Exploring Assistance in Sweden and the United States

Few international comparisons of health services are performed using microlevel data. Using such data, this paper compares the need for and receipt of assistance with activities of daily living (ADLs) in comparable samples in the United States and Sweden, a country with a universal system of community-based services.Design and Methods: Data from national surveys of community residents completed at approximately the same time in each nation are used to create comparable measures of need and assistance. Descriptive and logistic regression analyses compare need and assistance patterns across the nations and identify individual factors that explain receipt of assistance and unmet needs.Results:Our results indicate that a simple story of greater use of paid formal services in Sweden and more unpaid informal use in the United States masks a more complex relationship. Assistance with ADLs seems to be more targeted in Sweden; narrow differences in assistance widen considerably when the analysis is limited to those reporting need. Implications:Although these two different health systems result in similar levels of overall ADL assistance, a detailed microlevel comparison reveals key distinctions. Further microlevel comparisons of access, cost, and quality in cross-national data can further aid our understanding of the consequences of health policy.

INTEGRATED ASSESSMENT OF ANTHROPOGENIC, CLIMATE, AND POLICY INDUCED CHANGES OF PHOSPHORUS EXPORT IN THE UNITED STATES LAURENTIAN GREAT LAKES WATERSHEDS

Anthropogenic activities have increased phosphorus (P) loading in tributaries to the Laurentian Great Lakes resulting in eutrophication in small bays to most notably, Lake Erie. Changes to surface water quality from P loading have resulted in billions of dollars in damage and threaten the health of the world’s largest freshwater resource. To understand the factors affecting P delivery with projected increasing urban lands and biofuels expansion, two spatially explicit models were coupled. The coupled models predict that the majority of the basin will experience a significant increase in urban area P sources while the agriculture intensity and forest sources of P will decrease. Changes in P loading across the basin will be highly variable spatially. Additionally, the impacts of climate change on high precipitation events across the Great Lakes were examined. Using historical regression relationships on phosphorus concentrations, key Great Lakes tributaries were found to have future changes including decreasing total loads and increases to high-flow loading events. The urbanized Cuyahoga watersheds exhibits the most vulnerability to these climate-induced changes with increases in total loading and storm loading , while the forested Au Sable watershed exhibits greater resilience. Finally, the monitoring network currently in place for sampling the amount of phosphorus entering the U.S. Great Lakes was examined with a focus on the challenges to monitoring. Based on these interviews, the research identified three issues that policy makers interested in maintaining an effective phosphorus monitoring network in the Great Lakes should consider: first, that the policy objectives driving different monitoring programs vary, which results in different patterns of sampling design and frequency; second, that these differences complicate efforts to encourage collaboration; and third, that methods of funding sampling programs vary from agency to agency, further complicating efforts to generate sufficient long-term data to improve our understanding of phosphorus into the Great Lakes. The dissertation combines these three areas of research to present the potential future impacts of P loading in the Great Lakes as anthropogenic activities, climate and monitoring changes. These manuscripts report new experimental data for future sources, loading and climate impacts on phosphorus.

THE RELATIONSHIP BETWEEN OBESITY AND PSYCHOLOGICAL GENERAL WELL-BEING IN UNITED STATES WOMEN

While clinical studies have shown a negative relationship between obesity and mental health in women, population studies have not shown a consistent association. However, many of these studies can be criticized regarding fatness level criteria, lack of control variables, and validity of the psychological variables.^ The purpose of this research was to elucidate the relationship between fatness level and mental health in United States women using data from the First National Health and Nutrition Examination Survey (NHANES I), which was conducted on a national probability sample from 1971 to 1974. Mental health was measured by the General Well-Being Schedule (GWB), and fatness level was determined by the sum of the triceps and subscapular skinfolds. Women were categorized as lean (15th percentile or less), normal (16th to 84th percentiles), or obese (85th percentile or greater).^ A conceptual framework was developed which identified the variables of age, race, marital status, socioeconomic status (education), employment status, number of births, physical health, weight history, and perception of body image as important to the fatness level-GWB relationship. Multiple regression analyses were performed separately for whites and blacks with GWB as the response variable, and fatness level, age, education, employment status, number of births, marital status, and health perception as predictor variables. In addition, 2- and 3-way interaction terms for leanness, obesity and age were included as predictor variables. Variables related to weight history and perception of body image were not collected in NHANES I, and thus were not included in this study.^ The results indicated that obesity was a statistically significant predictor of lower GWB in white women even when the other predictor variables were controlled. The full regression model identified the young, more educated, obese female as a subgroup with lower GWB, especially in blacks. These findings were not consistent with the previous non-clinical studies which found that obesity was associated with better mental health. The social stigma of being obese and the preoccupation of women with being lean may have contributed to the lower GWB in these women. ^

