The socioeconomic distribution of non-communicable diseases in Europe: findings from the European Social Survey (2014) special module on the social determinants of health

Epidemiology and demographic patterns of cardiovascular diseases and neoplasms deaths in Western Europe: a 1990-2019 analysis

OBJECTIVES

Cardiovascular diseases (CVDs) and neoplasms have been considered as public health concerns worldwide. This study aimed to estimate the epidemiological patterns of death burden on CVDs and neoplasms and its attributable risk factors in Western Europe from 1990 to 2019 to discuss the potential causes of the disparities.

STUDY DESIGN AND METHODS

We collected data on CVDs and neoplasms deaths in 24 Western European countries from the Global Burden of Disease Study. We analyzed patterns by age, sex, country, and associated risk factors. The results include percentages of total deaths, age-standardized death rates per 100,000 population, and uncertainty intervals (UIs). Time trends were assessed using annual percent change.

RESULTS

In 2019, CVDs and neoplasms accounted for 33.54% and 30.15% of Western Europe's total deaths, with age-standardized death rates of 128.05 (95% UI: 135.37, 113.02) and 137.51 (95% UI: 142.54, 128.01) per 100,000. Over 1990-2019, CVDs rates decreased by 54.97%, and neoplasms rates decreased by 19.54%. Top CVDs subtypes were ischemic heart disease and stroke; top cancers for neoplasms were lung and colorectal. Highest CVD death burdens were in Finland, Greece, Austria; neoplasm burdens in Monaco, San Marino, Andorra. The major risk factors were metabolic (CVDs) and behavioral (neoplasms). Gender differences revealed higher CVDs death burden in males, while neoplasms burden varied by risk factors and age groups.

CONCLUSION

In 2019, CVDs and neoplasms posed significant health risks in Western Europe, with variations in death burdens and risk factors across genders, age groups, and countries. Future interventions should target vulnerable groups to lessen the impact of CVDs and neoplasms in the region.

Social inequality in prevalence of NCD risk factors: a cross-sectional analysis from the population-based Tromsø Study 2015-2016

OBJECTIVE

We aimed to examine associations between educational level, serving as an indicator of socioeconomic position, and prevalence of WHO-established leading behavioural and biological risk factors for non-communicable diseases (NCDs), in middle-aged to older women and men.

DESIGN

Population-based cross-sectional study.

SETTING

All inhabitants of the municipality of Tromsø, Norway, aged ≥40 years, were invited to the seventh survey (2015-2016) of the Tromsø Study; an ongoing population-based cohort study.

PARTICIPANTS

Of the 32 591 invited; 65% attended, and a total of 21 069 women (53%) and men aged 40-99 years were included in our study.

OUTCOME MEASURES

We assessed associations between educational level and NCD behavioural and biological risk factors: daily smoking, physical inactivity (sedentary in leisure time), insufficient fruit/vegetable intake (<5 units/day), harmful alcohol use (>10 g/day in women, >20 g/day in men), hypertension, obesity, intermediate hyperglycaemia and hypercholesterolaemia. These were expressed as odds ratios (OR) per unit decrease in educational level, with 95% CIs, in women and men.

RESULTS

In women (results were not significantly different in men), we observed statistically significant associations between lower educational levels and higher odds of daily smoking (OR 1.69; 95% CI 1.60 to 1.78), physical inactivity (OR 1.38; 95% CI 1.31 to 1.46), insufficient fruit/vegetable intake (OR 1.54, 95% CI 1.43 to 1.66), hypertension (OR 1.25; 95% CI 1.20 to 1.30), obesity (OR 1.23; 95% CI 1.18 to 1.29), intermediate hyperglycaemia (OR 1.12; 95% CI 1.06 to 1.19), and hypercholesterolaemia (OR 1.07; 95% CI 1.03 to 1.12), and lower odds of harmful alcohol use (OR 0.75; 95% CI 0.72 to 0.78).

CONCLUSION

We found statistically significant educational gradients in women and men for all WHO-established leading NCD risk factors within a Nordic middle-aged to older general population. The prevalence of all risk factors increased at lower educational levels, except for harmful alcohol use, which increased at higher educational levels.

Assessing the effects of population-level political, economic and social exposures, interventions and policies on inclusive economy outcomes for health equity in high-income countries: a systematic review of reviews

BACKGROUND

A fairer economy is increasingly recognised as crucial for tackling widening social, economic and health inequalities within society. However, which actions have been evaluated for their impact on inclusive economy outcomes is yet unknown.

OBJECTIVE

Identify the effects of political, economic and social exposures, interventions and policies on inclusive economy (IE) outcomes in high-income countries, by systematically reviewing the review-level evidence.

METHODS

We conducted a review of reviews; searching databases (May 2020) EconLit, Web of Science, Sociological Abstracts, ASSIA, International Bibliography of the Social Sciences, Public Health Database, Embase and MEDLINE; and registries PROSPERO, Campbell Collaboration and EPPI Centre (February 2021) and grey literature (August/September 2020). We aimed to identify reviews which examined social, political and/or economic exposures, interventions and policies in relation to two IE outcome domains: (i) equitable distribution of the benefits of the economy and (ii) equitable access to the resources needed to participate in the economy. Reviews had to include primary studies which compared IE outcomes within or between groups. Quality was assessed using a modified version of AMSTAR-2 and data synthesised informed by SWiM principles.

RESULTS

We identified 19 reviews for inclusion, most of which were low quality, as was the underlying primary evidence. Most reviews (n = 14) had outcomes relating to the benefits of the economy (rather than access to resources) and examined a limited set of interventions, primarily active labour market programmes and social security. There was limited high-quality review evidence to draw upon to identify effects on IE outcomes. Most reviews focused on disadvantaged groups and did not consider equity impacts.

CONCLUSIONS

Review-level evidence is sparse and focuses on 'corrective' approaches. Future reviews should examine a diverse set of 'upstream' actions intended to be inclusive 'by design' and consider a wider range of outcomes, with particular attention to socioeconomic inequalities.

The influence of socioeconomic status on the association between unhealthy lifestyle factors and adverse health outcomes: a systematic review

Background

Combinations of lifestyle factors (LFs) and socioeconomic status (SES) are independently associated with cardiovascular disease (CVD), cancer, and mortality. Less advantaged SES groups may be disproportionately vulnerable to unhealthy LFs but interactions between LFs and SES remain poorly understood. This review aimed to synthesise the available evidence for whether and how SES modifies associations between combinations of LFs and adverse health outcomes.

Methods

Systematic review of studies that examine associations between combinations of >3 LFs (eg.smoking/physical activity/diet) and health outcomes and report data on SES (eg.income/education/poverty-index) influences on associations. Databases (PubMed/EMBASE/CINAHL), references, forward citations, and grey-literature were searched from inception to December 2021. Eligibility criteria were analyses of prospective adult cohorts that examined all-cause mortality or CVD/cancer mortality/incidence.

Results

Six studies (n=42,467-399,537; 46.5-56.8 years old; 54.6-59.3% women) of five cohorts were included. All examined all-cause mortality; three assessed CVD/cancer outcomes. Four studies observed multiplicative interactions between LFs and SES, but in opposing directions. Two studies tested for additive interactions; interactions were observed in one cohort (UK Biobank) and not in another (National Health and Nutrition Examination Survey (NHANES)). All-cause mortality HRs (95% confidence intervals) for unhealthy LFs (versus healthy LFs) from the most advantaged SES groups ranged from 0.68 (0.32-1.45) to 4.17 (2.27-7.69). Equivalent estimates from the least advantaged ranged from 1.30 (1.13-1.50) to 4.00 (2.22-7.14). In 19 analyses (including sensitivity analyses) of joint associations between LFs, SES, and all-cause mortality, highest all-cause mortality was observed in the unhealthiest LF-least advantaged suggesting an additive effect.

Conclusions

Limited and heterogenous literature suggests that the influence of SES on associations between combinations of unhealthy LFs and adverse health could be additive but remains unclear. Additional prospective analyses would help clarify whether SES modifies associations between combinations of unhealthy LFs and health outcomes.

Registration

Protocol is registered with PROSPERO (CRD42020172588;25 June 2020).

