Possible Risk Factors and Their Potential Associations with Combined Heavy Metal Exposures in Pregnant Women in the Republic of Suriname

Background

The exposure of pregnant women to multiple environmental pollutants may be more disadvantageous to birth outcomes when compared to single-compound contaminations.

Objective

This study investigated the mixed exposures to mercury, manganese, or lead in 380 pregnant Surinamese women. The factors that might be associated with the heavy metal exposures and the relative risk of the potential factors to cause the mixed exposures were explored. The influencing factors of exposures to mixed contaminants assessed were living in Suriname's rural regions, several parts of which are contaminated with heavy metals emitted from artisanal and small-scale gold mining and agricultural activities; the consumption of potentially contaminated foods; advanced maternal age; as well as a relatively low formal educational level and monthly household income.

Methods

Descriptive statistics were used to calculate frequency distributions and χ2-contingency analyses to calculate associations and relative risks (RR) with 95% confidence intervals (CI).

Findings

Blood levels of two or three of the heavy metals above public health limits were observed in 36% of the women. These women were more often residing in the rural regions, primarily consumed potentially contaminated food items, were 35 years or older, were lower educated, and more often had a lower household income. However, only living in the rural regions (RR = 1.48; 95% CI 1.23-1.77) and a low household income (RR = 1.38; 95% CI 1.15-1.66) significantly increased the risk of exposure exceeding levels of concern to two or three of the heavy metals (by 48% and 38%, respectively).

Conclusion

More comprehensive pharmacological, ecological, and epidemiological studies about exposures to mixed heavy metal contaminations in pregnant women are warranted.

The impact of income level on skeletal muscle health in rural Chinese older residents: a study of mediating effects based on dietary knowledge

China's rural residents have basically solved the problem of subsistence, but due to aging, the prevalence of sarcopenia (abbreviated as sarcopenia) has been increasing year by year, especially the skeletal muscle health of the rural older residents has not been sufficiently paid attention to, so analyses of the impact of income level on the skeletal muscle health of the older people in rural areas of China are of great practical significance. Based on the annual data of the China Health and Nutrition Survey (CHNS) in 2006, 2009, and 2011, we introduced the mediator variable of dietary knowledge and used the Probit model regression, mediation effect model, and instrumental variable regression to assess the skeletal muscle health status of the rural older people in China and explore the mechanism of the influence of the income level on the skeletal muscle health of the rural older residents in China. The primary objectives of this study were to evaluate the impact of income level on the skeletal muscle health status of older adults living in rural areas of China and to investigate the underlying mechanisms. By analyzing the findings of this study, our aim is to establish a correlation between the economic status and skeletal muscle health of older adults in rural communities, as well as elucidate the influence of income level and dietary knowledge on their skeletal muscle health. Through the attainment of these objectives, we hope to provide valuable insights and recommendations for enhancing skeletal muscle health among the rural older population in China. Based on our research findings, it can be inferred that there was a significant association between the financial status of rural older adults and their skeletal muscle health. Additionally, the prevalence of sarcopenia was lower among individuals with higher income levels, and there was a negative correlation between the prevalence of sarcopenia and the level of dietary knowledge among rural older individuals. The knowledge of dietary knowledge level of rural older people plays a mediating role in the income level and the prevalence of sarcopenia. Moreover, with the change in income level and the increase in age, the change in skeletal muscle health status showed obvious heterogeneity, in which the effect on the relatively younger (65-70 years old) samples was greater. Therefore, sustained income growth remains an effective way to improve the skeletal muscle health of older rural residents. At the same time, improving dietary knowledge and dietary quality among the older people is important in preventing a decline in muscle strength and physical function and in preventing the onset of sarcopenia.

Impact of filial piety on residents' subjective well-being in China considering the moderating effect of income level

Subjective well-being (SWB) reflects an individual's subjective evaluation of overall life satisfaction and healthcare situation. As one of the most important concepts in traditional Chinese culture, filial piety refers to an ancient and significant ethical concept that originates from traditional Chinese culture. Filial piety emphasizes the respect, care, and filial devotion of children towards their parents, and has a complex influence on SWB. Moreover, in the context of rapid economic development, an individual's income level significantly moderates the influence of filial piety. Revealing the influence of different types of filial piety on SWB is of great significance for enhancing residents' SWB. However, existing studies rarely touch upon this topic. Therefore, this paper focuses on the 7 kinds of filial piety, establishes an ordered logit model based on the data from the China General Social Survey, and analyzes the influence of these 7 kinds of filial piety on SWB. On this basis, this study analyzes the moderating effect of income level. Finally, it further analyzes the regional heterogeneity of China in the influence of filial piety. Concepts such as constant respect for father's authority, enhancing parents' honor, and bearing sons for the purpose of lineage continuity, have negative impact on SWB. Superior economic conditions can neutralize and salvage these concepts to a certain extent, but they are ultimately negative. In regions with a minority population such as the 4 northeastern provinces, Inner Mongolia, Gansu, Ningxia, and Xinjiang, these concepts can increase SWB, which is restricted by the local economic level and might just be a transitional form of insufficient development. appreciating the kindness of upbringing; treating parents well under any circumstances; giving up personal ambitions to fulfill parents' wishes, positively influence individual SWB, especially when income is substantial. The research results indicate that different type of filial piety has different impacts on SWB; income level has a significant moderating effect; and there are significant regional heterogeneities in the influence of filial piety. The results of this study provide a theoretical basis and reference for enhancing residents' SWB.

