The contribution of health behaviors to socioeconomic inequalities in health: A systematic review

Associations between measures of socio-economic position and sustainable dietary patterns in the NutriNet-Santé study

OBJECTIVE

We aimed to explore the relationship between socio-economic characteristics and sustainable dietary patterns.

DESIGN

Dietary data were derived from a web-based FFQ. Diet sustainability was evaluated using a modified Sustainable Diet Index, comprising nutritional, environmental and cultural components (higher scores expressing higher sustainability). The socio-economic position markers were education, household income and occupation status. Multi-adjusted linear and Poisson regression models were used to assess the cross-sectional association of the markers of socio-economic status with a sustainable diet and sustainability subcomponents, respectively.

SETTING

France.

PARTICIPANTS

29 119 NutriNet-Santé participants.

RESULTS

Individuals with a more sustainable diet had slightly higher diet monetary cost, lower total energy intake and consumed less animal-based foods than their counterparts. Lower education level was associated with lower overall diet sustainability (βprimary v. postgraduate = -0·62, 95 % CI (-0·72, -0·51)) and nutrition, socio-cultural and environmental subscores. Manual workers and employees had a lower modified Sustainable Diet Index than intermediate professionals (βmanual workers v. intermediate professionals = -0·43, 95 % CI (-0·52, -0·33) and βemployees v. intermediate professionals = -0·56, 95 % CI (-0·64, -0·48)). Participants with the lowest v. highest incomes had a higher environmental subscore but a lower socio-cultural subscore, whereas the results were less marked for occupational status.

CONCLUSIONS

Overall, our results documented associations between socio-economic status and the level of diet sustainability, arguing for the implementation of appropriate food policies to promote sustainable diets at lower cost.

Beyond Individual Cognitions: Time for Intervention Science to Focus on Health Context and Audience

Intervention science faces a hazardous paradox: on the one hand, vulnerable populations (eg, patients, people from low socioeconomic background, older adults) are those for whom adoption of healthy behaviors is most urgent; on the other hand, behavior change models are less predictive, and interventions less successful, in these populations. This commentary presents 4 reasons that may explain this issue: (1) research mostly focuses on what causes behavior and how to change it, at the expense of investigating among whom and under what conditions models are valid; (2) models put an undue emphasis on individual cognitions; (3) most studies are not conducted on vulnerable populations; and (4) most researchers are from high-income countries. Several avenues are proposed to address this issue: (1) providing a central place to the context and audience in health behavior change modelization, through collaborations with researchers from other disciplines and countries, and with members of the targeted audience; (2) better reporting samples' sociodemographic characteristics and increasing samples' diversity; and (3) using more rigorous and innovative designs (eg, powered randomized controlled trials, N-of-1 trials, intensive longitudinal studies). In conclusion, it becomes urgent to change the way we do research: the social utility and credibility of intervention science depend on it.

Covid-19 restrictions: An opportunity to highlight the effect of neighbourhood deprivation on individuals' health-related behaviours

RATIONALE

Neighbourhood socio-economic deprivation is strongly related to health-risk behaviours, which are predictors of overall health and mortality. During the Covid-19 pandemic, individuals have been forced to spend more time within their residential areas, which might have had an effect on health-risk behaviours.

OBJECTIVE

We assess the consequences of living in a more or less deprived neighbourhood during the pandemic on individual behavioural changes in four health-related outcomes: smoking, drinking, physical activity and healthy eating. We hypothesise that the pandemic and related lock-downs had negative effects on health-related behaviours, but that this negative effect had been stronger for people living in more deprived areas. We additionally explore sex and ethnicity as sources of heterogeneity in these effects.

METHODS

We use data from four nationally representative cohort studies in England. We perform longitudinal individual and neighbourhood fixed effects estimations focusing on comparing the pre-pandemic period with the first lockdown (May 2020) period and up to one year after the outbreak of the pandemic (March 2021).

RESULTS

During the first lockdown, as compared to pre-pandemic levels, on average, people smoked more, drunk more and did more physical activity. However, compared to people in less deprived neighbourhoods, people living in more deprived areas showed a smaller increase in their levels of physical activity, consumed less fruit and vegetables and increased the number of cigarettes smoked. We additionally find that the combined effect of Covid-19 and area deprivation varies significantly by both sex and ethnicity.

CONCLUSION

Results add to evidence on the impact of the Covid-19 pandemic and associated lockdowns on health-risk behaviours, highlighting the relative contribution of the neighbourhood environment and individual characteristics. We argue that reducing levels of neighbourhood deprivation may contribute to positively influence behaviours, especially for some sub-groups of the population, leading to a reduction of social inequalities in health.

How do territorial characteristics affect spatial inequalities in the risk of coronary heart disease?

BACKGROUND

Cardiovascular diseases remain the leading cause of death and disabilities worldwide, with coronary heart diseases being the most frequently diagnosed. Their multifactorial etiology involves individual, behavioral and territorial determinants, and thus requires the implementation of multidimensional approaches to assess links between territorial characteristics and the incidence of coronary heart diseases.

CONTEXT AND OBJECTIVES

This study was carried out in a densely populated area located in the north of France with multiple sources of pollutants. The aim of this research was therefore to establish complex territorial profiles that have been characterized by the standardized incidence, thereby identifying the influences of determinants that can be related to a beneficial or a deleterious effect on cardiovascular health.

METHODS

Forty-four variables related to economic, social, health, environment and services dimensions with an established or suspected impact on cardiovascular health were used to describe the multidimensional characteristics involved in cardiovascular health.

RESULTS

Three complex territorial profiles have been highlighted and characterized by the standardized incidence rate (SIR) of coronary heart diseases after adjustment for age and gender. Profile 1 was characterized by an SIR of 0.895 (sd: 0.143) and a higher number of determinants that revealed favorable territorial conditions. Profiles 2 and 3 were characterized by SIRs of respectively 1.225 (sd: 0.242) and 1.119 (sd: 0.273). Territorial characteristics among these profiles of over-incidence were nevertheless dissimilar. Profile 2 revealed higher deprivation, lower vegetation and lower atmospheric pollution, while profile 3 displayed a rather privileged population with contrasted territorial conditions.

CONCLUSION

This methodology permitted the characterization of the multidimensional determinants involved in cardiovascular health, whether they have a negative or a positive impact, and could provide stakeholders with a diagnostic tool to implement contextualized public health policies to prevent coronary heart diseases.

Socioeconomic inequalities in self-assessed health and food consumption: the mediating roles of daily hassles and the perceived importance of health

BACKGROUND

Urgent daily hassles, which are more common among people with a lower socioeconomic position (SEP), might limit one's ability to address less pressing goals, such as goals related to health promotion. Consequently, health goals may be viewed as less focal, which could jeopardize one's health. This study examined an understudied pathway: whether a higher severity of daily hassles resulted in a lower perceived importance of health and whether these two factors sequentially mediate socioeconomic inequalities in self-assessed health (SAH) and food consumption.

METHODS

A cross-sectional survey among 1,330 Dutch adults was conducted in 2019. Participants self-reported SEP (household income, educational level), the severity of eleven daily hassles (e.g., financial hassles, legal hassles), the perceived importance of health (not being ill, living a long life), SAH, and food consumption. Structural equation modeling was used to examine whether daily hassles and the perceived importance of health sequentially mediated income and educational inequalities in SAH, fruit and vegetable consumption (FVC) and snack consumption.

RESULTS

No evidence of sequential mediation through daily hassles and the perceived importance of health was found. Daily hassles individually mediated income inequalities in SAH (indirect effect: 0.04, total effect: 0.06) and in FVC (indirect effect: 0.02, total effect: 0.09). The perceived importance of not being ill and living a long life both individually mediated educational inequalities in SAH (indirect effects: 0.01 and -0.01, respectively, total effect: 0.07).

CONCLUSIONS

Income inequalities in SAH and FVC were explained by daily hassles, and educational inequalities in SAH were explained by the perceived importance of health. Socioeconomic inequalities may not be sequentially explained by a more severe experience of daily hassles and a lower perceived importance of health. Interventions and policies addressing challenging circumstances associated with a low income may improve SAH and healthy food consumption among lower-income groups.

Education- and income-related differences in processed meat consumption across Europe: The role of food-related attitudes

PURPOSE

Dietary behaviors differ between socio-economic groups and are one key determinant of health inequalities. Psychological factors such as attitudes are assumed to underlie the relation between inequality and dietary behaviors, but this assumption has rarely been tested empirically. We focus on a specific food group shown as detrimental to health: processed meat.

METHODS

In two representative international surveys (Survey 1: N = 10,226 participants from nine European countries - Austria, France, Germany, Italy, Netherlands, Poland, Russia, Spain, UK; Survey 2: N = 9149 participants from the same countries, except not including Austria and the Netherlands), participants reported inequality indicators (education, income), processed meat consumption as well as their attitudes toward nutrition and food.

PRINCIPAL RESULTS

There were diverging relationships between indicators of inequality and processed meat consumption: the higher the educational attainment, the lower the consumption of processed meat (r_Survey1 = -0.062, p < .001; r_Survey2 = -0.071, p < .001). At the same time, higher income was related to higher processed meat consumption (r_Survey1 = 0.088, p < .001; r_Survey2 = 0.152, p < .001). A path model showed that four of seven attitude factors mediated the relation between education and processed meat consumption (i.e., indifference toward nutrition and food, preference for regional and fresh food, processed food consumption, health efforts); none of the attitude factors mediated the relation between income and overall processed meat consumption.