Global inequalities in mental health problems: understanding the predictors of lifetime prevalence, treatment utilisation and perceived helpfulness across 111 countries

Socio-economic inequalities in mental health problems are found in measures covering prevalence, treatment utilisation, and treatment helpfulness. However, whether these inequalities exist globally and what factors explain between-country variation is unclear. We use a nationally representative individual-level survey dataset (Wellcome Global Monitor, 2020) in 111 countries (N = 117,088) to test if socio-economic factors (household income, education), psycho-social factors (stigma perception, trust in health professionals) and country-level factors (GDP, Gini, health expenditure) predict (1) self-reported lifetime prevalence of anxiety and depression symptomology, (2) treatment utilisation and (3) perceived treatment helpfulness talking to a mental health professional and taking prescribed medication. Multi-level logistic regression models were used. Across both HICs and LMICs, being in the richest income quintile within each country is associated with a lower probability of experiencing symptoms of anxiety and depression compared to the poorest quintile (OR = 0.67 CI[0.64-0.70]), as well as a higher probability of talking to a mental health professional (OR = 1.25[1.14-1.36]), and of perceiving this treatment as very helpful (OR = 1.23[1.07-1.40]). However, being among the richest income quintile is not associated with taking prescribed medication (OR = 0.97[0.89-1.06]) and its perceived helpfulness (OR = 1.06[0.94-1.21]) across all countries. Trust in health practitioners is associated with higher mental health professional utilisation (OR = 1.10[1.06-1.14]) and helpfulness (OR = 1.32[1.25-1.40]). This analysis reveals a global 'triple inequality in mental health', whereby disadvantages of lower SES individuals persist in three outcomes (lifetime prevalence, treatment utilisation and helpfulness). Treatment utilisation and helpfulness also vary by trust in healthcare professionals and treatment type. Policymakers must address all three inequalities and their fundamental causes.

Meta-Analysis of Pulse Transition Features in Non-Invasive Blood Pressure Estimation Systems: Bridging Physiology and Engineering Perspectives

The pulse transition features (PTFs), including pulse arrival time (PAT) and pulse transition time (PTT), hold significant importance in estimating non-invasive blood pressure (NIBP). However, the literature showcases considerable variations in terms of PTFs' correlation with blood pressure (BP), accuracy in NIBP estimation, and the comprehension of the relationship between PTFs and BP. This inconsistency is exemplified by the wide-ranging correlations reported across studies investigating the same feature. Furthermore, investigations comparing PAT and PTT have yielded conflicting outcomes. Additionally, PTFs have been derived from various bio-signals, capturing distinct characteristic points like the pulse's foot and peak. To address these inconsistencies, this study meticulously reviews a selection of such research endeavors while aligning them with the biological intricacies of blood pressure and the human cardiovascular system (CVS). Each study underwent evaluation, considering the specific signal acquisition locale and the corresponding recording procedure. Moreover, a comprehensive meta-analysis was conducted, yielding multiple conclusions that could significantly enhance the design and accuracy of NIBP systems. Grounded in these dual aspects, the study systematically examines PTFs in correlation with the specific study conditions and the underlying factors influencing the CVS. This approach serves as a valuable resource for researchers aiming to optimize the design of BP recording experiments, bio-signal acquisition systems, and the fine-tuning of feature engineering methodologies, ultimately advancing PTF-based NIBP estimation.

The potential of intervening on childhood adversity to reduce socioeconomic inequities in body mass index and inflammation among Australian and UK children: A causal mediation analysis

BACKGROUND

Lower maternal education is associated with higher body mass index (BMI) and higher chronic inflammation in offspring. Childhood adversity potentially mediates these associations. We examined the extent to which addressing childhood adversity could reduce socioeconomic inequities in these outcomes.

METHODS

We analysed data from two early-life longitudinal cohorts: the Longitudinal Study of Australian Children (LSAC; n=1873) and the UK Avon Longitudinal Study of Parents and Children (ALSPAC; n=7085).

EXPOSURE

low/medium (below university degree) versus high maternal education, as a key indicator of family socioeconomic position (0-1 year).

OUTCOMES

BMI and log-transformed glycoprotein acetyls (GlycA) (LSAC: 11-12 years; ALSPAC: 15.5 years). Mediator: multiple adversities (≥2/<2) indicated by family violence, mental illness, substance abuse and harsh parenting (LSAC: 2-11 years; ALSPAC: 1-12 years). A causal mediation analysis was conducted.

RESULTS

Low/medium maternal education was associated with up to 1.03 kg/m2 higher BMI (95% CI: 0.95 to 1.10) and up to 1.69% higher GlycA (95% CI: 1.68 to 1.71) compared with high maternal education, adjusting for confounders. Causal mediation analysis estimated that decreasing the levels of multiple adversities in children with low/medium maternal education to be like their high maternal education peers could reduce BMI inequalities by up to 1.8% and up to 3.3% in GlycA.

CONCLUSIONS

Our findings in both cohorts suggest that slight reductions in socioeconomic inequities in children's BMI and inflammation could be achieved by addressing childhood adversities. Public health and social policy efforts should help those affected by childhood adversity, but also consider underlying socioeconomic conditions that drive health inequities.

Prevalence and sociodemographic determinants of selected noncommunicable diseases among the general population of Cyprus: A large population-based cross-sectional study

Background

Noncommunicable diseases (NCDs) are the leading cause of morbidity and mortality worldwide. The aim of this study was to determine the prevalence of NCDs among the population of Cyprus and to identify the distribution of the socioeconomic and demographic determinants among individuals with the most frequent NCDs.

Methods

A cross-sectional study was conducted using stratified sampling. Socioeconomic and demographic characteristics and the presence of NCDs were collected through a standardized questionnaire. The diseases were classified using the 10th revision of the International Classification of Diseases (ICD-10).

Results

In total, 1140 individuals participated in the study, among whom 590 (51.7%) had at least one chronic disease. The most prevalent NCDs were hyperlipidemia (17.4%), hypertension (12.9%), and thyroid diseases (8.4%). We identified more males than females with hyperlipidemia aged 25-44 years old and >65 years old (p = 0.024), more males compared to females with hypertension (p = 0.001) and more females compared to males with thyroid diseases (p < 0.001). Individuals with hypertension and hyperlipidemia were more likely to be married, to have completed a higher education, and to have a high annual income.

Discussion

In Cyprus, the majority of the general population had at least one NCD. Hyperlipidemia, hypertension, and thyroid disease are relatively common, even at younger ages, highlighting the need for the development of public health programs aimed at addressing and preventing NCDs.

Depressive and anxiety symptoms in first generation college students

Objectives: Depression and anxiety contribute to the burden of disease among college students. The current study determined if depressive and anxiety symptoms were more prevalent in first generation students and if social and emotional support moderated this relationship. Methods: Depressive and anxiety symptoms were measured in 432 U.S. college students via an online survey. Single items determined student generation status and available social support. The CES-D10 and GAD-7 measured depression and anxiety, respectively. Structural equation modeling was used to identify significant effects. Results: First generation status was associated with increased cognitive-emotional (p = 0.036) and somatic (p = 0.013) anxiety symptoms, but not depression. High social and emotional support appeared to suppress somatic anxiety symptoms experienced by first generation students (p = 0.004). Conclusions: Greater anxiety symptoms in first generation students may be due to increased general and acculturative stress, although more research is needed. Large national surveys of college students should consider adding a question about first generation status.

Inequalities in the burden of non-communicable diseases across European countries: a systematic analysis of the Global Burden of Disease 2019 study

BACKGROUND

Although overall health status in the last decades improved, health inequalities due to non-communicable diseases (NCDs) persist between and within European countries. There is a lack of studies giving insights into health inequalities related to NCDs in the European Economic Area (EEA) countries. Therefore, the aim of the present study was to quantify health inequalities in age-standardized disability adjusted life years (DALY) rates for NCDs overall and 12 specific NCDs across 30 EEA countries between 1990 and 2019. Also, this study aimed to determine trends in health inequalities and to identify those NCDs where the inequalities were the highest.

METHODS

DALY rate ratios were calculated to determine and compare inequalities between the 30 EEA countries, by sex, and across time. Annual rate of change was used to determine the differences in DALY rate between 1990 and 2019 for males and females. The Gini Coefficient (GC) was used to measure the DALY rate inequalities across countries, and the Slope Index of Inequality (SII) to estimate the average absolute difference in DALY rate across countries.

RESULTS

Between 1990 and 2019, there was an overall declining trend in DALY rate, with larger declines among females compared to males. Among EEA countries, in 2019 the highest NCD DALY rate for both sexes were observed for Bulgaria. For the whole period, the highest DALY rate ratios were identified for digestive diseases, diabetes and kidney diseases, substance use disorders, cardiovascular diseases (CVD), and chronic respiratory diseases - representing the highest inequality between countries. In 2019, the highest DALY rate ratio was found between Bulgaria and Iceland for males. GC and SII indicated that the highest inequalities were due to CVD for most of the study period - however, overall levels of inequality were low.

