Research Initiatives

This research explores associations between social/gender norms and adolescent health behaviors and outcomes using existing data. Use of existing data is likely to yield actionable information relatively more rapidly than an open-ended, exploratory prospective research approach, which may yield extremely valuable information but requires a much longer period of time and greater financial investment. This body of work will contribute to three papers in The Lancet Series on the Next Generation of Gender Equality: Paper 1 (Unlocking human potential through shaping gender norms), Paper 2 (Unlocking gender norm data), and Paper 3 (Unlocking gender norm change to achieve health and development impact at scale). Additional manuscripts and policy briefs will also be developed, providing new insights into promising approaches to shaping social and gender norms for improved adolescent health behaviors and health outcomes.

Although administrative datasets are increasingly plentiful there are many impediments to effective use of these data. Valuable data can be very difficult to identify and obtain without extensive investments of time invested in relationships and clearing regulatory hurdles and often considerable amounts of money. If an investigator is able to obtain data, they often require substantial human and digital infrastructure to use and keep secure and compliant from a regulatory standpoint.

To overcome these and other obstacles, the Stanford Center for Population Health Sciences has received a grant from the Sloan Foundation to build a model Data Core which will address these issues at Stanford and become a model that can be both shared with and replicated by partner institutions. Datasets in or Data Core will be presented in readily discoverable and documented on user-friendly portals; useable at low cost and presented with a wide array of analytic tools. The Data Core manages the relational, legal, financial and infrastructure aspects of data acquisition so that the researcher need only ask what they can learn from the data. PHS already has over 100 active users and is adding more every day. We are continually adding to our trove of data and look forward to serving the Stanford community and our partner institutions.

The Stanford University (SU) School of Medicine “Co-Creation” group will employ a mixed quantitative and qualitative methods approach to capture and share the knowledge and data gained from the Bill & Melinda Gates Foundation funded Ananya program in Bihar, India. SU will conduct this analysis through the lens of improving primary healthcare (PHC) system performance in Bihar, aiming to disseminate learning from Ananya to inform the scale-up of national and global family health (reproductive, maternal, newborn and child health and nutrition) interventions.  In close collaboration with the Gates Foundation’s India Country Office (ICO), Ananya grantees, and evaluation partner Johns Hopkins University (JHU), SU will analyze and synthesize a range of existing data sources, which – together with the primary qualitative data we will collect – will inform the development of a supplement of core publications and additional stand-alone publications and policy briefs. These insights will help the Gates Foundation’s Program Strategy Teams (PSTs), the government of Bihar, Ananya grantees, and the broader global health community make evidence-informed decisions to optimize the coverage, quality and impact of their investments in improving PHC system performance and family health outcomes.

The PHS Health Disparities Working Group has initiated the Mapping the American Sociome Project, an initiative to collect and distribute comprehensive data on social, economic, public health, and relevant public policy metrics, linked to health indices and outcomes, across the entire United States. The Group has finished collecting data at the county and state levels from 1968 through 2016 on health indicators, outcomes, behaviors, healthcare utilization, and relevant policies in 22 domains ranging from education to tobacco smoking to gun control. 

Clalit, an insurer and provider of health services to over half of the Israeli population, has been maintaining world class records (including most of its underserved population) on this stably insured population for over 15 years. In collaboration with Clalit Research Institute and the Stanford Department of Economics, PHS is developing a research agenda that will leverage this rich data. The initial collaborative work will focus on the following three areas:

• Economic studies, leveraging Clalit’s 15 years of detailed data on its served population, to assess why and how Israel produces such high-quality health outcomes while expending far less of its GDP on health care compared to the U.S.
• Socio-demographic studies to investigate why Israeli men live almost as long as Israeli women, a convergence in longevity achieved only in the wealthiest regions in North America (including Silicon Valley) and northern Europe.
• Studies in common conditions in the population, which requires data from large, longitudinally followed populations and are not typical of commercially insured U.S. databases. A particular opportunity may be the study of diseases that are more common in Israel for genetic or environmental reasons, including reproductive cancers and hereditary disorders.

