What does self rated health measure? Results from the British Whitehall II and French Gazel cohort studies

OBJECTIVES

To investigate the determinants of self rated health (SRH) in men and women in the British Whitehall II study and the French Gazel cohort study.

METHODS

The cross sectional analyses reported in this paper use data from wave 1 of the Whitehall II study (1985-88) and wave 2 of the Gazel study (1990). Determinants were either self reported or obtained through medical screening and employer's records. The Whitehall II study is based on 20 civil service departments located in London. The Gazel study is based on employees of France's national gas and electricity company (EDF-GDF). SRH data were available on 6889 men and 3403 women in Whitehall II and 13 008 men and 4688 women in Gazel.

RESULTS

Correlation analysis was used to identify determinants of SRH from 35 measures in Whitehall II and 33 in Gazel. Stepwise multiple regressions identified five determinants (symptom score, sickness absence, longstanding illness, minor psychiatric morbidity, number of recurring health problems) in Whitehall II, explaining 34.7% of the variance in SRH. In Gazel, four measures (physical tiredness, number of health problems in the past year, physical mobility, number of prescription drugs used) explained 41.4% of the variance in SRH.

CONCLUSION

Measures of mental and physical health status contribute most to the SRH construct. The part played by age, early life factors, family history, sociodemographic variables, psychosocial factors, and health behaviours in these two occupational cohorts is modest.

Pathways between socioeconomic determinants of health

STUDY OBJECTIVE

Many previous studies on socioeconomic inequalities in health have neglected the causal interdependencies between different socioeconomic indicators. This study examines the pathways between three socioeconomic determinants of ill health.

DESIGN, SETTING, AND PARTICIPANTS

Cross sectional survey data from the Helsinki health study in 2000 and 2001 were used. Each year employees of the City of Helsinki, reaching 40, 45, 50, 55, and 60 years received a mailed questionnaire. Altogether 6243 employees responded (80% women, response rate 68%). Socioeconomic indicators were education, occupational class, and household income. Health indicators were limiting longstanding illness and self rated health. Inequality indices were calculated based on logistic regression analysis.

MAIN RESULTS

Each socioeconomic indicator showed a clear gradient with health. Among women half of inequalities in limiting longstanding illness by education were mediated through occupational class and household income. Inequalities by occupational class were largely explained by education. A small part of inequalities for income were explained by education and occupational class. For self rated health the pathways were broadly similar. Among men most of the inequalities in limiting longstanding illness by education were mediated through occupational class and income. Part of occupational class inequalities were explained by education. Two thirds of inequalities by income were explained by education and occupational class.

CONCLUSIONS

Parts of the effects of each socioeconomic indicator on health are either explained by or mediated through other socioeconomic indicators. Analyses of the predictive power of socioeconomic indicators on health run the risk of being fruitless, if interrelations between various indicators are neglected.

Mortality after the death of a spouse: rates and causes of death in a large Finnish cohort

OBJECTIVES

This study examines excess mortality among Finnish persons after the death of a spouse, by sex, the subject's cause of death, duration of bereavement, and age.

METHODS

The subjects were 1580000 married Finnish persons aged 35 through 84 years who were followed up from 1986 through 1991.

RESULTS

Excess mortality among the bereaved was high from accidental, violent, and alcohol-related causes (50% to 150%), moderate for chronic ischemic heart disease and lung cancer (20% to 35%), and small for other causes (5% to 15%). Excess mortality was greater at short ( < 6 months) rather than long durations of bereavement and among younger rather than older bereaved persons for most causes of death; it was also greater among men that women.

CONCLUSIONS

The results are consistent with the hypothesis that excess mortality after the death of a spouse is partly caused by stress. The loss of social support or the inability to cope with stress may explain why men suffer from bereavement more than do women.

Within-sibship genome-wide association analyses decrease bias in estimates of direct genetic effects

Estimates from genome-wide association studies (GWAS) of unrelated individuals capture effects of inherited variation (direct effects), demography (population stratification, assortative mating) and relatives (indirect genetic effects). Family-based GWAS designs can control for demographic and indirect genetic effects, but large-scale family datasets have been lacking. We combined data from 178,086 siblings from 19 cohorts to generate population (between-family) and within-sibship (within-family) GWAS estimates for 25 phenotypes. Within-sibship GWAS estimates were smaller than population estimates for height, educational attainment, age at first birth, number of children, cognitive ability, depressive symptoms and smoking. Some differences were observed in downstream SNP heritability, genetic correlations and Mendelian randomization analyses. For example, the within-sibship genetic correlation between educational attainment and body mass index attenuated towards zero. In contrast, analyses of most molecular phenotypes (for example, low-density lipoprotein-cholesterol) were generally consistent. We also found within-sibship evidence of polygenic adaptation on taller height. Here, we illustrate the importance of family-based GWAS data for phenotypes influenced by demographic and indirect genetic effects.

