Human rights in the Horn of Africa: an index of child and maternal health

OBJECTIVE

To construct a territorial measure and classification of child and maternal health in the countries of the Horn of Africa based on the 2030 Agenda for Sustainable Development adopted by all United Nations Member States in 2015.

METHOD

The design of our index includes the variables child and maternal health defined in the Sustainable Development Goals (SDGs) to enable territorial ranking of the countries. For this purpose, we used Pena's distance method for 2017.

RESULTS

The results indicate a relatively high territorial disparity in maternal health between the countries of the Horn of Africa according to the differing values of the SDGs variables of child and maternal health.

CONCLUSIONS

We propose a territorial classification in the countries of the Horn of Africa. We believe that the most striking differences between countries relate to basic variables of maternal health such as being attended by skilled health personnel.

Financial difficulties are associated with greater total pain and suffering among patients with advanced cancer: results from the COMPASS study

BACKGROUND

The Universal Health Coverage goals call for access to affordable palliative care to reduce inequities in "total pain" and suffering. To achieve this, a patient-centred understanding of these inequities is required.

AIM

To assess association of total pain and suffering (i.e. physical, psychological, social, and spiritual health outcomes) and perceived health care quality with financial difficulties among stage IV solid malignancy patients.

DESIGN

Using baseline data from the COMPASS cohort study, we assessed total pain and suffering including physical (physical and functional well-being, pain, symptom burden), psychological (anxiety, depression, emotional well-being), social (social well-being), and spiritual (spiritual well-being, hope) outcomes and perceived health care quality (physician communication, nursing care, and coordination/responsiveness). Financial difficulties were scored by assessing patient perception of the extent to which their resources were meeting expenses for their treatments, daily living, and other obligations. We used multivariable linear/logistic regression to test association between financial difficulties and each patient-reported outcome.

SETTING/PARTICIPANTS

Six hundred stage IV solid malignancy patients in Singapore.

RESULTS

Thirty-five percent reported difficulty in meeting expenses. A higher financial difficulties score was associated with worse physical, psychological, social, spiritual outcomes, and lower perceived quality of health care coordination and responsiveness (i.e. greater total pain and suffering) (all p < 0.05). These associations persisted after adjustment for socio-economic indicators.

CONCLUSION

Results identify advanced cancer patients with financial difficulties to be a vulnerable group with greater reported total pain and suffering. A holistic patient-centred approach to care at end-of-life may help meet goals for Universal Health Coverage.

Challenges of using nationally representative, population-based surveys to assess rural cancer disparities

Population-based surveys provide important information about cancer-related health behaviors across the cancer care continuum, from prevention to survivorship, to inform cancer control efforts. These surveys can illuminate cancer disparities among specific populations, including rural communities. However, due to small rural sample sizes, varying sampling methods, and/or other study design or analytical concerns, there are challenges in using population-based surveys for rural cancer control research and practice. Our objective is three-fold. First, we examined the characterization of "rural" in four, population-based surveys commonly referenced in the literature: 1) Health Information National Trends Survey (HINTS); 2) National Health Interview Survey (NHIS); 3) Behavioral Risk Factor Surveillance System (BRFSS); and 4) Medical Expenditures Panel Survey (MEPS). Second, we identified and described the challenges of using these surveys in rural cancer studies. Third, we proposed solutions to address these challenges. We found that these surveys varied in use of rural-urban classifications, sampling methodology, and available cancer-related variables. Further, we found that accessibility of these data to non-federal researchers has changed over time. Survey data have become restricted based on small numbers (i.e., BRFSS) and have made rural-urban measures only available for analysis at Research Data Centers (i.e., NHIS and MEPS). Additionally, studies that used these surveys reported varying proportions of rural participants with noted limitations in sufficient representation of rural minorities and/or cancer survivors. In order to mitigate these challenges, we propose two solutions: 1) make rural-urban measures more accessible to non-federal researchers and 2) implement sampling approaches to oversample rural populations.

Housing as a determinant of health equity: A conceptual model

Housing is a major pathway through which health disparities emerge and are sustained over time. However, no existing unified conceptual model has comprehensively elucidated the relationship between housing and health equity with attention to the full range of harmful exposures, their cumulative burden and their historical production. We synthesized literature from a diverse array of disciplines to explore the varied aspects of the relationship between housing and health and developed an original conceptual model highlighting these complexities. This holistic conceptual model of the impact of housing on health disparities illustrates how structural inequalities shape unequal distribution of access to health-promoting housing factors, which span four pillars: 1) cost (housing affordability); 2) conditions (housing quality); 3) consistency (residential stability); and 4) context (neighborhood opportunity). We further demonstrate that these four pillars can lead to cumulative burden by interacting with one another and with other structurally-rooted inequalities to produce and reify health disparities. We conclude by offering a comprehensive vision for healthy housing that situates housing's impact on health through a historical and social justice lens, which can help to better design policies and interventions that use housing to promote health equity.

