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

Momentary health behaviour cues are moderated by educational attainment: Findings from two ecological momentary assessment studies

Socioeconomic status (SES), indicated e.g., through educational attainment substantially influences health outcomes through health behaviours. Many health behaviours such as smoking or consuming sugar-sweetened beverages (SSBs) are strongly influenced by momentary environmental and social cues in everyday life. This study examined the moderating role of SES on the relationship between such situational cues and smoking as well as SSB consumption. Data were drawn from two ecological momentary assessment studies with 46 daily smokers (Study 1) and 125 SSB consumers (Study 2) in Germany. Participants provided daily self-reports on behavioral cues and consumption over three weeks. Results revealed that lower educational attainment was associated with increased associations between situational social cues (e.g., observing others engaging in the behavior) and smoking, as well as between situational availability cues (e.g., access to SSBs) and SSB consumption. These findings suggest that individuals with lower educational attainment are both more exposed to and more susceptible to environmental cues promoting health-compromising behaviours. Addressing these disparities may require structural interventions to reduce the density and impact of such cues in disadvantaged environments.

Health inequality attributions and support for healthcare policy

This article examines popular explanations of health inequality and introduces a typology distinguishing between behavioural, biological, environmental, and healthcare attributions. Using data from an original survey among 6000 individuals in Germany, the findings reveal that explanations for the social gradient in health vary by income and political ideology. Lower-income groups primarily attribute health inequality to the healthcare system, whereas higher-income groups attribute them to behavioural factors. Similarly, right-wing individuals tend to view income-related health disparities as a consequence of individual behaviour, while left-wing individuals primarily attribute them to environmental health risks. Furthermore, the study shows that such health inequality attributions are associated with citizens' support for government responsibility for healthcare provision and willingness to pay higher taxes to improve healthcare. These findings suggest that health inequality attributions play an important role in the democratic legitimacy of healthcare policies. Divergent views on the causes of health disparities may undermine solidarity within healthcare systems.

Behavioural and metabolic mediators of socioeconomic inequalities in type 2 diabetes: comparing counterfactual and traditional mediation analysis

There is a well-established social gradient in the occurrence of type 2 diabetes, but the extent to which behavioural or metabolic risk factors explain these inequalities remains unclear. Leveraging data from 7123 adults and over 20 years of follow-up, we used counterfactual mediation analysis to estimate the direct effect of low socioeconomic status (measured as educational attainment and occupational class) on the risk of type 2 diabetes, and the indirect effect through behavioural and metabolic risk factors. Mediators included were smoking, high alcohol consumption, low physical activity, diet low in vegetables or fruits, high body mass index (BMI), high fasting glucose, and hypertension. We compared the results to mediation analysis using the difference and the product of coefficients methods. We found an association between low educational attainment 1.31 (95% CI 1.16, 1.45) and low occupational class 1.24 (95% CI 1.09, 1.38) with future risk of type 2 diabetes. In the counterfactual mediation analysis, behavioural and metabolic risk factors explained 60% (95% CI 41%, 75%) of the effect of low educational attainment and 42% (95% CI 19%, 65%) of the effect of occupational class on the risk of type 2 diabetes. The difference and product of coefficients methods yielded similar results. Well-established behavioural and metabolic mediators explained roughly half of the health inequalities in the incidence of type 2 diabetes. Public health interventions should consider alternative mechanisms to reduce disparities in the incidence of type 2 diabetes.

Individual and joint associations of socioeconomic inequalities and unhealthy lifestyle with incident gastric cancer: A prospective cohort study

OBJECTIVES

Gastric cancer (GC) remains a significant public health challenge, with accumulating evidence indicating an association between socioeconomic status (SES) and GC risk. This study aimed to examine the independent and synergistic effects of SES and lifestyle on GC incidence within a large prospective cohort.

STUDY DESIGN

Prospective cohort study.

METHODS

Data were analysed from 349,908 UK Biobank participants using latent class analysis to determine SES (household income, education, employment). Lifestyle was assessed based on smoking status, alcohol consumption, physical activity, body mass index and diet. Multivariable Cox regression tested associations between SES, lifestyle and GC, with mediation and interaction analyses used to explore their relationships.

RESULTS

SES was significantly associated with GC risk (hazard ratio [HR] = 1.35, 95 % confidence interval [CI], 1.20-1.52). An unhealthy lifestyle was also linked to increased GC risk (HR = 1.48, 95 % CI, 1.30-1.68). Individuals with low SES and an unhealthy lifestyle had a 195 % higher risk of GC compared to those with high SES and a healthy lifestyle (HR = 2.95, 95 % CI, 2.11-4.11). Mediation analysis indicated that 5.26 % of the SES-GC risk association was mediated by lifestyle factors. No significant interaction between SES and lifestyle was observed.

CONCLUSIONS

Low SES was related to an increased risk of GC, some of which may be mediated by unhealthy lifestyle. Public health initiatives should focus on addressing socioeconomic disparities and improving lifestyle factors to reduce GC incidence.

Socioeconomic differences in adolescent health behaviors and their effect on inequalities in adult depressed mood: findings from a 27-year longitudinal study

BACKGROUND

Health behaviors have been posited to partly explain the association between socioeconomic status (SES) and health (i.e., the behavioral explanation of health inequalities), yet few studies have examined whether health behaviors serve as pathways from adolescent SES to adult depressive symptoms. This study aimed to explore the effects of adolescent health behaviors on adult depressed mood using the adolescent pathway model (APM).

METHODS

Our sample consisted of n = 1109 Norwegians [45.5% female], who were surveyed from ages 13 to 40 across ten time points. Using linear regression analyses, we examined (1) the association between parental SES [household income and parental education] and adolescent health behaviors [breakfast regularity, leisure time physical activity (LTPA), difficulties falling asleep, alcohol consumption, and smoking], and (2) the associations between adolescent health behaviors and adult depressed mood, and whether these were moderated by indicators of parental SES. We also assessed how health behaviors are associated with social inequality in adult depressed mood. In this context, social inequality was defined as the covariance between adult SES (i.e., income and education) and adult depressed mood.

RESULTS

Higher household income predicted higher levels of LTPA, and higher parental education predicted greater breakfast regularity. None of the health behaviors were associated with adult depressed mood, nor did they show moderation by SES. Adolescent health behaviors did not independently account for social inequality in adult depressed mood.

CONCLUSIONS

The study suggests minimal socioeconomic differences in adolescent health behaviors, which do not significantly account for social inequalities in adult depressed mood. This offers limited support for the behavioral explanation of health inequalities within the framework of the APM. However, adolescent depressed mood emerges as the strongest predictor of adult depressed mood, highlighting its importance as a key focus for early intervention efforts.

Psychological determinants and evidence-based behavior change interventions in adherence to therapy for familial hypercholesterolemia

PURPOSE OF REVIEW

Patients with familial hypercholesterolemia have an elevated risk of premature atherosclerotic cardiovascular disease. Risks can be minimized through pharmacological and 'lifestyle' behavioral (low fat diet, physical activity) therapies, although therapeutic adherence is sub-optimal. Behavioral interventions to promote familial hypercholesterolemia therapy adherence should be informed by theory-based psychological determinants for maximal efficacy. The current review summarizes research on determinants of familial hypercholesterolemia therapy adherence and behavior change interventions, identifies limitations of the extant research, and sets future research agenda.

RECENT FINDINGS

A recent meta-analysis identified attitudes, subjective norms, self-efficacy, and risk perceptions as key determinants of familial hypercholesterolemia therapy adherence intentions, with intentions identified as a key correlate of concurrent behavior. Studies have specified techniques targeting key theory-based determinants that may be efficacious in interventions. Research is limited by overuse of cross-sectional correlational study designs, use of self-report behavioral measures, few theory-based intervention tests, and limited consideration of nonconscious processes and effects of socio-structural variables.

SUMMARY

Researchers should adopt study designs permitting better directional and causal inferences in determinant effects, provide tests of interventions targeting determinants and their mechanisms of action, consider determinants representing nonconscious processes (habits, implicit attitudes), and test determinants as mediators of socio-structural variables on familial hypercholesterolemia therapy adherence.

Perceived financial hardship and sleep in an adult population-based cohort: The mediating role of psychosocial and lifestyle-related factors

BACKGROUND

Social inequalities in sleep have been reported, but there is less research on the mechanisms underlying this association. This study investigates the relationship between financial hardship and sleep within the general adult population, focusing on the mediating effects of psychosocial and lifestyle-related factors.

METHODS

We used data from the Specchio cohort, a population-based study in Geneva, Switzerland, initiated in December 2020. Perceived financial hardship and sleep outcomes (insomnia, sleep quality, and sleep duration) were assessed by questionnaire in 2020 to 2021. Counterfactual mediation analysis was conducted to examine the extent to which perceived financial hardship impacts sleep through psychosocial (psychological distress and loneliness) and lifestyle-related (weight, smoking, and physical inactivity) pathways. Models were adjusted for age, sex, education, living alone, and chronic disease.

RESULTS

Among 4388 participants, those experiencing financial hardship had a greater risk of insomnia (odds ratio: 2.11; 95% confidence interval: 1.70-2.61), poor sleep quality (odds ratio: 1.69; 95%confidence interval: 1.41-2.02), and not meeting sleep duration guidelines (odds ratio: 1.40; 95% confidence interval: 1.18-1.66) compared to those without financial difficulties. Psychosocial factors explained 40% of the relationship of financial hardship with insomnia, 35% of the relationship with poor sleep quality, and 10% of the association with suboptimal sleep duration. The contribution of lifestyle-related factors was 8%, 12%, and 17%, respectively.

CONCLUSION

Perceived financial hardship is a significant predictor of poor sleep, and this association is mediated by psychosocial and, to a lesser extent, lifestyle-related factors. These findings highlight the need for integrative approaches addressing social inequalities in sleep.

