Pathways from deprivation to health differed between individual and neighborhood-based indices

Deprivation as a fundamental cause of morbidity and reduced life expectancy: an observational study using German statutory health insurance data

Across all developed countries, there is a steep life expectancy gradient with respect to deprivation. This paper provides a theoretical underpinning for this gradient in line with the Grossman model, indicating that deprivation affects morbidity and, consequently, life expectancy in three ways: directly from deprivation to morbidity, and indirectly through lower income and a trade-off between investments in health and social status. Using rich German claims data covering 6.3 million insured people over four years, this paper illustrates that deprivation increases morbidity and reduces life expectancy. It was estimated that highly deprived individuals had approximately two more chronic diseases and a life expectancy reduced by 15 years compared to the least deprived individuals. This mechanism of deprivation is identified as fundamental, as deprived people remain trapped in their social status, and this status results in health investment decisions that affect long-term morbidity. However, in the German setting, the income and investment paths of the effects of deprivation were of minor relevance due to the broad national coverage of its SHI system. The most important aspects of deprivation were direct effects on morbidity, which accumulate over the lifespan. In this respect, personal aspects, such as social status, were found to be three times more important than spatial aspects, such as area deprivation.

Social Vulnerability Association with Thyroid Cancer Disparities in the United States

Background: As thyroid cancer incidence rises, it is increasingly valuable to recognize disparities in treatment and diagnosis. Prior investigations into social determinants of health (SDoH) are limited to pediatric populations or studies looking at single factors such as race or environmental influences. Utilizing the CDC-social vulnerability index and SEER-patient database to assess the amalgamated, real-world influence of varied SDoH and their quantifiable impact on thyroid cancer disparities across the United States. Methods: In a retrospective cohort study, 199,340 adult thyroid cancer patients from 1975 to 2017 were assessed for significant regression trends in months of follow-up/surveillance, survival, late staging, and treatment receipt across thyroid cancer-subtypes with increasing overall social vulnerability, as well as in 15 SDoH variables regarding socioeconomic status, minority-language status, household composition, and housing-transportation across all the U.S. counties while accounting for sociodemographic regional differences. Results: With increasing overall social vulnerability, decreases in months of follow-up were observed with patients with papillary, follicular, medullary, oncocytic, and anaplastic thyroid cancer (p = 0.001). Comparing lowest with highest vulnerability cohorts, relative decreases in months of surveillance ranged from 55.6% (14.5-6.5 months) with anaplastic to 17% (108.6-90.2) with oncocytic. Socioeconomic status vulnerabilities, followed by vulnerabilities in household composition and housing-transportation type, contributed to these overall trends. Similar survival decreases occurred across all thyroid cancer patients, ranging from 55.9% (9.6-4.2) with anaplastic to 28.3% (97-69.5) with oncocytic. Minority-language status vulnerabilities and housing-transportation types largely contributed to these trends. Increasing overall vulnerability was associated with increased odds of advanced staging for papillary (odds ratio [OR] = 1.07 [confidence interval, CI 1.03-1.12]) and decreased odds of indicated treatment via surgery (lowest, medullary: 0.91 [CI 0.84-0.99]), radiation therapy (lowest, anaplastic: 0.88 [CI 0.82-0.93]), and chemotherapy (lowest, oncocytic: 0.81 [CI 0.67-0.98]) were observed. Vulnerabilities in minority-language status and housing-transportation, followed by socioeconomic status vulnerabilities, were differential contributors to these overall vulnerability trends. Conclusions: Our results show significant detriments in thyroid cancer care and prognosis in the United States with increasing overall social vulnerability while identifying which SDoH quantifiably contribute more to disparities in inter-relational, real-world-like contexts.

Who Is Able to Resist What Is Forbidden?—The Relationship between Health Literacy and Risk Behaviours in Secondary School Students in the Broader Social and Educational Context

In the last Health Behaviour in School-Aged Children (HBSC) survey conducted in Poland in 2018, a group of 17-year-old adolescents (n = 1663; mean age 17.63 ± 0.36 years) was included outside the international protocol. This allowed an assessment to be made of their level of health literacy (HL) using the 10-point HBSC research tool. The aim of the study was to investigate the relationship between HL and risk behaviours (RB). A standardised index of RB in the last 30 days was considered as an outcome measure. This index was significantly higher in the group with low HL (0.318 ± 1.269) in comparison with the group with high HL (−0.083 ± 0.962). In a multivariate linear regression model, the strongest predictors of RB were gender, academic performance and level of regional deprivation, but the association with HL remained significant. This significant association persisted in general schools and in girls but disappeared in vocational schools and in boys. It was also shown that in rural areas, good academic performance has a less significant impact on RB if the HL level is low. The analyses led to the conclusion that when examining the relationship between HL and RB in older adolescents, it is advisable to take into account gender, the educational track and neighbourhood characteristics.

Association between neighborhood disadvantage and fulfillment of desired postpartum sterilization

BACKGROUND

Adequacy of prenatal care is associated with fulfillment of postpartum sterilization requests, though it is unclear whether this relationship is indicative of broader social and structural determinants of health or reflects the mandatory Medicaid waiting period required before sterilization can occur. We evaluated the relationship between neighborhood disadvantage (operationalized by the Area Deprivation Index; ADI) and the likelihood of undergoing postpartum sterilization.

METHODS

Secondary analysis of a single-center retrospective cohort study examining 8654 postpartum patients from 2012 to 2014, of whom 1332 (15.4%) desired postpartum sterilization (as abstracted from the medical record at time of delivery hospitalization discharge) and for whom ADI could be calculated via geocoding their home address. We determined the association between ADI and sterilization completion, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery via logistic regression and time to sterilization via Cox proportional hazards regression.

