Indicators of socioeconomic position (part 2)

Socioeconomic status and risk of psychological distress and depression in the Stockholm Public Health Cohort: a population-based study

BACKGROUND

There is limited evidence whether the association between low socioeconomic status and risk of common mental disorders varies with symptom severity, type of socioeconomic indicator or gender.

METHODS

A population-based survey was conducted among a random sample of Stockholm County residents aged 18-84 years in 2002. Respondents were reassessed via a follow-up questionnaire in 2007. Participants in both surveys (n = 23794) were categorized according to socioeconomic status at baseline and followed up for onset of psychological distress (according to the twelve-item general health questionnaire) and depression (according to health data registers). Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Occupational class was not associated with risk of psychological distress, regardless of severity or gender. Occupational class was strongly associated with onset of depression in men (OR 3.0 [95% CI 1.5-5.9], comparing unskilled manual workers with higher non-manual workers) but not women. Income was associated with risk of onset of all outcomes, and risks increased with symptom severity. Belonging to the highest household income category was particularly protective of depression in women. Education was unrelated to either outcome in men and women overall.

LIMITATIONS

Retention rate at follow-up was 76% and depression was ascertained via health service use.

CONCLUSION

Low socioeconomic position is associated with onset of depression but not mild distress. Attributes of occupational class and household income may be respectively more relevant for the development of depression in men and women.

Associations with early-life socio-economic position in adult DNA methylation

BACKGROUND

Disadvantaged socio-economic position (SEP) in childhood is associated with increased adult mortality and morbidity. We aimed to establish whether childhood SEP was associated with differential methylation of adult DNA.

METHODS

Forty adult males from the 1958 British Birth Cohort Study were selected from SEP extremes in both early childhood and mid-adulthood. We performed genome-wide methylation analysis on blood DNA taken at 45 years using MeDIP (methylated DNA immunoprecipitation). We mapped in triplicate the methylation state of promoters of approximately 20,000 genes and 400 microRNAs. Probe methylation scores were averaged across triplicates and differential methylation between groups of individuals was determined. Differentially methylated promoter sites of selected genes were validated using pyrosequencing of bisulfite-converted DNA.

RESULTS

Variably methylated probes (9112 from n = 223,359 on the microarray) corresponded to 6176 gene promoters with at least one variable probe. Unsupervised hierarchical clustering of probes obtained from the 500 most variable promoters revealed a cluster enriched with high SEP individuals confirming that SEP differences contribute to overall epigenetic variation. Methylation levels for 1252 gene promoters were associated with childhood SEP vs 545 promoters for adulthood SEP. Functionally, associations with childhood SEP appear in promoters of genes enriched in key cell signalling pathways. The differentially methylated promoters associated with SEP cluster in megabase-sized regions of the genome.

CONCLUSIONS

Adult blood DNA methylation profiles show more associations with childhood SEP than adult SEP. Organization of these associations across the genome suggests a well-defined epigenetic pattern linked to early socio-economic environment.

Prevalence and socio-demographic correlates of stunting and thinness among Pakistani primary school children

Background

Child growth is internationally recognized as an important indicator of nutritional status and health in populations. Child under-nutrition is estimated to be the largest contributor to global burden of disease, and it clusters in South Asia but literature on under-nutrition among school-aged children is difficult to find in this region. The study aimed to assess the prevalence and socio-demographic correlates of stunting and thinness among Pakistani primary school children.

Methods

A population-based cross-sectional study was conducted with a representative multistage cluster sample of 1860 children aged 5-12 years in Lahore, Pakistan. Stunting (< -2 SD of height-for-age z-score) and thinness (< -2 SD of BMI-for-age z-score) were defined using the World Health Organization reference 2007. Chi-square test was used as the test of trend. Logistic regression was used to quantify the independent predictors of stunting and thinness and adjusted odds ratios (aOR) with 95% confidence interval (CI) were obtained. Linear regression was used to explore the independent determinants of height- and BMI-for-age z-scores. Statistical significance was considered at P < 0.05.

Results

Eight percent (95% CI 6.9-9.4) children were stunted and 10% (95% CI 8.7-11.5) children were thin. Stunting and thinness were not significantly associated with gender. Prevalence of stunting significantly increased with age among both boys and girls (both P < 0.001) while thinness showed significant increasing trend with age among boys only (P = 0.034). Significant correlates of stunting included age > 8 years, rural area and urban area with low SES, low-income neighborhoods, lower parental education, more siblings, crowded housing and smoking in living place (all P < 0.001). Significant correlates of thinness included rural area and urban area with low SES, low-income neighborhoods and lower parental education (all P < 0.001), and age > 10 years (P = 0.003), more siblings (P = 0.016) and crowded housing (P = 0.006). In multivariate logistic regression analyses adjusted simultaneously for all factors, older age (aOR 3.60, 95% CI 1.89-6.88), urban area with low SES (aOR 2.58, 95% CI 1.15-5.81) and low-income neighborhoods (aOR 4.62, 95% CI 1.63-13.10) were associated with stunting while urban area with low SES (aOR 2.28, 95% CI 1.21-4.30) was associated with thinness. In linear regression analyses adjusted for all factors, low-income neighborhoods and older age were associated with lower height-for-age z-score while rural area with low/disadvantaged SES was associated with lower BMI-for-age z-score.

Conclusions

Relatively low prevalence of stunting and thinness depicted an improvement in the nutritional status of school-aged children in Pakistan. However, the inequities between the poorest and the richest population groups were marked with significantly higher prevalence of stunting and thinness among the rural and the urban poor, the least educated, the residents of low-income neighborhoods and those having crowded houses. An increasing trend with age was observed in prevalence of stunting and thinness. Smoking in living place was associated with stunting. Findings suggest the need to implement evidence-based child health policy and strategies, prioritizing the poor and socially disadvantaged population.

Socioeconomic determinants of disability in Chile

BACKGROUND

Disability is a worldwide public health priority. A shift from a biomedical perspective of dysfunction to a broader social understanding of disability has been proposed. Among many different social factors described in the past, socioeconomic position remains as a key multidimensional determinant of health. The study goal was to analyze the relationship between disability and different domains of socioeconomic position in Chile.

METHODS

Cross-sectional analysis of an anonymized population-based survey conducted in Chile in 2006. Any disability (dichotomous variable) and 6 different types of disability were analyzed on the bases of their relationship with income quintiles, occupational status, educational level, and material living standards (quality of the housing, overcrowding rate and sanitary conditions). Confounding and interaction effects were explored using R statistical program.

RESULTS

Income, education, occupation, and material measures of socioeconomic position, along with some sociodemographic characteristics of the population, were independently associated with the chance of being disabled in Chile. Interestingly, classic measures of socioeconomic position (income, education, and occupation) were consistently associated with any disability in Chile, whereas material living conditions were partially confounded by these classic measures. In addition to this, each type of disability showed a particular pattern of related social determinants, which also varied by age group.

CONCLUSIONS

This study contributed to the understanding of disability in Chile and how different domains of socioeconomic position might be associated with this prevalent condition. Disability remains a complex multidimensional public health problem in Chile that requires the inclusion of a wide range of risk factors, of which socioeconomic position is particularly relevant.

Socioeconomic position, stage of lung cancer and time between referral and diagnosis in Denmark, 2001-2008

Introduction:

We investigated the association between socioeconomic position, stage at diagnosis, and length of period between referral and diagnosis in a nationwide cohort of lung cancer patients.

Methods:

Through the Danish Lung Cancer Register, we identified 18 103 persons diagnosed with lung cancer (small cell and non-small cell) in Denmark, 2001–2008, and obtained information on socioeconomic position and comorbidity from nationwide administrative registries. The odds ratio (OR) for a diagnosis of advanced-stage lung cancer (stages IIIB–IV) and for a diagnosis >28 days after referral were analysed by multivariate logistic regression models.