Association between overtime and depressive symptoms among Chinese employees

Objectives

This study examines the correlation between overtime and depressive symptoms, and analyzed the moderating effect of age, education level, and income level on their correlation by using a nationally representative sample from the Chinese Family Panel Studies (CFPS) in 2018.

Methods

Participants are divided into three groups: 30-44 h/week, 44.1-61.9 h/week (defined as overtime group), and ≥ 62 h/week (heavy overtime group). The multiple ordered logistic regression models are conducted to estimate the association between overtime and depressive symptoms. The interaction term of overtime and moderators including age, education level, and income level are introduced into the models to test the moderating effect.

Results

The overtime group have an increased probability of depressive symptoms (OR = 1.11, 95% CI 1.04-1.20) compared with those who reported working hours 30-44 h/week, after controlling for important confounders. What's more, the worsening of depressive symptoms is more pronounced in the heavy overtime group (OR = 1.32, 95% CI 1.22-1.44). The moderating effect results show that younger employees, employees with high education levels, and those with high income level are more likely to be affected by the negative effects of overtime.

Conclusion

Working overtime increased the likelihood of depressive symptoms. Younger employees, high-educated employees and employees with high income level are more vulnerable to the negative effects of overtime on mental health.

Equal Opportunities in Aging: Income Level Moderates the Relationship Between Infrequent Participation in Formal Social Activities and Loneliness Among Older Adults

Infrequent participation in formal social activities among older adults increases the risk of loneliness. We examined whether a higher income level moderates the relationship between infrequent participation and loneliness. Utilizing data from wave #6 of the European Health, Aging, and Retirement Survey, we included participants aged 65+ (i.e., older adults), non-participants in the labor force (N = 24 819). Loneliness was measured by the R-UCLA loneliness questionnaire, formal social activity by participation frequency in volunteer/charity activities, educational course/training, sports/social/other clubs, and political/community organizations. Hierarchical multiple regression models examined relationships between variables, controlled by country. Infrequent participation in formal social activity associated with higher risk of loneliness. However, income moderated the association between participation and loneliness; infrequently participating older adults with low-to-moderate income were more vulnerable to loneliness than higher income older adults, for whom infrequent participation did not increase loneliness. This reinforces the need to encourage formal social activity with subsidy for low-to-moderate income older adults.

Ultra-processed food consumption in Argentina according to income level and its association with the intake of healthy foods

Ultra-processed foods (UPFs) are associated with unhealthy diets and chronic diseases. Hence, knowing the consumption pattern of UPFs in the general population is crucial to design policies to improve public health, such as the recently approved law for the Promotion of Healthy Eating in Argentina (Law N° 27.642). The aim of the study was to characterise the consumption of UPFs according to income level and to assess their association with the intake of healthy foods in the Argentinian population. Healthy foods were defined in this study as those non-UPF groups that have been shown to reduce the risk of non-communicable diseases and excluded certain natural or minimally processed foods such as red meat, poultry and eggs. We retrieved data from the 2018-2019 National Nutrition and Health Survey (ENNyS 2), a cross-sectional, nationally representative survey performed in Argentina, including 15 595 inhabitants. We classified the 1040 food items recorded by the degree of processing using the NOVA system. UPFs represented nearly 26% of daily energy. The intake of UPFs increased with income, with a difference of up to 5 percentage points between the lowest (24%) and the highest (29%) income levels (p < 0.001). Cookies, industrial pastries, cakes and sugar-sweetened beverages were the most consumed UPF items, accounting for 10% of daily energy intake. We found that UPF intake was associated with a decrease in consumption of healthy food groups, mainly fruits and vegetables, where a difference of -28.3 g/2000 kcal and -62.3 g/2000 kcal between tertile 1 and tertile 3 was estimated, respectively. Therefore, Argentina still maintains a UPF consumption pattern of a low- and middle-income country, where UPF intake increases with income, but these foods also compete with the intake of healthy foods.

Domestic violence victimization among Chinese women and its relevance to their economic power

Introduction

This study conducted a survey of domestic violence victimization among women in China. Previously little research has been conducted on the subject of domestic violence against Chinese women as well as its relevance to their own economic power.

