Measures of social class based on education for use in health studies in developing countries

Associations between Socioeconomic Status, Social Participation, and Physical Activity in Older People during the COVID-19 Pandemic: A Cross-Sectional Study in a Northern Japanese City

Physical activity (PA) is a key determinant of health in older adults. However, little is known about the effect of social factors on PA among older adults during the coronavirus disease 2019 (COVID-19) pandemic. Therefore, we aimed to clarify the association between socioeconomic status, social participation, and PA during the pandemic. A cross-sectional study was conducted on 999 community-dwelling residents aged 65-90 years. A self-administered questionnaire was used to collect socioeconomic status, social participation, and PA data in August 2020. Multivariable logistic regression analyses were used to calculate the odds ratios (ORs) for the associations between socioeconomic status, social participation, and maintaining PA. For both sexes, PA was reduced by approximately 5%-10% after the onset of COVID-19-related distancing restrictions. Men with a low socioeconomic status were less physically active (OR = 0.49, 95% CI: 0.30-0.82). Women who reported social participation had higher odds of maintaining PA (OR = 1.67, 95% CI: 1.13-2.45) during the restrictions. Higher socioeconomic status and social participation levels before the COVID-19 pandemic may have helped older adults to maintain PA during the COVID-19 pandemic. Further research is needed to clarify the potential effects of these factors on the health of older adults.

Psychosocial mechanisms of psychological health disparity in Japanese workers

Recent epidemiologic research has shown that people with higher socioeconomic status (SES) (e.g., educational attainment) have better psychological health than those with lower SES. However, the psychosocial mechanisms of underlying this relationship remain unclear. To fill this gap, the current study examines the mediating effects of job demands and job resources in the relationship between educational attainment and psychological distress. The hypothesized model was tested using large data sets from two different studies: a cross-sectional study of 9,652 Japanese employees from 12 workplaces (Study 1), and a longitudinal study of 1,957 Japanese employees (Study 2). Structural equation modeling revealed that (1) educational attainment was positively related to psychological distress through job demands, (2) educational attainment was negatively related to psychological distress through job resources, and (3) educational attainment was not directly related to psychological distress. These results suggest that educational attainment has an indirect effect, rather than a direct one, on psychological distress among workers; educational attainment had both a positive and a negative relationship to psychological distress through job demands and job resources, respectively.

Using open-ended data to enrich survey results on the meanings of self-rated health: a study among women in underprivileged communities in Beirut, Lebanon

This study extends the debate on self-rated health by using different sources of data in the same study to explore the meanings of self-rated health among women who live in socio-economically disadvantaged communities in Beirut, Lebanon. Using data from the Urban Health Study, a cross-sectional household survey of 1,869 women between 15 and 59 years of age, multiple logistic regression models were developed to assess factors associated with self-rated health. Also, open-ended data was used to analyze women's explanations of their self-rated health ratings. Self-rated health was found to be a complex concept, associated not only with physical health but also with a combination of social, psychological, and behavioral factors. This open-ended analysis revealed new meanings of self-rated health that are often not included in self-rated health epidemiologic research, such as women's experiences with pain and fatigue, as well as exposure to financial stressors and the legacy of wars. We argue that triangulating survey and open-ended data provides a better understanding of the context-specific social and cultural meanings of self-rated health.

Determinants of birthweight: gender based analysis

The objective of this cross sectional study is to look at determinants of birth weight and their association with the gender of the baby in 2,795 full term children living in the occupied Palestinian territory, derived from a stratified random sample of 2,994 households in the West Bank and 2,234 households in the Gaza Strip. The response rate was 85%. Multivariable analysis using analysis of variance for mixed models showed that sex and birth order, maternal age and education and to a lesser extent region were determinants of birth weight for all children. The effect of maternal education on birth weight differed for female and male infants, tending to be relatively unchanged for male infants and with mean birth weights increasing with maternal education in female infants. The effect of birth order differed by maternal age, with mean birth weight increasing with maternal age for first and second births; but being unaffected by maternal age for infants of birth order greater than two. We conclude that birth weight is influenced by common biological determinants across cultures, but is also influenced by social, ethnic, and environmental factors that are culture specific, of which some might be gender related.

A nationwide cohort study of educational background and major causes of death among the elderly population in Japan

BACKGROUND

This prospective cohort study examined the association between educational level and major causes of death in Japan.

METHOD

A baseline survey was conducted between 1988 and 1990 among 110,792 inhabitants of 45 areas aged 40-79 years. Follow-up surveys were conducted annually and causes of death were identified from death certificates. The analysis was restricted to 16,715 men and 23,284 women.