Dietary patterns and 15-y risks of major coronary events, diabetes, and mortality

BACKGROUND

Few studies have examined the long-term effect of habitual diet on risks of incident diabetes, coronary heart disease, and mortality.

OBJECTIVE

We analyzed the prospective relation of dietary patterns with incident chronic disease and mortality during 15 y of follow-up in the Whitehall II study.

DESIGN

We conducted a prospective analysis (106,633 person-years at risk) among men and women (n = 7731) with a mean age of 50 y at the time of dietary assessment (127-item food-frequency questionnaire). Coronary death or nonfatal myocardial infarction and incident diabetes were verified by record tracing and oral-glucose-tolerance tests.

RESULTS

Cluster analysis identified 4 dietary patterns at baseline. The patterns were termed unhealthy (white bread, processed meat, fries, and full-cream milk; n = 2665), sweet (white bread, biscuits, cakes, processed meat, and high-fat dairy products; n = 1042), Mediterranean-like (fruit, vegetables, rice, pasta, and wine; n = 1361), and healthy (fruit, vegetables, whole-meal bread, low-fat dairy, and little alcohol; n = 2663). Compared with the unhealthy pattern, the healthy pattern reduced the risk of coronary death or nonfatal myocardial infarction and diabetes; hazard ratios (95% CI) were 0.71 (0.51, 0.98) and 0.74 (0.58, 0.94), respectively, after adjustment for age, sex, ethnicity, dietary energy misreporting, social position, smoking status, and leisure-time physical activity. Dietary pattern was not associated with all-cause mortality. Residual confounding by socioeconomic factors was unlikely to account for the observed dietary effects.

CONCLUSIONS

The healthy eating pattern reduced risks of diabetes and major coronary events. Such dietary patterns offer considerable health benefits to individuals and contribute to public health.

Is retirement good or bad for mental and physical health functioning? Whitehall II longitudinal study of civil servants

BACKGROUND

To determine whether retirement at age 60 is associated with improvement or deterioration in mental and physical health, when analysed by occupational grade and gender.

METHODS

Longitudinal study of civil servants aged 54 to 59 years at baseline, comparing changes in SF-36 health functioning in retired (n=392) and working (n=618) participants at follow up. Data were collected from self completed questionnaires.

RESULTS

Mental health functioning deteriorated among those who continued to work, but improved among the retired. However, improvements in mental health were restricted to those in higher employment grades. Physical functioning declined in both working and retired civil servants.

CONCLUSION

The study found that retirement at age 60 had no effects on physical health functioning and, if anything, was associated with an improvement in mental health, particularly among high socioeconomic status groups.

Changes in mortality inequalities over two decades: register based study of European countries

OBJECTIVE

To determine whether government efforts in reducing inequalities in health in European countries have actually made a difference to mortality inequalities by socioeconomic group.

DESIGN

Register based study.

DATA SOURCE

Mortality data by level of education and occupational class in the period 1990-2010, usually collected in a census linked longitudinal study design. We compared changes in mortality between the lowest and highest socioeconomic groups, and calculated their effect on absolute and relative inequalities in mortality (measured as rate differences and rate ratios, respectively).

SETTING

All European countries for which data on socioeconomic inequalities in mortality were available for the approximate period between years 1990 and 2010. These included Finland, Norway, Sweden, Scotland, England and Wales (data applied to both together), France, Switzerland, Spain (Barcelona), Italy (Turin), Slovenia, and Lithuania.

RESULTS

Substantial mortality declines occurred in lower socioeconomic groups in most European countries covered by this study. Relative inequalities in mortality widened almost universally, because percentage declines were usually smaller in lower socioeconomic groups. However, as absolute declines were often smaller in higher socioeconomic groups, absolute inequalities narrowed by up to 35%, particularly among men. Narrowing was partly driven by ischaemic heart disease, smoking related causes, and causes amenable to medical intervention. Progress in reducing absolute inequalities was greatest in Spain (Barcelona), Scotland, England and Wales, and Italy (Turin), and absent in Finland and Norway. More detailed studies preferably using individual level data are necessary to identify the causes of these variations.