Methods

Using online questionnaires, this study collected data about 412 women with current or previous marital status who came from four income brackets in Beijing and Shanghai.

Results

It revealed that the proportions of physical, emotional, economic, and sexual violence they experienced were about 27.91%, 62.38%, 21.12%, and 30.10%, respectively. Women belonging to the highest income bracket faced almost the same risk of domestic violence compared with other income groups. Furthermore, there was a slight upward tendency in physical and emotional violence victimization in the highest-income group. The binary logistic regression analysis showed that adverse childhood experiences, arguments between couples due to different opinions regarding gender ideologies, and the approval level for specific gender ideologies were common significant factors across different income brackets. When all income brackets were considered, a higher income was tested as a protective factor with regard to sexual violence. As for the income gap between couples, women whose incomes were "once higher than that of the husband but now lower/almost the same" or "always higher than that of the husband" faced a higher risk of physical violence than women whose incomes were "always lower than/almost the same as that of the husband."

Discussion

This study not only revealed the reality of domestic violence victimization in China but also suggested that more attention should be paid to high-income women's domestic violence victimization as well as the importance of helping them both through academia and domestic violence support institutions.

The impact of public health expenditure and gross domestic product per capita on the risk of catastrophic health expenditures for OECD countries

Introduction

Catastrophic health expenditure refers to situations where households face financial ruin due to high healthcare costs. For household spending on health services, the lack of pre-payment mechanisms to equalize the low payment capacity and risk, and the inability of countries' health financing systems to fulfill their duties adequately all contribute to the creation or increase of the risk of catastrophic health expenditure. This situation has devastating effects on poor households first, but if the prevention mechanisms are insouciant, it can threaten the health system of the entire country. The research aims to assess the impact of the pre-paid financing model implementations and income levels on the ability of countries to reduce the risk of catastrophic health expenditure.

Methods

The paragraph explains the data used in the study, which is taken from OECD countries between 2003 and 2019. It also mentions the statistical models used in the study, which are static and dynamic panel regression models.

Results

The findings indicate that pre-paid financing models, such as those based on taxation, can help reduce the risk of catastrophic health expenditure. The study also reveals that income levels play a role in this regard, with countries with higher incomes being better able to reduce the risk of catastrophic health expenditure.

Discussion

The study suggests that healthcare financing systems should aim to provide effective services and financial protection to improve universal health coverage and reduce the risk of catastrophic health expenditure. Further researches using different health indicators and inputs could add to the existing literature on how to limit catastrophic health expenses and address other related questions.

Exploring the Relationship between Sugar and Sugar Substitutes-Analysis of Income Level and Beverage Consumption Market Pattern Based on the Perspective of Healthy China

This paper estimates the impact of income level on household beverage consumption, analyzes the consumption trends of sugar-sweetened beverages and sugar-free beverages in households, explores the future changes in the beverage consumption market pattern, and predicts the possible impact of the sugar industry on the development of sugar substitutes based on the beverage consumption data of Kantar Consumer Index in China from 2015 to 2017. The research results show that, firstly, there is an "inverted U-shaped" relationship between income level and household consumption of sugar-sweetened beverages, which indicates that as income rises, household consumption of sugar-sweetened beverages tends to increase and then decrease. Secondly, income level has a positive effect on the household consumption of sugar-free beverages. Finally, in the future stage, with the further growth of income and the promotion of a healthy China, a large amount of sugar substitutes will be added to beverages instead of the original sugar, and the relationship between sugar and sugar substitute consumption will change from complementary to substitution. The findings of this paper have implications for encouraging food and beverage suppliers to produce "healthy", "nutritious" and "innovative" low-sugar products to meet the health needs of residents and ensure the healthy and orderly development of the sugar industry.

Relationship between Nutrient Intake and Hearing Loss According to the Income Level of Working-Aged Adults: A Korean National Health and Nutrition Survey

The relationship between hearing impairment and nutrition has been extensively investigated; however, few studies have focused on this topic in working-age adults by income level. Herein, we aimed to determine the differences in hearing impairment among working-age adults by income level and identify the nutritional factors that affect hearing loss in various socioeconomic groups. Seven-hundred-and-twenty participants had hearing impairment, while 10,130 had normal hearing. After adjustment for propensity score matching, income and smoking status were identified as significant variables. By assessing the relationship between hearing impairment and nutrient intake by income level using multiple regression analyses, significant nutrients differed for each income category. Carbohydrate and vitamin C levels were significant in the low-income group; protein, fat, and vitamin B1 levels were significant in the middle-income group; and carbohydrates were significant in the high-income group. Income was significantly associated with hearing impairment in working-age adults. The proportion of individuals with hearing impairment increased as income decreased. The association between hearing impairment and nutritional intake also differed by income level. Our findings may enable the establishment of health policies for preventing hearing impairment in working-age adults by income level.

