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Research on Determinants of Women’s Health

Improvements in women’s health require an understanding of the determinants of disease, functioning, and well-being and the capacity to intervene in connection with the determinants. Intervention can occur at any level from cells to communities. Some determinants are linked to specific disorders; others have broad effects. Addressing common determinants of multiple diseases increases the potential for a greater overall influence on women’s health.

Several models have been developed to illustrate determinants of population health. Although they are not specific to women, they are useful for describing the variety of factors in women’s health. Models of determinants of health have generally distinguished individual-level characteristics (such as biologic and physiologic factors and health-related behaviors) from the broader determinants (such as environmental and social determinants) in which the individual-level characteristics develop and are expressed. There is some variability among models with regard to labeling determinants of health and the organizing frameworks for determinants (Dahlgren and Whitehead, 1991; Evans and Stoddart, 1990; IOM, 2000a), but in general, biologic and physiologic, or “downstream,” determinants of health are identified as modifiable through complex pathways by proximal determinants (such as drugs, surgical interventions, and health behaviors) and “upstream” determinants (such as social and economic policies).

To organize its review of research on the determinants of women’s health, the committee adopted a model of health determinants similar to that described in The Future of the Public’s Health in the 21st Century (IOM, 2002a). Adapted from Dahlgren and Whitehead (1991), the model (see Figure 2-1) is consistent with this committee’s approach that determinants of health encompass biologic, behavioral, and social factors. In addition this model acknowledges the interac



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2 Research on Determinants of Women’s Health Improvements in women’s health require an understanding of the determi - nants of disease, functioning, and well-being and the capacity to intervene in connection with the determinants. Intervention can occur at any level from cells to communities. Some determinants are linked to specific disorders; others have broad effects. Addressing common determinants of multiple diseases increases the potential for a greater overall influence on women’s health. Several models have been developed to illustrate determinants of population health. Although they are not specific to women, they are useful for describing the variety of factors in women’s health. Models of determinants of health have gen - erally distinguished individual-level characteristics (such as biologic and physi - ologic factors and health-related behaviors) from the broader determinants (such as environmental and social determinants) in which the individual-level char- acteristics develop and are expressed. There is some variability among models with regard to labeling determinants of health and the organizing frameworks for determinants (Dahlgren and Whitehead, 1991; Evans and Stoddart, 1990; IOM, 2000a), but in general, biologic and physiologic, or “downstream,” determinants of health are identified as modifiable through complex pathways by proximal determinants (such as drugs, surgical interventions, and health behaviors) and “upstream” determinants (such as social and economic policies). To organize its review of research on the determinants of women’s health, the committee adopted a model of health determinants similar to that described in The Future of the Public’s Health in the st Century (IOM, 2002a). Adapted from Dahlgren and Whitehead (1991), the model (see Figure 2-1) is consistent with this committee’s approach that determinants of health encompass biologic, behavioral, and social factors. In addition this model acknowledges the interac - 

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 WOMEN’S HEALTH RESEARCH a Over the life span b Living and working conditions may include: • Psychosocial factors • Employment status and occupational factors • Socioeconomic status (income, education, occupation) • The natural and built c environments • Public health services • Health care services FIGURE 2-1 A guide to thinking about the determinants of population health. The model was originally adapted from Dahlgren and Whitehead (1991). The dotted lines between levels of the model denote interaction effects between and among the various levels of health determinants. aSocial conditions include economic inequality, urbanization, mobility, cultural values, and attitudes and policies related to discrimination and intolerance on the basis of race, sex, and other differences. Although race is an individual characteristic, its influence on health is strongly influenced by the social context of race. bOther conditions at the national level might include major sociopolitical shifts, such as FIGURE 2-1: recession, war, and government collapse. cThe built environment includes transportation, water and sanitation, housing, and other dimensions of urban planning. SOURCE: IOM (2002a). tion between and among the various levels of health determinants. The organizing framework includes the following determinants of health: • innate traits and characteristics; • individual behavior;

