 · see citing works
Ashaba, S., Cooper‐Vince, C. E., Maling, S., Satinsky, E. N., Baguma, C., Akena, D. H., Nansera, D., Bajunirwe, F., & Tsai, A. C. (2021) · Journal of Affective Disorders Reports · doi:10.1016/j.jadr.2021.100094 · Cited by 37 · see citing works
Self-citationThe multidimensional clustering of health and its ecological risk factors
Brazil, N. (2021) · Social Science & Medicine · doi:10.1016/j.socscimed.2021.113772 · Cited by 28 · see citing works
“(Tsai, 2018; Tsai et al., 2017).”
BackgroundMapping a Syndemic of Psychosocial Risks During Pregnancy Using Network Analysis
Choi, K. W., Smit, J. A., Coleman, J. N., Mosery, N., Bangsberg, D. R., Safren, S. A., & Psaros, C. (2019) · International Journal of Behavioral Medicine · doi:10.1007/s12529-019-09774-7 · Cited by 33 · see citing works
“While useful, such methods tend to consider all risk factors equally and/or additively influential [24], without capturing the complexity of interdependence among these factors, including how they mutually influence each other to varying degrees [25].”
Chakrapani, V., Kaur, M., Tsai, A. C., Newman, P. A., & Kumar, R. (2020) · Social Science & Medicine · doi:10.1016/j.socscimed.2020.112817 · Cited by 31 · see citing works
Self-citationDas‐Munshi, J., Schofield, P., Bhavsar, V., Chang, C., Dewey, M. E., Morgan, C., Stewart, R. J., Thornicroft, G., & Prince, M. J. (2019) · The Lancet Psychiatry · doi:10.1016/s2215-0366(19)30126-9 · Cited by 30 · see citing works
Beksinska, A., Karlsen, O., Gafos, M., & Beattie, T. (2023) · PLOS Global Public Health · doi:10.1371/journal.pgph.0001216 · Cited by 28 · see citing works
Maiorana, A., Kegeles, S. M., Brown, S. C., Williams, R., & Arnold, E. A. (2020) · Culture Health & Sexuality · doi:10.1080/13691058.2019.1688395 · Cited by 28 · see citing works
“The presence and interaction of these factors as syndemic conditions in the lives of young Black men who have sex with men, particularly in the USA South, deserve further examination, together with the pathways of causality between the socio-structural, biological and psychological factors that may interact to produce…”
BackgroundInfluentialApplying Syndemic Theory to Acute Illness
Rudd, K. E., Mair, C., & Angus, D. C. (2021) · JAMA · doi:10.1001/jama.2021.22583 · Cited by 28 · see citing works
Afroz, R., Muhibbullah, M., & Morshed, M. N. (2020) · Journal of Asian Finance Economics and Business · doi:10.13106/jafeb.2020.vol7.no4.155 · Cited by 27 · see citing works
“Tsai, Mendenhall, Trostle, and Kawachi (2017) delivered evidence that the e-learning system (BELS), which combines face-to-face classes with e-learning modules, has improved health education for nurses in the hospitals.”
BackgroundFort, M. P., Mundo, W., Paniagua-Ávila, A., Cardona, S., Figueroa, J. C., Hernández-Galdamez, D. R., Mansilla, K., Peralta-García, A., Roche, D., Palacios, E., et al. (2021) · BMC Health Services Research · doi:10.1186/s12913-021-06889-0 · Cited by 23 · see citing works
Alvarado, B., Mueses-Marín, H. F., Galindo, J., & Martínez-Cajas, J. (2020) · Biomédica · doi:10.7705/biomedica.5082 · Cited by 28 · see citing works
“These complex interactions relate to the notion of “syndemics”, a concept that has become widely used in HIV research and prevention (12,15).”