Results:

The adjusted OR for advanced-stage lung cancer was reduced among persons with higher education (OR, 0.92; 95% confidence interval (CI), 0.84–0.99), was increased in persons living alone (OR, 1.06; 95% CI, 1.01–1.13) and decreased stepwise with increasing comorbidity. Higher education was associated with a reduced OR for >28 days between referral and diagnosis as was high income in early-stage patients. Male gender, age and severe comorbidity were associated with increased ORs in advanced-stage patients.

Interpretation:

Differences by socioeconomic position in stage at diagnosis and in the period between referral and diagnosis indicate that vulnerable patients presenting with lung cancer symptoms require special attention.

Racial and ethnic disparities in disease activity and function among persons with rheumatoid arthritis from university-affiliated clinics

OBJECTIVE

Health outcomes in rheumatoid arthritis (RA) have improved significantly over the past 2 decades. However, research suggests that disparities exist by race/ethnicity and socioeconomic status, with certain vulnerable populations remaining understudied. Our objective was to assess disparities in disease activity and function by race/ethnicity and explore the impact of language and immigrant status at clinics serving diverse populations.

METHODS

We examined a cross-sectional study of 498 adults with confirmed RA at 2 rheumatology clinics: a university hospital clinic and a public county hospital clinic. Outcomes included the Disease Activity Score in 28 joints (DAS28) and its components, and the Health Assessment Questionnaire (HAQ), a measure of function. We estimated multivariable linear regression models including interaction terms for race/ethnicity and clinic site.

RESULTS

After adjusting for age, sex, education, disease duration, rheumatoid factor status, and medication use, clinically meaningful and statistically significant differences in DAS28 and HAQ scores were seen by race/ethnicity, language, and immigrant status. Lower disease activity and better function was observed among whites compared to nonwhites at the university hospital. This same pattern was observed for disease activity by language (English compared to non-English) and immigrant status (US-born compared to immigrant) at the university clinic. No significant differences in outcomes were found at the county clinic.

CONCLUSION

The relationship between social determinants and RA disease activity varied significantly across clinic setting with pronounced variation at the university, but not at the county clinic. These disparities may be a result of events that preceded access to subspecialty care, poor adherence, or health care delivery system differences.

Bayesian factor analysis to calculate a deprivation index and its uncertainty

BACKGROUND

Procedures for calculating deprivation indices in epidemiologic studies often show some common problems because the spatial dependence between units of analysis and uncertainty of the estimates is not usually accounted for. This work highlights these problems and illustrates how spatial factor Bayesian modeling could alleviate them.

METHODS

This study applies a cross-sectional ecological design to analyze the census tracts of 3 Spanish cities. To calculate the deprivation index, we used 5 socioeconomic indicators that comprise the deprivation index calculated in the MEDEA project. The deprivation index was estimated by a Bayesian factor analysis using hierarchical models, which takes the spatial dependence of the study units into account. We studied the relationship between this index and the one obtained using principal component analysis. Various analyses were carried out to assess the uncertainty obtained in the index.

RESULTS

A high correlation was observed between the index obtained and the non-Bayesian index, but this relationship is not linear and there is disagreement between the methods when the areas are grouped according to quantiles. When the deprivation index is calculated using summary statistics based on the posterior distributions, the uncertainty of the index in each census tract is not taken into account. Failure to take this uncertainty into account may result in misclassification bias in the census tracts when these are grouped according to quantiles of the deprivation index.

CONCLUSIONS

Not taking uncertainty into account may result in misclassification bias in the census tracts. This bias could interfere in subsequent analyses that include the deprivation index. Our proposal provides another tool for identifying groups with greater deprivation and for improving decision-making for public policy planning.

Socio-economic differences in exposure to television food advertisements in the UK: a cross-sectional study of advertisements broadcast in one television region

Objective

To document socio-economic differences in exposure to food advertising, including advertisements for foods high in fat, salt and sugar (HFSS) as defined by the UK Food Standards Agency's Nutrient Profiling Model.

Design

A cross-sectional survey. Information (including product advertised and viewing figures) on all advertisements broadcast in one UK region over one week (6–12 July 2009) was obtained. Food advertisements were identified and linked to nutritional information on the content of advertised foods.

Setting

UK Tyne-Tees television region.

Subjects

Data were sourced from a UK-wide television viewing panel.

Results

Eleven per cent of advertising seen was for food and 63 % of food advertising seen was for HFSS foods. The proportion of all advertising seen that was for food was smaller among viewers in the least v. most affluent social grade (OR = 0·98, 99 % CI 0·95, 1·00). There was no difference in the proportion of food advertising seen that was for HFSS food between viewers in the most and least affluent social grades. Total exposure to both all food advertising and HFSS food advertising was 2·1 times greater among the least v. the most affluent viewers.

Conclusions

While the least affluent viewers saw relatively fewer food advertisements, their absolute exposure to all food and HFSS food advertisements was higher than that of the most affluent viewers. Current UK restrictions prohibit advertisements for HFSS foods during programmes with a high proportion of child viewers. Extending these to all programming may reduce socio-economic inequalities in exposure to these advertisements and in diet and obesity.

Life course models of socioeconomic position and cardiovascular risk factors: 1946 birth cohort

PURPOSE

To identify the life course model that best describes the association between life course socioeconomic position (SEP) and cardiovascular (CVD) risk factors (ie, body mass index [BMI], systolic and diastolic blood pressure, total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides, and glycated hemoglobin) and explore BMI across the life course as mediators of the relationship.

METHODS

The Medical Research Council National Survey of Health and Development was used to compare partial F-tests of simpler nested life course SEP models corresponding to critical period, accumulation, and social mobility models with a saturated model. Then, the chosen life course model for each CVD risk factor was adjusted for BMI at age 53 and lifetime BMI (ages 4, 26, 43, and 53 years).

RESULTS

Among women, SEP was generally associated with CVD risk factors in a cumulative manner, whereas childhood critical period was the prominent model for men. When the best-fitting SEP models were used, we found that adjustment for BMI at age 53 reduced associations for all outcomes in both genders. Further adjustment for lifetime BMI (4, 26, 43, and 53 years) did not substantially alter most associations (except for triglycerides).

CONCLUSIONS

SEP at different points across life influences CVD risk factors differently in men and women.

Cardiovascular disease by diabetes status in five ethnic minority groups compared to ethnic Norwegians

Background

The population in Norway has become multi-ethnic due to migration from Asia and Africa over the recent decades. The aim of the present study was to explore differences in the self-reported prevalence of cardiovascular disease (CVD) and associated risk factors by diabetes status in five ethnic minority groups compared to ethnic Norwegians.

Methods

Pooled data from three population-based cross-sectional studies conducted in Oslo between 2000 and 2002 was used. Of 54,473 invited individuals 24,749 (45.4%) participated. The participants self-reported health status, underwent a clinical examination and blood samples were drawn. A total of 17,854 individuals aged 30 to 61 years born in Norway, Sri-Lanka, Pakistan, Iran, Vietnam or Turkey were included in the study. Chi-square tests, one-way ANOVAs, ANCOVAs, multiple and logistic regression were used.

Results

Age- and gender-standardized prevalence of self-reported CVD varied between 5.8% and 8.2% for the ethnic minority groups, compared to 2.9% among ethnic Norwegians (p < 0.001). Prevalence of self-reported diabetes varied from 3.0% to 15.0% for the ethnic minority groups versus 1.8% for ethnic Norwegians (p < 0.001). Among individuals without diabetes, the CVD prevalence was 6.0% versus 2.6% for ethnic minorities and Norwegians, respectively (p < 0.001). Corresponding CVD prevalence rates among individuals with diabetes were 15.3% vs. 12.6% (p = 0.364). For individuals without diabetes, the odds ratio (OR) for CVD in the ethnic minority groups remained significantly higher (range 1.5-2.6) than ethnic Norwegians (p < 0.05), after adjustment for age, gender, education, employment, and body height, except for Turkish individuals. Regardless of diabetes status, obesity and physical inactivity were prevalent in the majority of ethnic minority groups, whereas systolic- and diastolic- blood pressures were higher in Norwegians. In nearly all ethnic groups, individuals with diabetes had higher triglycerides, waist-to-hip ratio (WHR), and body mass index compared to individuals without diabetes. Age, diabetes, hypertension, hypercholesterolemia, and WHR were significant predictors of CVD in both ethnic Norwegians and ethnic minorities, but significant ethnic differences were found for age, diabetes, and hypercholesterolemia.