CONCLUSIONS

The inequality in level 1 NCDs DALYs rate is relatively low among all the countries. CVDs, digestive diseases, diabetes and kidney diseases, substance use disorders, and chronic respiratory diseases are the NCDs that exhibit higher levels of inequality across countries in the EEA. This might be mitigated by applying tailored preventive measures and enabling healthcare access.

Behavioral and Metabolic Risk Factors for Noncommunicable Diseases among Population in the Republic of Srpska (Bosnia and Herzegovina)

Noncommunicable diseases (NCDs) are the major cause of death worldwide, and they are attributable to genetic and physiological determinants, behavioral risk factors and environmental impacts. The aim of this study is to assess behavioral risk factors for metabolic disease using demographic and social-economic aspects of the population characterized by risk factors, and to investigate relations among lifestyle risk factors (alcohol consumption, tobacco use, physical inactivity, intake of vitamins, fruits and vegetables) that are responsible for the majority of NCD deaths in the Republic of Srpska's (RS's) population. This is a cross-sectional study based on the analysis of a survey conducted among 2311 adult (≥18 years) persons (54.0% women, and 46.0% men). The statistical analysis was carried out by using Cramer's V values, clustering, logistic regression (binomial, multinomial and ordinal), a chi-square test and odds ratios. In the case of logistic regression, we provide the prediction accuracy in percentages. A significant statistical correlation between demographic characteristics (gender and age) and risk factors was observed. The highest difference according to gender was observed in alcohol consumption (odds ratio (OR) = 2.705, confidence interval (95% CI) = 2.206-3.317), particularly in frequent consumption (OR = 3.164, 95% CI = 2.664-3.758). The highest prevalence of high blood pressure was registered in the elderly (66.5%); the same holds for hypertension (44.3%). Additionally, physical inactivity was one of the most common risk factors (33.4% physically inactive respondents). A significant presence of risk factors was confirmed among the RS population, with higher involvement of metabolic risk factors among the older population, while the prevalence of behavioral factors was related to younger age groups, particularly in the case of alcohol consumption and smoking. A low level of preventive awareness was observed among the younger population. Therefore, prevention is one of the most important instruments related to decreasing NCD risk factors in the RS population.

The influence of socioeconomic status on the association between unhealthy lifestyle factors and adverse health outcomes: a systematic review

Background: Combinations of lifestyle factors (LFs) and socioeconomic status (SES) are independently associated with cardiovascular disease (CVD), cancer, and mortality. Less advantaged SES groups may be disproportionately vulnerable to unhealthy LFs but interactions between LFs and SES remain poorly understood. This review aimed to synthesise the available evidence for whether and how SES modifies associations between combinations of LFs and adverse health outcomes. Methods: Systematic review of studies that examine associations between combinations of >3 LFs and health outcomes and report data on SES influences on associations. Databases (PubMed/EMBASE/CINAHL), references, forward citations, and grey-literature were searched from inception to December 2021. Eligibility criteria were analyses of prospective adult cohorts that examined all-cause mortality or CVD or cancer mortality/incidence. Results: Six studies (n=42,467–399,537; 46.5–56.8 years old; 54.6–59.3% women) of five cohorts were included. All examined all-cause mortality; three assessed CVD/cancer outcomes. Four studies observed multiplicative interactions between LFs and SES, but in opposing directions. Two studies tested for additive interactions; interactions were observed in one cohort (UK Biobank) and not in another (NHANES). All-cause mortality HRs (95% CIs) for unhealthy LFs (versus healthy LFs) from the most advantaged SES groups ranged from 0.68 (0.32–1.45) to 4.17 (2.27–7.69). Equivalent estimates from the least advantaged ranged from 1.30 (1.13–1.50) to 4.00 (2.22–7.14). In 19 analyses (including sensitivity analyses) of joint associations between LFs, SES, and all-cause mortality, highest all-cause mortality was observed in the unhealthiest LF-least advantaged suggesting an additive effect. Conclusions: Limited and heterogenous literature suggests that the influence of SES on associations between combinations of unhealthy LFs and adverse health could be additive but remains unclear. Additional prospective analyses would help clarify whether SES modifies associations between combinations of unhealthy LFs and health outcomes. Registration: Protocol is registered with PROSPERO (CRD42020172588; 25 June 2020).

Socioeconomic differences in animal food consumption: Education rather than income makes a difference

Background/aims

Evidence points toward more sustainable and health-conscious dietary behaviors among individuals with higher socioeconomic status. However, these differences vary considerably depending on which indicator of socioeconomic status is examined. Here, we present a systematic parallel investigation of multiple indicators of socioeconomic status as predictors of animal food consumption frequency and selected food-related behaviors in Germany.

Methods

Data from the German subsample of two large representative European consumer studies (Study 1 n = 1,954; Study 2 n = 2,045) was used. We assessed the associations between the socioeconomic indicators income, current occupation as well as education and consumption frequency of animal foods and selected food-related behaviors in separate ordinal logistic regressions.

Results

Individuals with higher educational attainment engaged in more sustainable and health-conscious dietary behaviors, indicated by significant associations between educational attainment and the consumption frequency of animal foods. Low- and middle-income participants consumed processed meat more frequently (Study 1 only; medium income: OR 1.5, CI 1.09-2.05, p = 0.012; low income: OR 1.43, CI 1.01-2.05, p = 0.047) and fish less frequently (Study 2 only; medium income: OR 0.76, CI 0.59-0.97, p = 0.026; low income: OR 0.061, CI 0.46-0.82, p < 0.001) than participants with high income. Current occupation did not predict the consumption of animal foods or food-related behaviors. Intake frequency of animal-based foods indicates that most participants exceeded national dietary recommendations for meat and processed meat and remained below recommendations for fish and dairy/eggs intake.

Conclusion

Educational attainment appears to be the strongest and most consistent socioeconomic indicator of sustainable dietary choices in Germany based on current large, representative studies. Future efforts should be directed toward education interventions about nutrition and interpretation of food labels to compensate for differences in dietary behavior among groups with different levels of education.

Social disparities in unplanned 30-day readmission rates after hospital discharge in patients with chronic health conditions: A retrospective cohort study using patient level hospital administrative data linked to the population census in Switzerland

Unplanned readmissions shortly after discharge from hospital are common in chronic diseases. The risk of readmission has been shown to be related both to hospital care, e.g., medical complications, and to patients’ resources and abilities to manage the chronic disease at home and to make appropriate use of outpatient medical care. Despite a growing body of evidence on social determinants of health and health behaviour, little is known about the impact of social and contextual factors on readmission rates. The objective of this study was to analyse possible effects of educational, financial and social resources of patients with different chronic health conditions on unplanned 30 day-readmission risks. The study made use of nationwide inpatient hospital data that was linked with Swiss census data. The sample included n = 62,109 patients aged 25 and older, hospitalized between 2012 and 2016 for one of 12 selected chronic conditions. Multivariate logistic regressions analysis was performed. Our results point to a significant association between social factors and readmission rates for patients with chronic conditions. Patients with upper secondary education (OR = 1.26, 95% CI: 1.11, 1.44) and compulsory education (OR = 1.51, 95% CI: 1.31, 1.74) had higher readmission rates than those with tertiary education when taking into account demographic, social and health status factors. Having private or semi-private hospital insurance was associated with a lower risk for 30-day readmission compared to patients with mandatory insurance (OR = 0.81, 95% CI: 0.73, 0.90). We did not find a general effect of social resources, measured by living with others in a household, on readmission rates. The risk of readmission for patients with chronic conditions was also strongly predicted by type of chronic condition and by factors related to health status, such as previous hospitalizations before the index hospitalization (+77%), number of comorbidities (+15% higher probability per additional comorbidity) as well as particularly long hospitalizations (+64%). Stratified analysis by type of chronic condition revealed differential effects of social factors on readmissions risks. Compulsory education was most strongly associated with higher odds for readmission among patients with lung cancer (+142%), congestive heart failure (+63%) and back problems (+53%). We assume that low socioeconomic status among patients with chronic conditions increases the risk of unplanned 30-day readmission after hospitalisation due to factors related to their social situation (e.g., low health literacy, material deprivation, high social burden), which may negatively affect cooperation with care providers and adherence to recommended therapies as well as hamper active participation in the medical process and the development of a shared understanding of the disease and its cure. Higher levels of comorbidity in socially disadvantaged patients can also make appropriate self-management and use of outpatient care more difficult. Our findings suggest a need for increased preventive measures for disadvantaged populations groups to promote early detection of diseases and to remove financial or knowledge-based barriers to medical care. Socially disadvantaged patients should also be strengthened more in their individual and social resources for coping with illness.