Ethical Consumption and Social Context: Experimental Evidence from Germany and the United States

This research examines the role of social context in ethical consumption, specifically, the extent to which anonymity and social control influence individuals' decisions to purchase organic and Fair Trade coffee. Our research design overcomes biases of prior research by combining framing and discrete choice experiments in a survey. We systematically vary coffee growing method (organic or not), import status (Fair Trade or not), flavor, and price across four social contexts that vary in degree of anonymity and normative social control. The social contexts are buying coffee online, in a large grocery store, in a small neighborhood shop, and for a meeting of a human rights group. Subjects comprise 1,103 German and American undergraduate students. We find that social context indeed influences subjects' ethical consumer decisions, especially in situations with low anonymity and high social control. In addition, gender, coffee buying, and subjective social norms trigger heterogeneity regarding stated ethical consumption and the effects of social context. These results suggest previous research has underestimated the relevance of social context for ethical consumption and overestimated altruistic motives of ethical consumers. Our study demonstrates the great potential of discrete choice experiments for the study of social action and decision making processes in sociology.

Representing Afghanistan: The United States and Democracy's Imposition

There is an ongoing mission in Afghanistan; a mission driven by external political forces. At its core this mission hopes to establish peace, to protect the populace, and to install democracy. Each of these goals has remained just that, a goal, for the past eight years as the American and international mission in Afghanistan has enjoyed varied levels of commitment. Currently, the stagnant progress in Afghanistan has led the international community to become increasingly concerned about the viability of a future Afghan state. Most of these questions take root in the question over whether or not an Afghan state can function without the auspices of international terrorism. Inevitably, the normative question of what exactly that government should be arises from this base concern. In formulating a response to this question, the consensus of western society has been to install representative democracy. This answer has been a recurring theme in the post Cold War era as states such as Bosnia and Somalia bear witness to the ill effects of external democratic imposition. I hypothesize that the current mold of externally driven state-building is unlikely to result in what western actors seek it to establish: representative democracy. By primarily examining the current situation in Afghanistan, I claim that external installation of representative democracy is modally flawed in that its process mandates choice. Representative democracy by definition constitutes a government reflective of its people, or electorate. Thus, freedom of choice is necessary for a functional representative democracy. From this, one can deduce that because an essential function of democracy is choice, its implementation lies with the presence of choice. State-building is an imposition that eliminates that necessary ingredient. The two stand as polar opposites that cannot effectively collaborate. Security, governing capacity, and development have all been targeted as measurements of success in Afghanistan. The three factors are generally seen as mutually constitutive; so improved security is seen as improving governing capacity. Thus, the recent resurgence of the Taliban in Afghanistan and a deteriorating security environment moving forward has demonstrated the inability of the Afghan government to govern. The primary reason for the Afghan government’s deficiencies is its lack of legitimacy among its constituency. Even the use of the term ‘constituency’ must be qualified because the Afghan government has often oscillated between serving the people within its territorial borders and the international community. The existence of the Afghan state is so dependent on foreign aid and intervention that it has lost policy-making and enforcing power. This is evident by the inability of Afghanistan to engage in basic sovereign state activities as maintaining a national budget, conducting elections, providing for its own national security, and deterring criminality. The Afghan state is nothing more than a shell of a government, and indicative of the failings that external state-building has with establishing democracy.

The medical malpractice insurance "crises" and federal medical malpractice tort reform: Collection and analysis of bills passed by the United States House of Representatives from 1995--2005