CONCLUSIONS

Processed meats are consumed very frequently across European countries. The relation between inequality and processed meat consumption is heterogeneous and partially mediated by attitudes. More research is needed to better understand how psychological factors explain social inequality in nutrition behaviors and health in general.

Life-course socioeconomic circumstances in acute, chronic and disabling pain among young employees: a double suffering

BACKGROUND

Pain is known to be socioeconomically patterned and associated with disability. However, knowledge is scarce concerning life-course socioeconomic circumstances and pain among young adults. Our aim was to examine the associations of childhood and current socioeconomic circumstances with acute pain and chronic pain with low and high disability levels among young Finnish municipal employees.

METHODS

We analysed questionnaire data retrieved from the Young Helsinki Health Study (n=4683) covering 18-39-year-old employees of the City of Helsinki, Finland. We included multiple indicators of childhood and current socioeconomic circumstances and examined their associations with acute pain and with chronic pain with low and high disability levels. The level of chronic pain-related disability was assessed by the chronic pain grade questionnaire. Multinomial logistic regression analyses were conducted with stepwise adjustments for sociodemographic, socioeconomic and health-related covariates.

RESULTS

Childhood and current socioeconomic disadvantage were associated with acute and chronic pain, particularly with chronic pain with high disability level. The strongest associations after adjustments for covariates remained between chronic pain with high disability level and low educational level (odds ratio (OR) 3.38, 95% confidence interval (CI) 2.18-5.24), manual occupation (OR 3.75, 95% CI 1.92-7.34) and experiencing frequent economic difficulties (OR 3.07, 95% CI 2.00-4.70).

CONCLUSIONS

Pain is a common complaint that contributes to disability among young employees, particularly the most socioeconomically vulnerable. There is a socioeconomic gradient in both pain chronicity and the level of chronic pain-related disability. Life-course socioeconomic factors should be considered in pain-preventing strategies and in clinical practice.

Identifying patterns of lifestyle behaviours linked to sociodemographic characteristics and health conditions among young adults in South Korea

AIMS

To identify specific patterns of lifestyle behaviours among young adults and examine the relationships of the patterns to sociodemographic characteristics and health conditions (hypertension, diabetes and obesity).

DESIGN

Descriptive, correlational study.

METHODS

Data from a nationally representative sample of 4562 young adults aged 19-39, who participated in the 2016-2018 Korea National Health and Nutrition Examination Survey, were analysed. Latent class analysis was used to identify the patterns of lifestyle behaviours, including smoking, alcohol use, physical activity and vaccination. Generalized linear regression analysis was used to examine the relationships among lifestyle behaviour patterns, sociodemographic characteristics and health conditions.

RESULTS

Three patterns of lifestyle behaviours were identified: physically active (6.9%), high risk (21.5%) and passive (71.6%). The membership of these three patterns was significantly associated with sociodemographic characteristics (age, sex, education level, occupation and living arrangement). Among the three groups, young adults in the high-risk group were found to be significantly associated with all three health conditions (hypertension, diabetes and obesity) while controlling for sociodemographic characteristics.

CONCLUSION

These results indicate that young adults are likely to engage in unhealthy lifestyle behaviours that are related to individual socioeconomic conditions, which could negatively affect their health conditions.

IMPACT

This study provides insights into the lifestyle behaviours among young adults who have been recognized to be socially disadvantaged. This could help develop education and prevention programmes tailored to specific patterns of lifestyle behaviours for improving health while considering their socioeconomic contexts.

NO PATIENT OR PUBLIC CONTRIBUTION

This applies to this research as the focus was on young adults in South Korea only.

Health inequalities in cause-specific mortality in Costa Rica: a population-based cohort study

OBJECTIVE

To analyze health inequalities in cause-specific mortality in Costa Rica from 2010 to 2018, observing the main causes for inequality in the country.

METHODS

The National Electoral Rolls were used to follow-up all Costa Rican adults aged 20 years or older from 2010 to 2018 (n = 2,739,733) in an ecological study. A parametric survival model based on the Gompertz distribution was performed and the event death was classified according to the ICD-10.

RESULTS

After adjustment for urbanicity, the poorest districts had a higher mortality than the wealthier districts for most causes of death except neoplasms, mental and behavioral disorders, and diseases of the nervous system. Urban districts showed significantly higher mortality than mixed and rural districts after adjustment for wealth for most causes except mental and behavioral disorders, diseases of the nervous system, and diseases of the respiratory system. Differences according to wealth were more frequent in women than men, whereas differences according to urbanicity were more frequent in men than in women.

CONCLUSIONS

The study's findings were consistent, but not fully similar, to the international literature.

Impact of a farmers' market healthy food subsidy on the diet quality of adults with low incomes in British Columbia, Canada: a pragmatic randomized controlled trial

BACKGROUND

Adults with low incomes have lower diet quality than their higher income counterparts. In Canada, the British Columbia Farmers' Market Nutrition Coupon Program (FMNCP) provides coupons to low-income households to purchase healthy foods in farmers' markets.

OBJECTIVE

The objective of this study was to examine the impact of the FMNCP on the diet quality of adults with low incomes.

METHOD

In a pragmatic randomized controlled trial conducted in 2019, adults with low incomes (≥18 y) were randomly assigned either to an FMNCP intervention (n = 143) or a no-intervention control group (n = 142). The FMNCP group received 16 coupon sheets valued at $21 per sheet over 10-15 wk to purchase healthy foods from farmers' markets. Participants completed a questionnaire and 2 24-h dietary recalls at baseline (0 wk), immediately post-intervention (10-15 wk), and 16-wk post-intervention (26-31 wk). Diet quality was calculated using the Healthy Eating Index-2015 (HEI-2015). Linear mixed-effects regression assessed differences in HEI-2015 total (primary outcome) and component scores (secondary outcomes) between the FMNCP and control groups at post-intervention and 16-wk post-intervention. Subgroup analyses examined program impacts by sex and age group (18-59 y, ≥60 y).

RESULTS

There were no significant differences in HEI-2015 total scores between the FMNCP and control groups at post-intervention (-0.07; 95% CI: -4.07, 3.93) or 16-wk post-intervention (1.22; 95% CI: -3.00, 5.44) overall or between subgroups. There were no significant between-group differences in HEI-2015 component scores at post-intervention, although there were significant differences in component scores for dairy and fatty acids at 16-wk post-intervention.

CONCLUSION

The FMNCP did not significantly improve diet quality among adults with low incomes over the study period. Further research is needed to explore whether higher subsidy amounts or a longer intervention period is needed to meaningfully improve diet quality among adults with low incomes. This trial was registered at [clinicaltrials.gov] as [NCT03952338].

Mediation of lifestyle-associated variables on the association between occupation and incident cardiovascular disease

The main aim was to examine the association between occupational groups and incident cardiovascular disease (CVD), and to which extent associations are mediated by lifestyle-associated variables (cardiorespiratory fitness, smoking, BMI, exercise, and diet). A total of 304,702 participants (mean age 42.5 yrs., 47% women), who performed a health profile assessment in Sweden between 1982 and 2019, were included in the analyses. CVD incidence was obtained from national registers. All participants were free from CVD prior to the health profile assessment. Occupational group was defined using the Swedish Standard Classification of Occupations and analyzed separately (13 different occupational groups) as well as after aggregation into four occupational groups (white-collar high-skilled, white-collar low-skilled, blue-collar high-skilled and blue-collar low-skilled). Cardiorespiratory fitness, BMI, exercise, smoking, and diet were included as mediators and analyzed separately in single models and simultaneously in one multiple mediation model. All mediation analyses were adjusted for sex, age, length of education and calendar time. White-collar high-skilled was set as reference in all analyses. Blue-collar and low-skilled occupation had a higher risk of incident CVD compared to the reference. Cardiorespiratory fitness, BMI, exercise, smoking, and diet mediated 48% to 54% of the associations between reference and the other aggregated occupational groups. In the single model, the strongest mediators were cardiorespiratory fitness, smoking and BMI. In conclusion, blue-collar and low-skilled occupations had a significantly higher risk for incident CVD compared to white-collar high-skilled workers, with the association mediated to a large extent by variation in lifestyle-associated variables.

Associations of Healthy Lifestyle and Socioeconomic Status with Cognitive Function in U.S. Older Adults

We investigated the complex relations of socioeconomic status (SES) and healthy lifestyles with cognitive functions among older adults in 1,313 participants, aged 60 years and older, from the National Health and Nutrition Examination Survey 2011-2014. Cognitive function was measured using an average of the standardized z-scores of the Consortium to Establish a Registry for Alzheimer’s Disease Word Learning and delayed recall tests, the Animal Fluency Test, and the Digit Symbol Substitution Test. Latent class analysis of family income, education, occupation, health insurance, and food security was used to define composite SES (low, medium, high). A healthy lifestyle score was calculated based on smoking, alcohol consumption, physical activity, and the Healthy-Eating-Index-2015. In survey-weighted multivariable linear regressions, participants with 3 or 4 healthy behaviors had 0.07 (95% CI: 0.005, 0.14) standard deviation higher composite cognitive z-score, relative to those with one or no healthy behavior. Participants with high SES had 0.37 (95% CI: 0.29, 0.46) standard deviation higher composite cognitive z-score than those with low SES. No statistically significant interaction was observed between healthy lifestyle score and SES. Our findings suggested that higher healthy lifestyle scores and higher SES were associated with better cognitive function among older adults in the United States.