Psychological Capital and Job Satisfaction Among Chinese Residents: A Moderated Mediation of Organizational Identification and Income Level

The present study examined the mediating effect of organizational identification on the relationship between psychological capital and job satisfaction, and whether the mediation was moderated by income level. A total of 310 Chinese residents were surveyed using the Psychological Capital Scale, Organizational Identification Scale, Job Satisfaction Scale, and a demographic questionnaire. The findings showed a significant positive correlation between psychological capital and job satisfaction of residents, and this relationship was partially mediated by organizational identification. Moreover, income level played a moderating role in the relationship between organizational identification and job satisfaction. For residents with more income, their organizational identification influenced their job satisfaction more strongly than those with less income. The current study contributes to a better understanding of the relationship between psychological capital and job satisfaction. Implications for resident management and policymaking are discussed.

Disparities in COVID-19 Vaccination among Low-, Middle-, and High-Income Countries: The Mediating Role of Vaccination Policy

Inequity in the access to and deployment of the coronavirus disease 2019 (COVID-19) vaccines has brought about great challenges in terms of resolving the pandemic. Aiming to analyze the association between country income level and COVID-19 vaccination coverage and explore the mediating role of vaccination policy, we conducted a cross-sectional ecological study. The dependent variable was COVID-19 vaccination coverage in 138 countries as of May 31, 2021. A single-mediator model based on structural equation modeling was developed to analyze mediation effects in different country income groups. Compared with high-income countries, upper-middle- (β = -1.44, 95% CI: -1.86--1.02, p < 0.001), lower-middle- (β = -2.24, 95% CI: -2.67--1.82, p < 0.001), and low- (β = -4.05, 95% CI: -4.59--3.51, p < 0.001) income countries had lower vaccination coverage. Vaccination policies mediated 14.6% and 15.6% of the effect in upper-middle- (β = -0.21, 95% CI: -0.39--0.03, p = 0.020) and lower-middle- (β = -0.35, 95% CI: -0.56--0.13, p = 0.002) income countries, respectively, whereas the mediation effect was not significant in low-income countries (β = -0.21, 95% CI: -0.43-0.01, p = 0.062). The results were similar after adjusting for demographic structure and underlying health conditions. Income disparity remains an important cause of vaccine inequity, and the tendency toward "vaccine nationalism" restricts the functioning of the global vaccine allocation framework. Stronger mechanisms are needed to foster countries' political will to promote vaccine equity.

A bibliometric analysis of food safety governance research from 1999 to 2019

Although the number of food governance-related studies increased rapidly in the recent decade, the current academic research still lacked systematic integration of food safety governance. To clarify the development trends of research therein, this study summarized research articles concerning food safety governance by the Web of Science Core Collection. An in-depth bibliometric analysis was then conducted through CiteSpace to summarize the current characters and hot spots of food safety governance research, and predicted future research trends. Results showed that food safety governance was multidisciplinary, which included environmental science, food science, economics, and agriculture. The United States had the largest number of relevant articles, and Wageningen University was the most influential scientific research institution. Among all the journals in this field, Food Policy ranked the first in publication volume and co-citation frequency. The development of food safety governance research was divided into three processes, namely the separate formulation of the standards for public and private sectors, the joint implementation of these standards, and co-governance by multiple sectors. The most popular research hot spots in this field were food safety policy integration and public-private partnership of food safety governance. Lower- and middle-income countries focused more on food supply and food system design, and regrettably not on food safety. Higher-income countries cared more about food safety and food nutrition. Besides, researchers of higher-income countries also concentrated on consumers' voices in participating in food safety governance. Food safety co-governance, online food governance, the willingness to buy safe food, and food safety governance under pandemics were considered as future research directions.

Differential characteristics and treatment of psoriasis patients by economic status in South Korea: An analysis of the National Health Insurance Database

Despite the enormous burden on patients with severe psoriasis, their utilization of medical care is not well understood in Korea.To compare the characteristics and treatment patterns of psoriasis patients by economic status as well as to examine the factors influencing systemic treatments of psoriasis.We conducted a descriptive cross-sectional study using National Health Insurance sample cohort data in 2015. Psoriasis patients were classified as either the "topical treatment only" or the "systemic treatment" group based on the types of treatment. Patients' economic status was defined by the deciles of health insurance premium, which was determined based on income and assets. Multivariate logistic regression analysis was performed to examine the factors influencing systemic treatments of psoriasis.We identified 6041 psoriasis patients; 39.5% were in the bottom 5 deciles of health insurance premium and 60.5% were in the top 5 deciles. Only 1.9% of the low economic status group and 4.0% of the high economic status group were treated with expensive biologics, although the difference was not statistically significant.Overall, psoriasis patients with higher economic status had a lower likelihood of receiving systemic treatments but had a higher probability of being treated with expensive biologics.

