Applying a historically informed multilevel perspective to Robinson's profoundly influential study, we demonstrate that meaningful analysis of individual-level relationships requires attention to substantial heterogeneity in state characteristics. The implication is that perils are posed by not only ecological fallacy but also individualistic fallacy. Multilevel thinking, grounded in historical and spatiotemporal context, is thus a necessity, not an option.

This study assesses the prevalence and determinants of postpartum depression (PPD). 396 women delivering in Beirut and a rural area (Beka'a Valley) were interviewed 24 hours and 3-5 months after delivery. During the latter visit, they were screened using the Edinburgh postnatal depression scale. The overall prevalence of PPD was 21% but was significantly lower in Beirut than the Beka'a Valley (16% vs. 26%). Lack of social support and prenatal depression were significantly associated with PPD in both areas, whereas stressful life events, lifetime depression, vaginal delivery, little education, unemployment, and chronic health problems were significantly related to PPD in one of the areas. Prenatal depression and more than one chronic health problem increased significantly the risk of PPD. Caesarean section decreased the risk of PPD, particularly in Beirut but also in the Beka'a Valley. Caregivers should use pre- and postnatal assessments to identify and address women at risk of PPD.

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Objective-To test whether reported associations between race/ethnicity and breast cancer estrogen receptor (ER) status are inflated due to missing ER data, lack of socioeconomic data, and use of the odds ratio (OR) rather than the prevalence ratio (PR).Methods-We geocoded and added census tract socioeconomic data to all cases of primary invasive breast cancer (n = 42,420) among women diagnosed between 1998 and 2002 in two California cancer registries (San Francisco Bay Area; Los Angeles County) and analyzed the data using log binomial regression.Results-Adjusting for socioeconomic position and tumor characteristics, in models using the imputed data, reduced the PR for the black versus white excess risk of being ER− from 1.76 (95% CI: 1.66, 1.86; adjusted for age and catchment area) to 1.47 (95% CI: 1.38, 1.56). The latter parameter estimate was 16% greater (i.e., 1.56) in models excluding women with missing ER data, and was 43% greater when estimated using the OR (i.e., 1.82). Conclusion(s)-Studieson race/ethnicity and ER status that fail to account for missing data and socioeconomic data and report the OR are likely to yield inflated estimates of racial/ethnic disparities in ER status. KeywordsBreast cancer estrogen receptor status; Health disparities; Epidemiology; Race/ethnicity; Socioeconomic position; Poverty; Black; Hispanic; Asian and Pacific Islander An apparent scientific consensus holds that US racial/ethnic groups intrinsically have disparate distributions of breast cancer estrogen receptor (ER) status, with white women purported to have the highest prevalence-and black women the lowest-of ER-positive (ER+) tumors Correspondence to: Nancy Krieger. NIH Public Access NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript [1][2][3][4]. Nevertheless, studies on this topic are affected by several limitations. Among US epidemiologic investigations designed to explore associations between race/ethnicity and ER status, virtually all of the 19 studies reporting positive associations (usually crude): (a) relied on medical records for ER status data, (b) had a high percentage of missing data on ER status (upwards of 10-20% or more), with the data most likely to be missing for women of color (largely if not solely comprised of black women), and (c) included little or no socioeconomic data [3,[5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. By contrast, the 9 studies reporting no association between race/ethnicity and ER status typically: (a) relied on laboratory assays performed specifically for the study, (b) had little or no missing data on ER status (0-3%), and (c) controlled for socioeconomic position, and also reported associations between socioeconomic position and ER status [21][22][23][24][25][26][27][28][29]. Thus, significant associations between race/ethnicity and breast cancer ER status (chiefly comparing US black to white women) derive chiefly from studies with a relatively high degree of missing data on ER status and no socioeconomic data.If the data on ER sta...