Smoking is an independent but not a causal risk factor for moderate to severe psoriasis: A Mendelian randomization study of 105,912 individuals

Background

Smoking is strongly associated with higher risk of psoriasis in several observational studies; however, whether this association is causal or can be explained by confounding or reverse causation is not fully understood. Randomized controlled trials are the gold standard when examining causality; however, when this method is not feasible, the Mendelian randomization design is an alternative. Herein genetic variants can be used as robust proxies for modifiable exposures and thereby avoiding confounding and reverse causation.In this study, we hypothesized that smoking is an independent and causal risk factor for psoriasis and tested this using a Mendelian randomization design.

Methods

We used data from the Copenhagen General Population Study including 105,912 individuals with full information on lifestyle factors, biochemistry, and genotype data. In total, 1,240 cases of moderate to severe psoriasis were included to investigate the association between smoking and psoriasis. To assess causality of the association, we used the genetic variant CHRNA3 rs1051730, where the T-allele is strongly associated with high lifelong cumulative smoking, as a proxy for smoking.

Results

In observational analyses, the multivariable adjusted hazard ratio of developing moderate to severe psoriasis was 1.64 (95% confidence interval: 1.35-2.00) in ever smokers with ≤ 20 pack-years and 2.23 (1.82-2.73) in ever smokers with > 20 pack-years compared to never smokers. In genetic analyses, the odds ratio of developing moderate to severe psoriasis was 1.05 (0.95-1.16) per CHRNA3 rs10511730 T-allele in ever smokers.

Conclusion

Smoking was an independent risk factor for moderate to severe psoriasis in observational analyses. However, using a genetic variant as a robust proxy for smoking, we did not find this association to be causal.

Relative deprivation patterns in social and geographical references for health trajectories in China: Investigations of gender and urban-rural disparities

OBJECTIVE

A pervasive link between relative deprivation and health has been well-documented. However, prior studies suffered from inadequate relative deprivation measures that fail to define appropriate reference groups to which individuals compare themselves, and few provided longitudinal evidence. This study explores latent relative deprivation patterns based on multiple social and geographic reference groups, examining their impacts on health trajectories and variations by gender and urban-rural areas.

METHODS

Using three waves (2013, 2015, & 2018) of the China Health and Retirement Longitudinal Study (n = 6035), we conducted latent class analysis (LCA) to identify the baseline latent relative deprivation patterns among five social and geographic reference groups (relatives, schoolmates, colleagues, neighbors, and other people in the city or county). The LCA results were linked to the latent growth curve parallel process modeling (PPM) to investigate the impacts of deprivation patterns on dual health trajectories (depressive symptoms and self-rated health), and the results were stratified to explore gender and urban-rural differences.

RESULTS

The LCA revealed a relatively deprived group (36.39%) and a non-deprived group (63.61%). The PPM results indicated that the relatively deprived group showed a higher initial level of depressive symptoms and a lower initial level of self-rated health than the non-deprived group. However, the relatively deprived group showed a slower growth rate in depressive symptoms than the non-deprived group. These findings were particularly evident among women and rural residents.

CONCLUSIONS

Findings emphasize the negative impact of relative deprivation on health. Furthermore, there is a complex interplay in these effects intertwined with gender and locality. Policies aimed at promoting mental health should not only consider relatively deprived groups, but also non-deprived women and rural residents who are at higher risk for later-life depression.

The social grounds of self-tracking in insurance: A mixed-method approach to adoption and use

Scholars have explored the role of self-tracking in mediating people's values, perceptions, and practices. But little is known about its institutionalised forms, although it is becoming a routine component of health policies and insurance programs. Furthermore, the role of structural elements such as sociodemographic variables, socialisations, and trajectories has been neglected. Using both quantitative (n  =  818) and qualitative (n  =  44) data gathered from users and non-users of an insurance program's self-tracking intervention, and drawing from Bourdieu's theoretical framework, we highlight the impact of users' social background on the adoption and use of the technology. We show that older, poorer, and less educated individual are less likely to adopt the technology, and describe four prototypical categories of users, the meritocrats, the litigants, the scrutinisers and the good-intentioned. Each category displays different reasons and ways to use the technology that are grounded in users' socialisations and life trajectories. Results suggest that too much emphasis may have been put on self-tracking's transformative powers and not enough on its reproductive inertia, with important consequences for both scholars, designers, and public health stakeholders.

Life-course socioeconomic factors are associated with markers of epigenetic aging in a population-based study

Adverse socioeconomic circumstances negatively affect the functioning of biological systems, but the underlying mechanisms remain only partially understood. Here, we explore the associations between life-course socioeconomic factors and four markers of epigenetic aging in a population-based setting. We included 684 participants (52 % women, mean age 52.6 ± 15.5 years) from a population and family-based Swiss study. We used nine life-course socioeconomic indicators as the main exposure variables, and four blood-derived, second generation markers of epigenetic aging as the outcome variables (Levine's DNAmPhenoAge, DunedinPoAm38, GrimAge epigenetic age acceleration (EAA), and the mortality risk score (MS)). First, we investigated the associations between socioeconomic indicators and markers of epigenetic aging via mixed-effect linear regression models, adjusting for age, sex, participant's recruitment center, familial structure (random-effect covariate), seasonality of blood sampling, and technical covariates. Second, we implemented counterfactual mediation analysis to investigate life-course and intermediate mechanisms underlying the socioeconomic gradient in epigenetic aging. Effect-size estimates were assessed using regression coefficients and counterfactual mediation parameters, along with their respective 95 % confidence intervals. Individuals reporting a low father's occupation, adverse financial conditions in childhood, a low income, having financial difficulties, or experiencing unfavorable socioeconomic trajectories were epigenetically older and had a higher mortality risk score than their more advantaged counterparts. Specifically, this corresponded to an average increase of 1.1-1.5 years for Levine's epigenetic age (β and 95 %CI range, β (minimum and maximum): 1.1-1.5 95 %CI[0.0-0.2; 2.3-3.0]), 1.1-1.5 additional years for GrimAge (β: 1.1-1.5 95 %CI[0.2-0.6; 1.9-3.0]), a 1-3 % higher DunedinPoAm38 age acceleration (β: 0.01-0.03 95 %CI[0.00; 0.03-0.04]), and a 10-50 % higher MS score (β: 0.1-0.4 95 %CI[0.0-0.2; 0.3-0.4]) for the aforementioned socioeconomic indicators. By exploring the life-course mechanisms underlying the socioeconomic gradient in epigenetic aging, we found that both childhood and adulthood socioeconomic factors contributed to epigenetic aging, and that detrimental lifestyle factors mediated the relation between socioeconomic circumstances in adulthood and EAA (31-89 % mediated proportion). This study provides emerging evidence for an association between disadvantaged life-course socioeconomic circumstances and detrimental epigenetic aging patterns, supporting the "sensitive-period" life-course model. Counterfactual mediation analyses further indicated that the effect of socioeconomic factors in adulthood operates through detrimental lifestyle factors, whereas associations involving early-life socioeconomic factors were less clear.

Associations between healthy lifestyle score and health-related quality of life among Chinese rural adults: variations in age, sex, education level, and income

PURPOSE

This study aimed to investigate the associations between overall lifestyles and HRQoL, as well as the variations in age, sex, education level, and income.

METHODS

A total of 23,402 participants from the Henan rural cohort were included. The healthy lifestyle score (HLS) consists of five lifestyle factors: smoking, alcohol drinking, physical activity, diet, and body mass index. HRQoL was assessed by the EQ-5D-5L questionnaire. The general linear model and Tobit regression model were utilized to assess the associations of HLS with visual analogue score (VAS) and utility index.

RESULTS

Compared with participants with an HLS of 0-2, the corresponding regression coefficients (β) and 95% confidence intervals (CI) of participants with an HLS of 3, 4, and 5 for VAS score were 1.09 (0.59, 1.59), 1.92 (1.38, 2.46), and 2.60 (1.83, 3.37); the corresponding β and 95% CI for utility index were 0.02 (0.01, 0.03), 0.05 (0.03, 0.06), and 0.06 (0.04, 0.07). Notably, these positive associations were greater among the elderly, female, and those with lower education level and average monthly income (p for interaction < 0.05). For instance, the corresponding β and 95% CI of individuals with an HLS of 5 for utility index in average monthly income < 500 RMB, 500-999 RMB, and ≥ 1000 RMB groups were 0.08 (0.05, 0.11), 0.06 (0.03, 0.09), and 0.02 (- 0.00, 0.05).

CONCLUSION

Engaging in healthier lifestyle habits was associated with a higher level of HRQoL, especially in the elderly, females, and those with low education level and average monthly income.