CONCLUSIONS

Over the past two decades, trends in inequalities in mortality have been more favourable in most European countries than is commonly assumed. Absolute inequalities have decreased in several countries, probably more as a side effect of population wide behavioural changes and improvements in prevention and treatment, than as an effect of policies explicitly aimed at reducing health inequalities.

Do risk factors and health behaviours contribute to self-ratings of health?

This study examined the relative importance of five risk factors and health behaviours (namely dietary habits, leisure time exercise, smoking, alcohol consumption and body mass index) on self-ratings of health among the Swedish adult population. The data come from the 1991 Swedish Level of Living Survey, a face-to-face survey interview based on a sample representative of the Swedish population aged between 18 and 75 years (n = 5306). The analyses were carried out using logistic regression analysis. With the exception of the consumption of dietary fat, all the risk factors and health behaviours studied were associated with self-rated health. When they were adjusted for health problems and functional limitations most of the associations weakened or disappeared altogether, but smoking and use of vegetables in the diet were still associated with self-rated health. Self-ratings of young adults (18-34 years) were found to be related to body mass index even when health problems were adjusted for, with both obesity and underweight contributing to less than good self-rated health. The results indicate that risk factors and health behaviours do not, in general, directly contribute to self-ratings of health. Instead, their effect is mediated by more specific health problems and their functional consequences. However, smoking and not consuming vegetables, as well as obesity and underweight among young respondents, were found to have an independent association with self-rated health. This may reflect the effects of health problems not captured by our indicators of ill health, but may also indicate that risk factors and risky behaviours are considered to have an effect on one's perceived health even in the absence of health consequences.

Incidence and prognostic implications of stable angina pectoris among women and men

CONTEXT

Stable angina pectoris in women has often been considered a "soft" diagnosis, with less-severe prognostic implications than in men, but large-scale population studies are lacking.

OBJECTIVE

To determine sex differences in the incidence and prognosis of stable angina in a large ambulatory population.

DESIGN

Prospective cohort study using linked national registers.

SETTING

All municipal primary health care centers, hospital outpatient clinics, occupational health care services, and the private sector in Finland.

PARTICIPANTS

Among ambulatory patients aged 45 to 89 years who had no history of coronary disease, we defined new cases of "nitrate angina" based on nitrate prescription (56,441 women and 34,885 men) or "test-positive angina" based on abnormal invasive or noninvasive test results (11,391 women and 15,806 men). Potentially eligible patients were evaluated between January 1, 1996, and December 31, 1998. Follow-up ended in December 2001.

MAIN OUTCOME MEASURES

Coronary mortality at 4 years (n = 7906 deaths) and fatal and nonfatal myocardial infarction at 1 year (n = 3129 events).

RESULTS

The age-standardized annual incidence per 100 population of all cases of angina was 2.03 in men and 1.89 in women, with a sex ratio of 1.07 (95% confidence interval [CI], 1.06-1.09). At every age, nitrate angina in women and men was associated with a similar increase in risk of coronary mortality relative to the general population. Women with test-positive angina who were younger than 75 years had higher coronary-standardized mortality ratios than men; for example, among those aged 55 to 64 years, it was 4.69 (95% CI, 3.60-6.11) in women compared with 2.40 (95% CI, 2.11-2.73) in men (P<.001 for interaction). There was a strong, graded relationship between amount of nitrates used and event rates; women using higher doses of nitrates had prognoses comparable with those of men. Among patients with diabetes and test-positive angina, age-standardized coronary event rates were 9.9 per 100 person-years in women vs 9.3 in men (P = .69), and the fully adjusted male-female sex ratio was 1.07 (95% CI, 0.81-1.41).

CONCLUSIONS

Women have a similarly high incidence of stable angina compared with men. Furthermore, stable angina in women is associated with increased coronary mortality relative to women in the general population and, among easily identifiable clinical subgroups, has similarly high absolute rates of prognostic outcomes compared with men.