RESULTS

Of the 1332 patients included in the analysis, patients living in more disadvantaged neighborhoods were more likely to be younger, more parous, delivered vaginally, Black, unmarried, not college educated, and insured via Medicaid. Compared to patients living in less disadvantaged areas, patients living in more disadvantaged areas were less likely to obtain sterilization (44.8% vs. 53.5%, OR 0.84, 95% CI 0.75-0.93), experienced greater delays in the time to sterilization (HR 1.23, 95% CI 1.06-1.44), were less likely to attend postpartum care (58.9% vs 68.9%, OR 0.86, CI 0.79-0.93), and were more likely to have a subsequent pregnancy within a year of delivery (15.1% vs 10.4%, OR 1.56, 95% CI 1.10-1.94). In insurance-stratified analysis, for patients with Medicaid, but not private insurance, as neighborhood disadvantage increased, the rate of postpartum sterilization decreased. The rate of subsequent pregnancy was positively associated with neighborhood disadvantage for both Medicaid as well as privately insured patients.

CONCLUSION

Living in an area with increased neighborhood disadvantage is associated with worse outcomes in terms of desired postpartum sterilization, especially for patients with Medicaid insurance. While revising the Medicaid sterilization policy is important, addressing social determinants of health may also play a powerful role in reducing inequities in fulfillment of postpartum sterilization.

Age-Friendly Environments, Active Lives? Associations Between the Local Physical and Social Environment and Physical Activity Among Adults Aged 55 and Older in Ireland

Despite the benefits, one in three older adults in Ireland has low activity levels. This study examined associations between the local social and built environment and physical activity of older adults to identify age-friendly factors that support physical activity among the aging population. Data were from the population-representative Healthy and Positive Ageing Initiative Age-Friendly City and Counties Survey (N = 10,540). Physical activity was measured using a short-form of the International Physical Activity Questionnaire. Mixed-effects negative binomial regression models were adjusted for known health and sociodemographic correlates of physical activity. Results are reported as unstandardized beta coefficients (β) with standard errors. Loneliness, community participation, and difficulty in accessing green spaces partially explained the differences in the number of minutes that respondents were physically active. Combined with individual-level behavior change interventions, improvements to the local environment and promoting social connectedness may also be useful in promoting physical activity among older adults.

Socioeconomic differences impact overall survival in advanced ovarian cancer (AOC) prior to achievement of standard therapy

PURPOSE

Survival difference between socioeconomic groups with ovarian cancer has persisted in the United Kingdom despite efforts to reduce disparities in care. Our aim was to delineate critical episodes in the patient journey, where deprivation has most impact on survival.

METHODS

A retrospective review of 834 patients with advanced ovarian cancer (AOC) between 16/8/07-16/2/17 at a large cancer centre serving one of the most deprived areas of the UK. Using the Index of Multiple Deprivation (IMD), patients were categorised into five groups.

RESULTS

Surgery was more common in less deprived patients (p < 0.00001). Across IMD groups, there were no differences in complete (R0) cytoreduction rate (r = 0.18, p > 0.05), age, or comorbidity. The R0/total cohort rate increased with increasing IMD group (p < 0.0001). Patients refusing any intervention belonged exclusively to the three most deprived groups; 5/7 patients who refused surgery belonged to the most deprived IMD group. Overall survival in the total patient group was less in IMD group 1-2 compared to 9-10 (p = 0.002). On multivariate analysis, IMD group was not an independent predictor of survival (p > 0.05).

CONCLUSIONS

Socioeconomic differences in survival manifest in patients not receiving surgical treatment for AOC and are not purely explained by comorbidity, age, stage, or histological factors.

[Indices of Multiple Deprivation for the analysis of regional health disparities in Germany : Experiences from epidemiology and healthcare research]

BACKGROUND

Deprivation indices allow material and social differences at the regional level to be described in a statistically efficient and concise manner and to use these in health analyses. Following the British example, Indices of Multiple Deprivation (IMDs) are now available for Germany, the German Index of Multiple Deprivation (GIMD) as well as its regional versions. In this study, empirical experiences based on the use of these indices in health studies will be presented.

METHOD

The German IMDs consist of seven deprivation domains, which represent single aspects of deprivation (income, employment, and educational deprivation, municipal revenue deprivation, social capital deprivation, environment and security deprivation). Specific indicators were generated from data of official statistics and assigned to the deprivation domains. The weighted single domains were finally combined to an overall index. The German IMDs are available at a municipal level and at a district level.

RESULTS

Analyses using the IMDs showed significant associations between regional deprivation and mortality, morbidity and aspects of health services research. Multilevel analyses showed significant associations with regional deprivation, independent of individual factors.

CONCLUSIONS

The German IMDs are valid and efficient tools for the use in epidemiology and health services research, but also for health policy. When constructing deprivation indices, several methodological challenges have to be considered.

Deprivation is associated with worse physical and mental health beyond income poverty: a population-based household survey among Chinese adults

PURPOSE

In studying health inequality, poverty as measured by income is frequently used; however, this omits the aspects of non-monetary resources and social barriers to achieving improved living standard. Therefore, our study aimed to examine the associations of individual-level deprivation of material and social necessities with general physical and mental health beyond that of income poverty.

METHODS

A territory-wide two-stage stratified random sample of 2282 community-dwelling Hong Kong adults was surveyed between 2014 and 2015. Income poverty and a Deprivation Index were used as the main independent variables. General health was assessed using the validated 12-item Short-Form Health Survey version 2, from which physical component summary and mental component summary were derived.

RESULTS

Our results in multivariable ordinal logistic regressions consistently showed that, after adjusting for income poverty, socio-demographic and lifestyle factors, being deprived was significantly associated with worse physical (OR 1.66; CI 1.25-2.20) and mental health (OR 1.83; CI 1.43-2.35). Being income poor was also significantly associated with worse mental health (OR 1.63; CI 1.28-2.09) but only marginally with physical health (OR 1.34; CI 1.00-1.80) after adjustments.