There have been three medical malpractice insurance "crises" in the United States over a time spanning roughly the past three decades (Poisson, 2004, p. 759-760). Each crisis is characterized by a number of common features, including rapidly increasing medical malpractice insurance premiums, cancellation of existing insurance policies, and a decreased willingness of insurers to offer or renew medical malpractice insurance policies (Poisson, 2004, p. 759-760). Given the recurrent "crises," many sources argue that medical malpractice insurance coverage has become too expensive a commodity—one that many physicians simply cannot afford (U.S. Department of Health and Human Services [HHS], 2002, p. 1-2; Physician Insurers Association of America [PIAA], 2003, p. 1; Jackiw, 2004, p. 506; Glassman, 2004, p. 417; Padget, 2003, p. 216). ^ The prohibitively high cost of medical liability insurance is said to limit the geographical areas and medical specializations in which physicians are willing to practice. As a result, the high costs of medical liability insurance are ultimately said to affect whether or not people have access to health care services. ^ In an effort to control the medical liability insurance crises—and to preserve or restore peoples' access to health care—every state in the United States has passed "at least some laws designed to reduce medical malpractice premium rates" (GAO, 2003, p.5-6). More recently, however, the United States has witnessed a push to implement federal reform of the medical malpractice tort system. Accordingly, this project focuses on federal medical malpractice tort reform. This project was designed to investigate the following specific question: Do the federal medical malpractice tort reform bills which passed in the House of Representatives between 1995 and 2005 differ in respect to their principle features? To answer this question, the text of the bills, law review articles, and reports from government and private agencies were analyzed. Further, a matrix was compiled to concisely summarize the principle features of the proposed federal medical malpractice tort reform bills. Insight gleaned from this investigation and matrix compilation informs discussion about the potential ramifications of enacting federal medical malpractice tort reform legislation. ^

Hormonal exposure and risk of pancreatic cancer in the United States

Background. In the United States, the incidence of pancreatic cancer has increased; more than 37,000 new cases of pancreatic cancer were diagnosed in the year 2007. Overall, the five-year survival rate is about 5% and pancreatic cancer ranks the fourth leading cause of cancer-related mortality among men and women. Despite the observed progress in cancer diagnosis and treatment, pancreatic cancer remains an unresolved significant public health problem in the United States. Familial pancreatic cancer has been confirmed to be responsible for approximately 10% of pancreatic cancer cases. However, 90% are still without known inherited predisposition. Until now, the role of oral contraceptive pills (OCPs) and hormonal replacement therapy (HRT) among women with pancreatic cancer remain unclear. We examined the association of exogenous hormonal uses in US women with risk of pancreatic cancer. ^ Methods. This was an active hospital-based case-control study which is conducted at the department of gastrointestinal medical oncology in The University of Texas M.D. Anderson Cancer Center. Between January 2005 and December 2007, a total of 287 women with pathologically confirmed pancreatic cancer (cases) and 287 healthy women (controls) were included in this investigation. Both cases and controls were frequency matched by age and race. Information about the use of hormonal contraceptives and hormonal replacement therapy (HRT) preparations as well as information about several risk factors of pancreatic cancer were collected by personal interview. Univariate and multivariate analyses were performed in this study to analyze the data. ^ Results. We found a statistical significant protective effect for use of exogenous hormone preparations on pancreatic cancer development (adjusted odds ratio [AOR], 0.4; 95% confidence interval [CI], 0.2–0.8). In addition, a 40% reduction in pancreatic cancer risk was observed among women who ever used any of the contraceptive methods including oral contraceptive pills (AOR, 6; 95% CI, 0.4–0.9). ^ Conclusions. Consistent with previous studies, the use of exogenous hormone preparations including oral contraceptive pills may confers a protective effect for pancreatic cancer development. More studies are warranted to explore for the underlying mechanism of such protection.^

Latino perceptions of and barriers to preventive healthcare maintenance in the southwest United States