Effect of transforming growth factor-beta 1 on proliferation and death of rat prostatic cells

The ability of transforming growth factor B1 (TGF beta 1) to inhibit proliferation and activate death of rat ventral prostatic glandular cells was tested both in vivo and in vitro. In vivo administration of 50 ng TGF beta 1/day directly to the regressed ventral prostate of previously castrated male rats had no effect on the proliferative regrowth of the prostatic glandular cells induced by exogeneous androgen replacement. In addition, androgen-stimulated ventral prostatic cell proliferation in vitro in organ culture was not affected by exposure to 0.1-20 ng/ml TGF beta 1. In contrast in vivo administration of 50 ng TGF beta 1/day directly to the ventral prostate of intact noncastrated male rats resulted in the death of about 25% of the prostatic glandular cells within 7 days of treatment. Such TGF beta 1 treatment did not lower serum testosterone, nor did it affect the size or DNA content of the seminal vesicles, demonstrating the local nature of the response. Likewise, in androgen-maintained ventral prostate organ cultures in vitro, there was a dose-response relationship between glandular cell death and TGF beta 1 concentration in the medium. These results demonstrate that TGF beta 1 can induce the death of androgen-dependent prostatic glandular cells even when physiological levels of androgen are present. Previous studies have demonstrated that both the receptor and the mRNA for TGF beta 1 increase rapidly in the ventral prostate after castration. Taken with the present data, these results suggest that TGF beta 1 may be a physiological intermediate in the programmed cell death of rat prostatic glandular cells activated after androgen ablation.

Trends in health inequalities in 27 European countries

Unfavorable health trends among the lowly educated have recently been reported from the United States. We analyzed health trends by education in European countries, paying particular attention to the possibility of recent trend interruptions, including interruptions related to the impact of the 2008 financial crisis. We collected and harmonized data on mortality from ca 1980 to ca 2014 for 17 countries covering 9.8 million deaths and data on self-reported morbidity from ca 2002 to ca 2014 for 27 countries covering 350,000 survey respondents. We used interrupted time-series analyses to study changes over time and country-fixed effects analyses to study the impact of crisis-related economic conditions on health outcomes. Recent trends were more favorable than in previous decades, particularly in Eastern Europe, where mortality started to decline among lowly educated men and where the decline in less-than-good self-assessed health accelerated, resulting in some narrowing of health inequalities. In Western Europe, mortality has continued to decline among the lowly and highly educated, and although the decline of less-than-good self-assessed health slowed in countries severely hit by the financial crisis, this affected lowly and highly educated equally. Crisis-related economic conditions were not associated with widening health inequalities. Our results show that the unfavorable trends observed in the United States are not found in Europe. There has also been no discernible short-term impact of the crisis on health inequalities at the population level. Both findings suggest that European countries have been successful in avoiding an aggravation of health inequalities.

Socioeconomic inequalities in mortality among women and among men: an international study

OBJECTIVES

This study compared differences in total and cause-specific mortality by educational level among women with those among men in 7 countries: the United States, Finland, Norway, Italy, the Czech Republic, Hungary, and Estonia.

METHODS

National data were obtained for the period ca. 1980 to ca. 1990. Age-adjusted rate ratios comparing a broad lower-educational group with a broad upper-educational group were calculated with Poisson regression analysis.

RESULTS

Total mortality rate ratios among women ranged from 1.09 in the Czech Republic to 1.31 in the United States and Estonia. Higher mortality rates among lower-educated women were found for most causes of death, but not for neoplasms. Relative inequalities in total mortality tended to be smaller among women than among men. In the United States and Western Europe, but not in Central and Eastern Europe, this sex difference was largely due to differences between women and men in cause-of-death pattern. For specific causes of death, inequalities are usually larger among men.

CONCLUSIONS

Further study of the interaction between socioeconomic factors, sex, and mortality may provide important clues to the explanation of inequalities in health.

Inequalities in Alcohol-Related Mortality in 17 European Countries: A Retrospective Analysis of Mortality Registers

BACKGROUND

Socioeconomic inequalities in alcohol-related mortality have been documented in several European countries, but it is unknown whether the magnitude of these inequalities differs between countries and whether these inequalities increase or decrease over time.