Social and Regional Factors Predict the Likelihood of Admission to a Nursing Home After Acute Hospital Stay in Older People With Chronic Health Conditions: A Multilevel Analysis Using Routinely Collected Hospital and Census Data in Switzerland

If hospitalization becomes inevitable in the course of a chronic disease, discharge from acute hospital care in older persons is often associated with temporary or persistent frailty, functional limitations and the need for help with daily activities. Thus, acute hospitalization represents a particularly vulnerable phase of transient dependency on social support and health care. This study examines how social and regional inequality affect the decision for an institutionalization after acute hospital discharge in Switzerland. The current analysis uses routinely collected inpatient data from all Swiss acute hospitals that was linked on the individual level with Swiss census data. The study sample included 60,209 patients 75 years old and older living still at a private home and being hospitalized due to a chronic health condition in 199 hospitals between 2010 and 2016. Random intercept multilevel logistic regression was used to assess the impact of social and regional factors on the odds of a nursing home admission after hospital discharge. Results show that 7.8% of all patients were admitted directly to a nursing home after hospital discharge. We found significant effects of education level (compulsory vs. tertiary education OR = 1.16 (95% CI: 1.03-1.30), insurance class (compulsory vs. private insurance OR = 1.24 (95% CI: 1.09-1.41), living alone vs. living with others (OR = 1.64; 95% CI: 1.53-1.76) and language regions (French vs. German speaking part: OR = 0.54; 95% CI: 0.37-0.80) on the odds of nursing home admission in a model adjusted for age, gender, nationality, health status, year of hospitalization and hospital-level variance. The language regions moderated the effect of education and insurance class but not of living alone. This study shows that acute hospital discharge in older age is a critical moment of transient dependency especially for socially disadvantaged patients. Social and health care should work coordinated together to avoid unnecessary institutionalizations.

Community Co-Design of Regional Actions for Children's Nutritional Health Combining Indigenous Knowledge and Systems Thinking

Children's nutrition is highly influenced by community-level deprivation and socioeconomic inequalities and the health outcomes associated, such as childhood obesity, continue to widen. Systems Thinking using community-based system dynamics (CBSD) approaches can build community capacity, develop new knowledge and increase commitments to health improvement at the community level. We applied the formal structure and resources of a Group Model Building (GMB) approach, embedded within an Indigenous worldview to engage a high deprivation, high Indigenous population regional community in New Zealand to improve children's nutrition. Three GMB workshops were held and the youth and adult participants created two systems map of the drivers and feedback loops of poor nutrition in the community. Māori Indigenous knowledge (mātauranga) and approaches (tikanga) were prioritized to ensure cultural safety of participants and to encourage identification of interventions that take into account social and cultural environmental factors. While the adult-constructed map focused more on the influence of societal factors such as cost of housing, financial literacy in communities, and social security, the youth-constructed map placed more emphasis on individual-environment factors such as the influence of marketing by the fast-food industry and mental wellbeing. Ten prioritized community-proposed interventions such as increasing cultural connections in schools, are presented with the feasibility and likely impact for change of each intervention rated by community leaders. The combination of community-based system dynamics methods of group model building and a mātauranga Māori worldview is a novel Indigenous systems approach that engages participants and highlights cultural and family issues in the systems maps, acknowledging the ongoing impact of historical colonization in our communities.

Socioeconomic inequalities in the prevalence and perceived dangerousness of SARS-CoV-2 infections in two early German hotspots: findings from a seroepidemiological study

OBJECTIVE

Evidence on socioeconomic inequalities in infections with the novel coronavirus (SARS-CoV-2) is still limited as most of the available studies are ecological in nature and individual-level data is sparse. We therefore analysed individual-level data on socioeconomic differences in the prevalence and perceived dangerousness of SARS-CoV-2 infections in local populations. Data were obtained from a population-based seroepidemiological study of adult individuals in two early German SARS-CoV-2 hotspots (n = 3903). Infection was determined by IgG antibody ELISA, RT-PCR testing and self-reports on prior positive PCR tests. The perceived dangerousness of an infection and socioeconomic position (SEP) were assessed by self-reports. Logistic and linear regression were applied to examine associations of multiple SEP measures with infection status and perceptions of dangerousness.

RESULTS

We found no evidence of socioeconomic inequalities in SARS-CoV-2 infections by education, occupation, income and subjective social status. Participants with lower education and lower subjective social status perceived an infection as more dangerous than their better-off counterparts. In successfully contained local outbreaks of SARS-CoV-2 in Germany, infections may have been equally distributed across the socioeconomic spectrum. But residents in disadvantaged socioeconomic groups might have experienced a higher level of mental distress due to the higher perceived dangerousness of an infection.

Higher educational level in patients with eosinophilic esophagitis: a comparative analysis

BACKGROUND

Eosinophilic esophagitis is a chronic inflammatory gastrointestinal disease with a high prevalence in younger, atopic males. In our clinical practice, we observed a striking preponderance of patients having a high educational background. The purposes of this study were first to assess the level of education of eosinophilic esophagitis patients and second to compare the findings to patients with inflammatory bowel disease, another chronic immune-mediated condition of the gastrointestinal tract, and with the Swiss general population.

METHODS

Using a questionnaire, we assessed the educational level of adult patients who have attended Swiss Eosinophilic Esophagitis Clinics in the past. In addition, the educational level of the parents was assessed as well. We calculated the proportions of patients and parents who have obtained a higher educational level. Data from the Swiss Inflammatory Bowel Disease Cohort Study and from the Swiss general population served as confirmation and as comparison, respectively.

RESULTS

A total of 277 successfully contacted patients (response rate 69.1%; mean age 51.1 years, 73% male) participated. A significantly higher proportion of surveyed eosinophilic esophagitis patients had a high International Standard Classification of Education level (66.8%, P < 0.001) compared with inflammatory bowel disease patients (n = 2534; 34.2%, P < 0.001) and to the Swiss general population (n = 6,066,907; 30.5% P < 0.001).

CONCLUSION

Our analysis confirms the clinical observation that eosinophilic esophagitis patients have a significantly higher educational level compared with the general population and to patients with other chronic inflammatory diseases of the gastrointestinal tract. As a limitation, this impressive finding remains on a purely descriptive level.

Gender differences in nutrition literacy levels among university students and employees: a descriptive study

The impact of nutrition information on public health is partly determined by the population's level of nutrition literacy (NL), which involves functional NL (such as knowledge of dietary guidelines) and critical NL (such as the ability to distinguish between evidence-based nutrition information and alternative facts). The aim of this cross-sectional study was to describe aspects of functional and critical NL and predictors of NL scores among university students and employees. We recruited at different university campuses, 414 students and 112 employees, of which 80 % were females and 69 % were in the ages of 18–30 years. In total, 82 % reported knowledge about where to find information on nutrition issues, and 70 % were familiar with Norwegian dietary guidelines. Being female, having higher age, being highly physically active and studying or working within health sciences were significant predictors of higher levels of functional nutrition knowledge. Significantly more women than men found it difficult to judge if media information on nutritional issues could be trusted (69 v. 54 %) and found it hard to distinguish between scientific and non-scientific information about diet (60 v. 42 %). Our findings indicate that for a sample of university students and employees, affiliation with health sciences, being female, having a higher age and being physically active were associated with higher functional NL. Women did, however, seem to have lower levels of some aspects of critical NL, e.g. how to critically judge nutrition information. A more thorough assessment of NL in university students and employees should therefore be conducted.

Dynamics of the complex food environment underlying dietary intake in low-income groups: a systems map of associations extracted from a systematic umbrella literature review

Background

Inequalities in obesity pertain in part to differences in dietary intake in different socioeconomic groups. Examining the economic, social, physical and political food environment of low-income groups as a complex adaptive system – i.e. a system of multiple, interconnected factors exerting non-linear influence on an outcome, can enhance the development and assessment of effective policies and interventions by honouring the complexity of lived reality. We aimed to develop and apply novel causal loop diagramming methods in order to construct an evidence-based map of the underlying system of environmental factors that drives dietary intake in low-income groups.

Methods

A systematic umbrella review was conducted on literature examining determinants of dietary intake and food environments in low-income youths and adults in high/upper-middle income countries. Information on the determinants and associations between determinants was extracted from reviews of quantitative and qualitative studies. Determinants were organised using the Determinants of Nutrition and Eating (DONE) framework. Associations were synthesised into causal loop diagrams that were subsequently used to interpret the dynamics underlying the food environment and dietary intake. The map was reviewed by an expert panel and systems-based analysis identified the system paradigm, structure, feedback loops and goals.

