Bias related to the exclusion of the economically inactive in studies on social class differences in mortality

Occupational socioeconomic risk associations for head and neck cancer in Europe and South America: individual participant data analysis of pooled case-control studies within the INHANCE Consortium

BACKGROUND

The association between socioeconomic disadvantage (low education and/or income) and head and neck cancer is well established, with smoking and alcohol consumption explaining up to three-quarters of the risk. We aimed to investigate the nature of and explanations for head and neck cancer risk associated with occupational socioeconomic prestige (a perceptual measure of psychosocial status), occupational socioeconomic position and manual-work experience, and to assess the potential explanatory role of occupational exposures.

METHODS

Pooled analysis included 5818 patients with head and neck cancer (and 7326 control participants) from five studies in Europe and South America. Lifetime job histories were coded to: (1) occupational social prestige-Treiman's Standard International Occupational Prestige Scale (SIOPS); (2) occupational socioeconomic position-International Socio-Economic Index (ISEI); and (3) manual/non-manual jobs.

RESULTS

For the longest held job, adjusting for smoking, alcohol and nature of occupation, increased head and neck cancer risk estimates were observed for low SIOPS OR=1.88 (95% CI: 1.64 to 2.17), low ISEI OR=1.74 (95% CI: 1.51 to 1.99) and manual occupations OR=1.49 (95% CI: 1.35 to 1.64). Following mutual adjustment by socioeconomic exposures, risk associated with low SIOPS remained OR=1.59 (95% CI: 1.30 to 1.94).

CONCLUSIONS

These findings indicate that low occupational socioeconomic prestige, position and manual work are associated with head and neck cancer, and such risks are only partly explained by smoking, alcohol and occupational exposures. Perceptual occupational psychosocial status (SIOPS) appears to be the strongest socioeconomic factor, relative to socioeconomic position and manual/non-manual work.

Socioeconomic Position, Multimorbidity and Mortality in a Population Cohort: The HUNT Study

Multimorbidity and socioeconomic position are independently associated with mortality. We investigated the association of occupational position and several multimorbidity measures with all-cause mortality. A cohort of people aged 35 to 75 years who participated in the Trøndelag Health Study in 2006-2008 and had occupational data was linked to the Norwegian National Population Registry for all-cause mortality from study entry until 1 February 2019. Logistic regression models for each occupational group were used to analyze associations between the number of conditions and 10-year risk of death. Cox regression models were used to examine associations between combinations of multimorbidity, occupational position, and mortality. Analyses were conducted for men and women. Included were 31,132 adults (16,950 women (54.4%)); occupational groups: high, 7501 (24.1%); low, 15,261 (49.0%)). Increased mortality was associated with lower occupational group, more chronic conditions, and all multimorbidity measures. The joint impact of occupational group and multimorbidity on mortality was greater in men than women. All multimorbidity measures are strongly associated with mortality, with varying occupational gradients. Social differences in multimorbidity are a public health challenge and necessitate consideration in health care. Men in lower occupational groups seem to be a particularly vulnerable group.

National organization of uterine cervical cancer screening and social inequality in France

Some of the inequality in uterine cervical cancer (UCC) screening uptake are due to the socioeconomic deprivation of women. A national organized screening programme has proven to be effective in increasing the uptake, but may increase socioeconomic inequality. Therefore, we compared inequality in uptake of UCC screening between two French departments, one of which is experimenting an organized screening programme. We used reimbursement data from the main French health insurance scheme to compare screening rates in the municipalities of the two departments over a three-year period. The experimental department had higher screening rates, but the increase in deprivation in municipalities had a greater effect on the decrease in participation in this department. Moreover, while screening rates were higher in urban areas, the negative effect of deprivation on participation was greater in rural areas. Although these departments were compared at the same time under different conditions, socioeconomic inequality between them may have been greater before the experimentation started. However, screening may have led to an increase in socioeconomic inequality between women screened. Special attention must be paid to changes in socioeconomic and geographic inequality in the uptake of UCC screening when the programme is rolled out nationally.

Socioeconomic inequalities in the prevalence of complex multimorbidity in a Norwegian population: findings from the cross-sectional HUNT Study

OBJECTIVES

Multimorbidity, the co-occurrence of multiple long-term conditions, is common and increasing. Definitions and assessment methods vary, yielding differences in estimates of prevalence and multimorbidity severity. Sociodemographic characteristics are associated with complicating factors of multimorbidity. We aimed to investigate the prevalence of complex multimorbidity by sex and occupational groups throughout adulthood.

DESIGN

Cross-sectional study.

SETTING

The third total county survey of The Nord-Trøndelag Health Study (HUNT), 2006-2008, Norway.

PARTICIPANTS

Individuals aged 25-100 years with classifiable occupational data and complete questionnaires and measurements.

OUTCOME MEASURE

Complex multimorbidity defined as 'the co-occurrence of three or more chronic conditions affecting three or more different body (organ) systems within one person without defining an index chronic condition'.

ANALYSIS

Logistic regression models with age and occupational group were specified for each sex separately.

RESULTS

38 027 of 41 193 adults (55% women) were included in our analyses. 54% of the participants were identified as having complex multimorbidity. Prevalence differences in percentage points (pp) of those in the low occupational group (vs the high occupational group (reference)) were 19 (95% CI, 16 to 21) pp in women and 10 (8 to 13) pp in men at 30 years; 12 (10 to 14) pp in women and 13 (11 to 15) pp in men at 55 years; and 2 (-1 to 4) pp in women and 7 (4 to 10) pp in men at 75 years.

CONCLUSION

Complex multimorbidity is common from early adulthood, and social inequalities persist until 75 years in women and 90 years in men in the general population. These findings have policy implications for public health as well as healthcare, organisation, treatment, education and research, as complex multimorbidity breaks with the specialised, fragmented paradigm dominating medicine today.

Socio-Economic Inequalities in Life Expectancy and Health Expectancy at Age 50 and over in European Countries

Abstract Based on the demographic ageing, many European governments have modified the statutory retirement age. However, in general, life expectancy (LE) and health expectancy (HE) are not uniformly distributed, being both lower among the least advantaged groups. Thus, a systematic search and review of the literature has been conducted to identify socioeconomic inequalities in LE and HE at age 50 and over in European countries. Twenty-nine studies were included in the review. Across Europe, people in a more advantaged position can expect to live longer, more years in good health and less in bad health, and therefore a lower percentage of their lives in bad health. Zusammenfassung: Sozioökonomische Ungleichheiten in der Lebens- und Gesundheitserwartung im Alter von 50 und älter in Europäischen Ländern. Erkenntnisse für die Debatte der Rentenpolitik Vor dem Hintergrund der demographischen Alterung haben viele europäische Regierungen das Renteneintrittsalter modifiziert. Allerdings sind Lebensund Gesundheitserwartungen nicht gleichmäßig verteilt, sondern sind in benachteiligten Bevölkerungsgruppen niedriger. Um sozioökonomische Ungleichheiten in der Lebens- und Gesundheitserwartung von Individuen im Alter von 50 Jahren und älter zu betrachten, wurde eine systematische Suche und Begutachtung der Literatur in den europäischen Ländern durchgeführt. Es wurden 29 Studien in der Begutachtung miteinbezogen. Es zeigt sich, dass Individuen in vorteilhaften Positionen erwarten können länger zu leben, länger gesund zu sein und weniger häufig einen schlechten Gesundheitszustand aufweisen, was der Grund dafür ist, dass sie auch einen geringeren Anteil ihrer Lebenszeit in schlechter Gesundheit verbringen.