Characteristics of participants and decliners from a randomized controlled trial on physical activity in patients with rheumatoid arthritis: a retrospective register-based cross-sectional study

OBJECTIVE

A randomized controlled trial [Joint Resources - Sedentary Behaviour (JR-SB) intervention] aimed to reduce sedentary behaviour and increase light-intensity physical activity in patients with rheumatoid arthritis (RA) through motivational counselling and text messages. Since a large proportion of invited patients declined to participate, this study aims to compare sociodemographic, clinical, and lifestyle factors between included patients and patients declining to participate (non-participants) in the JR-SB study and to investigate which characteristics were associated with participation.

METHOD

A register-based cross-sectional study was conducted. All patients invited to participate in the JR-SB study were identified in the DANBIO registry, from which patients' clinical and lifestyle data were also retrieved. Data on sociodemography and comorbidity were extracted from national registers. Differences between participants and non-participants were determined by an independent t-test or a chi-squared test. Logistic regression analyses adjusted for various confounders tested the association of patient characteristics with the likelihood of participation in the JR-SB study.

RESULTS

A total of 467 (58%) declined participation in the JR-SB study. Non-participants were older and less educated, more were smokers, fewer performed regular physical activity, and more had comorbidity compared to participants. Regression analyses showed that a higher educational level and absence of comorbidity in particular were associated with participation in the JR-SB study.

CONCLUSION

Patients with RA who are less educated and with certain types of comorbidity are less motivated to participate in a physical activity intervention. The findings may inform the recruitment process and implementation of physical activity interventions in rheumatology clinical practice.

The Role of Health Education, Policies, and Services on College Students' Health Behavior

Objective: In this study, we aimed to define the role of health education, health policies, and health service as factors in the health behavior of Chinese college students. It is critical to understand that there is an important role of health behavior in the life of college students in any society because the survival of society is dependent on better health status. Methods: We used SPSS software for analysis to test our hypotheses.Results: We found an important role for health education, health policies, and health services as determinants of health behavior. Conclusion: The focus of healthcare organizations must be to focus on health education, health policies, and health services by creating awareness in college students that ensures they are provided with the appropriate health sector solutions. Additionally, we found theoretical and practical implications to improve the health behavior of Chinese college students via a moderating role of information technology, because, in modern times, the role of information technology is critical to convey information productively.

Predictors of health self-management behaviour in Kazakh patients with metabolic syndrome: A cross-sectional study in China

BACKGROUND

Metabolic syndrome (MS) is common among Muslim patients living in China, most of whom are Kazakh adults. Continuous and effective health self-management plays a critical role in preventing negative health outcomes for individuals with MS. However, Muslim minority patients with MS face many difficulties in actively participating in health self-management, and the factors supporting their successful self-management of MS remain unclear.

OBJECTIVE

This study aimed to identify the factors predicting health self-management behaviour among Kazakh MS patients and provide empirical evidence for establishing recommendation guidelines or intervention programmes for health self-management among Muslim minorities.

METHODS

A cross-sectional study was conducted in Xinjiang Province, China, with the use of convenience sampling to explore the current health self-management behaviour of 454 Kazakh MS patients and its influencing factors. Univariate analysis and logistic regression were used to analyse the data.

RESULTS

The total health self-management behaviour score of Kazakh MS patients was 85.84±11.75, and the weaknesses in self-management behaviour were mainly reflected in three dimensions: disease self-monitoring, emotion management and communication with physicians. The significant positive predictors of health self-management behaviour were sex, education, family monthly income per capita, weight, knowledge of MS, and self-efficacy, while the significant negative predictors were blood pressure, the number of MS components, chronic disease comorbidities, and social support (objective support and utilization of support).

CONCLUSION

The health self-management behaviour of Kazakh MS patients is poor. Health care providers should aim to develop culturally specific and feasible health management intervention programmes based on the weaknesses and major modifiable influencing factors in Muslim minority MS patient health self-management, thus improving the health outcomes and quality of life of patients.

Disparities in fruit and vegetable intake at the intersection of gender and education in northern Sweden: a cross-sectional study

BACKGROUND

Even though the existence of inequalities in fruit and vegetable consumption has been well established, it is not clear how it is patterned across intersections of multiple social positions and identities. This study aims to investigate disparities in fruit and vegetable intake between groups at the intersection of education and gender in northern Sweden, and to estimate the discriminatory accuracy of the intersectional groups.

METHODS

Cross-sectional data from the 2018 Health on Equal Terms survey conducted in four regions in northern Sweden was used (N = 21,853). Four intersectional groups were created: high and low educated men, and high and low educated women. Prevalence differences corresponding to joint, referent, and excess intersectional inequalities, were estimated for three outcomes: inadequate fruit and vegetable intake combined, inadequate fruit intake, and inadequate vegetable intake. The discriminatory accuracy of the intersectional groups was estimated by the area under the receiver operating characteristic curve.

RESULTS

Low educated men had the highest prevalence of inadequate intake of fruits and vegetables combined (81.4%), fruits (83.4%), and vegetables (84.9%), while high educated women had the lowest (47.7, 60.2, and 51.8%, respectively). The joint disparities between high educated women and low educated men were both significant and substantial for all outcomes (34.6 percentage points (pp.), 25.2 pp., and 31.2 pp., adjusted), although differences in magnitude were noted between fruit and vegetable intake. The joint disparities were mostly explained by the two referent disparities for gender and education. The excess intersectional disparity - the part of the joint disparity not explained by either referent disparity - was negative for all three outcomes (-5.5 pp., - 4.2 pp., and - 4.6 pp. respectively, adjusted). The discriminatory accuracy of the intersectional groups was moderate (0.67, 0.65, and 0.68 respectively).

CONCLUSIONS

An intersectional approach can provide a more detailed view of inequalities in fruit and vegetable consumption between groups combining several social positions. The moderate discriminatory accuracy observed here suggests that interventions and policies aiming to reduce diet inequalities should not solely be targeted at certain groups, but also be universal.

Socioeconomic status across the life course and smoking cessation among older adult smokers in the U.S

INTRODUCTION

Socioeconomic status (SES) at different stages of the life course impacts late-life health. However, whether SES across the life course impacts smoking cessation in late-life is not known.

PURPOSE

Assess how life course SES impacts smoking cessation among older smokers.

METHODS

We identified 5,124 smokers, 50 years and older, from the 1998 to 2018 waves of the Health and Retirement Study. The outcome was self-reported smoking cessation. The main exposure was life course SES, defined as: low child and low adult SES (persistent low); low child, high adult SES (upward mobility); high child, low adult SES (downward mobility); and high child, high adult SES (persistent high). A multilevel mixed-effect logistic model was used to examine how life course SES predicts smoking cessation at age 65 and over time, adjusted for covariates.

RESULTS

Compared to those with persistent high SES, those with persistent low SES, upward and downward SES were more likely to be Hispanic or non-Hispanic Black. The adjusted results showed that at age 65, compared to those with persistent high SES, those with persistent low SES (OR= 0.69, 95 % CI = [0.51-0.92]), upward SES (OR= 0.49, [0.32-0.75]), and downward SES (OR= 0.55, [0.40-0.76]) were less likely to quit. However, as age increased, only those with downward or persistent low SES were significantly less likely to quit compared to those with persistent high SES.

DISCUSSION

Social mobility of SES from childhood to adulthood significantly impacts smoking cessation. Both stages of the life course should be considered to understand smoking behaviors.

Women carry the weight of deprivation on physical inactivity: Moderated mediation analyses in a European sample of adults over 50 Years of age

Deprived people are less physically active than privileged individuals. However, pathways underlying the association between deprivation and physical activity remain overlooked. We examined whether the association between deprivation and physical activity was mediated by body mass index (BMI). Consistent with an intersectional perspective (how the combination of belongingness to vulnerable social categories widens inequalities), we tested whether gender moderated this mediating pathway and hypothesized that the mediating effect of BMI would be stronger among women (vs men). Large-scale longitudinal data from 20,961 adults 50 years of age or older (57% women) from the Survey of Health, Ageing and Retirement in Europe were used. Social and material deprivation were measured by questionnaire, BMI and physical activity were reported from two to six years later. Simple mediation models showed that BMI partly mediated the association of material (total effect c = -0.14, proportion of mediated effect = 8%) and of social deprivation (c = -0.24, proportion of mediated effect = 4%) with physical activity. Moderated mediation models revealed that this mediating pathway was moderated by gender. The effect of deprivation on BMI was stronger among women (vs men), with BMI mediating 18% and 7% of the association of material and social deprivation with physical activity among women (vs 4% and 2% among men). Lower levels of physical activity observed among deprived older adults could be partly attributed to a higher BMI. Critically, this mechanism was exacerbated among women, reinforcing the need to understand how deprivation and gender interact to predict health behaviors.

•

Body mass index mediates the association of material and social deprivation with physical activity.

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This mediating pattern is more pronounced among women, relative to men.

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The association between deprivation and a higher body mass index is exacerbated among women, compared to men.

Socioeconomic correlates of face mask use among pedestrians during the COVID-19 pandemic: An ecological study

Background

Many countries have recommended using face masks for the general population in public places to reduce the risk of COVID-19 transmission. This study aimed to assess the effects of socioeconomic status on face mask use among pedestrians during the COVID-19 pandemic.