Effect of per Capita Income on the Relationship between Periodontal Disease during Pregnancy and the Risk of Preterm Birth and Low Birth Weight Newborn. Systematic Review and Meta-Analysis

This work analyzed the available evidence in the scientific literature about the risk of preterm birth and/or giving birth to low birth weight newborns in pregnant women with periodontal disease. A systematic search was carried out in three databases for observational cohort studies that related periodontal disease in pregnant women with the risk of preterm delivery and/or low birth weight, and that gave their results in relative risk (RR) values. Eleven articles were found, meeting the inclusion criteria. Statistically significant values were obtained regarding the risk of preterm birth in pregnant women with periodontitis (RR = 1.67 (1.17–2.38), 95% confidence interval (CI)), and low birth weight (RR = 2.53 (1.61–3.98) 95% CI). When a meta-regression was carried out to relate these results to the income level of each country, statistically significant results were also obtained; on the one hand, for preterm birth, a RR = 1.8 (1.43–2.27) 95% CI was obtained and, on the other hand, for low birth weight, RR = 2.9 (1.98–4.26) 95% CI. A statistically significant association of periodontitis, and the two childbirth complications studied was found, when studying the association between these results and the country’s per capita income level. However, more studies and clinical trials are needed in this regard to confirm the conclusions obtained.

Effect of Income Level and Perception of Susceptibility and Severity of COVID-19 on Stay-at-Home Preventive Behavior in a Group of Older Adults in Mexico City

Early information on public health behaviors adopted to prevent the spread of coronavirus (COVID-19) may be useful in controlling the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) transmission. The objective of this study was to assess the role of income level (IL) and the perception of older adults, regarding COVID-19 susceptibility and severity, on adopting stay-at-home preventive behavior during the first week of the outbreak in Mexico. Participants in this cross-sectional study were urban community dwellers, aged ≥ 65 years from Mexico City. A total of 380 interviews were conducted over the phone. The mean respondent age was 72.9 years, and 76.1% were women. Over half (54.2%) of the participants perceived their susceptibility to COVID-19 as very low or low. Similarly, 33.4% perceived COVID-19 severity as being very low or low, and 57.6% had decided to stay at home: this behavior was associated with IL (β = 1.05, p < 0.001), and its total effect was partially mediated (15.1%) by perceived severity. Educational attainment was also associated with staying at home (β = 0.10, p = 0.018) and its total effect was partially mediated (15.0%) by perceived susceptibility. Interventions aimed at low income and less educated older adults should be developed to improve preventive behaviors in this vulnerable group during the COVID-19 pandemic.

Impact of pneumococcal conjugate vaccine uptake on childhood pneumonia mortality across income levels in Brazil, Colombia, and Peru

Background: Pneumococcal conjugate vaccines (PCVs) have prevented deaths due to pneumonia among children. The effect may differ between higher- and lower-income populations due to various factors, such as differences in the distribution of pneumococcal serotypes, healthcare access, and PCV uptake. This study aims to evaluate an association between increasing PCV coverage and population-level declines in death due to pneumonia and its variation by socioeconomic status of subnational regions.

Methods: We analyzed municipality-level mortality data from 2005 and 2015 for children aged 2-23 months in Brazil, Colombia, and Peru. We fit Poisson regression models to estimate the relationship between changes in PCV uptake and deaths due to all-cause pneumonia among subnational regions with different income levels. We controlled for changes unrelated to PCV by using data on non-respiratory deaths over time.

Results: Uptake of the third dose of PCV varied across subnational regions and was higher in high-income regions. Higher uptake of PCV was associated with larger declines in pneumonia mortality. This association did not differ by income level of the region in Brazil and Colombia. In Peru, low-income regions observed larger declines in pneumonia deaths, but there was large uncertainty in the difference between the low- and high-income regions. We estimated that, with 90% coverage, there would be 4-38% declines in all-cause pneumonia mortality across income levels and countries.

Conclusions: Regions with higher PCV coverage experienced larger declines in pneumonia deaths, regardless of the income level. Having more reliable data on mortality records and vaccine uptake would improve the reliability of vaccine impact estimates.

Per-Prescription Drug Expenditure by Source of Payment and Income Level in the United States, 1997 to 2015

OBJECTIVES

To evaluate expenditures and sources of payment for prescription drugs in the United States from 1997 to 2015.

METHODS

The Medical Expenditures Panel Survey (MEPS) was used for this analysis. Individuals with one or more prescription medicines were eligible for inclusion. Outcomes were the inflation-adjusted cost per prescription across all payment sources (self or family, public, private, and other sources) before and after the Medicare Part D benefit and the Affordable Care Act.