Results

Findings from forty-three reviews and expert consensus were synthesised in an evidence-based map of the complex adaptive system underlying the food environment influencing dietary intake in low-income groups. The system was interpreted as operating within a supply-and-demand, economic paradigm. Five sub-systems (‘geographical accessibility’, ‘household finances’, ‘household resources’, ‘individual influences’, ‘social and cultural influences’) were presented as causal loop diagrams comprising 60 variables, conveying goals which undermine healthy dietary intake.

Conclusions

Our findings reveal how poor dietary intake in low-income groups can be presented as an emergent property of a complex adaptive system that sustains a food environment that increases the accessibility, availability, affordability and acceptability of unhealthy foods. In order to reshape system dynamics driving unhealthy food environments, simultaneous, diverse and innovative strategies are needed to facilitate longer-term management of household finances and socially-oriented practices around healthy food production, supply and intake. Ultimately, such strategies must be supported by a system paradigm which prioritises health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01164-1.

Urban social determinants of non-communicable diseases risk factors in Argentina

We examined associations of individual-, neighborhood- and city-level education -as proxies of SES at different levels-, with diabetes, hypertension, obesity, smoking and binge drinking (non-communicable disease risk factors -NCD/RF) among Argentinian adults. We estimated mixed models based on 21,415 individuals from the 2013 National Survey of Risk Factors, living in 2,698 neighborhoods and 33 cities. Gradients by individual-level education differed by gender and NCD/RF, and some were modified by city education. In addition, we identified contextual effects of neighborhood and city education on some NCD/RF. Urban efforts to tackle NCD/RF in Argentina should be context- and gender-sensitive, and mainly focused on socially disadvantaged groups.

On the importance of primary and community healthcare in relation to global health and environmental threats: lessons from the COVID-19 crisis

In the course of the COVID-19 pandemic, it has become clear that primary healthcare systems play a critical role in clinical care, such as patient screening, triage, physical and psychological support and also in promoting good community advice and awareness in coordination with secondary healthcare and preventive care. Because of the role of social and environmental factors in COVID-19 transmission and burden of disease, it is essential to ensure that there is adequate coordination of population-based health services and public health interventions. The COVID-19 pandemic has shown the primary and community healthcare (P&CHC) system’s weaknesses worldwide. In many instances, P&CHC played only a minor role, the emphasis being on hospital and intensive care beds. This was compounded by political failures, in supporting local community resilience. Placing community building, social cohesion and resilience at the forefront of dealing with the COVID-19 crisis can help align solutions that provide a vision of ‘planetary health’. This can be achieved by involving local well-being and participation in the face of any pervasive health and environmental crisis, including other epidemics and large-scale ecological crises. This paper proposes that P&CHC should take on two critical roles: first, to support local problem-solving efforts and to serve as a partner in innovative approaches to safeguarding community well-being; and second, to understand the local environment and health risks in the context of the global health perspective. We see this as an opportunity of immediate value and broad consequence beyond the control of the COVID-19 pandemic.

The contribution of employment and working conditions to occupational inequalities in non-communicable diseases in Europe

BACKGROUND

Social inequalities in non-communicable diseases (NCDs) are evident across all European regions. Employment and working conditions are important determinants of NCDs, however, few comparative studies have examined how these conditions contribute to health inequalities. This study therefore examines the association of non-standard employment and poor working conditions with occupational inequalities in multiple NCDs and whether there are differences by gender and across European regions.

METHODS

We used cross-sectional data from 20 European countries for women and men aged 25-75 (n = 19 876), from round 7 of the European Social Survey. Data were analyzed for self-rated health (SRH) and 9 NCDs: heart/circulatory problems, high blood pressure, arm/hand pain, breathing problems, diabetes, severe headaches, cancer, obesity and depression. We used logistic regression models, stratified by gender, and adjusted rate ratios to examine whether occupational inequalities in NCDs were reduced after adjusting for non-standard employment and poor working conditions, across European regions.

RESULTS

After adjustment, occupational inequalities were significantly reduced across all regions of Europe. Reductions were particularly large among the lowest occupational group and for poor-SRH, depression and obesity. For these conditions, reductions were in the range of 60-99%.

CONCLUSIONS

Employment and working conditions are important determinants of occupational inequalities in NCDs. Labour market regulations should therefore be considered in the formulation of NCD prevention strategies.

COVID-19 and the gender health paradox

This article examines gender-based health inequalities arising from the COVID-19 pandemic by drawing on insights from research into the 'gender health paradox'. Decades of international research shows that, across Europe, men have shorter life expectancies and higher mortality rates than women, and yet, women report higher morbidity. These gender-based health inequalities also appear to be evident within the pandemic and its aftermath. The article starts by providing an overview of the 'gender health paradox' and the biological, social, economic and political explanations for it. It then outlines the international estimates of gender-based inequalities in COVID-19 morbidity and mortality rates - where emerging data suggests that women are more likely to be diagnosed with COVID-19 but that men have a higher mortality rate. It then explores the longer term consequences for gender-based health inequalities of the aftermath of the COVID-19 pandemic, focusing on the impacts of government policy responses and the emerging economic crisis, suggesting that this might lead to increased mortality amongst men and increased morbidity amongst women. The essay concludes by reflecting on the pathways shaping gender-based health inequalities in the COVID-19 pandemic and the responses needed to ensure that it does not exacerbate gender-based health inequalities into the future.

Association between occupations and selected noncommunicable diseases: A matched case-control among Thai informal workers

OBJECTIVES

We conducted a matched case-control study of informal workers to determine the association between occupational classification and selected types of noncommunicable diseases (NCDs).

METHOD

We extracted data of patients aged ≥18 years from the Thai National Health Security Office database (NHSO) during 2011-2014. Cases were patients who had a primary diagnosis of: diabetes mellitus (E10-E14), hypertension (I10-I15), ischemic heart disease (I20-I25) or stroke (I60-69), or thyroid gland disorder (E00-E07). Controls were patients who had a primary diagnosis of intestinal or parasitic infections (A00-A09 and B25-B99), and were randomly matched 1:1 with cases of the same age and residential area. The four-digit occupation codes recorded in the NHSO were grouped and recoded based on the submajor groups of International Standard Classification of Occupations (ISCO-08) as follows: agricultural workers, unskilled workers, service, and sales workers. Analysis was performed using multivariable conditional logistic regression.

RESULTS

Occupation and sex inequalities were present among all the selected NCDs. Higher risk for the four selected NCDs was found among unskilled workers. Stronger risk for cardiovascular disease was present among males, while females had a higher risk for metabolic disorders.

CONCLUSIONS

There is a need to understand what are the key factors that increase the risk for NCDs among informal sector workers. Health promotion campaigns are needed to raise awareness among economically and social disadvantaged informal workers about the risk for NCDs. This will require collaboration between public health and the workforce, and allocation of government budgets to address the needs of these workers.

Health literacy and behavioral health factors in adults

OBJECTIVES

This study was to examine the relationship between health literacy (HL) and health behaviors in the South Bohemia Region in the Czech Republic (CR) and compare them to HL and health behaviors in the Visegrád group countries (Czech Republic, Hungary, Poland, and Slovakia). The paper reports the results from the research in the CR.

STUDY DESIGN

A quantitative descriptive study.

METHODS

The sample was stratified by sex and age and included a representative sample of 303 adults. The data were collected using the combination of a country-specific questionnaire with the HLS-EU-16 standardized questionnaire.

RESULTS

Exercise was significantly associated with perceived health and HL; those with a lower level of HL did not exercise during the previous month. Based only on full answers (N = 251), inadequate HL was identified in 17.5% of the respondents (44), marginal HL in 31.5% (77), and adequate HL in 51% (128) of the respondents. Nearly 49% of the participants evaluated their health as 'good', 25.7% rated their health as 'very good' and 'satisfactory' by 25.7%. But 41.6% experienced one or more chronic diseases, 37.6% had some limitations to their health, and 20.5% smoked. For alcohol consumption, 26% drank weekly and 23% drank two to three times a month. Exercise varied from never (29.7%) to daily (7.9%).

CONCLUSION

Based on our results, we conclude that health behavior risk factors are still present in the South Bohemia region of the CR regardless of levels of HL reported on the HLS-EU-16.