Particulate matter, socioeconomic status, and cognitive function among older adults in China

BACKGROUND

Both air pollution and low socioeconomic status (SES) are associated with worse cognitive function. The extent to which low SES may compound the adverse effect of air pollution on cognitive function remains unclear.

METHODS

7,087 older adults aged 65 and above were included from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) and followed up in 4 waves during 2008-2018. Cognitive function was measured repeatedly at each wave using the modified Chinese Mini-Mental State Examination (MMSE). Concentrations of particulate matter (PM1, PM2.5, and PM10) were evaluated using satellite-based spatiotemporal models. SES was measured based on five components and categorized into three levels (low, middle, and high). Generalized estimating equation models were used to estimate the association of PM and SES with cognitive function. Stratified analyses and effect modification by SES levels were further conducted.

RESULTS

Each 10 µg/m3 increase in PM1, PM2.5, and PM10 was associated with a 0.43 (95 % CI: -0.58, -0.27), 0.29 (95% CI: -0.37, -0.20), and 0.17 (95 % CI: -0.22, -0.13) unit decrease in MMSE scores, respectively. Lower SES was associated with worse cognitive function. Significant effect modifications were observed by SES, with the corresponding association of PM exposure being more pronounced among participants with a lower SES (p-interaction = 0.006, 0.001, and 0.006 for PM1, PM2.5, and PM10, respectively).

CONCLUSIONS

SES is an important effect modifier, and lower SES may compound the detrimental effect of PM on cognitive health. This finding may have implications for identifying vulnerable populations and targeted interventions against air pollution.

Proactive automatized multiple health risk behavior change intervention: reach and retention among general hospital patients

Although behavior change interventions are highly recommended in health care, their reach, a core dimension of the public health impact of interventions, is rarely evaluated. This study aimed to investigate whether an individualized, computer-based brief intervention to reduce co-occurring health risk behaviors (HRBs), namely tobacco smoking, at-risk alcohol use, insufficient physical activity, and unhealthy diet, can reach and retain a sufficiently large part of general hospital patients (>75%) and whether patients with high need, that is with more HRBs, low school education or current unemployment may be sufficiently reached and retained. Over 6 weeks in 2022, all 18-64-year-old patients admitted to 11 wards of five medical departments of a university hospital in Germany were asked to participate in a computer-based HRB screening and in a pre-post intervention study with three further assessments and individualized computer-generated feedback. To investigate associations between intervention reach and retention and patient characteristics, a logistic and a Poisson regression analysis were used. Screening reached 78.9% of all eligible patients (225/285). Of those eligible for the intervention study, 81.8% (175/214) participated in the intervention. Among these, 76.0% (133/175) participated at least once more after hospitalization. Patients' lifestyle and socio-economic characteristics were not significantly associated with reach or retention, Ps ≥ .467. Proactive computer-based multiple-HRB change interventions may reach and retain a sufficiently large part of general hospital patients, including those most in need. When proven efficacious and adequately implemented, this is a promising approach concerning public health impact in the reduction non-communicable diseases.

Trial registration:  ClinicalTrials.gov NCT05365269, 9 May 2022.

Social disadvantage accelerates aging

Social disadvantage, like advanced age, is a risk factor for a broad range of health conditions; however, whether it influences the aging process remains unclear. Here, using a multicohort approach, we investigated the associations of social disadvantage with age-related plasma proteins and age-related diseases. We found proteomic signatures of accelerated immune aging and 14 specific age-related proteins linked to social disadvantage during both early and later life. Individuals experiencing social disadvantage had an increased risk of 66 age-related diseases, with up to 39% of these associations mediated by the 14 age-related proteins (for example, DNAJB9, F2, HSPA1A, BGN). The main enriched pathway involved the upregulation of the pro-inflammatory regulator NF-κB24 and its downstream factor interleukin-8. Our findings support the hypothesis that social disadvantage throughout the life course may accelerate aging, a biological mechanism that could explain why social stratification plays such a fundamental role in determining human health.

Cardiovascular disease-specific and all-cause mortality across socioeconomic status and lifestyles among patients with established cardiovascular disease in communities of China: data from a national population-based cohort

BACKGROUND

Evidence of socioeconomic status (SES)-related health inequality is scarce in patients with cardiovascular diseases (CVDs) who need both lifestyle change and medical care, particularly in developing countries.

METHODS

The study employed a nationwide population-based cohort design, covering all 31 provinces of Chinese mainland from September 2014 to March 2021. Participants aged 35-75 years with self-reported CVD diagnoses were included. Information on SES and lifestyle details were collected via a questionnaire, and the unequal mortality across SES groups and the mediating effects of lifestyles were explored.

RESULTS

Among the 104 718 participants included, 27 943 (26.7%) were allocated to high SES, 35 802 (34.2%) were allocated to medium SES and 40 973 (39.1%) were allocated to low SES. During a mean follow-up of 48.9±18.9 months, 5010 deaths were recorded. Participants with low SES had a 65% (HR=1.65, 95% CI: 1.50 to 1.80) greater risk of all-cause death and a 95% (HR=1.95, 95% CI: 1.72 to 2.20) greater risk of CVD death in Chinese communities. A low SES with the worst lifestyle was associated with a significant increase in the risk of all-cause mortality by 172% (HR=2.72, 95% CI: 2.37 to 3.12) and CVD mortality by 218% (HR=3.18, 95% CI: 2.64 to 3.83) compared with a high SES with healthy lifestyle. The joint mediating effects of lifestyles on CVD mortality accounted for 19.6% (95%CI: 14.8% to 24.2%) of the excess mortality risk for individuals with low SES, and these effects varied by genders (p for interaction=0.013) and urbanity (p for interaction=0.004). Leisure-time physical activity was the strongest mediator, followed by dietary factors. For all-cause mortality, outcomes were similar to this.

CONCLUSIONS

Both SES-related health inequalities and lifestyle disparities should be comprehensively considered when caring for this population, and upstream structural interventions that integrate SES and lifestyle factors and are tailored to the target population are urgently needed.

TRIAL REGISTRATION NUMBER

NCT02536456.

Association of polysocial risk score, cardiovascular health status, and the risk of premature mortality: Findings from the UK Biobank

BACKGROUND

Evidence of the cumulative effects of social risk factors on premature mortality is quite limited. We aimed to examine the association between cumulative social risk factors and premature mortality by constructing a polysocial risk score, and to explore the influence of cardiovascular health on this association.

METHODS

A polysocial risk score was constructed by summing 11 social determinants of health. A cardiovascular health (CVH) score was calculated following the algorithm of "Life's Essential 8". Premature mortality was defined as death at an age younger than 75. Cox proportional hazards model was conducted.

RESULTS

A total of 314,039 participants in the UK Biobank were included (median age 56.0 years, 53.1% women). During a median of 12.7 years of follow-up, 13,888 premature deaths were reported. Compared with participants who had a low polysocial risk score (≤3), participants with a high polysocial risk score (≥7) were more than twice as likely to die prematurely in the follow-up period (HR 2.18, 95% CI 2.06-2.30). Compared with participants with ideal CVH and low polysocial risk score, those with poor CVH and high polysocial risk score had the highest risk of premature mortality (HR 5.25, 95% CI 4.48-6.14). A significant interaction was found between CVH status and polysocial risk score on premature mortality risk (P for interaction <0.001).

CONCLUSIONS

Polysocial risk score was associated with an increased risk of premature mortality, the association was exacerbated by poor CVH. Our findings indicate that limiting social inequities and encouraging people to achieve an ideal CVH are essential to reducing the burden of premature mortality.

Trends in educational inequalities in obesity-attributable mortality in England and Wales, Finland, and Italy

OBJECTIVE

We assessed trends in educational inequalities in obesity-attributable mortality (OAM) and their contribution to educational inequalities in all-cause mortality for people aged 30 years and older, in England and Wales (1991-2017), Finland (1978-2017), and Italy (1990-2018).

METHODS

In our population-level study, we estimated the shares of all-cause mortality due to OAM by educational level (i.e., low, middle, and high) by applying the population-attributable fraction formula to harmonized obesity prevalence data by educational level, along with sex- and age-specific relative risks of dying from obesity. We obtained OAM rates by multiplying the shares with individually linked all-cause mortality data by educational level. We measured absolute inequalities in OAM and all-cause mortality by the slope index of inequality.

RESULTS

OAM largely increased for the different sex- and education-specific populations and increased most strongly for those with low educational level up to 2010 to 2015. Educational inequalities in OAM initially increased but stabilized or declined from at least 2008 onward. Obesity contributed, on average, 15% to absolute educational inequalities in all-cause mortality in 1991 through 2017.

CONCLUSIONS

The mortality impact of the obesity epidemic by educational level changed over time. Although the observed change from increasing to declining or stable educational inequalities is encouraging, reducing OAM in all socioeconomic groups remains a challenge.

The association between total social exposure and incident multimorbidity: A population-based cohort study

Background

Multimorbidity, the co-occurrence of two or more chronic conditions, is associated with the social determinants of health. Using comprehensive linked population-representative data, we sought to understand the combined effect of multiple social determinants on multimorbidity incidence in Ontario, Canada.

Methods

Ontario respondents aged 20-55 in 2001-2011 cycles of the Canadian Community Health Survey were linked to administrative health data ascertain multimorbidity status until 2022. Additive total social exposure (TSE) was generated by summing 12 measures of social disadvantage captured from the survey. Weighted-additive TSE included 15 measures of social disadvantage summed across 5 equally weighted domains. Hazard ratios for the association between each TSE measure and multimorbidity were estimated using competing risk Cox-proportional hazards models. All analyses were sex-stratified.