Lung cancer and socioeconomic status in a pooled analysis of case-control studies

BACKGROUND

An association between low socioeconomic status (SES) and lung cancer has been observed in several studies, but often without adequate control for smoking behavior. We studied the association between lung cancer and occupationally derived SES, using data from the international pooled SYNERGY study.

METHODS

Twelve case-control studies from Europe and Canada were included in the analysis. Based on occupational histories of study participants we measured SES using the International Socio-Economic Index of Occupational Status (ISEI) and the European Socio-economic Classification (ESeC). We divided the ISEI range into categories, using various criteria. Stratifying by gender, we calculated odds ratios (OR) and 95% confidence intervals (CI) by unconditional logistic regression, adjusting for age, study, and smoking behavior. We conducted analyses by histological subtypes of lung cancer and subgroup analyses by study region, birth cohort, education and occupational exposure to known lung carcinogens.

RESULTS

The analysis dataset included 17,021 cases and 20,885 controls. There was a strong elevated OR between lung cancer and low SES, which was attenuated substantially after adjustment for smoking, however a social gradient persisted. SES differences in lung cancer risk were higher among men (lowest vs. highest SES category: ISEI OR 1.84 (95% CI 1.61-2.09); ESeC OR 1.53 (95% CI 1.44-1.63)), than among women (lowest vs. highest SES category: ISEI OR 1.54 (95% CI 1.20-1.98); ESeC OR 1.34 (95% CI 1.19-1.52)).

CONCLUSION

SES remained a risk factor for lung cancer after adjustment for smoking behavior.

Socioeconomic inequality in clusters of health-related behaviours in Europe: latent class analysis of a cross-sectional European survey

Background

Modifiable health-related behaviours tend to cluster among most vulnerable sectors of the population, particularly those at the bottom of the social hierarchy. This study aimed to identify the clusters of health-related behaviours in 27 European countries and to examine the socioeconomic inequalities in these clusters.

Methods

Data were from Eurobarometer 72.3–2009, a cross-sectional survey of 27 European countries. The analyses were conducted in 2016. The main sections of the survey included questions pertaining to sociodemographic factors, health-related behaviours, and use of services. In this study, those aged 18 years and older were included. We selected five health-related behaviours, namely smoking, excessive alcohol consumption, frequent fresh fruit consumption, physical activity and dental check-ups. Socioeconomic position was indicated by education, subjective social status and difficulty in paying bills. Latent class analysis was conducted to explore the clusters of these five behaviours. Multinomial logistic regression model was used to examine the relationships between the clusters and socioeconomic positions adjusting for age, gender, marital status and urbanisation.

Results

The eligible total population was 23,842. Latent class analysis identified three clusters; healthy, moderate and risky clusters in this European population. Individuals with the lowest socioeconomic position were more likely to have risky and moderate clusters than healthy cluster compared to those with the highest socioeconomic position.

Conclusions

There were clear socioeconomic gradients in clusters of health-related behaviours. The findings highlight the importance of adopting interventions that address multiple health risk behaviours and policies that tackle the social determinants of health-related behaviours.

Does survey non-response bias the association between occupational social class and health?

Aims: A non-response rate of 20—40%is typical in questionnaire studies. The authors evaluate non-response bias and its impact on analyses of social class inequalities in health. Methods: Set in the context of a health survey carried out among the employees of the City of Helsinki (non-response 33%) in 2000—02. Survey response and non-response records were linked with a personnel register to provide information on occupational social class and long sickness absence spells as an indicator of health status. Results: Women and employees in higher occupational social classes were more likely to respond. Non-respondents had about 20—30% higher sickness absence rates. Relative social class differences in sickness absence in the total population were similar to those among either respondents or non-respondents. Conclusions: In working populations survey non-response does not seriously bias analyses of social class inequalities in sickness absence and possibly health inequalities more generally.

Effect of living conditions in the parental home and youth paths on the social class differences in mortality among women

Aims: A longitudinal study was undertaken to assess the effects of parental home and youth paths on the adult social class differences in mortality among women. Methods: The study used population registration data on all Finnish women aged 30 - 34 in 1990 for whom information on their childhood characteristics and youth paths were available from the 1970, 1975, 1980, 1985, and 1990 censuses. Cause of death follow-up was for the period 1991-98 (1,185 deaths). Results: Adjusting for parental social class, family type, and number of siblings attenuated the effects of adult social class on cardiovascular disease mortality by 27%; for all external causes this attenuation was negligible. Educational, marital, and employment paths accounted for a substantial part (30 - 85%) of the social class differences in mortality for all specific causes of death. Conclusions: Although living conditions in the parental home were associated with mediating life trajectories in youth their effect on adult social class differences in mortality was moderate. Youth paths have a pervasive influence on mortality risks and social class differences in mortality in middle adulthood.

Socioeconomic differences in suicide mortality by sex in Finland in 1971—2000: A register-based study of trends, levels, and life expectancy differences

Aim: Suicide is a common cause of death in many Western countries and it has been predicted to become even more common worldwide. The authors analysed socioeconomic differences and trends in Finnish suicide mortality, and assessed the relevance to public health by calculating socioeconomic differences in years of life expectancy lost attributable to suicide. Data and methods: Census records were used, linked with the death records of men and women aged 25 years and over in 1971—2000 in Finland. Results: Suicide among male and female manual workers was 2.3 and 1.3 times higher respectively than among upper non-manual workers. The differences were largest among those in their thirties. Because of the decline in suicide among upper non-manual workers and a slower decrease or even an increase among other socioeconomic groups, the relative mortality differences increased somewhat during 1970—90, then decreased in the 1990s but remained higher than in the 1970s. In 1991—2000 the suicide-related life expectancy gap between the upper non-manual and manual male workers was 0.6 years, and this difference contributed 10% to the total difference in years of life expectancy lost between these socioeconomic groups. Conclusion: Large and persistent socioeconomic differences were found in suicide mortality and suicide was an important component of the socioeconomic difference in total mortality. Reducing these differences could significantly improve equity in health and reduce the burden of excess mortality.

Occupational prestige, social mobility and the association with lung cancer in men

BACKGROUND

The nature of the association between occupational social prestige, social mobility, and risk of lung cancer remains uncertain. Using data from the international pooled SYNERGY case-control study, we studied the association between lung cancer and the level of time-weighted average occupational social prestige as well as its lifetime trajectory.