Socioeconomic Factors in Patients with Ulnar Nerve Compression at the Elbow: A National Registry-Based Study

AIMS

To investigate demographics and socioeconomic status in patients with ulnar nerve compression and the influence of socioeconomic factors on patient-reported outcome measurements (PROM) as evaluated by QuickDASH (short version of Disabilities of Arm, Shoulder and Hand) after surgery for ulnar nerve compression at the elbow.

METHODS

Patients operated for primary ulnar nerve compression from 2010 to 2016 were identified in the National Quality Registry for Hand Surgery Procedures (HAKIR). Patients filled out questionnaires before and at three and 12 months after surgery. A total of 1346 surgically treated cases were included. Data from HAKIR were linked to data from Statistics Sweden (SCB) on socioeconomic status (i.e., education level, earnings, social assistance, immigrant status, sick leave, unemployment, and marital status).

RESULTS

Patients surgically treated for ulnar nerve compression at the elbow differed from the general population with lower levels of education, higher social assistance dependence, a high proportion of unemployment, and lower earnings. However, the results were not clear concerning the influence of socioeconomic factors on the outcome of surgery, except for long-term sick leave.

CONCLUSION

Patients surgically treated for ulnar nerve compression at the elbow are socioeconomically deprived, but only a history of long-term sick leave influences the outcome of surgery. This information is crucial in the diagnosis and treatment of these patients.

The role of perceived organisational justice in the experience of pain among male and female employees

This study examined the association of organisational justice with pain among employees of a large organisation. Employees (n = 1829) completed measures of pain, fair pay, organisational justice, job satisfaction and stress. Logistic regression analyses found that organisational justice was unrelated to pain among women, but men with higher perceptions of fair pay were more likely to report chronic pain as were men with lower perceptions of distributive justice. This is the first study indicating that fair pay and distributive justice are both unique predictors of chronic pain in men. The findings have implications for supporting employees with chronic pain.

Socioeconomic inequalities and COVID-19 - A review of the current international literature

Social epidemiological research describes correlations between socioeconomic status and the population's risk to become diseased or die. Little research of such correlations for SARS-CoV-2 and COVID-19 has so far been conducted. This scoping review provides an overview of the international research literature. Out of the 138 publications found, 46 were later included in the analysis. For the US and the UK, the reported findings indicate the presence of socioeconomic inequalities in infection risks as well as the severity of the course of the disease, with socioeconomically less privileged populations being hit harder. There are far fewer findings for Germany to date, as is the case for most other European countries. However, the scant evidence available so far already indicates that social inequalities are a factor in COVID-19. Most of these analyses have been ecological studies with only few studies considering socioeconomic inequalities at the individual level. Such studies at the individual level are particularly desirable as they could help to increase our understanding of the underlying pathways that lead to the development of inequalities in infection risks and the severity of disease and thereby could provide a basis to counteract the further exacerbation of health inequalities.

COVID-19 and digital inequalities: Reciprocal impacts and mitigation strategies

With more than three billion people in isolation, the status of digital spaces is switching from an amenity to a necessity, as they become not only the main way to access information and services, but also one of the only remaining vectors for economic, educational, and leisure activities as well as for social interactions to take place. However, not all are equals in terms of access to networks or connected devices, or when it comes to the skills required to navigate computerized spaces optimally. Digital inequalities were already existing, yet the COVID-19 crisis is exacerbating them dramatically. On the one hand, the crisis will worsen digital inequalities within the population. On the other hand, digital inequalities represent a major risk factor of vulnerability for exposure to the virus itself, and for the non-sanitary consequences of the crisis. Therefore, this paper aims at exploring the reciprocal impacts of the COVID-19 crisis and digital inequalities, and to propose operative solutions to help fight the nefarious consequences of the crisis. We first describe how digital inequalities are a determinant of health. We then investigate how COVID-19 can potentiate digital inequalities, and how digital inequalities potentiate vulnerability to COVID-19. Finally, in order to contribute to the mitigation of this crisis, we propose a set of multi-layered strategies focusing on actionability that can be implemented at multiple structural levels, ranging from governmental to corporate and community levels.

The association of periodontal diseases with metabolic syndrome and obesity

Periodontitis is a multifactorial chronic inflammatory disease associated with dysbiotic plaque biofilms and characterized by progressive destruction of the tooth-supporting apparatus. Globally, it is estimated that 740 million people are affected by its severe form. Periodontitis has been suggested to be linked to obesity and metabolic syndrome. Obesity, defined as excessive fat accumulation, is a complex multifactorial chronic inflammatory disease, with a high and increasing prevalence. Metabolic syndrome is defined as a cluster of obesity, dyslipidemia, hypertension, and dysglycemia. Obesity, metabolic syndrome and periodontitis are among the most common non-communicable diseases and a large body of evidence from epidemiologic studies supports the association between these conditions. Extensive research has established plausible mechanisms to explain how these conditions can negatively impact each other, pointing to a bidirectional adverse relationship. At present there is only limited evidence available from a few intervention studies. Nevertheless, the global burden of periodontitis combined with the obesity epidemic has important clinical and public health implications for the dental team. In accordance with the common risk factor approach for tackling non-communicable diseases, it has been proposed that oral healthcare professionals have an important role in the promotion of periodontal health and general well-being through facilitation of healthy lifestyle behaviours.

Educational inequalities in high- vs. low-preventable health conditions: Exploring the fundamental cause theory

AIM

To explore variations in educational gradients or gaps between high- and low-preventable health conditions.

BACKGROUND

This is one of the first European studies to test whether the association between socioeconomic status and morbidity is stronger for 10 high- than three low-preventable health conditions, by gender across 20 countries.

DATA AND METHODS

The 2014 European Social Survey included questions on 11 health conditions experienced over the last 12 months, cancer at any age, and symptoms of depression during the last week. We include respondents from 20 countries (N_men = 12,073; N_women = 13,488) aged 25 to 69. We estimated age-adjusted educational gradients on 13 conditions using logistic or OLS-regression stratified by country and gender, and high- and low-preventable pooled conditions variables on pooled country samples.

RESULTS

Both among men and women the proportion of educational gaps were larger for the high-preventable than the low-preventable conditions in most countries, supporting the Fundamental Cause Theory (FCT) hypothesis. However, there was large variations in the number of significant associations across countries and between genders. In the pooled conditions and countries analysis, no associations were significant among the low-preventable conditions. For the high-preventable conditions there was a weak significant educational gap among men, and a weak but nevertheless more distinctive and complete sigificant educational gradient among women.

CONCLUSION

In a first explorative comparative European analysis we found support for the FCT hypothesis. Thus, the FCT can be used on morbidity data classified as low- versus high-preventable. We recommend extending this framework with institutional theories to explain within- and between-country health inequalities.

Prevalence and socio-demographic characteristics of persons who have never had a headache among healthy voluntary blood donors - a population-based study

INTRODUCTION

Headache is an extremely prevalent disorder with a lifetime prevalence of 90-99%. However, a small fraction of people never experiences a headache. Research on people without headache could uncover protective factors in headache, but to our knowledge no study on headache-free individuals has been published. We aim to estimate the prevalence of headache-free individuals among Danish blood donors, and to describe the socio-demographics and health factors of headache-free participants.

MATERIALS AND METHODS

In all, 38,557 healthy volunteers were recruited as part of the Danish Blood Donor Study. Headache-free participants were identified based on the question "Have you ever experienced a headache of any kind?". Utilising the Danish registries and self-reported questionnaires, we analysed socio-demographic and lifestyle factors using logistic regression adjusted for age and sex.

RESULTS

The prevalence of headache-free individuals was 4.1% (n = 1362) with a female-male ratio of 1:2.2. To be headache free was significantly associated with an employment status as a student, a low level of income and a regular alcohol consumption.

DISCUSSION

The prevalence of headache-free individuals was comparable to population-wide studies of headache. To be headache free was not associated with a high socio-economic status. Further studies on people without headache will hopefully reveal protective factors in headache, and this novel approach might be useful in other very prevalent disorders.

Self-Reported Prevalence of Chronic Non-Communicable Diseases in Relation to Socioeconomic and Educational Factors in Colombia: A Community-Based Study in 11 Departments

Background:

Chronic non-communicable diseases are prevalent conditions in developing countries, such as Colombia. Several socioeconomic and educational factors have been associated with these pathologies. However, there is little country-specific information regarding the self-reported prevalence of chronic diseases and their association with the aforementioned factors in Colombia.

Objectives:

To evaluate the current situation of chronic non-transmissible diseases in Colombia by self-report and to analyze its potential relationship with sociodemographic, economic and educational factors.