Conclusions

Ethnic differences in the prevalence of CVD were prominent for individuals without diabetes. Primary CVD prevention including identification of undiagnosed diabetes should be prioritized for ethnic minorities without known diabetes.

Parental and offspring adiposity associations: insights from the 1958 British birth cohort

BACKGROUND/AIMS

Parent-offspring adiposity associations are well-established: offspring of obese parents have elevated risks of overweight/obesity. The aim of studies based on the 1958 British birth cohort has been to gain insights into explanations of these associations, such as whether parent-offspring BMI associations are due to offspring lifestyles or depend on socio-economic conditions.

METHODS

All major studies on intergenerational adiposity associations in the three generations of the 1958 birth cohort were reviewed. In addition, BMI data for parents (G1) and the cohort (G2) were analysed stratified by social class.

RESULTS

BMI of G1 and G2 were correlated both when offspring were children and in mid-adulthood: a 1 kg/m(2) higher parental BMI was associated with an average 0.24-0.35 kg/m(2) higher offspring (mothers/fathers vs sons/daughters) BMI at 45 years. Associations were little affected by adjustment for lifestyle and socio-economic factors, but varied by social class: average BMI gain in offspring relative to parents was greater in lower classes, e.g. for males vs fathers by 3.6 and 2.5 kg/m(2) in classes IV&V and I&II, respectively. Parent-offspring BMI associations were stronger for recent (G2 and G3) than older (G1 and G2) generations.

CONCLUSIONS

Parent-offspring associations in BMI were not explained by offspring lifestyles, but varied over successive generations and by social class, suggesting that intergenerational transmission of adiposity at a population level is modifiable rather than immutable.

Class Relations and All-Cause Mortality: A Test of Wright's Social Class Scheme Using the Barcelona 2000 Health Interview Survey

The aim of this study is to test the effects of neo-Marxian social class and potential mediators such as labor market position, work organization, material deprivation, and health behaviors on all-cause mortality. The authors use longitudinal data from the Barcelona 2000 Health Interview Survey (N = 7,526), with follow-up interviews through the municipal census in 2008 (95.97% response rate). Using data on relations of property, organizational power, and education, the study groups social classes according to Wright's scheme: capitalists, petit bourgeoisie, managers, supervisors, and skilled, semi-skilled, and unskilled workers. Findings indicate that social class, measured as relations of control over productive assets, is an important predictor of mortality among working-class men but not women. Workers (hazard ratio = 1.60; 95% confidence interval, 1.10–2.35) but also managers and small employers had a higher risk of death compared with capitalists. The extensive use of conventional gradient measures of social stratification has neglected sociological measures of social class conceptualized as relations of control over productive assets. This concept is capable of explaining how social inequalities are generated. To confirm the protective effect of the capitalist class position and the “contradictory class location hypothesis,” additional efforts are needed to properly measure class among low-level supervisors, capitalists, managers, and small employers.

Inequality in self-rated health among immigrants, their descendants and ethnic Danes: examining the role of socioeconomic position

OBJECTIVES

We investigated inequalities in self-rated health between immigrants, their descendants, and ethnic Danes and explored mediation by socioeconomic position and interactions between country of origin and socioeconomic position.

METHODS

Cross-sectional survey data on self-rated health from 4,985 individuals aged 18-66 years including immigrants from seven non-Western countries, their descendants, and ethnic Danes was linked to registry-based data on education, employment status, and income as indicators of socioeconomic position. Using multiple logistic regression analysis, we estimated the association between country of origin and self-rated health.

RESULTS

Immigrants reported poorer health compared with ethnic Danes [age-adjusted odds ratio (OR) = 2.0-7.3 for men; 2.1-10.5 for women, dependent on country of origin] as well as their descendants (OR = 1.6-3.8 for men; 1.5-2.0 for women). Adjustment for socioeconomic position attenuated this association. Stratified analysis indicated that the effect of socioeconomic position on self-rated health varied across the groups.

CONCLUSION

Policies addressing inequalities in health between immigrants, their descendants, and ethnic Danes should target underlying socioeconomic inequalities. Further research of the effects of socioeconomic position on health among immigrants and descendants is needed.

Area-based socioeconomic status and mood disorders: cross-sectional evidence from a cohort of randomly selected adult women

OBJECTIVE

Data suggest there are established socio-economic disparities associated with mental health although most research has focused on individual-level indicators of socio-economic position. The aim of this study was to investigate the association between mood disorders and area-based socio-economic status (SES), and whether both ends of the SES continuum experienced increased odds for a mood disorder.

METHODS

Using a clinical interview (SCID-I/NP), psychiatric history was ascertained in a population-based sample of 1095 women (20-93 years) from the Barwon Statistical Division, south-eastern Australia. SES was determined by cross-referencing residential addresses with Australian Bureau of Statistics 2006 census data for the region and categorised into three groupings of low, mid, and upper SES. The Index of Economic Resources (IER), Index of Education and Occupation (IEO), and Index of Relative Socioeconomic Advantage/Disadvantage (IRSAD) were utilised. Lifestyle factors were self-reported.

RESULTS

For IER, the low SES group had a 2.0-fold increased odds of a current mood disorder compared to the mid group, after adjustment for physical activity and current anxiety (OR=2.0, 95% CI 1.0-4.1, p=0.05). This pattern was similarly observed for IEO (OR=1.8, 95% CI 0.9-3.7, p=0.1) and IRSAD (OR=1.6 95% CI 0.8-3.4, p=0.2). Those within the upper SES group showed a non-significant increase in the odds of a current mood disorder compared to the mid-group; IER (OR=1.4, 95% CI 0.8-2.5, p=0.3), IEO (OR=1.2, 95% CI 0.07-2.3, p=0.5) and IRSAD (OR=1.2, 95% CI 0.7-2.1, p=0.6).

CONCLUSIONS

Women in the low SES category were most likely to have a mood disorder. Furthermore, being in an upper SES group may not be protective against mood disorders.

Live long and prosper? Childhood living conditions, marital status, social class in adulthood and mortality during mid-life: A cohort study

Aims: The aim of the present study was to investigate the impact of childhood living conditions, marital status, and social class in adulthood on the risk of mortality during mid-life. Two questions were addressed: Is there an effect of childhood living conditions on mortality risk during mid-life and if so, is the effect mediated or modified by social class and/or marital status in adulthood? Methods: A nationally representative, Swedish, level of living survey from 1968 was used as baseline. The study included those aged 25—69 at baseline (n = 4082). Social conditions in childhood and adulthood were assessed using self-reports. These individuals were then followed for 39 years using registry data on mortality. Results: The results showed associations between childhood living conditions, marital status, social class in adulthood and mortality during mid life. Social class and familial conditions during childhood as well as marital status and social class in adulthood all contributed to the risk of mortality during mid-life. Individuals whose father’s were manual workers, who grew up in broken homes, who were unmarried, and/or were manual workers in adulthood had an increased risk of mortality during mid life. The effects of childhood conditions were, in part, both mediated and modified by social class in adulthood. Conclusions: The findings of this study suggest that there are structural, social conditions experienced at different stages of the life course that affect the risk of mortality during mid-life.

Ethnic differences in diabetes-related mortality in the Brussels-Capital Region (2001-05): the role of socioeconomic position

OBJECTIVES

To examine if and to what extent ethnic differences in diabetes-related mortality are associated with differences in education and housing status.

METHODS

The data consist of a cohort study linking the 2001 census to emigration and mortality data for the period 2001-05. The study population comprises all Belgian and North African inhabitants of the Brussels-Capital Region (BCR) aged 25-74. Age-standardized mortality rates (ASMRs) (direct standardization) and mortality rate ratios (MRRS) (Poisson regression) are computed.