Between the 1990 and 2000 Censuses, the Latino population accounted for 40% of the increase in the nation’s total population. The growing population of Latinos underscores the importance for understanding factors that influence whether and how Latinos take care of their health. According to the U.S. Department of Human Health Service’s Office of Minority Health (OMH), Latinos are at greater risk for health disparities (2003). Factors such as lack of health insurance and access to preventive care play a major role in limiting Latino use of primary health care (Institute of Medicine, 2005). Other significant barriers to preventive health care maintenance behaviors have been identified in current literature such as primary care physician interaction, self-perceived health status, and socio-cultural beliefs and traditions (Rojas-Guyler, King, Montieth and 2008; Meir, Medina, and Ory, 2007; Black, 1999). Despite these studies, there remains less information regarding interpersonal perceptions, environmental dynamics and individual and cultural attitudes relevant to utilization of healthcare (Rojas-Guyler, King, Montieth and 2008; Aguirre-Molina, Molina and Zambrana, 2001). Understanding the perceptions of Latinos and the barriers to health care could directly affect healthcare delivery. Improved healthcare utilization among Latinos could reduce the long term health consequences of many preventable and manageable diseases. The purpose of this study was to explore Latino perceptions of U.S. health care and desired changes by Latinos in the U.S. healthcare system. The study had several objectives, including to explore perceived barriers to healthcare utilization and the resulting effects on health among Latinos, to describe culturally influenced attitudes about health care and use of health care services among Latinos, and to make recommendations for reducing disparities by improving healthcare and its utilization. The current study utilized data that were collected as part of a larger study to examine multidimensional, cross-cultural issues relevant to interactions between healthcare consumers and providers. Qualitative methods were used to analyze four Spanish-language focus group transcripts to interpret cultural influences on perceptions and beliefs among Latinos. Direct coding of transcript content was carried out by two reviewers, who conducted independent reviews of each transcript. Team members developed and refined thematic categories, positive and negative cases, and example text segments for each theme and sub-theme. Incongruities of interpretations were resolved through extensive discussion. Study participants included 44 self-identified Latino adults (16 male, 28 female) between age 18 and 64 years. Thirty seven (84.1%) of the participants were immigrants. The study population comprised eight ethnic subgroups. While 31% of the participants reported being employed on a full-time basis, only 18.4% had medical insurance that was private or employee sponsored. Five major themes regarding the perceptions and healthcare utilization behaviors of Latinos were consistent across all focus groups and were identified during the analysis. These were: (1) healthcare utilization, experience, and access; (2) organizational and institutional systems; (3) communication and interpersonal interactions between healthcare provider, staff, and patient; (4) Latinos’ perception of their own health status; (5) cultural influences on healthcare utilization, which included an innovation termed culturally-bound locus of control. Healthcare utilization was directly influenced by healthcare experience, access, current health status, and cultural factors and indirectly influenced by organizational systems. There was a strong interdependence among the main themes. The ability to communicate and interact effectively with healthcare providers and navigate healthcare systems (organizational and institutional access) significantly influenced the participant’s health care experience, most often (indirectly) impacting utilization negatively. ^ Research such as this can help to identify those perceptions and attitudes held by Latinos concerning utilization or underutilization of healthcare systems. These data suggest that for healthcare utilization to improve among Latinos, healthcare systems must create more culturally competent environments by providing better language services at the organizational level and more culturally sensitive providers at the interpersonal level. Better understanding of the complex interactions between these impediments can aid intervention developments, and help health providers and researchers in determining appropriate, adequate, and effective measurers of care to better increase overall health of Latinos.^

Determining the association between nativity status and mammography utilization among women in the United States using 2000 and 2005 NHIS data

Objective. To determine the association between nativity status and mammography utilization among women in the U.S. and assess whether demographic variables, socioeconomic factors healthcare access, breast cancer risk factors and acculturation variables were predictors in the relationship between nativity status and mammography in the past two years. ^ Methods. The NHIS collects demographic and health information using face-to-face interviews among a representative sample of the U.S. population and a cancer control module assessing screening behaviors is included every five years. Descriptive statistics were used to report demographic characteristics of women aged 40 and older who have received a mammogram in the last 2 years from 2000 and 2005. We used chi square analyses to determine statistically significant differences by mammography screening for each covariate. Logistic regression was used to determine whether demographic characteristics, socioeconomic characteristics, healthcare access, breast cancer risk factors and acculturation variables among foreign-born Hispanics affected the relationship between nativity status and mammography use in the past 2 years. ^ Results. In 2000, the crude model between nativity and mammography was significant but results were not significant after adjusting for health insurance, access and reported health status. Significant results were also reported for years in U.S. and mammography among foreign-born born women. In 2005, the crude model was also significant but results were not significant after adjusting for demographic factors. Furthermore, there was a significant finding between citizenship and mammography in the past 2 years. ^ Conclusions. Our study contributes to the literature as one of the first national-based studies assessing mammography in the past two years based on nativity status. Based on our findings, health insurance and access to care is an important predictor in mammography utilization among foreign-born women. For those with health care access, physician recommendation should further be assessed to determine whether women are made aware of mammography as a means to detect breast cancer at an early stage and further reduce the risk of mortality from the breast cancer.^

Policy implications of public health workforce development for disaster preparedness in the United States