Methods:

This is a cross-sectional baseline sub-analysis from the prospective, standardized collaborative PURE study in Colombia. Participants were recruited between 2005 to 2009, in 11 departments of the country, and included 7,485 subjects of 35 to 70 years old. Questionnaires of self-reported chronic non-communicable diseases, and demographic, socioeconomic and educational variables were applied.

Results:

Hypertension was the most prevalent chronic condition reported with a prevalence of 22.2% (21.2%–23.1%, 95% CI), followed by diabetes with a prevalence of 5.7% (5.1%–6.2%, 95% CI), asthma 2.7% (2.2%–3.0%, 95% CI), coronary heart disease 2.4% (2.0%–2.7%, 95% CI), stroke and heart failure 1.5% (1.2%–1.8%, 95% CI) each, chronic obstructive pulmonary disease 1.2% (0.6%–1.5%, 95% CI), and cancer 1.2% (1.0%–1.5%, 95% CI). Among the study sample, 23.3% (22.4%–24.3%, 95% CI) reported having one chronic NCDs, and 6.4% (5.9%–7.0%, 95% CI) reported having multiple chronic NCDs. The prevalence of multiple NCDs increased significantly with age, was more common in those from households with higher income, whereas it was significantly lower in persons with high education.

The central and central-east regions of the country are those with the higher prevalence of self-reported NCDs.

Conclusion:

The results of the current study indicate the presence of socioeconomic and educational inequalities in the distribution of chronic NCDs in the Colombian population.

Characterizing the Impact of Social Inequality on COVID-19 Propagation in Developing Countries

The world faces a pandemic not previously experienced in modern times. The internal mechanism of SARS-Cov-2 is not well known and there are no Pharmaceutical Interventions available. To stem the spread of the virus, measures of respiratory etiquette, social distancing and hand hygiene have been recommended. Based on these measures, some countries have already managed to control the COVID-19 propagation, although in the absence of pharmaceutical interventions, this control is not definitive. However, we have seen that social heterogeneity across populations makes the effects of COVID-19 also different. Social inequality affects the population of developing countries not only from an economic point of view. The relationship between social inequality and the health condition is not new, but it becomes even more evident in times of crisis, such as the one the world has been facing with COVID-19. How does social inequality affect the COVID-19 propagation in developing countries is the object of this study. We propose a new epidemic SEIR model based on social indicators to predict outbreak and mortality of COVID-19. The estimated number of infected and fatalities are compared with different levels of Non-Pharmaceutical Interventions. We present a case study for the Deep Brazil. The results showed that social inequality has a strong effect on the propagation of COVID-19, increasing its damage and accelerating the collapse of health infrastructure.

The SIPHER Consortium: Introducing the new UK hub for systems science in public health and health economic research

The conditions in which we are born, grow, live, work and age are key drivers of health and inequalities in life chances. To maximise health and wellbeing across the whole population, we need well-coordinated action across government sectors, in areas including economic, education, welfare, labour market and housing policy. Current research struggles to offer effective decision support on the cross-sector strategic alignment of policies, and to generate evidence that gives budget holders the confidence to change the way major investment decisions are made. This open letter introduces a new research initiative in this space. The SIPHER ( Systems Science in Public Health and Health Economics Research) Consortium brings together a multi-disciplinary group of scientists from across six universities, three government partners at local, regional and national level, and ten practice partner organisations. The Consortium’s vision is a shift from health policy to healthy public policy, where the wellbeing impacts of policies are a core consideration across government sectors. Researchers and policy makers will jointly tackle fundamental questions about: a) the complex causal relationships between upstream policies and wellbeing, economic and equality outcomes; b) the multi-sectoral appraisal of costs and benefits of alternative investment options; c) public values and preferences for different outcomes, and how necessary trade-offs can be negotiated; and d) creating the conditions for intelligence-led adaptive policy design that maximises progress against economic, social and health goals. Whilst our methods will be adaptable across policy topics and jurisdictions, we will initially focus on four policy areas: Inclusive Economic Growth, Adverse Childhood Experiences, Mental Wellbeing and Housing.

Development and multi-cohort validation of a clinical score for predicting type 2 diabetes mellitus

Background and aims

Many countries lack resources to identify patients at risk of developing Type 2 diabetes mellitus (diabetes). We aimed to develop and validate a diabetes risk score based on easily accessible clinical data.

Methods

Prospective study including 5277 participants (55.0% women, 51.8±10.5 years) free of diabetes at baseline. Comparison with two other published diabetes risk scores (Balkau and Kahn clinical, respectively 5 and 8 variables) and validation on three cohorts (Europe, Iran and Mexico) was performed.

Results

After a mean follow-up of 10.9 years, 405 participants (7.7%) developed diabetes. Our score was based on age, gender, waist circumference, diabetes family history, hypertension and physical activity. The area under the curve (AUC) was 0.772 for our score, vs. 0.748 (p<0.001) and 0.774 (p = 0.668) for the other two. Using a 13-point threshold, sensitivity, specificity, positive and negative predictive values (95% CI) of our score were 60.5 (55.5–65.3), 77.1 (75.8–78.2), 18.0 (16.0–20.1) and 95.9 (95.2–96.5) percent, respectively. Our score performed equally well or better than the other two in the Iranian [AUC 0.542 vs. 0.564 (p = 0.476) and 0.513 (p = 0.300)] and Mexican [AUC 0.791 vs. 0.672 (p<0.001) and 0.778 (p = 0.575)] cohorts. In the European cohort, it performed similarly to the Balkau score but worse than the Kahn clinical [AUC 0.788 vs. 0.793 (p = 0.091) and 0.816 (p<0.001)]. Diagnostic capacity of our score was better than the Balkau score and comparable to the Kahn clinical one.

Conclusion

Our clinically-based score shows encouraging results compared to other scores and can be used in populations with differing diabetes prevalence.

Subjective social status and inequalities in depressive symptoms: a gender-specific decomposition analysis for South Africa

Background

Inequalities in mental health are a notable and well documented policy concern in many countries, including South Africa. Individuals’ perception of their position in the social hierarchy is strongly and negatively related to their mental health, whilst the global burden of poor mental health is greater amongst women. This paper offers a first glimpse of the factors that shape gender-based health inequalities across subjective social status.

Methods

This study employs the cross-sectional 2014 South African Social Attitudes Survey (SASAS). The prevalence of depressive symptoms is measured with the aid of the CES-D 8-item scale, with analyses disaggregated by gender. Concentration indices (CI) are used to measure inequalities in depressive symptoms related to subjective social status. The study applies the Wagstaff decomposition to determine the factors that contribute to these gender-based inequalities.

Results

More than 26% of the study sample had depressive symptoms (95% CI 24.92–28.07). The prevalence of depressive symptoms is significantly more pronounced in females (28.46% versus 24.38%; p = 0.011). The concentration index for depressive symptoms is − 0.276 (95% CI -0.341 – − 0.211), showing large inequalities across subjective social status. The observed SSS-related inequality in depressive symptoms however is higher for males (CI = -0.304) when compared to females (CI = -0.240) (p = 0.056). The most important contributor to SSS-related inequalities in depressive symptoms, at 61%, is subjective social status itself (contributing 82% in females versus 44% in males). Other variables that make large contributions to the inequalities in depressive symptoms at 11% each are race (contributing 2% in females versus 25% in males) and childhood conflict (contributing 17% in females versus 4% in males).

Conclusion

Policy makers should target a reduction in the positive contribution of SSS to depression via the implementation of programmes that improve social welfare. Given the much greater contribution to inequalities among females, these policies should target women. Policies that protect children and especially the girl child from conflict can also be useful in reducing inequalities in depression related to subjective social status during adulthood. Overall, there is need for a multi-sectoral approach to address these inequalities.

Non-communicable diseases in Greece: inequality, gender and migration

Background

The relationship between gender, migration status and non-communicable diseases (NCDs) is rarely examined. In this study, we rely on data from the MIGHEAL Survey on health inequalities in Greece collected in 2016 comprising 1332 respondents of which 59.98% identified themselves as Greek-born, 24.02% as immigrants from Albania and 15.99% as immigrants from another country than Albania, to analyse this often neglected relationship. With the help of average risk ratios, this paper explores and explains gender inequalities in heart or circulation problems, high blood pressure, breathing problems, allergies, back or neck pain, muscular pain, stomach or digestion-related problems, skin conditions, severe headaches, and diabetes in Greece among Greek-born individuals, Albanian immigrants and among immigrants of 'other origin'. We found that both among Greek-born and among immigrant groups women report substantially higher rates of NCDs although gender inequalities are more pronounced among 'other-origin' immigrants. Further, our findings show that the observed gender inequalities are fostered by occupational factors both among Greek-born and migrants.