BackgroundRoll-out of HIV pre-exposure prophylaxis: a gateway to mental health promotion
Ikeda, D. J., Kidia, K. K., Agins, B., Haberer, J. E., & Tsai, A. C. (2021) · BMJ Global Health · doi:10.1136/bmjgh-2021-007212 · Cited by 26 · see citing works
Self-citationSyndemics among individuals enrolled in the PrEP Brasil Study
Boni, R. B. D., Machado, I. K., de Vasconcellos, M. T. L., Hoagland, B., Kallas, E. G., Madruga, J. V., Fernandes, N. M., Cerqueira, N. B., Moreira, R. I., Goulart, S. P., et al. (2018) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2017.12.016 · Cited by 23 · see citing works
Griffith, D. M., Holliday, C. S., Enyia, O. K., Ellison, J. M., & Jaeger, E. C. (2021) · Public Health Reports · doi:10.1177/00333549211026799 · Cited by 28 · see citing works
Stoicescu, C., Ameilia, R., Irwanto, I., Praptoraharjo, I., & Mahanani, M. M. (2019) · Journal of Urban Health · doi:10.1007/s11524-019-00352-6 · Cited by 25 · see citing works
Zvonareva, O., van Bergen, W., Кабанец, Н. Н., Alliluyev, A., & Filinyuk, O. V. (2018) · Journal of Biosocial Science · doi:10.1017/s0021932018000263 · Cited by 24 · see citing works
“Analysts have recently argued for developing new quantitative multilevel models that can account for both how individual-level risk factors interact to affect disease outcomes and how large-scale social forces condition the distribution of individual-level risk factors or expedite their interaction and translation int…”
Deutsch, A. R., Lustfield, R., & Jalali, M. S. (2021) · Systems Research and Behavioral Science · doi:10.1002/sres.2807 · Cited by 24 · see citing works
“Many stigmatized health issues are also co-morbid and form syndemic relationships (Singer et al., 2017; Tsai et al., 2017), and this co-morbidity can be important to represent.”
BackgroundInternet gaming, embodied distress, and psychosocial well-being: A syndemic-syndaimonic continuum
Snodgrass, J. G., Lacy, M. G., & Cole, S. W. (2019) · Social Science & Medicine · doi:10.1016/j.socscimed.2019.112728 · Cited by 25 · see citing works
Kiang, M. V., Acosta, R. J., Chen, Y., Matthay, E. C., Tsai, A. C., Basu, S., Glymour, M. M., Bibbins-Domingo, K. B., Humphreys, K. N., & Arthur, K. N. (2022) · The Lancet Regional Health - Americas · doi:10.1016/j.lana.2022.100237 · Cited by 22 · see citing works
Self-citationA mixed-methods, population-based study of a syndemic in Soweto, South Africa
Mendenhall, E., Kim, A. W., Panasci, A., Cele, L., Mpondo, F., Bosire, E. N., Norris, S. A., & Tsai, A. C. (2021) · Nature Human Behaviour · doi:10.1038/s41562-021-01242-1 · Cited by 22 · see citing works
“South Africa maintains (1) the highest number of people living with HIV globally, of which many also experience tuberculosis26 and, increasingly, diabetes27; (2) elevated rates of automobile accidents, intimate partner violence, rape and murder28,29; (3) elevated rates of infant and maternal mortality, despite a high…”
BackgroundSelf-citationLee, J. S., Bainter, S. A., Tsai, A. C., Andersen, L. S., Stanton, A. M., Magidson, J. F., Kagee, A., Joska, J. A., O’Cleirigh, C. M., & Safren, S. A. (2022) · AIDS and Behavior · doi:10.1007/s10461-022-03906-z · Cited by 20 · see citing works
Self-citationEthnic disparities in psychotic experiences explained by area-level syndemic effects
Coid, J. W., Rodriguez, R. G., Kallis, C., Zhang, Y., Bhui, K. S., Stavola, B. L. D., Bebbington, P., & Ullrich, S. (2019) · The British Journal of Psychiatry · doi:10.1192/bjp.2019.203 · Cited by 22 · see citing works
Kline, N. (2022) · Social Science & Medicine · doi:10.1016/j.socscimed.2020.113260 · Cited by 21 · see citing works
Compounding vulnerabilities: Syndemics and the social determinants of disease in the past
Perry, M. A., & Gowland, R. L. (2022) · International Journal of Paleopathology · doi:10.1016/j.ijpp.2022.09.002 · Cited by 24 · see citing works
Jenkins, E., Slemon, A., Richardson, C. G., Pumarino, J., McAuliffe, C., Thomson, K., Goodyear, T., Daly, Z., McGuinness, L., & Gadermann, A. (2022) · International Journal of Public Health · doi:10.3389/ijph.2022.1604685 · Cited by 22 · see citing works
“While epidemiological studies often reflect an “individualistic fallacy,” explaining emergent conditions through individual-level covariates [41], research that advances analyses of root systemic contributors to adverse mental health outcomes can more meaningfully support action toward addressing inequities and preven…”
BackgroundDemographic and Evolutionary Consequences of Pandemic Diseases
DeWitte, S. N., & Wissler, A. (2021) · Bioarchaeology International · doi:10.5744/bi.2020.0024 · Cited by 22 · see citing works
“That is, the Black Death likely represents a syndemic (Singer and Clair 2003; Singer et al. 2017; Tsai et al. 2017).”