Results

Both additive and weighted-additive TSE were associated with an increased risk of multimorbidity among females and males. A social gradient was observed for multimorbidity risk in all models. While adjusted models were attenuated, an increased risk of multimorbidity was observed among those experiencing the most social disadvantage, compared to those with the least social disadvantage in additive (HR Females = 2.16; 95%CI = 1.63, 2.86; HR Males = 1.90; 95%CI = 1.52, 2.38) and weighted-additive (HR Females = 1.94; 95%CI = 1.49, 2.53; HR Males = 1.72; 95%CI = 1.41, 2.10) models. The observed social gradient was retained.

Conclusions

These findings demonstrate the importance of considering the cumulative effects of multiple social determinants of health on multimorbidity.

Socioeconomic Status, Smoking, and Lung Cancer: Mediation and Bias Analysis in the SYNERGY Study

BACKGROUND

Increased lung cancer risks for low socioeconomic status (SES) groups are only partially attributable to smoking habits. Little effort has been made to investigate the persistent risks related to low SES by quantification of potential biases.

METHODS

Based on 12 case-control studies, including 18 centers of the international SYNERGY project (16,550 cases, 20,147 controls), we estimated controlled direct effects (CDE) of SES on lung cancer via multiple logistic regression, adjusted for age, study center, and smoking habits and stratified by sex. We conducted mediation analysis by inverse odds ratio weighting to estimate natural direct effects and natural indirect effects via smoking habits. We considered misclassification of smoking status, selection bias, and unmeasured mediator-outcome confounding by genetic risk, both separately and by multiple quantitative bias analyses, using bootstrap to create 95% simulation intervals (SI).

RESULTS

Mediation analysis of lung cancer risks for SES estimated mean proportions of 43% in men and 33% in women attributable to smoking. Bias analyses decreased the direct effects of SES on lung cancer, with selection bias showing the strongest reduction in lung cancer risk in the multiple bias analysis. Lung cancer risks remained increased for lower SES groups, with higher risks in men (fourth vs. first [highest] SES quartile: CDE, 1.50 [SI, 1.32, 1.69]) than women (CDE: 1.20 [SI: 1.01, 1.45]). Natural direct effects were similar to CDE, particularly in men.

CONCLUSIONS

Bias adjustment lowered direct lung cancer risk estimates of lower SES groups. However, risks for low SES remained elevated, likely attributable to occupational hazards or other environmental exposures.

The roles of physical activity and sedentary behavior in the relationship between socioeconomic status and depressive symptoms: Observations from a national study

BACKGROUND

While the association between socioeconomic status (SES) and depression is well-documented, the relative contributions of physical activity (PA) and sedentary behavior (SB) to this association remain unclear. This study was to explore the effects of PA, SB in the associations between SES and depressive symptoms, respectively.

METHODS

Our study included 15,906 adults (age≥20 years) from the National Health and Nutrition Examination Survey (NHANES), 2011-2020. A four-way decomposition was applied with PA and SB as mediators to explore the mediation and interaction effects between SES and depressive symptoms.

RESULTS

It was found that low SES was associated with greater risk of depressive symptoms (odds ratios 3.18, 95 % confidence interval 2.56 to 3.94), as well as insufficient moderate-to-vigorous recreational activities (MVRA) (1.45, 1.24 to 1.70) and prolonged SB (0.77, 0.67 to 0.90). MVRA also showed a significant mediation effect that accounted for 5.48 % of the total effect of SES on depressive symptoms. Meanwhile, the interaction between MVRA and SES was also significant, accounting for 28.25 % of the total effect. In the single measure of SES, only the interaction between employment status and MVRA was statistically significant and accounted for 39.41 % of the total effect.

LIMITATION

This study had a cross-sectional design, thus limiting our capacity to draw conclusive causal relationships.

CONCLUSION

People with low SES may be suffered from higher risk of depressive symptoms. However, our findings showed that sufficient MVRA (at least 150 min per week) could buffer against the risk of depressive symptoms, particularly for those who are unemployed.

Genetic contributions to the educational inequalities in coronary heart disease incidence: a population-based study of 32 000 middle-aged men and women

BACKGROUND

The background of educational disparities in coronary heart disease (CHD) risk is still not well understood. We used a polygenic score for education (PGSEDU), socioeconomic indicators and indicators of CHD risk to investigate whether these disparities result from causality or are influenced by shared factors.

METHODS

Population-based health surveys including baseline measures on cardiometabolic risk factors at 25-70 years of age (N=32 610) and PGSEDU were conducted in Finland between 1992 and 2011. Longitudinal information on education, social class, income and CHD incidence (1716 CHD cases up to 2019) was based on national registers. Linear regression, Poisson regression, Cox regression and linear structural equation models were used.

RESULTS

Education and PGSEDU were inversely associated with body mass index, systolic and diastolic blood pressure, total cholesterol and CHD incidence and positively associated with high-density lipoprotein cholesterol in men and women. Part of the associations of PGSEDU with CHD incidence (57% in men and 28% in women) and cardiometabolic factors (30%-55% and 31%-92%, respectively) were mediated by education, social class and income, but a substantial part of them was independent of socioeconomic factors. These associations were consistent across different levels of education.

CONCLUSIONS

PGSEDU captures CHD risk that is not solely attributable to education and other socioeconomic indicators. This suggests that not only causality affects the educational disparities of CHD risk but also factors reflected by PGSEDU can contribute to them. Identifying these factors can help to understand and reduce socioeconomic health disparities.

In Whom We Trust: The Effect of Trust, Subjective Norms, and Socioeconomic Status on Attitudes and COVID-19 Vaccination Intentions

As COVID-19 vaccination hesitancy remains a major public health issue, understanding the factors influencing attitudes and COVID-19 vaccination intentions is a public health priority. Applying the theory of planned behavior (TPB), this study examined the role of two forms of social trust - namely, particularized trust toward relationally close others and generalized trust toward people in general - in moderating the relationship between social norms (injunctive and descriptive) and COVID-19 vaccination attitudes and intent. In two studies (n = 235 for Study 1, n = 273 for Study 2, total N = 508), we found some support for the TPB in the context of COVID-19 vaccination, with attitudes and injunctive norms significantly predicting vaccination intention. However, perceived behavioral control was not a significant predictor of COVID-19 vaccination intention. Extending the TPB, we found that trust in others had an amplifying effect on the relationship between descriptive norms and COVID-19 vaccination attitudes. However, trust attenuated the link between injunctive norms and attitudes toward COVID-19 vaccination. The implications of these findings are discussed.

Bringing the group back in: Social class and resistance in adolescent smoking

Absolute prevalence of tobacco smoking has fallen in recent decades but inequalities by socioeconomic position (SEP) persist. Adolescence is a critical period for smoking initiation and habits formed during this period likely continue into adulthood. Explanations for inequalities in adolescent smoking have tended to focus on individualistic theories based on differentials in knowledge and psychology. These have been criticised for their blindness to processes of social stratification and social context that influence smoking behaviours. Based on previous social theories, we put forward, and test empirically, two potential structural explanations for inequalities in smoking, using nationally representative longitudinal cohort data on 6039 Irish young people aged 9-18 years. Descriptive analyses confirmed the adverse SEP gradient in smoking prevalence as well as SEP gradients in variables representing individual-level characteristics and structural-level explanations. Despite lower self-esteem being associated with a higher likelihood of smoking, there was no significant indirect pathway between SEP and smoking via self-esteem. Path analyses found that differentials in exposure to parental smoking and levels of oppositional values mediate the relationship between SEP and smoking. Our results favour structural and group-based explanations for inequalities, that is, the 'smoking exposure' and 'social resistance' models, over explanations based on individual psychology.

The impact of neighborhood environment on the mental health: evidence from China

Introduction

The community environment is a significant social determinant affecting individual mental health.

Purpose

This study explores the impact mechanisms and urban-rural heterogeneity in the relationship between socioeconomic status and individual mental health, focusing on community environmental perceptions and neighborhood interactions.

Methods

This study used data from the 2021 Chinese General Social Survey (CGSS), selecting a sample of 1,974 respondents. First, a structural equation modeling (SEM) approach was employed for path analysis. Second, a bias-corrected nonparametric percentile bootstrap method was used to test for mediation effects and estimate confidence intervals. Finally, the heterogeneity of the mediation model across urban and rural communities was examined based on community type.

Results

The results indicate that socioeconomic status is the primary determinant of mental health disparities. The mechanisms of environmental perception and social interaction play significant roles in bridging health disparities between social classes. Moreover, these mediating effects show considerable urban-rural heterogeneity. Specifically, the environmental perception mechanism has a stronger impact on rural residents, while social interaction mechanisms are more pronounced in urban communities.

Discussion

The study emphasizes the importance of addressing environmental pollution and enhancing community social interactions as key strategies to reduce health disparities. Improving ecological governance and fostering community engagement, are essential for narrowing the health gap across socioeconomic groups.

Differences in eHealth Access, Use, and Perceived Benefit Between Different Socioeconomic Groups in the Dutch Context: Secondary Cross-Sectional Study

BACKGROUND

There is a growing concern that digital health care may exacerbate existing health disparities. Digital health care or eHealth encompasses the digital apps that are used in health care. Differences in access, use, and perceived benefits of digital technology among socioeconomic groups are commonly referred to as the digital divide. Current research shows that people in lower socioeconomic positions (SEPs) use eHealth less frequently.

OBJECTIVE

This study aims to (1) investigate the association between SEP and eHealth access to, use of, and perceived benefit within the adult Dutch population and (2) evaluate disparities in eHealth access, use, and perceived benefit through three socioeconomic variables-education, standardized income, and the socioeconomic status of the neighborhood.

METHODS

A secondary analysis was conducted on data from the Nivel Dutch Health Care Consumer Panel (response rate 57%, 849/1500), to assess access to, use of, and perceived benefits from eHealth. These data were collected to monitor eHealth developments in the Netherlands. eHealth was examined through two concepts: (1) eHealth in general and (2) websites, apps, and wearables. Results were stratified into 9 SEP populations based on 3 indicators-education, standardized income, and socioeconomic status level of the neighborhood. Logistic regression analyses were performed to evaluate whether the outcomes varied significantly across different SEP groups. Age was included as a covariate to control for confounding.