Associations between local government expenditures and low birth weight incidence: Evidence from national birth records

Local governments play an integral role in providing public services to their residents, yet the population health benefits are frequently overlooked, especially when services are outside the traditional health domain. With data from the U.S. Census of Governments and national birth records (spanning from 1992 to 2014), we examined whether local government expenditures on parks and recreation services (PRS) and housing and community development (HCD) predicted county low birth weight outcomes (population incidence and black-white disparities). Hypotheses were tested using bias-corrected county-by-period fixed effects models in a sample of 956 U.S. counties with a total of 3619 observations (observations were defined as three-year pooled estimates), representing 24 million births. Adjusting for prior county low birth weight incidence, levels of total operational, health, and hospital expenditures, and time-varying county sociodemographics, an increase in per capita county PRS expenditures of $50 was associated with 1.25 fewer low birth weight cases per 1000. Change in county HCD expenditures was not associated with low birth weight incidence, and, contrary to hypotheses, neither expenditure type was linked to county black-white disparities. Further examination of the benefits to birth outcomes from increasing parks and recreation services is warranted.

•

Rising parks and recreation expenditures are linked to declining low birth weight.

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Housing and community expenditures are not associated with low birth weight.

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‘Health’ was the only expenditure type linked to black-white perinatal disparities.

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Benefits of parks and recreation services may include healthier birth outcomes.

Disparities in Stage at Diagnosis in an Equal-access Integrated Delivery System: A Retrospective Cohort Study of 7244 Patients With Bladder Cancer

BACKGROUND

Disparities in bladder cancer survival by race/ethnicity and gender are likely related to differences in diagnosis. We assessed disparities in stage at diagnosis and potential contributing factors within a large, integrated delivery system.

PATIENTS AND METHODS

We conducted a retrospective cohort study of 7244 patients with bladder cancer age ≥ 21 years diagnosed from January 2001 to June 2015 within Kaiser Permanente Southern California. Bivariate analyses compared stage at diagnosis - as well as comorbidities, health plan membership length, and health care utilization prior to diagnosis - by race/ethnicity, gender, and age. Multivariable generalized linear mixed models with urologist as a random effect were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for diagnosis of muscle-invasive bladder cancer (MIBC) versus non-muscle-invasive bladder cancer.

RESULTS

In multivariable analyses, stage at diagnosis varied significantly by race/ethnicity (P < .001). Non-Hispanic black patients had significantly higher odds of being diagnosed with MIBC than non-Hispanic white patients (OR, 1.33; 95% CI, 1.05-1.67), whereas Asian patients had significantly lower odds (OR, 0.67; 95% CI, 0.49-0.91). Women were significantly more likely to be diagnosed with MIBC than men (OR, 1.40; 95% CI, 1.22-1.61). Non-Hispanic black women had the highest proportion (39%) of MIBC diagnoses. Among Hispanic and Asian patients, a greater proportion of diagnoses occurred at younger ages.

CONCLUSIONS

Health care coverage within an equal-access system did not eliminate disparities in stage at diagnosis by race/ethnicity or gender. Studies are needed to identify etiologic factors and aspects of care delivery (eg, patient-physician interactions) that may affect the diagnostic process to inform efforts to improve health equity.

Disparities in Sarcoidosis Mortality by Region, Urbanization, and Race in the United States: A Multiple Cause of Death Analysis

PURPOSE

Sex, race/ethnicity, and geographic disparities in sarcoidosis-associated mortality were assessed for the most recent period.

METHODS

US data for multiple causes of death for 1999-2016 were used to determine numbers of deaths and age-adjusted rates for sarcoidosis as an underlying or a contributing cause of death using International Classification of Diseases, 10th Revision code D86 for Hispanics, non-Hispanic blacks, and non-Hispanic whites.

RESULTS

For persons of all ages in the United States in 1999-2016, there were a total of 28,923 sarcoidosis-associated deaths. In 2008-2016, 9112 deaths had sarcoidosis as the underlying cause (56%) compared with 16,129 with sarcoidosis listed as any cause. Age-adjusted annual death rates per 100,000 were 5.7 (95% confidence interval [CI], 5.6-5.8) for females and 4.1 (95% CI, 4.0-4.2) for males. Age-adjusted annual death rates were 1.5 (95% CI, 1.4-1.6) for Hispanics and 5.4 (95% CI, 5.3-5.4) for non-Hispanics. Rates in non-Hispanic blacks were 8 times those in non-Hispanic whites. Among females, the highest rate was in non-Hispanic blacks in the East-Central division. Between 1999-2007 and 2008-2016, rates increased most in non-Hispanic white males (52.5%) and least in non-Hispanic black females (5.8%).

CONCLUSIONS

Sarcoidosis-related multiple cause of death mortality rates were highest in females and in non-Hispanic blacks, and they varied geographically.

Racial and Ethnic Differences in Obesity in People With Spinal Cord Injury: The Effects of Disadvantaged Neighborhood

OBJECTIVE

To examine the role of neighborhood in the relation between race and obesity in people with spinal cord injury (SCI).

DESIGN

A cross-sectional analysis of survey data from National SCI Database linked with neighborhood data from American Community Survey by census tract.