RESULTS

North Africans have a higher diabetes-related mortality compared to Belgians. The ASMRs for North African and Belgian women are 54.8 (95% confidence interval (CI) 31.5-78.2) and 23.8 (95% CI 20.3-27.3), respectively. These differences in diabetes-related mortality largely disappear when differences in education are taken into account. The MRRs for North African versus Belgian origin drop from 1.62 (95% CI 1.11-2.37) to 1.19 (95% CI 0.73-1.93) in men and from 3.35 (95% CI 2.08-5.41) to 1.88 (95% CI 0.95-3.69) in women.

CONCLUSIONS

Differences in education play an important part in the excess diabetes-related mortality among North Africans in the BCR.

Assessing access barriers to tuberculosis care with the tool to Estimate Patients' Costs: pilot results from two districts in Kenya

Background

The poor face geographical, socio-cultural and health system barriers in accessing tuberculosis care. These may cause delays to timely diagnosis and treatment resulting in more advanced disease and continued transmission of TB. By addressing barriers and reasons for delay, costs incurred by TB patients can be effectively reduced. A Tool to Estimate Patients' Costs has been developed. It can assist TB control programs in assessing such barriers. This study presents the Tool and results of its pilot in Kenya.

Methods

The Tool was adapted to the local setting, translated into Kiswahili and pretested. Nine public health facilities in two districts in Eastern Province were purposively sampled. Responses gathered from TB patients above 15 years of age with at least one month of treatment completed and signed informed consent were double entered and analyzed. Follow-up interviews with key informants on district and national level were conducted to assess the impact of the pilot and to explore potential interventions.

Results

A total of 208 patients were interviewed in September 2008. TB patients in both districts have a substantial burden of direct (out of pocket; USD 55.8) and indirect (opportunity; USD 294.2) costs due to TB. Inability to work is a major cause of increased poverty. Results confirm a 'medical poverty trap' situation in the two districts: expenditures increased while incomes decreased. Subsequently, TB treatment services were decentralized to fifteen more facilities and other health programs were approached for nutritional support of TB patients and sputum sample transport. On the national level, a TB and poverty sub-committee was convened to develop a comprehensive pro-poor approach.

Conclusions

The Tool to Estimate Patients' Costs proved to be a valuable instrument to assess the costs incurred by TB patients, socioeconomic situations, health-seeking behavior patterns, concurrent illnesses such as HIV, and social and gender-related impacts. The Tool helps to identify and tackle bottlenecks in access to TB care, especially for the poor. Reducing delays in diagnosis, decentralization of services, fully integrated TB/HIV care and expansion of health insurance coverage would alleviate patients' economic constraints due to TB.

Motives to quit smoking and reasons to relapse differ by socioeconomic status

OBJECTIVE

To investigate motives, strategies and experiences to quit smoking and reasons to relapse as a function of socioeconomic status.

METHODS

A population-based study, Inter99, Denmark. Two thousand six hundred twenty-one daily smokers with a previous quit attempt completed questionnaires at baseline. Cross-sectional baseline-data (1999-2001) were analysed in adjusted regression analyses.

RESULTS

Consistent findings across the three indicators of socioeconomic status (employment, school education, higher education/vocational training): smokers with low socioeconomic status were significantly more likely than smokers with high socioeconomic status to report that they wanted to quit because smoking was too expensive (OR: 1.85 (1.4-2.4), for school education) or because they had health related problems (OR: 1.75 (1.4-2.2)). When looking at previous quit attempts, smokers with low socioeconomic status were significantly more likely to report that it had been a bad experience (OR: 1.41 (1.1-1.8)) and that they had relapsed because they were more nervous/restless/depressed (OR: 1.43 (1.1-1.8)).

CONCLUSIONS

This study shows that smokers with low socioeconomic status have other motives to quit and other reasons to relapse than smokers with high socioeconomic status. Future tobacco prevention efforts aimed at smokers with low socioeconomic status should maybe focus on current advantages of quitting smoking, using high cost of smoking and health advantages of quitting as motivating factors and by including components of mental health as relapse prevention.

Socioeconomic inequalities in prognostic markers of non-Hodgkin lymphoma: analysis of a national clinical database

The survival of non-Hodgkin lymphoma patients strongly depends on a range of prognostic factors. This registry-based clinical cohort study investigates the relation between socioeconomic position and prognostic markers in 6234 persons included in a national clinical database in 2000-2008, Denmark. Several measures of individual socioeconomic position were achieved from Statistics Denmark. The risk of being diagnosed with advanced disease, as expressed by the six prognostic markers (Ann Arbor stage III or IV, more than one extranodal lesion, elevated serum lactate dehydrogenase (LDH), performance status of two or more, presence of B symptoms and International Prognostic Index (IPI) of two or more), increased with decreasing level of education, in patients living alone, and in men. For instance, a significant decrease in the odds of being diagnosed with elevated LDH (p=0.02), high performance status (p=0.004), high IPI score (p=0.004) and B symptoms (p=0.02) was seen with higher level of education, whereas high stage of disease was significantly less likely in the higher educated (odds ratio [OR]=0.85 (0.74-0.99)). The difference in risk seemed not to be mediated by differences in histological subgroups reflecting aggressiveness of disease among the social groups. One of the most likely mechanisms of the social difference is longer delay in those with low socioeconomic position. The findings of social inequality in prognostic markers in non-Hodgkin lymphoma (NHL) patients could already be implemented in the clinical practice if general practitioners (GP's) and physicians on hospitals paid special attention to patients with low educational level and unspecific symptoms.

Socioeconomic position and participation in colorectal cancer screening

BACKGROUND

Colorectal cancer (CRC) screening with faecal occult blood test (FOBT) has the potential to reduce the incidence and mortality of CRC. Screening uptake is known to be inferior in people with low socioeconomic position (SEP) when compared with those with high position; however, the results of most previous studies have limited value because they are based on recall or area-based measures of socioeconomic position, and might thus be subject to selective participation and misclassification. In this study we investigated differences in CRC screening participation using register-based individual information on education, employment, and income to encompass different but related aspects of socioeconomic stratification. Also, the impact of ethnicity and cohabiting status was analysed.

METHODS

A feasibility study on CRC screening was conducted in two Danish counties in 2005 and 2006. Screening consisted of a self-administered FOBT kit mailed to 177 114 inhabitants aged 50-74 years. Information on individual socioeconomic status was obtained from Statistics Denmark.

RESULTS

A total of 85 374 (48%) of the invited returned the FOBT kits. Participation was significantly higher in women than in men (OR=1.58 (1.55-1.61)), when all socioeconomic and demographic variables were included in the statistical model. Participation also increased with increasing level of education, with OR=1.38 (1.33-1.43) in those with a higher education compared with short education. Also, participation increased with increasing income levels, with OR=1.94 (1.87-2.01) in the highest vs lowest quintile. Individuals with a disability pension, the unemployed and self-employed people were significantly less likely to participate (OR=0.77 (0.74-0.80), OR=0.83 (0.80-0.87), and OR=0.85 (0.81-0.89), respectively). Non-western immigrants were less likely to participate (OR=0.62 (0.59-0.66)) in a model controlling for age, sex, and county; however, this difference might be attributed to low SEP in these ethnic groups ((OR=0.93 (0.87-0.99), when adjusting for SEP indicators).

CONCLUSION

This study based on individual information on several socioeconomic dimensions in a large, unselected population allowed for identification of several specific subgroups within the population with low CRC screening participation. Improved understanding is needed on the effect of targeted information and other strategies in order to reduce socioeconomic inequalities in screening.

Associations between parental and offspring adiposity up to midlife: the contribution of adult lifestyle factors in the 1958 British Birth Cohort Study

BACKGROUND

Parent-offspring associations in adiposity are well known, but the extent to which they are explained by modifiable environmental and lifestyle factors remains to be elucidated.