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 RESEARCH ON DETERMINANTS OF WOMEN’S HEALTH • social, family, and community relationships and networks; • living and working conditions; and • societal, economic, cultural, and environmental policies and conditions. Some determinants may operate at more than one level, and most health outcomes will be related to determinants from more than one level of the model. The model is consistent with the committee’s belief that quality of life is a particularly important component of women’s health. The determinant-based framework has advantages over a strictly disease-based framework in that it more readily allows consideration of functioning, wellness, and quality of life in addition to the understanding, detecting, and treating of diseases. It also allows discussion of interventions that can occur at the individual, community, and population levels, and how determinants are related to health across a woman’s life span. This chapter presents evidence of the impact of a number of behavioral fac - tors (smoking, eating habits and physical activity, sexual risk behavior, and alco- hol use), social and community factors (violence against girls and women, social connections and stress, and social disadvantage), and societal factors (cultural factors and health care) that affect women’s health. Those factors are discussed as examples of factors that affect women’s health and should not be considered a comprehensive list of determinants of women’s health. Biologic determinants are discussed in Chapter 3 in the context of their roles in specific diseases. BEHAVIORAL FACTORS In the last 20 years, there has been substantial progress in understanding how behavior affects people’s health, including the health of women and girls. Research has identified modifiable risk factors for a variety of health outcomes and has led to a better understanding of the level at which behavior leads to im - provements in or deterioration of health. Human behavior is one of the biggest contributors to death and disease (McGinnis and Foege, 1993; McGinnis et al., 2002). With respect to US women, for example, substantial numbers of deaths have been attributed to smoking, physical inactivity, and dietary factors, which are preventable (Figure 2-2). As discussed in the Institute of Medicine (IOM) re - port Health and Behaior: The Interplay of Biological, Behaioral, and Societal Influences, the extent to which a given behavior affects health varies during the course of life (IOM, 2001a), and life span and stage of development are important to consider. Several IOM reports have also discussed strategies for modifying behavioral norms to improve the health of specific populations (IOM, 2000b, 2005a,b, 2010). This section discusses research on behavioral factors that are major contributors to morbidity and mortality among women: smoking, eating habits and physical activity, sexual risk behavior, and alcohol use.

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 WOMEN’S HEALTH RESEARCH Deaths attributable to individual risks (thousands) in women –50 50 150 250 High blood pressure Smoking Physical inactivity Overweight-obesity (high BMI) High blood glucose Cardiovascular High dietary sodium (salt) Cancer High LDL cholesterol Low dietary omega-3 fatty acids (seafood) Diabetes High dietary trans fatty acids Respiratory Low intake of fruits and vegetables Other NCDs Alcohol use Low PUFA (in place of SFA) Injury FIGURE 2-2 Deaths in women attributable to total effects of individual risk factors, by disease. Data are for all women and do not reflect differences across racial, ethnic, and socioeconomic groups. Figure 2-2.eps ABBREVIATIONS: BMI, body-mass index; LDL, low-density lipoproteins; NCD, non- communicable disease; PUFA, polyunsaturated fatty acid; SFA, saturated fatty acid. SOURCE: Danaei et al. (2009). Smoking The US surgeon general issued reports outlining the state of the evidence on the health consequences of smoking and progress in understanding the factors that influence smoking by women and girls in 1980 (HHS, 1980) and 2001 (HHS, 2001). Hundreds of observational studies conducted since the 2001 surgeon general’s report have been published and have added substantially to the knowl- edge base on smoking by women and girls and have helped to improve women’s health. In 2007, about one-fifth of US women 18 years old or older were current smokers1 (CDC, 2008a). Smoking has been declining in both women and men in recent decades, but the rate of decline has been slower in women. Similarly, declines in lung-cancer deaths have been slower in women than in men. Vulnerable Populations Smoking is strongly associated with socioeconomic status (Dube et al., 2009). The prevalence of smoking is over 3 times as high in women who have 9–11 years of education (33.6%) as in women who have an undergraduate degree 1 Definedas “those who smoked more than 100 cigarettes in their lifetime and now smoke every day or some days” (CDC, 2008a).