RESULTS

This study confirms the association between eHealth and SEP and shows that low SEP respondents have less access (odds ratio [OR] 5.72, 95% CI 3.06-10.72) and use (OR 4.96, 95% CI 2.66-9.24) of eHealth compared to medium or high SEP respondents. Differences were most profound when stratifying for levels of education.

CONCLUSIONS

The access to and use of eHealth has a socioeconomic gradient and emphasizes that SEP indicators cannot be used interchangeably to assess eHealth access and use. The results underline the importance of activities and policies aimed at improving eHealth accessibility and usage among low SEP groups to mitigate disparities in health between different socioeconomic groups.

Associations of socioeconomic status and chronic stress with incident atrial fibrillation among older adults: A prospective cohort study from the UK biobank

BACKGROUND

This study aimed to assess the relationship between socioeconomic status (SES) and chronic stress on the incidence of atrial fibrillation (AF) in older adults, and the potential role of chronic stress in the association.

METHODS

This study included 122,494 UK Biobank participants aged ≥60 years without AF at baseline. Latent class analysis was used to define the SES of participants. Chronic stress was measured using allostatic load (AL), and participants were categorized into low, medium and high AL groups. The Cox proportional hazards model, mediation, and interaction analyses were conducted to investigate the associations between SES, AL, and AF risk.

RESULTS

Low SES (hazard ratio [HR]: 1.10; 95 % confidence interval [CI]: 1.04-1.15) and high AL (HR: 1.37; 95 % CI: 1.30-1.45) were associated with an increased risk of AF, respectively. Individuals in the low SES and high AL groups exhibited the highest risk of AF compared to those in the high SES and low AL groups (HR: 1.46; 95 % CI: 1.32-1.61). We identified additive and multiplicative interactions in the low SES and high AL groups (relative risk due to interaction: 0.12 (95 % CI: 0.02-0.22); P for interaction = 0.0385). AL also exerted a partial mediating effect on the association between SES and the incidence of AF (mediation proportion: 17.3 %; 95 % CI: 5.9-28.7 %).

CONCLUSIONS

Our study revealed significant associations between SES, chronic stress, and the incidence of AF in older adults. Chronic stress was also shown to partially mediate the association.

The contribution of childhood adversity to adult socioeconomic gradients in mortality: A Swedish birth cohort analysis

BACKGROUND

"Child maltreatment is a leading cause of health inequality" according to a leading WHO report. This statement is often assumed, yet, the size of the contribution of childhood adversity to the adult socioeconomic gradient in mortality remains unknown. Inequalities in mortality have mostly been investigated by taking adult conditions as a starting point. The objective of this study is to quantify how much of the socioeconomic gradient in adult life expectancy is associated with childhood adversity.

METHODS

Drawing on a 1953 birth cohort from Stockholm (n = 14 210), we compared inequalities in adult mortality within the full cohort to a counterfactual scenario where individuals with a history of childhood adversity (indicated by involvement with child welfare services) experienced the mortality rates of those achieving the same adult socioeconomic position, but with no history of childhood adversity. The socioeconomic gradient across education and income quintiles (attained by age 29) is measured by the slope index of inequality of temporary life expectancy (ages 29-67).

RESULTS

The counterfactual scenario attenuated the education gradient by 40 percent for men and 54 percent for women. Similarly, inequalities by income were reduced in the counterfactual scenario by 49 percent for men and 47 percent for women.

INTERPRETATION

These results support that childhood adversity is an important determinant of inequalities in mortality. The size of their contribution is equivalent to established behavioural risk factors. Taking a life course approach might provide important policy entry points to mitigate health inequalities.

Role of Life's Essential 8 score in mediating socioeconomic status in the incidence of atrial fibrillation and heart failure: a population-based cohort study

OBJECTIVE

To assess whether the Life's Essential 8 (LE8) score mediates the association of socioeconomic status (SES) with atrial fibrillation (AF) and heart failure (HF).

METHODS

A total of 236,754 participants from the UK Biobank were included. SES was determined based on household income, education attainment, and employment status using latent class analysis. Cox regression was utilized to explore the association of SES with AF and HF after adjusting for age, sex, ethnicity, and alcohol status. Counterfactual mediation analysis was employed to calculate the mediation proportion of the LE8 score. Stratified analysis was conducted based on age and sex.

RESULTS

With a median of 13.61 years of follow-up, 14,635 cases of AF and 6878 cases of HF were documented. The HR (95% CI) of the total effect of SES on AF was 1.43 (1.36, 1.48). The indirect effect mediated by the LE8 score was 1.14 (1.13, 1.15), with the mediation proportion being 40.84 (36.97, 47.01)%. The total effect of SES on HF was 2.44 (2.26, 2.59). The indirect effect was 1.28 (1.25, 1.29), with the mediation proportion being 36.77 (34.59, 39.06)%. The mediation proportion was greater for AF in age < 60 years compared to age ≥ 60 years, and it was also higher in males than females for both AF and HF.

CONCLUSION

Approximately one-third of the socioeconomic inequalities in AF and HF could be explained by the LE8 score. These findings highlighted the importance of integrating cardiovascular health promotion into public health policies aimed at mitigating socioeconomic health inequalities.

Socioeconomic Status, Diet, and Behavioral Factors and Cardiometabolic Diseases and Mortality

Importance

It remains unclear how socioeconomic status (SES) is related to the association between diet and health, as well as the role of behavioral factors, in explaining socioeconomic disparities in health outcomes.

Objective

To investigate the associations of neighborhood and individual SES factors, as well as behavioral factors, particularly dietary pattern, with health outcomes.

Design, Setting, and Participants

This prospective cohort study included US health professionals without chronic diseases at baseline who were enrolled in the Health Professionals Follow-Up Study (calendar years 1988-2018), the Nurses' Health Study (calendar years 1992-2018), and the Nurses' Health Study II (calendar years 2001-2019). Data analysis was performed in September 2023.

Exposures

Repeated questionnaires were used to assess neighborhood and individual SES factors and behavioral factors, including dietary pattern (assessed using the Alternative Healthy Eating Index 2010), alcohol intake, body mass index, cigarette smoking, physical activity, sedentary television-viewing time, and sleep duration.

Main Outcomes and Measures

The main outcomes were incident major cardiovascular disease (CVD), type 2 diabetes (T2D), and total mortality. The associations of SES and behavioral factors with outcomes were analyzed using multivariable Cox proportional hazards regression models with hazard ratios (HRs) per 10th- to 90th-percentile increments.

Results

The study analyzed 152 192 participants for major CVD (mean [SD] age, 52.0 [8.7] years; 125 959 female [82.8%]), 151 217 participants for T2D (mean [SD] age, 52.0 [8.6] years; 125 231 female [82.8%]), and 141 145 participants for mortality (mean [SD] age, 51.6 [8.5] years; 117 627 female [83.3%]). A healthy dietary pattern was inversely associated with risk for major CVD (HR, 0.87 [95% CI, 0.82-0.93]), T2D (HR, 0.79 [95% CI, 0.75-0.84]), and total mortality (HR, 0.84 [95% CI, 0.81-0.88]). Without adjusting for neighborhood and individual SES factors, the HRs were 0.85 (95% CI, 0.80-0.91) for risk for major CVD, 0.78 (95% CI, 0.74-0.82) for T2D, and 0.82 (95% CI, 0.79-0.85) for total mortality. Neighborhood SES was inversely associated with risk for major CVD (HR, 0.90 [95% CI, 0.85-0.95]), T2D (HR, 0.92 [95% CI, 0.88-0.97]), and total mortality (HR, 0.91 [95% CI, 0.88-0.94]). Behavioral factors accounted for a large proportion of the associations with risk for major CVD (46.3% [95% CI, 32.5%-60.6%]), T2D (77.4% [95% CI, 64.5%-86.6%]), and total mortality (42.8% [95% CI, 32.9%-53.3%]).

Conclusions and Relevance

In this prospective cohort study of health professionals, associations between diet and health outcomes remained similar without adjusting for SES factors, while health behaviors, including diet, accounted for a large proportion of the associations between neighborhood SES and health. These findings highlight the importance of health behaviors, particularly high-quality diets, in promoting individual health and possibly reducing health disparities associated with SES.

Socioeconomic Inequalities in Dementia Risk Among a Population-Based Cohort: Quantifying the Role of a Broad Combination of Lifestyle Factors

OBJECTIVES

The complex associations of socioeconomic status (SES) and lifestyle with dementia are unclear. Our objective was to examine whether a broad combination of lifestyle factors mediates the associations of SES with incident dementia and the extent of interaction or joint relations of lifestyles and SES with dementia.

METHODS

A total of 274,871 participants from the UK Biobank were included. SES was assessed using the Townsend Deprivation Index. A lifestyle index was created based on smoking status, alcohol consumption, physical activity, social connections, sleep duration, diet, and sedentary behavior. Cox proportional hazards models were fitted. Mediation and interaction analyses were conducted to explore the relationship between lifestyles and SES in dementia.

RESULTS

The hazard ratios (HRs) and 95% confidence intervals (CIs) for when participants with low SES were compared with participants with high SES were 1.32 (1.22-1.42) for all-cause dementia, 1.25 (1.11-1.40) for Alzheimer's disease (AD), and 1.61 (1.37-1.90) for vascular dementia (VD). Lifestyles explained ≤7.8% of socioeconomic disparities in dementia. Unhealthy lifestyle categories were associated with a higher risk of dementia and its subtypes across all SES levels. The HRs (95% CIs) for all-cause dementia, AD, and VD comparing participants with low SES and the least healthy lifestyle versus those with high SES and the healthiest lifestyle were 1.82 (1.56-2.11), 1.51 (1.20-1.90), and 2.56 (1.81-3.61), respectively.