To learn more about Clalit, please visit the PHS Data Portal.

Definition of clinical benefit relies on characterizing the natural history of the disease. Relatively little is known in the case of desmoids. In order to address this, we have initiated a collaboration with the Fu Jen Catholic University in Taiwan to use a record linkage approach with the Taiwan National Health Insurance Research Data Base (NHIRD) and other databases to identify clinical characteristics of Desmoid and better define the natural history of this disease. Taiwan National Health Insurance Research Data Base (NHIRD) was established in 1995 and is one of the largest population databases in the world covering 99.5% of the residents in Taiwan. It contains data on 23 million people and includes details pertaining to clinical diagnoses, outpatient and inpatient procedures, and prescription medications. Data generated from this descriptive epidemiology project will be used to inform clinical trials of promising novel therapeutics for the treatment of desmoids. The pilot project could become the prototype of studying rare diseases using Big Data. To learn more about NHIRD, please visit the PHS Data Portal.

Stanford Precision Health for Ethnic and Racial Equity (SPHERE) was launched in April 2016 to build upon Stanford School of Medicine’s leadership around precision health and is one of five inaugural NIH precision health centers dedicated to the eradication of health disparities in the US. The 5-year $11.6 million-dollar award brings together diverse community stakeholders with a variety of scientific and medical disciplines to advance precision health research for the promotion of health equity. SPHERE is made up of five cores (Analytics and Modeling, Laboratory, Consortium, Implementation and Administration) and three research projects:

Project 1: BRAICELET – Bio-Repository for American Indian Capacity, Education, Law, Economics and Technology This study aims to reduce the myriad of health disparities in American Indian populations by forming a Lakota Health Community Advisory Board, establishing a Lakota Biobank infrastructure, and promoting health science literacy and education on genetics and precision medicine.

Project 2: Integrated Personalized Omics Profiling in High Risk Latino Children –This study aims to reduce health disparities by developing and applying ‘omics technologies to more effectively prevent and treat excess weight gain and diabetes risk among Latino children.

Project 3: Communicating Cancer Genetics Information – Differential Response of Latino and Chinese Families to Information on Cancer Genetics. This study aims to fill an important and growing knowledge gap about how ethnic minorities utilize and if they benefit from cancer genetic risk information and related recommendations.

For more information on contact the SPHERE Program Director, Jill Evans: jille@stanford.edu, 650-736-8074

The EARN-Health Trial is a randomized trial of the health effects of poverty relief programs. The trial will specifically study participants in the EARN.org program, which creates incentives to generate long-term financial savings and pay down debts among low-wage workers. The EARN program is an individual development account (IDA), one of a series of measures found to successfully reduce poverty and debt in the United States, and is hypothesized to reduce debt-related mental health and substance abuse conditions. The trial will compare participants in the program to a wait-listed control group. 

This study will explore the health effects of local minimum wage ordinances. Some neighboring cities in the Bay Area, such as Mountain View, have agreed to raise their minimum wages, while others have not. The 3-year study will examine before-and-after effects among workers in cities experiencing the minimum wage increase, as compared to control groups in cities not experiencing the increase, prior to longer-term wage policies slated to take effect statewide. 

Solano County borders Napa County and has an extremely socioeconomically and racially diverse population of approximately 425,000 people.  The Health Commissioner of Solano has implemented a state-of-the-art Health Information Exchange (HIE) that integrates the electronic medical records from all county residents, and has invited PHS to develop innovative uses of these data to address the goals of population health.  We are setting up a data “sandbox” where PHS investigators will have direct VPN access to these data. 

Health information exchanges integrate electronic health records from multiple healthcare facilities in a geographic region, and secondary use by researchers of the data from these large generalizable samples have tremendous potential for benefitting population health and informing public policy.  The absence of standard data sharing guidelines, however, has made health care organizations afraid to share data, and threats to individual privacy have risen with the recent explosion in the number of online information sources and rise in hacking incidents.  An interdisciplinary group of faculty with expertise in population health, epidemiology, biostatistics, health policy, computer science, bioethics and law will address these challenges from two perspectives: 

1. societal, legal and health policy aspects, assessing the public’s views regarding privacy risks and proposing legal and policy measures that would better achieve the balance of risks and benefits; and
2. cybersecurity aspects, addressing the key technological challenges for designing secure encryption systems and statistical techniques and identifying critical gaps where novel solutions are needed.