Public health efforts were initiated in the United States with legislative actions for enhancing food safety and ensuring pure drinking water. Some additional policy initiatives during the early 20th century helped organize and coordinate relief efforts for victims of natural disasters. By 1950's the federal government expanded its role for providing better health and safety to the communities, and its disaster relief activities became more structured. A rise in terrorism related incidents during the late 1990's prompted new proactive policy directions. The traditional policy and program efforts for rescue, recovery, and relief measures changed focus to include disaster preparedness and countermeasures against terrorism.^ The study took a holistic approach by analyzing all major disaster related policies and programs, in regard to their structure, process, and outcome. Study determined that United States has a strong disaster preparedness agenda and appropriate programs are in place with adequate policy support, and the country is prepared to meet all possible security challenges that may arise in the future. The man-made disaster of September 11th gave a major thrust to improve security and enhance preparedness of the country. These new efforts required large additional funding from the federal government. Most existing preparedness programs at the local and national levels are run with federal funds which is insufficient in some cases. This discrepancy arises from the fact that federal funding for disaster preparedness programs at present are not allocated by the level of risks to individual states or according to the risks that can be assigned to critical infrastructures across the country. However, the increased role of the federal government in public health affairs of the states is unusual, and opposed to the spirit of our constitution where sovereignty is equally divided between the federal government and the states. There is also shortage of manpower in public health to engage in disaster preparedness activities, despite some remarkable progress following the September 11th disaster.^ Study found that there was a significant improvement in knowledge and limited number of studies showed improvement of skills, increase in confidence and improvement in message-mapping. Among healthcare and allied healthcare professionals, short-term training on disaster preparedness increased knowledge and improved personal protective equipment use with some limited improvement in confidence and skills. However, due to the heterogeneity of these studies, the results and interpretation of this systematic review may be interpreted with caution.^

Dengue transmission risk maps of the continental United States

Dengue fever is a strictly human and non-human primate disease characterized by a high fever, thrombocytopenia, retro-orbital pain, and severe joint and muscle pain. Over 40% of the world population is at risk. Recent re-emergence of dengue outbreaks in Texas and Florida following the re-introduction of competent Aedes mosquito vectors in the United States have raised growing concerns about the potential for increased occurrences of dengue fever outbreaks throughout the southern United States. Current deficiencies in vector control, active surveillance and awareness among medical practitioners may contribute to a delay in recognizing and controlling a dengue virus outbreak. Previous studies have shown links between low-income census tracts, high population density, and dengue fever within the United States. Areas of low-income and high population density that correlate with the distribution of Aedes mosquitoes result in higher potential for outbreaks. In this retrospective ecologic study, nine maps were generated to model U.S. census tracts’ potential to sustain dengue virus transmission if the virus was introduced into the area. Variables in the model included presence of a competent vector in the county and census tract percent poverty and population density. Thirty states, 1,188 counties, and 34,705 census tracts were included in the analysis. Among counties with Aedes mosquito infestation, the census tracts were ranked high, medium, and low risk potential for sustained transmission of the virus. High risk census tracts were identified as areas having the vector, ≥20% poverty, and ≥500 persons per square mile. Census tracts with either ≥20% poverty or ≥500 persons per square mile and have the vector present are considered moderate risk. Census tracts that have the vector present but have <20% poverty and <500 persons per square mile are considered low risk. Furthermore, counties were characterized as moderate risk if 50% or more of the census tracts in that county were rated high or moderate risk, and high risk if 25% or greater were rated high risk. Extreme risk counties, which were primarily concentrated in Texas and Mississippi, were considered having 50% or greater of the census tracts ranked as high risk. Mapping of geographic areas with potential to sustain dengue virus transmission will support surveillance efforts and assist medical personnel in recognizing potential cases. ^

Risk factors for surgical site infections among patients undergoing major colon surgery in the United States 2007-2009