DISCUSSION

Adhering to a healthy lifestyle may prevent dementia across all socioeconomic groups, but socioeconomic inequalities in dementia cannot be fully addressed by promoting healthy lifestyles alone. The social determinants of dementia need to be better addressed.

Sugar-sweetened beverage consumption in Thailand: Determinants and variation across socioeconomic status

OBJECTIVES

Reducing consumption of sugar-sweetened beverages (SSBs) is a primary public health goal in Thailand, but information on the characteristics of SSB consumers remains limited. This study aims to gain knowledge about the characteristics of SSB consumers in Thailand.

STUDY DESIGN

Secondary analysis of survey data.

METHODS

The study used data from the Health Behaviour of Population Survey conducted by Thailand's National Statistics Office between February and May 2021. SSB consumption was sourced from a survey question about the consumption of prepackaged sugar-sweetened non-alcoholic beverages. The influence of demographic, socioeconomic, behavioural, habitual, and health factors on mean daily intake and daily consumption was assessed using a two-part model and logistic regression analysis, respectively. Decomposition analysis was conducted to understand how the impact of these factors affecting SSB consumption varied across socioeconomic groups.

RESULTS

Frequent SSB consumers exhibited various unhealthy behaviours, including smoking, unhealthy food consumption, low physical activity, and making food selections driven by appetitive motivations. Although higher socioeconomic status was associated with greater consumption of SSBs, it stabilised at elevated income levels. Increased SSB consumption in higher socioeconomic groups was linked to mixed eating habits, being overweight, and occasional drinking, while in lower socioeconomic groups, it was associated with unhealthy behaviours like smoking, regular alcohol drinking, appetitive food choices, and low physical activity.

CONCLUSIONS

SSB consumption in Thailand is multifactorial, varying by socioeconomic status. These insights are crucial for policy formation aimed at reducing SSB consumption in the country. Policymakers should explore interventions that address overall unhealthy behaviours alongside those targeting overconsumption of SSBs.

Socioeconomic-Status-Based Disrespect, Discrimination, Exclusion, and Shaming: A Potential Source of Health Inequalities?

Observing an association between socioeconomic status (SES) and health reliably leads to the question, "What are the pathways involved?" Despite enormous investment in research on the characteristics, behaviors, and traits of people disadvantaged with respect to health inequalities, the issue remains unresolved. We turn our attention to actions of more advantaged groups by asking people to self-report their exposure to disrespect, discrimination, exclusion, and shaming (DDES) from people above them in the SES hierarchy. We developed measures of these phenomena and administered them to a cross-sectional U.S. national probability sample (N = 1,209). Consistent with the possibility that DDES represents a pathway linking SES and health, the SES→health coefficient dropped substantially when DDES variables were controlled: 112.9% for anxiety, 43.8% for self-reported health, and 49.4% for cardiovascular-related conditions. These results illustrate a need for a relational approach emphasizing the actions of more advantaged groups in shaping health inequities.

Area-level sociodemographic differences in tobacco availability examined with nationwide tobacco product retail licence data in Finland

BACKGROUND

Differences in tobacco retailer density between areas by sociodemographic composition have been observed. However, little research comes from European jurisdictions and from countries with a tobacco retail licensing system. In Finland, the system consists of criteria for retailers and supervision fees.

METHODS

The tobacco product retail licence data and sociodemographic data were retrieved from corresponding Finnish authorities. Area-level tobacco availability was measured as the presence of a retailer and as the number of retailers per 1000 inhabitants by postcode area. Sociodemographic indicators included median income, percentage of inhabitants in the lowest income tertile, percentage of adults with higher education and unemployment rate. Analyses were based on logistic regression and Ordinary Least Squares regression with log-transformed density.

RESULTS

Lower area-level sociodemographic composition was mainly associated with higher tobacco availability. Income was the strongest correlate of the tobacco retailer availability: areas with higher median income had lower odds of having a tobacco retailer (OR 0.54, 95% CI 0.48 to 0.61 per €1000) and lower retailer density (-4.4% per €1000, Cohen's f=0.51). Areas with a greater proportion of people in the lowest income category had higher densities of tobacco retailers (+2.8% per percentage point, Cohen's f=0.07). Other sociodemographic indicators showed inconsistent associations with retailer presence and density.

CONCLUSION

Tobacco availability can be higher in areas with lower sociodemographic composition also in a country with a comprehensive tobacco retail licensing system and small income inequalities. Retailing policies should be further developed to reduce tobacco availability and narrow inequalities in tobacco use.

The impact of internet medical service on rural gender inequality in health opportunity: a cross-sectional study

BACKGROUND

The increasing popularity of Internet medical service may have alleviated the gender inequality in health opportunity faced by rural women. However, research to ascertain the association between Internet medical service and gender inequality in health opportunity is scarce. This study explored the impact of Internet medical service on gender inequality in health opportunity among rural women and the underlying mechanisms involved.

METHODS

A multistage stratified cross-sectional survey was conducted across six counties in three provinces in China, yielding 3,108 responses for a 97.13% response rate. The questionnaire was used to collect information on Internet healthcare use, health status, health behaviors, social activities and personal exercise, chronic disease status, and demographic and socio-economic characteristics of the participants. Based on Roemer's theory of equality of opportunity (EOP), we established a decomposition strategy for the fairness gap between genders, which we used for the measurement of the gender inequality in health opportunity Fixed effects models, propensity score matching (PSM), and least absolute shrinkage and selection operator (LASSO) regression were utilized to explore the impact of Internet medical service on rural gender inequality in health opportunity.

RESULTS

On average, rural women experienced a gender health fairness gap of 1.63. Internet medical service significantly mitigated this inequality (β = -0.0602, P = 0.0002), and this finding remained significant across propensity score matching (PSM) and LASSO regression analyses. Mechanistic analysis revealed that human capital positively moderates this effect (β = -0.0510, P < 0.01), while income (β = 0.0370, P < 0.001) and marital status (β = 0.2039, P < 0.001) have negative moderating effects.

CONCLUSIONS

By focusing on gender inequality in the digital era, this study highlights the mitigating role of Internet medical service on gender inequality in health opportunity in rural areas. This study proposes and validates the mechanisms through which Internet medical service alleviates gender inequality in health opportunity, suggesting that human capital amplifies this effect, while high personal income and marital status attenuate this effect. These findings contribute to understanding how the digital age can narrow gender health opportunity equality, providing support for future interventions aimed at promoting health equity and gender equality.

The alcohol harm paradox: is it valid for self-reported alcohol harms and does hazardous drinking pattern matter?

BACKGROUND

The alcohol harm paradox (APH) posits that alcohol harms are more prevalent in low socioeconomic position (SEP) groups compared to high SEP groups, when adjusted for alcohol consumption volume.

AIM

We explored whether APH is valid for self-reported alcohol harms and whether SEP differences in hazardous drinking patterns may explain SEP differences in alcohol harms, accounting for consumption volume.

DATA AND METHODS

We applied cross-sectional data from national population surveys in Norway, restricted to a subsample of past month drinkers aged 25-79 years (n = 8 171). Two binary outcome measures of self-reported alcohol-related harms were constructed from the AUDIT-10 items 4 through 10; alcohol dependence symptoms and alcohol related consequences. We separated two SEP groups based on education level: low versus high. Employing logistic regression models, we examined the extent to which SEP differences in alcohol-related harms were attributable to a more hazardous drinking pattern in terms of: (i) heavy episodic drinking and (ii) proportion of consumption volume by spirits, adjusting for consumption volume and demographic characteristics.

RESULTS

In the low SEP group, alcohol-related harms were significantly more prevalent as compared to the high SEP group when adjusted for gender and age, and more so after adjustment for consumption volume. Measures of hazardous drinking pattern and having a spouse could only to a minor extent account for the elevated risk of alcohol-related harm in the low SEP group. The findings were robust across various sensitivity analyses.

CONCLUSION

Low SEP was associated with alcohol-related harm and a more hazardous drinking pattern but also with lower consumption volume. The findings support the validity of the alcohol harm paradox for self-reported alcohol harms.

Friends, neighbors, country, and respect: Status ladders and health behaviors in the United States

Efforts to understand the relationship between socioeconomic status (SES) and health have expanded beyond traditional indicators of education, income, occupation, and wealth to individuals' own reports of where they stand. This more contemporary approach has enjoyed considerable success, in that self-reported SES standing, often measured on a ladder representing the entire U.S. socioeconomic hierarchy, is associated strongly with health even when traditional SES indicators are controlled. However, disparities in self-rated health across ladder measures typically are not assessed with regard to health behavior disparities. Here, we draw on two US national probability samples assessing diverse ladder reference groups, as well as a new ladder asking people to report how much respect, honor, or esteem they receive from other people. Respect or honor offers a distinct potential to measure social influence across circles of recognition. We find that U.S.-based ladder status is related to smoking currently or ever and to days of exercise. While friend, neighbor, and respect-based ladders do not relate to health behaviors net of U.S. ladder standing, they show relationships to ever smoking and physical activity, and self-rated health, in their own right. Physical activity accounts for 12-18% of self-rated health disparities by friend, neighbor, or country ladder status. Smoking and drinking do not robustly contribute to ladder-based disparities in self-rated health. Contrasting what is typically found for traditional SES measures, physical activity merits further research, as does the receipt of respect or honor. That status ladder health disparities go largely unexplained by behaviors suggests the potential roles of non-behavioral pathways including inflammation, hopelessness, or classism.

Psychosocial factors mediate social inequalities in health-related quality of life among children and adolescents

BACKGROUND

The present analysis aimed to assess the mediating role of psychosocial and behavioural factors in socio-economic inequalities in health-related quality of life (HRQoL) among children and adolescents.

