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Concept: Upper middle class


In this prospective study of upper middle class youth, we document frequency of alcohol and drug use, as well as diagnoses of abuse and dependence, during early adulthood. Two cohorts were assessed as high school seniors and then annually across 4 college years (New England Study of Suburban Youth younger cohort [NESSY-Y]), and across ages 23-27 (NESSY older cohort [NESSY-O]; ns = 152 and 183 at final assessments, respectively). Across gender and annual assessments, results showed substantial elevations, relative to norms, for frequency of drunkenness and using marijuana, stimulants, and cocaine. Of more concern were psychiatric diagnoses of alcohol/drug dependence: among women and men, respectively, lifetime rates ranged between 19%-24% and 23%-40% among NESSY-Os at age 26; and 11%-16% and 19%-27% among NESSY-Ys at 22. Relative to norms, these rates among NESSY-O women and men were three and two times as high, respectively, and among NESSY-Y, close to one among women but twice as high among men. Findings also showed the protective power of parents' containment (anticipated stringency of repercussions for substance use) at age 18; this was inversely associated with frequency of drunkenness and marijuana and stimulant use in adulthood. Results emphasize the need to take seriously the elevated rates of substance documented among adolescents in affluent American school communities.

Concepts: Nicotine, Drug addiction, Addiction, High school, Stimulant, Recreational drug use, Middle class, Upper middle class


In order to gather a global picture of vaccine hesitancy and whether/how it is changing, an analysis was undertaken to review three years of data available as of June 2017 from the WHO/UNICEF Joint Report Form (JRF) to determine the reported rate of vaccine hesitancy across the globe, the cited reasons for hesitancy, if these varied by country income level and/or by WHO region and whether these reasons were based upon an assessment. The reported reasons were classified using the Strategic Advisory Group of Experts (SAGE) on Immunization matrix of hesitancy determinants ( Hesitancy was common, reported by >90% of countries. The list of cited reasons was long and covered 22 of 23 WHO determinants matrix categories. Even the most frequently cited category, risk- benefit (scientific evidence e.g. vaccine safety concerns), accounted for less than one quarter of all reasons cited. The reasons varied by country income level, by WHO region and over time and within a country. Thus based upon this JRF data, across the globe countries appear to understand the SAGE vaccine hesitancy definition and use it to report reasons for hesitancy. However, the rigour of the cited reasons could be improved as only just over 1/3 of countries reported that their reasons were assessment based, the rest were opinion based. With respect to any assessment in the previous five years, upper middle income countries were the least likely to have done an assessment. These analyses provided some of the evidence for the 2017 Assessment Report of the Global Vaccine Action Plan recommendation that each country develop a strategy to increase acceptance and demand for vaccination, which should include ongoing community engagement and trust-building, active hesitancy prevention, regular national assessment of vaccine concerns, and crisis response planning (

Concepts: Immune system, Vaccination, Report, Income, Household income in the United States, Country, Upper middle class, The Sage Gateshead


US medical spending growth slowed between 2004 and 2013. At the same time, many Americans faced rising copayments and deductibles, which may have particularly affected lower-income people. To explore whether the health spending slowdown affected all income groups equally, we divided the population into income quintiles. We then assessed trends in health expenditures by and on behalf of people in each quintile using twenty-two national surveys carried out between 1963 and 2012. Before the 1965 passage of legislation creating Medicare and Medicaid, the lowest income quintile had the lowest expenditures, despite their worse health compared to other income groups. By 1977 the unadjusted expenditures for the lowest quintile exceeded those for all other income groups. This pattern persisted until 2004. Thereafter, expenditures fell for the lowest quintile, while rising more than 10 percent for the middle three quintiles and close to 20 percent for the highest income quintile, which had the highest expenditures in 2012. The post-2004 divergence of expenditure trends for the wealthy, middle class, and poor occurred only among the nonelderly. We conclude that the new pattern of spending post-2004, with the wealthiest quintile having the highest expenditures for health care, suggests that a redistribution of care toward wealthier Americans accompanied the health spending slowdown.

Concepts: Health care, Poverty, Household income in the United States, Wealth, Working class, Quintile, Upper middle class, American middle class


High achievement expectations and academic pressure from parents have been implicated in rising levels of stress and reduced well-being among adolescents. In this study of affluent, middle school youth, we examined how perceptions of parents' emphases on achievement (relative to prosocial behavior) influenced youth’s psychological adjustment and school performance, and examined perceived parental criticism as a possible moderator of this association. The data were collected from 506 (50 % female) middle school students from a predominately white, upper middle class community. Students reported their perceptions of parents' values by rank ordering a list of achievement- and prosocial-oriented goals based on what they believed was most valued by their mothers and fathers for them (the child) to achieve. The data also included students' reports of perceived parental criticism, internalizing symptoms, externalizing symptoms, and self-esteem, as well as school-based data on grade point average and teacher-reported classroom behavior. Person-based analyses revealed six distinct latent classes based on perceptions of both mother and father emphases on achievement. Class comparisons showed a consistent pattern of healthier child functioning, including higher school performance, higher self-esteem, and lower psychological symptoms, in association with low to neutral parental achievement emphasis, whereas poorer child functioning was associated with high parental achievement emphasis. In variable-based analyses, interaction effects showed elevated maladjustment when high maternal achievement emphasis coexisted with high (but not low) perceived parental criticism. Results of the study suggest that to foster early adolescents' well-being in affluent school settings, parents focus on prioritizing intrinsic, prosocial values that promote affiliation and community, at least as much as, or more than, they prioritize academic performance and external achievement; and strive to limit the amount of criticism and pressure they place on their children.