METHODS

We included 11,433 male cases and 14,147 male control subjects. Each job was translated into an occupational social prestige score by applying Treiman's Standard International Occupational Prestige Scale (SIOPS). SIOPS scores were categorized as low, medium, and high prestige (reference). We calculated odds ratios (OR) with 95 % confidence intervals (CI), adjusting for study center, age, smoking, ever employment in a job with known lung carcinogen exposure, and education. Trajectories in SIOPS categories from first to last and first to longest job were defined as consistent, downward, or upward. We conducted several subgroup and sensitivity analyses to assess the robustness of our results.

RESULTS

We observed increased lung cancer risk estimates for men with medium (OR = 1.23; 95 % CI 1.13-1.33) and low occupational prestige (OR = 1.44; 95 % CI 1.32-1.57). Although adjustment for smoking and education reduced the associations between occupational prestige and lung cancer, they did not explain the association entirely. Traditional occupational exposures reduced the associations only slightly. We observed small associations with downward prestige trajectories, with ORs of 1.13, 95 % CI 0.88-1.46 for high to low, and 1.24; 95 % CI 1.08-1.41 for medium to low trajectories.

CONCLUSIONS

Our results indicate that occupational prestige is independently associated with lung cancer among men.

Developing a new small-area measure of deprivation using 2001 and 2011 census data from Scotland

Material deprivation contributes to inequalities in health; areas of high deprivation have higher rates of ill-health. How deprivation is measured has a great impact on its explanatory power with respect to health. We compare previous deprivation measures used in Scotland and proposes a new deprivation measure using the 2001 and 2011 Scottish census data. We calculate the relative index of inequality (RII) for self-reported health and mortality. While across all age groups different deprivation measures provide similar results, the assessment of health inequalities among those aged 20–29 differs markedly according to the deprivation measure. In 2011 the RII for long-term health problem for men aged 20–24 was only 0.71 (95% CI 0.60–0.83) using the Carstairs score, but 1.10 (0.99–1.21) for the new score and 1.13 (1.03–1.24) for the income domain of Scottish Index of Multiple Deprivation (SIMD). The RII for mortality in that age group was 1.25 (0.89–1.58) for the Carstairs score, 1.69 (1.35–2.02) for the new measure and 1.76 (1.43–2.08) for SIMD. The results suggest that researchers and policy makers should consider the suitability of deprivation measures for different social groups.

•

Three measures of deprivation are associated with health similarly across all ages.

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The Carstairs score predicts lower health inequalities for people aged 20–29.

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The different result for the youth is driven by car ownership and overcrowding.

How can inequalities in mortality be reduced? A quantitative analysis of 6 risk factors in 21 European populations

BACKGROUND

Socioeconomic inequalities in mortality are one of the greatest challenges for health policy in all European countries, but the potential for reducing these inequalities is unclear. We therefore quantified the impact of equalizing the distribution of six risk factors for mortality: smoking, overweight, lack of physical exercise, lack of social participation, low income, and economic inactivity.

METHODS

We collected and harmonized data on mortality and risk factors by educational level for 21 European populations in the early 2000s. The impact of the risk factors on mortality in each educational group was determined using Population Attributable Fractions. We estimated the impact on inequalities in mortality of two scenarios: a theoretical upward levelling scenario in which inequalities in the risk factor were completely eliminated, and a more realistic best practice scenario, in which inequalities in the risk factor were reduced to those seen in the country with the smallest inequalities for that risk factor.

FINDINGS

In general, upward levelling of inequalities in smoking, low income and economic inactivity hold the greatest potential for reducing inequalities in mortality. While the importance of low income is similar across Europe, smoking is more important in the North and East, and overweight in the South. On the basis of best practice scenarios the potential for reducing inequalities in mortality is often smaller, but still substantial in many countries for smoking and physical inactivity.

INTERPRETATION

Theoretically, there is a great potential for reducing inequalities in mortality in most European countries, for example by equity-oriented tobacco control policies, income redistribution and employment policies. Although it is necessary to achieve substantial degrees of upward levelling to make a notable difference for inequalities in mortality, the existence of best practice countries with more favourable distributions for some of these risk factors suggests that this is feasible.

The use of parental occupation in adolescent health surveys. An application of ISCO-based measures of occupational status

BACKGROUND

Recent research has emphasised that the challenge in researching socioeconomic differences in adolescent health cross-nationally lies in providing valid and comparable measures of socioeconomic position (SEP) across regions. This study aims to examine measures of occupational status derived from the International Standard Classification of Occupations (ISCO), alongside commonly used affluence measures in association with adolescent self-rated health (SRH).

METHODS

Data were from the 2005/2006 'Health Behaviour in School-aged Children study' (HBSC); 27 649 individuals aged 11, 13 and 15 years from Germany, Macedonia, Norway, Turkey, Wales and Scotland. Three occupational scales were compared: the International Socioeconomic Index of Occupational Status (ISEI), the Standard International Occupational Prestige Scale (SIOPS) and the Erikson-Goldthorpe-Portocarero class categories (EGP). Correlation analyses compared these occupational scales with the family affluence scale (FAS) and a family well-off measure, while logistic regression assessed the association between occupational scales and poor SRH. Multiple imputation techniques investigated possible bias arising from parental occupation missingness.

RESULTS

Moderate correlations existed between occupational scales and FAS and family well-off. Socioeconomic inequalities in poor SRH were found for ISEI, SIOPS and EGP in all regions, independent of FAS and family well-off. Models of imputed data sets did not alter the results. The relationship between SEP and SRH was therefore not biased by high levels of missing values for ISCO.

CONCLUSIONS

ISCO-based indicators of occupational status in cross-national self-administered adolescent health surveys were found to be robust measures of SEP in adolescence. These measure different aspects of SEP independent of FAS and family well-off.

Occupational class inequalities in all-cause and cause-specific mortality among middle-aged men in 14 European populations during the early 2000s

This study analyses occupational class inequalities in all-cause mortality and four specific causes of death among men, in Europe in the early 2000s, and is the most extensive comparative analysis of occupational class inequalities in mortality in Europe so far. Longitudinal data, obtained from population censuses and mortality registries in 14 European populations, from around the period 2000–2005, were used. Analyses concerned men aged 30–59 years and included all-cause mortality and mortality from all cancers, all cardiovascular diseases (CVD), all external, and all other causes. Occupational class was analysed according to five categories: upper and lower non-manual workers, skilled and unskilled manual workers, and farmers and self-employed combined. Inequalities were quantified with mortality rate ratios, rate differences, and population attributable fractions (PAF). Relative and absolute inequalities in all-cause mortality were more pronounced in Finland, Denmark, France, and Lithuania than in other populations, and the same countries (except France) also had the highest PAF values for all-cause mortality. The main contributing causes to these larger inequalities differed strongly between countries (e.g., cancer in France, all other causes in Denmark). Relative and absolute inequalities in CVD mortality were markedly lower in Southern European populations. We conclude that relative and absolute occupational class differences in all-cause and cause specific mortality have persisted into the early 2000's, although the magnitude differs strongly between populations. Comparisons with previous studies suggest that the relative gap in mortality between occupational classes has further widened in some Northern and Western European populations.