CONCLUSIONS

Income does not capture all aspects of poverty that are associated with adverse health outcomes. Deprivation of non-monetary resources has an independent effect on general health above and beyond the effect of income poverty. Policies should move beyond endowment and take into account the multidimensionality of poverty, in order to address the problem of health inequality.

Neighbourhood socioeconomic deprivation and health-related quality of life: A multilevel analysis

Objective

To assess the relationship between socioeconomic deprivation and health-related quality of life in urban neighbourhoods, using a multilevel approach.

Methods

Of the population-based cohort EPIPorto, 1154 georeferenced participants completed the 36-Item Short-Form Health Survey. Neighbourhood socioeconomic deprivation classes were estimated using latent-class analysis. Multilevel models measured clustering and contextual effects of neighbourhood deprivation on physical and mental HRQoL.

Results

Residents from the least deprived neighbourhoods had higher physical HRQoL. Neighbourhood socioeconomic deprivation together with individual-level variables (age, gender and education) and health-related factors (smoking, alcohol consumption, sedentariness and chronic diseases) explained 98% of the total between-neighbourhood variance. Neighbourhood socioeconomic deprivation was significantly associated with physical health when comparing least and most deprived neighbourhoods (class 2—beta coefficient: -0.60; 95% confidence interval:-1.76;-0.56; class 3 –beta coefficient: -2.28; 95% confidence interval:-3.96;-0.60), and as neighbourhood deprivation increases, a decrease in all values of physical health dimensions (physical functioning, role physical, bodily pain and general health) was also observed. Regarding the mental health dimension, no neighbourhood clustering or contextual effects were found. However, as neighbourhood deprivation increases, the values of vitality and role emotional dimensions significantly decreased.

Conclusion

Neighbourhood socioeconomic deprivation is associated with HRQoL, affecting particularly physical health. This study suggests that to improve HRQoL, people and places should be targeted simultaneously.

Predictors of non-drug psychiatric/psychotherapeutic treatment in children and adolescents with mental or behavioural disorders

Children and adolescents with mental health problems need effective and safe therapies to support their emotional and social development and to avoid functional impairment and progress of social deficits. Though psychotropic drugs seem to be the preferential treatment, psychotherapy and psychosocial interventions are essential in mental health care. For Germany, current data on the utilization of psychotherapy and psychosocial interventions in children with mental health problems is lacking. To analyse why certain children and adolescents with mental or behavioural disorders do and others do not receive non-drug treatment, we assessed predictors associated with specific non-drug psychiatric/psychotherapeutic treatment including psychosocial interventions, psychotherapy and other non-drug treatments. The study is based on data of two large German health insurance funds, AOK and TK, comprising 30 % of the German child and adolescent population. Predictors of non-drug psychiatric/psychotherapeutic treatment were analysed for 23,795 cases and two controls for every case of the same age and sex in children aged 0-17 years following a new diagnosis of mental or behavioural disorder in 2010. Predictors were divided according to Andersen's behavioural model into predisposing, need and enabling factors. The most prominent and significant predictors positively associated with non-drug psychiatric/psychotherapeutic treatment were the residential region as predisposing factor; specific, both ex- and internalizing, mental and behavioural disorders, psychiatric co-morbidity and psychotropic drug use as need factors; and low area deprivation and high accessibility to outpatient physicians and inpatient institutions with non-drug psychiatric/psychotherapeutic department as enabling factors. In conclusion, the present study suggests that the residential region as proxy for supply of therapist and socioeconomic situation is an influencing factor for the use of psychotherapy. The analysis sheds further light on predisposing, need and enabling factors as predictors of non-drug psychotherapeutic/psychiatric treatment in children and adolescents with mental or behavioural health disorders in Germany. More research is needed to further understand the factors promoting the gap between the need and utilization of mental health care.

Explaining socioeconomic inequalities in self-rated health: a systematic review of the relative contribution of material, psychosocial and behavioural factors

BACKGROUND

Material, psychosocial and behavioural factors are important explanatory pathways for socioeconomic inequalities in health. The aim of this systematic review was to summarise the available evidence on empirical studies and to analyse the relative contribution of these factors for explaining inequalities in self-rated health.

METHODS

The study was performed in compliance with PRISMA guidelines. The literature search was conducted in the electronic databases PubMed and Web of Science (1996-2016) as well as by screening of reference lists of obtained articles. Two reviewers performed the search and critical appraisal of the studies. All studies that focus on explaining socioeconomic inequalities in self-rated health, including at least 2 of the 3 main pathways and analysing the relative contribution of these approaches in separate and joint models, were included.

RESULTS

Eleven publications were included. Separate analyses showed that material, psychosocial and behavioural factors contribute to the explanation of socioeconomic inequalities in self-rated health. However, the combined analyses revealed that material factors contributed most to differences in self-rated health because of their higher independent (direct) effect and additional shared (indirect) effect (through psychosocial and behavioural factors). These results were largely independent of age, gender and indicator of socioeconomic status.

CONCLUSIONS

The evidence presented might be used for policymakers to identify and to justify prioritisation in terms of prevention and health promotion. The findings show that multiple factors are important for tackling social inequalities in health. Strategies for reducing these inequalities should focus on material/structural living conditions as they shape conditions of psychosocial resources and health behaviour.

Overweight at four years of age in a Swedish birth cohort: influence of neighbourhood-level purchasing power

Background

A number of child/parental factors have been shown to be significant predictors of childhood overweight, although a better understanding of possible contextual influences of neighbourhood-level characteristics might provide new insights leading to tailored, targeted interventions. The aim of this study was to explore the impact of neighbourhood purchasing power and its relationship with other known risk factors related to childhood overweight in a prospective birth cohort.