RESULTS

During the follow-up period (377,139 person-years), 6628 deaths were recorded. Individuals with low levels of education had an increased overall risk of death [relative risk (RR)=1.16, 95% confidence interval (CI): 1.08, 1.25, in men; RR=1.26, 95% CI: 1.14, 1.39, in women], cancers (RR=1.17, 95% CI: 1.04, 1.32, in men; RR=1.10, 95% CI: 0.93, 1.30, in women), and death from external causes (RR=1.81, 95% CI: 1.29. 2.54, in men; RR=1.78, 95% CI: 1.18, 2.70, in women). Ischemic heart disease risk was marginally reduced in men with low levels of education (RR=0.77, 95% CI: 0.58, 1.01).

CONCLUSIONS

These results show that health inequalities exist in Japan, even though wealth inequalities are relatively low. Social and political initiatives will be needed to correct these inequities between different socioeconomic statuses.

Socioeconomic factors and the risk of anencephaly in a Mexican population: a case-control study

OBJECTIVE

The study was designed to evaluate the association between socioeconomic level (as measured by maternal education, maternal occupation, and monthly family income) and anencephaly.

METHODS

The authors conducted a case-control study using data from the Epidemiological Surveillance System Register for Neural Tube Defects for three states of the Mexican Republic: Puebla, Guerrero and the State of Mexico. Mothers of 151 cases of infants born with anencephaly and mothers of 151 control infants born during the period March 2000 to February 2001 were interviewed about their socioeconomic characteristics and other factors including reproductive history, use of prenatal care, use of tobacco and alcohol, fever during pregnancy, and folic acid supplementation.

RESULTS

After adjustment for potential confounders, a risk gradient was seen with decreasing maternal education. Women with less than a primary school education (adjusted odds ratio [OR]=3.0; 95% confidence interval [CI] 1.2, 7.6) and women who had completed primary school but had not completed junior high school (adjusted OR=2.2; 95% CI 0.9, 5.7) had higher risks of giving birth to an infant with anencephaly, compared to women with a higher educational level. A monthly income < or = 1,000 pesos (approximately dollars 100 U.S.) was also associated with a higher risk of anencephaly (OR=2.5; 95% CI 1.2, 5.1). Women employed in industry or agriculture during the acute risk period (three months prior to conception to one month after conception) had a risk 6.5 times (95% CI 1.4, 29.6) that of professional and business women.

CONCLUSIONS

This study helps to identify groups that may be especially vulnerable to this type of congenital malformation so that primary and secondary preventive strategies can be targeted to these groups.

Socioeconomic and physical distance to the maternity hospital as predictors for place of delivery: an observation study from Nepal

Background

Although the debate on the safety and women's right of choice to a home delivery vs. hospital delivery continues in the developed countries, an undesirable outcome of home delivery, such as high maternal and perinatal mortality, is documented in developing countries. The objective was to study whether socio-economic factors, distance to maternity hospital, ethnicity, type and size of family, obstetric history and antenatal care received in present pregnancy affected the choice between home and hospital delivery in a developing country.

Methods

This cross-sectional study was done during June, 2001 to January 2002 in an administratively and geographically well-defined territory with a population of 88,547, stretching from urban to adjacent rural part of Kathmandu and Dhading Districts of Nepal with maximum of 5 hrs of distance from Maternity hospital. There were no intermediate level of private or government hospital or maternity homes in the study area. Interviews were carried out on 308 women who delivered within 45 days of the date of the interview with a pre-tested structured questionnaire.

Results

A distance of more than one hour to the maternity hospital (OR = 7.9), low amenity score status (OR = 4.4), low education (OR = 2.9), multi-parity (OR = 2.4), and not seeking antenatal care in the present pregnancy (OR = 4.6) were statistically significantly associated with an increased risk of home delivery. Ethnicity, obstetric history, age of mother, ritual observance of menarche, type and size of family and who is head of household were not statistically significantly associated with the place of delivery.

Conclusions

The socio-economic standing of the household was a stronger predictor of place of delivery compared to ethnicity, the internal family structure such as type and size of family, head of household, or observation of ritual days by the mother of an important event like menarche. The results suggested that mothers, who were in the low-socio-economic scale, delivered at home more frequently in a developing country like Nepal.