SETTING

A total of 17 SCI Model Systems centers.

PARTICIPANTS

Individuals (N=3385; 2251 non-Hispanic whites, 760 non-Hispanic blacks, 374 Hispanics) who completed a follow-up assessment during 2006-2017 (mean duration of injury, 8.3±9.9y) and resided in 2934 census tracts.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Body mass index (BMI) (kg/m2).

RESULTS

The overall prevalence of obesity was 52.9% (BMI≥25.0) and 23.3% (BMI≥30.0). Hispanics were 67.0% more likely to be obese (BMI≥30.0 kg/m2) relative to non-Hispanic whites (odds ratio, 1.67; 95% confidence interval, 1.27-2.18), after controlling for demographic and injury-related characteristics. Most of the non-Hispanic blacks (66.8%) were living in neighborhoods with high concentrated disadvantaged index (CDI), compared to 35.0% of Hispanics and 9.2% of non-Hispanic whites living in this similar neighborhood status (P<.0001). After accounting for CDI, the odds of being obese in Hispanics decreased (odds ratio, 1.51; 95% confidence interval, 1.15-1.99). Regardless of race and ethnicity, people with SCI from disadvantaged neighborhoods were 42.0%-70.0% more likely to be obese than those from minimal CDI neighborhoods.

CONCLUSIONS

Neighborhood characteristics partially diminish racial differences in obesity. Weight management for the SCI population should target those who are Hispanic and living in the disadvantaged neighborhoods.

Measurement of Socioeconomic Position in Research on Cardiovascular Health Disparities in Korea: A Systematic Review

OBJECTIVES

The validity of instruments measuring socioeconomic position (SEP) has been a major area of concern in research on cardiovascular health disparities. The purpose of this systematic review is to identify the current status of the methods used to measure SEP in research on cardiovascular health disparities in Korea and to provide directions for future research.

METHODS

Relevant articles were obtained through electronic database searches with manual searches of reference lists and no restriction on the date of publication. SEP indicators were categorized into compositional, contextual, composite, and life-course measures.

RESULTS

Forty-eight studies published from 2003 to 2018 satisfied the review criteria. Studies utilizing compositional measures mainly relied on a limited number of SEP parameters. In addition, these measures hardly addressed the time-varying and subjective features of SEP. Finding valid contextual measures at the organizational, community, and societal levels that are appropriate to Korea's context remains a challenge, and these are rarely modeled simultaneously. Studies have rarely focused on composite and life-course measures.

CONCLUSIONS

Future studies should develop and utilize valid compositional and contextual measures and appraise social patterns that vary across time, place, and culture using such measures. Studies should also consider multilevel influences, adding a focus on the interactions between different levels of intertwined SEP factors to advance the design of research. More attention should be given to composite and life-course measures.

Ethnic inequalities and trends in stunting prevalence among Guatemalan children: an analysis using national health surveys 1995-2014

BACKGROUND

Guatemala has the highest prevalence of stunting among under-five children in Latin America. We aimed to compare indigenous and non-indigenous under-five child populations in relation to stunting, as well as to explore the intersectionality of ethnicity by wealth and by place of residence. We also studied how the ethnic inequalities changed over time, using five ENSMI surveys from 1995 to 2014.

METHODS

Five national health surveys carried out between 1995 and 2014 were analysed. World Health Organization (WHO) 2006 growth standards were used to calculate stunting prevalence. Self-reported ethnicity was classified as indigenous or nonindigenous. Wealth was measured through an asset-based index, and households were classified into quintiles (for analyses of the whole populations) or tertiles (for analyses of intersectionality with ethnicity). Area of residence was recorded as urban or rural, according to country definition.

RESULTS

Overall stunting prevalence declined by 9.8 percentage points (95% CI -16.4 to - 3.3) from 1995 to 2014. The slope index for absolute inequalities in stunting - which corresponds to the difference in prevalence between the wealthiest and poorest households - ranged from - 52.9 to - 60.4 percentage points, with no significant change over time. Children in rural areas were consistently more stunted than those in urban areas, but rural indigenous children were significantly worse than any other group. Indigenous children in the poorest tertile of family wealth consistently presented the highest stunting prevalence, compared to all other groups. Time trends in stunting were assessed through the average annual absolute change (AAAC). The fastest decline was observed among indigenous children from the middle wealth tertile (AAAC = - 1.21 percentage points per year (pp/y); 95% CI - 1.45 to - 0.96) followed by nonindigenous children also from the middle tertile (AAAC = - 0.80 pp./y; 95% CI - 0.99 to - 0.60). Stunting prevalence in the two poorest tertiles of indigenous children in 2015 was similar to what nonindigenous children presented in 1995, 20 years earlier. In the wealthiest tertile, indigenous children were far worse off than nonindigenous children 20 years earlier.

CONCLUSIONS

In terms of stunting prevalence, poor and rural indigenous children are twenty years behind nonindigenous children with similar characteristics.