METHODS

Cross-sectional data was drawn from the randomly selected SEROCoV-KIDS cohort study in Geneva, Switzerland. Associations of socio-economic conditions (parents' highest education, household financial situation) with HRQoL, psychosocial (parent-child relationship, school difficulties, friends, extracurricular activities) and behavioural factors (screen time, physical activity, green spaces time, sleep duration), along with associations of psychosocial and behavioural factors with HRQoL, were evaluated with generalized estimating equations. Counterfactual mediation analyses were conducted to test pathways linking socio-economic conditions to HRQoL.

RESULTS

Of 965 children and 816 adolescents, those with disadvantaged financial circumstances were more likely to have a poor HRQoL (adjusted Odds Ratio [aOR]: 3.80; 95% confidence interval [CI]: 1.96-7.36 and aOR: 3.66; 95%CI: 2.06-6.52, respectively). Psychosocial characteristics mediated 25% (95%CI: 5-70%) and 40% (95%CI: 18-63%) of financial disparities in HRQoL among children and adolescents, respectively. Health behaviours were weakly patterned by socio-economic conditions and did not contribute to financial differences in HRQoL.

CONCLUSIONS

These findings provide empirical evidence for mechanisms explaining socio-economic disparities in child HRQoL and could inform interventions aimed to tackle health inequalities.

Tobacco Smoke Exposure in Children and Adolescents: Prevalence, Risk Factors and Co-Morbid Neuropsychiatric Conditions in a US Nationwide Study

BACKGROUND

Tobacco smoke exposure (TSE) is a major public health concern, impacting not only smokers but also those around them, particularly children and adolescents. TSE is linked to various neuropsychiatric conditions and significantly impacts quality of life. This study examines the prevalence, socio-demographic factors, and the impact of TSE on the severity of neurological and psychiatric co-morbidities.

METHODS

Data from the National Survey of Children's Health (NSCH) in the US from 2020 to 2021 were used in this study. We included 91,404 children and adolescents aged between 0 to 17 years for the TSE prevalence and socio-demographic analysis, and 79,182 children and adolescents aged between 3 and 17 years for the neuropsychiatric co-morbidities analysis. The mean age of these individuals was 8.7 (standard deviation: 5.3), and 11,751 (12.9%) had confirmed TSE.

RESULTS

Our analysis showed that TSE is more common in males (53%) than females (47%). Additionally, the odds of TSE were higher in families with a lower income level and with American Indian/Native Alaska racial descent. We found that 36.4% of youths with TSE developed at least one co-morbid condition. The most common neuropsychiatric co-morbidities were anxiety problems (15.7%), Attention-Deficit Hyperactivity Disorder (ADHD) (15.5%), behavioral and conduct problems (13.7%), and learning disability (12%). Females had lower odds of co-morbid anxiety (OR: 0.3, p = 0.02) and Autism Spectrum Disorder (ASD) (OR: 0.9, p = 0.04) than males. Asians showed lower odds of co-morbid ADHD (OR: 0.3, p-value: 0.001), anxiety problems (OR: 0.4, p-value: 0.003), speech/other language disorder (OR: 0.4, p-value: 0.001), developmental delay (OR: 0.4, p-value: 0.001), behavioral and conduct problems (OR: 0.4, p-value: 0.003), and learning disability (OR: 0.5, p-value: 0.004). Conversely, American Indian children and adolescents had higher odds of co-morbid headaches (OR: 3, p-value: 0.005). TSE co-occurring with Tourette's Syndrome (TS) (OR: 4.4, p < 0.001), ADHD (OR: 1.3, p < 0.001), developmental delay (OR: 1.3, p < 0.001), behavioral problems (OR: 1.3, p < 0.001), headaches (OR: 1.3, p = 0.005), depression (OR: 1.2, p = 0.02), anxiety (OR: 1.2, p < 0.01), ASD (OR: 1.2, p < 0.001), and learning disability (OR: 1.2, p = 0.03) may contribute to a more severe manifestation.

CONCLUSIONS

ADHD, behavioral/conduct problems, and learning disabilities were the most prevalent co-occurring conditions with TSE. Our findings show that 36.4% of youths with TSE had at least one neuropsychiatric comorbidity. Screening for these conditions in youths exposed to TSE is crucial for early detection and interventions to increase their mental health and well-being.

A preventive integrated eHealth approach for individuals with a low socioeconomic position: protocol for a realist evaluation

BACKGROUND

Adoption of standalone eHealth tools is low among persons in lower socioeconomic groups. The preventive integrated eHealth approach combines blended care with an active and personal approach to facilitate access to local care, tailored to the needs of the participant. We describe the four step preventive integrated eHealth approach for individuals with a low socioeconomic position and the realist evaluation protocol of the intervention and implementation. The realist evaluation centers around the question, 'what works for whom in what circumstances and why'.

METHODS

The study population will consist of adult individuals with a low socioeconomic position, who participate in the preventive integrated eHealth approach in one of the participating locations in the Netherlands. The four-step intervention consists of: (1) a proactive invitation of participants by care professionals, (2) the use of an eHealth tool that produces a personalized health report, (3) a personal consultation with a care professional to discuss the personalized health report and set a goal to work on, and (4) active referral to local social and health care. An initial program theory theorized from literature and stakeholder involvement is presented. Qualitative and quantitative data collection and analysis with participants (survey at zero, three and twelve months and focus groups at six months) and professionals (interviews at three months) will inform the realist evaluation and serves to test and refine the initial program theory.

DISCUSSION

Our mixed-methods realist evaluation on the effect and implementation of a personal and active blended care approach will elucidate what elements trigger the mechanisms and responses of how individuals with a low socioeconomic position experience the preventive integrated eHealth approach. This will inform the way a preventative health check incorporating eHealth can be used to its full potential for low socioeconomic positioned groups to help close the digital divide and contribute to reduce health disparities.

Associations of socioeconomic status and healthy lifestyle with incident dementia and cognitive decline: two prospective cohort studies

Background

Little is known about the complex associations of socioeconomic status (SES) and healthy lifestyle with cognitive dysfunction.

Methods

Using data from the Health and Retirement Study (HRS) [2008-2020] and the English Longitudinal Study of Ageing (ELSA) [2004-2018], SES was constructed by latent class analysis using education level, total household income and wealth. Overall healthy lifestyle was derived using information on never smoking, low to moderate alcohol consumption (drinks/day: (0, 1] for women and (0, 2] for men), top tertile of physical activity, and active social contact.

Findings

A total of 12,437 and 6565 participants from the HRS and ELSA were included (40.8% and 46.0% men and mean age 69.3 years and 65.1 years, respectively). Compared with participants of high SES, those of low SES had higher risk of incident dementia (hazard ratio 3.17, 95% confidence interval 2.72-3.69 in the HRS; 1.43, 1.09-1.86 in the ELSA), and the proportions mediated by overall lifestyle were 10.4% (7.3%-14.6%) and 2.7% (0.5%-14.0%), respectively. Compared with participants of high SES and favorable lifestyle, those with low SES and unfavorable lifestyle had a higher risk of incident dementia (4.27, 3.40-5.38 in the HRS; 2.02, 1.25-3.27 in the ELSA) and accelerated rate of global cognitive decline (β = -0.058 SD/year; 95% CI: -0.073, -0.043 in the HRS; β = -0.049 SD/year; 95% CI: -0.063, -0.035 in the ELSA).

Interpretation

Unhealthy lifestyle only mediated a small proportion of the socioeconomic inequality in dementia risk in both US and UK older adults.

Funding

This work was supported by grants from the National Natural Science Foundation of China (82088102 and 82370819), the National Key R&D Program of China (2023YFC2506700), the Shanghai Municipal Government (22Y31900300), the Shanghai Clinical Research Center for Metabolic Diseases (19MC1910100), the Innovative Research Team of High-Level Local Universities in Shanghai, the Special Project for Clinical Research in Health Industry of Shanghai Municipal Health Commission (202340084), and Ruijin Hospital Youth Incubation Project (KY20240805). Y.X. is supported by the National Top Young Talents program.

Association between socioeconomic position of the household head, food insecurity and psychological health: an application of propensity score matching

BACKGROUND

Mental health outcomes can be influenced by various factors, one of which has recently gained attention, namely food security. Food security is paramount to maintaining not only physical, but also mental health. There is an increasing need to understand the interplay between food insecurity (FI) and mental health outcomes, especially among vulnerable populations. The objective of this study was to investigate the effect of FI on psychological health (anxiety and depression) as well as to examine the modifying effect of socioeconomic position on this relationship.

METHODS

A cross-sectional study was conducted in Maputo City, Mozambique, in 1,842 participants. Data were collected through structured interviews using a modified version of the US Department of Agriculture Household Food Security Module to measure FI, and the Hospital Anxiety and Depression Scale to measure anxiety and depression. A composite variable for psychological health was created. Propensity score matching and interaction effect analyses were employed to examine the effects of FI on psychological health and the moderating role of socioeconomic position.

RESULTS

Of the 1,174 participants randomly assigned to propensity score matching, 787 were exposed to FI while 387 were unexposed. The analysis revealed stark disparities in psychological health outcomes associated with FI. The risk of poor psychological health among those exposed to FI was 25.79%, which was significantly higher than the 0.26% in unexposed individuals. The risk difference was 25.54% points (95% CI: 22.44-28.63), with a risk ratio of 99.82. Our assessment of population attributable fractions indicated that nearly all the risk for poor psychological health in the exposed group could be ascribed to FI. The interaction effects analysis revealed that socioeconomic status modifies this relationship. Specifically, heads of food-insecure households with a lower socioeconomic position tended to report poor mental health compared to their food-secure counterparts with a higher position.

CONCLUSIONS

The findings underscore the profound impact of FI on the mental health of household heads in Maputo City, socioeconomic position being a significant modifier. Addressing household FI along with the socioeconomic position of household heads could be pivotal to mental health promotion, especially among vulnerable populations.