Trends in socio-economic inequalities in mortality by sex in Ireland from the 1980s to the 2000s

BACKGROUND

It has been recognised for some time that mortality rates vary across social class groups, with lower rates in the higher social classes. Internationally, but particularly in Ireland, many studies on the topic of inequalities in mortality have been confined to men, partly because the most frequently used socioeconomic classification, that based on occupation, can less easily be applied to women. Where research does exist, studies indicate that health inequalities are greater for men than for women. Given the issues around classification, there remains however, little knowledge of the socio-economic inequalities in female mortality in Ireland.

AIMS

Using annual mortality data from the Irish Central Statistics Office over the period 1984-2008 this paper calculates crude and standardised mortality rates per 100,000 population for men and women in different socio-economic groups (SEG) and examines trends in these over time. This means that for the first time, longitudinal comparisons can be made between men and women across an important period of recent Irish history.

RESULTS

There is a significant gradient in mortality rates across SEG for both men and women with the absolute and relative differential between professional and manual occupational groups increasing between the 1980s and 2000s even though the mortality rates were falling over time for all SEG groups for both sexes.

CONCLUSIONS

The results confirm international findings that women generally have smaller gradients than men across SEG with the ratio of male/female differentials (i.e. the ratio of the male SEG rate ratio to the female SEG rate ratio) decreasing between the 1980s and 2000s from 1.25 to 1.07.

Economically inactive, unemployed and employed suicides in Australia by age and sex over a 10-year period: what was the impact of the 2007 economic recession?

BACKGROUND

Suicide is higher among economically inactive and unemployed persons than employed persons. This paper investigates differences in this relationship by sex and age over the period 2001 to 2010 in Australia. It also examines changes in suicide among employed, unemployed and economically inactive persons during the recession of 2007-09.

METHOD

Suicide data from the National Coroners Information System were utilised for this retrospective study. Negative binomial and Poisson regression was used to estimate the association between suicide and employment status and to investigate differences in suicide rates over the period of the recession (2007-09) compared with the year before the recession (2006).

RESULTS

Results suggest that during 2001-10 economically inactive/unemployed males had a suicide rate ratio (RR) of 4.62 [95% confidence interval (CI) 4.10, 5.19; P<0.001] compared with employed males (RR=1.00), whereas economically inactive/unemployed females had a suicide RR of 8.44 compared with employed females (95% CI 7.38, 9.67; P<0.001). There was an increase in suicide among both employed (7% rise in 2007, P=0.003) and economically inactive/unemployed males during the GFC (22% in 2008, P<0.001). Suicide also increased among economically inactive/unemployed females (12% in 2007, P=0.03; 19% in 2008, P=0.001) but not among employed females.

CONCLUSIONS

These results suggest the need for adequate policy and social welfare responses to ameliorate the effects of the economic recession on the working age population. Particularly, these should target unemployed and economically inactive men and women in Australia, who may be at higher risk of suicide than previously thought.

Addressing social inequality in aging by the Danish occupational social class measurement

OBJECTIVE

To present the Danish Occupational Social Class (DOSC) measurement as a measure of socioeconomic position (SEP) applicable in a late midlife population, and to analyze associations of this measure with three aging-related outcomes in midlife, adjusting for education.

METHOD

Systematic coding procedures of the DOSC measurement were applied to 7,084 participants from the Copenhagen Aging and Midlife Biobank (CAMB) survey. We examined the association of this measure of SEP with chronic conditions, self-rated health, and mobility in logistic regression analyses, adjusting for school education in the final analysis.

RESULTS

The measure of SEP showed a strong social gradient along the social classes in terms of prevalence of chronic conditions, poor self-rated health, and mobility limitations. Adjusting for school education attenuated the association only to a minor degree.

DISCUSSION

The DOSC measure was associated with aging-related outcomes in a midlife Danish population, and is, thus, well suited for future epidemiological research on social inequalities in health and aging.

A population-based case-control study on social factors and risk of testicular germ cell tumours

OBJECTIVES

Incidence rates for testicular cancer have risen over the last few decades. Findings of an association between the risk of testicular cancer and social factors are controversial. The association of testicular cancer and different indicators of social factors were examined in this study.

DESIGN

Case-control study.

SETTING

Population-based multicentre study in four German regions (city states Bremen and Hamburg, the Saarland region and the city of Essen).

PARTICIPANTS

The study included 797 control participants and 266 participants newly diagnosed with testicular cancer of which 167 cases were classified as seminoma and 99 as non-seminoma. The age of study participants ranged from 15 to 69 years.

METHODS

Social position was classified by educational attainment level, posteducational training, occupational sectors according to Erikson-Goldthorpe-Portocarrero (EGP) and the socioeconomic status (SES) on the basis of the International SocioEconomic Index of occupational status (ISEI). ORs and corresponding 95% CIs (95% CIs) were calculated for the whole study sample and for seminoma and non-seminoma separately.

RESULTS

Testicular cancer risk was modestly increased among participants with an apprenticeship (OR=1.7 (95% CI 1.0 to 2.8)) or a university degree (OR=1.6 (95% CI 0.9 to 2.8)) relative to those whose education was limited to school. Analysis of occupational sectors revealed an excess risk for farmers and farm-related occupations. No clear trend was observed for the analyses according to the ISEI-scale.

CONCLUSIONS

Social factors based on occupational measures were not a risk factor for testicular cancer in this study. The elevated risk in farmers and farm-related occupations warrants further research including analysis of occupational exposures.

Divorce and changes in the prevalence of psychotropic medication use: a register-based longitudinal study among middle-aged Finns

The annual prevalence of psychotropic medication use exceeds 10 percent in Europe and the United States, the prevalence being higher among the divorced than the married. We analysed changes in the three-month prevalence of psychotropic medication use (psycholeptics and psychoanaleptics excluding medication for dementia) by proximity to divorce, sex, medication type and socio-demographic characteristics, using register-data on 304,111 Finns between 25 and 64 years of age, of whom 23,956 divorced between 1995 and 2003 and 142,093 were continuously married from 1995 to 2004. Five years before divorce, men and women already displayed about one percentage point higher prevalence of psychotropic medication use than those who continued their marriage. The excess prevalence increased with approaching divorce and peaked six to nine months before divorce, reaching 7.3 percent (95% CI 6.8-8.0) among divorcing men and 8.1 percent (95% CI 7.5-8.8) among divorcing women. The peak was followed by an 18-month decline, after which the excess compared to the continuously married settled at nearly three percentage points. The excess was not due to being socio-economically disadvantaged, and socio-demographic factors also seemed to have few modifying effects. The changes in prevalence were largest for antidepressants and almost non-existent for antipsychotics. Our results suggest that the high prevalence of psychotropic medication use among the divorced results both from selective factors already present five years before divorce and the acute and long-term causal effects of becoming and being divorced. Counselling is needed for individuals in the process of divorce, rather than economic support for divorced individuals.