Inequalities in child mortality in Mozambique: differentials by parental socio-economic position

This study investigates the relation between socio-economic parental position (education and occupation) and child death in Mozambique using data from the Mozambican Demographic and Health Survey carried out between March and July 1997. The analysis included 9142 children born within 10 years before the survey. In spite of the Western system of classification used in the study, the results partly showed a parental socio-economic gradient of infant and child mortality in Mozambique. Father's education seemed to reflect the family's social standing in the Mozambique context, showing a strong statistical association with postneonatal and child mortality. However, maternal education as a measure of socio-economic position was not statistically significantly associated with child mortality. This finding may partly be explained by the extreme hardships experienced by the country (civil war and natural disasters) and the implementation of the Economic Structural Adjustment Programme that have also affected the health of women and their children during the years covered by this study. Other measures of socio-economic position applicable to the rural African setting should be investigated.

Health inequalities in Seville, Spain: use of indicators of social deprivation and mortality in small areas

OBJECTIVES

To analyse the spatial distribution of social structure and mortality in Seville, and to examine the association between various social indicators and mortality.

METHODS

Small areas of the city were typified on the basis of four social indicators, which were used to derive a social index. Overall mortality and cause of death were studied in two age groups (1+years and 1-64 years). Pearson's correlation coefficient was used to examine the relationship between the social indicators and mortality.

RESULTS

Significant social and mortality differences, particularly in premature mortality of males, were found between the areas studied. However, when the basic health zones are grouped together by social level, these differences in mortality are not so clear. The social indicators that correlate most closely with mortality are unemployment and illiteracy. When the social index is used, the correlations are weaker. Premature death from trauma in males presents the highest coefficient of correlation with unemployment and illiteracy.

CONCLUSIONS

The social index used in the present study places less emphasis on material differences than those used by Townsend et al. and Carstairs and Morris. Also, it was not possible to study mortality by individual neighbourhoods in this study. Both factors could have influenced the finding that the correlations between both types of indicator are weaker with the social index than with unemployment and illiteracy.

Women's experiences of maternity care: satisfaction or passivity?

This study is a first attempt to describe Lebanese women's responses to the medical management of their pregnancy and delivery. A qualitative approach in data collection and analysis was adopted to gain an in-depth view of women's perceptions. Women of any parity undergoing a normal vaginal delivery during the three months preceding the interview were interviewed in different areas in Lebanon: one urban, one semi-rural and two remote rural. Childbirth for all the women interviewed was managed within the medical system. Findings show that women accord total trust to their physicians, and very rarely question the usefulness of many routinely applied procedures, even those which the literature shows are unnecessary. When probed, women report that many aspects of the technical care are intimidating and that they experience discomfort with these procedures. Women are more vocal about patient-provider communication and value good interaction with their provider. The extent of passivity and feelings of discontent women have varies according to their social class and the amount of psychosocial support they receive throughout the process of childbirth.

Testing a model of family stress and coping based on war and non-war stressors, family resources and coping among Lebanese families

This study was undertaken to describe the objective stressors, perceived stress, coping, and resources of families living in Beirut during the Lebanese war (1975-1991) and to test a model predicting the relationships of these variables to family adaptation. The sample consisted of 438 families chosen at random. Independent variables included objective stressors and perceived stress. The mediating variables were family resources and coping strategies. The dependent variables were health and interactional indicators of family adaptation: physical and psychological health, depression, and interpersonal and marital relationships. Findings provided support for the theoretical framework. Multiple regression analyses revealed that perceived stress, rather than the objective occurrence of events, predicted family adaptation. Family resources, particularly social support, positively impacted family adaptation and was associated with increased use of cognitive coping. The findings provide a theoretical model which, on further testing, can serve as a basis for practice by health professionals when working with traumatized families.

Socioeconomic status and stomach cancer incidence in men: results from The Netherlands Cohort Study

STUDY OBJECTIVE

To study the association between socioeconomic status (SES) and stomach cancer incidence (cardia and non-cardia) and the role of lifestyle factors in explaining this association.

DESIGN

Prospective cohort study on diet and cancer that started in 1986. Data were collected by means of a self administered questionnaire.

SETTING

Population originating from 204 municipalities in the Netherlands.

PARTICIPANTS

58,279 men aged 55-69 years. After 4.3 years of follow up, 162 incident stomach cancer cases were detected (49 cardia and 113 non-cardia cases).