RESULTS

The cost per prescription increased from $38.56 in 1997 to $73.34 in 2015. Nevertheless, consumers' out-of-pocket expenditures decreased from $18.19 to $9.61, whereas public program expenditures per prescription increased from $5.61 to $34.43 over this time. Out-of-pocket expenditures of individuals in the low-income group and near-poor group had larger declined percentages from 51.4% to 20.4% and 46.5% to 17.2% relative to individuals in higher-income groups before and after implementation of the Medicare Part D, respectively. Over 90% prescription purchases were covered by medical insurance by 2015. The per-prescription cost for medications consumed by uninsured individuals increased at a lower rate from $31.83 to $54.96 versus $40.12 to $75.58 for privately insured and $36.00 to $70.96 for publicly insured (P < .001).

CONCLUSIONS

Prescription drugs expenditures have increased over the past 2 decades, but public sources now pay for a growing proportion of prescription drugs cost regardless of health insurance coverage or income level. Out-of-pocket expenditures have significantly decreased for persons with lower incomes since the implementation of Medicare Part D and the Affordable Care Act.

HPV-vaccination and cancer cervical screening in 53 WHO European Countries: An update on prevention programs according to income level

Human papillomavirus (HPV) is the most common sexually transmitted disease in the world. The aim of our study is to describe the differences in HPV‐vaccination coverage and screening programs in WHO European Countries notably according to income levels. Multiple correspondence analysis was applied to examine the association among the following variables: Gross National Income (GNI) levels (Lower‐Middle Income, LMI; Upper‐Middle Income, UMI; and High Income, HI); type of CC screening program (coverage; opportunistic/organized); vaccination payment policies (free or partial or total charge); mortality rates/100 000 (≤3; >3‐6; >6‐9; >9); incidence rates/100 000 (≤7; >7‐15; >15‐21; >21). Data HPV‐vaccination start (years) (2006‐2008; 2009‐2011; 2012‐2014; >2014; no program); coverage HPV‐vaccination percentage (≤25; 26‐50; 51‐75; >75); data screening start (years) (<1960; 1960‐1980; 1981‐2000; >2000); primary screening test (HPV, cytology), and screening coverage percentage (≤25; >25‐50; >50‐75; >75). A high income is associated with: start of screening before 1960, medium‐high screening coverage, organized screening, start of vaccination in the periods 2009‐2011 and 2012‐2014 and high immunization coverage. On the other hand, lower‐middle income is associated with: late start of vaccination and screening programs with cytology as primary test, high mortality and incidence rates and lower‐medium vaccination coverage. Our results show a useful scenario for crucial support to public health decision‐makers. Public health authorities should monitor the HPV‐vaccinated population in order to determine more precisely the effects on short‐ and long‐term incidence and mortality rates. In fact, the greater the vaccination coverage, the greater will be the efficacy of the program for the prevention of CC and other HPV‐related diseases.

Education and Income Levels are Associated With Energy and Micronutrient Intake

Introduction: According to the literature, education and income are determinants factors of diet quality and consequently of micronutrient intake. However, this association is still little known among adults who live in middle-income countries. Objective: To estimate energy and micronutrients intake by men and women living in a capital city in southern Brazil, according to education and income levels, and to identify prevalence of inadequate micronutrient intake according also to education and income levels. Method: This is a second wave cross-sectional analysis of a population-based longitudinal study, the EpiFloripa Adultos, including 1,222 individuals of 22-63 years. Data on food consumption were obtained through applying two 24-hour dietary recalls, and the prevalence of inadequate micronutrient intake, following the recommendations of the Institute of Medicine and from the National Research Council. Results: A tendency of increased intake with an increase in income (calcium, vitamins C, E) and education levels (calcium, vitamins A, C, D) was observed for most of the micronutrients analyzed (p<0.05 in all cases); still, a prevalence of inadequacy according to Estimated Average Requirement (EAR) between 85.5-100% in intake of vitamins A, D and E were found for the whole sample. Iron inadequate intake was associated with education level and among women less than 50 years of age (p=0.018). Conclusion: The results showed an influence of the education and income levels on micronutrient intake, point to the need of daily food consumption, of minimally processed and in natura foods (as fruits, vegetables, whole grains, milk and its derivatives) as a means to reduce the encountered inadequacies.

Differences in colorectal cancer surveillance epidemiology and screening in the WHO European Region

The aim of this study was to describe the Colorectal Cancer (CRC) burden and prevention actions in 53 countries of the World Health Organization (WHO) European Region (ER). Multiple correspondence analysis was applied to examine the association among the following variables: Measures of occurrence; type of screening programme; existence of cancer registries; data quality and; and gross national income (GNI) level. The study demonstrated clear differences according to GNI: low-middle income (LMI) countries show low mortality rates and unorganized screening programme; upper-middle income (UMI) countries show no test offered, incomplete or absent data mortality, and low quality of the method used to estimate incidence and mortality rates; high income (HI) countries show high mortality rates, test offered (FOBT and colonoscopy), the existence of a national registry, screening population-based, insurance of payment policy, and high quality of the method used to estimate incidence and mortality rates. HI countries reflect a strong interest in epidemiological monitoring and produce accurate indicators of disease occurrence. On the other hand, surveillance strategies need to be improved in UMI and LMI countries: As national vital statistics are unavailable, partial or inaccurate, the coverage and completeness of the mortality data are frequently poor, there is a less efficient general organization. In conclusion, it is important to underline that the resources available (as measured by GNI) appear to be major factors in the Colorectal Cancer Surveillance Epidemiology and Screening in the WHO European Region.