Methods

This cross-sectional study was conducted in Ahvaz, southwest Iran in August 2020. A total of 10,440 pedestrians have been studied from 92 neighborhoods of the city. Three socioeconomic indicators including Land price, Literacy rate, and the Employment rate for each neighborhood were used in this study. Analysis of Covariance and partial correlation coefficients were applied to assess the relationship between prevalence rates of mask usage and SES indicators.

Results

The mean ± SD age of the pedestrians was 32.2 ± 15.1 years. Of 10,440 observed participants, 67.9% were male. The overall prevalence of face mask usage was 45.6%. The prevalence of mask usage in older people and women was significantly higher than the others. The three assessed socioeconomic indicators were directly correlated to the prevalence of mask usage at individual and neighborhood levels.

Conclusion

We found that literacy had the strongest correlation with the prevalence of mask usage compared to the land price and employment rate among the three assessed SES indicators. Hence, it can be concluded that the social component of socioeconomic status has a greater effect on mask usage by people than the economic component of socioeconomic status.

Can Sex Differences in Old Age Disabilities be Attributed to Socioeconomic Conditions? Evidence from a Mapping Review of the Literature

Old age disabilities are more common among women than men, and adverse socioeconomic conditions are associated with a higher prevalence of disabilities among older adults. The goal of this study was to complete a mapping review of the available evidence assessing the extent to which the observed sex differences in older adults’ disabilities can be attributed to sex differences in socioeconomic status. We searched three databases for articles published between 2009 and 2019, and after screening and looking at eligibility criteria, 6 articles were included in the review. For those studies that did not directly analyse the contribution of socioeconomic conditions, we used the ‘difference method’ to estimate the proportion of the sex gap in disabilities among older adults that could be attributed to socioeconomic conditions. Our review demonstrated that women generally have a higher prevalence of disabilities than men. In several studies, these differences could be partly attributed to sex differences in the distribution of socioeconomic conditions. We also find great elasticity in the magnitude of both the sex gap in disabilities and in the proportion that could be attributed to differences in socioeconomic conditions.

The magnitude and importance of perceived health dimensions define effective tailor-made health-promoting interventions per targeted socioeconomic group

Recent insights and developments on health and society urge a critical look at the positive relationship between socioeconomic status (SES) and health. We challenge the notions that it is sufficient to distinguish only between two groups of SES (low and high) and that only overall health is taken into account. A new grouping of SES was developed based on both income and education, resulting in six SES groups. Health was defined in terms of a new positive health concept, operationalized into six health dimensions generating a measure of total general health (TGH). Next, six socioeconomic and demographic determinants of health were included. Linear regression, T-tests and one-way ANOVA were applied to investigate the relationships in a Dutch sample. A subjective way to measure health was applied: self-rated health (SRH). As a result, four out of six dimensions of health determined TGH: bodily functions, daily functioning, quality of life, and social and societal participation. Three out of six socioeconomic and demographic determinants impacted TGH: housing situation, age, and difficulties meeting financial obligations. While this is the general picture for the entire sample, there were interesting similarities and differences between the six SES groups. The similarities lie in the positive impact of the evaluation of bodily functions and daily functioning on TGH in all SES groups. The other dimensions affected TGH in some groups, and some dimensions only in one SES group. None of the socioeconomic and demographic determinants affected TGH in all SES groups. New insights on health inequalities are provided. It is concluded, first that the well-known positive relationship between SES and health is confirmed in this study. Second, further refining the health concept into six dimensions provides more detailed insights on which dimensions impact health the most. The subjective approach applied offers more refined information to better understand which health issues really matter to people. This yields new insights to develop tailor-made interventions aimed at increasing healthy behaviour in specific societal groups.

Exploration of health and health behaviours of undergraduate nursing students: a multi-methods study in two countries

BACKGROUND

Nurses play a vital role in health promotion, and there may be a link between a nurse's own lifestyle practices and how they educate others. Supporting health and well-being in student nurses is critical given they will be educating others once registered and practicing.

OBJECTIVES

To explore the health and health behaviours of undergraduate nursing and midwifery students considering the demands of their profession, their public health role and their ability to be role models.

DESIGN

Multi-methods study.

METHODS

Undergraduate nursing students in the second and third years of their programme were invited to self-complete a health and health behaviour questionnaire in a Scottish and Australian Higher Education Institution. Qualitative data were collected from a convenience sample of 20 third-year nursing and midwifery students.

RESULTS

Two hundred and thirty-five Scottish students and 113 Australian students, 175 (85%) and 84 (74%), respectively, completed the questionnaire. Some differences and similarities were noted across groups, in particular, perceived physical health, the prevalence of binge drinking, smoking and being overweight/obese and some dietary measures were found to be less favourable among Scottish students. There were worryingly high levels of poor mental well-being at both higher education institutions, with scores on a mental well-being scale suggesting that (82) 34.7% of Scottish students and 33 (29.6%) of Australian students were at risk of depression. Nine Scottish students and 11 Australian students were interviewed. Key contributors and barriers to healthy behaviours were noted across both groups of students in relation to lifestyle. Students perceived that certain elements of their curriculum had implications on their ability or motivation to make healthy lifestyle choices.

CONCLUSION

The poor health and health behaviours of future nurses need to be addressed in their higher education to shape resilient role models for future nursing practice.

IMPACT STATEMENT

Priority should be given to supportive learning environments for student nurses that foster emotional support and encourage healthy lifestyles.

Socio-economic inequalities in the consumption of fruits and vegetables in Peru between 2014 and 2019

OBJECTIVE

To estimate the prevalence and socio-economic inequalities in adequate consumption of fruits and vegetables in Peru between 2014 and 2019.

DESIGN

Analytical cross-sectional study. The outcome variable was adequate consumption of fruits and vegetables, defined as the consumption of five or more servings of fruits and vegetables per d (yes/no). We used concentration curves and Erreygers concentration index to describe socio-economic inequalities and a microeconometric approach to determine the contribution of each variable to inequality.

SETTING

Peru.

PARTICIPANTS

Data from Peruvians aged 18 years or older collected by the Demographic and Family Health Survey.

RESULTS

The prevalence of adequate fruit and vegetable consumption did not change between 2014 (10·7 %; 95 % CI (10·0, 11·4)) and 2019 (11 %; 95 % CI (10·4, 11·7)). We found socio-economic inequalities in the adequate consumption of fruits and vegetables, with wealthier individuals having a higher prevalence of adequate consumption compared to poorer individuals in 2014 (19·2 % v. 3·5 %) and 2019 (18·6 % v. 4·7 %). The decomposition analysis found that education, urban areas and being wealthy were the main factors associated with socio-economic inequality in adequate fruit and vegetable consumption, being structural problems of society.

CONCLUSION

Despite the current regulations on healthy eating in Peru, adequate consumption of fruits and vegetables remains low, and there are socio-economic inequalities between the poorest and wealthiest individuals. Our findings suggest that more efforts are needed to increase the intake and assess the disparities in adequate fruit and vegetable consumption.

The socioeconomic gradient of alcohol use: an analysis of nationally representative survey data from 55 low-income and middle-income countries

BACKGROUND

Alcohol is a leading risk factor for over 200 conditions and an important contributor to socioeconomic health inequalities. However, little is known about the associations between individuals' socioeconomic circumstances and alcohol consumption, especially heavy episodic drinking (HED; ≥5 drinks on one occasion) in low-income or middle-income countries. We investigated the association between individual and household level socioeconomic status, and alcohol drinking habits in these settings.

METHODS

In this pooled analysis of individual-level data, we used available nationally representative surveys-mainly WHO Stepwise Approach to Surveillance surveys-conducted in 55 low-income and middle-income countries between 2005 and 2017 reporting on alcohol use. Surveys from participants aged 15 years or older were included. Logistic regression models controlling for age, country, and survey year stratified by sex and country income groups were used to investigate associations between two indicators of socioeconomic status (individual educational attainment and household wealth) and alcohol use (current drinking and HED amongst current drinkers).

FINDINGS

Surveys from 336 287 participants were included in the analysis. Among males, the highest prevalence of both current drinking and HED was found in lower-middle-income countries (L-MICs; current drinking 49·9% [95% CI 48·7-51·2] and HED 63·3% [61·0-65·7]). Among females, the prevalence of current drinking was highest in upper-middle-income countries (U-MIC; 29·5% [26·1-33·2]), and the prevalence of HED was highest in low-income countries (LICs; 36·8% [33·6-40·2]). Clear gradients in the prevalence of current drinking were observed across all country income groups, with a higher prevalence among participants with high socioeconomic status. However, in U-MICs, current drinkers with low socioeconomic status were more likely to engage in HED than participants with high socioeconomic status; the opposite was observed in LICs, and no association between socioeconomic status and HED was found in L-MICs.

INTERPRETATION

The findings call for urgent alcohol control policies and interventions in LICs and L-MICs to reduce harmful HED. Moreover, alcohol control policies need to be targeted at socially disadvantaged groups in U-MICs.

FUNDING

Deutsche Forschungsgemeinschaft and the National Center for Advancing Translational Sciences of the US National Institutes of Health.