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 RESEARCH ON DETERMINANTS OF WOMEN’S HEALTH (9.7%). The difference by education is even greater in pregnant women: 25.5% in pregnant women who have 9–11 years of education vs 2.2% in college graduates. Similarly, smoking is higher in women who live below the poverty level (31.7%) than in those living at or above the poverty level (17.0%). American Indian or Alaskan native women are more likely to smoke (22.4%) than women who are white (20.6%), black (17.8%), or Hispanic (10.7%); Asian American or Pacific Islanders (4.7%) are the least likely to do so (Dube et al., 2009). Health Consequences of Smoking Research has painted an increasingly bleak picture of the health conse- quences of smoking in women and girls. As is true for the US population as a whole, tobacco use is the leading cause of preventable death in women. Smoking substantially increases women’s risk of a number of cardiovascular outcomes, in- cluding coronary heart disease and stroke (Bermudez et al., 2002; Kawachi et al., 1993; Stampfer et al., 2000). In women who smoke and use oral contraceptives, the risk of heart attack is even greater; the risk of heart attack is increased by as much as a factor of 30 and the risk of stroke by a factor of 3 compared with the risk in nonsmokers who use oral contraceptives (Burkman et al., 2004). Smoking is the major cause of lung cancer in women, with about 80% of lung cancers in women attributable to smoking. In 1987 lung cancer surpassed breast cancer to become the leading cause of cancer deaths in women (HHS, 2004; RWJF, 2009). Observational studies have established that smoking also increases the risk of cancers of the larynx, oral cavity and esophagus, stomach, bladder, kidneys, and pancreas (HHS, 1980, 2001, 2004). For women specifically, smoking results in increased risk of cancers of the cervix and vulva and of such gynecologic and reproductive complications as menstrual problems, reduced fertility, and prema - ture menopause (Gold et al., 2001; Laurent et al., 1992; Luborsky et al., 2003). Postmenopausal women who smoke experience accelerated loss of bone mass, which may put them at increased risk for osteoporosis and hip fracture (HHS, 2001, 2004; Law and Hackshaw, 1997).2 Smoking during pregnancy can result in placental abruption and previa (CDC, 2007a; HHS, 2001; RWJF, 2009). Research on Smoking Initiation, Prevention, and Interventions Since the late 1960s the tobacco industry has targeted women and girls by using specific cigarette brands and marketing techniques (RWJF, 2009).3 The US surgeon general’s reports on women and smoking and more recent reports by the 2 For a fuller list of the health consequences of smoking for women and girls, see HHS (2001, 2004). 3 In 1968, Philip Morris introduced Virginia Slims, the first female-specific brand of cigarette (RWJF, 2009).

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0 WOMEN’S HEALTH RESEARCH National Cancer Institute, the Robert Wood Johnson Foundation, and others have described tobacco companies’ use of themes of associations between smoking and social desirability, independence, and weight control to target adolescent girls, who are at an impressionable age (HHS, 1980, 2001; NCI, 2008; RWJF, 2009). Such targeted marketing has been identified as a reason that lung cancer–death rates initially increased and then have been slower to decline in women than in men in recent years (Jemal et al., 2008; RWJF, 2009). The large majority of women who smoke, as with men, began doing so dur- ing adolescence; this is cause for concern because risks of many of the health consequences of smoking are a function of the duration (years smoked), in addi - tion to intensity (cigarettes per day) of use (Flanders et al., 2003; Hegmann et al., 1993; Terry and Rohan, 2002). Most interventions to prevent smoking initiation, therefore, have targeted adolescents. Interventions have included school-based or health-care–based educational and informational programs, environmental and policy change interventions that restrict tobacco advertising and youth access to tobacco products, smoking bans, and taxation of tobacco products (IOM, 2009a). Several interventions have been found to reduce youth smoking but, as discussed in a report of the surgeon general in 2001, little systematic effort has been focused on developing and evaluating prevention interventions specifically in girls (HHS, 2001), and more research on differences in smoking cessation for girls and boys is needed (Thorner et al., 2007). The Department of Health and Human Services report Treating Tobacco Use and Dependence: 00 Update concluded that women benefit from the same interventions as men but that the data are mixed as to whether they benefit by the same magnitude. The smoking quit ratio—proportion of ever smokers who are now former smokers—has increased in both men and women, but women have consistently had lower quit ratios (Gritz et al., 1996). Several factors are associated with poorer cessation outcomes in women and girls: being less ready to stop smoking; being more addicted to cigarettes, as indicated by the smoking of more cigarettes per day; having less confidence in resisting temptation; hav - ing less social support; and socioeconomic disadvantages (being unemployed and having less education and lower employment) (HHS, 2001). Psychosocial interventions—including telephone counseling, individually tailored followup, and advice to quit geared toward children’s health—are effective in women smokers (HHS, 2008a). Weight gain is associated with smoking cessation (Caan et al., 1996; Flegal et al., 1995), and is often of concern to women (Copeland et al., 2006). There is some evidence that exercise is effective in reducing weight gain after smoking cessation in women, but the findings are not consistent (HHS, 2008a). Several pharmacologic aids have been developed in the last 25 years to help smokers quit and to help prevent relapse by reducing cigarette cravings and with- drawal symptoms. A few trials have compared the benefit of the aids in women and men. In the overall population, nicotine-replacement therapies (NRTs), such