"Physical Activity Is Not the Answer to Everything, but It Is to a Lot": Stakeholders' Perceived Determinants of Implementing Physical Activity Interventions for Older Adults

Although many physical activity (PA) interventions for older adults have proven effective in controlled research settings, optimal implementation in real life remains challenging. This study identifies determinants perceived by stakeholders when implementing community-based PA interventions for older adults. We interviewed 31 stakeholders guided by the Consolidated Framework for Implementation Research (CFIR). Results showed that stakeholders are very specific about the role they can play in implementation, making collaboration between stakeholders crucial. Barriers and motivators were identified in the CFIR intervention characteristics domain (relative advantage, complexity and costs, evidence quality and strength, and adaptability and trialability), in the outer setting domain (cosmopolitism, patient needs, and external policy and incentives), in the inner setting domain (implementation climate, relative priority, compatibility and organizational incentives and rewards) and in the individual characteristics domain (knowledge and beliefs, and other personal attributes). An overarching theme was the stakeholders' emphasis on aiming for broad health goals in interventions, as they perceive PA as a means to reach these goals rather than an end in itself. Another overarching theme requiring attention in future implementation efforts is the need to tailor implementation efforts to the specific needs of older adults as the end users of the intervention.

Behavioral risk factors and socioeconomic inequalities in ischemic heart disease mortality in the United States: A causal mediation analysis using record linkage data

BACKGROUND

Ischemic heart disease (IHD) is a major cause of death in the United States (US), with marked mortality inequalities. Previous studies have reported inconsistent findings regarding the contributions of behavioral risk factors (BRFs) to socioeconomic inequalities in IHD mortality. To our knowledge, no nationwide study has been conducted on this topic in the US.

METHODS AND FINDINGS

In this cohort study, we obtained data from the 1997 to 2018 National Health Interview Survey with mortality follow-up until December 31, 2019 from the National Death Index. A total of 524,035 people aged 25 years and older were followed up for 10.3 years on average (SD: 6.1 years), during which 13,256 IHD deaths occurred. Counterfactual-based causal mediation analyses with Cox proportional hazards models were performed to quantify the contributions of 4 BRFs (smoking, alcohol use, physical inactivity, and BMI) to socioeconomic inequalities in IHD mortality. Education was used as the primary indicator for socioeconomic status (SES). Analyses were performed stratified by sex and adjusted for marital status, race and ethnicity, and survey year. In both males and females, clear socioeconomic gradients in IHD mortality were observed, with low- and middle-education people bearing statistically significantly higher risks compared to high-education people. We found statistically significant natural direct effects of SES (HR = 1.16, 95% CI: 1.06, 1.27 in males; HR = 1.28, 95% CI: 1.10, 1.49 in females) on IHD mortality and natural indirect effects through the causal pathways of smoking (HR = 1.18, 95% CI: 1.15, 1.20 in males; HR = 1.11, 95% CI: 1.08, 1.13 in females), physical inactivity (HR = 1.16, 95% CI: 1.14, 1.19 in males; HR = 1.18, 95% CI: 1.15, 1.20 in females), alcohol use (HR = 1.07, 95% CI: 1.06, 1.09 in males; HR = 1.09, 95% CI: 1.08, 1.11 in females), and BMI (HR = 1.03, 95% CI: 1.02, 1.04 in males; HR = 1.03, 95% CI: 1.02, 1.04 in females). Smoking, physical inactivity, alcohol use, and BMI mediated 29% (95% CI, 24%, 35%), 27% (95% CI, 22%, 33%), 12% (95% CI, 10%, 16%), and 5% (95% CI, 4%, 7%) of the inequalities in IHD mortality between low- and high-education males, respectively; the corresponding proportions mediated were 16% (95% CI, 11%, 23%), 26% (95% CI, 20%, 34%), 14% (95% CI, 11%, 19%), and 5% (95% CI, 3%, 7%) in females. Proportions mediated were slightly lower with family income used as the secondary indicator for SES. The main limitation of the methodology is that we could not rule out residual exposure-mediator, exposure-outcome, and mediator-outcome confounding.

CONCLUSIONS

In this study, BRFs explained more than half of the educational differences in IHD mortality, with some variations by sex. Public health interventions to reduce intermediate risk factors are crucial to reduce the socioeconomic disparities and burden of IHD mortality in the general US population.

Individual and area-level socioeconomic status, Life's Simple 7, and comorbid cardiovascular disease and cancer: a prospective analysis of the UK Biobank cohort

OBJECTIVES

We aimed to investigate the associations of individual and area-level socioeconomic status (SES) with incident cardiovascular diseases (CVD) alone, cancer alone, and comorbid CVD and cancer, and the mediation role of cardiovascular health score in these associations.

STUDY DESIGN

This was a population-based prospective cohort study.

METHODS

We used data from the UK Biobank, a population-based prospective cohort study. Latent class analysis was used to create an individual-level SES index based on three indicators (household income, education level, and employment status), and the Townsend Index was defined as the area-level socioeconomic status. We used the American Heart Association's (AHA) Life's Simple 7 (smoking, body weight, physical activity, diet, blood pressure, blood glucose, and total cholesterol) to calculate the cardiovascular health score. We used Cox proportional hazard regression models to estimate the hazard ratio (HR) and 95% confidence interval (CI) adjusted for demographic, environmental, and genetic factors.

RESULTS

Compared with high SES, the HRs in participants with low individual and area-level SES were 1.33 (95% confidence interval [CI] 1.29 to 1.38) and 1.24 (95% CI 1.20 to 1.29) for incident CVD, 0.96 (95% CI 0.93 to 0.99) and 0.95 (95%CI 0.92 to 0.98) for incident cancer, 1.32 (95%CI 1.24 to 1.40) and 1.15 (95%CI 1.08 to 1.22) for incident comorbid CVD and cancer, respectively. Additionally, the mediation proportion of CVD score for individual and area-level SES was 47.93% and 48.87% for incident CVD, 44.83% and 59.93% for incident comorbid CVD and cancer. The interactions between individual-level SES and CVD scores were significant on incident CVD, and comorbid CVD and cancer, and the protective associations were stronger in participants with high individual-level SES.

CONCLUSIONS

Life's Simple 7 significantly mediated the associations between SES and comorbid CVD and cancer, while almost half of the associations remained unclear.

Association between social determinants of health and survival among the US cancer survivors population

BACKGROUND

Racial and ethnic disparities in mortality persist among US cancer survivors, with social determinants of health (SDoH) may have a significant impact on these disparities.

METHODS

A population-based cohort study of a nationally representative sample of adult cancer survivors, who participated in the US National Health and Nutrition Examination Survey from 1999 to 2018 was included. Sociodemographic characteristics and SDoH were self-reported using standardized questionnaires in each survey cycle. The SDoH was examined by race and estimated for associations with primary outcomes, which included all-cause and cancer-specific mortality. Multiple mediation analysis was performed to assess the contribution of each unfavorable SDoH to racial disparities to all-cause and cancer-specific mortality.

RESULTS

Among 5163 cancer survivors (2724 [57.7%] females and 3580 [69.3%] non-Hispanic White individuals), only 881 (24.9%) did not report an unfavorable SDoH. During the follow-up period of up to 249 months (median 81 months), 1964 deaths were recorded (cancer, 624; cardiovascular, 529; other causes, 811). Disparities in all-cause and cancer-specific mortality were observed between non-Hispanic Black and White cancer survivors. Unemployment, lower economic status, education less than high school, government or no private insurance, renting a home or other arrangements, and social isolation were significantly and independently associated with worse overall survival. Unemployment, lower economic status, and social isolation were significantly associated with cancer-specific mortality. Compared to patients without an unfavorable SDoH, the risk of all-cause mortality was gradually increased in those with a cumulative number of unfavorable SDoHs (1 unfavorable SDoH: hazard ratio [HR] = 1.54, 95% CI 1.25-1.89; 2 unfavorable SDoHs: HR = 1.81, 95% CI 1.46-2.24; 3 unfavorable SDoHs: HR = 2.42, 95% CI 1.97-2.97; 4 unfavorable SDoHs: HR = 3.22, 95% CI 2.48-4.19; 5 unfavorable SDoHs: HR = 3.99, 95% CI 2.99-5.33; 6 unfavorable SDoHs: HR = 6.34 95% CI 4.51-8.90). A similar trend existed for cancer-specific mortality.

CONCLUSIONS

In this cohort study of a nationally representative sample of US cancer survivors, a greater number of unfavorable SDoH was associated with increased risks of mortality from all causes and cancer. Unfavorable SDoH levels were critical risk factors for all-cause and cancer-specific mortality, as well as the underlying cause of racial all-cause mortality disparities among US cancer survivors.

Health inequalities in a middle-income country: a systematic review of the Costa Rican case

Objective

This study systematically reviews evidence of socioeconomic health disparities in Costa Rica, a middle-income country, to elucidate the relationship between socioeconomic status and health outcomes.

Methods

Published studies were identified through a systematic review of PubMed (English) and Scielo (Spanish) databases from December 2023 to January 2024, following PRISMA guidelines. Search terms included socioeconomic status, social determinants, social gradient in health, and health inequalities.

Results

Of 236 identified references, 55 met the inclusion criteria. Findings were categorized into health inequalities in mortality (among the general population, infants, and older adults), life expectancy, cause-specific mortality, and health determinants or risk factors mediating the association between the social environment and health. The studies indicate higher mortality among the most disadvantaged groups, including deaths from respiratory diseases, violence, and infections. Higher socioeconomic status was associated with lower mortality rates in the 1990s, indicating a positive social gradient in health (RII = 1.3, CI [1.1-1.5]). Disparities were less pronounced among older adults. Urban areas exhibited concentrated wealth and increased risky behaviors, while rural areas, despite greater socioeconomic deprivation, showed a lower prevalence of risky behaviors. Regarding smoking, people living in rural areas smoked significantly less than those in urban areas (7% vs. 10%). Despite the relatively equitable distribution of public primary healthcare, disparities persisted in the timely diagnosis and treatment of chronic diseases. Cancer survival rates post-diagnosis were positively correlated with the wealth of districts (1.23 [1.12-1.35] for all cancers combined).