OBJECTIVES

The objectives were to assess whether 1) parent-offspring associations in body mass index (BMI; in kg/m(2)) persist from childhood to midadulthood, 2) parental BMI is associated with the offspring's adult lifestyle, and 3) parent-offspring BMI associations in midadulthood are explained by lifestyle factors.

DESIGN

Participants in the 1958 British Birth Cohort Study and their parents (n = 9346) were examined. Parental BMI was assessed in 1969; offspring (ie, cohort members) BMI was ascertained prospectively at 11 and 44-45 y. Lifestyle factors of the offspring, including diet, physical activity, alcohol consumption, and smoking, were assessed prospectively in adulthood.

RESULTS

Maternal and paternal BMI were positively associated with offspring BMI in both childhood and midadulthood, and the strength of the association did not diminish with offspring age. Maternal BMI was associated with several offspring lifestyle factors across adulthood; fewer associations were observed for paternal BMI. Parent-offspring BMI associations in adulthood were largely maintained after adjustment for multiple lifestyle and socioeconomic factors at different life stages: if parental BMI was 1 unit higher, offspring BMI at 44-45 y was higher by between 0.21 and 0.29 units in adjusted models.

CONCLUSIONS

Strong parent-offspring BMI associations are maintained into midlife. These associations are largely unaffected by adjustment for a wide range of lifestyle factors. Offspring of obese parents are an important target for interventions aimed at reducing population levels of overweight and obesity.

Occupational and behavioural factors in the explanation of social inequalities in premature and total mortality: a 12.5-year follow-up in the Lorhandicap study

The respective contribution of occupational and behavioural factors to social disparities in all-cause mortality has been studied very seldom. The objective of this study was to evaluate the role of occupational and behavioural factors in explaining social inequalities in premature and total mortality in the French working population. The study population consisted of a sample of 2,189 and 1,929 French working men and women, who responded to a self-administered questionnaire in mid-1996, and were followed up until the end of 2008. Mortality was derived from register-based information and linked to the baseline data. Socioeconomic status was measured using occupation. Occupational factors included biomechanical and physical exposures, temporary contract, psychological demands, and social support, and behavioural factors, smoking, alcohol abuse, and body mass index. Significant social differences were observed for premature and total mortality. Occupational factors reduced the hazard ratios of mortality for manual workers compared to managers/professionals by 72 and 41%, from 1.88 (95% CI: 1.17-3.01) to 1.25 (95% CI: 0.74-2.12) for premature mortality, and from 1.71 (95% CI: 1.18-2.47) to 1.42 (95% CI: 0.95-2.13) for total mortality. The biggest contributions were found for biomechanical and physical exposures, and job insecurity. The role of behavioural factors was very low. Occupational factors played a substantial role in explaining social disparities in mortality, especially for premature mortality and men. Improving working conditions amongst the lowest social groups may help to reduce social inequalities in mortality.

A population-based analysis of neighborhood socioeconomic status and injury admission rates and in-hospital mortality

BACKGROUND

Research indicates that neighborhood socioeconomic status (N-SES) is inversely related to injury and injury-related mortality. We hypothesized that injury-related hospitalization rates would vary by N-SES and that N-SES would be related to in-hospital mortality.

STUDY DESIGN

Adults (age 18 to 84 years) living in Shelby County, TN, were eligible for the study. Addresses of adults admitted to the only Level I trauma center in the county from 1996 to 2005 were geocoded and matched to 1 of 214 census tract groups. Census tract groups were divided into quintiles based on percent of the population living below the poverty level (lowest to highest income N-SES). Crude injury admission rate ratios (CIRR) and 95% confidence intervals (CI) were calculated. Multivariable logistic regression was used to determine if N-SES was associated with in-hospital mortality.

RESULTS

Compared with the highest N-SES, those in the lowest N-SES suffered significantly higher rates of blunt (CIRR 5.74; 95% CI 5.35, 6.15) and penetrating injuries (CIRR 20.98; 95% CI 18.03, 24.42). On multivariable logistic regression analysis, compared with the highest N-SES, decreasing N-SES was not associated with in-hospital mortality for blunt (high-middle [0.90; 95% CI 0.57, 1.44]; middle [1.22; 95% CI 0.78, 1.87]; low-middle [0.89; 95% CI 0.58, 1.39]; lowest [0.67; 95% CI 0.42, 1.08]); or penetrating injury (high-middle [1.35; 95% CI 0.48, 3.81]; middle [2.77; 95% CI 0.99, 7.25]; low-middle [1.44; 95% CI 0.55, 3.74]; and lowest [1.03; 95% CI 0.39, 2.73]).

CONCLUSIONS

N-SES was inversely related to crude injury rates for all mechanisms. However, in-hospital mortality was not associated with N-SES level.

Does educational status impact adult mortality in Denmark? A twin approach

To disentangle an independent effect of educational status on mortality risk from direct and indirect selection mechanisms, the authors used a discordant twin pair design, which allowed them to isolate the effect of education by means of adjustment for genetic and environmental confounding per design. The study is based on data from the Danish Twin Registry and Statistics Denmark. Using Cox regression, they estimated hazard ratios for mortality according to the highest attained education among 5,260 monozygotic and 11,088 dizygotic same-sex twin pairs born during 1921–1950 and followed during 1980–2008. Both standard cohort and intrapair analyses were conducted separately for zygosity, gender, and birth cohort. Educational differences in mortality were demonstrated in the standard cohort analyses but attenuated in the intrapair analyses in all subgroups but men born during 1921–1935, and no effect modification by zygosity was observed. Hence, the results are most compatible with an effect of early family environment in explaining the educational inequality in mortality. However, large educational differences were still reflected in mortality risk differences within twin pairs, thus supporting some degree of independent effect of education. In addition, the effect of education may be more pronounced in older cohorts of Danish men.

Conventional versus asset approaches: comparative appraisal of socioeconomic indicators for oral health research among adolescents in a developing country

The aim of the study was to assess the value of different indicators of socioeconomic status for oral health research among Sri Lankan adolescents. Six indicators of socioeconomic status were assessed in terms of their relationship to 2 oral health outcomes. The sample consisted of 15-year-old students (n = 1218) selected from 48 schools in the Colombo district using a stratified cluster sampling technique. Data collection included oral examinations of students and questionnaires to both students and their parents. The correlations between the 6 indicators were low to moderate. The indicators of household material assets and parental educational status emerged as significant predictors of the 2 oral health outcomes. Therefore, it is concluded that indicators of material assets-namely, the family affluence scale and the asset index-could be used as optimal measures of socioeconomic status in oral health research among adolescents in Sri Lanka.

Indicators for Measuring Material Affluence of Adolescents in Health Inequality Research in Developing Countries

The aim of the present study was to (i) develop a material affluence scale (MAS) for measuring adolescent SES in health inequality research in developing countries, (ii) compare the association of the MAS with the parental SES measures (parental occupation and education), and (iii) evaluate the association of parental SES and MAS with key health and health behaviour indicators. We used school-based cross-sectional survey conducted in thirty districts within three administrative regions in southern Ghana (a West African country) among adolescents ages 12-18-year old (N = 1,195) as an example. Principal Component Analysis (PCA) was used as the main statistical technique. MAS categorised adolescents into material affluence groups (MAS scores for the poorest, poor, average, affluent and most affluent were-1.679, -0.355, 0.354, 0.725 and 1.022 from the first principal component quintile respectively), it has adequate internal coherence (alpha = 0.622) and moderately correlates with parental SES (r = 0.39, p < 0.001). MAS and parental SES showed similar pattern of strength and direction of association with selected health and health behaviour indicators. MAS presents a viable alternative method for measuring adolescent's SES in health inequality research in developing countries and could be useful as well in western countries.