Chuang, D.-M., Newman, P. A., Fang, L., & Lai, M. (2021) · AIDS and Behavior · doi:10.1007/s10461-021-03269-x · Cited by 21 · see citing works
“Echoing previous calls [67, 68], to fully understand the interactive syndemic impact, further research should analyze the adverse conditions rooted at the structural level, such as sexual stigma, discrimination, and a hostile social environment, that may interact with PHCs at the individual level.”
BackgroundEffects of syndemic psychiatric diagnoses on health indicators in men who have sex with men.
Batchelder, A., Choi, K. W., Dale, S. K., Pierre‐Louis, C., Sweek, E. W., Ironson, G. H., Safren, S. A., & O’Cleirigh, C. M. (2019) · Health Psychology · doi:10.1037/hea0000724 · Cited by 22 · see citing works
“However, Tsai and colleagues emphasize that the negative implications of type II error in relation to testing interaction effects in relation to syndemics are overstated (Tsai & Burns, 2015; Tsai & Venkataramani, 2016; Tsai et al., 2017).”
BackgroundResultInfluentialWhy and How Epidemiologists Should Use Mixed Methods
Houghton, L. C., & Paniagua-Ávila, A. (2022) · Epidemiology · doi:10.1097/ede.0000000000001565 · Cited by 20 · see citing works
Context, COVID-19 and comorbidities: exploring emergent directions in syndemics and HIV research
Logie, C. H., Coelho, M., Kohrt, B., Tsai, A. C., & Mendenhall, E. (2022) · Current Opinion in HIV and AIDS · doi:10.1097/coh.0000000000000722 · Cited by 20 · see citing works
“Syndemic thinking introduces how interacting social and health factors cascade together to influence HIV prevention and care, and in turn provide insight to inform practice, research, and policy [4].”
BackgroundSelf-citationSatyanarayana, S., Rogers, B. G., Bainter, S. A., Christopoulos, K., Fredericksen, R. J., Mathews, W. C., Moore, R. D., Mugavero, M. J., Napravnik, S., Carrico, A. W., et al. (2021) · AIDS Patient Care and STDs · doi:10.1089/apc.2021.0004 · Cited by 19 · see citing works
“68,69 Fourth, a viral suppression threshold of HIV RNA 400 copies/mL is higher than the typical threshold of HIV RNA 200 copies/mL, suggesting that our estimates for the effects of syndemic conditions on viral suppression may be conservative.”