Conclusion

The study highlights the existence of social health inequalities in Costa Rica. However, despite being one of the most unequal OECD countries, Costa Rica shows relatively modest social gradients in health compared to other middle and high-income nations. This phenomenon can be attributed to distinctive social patterns in health behaviors and the equalizing influence of the universal healthcare system.

Trends in educational inequalities in smoking-attributable mortality and their impact on changes in general mortality inequalities: evidence from England and Wales, Finland, and Italy (Turin)

BACKGROUND

Socioeconomic mortality inequalities are persistent in Europe but have been changing over time. Smoking is a known contributor to inequality levels, but knowledge about its impact on time trends in inequalities is sparse.

METHODS

We studied trends in educational inequalities in smoking-attributable mortality (SAM) and assessed their impact on general mortality inequality trends in England and Wales (E&W), Finland, and Italy (Turin) from 1972 to 2017. We used yearly individually linked all-cause and lung cancer mortality data by educational level and sex for individuals aged 30 and older. SAM was indirectly estimated using the Preston-Glei-Wilmoth method. We calculated the slope index of inequality (SII) and performed segmented regression on SIIs for all-cause, smoking and non-SAM to identify phases in inequality trends. The impact of SAM on all-cause mortality inequality trends was estimated by comparing changes in SII for all-cause with non-SAM.

RESULTS

Inequalities in SAM generally declined among males and increased among females, except in Italy. Among males in E&W and Finland, SAM contributed 93% and 76% to declining absolute all-cause mortality inequalities, but this contribution varied over time. Among males in Italy, SAM drove the 1976-1992 increase in all-cause mortality inequalities. Among females in Finland, increasing inequalities in SAM hampered larger declines in mortality inequalities.

CONCLUSION

Our findings demonstrate that differing education-specific SAM trends by country and sex result in different inequality trends, and consequent contributions of SAM on educational mortality inequalities. The following decades of the smoking epidemic could increase educational mortality inequalities among Finnish and Italian women.

Health and income inequality: a comparative analysis of USA and Italy

Introduction

Socio-economic background is often an important determinant for health with low income households having higher exposure to risk factors and diminished access to healthcare and prevention, in a way that is specific to each country.

Methods

Here, we perform a comparative analysis of the relations between health and income inequality in two developed countries, USA and Italy, using longitudinal and cross-sectional data from surveys.

Results and discussion

We show that the income class determines the incidence of chronic pathologies, associated risk-factors and psychiatric conditions, but find striking differences in health inequality between the two countries. We then focus our attention on a fraction of very disadvantaged households in the USA whose income in persistently at the bottom of the distribution over a span of 20 years and which is shown to display particularly dire health conditions. Low income people in the USA also display comorbidity patterns that are not found in higher income people, while in Italy income appears to be less relevant for comorbidity. Taken together our findings illustrate how differences in lifestyle and the healthcare systems affect health inequality.

A dyadic longitudinal analysis of parent-adolescent inflammation trends and the role of shared socioeconomic characteristics on family inflammation

The objective of the present study was to evaluate the interdependency of parent-adolescent inflammation trends across time and to examine whether shared family socioeconomic characteristics explained between-family differences in parents' and adolescents' risk for inflammation. A total of N = 348 families, consisting of one parent and one adolescent child, were followed every two years in a three-wave longitudinal study. Sociodemographic questionnaires were used to determine parental educational attainment and family income-to-needs ratio (INR). At each time point, parents and adolescents collected dried blood spot (DBS) samples that were assayed for circulating CRP and log-transformed prior to analysis by longitudinal dyadic models. Models revealed significant differences in parents' and adolescents' inflammation trends over time (bint = - 0.13, p < 0.001). While parental CRP levels remained relatively stable across the study period, adolescent CRP increased by approximately 38% between study waves. Parents' average CRP levels were positively correlated with adolescents' average CRP (r = 0.32, p < 0.001), but parental change in CRP over time was not significantly related to change in adolescents' CRP over time. Family dyads with higher parental educational attainment had lower average CRP (b = -0.08, p = 0.01), but parental education did not predict change in dyads' inflammation over time. Study findings suggest that shared family socioeconomic characteristics contribute to baseline similarities in parents' and adolescents' inflammation and potentially point to adolescence as a period of inflammatory change where youth may diverge from parental inflammation trends.

Impacts of Poverty and Lifestyles on Mortality: A Cohort Study in Predominantly Low-Income Americans

INTRODUCTION

Low socioeconomic status has been linked to increased mortality. However, the impacts of poverty, alone or combined with health behaviors, on mortality and life expectancy have not been adequately investigated.

METHODS

Data from the Southern Community Cohort Study was used, including nearly 86,000 participants recruited during 2002-2009 across 12 US southeastern states. Analysis was conducted from February 2022 to January 2023.

RESULTS

During a median follow-up of 12.1 years, 19,749 deaths were identified. A strong dose-response relationship was found between household incomes and mortality, with a 3.3-fold (95%CI=3.1-3.6) increased all-cause mortality observed for individuals in the lowest income group (<$15,000/year) compared with those in the highest group (≥$50,000/year). Within each income group, mortality monotonically increased with declining healthy lifestyle score. Risk was significantly lower among those in the lowest income but healthiest lifestyle group, compared to those with the highest income but unhealthiest lifestyle (HR=0.82, 95%CI=0.69-0.97). Poor White participants appeared to experience higher all-cause mortality than poor Black participants. Life expectancy was more than 10.0 years shorter for those in the lowest income group compared with those in the highest income group.

CONCLUSIONS

Poverty is strongly associated with increased risk of death, but the risks could be modestly abated by a healthier lifestyle. These findings call for a comprehensive strategy for enhancing a healthy lifestyle and improving income equality to reduce death risks, particularly among those experiencing health disparities due to poverty.

Sociodemographic precursors of explicit and implicit attitudes towards physical activity

OBJECTIVE

In high-income countries, people with low socio-economic status (SES) engage in less leisure-time physical activity (PA) than those with higher SES. Beyond a materialistic account of this difference, the role of motivational precursors-among which attitudes are emblematic-remains poorly understood, particularly when it comes to dissociating the automatic vs. deliberative components of attitudes. This pre-registered study aimed to examine the associations between SES (i.e. income and educational attainment) and motivational precursors of PA (i.e. explicit and implicit attitudes), and whether gender and age may moderate these relationships.

METHOD

We used data from 970 adults (64% of women; mean age = 33 ± 12 years) from the Attitudes, Identities, and Individual Differences (AIID) study.

RESULTS

Results of multiple linear regression analyses showed that participants with the highest level of income (>150,000$ per year) reported more positive explicit and implicit attitudes towards PA than those with lower income. Exploratory analysis further showed that women reported weaker explicit attitudes towards PA, while both explicit and implicit attitudes towards PA became weaker at age increases. In contrast, educational attainment was not significantly associated with those attitudes, and there was only mixed evidence for a moderating role of participants' gender on the pattern of associations.

CONCLUSION

Our findings suggest that both the explicit and implicit attitudes towards PA may be socially patterned. Future intervention studies should examine whether these attitudinal differences could be reduced, and whether such a reduction could help buffer the unequal participation in PA behaviors across social groups.

Association of physical activity and socio-economic status on mortality in older adults: a retrospective cohort study of KNHANES-mortality linked data

We examined the joint association of physical activity (PA) and socio-economic status (SES) on all-causes and cardiovascular disease (CVD) mortality in 6945 elderly Koreans (mean age: 71.6 years, 41.8% male) using data from the Korean National Health and Nutrition Examination Survey (2007-2013) and death data from Statistics Korea (2019). The SES included household income and education level. PA was assessed using the IPAQ and categorized according to the 2018 PA Guidelines. In stratified analyses using Cox proportional hazards by SES adherence to PA guidelines those who low household income group was associated with a reduced risk of all-cause mortality and CVD mortality, while in the lowest educational level group, it was associated with a reduced risk of all-cause mortality and CVD mortality. In the joint analysis, PA was associated with a significant reduction in all-cause mortality in all groups when compared with those who did not meet PA those who had the lowest SES. However, PA with CVD mortality risk was not significantly associated in the 'upper-middle' income and 'high school' education groups. The study revealed that PA significantly association mortality, particularly among older adults with low SES. This finding suggests the potential for targeted government interventions to promote healthy aging.

The Interaction between Education and Sex with Alcohol Consumption during the COVID-19 Pandemic: A Cross-Sectional Analysis of Two Brazilian Cities

This cross-sectional study, carried out between October and December 2020 in two Brazilian cities, aimed to evaluate the joint association of education and sex with habitual and episodic excessive alcohol consumption during the COVID-19 pandemic. Habitual alcohol consumption was defined as drinking any quantity of alcohol at least once per week. Excessive episodic alcohol consumption was defined as the consumption of five or more drinks by men or four or more drinks by women at least once in the last 30 days. Adjusted multivariate logistic regression models were used to analyze associations of education and sex with alcohol consumption. Education was not associated with habitual alcohol consumption and excessive episodic alcohol consumption. However, when evaluating the joint effect between education and sex, it can be seen that men with low education were more likely to habitually consume (OR: 5.85; CI95:2.74-14.84) and abuse alcohol (OR: 4.45; IC95:1.54-12.82) and women with high education were more likely to have habitual (OR: 2.16; IC95:1.18-3.95) and abusive alcohol consumption (OR: 2.00; IC95:1.16-3.43). These findings highlight the modifying effect of sex on the relationship between education and alcohol consumption, such that education influenced alcohol consumption differently between sexes during the pandemic.