Does socio-economic status moderate the associations between psychosocial predictors and fruit intake in schoolchildren? The Pro Children study

This study tested whether socio-economic status (SES) moderated the association between the psychosocial constructs included in the attitude-social influence-self-efficacy (ASE) model and fruit intake in Norwegian schoolchildren. The sample consisted of 962 Norwegian sixth graders, mean age 11.3 years. They were split into three SES groups, and multi-group structural equation modeling (MSEM) was used. Children in the highest SES group reported eating fruit more frequently and reported more positive ASE variables than children in the lower SES groups. This was particularly true for social environmental factors, home availability of fruit and intention to eat fruit. MSEM showed that the relationships specified in the adapted ASE model were moderated by SES, as we did not find support for equal model structure across the three samples. Model modification for each SES group separately showed that the relation between home availability and fruit intake was not significant for the medium and low SES groups, and the relation between self-efficacy and intention to eat fruit was not significant for the medium SES group. Future interventions aiming at increasing fruit intake in children need to be sensitive to such SES-related differences and should in particular affect factors that may impede fruit intake in the lower SES groups.

Do early life exposures explain associations in mid-adulthood between workplace factors and risk factors for cardiovascular disease?

BACKGROUND

Workplace factors (night work, long working hours, psychosocial work stress) have been reported to be associated with increased risk of cardiovascular disease (CVD). We investigated whether (i) workplace factors are associated with CVD risk factors independently of each other, (ii) workplace factors interact, thereby modifying associations and (iii) associations are explained by early life exposures.

METHODS

A total of 7916 employed participants in the 1958 British birth cohort underwent a clinical assessment at age 45 years. Regression analysis was used to examine associations between workplace factors and CVD risk factor levels with adjustment for early life exposures.

RESULTS

Night work was associated with adverse levels of most CVD risk factors. Working > or =48 h/week was positively associated with body mass index (BMI) and waist circumference (WC). Low job control was positively associated with glycosylated haemoglobin (HbA1c) and inflammatory factors, and inversely associated with high-density lipoprotein (HDL)-cholesterol. Low demands were positively associated with systolic blood pressure (SBP), triglycerides and inflammatory factors and inversely associated with HDL-cholesterol. Several associations were weakened when workplace factors were adjusted for each other. Night workers in low-demand jobs had higher BMI [0.78 kg/m(2); 95% confidence interval (CI) 0.35, 1.21], WC (1.49 cm; 0.45, 2.52) and SBP (1.38 mmHg; -0.04, 2.81). HDL was lower for low control plus night work (-0.04 mmol/l; -0.08, -0.01) or long hours (-0.12; -0.18, -0.69). Adjustment for early life exposures explained 30-50% of most associations, e.g. night work/low demands associations reduced by 50% for BMI and WC, and by 39% for SBP.

CONCLUSIONS

Associations between workplace factors and CVD risk factors in mid-adulthood arise in part from social and health disadvantage originating earlier in life.

Personality, socioeconomic status, and all-cause mortality in the United States

The authors assessed the extent to which socioeconomic status (SES) and the personality factors termed the "big 5" (neuroticism, extraversion, openness to experience, agreeableness, conscientiousness) represented confounded or independent risks for all-cause mortality over a 10-year follow-up in the Midlife Development in the United States (MIDUS) cohort between 1995 and 2004. Adjusted for demographics, the 25th versus 75th percentile of SES was associated with an odds ratio of 1.43 (95% confidence interval (CI): 1.11, 1.83). Demographic-adjusted odds ratios for the 75th versus 25th percentile of neuroticism were 1.38 (95% CI: 1.10, 1.73) and 0.63 (95% CI: 0.47, 0.84) for conscientiousness, the latter evaluated at high levels of agreeableness. Modest associations were observed between SES and the big 5. Adjusting each for the other revealed that personality explained roughly 20% of the SES gradient in mortality, while SES explained 8% of personality risk. Portions of SES and personality risk were explained by health behaviors, although some residual risk remained unexplained. Personality appears to explain some between-SES strata differences in mortality risk, as well as some individual risk heterogeneity within SES strata. Findings suggest that both sociostructural inequalities and individual disposition hold public health implications. Future research and prevention aimed at ameliorating SES health disparities may benefit from considering the risk clustering of social disadvantage and dispositional factors.

Associations of income and wealth with health status in the Korean elderly

OBJECTIVES

This study aimed to verify the association between wealth or income level and health status after adjusting for other socio-economic position (SEP) indicators among Korean adults aged 45 and over.

METHODS

Data were obtained from the 1st wave of Korean Longitudinal Study of Ageing (households: 6,171, persons: 10,254). We used self-rated health status and activities of daily living (ADLs) as dependent variables. Explanatory variables included both net wealth measured by savings, immovables, the other valuated assets and total income including pay, transfer, property and so on. Binary logistic regression was conducted to examine the relationships. Also, in order to determine the relative health inequality across economic groups, we estimated the relative index of inequality (RII).

RESULTS

The inequality of health status was evident among various wealth and income groups. The wealthiest group (5th quintile) was much healthier than the poorest group, and this differential increased with age. Likewise, higher income was associated with better health status among the elderly. However, these effects, as measured by the odds ratio and RII, showed that wealth was more important in determining health status of elderly people.

CONCLUSIONS

This study suggests that economic capability plays a significant role in determining the health status and other health-related problems among the elderly. Particularly, our results show that health status of the aged is related more closely to the individual's wealth than income.

Income level and chronic ambulatory care sensitive conditions in adults: a multicity population-based study in Italy

BACKGROUND

A relationship between quality of primary health care and preventable hospitalizations has been described in the US, especially among the elderly. In Europe, there has been a recent increase in the evaluation of Ambulatory Care Sensitive Conditions (ACSC) as an indicator of health care quality, but evidence is still limited. The aim of this study was to determine whether income level is associated with higher hospitalization rates for ACSC in adults in a country with universal health care coverage.

METHODS

From the hospital registries in four Italian cities (Turin, Milan, Bologna, Rome), we identified 9384 hospital admissions for six chronic conditions (diabetes, hypertension, congestive heart failure, angina pectoris, chronic obstructive pulmonary disease, and asthma) among 20-64 year-olds in 2000. Case definition was based on the ICD-9-CM coding algorithm suggested by the Agency for Health Research and Quality - Prevention Quality Indicators. An area-based (census block) income index was used for each individual. All hospitalization rates were directly standardised for gender and age using the Italian population. Poisson regression analysis was performed to assess the relationship between income level (quintiles) and hospitalization rates (RR, 95% CI) separately for the selected conditions controlling for age, gender and city of residence.

RESULTS

Overall, the ACSC age-standardized rate was 26.1 per 10.000 inhabitants. All conditions showed a statistically significant socioeconomic gradient, with low income people being more likely to be hospitalized than their well off counterparts. The association was particularly strong for chronic obstructive pulmonary disease (level V low income vs. level I high income RR = 4.23 95%CI 3.37-5.31) and for congestive heart failure (RR = 3.78, 95% CI = 3.09-4.62). With the exception of asthma, males were more vulnerable to ACSC hospitalizations than females. The risks were higher among 45-64 year olds than in younger people.

CONCLUSIONS

The socioeconomic gradient in ACSC hospitalization rates confirms the gap in health status between social groups in our country. Insufficient or ineffective primary care is suggested as a plausible additional factor aggravating inequality. This finding highlights the need for improving outpatient care programmes to reduce the excess of unnecessary hospitalizations among poor people.

Education and smoking: confounding or effect modification by phenotypic personality traits?

BACKGROUND

Little is known about whether educational gradients in smoking patterns can be explained by financial measures of socioeconomic status (SES) and/or personality traits.

PURPOSE

To assess whether the relationship of education to (1) never smoking and (2) having quit smoking would be confounded by financial measures of SES or by personality; whether lower Neuroticism and higher Conscientiousness would be associated with having abstained from or quit smoking; and whether education effects were modified by personality.

METHOD

Using data from the Midlife Development in the US National Survey, 2,429 individuals were classified as current (n = 695), former (n = 999), or never (n = 735) smokers. Multinomial logistic regressions examined study questions.