Rising unemployment and increasing spatial health inequalities in England: further extension of the North-South divide

BACKGROUND

Unemployment negatively affects health. In this study, we quantify the impact of current and rising levels of unemployment on limiting long-term illness (LLTI), mental health problems and mortality in North and South England.

METHODS

Excess cases of LLTI and mental health problems in the unemployed were calculated as the difference in the prevalence between the employed and unemployed using data from large population surveys for England. Mortality due to unemployment was calculated using the formula for the population-attributable fraction.

RESULTS

Current levels of unemployment were estimated to be causing 1145 deaths per year and a total of 221 020 cases of mental health problems and 275 409 cases of LLTI in England. Rates of mortality, mental health problems and LLTI due to unemployment were distinctively higher in the North compared with the South. Considering hidden unemployment in the calculations considerably increased the proportion of women suffering from ill health due to unemployment.

CONCLUSIONS

Our study quantifies the detrimental effect of unemployment on health in England. There is a clear difference between North and South England highlighting the contribution of unemployment to spatial health inequalities. A public health priority should be to (i) prevent unemployment in the first place and (ii) provide support for the unemployed.

The methodological and conceptual aspects of mortality studies in psychiatry

An extensive literature documented a mortality differential for natural causes between psychiatric patients and the general population. Less clear is the pattern for cancer diseases. Methodological problems arise when trying to explain such mortality gap: selection bias and reverse causation; time-dependent confounders that are also intermediate variables; complex relationships within a life course have to be considered. We try to explain such problems in terms of causal graphs. Excess risk for causes of death which are not attributable to higher prevalence of risk factors or treatment side-effects and higher mortality rates for avoidable causes have been also documented. These findings underline the need for research on health promotion and preventive programs targeted to psychiatric patients.

Health behaviours, socioeconomic status, and mortality: further analyses of the British Whitehall II and the French GAZEL prospective cohorts

BACKGROUND

Differences in morbidity and mortality between socioeconomic groups constitute one of the most consistent findings of epidemiologic research. However, research on social inequalities in health has yet to provide a comprehensive understanding of the mechanisms underlying this association. In recent analysis, we showed health behaviours, assessed longitudinally over the follow-up, to explain a major proportion of the association of socioeconomic status (SES) with mortality in the British Whitehall II study. However, whether health behaviours are equally important mediators of the SES-mortality association in different cultural settings remains unknown. In the present paper, we examine this issue in Whitehall II and another prospective European cohort, the French GAZEL study.

METHODS AND FINDINGS

We included 9,771 participants from the Whitehall II study and 17,760 from the GAZEL study. Over the follow-up (mean 19.5 y in Whitehall II and 16.5 y in GAZEL), health behaviours (smoking, alcohol consumption, diet, and physical activity), were assessed longitudinally. Occupation (in the main analysis), education, and income (supplementary analysis) were the markers of SES. The socioeconomic gradient in smoking was greater (p<0.001) in Whitehall II (odds ratio [OR] = 3.68, 95% confidence interval [CI] 3.11-4.36) than in GAZEL (OR = 1.33, 95% CI 1.18-1.49); this was also true for unhealthy diet (OR = 7.42, 95% CI 5.19-10.60 in Whitehall II and OR = 1.31, 95% CI 1.15-1.49 in GAZEL, p<0.001). Socioeconomic differences in mortality were similar in the two cohorts, a hazard ratio of 1.62 (95% CI 1.28-2.05) in Whitehall II and 1.94 in GAZEL (95% CI 1.58-2.39) for lowest versus highest occupational position. Health behaviours attenuated the association of SES with mortality by 75% (95% CI 44%-149%) in Whitehall II but only by 19% (95% CI 13%-29%) in GAZEL. Analysis using education and income yielded similar results.

CONCLUSIONS

Health behaviours were strong predictors of mortality in both cohorts but their association with SES was remarkably different. Thus, health behaviours are likely to be major contributors of socioeconomic differences in health only in contexts with a marked social characterisation of health behaviours. Please see later in the article for the Editors' Summary.

Economic difficulties and physical functioning in Finnish and British employees: contribution of social and behavioural factors

BACKGROUND

Childhood and current economic difficulties are associated with physical health. However, evidence concerning the factors underlying these associations is sparse. This study examines the contribution of a range of social and behavioural factors to associations between economic difficulties and physical functioning.

METHODS

We used comparable data on middle-aged white-collar employees from the Finnish Helsinki Health Study cohort (n = 3843) and the British Whitehall II Study cohort (n = 3052). Our health outcome was physical functioning measured by the SF-36 Physical Component Summary. Relative indices of inequality (RII), calculated using logistic regression analysis, were used to examine associations between economic difficulties and physical functioning, and the contribution of further socio-economic circumstances, health behaviours, living arrangements and work-family conflicts to these associations.

RESULTS

In age-adjusted models, childhood (RII = 1.76-3.06) and current (RII = 1.79-3.03) economic difficulties were associated with poor physical functioning in both cohorts. Further adjusting for work-family conflicts attenuated the associations of current economic difficulties with physical functioning in both cohorts, and also those of childhood economic difficulties in the Helsinki cohort. Adjustments for other socio-economic circumstances also caused some attenuation, while health behaviours and living arrangements had small or negligible effects.

CONCLUSIONS

Conflicts between work and family contribute to the associations of economic difficulties with physical functioning among employees from Finland and Britain. This suggests that supporting people to cope with economic difficulties, and efforts to improve the balance between paid work and family may help employees maintain good physical functioning.

Sex, age, deprivation and patterns in life expectancy in Quebec, Canada: a population-based study

BACKGROUND

Little research has evaluated disparities in life expectancy according to material deprivation taking into account differences across the lifespan between men and women. This study investigated age- and sex-specific life expectancy differentials related to area-level material deprivation for the province of Québec, Canada from 1989-2004.

METHODS

Age- and sex-specific life expectancy across the lifespan was calculated for three periods (1989-1992, 1995-1998, and 2001-2004) for the entire Québec population residing in 162 community groupings ranked according to decile of material deprivation. Absolute and relative measures were calculated to summarize differences between the most and least deprived deciles.

RESULTS

Life expectancy differentials between the most and least deprived deciles were greatest for men. Over time, male differentials increased for age 20 or more, with little change occurring at younger ages. For women, differentials increased across the lifespan and were comparable to men at advanced ages. Despite gains in life expectancy among men relative to women, differentials between men and women were greater for most deprived relative to least deprived deciles.