METHODS AND FINDINGS

We collected and harmonized data on mortality from four alcohol-related causes (alcoholic psychosis, dependence, and abuse; alcoholic cardiomyopathy; alcoholic liver cirrhosis; and accidental poisoning by alcohol) by age, sex, education level, and occupational class in 20 European populations from 17 different countries, both for a recent period and for previous points in time, using data from mortality registers. Mortality was age-standardized using the European Standard Population, and measures for both relative and absolute inequality between low and high socioeconomic groups (as measured by educational level and occupational class) were calculated. Rates of alcohol-related mortality are higher in lower educational and occupational groups in all countries. Both relative and absolute inequalities are largest in Eastern Europe, and Finland and Denmark also have very large absolute inequalities in alcohol-related mortality. For example, for educational inequality among Finnish men, the relative index of inequality is 3.6 (95% CI 3.3-4.0) and the slope index of inequality is 112.5 (95% CI 106.2-118.8) deaths per 100,000 person-years. Over time, the relative inequality in alcohol-related mortality has increased in many countries, but the main change is a strong rise of absolute inequality in several countries in Eastern Europe (Hungary, Lithuania, Estonia) and Northern Europe (Finland, Denmark) because of a rapid rise in alcohol-related mortality in lower socioeconomic groups. In some of these countries, alcohol-related causes now account for 10% or more of the socioeconomic inequality in total mortality. Because our study relies on routinely collected underlying causes of death, it is likely that our results underestimate the true extent of the problem.

CONCLUSIONS

Alcohol-related conditions play an important role in generating inequalities in total mortality in many European countries. Countering increases in alcohol-related mortality in lower socioeconomic groups is essential for reducing inequalities in mortality. Studies of why such increases have not occurred in countries like France, Switzerland, Spain, and Italy can help in developing evidence-based policies in other European countries.

Socioeconomic inequalities in diabetes mellitus across Europe at the beginning of the 21st century

AIMS/HYPOTHESIS

The aim of this study was to determine and quantify socioeconomic position (SEP) inequalities in diabetes mellitus in different areas of Europe, at the turn of the century, for men and women.

METHODS

We analysed data from ten representative national health surveys and 13 mortality registers. For national health surveys the dependent variable was the presence of diabetes by self-report and for mortality registers it was death from diabetes. Educational level (SEP), age and sex were independent variables, and age-adjusted prevalence ratios (PRs) and risk ratios (RRs) were calculated.

RESULTS

In the overall study population, low SEP was related to a higher prevalence of diabetes, for example men who attained a level of education equivalent to lower secondary school or less had a PR of 1.6 (95% CI 1.4-1.9) compared with those who attained tertiary level education, whereas the corresponding value in women was 2.2 (95% CI 1.9-2.7). Moreover, in all countries, having a disadvantaged SEP is related to a higher rate of mortality from diabetes and a linear relationship is observed. Eastern European countries have higher relative inequalities in mortality by SEP. According to our data, the RR of dying from diabetes for women with low a SEP is 3.4 (95% CI 2.6-4.6), while in men it is 2.0 (95% CI 1.7-2.4).

CONCLUSIONS/INTERPRETATION

In Europe, educational attainment and diabetes are inversely related, in terms of both morbidity and mortality rates. This underlines the importance of targeting interventions towards low SEP groups. Access and use of healthcare services by people with diabetes also need to be improved.

Changes in alcohol-related mortality and its socioeconomic differences after a large reduction in alcohol prices: a natural experiment based on register data

The authors examined the effect of a large reduction in the price of alcohol in Finland in 2004 on alcohol-related mortality by age and socioeconomic group. For this register-based study of Finns aged >or=15 years, data on independent variables were extracted from the employment statistics of Statistics Finland. Mortality follow-up was carried out for 2001-2003 (before the price reduction) and 2004-2005 (after). Alcohol-related causes were defined using both underlying and contributory causes of death. Alcohol-related mortality increased by 16% among men and by 31% among women; 82% of the increase was due to chronic causes, particularly liver diseases. The increase in absolute terms was largest among men aged 55-59 years and women aged 50-54 years. Among persons aged 30-59 years, it was biggest among the unemployed or early-age pensioners and those with low education, social class, or income. The relative differences in change between the education and social class subgroups were small. The employed and persons aged <35 years did not suffer from increased alcohol-related mortality during the 2 years after the change. These results imply that a large reduction in the price of alcohol led to substantial increases in alcohol-related mortality, particularly among the less privileged, and in chronic diseases associated with heavy drinking.