RESULTS

Greater education was strongly associated with both never and former smoking, with no confounding by financial status and personality. Never smoking was associated with lower Openness and higher Conscientiousness, while have quit was associated with higher Neuroticism. Education interacted additively with Conscientiousness to increase and with Openness to decrease the probability of never smoking.

CONCLUSIONS

Education and personality should be considered unconfounded smoking risks in epidemiologic and clinical studies. Educational associations with smoking may vary by personality dispositions, and prevention and intervention programs should consider both sets of factors.

Night work, long working hours, psychosocial work stress and cortisol secretion in mid-life: evidence from a British birth cohort

OBJECTIVES

To examine the relationships between exposure to workplace factors (night work, extended working hours, psychosocial work stress) and cortisol secretion, and to test whether workplace factors interact, resulting in combined effects.

METHODS

Multiple linear and logistic regression was used to test relationships between workplace factors and cortisol secretion in the 1958 British birth cohort at 45 years. Salivary cortisol was measured twice on the same day to capture the post-waking decline, facilitating the analysis of different cortisol patterns: (1) time 1 (T1, 45 minutes post-waking); (2) time 2 (T2, 3 h after T1); (3) average 3 h exposure from T1 to T2 cortisol; and (4) T1 to T2 change. To identify altered diurnal cortisol patterns we calculated: (1) flat T1-T2 change in cortisol; (2) top 5% T1; (3) bottom 5% T1; and (4) T1 hypo-secretion or hyper-secretion. Models were adjusted for socioeconomic position at birth and in adulthood, qualifications, marital status, dependent children, and smoking status.

RESULTS

25% of men and 8% of women were exposed to >1 workplace factor (night work, extended work hours, job strain). Night work was associated with a 4.28% (95% CI 1.21 to 7.45) increase in average 3 h cortisol secretion independently of job strain or work hours. Night workers not exposed to job strain had elevated T1 cortisol (5.81%, 95% CI 1.61 to 10.19), although for T2 cortisol it was night workers exposed to low job control who had elevated levels (11.72%, 95% CI 4.40 to 19.55). Men (but not women) working >48 h/week had lower average 3 h cortisol secretion (4.55%, 95% CI -8.43 to -0.50). There were no main effects for psychosocial work stress. All associations for T2 and average 3 h cortisol secretion weakened slightly after adjustment for confounding factors, but associations for T1 cortisol were unaffected by adjustment.

CONCLUSIONS

Our study suggests that night work in particular is associated with elevated cortisol secretion and that cortisol dysregulation may exist in subgroups with specific combinations of stressors.

Interrelationships between education, occupational class, income and sickness absence

BACKGROUND

Socio-economic position measures, such as education, occupational class and income, are well-known determinants of health. However, previous studies have not paid attention to mutual interrelationships between these socio-economic position measures and medically confirmed sickness absence.

METHODS

The study is a register-based study. The participants were municipal employees of the City of Helsinki aged 25-59 years in 2003. There were 21,599 women and 5841 men participants. Three socio-economic position measures were used, namely three-level education, four-level occupational class and gross individual income quartiles. Main outcome measure was medically confirmed sickness absence spells of 4 days or longer. Inequality indices were calculated using Poisson regression analysis.

RESULTS

High education, occupational class and individual income were all consistently associated with lower sickness absence rates among both women and men. After mutual adjustment, education and occupational class remained independent determinants of sickness absence. The association of individual income with sickness absence was practically explained by temporally preceding education and occupational class.

CONCLUSIONS

Our results indicate that education and occupational class-rather than income-are strong determinants of sickness absence. Education, occupational class and income are complementary socio-economic position measures. To better inform sickness absence policy, future studies should aim to establish whether the observed socio-economic differences reflect broader differences in ill-health, lifestyle and working conditions.

Effects of socioeconomic position on 30-day mortality and wait for surgery after hip fracture

OBJECTIVE

In countries where the National Health Service provides universal health coverage, socioeconomic position should not influence the quality of health care. We examined whether socioeconomic position plays a role in short-term mortality and waiting time for surgery after hip fracture.

DESIGN

Retrospective cohort study.

SETTING

and participants From the Hospital Information System database, we selected all patients, aged at least 65 years and admitted to acute care hospitals in Rome for a hip fracture between 1 January 2006 and 30 November 2007. The socioeconomic position of each individual was obtained using a city-specific index of socioeconomic variables based on the individual's census tract of residence.

MAIN OUTCOME MEASURES

Three different outcomes were defined: waiting times for surgery, mortality within 30 days and intervention within 48 h of hospital arrival for hip fracture. We used a logistic regression to estimate 30-day mortality and a Cox proportional hazard model to calculate hazard ratios of intervention within 48 h. Median waiting times were estimated by adjusted Kaplan-Meyer curves. Analyses were adjusted for age, gender and coexisting medical conditions.

RESULTS

Low socioeconomic level was significantly associated with higher risk of mortality [adjusted relative risk (RR) = 1.51; P < 0.05] and lower risk of early intervention (adjusted RR = 0.32; P < 0.001). Socioeconomic level had also an effect on waiting times within 30 days.

CONCLUSIONS

Individuals living in disadvantaged census tracts had poorer prognoses and were less likely than more affluent people to be treated according to clinical guidelines despite universal healthcare coverage.

Capitalists, managers, professionals and mortality: Findings from the Barcelona Social Class and All Cause Mortality Longitudinal Study

Aims: To examine the effects of Neo-Marxian social class (i.e. measured as relations of control over productive assets) and potential mediators such as labour-market position, work organization, material deprivation and health behaviours upon mortality in Barcelona, Spain. Methods: Longitudinal data from the Barcelona 2000 Health Interview Survey (n = 7526) with follow-up interviews through the municipal census in 2008 (95.97% response rate) were used. Using data on relations of property, organizational power, and education, social classes were grouped according to Wright’s scheme: capitalists, petit bourgeoisie, managers, supervisors, and skilled, semi-skilled and unskilled workers. Results: Social class, measured as relations of control over productive assets, is an important predictor of mortality among working-class positions for men but not for women. Workers (hazard ratio 1.60, 95% confidence interval 1.10—2.35), managers and small employers had a higher risk of death than capitalists. Conclusions: The extensive use of conventional gradient measures of social stratification has neglected sociological measurements of social class conceptualized as relations of control over productive assets. This concept is capable of explaining how social inequalities are generated. To confirm the protective effect of the capitalist class position and the ‘‘contradictory class location hypothesis’’, additional efforts are needed to properly measure class among low-level supervisors, capitalists, managers, and small employers.

The mediating role of time perspective in socio-economic inequalities in smoking and physical activity in older English adults

Socio-economic variations in health behaviours contribute to socio-economic inequalities in health. Time perspective describes how individuals' consideration of future outcomes influences their present day behaviours and is associated with health behaviours and socio-economic position. Although theoretically plausible, the potential mediating role of time perspective in socio-economic inequalities in health behaviours has received little research attention. Analysis of data from wave 1 of the English Longitudinal Study of Ageing revealed that time perspective played a small partial mediating role in socioeconomic inequalities in smoking and physical activity. The data were self-report and cross-sectional, and the sample restricted to individuals aged 50+.

Do patient characteristics, disease, or treatment explain social inequality in survival from colorectal cancer?

This paper investigates the association between individually measured socioeconomic status (SES) and all-cause survival in colorectal cancer patients, and explores whether factors related to the patient, the disease, or the surgical treatment mediate the observed social gradient. The data were derived from a nationwide clinical database of all adenocarcinomas of the colon or rectum diagnosed in Denmark between 2001 and 2004 (inclusive). These data were linked to those from several central registries providing information on income, education, and housing status, as well as to data on comorbidity from previous hospitalizations and use of medication. Only patients with colorectal cancer as their first primary tumour and those born after 1920 were included. A total of 8763 patients were included in the study. Cox proportional hazard regression models revealed a positive social gradient in survival for increasing levels of education and income, and in owners versus renters of housing. A series of regression analyses were used to test potential mediators of the association between the socioeconomic indicators and survival by stepwise inclusion of lifestyle factors (smoking, alcohol intake, body mass index), comorbidity, stage of disease, mode of admission, type of operation, specialization of the surgeon, and curative versus palliative resection. A causal diagram guided the analyses. Inclusion of comorbidity, and to a lesser extent lifestyle, reduced the variation associated with SES, while no evidence of a mediating effect was found for disease or surgical treatment factors. This indicates that the difference in survival among colorectal cancer patients from different social groups was probably not caused by unintentional differences in treatment factors related to surgery, and suggests that primary prevention of chronic diseases among the socially deprived might be one way to reduce social differences in prognosis.