CONCLUSIONS

Similar to the US, differentials in life expectancy associated with area-level material deprivation increased steadily in Québec from 1989-2004 for males and females of all ages. Differentials were comparable between men and women at advanced ages. Previous research indicating that life expectancy differentials between most and least deprived areas are greater in men may be due to a focus on younger age groups.

Life course social mobility and risk of upper aerodigestive tract cancer in men

The aim of this study was to explore associations between social mobility and tumours of the upper aero-digestive tract (UADT), focussing on life-course transitions in social prestige (SP) based on occupational history. 1,796 cases diagnosed between 1993 and 2005 in ten European countries were compared with 1585 controls. SP was classified by the Standard International Occupational Prestige Scale (SIOPS) based on job histories. SIOPS was categorised in high (H), medium (M) and low (L). Time weighted average achieved and transitions between SP with nine trajectories: H --> H, H --> M, H --> L, M --> H, M --> M, M --> L, L --> H, L --> M and L --> L were analysed. Odds ratios (ORs) and 95%-confidence intervals [95%-CIs] were estimated with logistic regression models including age, consumption of fruits/vegetables, study centre, smoking and alcohol consumption. The adjusted OR for the lowest versus the highest of three categories (time weighted average of SP) was 1.28 [1.04-1.56]. The distance of SP widened between cases and controls during working life. The downward trajectory H --> L gave an OR of 1.71 [0.75-3.87] as compared to H --> H. Subjects with M --> M and L --> L trajectories ORs were also elevated relative to subjects with H --> H trajectories. The association between SP and UADT is not fully explained by confounding factors. Downward social trajectory during the life course may be an independent risk factor for UADT cancers.

[Selective loss of participants as a consequence of under-coverage and non-response in research among the aged: an overview]

This article presents an overview of biases in studies among the aged as a consequence of under-coverage and non-response. The question studied is whether participants and non-participants in research differed in their socioeconomic status (education; income; SES of neighbourhood), social integration (marital status; living arrangements; social participation; ethnicity) and health (general health situation; mortality in the period after study; lifestyle and risk factors, namely obesity and alcohol abuse; contact with physicians). In all, 65 studies were reviewed. The results showed that research participants had a higher socioeconomic status, were more integrated socially and in better health than research non-participants. The differences (effect sizes) were small to moderate. On the basis of these results, we can conclude that univariate distributions and prevalence estimates as well as relationships between variables in published research will frequently be biased.

Associations of multiple socio-economic circumstances with physical functioning among Finnish and British employees

BACKGROUND

To further increase our understanding of socio-economic health inequalities, we need studies considering multiple socio-economic circumstances and comparing different cultural contexts. This study compared the associations of past and present socio-economic circumstances with physical functioning between employees from Finland and Britain.

METHODS

Cross-sectional survey data from the Helsinki Health Study (n = 5866) and the Whitehall II Study (n = 3052) were used. Participants were white-collar public sector employees aged 45-60 years. Physical functioning was measured with the SF-36 physical component summary. The socio-economic indicators were parental and own education, childhood and current economic difficulties, occupational class, income, housing tenure.

RESULTS

Childhood and current economic difficulties were independently associated with physical functioning in both cohorts, although in London women childhood difficulties did not reach statistical significance. Own education was independently associated with physical functioning in Helsinki. Occupational class showed associations with physical functioning in both cohorts. These were mainly attenuated by education and income, but in London women there was a strong independent association. The association of income with physical functioning was attenuated by education (Helsinki) and occupational class (London). Parental education and housing tenure showed no consistent associations.

CONCLUSIONS

Past and present economic difficulties were independently associated with physical functioning. The conventional socio-economic indicators showed less consistent associations which were partly mediated through other indicators and modified by the national context. The associations that varied according to the indicators and between the cohorts highlight the importance of considering the multiplicity of socio-economic circumstances and comparing different cultural contexts in further studies.

Area disadvantage, individual socio-economic position, and premature cancer mortality in Australia 1998 to 2000: a multilevel analysis

OBJECTIVE

To examine associations between area and individual socio-economic characteristics and premature cancer mortality using multilevel analysis.

METHODS

We modeled cancer mortality among 25-64-year-old men and women (n = 16,340) between 1998 and 2000 in Australia. Socio-economic characteristics of Statistical Local Areas (n = 1,317) were measured using an Index of Relative Socio-economic Disadvantage (quintiles), and individual socio-economic position was measured by occupation (professionals, white and blue collar).

RESULTS

After adjustment for within-area variation in age and occupation, the probability of premature cancer mortality was highest in the most disadvantaged areas for all-cancer mortality for men (RR 1.48 95% CI 1.35-1.63) and women (RR 1.30 95% CI 1.18-1.43) and for lung cancer mortality for men (1.91 95% CI 1.63-2.25) and women (1.51 95% CI 1.04-2.18). Men in blue collar occupations had a higher rate of cancer mortality (RR 1.57 95% CI 1.50-1.65) and lung cancer mortality (RR 2.31 95 % CI 2.09-2.56), whereas men in white collar occupations had a lower all-cancer mortality rate (RR 0.78 95% CI 0.72-0.85). Compared with professionals, women in white collar occupations had an all-cancer mortality rate that was lower (RR 0.85 95% CI 0.80-0.90). When deaths from breast cancer were excluded, women in blue collar occupations had a significantly higher all-cancer mortality rate than professionals (RR 1.12 95% CI 1.02-1.22).

CONCLUSIONS

Area disadvantage and individual socio-economic position were independently associated with premature cancer mortality, suggesting that interventions to reduce inequalities should focus on places and people.

Do places affect the probability of death in Australia? A multilevel study of area-level disadvantage, individual-level socioeconomic position and all-cause mortality, 1998-2000

BACKGROUND

In Australia, studies finding an association between area-level socioeconomic disadvantage and mortality are often based on aggregate-ecological designs which confound area-level and individual-level sources of socioeconomic variation. Area-level socioeconomic differences in mortality therefore may be an artefact of varying population compositions and not the characteristics of areas as such.

OBJECTIVE

To examine the associations between area-level disadvantage and all-cause mortality before and after adjustment for within-area variation in individual-level socioeconomic position (SEP) using unlinked census and mortality-register data in a multilevel context. Setting, participants and

DESIGN

The study covers the total Australian continent for the period 1998-2000 and is based on decedents aged 25-64 years (n = 43,257). The socioeconomic characteristics of statistical local areas (SLA, n = 1317) were measured using an index of relative socioeconomic disadvantage, and individual-level SEP was measured by occupation.

RESULTS

Living in a disadvantaged SLA was associated with higher all-cause mortality after adjustment for within-SLA variation in occupation. Death rates were highest for blue-collar workers and lowest among white-collar employees. Cross-level interactions showed no convincing evidence that SLA disadvantage modified the extent of inequality in mortality between the occupation groups.