Concepts: Psychology, Parent, Middle school, High school, Mother, Father, Middle class, Upper middle class


There is a hypothesis that low socioeconomic status (SES) may explain the link between cannabis use and poorer academic performance and mental health. A key question, therefore, is whether adolescent cannabis use is associated with poorer academic performance and mental health in high SES communities where there is reduced potential for confounding.

Concepts: Socioeconomic status, Sociology, Middle class, Social class, Social status, Social classes, Lower middle class, Upper middle class


Objective: Climate change is affecting the ability of food systems to provide sufficient nutritious and affordable foods at all times. Healthy and sustainable (H&S) food choices are important contributions to health and climate change policy efforts. This paper presents empirical data on the affordability of a food basket that incorporates principles of health and sustainability across different food sub-systems, socioeconomic neighbourhoods and household income levels in Greater Western Sydney, Australia. Methods: A basket survey was used to investigate the cost of both a typical basket of food and a hypothetical H&S basket. The price of foods in the two baskets was recorded in five neighbourhoods, and the affordability of the baskets was determined across household income quintiles. Results: The cost of the H&S basket was more than the typical basket in all five socioeconomic neighbourhoods, with most disadvantaged neighbourhood spending proportionately more (30%) to buy the H&S basket. Within household income levels, the greatest inequity was found in the middle income neighbourhood, showing that households in the lowest income quintile would have to spend up to 48% of their weekly income to buy the H&S basket, while households in the highest income quintile would have to spend significantly less of their weekly income (9%). Conclusion: The most disadvantaged groups in the region, both at the neighbourhood and household level, experience the greatest inequality in affordability of the H&S diet. Implications: The results highlight the current inequity in food choice in the region and the underlying social issues of cost and affordability of H&S foods.

Concepts: Nutrition, Household, Sustainability, Household income in the United States, Income quintiles, Income in the United States, Quintile, Upper middle class


Intrusive parenting has been positively associated with child anxiety, although examinations of this relationship to date have been largely confined to middle to upper middle class families and have rarely used longitudinal designs. With several leading interventions for child anxiety emphasizing the reduction of parental intrusiveness, it is critical to determine whether the links between parental intrusiveness and child anxiety broadly apply to families of all financial means, and whether parental intrusiveness prospectively predicts the development of child anxiety. This study employed latent growth curve analysis to evaluate the interactive effects of maternal intrusiveness and financial means on the developmental trajectory of child anxiety from 1st grade to age 15 in 1,121 children (50.7 % male) and their parents from the NICHD SECCYD. The overall model was found to provide good fit, revealing that early maternal intrusiveness and financial means did not impact individual trajectories of change in child anxiety, which were stable from 1st to 5th grade, and then decrease from 5th grade to age 15. Cross-sectional analyses also examined whether family financial means moderated contemporaneous relationships between maternal intrusiveness and child anxiety in 3rd and 5th grades. The relationship between maternal intrusiveness and child anxiety was moderated by family financial means for 1st graders, with stronger links found among children of lower family financial means, but not for 3rd and 5th graders. Neither maternal intrusiveness nor financial means in 1st grade predicted subsequent changes in anxiety across childhood. Findings help elucidate for whom and when maternal intrusiveness has the greatest link with child anxiety and can inform targeted treatment efforts.

Concepts: Grade, Child, Mother, Trajectory, Trajectory of a projectile, Middle class, Upper middle class, American middle class


OBJECTIVE: To examine gender differences in access to prescribed medicines in 15 lower and middle income countries. METHODS: The proportion of consultations with at least one prescription for women in three age groups (<15, 15-59, 60+ years) with acute respiratory infections (ARI), depression and diabetes in routine audits was compared to the expected proportion calculated from WHO Global Burden of Disease estimates. Newer oral hypoglycaemic medication prescribing was also analysed. Differences reported by country, age group, and condition. FINDINGS: 487,841 consultations examined between January 2007 and September 2010 in low (n=1), lower middle (6), and upper middle income (8) countries. No country favoured one gender exclusively, but gender differences were common. Taking the 15 countries together, only diabetes treatment revealed a significant difference, with women being treated less often than expected (p=0.02). No consistent differences found across countries grouped by World Bank income category, WHO region or Global Gender Gap Index. Overall, women had equal access to newer oral hypoglycaemics. CONCLUSION: Gender differences in access to prescribed medicines for three common conditions are common, but favour neither gender consistently. This challenges prevailing hypotheses of systematic disparities in access to care for women. Evidence about gender disparities should influence policy design.

Concepts: Middle Ages, Gender, Gender role, Pharmaceutical drug, Income, Middle class, Country, Upper middle class


To examine the socioeconomic status (SES) health gradient for obesity, diabetes, and hypertension within a diverse group of health outcomes and behaviors among older adults (60+) in upper middle-income countries benchmarked with high-income countries.

Concepts: Health disparities, Nutrition, Myocardial infarction, Hypertension, Diabetes mellitus, Obesity, Sociology, Upper middle class


This article presents original research on relations between middle-class residents and informal-sector workers in Delhi, India. It shows how middle-class associations used their consumption preferences as well as relationships with local authorities to legitimize the work of street hawkers and waste workers. These findings suggest that the toleration of informality can be traced to governance regimes comprised of both state and non-state powerbrokers.

Concepts: Middle class, Social class, Working class, Upper middle class, Bourgeoisie