Associations between childhood socioeconomic position and adulthood obesity

Childhood socioeconomic position (SEP) is inversely associated with cardiovascular disease and all-cause mortality. Obesity in adulthood may be a biologic mechanism. Objectives were to systematically review literature published between 1998 and 2008 that examined associations of childhood SEP with adulthood obesity. Five databases (Cochrane Library, MEDLINE, EMBASE, PsycINFO, Web of Science) were searched for studies from any country, in any language. Forty-eight publications based on 30 studies were identified. In age-adjusted analyses, inverse associations were found between childhood SEP and adulthood obesity in 70% (14 of 20) of studies in females and 27% (4 of 15) in males. In studies of females showing inverse associations between childhood SEP and adulthood obesity, typical effect sizes in age-adjusted analyses for the difference in body mass index between the highest and lowest SEP were 1.0-2.0 kg/m(2); for males, effect sizes were typically 0.2-0.5 kg/m(2). Analyses adjusted for age and adult SEP showed inverse associations in 47% (8 of 17) of studies in females and 14% (2 of 14) of studies in males. When other covariates were additionally adjusted for, inverse associations were found in 4 of 12 studies in females and 2 of 8 studies in males; effect sizes were typically reduced compared with analyses adjusted for age only. In summary, the findings suggest that childhood SEP is inversely related to adulthood obesity in females and not associated in males after adjustment for age. Adulthood SEP and other obesity risk factors may be the mechanisms responsible for the observed associations between childhood SEP and adulthood obesity.

Can the influence of childhood socioeconomic status on men's and women's adult body mass be explained by adult socioeconomic status or personality? Findings from a national sample

OBJECTIVES

On the basis of a life-course risk-chain framework, the authors examined whether (a) residual associations between childhood socioeconomic status (SES) and adult obesity and body mass index (BMI) would be observed in women but not men after adjusting for adult SES, (b) adult Big Five personality traits would be associated with adult body mass in both genders, and (c) personality would explain unique variation in outcomes beyond child and adult SES.

DESIGN

National survey (Midlife Development in the United States study; N = 2,922).

MAIN OUTCOME MEASURES

BMI and obesity.

RESULTS

(a) In both genders, association between childhood SES and adult obesity were accounted for entirely by adult SES, but its effect on adult BMI was observed only in women; (b) higher conscientiousness was associated with lower obesity prevalence and BMI in both genders, although more strongly in women, and in men, greater obesity prevalence was associated with higher agreeableness and neuroticism; and (c) personality explained unique outcome variation in both genders.

CONCLUSIONS

Early social disadvantage may affect adult weight status more strongly in women owing to gender differences in the timing and nature of weight-management socialization. Personality may enhance or detract from risks incurred by childhood or adulthood SES in either gender, necessitating the consideration of dispositional differences in prevention and intervention programs.

Personality traits predict emergency department utilization over 3 years in older patients

BACKGROUND

Emergency department (ED) utilization by older patients has major implications for morbidity, mortality, and health costs, yet its behavioral determinants remain poorly understood. Powerfully tied to health in older adults, the "Big Five" personality traits of neuroticism, extroversion, openness to experience, agreeableness, and conscientiousness may predict ED use.

OBJECTIVES

Investigate the role of personality in prospective ED use among older patients.

RESEARCH DESIGN

Prospective cohort.

SUBJECTS

Adults aged 65 and older.

MEASURES

Participants completed the NEO Five Factor Inventory of personality at baseline, and interviewers administered the Cornell Services Index assessing ED use at baseline and 3 yearly follow-ups.

RESULTS

Controlling for income, education, gender, age, physician-assessed medical burden and physical functioning, and interviewer-assessed impairments in basic activities of daily living and physical self-maintenance, and depression, lower agreeableness and higher extroversion were each associated with increased odds of an ED visit over the follow-up period. A 1 sample deviation (SD) increase in extroversion (i.e., 50th versus 83rd population percentile) increased the odds of ED use by 51% (adjusted odds ratio [AOR] [95% CI] = 1.51 [1.03-2.21], z = 2.12, N = 923, p = 0.034). A 1-SD decrease in agreeableness (i.e., 50th versus 17th population percentile) increased odds of ED use by 54% (AOR [95% CI] = 1.54 [1.05-2.22], z = -2.25, N = 923, p = 0.034).

CONCLUSION

The greater assertiveness and social confidence signified by lower agreeableness and higher extroversion may help older adults overcome potential barriers to the ED. Overly introverted and agreeable older adults may require special encouragement to access the ED--particularly for time--sensitive conditions--to reduce morbidity and mortality.

Childhood living conditions, socioeconomic position in adulthood, and cognition in later life: exploring the associations

OBJECTIVES

This study examined the association between childhood living conditions, socioeconomic position in adulthood, and cognition in later life. Two questions were addressed: Is there an association between childhood living conditions and late-life cognition, and if so, is the association modified or mediated by adult socioeconomic position?

METHODS

Nationally representative data of the Swedish population aged 77 years and older were obtained from the 1992 and 2002 Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD). Cognition was assessed with an abbreviated version of the Mini-Mental State Examination scale. Childhood living conditions were assessed by self-reports of childhood living conditions.

RESULTS

The results showed independent associations between conflicts in the household during childhood, father's social class, education, own social class in adulthood, and cognition in later life. Exposure to conflicts during childhood, having a father classified as a manual worker, low education, and/or being classified as a manual worker in adulthood was associated with lower levels of cognition in old age. There seemed to be no modifying effect of adult socioeconomic position on the association between childhood conditions and cognition in later life.

DISCUSSION

This suggests the importance of childhood living conditions in maintaining cognitive function even in late life.

Health behaviour patterns in relation to hypertension: the English Longitudinal Study of Ageing

OBJECTIVE

Clinical guidelines emphasize that hypertensive individuals should be encouraged to maintain healthy lifestyles with respect to smoking, physical activity, alcohol consumption and diet. We assessed health behaviours in a large sample of older hypertensive individuals, and tested whether medication for hypertension leads to compensatory increases in cardiovascular risk behaviours.

METHODS

Analysis of wave 1 of the English Longitudinal Study of Ageing, involving 5231 men and 6292 women aged at least 50 years. We analysed the prevalence of smoking, heavy drinking, sedentary behaviour and vigorous physical activity in relation to self-reported hypertension, controlling for age, sex, socioeconomic status, comorbidity (coronary heart disease, diabetes, arthritis), impairments of mobility, activities of daily living and depression.

RESULTS

The prevalence of self-reported hypertension was 37.8%, and 77% of hypertensive participants were prescribed medication. Hypertensive participants were less likely to smoke than normotensive ones (14.8 vs. 19.7%), with reduced odds of smoking [odds ratio (OR) 0.72, 95% confidence intervals (CI) 0.56-0.83] after adjusting for covariates. Hypertensive individuals were more likely to be heavy drinkers (OR 1.34, CI 1.10-1.62), to be sedentary (OR 1.14, CI 1.02-1.27), and not engage in vigorous physical activity (OR 0.84, CI 0.75-0.94). There was no evidence for risk compensation in medicated hypertensive individuals compared with unmedicated ones.

CONCLUSION

Smoking rates are low among hypertensive individuals, but the patterns of alcohol consumption and physical activity are suboptimal. Compensatory increases in risky behaviours appear not to be present in medicated individuals. There is considerable scope for advice and counselling to older hypertensive individuals to improve patterns of health behaviour.