Methods

A prospective, population-based, birth-cohort study was conducted in south-western Sweden, comprising 2,666 infants born in 2007–2008. Childhood overweight was assessed by body mass index (BMI) data from follow-up examinations at four years of age (n = 2,026) and overweight defined according to the International Obesity Task Force. Using logistic regression analysis, the influential child/parental predictors were identified from the candidate predictors, viz. child’s gender, as well as birth weight adjusted for gestational age and parental factors at recruitment, including maternal smoking status, maternal BMI (before pregnancy), paternal BMI and parental educational level. The children’s residential parishes at follow-up were stratified by parish-level household purchasing power (<10 %, 10–19.9 %, 20–29.9 % and ≥30 % of all resident families with low purchasing power) and the “contextual” influence was analysed. In each such neighbourhood stratum, the adjusted overweight ratio (AOR), i.e. the ratio between the observed number of overweight children and the expected number, taking account of the influential child/parental predictors, was estimated.

Results

The prevalence of overweight at four years of age was 11.9 %. In the economically strongest neighbourhoods (i.e. <10 % of resident families with low purchasing power), the AOR was 0.60 (95 % confidence interval (CI): 0.34–0.98). The corresponding empirically Bayes-adjusted AOR was 0.73 (95 % CI: 0.46–1.02; 97 % posterior probability of AOR <1). In the other neighbourhood strata, the statistical evidence of a deviant AOR was weaker.

Conclusion

The economically strongest neighbourhoods had a lower prevalence than expected of overweight at four years of age. This finding should prompt studies to acquire more knowledge of potentially modifiable factors that differ between neighbourhoods and are related to childhood overweight, providing a basis for tailored, targeted interventions.

Neighbourhood disadvantage and smoking: Examining the role of neighbourhood-level psychosocial characteristics

PURPOSE

This study aims to determine if neighbourhood psychosocial characteristics contribute to inequalities in smoking among residents from neighbourhoods of differing socioeconomic disadvantage.

METHODS

This cross-sectional study includes 11,035 residents from 200 neighbourhoods in Brisbane, Australia in 2007. Self-reported measures were obtained for smoking and neighbourhood psychosocial characteristics (perceptions of incivilities, crime and safety, and social cohesion). Neighbourhood socioeconomic disadvantage was measured using a census-derived index. Data were analysed using multilevel logistic regression random intercept models.

RESULTS

Smoking was associated with neighbourhood disadvantage; this relationship remained after adjustment for individual-level socioeconomic position. Area-level perceptions of crime and safety and social cohesion were not independently associated with smoking, and did not explain the higher prevalence of smoking in disadvantaged areas; however, perceptions of incivilities showed an independent effect.

CONCLUSIONS

Some neighbourhood psychosocial characteristics seem to contribute to the higher rates of smoking in disadvantaged areas.

Application of a Spatial Intelligent Decision System on Self-Rated Health Status Estimation

Self- assessed general health status is a commonly-used survey technique since it can be used as a predictor for several public health risks such as mortality, deprivation, and fear of crime or poverty. Therefore, it is a useful alternative measure to help assessing the public health situation of a neighborhood or town, and can be utilized by authorities in many decision support situations related to public health, budget allocation and general policy-making, among others. It can be considered as spatial decision problems, since both data location and spatial relationships make a prominent impact during the decision making process. This paper utilizes a recently-developed spatial intelligent decision system, named, Spatial RIMER(+), to model the self-rated health estimation decision problem using real data in the areas of Northern Ireland, UK. The goal is to learn from past or partial observations on self-rated health status to predict its future or neighborhood behavior and reference it in the map. Three scenarios in line of this goal are discussed in details, i.e., estimation of unknown, downscaling, and predictions over time. They are used to demonstrate the flexibility and applicability of the spatial decision support system and their positive capabilities in terms of accuracy, efficiency and visualization.

Exploring Spatial Variability in the Relationship between Long Term Limiting Illness and Area Level Deprivation at the City Level Using Geographically Weighted Regression

Ecological influences on health outcomes are associated with the spatial stratification of health. However, the majority of studies that seek to understand these ecological influences utilise aspatial methods. Geographically weighted regression (GWR) is a spatial statistics tool that expands standard regression by allowing for spatial variance in parameters. This study contributes to the urban health literature, by employing GWR to uncover geographic variation in Limiting Long Term Illness (LLTI) and area level effects at the small area level in a relatively small, urban environment. Using GWR it was found that each of the three contextual covariates, area level deprivation scores, the percentage of the population aged 75 years plus and the percentage of residences of white ethnicity for each LSOA exhibited a non-stationary relationship with LLTI across space. Multicollinearity among the predictor variables was found not to be a problem. Within an international policy context, this research indicates that even at the city level, a "one-size fits all" policy strategy is not the most appropriate approach to address health outcomes. City "wide" health polices need to be spatially adaptive, based on the contextual characteristics of each area.

The influence of neighborhood socioeconomic status and race on survival from ovarian cancer: a population-based analysis of Cook County, Illinois

PURPOSE

Despite significant improvements in treatment for ovarian cancer, survival is poorer for non-Hispanic black (NHB) women compared to non-Hispanic white (NHW) women. Neighborhood socioeconomic status (SES) has been implicated in racial disparities across a variety of health outcomes and may similarly contribute to racial disparities in ovarian cancer survival. The purpose of this analysis is to assess the influence of neighborhood SES on NHB-NHW survival differences after accounting for differences in tumor characteristics and in treatment.

METHODS

Data were obtained from 2432 women (443 NHB and 1989 NHW) diagnosed with epithelial ovarian cancer in Cook County, Illinois between 1998 and 2007. Neighborhood (i.e., census tract) SES at the time of diagnosis was calculated for each woman using two well-established composite measures of affluence and disadvantage. Cox proportional hazard models measured the association between NHB race and survival after adjusting for age, tumor characteristics, treatment, year of diagnosis, and neighborhood SES.