Socioeconomic Differences in Physical Activity and Sedentary Behavior During the Retirement Transition: A Systematic Review of Longitudinal Studies

BACKGROUND

The retirement transition constitutes both a risk and an opportunity for changes in physical activity (PA) and sedentary behavior (SB). The present systematic review aims to summarize the current evidence regarding the differences between socioeconomic status (SES) groups in changes in PA and SB across the retirement transition.

METHODS

The authors searched 5 databases. Inclusion criteria were: investigating statutory retirement, measuring PA and/or SB at least once before and once after retirement, and reporting information on SES differences. Results are reported by means of a narrative synthesis, combined with harvest plots based on direction of effect.

RESULTS

We included 24 papers from 19 studies. Sixteen papers focused on PA, 3 on SB, and 5 investigated both. For total PA, occupational PA, and total sedentary time, nearly all publications reported more favorable changes for high SES groups. For recreational PA, active transport, and screen time, there seemed to be a tendency toward more favorable changes for high SES groups. Changes in household/caregiving PA did not appear to differ between SES groups.

CONCLUSIONS

Changes in movement behavior during the retirement transition are potentially more favorable for high SES adults. Nonetheless, the differences between SES groups seem to depend on the domain of movement behavior.

Examining rural-urban disparities in perceived need for health care services among adults with disabilities

Purpose

The purpose of this study is to parse out differences between unmet need and perceived need for health care services among rural and urban adults with disabilities in the United States. While unmet need focuses primarily on environmental factors such as access to health insurance or provider availability, perceived need relates to personal choice. This distinction between unmet and perceived need is largely ignored in prior studies, but relevant to public health strategies to improve access and uptake of preventive care.

Methods

Using Wave 2 data from the National Survey on Health and Disability, we explored rural and urban differences in unmet and perceived health care needs among working-age adults with disabilities for acute and preventive services.

Findings

Although we found no significant differences in unmet needs between rural and urban respondents, we found that perceived needs for dental care and mental health counseling varied significantly across geography. Using logistic regression analysis and controlling for observable participant characteristics, we found that respondents living in noncore counties relative to metropolitan counties were more likely to report not needing dental care (OR 1.89, p = 0.028), and not needing mental health counseling services (OR 2.15, p ≤ 0.001).

Conclusion

These findings suggest additional study is warranted to understand perceived need for preventive services and the levers for addressing rural disparities.

The role of family, school and neighbourhood in Explaining Inequalities in Physical Activity Trajectories between age 9 and 18

Differentials in physical activity (PA) between social and economic groups has been shown to contribute significantly to social gradients in health and life expectancy, yet relatively little is known about why differentials in PA emerge. This paper uses longitudinal data on a nationally representative sample of 6,216 young people aged between 9 and 18, from Ireland, to measure the role of family, school and neighbourhood level factors in accounting for differentials in PA trajectories between groups of young people, defined by level of maternal education, whilst adjusting for the individual characteristics of the young person (sex, age, personality, body mass index and health-status). Levels of PA fall significantly across the sample between 9 and 18, and the decline in PA is larger for the children of lower educated mothers. We find a clear gradient in PA at each age by maternal education for both males and females. Descriptive analyses found social gradients in the majority of our risk factors. Using multi-level, linear spline regression models to decompose differentials between groups, we find that family-level mechanisms account for the biggest proportion of the differential in PA for both males (50.8%) and females (35.1%). Differences in income across maternal education categories accounted for 24.1% of the differential for males and 14.7% among females, making it the second most effective mechanism in explaining the social patterning of PA. Neighbourhood-level processes resulted in a modest reduction in the same differential, while school level processes had the effect of equalising differences in PA across maternal education groups.

•

The potential social determinants of inequalities in physical activity were outlined.

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The role of family, school and neighbourhood in explaining these inequalities was quantified.

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The cumulative effect of social environment was observed over a 10-year period.

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Family-level characteristics were identified as the most effective explanatory mechanism.

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Highly educated mothers were observed to be enrolling their children in organised sport.

A Theoretical Perspective on Why Socioeconomic Health Inequalities Are Persistent: Building the Case for an Effective Approach

Despite policy intentions and many interventions aimed at reducing socioeconomic health inequalities in recent decades in the Netherlands and other affluent countries, these inequalities have not been reduced. Based on a narrative literature review, this paper aims to increase insight into why socioeconomic health inequalities are so persistent and build a way forward for improved approaches from a theoretical perspective. Firstly, we present relevant theories focusing on individual determinants of health-related behaviors. Thereafter, we present theories that take into account determinants of the individual level and the environmental level. Lastly, we show the complexity of the system of individual determinants, environmental determinants and behavior change for low socioeconomic position (SEP) groups and describe the next steps in developing and evaluating future effective approaches. These steps include systems thinking, a complex whole-system approach and participation of all stakeholders in system change.

Socio-economic inequalities in dietary intake in Chile: a systematic review

OBJECTIVE

Understanding the socio-economic inequalities in dietary intake is crucial when addressing the socio-economic gradient in obesity rates and non-communicable diseases. We aimed to systematically assess the association between socio-economic position (SEP) and dietary intake in Chile.

DESIGN

We searched for peer-reviewed and grey literature from inception until 31 December 2019 in PubMed, Scopus, PsycINFO, Web of Sciences and LILACS databases. Observational studies published in English and Spanish, reporting the comparison of at least one dietary factor between at least two groups of different SEP in the general Chilean population, were selected. Two researchers independently conducted data searches, screening and extraction and assessed study quality using an adaptation of the Newcastle Ottawa Quality Assessment Scale.

RESULTS

Twenty-one articles (from eighteen studies) were included. Study quality was considered low, medium and high for 24, 52 and 24 % of articles, respectively. Moderate-to-large associations indicated lower intake of fruit and vegetables, dairy products and fish/seafood and higher pulses consumption among adults of lower SEP. Variable evidence of association was found for energy intake and macronutrients, in both children and adults.

CONCLUSIONS

Our findings highlight some socio-economic inequalities in diets in Chile, evidencing an overall less healthy food consumption among the lower SEP groups. New policies to reduce these inequalities should tackle the unequal distribution of factors affecting healthy eating among the lower SEP groups. These findings also provide important insights for developing strategies to reduce dietary inequalities in Chile and other countries that have undergone similar nutritional transitions.

Overall lifestyles and socioeconomic inequity in mortality and life expectancy in China: the China health and nutrition survey

BACKGROUND

socioeconomic inequity in mortality and life expectancy remains inconclusive in low- and middle-income countries, and to what extent the associations are mediated or modified by lifestyles remains debatable.

METHODS

we included 21,133 adults from China Health and Nutrition Survey (1991-2011) and constructed three parameters to reflect participants' overall individual- (synthesising income, education and occupation) and area-level (urbanisation index) socioeconomic status (SES) and lifestyles (counting the number of smoking, physical inactivity and unhealthy diet and bodyweight). HRs for mortality and life expectancy were estimated by time-dependent Cox model and life table method, respectively.

RESULTS

during a median follow-up of 15.2 years, 1,352 deaths were recorded. HRs (95% CIs) for mortality comparing low versus high individual- and area-level SES were 2.38 (1.75-3.24) and 1.84 (1.51-2.24), respectively, corresponding to 5.7 (2.7-8.6) and 5.0 (3.6-6.3) life-year lost at age 50. Lifestyles explained ≤11.5% of socioeconomic disparity in mortality. Higher lifestyle risk scores were associated with higher mortality across all socioeconomic groups. HR (95% CI) for mortality comparing adults with low individual-level SES and 3-4 lifestyle risk factors versus those with high SES and 0-1 lifestyle risk factors was 7.06 (3.47-14.36), corresponding to 19.1 (2.6-35.7) life-year lost at age 50.

CONCLUSION

this is the first nationwide cohort study reporting that disadvantaged SES was associated with higher mortality and shorter life expectancy in China, which was slightly mediated by lifestyles. Risk lifestyles were related to higher mortality across all socioeconomic groups, and those with risk lifestyles and disadvantaged SES had much higher mortality risks.

Associations of Socioeconomic Status and Healthy Lifestyle With Incidence of Dyslipidemia: A Prospective Chinese Governmental Employee Cohort Study

Objective

The purpose of the study was to test whether primary lifestyles mediate associations of SES with incidence of dyslipidemia and to explore interaction relations of lifestyles and SES with incidence of dyslipidemia.

Methods

We included 9,901 individuals at baseline from January 2018 to November 2019, and incidence data were updated to 31 December 2020. Dyslipidemia was defined as total cholesterol (TC) 6.2 mmol/L TC ≥ or triglycerides (TG) ≥2.3 mmol/L or low-density lipoprotein cholesterol (LDL-C) ≥4.1 mmol/L or high-density lipoprotein cholesterol (HDL-C) <1.0 mmol/L; or physician diagnosed dyslipidemia or lipid-lowering drugs use. Lifestyles, socioeconomic factors, and personal characteristics were collected by a questionnaire. A latent class analysis based on education, family income, and occupational position was used to assess the SES. Lifestyle score was calculated using cigarette smoking, alcohol consumption, physical activity, and diet. Cox proportional hazard models and multivariate analyses were used to explore the associations. The mediation effect was evaluated using bootstrap method.