Social disparities and symptom burden in populations with advanced cancer: specialist palliative care providers' perspectives

Disparities in access to palliative care services for populations with social disparities have been reported in Western countries. Studies indicate that these populations tend to report higher symptom distress than other population groups. We need to further investigate how social disparities influence symptom burden to improve symptom relief in these populations.

PURPOSE

To examine the perspectives of specialist palliative care providers concerning the relationship between social disparities and symptom burden in populations with advanced cancer.

METHODS

Two sequential qualitative studies that followed a combination of interpretive and critical methodologies. The interpretive approach was outlined by van Manen's hermeneutic phenomenology while the critical component was informed by the works of Paulo Freire. Participants involved two specialist palliative care teams from a large acute care hospital and a large cancer center in Western Canada. Participants included 11 palliative care providers including registered nurses, nurse practitioners, physicians, and pharmacists.

RESULTS

Participants perceived that social conditions that might aggravate symptom burden included low income, low education, lack of social support, language barriers, and rurality. The relationship between income and symptom burden reflected diverse views. Participants identified populations prone to complex symptom burden including homeless individuals, Indigenous people, people with a history of addictions, and people with mental health or psychosocial issues.

CONCLUSION

Participants perceived that social disparities may increase symptom complexity in populations with advanced cancer. Participants did not identify ethnicity and gender as influencing symptom burden. Further research is needed to examine the interactions of social disparities, patient individuality, and symptom burden.

A Systematic Review of Patient- and Family-Level Inhaled Corticosteroid Adherence Interventions in Black/African Americans

BACKGROUND

Inhaled corticosteroid (ICS) adherence rates are suboptimal among adult black/African Americans. Comprehensive studies characterizing the effectiveness and the methodological approaches to the development of interventions to improve ICS adherence in adult black/African Americans have not been performed.

OBJECTIVES

Conduct a systematic review of patient/family-level interventions to improve ICS adherence in adult black/African Americans.

METHODS

We searched MEDLINE, EMBASE, Web of Science, and CINAHL from inception to August 2017 for English-language US studies enrolling at least 30% black/African Americans comparing patient/family-level ICS adherence interventions with any comparator. Two investigators independently selected, extracted data from, and rated risk of bias. We collected information on intervention characteristics and outcomes, and assessed whether studies were informed by behavior theory, stakeholder engagement, or both.

RESULTS

Among 1661 abstracts identified, we reviewed 230 full-text articles and identified 4 randomized controlled trials (RCTs) and 1 quasi-experimental (pre-post design) study meeting criteria. Study participants (N range, 17-333) varied in mean age (22-47 years), proportion black/African Americans studied (71%-93%), and sex (69%-82% females). RCTs evaluated problem-solving classes, self-efficacy training, technology-based motivational interviewing program, and the use of patient advocates. The RCT testing self-efficacy training was the only intervention informed by both behavior theory and stakeholder engagement. All 4 RCTs compared interventions with active control and rated as medium risk of bias. No RCTs found a statistically significant improvement in adherence.

CONCLUSIONS

Few studies assessing asthma adherence interventions focused on adult black/African-American populations. No RCTs demonstrated improved ICS adherence in participants. Future studies that are informed by behavior change theory and stakeholder engagement are needed.

[Socioeconomic determinants of mortality for very old men in Austria]

BACKGROUND

Although socioeconomic differences in the mortality of middle-aged persons is well-researched, little is known about socioeconomic inequalities in mortality in the very old population. Surveys and population census follow-up studies in this age group are associated with reliability and validity problems.

OBJECTIVE

The aim of the study was to investigate, by linking statistical information from register data, to what extent differences in mortality exist among very old Austrian men by socioeconomic variables (e.g. education and income) and if these can be explained by differences in health status.

MATERIAL AND METHODS

The data records on men aged 80-99 years counted in the Austrian register-based population census from 2011 were augmented by information from tax and social security data and merged with deaths in a 5-year follow-up period. Relative mortality risks were estimated by Cox regression. The health status was operationalized by the standardized level of care.

RESULTS

Even in very old men significant differences in mortality exist depending on the socioeconomic status. A systematic effect was found for education and a poverty effect for income. When controlling not just for age but also for the standardized level of care, no socioeconomic disparities in mortality were observed. The higher mortality risk for less educated and low income very old men is thus a result of a poorer health status.

CONCLUSION

At ages over 80 years the health status is the essential influencing factor on mortality. Measures to reduce socioeconomic disparities in mortality must therefore focus on earlier phases in life, in order to reduce the extent of care dependency among socially disadvantaged groups.

The Intersectional Discrimination Index: Development and validation of measures of self-reported enacted and anticipated discrimination for intercategorical analysis

BACKGROUND AND OBJECTIVE

Although intersectional approaches have gained traction in population health research, quantitative discrimination and health studies have tended to focus on a single axis of discrimination (e.g., racism, homophobia). As few discrimination measures function across multiple social identities or positions, we developed the Intersectional Discrimination Index (InDI) for intercategorical intersectionality research, including measures of Anticipated (InDI-A), Day-to-Day (InDI-D), and Major (InDI-M) discrimination that do not require attribution to particular grounds.