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 RESEARCH ON DETERMINANTS OF WOMEN’S HEALTH as the nicotine patch and chewing gum, double the odds of quitting smoking relative to placebo (Silagy et al., 2004). Although NRTs appear to lead to higher cessation rates in women than placebo especially when combined with cessation counseling (Reynoso et al., 2005), there is some evidence that NRTs are more efficacious in men than in women. In part because of concerns about exposure of the fetus to NRTs, few studies have tested NRTs in pregnant women (see for example, HHS, 2008a; Schnoll et al., 2007). Pregnancy appears to be a time of high motivation for many women to quit smoking, but relapse often occurs after birth (Reichert et al., 2004). In the health-care setting, multipronged psychosocial interventions (for example, a combination of pregnancy-specific self-help materials and counseling with a health educator) have been found to be significantly effective in getting women to quit smoking during pregnancy. Psychosocial interventions for postpartum abstinence from smoking had positive but nonsignificant effects (HHS, 2008a). Spousal support for quitting, including the spouse’s own change in smoking, is particularly helpful (HHS, 2004). Partner smoking is associated with continued smoking by women during pregnancy; this suggests the need for partner-fo - cused interventions along with interventions for pregnant women themselves (DiClemente et al., 2000). Eating Habits and Physical Activity The prevalence of obesity, defined as a body-mass index (BMI) of 30 or more, in the United States has more than doubled in the last 3 decades, with increases seen in women, men, and children (Flegal et al., 2002; Mokdad et al., 1999; Ogden et al., 2006; Sturm, 2003). More than one-third of US adults were obese and more than two-thirds of adults were either obese or overweight (BMI 25–29.9) in 2007–2008 (Flegal et al., 2010). Class 3 or extreme obesity, which has been defined as a BMI of 40 or more, is associated with an increased risk of all-cause mortality and comorbidities. The prevalence of Class 3 obesity more than doubled in women between the early 1990s and 2000, and in 2000 was 2.8%, which was about twice as high as in men. The prevalence was highest in black women (6%) and those without a high-school education (Freedman, 2002). Re - cent data from the National Health and Nutrition Examination Survey (NHANES) provide some evidence that the rate of increase in obesity is slowing, particularly in women. Unlike the increases seen between 1976–1980 and 1988–1994, and between 1988–1994 and 1999–2000, “the prevalence of obesity showed no sta - tistically significant changes over the 10-year period from 1999 through 2008” (Flegal et al., 2010). Eating habits and physical activity are the primary drivers of weight; over- consumption of calories and insufficient physical activity are fueling high rates of people who are overweight or obese (Patrick et al., 2004; Weinsier et al., 1998). Calorie consumption has increased over the past 4 decades, in part from larger