Results

Participant mean age was 36.5 years (SD = 0.11). The cumulative incidence of dyslipidemia was 11.0% over a mean follow-up of 13.4 months. Compared with participants of high SES, those with low SES had higher risk of incidence of dyslipidemia [hazard ratio 1.32, 95% confidence interval (CI): 1.01–1.73], after adjusting for lifestyle scores and other covariates. The proportion mediated by lifestyles was 5.41% (95%CI: 4.17–7.11). A significant additive interaction was found between lifestyles and SES, whereas association between lifestyle and incidence of dyslipidemia was stronger among those of high SES. Additionally, individuals with low SES and no or one healthy lifestyle behavior had a higher risk of developing dyslipidemia than those with high SES and 3 or 4 healthy lifestyles.

Conclusion

Unhealthy lifestyles play a small moderating role in socioeconomic inequity in incidence of dyslipidemia among Chinese governmental employees, suggesting that promoting healthy lifestyles alone may not significantly reduce socioeconomic inequalities in health, and measures to address other social determinants of health should also be considered alongside.

Healthcare Utilization and Smoking among South Carolina’s Long-Term Uninsured

Cigarette smoking and tobacco-related health conditions have continued to rise among persons of low social economic status. This study explored the association between healthcare utilization and smoking among the long-term uninsured (LTU). The sample consisted of South Carolina residents who had been without healthcare insurance for at least 24 months. Multivariable logistic regression was used to estimate differences in the likelihood of delaying healthcare due to cost and/or not filling a needed prescription between smokers and non-smokers. Among LTU, smoking was a significant predictor of delaying healthcare at the 10% level (AOR = 1.36, 95% CI = 0.99–1.86); the sensitivity analysis strengthened this association at the 5% level (AOR = 1.43, 95% CI = 1.06–1.93). Smoking was a significant predictor of not filling needed prescriptions (AOR = 1.44, 95% CI = 1.06–1.96). While neglected healthcare utilization was common among the LTU, this problem was more severe among smokers. The wider gap in access to healthcare services among the LTU, especially LTU who smoke, warrants further attention from the research community and policy makers.

Socioeconomic, intrapersonal and food environmental correlates of unhealthy snack consumption in school-going adolescents in Mumbai

Background

Unhealthy snacking habits in adolescents are typically triggered by obesogenic food environments and possibly perpetuated through interactions between socio-environmental factors and personal perceptions, attitudes, and motivations to change eating behaviors. This study attempted to address the knowledge gap regarding the association of intrapersonal, socioeconomic, and food environmental characteristics with unhealthy snack consumption in Indian adolescents, presenting several targets for effective interventions.

Methods

A representative sample of 10–12 years old adolescents (n 712) completed a cross-sectional survey including eating habits, characteristics of school and home food environments, and perceptions related to affordability, convenience, and barriers within the food environments. The frequency of unhealthy snack consumption was assessed using a validated qualitative food frequency questionnaire. Multivariate regression analyses determined the associated factors of unhealthy snack consumption in adolescents attending private and public schools.

Results

The mean age of adolescents was 10.9 (1.1) years, 48.2% were girls and 53.9% attended private schools. The most frequently consumed unhealthy snacks were biscuits/ cookies (5.2d/wk) followed by wafers (3.4d/wk) and Indian fried snacks- samosa/ vada pav (2.8 d/wk). Among the public-school adolescents, the odds of unhealthy snack consumption were 0.89 times lower when meals were had frequently at the dinner table and 4.97 times higher when the perceived barriers related to the affordability of healthy snacks were greater. Maternal education (OR 0.78, 95% CI 0.66–0.82, p < 0.001), family income (OR 2.15, 95% CI 1.98–2.32, p < 0.001), availability of unhealthy snacks (OR 2.98, 95% CI 1.36–3.46, p < 0.001) and fruits (OR 0.57, 95% CI 0.49–0.69, p < 0.001) at home, having evening meals together (OR 0.71, 95% CI 0.63–0.81, p 0.031), and perceived parental control during mealtimes (OR 0.67, 95% CI 0.62–0.72, p < 0.001) were associated with unhealthy snack consumption in adolescents attending private schools.

Conclusions

The results highlighted a pervasiveness of unhealthy snacks in adolescents’ food environments. Improving provisions and affordability of fruits and healthy snacks at schools, encouraging family mealtimes, and limiting the availability of unhealthy snacks at home whilst addressing the perceived barriers within food environments, and inculcating self-efficacy skills can improve snacking habits in Indian adolescents, irrespective of socioeconomic backgrounds.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13449-6.

Self-Regulatory Coping Behaviors and Stress Reactivity: Exploring the Environmental Affordance Model of Health Disparities

Objectives

To explore the relationship between self-regulatory coping behaviors (SRCB) and hypothalamic pituitary adrenal (HPA) stress reactivity.

Methods

Data came from the Richmond Stress and Sugar Study (n=125, median age: 57 years, 46% non-Hispanic White, 48% African American). The relationships between 11 SRCB (“health-harming” [e.g., smoking] and “health-promoting” [e.g., exercising]) with HPA stress reactivity, indicated by salivary cortisol response to the Trier Social Stress Test, was assessed using multi-level modeling.

Results

Health-harming and health-promoting SRCB were positively correlated (+0.33, p<0.001). Several individual behaviors were related to HPA stress reactivity, for example, smoking and meditation were associated with shallower increases in cortisol (smoking: −13.0%, 95%CI: −20.9% to −4.3%; meditation: −14.0%, 95%CI: −22.0% to −5.1%). However, SRCB summary measures were unrelated to stress reactivity.

Discussion

Health-harming and health-promoting SRCB are inter-related. Specific behaviors, rather than groupings as health-harming versus -promoting, are related to HPA stress reactivity.

Combined impact of lifestyle-related factors on total mortality among the elder Chinese: a prospective cohort study

Background

The combined impact of healthy lifestyle factors on total mortality among elder Chinese is unclear. This study aimed to investigate the overall impact of lifestyle factors on total mortality in a senior Chinese population, and determine whether these associations were consistent in the presence of different characteristics, including physical comorbidities.

Methods

The Chinese Longitudinal Healthy Longevity Survey (CLHLS) is a large population-based prospective cohort study in 22 of 31 provinces from mainland China. We included 15,163 adults aged ≥65 years recruited from 1998- to 2002 and followed-up until 2014. A healthy lifestyle score was calculated considering five lifestyle factors (exercise, smoking, dietary diversity, body mass index and drinking). The scores ranged from zero to five points and were classified into the following three categories: unhealthy (0-1 point), intermediate (2-3 points) and healthy (4-5 points). Cox proportional hazards regression analyses were used to assess the associations between the combined healthy lifestyle score and total mortality, adjusting for demographic characteristics and physical comorbidities, as appropriate. Stratification analyses and interaction analyses were further performed.

Results

Among the 15,163 participants, the mean age (SD) was 86.2 (11.6) years. During an average follow-up period of 12.5 (SD = 3.9) years, 9655 deaths occurred. The adjusted hazard ratios (HRs) of total mortality decreased as the number of healthy lifestyle factors increased. Compared to the unhealthy lifestyle group, the healthy lifestyle group had a HR and 95% CI of 0.78 and 0.72-0.83. The population attributable risk of total death among those without a healthy lifestyle was 25.2%. A healthier lifestyle pattern was associated with a lower total mortality risk among individuals with different severities of physical comorbidities, although the associations were stronger among those with fatal physical comorbidities (p_-interaction < .001).

Conclusions

In this large-scale study, a healthier lifestyle measured by regular exercise participation, never smoking, never drinking, good dietary diversity and normal weight, was inversely associated with total mortality, regardless of physical comorbidity status. These findings support the necessity of multiple lifestyle modifications to prevent premature death in both general elderly populations and those with physical comorbidities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02982-z.

Educational Attainment and Lifestyle Risk Factors Associated With All-Cause Mortality in the US

Question

To what extent can the association between socioeconomic status (SES) and mortality be explained by differential exposure to lifestyle factors (such that unhealthy lifestyle factors are more prevalent in groups with lower SES) and differential vulnerability to lifestyle factors (such that the same exposure to unhealthy lifestyle factors is associated with more deleterious outcomes in groups with lower SES)?

Findings

In this nationwide cohort study of 415 764 US adults, a mediation analysis showed that lifestyle factors explained 66% (men) and 80% (women) of the association between educational attainment and all-cause mortality. Inequalities in mortality were primarily a result of greater exposure and clustering of unhealthy lifestyle factors among groups with lower educational attainment; with some exception, there was little evidence for differential vulnerability to lifestyle factors.

Meaning

Public health interventions to create equality in the socioenvironmental contexts that shape lifestyle factors and to reduce exposure to lifestyle risk factors among groups with low SES have the potential to significantly increase life expectancy and reduce socioeconomic inequalities in mortality.

Importance

The US has experienced increasing socioeconomic inequalities and stagnating life expectancy. Past studies have not disentangled 2 mechanisms thought to underlie socioeconomic inequalities in health, differential exposure and differential vulnerability, that have different policy implications.

Objective

To evaluate the extent to which the association between socioeconomic status (SES) and all-cause mortality can be decomposed into a direct effect of SES, indirect effects through lifestyle factors (differential exposure), and joint effects of SES with lifestyle factors (differential vulnerability).