MAIN RESULTS AND CONCLUSIONS

After adjustment for age, a lower overall stomach cancer risk was found for men with the highest attained level of education (RR highest/lowest level = 0.54, 95% CI 0.33, 0.89, trend, p = 0.02). This association became less strong after additional adjustment for smoking, intake of vitamin C, beta carotene, alcohol and coffee, family history of stomach cancer, and history of stomach disorders (RR = 0.61, 95% CI 0.34, 1.07, trend, p = 0.11). No clear association was found between occupation based SES indicators and stomach cancer risk. Analyses per subsite of stomach cancer revealed that for people with the highest level of education the age adjusted rate ratio for cardia cancer changed from 0.37 (95% CI = 0.13, 1.00) to 0.60 (95% CI = 0.19, 1.87) after additional adjustment for lifestyle variables, whereas the rate ratio for non-cardia cancer (RR = 0.59, 95% CI 0.33, 1.05) did not change after additional adjustment.

Patient-doctor communication in cross-national perspective. A study in Mexico

The authors assessed the cross-national replicability previously used to study medical encounters in the United States by adapting them to Mexico. The main research questions focused on information-giving, gender and social class differences in communication, and attention to socioemotional concerns in primary encounters. Sixty-two primary care encounters were audiotaped. Questionnaires were translated into Spanish, then translated back into English. Coding and transcription techniques were taught to Spanish-speaking researchers. Measures of communication were treated as dependent variables and were related by nonparametric statistical analyses to characteristics of physicians, patients, and clinical settings. Doctors in Mexico spent an average of 2.1 minutes (+/- 1.7 standard deviation [SD]), or 16.7% (+/- 10.7 SD) of total interaction time, in information-giving. Mexican doctors asked an average of 27.3 questions per encounter (+/- 18.0 SD), whereas patients asked an average of 1.5 questions (+/- 2.0 SD). Substantial interphysician variability was observed in total time of interaction (Kruskal-Wallis analysis of variance, chi-square = 27.2, P = 0.000), physician time in information giving (chi-square = 16.4, P = 0.022), and physician questions (chi-square = 36.7, P = 0.000). Patient characteristics associated with physician information-giving included male gender (chi-square = 4.1, P = 0.04) and age (Kendall's tau-b = .17, P = 0.05) but not education (tau-b = .08, P = 0.41). Information-giving in public clinics did not differ from that in private practices (chi-square = 0.0, P = 0.91). A bootstrap approach to multiple nonlinear regression permitted additional analysis of physicians', patients', and situational characteristics in explaining measures of patient-doctor communication; this analysis further demonstrated the importance of interphysician variability in communicative behavior. Previous methods for studying patient-doctor communication can be adapted and replicated in a non-English-speaking society. With certain exceptions, findings from Mexico were similar to those obtained in the United States.

[Anemia and malnutrition in children at public schools in Osasco, São Paulo, Brazil]

The authors studied a sample of students entering the first grade in the Osasco public school system in order to determine both the prevalence of anemia and nutritional status. Osasco is part of the Greater S o Paulo Metropolitan Area. Diagnosis of anemia was made through the hemoglobin concentration of blood from digital puncture. World Health Organization (WHO) levels were used to define anemia. Nutritional Status assessment. was made through weight/age and height/age indices, using Z score distribution and the National Center for Health Statistics (NCHS) reference levels. Prevalence of anemia was 51%. Prevalence levels varied according to the schools' geographic location: 56.9% in peripheral neighborhoods and 41.7% in central areas. Children with illiterate parents had a higher prevalence of this condition. Risk of anemia was higher for children who were over eight years of age when entering the first grade. Acute malnutrition was not found. Prevalence was higher than expected and points to the urgent need to establish an anemia control program for schoolchildren in this population.

Differences in cancer incidence and mortality among socio-economic groups

OBJECTIVES

In this article studies on the association between socioeconomic status (SES) and risk for cancer at different sites are reviewed.

METHODS

The review is restricted to studies conducted in affluent societies, after 1970. Only studies using income, education and/or occupation as SES indicators are included.

RESULTS

A more or less consistent positive association between SES and cancer risk was found for colon and breast cancer. More or less consistent inverse associations were found for lung, stomach, oropharyngeal and esophageal cancer. Inconsistent associations were reported for cancer of the rectum and pancreas. Possible explanations for SES differences in cancer risk are discussed with special emphasis on lifestyle variables related to cancer risk.

CONCLUSIONS

It is concluded that it is still unclear whether the reported associations can be (partially) attributed to lifestyle related risk factors for cancer such as smoking, nutritional habits, drinking habits and reproductive factors.