Variations in the relation between education and cause-specific mortality in 19 European populations: a test of the "fundamental causes" theory of social inequalities in health

Link and Phelan have proposed to explain the persistence of health inequalities from the fact that socioeconomic status is a "fundamental cause" which embodies an array of resources that can be used to avoid disease risks no matter what mechanisms are relevant at any given time. To test this theory we compared the magnitude of inequalities in mortality between more and less preventable causes of death in 19 European populations, and assessed whether inequalities in mortality from preventable causes are larger in countries with larger resource inequalities. We collected and harmonized mortality data by educational level on 19 national and regional populations from 16 European countries in the first decade of the 21st century. We calculated age-adjusted Relative Risks of mortality among men and women aged 30-79 for 24 causes of death, which were classified into four groups: amenable to behavior change, amenable to medical intervention, amenable to injury prevention, and non-preventable. Although an overwhelming majority of Relative Risks indicate higher mortality risks among the lower educated, the strength of the education-mortality relation is highly variable between causes of death and populations. Inequalities in mortality are generally larger for causes amenable to behavior change, medical intervention and injury prevention than for non-preventable causes. The contrast between preventable and non-preventable causes is large for causes amenable to behavior change, but absent for causes amenable to injury prevention among women. The contrast between preventable and non-preventable causes is larger in Central & Eastern Europe, where resource inequalities are substantial, than in the Nordic countries and continental Europe, where resource inequalities are relatively small, but they are absent or small in Southern Europe, where resource inequalities are also large. In conclusion, our results provide some further support for the theory of "fundamental causes". However, the absence of larger inequalities for preventable causes in Southern Europe and for injury mortality among women indicate that further empirical and theoretical analysis is necessary to understand when and why the additional resources that a higher socioeconomic status provides, do and do not protect against prevailing health risks.

Predictors of early retirement in British civil servants

BACKGROUND

it is uncertain how recent changes in labour force dynamics may have influenced the increasing numbers of people taking early retirement in industrialized countries. The Whitehall II study provides an opportunity to examine the predictors of early retirement in one of the largest employers in the United Kingdom.

METHODS

we examined the factors predicting early retirement in a 7-year follow-up period from 1988 to 1995 using longitudinal data on 2532 male and female London-based civil servants aged between 50 and 59.5 years. Baseline data on employment grade and duration of time working for the Civil Service were obtained from self-completed questionnaires. The primary factors examined included health, work characteristics, questions about job demands and job satisfaction and financial insecurity, wealth and material problems. Time until early retirement was analysed using Cox proportional hazards model.

RESULTS

of the 2532 civil servants, 26.7% retired early during the follow-up period. We found that men and women in the higher-paid employment grades, those that had suffered from ill health and those that were less satisfied with their jobs were more likely to retire early, whereas material problems tended to keep people working.

CONCLUSIONS

our results show that self-perceived health, employment grade and job satisfaction are all independent predictors of early retirement. Qualitative analyses may further advance our understanding of the retirement process.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The association between self-rated health and mortality in different socioeconomic groups in the GAZEL cohort study

OBJECTIVES

Self-rated health (SRH) is considered a valid measure of health status as it has been shown to predict mortality in several studies. We examine whether SRH predicts mortality equally well in different socioeconomic groups.

METHODS

Data (14 879 men and 5525 women) are drawn from GAZEL, a prospective cohort study of French public utility workers. Data on SRH and the socioeconomic measures (education, occupational position and income) were taken from the baseline questionnaire (1989), when the average age of individuals was 44.2 years (SD = 3.5). Mortality follow-up was available for a mean of 17.2 years and analysed over the first 10 years and over the entire follow-up period. Associations between SRH and mortality were assessed using Cox regression models using the relative index of inequality (RII) to summarize associations.

RESULTS

The RII for the association between SRH and mortality over the first 10 years was 6.78 [95% confidence interval (CI) = 3.33-13.81] in the lowest occupational group and 2.10 (95% CI = 0.97-4.54) in the highest. For income, the RIIs were 8.82 (95% CI = 4.70-16.54) for the lowest and 1.80 (95% CI = 0.86-3.80) for the highest groups respectively. Findings over the full follow-up period were similar. The association between SRH and mortality was weaker in the high occupation and income groups, both in the short and the long term. The results for education were similar but generally weaker than for the other socioeconomic measures.

CONCLUSIONS

The predictive ability of SRH for mortality weakens with increasing socioeconomic advantage among middle-aged individuals. Thus SRH appears not to measure 'true' health status in a similar way across socioeconomic categories.