Design, Setting, and Participants

This nationwide, population-based cohort study used the cross-sectional US National Health Interview Survey linked to the National Death Index. Civilian, noninstitutionalized US adults aged 25 to 84 years were included from the 1997 to 2014 National Health Interview Survey and were followed up until December 31, 2015. Data were analyzed from May 1 to October 31, 2021. A causal mediation model using an additive hazard and marginal structural approach was used.

Exposures

Both SES (operationalized as educational attainment) and lifestyle risk factors (smoking, alcohol use, obesity, and physical inactivity) were assessed using self-reported questionnaires.

Main Outcomes and Measures

Time to all-cause mortality.

Results

Participants included 415 764 adults (mean [SD] age, 49.4 [15.8] years; 55% women; 64% non-Hispanic White), of whom 45% had low educational attainment and 27% had high educational attainment. Participants were followed up for a mean (SD) of 8.8 (5.2) years during which 49 096 deaths (12%) were observed. Low educational attainment (compared with high) was associated with 83.6 (men; 95% CI, 81.8-85.5) and 54.8 (women; 95% CI, 53.4-56.2) additional deaths per 10 000 person-years, of which 66% (men) and 80% (women) were explained by lifestyle factors. Inequalities in mortality were primarily a result of greater exposure and clustering of unhealthy lifestyle factors among low SES groups; with some exceptions among women, little evidence of differential vulnerability was identified.

Conclusions and Relevance

In this cohort study, differential exposure to lifestyle risk factors was an important mediator of socioeconomic inequalities in mortality. Public health interventions are needed, particularly among low SES groups, to address smoking, physical inactivity, alcohol use, and the socioenvironmental contexts within which these risk factors develop.

Modeling Years of Life Lost Due to COVID-19, Socioeconomic Status, and Nonpharmaceutical Interventions: Development of a Prediction Model

Background

Research in the COVID-19 pandemic focused on the health burden, thereby largely neglecting the potential harm to life from welfare losses.

Objective

This paper develops a model that compares the years of life lost (YLL) due to COVID-19 and the potential YLL due to the socioeconomic consequences of its containment.

Methods

It improves on existing estimates by conceptually disentangling YLL due to COVID-19 and socioeconomic status. By reconciling the normative life table approach with socioeconomic differences in life expectancy, it accounts for the fact that people with low socioeconomic status are hit particularly hard by the pandemic. The model also draws on estimates of socioeconomic differences in life expectancy to ascertain potential YLL due to income loss, school closures, and extreme poverty.

Results

Tentative results suggest that if only one-tenth of the current socioeconomic damage becomes permanent in the future, it may carry a higher YLL burden than COVID-19 in the more likely pandemic scenarios. The model further suggests that the socioeconomic harm outweighs the disease burden due to COVID-19 more quickly in poorer and more unequal societies. Most urgently, the substantial increase in extreme poverty needs immediate attention. Avoiding a relatively minor number of 4 million unemployed, 1 million extremely poor, and 2 million students with a higher learning loss may save a similar amount of life years as saving 1 million people from dying from COVID-19.

Conclusions

Primarily, the results illustrate the urgent need for redistributive policy interventions and global solidarity. In addition, the potentially high YLL burden from income and learning losses raises the burden of proof for the efficacy and necessity of school and business closures in the containment of the pandemic, especially where social safety nets are underdeveloped.

Education inequalities in cardiovascular and coronary heart disease in Italy and the role of behavioral and biological risk factors

BACKGROUND AND AIMS

Behavioral and biological risk factors (BBRF) explain part of the variability in socioeconomic differences in health. The present study aimed at evaluating education differences in incidence of cardiovascular disease (CVD) and coronary heart disease (CHD) in Italy and the role of BBRF.

METHODS AND RESULTS

All subjects aged 30-74 years (n = 132,686) who participated to the National Health Interview Surveys 2000 and 2005 were included and followed-up for ten years. Exposure to smoking, physical activity, overweight/obesity, diabetes and hypertension at baseline was considered. Education level was used as an indicator of socioeconomic status. The outcomes were incident cases of CVD and CHD. Hazard ratios by education level were estimated, adjusting for sociodemographic covariates and stratifying by sex and geographic area. The contribution of BBRF to education inequalities was estimated by counterfactual mediation analysis, in addition to the assessment of the risk attenuation by comparing the models including BBRF or not. 22,214 participants had a CVD event and 6173 a CHD event. After controlling for sociodemographic factors, the least educated men showed a 21% higher risk of CVD and a 17% higher risk of CHD compared to the most educated (41% and 61% among women). The mediating effect (natural indirect effect) of BBRF between extreme education levels was 52% for CVD and 84% for CHD among men (16% among women for CVD).

CONCLUSIONS

More effective strategies aiming at reducing socioeconomic disparities in CVD and CHD are needed, through programs targeting less educated people in combination with community-wide initiatives.

Socioeconomic status and its relation with breast cancer recurrence and survival in young women in the Netherlands

BACKGROUND

Associations between socioeconomic status (SES) and breast cancer survival are most pronounced in young patients. We further investigated the relation between SES, subsequent recurrent events and mortality in breast cancer patients < 40 years. Using detailed data on all recurrences that occur between date of diagnosis of the primary tumor and last observation, we provide a unique insight in the prognosis of young breast cancer patients according to SES.

METHODS

All women < 40 years diagnosed with primary operated stage I-III breast cancer in 2005 were selected from the nationwide population-based Netherlands Cancer Registry. Data on all recurrences within 10 years from primary tumor diagnosis were collected directly from patient files. Recurrence patterns and absolute risks of recurrence, contralateral breast cancer (CBC) and mortality - accounting for competing risks - were analysed according to SES. Relationships between SES, recurrence patterns and excess mortality were estimated using a multivariable joint model, wherein the association between recurrent events and excess mortality (expected mortality derived from the general population) was included.

RESULTS

We included 525 patients. The 10-year recurrence risk was lowest in high SES (18.1%), highest in low SES (29.8%). Death and CBC as first events were rare. In high, medium and low SES 13.2%, 15.3% and 19.1% died following a recurrence. Low SES patients had shorter median time intervals between diagnosis, first recurrence and 10-year mortality (2.6 and 2.7 years, respectively) compared to high SES (3.5 and 3.3 years, respectively). In multivariable joint modeling, high SES was significantly related to lower recurrence rates over 10-year follow-up, compared to low SES. A strong association between the recurrent event process and excess mortality was found.

CONCLUSIONS

High SES is associated with lower recurrence risks, less subsequent events and better prognosis after recurrence over 10 years than low SES. Breast cancer risk factors, adjuvant treatment adherence and treatment of recurrence may possibly play a role in this association.

Low Adherence to the Mediterranean Diet Is Associated with Poor Socioeconomic Status and Younger Age: A Cross-Sectional Analysis of the EpiDoC Cohort

The Mediterranean diet (MD) is recognized as one of the healthiest dietary patterns as it has been consistently associated with several beneficial health outcomes. Adherence to the MD pattern has been decreasing in southern European countries for the last decades, especially among low socioeconomic groups. The aim of this study was to assess the adherence to the MD in Portugal, to evaluate regional differences, and explore associated factors (sociodemographic, economic, and lifestyles behaviors). This study used the third data collection wave of the Epidemiology of Chronic Diseases Cohort Study (EpiDoC 3). MD adherence was assessed using the Portuguese-validated MD adherence score (MEDAS) questionnaire. Non-adjusted and adjusted logistic regression models were used to assess the risk factors for low MD adherence and individual MEDAS items. In this cross-sectional evaluation of the EpiDoC 3 cohort study (n = 5647), 28.8% of the Portuguese population had low adherence to a MD. Azores and Madeira had lower adherence to the MD than the rest of the country. Younger individuals in lower income categories (e.g., OR_{finding it very difficult} = 1.48; 95% CI 1.16-1.91) and with a lower educational level (e.g., OR_{0-4 years} = 2.63; 95% CI 2.09-3.32) had higher odds of having a lower adherence to the MD. Portuguese adults have a high prevalence of low adherence to the MD, especially among those who are younger and have lower socioeconomic status. Public health policies to promote adherence to the MD should pay special attention to these groups.

Factors Affecting Depression in Middle-Aged and Elderly Men Living Alone: A Cross-Sectional Path Analysis Model

The main objectives of this cross-sectional study were to determine the relationship between socioeconomic status (SES) and depression and to estimate the mediating effects of social network satisfaction, self-esteem, and perceived health status among middle-aged and elderly men living alone, based on the reserve capacity model. Secondary data from a sample of 394 middle-aged and elderly men aged 45 years or older from the 15th Korea Welfare Panel Study (KOWEPS) were analyzed. A path analysis model was constructed to evaluate the relationship among SES, social network satisfaction, self-esteem, perceived health status, and depression. The path analysis exhibited significant direct effects of social network satisfaction, self-esteem, and perceived health status on depression and significant indirect effects of SES on depression. There was no direct effect of SES on depression. Social network satisfaction and self-esteem had significant mediating effects of SES on depression. Among middle-aged and elderly men, intrapersonal reserves, which are psychosocial factors including social network satisfaction, self-esteem, and perceived health status, showed more association with depression than tangible reserves such as SES. This suggests that interventions promoting self-esteem and perceived health status could prevent depression.