Background: Surgical site infections (SSIs) after abdominal surgeries account for approximately 26% of all reported SSIs. The Center for Disease Control and Prevention (CDC) defines 3 types of SSIs: superficial incisional, deep incisional, and organ/space. Preventing SSIs has become a national focus. This dissertation assesses several associations with the individual types of SSI in patients that have undergone colon surgery. ^ Methods: Data for this dissertation was obtained from the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP); major colon surgeries were identified in the database that occurred between the time period of 2007 and 2009. NSQIP data includes more than 50 preoperative and 30 intraoperative factors; 40 collected postoperative occurrences are based on a follow-up period of 30 days from surgery. Initially, four individual logistic regressions were modeled to compare the associations between risk factors and each of the SSI groups: superficial, deep, organ/space and a composite of any single SSI. A second analysis used polytomous regression to assess simultaneously the associations between risk factors and the different types of SSIs, as well as, formally test the different effect estimates of 13 common risk factors for SSIs. The final analysis explored the association between venous thromboembolism (VTEs) and the different types of SSIs and risk factors. ^ Results: A total of 59,365 colon surgeries were included in the study. Overall, 13% of colon cases developed a single type of SSI; 8% of these were superficial SSIs, 1.4% was deep SSIs, and 3.8% were organ/space SSIs. The first article identifies the unique set of risk factors associated with each of the 4 SSI models. Distinct risk factors for superficial SSIs included factors, such as alcohol, chronic obstructive pulmonary disease, dyspnea and diabetes. Organ/space SSIs were uniquely associated with disseminated cancer, preoperative dialysis, preoperative radiation treatment, bleeding disorder and prior surgery. Risk factors that were significant in all models had different effect estimates. The second article assesses 13 common SSI risk factors simultaneously across the 3 different types of SSIs using polytomous regression. Then each risk factor was formally tested for the effect heterogeneity exhibited. If the test was significant the final model would allow for the effect estimations for that risk factor to vary across each type of SSI; if the test was not significant, the effect estimate would remain constant across the types of SSIs using the aggregate SSI value. The third article explored the relationship of venous thromboembolism (VTE) and the individual types of SSIs and risk factors. The overall incidence of VTEs after the 59,365 colon cases was 2.4%. All 3 types of SSIs and several risk factors were independently associated with the development of VTEs. ^ Conclusions: Risk factors associated with each type of SSI were different in patients that have undergone colon surgery. Each model had a unique cluster of risk factors. Several risk factors, including increased BMI, duration of surgery, wound class, and laparoscopic approach, were significant across all 4 models but no statistical inferences can be made about their different effect estimates. These results suggest that aggregating SSIs may misattribute and hide true associations with risk factors. Using polytomous regression to assess multiple risk factors with the multiple types of SSI, this study was able to identify several risk factors that had significant effect heterogeneity across the 3 types of SSI challenging the use of aggregate SSI outcomes. The third article recognizes the strong association between VTEs and the 3 types of SSIs. Clinicians understand the difference between superficial, deep and organ/space SSIs. Our results indicate that they should be considered individually in future studies.^

A comparative analysis of road financing approaches in Europe and the United States

• The viability of the present system of road funding has in recent years been widely questioned, for it has proved insufficient to support spending programs at their current levels. • Some transfers from the general fund have been needed since 2008 to keep the HTF solvent. • Fuel taxes, the primary source for funding roads in the US, have not kept pace with inflation for years. • A wide variety of measures to increase revenue has been presented: raising fuel taxes, extending toll highways, implementing a VMT fee, etc.

Comparison of Reading Development Across Socioeconomic Status in the United States

It is well known that higher parental socioeconomic status (SES) predicts better child reading outcomes, but little work has been done to unpack this finding. The main overall question addressed by this project was whether cognitive models of the two main reading outcomes, single word reading (SWR) and reading comprehension (RC), performed similarly across levels of parental SES. The current study predicted a differential relation between parental SES and both predictors and outcomes because of the known large relation between parental SES and child oral language development. Three questions examined the mediating effects of cognitive predictors on the relation between parental SES and reading outcomes, the moderating effects of SES on the developmental trajectories of reading outcomes, and the strength of the relationship between SES and the two reading outcomes. Participants were part of two large and comprehensive datasets: the cross-sectional Colorado Learning Disability Research Center (CLDRC; n=1554) sample, and the International Longitudinal Twin Study (ILTS; n=463 twin pairs) sample. In terms of cognitive predictors, the relation between SES and SWR was disproportionately mediated by two language skills, vocabulary (VOC) and phonological awareness (PA). For the RC models, both SWR and oral listening comprehension (OLC) did not disproportionally mediate the relation between RC and SES; however, full mediation was not exhibited. With regard to the trajectory of reading outcomes, SES moderated the starting values of SWR and RC, and the slopes of SWR development. When performance on the control measures of early reading skills (e.g., print knowledge, vocabulary, and decoding skills) was included the models, the moderating effects of SES were completely accounted for by these measures. In terms of outcomes, SES had a stronger relation to RC than to SWR, especially at later ages. These findings have implications for interventions aimed at improving reading outcomes in children from lower SES families.