The effects of public health policies on health inequalities in high-income countries: an umbrella review

BACKGROUND

Socio-economic inequalities are associated with unequal exposure to social, economic and environmental risk factors, which in turn contribute to health inequalities. Understanding the impact of specific public health policy interventions will help to establish causality in terms of the effects on health inequalities.

METHODS

Systematic review methodology was used to identify systematic reviews from high-income countries that describe the health equity effects of upstream public health interventions. Twenty databases were searched from their start date until May 2017. The quality of the included articles was determined using the Assessment of Multiple Systematic Reviews tool (AMSTAR).

RESULTS

Twenty-nine systematic reviews were identified reporting 150 unique relevant primary studies. The reviews summarised evidence of all types of primary and secondary prevention policies (fiscal, regulation, education, preventative treatment and screening) across seven public health domains (tobacco, alcohol, food and nutrition, reproductive health services, the control of infectious diseases, the environment and workplace regulations). There were no systematic reviews of interventions targeting mental health. Results were mixed across the public health domains; some policy interventions were shown to reduce health inequalities (e.g. food subsidy programmes, immunisations), others have no effect and some interventions appear to increase inequalities (e.g. 20 mph and low emission zones). The quality of the included reviews (and their primary studies) were generally poor and clear gaps in the evidence base have been highlighted.

CONCLUSIONS

The review does tentatively suggest interventions that policy makers might use to reduce health inequalities, although whether the programmes are transferable between high-income countries remains unclear.

TRIAL REGISTRATION

PROSPERO registration number: CRD42016025283.

Variations in diagnostic testing utilization in Italy: Secondary analysis of a national survey

Background

According to the principle of horizontal equity, individuals with similar need may have the same possibility of access to health services. The aim of this study is to identify patterns of diagnostic services utilization, in people with, and without chronic disease in Italy.

Methods

Secondary analysis of data from the national survey on Health and use of health care in Italy, carried out in 2013, including 99,497 participants. Multilevel analysis has been used to study the variables associated to diagnostic services utilization.

Results

13.78% of participants have had one diagnostic testing in the four weeks before the interview. In healthy people, utilization of diagnostic testing is reduced in people with low educational level (OR 0.75; 95%CI 0.67–0.84), in housewives (OR 0.66; 95%CI 0.51–0.87), or in those unable to work (OR 0.48; 95%CI 0.26–0.87), while increased in those perceiving a worse health status (up to OR 4.00, 95%CI 2.00–8.01 in very bad health). In people afflicted with chronic disease, access to diagnostic assessment is impaired by educational level (OR 0.69; 95%CI 0.61–0.78) and low household income (OR 0.75; 95%CI 0.58–0.97), while it is increased in the presence of a ticket exemption (OR 1.55, 95%CI 1.42–1.68), and fixed-term occupation (OR2.28, 95%CI 1.31–3.95). Being former-smokers in associated to an increased utilization of services in both groups.

Conclusions

Despite a universal and theoretically egalitarian, public, health care system, variations in diagnostic services utilization are still registered in Italy, both in healthy people and those afflicted by chronic diseases, on socio-economic/occupational basis, and self-perceived health status. Moreover, this significant effect of occupation on healthcare utilization, suggests the need for a comprehensive evaluation of economics in occupational health.

Socioeconomic Correlates and Determinants of Cardiorespiratory Fitness in the General Adult Population: a Systematic Review and Meta-Analysis

BACKGROUND

This review aims to (1) consolidate evidence regarding the association between socioeconomic status (SES) and cardiorespiratory fitness (CRF), (2) conduct a meta-analysis of the association between SES and CRF using methodologically comparable data, stratified by sex, and (3) test whether the association varies after adjustment for physical activity (PA).

METHODS

A systematic review of studies from MEDLINE, EMBASE, Latin American and Caribbean Health Sciences (LILACS), Scientific Electronic Library Online (ScIELO), and Cochrane Library without time or language restrictions, which investigated associations between SES and CRF. Risk of bias within studies was assessed using a customized quality assessment tool. Results were summarized in table format and methodologically similar studies were synthesized using meta-analysis of Hedges' g effect sizes. Synthesized results were appraised for cross-study bias. Results were tested for the impact of PA adjustment using meta-regression.

RESULTS

Compared to individuals with low education, both men and women showed higher CRF among individuals with high education (men 0.12 [0.04-0.20], women 0.19 [0.02-0.36]), while participants with medium education showed no significant difference in CRF (men 0.03 [- 0.04-0.11], women 0.09 [- 0.03-0.21]). Adjustment for PA did not significantly impact the association between education and CRF.

CONCLUSIONS

There is fair evidence for an association between high levels of education and increased CRF. This could have implications for monitoring, of health target compliance and of chronic disease risk among higher risk populations, to detect and prevent non-communicable diseases (NCDs) and to diminish social health inequalities.

TRIAL REGISTRATION

PROSPERO, CRD42017055456.

Post-millennial trends of socioeconomic inequalities in chronic illness among adults in Germany

Objective

Time trends in health inequalities have scarcely been studied in Germany as only few national data have been available. In this paper, we explore trends in socioeconomic inequalities in the prevalence of chronic illness using Germany-wide data from four cross-sectional health surveys conducted between 2003 and 2012 (n = 54,197; ages 25–69 years). We thereby expand a prior analysis on post-millennial inequality trends in behavioural risk factors by turning the focus to chronic illness as the outcome measure. The regression-based slope index of inequality (SII) and relative index of inequality (RII) were calculated to estimate the extent of absolute and relative socioeconomic inequalities in chronic illness, respectively.

Results

The results for men revealed a significant increase in the extent of socioeconomic inequalities in chronic illness between 2003 and 2012 on both the absolute and relative scales (SII₂₀₀₃ = 0.06, SII₂₀₁₂ = 0.17, p-trend = 0.013; RII₂₀₀₃ = 1.18, RII₂₀₁₂ = 1.57, p-trend = 0.013). In women, similar increases in socioeconomic inequalities in chronic illness were found (SII₂₀₀₃ = 0.05, SII₂₀₁₂ = 0.14, p-trend = 0.022; RII₂₀₀₃ = 1.14, RII₂₀₁₂ = 1.40, p-trend = 0.021). Whereas in men this trend was driven by an increasing prevalence of chronic illness in the low socioeconomic group, the trend in women was predominantly the result of a declining prevalence in the high socioeconomic group.

The Magnitude of Occupational Class Differences in Sickness Absence: 15-Year Trends among Young and Middle-Aged Municipal Employees

Background: Our aim was to examine the magnitude of relative occupational class differences in sickness absence (SA) days over a 15-year period among female and male municipal employees in two age-groups. Methods: 18-34 and 35-59-year-old employees of the City of Helsinki from 2002 to 2016 were included in our data (n = ~37,500 per year). Occupational class was classified into four groups. The magnitude of relative occupational class differences in SA was studied using the relative index of inequality (RII). Results: The relative occupational class differences were larger among older than younger employees; the largest differences were among 35-59-year-old men. Among women in both age-groups the relative class differences remained stable during 2002-2016. Among younger and older men, the differences were larger during the beginning of study period than in the end. Among women in both age-groups the RII values were between 2.19 (95% confidence intervals (CI) 1.98, 2.42) and 3.60 (95% CI 3.28, 3.95). The corresponding differences varied from 3.74 (95% CI 3.13, 4.48) to 1.68 (95% CI 1.44, 1.97) among younger and from 6.43 (95% CI 5.85, 7.06) to 3.31 (95% CI 2.98, 3.68) among older men.

CONCLUSIONS

Relative occupational class differences were persistent among employees irrespective of age group and gender. Preventive measures should be started at young age.

The health of European populations: introduction to the special supplement on the 2014 European Social Survey (ESS) rotating module on the social determinants of health

This introduction summarizes the main findings of the Supplement 'Social inequalities in health and their determinants' to the European Journal of Public Health. The 16 articles that constitute this supplement use the new ESS (2014) health module data to analyze the distribution of health across European populations. Three main themes run across these articles: documentation of cross-national variation in the magnitude and patterning of health inequalities; assessment of health determinants variation across populations and in their contribution to health inequalities; and the examination of the effects of health outcomes across social groups. Social inequalities in health are investigated from an intersectional stance providing ample evidence of inequalities based on socioeconomic status (occupation, education, income), gender, age, geographical location, migrant status and their interactions. Comparison of results across these articles, which employ a wide range of health outcomes, social determinants and social stratification measures, is facilitated by a shared theoretical and analytical approach developed by the authors in this supplement.