RESULTS

There was a strong association between ovarian cancer survival and both measures of neighborhood SES (P < .0001 for both affluence and disadvantage). After adjusting for age, tumor characteristics, treatment, and year of diagnosis, NHB were more likely than NHW to die of ovarian cancer (hazard ratio [HR] = 1.47, 95% confidence interval [CI]: 1.28-1.68). The inclusion of neighborhood affluence and disadvantage into models separately and together attenuated this risk (HRaffluence = 1.37, 95% CI: 1.18-1.58; HRdisadvantage = 1.28, 95% CI: 1.08-1.52; and HRaffluence + disadvantage = 1.28, 95% CI: 1.08-1.52.

CONCLUSIONS

Neighborhood SES, as measured by composite measures of affluence and disadvantage, is a predictor of survival in women diagnosed with ovarian cancer in Cook County, Illinois and may contribute to the racial disparity in survival.

Area deprivation and the prevalence of type 2 diabetes and obesity: analysis at the municipality level in Germany

Background

The objective of this study was to analyse the association between area deprivation at municipality level and the prevalence of type 2 diabetes (T2D) and obesity across Germany, controlling for individual socioeconomic status (SES).

Methods

The analyses are based on a large survey conducted in 2006. Information was included from 39,908 adults aged 20 years or above. Area deprivation was assessed using the German Index of Multiple Deprivation (GIMD) at municipality level. About 4,700 municipalities could be included and assigned to a deprivation quintile. Individual SES was assessed by income and educational level. Multilevel logistic models were used to control for individual SES and other potential confounders such as age, sex and physical activity.

Results

We found a positive association of area deprivation with T2D and obesity. Controlling for all individual-level variables, the odds ratios for municipalities in the most deprived quintile were significantly increased for T2D (OR 1.35; 95% CI 1.12–1.64) as well as for obesity (OR 1.14; 95% CI 1.02–1.26). Further analyses showed that these associations were relatively similar for both men and women.

Conclusions

Based on a nationwide dataset, we were able to show that area deprivation at municipality level is significantly associated with the prevalence of T2D and obesity. It will be important to focus preventive efforts on very deprived municipalities.

Population-based incidence trends of oropharyngeal and oral cavity cancers by sex among the poorest and underprivileged populations

BACKGROUND

Oral cancer is an important health issue, with changing incidence in many countries. Oropharyngeal cancer (OPC, in tonsil and oropharygeal areas) is increasing, while oral cavity cancer (OCC, other sites in the mouth) is decreasing. There is the need to identify high risk groups and communities for further study and intervention. The objective of this study was to determine how the incidence of OPC and OCC varied by neighbourhood socioeconomic status (SES) in British Columbia (BC), including the magnitude of any inequalities and temporal trends.

METHODS

ICDO-3 codes were used to identify OPC and OCC cases in the BC Cancer Registry from 1981-2010. Cases were categorized by postal codes into SES quintiles (q1-q5) using VANDIX, which is a census-based, multivariate weighted index based on neighbourhood average household income, housing tenure, educational attainment, employment and family structure. Age-standardized incidence rates were determined for OPC and OCC by sex and SES quintiles and temporal trends were then examined.

RESULTS

Incidence rates are increasing in both men and women for OPC, and decreasing in men and increasing in women for OCC. This change is not linear or proportionate between different SES quintiles, for there is a sharp and dramatic increase in incidence according to the deprivation status of the neighbourhood. The highest incidence rates in men for both OPC and OCC were observed in the most deprived SES quintile (q5), at 1.7 times and 2.2 times higher, respectively, than men in the least deprived quintile (q1). For OPC, the age-adjusted incidence rates significantly increased in all SES quintiles with the highest increase observed in the most deprived quintile (q5). Likewise, the highest incidence rates for both OPC and OCC in women were observed in the most deprived SES quintile (q5), at 2.1 times and 1.8 times higher, respectively, than women in the least deprived quintile (q1).

CONCLUSION

We report on SES disparities in oral cancer, emphasizing the need for community-based interventions that address access to medical care and the distribution of educational and health promotion resources among the most SES deprived communities in British Columbia.

Area level deprivation is an independent determinant of prevalent type 2 diabetes and obesity at the national level in Germany. Results from the National Telephone Health Interview Surveys 'German Health Update' GEDA 2009 and 2010

Objective

There is increasing evidence that prevention programmes for type 2 diabetes mellitus (T2DM) and obesity need to consider individual and regional risk factors. Our objective is to assess the independent association of area level deprivation with T2DM and obesity controlling for individual risk factors in a large study covering the whole of Germany.

Methods

We combined data from two consecutive waves of the national health interview survey ‘GEDA’ conducted by the Robert Koch Institute in 2009 and 2010. Data collection was based on computer-assisted telephone interviews. After exclusion of participants <30 years of age and those with missing responses, we included n = 33,690 participants in our analyses. The outcome variables were the 12-month prevalence of known T2DM and the prevalence of obesity (BMI ≥30 kg/m²). We also controlled for age, sex, BMI, smoking, sport, living with a partner and education. Area level deprivation of the districts was defined by the German Index of Multiple Deprivation. Logistic multilevel regression models were performed using the software SAS 9.2.

Results

Of all men and women living in the most deprived areas, 8.6% had T2DM and 16.9% were obese (least deprived areas: 5.8% for T2DM and 13.7% for obesity). For women, higher area level deprivation and lower educational level were both independently associated with higher T2DM and obesity prevalence [highest area level deprivation: OR 1.28 (95% CI: 1.05–1.55) for T2DM and OR 1.28 (95% CI: 1.10–1.49) for obesity]. For men, a similar association was only found for obesity [OR 1.20 (95% CI: 1.02–1.41)], but not for T2DM.

Conclusion

Area level deprivation is an independent, important determinant of T2DM and obesity prevalence in Germany. Identifying and targeting specific area-based risk factors should be considered an essential public health issue relevant to increasing the effectiveness of diabetes and obesity prevention.