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 WOMEN’S HEALTH RESEARCH portion sizes, increased consumption of high-sugar and high-fat foods, increased consumption of high-calorie and low-nutrient food and beverages (for example, sodas), and increased eating out (Levi et al., 2009). Over the past 5 decades, physical activity has decreased with Americans walking less, having less time to exercise in part from longer working hours and longer commutes, and reduced physical demands of work, household management, and travel (Levi et al., 2009). In addition, the built environment4 can “facilitate or constrain physical activity” (NRC, 2005), and many people live in areas that facilitate driving rather than walking, or in areas where parks and recreational facilities are not considered safe (Levi et al., 2009). Substantial headway has been made over the last 20 years in understanding how eating habits and physical activity affect the health of women. Whereas prior evidence came largely from studies of men, several large US cohort stud - ies of women—such as the Nurses’ Health Study, the Women’s Health Initiative (see Box 2-1 for a brief description), the Women’s Health Study, and the Black Women’s Health Study—have resulted in a vast literature on the roles of eating habits and physical activity in women’s health (Hu et al., 2001; Martinez et al., 1997). That research has informed the design of interventions to increase physical activity and improve eating habits in women and girls. Much more is known about determinants of being overweight and obese, but there is still a lack of effective interventions. Although the rate of increase in obesity has decreased, the prevalence of obesity doubled in the last 2 decades (Flegal et al., 2002; Mokdad et al., 1999; Sturm, 2003); in 2001–2004, more than one-third of US adults were obese (BMI, over 30), and two-thirds were overweight or obese (BMI, 25–29.9) (Ogden et al., 2006). According to a self-report survey of adults conducted in 2007, 40% of US women did not meet the 00 Physical Actiity Guidelines for Americans for adequate physical activity (CDC, 2008b),5 despite the documented health benefits of physical activity. The eating habits of women in the United States are also far from optimal. For example, less than one-third of women in 2005 met recom- mendations to eat five or more servings of fruits and vegetables per day (CDC, 2007b). It is a reflection of the poor diets and lack of physical activity of most 4The built environment is “defined broadly to include land use patterns, the transportation system, and design features that together provide opportunities for travel and physical activity. Land use patterns refer to the spatial distribution of human activities. The transportation system refers to the physical infrastructure and services that provide the spatial links or connectivity among activities. Design refers to the aesthetic, physical, and functional qualities of the built environment, such as the design of buildings and streetscapes, and relates to both land use patterns and the transportation system” (NRC, 2005). 5According to the guidelines, the minimum recommended aerobic physical activity required to produce substantial health benefits in adults is 150 minutes of moderate-intensity activity, or 75 min - utes of vigorous-intense activity, or an equivalent combination of moderate- and vigorous-intensity physical activity per week (CDC, 2008b).

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 RESEARCH ON DETERMINANTS OF WOMEN’S HEALTH BOX 2-1 General Description of Women’s Health Initiative The Women’s Health Initiative (WHI) was a multi-million-dollar, large prospec- tive clinical study coordinated by the National Heart Lung and Blood Institute. Enrollment of 68,132 postmenopausal women ages 50 to 79 ran from 1993 to 1998. To address some research questions, women were randomized to various studies: (1) a dietary modification arm, which assigned 48,835 women to follow a 20% low-fat eating plan or self-selected diet; (2) a hormone therapy arm consist- ing of conjugated equine estrogen-plus-progestin or placebo for 16,608 women with uterus; or (3) another hormone therapy arm consisting of conjugated equine estrogen-only or placebo for 10,739 women with a hysterectomy. Other WHI studies included 8,050 women who followed both the dietary modification and a hormone therapy, and a calcium and vitamin D study that started 1 year later and included 36,282 of the women. In addition, 93,676 women from the same popula- tion agreed to be in an observational study (Prentice and Anderson, 2008). women that over 60% of women 20 years old and older are overweight or obese (Ogden et al., 2006).6 This can have serious effects on subsequent generations as studies have shown that a child with an obese parent is 60% as likely to become an obese adult (IOM, 2005b; Whitaker et al., 1997). A greater proportion of women than men are obese; the difference is greatest among some racial and ethnic populations (see Figure 2-3) (CDC, 2009a). Non- Hispanic black women (about 53%) and Mexican-American women (about 42%) are more likely to be obese than non-Hispanic white women (about 32%). The percent of obese non-Hispanic Black women is higher (about 61%) in women 60 years old and older (Pan et al., 2009). Physical Activity With some consistency, studies have shown that women engage in less physical activity than do men and that activity declines with age and is lower in nonwhite women (Biddle and Mutrie, 2008). Both girls and women have been found to engage in leisure-time physical activity,7 such as sports and recreational 6 On the basis of data from the NHANES for the period 2003–2006. Definitions: healthy weight = BMI ≥ 18.5 to < 25; overweight = BMI ≥ 25 to < 30; obesity = BMI ≥ 30; and extreme obesity = BMI ≥ 40. 7 Leisure-time physical activity has been measured and defined differently among studies but gener- ally does not include activity in working, in performing household tasks, or in transportation-related activity, such as walking to work.