Self-rated health and mortality: short- and long-term associations in the Whitehall II study

OBJECTIVES

To determine if self-rated health (SRH), a single-item measure of health status where individuals are asked to rate their own health, predicts mortality in a middle-aged sample and if the predictive ability of SRH diminishes with time.

METHODS

Data (6316 men and 3035 women) are drawn from the Whitehall II study. SRH and covariates were measured at baseline (1985-1988) when the average age of individuals was 44.5 years (SD = 6.1). The mortality follow-up was available for a mean of 17.5 years and was classified as having occurred in the first 10 years or the subsequent follow-up period (range 6 to 9 years). The association between SRH and mortality was assessed using a Cox regression model with relative index of inequality (RII) to summarize associations.

RESULTS

There were no sex differences in the association between SRH and mortality in either the short (p = .39) or the long term (p = .16). Sex-adjusted short-term association (RII = 3.80; 95% confidence interval (CI) 2.28, 6.35) was significantly (p = .004) stronger than the long-term association (RII = 1.56; 95% CI 1.04, 2.34). Explanatory variables accounted for 80% of the SRH-mortality association in men and 29% in women.

CONCLUSIONS

SRH predicts mortality equally well in men and women. However, the covariates explained a much larger proportion of the SRH-mortality relationship in men compared with women. In this middle-aged cohort, SRH predicts mortality strongly in the short term but only weakly in the long term.

Associations of job strain and working overtime with adverse health behaviors and obesity: evidence from the Whitehall II Study, Helsinki Health Study, and the Japanese Civil Servants Study

Adverse health behaviors and obesity are key determinants of major chronic diseases. Evidence on work-related determinants of these behavioral risk factors is inconclusive, and comparative studies are especially lacking. We aimed to examine the associations between job strain, working overtime, adverse health behaviors, and obesity among 45-60-year-old white-collar employees of the Whitehall II Study from London (n=3,397), Helsinki Health Study (n=6,070), and the Japanese Civil Servants Study (n=2,213). Comparable data from all three cohorts were pooled, and logistic regression analysis was used, stratified by cohort and sex. Models were adjusted for age, occupational class, and marital status. Outcomes were unhealthy food habits, physical inactivity, heavy drinking, smoking, and obesity. In London, men reporting passive work were more likely to be physically inactive. A similar association was repeated among women in Helsinki. Additionally, high job strain was associated with physical inactivity among men in London and women in Helsinki. In London, women reporting passive work were less likely to be heavy drinkers and smokers. In Japan, men working overtime reported less smoking, whereas those with high job strain were more likely to smoke. Among men in Helsinki the association between working overtime and non-smoking was also suggested, but it reached statistical significance in the age-adjusted model only. Obesity was associated with working overtime among women in London. In conclusion, job strain and working overtime had some, albeit mostly weak and inconsistent, associations with adverse health behaviors and obesity in these middle-aged white-collar employee cohorts from Britain, Finland, and Japan.

Effects of the characteristics of neighbourhoods and the characteristics of people on cause specific mortality: a register based follow up study of 252,000 men

STUDY OBJECTIVE

To assess the strength of the associations between neighbourhood characteristics and mortality, after adjusting for individual characteristics.

DESIGN AND SETTING

1990 census records of over 25 year old men in the Helsinki Metropolitan area linked to death records in 1991-1995; almost 1.22 million person years and 15 000 deaths. Individual characteristics were education, occupation based social class, housing tenure, housing density, and living arrangements. Proportion of manual workers, proportion of over 60 year olds, and social cohesion were measured for 55 small areas, and SAS Glimmix was used to fit multilevel models.

MAIN RESULTS

Men in areas with high proportion of manual workers and low social cohesion have high mortality, particularly among 25-64 year olds. About 70% of this excess mortality is explained by compositional differences of people living in these areas. Accidents and violence, circulatory diseases, and alcohol related causes contribute most to these area effects. Area characteristics do not consistently modify or mediate the effects of individual socioeconomic characteristics on mortality.

CONCLUSIONS

As compared with individual characteristics neighbourhood characteristics have modest independent effects on male mortality. Furthermore, individual socioeconomic characteristics are associated with mortality independently of area characteristics. Rather than the characteristics of areas, other social contexts, such as peer groups and family settings may be more fruitful targets for further research and policy on contextual effects on mortality.