Socioeconomic environment and cancer incidence: a French population-based study in Normandy

BACKGROUND

The struggle against social inequalities is a priority for many international organizations. The objective of the study was to quantify the cancer burden related to social deprivation by identifying the cancer sites linked to socioeconomic status and measuring the proportion of cases associated with social deprivation.

METHODS

The study population comprised 68 967 cases of cancer diagnosed between 1997 and 2009 in Normandy and collected by the local registries. The social environment was assessed at an aggregated level using the European Deprivation Index (EDI). The association between incidence and socioeconomic status was assessed by a Bayesian Poisson model and the excess of cases was calculated with the Population Attributable Fraction (PAF).

RESULTS

For lung, lips-mouth-pharynx and unknown primary sites, a higher incidence in deprived was observed for both sexes. The same trend was observed in males for bladder, liver, esophagus, larynx, central nervous system and gall-bladder and in females for cervix uteri. The largest part of the incidence associated with deprivation was found for cancer of gall-bladder (30.1%), lips-mouth-pharynx (26.0%), larynx (23.2%) and esophagus (19.6%) in males and for unknown primary sites (18.0%) and lips-mouth-pharynx (12.7%) in females. For prostate cancer and melanoma in males, the sites where incidence increased with affluence, the part associated with affluence was respectively 9.6% and 14.0%.

CONCLUSIONS

Beyond identifying cancer sites the most associated with social deprivation, this kind of study points to health care policies that could be undertaken to reduce social inequalities.

Associations between neighborhood characteristics and self-rated health: a cross-sectional investigation in the Multi-Ethnic Study of Atherosclerosis (MESA) cohort

Quantifying the effects of specific neighborhood features on self-reported health is important in understanding the global health impact of neighborhood context. We investigated associations of neighborhood poverty, sociability and walkability with self-rated physical and mental health in the Multi-Ethnic Study of Atherosclerosis (MESA). In separate models, each neighborhood variable was associated with physical health but associations with sociability and walkability were stronger than those for poverty. Only walkability remained significant after adjusting for the other neighborhood variables. There was no evidence that self-rated mental health as assessed by the SF12 was associated with neighborhood poverty, walkability or sociability. This study provides information on how neighborhood context is associated with global health in diverse midlife and older persons.

The combined effect of individual and neighborhood socioeconomic status on nasopharyngeal cancer survival

Background

The relationship between individual and neighborhood socioeconomic status (SES) and mortality rates in patients with nasopharyngeal carcinoma (NPC) is unknown. This population-based study aimed to examine the association between SES and survival of patients with NPC in Taiwan.

Materials and Methods

A population-based follow-up study was conducted of 4691 patients diagnosed with NPC between 2002 and 2006. Each patient was traced to death or for 5 years. Individual SES was defined by enrollee job category. Neighborhood SES was based on household income dichotomized into advantaged and disadvantaged areas. Cox proportional hazards model was used to compare the death-free survival rates between the different SES groups after adjusting for possible confounding factors and risk factors.

Results

In NPC patients below the age of 65 years, 5-year overall survival rates were worst for those with low individual SES living in disadvantaged neighborhoods. After adjusting for patient characteristics (age, gender, Charlson Comorbidity Index Score), NPC patients with low individual SES residing in disadvantaged neighborhoods were found to have a 2-fold higher risk of mortality than patients with high individual SES residing in advantaged neighborhoods. We found no significant difference in mortality rates between different SES groups in NPC patients aged 65 and above.

Conclusions

Our findings indicate that NPC patients with low individual SES who live in disadvantaged neighborhoods have the higher risk of mortality than their more privileged counterparts. Public health strategies and welfare policies would be well advised to try to offset the inequalities in health care and pay more attention to addressing the needs of this vulnerable group.

The impact of regional deprivation and individual socio-economic status on the prevalence of Type 2 diabetes in Germany. A pooled analysis of five population-based studies

AIM

Our objective was to test the hypothesis that the prevalence of Type 2 diabetes increases with increasing regional deprivation even after controlling for individual socio-economic status.

METHODS

We pooled cross-sectional data from five German population-based studies. The data set contained information on n = 11,688 study participants (men 50.1%) aged 45-74 years, of whom 1008 people had prevalent Type 2 diabetes (men 56.2%). Logistic multilevel regression was performed to estimate odds ratios (OR) and 95% confidence intervals (CI) for diabetes prevalence. We controlled for sex, age and lifestyle risk factors, individual socio-economic status and regional deprivation, based on a new small-area deprivation measure, the German Index of Multiple Deprivation.

RESULTS

Adjusted for sex, age, body mass index (BMI), physical activity, smoking status and alcohol consumption, the prevalence of Type 2 diabetes showed a stepwise increase in risk with increasing area deprivation [OR 1.88 (95% CI 1.16-3.04) in quintile 4 and OR 2.14 (95% CI 1.29-3.55) in quintile 5 compared with the least deprived quintile 1], even after controlling for individual socio-economic status. Focusing on individual socio-economic status alone, the risk of having diabetes was significantly higher for low compared with medium or high educational level [OR 1.46 (95% CI 1.24-1.71)] and for the lowest compared with the highest income group [OR 1.53 (95% CI 1.18-1.99)].

CONCLUSION

Regional deprivation plays a significant part in the explanation of diabetes prevalence in Germany independently of individual socio-economic status. The results of the present study could help to target public health measures in deprived regions.

Exploring racial disparities in CHD mortality between blacks and whites across the United States: a geographically weighted regression approach

Coronary heart disease (CHD) mortality is one of the major contributors to racial disparities in health in the United States (US). We examined spatial heterogeneity in black-white differences in CHD mortality across the US and assessed the contributions of poverty and segregation. We used county-level, age-adjusted CHD mortality rates for blacks and whites in the continental US between 1996 and 2006. Geographically weighted regression was employed to assess spatial heterogeneity. There was significant spatial heterogeneity in black-white differences in CHD mortality (median black-white difference 17.7 per 100,000, 25th-75th percentile (IQR): 4.0, 34.0, P value for spatial non-stationarity <0.0001) before controlling for poverty and segregation. This heterogeneity was no longer present after accounting for county differences in race-specific poverty and segregation and interactions of these variables with race (median black-white difference -13.5 per 100,000, IQR: -41.3, 15.7,P value for spatial non-stationarity=0.4346). The results demonstrate the importance of spatial heterogeneity in understanding and eliminating racial disparities in CHD mortality. Additional research to identify the individual and contextual factors that explain the local variations in racial disparities is warranted.