Pontzer, H. (2021) · American Journal of Human Biology · doi:10.1002/ajhb.23579 · Cited by 21 · see citing works
Dias, S., Gama, A. F., Abrantes, P., Gomes, M. I., Fonseca, M., Reigado, V., Simões, D., Carreiras, E., Mora, C., Ferreira, A. P., et al. (2019) · The Journal of Sex Research · doi:10.1080/00224499.2019.1601154 · Cited by 19 · see citing works
Transcultural Pain Management: Theory, Practice, and Nurse-Client Partnerships
Rosa, W. E. (2017) · Pain Management Nursing · doi:10.1016/j.pmn.2017.10.007 · Cited by 19 · see citing works
Malnutrition, illness, poverty, and infant growth: A test of a syndemic hypothesis in Nuñoa, Peru
Hoke, M. K., & McCabe, K. A. (2022) · Social Science & Medicine · doi:10.1016/j.socscimed.2021.113720 · Cited by 18 · see citing works
Darvishian, M., Butt, Z. A., Wong, S., et al. (2021) · Therapeutic Advances in Medical Oncology · doi:10.1177/1758835921992987 · Cited by 18 · see citing works
Maclin, B. J., Wang, Y., Rodriguez-Diaz, C., Donastorg, Y., Perez, M., Gomez, H., Barrington, C., & Kerrigan, D. (2023) · PLOS ONE · doi:10.1371/journal.pone.0291314 · Cited by 18 · see citing works
Kirschbaum, A. L., Metheny, N., Skakoon‐Sparling, S., Grace, D., Yakubovich, A. R., Cox, J., Palachi, A., Sang, J. M., O'Campo, P. J., Tan, D. H. S., et al. (2023) · LGBT Health · doi:10.1089/lgbt.2023.0117 · Cited by 16 · see citing works
“43 In the context of the current study, this suggests that treating depression alone, for example, may serve to decrease the risk of bidirectional IPV, or that an intervention focused on reducing bidirectional IPV may ultimately lead to a decrease in problematic drinking, therefore eliminating the…”
She, R., Mo, P. K. H., Ma, T., Liu, Y., & Lau, J. T. F. (2021) · AIDS and Behavior · doi:10.1007/s10461-020-03108-5 · Cited by 15 · see citing works
“, social marginalization and discrimination) [10]; these multiple health conditions interact and reinforce with one another, either via biological or social or behavioral or psychological pathways, and ultimately result in magnified or worsened health consequences [11].”
BackgroundMcDaid, L. M., Flowers, P., Ferlatte, O., McAloney‐Kocaman, K., Gilbert, M., & Frankis, J. S. (2019) · SSM - Population Health · doi:10.1016/j.ssmph.2019.100519 · Cited by 16 · see citing works
“have also noted that while syndemics theory suggests disease interaction operates at the individualand population-level, empirical literature includes only individual-level outcome and covariate data (and none have included ecological, multilevel or experimental study designs) (Tsai et al., 2017).”
BackgroundInfluentialPrecision global health and comorbidity: a population-based study of 16 357 people in rural Uganda
Chami, G. F., Kabatereine, N. B., Tukahebwa, E. M., & Dunne, D. W. (2018) · Journal of The Royal Society Interface · doi:10.1098/rsif.2018.0248 · Cited by 16 · see citing works
Jolley, S. E., Hough, C. L., Clermont, G., Hayden, D., Hou, S., Schoenfeld, D., Smith, N. L., Thompson, B., Bernard, G. R., & Angus, D. C. (2017) · Annals of the American Thoracic Society · doi:10.1513/annalsats.201611-906oc · Cited by 16 · see citing works
Ofosu, N. N., Luig, T., Chiu, Y., Mumtaz, N., Yeung, R. O., Lee, K. K. C., Wang, N., Omar, N., Yip, L., Aleba, S., et al. (2022) · BMC Public Health · doi:10.1186/s12889-021-12305-3 · Cited by 16 · see citing works
“We therefore drew on syndemic theory [9, 10] and the population health approach [11] to capture determinants of health, and synergistic effects of health, illness experience and vulnerable conditions.”
MethodAssociation of Poor Mental-Health Days With COVID-19 Infection Rates in the U.S.
Ransome, Y., Luan, H., Song, I., Fiellin, D., & Galea, S. (2021) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2021.08.032 · Cited by 14 · see citing works
“Higher rates of dysregulated neural circuit function and allostatic load among people without sufficient medical care, therefore, leaves community members more susceptible to COVID-19 infections and correspond to an increase in the population rate of those who succumb to infectious and other diseases.(20,21) Given the…”
BackgroundSlagboom, M. N., Reis, R., Tsai, A. C., Büchner, F. L., Dijk, D. J. A. V. D.-V., & Crone, M. R. (2021) · Journal of Global Health · doi:10.7189/jogh.11.04029 · Cited by 17 · see citing works
Self-citationClemenzi-Allen, A., Hickey, M. D., Conte, M., Das, D., Geng, E. H., Riley, E. D., Havlir, D. V., Gandhi, M., & Imbert, E. (2020) · Current HIV/AIDS Reports · doi:10.1007/s11904-020-00488-0 · Cited by 15 · see citing works
Córdova, D., Heinze, J. E., Hsieh, H., Mistry, R., Salas‐Wright, C. P., Cook, S., & Zimmerman, M. A. (2017) · AIDS · doi:10.1097/qad.0000000000001717 · Cited by 15 · see citing works
“Consistent with syndemic theory [13,14], the additive effects of psychosocial risk indicate a need for intervention strategies that address multiple risk factors [49,50].”