METHODS

We conducted a validity and reliability study with 2016 online survey panel data from Canada and the United States (n = 2583). Internal consistency and dimensionality of the InDI-A were evaluated with exploratory and confirmatory factor analyses. Construct validation included known-groups comparisons, associations with psychological distress, and convergence with existing discrimination measures. Test-retest reliability was examined in a subgroup (n = 150).

RESULTS

We found support for use of the InDI-A as a unidimensional scale. As hypothesized, racial and sexual/gender minorities reported higher frequencies of all discrimination types (all p < 0.001), and discrimination varied across intersectional categories. Each InDI component was significantly positively associated with psychological distress after controlling for potential confounders. Frequency scores were strongly positively correlated with existing scales. Intraclass correlation coefficients for test-retest reliability of anticipated, lifetime day-to-day, and lifetime major discrimination ranged from 0.70 to 0.72.

CONCLUSIONS

Final InDI measures include the 9-item InDI-A, 9-item InDI-D, and 13-item InDI-M, for which we have found initial evidence of construct validity and reliability. In combination with sociodemographic information, the InDI measures can be used to evaluate the role of discrimination as a mediator of intersectional health inequalities, and to monitor the prevalence and impacts of discrimination in heterogeneous populations.

Racial and ethnic differences in post-stroke subjective cognitive decline exist

BACKGROUND

Racial and ethnic minorities consistently demonstrate disparate post-stroke outcomes. However, there is a paucity of literature related to whether this disparity exists specifically in post-stroke cognitive decline.

OBJECTIVE

To determine if racial and ethnic disparities exist in post-stroke subjective cognitive decline (SCD) among non-Hispanic Blacks (Blacks), American Indians or Alaska Natives (AI/ANs), Hispanics, and non-Hispanic Whites (Whites) in the United States using data from the Behavioral Risk Factor Surveillance System (BRFSS).

METHODS

A retrospective analysis was completed using the 2016 BRFSS data in adults who self-reported stroke and SCD. Descriptive statistics were completed for baseline comparisons using chi squared tests for categorical variables. A binary logistic regression controlling for baseline differences was completed to examine racial and ethnic differences in SCD.

RESULTS

Significant differences in SCD were identified across all racial and ethnic groups. When compared to Whites, Blacks, AI/ANs, and Hispanics more frequently reported worsening confusion or memory loss that interfered with day-to-day activities and the ability to work, volunteer, and engage in social activities outside of the home. AI/ANs who reported SCD were more likely than Whites to have help available. Hispanic persons with SCD or their family members were most likely to discuss SCD with a healthcare provider.

CONCLUSION

Although persons from all racial and ethnic groups in this study experienced some degree of SCD, Blacks, AI/ANs, and Hispanics most frequently reported worsening confusion or memory loss impacting engagement in day-to-day activities and the ability to work, volunteer, and engage in social activities outside of the home.

Factors Considered by Nephrologists in Excluding Patients from Kidney Transplant Referral

BACKGROUND

Provider perceptions about patient candidacy for kidney transplant (KT) are potentially significant contributors to disparities in KT.

OBJECTIVE

To examine nephrologists' perceptions about factors that are important in excluding patients from KT referral, and to analyze the association between these perceptions and nephrologists' demographic and practice characteristics.Methods: Invitations were sent to 3180 nephrologists. Among those who consented, 822 fulfilled the inclusion criteria, and 250 were randomly invited to complete a questionnaire about perceptions of factors essential in deciding not to refer patients for KT.

RESULTS

Responses from 216 participants with complete responses were analyzed. The 3 most common reasons for excluding patients were "patient's inadequate social support" (44%), "limited understanding of the process due to patient's inadequate education" (32%), and "patient's age above 65" (26%). Nephrologists practicing in rural settings were more likely to consider inadequate support and limited education of patients as reasons not to refer for KT. In multivariate analysis, physicians with 2 or fewer transplant centers within 50 miles were more likely to report inadequate social support (OR: 3.15, 95% CI: 1.59-6.24) and age greater than 65 years (OR: 1.88, 95% CI: 1.01-3.49) as reasons to exclude patients from KT referral. Nephrologists whose practice included patients majority of whom had not completed high school were more likely to consider limited understanding due to inadequate education as an important reason to exclude patients from KT (OR: 3.31, 95% CI: 1.60-6.86).

CONCLUSION

Patient's social support, understanding, and age were the most common factors regarded by nephrologists as important in not referring patients for KT evaluation. Practice location, particularly rural setting, proximity to a transplant center, and the education level of a nephrologist's patient population were important determinants of referral for KT.