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 WOMEN’S HEALTH RESEARCH FIGURE 2-3 Prevalence of obesity, defined as a body-mass index (weight [kg]/height [m2]) ≥ 30, in the United States. Prevalence estimates are age-adjusted to the 2000 US Figure 2-3.eps standard population. Age-adjusted percentage of adults 20 years old or older who were obese during 2003–2006 varied by race or ethnicity in women and ranged from 53.3% bitmap of non-Hispanic black women to 41.8% of Mexican American women and 31.6% of non-Hispanic white women. Obesity levels were more similar among Mexican American men (28.8%), non-Hispanic black men (35.0%), and non-Hispanic white men (32.0%). None of the groups had met the Healthy People 00 target of 15% (objective 19-02). Non-Hispanic black and non-Hispanic white include persons who reported only one race and exclude persons of Hispanic ethnicity. Persons of Mexican American ethnicity might be of any race. ¶95% confidence interval. SOURCE: CDC (2009a). activities, less often than their male counterparts, and there is a substantial de - crease in activity in girls during adolescence (Kimm et al., 2002; Sallis et al., 2000; Trost et al., 2002).8 There is some evidence that girls become less active during adolescence because of shifting self-perceptions associated with pubertal development, heightened awareness of peers, and changes in self-esteem (Kimm et al., 2001; Murdey et al., 2004). Findings depend on the type of physical activity assessed. For instance, al - though older women engage in fewer sports and less planned exercise than men, 8 In a 10-year longitudinal study of youth assessed at ages 9–19 years, rates of habitual physical activity among girls (including sports and leisure activities) declined by 83% from year 1 (ages 9–10 years) to year 10 (18–19 years) (Kimm et al., 2002).

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 RESEARCH ON DETERMINANTS OF WOMEN’S HEALTH reported activity levels may increase when household and caregiving activities are considered (Sternfeld et al., 2000). White women and those with more education and income, who generally have more resources and flexibility, are more likely to engage in leisure activities, whereas other groups of women are more likely to be classified as physically active when occupational activity, household activity, and walking for transportation are considered as physical activities (Brownson et al., 2000; Eyler et al., 2002; Sternfeld et al., 1999; Young and Cochrane, 2004). Childbearing and motherhood, especially the early years of raising children, have been identified as common barriers to regular physical activity in women 25–35 years old (Cramp and Brawley, 2006). Whereas in the past it was recom - mended that pregnant women limit strenuous exercise or stop altogether (ACOG, 1985), today, moderate exercise has been established as safe for healthy women and has been shown to reduce gestational diabetes and pre-eclampsia and to help in preventing excess maternal weight gain (Clapp and Little, 1995; Dempsey et al., 2004a; Saftlas et al., 2004; Sorensen et al., 2003). Because of a lack of dis - semination of that evidence, however, some women may remain uncertain about the safety of exercise during pregnancy (Mudd et al., 2009). Indeed, evidence from both retrospective and prospective studies shows that intensity and duration of leisure-time physical activity are lower during pregnancy than before it and lower in the third trimester than in the first (Poudevigne and O’Connor, 2006). There appear to be smaller decreases in household and caregiving activities dur- ing pregnancy (Mottola and Campbell, 2003; Schmidt et al., 2006; Taber-Chasan et al., 2007). One of the strongest determinants of whether a woman will be active during pregnancy is her level of activity during the year before pregnancy; inac- tivity during pregnancy is more common among multiparous women, especially those who are economically disadvantaged or who have less education (Ning et al., 2003; Poudevigne and O’Connor, 2006). In recent years, there has been wide use of ecologic models that emphasize social and environmental influences on physical activity in addition to individual- level influences (Biddle and Mutrie, 2008; King et al., 2002; Spence and Lee, 2003). Evidence from mostly cross-sectional studies shows that attributes of the neighborhood environment—such as availability of recreational facilities and parks, low crime rates, seeing others exercise, less traffic, sidewalks, and street lighting—are associated with more physical activity (Duncan et al., 2005; Humpel et al., 2004; Owen et al., 2004). A recent dissertation on the effect of elementary school policies on physical activity and obesity in children found that the presence of a gymnasium in a school is associated with more time in physical education class and that children from disadvantaged backgrounds are less likely to have a gymnasium, but it did not find a significant correlation between pres - ence of a school gymnasium and rates of being overweight or obese (Fernandes, 2010). Having the recommended time for recess and physical education was as- sociated with a decrease in BMI for boys, but not for girls (Fernandes, 2010).

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