BackgroundJackson-Morris, A. M., Masyuko, S. J., Morrell, L. C., Kataria, I., Kocher, E. L., & Nugent, R. A. (2024) · PLOS Global Public Health · doi:10.1371/journal.pgph.0003114 · Cited by 14 · see citing works
“A nascent literature on syndemic disease—defined as clusters of two or more socially-driven diseases, the interaction of which yields worse health outcomes than those diseases individually—highlights the need to understand comorbid disease through a public policy lens [3–6].”
BackgroundBhui, K. S., Halvorsrud, K., Mooney, R., & Hosang, G. M. (2021) · The British Journal of Psychiatry · doi:10.1192/bjp.2021.142 · Cited by 14 · see citing works
“We assessed completion rates of relevant independent variables identified from previous syndemic models 38,39 and in particular Beckie ’ s heuristic model of allostatic load, health and health disparities.”
How to capture the individual and societal impacts of syndemics: the lived experience of COVID-19
Boes, S., Sabariego, C., Bickenbach, J. E., & Stucki, G. (2021) · BMJ Global Health · doi:10.1136/bmjgh-2021-006735 · Cited by 15 · see citing works
Allan, J., Kleinschafer, J., Saksena, T., Rahman, A., Lawrence, J., & Lock, M. (2022) · BMC Public Health · doi:10.1186/s12889-022-13643-6 · Cited by 13 · see citing works
“COVID-19, converging with existing social and health conditions, including an epidemic of poor mental health, has the potential to cause a syndemic for First Nations Australians [9, 10].”
BackgroundAn Emerging Syndemic of Smoking and Cardiopulmonary Diseases in People Living with HIV in Africa
Peprah, E. K., Armstrong-Hough, M. J., Cook, S., Mukasa, B., Taylor, J. Y., Xu, H., Chang, L., Gyamfi, J., Ryan, N., Ojo, T., et al. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18063111 · Cited by 14 · see citing works
“The causality between synergistic epidemics is not unidirectional, but rather multidirectional, and contributes to an overall greater burden of disease [99].”
BackgroundVoisin, D. R., & Takahashi, L. M. (2021) · Journal of Adolescent Health · doi:10.1016/j.jadohealth.2020.11.015 · Cited by 12 · see citing works
Designing a toolkit for the assessment of Health in All Policies at a national scale in Iran
Damari, B., Heidari, A., Bonab, M. R., et al. (2020) · Health Promotion Perspectives · doi:10.34172/hpp.2020.38 · Cited by 14 · see citing works
- Authors
- Tsai, A. C., Mendenhall, E., Trostle, J. A., & Kawachi, I.
- Affiliations
- Harvard University (US)
- Georgetown University (US)
- Trinity College (US)
- Corresponding author
- Tsai, Alexander C
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2017-03
- Volume
- 389
- Issue
- 10072
- Pages
- 978-982
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- PMC
- PMC5972361
- OpenAlex
- W2592578483
- Cited by
- 268
- References
- 53
- Citations by year
- 2026: 21 · 2025: 25 · 2024: 25 · 2023: 32 · 2022: 33 · 2021: 47 · 2020: 32 · 2019: 27 · 2018: 14 · 2017: 12
- FWCI
- 7.16
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- The Lancet (acceptedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- US National Institutes of Health (K23MH096620)
- US National Science Foundation (EAR-1360330)
- Topics
- Social Sciences › Sociology and Political Science › Historical and modern epidemiology studies
- Health Sciences › Medicine › Epidemiology › Chronic Disease Management Strategies
- Social Sciences › General Social Sciences › HIV, TB, and STIs Epidemiology
- Keywords
- syndemic, disease interaction, social determinants of health, population health, fundamental causes, HIV, tuberculosis, health disadvantage
- MeSH terms
- Population Health, Humans, Syndrome, HIV Infections, Cost of Illness, Epidemics, Coinfection
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