Socioeconomic status and colon cancer incidence: a prospective cohort study

The association between socioeconomic status and colon cancer was investigated in a prospective cohort study that started in 1986 in The Netherlands among 120,852 men and women aged 55-69 years. At baseline, data on socioeconomic status, alcohol consumption and other dietary and non-dietary covariates were collected by means of a self-administered questionnaire. For data analysis a case-cohort approach was used, in which the person-years at risk were estimated using a randomly selected subcohort (1688 men and 1812 women). After 3.3 years of follow-up, 312 incident colon cancer cases were detected: 157 men and 155 women. After adjustment for age, we found a positive association between colon cancer risk and highest level of education (trend P = 0.13) and social standing (trend P = 0.008) for men. Also, male, upper white-collar workers had a higher colon cancer risk than blue-collar workers (RR = 1.42, 95% CI 0.95-2.11). Only the significant association between social standing and colon cancer risk persisted after additional adjustment for other risk factors for colon cancer (trend P = 0.005), but the higher risk was only found in the highest social standing category (RR highest/lowest social standing = 2.60, 95% CI 1.31-5.14). In women, there were no clear associations between the socioeconomic status indicators and colon cancer.

Lung cancer: is there an association with socioeconomic status in The Netherlands?

STUDY OBJECTIVE

To evaluate if there are differences in lung cancer incidence between socioeconomic groups in the Netherlands and if so, if smoking habits and other lifestyle characteristics could explain these differences.

DESIGN

Prospective cohort study. Baseline measurement included information on socioeconomic status, smoking habits, and other covariates by means of a self-administered questionnaire. Follow up was established by computerised record linkage to cancer registries and a pathology register.

SETTING

Population originating from 204 municipalities in The Netherlands.

PARTICIPANTS

58,279 men aged 55-69 years in September 1986. After 3.3 years of follow up 490 microscopically confirmed incident lung cancer cases were detected.

MAIN RESULTS

An inverse association between lung cancer risk and highest level of education was found, which persisted after adjustment for age, smoking, dietary intake of vitamin C, beta-carotene and retinol (rate ratio (RR) highest/lowest level of education = 0.52, 95% CI 0.33, 0.82, trend p < 0.001). Men with a lower white collar profession had a significantly lower relative rate of lung cancer compared with blue collar workers (RR = 0.66, 95% CI 0.47, 0.96), but after adjustment for smoking habits this difference was reduced (RR = 0.73, 95% CI 0.51, 1.08).

CONCLUSIONS

There is an inverse association between highest level of education and lung cancer, which is still apparent after adjustment for age, smoking, dietary intake of vitamin C, beta-carotene and retinol. The significantly lower lung cancer risk of lower white collar workers compared with the risk of blue collar workers could be partially explained by smoking habits.

Measures of socioeconomic status for child health research: comparative results from Bangladesh and Pakistan

This paper examines the reliability and validity of several hypothesized indicators of socioeconomic status for use in epidemiologic research, particularly in studies of child health in the less developed world. Population-based surveys of child health and disability were completed in Bangladesh and Pakistan using standard questionnaires designed to measure four domains of household socioeconomic status: wealth, housing, parental education and occupation. Test-retest data indicate moderate to excellent reliability of most of the socioeconomic indicators in both countries. Loadings from factor analyses of the survey data provide further evidence of the reliability of the data, and confirm that the questionnaire measures housing and wealth as distinct domains in both countries. Parental education and occupation are correlated with housing and/or wealth in these data sets. Bivariate logistic regression analyses show that, although 11 of 12 dichotomous indicators of low socioeconomic status constructed from the data are predictive of child death in at least one of the four sub-populations studied (rural and urban Bangladesh, and rural and urban areas of Karachi, Pakistan), no single indicator is predictive of child death in all four sub-populations. These along with multivariate results demonstrate the importance of including multiple measures of distinct domains if the research aims include investigation and/or control of the effects of socioeconomic status on health in diverse populations.

Education and mortality from cancer in São Paulo, Brazil

This study investigated social class differentials in cancer mortality in São Paulo county, Brazil, for the period 1978 to 1982. A measure of socioeconomic status based on education was used, and cancer risk by level of education was estimated by a case-control approach in which other cancers were considered as controls. For most cancers, the socioeconomic differences in risk were similar to those found in western Europe and North America. For lung cancer, however, the highest risk was observed in men and women with the most education. Other cancers related to tobacco--cancer of the larynx, pharynx, and esophagus--showed a negative association with education. The differences between social classes in consumption habits of alcohol and maté and the use of black tobacco are probably responsible for these contrasting patterns. For breast and cervix uteri cancer the social class patterns were similar to those found in developed countries--a positive relationship for breast and a negative one for cervix uteri cancer. The magnitude of the differences observed between social classes for these cancers was frequently greater in South America than in the United States or western Europe.