Co-occurring vulnerabilities and menthol use in U.S. young adult cigarette smokers: Findings from Wave 1 of the PATH Study, 2013-2014

This study incorporates intersectionality theory to address potential effects of age on other documented risk factors for current smoking and menthol cigarette use in young adults aged 18-34 using Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2014). We explored known correlates of current cigarette and menthol cigarette smoking and interaction analyses by age group (18-24 vs. 25-34), accounting for survey weighting. Use of non-cigarette tobacco products and e-cigarettes was characterized among current cigarette smokers. Young adults experience multiple vulnerabilities to smoking beyond age and some of these known risk factors for smoking place those aged 18-24 at different risk of cigarette smoking compared to their 25-34 year old counterparts. These include lower odds of cigarette smoking by age for sex (female; AOR = 0.62 in those aged 18-24 vs. 0.72 in those aged 25-34) and Hispanic ethnicity (vs. White; AOR = 0.77 vs. 0.45), and higher odds of smoking among past 30-day alcohol users aged 18-24 vs. 25-34 (AOR = 1.62 vs. 1.32). Correlations between lower education and smoking were nearly two-fold higher in 25-34 than 18-24 year olds. Having any medical comorbidity had opposite effects on current smoking by age (18-24 positive correlation, AOR = 1.17; 25-34 negative correlation, AOR = 0.84). Lower education was correlated with menthol cigarette use among young adult smokers. This study suggests that higher smoking prevalence among young adults is associated with the intersection of multiple vulnerabilities to smoking.

Wealth and occupation determine health deficit accumulation onset in Europe - Results from the SHARE study

While socio-economic characteristics have been shown to be associated with health deficit accumulation (DA) trajectories, their effect on the age at DA onset remains unclear. The objective of this study was to compare the median age at DA onset across nine European countries and to investigate the effects of income, occupation and wealth on DA onset after age 50. We used population samples aged 50 years and older from the SHARE (Survey of Health, Aging and Retirement in Europe) study. Participants from nine European countries with longitudinal data from at least three of the 2004/05, 2006/07, 2010/11, 2012/13 and 2014/15 waves were included in the analysis. A Frailty Index (FI, range 0-1) was constructed from 50 health deficits. DA onset was defined as having FI values > 0.08 in at least two consecutive measurements following an initial FI value ≤ 0.08. We investigated the effect of income, occupation and wealth on DA onset using a random effects model for time-to-event data. Potential confounding variables were identified using directed acyclic graphs. Out of 8616 (mean age 62 years, 49.0% female) participants initially at risk, 2640 (30.6%) experienced a subsequent DA onset. Median age at onset was 71 years overall, ranging from 66 years (Germany) to 76 years (Switzerland). Wealth and occupation were found to have significant effects on DA onset which decreased with age. In sum, the median age at DA onset differs between European countries. On an individual-level, wealth and occupation, but not income influence the age at DA onset.

Towards a global monitoring system for implementing the Rio Political Declaration on Social Determinants of Health: developing a core set of indicators for government action on the social determinants of health to improve health equity

Background

In the 2011 Rio Political Declaration on Social Determinants of Health, World Health Organization (WHO) Member States pledged action in five areas crucial for addressing health inequities. Their pledges referred to better governance for health and development, greater participation in policymaking and implementation, further reorientation of the health sector towards reducing health inequities, strengthening of global governance and collaboration, and monitoring progress and increasing accountability. WHO is developing a global system for monitoring governments’ and international organizations’ actions on the social determinants of health (SDH) to increase transparency and accountability, and to guide implementation, in alignment with broader health and development policy frameworks, including the universal health coverage and Sustainable Development Goals (SDG) agendas. We describe the selection of indicators proposed to be part of the initial WHO global system for monitoring action on the SDH.

Methods

An interdisciplinary working group was established by WHO, the Public Health Agency of Canada, and the Canadian Institutes of Health Research—Institute of Population and Public Health. We describe the processes and criteria used for selecting SDH action indicators that were of high quality and the described the challenges encountered in creating a set of metrics for capturing government action on addressing the Rio Political Declaration’s five Action Areas.

Results

We developed 19 measurement concepts, identified and screened 20 indicator databases and systems, including the 223 SDG indicators, and applied strong criteria for selecting indicators for the core indicator set. We identified 36 suitable existing indicators, which were often SDG indicators.

Conclusions

Lessons learnt included the importance of ensuring diversity of the working group and always focusing on health equity; challenges included the relative dearth of data and indicators on some key interventions and capturing the context and level of implementation of indicator interventions.

What Explains Socioeconomic Inequality in Health-related Quality of Life in Iran? A Blinder-Oaxaca Decomposition

OBJECTIVES

This study aimed to explain the health-related quality of life (HRQoL) gap between the poorest and the wealthiest quintiles in the capitals of Kermanshah and Kurdistan Provinces (Kermanshah and Sanandaj), in western Iran.

METHODS

This was a cross-sectional study conducted among 1772 adults. Data on socio-demographic characteristics, socioeconomic status (SES), lifestyle factors, body mass index, and HRQoL of participants were collected using a self-administered questionnaire. The slope and relative indices of inequality (SII and RII, respectively) were employed to examine socioeconomic inequality in poor HRQoL. Blinder-Oaxaca (BO) decomposition was used to quantify the contribution of explanatory variables to the gap in the prevalence of poor HRQoL between the wealthiest and the poorest groups.