CONCLUSIONS

Multilevel analysis can be used to examine area variation in mortality using unlinked census and mortality data, therefore making it less necessary to use aggregate-ecological designs. In Australia, area-level and individual-level socioeconomic factors make an independent contribution to the probability of premature mortality. Policies and interventions to improve population health and reduce mortality inequalities should focus on places as well as people.

The Effects of Childhood Circumstances, Adult Socioeconomic Status, and Material Circumstances on Physical and Mental Functioning: A Structural Equation Modelling Approach

PURPOSE

We sought to examine the importance of childhood circumstances, adult socioeconomic status, and material circumstances to physical and mental functioning among middle-aged women and men.

METHODS

The data were collected among the employees of the City of Helsinki by mailed questionnaires from 2000 to 2002 (7148 women and 1799 men, response rate 67%). Three latent variables covering childhood circumstances, adult socioeconomic status, and material circumstances were constructed from 10 observed socioeconomic indicators. Direct and indirect effects of the latent variables on physical and mental functioning, measured by the SF-36 component summaries, were examined using structural equation modelling.

RESULTS

Childhood circumstances were not directly associated with either physical or mental functioning but had some effect through socioeconomic status. Low socioeconomic status was associated with poor physical functioning, but mental functioning was poorer among those in higher positions. Material circumstances were associated with physical and especially with mental functioning.

CONCLUSIONS

Low socioeconomic status and material circumstances are both important for physical functioning. However, mental functioning does not necessarily follow a similar socioeconomic pattern and the results are heavily influenced by how socioeconomic position is measured.

Mortality after acute myocardial infarction according to income and education

OBJECTIVE

To study how income and educational level influence mortality after acute myocardial infarction (AMI).

DESIGN AND SETTING

Prospective analysis using individual level linkage of registries in Denmark.

PARTICIPANTS

All patients 30-74 years old hospitalised for the first time with AMI in Denmark in 1995-2002.

MAIN OUTCOME MEASURES

Relative risk (RR) of 30 day mortality and long term mortality (31 days until 31 December 2003) associated with income (adjusted for education) or educational level (adjusted for income) and further adjusted for sex, age, civil status, and comorbidity.

RESULTS

The study identified 21 391 patients 30-64 years old and 16 169 patients 65-74 years old. The 30 day mortality was 7.0% among patients 30-64 years old and 15.9% among those 65-74 years old. Among patients surviving the first 30 days, the long term mortality was 9.9% and 28.3%, respectively. The adjusted RR of 30 day mortality and long term mortality among younger patients with low compared with high income was 1.54 (95% confidence interval 1.36 to 1.79) and 1.65 (1.45 to 1.85), respectively. The RR of 30 day and long term mortality among younger patients with low compared with high education was 1.24 (1.03 to 1.50) and 1.33 (1.11 to 1.59), respectively. The RR of 30 day and long term mortality among older patients with low compared with high income was 1.27 (1.15 to 1.41) and 1.38 (1.27 to 1.50), respectively. Older high and low education patients did not differ in mortality.

CONCLUSION

This study shows that both educational level and income substantially and independently affect mortality after AMI, indicating that each indicator has specific effects on mortality and that these indicators are not interchangeable.

Multiple measures of socioeconomic circumstances and common mental disorders

While serious mental disorders typically show socioeconomic differences similar to physical illness-that is, that lower positions imply poorer health-differences for common mental disorders have been inconsistent. We aim to clarify the associations and pathways between measures of socioeconomic circumstances and common mental disorders by simultaneously analysing several past and present socioeconomic measures. The data were derived from middle-aged women and men employed by the City of Helsinki. Cross-sectional surveys were conducted in 2000-2002 among employees who, during each year, reached 40, 45, 50, 55 or 60 years of age. The pooled data include 8970 respondents (80% women; response rate 67%). Common mental disorders were measured by GHQ-12 and the SF-36 mental component summary. Seven socioeconomic measures were included: parental education, childhood economic difficulties, own education, occupational class, household income, home ownership, and current economic difficulties. Logistic regression analysis was used to examine associations between the socioeconomic circumstances and common mental disorders. Past and present economic difficulties were strongly associated with common mental disorders, whereas conventional past and present socioeconomic status measures showed weak or slightly reverse associations. Adjusting for age and gradually for each socioeconomic measure did not affect the main findings, which were very similar for women and men, as well as for both measures of common mental disorders. While the associations of conventional socioeconomic status measures with common mental disorders were weak and inconsistent, our results highlight the importance of past and present economic difficulties to these disorders.

Indicators of socioeconomic position (part 1)

This glossary presents a comprehensive list of indicators of socioeconomic position used in health research. A description of what they intend to measure is given together with how data are elicited and the advantages and limitation of the indicators. The glossary is divided into two parts for journal publication but the intention is that it should be used as one piece. The second part highlights a life course approach and will be published in the next issue of the journal.

Mortality inequality in two native population groups

A sample of people aged 40-67 years, taken from a longitudinal register compiled by Statistics Finland, is used to analyse mortality differences between Swedish speakers and Finnish speakers in Finland. Finnish speakers are known to have higher death rates than Swedish speakers. The purpose is to explore whether labour-market experience and partnership status, treated as proxies for measures of variation in health-related characteristics, are related to the mortality differential. Persons who are single, disability pensioners, and those having experienced unemployment are found to have substantially higher death rates than those with a partner and employed persons. Swedish speakers have a more favourable distribution on both variables, which thus notably helps to reduce the Finnish-Swedish mortality gradient. A conclusion from this study is that future analyses on the topic should focus on mechanisms that bring a greater proportion of Finnish speakers into the groups with poor health or supposed unhealthy behaviour.

Social inequalities and cancer mortality in France, 1975-1990

OBJECTIVE

to investigate social inequalities in cancer mortality from 1975 through 1990 among men and women in France.

METHODS

A sample, that included census data for approximately 1% of the French population, has been followed for mortality from 1975 to 1990. Causes of death were obtained through a record-linkage with the French national cause-of-death file. The analysis was restricted to those aged 35:59 in 1975 and included 61,876 men and 65,291 women. Occupational class, coded according to the social class scheme of Erikson, Goldthorpe and Portecarero in 7 categories, and educational level (in 4 categories) in 1975 have been studied. The analysis has been conducted for 15 cancer sites among men and 13 among women. Analysis used a Cox proportional hazards model.

RESULTS

For educational level, inequalities among men were more pronounced for cancers of the pharynx Relative Risk (RR) lowest versus highest educational level=9.2, 95% Confidence Interval (CI) 2.9-29.1, larynx (RR=6.2, CI=3.0:12.6), oral cavity (RR=2.7, CI=1.3-5.3), lung (RR=3.5, CI=2.5-4.8), esophagus (RR=3.1, CI=1.9-5.2), stomach (RR=2.5, CI=1.2-5.3) and rectum (RR=3.4, CI=1.2-9.6). No association between educational level and cancer mortality was observed for cancers of either the colon or lymphatic and hematopoietic tissue. Social inequalities were less pronounced among women but nevertheless observed for cancer of the uterus (RR=1.9, CI=1.0-3.6), stomach (RR=4.1, CI=1.0-17.1) and lung (RR=1.6, CI=0.7-3.7). No associations were found for mortality from breast or ovarian cancers. Results were similar when socioeconomic status was measured by occupational class.