The project is being led by Dr. Lorene Nelson, Associate Director of the Center for Population Health Sciences, and is funded by the Stanford Cyber Initiative.

INDEPTH is a research network of 53 health and demography surveillance sites in 24 low- and middle-income countries in Africa and Asia. The network maintains ongoing surveillance of large population blocks, ranging from 10,000 to 300,000 people, each of whom are visited at least once a year, a total of 4.5 million people under direct observation for 10 to 40 years. PHS researchers will be partnering with INDEPTH through local universities on a range of projects, from studying the determinants of changes in the microbiome as they relate to health patterns, with a focus on the role of these environmental changes to cancer risks.

Danish registers include data on all Danish residents, over 5 million people, for over 30 years. This includes details of medical diagnoses, socioeconomic information, and neighborhood environments. We have partnered with colleagues in Denmark to use these data to examine the influence of neighborhood environments on chronic disease, perinatal health, and other outcomes.  Collaborators include researchers at the Statens Serum Institut, the University of Copenhagen, and Statistics Denmark. 

The Danish National Biobank contains more than 15 million biological specimens that are linkable to social, economic and health care data for the population of Denmark. This also allows linkage of these specimens to ongoing birth cohorts to allow extremely detailed life course data in relation to disease and disability.

The goal of this proposed study is to examine the social, economic, behavioral and environmental predictors of site-specific DNA methylation in a young population that is not yet experiencing chronic disease. The study rationale is that socioeconomically related exposures that are detrimental to health may already early in life be associated with site-specific differential DNA methylation. The significance of testing this hypothesis for sociodemographic factors and associated behavioral and environmental pathways is that this could give insight into biological pathways of disease pathogenesis that have relevance in human populations, and in to mechanisms of how early life exposures may impact disease later in life. The underlying hypothesis is that healthy, young people living under more adverse social circumstances will have quantitatively and qualitatively different patterns of DNA methylation in specific gene expression related regions as compared to people from higher socioeconomic backgrounds.

According to the U.S. National Institutes of Health (NIH), both sex (biological characteristics) and gender (sociocultural beliefs, attitudes, and behaviors) “play a role in how health and disease processes differ among individuals.” In January 2016 the NIH required investigators to explain how “relevant biological variables, such as sex, are factored into research designs and analyses for studies in vertebrate animals and humans.” While methods for analyzing sex are increasingly well understood, methods for analyzing gender-related health variables are not. This project seeks to identify and develop gender-related variables for prevention research and patient questionnaires in health research.

We propose to use an alternative method for the creation of a national cancer registry, by using the information contained in the electronic medical record (EMR) of patients with breast cancer treated at the Mexican Institute of Social Security (IMSS), the largest healthcare system in Mexico. The integration of data from the EMR to build cancer registries is a novel approach that could be extended to other health systems. By understanding the information contained in the EMR, better measures of cancer incidence, diagnosis characteristics, and an epidemiological perspective of cancer will be obtained.

Autoimmune hemolytic anemia (AIHA) is a group of rare but serious blood disorders. They occur when the body destroys red blood cells more rapidly than it produces them. The aim of this project is to analyze the clinical characteristics and risk for venous and arterial thromboses in patients with AIHA. The proposed analysis will provide insight into the clinical course of patients with AIHA, a rare disorder. Understanding the clinical course, complications, and events associated with the episodes of thromboses would help develop strategies to optimize management of patients with this disease.

To address a lack of evidence on the causal relationship between neighborhood‐level socioeconomic conditions and health, we propose to exploit a quasi‐experimental policy in Denmark, in which the government dispersed incoming refugee families to different neighborhoods. We aim to use this policy to identify the long‐term impact of several measures of neighborhood‐level socioeconomic status on the health outcomes and behaviors of children of refugee families. We will link national registry and survey data, and use regression techniques to ascertain the effects of characteristics of assigned neighborhoods on the health outcomes and behaviors of children of refugee families.