Socio-economic and demographic determinants of childhood obesity prevalence in Greece: the GRECO (Greek Childhood Obesity) study

OBJECTIVE

Given the rapid increase in the prevalence of childhood obesity, identifying the sociodemographic influences on obesity status is important for planning and implementing effective prevention initiatives. However, this type of data is limited for Greek children. Therefore the aim of the present study was to identify possible sociodemographic factors associated with childhood obesity at the national level.

DESIGN

Cross-sectional, population-based survey, carried out from October to May 2009. Setting Under the context of the GRECO (Greek Childhood Obesity) study, a nationwide sample of 2315 primary-school children.

SUBJECTS

Children aged 10-12 years and their parents were voluntarily enrolled. Direct anthropometric measurements of the children were obtained and information on sociodemographic characteristics of the parents, as well as their self-reported values of body weight and height, were collected.

RESULTS

Overweight and obesity prevalence was 29·5 % and 13·1 %, respectively, among boys; 29·5 % and 9·0 %, respectively, among girls. Multiple logistic regression analysis revealed that the most important sociodemographic predictors of childhood obesity were mother's age, parental BMI classification and father's type of occupation. More specifically, increased mother's age and normal BMI status of the parents seemed to have a protective effect on the likelihood of having an overweight/obese child. Additionally, the odds of a female child of being overweight/obese were reduced when the father's type of occupation tended to be less manual.

CONCLUSIONS

Anti-obesity health policy interventions have to address to the parents and promote their active involvement, to effectively confront the alarming magnitude of the paediatric obesity problem in Greece.

Relationship between prevalence of childhood obesity in 17-year-olds and socioeconomic and environmental factors: prefecture-level analysis in Japan

To investigate the association between childhood obesity and neighborhood-level socio-economic and environmental factors in Japan. The prevalence of childhood obesity in 2008 was obtained from annual reports of the School Health Survey. The following 12 factors were publicly available: income per person, ratio of people completing up to college or university education, population density, total length of roads per square kilometer, number relative to the population of food and drink stores, restaurants, large-scale retail stores, convenience stores, passenger cars, traffic accidents, criminal offenses, and death by accidents. The ratio of people completing up to college or university education was inversely associated with obesity in boys and girls. No association was found between obesity and the other factors examined. An inverse association was shown between educational level and childhood obesity in both boys and girls. Further studies integrating associations between childhood obesity and neighborhood-level factors are needed.

Association between a 45-bp 3'untranslated insertion/deletion polymorphism in exon 8 of UCP2 gene and neural tube defects in a high-risk area of China

Uncoupling protein 2(UCP2) is an attractive candidate gene for screening neural tube defects (NTDs) risk. In this study, polymerase chain reaction and agarose gel electrophoresis were used to determine the distribution of the polymorphism in a case group of 140 deliveries with NTDs, and a control group of 251 normal newborns. We found that the frequencies of allele I and genotypes ID + II were higher in the case group than in the control group (P = .167, OR = 1.4, 95% CI, 0.9-2.1; P = .132, OR = 1.44, 95% CI, 0.89-2.33, respectively); and at low maternal educational level, the frequency of ID + II genotypes was significantly higher in the NTD case group (P < .05, OR = 1.7, 95% CI, 1.01-2.79). The result suggested that the polymorphism in UCP2 may be a potential genetic risk factor for NTDs in a high-risk area of China, and the association was influenced by maternal education.

Head and neck cancer-specific survival based on socioeconomic status in Asians and Pacific Islanders

BACKGROUND

Lower socioeconomic status (SES) has been linked to higher incidence of head and neck cancer (HNC) and lower survival. However, little is known about the effect of SES on HNC survival in Asians and Pacific Islanders (APIs). This study's purpose was to examine the effect of SES on disease-specific survival (DSS) and overall survival (OS) in APIs with HNC using population-based data.

METHODS

A total of 53,544 HNC patients (4,711 = APIs) were identified from the California Cancer Registry from 1988 to 2007. Neighborhood (block-group-level) SES, based on composite Census 1990 and 2000 data, was calculated for each patient based on address at diagnosis, categorized into statewide quintiles, and collapsed into 2 groups for comparison (low SES = quintiles 1-3; high SES = quintiles 4-5). DSS and OS were computed by the Kaplan-Meier method. Adjusted hazards ratios (HR) were estimated using Cox proportional hazards regression models.

RESULTS

Among APIs, lower neighborhood SES was significantly associated with poorer DSS (HR range for oral cavity, oropharynx, or larynx/hypopharynx cancer, 1.07-1.34) and OS (HR, 1.13-1.37) after adjusting for patient and tumor characteristics. Lower SES was significantly associated with poorer survival in API with all HNC sites combined: DSS HR: 1.26 (95% confidence interval [CI], 1.08-1.48) and OS HR, 1.30 (95% CI, 1.16-1.45).

CONCLUSIONS

Neighborhood SES was associated with longer DSS and OS in API with HNC. The effect of SES on HNC survival should be considered in future studies, and particular attention should be paid to clinical care of lower-SES HNC patients.