RESULTS

The overall crude and age-adjusted prevalence of poor HRQoL among adults was 32.0 and 41.8%, respectively. The SII and RII indicated that poor HRQoL was mainly concentrated among individuals with lower SES. The absolute difference (%) in the prevalence of poor HRQoL between the highest and lowest SES groups was 28.4. The BO results indicated that 49.9% of the difference was explained by different distributions of age, smoking behavior, physical inactivity, chronic health conditions, and obesity between the highest and lowest SES groups, while the remaining half of the gap was explained by the response effect.

CONCLUSIONS

We observed a pro-rich distribution of poor HRQoL among adults in the capitals of Kermanshah and Kurdistan Provinces. Policies and strategies aimed at preventing and reducing smoking, physical inactivity, chronic health conditions, and obesity among the poor may reduce the gap in poor HRQoL between the highest and lowest SES groups in Iran.

Supporting parenting to address social inequalities in health: a synthesis of systematic reviews

Background

In 2009, the World Health Organization’s Commission on Social Determinants of Health set out its recommendations for action, which included establishing equity from early childhood onwards by enabling all children and their mothers to benefit from a comprehensive package of quality programmes. In order to address social inequalities in health, it is recommended that action be taken from early childhood, and actions providing support for parenting are an effective lever in this respect.

The aim of this review of systematic reviews is to analyse, on the one hand, the components and characteristics of effective interventions in parenting support and, on the other, the extent to which the reviews took into account social inequalities in health.

Methods

A total of 796 reviews were selected from peer-reviewed journals published between 2009 and 2016 in French or English. Of these, 21 reviews responding to the AMSTAR and selected ROBIS criteria were retained. These were analysed in relation to the consideration they gave to social inequalities in health according to PRISMA-equity.

Results

The reviews confirmed that parenting support programmes improved infants’ sleep, increased mothers’ self-esteem and reduced mothers’ anger, anxiety and stress levels. The mainly authors noted that the contexts in which the interventions had taken place were described either scantly or not at all, making it difficult to evaluate them.

Only half of the reviews had addressed the question of social inequalities in health. In particular, there had been little research conducted on the relational aspect and the social link.

Conclusion

In terms of addressing social inequalities in perinatal health, the approach remains both modest and reductive. Understanding how, for whom and in what conditions interventions operate is one way of optimising their results. Further research is needed to study the interactions between the interventions and their contexts.

Sleep and cardiometabolic health by government-assisted rental housing status among Black and White men and women in the United States

OBJECTIVES

To investigate Black-White disparities in suboptimal sleep and cardiometabolic health by government-assisted rental housing status.

DESIGN

National Health Interview Survey (NHIS) pooled cross-sectional data (2004-2016).

SETTING

United States.

PARTICIPANTS

Black and White adult participants (n = 80,880).

MEASUREMENTS

Poisson regression with robust variance was used to estimate prevalence ratios (PRs) and 95% confidence intervals for self-reported unrecommended (<6 hours), short (≤6-<7 hours), and long (>9 hours) sleep duration (each separately vs recommended (≤7-9 hours)) and sleep difficulties (eg, trouble falling/staying asleep ≥3 days/week) (yes vs no) among Blacks compared to Whites within rental housing categories (government-assisted vs unassisted), separately, for men and women. Within sex/housing categories, we applied the same approach to compare cardiometabolic health outcomes (ie, overweight/obesity, hypertension, diabetes, heart disease, stroke) between Blacks with worse sleep and Whites with recommended sleep. Models were adjusted for age and other potential confounders.

RESULTS

Participants' mean age was 42 ± 18 years, 57% were female, and 30% Black. Blacks in unassisted housing had a higher prevalence of unrecommended and short sleep (PR = 1.22 [1.15-1.30] -men, PR = 1.14 [1.08-1.21] -women) compared to their White counterparts (p_{housing⁎race} = 0.001 -men, p_{housing⁎race} = 0.008 -women), but no Black-White differences (PR = 0.88 [0.73-1.07] -men, PR = 0.98 [0.89-1.09] -women) were observed among government-assisted renters. Generally, Blacks were less likely to report sleep difficulties than Whites. Cardiometabolic health disparities between Blacks with worse sleep and Whites with recommended sleep were generally smaller among government-assisted renters, but relationships varied by sex.

CONCLUSIONS

There were no racial disparities in short sleep duration, and cardiometabolic health disparities were generally attenuated when Blacks and Whites resided in government-assisted rental housing.