CONCLUSION

The analysis showed substantial inequalities in cancer mortality in France, with large differences according to cancer site.

Do social and economic reforms change socioeconomic inequalities in child mortality? A case study: New Zealand 1981-1999

BACKGROUND

Socioeconomic inequalities in child mortality are known to exist; however the trends in these inequalities have not been well examined. This study examines the trends in child mortality inequality between 1981 and 1999 against the background of the rapid and dramatic social and economic restructuring in New Zealand during this time period.

METHODS

Record linkage studies of census and mortality records of all New Zealand children aged 0-14 years on census night 1981, 1986, 1991, 1996, each followed up for three years for mortality between ages 1-14 years. Socioeconomic position was measured using maternal education, household income, and highest occupational class in the household. Standardised mortality rates, rate ratios, and rates differences as well as regression based measures of inequality were calculated.

RESULTS

Mortality in all socioeconomic groups fell between 1981 and 1999. Socioeconomic inequality in child mortality existed by all measures of socioeconomic position, however only trends by income suggested a change over time: the relative index of inequality increased from 1.5 in 1981-84 to 1.8 in 1996-99 (p trend 0.06), but absolute inequality remained stable (slope index of inequality 15/100 000 in 1981-84 and 14/100 000 in 1996-99.

CONCLUSIONS

Dramatic changes in income in New Zealand possibly translated into increasing relative inequality in child mortality by income, but not by education or occupational class. The a priori hypothesis that socioeconomic inequalities in child mortality would have increased in New Zealand during a period of rapid structural reform and widening income inequalities was only partly supported.

Occupational class inequalities across key domains of health: Results from the Helsinki Health Study

BACKGROUND

Studies comparing socioeconomic inequalities in health using several health indicators are scarce. Therefore, this study aims to compare the shape and magnitude of occupational class inequalities across key domains of health, i.e. the subjective, functional and medical domains. Additionally, we examine whether physical or mental workload will affect these inequalities, and whether these effects are specific to particular health indicators.

METHODS

Cross-sectional survey data from the Helsinki Health Study in 2000 and 2001 were used. Each year employees of the City of Helsinki, reaching 40, 45, 50, 55 and 60 years received a mailed questionnaire. 6243 employees responded (80% women, response rate 68%). The socioeconomic indicator was occupational social class. Nine health indicators were included: self-rated health, pain or ache, GHQ-12 mental well-being, limiting long-standing illness, SF-36 physical and mental health functioning, Rose angina symptoms, circulatory diseases and mental problems. Prevalence percentages, odds ratios and inequality indices from logistic regression analysis were calculated.

RESULTS

Occupational class inequalities were found for self-rated health, pain or ache, limiting long-standing illness, physical health functioning, angina symptoms, and circulatory diseases. Physical or mental workload did not account for these inequalities. Inequalities were non-existent or slightly reversed for GHQ-12 mental well-being, SF-36 mental health functioning and mental problems.

CONCLUSION

Expected occupational class inequalities in health among both women and men were found for global and physical health but not for mental health. The observed inequalities could not be attributed to physical or mental workload.

Socioeconomic position and self-rated health: the contribution of childhood socioeconomic circumstances, adult socioeconomic status, and material resources

OBJECTIVES

We examined socioeconomic inequalities in self-rated health by analyzing indicators of childhood socioeconomic circumstances, adult socioeconomic position, and current material resources.

METHODS

We collected data on middle-aged adults employed by the City of Helsinki (n=8970; 67% response rate). Associations between 7 socioeconomic indicators and health self-ratings of less than "good" were examined with sequential logistic regression models.

RESULTS

After adjustment for age, each socioeconomic indicator was inversely associated with self-rated health. Childhood economic difficulties, but not parental education, were associated with health independently of all other socioeconomic indicators. The associations of respondents' own education and occupational class with health remained when adjusted for other socioeconomic indicators. Home ownership and economic difficulties, but not household income, were the material indicators associated with health after full adjustment.

CONCLUSIONS

Own education and occupational class showed consistent associations with health, but the association with income disappeared after adjustment for other socioeconomic indicators. The effect of parental education on health was mediated by the respondent's own education. Both childhood and adulthood economic difficulties showed clear associations with health and with conventional socioeconomic indicators.

A comparison of socioeconomic differences in physical functioning and perceived health among male and female employees in Britain, Finland and Japan

We compared the pattern of socioeconomic inequalities in physical functioning and perceived health among male and female employees in Britain, Finland and Japan. Participants were male and female public sector employees in Britain, Finland and Japan, who were economically active and 40-60 year-olds at the time of data collection. We measured perceived health and physical functioning (SF-36 physical component summary) with standardized health questionnaires. The results obtained here reconfirm the similarity of the patterns of ill-health of those with lower socioeconomic status among non-manual men and women in Britain and Finland. These data also provide good evidence for a socioeconomic gradient in ill-health among Japanese non-manual men, although this gradient was less systematic. For Japanese men poorer health of manual workers as compared to non-manual workers was well demonstrated. However, among Japanese women socioeconomic differences in health were small and inconsistent. In conclusion, Britain, Finland and Japan--representing 'liberal', 'Nordic' and 'conservative' welfare state regimes--produce broadly similar patterns of socioeconomic differences in health among men. However, different patterns of labour force participation and welfare provision in different welfare regimes may bring about different patterns of socioeconomic differences in health for working women. This is exemplified by the lack of health inequalities among employed Japanese women.

The New Zealand Socio-economic Index of Occupational Status: methodological revision and imputation for missing data

OBJECTIVES

To revise and update the New Zealand Socio-economic Index (NZSEI) in the light of methodological issues in its construction, and to develop an imputation method for use where occupational information is not available.

METHODS

Data were drawn from the following New Zealand national surveys: 1996 Population Census; 1996/97 and 1997/98 Household Economic Surveys; 1996/97 Household Health Survey. Three sets of statistical analyses were applied: alternating least squares to generate socio-economic scores; cluster and discriminant function analyses to identify cut-points; and regression and logistic regression to develop and test imputation methods.

RESULTS

Socio-economic scores for the full-time workforce in 1996 showed a different distribution, but much the same occupational ordering, as in 1991. The introduction of part-time workers and income adjustment multipliers for self-employed workers significantly affected scores for management and agricultural titles. The application of cluster and discriminant function analyses generated six groupings that were relatively distinct occupationally. An imputation method based on an averaging of scores within age/qualification categories was found to achieve acceptable results.

CONCLUSIONS

Methodological improvements in the construction of the NZSEI have enhanced its empirical robustness, while a simple imputation technique has widened the potential application of the scale.