Child obesity associated with social disadvantage of children's neighborhoods

Evidence suggests variability in adult obesity risk at a small-scale geographic area is associated with differences in neighborhood socioeconomic status (SES). However, the extent to which geographic variability in child obesity is associated with neighborhood SES is unknown. The objective of this paper was to estimate risk of child obesity associated with multiple census tract SES measures and race within a large urban U.S. county. Height, weight, age, sex, medical insurance type and census tract residence were obtained for 6-18 year old children (n=8616) who received medical care at a health plan in King County, Washington, in 2006. Spatial analyses examined the individual risk of obesity (BMI > or = 95th percentile) with 2000 US census tract measures of median household income, home ownership, adult female education level, single parent households, and race as predictors. Conditional autoregressive regression models that incorporated adjacent census tracts (spatial autocorrelation) were applied to each census tract variable, adjusting for individual variables. We found that in adjusted spatial models, child obesity risk was significantly associated with each census tract variable in the expected direction: lower household income, lower home ownership, and for each 10% increase in less educated women, and single parent households, as well as non-white residents. In a spatial model including all variables, the SES/race variables explained approximately 24% of geographic variability in child obesity. Results indicated that living in census tracts with social disadvantage defined by multiple different measures was associated with child obesity among insured children in a large U.S. urban county. These results contribute new information on relationships between broader social and economic context and child obesity risk using robust spatial analyses.

The predictors of self-rated health and the relationship between self-rated health and health service needs are similar across socioeconomic groups in Canada

OBJECTIVE

To examine if there are systematic differences in the predictors of self-rated health (SRH) and to examine the relationship between SRH and health care utilization across socioeconomic groups.

STUDY DESIGN AND SETTING

We used cross-sectional data from the Canadian Community Health Survey linked to the Ontario Health Insurance Plan (N=17,109). We examined relative differences in the factors associated with different levels of SRH across socioeconomic groups (as assessed by education and household income) using probit models separately for men and women. We then examined differences in expected health care costs, as assessed by adjusted clinical group weights using administrative health care records, between socioeconomic groups within the same level of SRH.

RESULTS

We found limited differences across the predictive ability of a broad range of physical, mental, health service/care utilization, and health behavior variables on SRH across socioeconomic groups. In addition, no differences were found in the expected health care utilization costs across socioeconomic groups within the same level of SRH.

CONCLUSIONS

The results of this study suggest that SRH assesses a broad variety of factors, including physical health status, mental health status, health service/care utilization, and health behaviors, relatively equally across socioeconomic groups, measured as either education or income.

Geographic variation and effect of area-level poverty rate on colorectal cancer screening

BACKGROUND

With a secular trend of increasing colorectal cancer (CRC) screening, concerns about disparities in CRC screening also have been rising. It is unclear if CRC screening varies geographically, if area-level poverty rate affects CRC screening, and if individual-level characteristics mediate the area-level effects on CRC screening.

METHODS

Using 2006 Missouri Behavioral Risk Factor Surveillance System (BRFSS) data, a multilevel study was conducted to examine geographic variation and the effect of area-level poverty rate on CRC screening use among persons age 50 or older. Individuals were nested within ZIP codes (ZIP5 areas), which in turn, were nested within aggregations of ZIP codes (ZIP3 areas). Six groups of individual-level covariates were considered as potential mediators.

RESULTS

An estimated 51.8% of Missourians aged 50 or older adhered to CRC screening recommendations. Nearly 15% of the total variation in CRC screening lay between ZIP5 areas. Persons residing in ZIP5 areas with > or = 10% of poverty rate had lower odds of CRC screening use than those residing in ZIP5 areas with <10% poverty rate (unadjusted odds ratio [OR], 0.69; 95% confidence interval [95% CI], 0.58-0.81; adjusted OR, 0.81; 95% CI, 0.67-0.98). Persons who resided in ZIP3 areas with > or = 20% poverty rate also had lower odds of following CRC screening guidelines than those residing in ZIP3 areas with <20% poverty rate (unadjusted OR, 0.66; 95% CI, 0.52-0.83; adjusted OR, 0.64; 95% CI, 0.50-0.83). Obesity, history of depression/anxiety and access to care were associated with CRC screening, but did not mediate the effect of area-level poverty on CRC screening.

CONCLUSION

Large geographic variation of CRC screening exists in Missouri. Area-level poverty rate, independent of individual-level characteristics, is a significant predictor of CRC screening, but it only explains a small portion of the geographic heterogeneity of CRC screening. Individual-level factors we examined do not mediate the effect of the area-level poverty rate on CRC screening. Future studies should identify other area- and individual-level characteristics associated with CRC screening in Missouri.

Socioeconomic status and adiposity in childhood: a systematic review of cross-sectional studies 1990-2005

BACKGROUND

Sobal and Stunkard's review (1989) of 34 studies from developed countries published after 1941, found inconsistent relationships between socioeconomic status (SES) and childhood adiposity. Inverse associations (36%), no associations (38%), and positive associations (26%) were found in similar proportions. In view of the trends in pediatric obesity, the relationship between SES and adiposity may have changed.

OBJECTIVE

To describe the cross-sectional association between SES and adiposity in school-age children from western developed countries in epidemiological studies since 1989.

METHODS AND PROCEDURES

PubMed database was searched to identify potentially relevant publications. Epidemiological studies from western developed countries presenting cross-sectional data on the bivariate association between an SES indicator and objectively measured adiposity in childhood (5-18 years), carried out after 1989 were included. SES indicators included parental education, parental occupation, family income, composite SES, and neighborhood SES.

RESULTS

Forty-five studies satisfied the review criteria. SES was inversely associated with adiposity in 19 studies (42%), there was no association in 12 studies (27%), and in 14 studies (31%) there was a mixture of no associations and inverse associations across subgroups. No positive SES-adiposity associations were seen in unadjusted analyses. With parental education as the SES indicator, inverse associations with adiposity were found in 15 of 20 studies (75%).

DISCUSSION

Research carried out within the past 15 years finds that associations between SES and adiposity in children are predominately inverse, and positive associations have all but disappeared. Research is needed to understand the mechanisms through which parental social class influences childhood adiposity.