State-level minimum wage and heart disease death rates in the United States, 1980-2015: A novel application of marginal structural modeling

Despite substantial declines since the 1960's, heart disease remains the leading cause of death in the United States (US) and geographic disparities in heart disease mortality have grown. State-level socioeconomic factors might be important contributors to geographic differences in heart disease mortality. This study examined the association between state-level minimum wage increases above the federal minimum wage and heart disease death rates from 1980 to 2015 among 'working age' individuals aged 35-64 years in the US. Annual, inflation-adjusted state and federal minimum wage data were extracted from legal databases and annual state-level heart disease death rates were obtained from CDC Wonder. Although most minimum wage and health studies to date use conventional regression models, we employed marginal structural models to account for possible time-varying confounding. Quasi-experimental, marginal structural models accounting for state, year, and state × year fixed effects estimated the association between increases in the state-level minimum wage above the federal minimum wage and heart disease death rates. In models of 'working age' adults (35-64 years old), a $1 increase in the state-level minimum wage above the federal minimum wage was on average associated with ~6 fewer heart disease deaths per 100,000 (95% CI: -10.4, -1.99), or a state-level heart disease death rate that was 3.5% lower per year. In contrast, for older adults (65+ years old) a $1 increase was on average associated with a 1.1% lower state-level heart disease death rate per year (b = -28.9 per 100,000, 95% CI: -71.1, 13.3). State-level economic policies are important targets for population health research.

Income inequalities in multimorbidity prevalence in Ontario, Canada: a decomposition analysis of linked survey and health administrative data

BACKGROUND

The burden of multimorbidity is a growing clinical and health system problem that is known to be associated with socioeconomic status, yet our understanding of the underlying determinants of inequalities in multimorbidity and longitudinal trends in measured disparities remains limited.

METHODS

We included all adult respondents from four cycles of the Canadian Community Health Survey (CCHS) (between 2005 to 2011/12), linked at the individual-level to health administrative data in Ontario, Canada (pooled n = 113,627). Multimorbidity was defined at each survey response as having ≥2 (of 17) high impact chronic conditions, based on claims data. Using a decomposition method of the Erreygers-corrected concentration index (C_Erreygers), we measured household income inequality and the contribution of the key determinants of multimorbidity (including socio-demographic, socio-economic, lifestyle and health system factors) to these disparities. Differences over time are described. We tested for statistically significant changes to measured inequality using the slope index (SII) and relative index of inequality (RII) with a 2-way interaction on pooled data.

RESULTS

Multimorbidity prevalence in 2011/12 was 33.5% and the C_Erreygers was - 0.085 (CI: -0.108 to - 0.062), indicating a greater prevalence among lower income groups. In decomposition analyses, income itself accounted more than two-thirds (69%) of this inequality. Age (21.7%), marital status (15.2%) and physical inactivity (10.9%) followed, and the contribution of these factors increased from baseline (2005 CCHS survey) with the exception of age. Other lifestyle factors, including heavy smoking and obesity, had minimal contribution to measured inequality (1.8 and 0.4% respectively). Tests for trends (SII/RII) across pooled survey data were not statistically significant (p = 0.443 and 0.405, respectively), indicating no change in inequalities in multimorbidity prevalence over the study period.

CONCLUSIONS

A pro-rich income gap in multimorbidity has persisted in Ontario from 2005 to 2011/12. These empirical findings suggest that to advance equality in multimorbidity prevalence, policymakers should target chronic disease prevention and control strategies focused on older adults, non-married persons and those that are physically inactive, in addition to addressing income disparities directly.

Income inequalities in multimorbidity prevalence in Ontario, Canada: a decomposition analysis of linked survey and health administrative data

BACKGROUND

The burden of multimorbidity is a growing clinical and health system problem that is known to be associated with socioeconomic status, yet our understanding of the underlying determinants of inequalities in multimorbidity and longitudinal trends in measured disparities remains limited.

METHODS

We included all adult respondents from four cycles of the Canadian Community Health Survey (CCHS) (between 2005 to 2011/12), linked at the individual-level to health administrative data in Ontario, Canada (pooled n = 113,627). Multimorbidity was defined at each survey response as having ≥2 (of 17) high impact chronic conditions, based on claims data. Using a decomposition method of the Erreygers-corrected concentration index (CErreygers), we measured household income inequality and the contribution of the key determinants of multimorbidity (including socio-demographic, socio-economic, lifestyle and health system factors) to these disparities. Differences over time are described. We tested for statistically significant changes to measured inequality using the slope index (SII) and relative index of inequality (RII) with a 2-way interaction on pooled data.

RESULTS

Multimorbidity prevalence in 2011/12 was 33.5% and the CErreygers was - 0.085 (CI: -0.108 to - 0.062), indicating a greater prevalence among lower income groups. In decomposition analyses, income itself accounted more than two-thirds (69%) of this inequality. Age (21.7%), marital status (15.2%) and physical inactivity (10.9%) followed, and the contribution of these factors increased from baseline (2005 CCHS survey) with the exception of age. Other lifestyle factors, including heavy smoking and obesity, had minimal contribution to measured inequality (1.8 and 0.4% respectively). Tests for trends (SII/RII) across pooled survey data were not statistically significant (p = 0.443 and 0.405, respectively), indicating no change in inequalities in multimorbidity prevalence over the study period.

CONCLUSIONS

A pro-rich income gap in multimorbidity has persisted in Ontario from 2005 to 2011/12. These empirical findings suggest that to advance equality in multimorbidity prevalence, policymakers should target chronic disease prevention and control strategies focused on older adults, non-married persons and those that are physically inactive, in addition to addressing income disparities directly.