Internal migration is an important dynamic linking poverty and well-being in the developing world. There are active debates about the extent to which people migrate to explore opportunities at the destination, including “pull factors” such as job prospects or government services, versus “push factors” such as destitution and hunger at the location of origin. Characterizing the causes leading to migration therefore could shed light on the health implications of migration. We will use detailed longitudinal INDEPTH data to characterize the role of climate in driving migration.

We use geospatial smoothing tools to translate GPS-tagged household survey information into a smoothed map that illustrates where are the "hotspots" and the "islands of health" with respect to under-five mortality in Sub-Saharan Africa. We use the variation in child mortality to study the relative contribution of country-level factors as opposed to local-area factors in explaining both the levels and changes in child mortality since the 1980s. 

Our understanding on the effects of temperatures on mortality among young children is limited to studies from developed countries. Measurements of temperature and precipitation in low-resource settings such as Sub-Saharan Africa and South Asia are limited by sparse weather station data. However, recent improvements in remote sensing equipment now provide high-precision longitudinal data on climate from areas where some of the world's most vulnerable populations live. We will use the new information to characterize the relationships and hypothesize some pathways linking temperature to child mortality. We expect to expand this work to air pollution as well. 

We explore whether cognitive decline in working years has a causal impact on retirement age. To do so, we use the HRS cohort and apply an instrumental variable approach with a genetic risk score as an instrument (referred to as a Mendelian Randomization approach). After demonstrating that the genetic risk score meets reasonable criteria to be used as an instrument, we find that, though the study is underpowered, there is suggestive evidence that early forms of cognitive decline may indeed be causally related to earlier age of retirement. Plans are in motion to expand the study in a large data sample with more statistical power.

Using the Alcoa data, this project seeks to characterize trajectories of periods of work, disability and leave across their entire working histories of over 40,000 workers. It also explores how these trajectories are associated with demographic characteristics, working conditions and health conditions. To do so, we employ two techniques. We use sequence analysis to group workers across common trajectories of work and disability and describe demographic and job- specific characteristics associated with these trajectories. Results show that while the majority of workers experience little to no disruption in their working life, nearly one third experience more than one episode of disability, with a majority experiencing a number of disability episodes. We also find suggestive evidence of selection out of difficult manual jobs early in a worker’s employment.

Our project addresses the important question of how legal status of immigrant parents impacts the health of U.S. children in immigrant families. This question has important national implications, and explores critical policy concerns: interest in assessing the effect of legal status and administrative relief policies on immigrant integration; conducting innovative analyses of new data as well as in-depth qualitative interviews; and a multi-disciplinary team utilizing different approaches from economics, political science, sociology and public health. We believe that this project can both advance our shared knowledge of the effects of immigration policy on immigrant children, and strengthen the data and methods of social science research. 

We use a unique data linkage to combine social and economic contextual data on early life state of residence, work environment, along with current census tract, current state and current county for 23,488 United States blue and white-collar Alcoa workers that were observed between 1996 and 2012. The health outcome of focus is prevalence of hypertension assessed using medical claims data. Using three different modeling techniques, our findings support additional attention towards the importance of both early life state context and workplace context as important risk factors for incident hypertension in working age adults. 

Using the data in Center for Policy, Outcomes, and Prevention (CPOP) and newly acquired access to school records, this project will assess the relationships between health at birth and early life and subsequent school performance. The study aims to determine remediable factors—social and medical—for which there may be promising interventions to ameliorate widening educational disparities.

Because of rapid introduction of women into the U.S. workplace since the 1960’s, there is far less known about the health impacts of work on women than men. The Women’s Health Initiative is an enormous cohort of women, initially recruited to study the impact of hormones on menopause and subsequent health-- with over 100,000 still alive and under regular observation. Among the many ongoing studies at Stanford and elsewhere, a local team is using the work histories to explore this important life stage for women.