Variation in the rate of well-controlled status of chronic disease by income level in Korea: 2010 to 2015

Although it is known that the prevalence rates of chronic diseases depend on income level, annual changes of the control rate have not been evaluated. In this cross-sectional study, we analyzed the variation in rate of well-controlled status of chronic diseases based on the annual income level using data from national nutrition surveys conducted between 2010 and 2015.Prevalence and controlled rate of hypertension, diabetes mellitus, and chronic kidney disease were analyzed in relation to annual income levels, using data from the Korea National Health and Nutrition Examination Survey (KNHANES), obtained from 2010 to 2015. We also analyzed the incidence of use of necessary medical care services and the reasons cited for not using these services.The data of 28,759 persons were analyzed. The average age increased, and sex ratio remained unchanged over the study period. Although the prevalence rates of diabetes increased, that of increased glycated hemoglobin gradually decreased. A significant change has been shown recently on the prevalence rates of hypertension patients. The prevalence rates of chronic kidney disease stayed unchanged during the course of the study period. The incidence of controlled chronic disease status increased with the income level, and over time during the study, in the case of diabetes and chronic kidney disease. However, while controlled hypertension status rate increased from year to year, there was no trend of increase with increased income level. The incidence of participants not using hospital services declined with increasing income level, but the rate of economic causes being cited as reasons for not using hospital services increased over time and showed no change among income levels. Results of regression analysis of prevalence rates of chronic diseases by income level showed that lower income groups tended to have higher odds ratios for chronic diseases.Our results suggest that the incidence rate of well-controlled chronic disease status remains low in lower income groups. These results imply that financial status may play an important role in the management of chronic diseases.

Hospitalisation cost analysis on hip fracture in China: a multicentre study among 73 tertiary hospitals

OBJECTIVE

To describe and analyse the hospitalisation cost of patients with hip fracture under the influence of various factors and to provide references for Chinese national medical insurance policy.

MATERIALS AND METHODS

All data were collected from the Chinese National Medical Data Centre database, which contained the hospitalisation data of 73 tertiary hospitals from 24 provinces. The included patients were first hospitalised with the main diagnosis of femoral neck or intertrochanteric fracture, and were discharged between 1 January 2014 and 31 December 2015. Secondary hospitalisation, multiple trauma or pathologic fracture (except for osteoporotic fracture) patients or patients with missing data were excluded. The impact of various factors on the cost was investigated using analysis of variance and multivariable linear regression analysis. The Gross Domestic Product per capita and average annual disposable income were obtained from the website of the National Bureau of Statistics.

RESULTS

27 205 cases were included in the study. The mean cost of all patients was ¥53 440. 60-69 years age group had a significantly higher cost compared with 80 years and above age group. The mean cost of femoral neck fractures was lower than that of the patients with intertrochanteric fractures; the mean cost of hip replacement was higher than that of internal fixation, which showed a strong effect of the surgical approach to the cost. Patients in low-income provinces spent less than those in high-income provinces, while the gap between high-income and middle-income provinces were relatively small.

CONCLUSION

The hospitalisation cost of hip fracture has become a great burden to the patients' families. The Chinese medical insurance policy may need further consideration of the demographic and economic factors.

Sociodemographic Determinants of Out-of-Pocket Expenditures for Patients Using Prescription Drugs for Rheumatoid Arthritis

BACKGROUND

Rheumatoid arthritis (RA) is a chronic inflammatory disease that has a substantial economic impact on patients. Patients with RA are at an increased risk for disability and for loss of income. The inclusion of biologic drugs in RA therapy has increased the cost of treatment. Little is known about the relationship between sociodemographic characteristics and the out-of-pocket (OOP) expenditures for prescription drugs for patients with RA, including biologics, disease-modifying antirheumatic drugs (DMARDs), nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and analgesics.

OBJECTIVES

To explore the relationship between sociodemographic characteristics, personal characteristics, and OOP expenditures associated with RA prescription medications. A secondary objective was to measure the average OOP expenditures for different therapeutic classes of RA medications, including biologics, DMARDs, NSAIDs, corticosteroids, and analgesics.

METHODS

In this retrospective analysis of Medical Expenditure Panel Survey (MEPS) data from 2009 to 2012, we identified a patient sample of 1090 adults with RA, which represented approximately 9.71 million patients in the MEPS database. The total OOP expenditure was calculated based on the OOP expenditure for each prescription drug corresponding to an individual. Patient variables included age, race, sex, insurance status, number of comorbid conditions, region, area of living, annual family income, and marital status. Logistic regression and generalized linear models were used for analysis. The mean OOP expenditure for therapeutic classes was estimated using nonparametric percentiles from 1000 cluster bootstrap estimates.

RESULTS

Overall, the mean annual OOP expenditure was $273.99 (95% confidence interval [CI], $197.07-$364.75). The OOP expenditures were lower for privately insured (0.31; 95% CI, 0.21-0.45) patients and publicly insured (0.18; 95% CI, 0.12-0.27) patients versus uninsured patients, and for poor (0.60; 95% CI, 0.43-0.84) and low-income (0.69; 95% CI, 0.49-0.97) patients versus high-income patients. The mean annual OOP expenditure decreased with age (0.98; 95% CI, 0.97-0.99), was lower (0.73; 95% CI, 0.58-0.92) for male patients than for female patients, and increased with the presence of comorbidities (1.16; 95% CI, 1.07-1.25). The average annual OOP expenditure was highest for biologics ($2556.73), followed by DMARDs ($89.37). The average annual OOP expenditures were $27.97, $52.36, and $72.51 for corticosteroids, NSAIDs, and narcotic analgesics, respectively.

CONCLUSIONS

Age, sex, race, income level, insurance status, and comorbidity status significantly affected patient OOP expenditure. Higher OOP expenditures among the uninsured, female patients, patients with low income levels, and patients with several comorbidities could adversely affect RA therapy. The use of expensive biologics needs to be monitored to reduce prescription-related cost-sharing among patients with RA.

Racial/Ethnic and Income Differences in Obesity Among Older Adults: The Role of Leisure-time Physical Activity and Neighborhood Social Cohesion

BACKGROUND

Few studies have examined the associations among social cohesion, physical activity, and obesity in older adults. This study explored the influences of social cohesion and leisure-time physical activity on obesity in older adults, and tested whether these relationships varied by race/ethnicity and income level.

METHODS

A cross-sectional analysis of adults in the 2013 National Health Interview Study (NHIS) who were over 65 years of age (N = 7714) was used. Logistic regressions were performed to examine the impacts of social cohesion and physical activity on obesity, and the relative risks (RR) were reported.

RESULTS

The median age was 73 years old, and 59.8% of respondents were female; 23.8% met the recommended level of moderate physical activity. Neighborhood social cohesion was not associated with obesity for older adults. Meeting the recommended level of vigorous physical activity was related to a lower probability of obesity only for older Hispanic adults (RR = 0.41, 95% CI: 0.31 to 0.50), while older adults were less likely to be obese if they met the recommended level of moderate physical activity.

CONCLUSIONS

Increasing the level of physical activity may profoundly reduce the probability of obesity for older adults. Moreover, the results implied the need for future physical activity interventions for minorities.

Macro influencers of electronic health records adoption

While adoption rates for electronic health records (EHRs) have improved, the reasons for significant geographical differences in EHR adoption within the USA have remained unclear. To understand the reasons for these variations across states, we have compiled from secondary sources a profile of different states within the USA, based on macroeconomic and macro health-environment factors. Regression analyses were performed using these indicator factors on EHR adoption. The results showed that internet usage and literacy are significantly associated with certain measures of EHR adoption. Income level was not significantly associated with EHR adoption. Per capita patient days (a proxy for healthcare need intensity within a state) is negatively correlated with EHR adoption rate. Health insurance coverage is positively correlated with EHR adoption rate. Older physicians (>60 years) tend to adopt EHR systems less than their younger counterparts. These findings have policy implications on formulating regionally focused incentive programs.

National use of asbestos in relation to economic development

BACKGROUND

National disparities in asbestos use will likely lead to an unequal burden of asbestos diseases.

OBJECTIVES

As economic status may be linked to asbestos use, we assessed, globally, the relationship between indicators of national economic development and asbestos use.

METHODS

For the 135 countries that have ever used asbestos, per capita asbestos use (kilograms per capita per year) was compared with per capita gross domestic product (GDP) in 1990 Geary-Khamis dollars (GKD) for the period 1920-2003. Countries were grouped into three income levels (high, middle, and low) that were adapted from the 2003 World Bank categories.

RESULTS

The historical pattern of asbestos use followed the environmental Kuznets curve in which use by high-income countries peaked when incomes attained 10,000-15,000 GKD and essentially ceased at income levels over 20,000 GKD. Currently, middle- and low-income countries are increasing their use of asbestos, closely following the paths once traced by higher income countries.

CONCLUSIONS

Developing countries have the opportunity to eliminate asbestos use sooner than high-income countries and thus reduce the future burden of asbestos diseases.